TREATMENT OF COMPLEX FRACTURES

PREFACE

PHILIP J. KREGOR, MARC F. SWIONTKOWSKI,

MD MD
Guest Editors

We are delighted to bring to you this issue on the treatment of complex fractures. These
injuries continue to be problematic for the treating surgeon, and more importantly, for the
patient. Each of the articles is written by surgeons who truly are on the front lines, and
who deal with these complex fractures on a daily basis. In reading the articles, the passion
that each surgeon has for the particular injury hopefully is clear.
Patient expectations for improved outcomes following severe injuries have increased.
Although we, as an orthopedic community, have improved the treatment of such severe
injuries as complex tibial plateau fractures, we continue to be plagued by problems such as
wound infection, joint stiffness, and post-traumatic arthritis. Basic tenets for complex frac-
ture surgery have emerged in the past three decades. These include careful reduction
and rigid xation of the articular surface, appropriate rigid xation of the metaphyseal/
diaphyseal component of the fracture, preservation of the soft tissue environment around
the fracture, and early mobilization of the joint and patient.
Each of the treatment algorithms described in the following articles are logically derived
and follow the above principles. As new technologies and techniques emerge, we must
critically assess their efcacy, if possible, with multi-center, randomized clinical trials and
prospective functional outcome studies based-on active, planned follow-up. Only then will
we be certain that we are truly improving the lives of our patients.
Each of the authors has sacriced time away from clinical practice, research, and family
to present their expertise. We are indebted to them. We would also like to thank Ms. Deb
Dellapena and Ms. Ali Gavenda of W.B. Saunders, and Mrs. Jackie Manuel of the University
of Mississippi for organizing the entire project. Truly, without their efforts, this issue would
not be possible. We hope you nd it enjoyable.
PHILIP J. KREGOR, MD, and
MARC F. SWIONTKOWSKI, MD
Guest Editors
Division of Orthopedic Trauma
Department of Orthopedics and Rehabilitation
Vanderbilt University Medical Center
Nashville, Tennessee 37232

Department of Orthopaedic Surgery

University of Minnesota
UMHC # 492
420 Delaware Street, SE
Minneapolis, MN 55455

xiii
TREATMENT OF COMPLEX FRACTURES
The rst investigator to publish on the
topic of scapula fractures was Desault in
1805.7 Because of the rarity of this injury, the
literature is replete with small case series or
retrospective reports with poorly controlled
variables. Fractures of the scapula account for
3% to 5% of all fractures about the shoulder
girdle5, 30, 49, 54 and make up less than 1% of all
broken bones according to a Massachusetts
General Hospital review of 4,390 cases by
Wilson in 1938.57 It is likely that the injury is
rare because of the well-endowed muscular
envelope in which it lies, the mobility of the
scapula on the thoracic cage, and surround-
ing musculoskeletal structures (proximal hu-
merus, acromioclavicular joint, and clavicle),
which usually yield rst.
These injuries typically occur in victims
of high-energy trauma and therefore demon-
strate a preponderance in young and middle-
aged men who sustain direct force impact
to the posterosuperior and lateral forequar-
ter. Because of the location and energy of
these forces, it is not surprising that associ-
ated injuries occur in approximately 90% of
these patients.5, 29, 36 These associated injuries
frequently divert attention from appropriate
diagnosis and treatment of the shoulder girdle
because of their life-threatening nature.
The purpose of this review is severalfold.
The reader should develop a better under-
standing of the injured scapula in the con-
text of a patient who is likely multiply in-
jured and direct a diagnostic workup that
will elucidate operative and nonoperative in-
dications based on what is known regarding
From the Department of Orthopedics, University of Minnesota, Regions Hospital, Saint Paul, Minnesota
ORTHOPEDIC CLINICS OF NORTH AMERICA
VOLUME 33 NUMBER 1 JANUARY 2002
00305898/02 $15.00 + .00
SCAPULA FRACTURES
Peter Alexander Cole, MD
outcomes of management. In addition, surgi-
cal approaches and xation techniques is de-
scribed for the most commonly encountered
fracture patterns. Lastly, rehabilitation of these
patients is discussed.
ANATOMY AND BIOMECHANICS
The scapula is approximately a at and tri-
angular bone, with a thin translucent body,
surrounded by borders that are well devel-
oped because of their positions as muscu-
lar origins and insertions (Fig. 1). The scapula
spine divides the superior and inferior angles
of the scapula, thus forming the supraspinatus
and infraspinatus fossae, which are origins for
their respectively named muscles. Its concave
anterior surface serves as a broad origin for the
subscapularis muscle.
The spine of the scapula ends laterally as
the acromion, which arches over the humeral
head from which it is separated by the rota-
tor cuff and subacromial bursae. Along with
the clavicle, it serves as origin for the deltoid
muscle. The trapezius also originates on the
acromion and spine anteriorly. The medial
border of the scapula is the site of attach-
ment of the serratus anterior, which functions
in scapula protraction, and rhomboid mus-
cles, the function of which is scapula retrac-
tion. The levator scapulae muscle inserts on
the superior medial border and is specically
named for its function. The lateral border of
the scapula sweeps up from the inferior an-
gle, forming a thick condensation of bone that
1
2 COLE
Figure 1. Posterior image of a scapula depicting osseous landmarks. The well-developed
borders and processes of the scapula are also strategic opportunities for xation.
ends in the neck of the scapula. The lateral
border is the site of origin of the teres major
and minor muscles, as well as the insertion
for the long head of the triceps on the neck,
and part of latissimus dorsi at the inferior
angle. The coracoid process is a curved os-
seous projection off the anterior neck, which
is the origin for the coracoclavicular and
coracoacromial ligaments, and for the coraco-
brachialis and short head of biceps muscles, as
well as the insertion for the pectoralis minor.
Just proximal to it on the superior margin is
the scapula incisura, traversed by the trans-
verse scapular ligament, above which lies the
suprascapular artery and below which runs
the same nerve.
The pear-shaped glenoid fossa lies at the lat-
eral angle, its margin covered by a brocar-
tilaginous labrum, which is conuent above
with the long head of the biceps tendon at the
supraglenoid tubercle. This labrum enhances
the depth of the glenoid by 50%.26 The glenoid
fossa is approximately 39 mm in a superior
inferior direction and 29 mm in an anterior
posterior direction in its lower half, which is
20% wider than the top half.27
The scapula is part of a suspensory mech-
anism, which attaches the upper extremity
to the axial skeleton by the clavicle. Eigh-
teen muscular origins and insertions on the
scapula39 aid in its function to provide a stable
base from which glenohumeral mobility can
occur.55
Motion of the humerus results from simulta-
neous motion at the sternoclavicular, acromio-
clavicular, scapulothoracic, and glenohumeral
articulations. This concert of muscular forces
constrain the scapula body on the thorax at
approximately 35 , anteverted to the coronal
plane, and position the glenoid fulcrum so that
the rotator cuff can function as a dynamic sta-
bilizer of the proximal humerus.40 This force
vector of the rotator cuff, compressing the
humeral head against the glenoid, counter-
acts the shear forces on the glenohumeral joint
imparted by the large deltoid muscle.51 These
forces are formidable even during ordinary ac-
tivities; when the arm is held in 90 of abduc-
tion, the joint reactive force is 90% of body
weight.46
CLASSIFICATION
Because of the rarity of this injury, only a
few classications are commonly recognized

for fractures of the scapula. Each of these
classications are based on radiographic nd-
ings. The authors of these schemes have asso-
ciated clinical outcomes with certain fracture
variants; however, to date, no functional out-
come study has been prospectively performed
with a meaningful number of subjects to vali-
date a classication system.
The classications of Ada and Miller,1 as
well as that of Hardegger et al,22 are com-
prehensive and anatomically dened. The for-
mer is based on a retrospective experience of
116 scapulae, for which nomenclature was de-
veloped for fractures of each scapula process
(acromion and coracoid), three types of neck
fractures, as well as the glenoid and body. The
Hardegger classication is similar but names
two types of glenoid and two types of neck
fractures. This classication is based on the
experience of 37 operatively treated fractures.
Two recent classications were developed
specically for intra-articular glenoid frac-
tures: (1) Ideberg28, 29 and (2) Mayo et al.35 The
Ideberg classication is based on 100 glenoid
fractures reviewed over a 10-year period, and
its merit lies largely in the epidemiologic con-
text in which it was written. Goss17 published
a variation on this scheme with more subdi-
visions for improved discussion of operative
management of these injuries. The scheme of
Mayo et al is actually a reorganized version of
the Ideberg classication as well, but is based
on the imaging and operative ndings of 27
intra-articular glenoid fractures, the largest
published surgical experience to date. The
intent of the latter authors was to correlate
a scheme with common patterns to direct
surgical decision making. In so doing, there
is emphasis on the associated scapula body
and process fractures with which glenoid
fractures commonly occur. Specically, types 1
to 3 describe the location of the intra-articular
fractureanterior, superior, inferior respec-
tively, whereas type 4 is associated with a
fractured body, and type 5 variants have as-
sociated coracoid, acromion, or neck fractures
(Fig. 2). This application may be the most
useful for glenoid surgery.
Combination lesions of the shoulder sus-
pensory complex are not uncommon in the
setting of scapula fractures. Goss17 has clas-
sied double disruptions of this suspensory
complex and aided in the understanding of
the role of this bonesoft tissue ring made up
by the glenoid, coracoid, and acromion pro-
cesses, with the distal clavicle, coracoclavic-
ular ligaments, and acromioclavicular joint.
SCAPULA FRACTURES 3
Lesions to any two of these structures pro-
duce an unstable anatomic situation with loss
of suspension for the appendicular skeleton.
It is likely that future series will be re-
ported using the Orthopaedic Trauma Asso-
ciation (OTA) Classication System published
in 1996 by the OTA Committee for Coding
and Classication.45 This alphanumeric sys-
tem was developed out of the need for a sys-
tematic classication of fractures to allow for
standardization of research and communica-
tion (Fig. 3). Although this scheme may be
useful in this regard, it has not been validated
clinically.
EVALUATION
History
Knowledge of injury mechanism will assist
in diagnosis. Low-energy injuries that may oc-
cur on the ball eld for example, may result
from landing on the elbow or dislocating the
shoulder. Glenoid rim fractures are not un-
common in this setting. High-energy injuries,
on the other hand, can result from a massive
blow to the hemithorax or forequarter. These
mechanisms result in scapula neck and body
fractures, sometimes with extension into the
glenoid. Direct blows to the superior shoulder
can result in comminuted scapula spine and
displaced acromion fractures. A traction force
to the upper extremity may result in cora-
coid and acromion avulsion fractures, proxi-
mal humerus fractures, severe neurovascular
lesions, and even scapulothoracic dissociation.
Associated Injuries
Eighty to ninety-ve percent of patients
with scapula fractures have associated inju-
ries,2, 21, 30, 36 thus underscoring the energy typ-
ically imparted to these patients. These
patients had an average of 3.9 other major in-
juries in one study54 ; therefore, it is somewhat
surprising that the associated mortality rate is
only 10% to 15%, usually from pulmonary sep-
sis or head injury.2, 54 Approximately 50% of
patients sustain thoracic injuries; 15%, cranial;
and 10%, spinal injuries.2, 17, 37, 54 Approxi-
mately one half of all patients with scapula
fractures have other injuries to the ipsilat-
eral extremity,2, 17, 29, 37 including vascular and
brachial plexus lesions in 13%.37, 54 Anterior
glenoid rim fractures are associated with
4

TYPE V Variants

Type II
TPYE I

A B
TYPE III TYPE IV

Figure 2. A and B, This modication of the Ideberg classication by Mayo et al is useful for common
patterns of glenoid fractures. It emphasizes the associated fractures of the scapula body and pro-
cesses. (From CORR 347:124, 1998, with permission.)
 Figure 3. This classication system for scapula fractures is part of the Fracture and Dislocation Com-
pendium developed by the Orthopaedic Trauma Association Committee for Coding and Classication.
The intent of its authors was to develop a consistent scheme that systematically integrates all long
bone fractures for the purpose of standardization of communication and research. (From Lippincott
5

Williams & Wilkins, JOT 10(suppl 1):8284, 1996; with permission.)

6 COLE
shoulder dislocations in two thirds of patients.
Although these fractures are also the most
commonly associated with nerve lesions ac-
cording to Ideberg et al,29 another study found
that 71% of brachial plexus and two thirds of
arterial lesions occurred in patients with ma-
jor fractures of the scapula body. Heightened
awareness during physical examination is es-
pecially crucial for these patients.
Physical Examination
The physical examination should reect
an understanding of the commonly associ-
ated injuries, particularly those that are life
threatening. Shoulder girdle and their fre-
quently associated neurovascular injuries
demand an appropriate assessment of the
brachial plexus and distal perfusion. Although
the suprascapular and axillary nerve are at
particular risk, it is sometimes impossible to
assess their end muscular function because
of fracture displacement; however, axillary
nerve sensation should be documented. Abra-
sions over the scapula spine and acromion are
common; therefore, skin integrity should be
assessed for appropriate timing of surgery.
Radiographic Imaging
Radiographic imaging for assessment of
scapula fractures should begin with an antero-
posterior (AP), axillary, and scapula Y view.
The AP view should be tangential to the
glenoid, and therefore the radiographic gantry
should project 35 off the perpendicular to
the body in a medial to lateral direction. In
the normal shoulder, this will allow for vi-
sualization of the glenohumeral joint space.
With angulated fractures of the scapula neck
and body, visualization of this joint space may
not be possible (Fig. 4A and B). Medialization
of the glenoid should be appreciated on this
view. On the axillary view, fractures of the
glenoid, acromion, and coracoid can most of-
ten be elucidated. Furthermore, luxation of the
humeral head will be demonstrated. It is often
said that the patient with a broken humerus
or scapula has too much pain to abduct the
arm sufciently for the axillary view. For this
circumstance, the shoulder simply needs to be
abducted slightly and forward elevated. The
radiograph can then be taken by projecting
from just lateral to the hip toward the axilla.42
The scapula-Y radiograph reveals angular
deformity of neck and body fractures and
translatory displacement (Fig. 4C).
The chest radiograph must be evaluated for
commonly associated abnormalities, such as
clavicle and rib fractures and hemopneumoth-
oraces. Close inspection of the trauma chest
radiograph is often the tip-off for scapula frac-
tures themselves. Other special x-rays may be
helpful for further assessment of particular
scapula anatomy such as the West Point view
for anterior glenoid fractures,42 or the oblique
angled view for coracoid fractures.15 The two-
dimensional CT scan may be the best adjunc-
tive study for assessment of scapula spine and
process fractures, particularly the glenoid. Re-
formatted three-dimensional imaging is par-
ticularly helpful in understanding these frac-
ture variants because multiple fracture planes
and angular deformity become vivid (Fig. 4D
and E). After the fracture is well understood
by a careful analysis of the plain radiographs
and CT if necessary, the surgeon can consider
treatment options.
TREATMENT
Surgical Indications
The management of scapula fractures has
historically been nonoperative, perhaps in
part because of the paucity of information
regarding outcomes, combined with a relative
unfamiliarity in treating these injuries. Treat-
ment has emphasized symptom relief and
early motion to prevent long-term stiffness.
After motion is restored in the rst four to
6 weeks, therapy is directed at rehabilitating
the rotator cuff and strengthening parascapu-
lar musculature. Because more than 90% of
scapula fractures are minimally displaced,19
this noninvasive approach is effective for
most.2, 30, 34, 37, 49, 56, 58 No well-documented role
for closed reduction techniques or effective
orthotic management exists.
However, a number of investigators have
accumulated data about injury characteristics
that may portend a poor prognosis, shedding
light on potential indications for surgery.
These recommendations fall more in line
with contemporary management principles
for other periarticular fractures. Displaced
articular fractures of the glenoid, for exam-
ple, are the clearest indication for surgery. If
humeral head subluxation, early arthrosis,
and a poor outcome are to be prevented, open
reduction internal xation (ORIF) should be

performed.5, 17, 18, 21, 22, 29, 35 Signicant articular
displacement was dened as 5 mm in several
studies1, 17, 35 and 4 mm in another study.32
Mayo et al,35 in the largest operative series
of intra-articular glenoid fractures, docu-
mented 82% good or excellent results among
27 patients evaluated clinically and radio-
graphically at 43 months postoperatively.
Fractures of the scapula neck should be
treated operatively if displacement or angula-
tion renders functional imbalance to the paras-
capular musculature. Ada and Miller1 have
recommended ORIF if the glenoid is medially
displaced more than 9 mm or there is more
than 40 of angular displacement.39 This rec-
ommendation is based on a follow-up of 16
such patients treated nonoperatively, of whom
50% had pain, 40% had exertional weakness,
and 20% had decreased motion at a minimum
of 15 months follow-up. A group of eight pa-
tients in this same study were treated oper-
atively, and all achieved a painless range of
motion. Hardegger et al22 achieved 79% good
or excellent results in a series of 37 patients
treated operatively, although only 5 cases were
severely displaced or unstable scapula neck
fractures, and these were not analyzed sep-
arately. Nordqvist and Petersson41 analyzed
68 patients with a mean 14-year follow-up and
found that 50% of patients with residual de-
formity have shoulder symptoms. Armstrong
and Van Der Spuy2 noted that 6 of 11 pa-
tients with displaced scapula neck fractures
had residual stiffness at 6 months.
Double disruption of the superior shoulder
suspensory complex (SSSC) is an entity that
has gained distinct attention since Goss16
discussed its signicance in relation to scapula
fractures. The signicance of this entity was
recognized much earlier, however, by a num-
ber of investigators noting that the weight
of the arm and the muscle forces acting on
the humerus result in a typical pattern of
displacement inferior and anteromedial.14, 22, 53
The SSSC is a bonysoft tissue ring made
up by the glenoid, coracoid, and acromion
processes, as well as the distal clavicle, the
acromioclavicular joint, and coracoclavicular
ligaments. The superior strut is the middle
clavicle, and the inferior strut is the lateral
scapula. Lesions to two of these structures
allow for signicant displacement at the
individual site and the entire SSSC itself.
Therefore, treatment recommendations have
consisted of stabilizing one or both lesions
to restore integrity to the SSSC, thereby pre-
serving its function of maintaining a stable
SCAPULA FRACTURES 7
relationship between the upper extremity and
axial skeleton, and providing a rm attach-
ment for the many soft tissues that enable
shoulder function.16
Herscovici et al24 reported on ORIF of seven
clavicle fractures in patients with ipsilateral
scapula neck fractures. In this series, all pa-
tients achieved excellent functional results
with no deformity at 48.5-month follow-up.
Two other patients in this series treated non-
operatively had signicant shoulder drooping
and decreased range of motion. Others have
advocated internal xation of just the clavicle
as well for restoration of length and sufcient
stability.22, 48 Leung et al33 treated 15 such
patients with internal xation of both the frac-
tures and discovered good or excellent results
in 14 patients 25 months after surgery.
Ramos et al,48 on the other hand, reviewed
16 patients with ipsilateral clavicle and scapu-
la neck fractures treated conservatively.
Ninety-two percent had good or excellent
results at 7.5-year follow-up. A signicant
shortcoming of the three former studies is
that none documented the degree of displace-
ment of the scapula neck fracture, and in the
latter, the radiologic outcome was noted to
be good in all but one, suggesting minimal
original displacement. In a recent retrospec-
tive study by Edwards et al,10 the outcome of
noninvasive treatment of ipsilateral clavicle
and scapula fractures was assessed at a mean
28-months follow-up. Nineteen of 20 healed
uneventfully, with excellent range of motion
and function. This study did document the
degree of displacement of the clavicle and
scapula fracture. Interestingly, this is a study
of mostly minimally displaced injuries; only
2 of 20 scapulas and 8 of 20 clavicles were
displaced more than 1 cm.
This authors recommended approach to
these double lesions is to restore integrity
through ORIF of the clavicle or AC joint (if
disrupted), unless the scapula fracture is sig-
nicantly displaced or angulated such that it
would yield poor biomechanical function of
the glenohumeral joint (Fig. 5). This author de-
pends on an opposite shoulder AP radiograph
and a CT scan to make such a determination.
It is not uncommon to be mislead with an AP
of the injured shoulder because the glenoid
may be signicantly displaced and angulated,
therefore making it impossible to get a view
through the glenohumeral joint perpendicular
to the normal plane of the scapula (seen in
Fig. 4A). The author regards approximate op-
erative indications for extra-articular scapula
Text continued on page 12
8 COLE

A C

Figure 4. A, AP shoulder radiograph of a 58-year-old man, whose car was struck by

an 18-wheeler truck. Appreciate the comminuted scapula neck and body, as well as
the distal clavicle fracture. Medialization of the glenoid is striking. B, This inverted AP
view of the opposite shoulder highlights the injured glenoid displacement, which is
appreciated by comparing the relationships of the glenoid neck to the lateral border.
C, The scapula-Y radiograph shows marked translatory displacement of the fractured
lateral border.
Illustration continued on opposite page
 SCAPULA FRACTURES 9

D E

Figure 4 (Continued ). D, Axial CT scan cuts through the glenohumeral joint. Although one can deter-
mine an upper rib fracture and a suggestion of medialization of the glenoid, it is challenging to appreci-
ate the degree of medialization, extent of comminution, translation of the lateral border, and angular
relationship of the glenoid to the body. E, One three-dimensional (3D) reconstruction image of the
same scapula can assist greatly in understanding anatomic relationships. On this posterior view, per-
pendicular to the plane of the scapula, the extent of glenoid medialization noted is dramatic. The com-
minution of the body is better appreciated, as are the fracture planes exiting the medial and lateral bor-
ders and the scapula spine. Angular deformity is better appreciated in an image plane parallel to the
body.
10 COLE

A B

C D

Figure 5. A, Anteroposterior shoulder radiograph of a righthanded architectural draftsman involved in

a car crash. He has a displaced, multifragmentary, scapula body fracture. Appreciate the medialization
of the glenoid over 2 cm, with resultant impingement at the lateral border spike. The clavicle fracture
represents a double disruption to the superior shoulder suspensory complex. B, Although the scapula-
Y radiograph shows minimal fracture angulation or translation of the body, medialization of the glenoid
represented the indication for surgery. The coracoid and acromion are noted to be intact on this view.
C, The 3D CT scan helps to identify areas of comminution, which borders will need xation, and what
reduction maneuvers will be necessary. Volume averaging required for these reconstructions often ob-
scures minimally displaced fractures such as the one entering the spine. D, The 3D CT scan parallel to
the plane of the scapula body aides in recognizing angular displacement and fractures of the spine.
Illustration continued on opposite page
 SCAPULA FRACTURES 11

E G

Figure 5 (Continued ). E, Anteroposterior radiograph of the shoulder after xation. The comminuted
neck was stabilized with a 2.7 mm reconstruction and a 2.7 mm dynamic compression plate. A one-
third tubular plate was used for displaced body comminution using a spring plate concept. The scapula
spine and medial border were xed with a single 14-hole 2.7 mm reconstruction plate. Length has
been restored to the clavicle, which is then treated nonoperatively since suspension has been restored
to the injured appendicular skeleton. F, View 1 year after the injury shows the patients nearly symmet-
ric external rotation. He had sustained a highly comminuted fracture-dislocation of the ipsilateral ole-
cranon, but was back to work 6 months after the injury. G, View of patients forward elevation. He had
no pain or weakness, and almost no limitation of active shoulder motion. He did have a 15 exion con-
tracture of the elbow from injuries sustained to the olecranon.
12 COLE
fractures as being 100% translation of the lat-
eral border, or 25 of angular deformity of the
glenoid, or 1 cm of medialization. These crite-
ria are not absolute and must be placed in con-
text of the patients age, activity demands, and
extremity dominance. Well-controlled studies
are needed to validate this surgical algorithm
and further elucidate prognostic variables.
Other extra-articular fractures that re-
quire ORIF include displaced fractures of the
spine, coracoid, and acromion. These frac-
tures carry a poor prognosis when treated
nonoperatively.1, 20, 36, 39, 43, 44
Operative Approaches
and Techniques
Logical operative approaches should ef-
fect exposure of the lesion, produce as little
structural damage as possible, and consider
the restorative capacity of the repair process.3
Most scapula fractures are best operated by
the posterior approach of Judet or the anterior
deltopectoral approach.
The posterior approach through an exten-
sile Judet incision is the workhorse for scapula
neck and body fractures. It allows access to
each of the scapula borders and neck which
yield the best bonestock for xation. The inci-
sion parallels the palpable scapula spine, be-
ginning at the acromion base and coursing to-
ward the medial angle. A smooth turn is then
taken down along the medial border toward
the inferior angle of the scapula (Fig. 6A). The
author prefers to elevate the subcutaneous tis-
sue above the muscular fascia and use only the
intervals necessary for desired xation, thus
protecting as much of the infraspinatus and
deltoid muscle origins as possible (Fig. 6B).
The interval between the teres minor and in-
fraspinatus is most often developed for ac-
cess to the lateral border for best xation and
restoration of the glenoid angle (Fig. 6C). In
scapula fractures that involve displacement of
the lateral and medial border as well as the
spine, it may be necessary to expose the entire
infraspinatus fossa by detaching the entire in-
fraspinatus and posterior deltoid muscle ori-
gin (Fig. 7A and B).
Other variations of the posterior approach
may include division of the infraspinatus
tendon6,50 ; however, this may prolong reha-
bilitation. Osteotomizing the acromion has
been suggested to be useful in decreasing
traction on the suprascapular nerve.8 A capsu-
lotomy similar to that described by Kavanagh
et al32 may be performed through a posterior
approach. This adjunct is very useful for ad-
dressing concomitant intra-articular glenoid
fractures.
However, for most isolated intra-articular
glenoid fractures, particularly the commonly
encountered anterior rim fracture associated
with a glenohumeral dislocation, the del-
topectoral approach is optimal (Fig. 8A). The
deltopectoral sulcus is developed and the
cephalic vein retracted laterally for exposure
of the subscapularis muscle. The humerus is
rotated so that the subscapularis tendon can
be tenotomized near its origin, thus exposing
the capsule, which is incised and tagged for
closure (Fig. 8B). Retraction of the humeral
head then allows for visualization, reduction,
and xation of the glenoid fragments (Fig. 8C).
Implants for xation of neck and body frac-
tures have commonly included 3.5-mm dy-
namic compression and reconstruction plates
as well as one-third tubular plates. The au-
thor has found that the lower-prole 2.7-mm
reconstruction and dynamic compression
plates are easy to contour, sufciently rigid,
and offer more points of xation. At times,
other minifragment plates may be useful for
angulated intercalary body fragments. It is
challenging at times to effect and hold the
reduction, particularly of the lateral border
and neck of the scapula. This reduction ma-
neuver is particularly difcult in the highly
medialized and angulated glenoid present-
ing beyond 1 week. In these circumstances,
it is helpful to place a 4-mm Schanz pin in
the neck and another in the lateral border
away from the proposed plate position. These
pins serve as joysticks for each fragment and
may be used with a small external xator
for maintenance of reduction while applying
the desired plate (see Fig. 7B). Glenoid frac-
tures usually are xed with minifragment
or small-fragment lag screws (cannulated if
desired), and in the setting of comminution,
a minifragment buttress plate may be useful.
Regardless of the choice of implants, the goal
of fracture xation must be stability that al-
lows for early motion, which is the rst crucial
step in successful rehabilitation. A perfect
xation will end in failure if it is not followed
by an effective plan of rehabilitation.
REHABILITATION
The plan of rehabilitation must take into
consideration the surgical approach, if used,
and the patients associated injuries. The
goal in modern fracture surgery is to render
 SCAPULA FRACTURES 13

A B

Figure 6. A, This patient is in the left lateral decubitus position leaning slightly forward. The line is
drawn for a posterior approach, using the scapula spine and medial border as the palpable landmarks.
It is preferred to incise slightly inferior to the spine and lateral to the medial border, and not to cut the
superior angle too sharp. B, The subcutaneous tissue is elevated as a ap directly above the fascia
of the deltoid, infraspinatus, and teres minor muscles. C, The interval between infraspinatus and teres
minor can be developed to expose the lateral border for reduction and xation. The lateral border was
restored with a 2.7 mm reconstruction plate, and angulated body fragments trapped and xed with a
one-quarter tubular plate and 2-mm T-plate. The inferior medial border is also exposed and xed with a
one quarter tubular plate through the same interval.
14 COLE

A B

Figure 7. A, A posterior view (leftside medial) after a posterior approach to the scapula. In this
case, there were fractures exiting at seven different sites along the scapula perimeter, excluding the
glenoid; therefore, the infraspinatus was completely elevated from medial to lateral in one perios-
teocutaneous ap, also detaching its origin (with the deltoid) on the scapula spine superiorly. The
glenoid neck is out of view as it is displaced anterior and medial. This intraoperative photograph is
of the patient whose radiographs are depicted in Figure 4. B, The surgical tactic in this case was
to restore the relationship of the scapula spine and medial border rst. The rational here was to re-
construct the scapula body to provide a building block on which the glenoid neck could be placed.
The usual strategy is to begin by restoring the lateral border, but extensive comminution in this case
warranted a different sequence. Note the 20-hole 2.7 reconstruction plate used to restore the medial
angle relationship between the scapula spine and medial border. A single plate provides a stronger
construct then multiple plates with little screwhold and greater stress concentration on either side of
each fracture. Having xed the body, there is a small external xator with a pin in the neck, and one
lower at the lateral margin to resist deforming forces while restoring the lateral border with 2.7-mm
plates.
 SCAPULA FRACTURES 15

B C

Figure 8. A, This patient who sustained a modied Ideberg Type II glenoid fracture as
shown in Figure 2 is in a beach chair position, and bony landmarks highlighted. The del-
topectoral incision runs from the coracoid toward the deltoid muscle insertion in the del-
topectoral groove. B, The incision was taken more cephalad for exposure of the coracoid
and supraglenoid region. The cephalic vein is retracted laterally with the deltoid (inferior re-
tractor), and the pectoralis major is retracted medially with the coracobrachialis. Sutures are
used to retract the subscapularis and capsule for exposure of the glenoid. There is a shantz
pin in the coracoid for manipulation of the superior fragment to which the articular surface is
attached. The superior glenoid articular surface is stepped off and translated signicantly in
relation to the inferior articular surface. C, Applied xation securing the glenoid reduction as
well as the fracture extension which runs inferior to the coracoid.
16 COLE

stability to the fracture. At the very least, sta-
bility ought to mean that the bones can with-
stand physiologic motion. Motion is partic-
ularly important in the shoulder that has a
propensity to become stiff with immobility. It
can be argued that most patients with unxed
and displaced scapula fractures are very un-
comfortable with attempts at motion. These
patients tend to resist exercises until the frac-
ture consolidates, and invariably they end up
with functional loss (Fig. 9).
If the scapula fracture is treated nonopera-
tively, the patient should begin passive motion
immediately. It is helpful to begin with pendu-
lum exercises and increase the passive range
under the guidance of a therapist within the

C D

Figure 9. A, Anteroposterior radiograph of a shoulder demonstrating a malunion of the scapula body.

Appreciate signicant medialization of the glenoid by following the lateral border from the inferior an-
gle of the scapula to the large stepoff at the scapula neck. B, The scapula Y radiograph depicting the
gross angular deformity of the malunion. C, The patients radiographs are shown in Figures 8. Note
the signicant depression of the right forequarter, which mimics her psychological depression depicted
well by facial expression. D, Note patients maximum shoulder abduction. Despite months of physical
therapy, she complained of chronic aching shoulder pain and a sense of heaviness of her arm, as well
as weakness and fatigue.

rst few days. The patient should be taught
to use the uninvolved extremity, as well as
friends or family members, to assist with exer-
cises. Initially, a sling may be used for comfort.
Elbow and wrist active exercises are encour-
aged in the immediate phase. Scapula frac-
tures, because of a well-endowed blood sup-
ply, heal rapidly. Therefore, active range of
motion can be started at 4 weeks and max-
imized quickly. Resistive exercises are begun
by 8 weeks, and restrictions lifted (includ-
ing weight-bearing) as symptoms allow by
3 months.
The deltoid approach requires division of
the subscapularis muscle and anterior joint
capsule, although the posterior approach
sometimes requires taking down some of the
infraspinatus or posterior deltoid muscle ori-
gins. Thus, for the anterior approach, external
rotation is limited to 30 for the rst month,
and for the posterior approach, adduction
past midline is limited for the same duration.
The exact same promotion of activity and
exercise as described in the last paragraph for
nonoperative scapula fractures is used after
1 month.
SUMMARY
Scapula fractures are rare injuries that typ-
ically occur in patients who have sustained
a shoulder dislocation, as is the case with
many fractures of the glenoid rim or high-
energy trauma to the forequarter. An ele-
vated suspicion for other abnormality, espe-
cially life-threatening injuries to the cranium,
cervical spine, and thorax, should underlie
the diagnostic workup. A physical examina-
tion should uncover common injuries to the
brachial plexus, axillary artery, as well as ipsi-
lateral musculoskeleton.
A review of the AP and axial view of the
shoulder and a scapula-Y radiograph should
then guide the need for a CT scan. A dis-
placed intra-articular glenoid fracture is the
least disputed surgical indication. Double dis-
ruptions of the superior shoulder suspensory
complex, signicant angulatory and transla-
tory displacement of the scapula neck, marked
medialization of the glenoid, and displaced
scapula process fractures are relative operative
indications that must be placed in the context
of a patients lifestyle, work demands, and ex-
tremity dominance.
Although patient outcomes can be largely
affected by associated injuries, nonoperative
management can yield quite satisfactory re-
SCAPULA FRACTURES 17
sults in most cases of scapula fractures. Most
scapula fractures, however, are minimally dis-
placed. For scapula fractures that are intra-
articular, markedly displaced, or associated
with other injuries to the shoulder suspen-
sory complex, excellent outcomes also can be
realized with operative intervention, assum-
ing a well-executed operation and plan of
rehabilitation.
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Address reprint requests to
Peter Alexander Cole, MD
Department of Orthopedics and Rehabilitation
University of Mississippi Medical Center
2500 North State Street
Jackson, MS 39216-4505
e-mail: pcole@orthopedics.umsmed.edu
TREATMENT OF COMPLEX FRACTURES
MANAGEMENT OF THE SMASHED
DISTAL HUMERUS
Shawn W. ODriscoll, PhD, MD, Joaquin Sanchez-Sotelo, MD, PhD,
Among the most dreaded of injuries that the
orthopedic surgeon on call for trauma must
treat is what can be referred to simply as the
smashed distal humerus. Resulting from high-
energy injuries, such as motor vehicle acci-
dents and falls from a great height, these frac-
tures present special challenges to even the
most experienced elbow or trauma surgeon.
Not only can there be extensive comminution
of both the joint surface and the supracondy-
lar metaphyseal region but also signicant
bone loss may have occurred. To make mat-
ters much worse, these elbows usually present
with open wounds and sometimes soft tissue
loss (Fig. 1).
When faced with such a daunting task of
treating this type of elbow, it is helpful to
pause and consider the ultimate goals of treat-
ment, which include:
1. Soft tissue healing without infection
2. Restoration of diaphyseal bone stock
3. Union between the distal fragments and
the shaft
4. A stable and mobile articulation
When sufcient bone loss precludes a sta-
ble anatomic reduction, a nonanatomic recon-
struction that is stable and that achieves all
four of these goals is the preferable plan.
Restoration of painless and satisfactory
elbow function after a fracture of the distal
humerus requires anatomic reconstruction of
the articular surface, restitution of the overall
From the Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota (SWO, MET); and the Shoulder and
Elbow Service, Hospital La Paz, University of Autonoma de Madrid, Spain ( JSS)
ORTHOPEDIC CLINICS OF NORTH AMERICA
VOLUME 33 NUMBER 1 JANUARY 2002
00305898/02 $15.00 + .00
and Michael E. Torchia, MD
geometry of the distal humerus, and stable x-
ation of the fractured fragments to allow early
and full rehabilitation.2, 4, 6, 810, 12 Although
these goals are now widely accepted by the or-
thopedic community, they may be technically
difcult to achieve, especially in the presence
of bone loss, substantial comminution, or os-
teoporosis.12
When treatment of severe distal humerus
fractures fails, it does so either because of
nonunion at the supracondylar level or stiff-
ness resulting from prolonged immobilization
that has been used in an attempt to avoid fail-
ure of inadequate xation.12 Either way, the
limiting factor is xation of the distal frag-
ments to the shaft. Achieving the goals stated
earlier and, therefore, successful treatment of
the smashed elbow require a departure from
traditional teaching, such as the misconcep-
tion that plates must be applied in two per-
pendicular planes, 90 to each other, as is
recommended by the Arbeitgemeinshaft fur
Osteosynthesefragn/Association for the Study
for Internal Fixation (AO/ASIF) group and
currently used by most surgeons.5, 9, 12, 14 Us-
ing existing techniques, different investigators
have reported unsatisfactory results in 20% to
25% of the patients.2, 4, 6, 810
In an effort to increase the yield of excel-
lent and satisfactory results obtained after
xation of distal humerus fractures and to
reproducibly obtain stable xation in the
presence of osteoporosis or comminution, the
19
20 ODRISCOLL et al

A B

Figure 1. A and B, A smashed distal humerus. These high-energy injuries usually occur from motor
vehicle accidents or falls from a great height. They are characterized by extensive intra-articular and
supracondylar comminution, and often bone loss. In this case, a 4-cm length of the lateral column is
missing. The lateral half of the trochlea is missing, while the medial half is in multiple pieces. Com-
minution sometimes extends well up into the diaphysis.

authors have developed and used for the
past 11 years an alternative philosophy and
technique based on principles that maxi-
mize xation in the distal fragments and
compression at the supracondylar level. The
stability achieved has allowed the authors
to routinely commence an intensive rehabil-
itation program 36 hours postoperatively,
including full active motion with no external
protection.
This discussion expands on the general
principles of the authors current approach to
these fractures, the specic technical details,
the postoperative program, and the potential
complications.
PRINCIPLES AND
TECHNICAL OBJECTIVES
Before discussing the details of surgical
techniques, it is imperative that the treating
surgeon understand the principles and tech-
nical objectives that, if followed and achieved
respectively, will maximize the likelihood of
a successful outcome from treatment of these
severe fractures.
The principles by which the earlier-men-
tioned goals are achieved, and the technical
objectives at the time of surgery for achieving
them, are:
1. Soft tissue healing without infection
Principles
Extensive debridement to minimize
risk for infection with open fractures.
Shorten the limb to relax soft tissues.
Technical objectives
Leave clean surfaces on all soft tissues
and bones.
Cover essential structures (nerves, ten-
dons, hardware).
Obtain early closure (35 days).
Osteotomy of distal end of shaft to
permit 0.5 to 2.0 cm of supracondy-
lar shortening, with maximal con-
tact and interfragmentary compres-
sion between the distal fragments
and the shaft
2. Restoration of diaphyseal bone stock
Principles
Obtain an anatomic reduction and sta-
ble xation.
Bone graft as necessary
Technical objectives
Diaphyseal bone segments should be
reduced and xed with interfrag-
mentary compression.
At least one dynamic compression or
equivalent strength plate should ex-
tend an adequate length and num-
ber of screws (usually eight cortices)
proximal to the fracture.
 MANAGEMENT OF THE SMASHED DISTAL HUMERUS
Dual plating is not required for the dia-
physeal region.
3. Union between the distal fragments and
the shaft
Principles
Maximize xation in the distal frag-
ment.
All xation in distal fragments should
contribute to stability between the
distal fragments and the shaft.
Technical Objectives
Concerning screws in the major distal
fragments (articular segment):
Each screw should pass through a
plate.
Each screw should engage a frag-
ment on the opposite side that is
also xed 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.
Concerning the plates used for xation:
Plates should be applied such
that compression is achieved at
the supracondylar level for both
columns.
Plates used must be strong enough
and stiff enough to resist break-
ing or bending before union oc-
curs at the supracondylar level.
4. A stable and mobile articulation
Principles
Restore or recreate a stable hinge artic-
ulation for exionextension.
Technical objectives
Preserve all ligaments and tendons at-
tached to the distal fragments.
Obtain a stable congruous reduction
of either the trochlea, or the me-
dial trochlea and capitellum; these
are the minimum requirements for a
functioning hinge articulation.
Ensure that xation is adequate to per-
mit immediate rehabilitation of the
joint and limb starting within a few
days of surgery.
SURGICAL TECHNIQUE
Exposure
The patient is placed in the supine posi-
tion and the affected upper extremity is pre-
21
pared and draped in the usual fashion. The
lateral position with the arm on a support
can be used, but hyperexion (which is neces-
sary with the triceps reecting anconeus pedi-
cle [TRAP] approach) is easier in the supine
position. A sterile tourniquet can be used for
the initial ulnar nerve dissection, but the au-
thors prefer to avoid the use of the tourni-
quet. The ulnar nerve is routinely identied,
isolated, and transposed subcutaneously. Ole-
cranon osteotomy is the most commonly used
and recommended approach, but the TRAP
approach11 allows for wide exposure with-
out the need for an olecranon osteotomy. This
is especially important in older patients, in
whom elbow replacement may be necessary.
The details of the TRAP exposure have been
described elsewhere.11 With this approach, the
intact proximal ulna and radial head can be
used as a template against which the distal
humerus can be reconstructed. In addition, the
potential complications associated with ole-
cranon osteotomies are avoided,4, 15 and the in-
nervation of the anconeus is preserved.11
The rst priority (goal 1) in managing open
injuries is to obtain soft tissue healing without
deep infection. With open wounds, the em-
phasis is on extensive sharp debridement of all
devitalized and potentially contaminated tis-
sues. Prevention of infection is of paramount
importance even if the internal xation fails
because later reconstructive options may be
limited if infection occurs. Lavage, regard-
less of the number of liters of saline used, is
not nearly as effective as debridement with
a scalpel. With extensive soft tissue injuries
and occasionally soft tissue loss, it is not al-
ways possible to cover the essential structures.
The senior author (SOD) reasoned that, as
in limb replant surgery, shortening the limb
would facilitate stable bony reduction (see
subsequent discussion) and relax the soft tis-
sues, making coverage of the essential struc-
tures more achievable. Shortening of up to
1 cm is of negligible consequence, and up to
2 cm of shortening is well tolerated if needed.
More extensive soft tissue defects that cannot
be covered by such shortening should be con-
sidered for free or pedicle ap coverage.
In the authors experience, it is preferable
to stabilize or x the fractures acutely, even in
the face of signicant soft tissue damage, loss,
or contamination. The wound is cleaner than
it will be a few days later after very thor-
ough surgical debridement. Soft tissue edema
will only increase in the days following injury,
making both surgery and closure more dif-
cult. Finally, the stability provided by fracture
22 ODRISCOLL et al
xation permits optimized position of the limb
for nursing, wound care, and edema control.
Bony Reconstruction
Diaphyseal Region
For any fracture xation or delayed recon-
struction, restoration of diaphyseal bone stock
is required (goal 2). Diaphyseal bone segments
should be reduced and xed with interfrag-
mentary compression. At least one dynamic
compression or equivalent strength plate
should extend an adequate length and number
of screws (usually eight cortices) proximal to
the fracture. Dual plating is not required for
the diaphyseal region.
Articular Surface
The articular surface of the distal humerus
should be reconstructed anatomically unless
bone is missing. If bone is missing, two im-
portant principles should be taken into con-
sideration. First, the anterior aspect of the dis-
tal humerus is the critical part that needs to
be xed to have a functional joint; reconstruc-
tion of the posterior half is important but not
as crucial. Second, stability of the articulation
(goal 4) requires the medial trochlea and either
the lateral half of the trochlea or the capitel-
lum. Thus, the medial trochlea is essential to
obtain a stable and well-aligned joint. Struc-
tural bone grafts, such as tricortical or bicorti-
cal grafts from the iliac crest, can be used to ll
defects in the joint surface.
The articular surface is xed provision-
ally with small smooth Kirschner wires. In
addition, or alternatively, very small (0.035,
0.045) threaded Kirschner wires can be placed
in the subchondral bone and left in place
for denitive xation after cutting them off.
No screws are placed in the distal fragments
before applying the plates. Although this goes
against what has traditionally been taught by
the AO/ASIF group, the reason for this ap-
proach relates to the technical objective Every
screw in the distal fragments should pass
through a plate. Doing so enhances xation
of the distal fragments, but, more important,
it contributes to stability between the distal
fragments and the shaft (goal 3).
Fixation of the Articular
Segment to the Shaft
By far, most xation failures after a distal
humerus fracture occur at the supracondylar
level, whereas the intra-articular fractures
typically unite. Based on current practice and
recommendations, this should not be surpris-
ing. Many of the fractures are dependent on
only two or three screws for stability at the
supracondylar level. The xation strategy
should concentrate on maximizing stability
between the distal fragments and the shaft of
the humerus at the metaphyseal level. These
principles are achieved by the successful
execution of the seven technical objectives
listed earlier, each of which contributes to
maximizing stability between the articular
segment and the shaft (see goal 3).
The practical application of these princi-
ples involves parallel plates that permit a to-
tal of four to six long (4570 mm) screws to
be placed in the distal fragments, from one
side across the other (the plates are placed
with a slight offset, posteromedially and pos-
terolaterally). The screws are placed at the
epiphyseal level interdigitate, which greatly
increases the stability of the construct. The
plates must be contoured or precontoured to
the normal geometry of the distal humerus
to allow for screw placement at the appropri-
ate places and also not to be too prominent
under the skin. One can contour a 3.5-mm
dynamic compression plate (DCP) or a pelvic
reconstruction plate (Synthes USA, Paoli,
PA) on the medial side and a DuPont plate
(Howmedica, Rutherford, NJ) on the lateral
side. Currently, the authors use the Mayo
Congruent Elbow Plates (Acumed, Portland,
OR), which are custom designed for the distal
humerus (see Figs. 47 and 10). They are pre-
contoured to the geometry of the distal humer-
us and designed to permit placement of mul-
tiple long screws (2.7 or 3.5 mm) in the distal
fragments by clustering the distal screw holes.
They have a dynamic compression prole in
the diaphyseal and metaphyseal regions, with
a continuously tapering articular region that
is low prole. The undersurface of the dia-
physeal and metaphyseal regions is tubular in
cross-section to greatly enhance sagittal plane
stability and to permit provisional xation
with a singe screw in the slotted hole.
Interfragmentary compression is obtained
both between articular fragments and at the
metaphyseal level with large bone clamps that
provide compression during the insertion of
the screws. This is done instead of using lag
screws to provide maximum thread purchase
for each screw. Additional compression at the
metaphyseal level results from slight under-
contouring of the plates and the use of dy-
namic compression holes in the plates.
 MANAGEMENT OF THE SMASHED DISTAL HUMERUS 23

Provisional Assembly of the
Articular Surface
Once the fracture is exposed, the rst step
is the anatomic reconstruction of the articular
surface. The intact ulna and radial head can
be used as a template for the reconstruction
of the distal humerus. The articular fragments
are assembled paying attention to their rota-
tional alignment and are held in place provi-
sionally with smooth Kirschner wires (Fig. 2).
Fine-threaded wires (0.030 or 0.045) are used
in cases with extensive comminution, cut off,
and left in as denitive adjunct xation. The
articular fragments are xed in the following
order:
1. Anterior trochlea and capitellum
2. Medial trochlea
3. Posterior fragments
As stated earlier, in cases with severe intra-
articular comminution, all efforts should be
directed to reconstruct the anterior half of
the distal humerus articular surface and the
condyle and medial trochlea. It is necessary
that all wires are placed at the subchondral
level so as not to interfere with plate appli-
cation nor with passage of screws from the
plates into the distal fragments. No screws are
placed in the distal fragments until the plates
are applied.
Supracondylar Shortening
In cases of supracondylar bone loss or
severe comminution that are interpreted to
preclude anatomic reduction and stable xa-
tion, supracondylar shortening osteotomy is a
viable option (Fig. 3). This is especially true
if structural bone grafting is contraindicated,
particularly when associated with severe soft
tissue injuries. The principles and details of
the technique are described later.
Plate Placement and
Provisional Reduction
The next step is to contour plates to t the
distal humerus medially and laterally or to
chose medial and lateral precontoured plates
from the Mayo Congruent Elbow Plate Sys-
tem (Acumed, Portland, OR). This set also
provides for triple plating with both lateral
and posterolateral plates; however, in the au-
thors experience with parallel plating, de-
scribed later, triple plating has never been nec-
essary thus far. At the medial side, a 3.5-mm

Figure 2. Provisional assembly of the articular surface. The articular frag-

ments, which tend to be rotated toward each other in the axial plane, are
reduced anatomically and provisionally held with 0.035 or 0.045 smooth
Kirchner wires. It is essential that they be placed close to the subchondral
level to avoid interference with later screw placement, and away from where
the plates will be placed on the lateral and medial columns. One or two large
(2-mm) pins are placed through the epicondyles where a hole in the plate will
be (see Fig. 4) and are later replaced by screws. One or two strategically
placed pins can be used to provisionally hold the distal fragments aligned
with the shaft.
24 ODRISCOLL et al
Figure 3. Supracondylar shortening osteotomy. In cases
of supracondylar bone loss, and in some cases of severe
comminution, anatomic placement of the distal humerus
with respect to the shaft would leave a large structural
defect in one or other column, and only point contact
in the other. In such cases, a supracondylar shortening
osteotomy is a viable option when an anatomic recon-
struction is thought not to be possible or structural bone
grafting is undesirable, particularly when associated with
severe soft tissue injuries. This involves reshaping the dis-
tal end of the shaft (solid lines, never the articular seg-
ments) to enhance contact between the distal articular
segment and the shaft. Usually, only a small amount of
bone is resected off one side distally, and sometimes off
one side (for side-to-side apposition and compression).
The limb is shortened through the fracture site to per-
mit interfragmentary compression between the trochlea
and the distal shaft, between the capitellum and the distal
shaft, and side to side on one or both sides. Once these
surfaces have been compressed and xed with the plates,
stability is strong enough to permit immediate motion and
rehabilitation. It is acceptable to translate the distal seg-
ment medially or laterally, and also slightly anteriorly, pro-
vided that rotational and valgus alignment are maintained.
pelvic reconstruction plate is used unless the
patient size or fracture comminution require
the use of a stronger DCP. One-third tubular
plates are not strong enough. The medial plate
can be extended to the articular margin in
very low or comminuted fractures and is con-
toured to the shape of the medial epicondyle.
If a precontoured DuPont plate (Howmedica,
Rutherford, NJ) is used at the lateral side,
it must be slightly uncontoured at the distal
end or placed more posteriorly to prevent im-
pinging on, or cutting into, the common ex-
tensor tendon and lateral collateral ligament
complex. Both plates should be slightly under-
contoured to provide additional compression
at the metaphyseal region when applied. The
length of the plates is selected so that at least
three screws are placed on each side proximal
to the metaphyseal component of the fracture.
Ideally, the plates should end at different lev-
els to avoid the creation of a stress riser. The
Mayo Congruent Plates are designed to al-
ways stop at different levels regardless of how
they are combined. The plates are then pro-
visionally applied according to the following
steps (Fig. 4):
1. Two 2.0-mm smooth Steinmann pins
are introduced at the medial and lateral
epicondyles through holes in the plates
while they are held accurately against
the bone; the most commonly used holes
are the second laterally and the third
medially.
2. The appropriate reduction of the dis-
tal fragments to the humeral shaft at
the supracondylar level is conrmed. If
supracondylar shortening is chosen over
anatomic reduction at the metaphyseal
level (see later section on metaphyseal
region), the appropriate alignment is set
and held.
3. One cortical screw is inserted into the
slotted hole in each plate, but not fully
tightened, to provide for provisional re-
duction of the distal fragments with re-
spect to the shaft. The use of slotted holes
for these screws facilitates later adjust-
ments in plate positioning. The tubular
contour under the Mayo Clinic Congru-
ent Elbow Plates ensures alignment of the
plate on the bone and greatly simplies
provisional reduction and xation.
Articular and Distal Fixation
Once the plates are provisionally applied,
distal medial and lateral screws are introduced
to provide stable xation of the intra-articular
fragments and rigid anchorage of the plates
distally (Fig. 5).
1. Two distal screws, one medial and one
lateral, are inserted. As stated earlier, the
screws should be as long as possible, pass
through as many fragments as possible,
and engage in the opposite column. Be-
fore their application, a large bone clamp
is used to compress the intra-articular
fracture lines unless a gap is present
in the articular surface. This ensures in-
terfragmentary compression without the
need for lag screws. If a segmental de-
fect is present, iliac crest bone graft can
 MANAGEMENT OF THE SMASHED DISTAL HUMERUS 25

Figure 4. Plate placement and provisional reduction. A, Medial and lateral precontoured plates are
placed and held apposed to the distal humerus, while one smooth 2.0-mm Steinmann pin is in-
serted through hole No. 2 (numbered from distal to proximal) of each plate through the epicondyles
and across the distal fragments, to maintain provisional xation of the plates to the distal fragments.
B, A screw is placed in the slotted hole ( No. 5) of each plate, but not fully tightened, leaving some free-
dom for the plate to move proximally during compression later. Because the undersurface of each plate
is tubular in the metaphyseal and diaphyseal regions, the screw in the slotted hole only needs to be
tightened slightly to provide excellent provisional xation of the entire distal humerus.
26 ODRISCOLL et al

Figure 5. Articular and distal xation. Screws are inserted through hole No. 1 of the lat-
eral plate and across the distal articular fragments from lateral to medial and tightened. This
step is repeated on the medial side, using hole No. 3. In young patients, 3.5 cortical screws
are used (to prevent breakage) while long 2.7 screws are used in patients with osteoporotic
bone. The distal screws should be as long as possible, passing through as many fragments
as possible, and engaging the condyle or epicondyle of the opposite column.

be inserted but should be contoured to re- ternative reconstructive technique supracondy-

main below the level of the preexisting
articular cartilage so that it does not ar-
ticulate with the ulnar cartilage or radial
head.
2. The 2.0-mm Steinmann pins can be re-
placed with screws at this point, but the
authors usually wait until the plates have
been rigidly xed to the shaft to do so
because it leaves more exibility in mak-
ing ne adjustments to the supracondylar
reduction.
Metaphyseal Region: Supracondylar
Compression and Proximal Plate Fixation
The metaphyseal region of the distal hu-
merus can be xed in two ways. An anatomic
reconstruction is desirable whenever possi-
ble; however, adequate bony contact with in-
terfragmentary compression is necessary to
ensure the stability of the construct and even-
tually fracture union at this level. If meta-
physeal comminution or bone loss preclude
an anatomic reconstruction with satisfactory
bony contact, the humerus can be shortened at
the metaphyseal fracture site provided that the
overall alignment and geometry of the distal
humerus are restored. The authors call this al-
lar shortening. This technique is specially use-
ful in cases of combined soft-tissue and bone
loss. Shortening by 1 cm or less creates no
apparent loss of function, and up to 2 cm
of shortening can be tolerated without severe
disturbance of elbow biomechanics.7 Maxi-
mum stability and, therefore, minimum likeli-
hood of nonunion at the supracondylar level
are achieved by maximizing interfragmentary
compression between the distal fragments and
the shaft (Fig. 6). The technical details for per-
forming the supracondylar shortening are de-
scribed below.
1. A large tenaculum is used to apply
compression across the fracture at the
supracondylar level of the lateral col-
umn (Fig. 6A). A screw then is inserted
through the lateral plate proximally in
compression mode to maintain the inter-
fragmentary compression. Care should
be taken not to change the varusvalgus
or rotational alignment of the articu-
lar surface when the bone clamps are
applied.
2. The same steps are followed on the oppo-
site side (Fig. 6B). The amount of stability
achieved after this step is nished is typi-
cally very gratifying already.
 MANAGEMENT OF THE SMASHED DISTAL HUMERUS 27

Figure 6. Supracondylar compression and proximal plate xation. A, Using a large tenaculum to pro-
vide interfragmentary compression across the fracture at the supracondylar level, the lateral column
is rst xed. A screw is placed in dynamic compression mode (inset ) in hole No. 4 of the lateral
plate. Tightening this further enhances interfragmentary compression at the supracondylar level (open
arrows) to the point of causing some distraction at the medial supracondylar ridge (solid arrows).
B, The medial column is then compressed in a similar manner using the large tenaculum and a screw
inserted in the medial plate in dynamic compression mode.
28 ODRISCOLL et al
3. The remaining diaphyseal screws are
then introduced providing additional
compression as a result of the under-
contoured plates being pushed to gain
intimate contact with the underlying
bone. The two Steinmann pins then are
replaced with distal screws that again
follow the principles mentioned earlier
regarding length and positioning. (Fig. 7)
Fixation of Remaining Intra-Articular
Fragments and Motion Verication
Once the overall architecture of the distal
humerus has been rigidly restored, any poste-
rior articular fragments remaining to be xed
are addressed, and intraoperative range of
motion is veried.
1. Posterior articular fragments often re-
quire denitive xation with either
threaded metallic Kirschner wires or
ideally bioabsorbable pins.
2. Any remaining provisional wires are
removed.
3. The nal step before closure is to as-
sess the range of motion. The arc of mo-
tion should be smooth and free of im-
pingement of the coronoid or olecranon
at their respective fossae, which would
limit exion or extension. The tip of the
Figure 7. The remainder of the screws are inserted, in-
cluding the distal screws, which interdigitate for maximum
xation in the distal articular fragments. If the plates are
slightly undercontoured, they can be compressed against
the metaphysis with a large bone clamp, giving further
supracondylar compression.
olecranon can be partially removed if it
impinges in extension-limiting motion.
Recreating the olecranon fossa with a
burr can be performed if the fossa has
been obliterated because of supracondy-
lar shortening (Fig. 8).
4. The nal intraoperative motion achieved
should be recorded as a baseline to moni-
tor postoperative progress. One deep and
one subcutaneous drain are placed and
the type of approach used dictates the
closure. The skin should be closed with
staples or interrupted sutures.
Supracondylar Shortening
Principles
In cases with supracondylar bone loss or ex-
tensive comminution, it is not possible to per-
form an anatomic reconstruction and main-
tain enough bone contact at the supracondylar
level. A supracondylar shortening allows for
restoration of bony contact and functional el-
bow reconstruction provided that the follow-
ing guidelines are followed.
1. Shortening should be limited to no more
than 2 cm.
2. The distal fragments can be translated
laterally or medially with respect to the
center of the humeral canal to improve
bone contact at the metaphyseal level, but
the rotational and varusvalgus align-
ment of the distal articular surface should
be restored carefully.
3. The coronoid and olecranon fossae
should be recreated. A convenient meth-
od to provide room for the coronoid
and olecranon is to translate the epiphy-
seal segment anteriorly (taking care not
to ex it) and to sculpt the olecranon
fossa with a burr once the xation is
complete. The tip of the olecranon can
also be resected to allow extension to at
least 10 to 20 .
Technique
The rst step is to provisionally reduce the
articulation. At that point, one attempts to de-
termine how the existing contour of the dis-
tal segment would best t against the shaft for
maximum bone contact (see Fig. 3). The end of
the shaft then is trimmed to match that con-
tour until maximum bony contact exists, while
the distal segment is positioned in proper
 MANAGEMENT OF THE SMASHED DISTAL HUMERUS 29

Figure 8. After shortening the distal humerus, the olecranon

fossa will be compromised. To preserve terminal extension,
the olecranon fossa can be recreated by burring out the same
shape from the distal end of the shaft. The tip of the olecranon
can be removed. The coronoid fossa and radial fossa are best
preserved by offsetting the distal segment anteriorly. It is tech-
nically easier to recreate a fossa posteriorly than anteriorly.

varusvalgus and rotational alignment. After
applying the rst two principles just men-
tioned, the plates are applied medially and lat-
erally and the fractures xed. Bone graft can
be placed under the plates in the triangular de-
fects between the plate and bone, adjacent to
where the shortening was performed.
When a supracondylar shortening has been
performed, the loss of the coronoid and radial
fossae need to be compensated for by ante-
rior translation of the distal fragment, with-
out changing its position in other planes. In
addition, the olecranon fossa may need to
be sculpted with a burr removing bone only
from the shaft, not from the distal fragments.
Whenever the burr is used, the eld should
be covered with sponges except for the region
where bone needs to be removed, and irriga-
tion should be used thoroughly to avoid leav-
ing bone dust in the wound that might facili-
tate heterotopic bone formation.
Postoperative Treatment
Immediately after closure the elbow is
placed in a bulky, noncompressive Robert-
Jones dressing with an anterior plaster slab to
keep the elbow in extension, and the upper
extremity is kept elevated for 36 hours. After
that, the Robert-Jones dressing is removed; an
elastic, nonconstrictive sleeve is applied over
an absorbent dressing placed on the wound;
and a program of continuous passive motion
(CPM) is started with the goal being to ex
and extend the elbow as much as tolerated to
avoid uid accumulation at the elbow region.
If the fracture unites with the normal
anatomic relationships restored and hetero-
topic bone formation does not occur, the
ultimate range of motion will depend on
the avoidance of intra-articular adhesions
and the characteristics the connective tissue
deposited in response to the traumatic and
surgical insult. An intensive program of CPM
is a reliable method to achieve a satisfactory
range of motion. The CPM is used to avoid
uid accumulation at the elbow. Experimental
and clinical data support the use of CPM for
this purpose.3 The uid that would tend to
accumulate at the surgical site as part of the
inammatory response is literally squeezed
out of the elbow region by the high hydrostatic
pressures generated when maximally exing
and extending the elbow. The stability of the
30 ODRISCOLL et al
bony reconstruction allows such motion with-
out fear of failure of xation. The only factors
limiting full range of motion immediately
after the operation are the amount of swelling,
the response of the overlying skin, and any
problems with pain control.
The CPM program is labor intensive. The
CPM machine is adjusted so that the elbow is
higher than the shoulder. For the rst days, the
CPM is continued virtually 23.5 to 24.0 hours
and the patient is allowed out of bed only
for bathroom privileges. During this time, the
patient works on progressively stretching the
end ranges of exion and extension. Full ex-
tension is normally easier to achieve because
the elbow was initially splinted in extension.
The patient lets the machine extend his or her
elbow to the point at which the patient feels
tightness. The patient then backs the elbow
into exion a few degrees and keeps the el-
bow in that position for approximately 1 or
2 minutes while the uid is being squeezed
from the tissues. After that couple of min-
utes, the patient will tolerate further exten-
sion and continues working with several stops
and starts until full extension is achieved. The
same sequence is then repeated for exion.
Once a full range of motion is achieved, the
patient does not need to actively control the
machine and can let the elbow be moved
through the whole range. On the second or
third day, the patient can try to gain more
motion than the CPM machine will provide
by placing a folded towel alternatively under
the wrist to increase exion and under the
elbow to increase extension. As part of the
postoperative management, the patient is also
encouraged to work on passive and active-
assisted pronation and supination exercises.
Finally, thorough massage of the elbow by the
patient or a relative will help with squeez-
ing the uid out of the elbow region and also
partially desensitize it to pain. Close atten-
tion should be paid to the neurovascular sta-
tus and the condition of the skin while the
patient is in the CPM machine. The patient
should be encouraged to continuously read-
just his or her position in the machine to avoid
radial nerve dysfunction secondary to contin-
uous pressure on the posterior aspect of the
arm if it is held in a xed position for long pe-
riods of time. Some discoloration of the poste-
rior skin is to be expected with elbow motion,
but if the integrity of the skin is in doubt, the
CPM should be stopped and the arm elevated
in a Robert-Jones dressing until the status of
the skin improves.
The CPM program is continued at home
for 3 to 4 weeks. The patient determines how
much time he can spend out of the machine
each day: if, by the time he or she goes back
to the CPM machine, the elbow is more dif-
cult to move through its whole range, the time
out of the CPM was too long. Most commonly,
the CPM machine will be used for approxi-
mately 20 hours a day for the rst week, and
the number of hours spent in the CPM ma-
chine is decreased progressively in the follow-
ing weeks. If, by the fourth week, motion is
still substantially less than what was achieved
intraoperatively, formation of heterotopic os-
sication should be investigated and a pro-
gram of patient-adjusted static exion and
extension splints used up to 3 to 4 months af-
ter surgery.
RESULTS TO BE EXPECTED
In the authors experience, the stability of
the xation has been adequate to permit an
immediate intensive rehabilitation program
consisting of active and passive motion, re-
gardless of the severity of the fracture. A few
cases have had severe soft tissue injuries that
delayed the rehabilitation. By combining these
principles to obtain truly rigid xation and
commencing early aggressive rehabilitation,
excellent clinical results are possible (Fig. 9).
The main challenges relate to xation of the
distal fragments to the shaft and being able to
contour strong plates to the complex anatomy
of the distal humerus (especially considering
that it has been fractured and cannot be used
easily as a templating surface). These tasks are
made easier by the use of precontoured plates
that are specially designed for these fractures
(Fig. 10).
POTENTIAL COMPLICATIONS
The main complications that have been re-
ported after internal xation of distal humerus
fractures are residual decreased range of mo-
tion, xation failure with nonunion or malu-
nion, nerve dysfunction, extensor mecha-
nism dysfunction, posttraumatic degenerative
changes, wound and skin problems, and avas-
cular necrosis.12, 4, 6, 810, 15
As stated earlier, the neurovascular status
and the condition of the skin should be fol-
lowed carefully during the postoperative pe-
riod. Anterior subcutaneous transposition of
 MANAGEMENT OF THE SMASHED DISTAL HUMERUS 31

A B

C D

Figure 9. Radiographic (A and B ) and clinical (C and D ) outcome 9 months after xing the smashed
distal humerus fracture shown in Figure 1 by applying the principles laid out in this article.

the ulnar nerve prevents many of the ulnar
nerve complications.16 A radial neurapraxia
may develop secondary to sustained pressure
on the dorsal aspect of the arm if the pa-
tient does not readjust his position while using
the CPM machine. Most skin problems can be
avoided if motion is held and the elbow ele-
vated in extension as soon as the aspect of the
skin is worrisome.
The biggest impediment to successful ap-
plication of this principle-based technique is
the misconception that plates must be applied
in two perpendicular planes. Although that
used to be true when very weak, 3.5, one-
third tubular plates were used, it most cer-
tainly is not true when strong plates are used.
The parallel, double-plate construct has been
shown to provide excellent stability even in
the presence of supracondylar gaps.13 In fact,
Schemitsch et al13 showed that the combina-
tion of a medial reconstruction and lateral
DuPont plate in parallel planes was stronger
32 ODRISCOLL et al

A B

Figure 10. A, A smashed elbow with extensive bone loss and comminution that was referred by a col-
league as unxable. In this case, as is frequently so, the olecranon and proximal ulna are also severely
fractured. B, The fractures are most conveniently and effectively xed using the Mayo Clinic Congruent
plates (Acumed, Portland, Oregon) that are specially designed for these fractures. They are precon-
toured to t each bone and fracture pattern. Unique design features permit provisional xation, greatly
enhanced xation in the articular fragments, increased sagittal plane stability, and ease of application.

than were two reconstruction plates placed
in two planes 90 to each other, as is recom-
mended by the AO/ASIF group and currently
used by most surgeons.5, 9, 12, 14
With the internal xation technique de-
scribed earlier, the authors have experienced
only one case of xation failure. A 3.5 recon-
struction plate experienced fatigue fracture
6 months after surgery in a patient with a
severe open injury treated by supracondylar
shortening and coverage with a local ap and
skin graft. The lateral column had healed, ne-
cessitating only rexation and bone grafting of
the medial column, which did result in union.
His nal range of motion was 20 to 120 .
Decreased range of motion may occur se-
condary to heterotopic ossication, intra-
articular adhesions, or capsular contracture.
If motion does not respond to a program of
splinting, the patient may require a capsular
release that can be performed 6 months to
1 year after the initial surgery; at the time
of capsular release, the hardware should be
removed if the fracture is strongly healed.
Dysfunction of the extensor mechanism
may occur if the triceps tendon fails to heal to
the olecranon. Careful attention to reattach-
ment of the extensor mechanism at surgery
should help prevent this complication. The
reconstruction should be solid enough to
allow passive elbow exion. Weakness does
not seem to be a major problem with use of the
TRAP approach for distal humerus fractures.
Should discontinuity or subluxation of the
extensor mechanism occur, it can be surgically
treated by primary repair or augmentation
with an Achilles tendon allograft. Patients
might experience a degree of triceps weak-
ness following supracondylar shortening,
but weakness is not uncommon following
 MANAGEMENT OF THE SMASHED DISTAL HUMERUS
these severe injuries. Thus, the authors have
not been able to discern clinically any conse-
quences of the approach or treatment, separate
from those of the injuries themselves.
Joint deterioration may be secondary to the
cartilage damage sustained at the initial in-
jury or the avascular necrosis secondary to
the devascularization of some articular frag-
ments in severely comminuted injuries. The
authors have had one case of osteonecrosis in a
severely multifragmentary fracture. If the like-
lihood of this complication is to be minimized,
it is necessary to leave all soft tissues attached
to the distal fragments during surgery.
Finally, a question that is often asked re-
lates to blocking of motion caused by loss of
the olecranon fossa. These injuries for which
supracondylar shortening is indicated are so
severe that even experienced surgeons would
be pleased to reliably obtain healing of the
soft tissues and bones with a functional arc
of motion (30 130 ). If motion is sufcient
to permit impingement, the hardware can be
removed and the bone recontoured at a later
date.
References
1. Ackerman G, Jupiter JB: Non-union of fractures of
the distal end of the humerus. J Bone Joint Surg Am
70:7583, 1998
2. Gabel GT, Hanson G, Bennett JB, et al: Intraarticu-
lar fractures of the distal humerus in the adult. Clin
Orthop 219:99108, 1987
3. Giori NJ, ODriscoll SW: Continuous passive motion
33
(CPM): Theory and principles of clinical application.
J Rehabil Res Dev 37:179188, 2000
4. Henley MB, Bone LB, Parker B: Operative man-
agement of intra-articular fractures of the distal
humerus. J Orthop Trauma 1:2435, 1987
5. Helfet D, Hotchkiss R: Internal xation of the distal
humerus: A biomechanical comparison of methods.
J Orthop Trauma 4:260264, 1990
6. Holdsworth BJ, Mossad MM: Fractures of the adult
distal humerus: Elbow function after internal xation.
J Bone Joint Surg Br 72:362365, 1990
7. Hughes RE, Schneeberger AG, An KH, et al: Reduc-
tion of triceps muscle force after shortening of the
distal humerus: A computational model. J Shoulder
Elbow Surg 6:444448, 1997
8. John H, Rosso R, Neff U, et al: Operative treatment
of distal humeral fractures in the elderly. J Bone Joint
Surg Br 76:793796, 1994
9. Jupiter JB, Neff U, Holzach P, et al: Intercondylar frac-
tures of the humerus. J Bone Joint Surg Am 67:226
239, 1985
10. Letsch R, Schmit-Neuerburg KP, Sturmer KM, et al:
Intraarticular fractures of the distal humerus. Surgical
treatment and results. Clin Orthop 241:238244, 1989
11. ODriscoll SW: The triceps-reecting anconeus pedi-
cle (TRAP) approach for distal humeral fractures and
nonunions. Orthop Clin North Am 31:91101, 2000
12. Ring D, Jupiter JB: Fractures of the distal humerus.
Orthop Clin North Am 31:103113, 2000
13. Schemitsch EH, Tencer AF, Henley MB: Biomechani-
cal evaluation of methods of internal xation of the
distal humerus. J Orthop Trauma 8:468475, 1994
14. Self J, Viegas SF, Buford WL, et al: A comparison
of double-plate xation methods for complex distal
humerus fractures. J Shoulder Elbow Surg 4:1016,
1995
15. Soderg
ard J, Sandelin J, Bostman
O: Postopera-
tive complications of distal humeral fractures. Acta
Orthop Scand 63:8589, 1992
16. Wang KC, Shih HN, Hsu KY, et al: Intercondylar frac-
tures of the distal humerus: Routine anterior subcuta-
neous transposition of the ulnar nerve in a posterior
operative approach. J Trauma 36:770773, 1994
Address reprint requests to
Shawn W. ODriscoll, MD, PhD
Medical Sciences Building, 369
Mayo Clinic
200 First Street SW
Rochester, MN 55905
e-mail: odriscoll.shawn@mayo.edu
TREATMENT OF COMPLEX FRACTURES
Douglas P. Hanel, MD, Marci D. Jones, MD,
Historically, fractures of the distal portion
of the radius often were thought of as dislo-
cations of the carpus. Hippocrates described
4 directions of dislocation of the carpus; these
descriptors were used until the eighteenth
century. Pouteau, continuing the work of Petit,
began to recognize these injuries as likely frac-
tures most often taken for contusions, luxa-
tions incomplete, or for separation of the ra-
dius from the ulnar at their junction near the
wrist. Colles, whose name is associated most
often with fractures of the distal radius, pub-
lished a seminal article in 1814 describing in-
juries to the wrist as fractures and comment-
ing on treatment and outcome. This article
shifted the focus away from treatment of dis-
location and onto recognition and treatment of
fracture.13
Distal radius fractures account for 14% of
all extremity injuries and 17% of all fractures
treated in the emergency department.19 Distal
radius fractures occurring as a result of a high-
energy injury represent a subset of fractures,
often with resultant signicant injury and im-
pairment to the upper extremity. These frac-
tures frequently have a high degree of com-
minution, instability, and associated soft tissue
injuries.
In older age groups, more women than
men have fractures of the distal radius, often
resulting from low-energy falls. The rela-
tionship between distal radius fracture and
osteoporosis has been evaluated. Earnshaw
et al10 evaluated 106 of 149 consecutive post-
From the Department of Orthopaedics and Sports Medicine, Section of Hand and Microvascular Surgery, University
of Washington, Harborview Medical Center, Seattle, Washington (DPH, MDJ, TET); and Department of Orthopaedic
Surgery, University of Arizona, Tuscon, Arizona (MDJ)
ORTHOPEDIC CLINICS OF NORTH AMERICA
VOLUME 33 NUMBER 1 JANUARY 2002
00305898/02 $15.00 + .00
WRIST FRACTURES
and Thomas E. Trumble, MD
menopausal women with dual-energy x-ray
absorptiometry (DXA) within 2 weeks of
fracture and found that half of the patients
had osteoporosis at the spine, hip, or radius.
Patients younger than age 65 years had signif-
icantly lower bone mineral density (BMD) at
the hip compared with age expected values.
Similarly, Wigderowitz et at 43 measured BMD
by single-photon absorptiometry in 31 women
with Colles fracture and compared this with a
control group of similarly aged women. They
found that 25 of 31 women had BMD less than
1 standard deviation below the control group
and that in patients younger than age 66 years,
BMD was signicantly lower than that in the
control group. Currently the World Health
Organization advises that fracture of the distal
radius in a postmenopausal woman is an
indication for evaluation of BMD, and the Na-
tional Osteoporosis Foundation recommends
bone density testing for all postmenopausal
women presenting with a fracture. Freed-
man et al15 reviewed a national insurance
database to evaluate the rate of diagnosis or
treatment for osteoporosis within 6 months
of distal radius fracture in women older than
age 55. Of the 1162 patients included in the
study, the authors found that less than 3%
underwent BMD evaluation, and less than
23% were treated with at least one medication
for osteoporosis (estrogen, bisphosphonates,
or calcitonin). These studies underscore the
importance of recognizing the association of
distal radius fracture with osteoporosis, and
35
36 HANEL et al

counseling patients appropriately to decrease

risk of future fracture.

ANATOMY

The distal radius articular surface is angu-

lated 20 in the anteroposterior view and 5
to 11 in the lateral plane (Fig. 1). The dor-
sal cortex is thickened to form Listers tuber-
cle and the osseous prominences supporting
the radial wrist extensors in the second dor-
sal compartment. A central ridge divides the
articular surface into the scaphoid and lunate
facets (Fig. 2). A second articular surface ex-
ists in the sigmoid notch, where the radius ar-
ticulates with the ulna at the distal radioulnar
joint (DRUJ). These areas of bony thickening
direct the dissipation of energy delivered to Figure 2. Anteriorposterior radiograph. Bony ridge (aster-
the wrist and account for the frequently seen isks) divides the distal radius into a scaphoid fossa and lu-
nate fossa. Second articulation occurs between the radius
fractures occurring between the scaphoid and and ulna (double-lined circle).
lunate facets of the radius. The nature of the
applied load alters the exact fracture pattern
and may cause coronal or sagittal splits in the of the radius, inserting onto the radial sty-
lunate or scaphoid facets. loid. The remaining extrinsic wrist tendons in-
The soft tissue structures about the dis- sert more distally in the extremity. The extrin-
tal radius also may contribute to the fracture sic ligaments of the wrist, the scapholunate
pattern. The triangular broscartilage extends interosseous and lunotriquetral interosseous
from the rim of the sigmoid notch to the ul- ligaments, hold the scaphoid, lunate, and tri-
nar styloid. Fracture of the ulnar styloid, par- quetrum in place and form a smooth surface
ticularly at its base, may represent instability for articulation with the scaphoid and lunate
of the DRUJ. The brachioradialis tendon is the facets of the distal radius and the triangu-
only tendon to insert onto the distal portion lar brocartilage. Most distal radius fractures

Figure 1. Anteroposterior and lateral radiograph. Coronal ra-

dial inclination is 21 radial inclination. Saggital radial articu-
lar surface is tilted 5 to 11 palmarward palmar tilt.

result from compression forces during a fall.
The scaphoid and lunate may split apart as the
radius fractures. Likewise, distracting forces
that result in avulsion fractures of the radial
styloid may lead to the scaphoid being pulled
apart from the lunate following the common
perilunate dislocation pattern.
CLASSIFICATION
Myriad classication schemes exist for fra-
ctures of the distal radius and ulna, varying
on mechanism, fracture pattern, degree of
comminution, or intra-articular extent. Tradi-
tional fracture eponyms include Colles (extra-
articular fractures with dorsal displacement
of the distal fragment), Bartons (either dorsal
or palmar marginal rim fracture with subluxa-
tion of the carpus), Smiths (intra-articular or
extra-articular fractures with palmar displace-
ment of the distal fragment), Hutchinsons
or Chauffeurs (shear fracture of the radial
styloid often associated with scapholunate
dissociation), and others. The most useful clas-
sication system would be easy to understand
and reproduce. It would give useful informa-
tion about mechanism of injury and treatment
and allow for meaningful comparison across
series of fractures to evaluate outcome. Al-
though some systems come close, none fulll
the desired goal. The AO classication is
detailed, with three main categories of frac-
ture: extra-articular, partial articular, and com-
Table 1. UNIVERSAL CLASSIFICATION OF DISTAL RADIUS FRACTURES AND TREATMENT
Classication of Fracture Preference
I. Nonarticular, nondisplaced
II. Nonarticular, displaced
a. Reducible, stable
b. Reducible, unstable
c. Irreducible
III. Articular, nondisplaced
IV. Articular, displaced
a. Reducible, stable
b. Reducible, unstable
c. Irreducible
d. Complex
Included are volar shearing fractures, open fractures, fracture-dislocations and joint depression fractures.
Data from Cooney WP: Fractures of the distal radius: A modern treatment-based classication. Orthop Clin North Am 24:211216,
1993.
WRIST FRACTURES 37
plete articular. Each of these is subdivided
into three subgroups based on fracture pat-
tern, degree of comminution, and associated
injuries. Kreder et al27 have shown that when
intra-observer and interobserver variability is
taken into account, only the 3 main categories,
extra-articular, partial articular, and complete
articular, nd consistent agreement. The Uni-
versal Classication (Table 1) shows 4 main
groups of fractures, based on intra-articular
extension, displacement, and metaphyseal
stability.8 This classication also proposes a
treatment algorithm based on the classica-
tion. Fernandez and Jupiter14 propose a similar
classication that separates fractures into ve
main types based on mechanism: bending
of the metaphysis, shearing of the articular
surface, compression of the articular surface,
avulsion and radiocarpal fracture-dislocation,
and combined-complex open injury (Fig. 3).
This system also gives guidelines for treat-
ment based on fracture type and includes
associated DRUJ pathology as stable, unstable,
or potentially unstable.
HISTORY AND
PHYSICAL EXAMINATION
Most patients with distal radius fractures
initially are evaluated in the emergency
department. It is important that this initial
examination include the history of the injury
to assist in determining the degree of energy
Treatment
Cast/splint immobilization
Cast/splint immobilization
Percutaneous pins
external xation
Open reduction and internal xation external
xation
Cast immobilization percutaneous pins
Closed reduction/percutaneous pins
Closed reduction external xation percutaneous
pins
Open reduction percutaneous pins internal
xation external xation
Open reduction/external xation; plate xation
+ bone graft percutaneous pins
38 HANEL et al

Figure 3. Fernandez classication of the distal a-radius fractures. A, Bendinglow energy injury.
B, Shearingthese include volar, dorsal, and radial axial load resulting isolated articular fractures.
This is a volar shearing type. C, Compressionthe most common radius fracture. Direct axial load re-
sults in fractures about the distal radioulnar joint and the radiocarpal joint. D, Avulsion and radio-carpal
fracture dislocationthe radius portion of these injuries can appear to be quite simple (black arrows),
the associated perilunate fractures and dislocations (curved arrow, right panel).
Illustration continued on opposite page

involved. Evaluation for concomitant injuries
is imperative. The carpus should be evaluated
for fractures or fracture-dislocations. Vascular
compromise occurs rarely, but neurologic
lesions are relatively frequent. Objective mea-
sures of sensibility should be documented.
Monolament, vibratory, or 2-point discrimi-
nation before and after reduction are essential.
Nerve decit most often involves the median
nerve but also can involve the ulnar or radial
nerves. In the emergency setting, Cooney et al9
reviewed 565 cases and found persistent
neuropathy in 31%. If patients do not expe-
rience improvement of sensibility after re-
duction or if sensibility worsens over serial
examinations, one should measure carpal tun-
nel pressure and if elevated proceed directly
with an urgent carpal tunnel release. (The se-
nior author [DPH] believes that deteriorating
objective sensory ndings after distal radius
 WRIST FRACTURES 39

Figure 3 (Continued ). E, Combined-complex: Any of the aforementioned as-

sociated with open fractures. This injury resulted from the hand being caught
in a pulley system. (Modied from Fernandez D, Jupiter J: Fractures of the dis-
tal radius. A practical approach to management. New York, Springer, 1996;
with permission.)

manipulation is all that is necessary to warrant
operative intervention. He combines fracture
stabilization with a carpal tunnel release.)
RADIOGRAPHIC EVALUATION
Radiographic evaluation includes antero-
posterior, lateral, and oblique views; these
views show the extent and direction of the
initial displacement. After closed reduction,
radiographs should be repeated to identify
the residual deformity and the amount of
comminution. Most measurements reference
the anteroposterior and lateral views; these are
described in the following section. The oblique
view helps evaluate intra-articular step-off
and diastases.33
Measurement of the extra-articular align-
ment of the distal radius is necessary to deter-
mine if fracture alignment is adequate. Palmar
inclination is measured on the lateral radio-
graph in degrees, as the angle between a line
drawn parallel to the distal radius articular
surface and a line parallel to the shaft of the
radius (see Fig. 1). A negative palmar inclina-
tion indicates that the distal radius articular
surface is dorsally angulated. On the antero-
posterior radiograph, ulnar inclination is mea-
sured in degrees as the angle between a line
drawn parallel to the distal radius articular
surface and a line parallel to the radial shaft.
The ulnar variance, in millimeters, also is mea-
sured on the anteroposterior lm. The ulnar
variance is the distance from a line drawn par-
allel to the ulnar head articular surface to a
line drawn tangential to the lunate facet of the
distal radius perpendicular to the shaft of the
radius.28, 37
Evaluation of the intra-articular extent of
the fracture is crucial. Knirk and Jupiter25
found that 2.0 mm or greater of distal radial
articular displacement can lead to posttrau-
matic arthrosis. Trumble34 evaluated factors
affecting outcome in displaced intra-articular
fractures and suggested that a substantial de-
crease in patients functional results occurred
with a postoperative gap of greater than
1.0 mm, based on readings of postoperative
radiographs by 1 author at 1 point in time. The
ability to evaluate radiographs to this degree
of accuracy also has been examined. Kreder
et al28 reviewed 16 raters of various training
and experience to determine the intraobserver
and interobserver variability in the aforemen-
tioned measurements of healed fractures on
standard radiographs. These authors found
that extra-articular measurements, including
40 HANEL et al
ulnar variance and palmar inclination, have
a higher rater agreement, but that even ex-
perienced clinicians did not agree with them-
selves or others on intra-articular measure-
ments. Using their methods, it is expected
that two randomly chosen orthopedic clini-
cians measuring step and gap deformity will
differ by greater than 3 mm 10% of the time,
and repeated measurements by the same
clinician can be expected to differ by more
than 2 mm 10% of the time. Disagreement re-
garding 1-mm displacement occurs more often
than not.
In an attempt to evaluate better the frac-
ture pattern and components, plain or com-
puted tomography (CT) is useful to determine
if surgery is recommended when the amount
of displacement is unclear or the fracture pat-
tern is difcult to visualize on plain radio-
graphs. These scans are made in the sagittal
and coronal planes, oriented along lines par-
allel to the shaft of the radius. CT scanning
is highly recommended in die-punch fractures
(with central depression of the articular sur-
face), volar rim fractures, and fractures involv-
ing the scaphoid facet.40
Cole et al7 evaluated the reliability of CT
compared with plain radiography to deter-
mine better its utility for detecting small
displacements of articular fragments. They
looked for a reliable and reproducible method
for measurement of fracture displacement.
These authors had 5 independent blinded
observers evaluate plain radiographs and CT
scans of 19 acute intra-articular distal radius
fractures and determined that there was a
poor correlation between plain lms and for
displacement of greater than 2 mm and that
30% of plain radiographs signicantly over-
estimated or underestimated displacement
compared with CT. Additionally, they found
the most reliable method of measurement
on CT was the arc method. This method is
performed by matching a template to the
radius of curvature of the distal radius (Fig. 4).
Two points are made on the subchondral
surface of the fragments to be measured,
and a line is drawn through the geometric
center of the circle to the point on the more
displaced fragment, and a third point is made
intersecting the line and the arc of the circle.
Step displacement is measured by determin-
ing the distance between the point on the
arc of the circle and the displaced fragment;
diastass is measured by determining the
distance between the 2 points on the arc of the
circle.
Figure 4. Articular step-off can be assessed with sagittal
CT scans. This method is performed by matching a tem-
plate to the radius of curvature of the distal radius. Two
points are then made on the subchondral surface of the
fragments (a and b) to be measured, and a line is drawn
through the geometric center of the circle to the point
on the more displaced fragment. A third point is made
intersecting the line and the arc of the circle (c). Step
displacement is measured by determining the distance
between point b and c. Diastases is measured by deter-
mining the distance between the two points on the arc of
the circle, a and c. (Modied from Cole RJ, Bindra RR,
Evanoff BA, et al: Radiographic evaluation of osseous dis-
placement following intra-articular fractures of the distal
radius: Reliability of plain radiography versus computed
tomography. Am J Hand Surg 22:792800, 1997; with
permission.)
TREATMENT
Background
Treatment of distal radius fractures is con-
troversial; there is no single denitive treat-
ment method that is considered the standard
of care. Published clinical trials directly com-
paring treatment regimens of indirect reduc-
tion, external xation, and percutaneous pin-
ning with open reduction and internal xation
for intra-articular fractures are lacking. The re-
sults of the currently published data are dif-
cult to compare. Most studies are retrospec-
tive in nature and use various classications
and inconsistent outcome tools, especially in
regard to comminuted fractures with joint
incongruity.
Kreder et al26 presented results of a multi-
center randomized, controlled trial of 147 pa-
tients younger than age 75 years with dis-
placed intra-articular distal radius fractures
followed prospectively. Patients were ran-
domized into two groups. Group 1 was treated
with indirect reduction and percutaneous
xation, with or without external xation.

Group 2 was treated with open reduction and
internal xation and bone graft as needed.
Surgical goals for both groups were the
same:
Ulnar inclination greater than 10
Palmar inclination greater than or equal
to 0
Ulnar variance of 0 mm
Articular diastases and displacement of less
than 2 mm
A stable DRUJ
If in the case of group 1 the goals could
not be met, patients were treated open and
placed in group 2. Evaluation 6 months after
treatment included general health status,
Jebson-Taylor hand function testing, grip
and pinch strength, pain, return to work, and
complications. Results at 6 months showed
that patients treated with indirect reduction
and percutaneous xation had signicantly
better function than patients treated with open
reduction and internal xation. No signicant
differences were seen in Jebson-Taylor scores,
grip and pinch strength, and range of motion.
Further follow-up at 2 years revealed that the
functional status had nearly equalized and
that pain scores were similar for the treatment
groups at 6 months and 2 years. From these
data, it is evident that indirect reduction, ex-
ternal xation, and percutaneous xation are
appropriate if the radiographic parameters set
by Kreder et al26 can be achieved. Similarly, if
the radiographic parameters cannot be met,
open reduction and internal xation should
be undertaken. Based on this study, the au-
thors use the radiographic parameters listed
previously as their treatment goals.
Kapoor et al23 achieved similar results
when 90 patients with closed intra-articular
fractures were treated randomly with closed
reduction and plaster immobilization, exter-
nal xation, or open reduction and internal
xation, with follow-up at an average of
4 years. Although it is difcult to determine
their randomization protocol, the treatment
groups showed no signicant differences
in age, sex, or fracture classication. Plaster
immobilization was inadequate in main-
taining reduction in most patients. External
xation improved functional scores (based
on residual deformity, subjective evaluation,
objective evaluation, and complications), and
open reduction and internal xation best cor-
rected palmar angulation and intra-articular
step-off.
WRIST FRACTURES 41
Closed Reduction Versus
Open Reduction
Despite emphasis on invasive fracture man-
agement, some distal radius fractures can be
managed closed. Making the choice between
closed and various open procedures can be as-
sisted by the universal classication (see Table 1)
combined with the following 4 parameters8 :
1. Patient age. As the age of the popula-
tion increases, the viability and recreation
of individuals who by age alone would
have been considered inactive in past gen-
erations has changed markedly. The de-
mands for an excellent repair of a dis-
tal radius fracture in 70-year-old skiers,
snow boarders, golfers, and rowers are
the same as those of 30-year-olds.
2. Articular step-off. As noted earlier, artic-
ular displacement greater than 2 mm is
signicant.28
3. Metaphyseal instability dened as:
a. Fractures with volar obliquity, dis-
placed more than 2 mm (Fig. 5). These
fractures require xation to push the
palmarly displaced fragment into
its reduced position and to butters it
while it is healing.11
b. Die punch fractures, because even if the
articular realignment is procured, the
metaphyseal void would not support
the reduction.
Figure 5. Volar shearing injuries can not be pulled into
position because they need to be pushed. This applies
to the isolated volar shearing injuries (A) as well as the
volar ulnar corner (asterisk ) involved in compression type
fractures (B).
42 HANEL et al

c. Fractures with greater than 20 of dor- Closed Reduction

sal angulation or dorsal comminu-
tion greater than one third of the
anteroposterior diameter of the radial
shaft. Although potentially reducible,
the axis of rotation falls volar to the
midaxis of the radial shaft, and the ex-
trinsic forces acting on the distal frag-
ment promote dorsal displacement.
d. Any fracture that loses reduction
within weeks of initial treatment.
Although this may seem redundant,
it is included here to emphasize the
point that the closed treatment of
distal radius fractures requires weekly
vigilance. By denition, progressive
displacement after reduction implies
failure to appreciate instability.
4. DRUJ stability. DRUJ stability is deter-
mined after reconstruction of the radius.
Melone32 pointed out that reconstruction
of the sigmoid notch frequently leads to
stabilization of the DRUJ and in so do-
ing emphasizes that consideration of the
unstable ulnar joint always should be
preceded by reduction and xation of the
radius, specically the sigmoid notch.
Whether a fracture can be treated open
or closed is centered about the ndings at
the time of closed reduction. Although most
high-energy injuries require open reduction,
invaluable information regarding metaphy-
seal comminution, volar stability, and artic-
ular depression can be gleaned from closed
reduction.
Agee1 described an excellent method of re-
duction that takes advantage of ligamento-
taxis, provides detailed information regarding
metaphyseal stability, and when used in the
setting of a stable fracture allows closed treat-
ment without placing undo pressure on the
contents of the carpal tunnel. The reduction
is performed as follows. After adequate anal-
gesia or anesthesia has been obtained, nger
traps are placed on the index and long n-
ger, and 1016 of longitudinal traction is ap-
plied. Ten minutes is allowed to pass, then the
metacarpal-carpal complex is translated pal-
marward, while the hand is pronated slightly
relative to the forearm. Wrist exion and forearm
pronation is avoided with this maneuver (Fig. 6). If
viewed with image intensication, one would

Figure 6. The reduction maneuver described by Agee. A, Longitudinal traction which restores length.
B, Palmar translation of the hand relative to the forearm, along with slight pronation of the hand rel-
ative to forearm restores volar tilt (and determines the extent of volar integrity). (Modied from Agee
JM: External xation. Technical advances based upon multiplanar ligamentotaxis. Orthop Clin North
Am 24:265274, 1993; with permission.)
 WRIST FRACTURES 43

note that length is restored with traction and

that palmar tilt and ulnar inclination are re-
stored with palmar translation and pronation
of the hand. If articular step-offs continue af-
ter reduction, percutaneous or open methods
would be required. If the distal radius fracture
fragments translate palmar to the radial shaft,
there is inadequate volar support, and buttress
plating is essential.

Closed Reduction and Splint

or Cast Alone

If the goals of reduction are met (see previ-

ous list) and there is no evidence of metaphy-
seal instability, cast or splint immobilization is
recommended. A long arm thumb spica splint
with the forearm in supination and the thumb
interphalangeal joint free is used for the rst
week and changed to a circular cast the second
and third weeks. The forearm is supinated to
overcome the pull of the brachioradialis, and a
thumb spica is worn to prevent irritation of the
radial sensory nerve by the leading edges of
cast that do not include the thumb. The wrist
is maintained in a neutral position through-
out treatment. A short arm cast is worn dur-
ing weeks 3 through 6. If closed reduction and
casting is the chosen treatment, weekly or at
least biweekly radiographs are imperative. Ra-
diographs must be compared with the origi-
nal postreduction radiographs. Changes in the
alignment may occur slowly, and what seems
to be a subtle difference compared with the
previous weeks radiographs may be dramat-
ically different from the postreduction lm
(Fig. 7).
External Fixation
External xation overcomes the muscular
pull of the forearm (i.e., it holds the fracture
out to length) (Fig. 8). In the setting of signif-
icant metaphyseal comminution, a xator al-
lows alignment of the articular surface with
the shaft of the radius without reliance on the
support of the metaphysis. External xators
cannot reduce displaced intra-articular frac-
tures. Indications for external xation include:
1. Longitudinal traction for extra-articular
fractures with an unstable metaphysis
2. An indirect reduction assistant during
open reduction and internal xation
3. An adjunct to percutaneous pin xation
4. Spanning open fractures
Figure 7. Closed treatment demands vigilance. This frac-
ture displaced 3 weeks after cast application.
Multiple external xators are available.
They differ in variation of pin placement,
stiffness, ability to adjust after placement, and
cost. Frykman et al16 evaluated 13 external
xators for weight, cost, rigidity in different
planes, ability for controlled adjustment of
fracture reduction, ability to dynamize, and
ability to be placed radius to radius. These au-
thors concluded that the selection of a specic
device depends mostly on ease of application
and the surgeons familiarity with the device.
They suggested that dynamic xators, which
allow early joint motion, would be benecial.
Studies suggest the opposite, however. Recur-
rent dorsal angulation and nearly 20% fair or
poor radiographic results were reported when
using dynamic wrist xators.20, 24, 38
Augmentation of the external xator with
a radial styloid or dorsally placed Kirschner
wire xation is recommended in fractures in
which an articular reduction was obtained.
Wolfe et al44, 45 and Weiland42 showed that ad-
ditional xation signicantly reduces move-
ment at the fracture site and increases the sta-
bility of extra-articular fractures.
McQueen et al,30 reviewing their experience
with radius-to-radius xation, found it to
be a favorable adjunct to fracture manage-
ment. Radius-to-radius xation is the one
method of external xation that can restore
44 HANEL et al

Figure 8. Radiographs of three commonly used xator congurations. A, Typical bridging external x-
ator with two pins in the second metacarpal and two pins in the radius shaft. B, Nonbridging xator
with distal pins in the subchondral bone. C, An internal splint introduced through separate forearm
and hand incision. The plate is passed along the second dorsal compartment. The implant used in
this case is a 2.4-mm Synthes (Synthes USA, PA) mandibular reconstruction plate. It was removed
10 weeks after placement.

and maintain palmar angulation. Although
McQueen et al30 suggested using this method
for intra-articular fracture, the authors have
limited their experience to extra-articular fra-
ctures with metaphyseal comminution as
shown in Figure 8B.
Another unique variation of external xa-
tion is the percutaneous application of a xa-
tion plate that spans the wrist from the radial
diaphysis to the second or third metacarpal.
A 3- to 5-cm incision is made proximal to
the outcropping muscles. The plate is intro-
duced deep to those muscles, passed through
the second dorsal compartment, and afxed
to the second metacarpal through a separate
incision. This xator-internal is removed 8 to
10 weeks later. Burke and Singer5 introduced
the technique and have used it in more than
300 cases. The authors nd this technique to
be particularly helpful in the management
of multiply-injured patients, in whom inter-
nal xation would not be otherwise neces-
sary and external xation adds a burden to
nursing care. Also, the rigidity of such a con-
struct is far greater than any other external
xator that allows weight bearing for bed-
to-chair transfers or in conjunction with ambu-
latory assist devices.3, 4 Burke and Singer5 used
3.5-mm Synthes dynamic compression plates.
The authors use 2.4-mm plates from the Syn-
thes mandibular reconstruction set. The holes
in this 2.4-mm plate accommodate a set screw
interface such that the construct becomes a
xed angle device and the smaller plate size
can be passed more easily through the second
dorsal compartment of the wrist. An example
is shown in Figure 8C.
Placement of the xation pins into the ra-
dius and metacarpals is done under anesthesia
with image intensication. The reduction
described previously is performed, and the
proximal pins are inserted. Multiple small
incisions (1 to 2 cm) or one large incision (2.5
to 3 cm) is made along the radial border of the
forearm in the area of the planned pin place-
ment. Care must be taken to avoid the interval
between the extensor carpi radialis longus and
brachioradialis. The radial sensory nerve runs
in this interval. Instead the interval between
the extensor carpi radialis longus and extensor
carpi radialis brevis is identied. The extensor
carpi radialis longus is retracted palmarly, the
extensor carpi radialis brevis dorsally, and the
radial bone surface identied (Fig. 9). Under
direct vision, a drill guide is placed, and the
xator pins are passed through both cortices
using uoroscopic guidance. The distal pins
are placed similarly into the radial surface of
the index metacarpal; the rst pin is placed in
the proximal metadiaphyseal junction, and the
more distal pin is directed by the congura-
tion of the xator clamps. Terminal branches
of the radial sensory nerve must be protected
during distal pin placement.36 Whether or
not pins are predrilled depends on the tip
conguration. Drill-tipped pins are becoming
increasingly popular; those that are not should
be predrilled.
 WRIST FRACTURES 45

Drill guide and fixator pin

ECRL
ECRB

Radius Brachioradialis

Ulna Radial nerve

ECRB
ECRL
Fixator pins between
ECRB and ECRL

Incision for fixator pin

Brachioradialis
Sensory branch
of radial nerve

External fixator

ECRB

ECRL

Brachioradialis
Radius
MC II

Figure 9. The interval for safe passage of external xator pins is be-
tween the extensor carpi radialis longus (ECRL) and extensor carpi ra-
dialis brevis (ECRB) tendons of the forearm. The insertion of distal pins
is along the lateral or dorsal lateral aspect of the second metacarpal.
(From Trumble TE, Culp R, Hanel DP, et al: J Bone Joint Surg 80A
4:596, 1998; with permission.)

Percutaneous Pin Fixation With or equate closed reduction is achieved under

Without Limited Dorsal Approach
Various congurations of percutaneously
placed pins have been advocated for the
stabilization of distal radius fractures.35 Percu-
taneous pinning has been used for displaced
extra-articular fractures with or without
dorsal comminution, early loss of reduction
after closed manipulation, and comminuted
intra-articular fractures when adequate closed
reduction is able to be obtained but likely not
maintained without addition support.19
Interfocal pinning, pins passed through
fracture fragments, is appropriate when ad-
image intensication. Smooth Kirschner wires
0.045 inch (1.1 mm) or 0.062 inch (1.6 mm)
are used. Clancey6 popularized the use of
2 pins passed through the radial styloid and
1 to 2 additional pins passed through the
distal dorsal-ulnar corner of the radius be-
tween the fourth and fth compartments.
The planned site for placement of the wires
is evaluated under uoroscopy, and a small
incision is made for pin insertion. Blunt dis-
section exposes the bone surface, and a tissue
guard protects the radial sensory nerve, while
the wires are drilled through the fracture
fragments (Fig. 10A).
46 HANEL et al
Figure 10. A, Interfocal pinning technique with wires
passing through the reduced facture fragments into the
metaphyseal bone. One or two pins support the radial sty-
loid and one pin supports the dorsal ulnar corner. B, With
intrafocal pinning, the pins are introduced into the frac-
tures and used as levers to restore volar tilt and radial in-
clination. When the reduction is completed, the pins are
driven into the far cortex.
Intrafocal pinning, promoted by Kapandji,22
places 0.062-inch (1.6 mm) Kirschner wires di-
rectly into the fracture site. One to 3 pins are
used to correct ulnar inclination and radial
translation. The pins are passed through the
fracture and along the radial cortex of the dis-
tal radius, levered distally, then driven into the
opposite cortex in the anteroposterior and lat-
eral planes. If more than 1 pin is used, they
are placed between the rst and second com-
partments, dorsal to the second compartment
and into Listers tubercle. Additional pins are
placed dorsally to correct the palmar inclina-
tion (Fig. 10B). Results of intrafocal pinning
alone are better in younger patients, likely ow-
ing to better bone quality and the ability to
maintain reduction. Trumble et al41 reviewed
their experience with intrafocal pinning with
and without external xation in 61 patients,
23 of whom were older than age 55. The re-
sults suggested that intrafocal pinning alone
in older patients is functionally and radio-
graphically inferior to intrafocal pinning com-
bined with external xation. In younger pa-
tients, intrafocal pinning was not affected by
the use of external xators.
Percutaneous pin xation increasingly is
combined with a small incision through which
elevators or Kirschner wires are used as joy-
sticks to manipulate fracture fragments. This
approach is particularly helpful in patients
with a die-punch fracture, in which elevation
can be achieved through a limited dorsal ap-
proach and the need for an arthrotomy is cir-
cumvented. If there is an associated radial
styloid fracture, 0.062-inch (1.6-mm) pins are
drilled into the styloid and directed to but not
across the fracture line. One pin is directed
proximally to capture the radial shaft, and
the other pins are passed immediately sub-
chondral to the ulnar extent of the scaphoid
fossa. A small (< 3 cm) incision is made adja-
cent to Listers tubercle, and blunt dissection
identies the fracture fragments. Assisted by
image intensication, small elevators, dental
picks, and free-hand Kirschner wires are used
to reduce the die-punch fragment. The pre-
viously placed Kirschner wires also are used
as joysticks and are driven across the fracture
site when proper alignment is procured. Addi-
tional Kirschner wires or small (2.0 to 2.7 mm)
plates can be used to buttress the reduction. In
most cases, the authors pack bone graft into
the metaphyseal defect left by the die-punch
fracture (Fig. 11).
Pins that are to remain in place for less
than 6 weeks are left protruding from the skin.
Pins that are to be left in place longer than
6 weeks are buried. Pins that left out of the
skin and external xation pins are treated sim-
ilarly. They are cleansed daily with dilute hy-
drogen peroxide, crusts are removed, and just
enough dressings are applied to minimize the
motion about the pins. Ointments specically
are avoided because they cannot seal a pin
tract and serve only to trap bacteria about the
pin site. If pin sites become inamed a short
course (5 to 7 days) of a broad-spectrum oral
antibiotic is prescribed, and pin tract care is
reinforced. If the inammation continues and
the pin is crucial to the fracture stabilization,
it is replaced through a distant incision. If the
pin is not crucial, it simply is removed.
Operative Approaches to
Distal Radius
Three approaches, two volar and one dorsal,
are used most frequently for exposure and x-
ation of the distal radius. The approach chosen
is based on the conguration of the frac-
ture and the planned placement of xation.
Although most high-energy injuries are
treated through a dorsal incision, the essen-
tial rst step is to determine whether or not
palmar stability exists. As detailed in the
section on closed reduction and reiterated
here, a uoroscopically assisted reduction is

Figure 11. A, Radiographs of a 34-year-old carpenter
2 weeks after injury. Longitudinal traction resulted only in
volar translation of the large volar portion of the lunate sul-
cus. B, Using an extended carpal tunnel approach, the
volar fragment was manipulated under direct vision and
the reduction held with a 2.7-mm Synthes plate. The ra-
dial styloid was pulled out to length and transxed with
a k-wire. Dorsal metaphyseal comminution was pushed
against the now intact volar cortex and an external xa-
tor was used to reinforce the reduction. C, The external
xator and k-wire were removed 6 weeks after reduction.
These radiographs were obtained 6 months postopera-
tively (From Hanel DP: Volar plate xation of distal ra-
dius fractures. Atlas of Hand Clinics 2:124, 1997; with
permission.)
carried out on the anesthetized limb. Longi-
tudinal traction is applied, while the hand
is translated palmarward against a stable
forearm. If the fracture translates beyond
the palmar extent of the radius or the carpus
subluxates palmarly, palmar instability exists
(see Fig. 11A). Malunion is prevented with a
volar buttress support. Melone32 pointed out
the volar fragments may include the ulnar
aspect of the sigmoid notch. The reduction
of this crucial cornerstone of the distal radius
comes rst, and the remainder of the fracture
fragments are built around it. To that end,
if the previous reduction maneuver reveals
palmar instability, the authors follow Melones
advice and proceed directly to volar reduction
WRIST FRACTURES 47
and xation. If the palmar support is stable the
authors use a dorsal approach.
Radial and Ulnar Volar Approaches
The choice of a radial or ulnar volar ap-
proach is based on the fracture pattern and
the exposure necessary for reduction. A ra-
dial volar, or Henry, approach is used for frac-
tures involving the palmar radial surface or
for large, 1-piece shear fractures of the pal-
mar surface. Comminuted fracture patterns
that include a fracture of the volar ulnar sig-
moid notch necessitate a volar ulnar exposure.
This exposure, variously named as an extended
carpal tunnel incision or the universal approach,
allows direct line of sight for reduction and
placement of xation devices.20a
The volar radial approach is the most com-
monly used palmar approach and uses the in-
terval between the exor carpi radialis (FCR)
and the radial artery. An incision is made
just radial to the FCR tendon, and careful
dissection protects the radial artery, which
usually is retracted radially with the brachio-
radialis. The FCR and other exor tendons are
retracted ulnarly, and the pronator quadratus
is elevated from the radial surface of the distal
radius (Fig. 12). This exposure can be extended
distally by releasing the FCR from its attach-
ments to the trapezium. This release allows vi-
sualization of the radial styloid and volar rim
of the distal radius. The volar carpal branch
of the radial artery usually is encountered
and divided in the extended exposure. Frac-
ture fragments are reduced and temporarily
held with Kirschner wires. In cases in which
the radial styloid is a single large fragment
and the remainder of the volar radius is in-
tact, the radial artery is mobilized toward the
FCR, and the brachioradialis insertion is di-
vided. This dissection and reduction can be fa-
cilitated further with subperiosteal elevation
of the rst dorsal compartment from the dis-
tal radius. Similar to the other volar fragments,
the styloid is reduced and held with multi-
ple Kirschner wires. If the dorsal cortex of
the radius is intact, xation plates can be ap-
plied with the central portion of the plate el-
evated 1 to 2 mm off of the underlying cor-
tex. As the plate is afxed to the radius, it
acts as a spring pushing the fracture frag-
ments together (Fig. 13). One should be cau-
tious with this technique; overenthusiastic ap-
plication leads to stenosis of the distal radius
articular surface. Failure to recognize dorsal
instability results in overreduction of the distal
48 HANEL et al

Figure 12. Standard anterior approach. A, The incision starts at the distal wrist crease, adjacent to the
exor carpi radialis and extends proximally to the junction of the mid and distal one-third of the fore-
arm. The interval between the exor carpi radialis and the artery is widened and the distal radius ex-
posed. B, Cross section at wrist level demonstrating the interval of dissection. (Modied from Hanel
DP: Volar plate xation of distal radius fractures. Atlas of Hand Clinics 2:124, 1997; with permission.)

radius fracture, reversing the sagittal articu-
lar angle of the radius. Radial styloid fractures
can be maintained with Kirschner wires or ap-
plication of a recently developed xation plate
that incorporates the Kirschner wires into an
antiglide construct (Fig. 14).
The second volar approach uses the distal
portion of an incision described for extensile
exposure of the median nerve, release of fore-
arm compartmental syndromes, and manage-
ment of distal forearm fractures (Fig. 15). The
incision starts at the midpalm and is directed
proximally in line with the radial aspect of
ring nger. (The hypothenar crease is a read-
ily available landmark.) At the distal palmar
crease, the incision travels ulnarly at 45 un-
til coming to within 5 mm of the radial bor-
der of the exor carpi ulnaris. At this point,
the incision is aimed 90 radially toward the
junction of the mid and distal one third of the
radius diaphysis. In the distal extent of this in-
cision, the palmar fascia and transverse carpal
tunnel ligament are divided. Proximally the
forearm fascia is divided, and the interval be-
tween the ulnar neuromuscular bundle and
the contents of the carpal tunnel is developed.

Contact
point
First screw Contact
placed here point

Figure 13. Spring plate applied with a 12 mm gap. The fragments are
pushed together as the screws are secured. An intact dorsal cortex is
essential. (Modied from Hanel DP: Volar plate xation of distal radius
fractures. Atlas of Hand Clinics 2:124, 1997; with permission.)
 WRIST FRACTURES 49

Figure 14. A Trimed (Trimed, Inc.,CA) xation system incorpo-

rates K-wires used for initial xation into the antiglide plates.

Figure 15. Extensile exposure of the carpal tunnel and distal radius. A, The incision starts at the mid-
palm and crosses the wrist creases in an ulnar oblique direction. When the radial border of the exor
carpi ulnaris is encountered, the incision is directed radially. B, The contents of the carpal tunnel are
retracted radially. The ulnar neurovascular bundle is retracted ulnarly (a). In rare incidences, interval
(b) is developed, but it puts the palmar cutaneous branch of the ulnar at risk. (Modied from Hanel DP:
Volar plate xation of distal radius fractures. Atlas of Hand Clinics 2:124, 1997; with permission.)
50 HANEL et al

The pronator quadratus is divided at its ori-
gin and lifted radialward off of the volar ra-
dius. As the radius is exposed, the contents
of the carpal tunnel fall forward and are re-
tracted easily from the fracture site. This ex-
posure allows direct visualization of the whole
of the distal radius, especially the sigmoid
notch; releases the carpal tunnel; and is di-
rected easily cephalad when forearm compart-
ment releases are necessary. A problem with
this exposure is that the pronator quadratus
tends to be destroyed with the dissection and
frequently is discarded during the procedure.
(One might consider this advantageous when
removal of the pronator quadratus provides
room for implants and compensates for soft
tissue swelling.) Whether the pronator teres is
preserved or not, care must be taken to pre-
serve the capsule of the DRUJ, especially the
attachments to the volar ulnar fracture frag-
ments. Another problem with this approach is
exposing the radialmost aspect of the radial
styloid. This problem can be overcome by ex-
tending the proximal limb of the incision to
the radial border of the forearm and mobiliz-
ing the skin aps proximal to the wrist creases,
protecting the palmar cutaneous branch of the
median nerve and developing the interval be-
tween the FCR and the radial artery as de-
scribed for the rst exposure.
When the fracture fragments are assessed
and the personality of the fracture determined,
reduction and provisional xation is carried
out. The clinicians inclination may be to re-
duce large radial styloid fracture fragments
rst, but this must be done with caution.
Malreduction of the radial styloid, however
slight, makes the reduction of the volar ulnar
corner difcult if not impossible. The volar ul-
nar corner, should be reduced rst, and the
distal radius should be built around this cru-
cial corner. Temporary xation is procured
with Kirschner wires.31 Permanent xation is
provided with a plate (2.0, 2.4, or 2.7 mm) con-
toured to the volar surface. In the setting of
combined volar and dorsal comminution, the
buttress plate must be contoured to take into
consideration the volar angulation of the dis-
tal radius. If it is not, the distal radius is forced
into a reverse sagittal tilt malunion (Fig. 16B ).

A B

C D

Figure 16. A, This high-energy compression type facture is volarly and dorsally unstable.
B, The volar plate was contoured to the shape of the distal radius and can only serve as a
buttress. C, Dorsal exposure, bone graft and plates. D, Two years postrepair. Patient is pain-
free, distal radioulnar joint (DRUJ) is stable. There is loss of motion 20 of exion. Other wrist
and forearm motion is equal to the uninjured side.

In the most comminuted fractures, a second
dorsal incision may be necessary and the re-
duction completed as described subsequently.
Isolated volar shearing injuries deserve spe-
cial note. These inherently unstable fractures
come in three varieties: simple two-part frac-
tures, three-part fractures that involve the
radiocarpal and the radioulnar joint, and
fractures associated with metaphyseal com-
minution. The volar radial approach is used
for the simple two-part fractures, whereas
the volar ulnar approach is used for the more
comminuted fractures. In two-part fractures,
the intact dorsal cortex can be used to advan-
tage as previously shown in Figure 13. With
comminuted fractures, the amount of spring
that is put into a plate should be tempered.
Overreduction leads to distal radius stenosis
or reversal of normal volar tilt, both of which
are associated with poor results.21 Reduction
of comminuted fractures starts at the crucial
volar ulnar corner and builds from there.
Provisional Kirschner wire xation precedes
plate application (Fig. 17).
A B
C D
Figure 17. A, The interdigitation of proximal fracture lines
(arrows) can be used as the template for reduction in
most volar shearing fractures. The volar capsule should
not be violated to procure reduction. B, The reduction
starts at the sigmoid notch and builds from there. C and
D, Placement of the xation plate may require adjustment
of the provisional xation wires. Rather than changing the
position of a wire, as shown here, obstructing wire can be
driven out the dorsum of the wrist, leaving just enough on
the volar surface of secure xation and not interfere with
plate placement. (Modied from Hanel DP: Volar plate x-
ation of distal radius fractures. Atlas of Hand Clinics 2:1
24, 1997; with permission.)
WRIST FRACTURES 51
Neither volar approach allows visualization
of the articular surface. The volar capsular
ligaments are sacrosanct and should not be
violated in this exposure. Reduction is ob-
tained by cortical interdigitation of the meta-
physeal portion of the fractures and observing
the effect of the reduction with image inten-
sication. If the reduction is questionable, the
fracture is visualized through a dorsal arthro-
tomy or by placing an arthroscope through
the space of Poirier volarly or the 34 portal
dorsally.
Dorsal Approach
A longitudinal incision over the dorsum of
the wrist just ulnar to Listers tubercle is made.
The extensor pollicis longus tendon is iden-
tied distally and followed to the third dor-
sal compartment over the wrist. This com-
partment often is identiable by its distention
with hematoma because intra-articular frac-
ture splitting the scaphoid and lunate facets
continues through the base of the third com-
partment, avoiding the thicker bone at Listers
tubercle. In most high-energy injuries, Listers
tubercle is a free-oating fragment with no ar-
ticular component. We usually remove it while
keeping capsular attachments intact. The third
and fourth dorsal compartments and dorsal
wrist ligaments are elevated sharply off of the
dorsal surface of the radius as a unit. This el-
evation obviates the need to repair the exten-
sor retinaculum at the time of closure, which
can be difcult because of swelling. If these
compartments are entered and not repaired,
the tendons bowstring with extension of the
wrist. The dissection stops at the ulnarmost
edge of the fourth compartment, preserving
the capsular attachment of the ulnar to the
dorsal sigmoid notch (Fig. 18).
Small elevators or probes are used to align
the articular fragments. The reduction is per-
formed under direct vision, conrmed by im-
age intensication. Similar to on the volar side,
the lunate fossa, including the sigmoid notch,
is reconstructed rst followed by scaphoid
fossa and radial styloid. The reduction is sta-
bilized with Kirschner wires in the subchon-
dral bone. Subcortical defects are supported
by bone graft and denitive xation often calls
on the use of xation plates (see Fig. 16C, D).
There are an increasing number of internal x-
ation devices specially designed for the ra-
dius or specic fractures of the radius. To date,
none have proved to be superior to or a sub-
stitute for the surgeons ability to reduce the
fracture. In this article, the implants used were
52 HANEL et al

Scaphoid Torn
Extensor digitorum articular scapholunate
comminus in surface ligament
compartment 4 of
extensor retineculum
Release EPL from
compartment 3

Lunate
articular
surface

ECRB
ECRL Distal radial Ulna
fracture

Radius

A B
Figure 18. Dorsal exposure of the distal radius. A, Using a straight line incision oriented along the
base of the third metacarpal, Listers tubercle and the radial shaft, the dorsal retinaculum is exposed.
The third dorsal compartment is incised and the extensor pollicus longus is mobilized. B, The dorsal
joint capsule is incised radial to the fourth dorsal compartment. The capsule and the adjacent com-
partments are elevated as units off of the radius. The dissection stops ulnarly at the fth compartment
and radially at the rst compartment. The integrity of the scapholunate joint is determined in the distal
extent of the wound. Similarly, the capsule and second compartment are elevated. (From Trumble TE,
Culp R, Hanel DP, et al: J Bone Joint Surg 80A 4:596, 1998; with permission.)

designed to handle small fracture fragments
not specic to the radius. They use 2-, 2.4-, and
2.7-mm screws.
Closure is achieved by loosely suturing the
edge of the fourth compartment capsule of the
wrist to the edge of the second or to what re-
mains of the third compartment. The extensor
pollicis longus is left out of its sheath. This ten-
don does not bowstring owing to its oblique
course across the wrist.
High-Energy Injuries
High-energy, complex intra-articular frac-
tures may require a dorsal and a volar ap-
proach to achieve adequate reduction and
xation. As mentioned previously, it is rec-
ommended that the volar rim undergo stabi-
lization rst, followed by a dorsal approach.
Closure of the volar wound before making
the dorsal incision helps tissue swelling and
wound separation; however, delayed primary
closure or split-thickness skin grafting may be
necessary to close the dorsal wound. Through
the dorsal exposure, intra-articular fractures
are reduced under direct visualization, xed
with Kirschner wires supported with bone
graft and stabilized further with dorsal plates
(see Fig. 16). If the stability of the fracture con-
struct is questionable, spanning xators are
used. The xator can be a traditional exter-
nal conguration or the internal xator champi-
oned by Burke and Singer 5 (Fig. 19).
Open fractures are addressed with aggres-
sive debridement, removal of all doubtfully
viable tissue, and stabilization with either in-
ternal or external xation. Soft tissue cover-
age should be secured within 1 week of in-
jury, and bone grafting is done when the soft
tissues have healed. In cases requiring skin
grafts, we usually wait until the transferred
skin stops desquamating; this is usually 6 to
8 weeks after injury. In a closed high-energy
fracture, swelling often is extensive. In this
case, delaying the procedure several days until
the swelling has subsided is appropriate. The
authors also decrease perioperative swelling
by limiting tourniquet time to that required
to isolate and protect crucial neurovascular
structures and initial fracture reduction.
High-energy injuries, especially those invol-
ving shearing or avulsion of the radial styloid,
frequently are associated with scapholunate
 WRIST FRACTURES 53

Figure 19. A, One of many fractures sustained by this patient included an intra-articular radius frac-
ture. B, Management included the reduction maneuver described in the text, percutaneous K-wire xa-
tion, and application of the internal splint. The plate was removed 10 weeks after injury. C and D, The
radiographic and clinical results 8 months after injury.

and other intercarpal injuries.18, 33 These
should be treated with pin xation at the least
and repaired as part of any open procedure
(Fig. 20).
Treatment of the Distal Radioulnar
Joint and Associated Ulnar
Styloid Fractures
Evaluating the stability of the DRUJ is
essential in the treatment of wrist fractures
(Table 2). Although a sense of the degree of
subluxation or dislocation can be obtained
from the initial injury radiographs, the deni-
tive assessment can be made only after
addressing the radius fracture. Frequently a
grossly unstable DRUJ is secured with recon-
struction of the sigmoid notch. The stability of
DRUJ is examined clinically and uoroscop-
ically in supination and pronation. A sense
of the general stability of this joint can be
obtained by examining the opposite uninjured
wrist preoperatively or intraoperatively.
If the DRUJ is stable in supination but not
pronation, treatment consists of splinting in
a long arm or Munster-type cast for 3 weeks
in supination, followed by 3 weeks of immo-
bilization in neutral pronosupination. If the
DRUJ is stable in pronation but not supina-
tion, the authors reevaluate the reduction of
the volar-ulnar radius. If the reduction is satis-
factory, the ulnar head is reduced into the sig-
moid notch. With the forearm in mid prono-
supination, the reduction is maintained with
20.062-inch (1.6-mm) Kirschner wires, placed
just below the articular surface of the ulnar
head. The authors do not recommend im-
mobilizing the forearm in pronation because
of the difculty that patients have regaining
supination postoperatively and because of the
increased deforming force of the brachioradi-
alis muscle on distal radius fractures when the
forearm is pronated.
If the DRUJ is unstable throughout the
range of motion, even with the sigmoid notch
reconstructed, treatment is based on 1 of
3 radiographic ndings: no associated ulnar
54 HANEL et al
Figure 20. This radial shearing injury had an associated
scapholunate disruption. Treatment consisted of closed
reduction, screw xation of the radius, and open repair
with K-wire stabilization of the intercarpal dissociation.
fractures, an associated ulnar styloid fracture,
or an associated ulnar neck fracture. When
the ulnar head and styloid are not fractured,
two options can be exercised. First the ulnar
head can be reduced into the sigmoid, the fore-
arm placed in neutral pronosupination, and
the reduction secured with Kirschner wires as
described previously. The second treatment
method is prompted by Geisslers nding17
that in these cases the triangular complex is
avulsed from the styloid and can be anchored
back to the styloid through a limited incision
or through arthroscopically assisted methods.
Table 2. TREATMENT OF THE DISTAL RADIOULNAR JOINT
DRUJ Examination
Stable
Unstable in pronation/stable in supination
Stable in pronation/unstable in supination
Unstable in supination and pronation
No ulnar fracture
Ulnar styloid fracture
Ulnar head fracture
DRUJ = Distal radioulnar joint.
When an ulnar styloid fracture is associ-
ated with DRUJ instablity, it is likely that the
triangular cartilage complex is attached to
the styloid fragment. Fracture xation sta-
bilizes the DRUJ. Flexing the elbow 90 and
placing the forearm in maximal supination
reduces the fracture. If the fragment is large
enough, xation can be done percutaneously
with a 0.035-inch (0.89-mm) or 0.045-inch
(1.1-mm) Kirschner wire. If the closed reduc-
tion cannot be obtained, an incision is made
along the distal ulna immediately volar and
ulnar to the extensor carpi ulnaris tendon.
This exposure should be done while main-
taining elbow exion and forearm supination.
(Attempting to perform a reduction of ul-
nar styloid with the forearm in pronation,
outstretched on an arm table, proves to be
frustrating. The ulnar shaft and ulnar sty-
loid are misaligned by forearm pronation.)
Dissecting along the subcutaneous border
of the distal ulna exposes the fracture. Soft
tissue stripping stops when the fracture site is
encountered. Just distal to this point, the ulnar
styloid is palpated and reduced with a dental
pick. All soft tissue attachments are left on this
fragment. Fixation of the fracture is secured
with Kirschner wires, cannulated screw, or
tension band wiring (Fig. 21A and B).
When DRUJ instability is associated with
an ulnar neck fracture, the authors reduce
the fracture closed and introduce a 0.062-inch
(1.6-mm) wire in the ulnar styloid and pass
it down the medullary canal. Others have de-
scribed using blade plates for these fractures
(Fig. 21C and D).12
Bone Graf t
Bone graft or bone graft substitutes fre-
quently are necessary in the treatment of dis-
tal radius fractures. Bone graft is used for
Recommended Treatment
No treatment
Long arm cast in supination for 3 weeks,
neutral pronosupination for 3 weeks
Reduce and pin in neutral
Pin xation in neutral or supination
Pin xation and/or tension band
Transverse (blade) plate, intra-medullary
rod or pin xation
 WRIST FRACTURES 55

Figure 21. Fixation of the distal radioulnar joint. A, Two 0.062 inch
(1.6 mm) k-wires transx the distal ulna to the radius. The pins pur-
posely avoid the articular surface of the sigmoid notch. B, Tension
band xation. C, A K-wire or Stienman pin passes through the ulnar
styloid down the medullary. The pin is cut off at the level of the sty-
loid. D, This xed angled blade plate is an alternative to treatment of
unstable transverse ulnar meta-diaphyseal fractures.

fractures with signicant metaphyseal com-
minution for added support of the articular
surface during healing and to ll a bony void
left by the comminuted fragments. Autoge-
nous bone graft is considered the standard
because it has osteoinductive and osteocon-
ductive properties, is readily available, has
structural support, and becomes incorporated
into the fracture site. There is signicant mor-
bidity associated with this procedure, how-
ever, especially with the use of iliac crest graft.
Morbidity is associated with increased opera-
tive time, blood loss, postoperative pain, and
increased hospital stay. Arrington et al2 re-
viewed 414 bone grafting procedures over a
10-year period; the numbers of anterior and
posterior procedures were not specied. They
found an incidence of 5.8% major compli-
cations (those requiring a major change in
treatment or a return to the operating room)
and 10% minor complications. Major compli-
cations related to anterior iliac crest bone graft
harvesting included 2 donor defect hernia-
tions of small bowel, 3 cases of meralgia pares-
thetica with no noted association to the surgi-
cal incision site, and 2 cases of pelvic iliac wing
fracture. Seven deep infections and 4 deep
hematomas developed; these were not iden-
tied by site. Minor complications included
5 supercial infections, 20 supercial seromas,
and 16 minor hematomas.2
There are multiple allograft preparations
and synthetic graft substitutes. Ladd and
Pliam29 published a detailed review of the
use of bone graft substitutes in distal radius
fractures. Early reports suggest that bone graft
substitutes are useful alternatives to auto-
graft and offset the morbidity and possible
complications of its use. Most studies are not
comparative, do not use standardized out-
come measures, and often are supported by
the commercial developers of the bone graft
substitutes. This area of biotechnology is bur-
geoning, and further objective, comparative,
longer term studies are necessary to assist the
surgeon in decision making.
Allograft, or banked human bone, is the
authors treatment of choice in distal radius
fractures. Allograft has the advantage of de-
creasing the morbidity and operative time
associated with autograft harvesting. Allo-
graft bone partially retains the properties
of autograft, including structural support,
osteoconductivity, and osteoinductivity. The
56 HANEL et al
extent to which a graft carries these properties
is modulated by its preparation method, with
frozen bone maintaining greater strength than
either freeze-dried or irradiated bone.29 Allo-
graft has the theoretical possibility of disease
transmission.
Postoperative Care
After surgery, the injured extremity is
placed into a bulky dressing, including a short
or long arm thumb spica splint. Complete
digit range of motion is encouraged immedi-
ately, and the 6-pack exercises of Palmer34 are
begun on postoperative day 1. The exercises
include active range of motion for metacar-
pophalangeal, proximal interphalangeal, and
distal interphalangeal joint through a series
of congurations of the hand (arrow, spread
table-top, st, claw, in-and-out, and thumb-
to-tip). If the DRUJ is stable, supination is
emphasized, noting that pronation returns
with little effort. After 2 to 3 weeks, stable
fractures are placed in removable thermo-
plastic short arm splints, and gentle wrist
range of motion is begun. This splint is worn
until edema resolves. Resistive exercises begin
when there is evidence of radiographic consol-
idation. Static progressive or dynamic splints
have been used for patients who fail to achieve
range-of-motion goals.
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5. Burke EF, Singer RM: Treatment of comminuted dis-
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17. Geissler WB: Arthroscopically assisted reduction of
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18. Geissler WB, Freeland AE, Savoie FH, et al: In-
tracarpal soft-tissue lesions associated with an intra-
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19. Gellman H: Fracture of the Distal Radius. American
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20a. Hanel DP: Volar plate xation of distal radius frac-
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22. Kapandji A: Internal xation by double intrafocal
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23. Kapoor H, Agarwal A, Dhaon BK: Displaced intra-
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24. Kawaguchi S, Sawada K, Nabeta Y, et al: Recur-
rent dorsal angulation of the distal radius fracture
during dynamic external xation. J Hand Surg Am
23:920925, 1998
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of Orthopaedics Surgeons 66th Annual Meeting,
Anaheim, CA, 1999
27. Kreder HJ, Hanel DP, McKee M, et al: Consistency
of AO fracture classication for the distal radius.
J Bone Joint Surg Br 78:726731, 1996

28. Kreder HJ, Hanel DP, McKee M, et al: X-ray lm
measurements for healed distal radius fractures.
J Hand Surg Am 21:3139, 1996
29. Ladd AL, Pliam NB: Use of bone-graft substitutes
in distal radius fractures. J Am Acad Orthop Surg
7:279290, 1999
30. McQueen MM, Simpson D, Court-Brown CM: Use
of the Hoffman 2 compact external xator in the
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103111, 1986
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33. Mudgal C, Hastings H: Scapho-lunate diastasis
in fractures of the distal radius: Pathomechanics
and treatment options. J Hand Surg Br 18:725729,
1993
34. Palmer AK: Fractures of the distal radius. In Green
DP (ed): Operative Hand Surgery. New York,
Churchill Livingstone, 1993, pp 929972
35. Rayhack JM: The history and evolution of percuta-
neous pinning of displaced distal radius fractures.
Orthop Clin North Am 24:287300, 1993
36. Seitz WH Jr, Putnam MD, Dick HM: Limited open
surgical approach for external xation of distal ra-
dius fractures. J Hand Surg Am 15:288293, 1990
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osteotomy for malunited, volarly displaced fractures
WRIST FRACTURES 57
of the distal end of the radius. J Bone Joint Surg Am
79:18161826, 1997
38. Sommerkamp TG, Seeman M, Silliman J, et al: Dy-
namic external xation of unstable fractures of the
distal part of the radius: A prospective, randomized
comparison with static external xation. J Bone Joint
Surg Am 76:11491161, 1994
39. Trumble TE, Schmitt SR, Vedder NB: Factors affect-
ing functional outcome of displaced intra-articular
distal radius fractures. Am J Hand Surg 19:325340,
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40. Trumble TE, Culp RW, Hanel DP, et al: Intra-
articular fractures of the distal aspect of the radius.
Instr Course Lect 48:465480, 1999
41. Trumble TE, Wagner W, Hanel DP, et al: Intrafocal
(Kapandji) pinning of distal radius fractures with
and without external xation. J Hand Surg Am
23:381394, 1998
42. Weiland AJ: External xation, not ORIF, as the treat-
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43. Wigderowitz CA, Rowley DI, Mole PA, et al: Bone
mineral density of the radius in patients with Colles
fracture. J Bone Joint Surg Br 82:8789, 2000
44. Wolfe SW, Austin G, Lorenze M, et al: Biomechan-
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Address reprint requests to
Douglas P. Hanel, MD
Box 359798
Harborview Medical Center
325 Ninth Avenue
Seattle, WA 981042499
e-mail: dhanel@u.washington.edu
TREATMENT OF COMPLEX FRACTURES
HIGH-ENERGY PELVIC
M. L. Chip Routt, Jr, MD, Sean E. Nork, MD, and William J. Mills, MD
High-energy pelvic ring disruptions re-
sult from signicant traumatic events and
are associated with a variety of primary or-
gan system injuries. Severe pelvic ring in-
stability causes life-threatening hemorrhage
and must be treated rapidly and efciently.
For these patients, initial diagnostic evalua-
tions and resuscitations proceed simultane-
ously. A multispecialty team of experienced
personnel facilitates successful management.
Acute resuscitation of the patient must include
a mechanism to decrease pelvic instability,
which, in turn, diminishes pelvic bleeding,
provides patient comfort, and expedites the
ongoing evaluation. Numerous techniques
are available to treat acute pelvic traumatic
instability.
INJURY AND MECHANISM
Unstable pelvic ring disruptions result from
high-energy traumatic events. Motor vehicle
accidents, including automobile, motorcycle,
and automobile and pedestrian accidents, ac-
count for most pelvic ring disruptions. In a se-
ries of 68 patients with unstable pelvic frac-
tures treated operatively at a level 1 trauma
center, Routt et al42 reported 74% were due
to vehicular trauma. Other common injury
mechanisms include falls from a signicant
height or crush injuries by a heavy object
or animal. Except in unusual instances of
complex injury mechanisms, the pelvic ring
From the Department of Orthopedic Surgery, Harborview Medical Center, Seattle, Washington
ORTHOPEDIC CLINICS OF NORTH AMERICA
VOLUME 33 NUMBER 1 JANUARY 2002
00305898/02 $15.00 + .00
RING DISRUPTIONS
disruption pattern reects the traumatic load
application. For this reason, pelvic ring in-
juries were classied based on plain pelvic ra-
diographs according to the direction of the
force producing the injury by Pennal et al.38
They described anteroposterior compression,
lateral compression, and vertical shear pat-
terns. Other authors have elaborated on this
simple pelvic fracture classication scheme in
attempts to describe the associated injuries
better.7
Patients with high-energy traumatic events
sustain pelvic ring disruptions along with
associated primary organ system injuries,
including chest and abdominal, urogenital,
craniocerebral, and other skeletal injuries. In
numerous clinical reports, a variety of meth-
ods have been used to reect these associated
injuries.17, 42, 57 For these reasons, an effective
pelvic fracture classication system should
include the precise locations of pelvic ring
injuries, their displacement patterns, and their
associated injuries.
EVALUATION AND RESUSCITATION
The initial evaluation and resuscitation of
the injured patient begin at the accident scene
and continue in the hospital with airway
control, predictable ventilation, and adequate
circulation. Large-diameter intravenous cathe-
ters are inserted, and volume resuscitation
is initiated by the paramedics. The patients
59
60 ROUTT et al

core temperature is optimized by covering is aspirated with routine suction equipment

the patient with warm blankets, using heat
lamps, and providing warmed intravenous
uids. In patients with high-energy pelvic
injuries, pelvic ring mechanical instability is
identied by a single examination of the pelvis
at the accident scene or in the emergency
department. Gentle manual compression over
both iliac crests bilaterally causes pain and
reveals pelvic ring instability. Bony crepitus
may be noted. Pelvic and associated lower ex-
tremity deformities, such as malrotation, iliac
crest asymmetry, and subcutaneous palpable
bone, indicate potential pelvic injury. Open
pelvic wounds, typically located along the
iliac crest or perineal areas, should be cleansed
quickly and dressed aseptically while manual
pressure controls related bleeding.
The injured pelvis is immobilized at the ac-
cident scene before patient transport using a
variety of simple techniques. A vacuum bean-
bag, a large circumferential sheet, or military
antishock trousers (MAST) are recommended
to stabilize the pelvis temporarily.31 Circum-
ferential pelvic sheeting is the least expensive
and most readily available option. The folded
sheet is wrapped snugly around the pelvis and
either clamped or knotted anteriorly.44 The
sheet can be positioned around the hips if ab-
dominal access is needed (Fig. 1). A vacuum
beanbag can be positioned beneath the patient
and wrapped around each ank. The beanbag
at the scene. Both techniques allow abdom-
inal and lower extremity access. These are
only temporary stabilization methods because
of skin pressure concerns. Regardless of the
chosen technique, pelvic overcompression is
avoided (Fig. 2).
The peripheral neurologic examination is
documented in alert patients. A digital rectal
examination assesses the prostate gland loca-
tion and the rectal mucosal surface and tests
for gross and occult blood. A bimanual vagi-
nal examination is performed in female pa-
tients. Speculum vaginal evaluations are de-
ferred until initial pelvic stability is achieved,
allowing safe placement of the patient in the
lithotomy position. Lower extremity deformi-
ties are realigned carefully, then splinted.
Scrotal swelling or ecchymoses and the
presence of urethral meatal bleeding are de-
layed signs of a urethral disruption and are
noted in male patients. Similarly the inability
to urinate or insert a urinary catheter easily
are signs of urethral disruption. In a retro-
spective review of 405 male patients with
pelvic fractures treated at a level 1 trauma
center, Lowe et al29 identied a 5% incidence
of urethral injuries, especially in patients
with displaced pubic ramus fractures and
sacroiliac joint disruptions. They found that
physical signs suggesting a urethral injury
were absent in 57% of the patients and were

A B

Figure 1. A, This 19-year-old female patient was injured in a high speed motorcycle accident.
Her physical examination conrmed an unstable pelvis along with a right labial traumatic lacer-
ation. The open labial wound drained blood and urine. Her plain pelvic radiograph before sheet
application demonstrates the disrupted symphysis pubis, ramus fractures, and posterior pelvic in-
juries. B, The subsequent radiograph reveals the pelvic reduction accomplished by the circumferential
pelvic sheet.

Figure 2. The pelvic sheet worsened the pelvic defor-
mity in this patient with a right sided transforamenal sacral
fracture, risking neurologic injury.
related directly to the time interval since
injury. Lowe et al29 recommended that male
patients with the combination of pubic ramus
fractures and a sacroiliac joint disruption un-
dergo retrograde urethrograms before urethral
instrumentation. The prompt recognition and
appropriate management of these injuries
may have a signicant impact on subsequent
morbidity.
RADIOLOGY AND COMMON
ZONES OF INJURY
At hospital presentation, a screening antero-
posterior pelvic radiograph usually reveals
the pelvic ring injury. After high-energy trau-
matic events, signicant pelvic instability may
be present, but the radiograph may show only
minor displacements. When indicated, the ra-
diographic evaluation is performed without
removing the circumferential sheet or vac-
uum beanbag. In certain instances, the pelvic
radiograph obtained with the circumferen-
tial pelvic sheet or wrap in place underesti-
mates the extent of pelvic displacement and
instability.10
Pelvic inlet and outlet plain radiographs
identify the major pelvic ring disruptions
and their associated displacements.38 Lat-
eral sacral plain radiographs are obtained
in patients with sacral fractures. Most pa-
tients with pelvic ring disruptions undergo
abdominal computed tomography (CT) scans,
which can be reformated to provide valuable
pelvic osseous and soft tissue details. Osseous
pelvic CT scans consist of sequential axial
HIGH-ENERGY PELVIC RING DISRUPTIONS 61
images in 3-mm increments. Other helpful
imaging studies include pelvic angiography,
cystography, retrograde urethrography, and
two-dimensional or three-dimensional pelvic
CT. The angiographic image intensier can
be used to visualize and quantify the pelvic
instability sites during a careful manual ex-
amination under uoroscopy.35 Using these
diagnostic tools, the orthopedic surgeon
gathers an improved understanding of the
injury.
High-energy pelvic ring disruptions occur
in predictable locations. The symphysis pu-
bis yields through ligaments. Superior pubic
ramus fractures occur in the parasymphyseal
region, midramus, or adjacent to the acetabu-
lum. Frequently the anterior aspect of the ac-
etabulum is involved in so-called pubic root
fractures. These are low anterior column ac-
etabular fractures occurring as a component of
a pelvic ring disruption. Combination injuries
occur in the anterior pelvic ring. Segmental
pubic ramus fractures and pubic ramus frac-
tures with associated symphyseal disruptions
are common in high-energy pelvic injuries.
Iliac fractures are divided into 3 types. Two of
the 3 types spare the sacroiliac joint. Periph-
eral iliac fractures are conned to the iliac crest
area and may be comminuted and associated
with open iliac wounds. Other iliac fractures
extend from the iliac crest into the greater sci-
atic notch, sparing the sacroiliac joint. These
iliac fractures may be associated with gluteal
vascular injuries.56 The third iliac fracture type
extends from the iliac crest into the anterior
sacroiliac joint, the so-called crescent fracture-
dislocation. The posterior iliac fracture com-
ponent remains attached to the dorsal sacrum
and is the stable portion in these injuries
(Fig. 3).5
Sacroiliac joint dislocations are variable.
They may present as incomplete anterior
articular disruptions or complete ligamentous
injuries with signicant displacement. Poste-
rior iliac and dorsal sacral avulsion fractures
are noted infrequently in association with
complete sacroiliac joint disruptions. Anterior
sacral impaction fractures are noted in asso-
ciation with certain sacroiliac joint injuries.
Sacral fractures were classied according to
Denis et al13 as alar, transforaminal, or in-
volving the central or vertebral portion of the
sacrum. In high-energy trauma, lumbosacral
nerve root injuries can occur when the sacral
fracture involves the nerve root pathway or
central vertebral body and with signicant
hemipelvic displacements.
62 ROUTT et al

Figure 3. A, This 18-year-old female patient was ejected from an

automobile during a high-speed rollover accident that caused other
occupant deaths at the accident scene. Her pelvis was unstable to
examination, and she had sustained hypotension, despite adequate
volume resuscitation. Her plain pelvic radiograph reveals left-sided
comminuted pubic ramus fractures and an iliac crescent fracture-
sacroiliac dislocation injury. B, The abdominal CT scan axial image
further delineates the posterior pelvic injury pattern.

EARLY TREATMENT surgery, neurosurgery, interventional radiol-

Pelvic xation controls instability, decreases
bleeding, diminishes pain, and allows pa-
tient mobilization. Pelvic stability should be
achieved as soon as possible after injury and
evaluation. For patients with ongoing hem-
orrhage, pelvic stabilization is a vital portion
of the resuscitation. Early pelvic xation has
been shown to improve patient outcomes.27, 57
Optimal treatment is coordinated using a
multidisciplinary team and should consist of
a general surgeon leader along with numer-
ous subspecialty consultants. Because of the
complexity of such patients, the usual consul-
tants include experts in urology, orthopedic
ogy, pulmonology, and others. The combined
expertise facilitates the evaluation and man-
agement of these difcult patients. Early
coordinated treatment decisions have a sig-
nicant impact on patient survivability and
eventual function. Controversy arises in these
patients when emergent treatments are pri-
oritized. Open communication and physician
availability are mandatory to maximize ef-
cient and effective care. The general surgeon
leader should be experienced to coordinate
the patients care wisely. The team members
always must anticipate the impact of their
treatment plans. Aggressive tactics, such as
acute open reduction and internal xation,
 HIGH-ENERGY PELVIC RING DISRUPTIONS 63

should be reasonable and are reserved for rare
patients in whom routine efforts fail. Ideally,
early treatment should be denitive treatment.
Pelvic external xation frames have been
advocated for these patients, especially in situ-
ations of ongoing venous bleeding.21 Similar to
the circumferential sheet, anterior pelvic exter-
nal frames are designed to stabilize the pelvis,
allow clot formation, and diminish the po-
tential volume of the pelvis. Usually the pins
are inserted into the iliac crest and connected
anteriorly using a variety of constructs. Closed
reduction of the pelvic deformity and uo-
roscopic imaging facilitate improved pelvic
external xation.59 Certain fracture patterns,
specically comminuted iliac fractures, pro-
hibit placement of routine external xation
iliac pins. In these instances, anterior inferior
iliac pin sites often are useful. These pins also
are inserted after closed reduction and using
uoroscopy (Fig. 4). Poorly applied anterior
pelvic external xation frames obstruct ab-
dominal access and hip exion. Abdominal ac-
cess is important for exploratory laparotomy,
serial abdominal examinations, and ileus
accommodation. Patient mobilization from re-
cumbency is affected by a frame that obstructs
hip exion. Anterior pelvic external xation is
mechanically inferior compared with internal
xation techniques. Failure to maintain an
accurate pelvic reduction is common when
anterior pelvic external xation is used alone
for certain unstable fracture patterns. Pelvic
malreduction progresses to malunion, which
causes chronic pain and gait disturbances.
Pelvic malreduction should be corrected
before malunion.54 Nepola et al33 evaluated
33 patients with unstable and displaced pelvic
fractures, however, and found no correlation
between patient outcomes and residual pelvic
displacements.
Pelvic antishock clamps are posterior pelvic
external xation devices. These antishock
clamps are applied percutaneously to stabilize
the posterior pelvic ring in an attempt to limit
pelvic expansion and bleeding. The antishock
clamp pivots around posterior pelvic xa-
tion pins and allows access to the abdomen
or perineum.14 Application of the clamp is
difcult in patients with severe posterior
pelvic deformity or obesity. Certain posterior
pelvic ring fracture patterns, such as iliac
crescent fractures, limit the use of this device.
Overcompression is avoided in patients with
transforaminal sacral fractures. The anti-
shock clamp and the anterior external xation
frame can be applied after a closed pelvic
reduction is achieved temporarily using the
circumferential sheet. Similarly, these external
xation devices can be inserted while the
patient is in the angiography suite using the
uoroscope to assess pelvic closed reduction,
direct pin placement, and avoid application
errors.

A B

Figure 4. A, This 42-year-old woman was crushed by a tractor-trailer truck. She had a comminuted
iliac crest fracture and severely comminuted fractures and dislocations of the posterior pelvic ring. B,
On the day of injury, an anterior external xation device was applied using anterior inferior iliac pin
locations because of the iliac crest comminution bilaterally. Closed manipulative pelvic reduction was
achieved and secured using the anterior simple frame construct along with percutaneously inserted
bilateral iliosacral screws.
64 ROUTT et al
Intraoperative uoroscopic pelvic imaging
advances and improved implant designs have
led to the use of percutaneous pelvic xa-
tion in the acute setting for anterior and pos-
terior pelvic ring injuries. Iliosacral screws
are inserted percutaneously through the but-
tock, from the lateral ilium, and spanning the
sacroiliac joint or sacral injury stabilize cer-
tain posterior pelvic injury patterns. Iliosacral
screws are advocated only when closed ma-
nipulative reduction of the posterior pelvic
ring is successful, the surgeon understands the
upper sacral morphology and its uoroscopic
imaging, and accurate posterior pelvic uo-
roscopy is possible (Fig. 5).17, 42, 45, 46 Keating
et al20 noted unacceptable xation failure rates
when iliosacral screws were combined with
anterior pelvic external xation devices. In
their series, 38 unstable pelvic fractures were
treated using iliosacral screw xation. They
identied increased malunion rates in patients
treated without stable anterior pelvic internal
xation. They found iliosacral screw xation is
a useful method of xation for unstable pelvis
injuries when augmented by rigid anterior x-
ation. A variety of iliosacral screw complica-
tions have been described.2, 49, 55
Similarly, unstable superior pubic ramus
fractures are stabilized acutely using uoro-
scopically directed, percutaneously inserted
medullary screws (Fig. 6). Routt et al48 used
these ramus screws in combination with pos-
terior iliosacral screw xation in 26 patients
with unstable pelvic ring injuries. One screw
was misplaced superior to the pubic ramus
and noted only on the postoperative CT scan.
Another patient experienced symptomatic
screw disengagement that required reoper-
ation. All of the fractures healed, and there
were no infections. Blood loss was minimal for
these percutaneous procedures. Routt et al48
noted that the technique provided anterior
pelvic stability without the need for extensile
surgical exposures.
ASSOCIATED INJURIES
Open Wounds
Open pelvic fractures are among the most
devastating injuries in orthopedic trauma.
Open wounds are common in association with
high-energy pelvic ring disruptions and have
been associated with high mortality rates.
Traumatic pelvic lacerations are noted most
frequently adjacent to the iliac crest and in
the perineum. Open pelvic wounds result
from bone fragment laceration or penetrating
trauma. Certain open pelvic wounds may not
be obvious initially. Traumatic lacerations in
the gluteal cleft, buttock fold, vaginal vault,
and other locations are identied only with
careful and complete physical examinations
based on a high index of suspicion. Ballistic in-
juries also occur. Digital exploration of pelvic
open wounds determines their limits, rectal or
vaginal involvement, level of contamination,
and fracture relationship. The open pelvic
wound should be cleansed thoroughly and
debrided of necrotic tissue. Bleeding is con-
trolled initially with tamponade and fracture
stability. Devitalized bone fragments facilitate
accurate reconstruction of the fracture but
should not remain in the wound. All foreign
material should be removed completely from
the wound. Shotgun wadding may be difcult
to identify using plain pelvic radiographs but
is noted on pelvic CT scan.23
Open wound management using serial
debridement is necessary in high-energy open
pelvic wounds. Open perineal wounds involv-
ing the rectum require sphincter repair and
open wound management. Several studies
have conrmed that fecal diversion is reserved
for patients with rectal involvement by the
open perineal wound. Pell et al37 found that
colostomy may not be necessary in all patients
with open pelvic fracture. They noted that
their protocols for fecal diversion based on
open wound location were safe and decreased
resource usage and subsequent morbidity
related to colostomy closure. Woods et al62
noted infections in 27% of patients who un-
derwent fecal diversion compared with 29%
in patients who did not. In their study, only
mechanical instability was determined by
stepwise logistic regression to be associated
signicantly with pelvic infection. This associ-
ation was not altered by fecal diversion status.
Woods et al62 concluded that diversion of the
fecal stream to protect open pelvic fractures
was not associated with a lower incidence
of abdominopelvic infectious complications.
They postulated that fecal diversion may offer
protection to select patients with extensive
perineal soft tissue injury or posterior pelvic
wounds.
In a series of patients with pelvic fractures,
Brenneman et al6 found a 4% incidence of
open pelvic injuries. Most occurred in younger
male patients injured in motorcycle accidents.
These patients had signicant transfusion
requirements. Deep infections resulted in
 HIGH-ENERGY PELVIC RING DISRUPTIONS 65

A B

C D

Figure 5. A, This patient sustained symphyseal and right-sided sacroiliac joint dislocations. He was
hemodynamically unstable and had pelvic angiographic embolizations. This intraoperative uoroscopic
image demonstrates complete right-sided sacroiliac joint disruption, despite anatomic reduction and
plate xation of the symphysis pubis acutely. A guide pin has been inserted across the SI joint using
uoroscopic guidance. The embolic coil is seen (arrow). B, The iliosacral lag screw is positioned to
compress the SI joint disruption. C and D, As the screw is tightened, the SI joint surfaces are reduced
and secured. E, A second fully threaded iliosacral screw has been inserted to secure the xation.
66 ROUTT et al

A B

Figure 6. A, This patient had an extraperitoneal bladder disruption and pelvic ring injuries. The intraop-
erative uoroscopic image demonstrates minimally displaced pubic ramus fractures that were believed
to be stable based on their radiographic appearance. B, Gentle bilateral iliac crest manual compres-
sion revealed pelvic instability. The pubic ramus instabilities and displacements are shown. Her blad-
der was repaired, and the superior pubic ramus fracture was stabilized with a retrograde medullary
screw.

patients not treated with fecal diversion.
Based on outcome evaluations, surviving pa-
tients with open pelvic fractures noted chronic
pain and residual disabilities in physical
functioning and physical roles.
Open wounds occur in association with
iliac fractures. Switzer et al56 reported that
comminuted iliac fractures occur in 2 distinct
patterns and are associated with numerous
local injuries that complicate management. To
avoid infections, these authors recommended
early open reduction and stable internal x-
ation of the iliac fracture without primary
closure of the traumatic open wound. Open
wound management with subsequent wound
irrigation and debridement may be followed
with delayed wound closure as indicated.
Pelvic internal xation can be used in patients
with open pelvic fractures when there is not
gross contamination of the fracture region.
In situations of environmental or fecal con-
tamination of the fracture site, external pelvic
xation is preferred.
Closed Degloving Injury
Closed internal degloving is a signicant
soft tissue condition associated with high-
enegy pelvic injury in which the subcutaneous
tissue is separated traumatically from the
underlying fascia. A large potential space
containing hematoma and necrotic fat results.
The closed internal degloving injury may
compromise skin vascularity, resulting in
eschar formation. The ank, proximal lateral
thigh, and lumbodorsal region are common
locations. Treatment options include open
debridement with closure over suction drains,
open packing after debridement, or obser-
vation. Hak et al18 reviewed 24 patients with
closed internal degloving injury and pelvic
area trauma. Three patients developed deep
bone infections. They recommended early
debridement of the injured soft tissues prefer-
ably at the time of fracture xation. They also
recommended open wound management.
Kottmeier et al24 recommended early recog-
nition of degloving injuries. They advocated
aggressive early debridement and closure
over suction drains to optimize outcome and
avoid catastrophic complication.
Genitourinary Injury
Patients with high-energy pelvic ring dis-
ruptions have associated urologic injuries.
Bladder disruptions are divided into intraperi-
toneal or extraperitoneal types. Urethral inju-
ries in male patients occur in association with
unstable pubic ramus fractures. Urethral inju-
ries and associated vaginal lacerations occur
less frequently in females.
Lowe et al29 found that the likelihood for
the presence of physical signs of genitourinary
disruptions is related directly to the interval
since injury. They concluded that men with the

combination of ramus fractures and sacroil-
iac disruption should undergo retrograde ure-
thrograms before urethral instrumentation. In
their series, physical signs were unreliable in-
dicators for urethral injuries, especially soon
after the injury. Patients with combined geni-
tourinary system injuries and unstable pelvic
ring disruptions are treated optimally using a
team approach. The combined expertise is not
only helpful initially when managing these
difcult patients but also later as problems
develop. In one clinical series, 23 patients
with unstable pelvic fractures and associated
bladder or urethral disruptions or both were
treated surgically with open reduction and in-
ternal xation of the anterior pelvic ring in-
juries at the same anesthesia and using the
same surgical exposure as the urethral realign-
ments or bladder repairs or both. There was
1 deep wound infection (4.3%) that presented
6 weeks after injury. It was concluded that
a low infection rate can be expected despite
the use of internal xation, early urethral
indirect realignments avoid more difcult de-
layed open repairs, early direct bladder repairs
are performed easily at the time of anterior
pelvic open reduction and internal xation,
and suprapubic tubes are not necessary to di-
vert the urine adequately when large-diameter
urethral catheters are used in these patients.47
Other authors reported good results when
combined urologic and pelvic ring disrup-
tions were treated surgically using a team
approach.63
Neurologic Injury
High-energy pelvic ring disruptions are as-
sociated with neurologic injuries, particularly
to the lumbosacral plexus.36 Sacral fractures,
often undiagnosed and untreated, frequently
result in neurologic symptoms and decits to
the lower extremities and urinary, rectal, and
sexual dysfunctions.26 These same neurologic
problems often remain the major chronic se-
quelae after the more obvious pelvic ring dis-
ruption has healed. Denis et al13 reviewed
236 consecutive patients with sacral fractures.
They classied sacral fractures based on their
location as alar (zone I), involving the nerve
root pathway (zone II), and involving the cen-
tral portion of the sacrum (zone III). Neuro-
logic injuries correlated with the area of sacral
fracture. Zone I fracture occasionally was asso-
ciated with partial damage to the fth lumbar
HIGH-ENERGY PELVIC RING DISRUPTIONS 67
root. Zone II fracture frequently was associ-
ated with sciatica but rarely with bladder dys-
function. Zone III fractures frequently were as-
sociated with saddle anesthesia and loss of
sphincter function.
In a retrospective study of 44 patients with
sacral fractures, Gibbons et al15 conrmed the
ndings of Denis et al.13 Fractures through the
ala sacralis only (zone I, 25 patients) or in-
volving the neural pathway but not the cen-
tral canal (zone II, 7 patients) were less likely
to cause nerve injury (24% and 29%). Frac-
tures involving the central sacrum (zone III,
12 patients) were more likely to cause neuro-
logic injury (58%). In their patients, neurologic
decits in zone I and II injuries usually were
unilateral lumbar and sacral radiculopathies,
whereas zone III decits usually were bilateral
and severe. Bowel or bladder incontinence or
both were present in 6 of the 12 patients with
zone III injuries. The nerve decits generally
improved with time, and Gibbons et al15 ad-
vocated operative reduction and internal x-
ation particularly in patients with unilateral
root symptoms.
Frequently, patients with transforaminal
sacral fractures have associated nerve root
decit and obvious bone debris within the
sacral neural tunnel. In these patients, the
nerve root decompression is performed at
the same procedure as open reduction and
internal xation of the fracture. Foraminal
debridements are recommended for patients
in whom the anticipated reduction maneuver
would cause nerve root injury because of the
bone debris within the sacral neural tunnel.
Occult Orthopedic Injuries
Delay in diagnosis of musculoskeletal injury
in polytraumatized patients, especially those
with high-energy pelvic ring disruptions, may
lead to functional or cosmetic disability. Born
et al4 noted an incidence of 4% occult fracture
in such patients with numerous injuries. Delay
in recognition ranged from 1 to 91 days. They
recommended secondary clinical and appro-
priate radiographic skeletal surveillance in
polytraumatized patients. Special attention on
physical examination is directed to the hands
and feet, shoulder, spine, and areas beneath
bandages and intravenous catheters. Repeti-
tive daily musculoskeletal evaluations should
diminish the incidence and diagnostic delay of
occult orthopedic injuries.
68 ROUTT et al
DEFINITIVE TREATMENT
Denitive treatment consists of accurate
pelvic ring reduction, stable and safe xation,
and appropriate management of associated
injuries. In certain patients, the initial xation
is the denitive xation. Early management
decisions have a dramatic impact on eventual
treatment and outcome. Examples of poor
decisions in the acute phase of treatment in-
clude anterior pelvic external xation applied
inappropriately resulting in pelvic instability,
malreduction, and contaminated zones of
future surgical exposures (e.g., placement of
suprapubic catheters or colostomy sites within
the area of future pelvic surgical exposures
for reduction and xation). The orthope-
dic surgeon must consider the pelvic injury
zones, their displacements, the local soft tissue
condition, and the overall patient condition
when planning early and denitive pelvic
stabilization.
Denitive treatment of pelvic ring insta-
bility begins with accurate reduction of the
displacements. In the acute clinical situation,
closed reduction is possible because the asso-
ciated fracture hematoma is not organized and
accommodates manipulative reduction. Spica
casting and circumferential pelvic wrapping
have been shown to provide accurate pelvic
closed reduction in certain injury patterns.12, 44
Closed reduction also is accomplished us-
ing pelvic external xation pins inserted at
the iliac crest or anterior inferior iliac spine.
The pins are used as pelvic manipulators man-
ually or by connecting them using an ex-
ternal xation system. Certain external xa-
tion systems have threaded connecting bars
that can be positioned to provide satisfactory
closed reduction.3 Distal femoral skeletal trac-
tion also aids closed pelvic reduction in many
situations.
For most high-energy pelvic ring disrup-
tions, the pelvic external xator alone rarely
provides sufcient stability to be used deni-
tively. The external pelvic frame can be used,
however, to support internal xation in these
unstable situations. In their series, Lindahl
et al28 found that pelvic external xation may
be useful in the acute phase of resuscitation,
but it is of limited value in the denitive treat-
ment of an unstable type C injury and even in
type B open-book injuries.28
Denitive posterior pelvic xation de-
pends on the injury. Percutaneous iliosacral
screw xation has become popular as in-
traoperative uoroscopic techniques have
improved, allowing accurate visualization of
the posterior pelvis. Percutaneous iliosacral
screw xation has been advocated for sacral
fractures, sacroiliac disruptions, certain iliac
fracturesacroiliac dislocations, and combined
posterior pelvic injuries. An accurate closed
reduction, excellent intraoperative imaging,
and a thorough understanding of the tech-
nique are necessary for this xation to be
successful.8, 43, 45 Some authors advocate nerve
monitoring during iliosacral screw insertion.60
Several clinical series noted the complica-
tions associated with iliosacral screws.20, 49
Percutaneous xation techniques have been
recommended for unstable pubic ramus
fractures.48
Open reduction of a high-energy pelvic ring
disruption is selected when other less invasive
techniques are not possible. For the anterior
pelvic ring, a Pfannenstiel exposure and its ex-
tensions allow open reduction of symphysis
pubis injuries and pubic ramus fractures.9, 19
After reduction, the injury is stabilized
denitively using plate xation. Pelvic re-
construction plates are adjusted to t the
individual pelvic anatomy.25 For symphyseal
disruptions, Webb et al61 advocated plate
xation using a 2-hole implant. This exible
implant may show early xation failure in
high-energy, unstable pelvic ring disruptions.
Because of this possibility, many surgeons
use anterior pelvic implants with more than
1 screw securing each component of the injury
(Fig. 7). In these patients, posterior pelvic xa-
tion improves overall pelvic stability clinically
and in laboratory evaluations.20, 52
Iliac fractures and the sacroiliac joint can
be exposed using an iliac surgical approach.53
Pelvic reconstruction plates and lag screws
are used to stabilize these injuries.25, 50, 56 The
posterior pelvic surgical exposure is recom-
mended for sacral fractures and posterior iliac
fracturesacroiliac disruptions.30 Kellam et al22
reported signicant wound complications af-
ter open reduction of the posterior pelvis.
Moed and Karges32 described various tech-
niques for posterior pelvic surgical exposure,
reduction, and xation. Surgical implants ap-
plied between the posterior iliac crests for sta-
bility after open reduction include sacral bars,
tension band plates, and screws.1
Iliosacral screws are inserted using uoro-
scopic guidance after open reduction as af-
ter closed reduction. Iliosacral screws can be
used in combination with other implants pos-
teriorly (Fig. 8). Other techniques are emerg-
ing for posterior pelvic xation. Schildhauer
 HIGH-ENERGY PELVIC RING DISRUPTIONS 69

B C

Figure 7. A, This man was crushed by heavy logs sustaining complete symphyseal and left-sided
sacral injuries. The postoperative radiograph demonstrates the reductions. B and C, Fixation failure
was noted several weeks after surgery.

et al51 described lumbopelvic xation of suf-
cient stability to permit early weight bearing.
Local plate osteosynthesis after open reduc-
tion has been evaluated and recommended for
sacral fractures.39
OUTCOMES AND COMPLICATIONS
Outcome after pelvic ring disruption has
been investigated by numerous authors. Tor-
netta and Matta58 described 46 patients with
48 operatively xed unstable posterior pelvic
ring disruptions observed for an average of
44 months after surgery. Two thirds of the
patients returned to their original jobs, and
16% changed jobs because of an associated
injury. Of the patients, 63% had no pain or
pain only on strenuous activity and ambulated
without limitation; however, 35% had signif-
icant neurologic injuries that compromised
the nal study result. Tornetta and Matta58
reported that associated injuries continued
to be a major source of disability in these
patients. Other authors have identied
similar clinical results. In a large series of
patients with unstable pelvic ring fractures,
Pohlemann et al40 found that open reduction
and internal xation provided the best stabil-
ity of xation and the best late clinical results.
Their follow-up included a detailed clinical
and radiologic examination, an evaluation
of the patients general social status, and a
detailed neurologic and urologic screening.
They noted that anatomic reduction and union
do not guarantee an acceptable result.
Gruen et al16 evaluated 48 patients of 54
treated operatively for an unstable pelvic
ring injury. All 48 had osseous union and
an anatomic alignment of the pelvis. They
measured disability at a minimum of 1 year
after injury using the Sickness Impact Pro-
le (SIP). Of the patients, 37 (77%) had mild
disability (SIP, < 10); 11 (23%) had moderate
70 ROUTT et al

A B

Figure 8. A, This patient was injured in an automobile accident. She had a symphysis pubis disruption,
bilateral incomplete pubic ramus fractures, right-sided sacral fracture, and left incomplete sacroiliac
joint injury. B and C, Open reduction with neurodiagnostic monitoring was selected for her transfora-
menal displaced sacral alar fracture. Because of her upper sacral dysmorphism, the iliosacral screw
was inserted into the second sacral vertebral segment using uoroscopic imaging. A posterior tension
band plate supported the xation. The symphyseal open reduction was secured with sutures.

disability (SIP, > 10). Of the patients who were
employed before injury, 76% were employed;
62% had returned to full-time work, and 14%
had returned with job modication. Oliver
et al34 similarly followed 55 multiply-injured
patients with operatively treated unstable
pelvic fractures. Their patients were evalu-
ated for patient-oriented outcome measures.
Forty-six adult patients were eligible to com-
plete the Short-Form Health Survey (SF-36)
medical outcome score and completed it by
postal questionnaire at a mean follow-up to
2 years. The average Injury Severity Score of
the eligible adult patients was 17.5. There was
a 14% impairment in physical outcome score
and a 5.5% impairment in mental outcome
score compared with the normal population.
Residual vertical displacement related to
poor outcome in patients with pelvic injuries
according to some studies.54 Nepola et al33
studied 33 patients with vertical shear (Tile C)
fractures and residual displacements. Out-
comes were quantied using SF-36 and
the Iowa Pelvic Score (IPS). They found no

correlation between IPS or SF-36 scales and
residual pelvic vertical displacement, suggest-
ing other factors reponsible for poor outcomes
after unstable pelvic fracture. In a clinical
study, Poole et al41 stressed the impact of asso-
ciated injuries on the clinical outcome of pelvic
fracture patients.
Pelvic ring disruptions cause unique prob-
lems for female patients. Copeland et al11
found that pelvic trauma negatively affected
genitourinary and reproductive function in
female patients. They identied an increased
rate of cesarean section in women after pelvic
trauma, which they postulated to be multifac-
torial in origin.
SUMMARY
Successful treatment of high-energy pelvic
ring disruptions relies on early intervention,
accurate reduction, stable xation, and a low
rate of associated injuries and complications.
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tion of pelvic ring disruptions. Clin Orthop 375:15
29, 2000
44. Routt ML Jr, Schildhauer TS, Falicov A, et al: Circum-
ferential pelvic antishock sheeting (CPAS). J Orthop
Trauma 2001 (in press)
45. Routt ML Jr, Simonian PT, Agnew SG, et al: Ra-
diographic recognition of the sacral alar slope for
optimal placement of iliosacral screws: A cadav-
eric and clinical study. J Orthop Trauma 10:171177,
1996
46. Routt ML Jr, Simonian PT, Ballmer F: A ratio-
nal approach to pelvic trauma: Resuscitation and
early denitive stabilization. Clin Orthop 318:6174,
1995
47. Routt ML Jr, Simonian PT, Defalco AJ, et al: In-
ternal xation in pelvic fractures and primary re-
pairs of associated genitourinary disruptions: A team
approach [published erratum appears in J Trauma
1997 May;42(5):981]. J Trauma 40:784790, 1996
48. Routt ML Jr, Simonian PT, Grujic L: The retrograde
medullary superior pubic ramus screw for the treat-
ment of anterior pelvic ring disruptions: A new tech-
nique. J Orthop Trauma 9:3544, 1995
49. Routt ML Jr, Simonian PT, Mills WJ: Iliosacral screw
xation: Early complications of the percutaneous
technique. J Orthop Trauma 11:584589, 1997
50. Routt ML Jr, Simonian PT, Swiontkowski MF: Stabi-
lization of pelvic ring disruptions. Orthop Clin North
Am 28:369388, 1997
51. Schildhauer TA, Josten C, Muhr G: Triangular os-
teosynthesis of vertically unstable sacrum fractures:
A new concept allowing early weight-bearing.
J Orthop Trauma 12:307314, 1998
52. Simonian PT, Routt ML Jr: Biomechanics of pelvic
xation. Orthop Clin North Am 28:351367, 1997
53. Simpson LA, Waddell JP, Leighton RK, et al: Anterior
approach and stabilization of the disrupted sacroiliac
joint. J Trauma 27:13321339, 1987
54. Slatis P, Huittinen V: Double vertical fractures of the
pelvis: A report on 163 patients. Acta Chir Scand
138:799807, 1972
55. Stephen DJ: Pseudoaneurysm of the superior gluteal
arterial system: An unusual cause of pain after a
pelvic fracture. J Trauma 43:146149, 1997
56. Switzer JA, Nork SE, Routt ML Jr: Comminuted frac-
tures of the iliac wing. J Orthop Trauma 14:270276,
2000
57. Tile M: Pelvic ring fractures: Should they be xed?
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58. Tornetta 3rd P, Matta JM: Outcome of operatively
treated unstable posterior pelvic ring disruptions.
Clin Orthop 329:186193, 1996
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terior pelvic external xation. J Trauma 49:989994,
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graphy monitoring for percutaneous placement of
iliosacral screws. J Orthop Trauma 14:245254, 2000
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plate xation for traumatic symphysis pubis diasta-
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Address reprint requests to
M. L. Chip Routt, Jr, MD
Department of Orthopaedic Surgery, Box 359798
Harborview Medical Center
325 Ninth Avenue
Seattle, WA 98104
e-mail: mlroutt@u.washington.edu
TREATMENT OF COMPLEX FRACTURES 00305898/02 $15.00 + .00

ASSOCIATED INJURIES
COMPLICATING THE
MANAGEMENT OF
ACETABULAR FRACTURES
Review and Case Studies

Philip J. Kregor, MD, and David Templeman, MD

The management of acetabular fractures
has improved considerably since the 1970s.
Letournel2730 elucidated the interpretation of
plain radiographs of the pelvis, presented a
classication system for acetabular fractures,
and developed operative approaches and tac-
tics for their surgical management. Letournel30
also documented the outcome of 569 surgi-
cally managed acute acetabular fractures.
From his work, several principles for the
management of acetabular fractures have been
established, as follows:
A thorough understanding of normal
pelvic anatomy and plain radiographs is
necessary to understand fracture patterns.
An understanding of the Letournel classi-
cation aids the surgeon in understanding
the individual fracture pattern, in plan-
ning the surgical approach, and in un-
derstanding surgical reduction techniques
for a given fracture. (For example, an un-
derstanding of the common displacement
and rotational deformity of a transverse
fracture gives the surgeon an appreciation
for reduction strategies for the operative
management of a particular fracture.)
The goal of open reduction and internal
xation of an acetabular fracture is a per-
fect reduction, dened as 0 to 1 mm of
displacement on all 3 acetabular views.30, 35
Letournel and Judet 30 and Matta35 have
shown that clinical outcome correlates di-
rectly with the quality of the reduction.
In Mattas series,35 a perfect reduction was
associated with an overall good or excel-
lent clinical result in 83% of cases. With
an imperfect reduction (2 to 3 mm of dis-
placement on any acetabular view), an
overall good or excellent clinical result
was obtained in only 68% of cases. This
number drops further to 50% (9 of 18 hips)
when the reduction is poor (> 3 mm of dis-
placement on any acetabular view).
The ability to preserve the native hip joint
with appropriate management is quite
good, although 16% of patients in the
series by Matta35 had a poor clinical result,
and 6% had a total hip arthroplasty per-
formed at an average follow-up of 6 years.
Impaction loading of articular cartilage has
been shown experimentally to result in al-
tered chondrocyte metabolism and histologic

From the Division of Orthopaedic Trauma, Department of Orthopaedics and Rehabilitation, Vanderbilt University Med-
ical Center, Nashville, Tennessee (PJK); and Department of Orthopaedic Surgery, Hennepin County Medical Center,
Minneapolis, Minnesota (DT)

ORTHOPEDIC CLINICS OF NORTH AMERICA

VOLUME 33 NUMBER 1 JANUARY 2002 73

74 KREGOR & TEMPLEMAN
evidence of structural damage.5, 14, 46, 58 Trau-
matic injury to the articular surface or bone
of the femoral head has been shown by
Letournel and Judet30 and Matta35 to be signi-
cantly predictive of a worse clinical prognosis.
Age at the time of injury is predictive of a
worse clinical prognosis, but only in that it
is more difcult to achieve an anatomic re-
duction in patients who are older than age
40 years.35 Patients younger than age 40 years
have an overall 81% chance of a good or ex-
cellent result, whereas patients older than
age 40 have a 68% chance of a good or ex-
cellent result.35 The quality of the reduction
able to be achieved in the rst 3 weeks after
injury also has been shown to be better than
that achieved in delayed cases, or in surgical
revisions.23, 30, 37 There are several factors that
Letournel and Judet30 and Matta35 have shown
do not inuence clinical outcome, including:
The type of fracture pattern
The initial displacement of the fracture
The timing of the reduction of an associated
posterior hip dislocation
The presence of intra-articular fragments or
acetabular impaction
Several associated fractures and injuries af-
fect the management or outcome of acetab-
ular fractures. Although several of these as-
sociated injuries are discussed by Letournel30
and others, specic protocols have not been
developed because of the uncommon occur-
rence of specic injury combinations. This ar-
ticle reviews the literature available on such
injuries and discusses the surgical manage-
ment of these injuries through multiple case
examples. It is not possible to present signif-
icant data on the clinical outcome of these
injuries using current reduction and xation
schemes. The combinations of injuries to be
discussed include an acetabular fracture with
an associated:
Hip dislocation
Femoral head fracture
Femoral head impaction
Femoral neck fracture
Proximal femur fracture
Femoral shaft fracture
The purpose of this article is to develop
treatment strategies for the acetabular fracture
surgeon and for the orthopedic surgeon, who
will treat the associated injury denitively,
then refer the patient for denitive treatment
of the acetabular fracture. Because the initial
management of associated injuries affects the
later treatment of the acetabular fracture, it is
important to develop treatment strategies that
achieve the best result for both injuries. Impor-
tant factors include placement of incisions that
allow optimal treatment of both injuries, tim-
ing of surgery, and consideration of whether
the injury should be treated in 1 or 2 surgeries.
Certain requirements should be met before
open reduction and internal xation of acetab-
ular fractures, including the following:
1. A stable, well-resuscitated patient who
has had other life-threatening and limb-
threatening injuries addressed
2. Appropriate radiologic work-up of
the injury (anteroposterior, Judet, and
inlet/outlet radiographs and computed
tomography scan)
3. Adequate personnel and facilities
Specic injuries (e.g., a femoral neck frac-
ture in a young adult) require that the as-
sociated injury be treated in an emergent
fashion.17, 24, 56, 57 In such cases, the intervention
should be performed in such a way not to
interfere with future surgeries. In other cases,
such as unstable hip dislocation associated
with a posterior wall fracture, there should
be a sense of urgency to perform an open re-
duction and internal xation of the acetabular
fracture with an open reduction of the femoral
head dislocation. This procedure should not
be performed, however, if the above-listed
preoperative criteria are not met. If the treat-
ing orthopedic surgeon does not perform
xation of acetabular fractures routinely, he or
she should not proceed simply because of the
hip dislocation. An urgent referral to a trauma
center should be considered.
It is important to have a good understand-
ing of the surgical approaches performed for
acetabular fractures. As dened by Letournel
and others,30, 35, 36, 49 three approaches are used
routinely for the operative management of ac-
etabular fractures:
1. Kocher-Langenbeck approach. The Kocher-
Langenbeck approach is used in posteri-
or wall fractures, posterior column frac-
tures, posterior column and posterior
wall fractures, most transverse fractures
with posterior wall fractures, most trans-
verse fractures with predominantly pos-
terior displacement, and some T-type
fractures.
2. Ilioinguinal approach. The ilioinguinal ap-
proach was developed by Letournel and
Judet30 and is used in cases of anterior
wall fractures, anterior column fractures,
 ASSOCIATED INJURIES COMPLICATING THE MANAGEMENT OF ACETABULAR FRACTURES
some transverse fractures (with predom-
inantly anterior displacement), anterior
column and posterior hemitransverse
fractures, and most fractures of both
columns.
3. Extended iliofemoral approach. The exten-
ded iliofemoral approach was developed
by Letournel and Judet30 to give exten-
sive exposure to the outer aspect of the
innominate bone and to provide simul-
taneous visualization and control of the
anterior and posterior columns. It is used
predominantly in cases of transtectal
transverse fractures, transtectal trans-
verse fractures with posterior wall frac-
tures, certain T-type fractures, fractures
of both columns (especially with high
greater sciatic notch involvement), and
delayed (> 3 weeks) reconstructive cases.
Certain associated injuries are discussed
subsequently with case examples.
ACETABULAR FRACTURE WITH
ASSOCIATED HIP DISLOCATION
In hip dislocations not associated with an
acetabular fracture, the timing of reduction
has been shown to correlate with clinical out-
come. An increased length of time before re-
duction of a hip dislocation (without an acetab-
ular fracture) is associated with an increased
incidence of avascular necrosis.15, 19, 21 In 1951,
Thompson and Epstein59 classied posterior
hip dislocations into 5 types:
Type Iposterior hip dislocation without
an associated fracture or a small fracture
of the posterior wall
Type IIposterior hip dislocation with a
large single fracture of the posterior wall
Type IIIposterior hip dislocation with
a comminuted fracture of the posterior
wall, with or without a major fragment
Type IVposterior hip dislocation with an
acetabular fracture, including the associ-
ated posterior wall
Type Vposterior hip dislocation with a
fracture of the femoral head
In 1974, Epstein15 reported on the clini-
cal outcome of 242 patients with a posterior
hip dislocation associated with a fracture of
the acetabulum or the femoral head or both.
Attempts at closed reductions of these injuries
were unsuccessful. Only 12% of patients un-
dergoing a closed reduction as denitive treat-
ment had a satisfactory result. A satisfactory
75
result could entail a slight limp, 25% loss
of joint motion, and radiographic evidence
of joint space narrowing and spur formation.
Satisfactory outcomes were seen in 42% of pa-
tients who underwent an open reduction after
a closed reduction and in 63% of patients un-
dergoing a primary open reduction. Epstein15
noted that no attempt was made to reduce or
x the fracture into the oor of the acetabu-
lum. At the time, routine xation of acetabu-
lar fractures, other than isolated posterior wall
fractures, was not being performed. The ac-
etabular fractures with an associated posterior
hip dislocation had a poor clinical outcome.
Epstein15 commented, The extent of the in-
jury in Type IV fracturedislocations makes a
poor result almost certain because of the de-
gree of disruption of the acetabulum. Later,
in 1985, Epstein et al16 recommended primary
open reduction for all fracture-dislocations of
the hip to remove loose fragments from the
hip joint, to restore stability to the joint by
open reduction and internal xation of any
large fragments of the acetabulum, and to as-
sure accurate reduction of the dislocation.
The presence of a posterior hip dislocation
or an extended period of time before reduc-
tion does not correlate signicantly with a
worse clinical outcome.30, 35 In Mattas series35
of 262 displaced acetabular fractures, 83 hips
(32%) had a posterior dislocation of the
femoral head, whereas 140 hips (68%) did not.
A good or excellent outcome was seen in 71%
of the hips that had a posterior dislocation and
78% of the hips that did not have a posterior
dislocation. These outomes are in contrast to
a pure hip dislocation, in which an increased
length of time before reduction of a simple hip
dislocation (without acetabular fracture) has
been associated with an increased incidence
of avascular necrosis.15, 19, 21 The reason for
the difference between the effect of timing of
reduction between a simple hip dislocation
and hip dislocation with acetabular fracture is
unclear. It may be that other factors (e.g., qual-
ity of reduction) affect the clinical outcome
more signicantly.
It is prudent to reduce a posterior hip dis-
location as soon as possible, however.30, 35 This
reduction should be done under conscious se-
dation in the emergency department. A small
percentage of hip dislocations cannot be re-
duced (Fig. 1). Possible reasons include:
Inadequate muscle paralysis
Reduction of the femoral head being pre-
vented by the hip capsule or short exter-
nal rotators of the hip
76 KREGOR & TEMPLEMAN

A B

D
C

E F

Figure 1. A 17-year-old female patient who was involved in a motor vehicle collision and sustained an
isolated transtectal transverse with posterior wall acetabular fracture associated with a posterior hip
dislocation. A, Injury AP radiographs of the pelvis. Arrow indicates the posterior wall in the hip joint.
B, An attempt at closed reduction was not successful. Although the femoral head is more inferior, it
is not sitting well within the hip socket. C, CT scan at the level of the joint demonstrates the poste-
rior wall fragment inside the hip joint, preventing reduction of the femoral head. D, The patient was
taken to the operating room in the rst 8 hours after injury. A prone Kocher-Langenbeck approach was
performed. Intraoperatively, the femoral head was found to be button-holed between the obturator in-
ternus tendon and the capsule/piriformis. The piriformis was released 1 cm from its insertion or the
posterior border of the greater trochanter, and the hip joint was distracted. The posterior wall fragment
was then ipped out of the hip joint, with care taken to maintain its soft tissue/capsular attachments.
E, Intraoperative view of the hip joint while distracted. The posterior wall fragment, now removed
from the hip joint, is labeled. An arrow indicates transverse acetabular fracture line. The transverse
fracture involves the weight-bearing bone (transtectal transverse fracture line). Reduction and xation
was carried out. F, AP radiograph 6 months postinjury.
 ASSOCIATED INJURIES COMPLICATING THE MANAGEMENT OF ACETABULAR FRACTURES 77

An interposed fragment of the posterior

wall in the acetabulum
A femoral fracture, which makes control of
the proximal femur difcult
With a femoral fracture, attempted reduc-
tion under general anesthesia may be per-
formed and may be aided by a Schantz pin
in the proximal femoral region (at the level
of the lesser trochanter) to aid the reduction
of the hip dislocation. If a closed reduction is
not possible in the operating room, a decision
should be made by the treating surgeon to pro-
ceed with an open reduction and internal xa-
tion of the acetabular fracture or proceed with
a referral.
In another scenario, the reduction may be
possible but is not stable. The cause most com-
monly is a large posterior wall fracture or a su-
perior posterior wall fragment or both. In such
cases, abduction or skeletal traction or both of
the limb may be of benet. In most cases, how-
ever, urgent stabilization of the posterior wall
fragment is warranted. Repeated attempts at
closed reductions may damage the articular
surface further because there is often a large
exposed raw cancellous bone surface at the in- Figure 2. Pipkin classication for femoral head fractures.
tact ilium, which may injure the cartilage on (From Swiontkowski MF: Hip dislocations and femoral
the femoral head further. head fractures. In Hansen ST, Jr, Swiontkowski MF [eds]:
Traditionally the use of skeletal traction for Orthopaedic Trauma Protocols. New York, Raven Press,
acetabular fractures is limited.30, 35 Certain sit- 1993; with permission.)
uations may be aided by its use, however, such
as an acetabular fracture with:
Large intra-articular fragments, which may Pipkin IVfemoral head fracture associated
cause damage to the femoral head with an acetabular fracture
Unstable hip dislocations, which may be
stabilized by skeletal traction with the leg Brumback et al7 classied femoral head frac-
in abduction tures further (Table 1). This classication is
A transverse pattern with signicant medi- more complete in that it differentiates be-
alization of the femoral head, in which the tween anterior and posterior dislocations of
femoral head may be in contact with the the femoral head. The Pipkin IV category is the
fracture surface on the intact ilium (see subject of this subsection.
Fig. 8) Epstein et al16 reported in 1985 on 55
Thompson/Epstein type V injuries (poste-
rior fracture-dislocation of the hip associated
FEMORAL HEAD FRACTURE with a fracture of the femoral head). Poor
WITH ASSOCIATED results were obtained with closed reduction
ACETABULAR FRACTURE or with open reduction after an attempt at
closed reduction. Although Epstein et al16
Pipkin42 classied femoral head fractures recommended open reduction for the injury,
into 4 categories (Fig. 2): only 47% of the patients overall had a good
Pipkin Ifemoral head fracture with frac- result. Signicant complications were noted,
ture plane below the fovea with 11 cases of traumatic arthritis, 11 cases
Pipkin IIfemoral head fracture with frac- of avascular necrosis, and 3 cases of hip in-
ture plane above the fovea fection. Epstein et al16 concluded, Traumatic
Pipkin IIIfemoral head fracture associated dislocation of the hip is a very serious injury;
with a femoral neck fracture Type V dislocations give a low percentage of
78 KREGOR & TEMPLEMAN

Table 1. BRUMBACK CLASSIFICATION OF HIP DISLOCATIONS

Type I A posterior hip dislocation with a femoral head fracture involving the inferomedial nonweight-bearing
portion of the femoral head
IA With minimal or no fracture of the acetabular rim and a stable hip joint after reduction
IB With signicant acetabular fracture and hip joint instability
Type II A posterior hip dislocation with a femoral head fracture involving the superomedial weight-bearing portion
of the femoral head
IIA With minimal or no fracture of the acetabular rim and a stable hip joint after reduction
IIB With signicant acetabular fracture and hip joint instability
Type III A dislocation of the hip from an unspecied direction with an associated femoral neck fracture
IIIA Without fracture of the femoral head
IIIB With fracture of the femoral head
Type IV An anterior dislocation of the hip with fracture of the femoral head
IVA Indentation type, with a depression in the superolateral weight-bearing surface of the femoral head
IVB Transchondral type, with an osteocartilaginous shear fracture on the weight-bearing surface of the femoral
head
Type V A central fracture-dislocation of the hip with fracture of the femoral head

Modied from Swiontkowski MF: Hip dislocations and femoral head fractures. In Hansen Jr ST, Swiontkowski MF (eds):
Orthopaedic Trauma Protocols. New York, Raven Press, 1993; with permission.

good results, regardless of the method or type
of treatment.
In general, the acetabular fracture and
femoral head fracture are treated at the same
operative intervention. No signicant data are
available in the literature for this relatively
rare injury utilizing modern reduction tech-
niques. In reviewing results from femoral
head fractures alone, Swiontkowski et al55
recommended open reduction and internal
xation for Pipkin I and II fractures with
greater than 1 mm of displacement. They
reported on 43 femoral head fractures in
41 patients. Of 43 patients, 26 were managed
operatively. There were 24 patients available
for minimal 2-year follow-up. Of patients,
12 were treated with a posterior surgical ap-
proach, and 12 were treated with an anterior
surgical approach (Smith-Peterson approach).
Swiontkowski et al55 commented that the
anterior approach allowed for better visu-
alization of the femoral head fracture and
was not associated with cases of avascular
necrosis. An increased incidence of hetero-
topic ossication was seen with the anterior
approach, perhaps attributable to dissection of
the tensor fascia lata muscle off the iliac crest.
Moed and Smith39 showed the benet of using
the Judet views to assess the displacement of
the femoral head fracture because the fracture
plane is in the frontal plane and may not be
diagnosed on a routine anteroposterior pelvic
radiograph.
The most common presentation for this
injury is that of a posterior wall fracture,
posterior hip dislocation, and associated
femoral head fracture. The goal of the treat-
ment of such an injury should be restoration
of normal anatomy, with ultimate normal
hip function. Although the effects of the ini-
tial impact on the articular cartilage of the
femoral head cannot be undone, mechanical
symptoms of the hip joint can be avoided by
normal restoration of the femoral head and
acetabular fracture. An inferiorly displaced
femoral head fracture can decrease normal
hip function, especially in exion and internal
rotation (Fig. 3). Options available for this
injury include the following:
Debridement of the femoral head frag-
ment and joint, with open reduction and
internal xation of the posterior wall frac-
ture through a Kocher-Langenbeck ap-
proach. This approach may be reasonable
if the femoral head fragment itself is in-
frafoveal and relatively small.
Open reduction and internal xation
of the femoral head through a Smith-
Peterson approach, followed by nonop-
erative treatment of the posterior wall
fracture. After xation of the femoral head
fracture, an examination under anesthe-
sia may reveal no instability of the hip.
Tornetta60 described the stress view for
this purpose. If no instability is noted,
especially in the setting of a low posterior
wall fracture, nonoperative management
of the posterior wall fracture may be
warranted.
Open reduction and internal xation
of the femoral head during posterior
surgical dislocation, followed by open
reduction and internal xation of the
posterior wall fracture, all through a
Kocher-Langenbeck approach. Given the
 ASSOCIATED INJURIES COMPLICATING THE MANAGEMENT OF ACETABULAR FRACTURES 79

C D

Figure 3. A 22-year-old woman sustained an inferior posterior wall fracture, posterior hip disloca-
tion, and an infrafoveal femoral head fracture. She was treated nonoperatively. She was referred at
7 months postoperatively as she had signicant groin pain with running. In addition, she had pain
with exion and internal rotation of the hip. A, AP radiograph at 7 months post-trauma. The arrow
indicates the healed inferiorly displaced femoral head fragment. B, The obturator oblique view
demonstrates best the inferior displacement of the femoral head fragment. C, Coronal plane CT re-
construction demonstrates the inferiorly displaced femoral head fragment. With exion and internal
rotation, this would cause impingement and groin pain. D, Intraoperative nding at the time of surgi-
cal dislocation of the hip. The inferiorly displaced femoral head fragment is seen. The patient under-
went a femoral head debridement and varus/exion intertrochanteric osteotomy.

typical frontal plane nature of the fracture,
anterior-to-posterior lag screws are de-
sired. This approach does not provide
optimal exposure for reduction and
xation of the femoral head fragment.
Visualization of the femoral head fracture
is possible with maximal exion, inter-
nal rotation, and adduction of the hip. If
the femoral head fragment is above the
fovea, however, the attached ligamentum
teres prevents reduction of the femoral
head fracture. This approach should be
reserved for relatively small infrafoveal
fragments that the surgeon wishes to
internally x or debride (Fig. 4). If the
posterior wall fracture is addressed and
adequate reduction of the femoral head is
not possible, a sequential Smith-Peterson
approach is possible, as described next.
Open reduction and internal xation
of the posterior wall fracture through a
Kocher-Langenbeck approach followed
by sequential open reduction and internal
xation of the femoral head through a
Smith-Peterson approach (Fig. 5). These
sequential approaches give appropriate
visualization of the femoral head fracture
and the posterior wall fracture. The
strategy is especially helpful in the set-
ting of a femoral head fracture that is
80 KREGOR & TEMPLEMAN

B C

D E

Figure 4. A 38-year-old man sustained a posterior wall fracture, posterior hip dislocation, and in-
frafoveal femoral head fracture. A closed reduction was performed in the emergency room. A, Injury
AP radiograph after reduction of posterior hip dislocation. Note the nonconcentric reduction. B, CT
scan demonstrating the posterior wall fracture. C, CT scan in the hip joint demonstrating the femoral
head fracture. D, CT scan slightly more caudad demonstrating the inferior displacement of the femoral
head fragment. E, The patient underwent open reduction internal xation all by way of a Kocher-
Langenbeck approach with surgical dislocation of the femoral head. AP radiograph at 5 years post-
trauma. The patient has a totally normal hip.
 ASSOCIATED INJURIES COMPLICATING THE MANAGEMENT OF ACETABULAR FRACTURES 81

A B

C D

Figure 5. A 17-year-old male patient sustained a posterior hip dislocation, posterior wall fracture, and
femoral head fracture. A, Injury AP radiograph of the hip. B, CT scan demonstrating posterior wall frac-
ture. C, CT scan demonstrating inferiorly displaced femoral head fracture. D, The patient underwent
open reduction internal xation of his posterior wall fracture using a Kocher-Langenbeck approach, fol-
lowed by xation of his femoral head fracture by way of a Smith-Peterson approach. AP radiograph of
the hip at 1 year post-trauma.
82 KREGOR & TEMPLEMAN
suprafoveal, in which the ligamentum
teres would be expected to remain intact
to the femoral head fragment. In this case,
any attempt at visualization and xation
of the femoral head fracture through sur-
gical dislocation of the femoral head (with
or without a trochanteric ip osteotomy
described subsequently) would require
division of the ligamentum teres and
possible compromise of the femoral head
fragment vascularity.
The trochanteric ip osteotomy, as de-
scribed by Siebenrock et al52 for treatment
of acetabular fractures (Fig. 6). The ap-
proach permits dislocation of the femoral
head through capsulotomy, while main-
taining the femoral head blood supply. A
capsulotomy can be performed around
the perimeter of the labrum, allowing for
complete visualization of the femoral head
and surgical dislocation of the femoral
head with hip exion, external rota-
tion, and adduction. The approach is
performed through a traditional Kocher-
Langenbeck incision, with the patient in
the lateral position. After identifying the
obturator internus and piriformis tendon,
a longitudinal trochanteric osteotomy of
approximately 1.5 cm thick is created,
with the distal end attached to the vastus
lateralis and the proximal end attached
to the gluteus medius and minimus (also
called the digastric or two-belly approach).
The hip joint may be debrided, the femoral
head fracture is reduced and internally
xed, and any transverse fracture is re-
duced under direct visualization with
the hip dislocated. After the hip is re-
duced, any posterior wall component is
addressed. The femoral head fracture is
internally xed with anterior-to-posterior
cortical lag screws or variable pitch screws
(e.g., Herbert screws) (Fig. 7).
FEMORAL HEAD INJURY
WITH ASSOCIATED
ACETABULAR FRACTURE
Femoral head injury with associated acetab-
ular fracture is distinguished from Pipkin frac-
ture in that it is not a true frontal plane fracture
of the femoral head, but rather can be thought
of as an impaction or divot in the femoral head.
Letournel and Judet30 described 20 cases of a
localized subsidence of the femoral head in
its superolateral quadrant . . . produced at the
time of trauma by localized contact between
the head and an intact part of the innominate
bone (Fig. 8). Delee et al13 noted an indentation
fracture in 9 of 15 anterior dislocations of the
hip and noted the poor clinical outcome in its
presence.
Matta35 noted injury to the cartilage or bone
of the femoral head in 19% of operatively
treated acetabular fractures. He noted its sig-
nicance in the clinical outcome of the pa-
tients. In patients with damage to the femoral
head, a good or excellent result was seen in
60% of cases, with a mean dAubigne-Postel
clinical score of 14 out of a possible 18 points.
In contrast, a good or excellent clinical out-
come was seen in 80% of patients with-
out femoral head damage, with a mean
dAubigne-Postel clinical score of 16. Matta35
commented, Finally, the most clearly predic-
tive initial factor was injury to the cartilage
or bone, or both, of the femoral head; this
fact was signicantly predictive of a worse
prognosis.
Femoral head damage has been evaluated
by magnetic resonance imaging in 37 patients
with acetabular fractures.43 As expected,
computed tomography scans were seen to
be superior to magnetic resonance imaging
in detecting intra-articular fragments. Of
the fractures, 27% were associated with a
fracture of the femoral head, and in 24 of
37 cases, a subchondral contusion was seen.
As was pointed out, the clinical impact of
these subchondral contusions is unknown, but it
may account for a poor outcome, even in the
setting of an anatomic reduction.
A macroscopic injury to the femoral head
most commonly occurs in two fracture
patterns:
1. The impaction can occur in the setting of
a transverse acetabular fracture, in which
the inferior ischiopubic fragment is dis-
placed medially and the femoral head is
impacted onto the intact ilium (Fig. 8).
2. The impaction can occur in the setting
of a posterior wall fracture, or extended
posterior wall fracture (which extends
superior and anterior). In this case, the
femoral head impacts on the outer aspect
of the intact ilium and may impact on
cancellous bone.
A reliable method for surgical reconstruc-
tion for impaction of the femoral head has not
been described. In the young patient, one may
consider an intertrochanteric osteotomy to
 ASSOCIATED INJURIES COMPLICATING THE MANAGEMENT OF ACETABULAR FRACTURES 83

B
Figure 6. The trochanteric ip osteotomy as described by Siebenrock et al. A, The hip capsule is ex-
posed after the trochanteric osteotomy. B, A capsulotomy permits surgical dislocation of the hip, with
exion, external rotation, and adduction of the hip. (From Siebenrock KA, Gautier E, Ziran BH, et al:
Trochanteric ip osteotomy for cranial extension and muscle protection in acetabular fracture xation
using a Kocher-Langenbeck approach. J Orthop Trauma 12:387381, 1998; with permission.)
84 KREGOR & TEMPLEMAN

A B

C D

Figure 7. A 48-year-old woman was involved in a motor vehicle collision and sustained a left sacroiliac
joint injury, left pubic root fracture, symphysis disruption, left posterior wall fracture, left posterior hip
dislocation, and left femoral head fracture. A, Injury AP radiograph of the pelvis. Closed reduction of
the hip was not possible. B, CT scan demonstrating the superior-posterior dislocation of the femoral
head. C, CT scan demonstrating the femoral head fragment in the hip joint. D, Intraoperative view of
the hip joint following trochanteric ip osteotomy. The femoral head fragment was seen to be rotated
180 and was detached from the ligamentum teres.
Illustration continued on opposite page
 ASSOCIATED INJURIES COMPLICATING THE MANAGEMENT OF ACETABULAR FRACTURES 85

E F

Figure 7 (Continued ). E, The fragment underwent reduction and internal xation. Posterior to ante-
rior lag screws were used because patient positioning prevented the placement of normal anterior to
posterior screws. F, Postoperative obturator oblique radiographs. G, AP radiograph at 10 months post-
trauma. The patient has moderate pain secondary to signicant joint space narrowing.
86 KREGOR & TEMPLEMAN

B C

D E

Figure 8. A 52-year-old man was involved in a motor vehicle collision and sustained a left transverse
acetabular fracture, right T-type acetabular fracture, and left fracture-dislocation of his shoulder. The
patient was referred 4 weeks post-trauma. A, AP radiograph. Note the signicant medialization of the
femoral head. B, The patient was taken to the operating room for a closed reduction of his hip. Note
the triangular divot in the superolateral aspect of the femoral head (arrow). C, The patient under-
went open reduction internal xation of his right acetabular fracture at 4.5 weeks using a Kocher-
Langenbeck approach in the prone position. AP radiograph at 6 weeks postoperative. Residual
anterior column displacement is seen. The left hip was treated nonoperatively. D, Iliac oblique view at
6 weeks postoperative. E, Obturator oblique view at 6 weeks postoperative.

derotate the lesion out of the weight-bearing
surface of the hip joint.34 This method can
be likened to an intertrochanteric osteotomy
for avascular necrosis, in which the compro-
mised portion of the head is rotated out of the
major weight-bearing area of the acetabular
dome, which has been well described.22, 33 In
the elderly patient, the goal is an anatomic
restoration of the hip joint. If the clinical im-
pact of the femoral head injury results in a
signicant posttraumatic arthritis, however, a
total hip arthroplasty is a good clinical option.
 ASSOCIATED INJURIES COMPLICATING THE MANAGEMENT OF ACETABULAR FRACTURES 87

FEMORAL NECK FRACTURE 1. Emergent timing of operative interven-

WITH ASSOCIATED
ACETABULAR FRACTURE
Several review articles on the treatment
of femoral neck fractures have been writ-
ten.24, 32, 56 It is helpful to consider the two
fractures as separate entities and to provide
the optimal treatment for each of the injuries.
One should consider the physiologic age of the
patient. In patients younger than age 65 years
with a displaced femoral neck fracture, the
operative management is considered an ortho-
pedic emergency.17, 57 Historical reports on the
treatment of femoral neck fracture have had
relatively disastrous results, with a reported
rate of 86% poor results.44 Swiontkowski et al57
and Gerber et al17 have reported on the op-
erative treatment of femoral neck fractures
in young adults, with a 0% to 17% rate of
nonunion and 10% to 20% rate of avascular
necrosis. The improved outcome probably is
related to the tenets emphasized in both series:
tion
2. Open visualization of the fracture and
capsulotomy to release intracapsular
tamponade, all through a Watson-Jones
approach
3. Rigid xation of the fracture through
three cancellous lag screws
The femoral neck in a young adult should
be treated in an emergent fashion. In this
situation, it would be an unusual circum-
stance to treat the associated acetabular frac-
ture at the same operative intervention. This
situation mandates the planning of two surgi-
cal incisions. The Watson-Jones approach is a
curvilinear incision centered over the anterior
aspect of the greater trochanter (Fig. 9).54 The
muscular interval is between the tensor fascia
lata and gluteus medius muscles. With proper
planning, the Watson-Jones approach can be
placed slightly anterior and not compromise
the Kocher-Langenbeck approach. In the

B
Figure 9. Watson-Jones approach for xation of a femoral neck fracture
in a young adult. A, The patient is positioned with the leg free or on a
fracture table. The interval between the tensor fascia lata and gluteus
medius muscle is developed. B, The vastus lateralls muscle belly is el-
evated off the interochamteric ridge of the proximal femur. The hip cap-
sule is exposed. C, A T capsulotomy is performed, exposing the femoral
neck fracture. (From Swiontkowski MP: Hip dislocations and femoral
head fractures. In Hansen ST, Jr, Swiontkowski MF [eds]: Orthopaedic
Trauma Protocols. New York, Raven Press, 1993; with permission.)
88 KREGOR & TEMPLEMAN
setting of an associated femoral neck fracture
with an acetabular fracture, one rst should
address the femoral neck fracture through a
Watson-Jones approach (Fig. 10). Then the
acetabular fracture can be addressed through
a separate approach. Alternatively the inferior
limb of the Watson-Jones approach can be
incorporated into the Kocher-Langenbeck
approach.
The combination of a displaced femoral
neck fracture associated with an acetabular
fracture in an elderly adult (> 65 years old)
is rare. Treatment of the displaced femoral
neck fracture in the elderly adult is contro-
versial. Lu-Yao et al32 performed a compre-
hensive meta-analysis of displaced femoral
neck fractures in adults older than age 65
and concluded that there was an increased
chance of need for reoperation if the frac-
ture was treated with internal xation versus
prosthetic replacement. In most cases, optimal
treatment of the displaced isolated femoral
neck fracture in an elderly adult is hemiarthro-
plasty. Outcomes of operatively treated ac-
etabular fractures in elderly adults are reason-
ably favorable.18 Results from immediate total
hip arthroplasty for acetabular fractures are
not favorable.38 Individualization of treatment
A B
Figure 10. This 18-year-old male patient sustained a left transverse acetabular fracture, left basilar
femoral neck fracture, and a left midshaft femur fracture. A, AP radiograph of left proximal femur.
B, AP radiograph of the pelvis. The patient had a right parasymphyseal injury.
is important when faced with an elderly pa-
tient with a combined femoral neck fracture
and acetabular fracture. One must consider
the physiologic status of the patient, fracture
pattern, and ability to reconstruct the acetab-
ular fracture. Often a reasonable approach in
the setting of signicant trauma may be open
reduction and internal xation of the acetabu-
lar fracture with a Girdlestone procedure, with
delayed total hip arthroplasty.
PROXIMAL FEMORAL FRACTURE
WITH ASSOCIATED
ACETABULAR FRACTURE
Proximal femur fractures associated with
acetabular fractures can be divided into in-
tertrochanteric hip fractures and subtrochan-
teric femur fractures. Optimal treatment of
both injuries should be undertaken, with-
out compromising the treatment of either.
In general, the acetabular fracture is treated
through the optimal approach. If the Kocher-
Langenbeck or extended iliofemoral approach
is chosen, the fracture can be addressed
through the same surgical approach. If an
ilioinguinal approach is used, a separate
approach can be made for the proximal femur.
Illustration continued on opposite page
 ASSOCIATED INJURIES COMPLICATING THE MANAGEMENT OF ACETABULAR FRACTURES 89

C D

Figure 10 (Continued ). C, On the night of his injury, he underwent open reduction internal xation of
his left femoral neck by way of a Watson-Jones approach. A capsulotomy was performed. A submus-
cular plating of the femur fracture was performed, with the plate introduced through the Watson-Jones
approach. D, AP radiograph after xation of the femoral neck and shaft. E, Open reduction internal
xation of his left acetabular fracture by way of an ilioinguinal approach on hospital day 3. This AP
radiograph at 3 months demonstrates slight adduction of the lower ischiopubic fragment.

The gold standard treatment for the in- 1. Is the piriformis fossa involved?
tertrochanteric femur fracture is the dynamic 2. Does the fracture extend proximal to or
hip screw.1, 12, 20, 25, 26, 45 Baumgartner et al2, 3 involve the lesser trochanter?
showed that appropriate placement of the hip
Based on the answers to these two ques-
screw is crucial in ensuring a good surgical
tions, one can divide the fracture into the fol-
outcome (Fig. 11).
lowing classication groups:
Russell and Taylor50 presented a useful clas-
sication scheme for subtrochanteric femur Type IAfracture extension with no degree
fractures. One must ask the following two of comminution below the level of the
questions regarding the morphology of the lesser trochanter with no extension into
subtrochanteric femur fracture: the piriformis fossa
90 KREGOR & TEMPLEMAN

A B

C D

Figure 11. A 64-year-old woman who was involved in a motor vehicle collision. She sustained a left
pilon fracture, left tibial plateau fracture, left pertrochanteric hip fracture, and left transverse with pos-
terior wall acetabular fracture. She underwent xation of her acetabular fracture, followed by xation of
her pertrochanteric hip fracture. Both were performed in the prone position with a Kocher-Langenbeck
approach. A, Injury AP radiograph of hip. B, AP radiograph of pelvis at 1 year. She is fully ambulatory
without aids and has minimal pain. C, Iliac oblique view at 1 year. D, Obturator oblique view at 1 year.
 ASSOCIATED INJURIES COMPLICATING THE MANAGEMENT OF ACETABULAR FRACTURES
Type IBfracture extension involving the
lesser trochanter with no extension into
the piriformis fossa
Type IIAfracture extension into the piri-
formis fossa, but not involving the lesser
trochanter
Type IIBfracture involving the piriformis
fossa and lesser trochanter
Options available for treatment of sub-
trochanteric fracture include antegrade in-
tramedullary nailing, cephalomedullary in-
tramedullary nailing, a 95 angled blade plate,
and a 95 condylar screw.50 Special situations
arise regarding the positioning of the pa-
tient. Depending on the approach necessary
for treatment of the acetabular fracture, the
patients position may be prone, lateral, or
supine. In each of these positions, xation of
the proximal femur fracture may be accom-
plished in the same position. It does present
unusual surgical situations, however, such
as placement of an implant for the proximal
femur in the prone position.
Another consideration is the timing of
treatment of the two injuries. In contrast to
the situation of the femoral neck fracture in
the young adult, the proximal femur fracture
does not need to be internally xed in an
urgent or emergent fashion. The surgeon has
two options:
1. Fixation of the proximal femur fracture
followed by future xation for the acetab-
ular fracture
2. Fixation of the proximal femur fracture at
the same operative intervention with ei-
ther separate or identical incisions
FEMORAL SHAFT FRACTURE
WITH ASSOCIATED
ACETABULAR FRACTURE
A relatively infrequent and challenging situ-
ation is that of the femoral shaft fracture with
an acetabular fracture. The gold standard for
treatment of a femoral shaft fracture is an an-
tegrade reamed intramedullary nail.811, 63 It
is associated with a 98% to 99% union rate
and low chance of infection (1% to 2%), even
when used in open fractures.811, 63 In the set-
ting of an associated acetabular fracture, ini-
tial antegrade intramedullary nailing before
acetabular fracture xation may be problem-
atic. Its use may be limited because of the
following:
91
Relative instability or deformity of the
proximal end of the femur secondary to
the acetabular fracture (e.g., both column
acetabular fracture)
Concern regarding ultimate surgical ap-
proaches for treatment of the acetabular
fracture (e.g., a large devitalization of the
abductor musculature may make a fu-
ture Kocher-Langenbeck approach prob-
lematic)
Irreducible or unstable posterior disloca-
tion of the femoral head
Concern regarding articular damage to the
femoral head or acetabulum or both dur-
ing intramedullary nailing
Possible concern regarding avascular
necrosis. Avascular necrosis after ante-
grade femoral nailing in adults is not a
known entity. Theoretically, however,
antegrade femoral nailing could compro-
mise the blood supply of the femoral head
in the setting of an acetabular fracture.
(The normal blood supply to the femoral
head may be compromised by the initial
trauma.)
Possible abductor weakness after ante-
grade femoral nailing4
For these reasons, alternative methods of
dealing with the combination of a femoral
shaft fracture and acetabular fracture often are
used. These include the following:
Sequential open reduction and internal xa-
tion of the acetabulum followed by ante-
grade intramedullary nailing of the femur
(same anesthesia)
Sequential open reduction and internal x-
ation of the acetabulum followed by plat-
ing of the femoral shaft (same anesthesia)
(Fig. 12)
Retrograde nailing of the femoral shaft frac-
ture followed by later open reduction
and internal xation of the acetabulum
(Fig. 13)
Retrograde femoral nailing in the setting of
an ipsilateral acetabular fracture has the ad-
vantages of intramedullary nailing, sparing of
the abductor musculature, and avoidance of
incisions in the region of future acetabular sur-
gical approaches. It has been associated with a
slightly higher nonunion rate when compared
with antegrade intramedullary nailing.40, 41, 61
A report has noted, however, no difference in
union between antegrade and retrograde in-
tramedullary nailing.47 The long-term effects
of intra-articular nail placement are unknown.
92 KREGOR & TEMPLEMAN

A B

C D

Figure 12. A 34-year-old man who was involved in a motor vehicle collision. He sustained a left pos-
terior hip dislocation, left posterior wall fracture, and left proximal one third femoral shaft fracture.
A, Injury AP radiograph of the pelvis. The arrow marks the posterior wall fracture. B, Injury AP
radiograph of the proximal femur. Closed reduction of the hip dislocation was not possible. The pa-
tient was taken expediently to the operating room for open reduction internal xation of his left acetab-
ular fracture and left femur fracture. This was accomplished in the prone position by way of a Kocher-
Langenbeck approach. C, Postoperative radiograph. D, AP radiograph of pelvis at 5 years postinjury.
The patient has a normal hip.
Illustration continued on opposite page
ASSOCIATED INJURIES COMPLICATING THE MANAGEMENT OF ACETABULAR FRACTURES 93

Figure 12 (Continued ). E, Healing of the femur fracture was uneventful.

A B

Figure 13. A 28-year-old woman who sustained a right transverse/posterior wall acetabular fracture,
right proximal one third femur fracture, right tibial shaft fracture, and right calcaneus fracture. At the
outside institution, retrograde nailing of the femur and intramedullary nailing of the tibia was per-
formed. A, AP radiograph of the proximal femur following retrograde intramedullary nailing. B, AP ra-
diograph of pelvis following open reduction internal xation of her right acetabular fracture.
94 KREGOR & TEMPLEMAN
Plating of the femoral shaft is a viable op-
tion. Although historically associated with
a higher rate of infection and need for bone
grafting,6, 31, 48, 51, 53 new submuscular techni-
ques reliably lead to union.62 The plate may
be introduced through the inferior limb of the
Kocher-Langenbeck incision.
SUMMARY
The initial and denitive management of ac-
etabular fractures can be complicated by a va-
riety of associated injuries. As with all injuries,
a careful analysis of the patient and the injury
pattern is paramount. The orthopedic surgeon
must recognize associated injuries in the prox-
imity of the acetabular fracture because they
have an impact on the timing, surgical ap-
proaches, and outcome from the acetabular
fracture. A plan must be formulated that opti-
mally treats both injuries, either in a sequential
or a simultaneous manner.
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Skeletal Trauma, ed 2. Philadelphia, WB Saunders,
1998
55. Swiontkowski MF, Thorpe M, Seiler JG, et al: Oper-
ative management of femoral head fractures. Orthop
Trans 13:51, 1989
56. Swiontkowski MF: Current concepts review: Intra-
capsular fractures of the hip. J Bone Joint Surg Am
76:129138, 1994
57. Swiontkowski MF, Winquist RA, Hansen ST: Frac-
tures of the femoral neck in patients between the ages
of twelve and forty-nine years. J Bone Joint Surg Am
66:837846, 1984
58. Thompson RC, Oegema Jr TR, Lewis JL, et al: Os-
teoarthrotic changes after acute transarticular load:
An animal model. J Bone Joint Surg Am 73:9901001,
1991
59. Thompson VP, Epstein HC: Traumatic dislocation of
the hip. J Bone Joint Surg Am 33:746777, 1951
60. Tornetta P: Non-operative management of acetabu-
lar fractures: The use of dynamic stress views. J Bone
Joint Surg Br 81:6770, 1999
61. Tornetta P, Tiburzi D: The treatment of femoral shaft
fractures using intramedullary interlocked nails with
and without intramedullary reaming: A preliminary
report. J Orthop Trauma 11:8992, 1997
62. Wenda K, Runkel M, Degreif J, et al: Minimally in-
vasive plate xation in femoral shaft fractures. Injury
28(suppl 1):A13A19, 1997
63. Winquist RA, Hansen ST: Comminuted fractures of
the femoral shaft treated by intramedullary nailing.
Orthop Clin North Am 11:633648, 1980
Address reprint requests to
Philip J. Kregor, MD
Division of Orthopaedic Trauma
Department of Orthopaedics and Rehabilitation
Nashville, TN 37232
e-mail: philip.kregor@vanderbilt.edu
TREATMENT OF COMPLEX FRACTURES
FEMORAL NECK FRACTURES
Andrew H. Schmidt, MD, and Marc F. Swiontkowski, MD
Femoral neck fractures remain a vexing
clinical problem for orthopedic surgeons.
Attempting to salvage the femoral neck often
leads to healing complications, while the more
predictable operation (prosthetic replacement)
is associated with poorer function and has
signicant complications of its own. Added
to this dilemma is the high mortality rate of
patients in the age group that most often sus-
tains these fractures. The orthopedic literature
is replete with case studies and retrospective
comparative trials on the treatment of femoral
neck fractures, but the quality of evidence
that we have to guide us is poor. Lu-Yao
et al51 attempted to perform a meta-analysis
of the outcome of displaced femoral neck
fractures. Nonunion was twice as common
as osteonecrosis (33% and 16%, respectively).
Although reoperation was more common
after internal xation than after prosthetic
replacement, the investigators were not able to
draw any statistically valid conclusions about
the factors that affect the outcome of femoral
neck fractures.
EPIDEMIOLOGY
The incidence of femoral neck fracture is
increasing dramatically as the mean age of
the population increases.68 The number of hip
fractures in the United States doubled from
the mid-1960s to the 1980s. It has been pre-
dicted that by 2050, the number of hip frac-
From the Department of Orthopaedic Surgery, University of Minnesota (AHS, MFS) and Hennepin County Medical
Center (AHS), Minneapolis, Minnesota
ORTHOPEDIC CLINICS OF NORTH AMERICA
VOLUME 33 NUMBER 1 JANUARY 2002
00305898/02 $15.00 + .00
tures would triple.27 As a consequence, proxi-
mal femur fractures are a signicant cause of
morbidity and mortality in all age groups, es-
pecially in the elderly.
At the present time, more than 250,000
hip fractures occur in the United States each
year, with associated health care costs of
$8.7 billion.66 Extensive debate continues over
the cost-effectiveness of various medical and
surgical therapies, including the treatment
of fractures of the hip. Using the concept
of quality-adjusted life years, Parker et al64
determined that operative treatment was
cost-effective for displaced intracapsular and
all extracapsular fractures of the hip. The
proper care of hip fractures is important not
only for the continued health and vitality of
our population but also for the health of our
economy.
Femoral neck fractures occur most com-
monly in the elderly patient after a seem-
ingly minor fall or twisting injury and are
more common among women.66 Numerous
factors are related to the high incidence of
hip fractures in the elderly population, in-
cluding osteoporosis, malnutrition, decreased
physical activity, impaired vision, neurologic
disease, poor balance, altered reexes, and
muscle atrophy. Chronically ill elderly pa-
tients have an increased risk for infection and
other systemic complications after fracture de-
spite appropriate medical and surgical man-
agement. Osteoporosis remains the most im-
portant contributing factor to hip fractures,
97
98 SCHMIDT & SWIONTKOWSKI

and its incidence has been well documented

with respect to age-, race-, and sex-matched
controls.48, 50, 56, 75, 79 The absolute rate of hip
fracture is highest for white women, followed
by white men, black women, and black men.38
These differences in incidence are thought to
reect the difference in bone density, which
is greater in blacks than in whites. Alffram1
reported that patients with intertrochanteric
fractures are slightly older and have higher
morbidity and mortality rates than do those
with femoral neck fractures.
Femoral neck fractures also occur in the
young but less frequently. In the young, these
fractures are usually the result of high-energy
trauma and often are associated with other in-
juries. In the young, hip fractures are more
common in males, who are also more prone to
trauma.

BIOLOGICAL AND
MECHANICAL CONSIDERATIONS

Most of the vascular supply to the femoral
head originates from the medial and lateral
femoral circumex arteries, which form an
extracapsular ring around the femoral neck.
Ascending cervical branches pass the femoral
neck proximally and enter the capsule at
its insertion. Fractures of the femoral neck
may disrupt the vascularity of the femoral
head18, 69, 70 ; however, displaced fractures of the
femoral head can occur without disruption of
the medial femoral circumex or lateral epi-
physeal systems.22 Therefore, urgent anatomic
reduction and internal xation of displaced
femoral neck fractures is advocated to restore
blood ow in vessels that may be kinked by
the displaced fragments. Rarely, collateral
circulation can maintain the viability of the
femoral head when the primary vessels are
disrupted.70
The bony anatomy of the upper end of
the femur is extremely important because it
determines where internal xation devices
should be implanted for maximum purchase
in the femoral head (Fig. 1). With increasing
age, the cortex of the femoral neck thins and
cancellous trabeculae are resorbed, signi-
cantly weakening the proximal femur.71 This
increases the risk for fracture with loading and
makes internal xation more prone to failure.
Study of the trabecular pattern allows sur-
geons to estimate the degree of osteoporosis
and the likelihood of successful internal xa-
tion, although the subjectivity of evaluating
Figure 1. A healed femoral neck fracture, showing ideal
screw placement in the center of the femoral head,
at the convergence of the tension and compression
trabeculae.
these patterns has made its use unreliable44
(Fig. 2).
The two major forces acting on the hip joint
are abductor muscles and body weight, as
dened by the joint reaction force. In men, the
normal joint reaction forces can be as much
as four- to sevenfold body weight, and in
women, 2.5- to fourfold body weight.60 Stair
climbing causes maximum hip forces of up
to sevenfold body weight.25 The use of a bed-
pan produces forces on the hip equivalent to
walking with the use of external supports.60
Nordin and Frankel60 showed with instru-
mented nailplate implants that only one
fourth of the total load is borne by the xation
device if bone fragments are allowed to im-
pact. Implants designed for fracture xation
must withstand extremely high loads and
bending moments. Fortunately, many stud-
ies have shown that full weight-bearing is
not detrimental if stable internal xation is
achieved.45 This is important because mobi-
lization of the patient is important to avoid
systemic complications. Even after fracture
union, the risks for osteonecrosis and arthrosis
remain. If these late complications ensue,
the patient is subject to further costs and the
hazards of secondary intervention.

A B
Figure 2. A failed attempt to repair a femoral neck fracture with screws. Careful study of the preop-
erative radiograph (A) shows that there are no bone trabeculae within the femoral neck causing the
screw xation to fail (B).
CLASSIFICATION
The Garden classication of femoral neck
fractures remains in wide use.29, 32, 67 The Gar-
den classication is based on the amount of
fracture displacement evident on anteroposte-
rior (AP) radiography of the hip, although sur-
geons must be aware that signicant displace-
ment may be apparent on lateral radiography
and not seen on AP radiography. The grades
correlate with the prognosis for healing and
the rates of avascular necrosis or nonunion.
Garden I and II fractures are nondisplaced.
Garden III and IV fractures are displaced
and have a worse prognosis for healing and
osteonecrosis. Recently, it has been shown
that the inter- and intraobserver reliability of
the Garden classication is poor 86 ; however,
agreement was improved when fractures
were grouped into either undisplaced (stage I
and II) or displaced (stage III and IV) classes.86
An alternative way to classify femoral neck
fractures is based on the angle of the fracture
line with the horizontal plane.63 More vertical
fractures have higher shear forces across the
femoral neck and may have a greater potential
for hardware failure; however, recent retro-
spective reviews have failed to conrm that
the fracture angle is of any value for predicting
the risk for xation failure.63
In addition to displacement, the rotation of
the femoral head must be evaluated to give the
FEMORAL NECK FRACTURES 99
surgeon the best estimate of the severity and
the comminution of the fracture. Rotational
moments are a signicant part of the normal
loading of the hip, and resistance to rotation
is an important factor in fracture stability.
Posterior comminution increases the potential
for rotational and varus instability (Fig. 3).
Rotational malignment is present when the
major compressive trabeculae in the femoral
head do not accurately align themselves
despite overall good alignment of cortical
shells.
TREATMENT
The treatment of femoral neck fracture de-
pends primarily on the age and activity of the
patient, the severity of fracture displacement,
the age of the fracture, and the degree of
osteoporosis present. Elderly patients with
medical comorbidities should have their
condition optimized.43 The optimum timing
of internal xation of femoral neck fractures
remains controversial.65 It has been suggested
that the incidences of avascular necrosis and
nonunion are decreased by xation within
6 hours after injury 53 ; however, some studies
have not shown an increase in the rate of os-
teonecrosis or nonunion with delayed xation
of up to 1 week. Because of the biological
advantages, the authors perform stabilization
100 SCHMIDT & SWIONTKOWSKI
Figure 3. Posterior comminution of the femoral neck, with posterior an-
gulation, impaction, and malrotation.
of the fracture as soon as the patient has been
evaluated medically and is stable.
For undisplaced fractures, in situ xation is
advisable because the risk for displacement
with nonoperative treatment is as high as
20%.26 Displaced femoral neck fractures are
treated according to the age and functional
demands of the patient. Patients with these
fractures are at high risk for avascular necro-
sis and nonunion, averaging 30% and 15%,
respectively.33, 51, 67, 82 In healthy, active patients,
the treatment of choice is reduction and in-
ternal xation. An anatomic reduction must
be obtained for a good result. Femoral neck
fractures reduced anatomically are best xed
with three pins or screws.83 A closed reduction
may sufce, but the capsule should be opened
to decompress the hemarthrosis that may
impair head perfusion. If a satisfactory closed
reduction is not achieved, an open reduction is
indicated. One should avoid repeated at-
tempts at performing closed reduction ma-
neuvers because repeated manipulations
may cause additional trauma and potential
vascular insult. The most important factor
leading to success in the treatment of the
young patient with a femoral neck fracture
is immediate anatomic reduction with stable
internal xation. In the series from the Ortho-
pedic Trauma Hospital Association,46 multiple
screws seemed to be the best choice for xa-
tion, with complications that include 13% with
avascular necrosis and nonunion in 14%. In
contrast, the use of hip compression screws led
to 50% avascular necrosis and 40% nonunions.
Malreduction with varus angulation resulted
in 60% avascular necrosis and 40% nonunion.
Ten degrees or more of anterior or posterior
angulation also led to increased complications.
Muscle pedicle grafting was of no benet
in preventing either avascular necrosis or
nonunion and was associated with a 13%
infection rate. Swiontkowski et al82 reported
avascular necrosis in 19% and no nonunions in
a smaller series of young patients with femoral
neck fractures treated with multiple screws.
Inactive or chronically ill patients may be
considered for primary prosthetic replace-
ment to avoid the complications from loss of
xation or osteonecrosis. A prosthetic replace-
ment also may be desired in a patient with hip
arthritis in conjunction with a femoral neck
fracture.
CLOSED REDUCTION OF FEMORAL
NECK FRACTURES
Closed reduction of the femoral neck is per-
formed with the patient under general anes-
thesia using image intensication. In general,
a simple combination of traction in extension
and gentle internal rotation is all that is nec-
essary. Alternatively, Leadbetters maneuver
 FEMORAL NECK FRACTURES 101

may be performed and involves reducing the

femoral neck in exion. First, the hip is exed
90 and the thigh is rotated internally. With
traction applied in line with the femur and
while internal rotation is maintained, the limb
is then circumducted into an abducted posi-
tion and then brought into extension. If closed
reduction is successfully achieved, one may
proceed with internal xation. Release of the
capsule should be performed at the same time
to decompress the joint and relieve possible
intra-articular tamponade.78, 84

INTERNAL FIXATION OF THE

FEMORAL NECK

Placement of multiple screws across the A

fractured femoral neck is the treatment of
choice and may be performed following either
closed or open reduction using a standard lat-
eral approach or a more limited percutaneous
technique. Many types of screws are available,
including solid or cannulated screws made
from either stainless steel or titanium.
Good results are to be expected following
xation of nondisplaced femoral neck frac-
tures. The outcome after xation of displaced
fractures is less predictable, and the manage-
ment of displaced fractures is more controver-
sial. Swiontkowski and Hansen80 reported on
the results of percutaneous pinning of femoral
neck fractures in 32 medically debilitated pa- B
tients. Technical complications occurred only
in the group with displaced fractures, none of Figure 4. A and B, Correct screw placement, with the
whom regained functional ambulation. In con- screws against the inferior and posterior cortices, and
trast, 92% of the patients with nondisplaced or within 5 mm of subchondral bone in the center of the
impacted fractures were ambulatory at 2-year femoral head.
follow-up.
To minimize complications, pins or screws
should be placed within the central two thirds Bout et al14 achieved union in 35 of 40 dis-
of the femoral head.59 The authors aim for cen- placed femoral neck fractures. Four of the ve
tral screw placement, with the tip of the screw failures were associated with clear faults in
no closer than 5 mm to subchondral bone. The the operative technique.14 Imperfect fracture
authors recommend that one inferior screw reductions may prevent reestablishment of the
should be placed along the medial femoral blood supply to the femoral head and decrease
neck, with two more proximal screws placed the amount of bony apposition at the fracture,
in a triangular conguration both anteriorly causing poor mechanical stability after xa-
and posteriorly in the femoral neck (Fig. 4). tion. Garden31 showed that valgus reduction
Placing the screws adjacent to the cortex of of more than 20 is associated with higher
the femoral neck may improve stability.13 The rates of avascular necrosis. Any amount of
inferior screw must exit the lateral femoral varus deformity after reduction is associated
cortex at or above the lesser trochanter. The with increased rates of avascular necrosis
authors have seen subsequent subtrochanteric and nonunion.46 AP angulation of more than
fracture at the distal screw when it is placed 10 should not be accepted, particularly in
distal to the lesser trochanter. Using the osteoporotic bone, because of the potential for
three-point principle, with screws placed further displacement. On lateral radiography,
adjacent to the inferior and posterior cortices, surgeons should pay particular attention to
102 SCHMIDT & SWIONTKOWSKI
the degree of posterior comminution. Both
Garden and Banks have shown that fractures
with marked posterior comminution have a
high incidence of nonunion.8, 30, 32 In a study
using cadaveric femora with simulated pos-
terior comminution, fractures xed with four
screws were signicantly stronger than were
those repaired with three screws.42 In cadaver
bone, the use of a calciumphosphate cement
dramatically improved the load to failure of
femoral neck fractures xed by three 7-mm
cannulated screws.74
If closed reduction within acceptable lim-
its cannot be obtained, the surgeon should
proceed to open reduction, which affords
surgeons several advantages. First, it decom-
presses the hip. Second, it is the best way
to ensure appropriate rotational alignment
of the femoral head. Finally, drilling of the
femoral head may allow surgeons to assess
the viability of the femoral head.34 Open
reduction may be performed by extending the
lateral incision and using the interval between
the tensor fascia lata and gluteus medius
(Watson-Jones approach) or by an anterior
approach. In the latter case, a separate incision
may be necessary for screw placement. If the
patient is a candidate for arthroplasty and the
surgeon is unwilling or unable to perform an
adequate open reduction, the treatment plan
for reduction and xation may be abandoned
and the surgeon may proceed with prosthetic
replacement.
SLIDING HIP SCREWS
Many experts advocate the use of a slid-
ing hip screw for the xation of basicervical
fractures (Fig. 5).10 In a biomechanical study,
a sliding hip screw with or without a derota-
tion screw was stronger than three cannulated
screws in axial loading10 ; however, a clinical
study found that the union rate of displaced
femoral neck fractures was higher after xa-
tion with four cancellous screws than with a
sliding screw plate.52 Sliding hip screws pro-
vide improved xation of vertically oriented
fractures,4 and these devices should be consid-
ered in the treatment of such fractures.
PROSTHETIC REPLACEMENT
Prosthetic replacement of the displaced
femoral neck fracture is advocated by some
because of the high rates of nonunion and
avascular necrosis; however, the relative mer-
its of attempting xation versus performing
arthroplasty are controversial. In one study
of more than 500 femoral neck fractures
treated with internal xation, 79% of the pa-
tients retained their femoral head and 67%
required only one operation.57 The incidence
of reoperation was actually lower among
the patients over age 70 years than among
younger patients. Other studies have found
arthroplasty to be associated with lower com-
plication rates than internal xation.39 Gerber
et al33 found that local complications pre-
dominated after internal xation, whereas
systemic complications were more common
after hemiarthroplasty. Bogoch et al12 reported
that internal xation of displaced femoral neck
fractures in patients with rheumatoid arthritis
failed in 64%, whereas primary total hip re-
placement was successful in 95%. Carpenter
et al17 found that the reoperation rate follow-
ing internal xation was much higher (28%)
than that following either unipolar (5%) or
bipolar (3%) arthroplasty. In general, it is best
to salvage the femoral head whenever pos-
sible. The use of a study implant that main-
tains a valgus neck-shaft angle, controls
potential rotation, and allows for controlled
compression of the fracture; it provides the
best results with minimal complications. In
older and less active patients with displaced
femoral neck fractures, hemiarthroplasty
seems to be the optimum management. Bray
et al15 performed a prospective, random-
ized comparison of bipolar hemiarthroplasty
to internal xation. Fewer complications
and better function at 2-year follow-up
were found in the hemiarthroplasty-treated
group.
Options for prosthetic replacement include
unipolar hemiarthroplasty, bipolar hemiar-
throplasty, and total hip arthroplasty. Ce-
mented or uncemented devices may be used.
Early unipolar devices were found to have
frequent complications, including disabling
pain and acetabular erosion.41 Bipolar hemi-
arthroplasty was developed in hopes of less-
ening this complication, but clinical reports
suggest that measurable acetabular erosion
still occurs.11, 47 Nevertheless, clinical studies
comparing unipolar with bipolar prostheses
suggest better results with the latter devices.61
Other potential complications include stem
loosening, dislocation, femoral shaft perfora-
tion, periprosthetic fracture, and infection.
Total hip replacement provides the best re-
sults of any form of prosthetic replacement

A B
C D
Figure 5. A and B, A basicervical fracture treated with a sliding hip screw and single derotation screw
(C and D).
for displaced femoral neck fracture; however,
several investigators have found that disloca-
tion after hip arthroplasty for fracture is more
common than after operations for arthritis.35, 86
In 50 patients equally divided between frac-
tures and arthritics, the hip range of mo-
tion was signicantly greater among those
FEMORAL NECK FRACTURES 103
undergoing surgery for fractures.35 This in-
creased movement is thought to be a pre-
disposing factor for dislocation in patients
managed with hip arthroplasty for femoral
neck fractures. Total hip arthroplasty after
a displaced femoral neck fracture should be
reserved for patients with preexisting arthritis
104 SCHMIDT & SWIONTKOWSKI

or for very high-demand patients in whom in-
ternal xation is not possible or has failed.
COMPLICATIONS
Loss of Fixation
Implants that are used for internal xation
of the proximal femur can fail because of the
large bending loads that are present in the
proximal femur and the poor bone quality that
is usually associated with fracture. Many dis-
placed fractures are unstable and have poste-
rior and medial comminution with loss of a
stable medial buttress. The implant may cut
out of the superior femoral neck as the frac-
ture settles into varus displacement; break at
the site of the fracture; or, in the case of a side-
plate device, pull out from the femoral shaft
(see Fig. 2). Technical problems that may lead
to failure include poor screw position, place-
ment of screws with threads that cross the
fracture site, and imperfect fracture reduction.
Failure of internal xation of a femoral neck
fracture with either multiple pins of a sliding
hip screw is most dependent on bone quality
and screw placement.24, 87 Swiontkowski et al83
found no benet to using more than three pins
and that bone density is a useful predictor of
the success of xation.
The treatment of failed osteosynthesis of
the femoral neck depends on the timing and
mode of failure and the patients general
condition and activity level. Repeat xation
may be considered in younger or more active
patients if the bone stock is adequate. Often,
a valgus osteotomy with blade plate xation
is necessary to restore the correct mechanical
axis of the femoral neck (Fig. 6). Conversion

A B

C D

Figure 6. A femoral neck nonunion (A), conrmed by CT scan (B). Union was achieved after valgus
osteotomy and blade plate xation (C and D). (Courtesy of David Templeman, MD, Minneapolis, MN.)

to an arthroplasty is needed if osteonecrosis
ensues or because of poor bone quality. Long-
stem devices should be used to ensure that
the tip of the stem is distal to the screw holes
in the lateral femoral cortex (Fig. 7). Franzen
et al28 found that the results of total hip arthro-
plasty for failed xation of femoral neck
fractures was age dependent. Patients aged
more than 70 years who underwent primary
hip replacement after fracture had a vefold
risk for prosthetic failure compared with age-
matched patients undergoing hip replacement
for osteoarthritis.
Nonunion
Delayed or nonunion of a femoral neck
fracture often is manifested by continued pain
with weight-bearing beyond 3 months af-
ter xation. Nonunion of femoral neck frac-
tures has a reported incidence from 2% to 22%
and generally becomes apparent within
1 year.2, 7, 8, 19 The risk for nonunion is greater
with displaced fractures and has been reported
to be as high as 30% in some series.21, 62, 66, 72
Figure 7. A total hip performed for a failed proximal femur fracture treated with a sliding
hip screw. Two screw holes are present in the femoral shaft below the tip of the prosthe-
sis (A). A displaced periprosthetic fracture occurred within 2 weeks after surgery (B).
FEMORAL NECK FRACTURES 105
The variability in the incidence of nonunion
in different series of cases may be explained
by differences in patients, fracture type and
by the investigators method of reduction and
xation technique.62 Madsen et al52 found that
the union rate of displaced femoral neck frac-
tures was higher after xation with four can-
cellous screws (84%) than with a sliding screw
plate (64%). Nonunion is associated with
pin migration.54 Furthermore, nonunion and
pin migration occurred only in the displaced
fracture patterns. Valgus reduction seemed to
protect against pin migration.54 Hammer 37 re-
viewed 141 patients following osteosynthesis
of a femoral neck fracture with 6.5-mm AO
screws. The rate of nonunion was correlated
with the Garden classication and was 1% for
Garden I fractures and over 25% in Garden III
and IV fractures. Irrespective of the Garden
classication, a vertical fracture orientation
resulted in a 40% rate of nonunion.37 Parker 62
found that the best predictor of nonunion
was patient age and preoperative fracture
displacement.
Nonunion may be accompanied by avascu-
lar necrosis. If nonunion occurs, the surgeon
106 SCHMIDT & SWIONTKOWSKI
should use MR imaging to evaluate vascular
supply to the femoral head before continuing
with treatment options. Fixation of the femoral
neck with titanium screws aids in accuracy
of MR imaging interpretation by minimizing
scatter of the image that occurs with the use of
stainless steel screws. MR imaging has largely
supplanted scintigraphy in the evaluation of
femoral head viability.
Options for the treatment of nonunion in-
clude repeat internal xation, bone or muscle-
pedicle grafting, valgus osteotomy, and hip
arthroplasty. In active patients, nonunion is
treated with a valgus osteotomy and repeat
xation. Marti et al55 reported a series of
50 patients aged less than 70 years who under-
went valgus osteotomy for ununited femoral
neck fractures. Six cases required reoperation
because of technical complications. Seven hips
underwent later replacement: three hips for
persistent nonunion, three hips for severe os-
teonecrosis, and one hip for hardware break-
age. The remaining 43 fractures had 7 years
average follow-up. Although avascular necro-
sis was evident in 22, only 3 patients had
symptoms sufently severe to require arthro-
plasty. In a series of 17 patients, union was
achieved in all but one after osteotomy.6 Five
patients required an additional operation. Al-
though the operation is difcult, this study
recommends osteotomy in younger, active pa-
tients with nonunion of the femoral neck.6, 55
Only smaller series have reported on the
use of a posterior muscle pedicle graft and
bone graft as an adjunct to internal xation
of a femoral neck nonunion.5 The success of
this treatment is difcult to assess because
the series report a limited experience. Most
nonunions have drifted into some varus an-
gulation, and a valgus osteotomy and xation
are essential to apply compression loads at
the fracture site and promote healing. There-
fore, the best option is an intertrochanteric os-
teotomy with realignment of the proximal fe-
mur into valgus if salvage of the femoral head
is warranted.
In some instances, such as if severe os-
teonecrosis is present or in elderly community
ambulators, nonunion may be treated best by
total hip replacement. Unfortunately, no com-
parative studies are available to aid clinicians
in decision making for this complex problem.
Avascular Necrosis
The lateral epiphyseal artery supplies most
of the femoral head circulation. This vessel is
at considerable risk of lacuation or kinking af-
ter femoral neck fracture; it runs in the su-
perior capsule, which frequently is disrupted
by such fractures, especially when displaced.
Most clinically relevant avascular necrosis fol-
lows displaced intracapsular fractures.
Most studies report osteonecrosis rates in
displaced femoral neck fractures of 10% to
20%.33, 51, 82 Differences may be explained by
the fracture type and by the investigators
method of reduction and xation. Stromqvist
et al76, 77 examined the use of scintigraphy to
assess the viability of the femoral head after
femoral neck fracture. Decreased radionuclide
uptake within the rst 2 weeks of injury is 91%
predictive of healing complications.77 Further-
more, decreased uptake is found in some frac-
tures preoperatively; these patients invariably
experience healing complications.76 In other
patients, decient uptake is seen only postop-
eratively, indicating that perioperative factors
(e.g., intra-articular tamponade, traction, of re-
duction maneuvers, also inuence the devel-
opment of osteonecrosis. Patients with normal
uptake 2 weeks after injury are unlikely to de-
velop osteonecrosis.77
The risk for avascular necrosis is propor-
tionate to the degree of displacement and the
time to reduction. Operation within 6 hours of
injury leads to improved union rates and a de-
creased incidence of femoral head collapse.53
Late-onset avascular necrosis is manifested
by bone sclerosis, subchondral collapse and,
eventually, secondary degenerative changes
of the hip. In the early stages of symptoms,
radiographic ndings are normal. MR imag-
ing provides the most sensitive and specic
means of identifying avascular necrosis in
the early stages, when treatment may be ben-
ecial; however, MR imaging performed at
the time of injury is unable to predict which
intracapsular fractures will develop clinical
avascular necrosis.3, 73 Furthermore, treat-
ment should not be based on the results of
MR imaging alone; the severity of clinical
symptoms, the degree of femoral head col-
lapse, and the amount of degenerative change
on radiographs are more important clinical
factors.
Surgeons can minimize the risk for os-
teonecrosis in several ways. Urgent reduction
and xation may be the most important. Sev-
eral investigators have shown that intracap-
sular fractures of the proximal femur result in
markedly elevated intracapsular pressures se-
condary to hematoma formation.24, 40, 78 Using
laser Doppler owmetry, Swiontkowski, et al84
showed signicant diminution of femoral

head blood ow with elevated intracapsu-
lar pressures in an animal model. Crawfurd
et al24 used ultrasonography to show capsu-
lar distension following both nondisplaced
and displaced femoral neck fractures and
documented elevated intracapsular pressures
associated with joint hemarthrosis. Some dis-
placed fractures showed evidence of capsular
disruption with extracapsular hematoma;
this subgroup of hips had low pressures
consistent with decompression of the hip.
Capsulotomy is recommended to relieve the
intracapsular hematoma and restore blood
ow.24, 84 Stromqvist et al78 showed that the
intracapsular pressure is highest with the leg
internally rotated and lowest in a position
of mild exion and external rotation. These
workers also demonstrated, that following
hip aspiration, intracapsular pressures de-
creased to zero, and scintigraphic uptake
increased in most hips, consistent with im-
proved blood ow. Although the need for
capsulotomy in femoral neck fracture remains
controversial, it is so simple to perform that
it should be recommended. Another benet
of capsulotomy is that it allows for direct
visualization of the femoral head and its ca-
pacity to bleed. Gill et al34 drilled a 2-mm hole
into the femoral head fragment at surgery;
none of 56 patients with bleeding from the
drill hole developed avascular necrosis at
2 years of follow-up or more. In contrast, all
8 patients without bleeding developed avas-
cular necrosis. Intraoperative drilling may be
the best method to assess the risk for avascular
necrosis, although longer-term follow-up is
needed.
The treatment of avascular necrosis re-
mains controversial. Often, osteonecrosis does
not involve the entire femoral head. In many
cases, collapse of the head does not occur.
If the patient is asymptomatic, no further
treatment is indicated. If collapse of the os-
teonecrotic fragment has occurred and the
patient is symptomatic, then surgical treat-
ment may be indicated. The degree of involve-
ment on imaging studies does not necessarily
correlate with the severity of symptoms.
In general, young, active patients are more
disabled by avascular necrosis than are seden-
tary patients. Treatment options are based on
age, activity level, and severity of symptoms
and include core decompression, proximal
femoral osteotomy, arthrodesis, and prosthetic
replacement. Core decompression may be
performed in painful lesions that have not col-
lapsed. In younger patients or those with
well-circumscribed lesions, osteotomy is ap-
FEMORAL NECK FRACTURES 107
propriate. Although arthrodesis is more dif-
cult because of the avascular bone, it may
be considered for younger patients with
more severe involvement that precludes
osteotomy. For the management of severe
osteonecrosis in the older patients, total hip
arthroplasty is recommended. Whether ce-
mented or uncemented implants are better
is unknown; surgeons should select what-
ever technique and implant they are most
familiar with. Hemiarthroplasty is performed
in elderly patients with minimal functional
demands.
FEMORAL NECK FRACTURES
IN CHILDREN
Children rarely sustain fractures near the
hip; when they occur, they are often the result
of high-energy trauma. Multiple injuries are
present in half of these cases, and these pa-
tients traditionally are considered to have a
poor prognosis. Potential complications in-
clude osteonecrosis, nonunion, coxa vara, and
premature physeal closure with trochanteric
overgrowth and leg-length inequality.16
Twenty percent of cases are associated with
ipsilateral femoral shaft fractures. Complica-
tion rates are proportional to the initial degree
of displacement,16 and studies that have fol-
lowed up patients into adulthood have shown
that the initial results deteriorate signicantly
with time.49
Delbet20, 58 has classied these fractures into
four types: type I, transepiphyseal; type II,
transcervical; type III, cervicotrochanteric; and
type IV, intertrochanteric. Proximal femur
fractures involving the growth plate (type I)
are reported to result in avascular necrosis and
premature physeal closure in 80% to 100% of
patients.16 Early hip decompression in type I
injuries does not affect the incidence of avas-
cular necrosis, suggesting that the vessels are
disrupted.58 Nevertheless, the best results of
treatment overall have been with immediate
decompression of the joint by capsulotomy
and rigid internal xation.20, 58 Despite the
lack of documented efcacy, decompression
of type I fractures still should be attempted.
Early hip decompression seems to decrease
the risk for avascular necrosis in type II and III
fractures and should be performed in all such
cases.20, 58, 81 In one series, hip capsulotomy re-
duced the rate of avascular necrosis in type II
and III fractures from 41% to 8%.58 Cheng and
Tang 20 had no cases of avascular necrosis in
a series of 14 patients with a mean follow-up
108 SCHMIDT & SWIONTKOWSKI
of almost 5 years. These investigators per-
formed hip aspiration, closed reduction, and
internal xation within 24 hours of injury.
By using an aggressive operative approach
with early open reduction, capsulotomy, and
compression screw xation, Swiontkowski
and Winquist 81 reported good results in
eight patients with 2-year follow-up. One
patient had a type I (transepiphyseal) fracture
in their series; this patient developed radio-
graphic evidence of partial avascular necrosis
of the femoral head but was asymptomatic
at the 2-year follow-up examination. Imme-
diate anatomic reduction and screw xation
are recommended for all children with frac-
tures of the proximal femur, except for there
with undisplaced basilar neck fractures or
fractures in the intertrochanteric region (type
IV), which may be treated by spica casting.81
As in fractures in adults, hip decompression
should be performed in all femoral neck
fractures in children.81
COMBINED FRACTURES OF THE
FEMORAL NECK AND SHAFT
Ipsilateral fractures of the femoral neck
and shaft are uncommon and challenging
injuries that typically occur in multitrauma
patients. Often, the femoral neck fracture is
not recognized at the time that the shaft frac-
ture is treated.88 In a review of the literature,
Bennett et al9 reported that the incidence of
delayed diagnosis was 31%. The associated
femoral shaft fracture often is comminuted or
open and usually occurs in the proximal to
middle third of the femur.88 In contrast, the
femoral neck fracture usually is minimally
displaced and is typically extracapsular, which
may contribute to the difculty in diagnosis.
The injury of primary importance in this
fracture complex is the femoral neck fracture.
Most surgeons recommend immediate re-
duction and stabilization of the femoral neck
fracture with compression screws, followed
by subsequent stabilization of the femoral
shaft fracture.88 In unstable multitrauma pa-
tients, a delay in xation of several days to
weeks should not preclude xation because
the complication rate does not seem to be
increased.88
One possible choice for xation is a second-
generation interlocking nail, which may be
used to stabilize both the femoral neck and
shaft fractures; however, this technique may
compromise the reduction and xation of
the femoral neck and may lead to complica-
tions. Poor results have been reported with
the reconstruction nail, with complications
in as many as 75% of cases in one series.88
Another option is antegrade nailing of the
shaft, with supplemental screw xation of
the neck. In this circumstance, two addi-
tional lag screws are placed anterior to the
nail. As mentioned earlier, it is of paramount
importance to avoid displacing the femoral
neck fracture when this technique is used.
An acceptable alternative is routine stabiliza-
tion and xation of the femoral neck fracture
with multiple screws, followed by plating
or retrograde nailing of the femoral shaft
(Fig. 8).
Avascular necrosis seems to be less common
in cases of ipsilateral neck and shaft fractures
than of isolated neck fractures.9 Occasionally,
the femoral neck fracture is not identied un-
til after, or may occur during, intramedullary
nailing of a diaphyseal fracture. This also
calls for emergent reduction and stabilization
of the femoral neck, and multiple cancellous
lag screws generally can be placed around
the proximal femoral nail. Higher rates of os-
teonecrosis and nonunion should be expected
in these situations.88
THE FUTURE TREATMENT OF
FEMORAL NECK FRACTURES
Future advances in the surgical manage-
ment of femoral neck fractures depend on
an improvement in the methods of orthope-
dic research and advances in the management
of osteoporosis. Certainly, as physicians learn
of the results of well-designed randomized
prospective trials, treatment will become ev-
idence based rather than anecdotal. In addi-
tion, it is likely that physicians will have bet-
ter methods to manage one of the biggest
problems in the xation of femoral neck frac-
tures, namely, poor bone quality. The med-
ical management of osteoporosis is improv-
ing, and the incidence of osteoporosis will be
less in the future. In addition, fracture com-
minution likely will be managed by augment-
ing the bone with some sort of injectable
bone graft substitute. Specically, augmenta-
tion with calciumphosphate cement has been
shown to improve signicantly the strength
and stiffness of xation in cadaveric bone
xed with screws.36, 74 Clinical pilot studies of
this technique are in progress.36
 FEMORAL NECK FRACTURES 109

A B

Figure 8. An ipsilateral femoral neck and shaft fracture. The radiograph clearly shows both frac-
tures (A). The patient underwent closed reduction and screw xation of the femoral neck, followed
by retrograde nailing of the femoral shaft (B and C).

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Address reprint requests to
Andrew H. Schmidt, MD
701 Park Avenue
Minneapolis, MN 55415
TREATMENT OF COMPLEX FRACTURES
FEMORAL FRACTURES
Subtrochanteric femoral fractures de-
serve special consideration when discussing
femoral fractures because of the difculties in
their management and reported signicant
rates of complications with their surgical treat-
ment.9, 42, 46, 49, 50, 56, 57 The subtrochanteric area
has been dened in various ways, but most
commonly this term has been used to de-
scribe the area between the inferior border
of the lesser trochanter and the isthmus of
the femoral shaft or the inferior border of
the lesser trochanter to the junction of the
proximal and middle one third of the femur.
The lower border of the subtrochanteric area
is not well dened, but generally the area 5 cm
below the level of the lesser trochanter is in-
cluded. Subtrochanteric fractures are fractures
in which the major portion of the fracture
involves this area. These fractures may have
proximal trochanteric extension, which is
important in choosing between treatment
options.
The difculties encountered in the treatment
of subtrochanteric fractures are related to the
anatomic and biomechanical features unique
to this area. Anatomically the subtrochanteric
area consists of mostly cortical bone, which
often is comminuted and tends to heal more
slowly than metaphyseal bone. Just proxi-
mal, the canal widens in the intertrochanteric
area, which leads to less optimal xation with
intramedullary devices because of the wide
canal and short segment proximally. Biome-
chanically the subtrochanteric area is an area
of high stress concentration, and the muscle at-
From the Carolinas Medical Center; and the Miller Orthopaedic Clinic, Charlotte, North Carolina
ORTHOPEDIC CLINICS OF NORTH AMERICA
VOLUME 33 NUMBER 1 JANUARY 2002
00305898/02 $15.00 + .00
SUBTROCHANTERIC
Stephen H. Sims, MD
tachments lead to strong deforming forces that
can make fracture reduction difcult.
ANATOMY AND BIOMECHANICS
The greater trochanter is a large bony emi-
nence at the proximal femur that provides an
insertion site for the tendons of the gluteus
medius and gluteus minimus that function as
strong hip abductors. The piriformis, gemellus
superior and gemellus inferior, and obtura-
tor internus tendons also insert in this area
and function as external rotators of the hip.
The lesser trochanter is a bony eminence
posteromedially on which the iliopsoas ten-
don attaches. The insertion and action of these
muscles is important in understanding the
stresses and reaction forces in this area and
the typical deformity that results with sub-
trochanteric femoral fractures as a result of the
deforming forces of these muscles acting on
the individual fragments. Classically the prox-
imal fragment assumes a position of exion,
abduction, and external rotation.21 The gluteus
medius and gluteus minimus account for
the position of abduction. The iliopsoas ac-
counts for the position of exion and the
external rotation results from the forces of
the short external rotators and the iliopsoas.
This deformity complicates attempts at closed
reduction. The angle formed by the axis of
the femoral neck and femoral shaft is 127
to 130 . If this angle is decreased, as would
occur with a varus reduction of a fracture,
113
114 SIMS
the distance between the head and shaft is
increased, which increases the moment arm
and the bending forces across the fracture and
may produce varus collapse. Joint reaction
forces at the hip result from the compressive
forces of the bodys weight and most impor-
tantly the forces generated by the muscles
that cross the hip. Forces on the hip and prox-
imal femur have been analyzed by numerous
investigators.19, 20, 30, 43, 44, 52 Koch30 showed that
forces greater than 1200 lb per square inch
of force could be generated by a 200-lb man.
Major compressive stresses in the femur are
greatest in the medial cortex 1 to 3 inches
below the lesser trochanter and exceed 1200 lb
per square inch. This is the most highly
stressed region in the body. Tensile stresses
of approximately 25% less occur at the lateral
cortex slightly more proximal. These high
compressive forces medially explain the high
instance of implant failure and complications
seen historically in these fractures when the
medial buttress could not be restored because
of comminution. If the posterior and medial
cortex is intact or reduced anatomically with
bone-to-bone contact, internal xation devices
act as a tension band on the lateral femoral
cortex. If this medial buttress is not intact
or cannot be reestablished, the internal xa-
tion devices are subjected mainly to bending
stresses, and the loads are concentrated in
this high stress area.19 This concentration may
result in implant failure or loss of xation.
Intramedullary nails have a biomechanical
advantage over plates in this situation. Their
intramedullary position reduces the moment
arm on the nail by reducing the distance over
which the bending forces act compared with a
plate on the lateral cortex. Others have shown
the signicant forces at the hip and proximal
femur.19, 20, 30, 43, 44, 52 Forces about the hip have
been measured using mathematical models,43
cadaver systems that attempt to simulate
normal hip forces,52 and insertion of pressure
measuring instrumented implants.44 It seems
that pressures from normal gait may reach 5 to
7 times body weight or higher, and signicant
pressures approaching this can occur with
supine straight-leg raising or getting on and
off a bedpan.20
INCIDENCE AND MECHANISM
OF INJURY
Of the fractures of the proximal femur, 7%
to 34% primarily involve the subtrochanteric
region. There tends to be a bimodal distri-
bution of the fractures. Fractures occurring
in younger patients result from high-energy
trauma and often have signicant comminu-
tion. These most commonly result from motor
vehicle accidents or falls from a height. Pene-
trating trauma secondary to gunshot wounds
is another common mechanism of fractures in
young patients in most series. Older patients
often present with low-energy subtrochanteric
fractures. These usually have less comminu-
tion, and long spiral fractures in this popu-
lation are common. Older patients also may
present with pathologic fractures or impend-
ing pathologic fractures, but these are note
discussed in this article. The relative percent-
ages of these fracture patterns depend on the
type of center from which the patient popu-
lation is obtained. Trauma centers tend to see
higher percentages of high-energy and pene-
trating fractures in younger patients, whereas
other centers may see a higher percentage of
low-energy fractures in older patients.
CLASSIFICATION
Many classication systems for subtro-
chanteric fractures have been proposed. Some
of the more frequently mentioned are re-
viewed. Boyd and Grifn8 divided all tro-
chanteric fractures into 4 groups. Type I and
II are intertrochanteric fractures, type III are
subtrochanteric fractures, and type IV are sub-
trochanteric fractures with intertrochanteric
extension. An analysis of the specic subtro-
chanteric fracture patterns was not done. The
classication of Fielding et al19 was specically
for subtrochanteric fractures and included
three types based solely on the location of the
primary fracture line. Type I are fractures at
the level of the lesser trochanter, type II are
fractures within 1 inch of the lesser trochanter,
and type III are fractures 1 to 2 inches be-
low the lesser trochanter. This classication
does not take into account fracture com-
minution, which is important in assessing
fracture stability and planning treatment.
Fracture patterns, such as spiral fractures,
may be difcult to classify with this system.
Seinsheimer49 devised a classication system
for subtrochanteric fractures based on the
number of major fragments and the location
and shape of the fracture lines. Implant fail-
ures and nonunions occurred in his series
with a higher incidence in the type IIIA and IV
fractures. These are the fracture patterns with

medial comminution, and their higher inci-
dence pointed to the importance of the medial
buttress. Waddell56 devised a system that clas-
sied fractures based on their fracture pattern.
In this scheme, type I fractures included the
transverse and short oblique fractures; type II,
the long oblique or spiral fractures; and type
III, the comminuted fractures.
Delee16 proposed the concept of stable and
unstable fractures in place of a specic classi-
cation system.55 Stable subtrochanteric frac-
tures were dened as those in which it is
possible to reestablish bone-to-bone contact
of the medial and posterior femoral cortex
anatomically.
In the comprehensive classication of frac-
tures, subtrochanteric fractures are classied
as diaphyseal fractures and appear under the
classication for the diaphyseal segment. The
dividing line between the subtrochanteric and
trochanteric area is a horizontal transverse line
at the inferior border of the lesser trochanter.
This classication often is believed to be too
cumbersome to use in routinely describing
fractures but is important for research and
data collection. Additionally, if one spends
some time becoming familiar with this system,
it can be used in routine fracture and treatment
analysis.
The Russell-Taylor classication has proved
to be useful because it has implications re-
garding the appropriate treatment and appro-
priate choice of implants with the implants
that currently are used most commonly. This
classication divides subtrochanteric fractures
into two major groups. Type I fractures are
fractures that do not have extension into the
piriformis fossa. These fractures can be treated
with intramedullary xation. In type IA frac-
tures, comminution and fracture lines extend
from below the level of the lesser trochanter
only. In type IB fractures, fracture lines and
comminution do involve the area of the lesser
trochanter. The importance of this distinction
is that in type IA fractures, it may be suitable
for standard interlocking nailing, whereas the
type IB fractures would be more suitable for
cephalomedullary nails if an intramedullary
nail is chosen. Type II fractures extend prox-
imally into the greater trochanter and do in-
volve the piriformis fossa. This distinction is
important because it may lead one to con-
sider this a contraindication to intramedullary
nailing. Type IIA fractures extend from the
lesser trochanter to the isthmus with exten-
sion into the piriformis fossa, but signicant
comminution of the lesser trochanter is not
SUBTROCHANTERIC FEMORAL FRACTURES 115
present. In type IIB fractures, there is exten-
sion into the greater trochanter area with sig-
nicant comminution of the medial femoral
cortex and loss of continuity of the lesser
trochanter; this likewise has important impli-
cations for treatment.
PATIENT ASSESSMENT
As with all injuries, an adequate history and
physical examination of the patient is essen-
tial. In patients with low-energy trauma, the
history and physical examination should con-
sider the possibility of a pathologic fracture
secondary to neoplasm or metabolic bone dis-
ease. Patients involved in high-energy trauma
should proceed through a trauma system
and ATLS guidelines to evaluate for other in-
juries. Neurologic and vascular examination
of the extremities should be documented, es-
pecially in patients with penetrating trauma.
Assessment of the surrounding local soft tis-
sues is important when planning surgery. Ra-
diographic evaluation should include antero-
posterior and cross-table lateral radiographs
centered on the hip and anteroposterior and
lateral radiographs of the entire femur to rule
out other fractures in the femur more distal
and to assess adequately the subtrochanteric
fracture. It is important to assess the most
proximal extent of the fracture and to detect
any trochanteric extension of the fracture. It is
important to note if the fracture involves the
area of the piriformis fossa. Manual traction
on the extremity while the radiographs are
being taken may aid in more accurate visu-
alization of the proximal fragment. Placing a
bump beneath the hip to roll the patient, as
one would do to obtain an obturator oblique
view of the pelvis, may give a better antero-
posterior and lateral radiograph if the proxi-
mal fragment does have signicant external
rotation. Occasionally, radiographs of the op-
posite hip may be of benet in preoperative
planning. Leg length may be difcult to deter-
mine in patients with severe comminution. In
these patients, preoperative measurement of
the opposite leg using a radiopaque ruler can
be helpful. Measures from the femoral head or
greater trochanter to the end of a condyle or
physeal scar can be determined and matched
on the operative side. This measurement of
the intact leg also can be made on the com-
puted tomography scan with the use of a cal-
ibrated cursor on the scout lm of the femur.
This measurement may be useful if the patient
116 SIMS
is in the computed tomography scanner pre-
operatively for other reasons.
TREATMENT
Treatment Options
Nonoperative treatment of subtrochanteric
femoral fractures requires prolonged immobi-
lization and is associated with high morbidity
and mortality rates for the patient and high
rates of local complications related to frac-
ture healing (nonunions, delayed unions,
and malunions).1, 8, 27, 28, 55, 56 For these reasons,
nonoperative treatment of subtrochanteric
femoral fractures has little or no role in the
denitive treatment.
Internal xation of these fractures has
evolved through a long list of implants. Many
of the early reports have high incidences of
loss of xation and implant failure. Improved
manufacturing abilities, a better understand-
ing of the local stresses, and application of
improved engineering principles have led
to stronger implants with greater fatigue
life for use in these fractures. Additionally,
preservation of soft tissue attachments and
blood supply in the fracture zone has yielded
a better biologic response with these fractures
and more rapid healing. The results have
been fewer complications in the operative
treatment of these fractures if the principals
of fracture xation are understood and adher-
ence to these principles is not compromised.
Implants commonly used currently include in-
tramedullary devices and xed angled plates.
Intramedullary devices currently suitable for
these fractures include locked intramedullary
nails and a variety of cephalomedullary nails
that allow for xation into the femoral head
and neck proximally and distally locking with
screws. Fixed angle plates currently suitable
for treatment of these fractures including the
95 condylar blade plate, the 95 dynamic
condylar screw, and compression hip screws
(dynamic hip screws [DHS]). Reports of use
of the Medhoff plate have appeared also that
may allow a sliding at the plate junction and
along the plate.33
Principles of Treatment
Operative treatment of these fractures must
adhere carefully to the basic principles of frac-
ture xation of diaphyseal fractures. These
principles must be considered carefully be-
cause fractures in this area are unforgiving of
anything other than the most thoughtful, well-
planned surgery that is executed carefully and
accurately.
The rst principle is careful preoperative
planning for the surgery. After thoughtful
assessment of the radiographs and fracture
pattern, the reduction technique and implant
should be selected. The surgeon needs to be
sure that the equipment needed will be avail-
able. Also, the surgeon needs to decide if he or
she has the expertise and support available to
treat the fracture properly; if not, the surgeon
should transfer the patient to an appropriate
facility. There is evidence to support that early
xation of femoral fractures decreases patient
morbidity; however, short delays to assemble
the appropriate operative team may avoid in-
traoperative delays.
The second principle is to accomplish the
goals of fracture xation for fractures in this
area, including to restore length, to restore
axial rotation, to restore angular alignment,
and to obtain union. The surgeon must plan
the reduction technique and choose the ap-
propriate implant to obtain stable xation,
while preserving the vitality of the bone.
Anatomic reduction of each fracture surface is
not crucial, and it should not be the absolute
goal of surgery in the diaphysis, especially
if the tradeoff for anatomicity is the devi-
talization of the fracture zone. The surgeon
must remember that living bone will heal. If
there is question of the preservation of living
bone in the fracture zone in these fractures,
autogenous bone graft should be considered.
The third principle is the postoperative care,
which is as important as the operative treat-
ment. The postoperative rehabilitation needs
to be individualized for patient factors, the
fracture pattern, and the operative result. The
ultimate goal is the best possible functional
outcome.
Intramedullary Fixation
Intramedullary xation offers mechani-
cal, technical, and biologic advantages over
other forms of xation. Statically locked in-
tramedullary nails are probably the most
commonly used implant in the treatment of
subtrochanteric femoral fractures and consid-
ered by many as the implant of choice. For

fractures that are completely below the level
of the lesser trochanter, a standard statically
locked intramedullary nail has been used with
good results. For fractures that extend into
the lesser trochanter but do not involve the
greater trochanter at the area of the piriformis
fossa, a cephalomedullary, statically locked
intramedullary nail may be employed with ex-
pectations of good results. Cephalomedullary
nails have been shown to provide improved
stability for proximal fractures so that in this
situation in which there is some question
of the proximal extent of the fracture or in
situations in which increased stability may be
thought to be important, one should lean in
the direction of using the cephalomedullary
nails over standard locked nails.41 These situa-
tions may include fractures at the level of the
lesser trochanter with severe comminution or
patients with concerns of poor bone quality.
Intramedullary nails are not recommended
generally for subtrochanteric fractures that
involve the greater trochanter and the area
of the piriformis fossa. In these situations,
the nail may be inserted through the frac-
ture and lead to further displacement of the
intertrochanteric component of the fracture.
Intramedullary hip screw devices have been
used for some intertrochanteric fractures and
subtrochanteric fractures. These devices are
inserted through a greater trochanteric inser-
tion site and may extend the indications for
intramedullary xation to the fractures that in-
volve the piriformis fossa. Their use has led to
acceptable union rates with decreased blood
loss and short operative times.4, 5, 7, 14, 31, 35, 45, 54
Concerns with these devices are their large
diameter proximally, which may require
reaming at the trochanter to 17 or 18 mm.
The long-term importance of removing this
amount of bone from the proximal femur in a
young patient is unknown and should be con-
sidered cautiously when considering the use
of these implants in young patients. Also, this
amount of reaming at the greater trochanter
may have an effect on the abductor insertion.
The biomechanical advantages of in-
tramedullary nails in these types of fractures
have been alluded to earlier and are generally
well known. For fractures below the lesser
trochanter, which basically are diaphyseal
fractures, intramedullary nails have a proven
References 2, 1012, 22, 25, 26, 28, 34, 37, 47, 53, and
59.
SUBTROCHANTERIC FEMORAL FRACTURES 117
track record. They provide relative stability to
the fracture and have high union rates with a
low incidence of nonunion, hardware failure,
or loss of alignment. The cephalomedullary
nails have a biomechanical advantage over
plates. Nails because of their intramedullary
position have a shorter distance to the tip
of the portion of the implant in the femoral
head than do the plate systems that are on
the lateral border of the bone. The shorter the
distance over which the bending forces act, the
lower the moment is on the implant. This is
especially important in fractures in which the
medial buttress cannot be restored. In some
fracture patterns, early weight bearing may
be allowed with intramedullary xation. The
biologic advantage of intramedullary nails
also is well known. These devices allow for
indirect reduction without exposure of the
fracture. This maintenance of the vitality of the
bone in the area of the fracture usually leads
to rapid healing with abundant callus. It is
postulated that reamings may spill into the
fracture site and may function as bone graft
material. The relative importance of these
reamings is unclear. Reaming itself does have
some impact on blood ow to this area, which
may stimulate periosteal reaction and healing.
Technically, intramedullary nails offer
advantages and disadvantages. Most ortho-
pedic surgeons are familiar with techniques
for intramedullary nailing of femoral frac-
tures. Also, the surgery can be accomplished
through small incisions with some amounts of
external blood loss.
These fractures do offer a technical chal-
lenge to obtain a good reduction and restore
axial rotational and angular alignment and re-
store length (Fig. 1). These fractures usually
are abducted because of the pull of the hip ab-
ductors on the greater trochanter. This posi-
tion may cause difculty in nding the appro-
priate starting point and being able to pass a
reamer in the appropriate direction down the
intramedullary canal. The greater trochanter
tends to be in the way with a proximal frag-
ment abducted, and the guidewire and ream-
ers tend to go from a more lateral starting
point than ideal and pass medial toward the
medial cortex. Additionally, the pull of the
iliopsoas on the proximal fragment leads to
exion. This exion should be corrected while
reaming to prevent completely reaming away
the posterior cortex of the short proximal frag-
ment. The alignment of the fracture may re-
quire a small incision to allow a pushing
118 SIMS

Figure 1. A, AP radiograph of proximal femur in a 60-year-old patient involved in a motor vehicle acci-
dent with a subtrochanteric femur fracture with involvement of the area of the lesser trochanter without
extension into the piriformis fossa. B and C, Postoperative AP and lateral radiographs after insertion
of a sliding intramedullary hip screw (Gamma nail, Howmedica, Rutherford). This shows a typical
maintenance of malalignment commonly seen after intramedullary nailing of these subtrochanteric
femur fractures with the proximal fragments remaining in some varus angulation, with signicant per-
sistent exion of the proximal fragment leading to an apex anterior deformity.
 SUBTROCHANTERIC FEMORAL FRACTURES 119

tool to be used to push the proximal frag-
ment toward adduction and extension, while
manipulating the leg to help maneuver the
distal fragment (Fig. 2). Occasionally, placing
a clamp at the fracture may be required. Good
anteroposterior and lateral radiographs are
essential, and the alignment must be assessed
carefully during each stage of the surgery.
Rotational alignment also must be assessed
carefully because the proximal fragment may
be externally rotated; this should be compared
with the opposite extremity and conrmed to
be symmetric with the opposite leg clinically
and radiographically before leaving the op-
erating room. In comminuted fractures, leg
length may be determined by measurement

Figure 2. A, The preoperative AP radiograph of a subtrochanteric femur fracture

with extension into the area of the lesser trochanter in a young patient with high-
energy trauma. B, Intraoperative C-arm view after making a 5-cm incision cen-
tered over the area of the fracture. An elevator is then placed anteriorly and lat-
erally on the distal portion of the proximal fragment to push this fragment into
anatomic alignment. This was done by pushing posteriorly to resolve the exion
of the proximal fragment and pushing in the medical direction to solve the abduc-
tion deformity forces. This is maintained in alignment throughout the procedure by
an assistant while a guide-wire and reamers, and subsequently the intramedullary
nail, are passed across the fracture site. C and D, AP and lateral radiographs of
this fracture at approximately 2 months postoperatively, with good alignment and
callus formation.
120 SIMS
of the opposite leg and choosing a nail length
based on this measurement. Leg lengths
should be checked clinically before leaving
the operating room and adjusted if needed.
Residual apex anterior angulation with exion
of the proximal fragment often is seen after in-
tramedullary xation of subtrochanteric fem-
oral fractures. This angulation may be recog-
nized more easily in the long spiral fractures
typically associated with low-energy trauma
of older patients because the length of the
fracture magnies the offset seen. The ef-
fects of this angulation on the functional and
long-term outcome of patients are not clear.
Sliding Hip Screws
Sliding hip screw devices have been em-
ployed with good success in the treatment
of subtrochanteric femoral fractures.6, 36, 42, 56, 58
Union rates of 95% and average healing times
of 2.5 months have been reported. These im-
plants do offer some advantages. They are
strong implants with low rates of fatigue fail-
ures. They are familiar implants to most ortho-
pedists because of their common use and in-
tertrochanteric fractures, which may decrease
some of the technical difculties. Cutout of the
implants can be avoided with proper place-
ment of the compression screw in the center of
the femoral head and the design allowing slid-
ing of the screw on the plate. Best results with
this type of device have stressed the impor-
tance of restoring the medial buttress, if neces-
sary with bone grafting.
These implants do have some disadvan-
tages and limitations. As stated earlier, intact
medial buttress is important with these im-
plants. To obtain an intact buttress may re-
quire stripping of bone fragments medially
and placement of lag screws. Bone graft is nec-
essary in these situations to avoid nonunion
with subsequent fatigue of the plate. In frac-
ture patterns that are complex and multifrag-
mentary, especially over a segmental area,
these implants are not appropriate because
they telescope until the threads of the com-
pression screw reach the barrel of the plate.
This situation prevents further sliding, which
may make head penetration more likely; this
also results in an excessive medialization of
the shaft of the femur. Maintenance of normal
anatomic relationship of the proximal head
and neck fragments to the femoral shaft is
often not maintained in these fragments for
2 reasons. First, any sliding of the compression
screw in the plate results in medial transla-
tion with subtrochanteric fractures, in contrast
to intertrochanteric fractures, in which it leads
only to impaction of the fracture fragments
without change in their position. Second, with
only the compression screw through the bar-
rel of the proximal fragment, sagittal plane de-
formities may be difcult to avoid. Although
the compression screw is keyed into the bar-
rel of the plate, the head may spin on the
screw, and exion of the proximal fragment
may occur. If the fracture pattern allows ad-
ditional screws through the plate to be placed
in the proximal fragment, it helps resist this
type of reduction; however, it also may pre-
vent the sliding hip screw to slide as it is de-
signed. Finally, the implant does not lend it-
self to axial loading with a tensioning device,
which has been reported to be important.29
There have been reports of poor results with
loss of reduction and loss of xation with these
devices leading to unacceptable rates of re-
vision surgery.23 This implant was designed
for treatment of intertrochanteric fractures and
should be used cautiously in rare instances
only for treatment of subtrochanteric femoral
fractures.
95 Fixed Angle Devices
The 95 condylar blade plate and the 95
condylar screw devices are discussed together
in this section. These implants have unique
characteristics, which should be considered,
but both function as a 95 xed angle device
when placed. The angled blade plates are a
xed angle 1-piece device rst developed by
the AO group in 1959. The 95 condylar blade
plate was released later in the 1970s and still
is useful in the treatment of subtrochanteric
fractures.3, 21, 38, 47, 49, 5557 The 1-piece design cre-
ates the disadvantage of increased difculty
with insertion. The plate has to be inserted in
the appropriate location in the head at the cor-
rect angle. Additionally, the blade must be in-
serted so that the plate portion of the condylar
blade plate lines up with the axis of the shaft
at the end of the procedure. Good radiographs
and careful attention to detail are required be-
cause the blade is inserted with the fragments
still in a displaced position, and the implant
is used to accomplish the reduction. Malalign-
ments are not easily adjustable after the blade
has been placed.

The technical difculties led to the later
development of the dynamic condylar screw,
which was designed primarily for the distal
femur but also proved useful in the treatment
of subtrochanteric femoral fractures. This
implant, the dynamic condylar screw, has in-
creased thickness, which makes it more
resistant to fatigue fracture than the 95 condy-
lar blade plate, and allows for easier adjust-
ment in the alignment in the sagittal plane
after the screw is placed. It does require more
bone to be removed for its placement, how-
ever, which may complicate further surgery
should a nonunion or other complication
occur.
These 95 xed angled implants were rec-
ommended for use as a lateral tension band
system requiring reconstruction of the me-
dial buttress and additional bone grafting.
Nonunion rates were reported in 10% to 18%
of patients, and these nonunions often were
explained as being secondary to not recon-
structing the medial cortex, and their use was
urged to be restricted only to cases in which
the medial cortex could be restored. This rec-
ommended plate technique requires visualiza-
tion of the fracture line, necessitating suf-
cient medial dissection to verify the quality
of the reduction and the stabilization of frac-
ture fragments. More recently, the importance
of maintaining the blood supply and vitality
of all fragments by avoidance of medial dis-
section has been emphasized. Medial dissec-
tion is avoided by determining the entry site of
the blade by a preoperative plan using a radio-
graph of the opposite hip. Image intensica-
tion may be used to conrm proper placement
of the implant. No dissection of the fracture
area and no attempts at reduction are made up
to this point. The shaft of the plate is applied
to the main distal fragment with a clamp dis-
tal to the fracture zone with care to avoid
stripping any soft tissues in the fracture zone
(Fig. 3).
The femoral distractor occasionally may be
of assistance to gain length. Axial loading by
use of a tensioning device increases stability of
this system and allows the bone to share some
of the load with the plate. These plates may
be slid submuscularly from proximal to distal
without removing any muscle from the femur
in the fracture zone. The bone can be exposed
only at the entry point proximally and distally
at the area of the screws insertion. It is possi-
ble to accomplish this surgery with only small
skin incisions proximally and distally in some
SUBTROCHANTERIC FEMORAL FRACTURES 121
situations. This technique of indirect reduction
with a 95 xed angle implant and tensioning
of the system has led to improved results
reported as 100% union rate and 4.2 months
time to healing without bone grafting.29
This is a very exact technique and requires
preoperative planning and careful surgical
technique to duplicate these excellent results
(Figs. 4 and 5).
SUMMARY
Subtrochanteric femoral fractures can be
complex fractures for treatment with high
complication rates historically. Multiple im-
plants have been used with varying rates of
success. The Russell-Taylor classication is
useful in planning the type of internal xation
best suited for the fracture with the implants
that currently are used most commonly. For
fractures located below the level of the lesser
trochanter, standard locked intramedullary
nails can be used effectively. For fractures that
extend into the lesser trochanter but do not
involve the piriformis fossa, the options of a
cephalomedullary nail versus a 95 xed angle
device have yielded the best results. The ad-
vantages and disadvantages of these 2 systems
have been discussed. If one chooses a 95 xed
angle device, careful adherence to indirect
reduction techniques with preservation of the
blood supply to the fracture zone should be
employed. Implant device of choice should
be based on careful review of the fracture
pattern and the surgeons experience with
fractures in this region. The 95 condylar blade
plates still serve an important role for fractures
in this area because they greatly facilitate a
return of an anatomic reduction and good
maintenance of this reduction until fracture
healing if careful indirect reduction techniques
are employed. Good results also can be ob-
tained with cephalomedullary implants. For
fractures that do have proximal trochanteric
extension into the area of the piriformis fossa
or greater trochanter, sliding nail screw de-
vices may have some usefulness in the future;
however, outcomes are not well documented
at this time. Otherwise, fractures in this area
are suited best to the use of an appropriate
95 xed angle device. The DHS implant in
the authors opinion has limited usefulness
and is not employed for the treatment of
subtrochanteric femoral fractures.
 Figure 3. A, The preoperative radiograph in a young patient involved in a high-energy trauma with a
segmental area of multifragmentary fracture extending from the area of the lesser trochanter to the
area of the isthmus. B and C, AP and lateral postoperative radiographs after insertion of a 95 DCS
device. This operation was performed through a small proximal incision and a small distal incision with-
out any skin incision or any exposure over the area of the fracture. The entry port was established
proximally and the plate was then slid submuscularly to assure indirect reduction techniques and no
damage to the vitality of the fracture zone. No attempt to restore the medial buttress and no bone graft-
ing was performed. D and E, Radiographs obtained 10 weeks postoperatively with abundant callus
formation already present. At this time, the patient is full weightbearing without pain. F and G, The -
nal radiographs obtained at 5 months postoperatively with complete healing of the fracture treated with
122 this 95 device and indirect reduction technique with submuscular plating.
 SUBTROCHANTERIC FEMORAL FRACTURES 123

Figure 4. A, The preoperative radiograph a young patient involved in a high-energy trauma with an
area of segmental multifragmentary fracture involving the lesser trochanter, as well as with extension
proximally into the piriformis fossa and greater trochanter. B and C, The AP and lateral postopera-
tive radiographs of this fracture treated with a 95 condylar blade plate. This was done without taking
the muscle down off of the area of the fracture zone and using the 95 condylar blade plate to estab-
lish the reduction after the blade had been placed in the proximal fragment. No attempt to reconsti-
tute the medial buttress was made and no bone grafting was performed. D and E, The AP and lateral
radiograph obtained at 10 weeks postoperatively with abundant callus formation. The patient began
full weightbearing at this point and did go on to uneventful union with excellent radiographic and func-
tional outcome, again demonstrating the ability of this area to heal with careful indirect reduction tech-
niques avoiding damage to the vascularity of the fracture zone.
124 SIMS

Figure 5. A and B, AP and lateral preoperative radiographs in a young patient with this sub-
trochanteric femur fracture that extends into the area of the lesser trochanter, but does not extend
proximal to this. This demonstrates the typical picture seen of abduction, external rotation, and ex-
ion of the proximal fragment due to strong muscle forces that pull on it and can lead to difculties with
closed reductions. C and D, The postoperative AP and lateral radiographs obtained at 45 months
postoperatively. Reconstitution of alignment with healing with abundant callus in this fracture was
treated with an indirect reduction technique using the 95 condylar blade plate to accomplish the re-
duction after it had been xed to the proximal fragment in the appropriate position.

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Address reprint requests to
Stephen H. Sims, MD
Miller Orthopaedic Clinic
1001 Blythe Boulevard, #200
Charlotte, NC 28203
TREATMENT OF COMPLEX FRACTURES 00305898/02 $15.00 + .00

COMPLICATED FEMORAL
SHAFT FRACTURES
George V. Russell, Jr, MD, Philip J. Kregor, MD,
Christopher A. Jarrett, MD, and Michael Zlowodzki, MD

Since the advent and popularization of in-
tramedullary nailing, the treatment of femoral
shaft fractures has become a good, safe, and
reproducible procedure for the successful
management of femoral shaft fractures. Many
orthopaedic surgeons have been trained well
in the nailing of femoral shaft fractures and
commonly treat these injuries; however, many
femoral shaft fractures are complicated by
associated fractures, extensive comminution,
extensive contamination, arterial injury, and
compartment syndrome. Other problematic
situations include existing nonunion with
broken hardware, deformed nails with acute
injury, and associated femoral shaft and
femoral neck fractures. The management of
these complex femur fractures is not common
and demands special techniques to obtain a
successful outcome. The techniques to suc-
cessfully treat several types of complicated
femoral shaft fractures are discussed herein.
OPEN FRACTURES
Considerable energy is required to create
a femoral shaft fracture, and even greater
energy is required to create an open femoral
shaft fracture. Open femoral shaft fractures
usually result from motor vehicle accidents
and often are associated with other injuries
and fractures. The rst priority in a patient
with an open femoral shaft fracture is eval-
uation and stabilization of life-threatening
injuries. After resuscitation and medical stabi-
lization, one must consider surgical stabiliza-
tion of the femoral shaft fracture.
Historically, open femoral shaft fractures
were treated with operative debridement and
skeletal traction. As management of femoral
shaft fractures has evolved, several investiga-
tors have demonstrated benecial effects to
patient management with early stabilization
of femur fractures. Early retrospective stud-
ies evaluating the efcacy of early fracture
stabilization of multitrauma patients found
that the incidence of acute respiratory distress
syndrome and other complications associated
with prolonged recumbency were consider-
ably decreased.27, 58 Also, the mortality rate
was decreased in multiply injured patients
who underwent early fracture stabilization.27
Bone et al,8 in a prospective study compar-
ing early versus delayed xation of femur
fractures, found the incidence of pulmonary
complications, hospital stay, and intensive
care unit stay were all decreased in patients
who underwent early stabilization of femur
fractures.
As early stabilization of open femoral shaft
fractures became widely accepted, various
techniques and implants evolved to stabilize
these fractures. Early management included
ORIF using plates,45, 60 open intramedullary

From the Department of Orthopaedic Surgery, University of Mississippi Medical Center, Jackson, Mississippi (GVR,
PJK, MZ); and the Department of Orthopaedic Surgery, University of South Alabama Medical Center, Mobile,
Alabama (CAJ)

ORTHOPEDIC CLINICS OF NORTH AMERICA

VOLUME 33 NUMBER 1 JANUARY 2002 127

128 RUSSELL et al
nailing with cerclage wires,38, 71 and external
xation.1, 30, 49 These techniques have been
largely abandoned because of a considerable
complication prole and the success of closed
intramedullary nailing in the treatment of
open femoral shaft fractures.
Closed intramedullary nailing has become
the standard of care for both closed and
open femoral shaft fractures. Chapman15 re-
ported no infections and good functional
results after delayed (1014 days after in-
jury) closed intramedullary nailing of open
femur fractures, but this technique negated
the benets of early patient mobilization.
Brumback et al11 had no infections in patients
with type 1 or 2 open femoral shaft fractures
stabilized in either early or delayed fashion
with closed, reamed intramedullary nailing.
Winquist et al74 reporting on 520 femoral
nailings, of which 86 were type 1 or 2 open
fractures, found a 2% infection rate. Lhowe
and Hansen42 found a 5% infection rate in their
series of 67 patients who underwent imme-
diate closed reamed nailing for open femoral
shaft fractures.
Treatment of type 3 open femoral shaft
fractures with reamed intramedullary nailing
has demonstrated good results with accept-
able infection rates. OBrien et al50 found ve
supercial and three deep infections among
63 open femoral shaft fractures treated with
early closed nailing. Lhowe and Hansen42
found no infections among eight patients with
type 3 open fractures. Similarly, Wolinsky
et al80 reported no infections among 15 pa-
tients with type 3 open fractures treated with
intramedullary nailing. Brumback et al11 re-
ported no infections among patients with type
3A open fractures, but 3 of 27 patients with
type 3B open fractures developed infections.
Some have advocated the use of unreamed
nails in the treatment of open femoral shaft
fractures to decrease infectious complications;
however, the complication prole is similar
to that of reamed nails, and the use of un-
reamed nails requires more secondary surgical
procedures.19
Retrograde nailing has gained popularity
for the stabilization of femoral shaft fractures,
but the role of retrograde femoral nails has not
been clearly established with open fractures.
Fear of knee joint contamination and subse-
quent septic knee arthrosis has deterred some
from its use in open fractures. Ostrum et al,52
using reamed retrograde nails, recommended
against their use in patients with type 3 open
fractures despite the fact that the only sep-
tic knee occurred in a patient with a closed
fracture and not in the 16 patients with open
fractures. Moed et al,48 using unreamed ret-
rograde femoral nails, did not have any in-
fections or septic knees in their series, which
included 11 open fractures, but one third of
the patients required dynamization to achieve
union.
Management of types 1 and 2 open femoral
shaft fractures should consist of urgent irri-
gation and debridement followed by closed,
reamed, antegrade femoral nailing; however,
management of type 3 open fractures can
be controversial. For type 3A open fractures,
good results have been demonstrated with
closed, reamed femoral nailing and can be
safely recommended. A consensus statement
is difcult to make regarding management of
type 3B open fractures or those open frac-
tures associated with massive contamination.
The difculty lies in part because previous
literature does not typically distinguish be-
tween type 3A and type 3B open fractures and
also because of the relative paucity of these
types of injuries. Most patients with type 3B
open femoral shaft fractures can be managed
safely with urgent irrigation and debridement
followed by closed, reamed intramedullary
nailing. If, however, extensive contamination
is encountered, a provisional spanning exter-
nal xator may be applied until the open
wound is clean enough to allow for antegrade
nailing.
Retrograde femoral nailing is not routinely
performed for open fractures at the authors
institution; however, reamed retrograde nail-
ing techniques have been used safely in types
1 and 2 open femoral shaft fractures in patients
with associated ipsilateral acetabular, patel-
lar, and tibial shaft fractures (Fig. 1). Similar
patients with type 3 open fractures also have
been managed with retrograde nailing tech-
niques, but concerns about knee joint contami-
nation have limited the use of retrograde nails
in these patients. Recently, the senior author
(GVR) stabilized open femoral shaft fractures
with plates, emphasizing indirect fracture re-
duction techniques with good results seen at
early follow-up.
SEGMENTAL FEMORAL
SHAFT FRACTURES
Segmental femoral shaft fractures occur in
approximately 5% of femoral shaft fractures.76
Segmental fractures of the femur result from
high-energy injuries and are usually accom-
panied by massive soft tissue damage.76, 82

Figure 1. This 17-year-old female patient sustained bi-
lateral transforaminal sacral fractures, bilateral acetabular
fractures, right closed femoral shaft fracture, left Gustilo
Type II open femoral shaft fracture, and left patella frac-
ture, as a result of a motor vehicle crash. Her femoral
shaft fractures were stabilized the day of the injury in a
single operative anesthetic, allowing for concomitant left
patellar fracture xation without jeopardizing planned op-
erative exposures for the acetabular fractures.
The resultant fracture can be characterized
by the position of the segmental component
as a purely diaphyseal intercalary segment,
a subtrochanteric-diaphyseal component, a
diaphyseal-supracondylar segment, or a vari-
ation thereof. Also, the intercalary fracture
fragment can be a simple intercalary fragment,
a fragment with multiple fracture planes, or a
comminuted intercalary fragment.
Although technically difcult, intramedul-
lary nailing has been recommended by sev-
eral investigators and has demonstrated
good results.2, 67, 75, 76 When electing intramed-
ullary nailing, care must be taken for proper
nail selection. Standard interlocking in-
tramedullary nails may be used successfully
for fractures that are distal to the lesser
trochanter; however, this may require leaving
the nail proud to ensure proximal xa-
tion. Cephalomedullary nails are required
COMPLICATED FEMORAL SHAFT FRACTURES 129
for fractures that are proximal to the lesser
trochanter but do not involve the piriformis
fossa. Fractures with proximal extension to
the piriformis fossa are best treated with a
xed-angle device. Retrograde nails are also
an option if the proximal fragment is long
enough to ensure adequate stabilization with
the proximal locking bolts.
Patients with segmental femoral shaft frac-
tures are best treated on a fracture table using
traction to reestablish proper length, rotation,
and alignment. A full-length radiograph of the
contralateral femur is benecial in establishing
proper length and alignment. Proper rotation
may be difcult to determine but can be as-
sisted by clinical examination of the contralat-
eral thigh or if this is not possible radiographic
analysis is possible using intraoperative uo-
roscopic imaging.70
The starting hole is crucial, and care must
be taken to ensure that it is within the piri-
formis fossa and aligned with the long axis
of the proximal femur in the AP and lateral
uoroscopic images. Cephalomedullary nails
require a slightly anterior starting hole to
allow for passage of screws or spiral blade
through the femoral neck into the femoral
head. A helpful technique, if the fracture
pattern allows, is to reduce the segmental
component to the proximal fragment and then
pass the guidewire in the center of each frag-
ment using uoroscopic imaging. Reaming is
then undertaken to the appropriate diameter.
After reaming proximally, the distal fracture
is then reduced and the guidewire is passed
into the distal fracture fragment. Reaming
then is performed in the distal fragment to the
same diameter as was done proximally. For
fractures with a large comminuted segmental
fracture, the guidewire is passed through
the proximal and distal intact femur and
reaming is undertaken bypassing the com-
minuted injury zone, with care to maintain
reduction.
Obtaining and maintaining reduction is
often difcult without an intact diaphysis to
use as a template for reduction. Also, multi-
ple fracture lines often are difcult to align
with closed manipulative means. Reduction
devices commonly are required to obtain
and maintain reductions. Mallets and spiked
pushers, found on the pelvic reduction tray,
are useful to push fragments into position.
Various hooks are also useful if fragments
require a pull to obtain reduction. Unicortical
diaphyseal or bicortical metaphyseal Schanz
pins are frequently benecial in aligning
intercalary fractures and the distal metaphysis
130 RUSSELL et al
during guidewire placement, reaming, and
nail placement.
Passage of the nail requires vigilance to
maintain an appropriate reduction. Without
an intact diaphysis to capture the nail, the
nail tends to translate medially. This can be
particularly problematic in patients with large
buttocks in whom there is difculty in ad-
ducting the proximal nail and jig against the
soft tissues, which exacerbates distal medial
nail translation. Occasionally, it may be nec-
essary to guide the nail into the distal meta-
physis with a percutaneously placed hook.
With introduction of the nail into the distal
femoral metaphysis, alignment must be mon-
itored because the nail will have a tendency
for eccentric placement leading to fracture
malalignment. Reduction must be reexamined
after the nail is seated, and locking screw
positions must be ensured both proximally
and distally. Based on the fracture pattern,
it may be necessary to place a slightly long
nail proud to ensure adequate locking bolt
placement.
Plating of segmental femoral shaft fractures
is also an option, particularly when associ-
ated with peritrochanteric fractures. Plating of
segmental femur fractures has been associated
with periosteal stripping, increased blood loss,
and increased operating room time.76 Despite
these reported disadvantages, plating has the
advantages of direct visualization to assist
with fracture reduction and also management
of very proximal and very distal fractures
are frequently easier with plating techniques.
Periosteal stripping can be minimized with in-
direct reduction techniques despite an open
surgical wound. Bridge plating of commin-
uted fracture zones also minimizes periosteal
stripping and allows for healing by callus
formation.
Patients may be placed on a radiolucent
table or a fracture table. If a radiolucent
table without traction is used, a femoral
distractor is recommended to maintain the
appropriate femoral length. A fracture table
is recommended for fractures with extensive
comminution or when proximal fracture ex-
tension is into the peritrochanteric region.
Traction is benecial to attain and maintain
proper length, rotation, and alignment during
reduction and plating. The surgical exposure
is based on the fracture pattern. If a long surgi-
cal exposure is required, periosteal stripping
should be minimized laterally and medial
soft tissue stripping should be avoided. If a
submuscular plating technique is performed,
only small incisions are required and soft
tissue stripping is minimized.
Fixed-angle devices are recommended for
fractures that enter into piriformis fossa and
usually require long surgical exposures for
plate placement; however, a dynamic condy-
lar screw and side plate can be placed using a
percutaneous technique.61 A standard 4.5-mm
broad low contact dynamic compression
(LCDC) plate is also an option if adequate
screw purchase can be obtained proximal and
distal to the fracture. A careful preoperative
plan is required before surgery. Reduction
techniques are typical for many other fractures
in which plates are applied with an emphasis
on minimizing soft tissue stripping. Using
techniques to decrease soft tissue stripping
and other techniques to promote healing with
callus formation, good results can obtained
plating segmental femoral shaft fractures.46
FEMORAL SHAFT FRACTURES IN
COMBINATION WITH IPSILATERAL
FEMORAL NECK FRACTURES
An ipsilateral fracture of the femoral neck
is a signicant nding in patients with a
femoral shaft fracture, occurring in 2% to
6% of femoral shaft fractures.6, 69, 74, 83, 84 Most
of these double fractures result from high-
energy trauma,16, 26, 34, 55, 79 with motor vehicle
accidents, motorcycle accidents, and falls from
signicant heights being the most common
causes.79 Frequently, the femoral neck frac-
ture is not initially diagnosed; several series
have shown that as many as 33% of associ-
ated femoral neck fractures were not initially
diagnosed.6, 68, 69
Most commonly, the femoral neck fracture
is a minimally displaced vertical fracture.40
Daffner et al,21 in explaining the high percent-
age of initially missed femoral neck fractures,
noted that these fractures tend not to displace
during the initial evaluation period. Often, an
external rotation deformity of the proximal
femoral fragment is present secondary to the
femoral shaft fracture, and the femoral neck
is not well visualized in this position. Several
investigators have noted that the most accu-
rate visualization of the femoral neck occurs
with 15 of internal rotation.39, 69 A commin-
uted midshaft femoral fracture secondary to
axial loading should alert the treating physi-
cian to the possibility of an associated femoral
neck fracture.55
As part of the Advanced Trauma Life
Support protocol, all traumatized patients

undergo AP pelvic radiography on presen-
tation to the emergency department. Gill
et al26 recommend, in addition to the initial
AP pelvic radiography, specic hip radiogra-
phy to better detect associated femoral neck
fractures. Hughes et al36 recommend a femoral
neck CT scanning in obtunded multitrauma
patients with high-energy femoral shaft frac-
tures but further state that pelvic CT scans
taken for other purposes also can be useful to
detect a neck fracture. Several investigators
report that the femoral neck can fracture after
the antegrade insertion of a nail for femoral
shaft fracture treatment.17, 31, 66 Therefore, the
authors recommend intraoperative radio-
graphy of the femoral neck in 15 internal
rotation after insertion of the femoral nail.
Ipsilateral femoral neck and femoral shaft
fractures typically occur in multitrauma
patients. Therefore, treatment options should
highlight decreased operative time, decreased
blood loss, and decreased technical difculty.
Also, xation of either fracture potentially
compromises xation of the other fracture, but
the ultimate goal of any treatment plan should
be anatomic reduction of the neck fracture and
stable xation of the femoral neck and shaft
fractures.6, 14, 68, 69, 79
Treatment options are ORIF of the femoral
neck and antegrade nailing of shaft fracture,
ORIF of the femoral neck and retrograde nail-
ing of femoral shaft, a cephalomedullary nail
(e.g., Russell-Taylor reconstruction femoral
nail) or ORIF of the femoral neck and plating
of the femoral shaft fracture (Fig. 2).
Several investigators recommend immedi-
ate internal xation of the femoral neck frac-
ture followed by femoral shaft stabilization
given the potentially devastating complica-
tions of the femoral neck fracture, especially
in young patients (e.g., avascular necrosis,
nonunion, and malunion).14, 25, 55, 69 Other in-
vestigators believe, however, that a delay of
days to weeks does not seem to increase the
complication rate.6, 83
Swiontkowski et al69 reported a series of
15 patients treated with urgent ORIF of the
femoral neck fracture with multiple cancel-
lous screws. The associated femoral shaft
fractures were treated either with closed
retrograde intramedullary nailing; dynamic
compression plating; and, in a single case of
a very distal femoral shaft fracture, a blade
plate. All of the fractures united 4 months
postoperatively, and of the nine patients
followed up for at least 3 years, two devel-
oped aseptic necrosis of the femoral head.
COMPLICATED FEMORAL SHAFT FRACTURES 131
Geissler et al24 also treated six patients with
screw xation of the femoral neck and com-
pression plate xation of the femoral shaft
with uncomplicated union of both fracture
types.
Antegrade intramedullary nailing followed
by screw xation of the neck is also a widely
used treatment option. Wu and Shih83 treated
22 patients with this protocol without any
osteonecrosis or nonunions noted at 26-month
follow-up. Benett et al6 also managed
19 patients with a similar protocol, and no
patient demonstrated either nonunion or os-
teonecrosis at 12-month follow-up. Their re-
sults regarding osteonecrosis are not convinc-
ing, however, because of limited follow-up
and the fact that osteonecrosis may not
develop for more than 3 years after injury, par-
ticularly in young patients.68, 69 Despite the
popularity of this management sequence,
several difculties must be noted, including
difculty achieving stable xation of the
femoral neck, technical difculty of placing
screws anterior to the femoral nail, potential
compromise of the femoral head blood supply,
malunion and nonunion.78
Another treatment option is the use of a
cephalomedullary femoral nail. These nails
allow for the placement of either screws or a
spiral blade device across the femoral neck
fracture into the femoral head. The same dis-
advantages as with the standard antegrade in-
tramedullary nail regarding the blood supply
to the femoral head and xation of the femoral
neck fracture also apply to this nail. Randelli
et al56 treated 27 ipsilateral femoral neck and
shaft fractures with the Russell-Taylor re-
construction nail. The femoral neck fractures
healed at an average of 3.7 months, and
femoral shaft fractures healed within an av-
erage of 4.8 months. Complications included
one case of avascular necrosis of the femoral
head, and varus malunion of a femoral neck
fracture. Several other series showed similar
results with a limited complication prole;
however, instances of nonunion and malu-
nion of the femoral neck were noted in each
series.6, 9, 51, 79
Although each management protocol has
demonstrated successful results, each has as-
sociated difculties particular to the service of
xation and the implant selection. No method
has been established as the gold standard.
The choice of treatment hinges on many pa-
tient, surgeon, and implant variables, and the
choice of treatment must be framed within this
context.
132 RUSSELL et al

Figure 2. A 22-year-old woman was involved in a motor vehicle crash and sustained a ruptured
spleen necessitating a laparotomy. She was hemodynamically unstable. Her orthopaedic injuries in-
cluded bilateral sacroiliac joint disruptions, symphysis pubis disruption, and a right femoral neck frac-
ture. A, Injury AP radiograph. B, AP radiograph of right proximal femur. C, The patient underwent
open reduction-internal xation of the right femoral neck through a Watson-Jones approach. Sub-
muscular plating of the right femur was then performed, introducing the plate proximally through
the Watson-Jones incision. Because of her signicant instability, external xation and percutaneous
iliosacral screws were chosen for denitive xation of her pelvis. AP radiograph of the right femur post-
operatively. D, AP radiograph at 1 year. The patient had a mild Trendelenburg limp, but was otherwise
asymptomatic. E, Uneventful healing of the femur at 1 year.

FEMORAL SHAFT injury are rare (1%).41 Because of the low

FRACTURES ASSOCIATED incidence of associated arterial injury with
WITH VASCULAR INJURY femoral shaft fractures, detection of these
injuries can be delayed.4 Several types of ar-
Vascular injuries associated with femoral terial injuries have been described, including
shaft fractures not resulting from a penetrating complete laceration, thrombosis, intramural
 COMPLICATED FEMORAL SHAFT FRACTURES 133

hematoma, spasm, stretch injury, and intimal ow, such as intimal tears and small pseudoa-
tears.20 Associated vascular injuries most neurysms. Also, API results may be inaccurate
commonly associated with femur fractures in patients in hypovolemic shock, and attain-
result from tethering injuries of the supercial ing pressure measurements may not be practi-
femoral artery (SFA) at the adductor hiatus cal in some multitrauma patients.37
in combination with distal femoral shaft and
supracondylar fractures32 (Fig. 3). Lacerations
FEMORAL SHAFT FRACTURES
of a branch of the profunda femoris artery
ASSOCIATED WITH
have been reported and usually manifest
COMPARTMENT SYNDROME
themselves as a thigh hematoma; however,
unlike SFA injuries, the risk for limb gangrene
Compartment syndrome of the thigh is a
is not present.12 Unless a patient presents
rare nding after an isolated femoral shaft
with obvious signs of vascular compromise,
fracture. Schwartz et al64 found only 21 cases
the evaluation of vascular injury associated
of thigh compartment syndrome in 17 patients
with femoral shaft fractures must begin with
after reviewing more than 6000 patient admis-
a high index of suspicion. Intimal tears and
sions over a 4.5-year period. Ten of the cases
intramural hematomata may present with
of thigh compartment syndrome were found
palpable pulses and have contributed to de-
to be associated with either open or closed
layed diagnoses of vascular injuries associated
femur fractures. Compartment syndrome of
with femoral shaft fractures.4 Also, collateral
the thigh is seen more often in multitrauma
ow may account for palpable pulses in the
patients who often present with risk factors
face of an SFA injury.12 Patients with an open
for the development of thigh compartment
injury and signs of vascular compromise
syndrome, such as systemic hypotension, co-
should be taken immediately to the operating
agulopathy, vascular injury, prolonged limb
room for intraoperative angiography and
compression, and the use of military antishock
emergent revascularization. In other patients,
trousers.64
the pulse should be palpated and, if unsuc-
Diagnosis of thigh compartment syndrome
cessful, Doppler signals should be sought. For
demands a high index of suspicion, particu-
patients with diminished pulses, biplanar, se-
larly in unresponsive patients. Patients who
quential angiography is the gold standard for
are responsive typically complain of severe
detecting subtle vascular injuries20 ; however,
pain in the thigh, which may be difcult to
widespread use of angiography, so-called
distinguish from fracture-related pain. The
exclusion angiography, has been called into
presence of a tense thigh should prompt
question because of its invasive nature and its
compartment pressure measurement of the
tendency to document many injuries that are
three thigh compartments. The threshold
benign and warrant only observation, such as
for decompression is debatable, but many
spasm.37
investigators recommend fasciotomy for in-
The use of a Doppler arterial pressure in-
tracompartmental pressures between 30 and
dex (systolic arterial pressure in the injured ex-
45 mm Hg.10, 47, 64, 73
tremity divided by the arterial pressure in an
Treatment of a patient with recognized
uninvolved arm) has proven efcacy in the as-
thigh compartment syndrome in association
sessment of potential vascular injuries in the
with a femur fracture is emergent, three-
extremities. Johansen et al37 found that an ar-
compartment fasciotomy followed by femoral
terial pressure index (API) of less than 0.9 was
fracture stabilization. The patient should be
95% sensitive and 97% specic in detecting
returned to the operating room every 48 hours
major arterial injury. The investigators estab-
for irrigation and debridement until the
lished a protocol in which patients with an
wound is clean, at which time wound closure
API of less than 0.9 underwent arteriography,
can be performed.
and patients with an API of 0.9 or more were
followed up with serial API measurements.
Using this protocol, the investigators avoided FEMORAL SHAFT FRACTURE
many unnecessary angiograms without jeop- ASSOCIATED WITH
ardizing limb viability.37 Despite its success, IMPLANT FAILURE
the use of APIs to detect arterial injury has
several limitations, such as an inability to de- Secondary fractures of the femoral shaft as-
tect lesions of the profunda femoris artery and sociated with implant failure can be classied
an inability to detect lesions that do not reduce broadly as (1) implant failure associated with
134 RUSSELL et al

Figure 3. A 23-year-old man was involved in a motorcycle crash and sustained a head injury,
right distal radius fracture, right distal femoral shaft fracture, and profunda femoris artery injury.
The patient developed elevated compartment pressures in his thigh. He had a previous right fe-
mur fracture, which had been treated with an intramedullary nail. The nail had since been removed.
A, Injury AP radiograph of the pelvis. The femoral neck fracture is indicated by the arrow. B, Distal fe-
mur fracture at the site of the old femur fracture. C, Arteriogram indicating complete cut off of the pro-
funda femoral artery at the level of the fracture. D, The patient was taken to the emergency room for
fasciotomy of the thigh, expedient plating of the femur, vascular repair, four compartment fasciotomy of
the lower leg, and open reduction-internal xation of the right femoral neck by way of a Watson-Jones
approach. Intraoperative photo of the right lower extremity is shown. The plating of the femur was done
through the thigh fasciotomy incision. E, AP radiograph of the plated femur. F, AP radiograph of the
right hip/proximal femur. The patient had skin grafts over his fasciotomy sites. He went on to an un-
eventful healing.

acute injury or (2) more commonly, presenta-
tion of implant failure secondary to nonunion.
Management of patients with secondary frac-
tures in association with hardware failure
shares many similarities regardless of whether
it results from a nonunion or an acute injury;
however, patients who present with nonunion
must be evaluated for a nascent infection. Pre-
operatively, a white blood count, erythrocyte
sedimentation rate, and a C-reactive protein
should be examined. Several intraoperative
Gram stains and cultures also should be ex-
amined in patients with nonunions. Despite
the presence of an infection, management
principles dictate for fracture stability to cure
the infection. With this in mind, the princi-
ples of secondary fracture management and
implant failure are discussed here and the
specic of infected nonunions are discussed in
a subsequent section.
Most implant failures associated with
femoral shaft fractures occur after femoral
plating. Secondary fractures after ORIF after
plating of femoral shaft fractures have been
reported in as many as 13% of cases.43, 45, 57, 60
Soft tissue stripping required for fracture
reduction and plate application plate can
lead to increased healing time, resulting in
hardware fatigue, and secondary fracture.
Also, the eccentric position of the plate on the
femoral shaft increases the bending stresses on
the plate, which may contribute to hardware
failure.
The incidence of implant failure associ-
ated with a prior intramedullary nail is very
low and has been recorded infrequently.5, 12
Bucholtz et al13 noted in their series that
the presence of fracture extension in close
proximity to the distal interlocking screws
was a risk factor for nail breakage secondary
to increased stresses on the nail that were
greater than the fatigue endurance of the nail.
Patient-associated factors contributing to early
implant failure include fracture comminution,
bone loss, severe open fractures, and patient
noncompliance. Technical factors associated
with early nail failure are scoring the nail with
an interlocking screw, improper nail inser-
tion site, small diameter nail insertion, and
under-reaming of the femoral canal.23 Several
mechanical factors, which have been largely
corrected, associated with early nail failure in-
clude fabrication defects, proximal nail welds,
anterior slots, large interlocking screw holes,
and thin nail wall diameter.5, 12, 23, 72
Treatment of femoral shaft fractures with
retained plates usually requires removal of
COMPLICATED FEMORAL SHAFT FRACTURES 135
the plate, followed by intramedullary nailing
with expected good results57 ; however, dif-
culties may arise when plates have been over-
grown by periosteal bone formation and the
medullary cavity has been overgrown with
endosteal callus. In these circumstances, it is
frequently necessary to remove the bone that
has overgrown the plate before plate removal.
Because of intramedullary callus, a plate may
be the implant of choice to restabilize the frac-
ture. It is helpful to identify the vendor of the
previous plate if possible to secure the proper
tools for plate extraction. Occasionally, a sec-
ond plate may be placed around the original
plate to obtain fracture stabilization without
removal of the original plate.
Removal of broken intramedullary nails
also is facilitated by identication of the im-
planted nail. Many nail manufacturers have
designed extraction devices to retrieve their
specic nails. If the vendor cannot be identi-
ed, then a Snap-On set (Snap-On-Tools, Med-
ical Products, Kenosha, WI) is recommended.
Usually the proximal segment of the nail
is removed easily with an extraction bolt
and a slap-hammer following removal of
proximal interlocking screws. The proximal
intramedullary canal should then be reamed
2 mm more than the diameter of the broken
nail while reduction at the fracture site is
maintained.23 The distal interlocking screws
are removed next in preparation for extraction
of the distal nail segment. If the nail has a large
inner diameter, hooks can be passed through
the nail and anchored at the end of the nail or
through an interlocking screw hole, and the
nail is removed.
Extraction of femoral nails with a small
inner diameter requires different techniques
for removal from the intramedullary canal.
The proximal fragment usually can be re-
moved as previously described using an ex-
traction bolt and a slap hammer. The proximal
intramedullary canal should be over-reamed
2 mm more than the diameter of the nail. After
this, a ball-tip guidewire is inserted through
the distal nail fragment through the end of
the nail. A second, straight guidewire then is
inserted through the distal fragment through
the nail. At this point, the ball-tip guidewire
is grasped with a T-handle chuck. Using a
mallet against the T-handle chuck, the ball-tip
guidewire is backed out until it incarcerates
against the straight guidewire. With repeated
taps with the mallet, the distal nail fragment
is removed (Fig. 4). Long pituitary rongeurs
or cement-removal rongeurs also can prove
136 RUSSELL et al

Figure 4. A 23-year-old man was referred for a right femoral nonunion 18 months after intramedullar
nailing for a femoral shaft fracture. He was 18 months after his original treatment. There was no sus-
picion of infection. A, AP radiograph demonstrating a right femoral nonunion and broken nail (arrow)
approximately 2 cm proximal to the nonunion site. B, Lateral radiograph. C, The proximal aspect of the
nail was removed and reamed 2 mm larger than the nail. The inside of the nail was then cleaned of soft
tissue with a long trocar guide wire. D, A replica of the exact broken nail is placed on the back table.
The correct combination of smooth and bulb-tipped guide rods are chosen in order to wedge the guide
wires in the end of the nail. The bulb-tipped guide wire is placed down the canal, followed by the
smooth-tipped wire to wedge the two wires in the end of the distal aspect of the broken intramedullary
nail. E, The nail is then back-slapped out of the distal femur by use of a handle connected to the guide
wires.
Illustration continued on opposite page
 COMPLICATED FEMORAL SHAFT FRACTURES 137

Figure 4 (Continued ). F, Close-up of the two guide wires in the extracted bro-
ken nail. G, The patient underwent exchange intramedullary nailing with iliac crest
bone grafting. The nail placed was 3 mm larger in diameter. Rapid healing ensued.
AP radiograph at 3rd month. H, Lateral radiograph at 3 months. (The authors ac-
knowledge the teaching of Robert Winquist, MD regarding this technique. The bro-
ken Nail Guide Wire set is commercially available through Zimmer [Warsaw, IN].)

helpful in removing nails with small inner di-
ameters and closed-section nails. Should these
measures fail, then a corticotomy may be per-
formed to facilitate nail extraction. Another
technique that may be used as a last resort is
to prepare the distal femur as if implanting
a retrograde nail and removing the nail with
cement-removal rongeurs through the knee.
Retrieval of bent nails usually requires
straightening of the nail, followed by nail
removal. The patient should be taken to the
operating room, and, with the patient under
general anesthesia, attempts should be made
to straighten the nail using a femoral wrench
(Fig. 5). Should this prove unsuccessful, an
open procedure is performed by transecting
the nail, straightening the limb, and then treat-
ing the injury as a broken nail as described
earlier.
FEMORAL SHAFT FRACTURES
RESULTING FROM
GUNSHOT WOUNDS
Injuries sustained as a result of gunshot
wounds are generally divided into two groups
based on the kinetic energy (KE = 1/2 mv2 )
of the projectile. Low-energy injuries usu-
ally occur secondary to handgun shots in
138 RUSSELL et al

Figure 5. A 23-year-old woman was involved in a motor vehicle crash and sustained a right femoral
neck fracture and a left femoral shaft fracture in the area of a previous fracture. She was 18 months
following a right acetabular fracture and left femoral neck/shaft fracture. She had undergone recon-
struction nailing of the left neck/shaft fracture combination. Attempts at completely bending the nail
back to a straight position were not successful. A, AP radiograph of the femur. B, A femoral neck frac-
ture nonunion was evident when the proximal screws were removed from the nail. C, The nail be-
ing removed. Note that the angulation of the nail is proximal to the fracture angulation. D, A new in-
tramedullary nail 2 mm larger in diameter was placed. Screws were placed anterior and posterior to
the nail. E, Uneventful healing ensued of both fractures. AP radiograph at 6 months.

which the velocity of the projectile is less
than 1000 ft/s. High-energy injuries usually
result from ries in which projectile velocity
is greater than 2000 ft/s or from close-range
shotguns in which the mass of the projectile
factors signicantly to increase the kinetic
energy imparted to the tissues.22, 65
Femoral shaft fractures resulting from
low-energy gunshot wounds can be thought
of as type 1 open fractures. After a normal
neurovascular examination has been ensured,
the fracture can be addressed. Treatment of the
open wound does not require a formal irriga-
tion and debridement, and good results have

been reported with minimal, local wound
care.7, 35, 62, 81 Early closed reamed nailing has
become the treatment of choice for these
injuries, with infection rates comparable to
reamed intramedullary nailing for closed
fractures.7, 81 Antibiotic use usually consists
of a rst-generation cephalosporin that is
continued for 48 hours postoperatively.7, 81
Management of high-energy gunshot
wounds resulting in femoral shaft fractures
is more difcult because of the associated
severe soft tissue trauma caused by crushing
from the projectile, formation of shock waves,
and cavitation.28, 33, 63 These injuries should be
approached as any type 3B open fracture with
the realization that extensive and multiple
debridement will likely be required. Stabi-
lization of these fractures should follow the
guidelines established for the treatment of
type 3B open fractures, with an emphasis on
immediate closed nailing.11, 50
Management of close-range shotgun in-
juries parallels that of other high-energy
gunshot wounds, with one notable exception:
wadding is a common added contaminant65
of the open wound. Wadding usually consists
of paperboard, felt, or plastic. Felt is partic-
ularly irritable to the body and can incite an
intense inammatory response.65 Multiple
debridement often is required to achieve a
clean wound, at which time the wound can
be closed in a delayed primary fashion. Re-
current wound drainage is not uncommon
and may ultimately require open treatment of
the wound. A rst-generation cephalosporin
and aminoglycoside antibiotics should be
administered until the wound is sealed if
closed primarily. If the wound is managed in
an open fashion, intravenous antibiotics are
not required if the patient does not manifest
symptoms of septicemia. Oral antibiotics
may assist in maintaining a clean wound as it
granulates.
INFECTED FEMORAL
SHAFT FRACTURES
The incidence of infection after a closed
intramedullary nailing for a closed femoral
shaft fracture has been reported to occur in
1% or less of cases.18, 59, 74, 77, 80 If an open nail-
ing is performed for a closed femur fracture,
however, then the incidence of infection in-
creases to 2% to 9%.38, 71 The management of
open femoral shaft fractures with closed in-
tramedullary nailing has demonstrated good
COMPLICATED FEMORAL SHAFT FRACTURES 139
results, especially for the low-energy frac-
tures. Several investigators have reported
infection rates comparable to those of closed
fractures treated with closed intramedullary
nailing.11, 15, 42, 74 Type 3 open femoral shaft
fractures treated with intramedullary nails
have demonstrated infection rates of 0% to
6.5%,3, 11, 15, 42 but it was the type 3B fractures
that led to infection in the series that distin-
guished between the type 3 injuries.11
Detection of infection associated with a
femoral shaft fracture may be difcult if obvi-
ous signs, such as persistent wound drainage,
erythema, and cellulitis are not present. Any
nonunion should be thought of as infected un-
til proven otherwise. Plain radiographs should
be evaluated for nonunion, periosteal reaction,
sequestrum, and involucrum. Tomograms and
CT also can be helpful in the search for a se-
questrum. Laboratory examinations also may
be helpful in the diagnosis of infection. An
elevated white blood cell count, erythrocyte
sedimentation rate, and a C-reactive protein
are indirect indicators of an infectious process
and can be used to assist in the evaluation of a
suspected infection.
A general guideline for the management
of infections is to classify them as either
supercial or deep. Supercial infections
often are detected early and are commonly
wound infections, which usually respond to
debridement, irrigation, and a short course
of intravenous or oral antibiotics. Deep in-
fections frequently present remotely after
treatment and often involve the bone (Fig. 6).
The primary goal in treating established
infections after femoral shaft fractures is
achievement of fracture union assisted by sur-
gical debridement and antibiotics to suppress
the infection.44, 53
Initial management of a patient with an in-
fection after a femoral shaft fracture is assess-
ment of fracture stability. For patients who
demonstrate fracture stability, the nail should
be retained and the patient should be placed
on culture-specic intravenous or oral antibi-
otics to suppress the infection while the frac-
ture heals.29, 44, 54 Patients who demonstrate in-
stability at the fracture site should undergo a
reamed exchange nailing supplemented with
culture-specic antibiotics to suppress the in-
fection while the fracture healing occurs.
After fracture union, further attempts to
cure the infection, if it is still present, should
be made. Patients without evidence of infec-
tion after fracture union do not require further
treatment, and the nail may be retained.29, 44, 54
140 RUSSELL et al

Figure 6. A 32-year-old man was referred with an acute Pseudomonas aeruginosa

infection of the left proximal femur after intramedullary nailing. The patient underwent
irrigation and debridement and placement of antibiotic beads. Intravenous aminoglyco-
side coverage was administered for 6 weeks. A, AP radiograph at 6 weeks postinjury.
B, The patient underwent repeat irrigation and debridement and exchange reamed
nailing at 10 weeks to remove the previous infected nail. Uneventful healing ensued.
AP radiograph at 5 months. C, AP radiograph at 5 months. D, Lateral radiograph at
5 months.

Patients with persistent infection after frac- References

ture union require further surgical and antibi-
otic intervention. Necrotic bone and soft tissue
should be debrided. The retained femoral nail
should be removed and the intramedullary
canal reamed and irrigated. A corticotomy at
the site of the distal interlocking screws on
the medial thigh is helpful to allow for eas-
ier egress of the reaming contents. A cortico-
tomy can be performed on the lateral thigh;
however, the iliotibial band often can act as a
barrier to easy uid egress. Reamings should
be sent for culture evaluation, and antibiotic
treatment again should be instituted based on
culture results.
Using this protocol, MacAusland and
Eaton44 eradicated infections in 12 of
14 patients with infections after femur frac-
tures. Green et al29 treated 12 patients with a
combination of nailing and external xation
and were able to eradicate the infections in 10
of 12 patients. Patzakis et al54 reported similar
results, but their study included both tibial
and femoral nails. Despite the encouraging re-
sults of these studies, all of these investigators
cautioned that infection can recur at any time
and necessitate further surgical and antibiotic
intervention.29, 44, 54
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Address reprint requests to
George V. Russell, Jr, MD
Department of Orthopaedic Surgery
University of Mississippi Medical Center
2500 North State Street
Jackson, MS 39216
e-mail: grussell@orthopedics.umsmed.edu
TREATMENT OF COMPLEX FRACTURES 00305898/01 $15.00 + .00

PERIPROSTHETIC FRACTURES
OF THE FEMUR
Andrew H. Schmidt, MD, and Richard F. Kyle, MD

Periprosthetic fractures of the femur repre-
sent a heterogeneous and challenging prob-
lem for the orthopedist. The incidence of these
fractures is dramatically increasing, as there
are more and more patients with aging to-
tal joint replacements.13 The fractures may oc-
cur as the result of a traumatic event but
more often are the result of minor trauma
spontaneous fracture, and they are frequently
associated with preexisting sometimes ne-
glected problems with the associated joint
replacement.2
FRACTURES AROUND THE
FEMORAL COMPONENT OF A
TOTAL HIP ARTHROPLASTY
Epidemiology
the need for a tight press t. Reported rates vary
from 4.1% to 27.8% after uncemented hip re-
placement, compared with less than 3% when
cemented stems are used.18 Schwartz et al18
reviewed 1318 consecutive arthroplasties per-
formed with the Anatomic Medullary Locking
stem (DePuy, Warsaw, IN) and found an inci-
dence of 3%. The fractures occurred in the prox-
imal femur or at the tip of the stem and most
were incomplete. Only one-half were recog-
nized at the time they occurred. The occurrence
of fracture did not affect the ultimate success
of the arthroplasty.18 In contrast, in another re-
port of 40 intraoperative fractures that occurred
during uncemented stem insertion, all but two
were recognized at the time of occurrence.10
However, in three patients, the fracture was felt
to have contributed to the eventual loosening
of the prosthesis.10

The incidence of periprosthetic femur frac-

ture following total hip arthroplasty varies by
more than 10-fold, depending on the clinical
situation.18 The exact incidence is difcult to
determine because of the problems with long-
term follow-up. The incidence is much higher
after revision surgery than primary hip re-
placement and is similarly increased when un-
cemented stems are used.18
Intraoperative fractures of the femur dur-
ing total hip replacement are more common
when uncemented stems are used because of
Biologic and Mechanical
Considerations
Periprosthetic fractures are generally associ-
ated with stress risers in the bone, frequently
osteolytic lesions or areas of cortical perfora-
tion (Fig. 1). In addition, the tip of an implant
functions as a stress riser. The combination of
an osteolytic lesion located at the tip or just
distal to a femoral stem should be considered
an impending pathologic fracture in the same

From the Department of Orthopaedic Surgery, University of Minnesota; and Hennepin County Medical Center,
Minneapolis, Minnesota

ORTHOPEDIC CLINICS OF NORTH AMERICA

VOLUME 33 NUMBER 1 JANUARY 2002 143

144 SCHMIDT & KYLE
Figure 1. A and B, An early postoperative femoral shaft fracture that occurred at
the site of a preexisting stress riser in the femur, namely, empty screw holes from
a previous sliding hip screw.
manner that a metastatic lesion in the sub-
trochanteric region would be.
When the surgeon is evaluating a peripros-
thetic fracture, specic mechanical factors that
are unique to each case must be identied and
considered. This includes limb alignment, bone
density, fracture location, fracture pattern, the
location of any bone defects, and the presence
of any implants. Fractures that occur within
the proximal region are often longitudinal
splits that occur intraoperatively. These may
be divided into stable and unstable patterns.
Longitudinal splits above the lesser trochanter
are considered stable, provided a collared pros-
thesis is used. A proximal femoral split should
be considered unstable if it extends below the
lesser trochanter, as it may threaten the stabil-
ity of the implant. Fractures in the middle third
of the femur are typically associated with pros-
thetic loosening or osteolysis. Those that oc-
cur between the lesser trochanter and the pros-
thetic tip may be stable if the stem stays within
the distal canal. Fractures within the distal re-
gion are less often associated with prosthetic
loosening but may occur with osteolysis or os-
teopenia.
Classication
In general, the goals of fracture classication
are to suggest treatment, estimate prognosis,
and indicate likely complications. Factors to
consider when evaluating a periprosthetic fe-
mur fracture include such things as the age and
health of the patient, the location and pattern
of the fracture, and the stability of xation of
the prosthesis. Other factors, such as a history
of tobacco use, chronic medical illness, and im-
munosuppression, may play an important role
in perioperative decision making. Local factors
that inuence prognosis and treatment include
a history of previous irradiation, osteoporosis,
osteolysis, the type of implant (i.e., press t
versus cemented, short versus long stem, or
more than one implant), a history of previous
fracture, and the presence of any other stress
risers in the bone. The surgeon can consider
 PERIPROSTHETIC FRACTURES OF THE FEMUR 145

these items as they affect either the biologic different examiners.3 The Vancouver classi-
or mechanical aspects of the fracture and its cation is based on the fracture location, the
consequences. quality of xation of the stem, and the qual-
Factors affecting treatment of periprosthetic ity of the bone. It was developed with the goal
femoral fractures include: that treatment decisions would naturally fol-
Patient characteristics low from correct classication of the fracture.
General factors The Vancouver classication divides peripros-
Age thetic femoral fractures into three main types
Health based on the location of the fracture. These are
Tobacco use further subdivided based on bone stock or bone
Immunosuppression quality (Table 1).
Local factors Beals and Tower1 proposed another classi-
Previous irradiation cation, which is worth discussing because
Osteoporosis it identies a few other clinically important
Osteolysis fracture subtypes. These authors added a
History of previous fracture fourth broad category: the proximal metaphy-
Presence of other stress risers seal/diaphyseal fracture, which occurs around
Fracture characteristics the stem but does not involve the stem tip
Location which and was seen only in patients with un-
Pattern cemented implants (12% of their series). These
Implant characteristics authors further note that this fracture was of-
Stability ten unstable and usually required revision of
Well xed the prosthesis.1 Additionally, a subcategory
Loose of supracondylar fracture was identieda
Type of implant distal femur fracture occurring below a long
Press-t versus cemented femoral stem. Nonoperative management with
Short versus long stem traction and cast braces was often chosen for
More than one implant these fractures because of the difculty in
achieving any type of xation about the long
At least 11 different classications have been femoral stem. Nonetheless, successful union of
suggested for periprosthetic femoral fractures these fractures was obtained.
with hip prostheses.1, 2, 5, 9, 11, 12, 1416, 18, 21 All of the
classications separate fractures into different
groups by fracture location. Other factors, such METHODS OF TREATMENT
as the time of fracture (intraoperative or post-
operative), status of the implant (loose or sta- The primary considerations in deciding on
ble), and type of implant (cemented or unce- a rationale treatment plan for a periprosthetic
mented), are considered differently by various femur fracture are whether to treat the frac-
authors. ture operatively or not, and if an operative ap-
The Vancouver classication proposed by proach is warranted, whether to proceed with
Duncan and Masri9 is becoming the standard fracture repair or revision arthroplasty. There
system for assessing and reporting peripros- is no single approach that is applicable to all
thetic femur fractures (Table 1). It is the only cases. In general, displaced fractures should
classication that has been rigorously evalu- be stabilized. Similarly, loose stems should be
ated, and its reliability and validity are ac- replaced with long stems extending well be-
ceptable with consistent agreement among yond the fracture. In the following sections,

Table 1. THE VANCOUVER CLASSIFICATION OF PERIPROSTHETIC FEMORAL FRACTURES

Type Proportion
A 4%
B 87%
C 9%
Location Subtype
Trochanteric A(G): Greater trochanter
A(L): Lesser trochanter
About the stem tip B(1): Prosthesis stable (18%)
B(2): Prosthesis loose (45%)
B(3): Bone stock inadequate (37%)
Well below the stem tip

From Duncan CP, Masri BA: Fractures of the after hip placement. Instr Course Lect 44:293304, 1995; with permission.
146 SCHMIDT & KYLE
individual treatment options will be discussed,
and then each clinical situation is reviewed in
order to summarize the appropriate options for
that specic fracture.
Nonoperative Treatment
Nonoperative treatment is appropriate in the
case of a stable fracture about a well-xed
implant. Examples of this would be nondis-
placed trochanteric fractures or longitudinal
cracks in the femoral neck that are recog-
nized postoperatively (Fig. 2). Displaced frac-
tures are rarely treated nonoperatively because
of the morbidity associated with immobiliza-
tion of the elderly patient and the problem of
malunion.
Cerclage Fixation
Cerclage xation with monolament wire or
braided cable may be considered for the man-
agement of spiral or long oblique fractures as
well as for the xation of plate or cortical strut
grafts. Specialized instruments for passing the
wire or cable about the femur are necessary,
Figure 2. A nondisplaced greater trochanter fracture found
after this patient fell several months after undergoing total
hip replacement.
and unnecessary periosteal stripping should
be avoided. Because of its poor biomechanic
strength, cerclage xation is rarely appropriate
as the sole form of xation. The exception to
this would be the management of a longitu-
dinal crack in the proximal femur that occurs
during stem insertion.10 Usually, cerclage xa-
tion is combined with plate or intramedullary
xation.
Plating
Traditional internal xation with plates is
generally performed for diaphyseal fractures
that occur about well-xed implants. In order
to achieve success with plating of peripros-
thetic femoral fractures, the surgeon should en-
sure that the prosthesis is well xed and that the
limb and prosthesis are in correct alignment.
Tadross et al20 reported a series of nine patients
that were treated with the Dall-Miles plate. Six
of the nine cases had unsatisfactory results be-
cause of varus malunion or nonunion. In all
six cases, the femoral stem had been initially
inserted in a varus position. In the three cases
that were successfully treated, the components
were in neutral alignment.20 Thus, varus align-
ment of the stem may be a contraindication
for plate xation. In contrast, Serocki et al19 re-
ported the results of 10 patients treated with
compression plating, achieving a minimum of
eight cortices of xation on each side of the frac-
ture. The patients were immediately mobilized
(touch-down weight bearing), and nine of the
10 fractures united in an average of 5 months.19
It is often necessary (and probably desirable)
for the plate to overlap the intramedullary im-
plant. Fixation of the plate over the femoral
stem is problematic. Often, cerclage xation is
used for the portion of the plate that spans
the stem. Specialized plates with wire mounts
are available. Small fragment screws can of-
ten be angled and directed either anterior or
posterior to the implant (Fig. 3). Alternatively,
unicortical screws can be used.19 Dennis et al7
compared ve options for plate xation about
femoral stems: plate with cable only, plate with
proximal cable and distal bicortical screws,
plate with proximal unicortical screws and dis-
tal bicortical screws, plate with proximal ca-
ble plus unicortical screws and distal bicortical
screws, and two allograft struts xed with ca-
bles. The specimens were tested in axial com-
pression, lateral bending, and torsion. The two
constructs that contained proximal unicortical
screws (either alone or combined with cerclage
 PERIPROSTHETIC FRACTURES OF THE FEMUR 147

healing may be incomplete and the grafts may

be prone to stress fracture or loosening. Finally,
cortical strut grafts can be a potential source of
infection.
The results of cortical strut grafting are fa-
vorable. Wong and Gross22 reviewed 52 corti-
cal strut grafts used in revision hip arthroplasty
with 5-year follow-up.22 Four of the grafts (8%)
failed either because of resorption or nonunion;
there were no graft fractures.

Revision Arthroplasty

Long-stem revision arthroplasty is the pro-

cedure of choice for most periprosthetic frac-
tures associated with loose prostheses. Use of
an uncemented stem with distal xation, sup-
plemented with cortical strut grafting, is the
standard approach to these fractures (Fig. 5).
Occasionally, a long cemented stem may be ap-
propriate in the case of an elderly patient with
poor bone stock, but the surgeon must be care-
ful to avoid placing methylmethacrylate within
the fracture site.

Figure 3. An example of screw xation about a femoral

stem. Screws are angled anterior and posterior to the stem,
providing optimal xation.

wires) were signicantly more stable than the

other constructs.7

Cortical Strut Grafts

Allograft cortical struts are generally frozen

and irradiated. They are usually segments of
cortical bone from the tibia, bula, or humerus.
Cortical strut allografts have an established
role in the treatment of periprosthetic fractures
of the femoral shaft. Cortical struts may be used
in several ways. First, strut grafts may be used
to augment the junction between host bone and
a structural allograft. Second, the cortical struts
may be used to augment xation with a stan-
dard metal plate (Fig. 4). Last, cortical struts
may be used alone as a biologic bone plate. In
general, such struts are xed to the femoral di-
aphysis with cerclage wires or cables. Potential
advantages of cortical strut grafts relate to the
possibility that they will heal to the host bone
and remodel over time, thereby restoring bone
Figure 4. Intraoperative view of a spiral femoral shaft
stock for the future. Potential disadvantages of periprosthetic fracture treated with a lateral plate and aug-
cortical struts include the prolonged time that mented by an anterior cortical strut allograft. Note the cer-
graft incorporation takes as well as the fact that clage bandsbicortical screws were used in addition.
148 SCHMIDT & KYLE

Figure 5. A periprosthetic femoral fracture treated by revision total hip replacement. A, The initial radio-
graph shows a loose, cemented stem with osteolysis and a displaced spiral fracture. B, The fracture was
treated by revision to a long porous-coated stem with cortical strut grafting. C, A follow-up radiograph
taken 3 years later shows a stable femoral stem and healing of the fracture.

Whole structural allografts may be indicated
in cases with severe, circumferential bone loss.
The existing prosthesis is removed through a
longitudinal or sliding trochanteric osteotomy,
and the host bone is maintained for xa-
tion around the allograft. A long-stemmed
femoral component with a narrow proximal
dimension is cemented into the graft, and
the stem is press t into host bone. A step-
cut is helpful in maintaining rotation. Corti-
cal allograft struts are generally placed around
the osteotomy site and the tip of the long
stem for additional support. Using this tech-
nique, Wong and Gross22 report that 13 of
15 cases were successful with average 5-year
follow-up.
Intramedullary Nails
Retrograde intramedullary nailing may be
performed for distal femoral fractures be-
low a proximal femoral prosthesis. If this is
performed, the surgeon must be careful of not
leaving a small area of bone between the tip
of the femoral stem and the retrograde nail.
This represents a severe stress riser and may
doom the patient to suffer another peripros-
thetic fracture between the two implants
(Fig. 6).
TYPES OF FEMUR FRACTURES
ASSOCIATED WITH TOTAL HIP
ARTHROPLASTY
Intraoperative Fractures
Intraoperative fractures must be recognized
in order for them to be treated appropriately.
Cerclage wires sufce to stabilize longitudinal
fractures of the proximal femur.10, 18 Perfora-
tions about the tip of the stem may be man-
aged with cortical strut grafting and use of a
long-stem implant that achieves distal xation
and bypasses the defect by several centimeters.
 PERIPROSTHETIC FRACTURES OF THE FEMUR
Figure 6. A fracture occurring between a hip hemiarthro-
plasty and a short retrograde femoral nail.
Rarely, open reduction and plate xation will
be necessary for displaced fractures of the dis-
tal femur.
Trochanteric Fractures
Fractures of the greater trochanter may
be undisplaced or displaced. Undisplaced
fractures are treated nonoperatively (see Fig. 2).
Displaced fractures should be treated with ten-
sion band wiring as long as the health of the
patient and the local skin condition is favor-
able. Intertrochanteric fractures are rare but are
generally stable as long as the implant is stable
and in good position, and they can be treated
nonoperatively.14 Intertrochanteric fractures
that occur around loose implants should be
treated by long-stem revision arthroplasty.
Diaphyseal Fractures
Femoral shaft fractures are treated accord-
ing to the status of the implant and the
bone stock. Traction treatment appears to
have inferior results compared with operative
149
treatment.1, 14 Fractures occurring about stable,
well-aligned stems should be repaired with
plates. Proximally, a combination of unicorti-
cal or bicortical screws and cerclage wires is
used. Distally, bicortical screws are used. If the
distal aspect of the plate extends to the supra-
condylar region, it has been found that a xed
angle blade plate or dynamic condylar screw
has the best xation (see Fig. 3).
Fractures Distal to Femoral Stems
Fractures that occur below a femoral stem
can be treated essentially without regard to the
implant, as long as the stem does not exhibit
loosening. Either nonoperative or internal x-
ation may be appropriate, depending on the
health and activity level of the patient. If in-
ternal xation is chosen, plating is generally
preferred, usually with a long dynamic condy-
lar screw or blade plate with a long side plate.
A preferred method is to overlap the stem, so
as not to leave an unprotected region of femur
that may serve as the location for a potential
future periprosthetic fracture.
FEMORAL FRACTURES ABOVE
TOTAL KNEE ARTHROPLASTY
Supracondylar fractures of the femur may
occur about total knee components and are
similarly difcult to manage. Distal femoral
osteolysis, osteoporosis, or the presence of a
supracondylar notch are risk factors for supra-
condylar fracture and are frequently present.
Classication
Several classications have been proposed
for femoral fractures after total knee replace-
ment.4, 8, 17 As is the case for fractures about to-
tal hip replacement, many common themes are
evident in the different classication schemes.
Fractures are generally grouped according to
the degree of displacement and comminution
and the stability of the prosthesis. The schema
of Rorabeck17 has proven useful. Supracondy-
lar fractures are divided into three types. Type I
fractures are undisplaced and adjacent to a sta-
ble prosthesis. Type II fractures are displaced
but with a prosthesis intact. Type III fractures
are those that are associated with a prosthesis
that is loose or failing.
150 SCHMIDT & KYLE

Methods of Treatment

It has been found that displaced distal

femoral fractures that occur adjacent to a total
knee replacement can be managed according
to the same principles as fractures about total
hip implants. When the prosthesis is stable, in-
ternal xation is readily performed with either
a retrograde nail or xed-angle plate. When
the implant is loose, revision of the femoral
component to a long-stem implant may be
performed.

Nonoperative Treatment
Although operative methods are frequently
chosen for the treatment of displaced supra-
condylar femoral fractures, it remains contro-
versial whether outcomes are in fact better after
operative treatment compared with nonoper-
ative management.4 Chen et al4 performed a
literature review of 12 articles (195 fractures)
and found no differences in the proportion of
successful results between operative (69%) and
nonoperative (67%) treatment groups.
Nondisplaced fractures can be successfully
treated nonoperatively4 ; however, the rate of
malunion is high, and in one study, 50% of the Figure 7. A supracondylar fracture in a patient who under-
went total knee replacement and sustained a previously
patients had increased pain or decreased am- plated femoral shaft fracture at the tip of an ipsilateral total
bulatory status following nonoperative man- hip replacement, which had healed in varus malalignment.
agement compared with 13% of those who re- The fracture was treated by revision to a long-stem dynamic
ceived operations.6 condylar screw. The side plate of the condylar screw was
bent to accommodate the existing varus deformity of the
distal femoral shaft.
Open Reduction and Internal Fixation
Internal xation is recommended whenever
the implant is considered to be stable. The are wide enough (Fig. 8). A preferred method
choice of device depends on the pattern and is to nail over the plate xation if the fracture
location of the fracture and the bone quality. is comminuted, extends into the diaphysis, or
Plating is preferred when the bone quality is if the bone quality is poor.
adequate. In most cases, it is possible to insert a
dynamic condylar screw or blade plate into the
femoral condyle between the anges of the im- FRACTURES BETWEEN IMPLANTS
plant (Fig. 7). Polymethylmethacrylate can be
inserted into screw tracks to improve xation. Fractures that occur between implants, such
as between ipsilateral total knee and hip re-
Intramedullary Nails placements or between a joint prosthesis and a
fracture implant at the other end of the femur,
Standard antegrade intramedullary nailing are especially challenging to treat. In the case of
can be performed in the patient with a femoral a previous fracture, it is important to determine
shaft fracture above a total knee replacement whether the fracture has healed and whether
as long as adequate bone stock for distal inter- the implant needs to be removed. If the fracture
locking is present. Retrograde intramedullary is united, the preexisting plate may sometimes
nailing may be performed in some cases of be exchanged for a longer implant. In cases of
supracondylar femur fracture about total knee ipsilateral hip and knee prostheses, treatment
replacement (Fig. 8). Retrograde nailing is pos- depends on whether either implant is loose. In
sible if the dimensions of the intercondylar box the case of stable implants, plating is the only
 PERIPROSTHETIC FRACTURES OF THE FEMUR 151

Figure 8. A and B, A supracondylar femur fracture above a total knee replacement. C and
D, The fracture was treated with a retrograde nail. This technique typically produces some
extension of the fracture because of the necessity to avoid the intercondylar box of the femoral
prosthesis, resulting in a nonanatomic posterior starting point.
152 SCHMIDT & KYLE
option for these cases as both ends of the fe-
mur are occupied by existing implants. If the
prosthesis is loose, whether it is a hip or a knee,
a long-stem revision may be considered. Corti-
cal strut grafting in conjunction with plating is
recommended. Fixed angle devices obtain the
best purchase in the distal femur.
PREVENTION OF PERIPROSTHETIC
FEMORAL FRACTURES
There are a number of things that orthope-
dists can do to lessen the risk for peripros-
thetic fracture. By denition, intraoperative
fractures are often associated with errors in
surgical planning or technique. Wide surgical
exposure is necessary to avoid placing exces-
sive force, especially torque, on the femur. De-
cient bone must be identied prior to surgery
and efforts made to avoid further bone dam-
age. Implant removal must be done carefully.
Extended trochanteric osteotomy may be per-
formed to better expose the medullary canal
and facilitate cement or prosthesis removal. Vi-
sualization of the femur is further facilitated
by the use of headlamps or handheld, battery-
powered lights and suction instruments. Intra-
operative uoroscopy can be considered when
instrumentation of the distal femoral shaft is
performed to lessen the chance of unrecog-
nized cortical perforation.
Postoperative fractures are best avoided
by performing timely revision surgery. The
biomechanic consequences of endosteal de-
fects can be signicant, especially when they
are located at the tip of an intramedullary stem.
Proximal osteolytic lesions may be observed if
asymptomatic, but lesions within 2 cm of the
stem tip should be considered an indication for
revision surgery or strut grafting even if they
are asymptomatic.
References
1. Beals RK, Tower SS: Periprosthetic fractures of the
femur: An analysis of 93 fractures. Clin Orthop 327:
238246, 1996
2. Bethea JS III, DeAndrade JR, Fleming LL, et al:
Proximal femoral fractures following total hip arthro-
plasty. Clin Orthop 170:95106, 1982
3. Brady OH, Garbuz DS, Masri BA, et al: The reliability
and validity of the Vancouver Classication of femoral
fractures after hip replacement. J Arthroplasty 15:59
62, 2000
4. Chen F, Mont MA, Bachner RS: Management of ipsi-
lateral supracondylar femur fractures following total
knee arthroplasty. J Arthroplasty 9:521526, 1994
5. Cooke PH, Newman JH: Fractures of the femur in re-
lation to cemented hip prostheses. J Bone Joint Surg
70:386389, 1988
6. Culp RW, Schmidt RG, Hanks G, et al: Supracondylar
fracture of the femur following prosthetic knee arthro-
plasty. Clin Orthop 222:212222, 1987
7. Dennis MG, Simon JA, Kummer FJ, et al: Fixation of
periprosthetic femoral shaft fractures occurring at the
tip of the stem: A biomechanical study of 5 techniques.
J Arthroplasty 15:523528, 2000
8. DiGioia AM, Rubash HE: Periprosthetic fractures of
the femur after total knee arthroplasty: A literature re-
view and treatment algorithm. Clin Orthop 271:135
142, 1991
9. Duncan CP, Masri BA: Fractures of the after hip re-
placement. Instr Course Lect 44:293304, 1995
10. Fitzgerald RH Jr, Brindley GW, Kavanagh BF: The
uncemented total hip arthroplasty: Intraoperative
femoral fractures. Clin Orthop 235:6166, 1988
11. Gonzalez MH, Barmada R, Fabiano D, et al: Femoral
shaft fracture after hip arthroplasty: A system for clas-
sication and treatment. J S Orthop Assoc 8:240248,
1999
12. Johansson JE, McBroom R, Barrington TW, et al: Frac-
ture of the ipsilateral femur in patients with to-
tal hip replacement. J Bone Joint Surg 63:14351442,
1981
13. Lewallen DG, Berry DJ: Periprosthetic fracture of the
femur after total hip arthroplasty: Treatment and re-
sults to date. Inst Course Lect 7:243249, 1998
14. Mont MA, Maar DC: Fractures of the ipsilateral fe-
mur after hip arthroplasty: A statistical analysis of out-
come based on 487 patients. J Arthroplasty 9:511519,
1994
15. Morrey BF, Kavanaugh BF: Complications with revi-
sion of the femoral component of total hip arthroplasty:
Comparison between cemented and uncemented tech-
niques. J Arthroplasty 7:7179, 1992
16. Roffman M, Mendes DG: Fracture of the femur after
total hip arthroplasty. Orthopedics 12:10671070, 1989
17. Rorabeck CH, Taylor JW: Periprosthetic fractures of
the femur complicating total knee arthroplasty. Orthop
Clin North Am 30:265277, 1999
18. Schwartz JT Jr, Mayer JG, Engh CA: Femoral fracture
during non-cemented total hip arthroplasty. J Bone
Joint Surg 71:11351142, 1989
19. Serocki JH, Chandler RW, Dorr LD: Treatment of frac-
tures about hip prostheses with compression plating.
J Arthroplasty 7:129135, 1992
20. Tadross TSF, Nanu AM, Buchanan MJ, et al: Dall-Miles
plating for periprosthetic B1 fractures of the femur.
J Arthroplasty 15:4751, 2000
21. Whittaker RP, Sotos LN, Ralston EL: Fractures of the
femur about femoral endoprostheses. J Trauma 14:675
694, 1974
22. Wong P, Gross AE: The use of structural allografts for
treating periprosthetic fractures of the hip and knee.
Tech Orthop 14:102106, 1999
Address reprint requests to
Andrew H. Schmidt, MD
701 Park Avenue
Minneapolis, MN 55415
TREATMENT OF COMPLEX FRACTURES 00305898/02 $15.00 + .00

DISTAL FEMUR FRACTURES

WITH COMPLEX
ARTICULAR INVOLVEMENT
Management by Articular Exposure and
Submuscular Fixation

Philip J. Kregor, MD

The treatment of distal femur fractures re-
mains a signicant surgical challenge. Sig-
nicant advances in patient outcome have
been achieved with internal xation com-
pared with historical controls of nonoperative
treatment.3234 A variety of implants and
standard surgical approaches are helpful for
xation of most supracondylar femur frac-
tures. The A.O./O.T.A. Classication is help-
ful in determining the surgical treatment for
the fracture (Fig. 1).
For A.O./O.T.A. Classication A-type (non-
articular supracondylar femur fractures) and
C1/C2 (supracondylar femur fractures with
simple articular splits), a variety of implants
have proved efcacy:
95 dynamic condylar screw30
95 condylar blade plate2, 3, 29, 3234, 36
Retrograde supracondylar nail5, 810, 12, 35
Antegrade intramedullary nail23
The C3 distal femur fracture remains a dif-
cult surgical challenge, however, because of
several factors:
Adequate exposure of articular surface, es-
pecially of the medial femoral condyle, is
challenging, without large surgical expo-
sure or tibial tubercle osteotomy.
Standard implants used for other supra-
condylar femur fractures (e.g., condylar
blade plate and retrograde nails) may
jeopardize the articular surface reduction
and xation.
Especially in the setting of a short distal
segment, varus collapse or loss of xation
of the distal femoral block can occur.
This article reviews the past experience with
treatment of supracondylar femur fractures, in
particular the C3 distal femur fracture. The
pertinent anatomy and injury patterns seen
with the C3 fracture are discussed. Finally,
the technique of visualization, reduction, and
xation of the articular surface by a lateral
parapatellar approach, followed by submus-
cular xation of the metaphyseal/diaphyseal
component of the fracture, as developed by
Krettek et al, will be discussed.19, 22
CLINICAL RESULTS IN THE
TREATMENT OF DISTAL
FEMUR FRACTURES
In nonoperative treatment of distal femur
fractures with or without signicant articular
involvement, problems included malunion,

From the Division of Orthopaedic Trauma, Department of Orthopaedics and Rehabilitation, Vanderbilt University
Medical Center, Nashville, Tennessee

ORTHOPEDIC CLINICS OF NORTH AMERICA

VOLUME 33 NUMBER 1 JANUARY 2002 153

154 KREGOR

Figure 1. The A.O./O.T.A. Classication divides supracondylar femur frac-

tures into type A (extra-articular), type B (partial articular), and type C (ar-
ticular involvement). Type C1 and C2 distal femur fractures have simple ar-
ticular injury. The type C3 fracture has complex articular involvement. This
articular injury may be comprised of Hoffa frontal plane and multiplane
articular fractures. (From Hansen ST, Swiontkowski MF (eds): Orthopaedic
Trauma Protocols. Raven Press, New York, 1993, p 296; with permission.)

nonunion, and joint stiffness. Early compar-
ison of distal femoral fracture treatments
favored nonoperative versus operative
methods.27, 39 In 1967, Neer et al,27 in dis-
cussing supracondylar femur fractures, stated,
No category of fracture at this level seemed
well suited for internal xation, and sufcient
xation to eliminate the need for external
support or to shorten convalescent was rarely
attained. They evaluated 110 patients with
 DISTAL FEMUR FRACTURES WITH COMPLEX ARTICULAR INVOLVEMENT 155

fractures in the distal 3 inches of the femur
treated between 1942 and 1966. Of these,
71 patients were treated with traction and
subsequent casting, 36 patients were treated
with internal xation, and three required
primary amputation for peripheral vascular
disease. Sixty-seven fractures were suitable
for result analysis. In fractures treated with
internal xation, 52% were deemed satisfac-
tory, whereas with closed treatment, 90% were
satisfactory.
Stewart et al,39 in 1966, reported on the treat-
ment of 215 supracondylar femur fractures. Of
142 fractures treated by closed methods, 67%
were rated good or excellent, whereas 54%
treated by ORIF were rated as good or excel-
lent. Ten of 69 patients treated operatively de-
veloped a delayed union, and an additional
10 developed a nonunion. Stewarts conclu-
sions regarding internal xation were: The
additional trauma of surgery and the prox-
imity of metallic implants to the joint predis-
pose to excessive reaction and subsequent ad-
hesions. Even though one obtains an excellent
roentgenographic result with solid union, nal
xation may be quite poor. The functional
expectations for treatment of a supracondylar
femur fracture were relatively low, however.
For example, to obtain a satisfactory Neer
score of 72, one could have pain with fatigue,
have restricted function (requiring going up-
stairs side ways), have motion of 100 , do reg-
ular work with handicap, and have 5 of angu-
lation or 0.5 cm of shortening.
With the advent of rigid internal xation of
distal femur fractures, the surgeons were able
to obtain earlier and more aggressive knee
motion. Several complications occurred, how-
ever, including nonunion, need for bone graft-
ing, malunion, failure of hardware, infection,
and loss of motion (Fig. 2). Wenzl et al,40 in
1970, published the rst results of blade plate
xation of supracondylar femur fractures, re-
porting 73.5% good or excellent results in
112 patients treated with rigid xation and
early full, unsupported, unrestricted early mo-
tion. Olerud,28 in 1972, reported on 16 cases
of supracondylar femur fractures treated with
blade plate xation using a large, Y-shaped in-
cision with osteotomy of the tibial tubercle.

Figure 2. This 63-year-old man was referred after undergoing open re-
duction internal xation of a right AO/OTA Classication C2 injury and a
left C3 injury. At 3 months postoperatively, the right distal femur had un-
dergone irrigation and debridement, and placement of antibiotic beads
for infection with methicillin-resistant Staphylococcus aureus. The left
C3 injury was treated with a condylar buttress plate and had shortened
and displaced into varus collapse, (arrow). Postoperative immobilization
resulted in stiff knees with a exion arc of 10 bilaterally.
156 KREGOR
Bone grafting was used in 6 of 16 fractures,
and using this extensile approach, ve ma-
jor complications were seen, including os-
teomyelitis, loss of xation, septic arthritis,
and postoperative infection. In addition, 5 of
16 patients had a range of motion of less than
90 of exion. In 1974, Schatzker32 reported
on the results of rigid xation versus nonop-
erative methods. Seventy-ve percent of pa-
tients had good or excellent results with rigid
xation, whereas 32% of patients had similar
results with nonoperative methods. In 1979,
however, Schatzker did point out the possible
failure of internal xation.34 Forty-nine frac-
tures in 47 patients were described, with the
fractures occurring in the distal 15 cm of the fe-
mur. He noted common errors, including inac-
curate reduction, failure to achieve interfrag-
mental compression with lag screws, medial
protrusion of the blade plate, and the blade
plate being introduced too proximal from the
knee joint. In 18 cases, poor results were seen:
two malunions affecting joint congruity, six
delayed unions, two nonunions, seven blade
plate loosenings, three broken plates, two me-
dial protrusions of the plate, one refracture,
one fracture above the plate, and two in-
fections. Siliski et al36 reported on 52 supra-
condylar intercondylar fractures of the femur
which were treated in Graz, Austria, between
1968 and 1983. There were 13 C1, 26 C2, and
13 C3 fractures. Twenty of 52 fractures had
open wounds, and 10 were associated with a
patella fracture. Fixation used included 42 95
angle condylar blade plates, 7 condylar but-
tress plates, 2 T-plates, and one straight plate.
Cancellous bone grafting was used in 19 of
the 52 fractures. Average time to healing was
13.6 weeks. Seven fractures healed in 4 to 8
of varusvalgus malalignment and three frac-
tures healed in 5 to 10 of recurvatum. Short-
ening of 1 to 3 cm occurred in 15 patients.
The average eventual arc of motion of the knee
averaged 107 , with the average knee motion
being 113 for C1 fractures and 99 for C3
fractures. Overall, C1 fractures resulted in a
good or excellent outcome in 92% of cases,
whereas C2 and C3 fractures resulted in 77%
excellent or good results as based on the rat-
ing system of Neer et al. Three major infec-
tions were seen, resulting in two amputations
and one need for arthrodesis. Thus, as seen in
the series by Schatzker and Siliski et al, while
anatomic reduction and rigid xation did offer
improvement in function, it did not guarantee
uniform satisfactory results.33, 34, 36
In the early experience with rigid xation of
supracondylar femur fractures, bone grafting
was used liberally. Bone grafting rates docu-
mented in the treatment of supracondylar fe-
mur fractures ranged between 23% and 87%.26
The relatively slow rate of healing of supra-
condylar femur fractures and other fractures,
as well as the rather extensive need for bone
grafting, led to the clinical need for improved
soft tissue handling around fractures.
Mast et al25 popularized the concept of in-
direct reduction of fractures, which relies on:
Maintenance of the soft tissue attach-
ments and vascularity to the cortical bone
fragments
Anatomic restoration of the articular sur-
face in the traditional sense
Restoration of the appropriate length, ro-
tation, and alignment of the metaphyseal
diaphyseal region of the fracture, without
preoccupation with complete anatomic
restoration of this region
The goal of anatomic restoration of the ar-
ticular surface, avoidance of soft tissue devi-
talization, and xation to allow for early mo-
bilization can be accomplished by traditional
articular reconstruction, followed by:
Plating with an emphasis on preserva-
tion of the muscular attachments to the
diaphyseal and metaphyseal area of the
femur
Retrograde intramedullary nail xation
External xation
In 1996, Bolhofner et al3 reported on the
treatment of 57 cases of supracondylar fe-
mur fractures treated with biological reduc-
tion techniques, stating, the xed angle of the
blade and the known relationship of the blade
and the plate to the normal distal femoral
anatomy allows for exploitation of the plate,
both as a reduction tool and a xation im-
plant simultaneously. They reported on the
treatment of a total of 57 cases: eight cases of
AO/OTA Classication A2 fractures, 14 cases
of A3 fractures, 10 cases of C1, 16 cases of
C2, and 9 cases of C3 fractures. No type IIIB
or IIC open fractures were included because
it was believed that the biology was signif-
icantly disrupted about the fracture in these
open injuries. Twenty-nine condylar buttress
plates and 28 95 angle blade plates were
used. Nineteen of the fractures were open.
No bone grafting or dual plating of frac-
tures was used. At 1-year follow-up, the re-
sults were 40% excellent and 44% good, with
16% of the cases resulting in unsatisfactory
outcomes. The time to radiographic union
 DISTAL FEMUR FRACTURES WITH COMPLEX ARTICULAR INVOLVEMENT
and full weight-bearing was 10.7 weeks. Two
delayed unions occurred. No nonunions de-
veloped. Ostrum and Geel29 have reported
on a similar series, in which maintenance
of the soft tissue around the metaphyseal
diaphyseal component of the fracture was as-
sociated with early consolidation of the frac-
ture, a low need for bone grafting, and paucity
of infection and soft tissue problems.
CLINICAL RESULTS IN
TREATMENT OF THE C3
DISTAL FEMUR FRACTURE
By denition, a C3 distal femur fracture has
a complex articular injury with or without a
Hoffa (frontal plane) fracture. Treatment op-
tions for internal xation of C3 distal femur
fractures include:
Condylar Buttress Plate, with or without
medial plating3, 15, 16, 31
Retrograde Intramedullary Nail4, 5
External xation11, 24
The use of a 95 condylar buttress blade
plate or dynamic condylar screw is not recom-
mended for these injuries30, 3234 because of two
factors:
1. If a Hoffa or frontal plane split is
present in the medial or lateral femoral
condyle, introduction of the blade plate or
condylar screw would jeopardize xation
of this fracture.
2. Often, the distal femoral block is rel-
atively short and therefore does not
allow for placement of the xation de-
vice. (For introduction of the dynamic
condylar screw, 4 cm of distal femur is
recommended.)
Articular reconstruction followed by exter-
nal xation of the C3 distal femur fracture
also has been described, both with half-pin ex-
ternal xation and tensioned-wire xation.11, 24
Marsh et al24 described three C3 distal femur
fractures treated with limited internal xation
of the articular surface, followed by half-pin
external xation. Hutson and Zych11 reported
on the use of articular reconstruction followed
by distal femoral tensioned-wire external x-
ation for 16 C3 distal femur fractures. Tradi-
tional internal xation of the articular surface
was carried out using a lateral approach; in
four cases, this tibial tubercle osteotomy was
used. The average time in the external x-
ator was 24 weeks. Eight patients had less
157
than 90 of motion. Five of these patients un-
derwent Judet quadricepsplasty. Varusvalgus
deformities were reported if greater than 10 .
Deformities seen were one case of 12 of val-
gus deformity, two cases of procurvatum de-
formity, and six cases of recurvatum defor-
mity. Three cases of infectious complications
and two cases of refracture were seen. The in-
vestigators noted that high-energy soft tissue
injury (e.g., extensor mechanism disruption)
or articular surface bone loss had a large im-
pact on the clinical outcome of the patient.
The use of the condylar buttress plate in
the setting of the C3 distal femur fracture
has been particularly challenging. Numerous
investigators have commented on the rela-
tive instability of the distal femoral block
with its use and varus collapse (caused by
screw toggling).1, 3, 16, 3134, 37 A variety of strate-
gies have been attempted to counteract this.
Sanders et al31 reported on double plating and
bone grafting in nine C3 distal femur fractures
with a decient medial cortical buttress. All
fractures healed, with ve good and four fair
results; however, no patient achieved greater
than 100 of exion. Three patients had less
than 90 of exion, and six had between 90
and 100 of exion. In addition, four patients
had an extensor lag of 5 . Simonian et al37
showed that a screw could improve the biome-
chanical stability against varus collapse diago-
nally placed from proximal aspect of the plate
into the medial femoral condyle. In addition,
distal screws, which lock in to the side of the
plate, and locked double plating also greatly
improve biomechanical stability13, 17 ; however,
probably the most proven method to mini-
mize varus collapse and loss of xation is an
emphasis on soft tissue preservation, rather
than mechanical stability.3, 29 Bolhofner et al3
reported on nine C3 injuries, eight of which
were treated with a condylar buttress plate.
Although open fracture types IIIB and IIIC in-
juries were excluded from his study, seven of
nine of the injuries healed with good or excel-
lent results. Two poor results were seen.
ANATOMY
The distal femoral articular surface is at an
angle of 7 to 8 of valgus to the long axis of
the femur in males, and 8 to 9 of valgus in
females. The lateral cortex of the distal femur
slopes approximately 10 to 15 , and the me-
dial cortex slopes approximately 25 (Fig. 3).
The anterior cruciate ligament occupies the in-
tercondylar notch. A line drawn across the
158 KREGOR

anterior aspect of the lateral femoral condyle

and medical femoral condyle slopes by ap-
proximately 10 to 15 .

INJURY PATHOANATOMY

A C3 distal femur fracture is characterized

from other supracondylar and intercondylar
femur fractures by its complex involvement of
the articular surface. The articular surface may
be involved with:
An intercondylar split with an intercalary
articular segment (thus, differentiating it
Figure 3. End-on view of the distal femur. The lateral cor- from a C1 or C2 injury)
tex of the distal femur slopes 10 to 15 , and the medial
cortex slopes 20 to 25 . A line drawn across the ante- Medial or lateral condylar frontal plane
rior aspect of the femoral condyles slopes medially 10 to fractures (Hoffa fractures; Fig. 4)
15 . These relationships are important in placement of Separate intercondylar notch fragments
internal xation in the distal femur. (From Hansen ST, (Fig. 5)
Swiontkowski MF (eds): Orthopaedic Trauma Protocol.
Raven Press, New York, 1993, p 295; with permission.)
Multiplane complex articular surface in-
volvement (Fig. 5)

Traction, anteroposterior, lateral, and obli-

que radiographs help to delineate the distal

Figure 4. A 39-year-old woman sustained a type IIIa open right C3 distal femur. A, Injury AP traction
radiograph. B, Injury lateral radiograph. The lateral radiograph should always be inspected for a frontal
plane Hoffa fracture (arrow). C, Sagittal plane CT reconstruction of the distal femur with Hoffa fracture,
(arrow).
Illustration continued on opposite page
 DISTAL FEMUR FRACTURES WITH COMPLEX ARTICULAR INVOLVEMENT 159

Figure 4 (Continued ). D, Intraoperative view of the distal femoral articular injury. The distal femur was
exposed by way of a lateral peripatellar approach. The arrows indicate the two-level Hoffa plane frac-
ture in the lateral femoral condyle. E, Intraoperative view of the articular reduction after clamp applica-
tion. Depth gauges are in the various anterior to posterior directions for screw placement for xation
of the frontal plane fractures. The patella is everted. F, The articular reduction after screw placement.
G, Fixation by way of submuscular xation utilizing the LISS xator (described in text). (Courtesy of
Peter A. Cole, MD, Minneapolis, Minnesota)

extent of the fracture, better clarifying articu-
lar involvement, and allow one to perform the
preoperative plan. If these lms are not ob-
tained, it is relatively easy to underestimate
the articular injury.
PREOPERATIVE ASSESSMENT
AND PLANNING
A careful history and physical examination
are mandatory for patients with high-energy
C3 distal femur fractures. In addition to as-
sessing these patients for other injuries, the
treating surgeon must ask the following perti-
nent questions:
1. What is the status of the soft tissue en-
velope around the distal femur; are there
any open wounds?
2. Is there any vascular injury in the lower
extremity?
3. Is there any sign of impending compart-
ment syndrome?
One must recognize that concomitant with
the high energy needed to cause a signicant
160 KREGOR

Figure 5. A 39-year-old woman sustained a closed C3 distal femur fracture. A, Traction AP radiograph.
B, Traction lateral radiograph demonstrates frontal plane fracture in articular surface, (arrow). C, Axial
CT scan demonstrating multiplane articular involvement. D, Frontal CT scan demonstrating separate
osteochondral fragment in intercondylar notch (arrow).
Illustration continued on opposite page
 DISTAL FEMUR FRACTURES WITH COMPLEX ARTICULAR INVOLVEMENT 161

Figure 5 (Continued ). E, Intraoperative view of articular injury as viewed from a lateral peripatellar ap-
proach. F, Intraoperative uoroscopic AP view of articular surface reduction. G, Articular surface re-
duction. Multiple 3.5 mm lag screws were used for xation of the articular surface. A variable pitch
screw was used for xation of the intercondylar notch fragment. H, AP radiograph at 24 months. Sig-
nicant medial callus develops with maintenance of the soft tissue envelope around the metaphyseal
region of the fracture (arrow). I, Lateral radiograph of the distal femur at 24 months postoperatively.
162 KREGOR

articular injury is the potential for other high-
energy effects on the distal femur or injured
lower extremity.
Radiographic assessment, at a minimum,
must consist of good quality anteroposterior,
lateral, and oblique radiographs centered at
the knee. Traction radiographs are helpful in
aiding visualization of the articular surface
and in assessing potential closed reduction
of the metaphysealdiaphyseal components of
the fracture. The oblique radiographs are often
helpful in assessing the articular involvement;
often, the patella obscures the intercondylar
fracture. The Hoffa or frontal plane fracture
is best seen on lateral radiography. Axial CT
scans with sagittal and frontal plane recon-
structions are helpful to conrm interpreta-
tion of plain radiographs and in more closely
delineating articular involvement. In particu-
lar, it is helpful to map out the articular in-
volvement in multiplane fractures and to ver-
ify the presence or absence of intercondylar
notch fragments.
The Ankle-Brachial Index or Ankle-Ankle
Index is helpful as a screening tool for pos-
sible arterial injury.14 If additional study is
warranted, arteriography may be performed.
Signicant displacement of the fracture may
potentially cause a venous intimal injury.
Although an association with deep venous
thrombosis is not described in the literature,
surveillance for it is warranted.
THE TARPO TECHNIQUE
The transarticular percutaneous osteosyn-
thesis (TARPO) technique was rst described
by Krettek et al19, 22 in 1996 (Fig. 6). It sought to
address at least two problems common in the
treatment of C3 distal femur fractures:
1. Difculty with complete articular surface
visualization (and, therefore, reduction
and xation)
2. Devitalization of the metaphysis by large
surgical incisions, with the resultant
problems of infection, need for bone
grafting, and potential nonunion
Although the entire articular surface and
lateral cortex of the femur can be exposed by
one surgical approach (the swashbuckler
approach), it does create a large surgical
exposure.38 The TARPO technique involves
a lateral peripatellar approach much like a
medial peripatellar approach used for a total
knee arthroplasty.19, 22 This approach allows
for complete visualization of the entirety of the
distal femur, without signicant devitalization
of the metaphyseal area of the fracture. As

Figure 6. The TARPO (Trans-articular Percutaneous Osteosynthesis) technique as described by

Krettek, et al.19, 22 (Courtesy of Christian Krettek, MD, Hannover, Germany). A and B, Approach for
lateral peripatellar approach. C, With subluxation or eversion of the patella, appropriate exposure
of the articular surface is obtained, without signicant metaphyseal diaphyseal soft tissue stripping.
D, A plate can then be slid in a submuscular manner after articular reconstruction.
 DISTAL FEMUR FRACTURES WITH COMPLEX ARTICULAR INVOLVEMENT 163

such, it is helpful when addressing multi-

plane fractures, separate intercondylar notch
fragments, and Hoffa fragments, especially
when on the medial femoral condyle. Eversion
of the patella can be performed to expose the
distal femoral condyle.
The articular surface can then undergo re-
duction provisional xation, followed by def-
inite xation. Traditionally, screw xation is
accomplished by 6.5-mm, partially threaded
lag screws. The author has found it helpful to
use small fragment (3.5- or 2.7-mm) cortical
screws placed in true lag mode. Their use
grew out of similar use of such screws in the
proximal tibia, popularized by Benirschke.
Although each fracture conguration is
intrinsically different, certain screws remain
very helpful for xation of complex mul-
tiplane articular fragments. In particular,
several specic strategies are helpful:
1. 3.5-mm cortical lag screws can be placed
from lateral to medial about the periph-
Figure 7. Typical Hoffa plane fracture in femoral condyle.
ery of the lateral femoral condyle to Its orientation is in the frontal plane and can be xed
secure the lateral condylar block to the with cortical lag screws placed from the anterior to pos-
medial condylar block (see Figs. 4 and 5). terior direction. The starting position for the screws is
2. Separate minifragment lag screws or just proximal to the articular surface. (From Hansen ST,
variable pitch lag screws can be used Swiontkowski MF (eds): Orthopaedic Trauma Protocols.
Raven Press, New York, 1993, p 300; with permission.)
to address small separate intercondy-
lar notch fragments (see Figs. 4 and 5); Appropriate length, axis, and rotational
although these small fragments are usu-
restoration
ally not important from a structural or Stable, but not necessarily rigid xation
articular surface standpoint, they may
connecting the distal femoral block to the
be attached to bers of the anterior cru-
proximal femur
ciate ligament. In such a case, a suture Avoidance of metaphysealdiaphyseal
rendered repair of the anterior cruciate
soft tissue stripping
ligament through drill holes in the lateral
femoral cortex may be warranted.
3. Anterior-to-posterior 3.5-mm lag screws The advantages of submuscular xation
can then be placed to address Hoffa of distal femur fractures have been well
frontal plane fractures in the femoral shown, both in the experimental and clinical
condyle (Fig. 7). The starting point for setting.6, 7, 1922 Naturally, the surgeon may
these screws is just cephalad to the ar- envision that a plate placed in a submuscular
ticular surface of the femoral condyle. In manner would disrupt a signicant soft tissue
placing the screws in this manner, there or vascular disruption. Such is not the case
is a corridor of bone left for placement because there is a potential space beneath the
of future screws that will afx the distal vastus lateralis muscle belly that allows for
femoral block to the plate and proximal the passage of the plate beneath the muscle.
femur. Farouk et al6, 7 compared the vascular distur-
4. Similar screws to the Hoffa screws can be bance to the femoral perforating and nutrient
placed on the diagonal from one femoral arteries of the distal femur using silicone dye
condyle to the other. These screws then injection in matched pairs of 10 fresh cadav-
lock in one condyle with the other, ers. Comparing conventional plating versus
which can be helpful in the setting of a submuscular plating, better periosteal and
short distal segment. medullary perfusion was seen in 70% of the
cases with submuscular plating. The use of
After the articular surface is reduced and in- dynamic condylar screw in a submuscular
ternally xed, the goals are: manner has proven efcacy20 (Fig. 8). Articular
164 KREGOR

Figure 8. A 67-year-old women sustained a nonarticular supracondylar femur fracture. The use of a
dynamic condylar screw in a submuscular manner is demonstrated. A, Injury AP traction radiograph.
Note long proximal extension. B, Many options are available for treatment of this fracture. In this case,
the intraoperative view demonstrates placement of the dynamic condylar screw through a small lateral
incision. Note the supracondylar bump posterior to the supracondylar region to counteract the hyper-
extension deformity of the distal femur.
Illustration continued on opposite page
 DISTAL FEMUR FRACTURES WITH COMPLEX ARTICULAR INVOLVEMENT 165

Figure 8 (Continued ). C, Intraoperative uoroscopic view demonstrating placement of the dynamic

condylar screw parallel to the joint surface. D, Postoperative AP radiograph. Appropriate alignment
was performed utilizing manual traction. The side plate for the dynamic condylar screw was placed in
a submuscular manner, and the proximal screws were placed in a percutaneous manner. E, Postoper-
ative lateral radiograph.
166 KREGOR
reconstruction by a lateral peripatellar ap-
proach, followed by submuscular plate xa-
tion, was reported by Krettek et al19 in eight
cases of C2 and C3 distal femur fractures.
Average time to healing was 12 weeks, with
no infections seen; however, the investiga-
tors did note two varusvalgus deformities of
more than 5 , two leg length discrepancies of
more than 10 mm, and two rotational defor-
mities of 15 . These ndings point out that,
although submuscular plating leads to rapid
consolidation of the fracture, obtaining correct
alignment and rotation may be difcult using
closed reduction.
After the articular surface is addressed, the
surgeon can then carry out xation of the
supracondylar component of the fracture us-
ing either a biological plating technique or
a submuscular technique. Although a care-
fully performed soft tissuesparing lateral ap-
proach to the proximal femoral shaft may
be connected to the lateral peripatellar ap-
proach, this does make a rather large incision.
Without the lateral peripatellar approach, one
may not be able to obtain the visualization
of the articular surface. Thus, the usefulness
of the TARPO technique lies in its ability to
expose well the articular surface and to pre-
serve the soft tissues around the metaphyseal
diaphyseal component of the fracture.
IMPLANT OPTIONS
Ideally, the plate implant for the distal fe-
mur should have angular stability in the dis-
tal screws to help avoid varus collapse. The
clinical problem of varus collapse is being ad-
dressed by several new plate designs, all of
them having the common denominator of dis-
tal xed-angled locked screws. This idea is at-
tributed to Jeff Mast, MD, who originated the
idea of Schuli
(Synthes, USA) devices, which
lock a cortical screw into a compression plate.
A locking condylar buttress plate (Synthes,
USA) has been introduced and features screws
that lock into the distal aspect of the plate.
In such a C3 fracture, the locking condylar
buttress plate may be passed in a submuscu-
lar manner and percutaneous proximal screws
placed. Alternatively, a separate proximal in-
cision can be used for the attachment of the
proximal end of the plate to the proximal fe-
mur after closed reduction of the metaphysis.
Undoubtedly, other similar plate systems will
be introduced in the next years.
Less Invasive Stabilization System
for Distal Femur Fractures
The Less Invasive Stabilization System
(LISS; Synthes, USA) was introduced recently.
Mathys Corporation in Switzerland and the
A.O. Development Institute in Switzerland
were responsible for its development (Fig. 9).
Its characteristics include:
1. Multiple, xed angled screws which lock
into the distal end of the xator
2. An insertion handle that allows for sub-
muscular sliding of the xator and for
placement of percutaneous, self-drilling,
unicortal screws for xation of the dia-
physeal component of the fractures
The LISS system should be viewed as a
new surgical technique and not as an implant.
The major characteristics of the LISS technique
entail:
Direct visualization and classic ORIF of
the articular fracture surface
Closed manipulation of the metaphyseal
diaphyseal component of the fracture, us-
ing reduction aids
The characteristics of the technique and
implant, when viewed together, allow for both
submuscular xation of the supracondylar
component of the fracture and placement of
multiple xed-angle locked screws in the dis-
tal femoral fragment. The ability to maintain
the soft tissue envelope around the frac-
ture can be attributed to the LISS technique,
while the improved distal femoral condyle
purchase corresponds to the multiple distal
xed-angle locked screws.
THE LISS IS AN
INTERNAL FIXATOR
Given the biomechanics of the LISS system
as just discussed, it is most helpful to consider
the LISS system as an internal xator rather
than as a plate. The characteristics of the LISS
parallel that of an external xator in several
ways:
The LISS screws have self-drilling,
self-tapping, and cutting utes similar
to several current Schanz pin designs used
in external xators. Just as self-drilling
external xation pins will push away the
bone when inserted, so too do the LISS
 DISTAL FEMUR FRACTURES WITH COMPLEX ARTICULAR INVOLVEMENT 167

B C

Figure 9. The less invasive stabilization system (LISS [Synthes, USA]) has been developed to allow
for submuscular xation of supracondylar-intercondylar femur fractures. All screws lock into the plate,
making it an internal external xator, rather than a plate. A, The LISS has an outrigger device that al-
lows for percutaneous placement of the proximal screws. Screws are self-drilling, self-tapping, and are
drilled in under saline cooling provided by an irrigation system. B, The screws are 5.0 mm in diameter
and are self-drilling and self-tapping. The proximal cortical screws are 26 mm in length, and the dis-
tal screws are 55, 65, 75, and 85 mm in length. C, The screws lock into the LISS xator, as the screw
heads are threaded that screw into the xator.
168 KREGOR
screws tend to push away the bone during
screw insertion with a power drill.
The xation will maintain, but not obtain,
fracture reduction. Using conventional
plating techniques, xation of a reduced
fracture with an improperly contoured
plate will result in loss of fracture reduc-
tion. Conversely, a properly contoured
plate can aid in fracture reduction be-
cause the screws will approximate the
bone to the plate. The exact opposite is
the case with the LISS system. Acting as
an internal xator, the fracture reduc-
tion must be achieved before the LISS is
internally xed, just as one would ob-
tain an appropriate femoral diaphyseal
reduction before placing on an external
xator. One cannot rely on the xator to
help afford the reduction. This in sharp
distinction to the use of the 95 angle
condylar blade plate, in which the estab-
lishment of proper placement of the blade
plate in the distal femoral region will
ensure appropriate axial and sagittal plane
alignment.
The articular surface is addressed with
direct visualization and traditional ORIF.
This may be liked to treatment of a prox-
imal tibial plateau fracture with articular
involvement. Although the metaphyseal
diaphyseal component of the fracture may
be addressed with external xation, the
joint surface is addressed with classic joint
surface visualization, reduction, and lag
screw xation.
Longer constructs than with conventional
plating techniques are used. As longer x-
ator placement (i.e., 13-hole versus 9-hole)
is not associated with longer surgical inci-
sions, longer xators tend to be used.
Articular Surface
Reduction strategies for the articular surface
are aided by a well-thought-out preoperative
plan, aided by a thorough understanding of
the injury. Early intervention minimizes the
need for debridement of the cancellous bone
surfaces. The accuracy of the reduction in a
multiplane fracture is usually aided by com-
plete provisional xation of all fractures to as-
sure anatomic reduction. A common malre-
duction is to have rotational mismatch of one
femoral condyle or the other.
Often, rotational control of one condyle
is aided by a Schanz screw placed into the
medial femoral condyle. Large tenaculum
clamps (Weber clamps) or pelvic reduction
clamps in conjunction with Kirschner wire
xation can be used for provisional xation of
the articular splits. Dental picks can be helpful
for manipulation of small fragments.
Metaphysis and Diaphysis
Closed reduction of the metaphyseal
diaphyseal component of the fracture is often
possible, as known from intramedullary nail
xation of distal femur fractures. In general,
a multifragmentary metaphyseal fracture is
easier to reduce than is the spiral metaphyseal
fracture. In one series of 66 supracondylar
femur fractures treated with attempted closed
reductions, in two cases, a closed reduction
was not possible.18 Both cases consisted of
a simple spiral fracture of the metaphyseal
region. Closed reduction of the metaphysis is
aided by:
Early intervention
Complete clinical paralysis
Manual traction
Supracondylar bumps
The supracondylar bumps are made of
rolled operating room towels of various num-
bers and are placed posterior to the supra-
condylar region. These bumps are placed to
counteract the normal hyperextension defor-
mity of the distal femur seen secondary to the
pull of the gastrocnemius. In addition to these
modalities, the use of the femoral distractor or
external xator may be helpful to gain length.
Additional case examples are demonstrated in
Figures 10 and 11.
SUMMARY
The C3 distal femur fracture remains a prob-
lematic one because of severe articular injury,
signicant soft tissue disruption, bone loss,
and fracture patterns that compromise xa-
tion quality. Optimal visualization of the ar-
ticular surface, followed by soft tissue preser-
vation around the metaphyseal component of
the fracture, is advantageous. This may be ac-
complished by a lateral peripatellar approach,
followed by submuscular xation.
(Text continued on page 174)
 DISTAL FEMUR FRACTURES WITH COMPLEX ARTICULAR INVOLVEMENT 169

A B C

Figure 10. A 42-year-old man sustained a left Type IIIA open distal femur fracture and a right Lisfrancs
fracture-dislocation of the foot. A, Traction AP radiograph of the distal femur. B, Lateral radiograph. The
arrow points out the Hoffa frontal plane fracture (arrow). C, Close-up lateral of distal femur. The ar-
row indicates the Hoffa plane fracture. D, Initial operative view of left femur. The patient sustained a
prepatellar traumatic laceration, which was repaired. The arrow indicates the traumatic injury after irri-
gation and debridement of the open fracture wound. This wound was extended distally to give appro-
priate visualization of articular surface. Anterior to posterior lag screws were placed to address both
the medial and lateral Hoffa fractures. Submuscular xation was then placed utilizing LISS xation.
The proximal incision is to ensure the xator is in the appropriate position on the proximal femur.
Illustration continued on following page
170 KREGOR

E F G

Figure 10 (Continued ). E, Postoperative AP radiograph. F, Postoperative lateral radiograph. Note the

anterior to posterior direction of the lag screws to address the Hoffa plane fracture. G, AP radiograph
at 6 weeks. H, Lateral radiograph at 6 weeks. I, AP radiograph at 9 months. The patient had full range
of motion (0130 of exion). J, Close-up of distal femur at nine months post-trauma. K, Lateral radio-
graph at nine months. Complete consolidation is seen.
Illustration continued on opposite page
 H I

J K

Figure 10 See legand on oppsite page.

171
172 KREGOR

A B C

D E

Figure 11. An 18-year-old woman sustained an isolated closed left C3 distal femur fracture in a mo-
torcycle accident. A, Injury AP traction radiograph. B, Injury lateral traction radiograph. A multiplane
articular fracture is seen. The patella is seen to divide the articular surface (arrow). C, Axial CT scan
demonstrates patella driven into midsubstance of lateral femoral condyle (arrow). D, Intraoperative
view of articular injury, as seen by way of the lateral peripatellar approach. E, Provisional xation of
the articular surface.
Illustration continued on opposite page
 DISTAL FEMUR FRACTURES WITH COMPLEX ARTICULAR INVOLVEMENT 173

Figure 11 (Continued ). F, Lateral view of articular reconstruction. Note short segment of distal femur
(arrow). G, Intraoperative view of distal femoral block with LISS xator in place. The 3.5-mm corti-
cal lag screws are placed around the periphery of the condyle (arrow). Note preservation of the soft
tissues around the metaphyseal region. H, Three months postoperative AP radiograph. The patient re-
gained only 90 of exion despite immediate range of motion. She had signicant extensor mechanism
injury. I, Postoperative lateral at 3 months.
174 KREGOR
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Address reprint requests to
Philip J. Kregor, MD
Division of Orthopaedic Trauma
Department of Orthopaedics and Rehabilitation
Vanderbilt University Medical Center
Nashville, Tennessee 37232
e-mail: philip.kregor@vanderbilt.edu
TREATMENT OF COMPLEX FRACTURES
OPEN REDUCTION AND INTERNAL
FIXATION OF HIGH-ENERGY TIBIAL
PLATEAU FRACTURES
Proximal tibial articular fractures are caused
by a variety of mechanisms and are character-
ized by numerous distinct fracture patterns.
Surgical treatment for other than minimally
displaced or nondisplaced fractures is rec-
ommended to restore joint congruity and
limb alignment and to allow early, stable knee
motion.1, 4, 20, 37 Potential complications vary
with the degree of energy absorbed during
the injury and include soft tissue compro-
mise requiring coverage procedures, lower
extremity compartmental syndrome, peroneal
nerve injury, vascular injury, and eventual
knee arthrosis.15 Associated injuries include
ipsilateral femoral and tibial diaphyseal
fractures, cruciate and collateral ligament
injuries, and meniscal tears.3 Each of these
injuries affects early surgical treatment and
long-term outcomes. A heightened awareness
of these potential injuries and complications
has altered the approach to complex proximal
tibial articular fractures. Internal and exter-
nal xation design advances have changed
several of the techniques of fracture xation.
Similarly a greater appreciation of soft tissue
injuries about the proximal tibia has changed
treatment protocols to limit potential surgical
morbidity.
Another article in this issue describes sur-
gical treatment of high-energy tibial plateau
fractures using limited periarticular inter-
nal xation combined with external xation.
From the Department of Orthopedic Surgery, University of Washington, Harborview Medical Center, Seattle,
Washington
ORTHOPEDIC CLINICS OF NORTH AMERICA
VOLUME 33 NUMBER 1 JANUARY 2002
00305898/02 $15.00 + .00
William J. Mills, MD, and Sean E. Nork, MD
This article discusses the surgical stabiliza-
tion of these fractures with plate and screw
constructs. The features of high-energy com-
plex tibial plateau fractures identied by
Watson45 include signicant articular depres-
sion, condylar displacement, metadiaphyseal
fracture extension, and open wounds or exten-
sive closed degloving injuries of the proximal
tibia (Fig. 1). Although soft tissue injuries may
make open reduction and internal xation
(ORIF) difcult, in many instances it has cer-
tain advantages over external xation and
frequently can be accomplished safely in the
setting of high-energy blunt trauma to the
proximal tibia. The goals of both treatment
methods include anatomic reconstruction of
the proximal tibial articular surfaces, restora-
tion of the limb axis, spanning metaphyseal
comminution if present, and minimization of
further morbidity to an already traumatized
soft tissue envelope. These goals can be ac-
complished in the proximal tibia with plate
and screw constructs if one uses appropriate
and limited incisions when necessary, longer
bridging plate constructs in comminuted
fractures, and xed angled implants or me-
dial external xation supplementation when
isolated conventional plates are insufcient.
The concept of spanning areas of severe frac-
ture comminution evolved in the 1990s as
proponents of indirect fracture reduction and
biologic internal xation reported increased
177
178 MILLS & NORK

A B

Figure 1. A and B, This 56-year-old woman sustained a severe injury to her left proxi-
mal tibia after a fall from height. Note the signicant articular depression and distal ex-
tension. The soft tissue injury delayed denitive operative treatment for 3 weeks.

rates of fracture healing with decreased infec-
tion rates.23 Delaying denitive treatment until
optimal soft tissue conditions exist also min-
imizes complications. Temporary knee span-
ning external xation is a useful adjunct in
injuries with soft tissue compromise.
Potential advantages of ORIF over some
external xation techniques include the ability
to recognize and repair associated menis-
cal and collateral ligament injuries, greater
visualization of the articular surface for
restoration of joint congruence, and avoid-
ance of prolonged external xation half-pins
and wires. These pins and wires can lead to
some of the complications they are designed
to avoid, including cellulitis, osteomyelitis,
and septic arthritis. Marsh et al27 reviewed
their experience with external xation and
limited internal xation of complex Schatzker
type IV, V, and VI tibial plateau fractures in
20 patients. In only 2 knees was an arthro-
tomy performed for direct visualization of
the articular reduction. Meniscal or collateral
ligament pathology was not addressed in any
patient. Although Marsh et al27 concluded that
this was a satisfactory technique for treatment
of certain complex plateau fractures, they
noted clinical ligamentous laxity in 7 patients,
posttraumatic osteoarthritis in 5 patients,
and septic arthritis requiring surgical treat-
ment in 2 patients. These authors also con-
ceded an average residual joint displacement
of 2 mm.
The optimal treatment for high-energy tibial
plateau fractures frequently is not limited to
purely internal or external xation but com-
monly combines elements of both. Authors
who advocate predominantly tensioned ne
wire or hybrid external xation for high-
energy plateau fractures do so with the caveat
that restoration of the articular surface with
limited internal xation should be performed
before spanning the metaphysis with external
xation.11, 12, 43, 45 Similarly, ORIF of high-
energy plateau fractures can be combined with
temporary knee spanning external xation
or supplemental medial external xation to
neutralize deforming forces when signicant
cortical comminution is present.45
Published series describing internal and ex-
ternal xation as treatment of high-energy
plateau fractures have reported high rates
 OPEN REDUCTION AND INTERNAL FIXATION OF HIGH-ENERGY TIBIAL PLATEAU FRACTURES 179

of soft tissue and infectious complica-
tions.17, 26, 30, 47 For this reason, the common
theme in management of these complicated
injuries is respect for the soft tissue envelope.
The authors approach to operative treat-
ment of most closed high-energy plateau
fractures typically is coupled with temporary
knee spanning external xation (Fig. 2) and
delayed treatment when needed to allow
soft tissue recovery. It also is helpful to use
2 plate constructs placed through 2 incisions,
to avoid anterior midline approaches, to use
medial external xation or xed angled plates
on occasion to avoid a medial surgical ap-
proach, and to perform soft tissue coverage
procedures to treat local injuries.
NONOPERATIVE TREATMENT
This article focuses specically on the oper-
ative treatment of tibial plateau fractures us-
ing ORIF techniques. There is a role for non-
operative treatment of certain tibial plateau
fractures in selected patients. The indications
for closed treatment include nondisplaced or
minimally displaced (< 3 mm of articular in-
congruity) fractures; peripheral (submeniscal)
plateau fractures; and fractures in elderly, low-
demand, or osteoporotic patients. The concept
of mandating closed treatment solely on the
basis of age has been challenged, however,
by Houben et al,16 who found that patients
older than age 60 with surgically treated tibial
plateau fractures had less functional loss than
younger patients treated with ORIF.
CLASSIFICATION
Any discussion of fracture treatment bene-
ts from a useful classication system. Tibial
plateau fractures have been classied by many
authors.14, 21, 3032, 39, 41 Although each has its
advantages and disadvantages, the Schatzker
classication currently is accepted most
widely and is employed here. In tibial plateau
fractures, as in any lower extremity periartic-
ular fracture, the articular cartilage damage at
the time of injury signicantly affects patient
outcome. No current classication incorpo-
rates the degree of cartilage injury. Although
cartilage injury can be inferred by the degree
of fracture displacement and the presumed en-
ergy absorption in these fractures, there is no
direct correlation between fracture type and
prognosis. Injuries to the local soft tissues, in-
cluding the menisci, collateral ligaments, and
adjacent neurovascular structures, are com-
mon. Although these injuries are not a part
of standard classication schemes, they have
a signicant impact on patient outcomes.3
Finally, signicant intraobserver and inter-
observer variability has been documented

Figure 2. A temporary knee spanning external xator is useful for main-

taining the length and alignment of the limb while the soft tissue swelling
resolves. Care should be taken to place the pins proximal to the knee
joint capsule at the femur and distal to the proposed operative incisions
at the tibia.
180 MILLS & NORK
when the Schatzker classication has been
employed.9
RADIOGRAPHIC ASSESSMENT
Standard preoperative radiographic evalu-
ation includes plain radiographs and com-
puted tomography (CT) scans. The most help-
ful plain radiographs include anteroposterior,
lateral, and plateau views. The plateau view is
obtained by tilting the radiographic beam ap-
proximately 10 caudad, to parallel the prox-
imal tibial articular surface. The anteroposte-
rior and plateau views help dene the extent
of medial and lateral plateau involvement.
The plateau and lateral views give an in-
dication of the degree of comminution and
joint depression. The lateral view is particu-
larly helpful in assessing posterior displace-
ment of one (usually the medial) or both tibial
condyles (Fig. 3) and may show associated tib-
ial tubercle avulsions or nondisplaced tubercle
fractures. Preoperative two-dimensional axial
Figure 3. The lateral injury radiograph demonstrates pos-
terior displacement of the proximal tibial articular injury. In
this case, the posteromedial fragment is separated from
an additional depressed central medial fragment.
CT scans with coronal and sagittal reforma-
tions are helpful for (1) enhancing the under-
standing of the fracture pattern, (2) showing
more precisely locations and degrees of artic-
ular depression and incongruity, and (3) plan-
ning optimal screw and plate placement. The
axial and coronal images frequently identify
the intact region of the plateau from which
a stable construct can be built or into which
screws will achieve optimal purchase.
CT scans with three-dimensional recon-
structions have been recommended for eval-
uation, classication, and surgical planning
in tibial plateau fractures.24, 46 Others have
suggested the superiority of magnetic reso-
nance imaging for evaluating plateau fractures
because of its superior soft tissue evaluation.7, 8
These images are especially helpful in delin-
eating meniscal tears. In most cases, a careful
assessment of plain radiographs and standard
two-dimensional CT reformations provides
sufcient information to allow the generation
of a proper surgical plan.
TREATMENT
Type I Through III Fractures
The major emphasis of this article is a de-
tailed discussion of the open treatment of
more complex tibial plateau injuries, such as
type IV, V, and VI fractures, with the great-
est emphasis on type V and VI fractures.
A general discussion is presented, however,
of all fracture types (I through VI), includ-
ing fractures with associated ligamentous and
meniscal injuries and fractures associated with
vascular injuries.
Type I through III fractures involve the lat-
eral tibial plateau. These tend to be lower en-
ergy, axial loading injuries and usually are
closed. The type I fracture originally was de-
scribed as a pure cleavage (split) fracture;
the type II fracture, a cleavage (split) com-
bined with lateral articular depression; and
the type III fracture, a pure articular surface
depression.
Lateral plateau fractures can be approached
surgically in a variety of ways. Many authors
advocate arthroscopically assisted treatment
of unicondylar (generally lateral) plateau
fractures.6, 28, 33 One advantage of arthroscopy
is the ability to identify associated meniscal
and ligamentous injuries. Scheerlinck et al42
noted that 15 of 28 patients (54%) with tibial
 OPEN REDUCTION AND INTERNAL FIXATION OF HIGH-ENERGY TIBIAL PLATEAU FRACTURES
plateau fractures had meniscal tears or cruci-
ate ligament injuries or both. These authors
reported no signicant complications with the
arthroscopic technique and good-to-excellent
results in 91% of patients at a mean follow-up
of 5 years. All but one of their patients with
long-term follow-up had a unicondylar frac-
ture. Published comparison studies of open
or uoroscopically assisted percutaneous
procedures versus arthroscopically assisted
procedures are rare and have yet to show an
advantage of one approach.25
A common surgical approach for ORIF of
type I, II, and III lateral plateau fractures can
be employed. This incision also is used for ap-
proaching lateral plateau fractures occurring
as a component of type V and VI fractures.
It is a standard anterolateral incision begin-
ning 1 to 2 cm lateral to the patella, extend-
ing distally over Gerdys tubercle and 1 cm
lateral to the crest of the tibia (Fig. 4). The
deep dissection reects the iliotibial band from
Gerdys tubercle and extends distally to in-
cise the anterior compartment fascia, leaving a
narrow cuff attached to the tibial crest for po-
tential repair at the time of closure. The an-
terior compartment musculature is elevated
carefully from the proximal lateral tibia, ex-
posing lateral plateau fracture lines and the
lateral knee capsule. A transverse submenis-
cal arthrotomy is made, leaving a small cuff
of coronary ligament attached to the proximal
tibia for later arthrotomy closure. Many mod-
ications of this approach exist and have their
advantages. One key to successful fracture re-
duction is application of a lateral femoral dis-
tractor; this virtually always enhances articu-
lar surface visualization. A headlamp worn by
the primary surgeon also is a valuable tool.
Detachment of the anterior horn of the lat-
eral meniscus has been advocated by some
to improve visualization of the lateral plateau
fracture34, 35 but is generally unnecessary. The
surgeon should consider the need for bone
graft in most plateau fractures. Patients rou-
tinely should be consented for iliac crest au-
tograft and allogeneic cancellous bone graft.
Careful evaluation of the preoperative radio-
graphs and CT scan helps determine the po-
tential role for bone graft or graft substitutes.
Although most type II or III fractures are not
likely to require more than 10 to 15 cm3 of
supporting graft, high-energy bicondylar frac-
tures often require larger volumes.
Newer plate designs have simplied the
treatment of lateral plateau fracture pat-
181
terns. In the past, large fragment implants
commonly were used to treat type I through
III fractures.40 More recently, authors have
supported the clinical and biomechanical
efcacy of small-fragment, low-prole im-
plants, such as T-plates with a subchondral raft
of 3.5-mm screws (Fig. 5) for these lateral
fractures.13 New low-prole precontoured
plate designs have been introduced to simplify
lateral plate application, and most include
perforations in the plate to increase the ease of
the submeniscal arthrotomy repair.
Type IV Fractures
Type IV fractures of the medial plateau can
be considered a transitional injury between
the type I through III fractures and type V and
VI fractures. Although they generally occur as
a result of high-energy trauma in all but the el-
derly, osteopenic patient,40 the fracture pattern
tends to be a relatively simple split resulting
in an intact wedge of medial plateau (Fig. 6).
Although central depression or eminence frac-
tures may occur, marked comminution rarely
is encountered. Typically the medial plateau
portion of the fracture remains in continuity
with the distal femur, whereas the associated
lateral tibia and bula translate laterally and
shorten. Although fracture xation schemes
generally can be limited to unilateral medial
neutralization plating, one must be aware of
potential soft tissue injuries. Signicant lateral
translation of the lateral plateau and the intact
tibial shaft may occur, resulting in lateral col-
lateral ligament and capsular disruption. Most
authors suggest repairing the lateral collateral
ligament acutely in this setting.3, 40 The per-
oneal nerve and popliteal artery also are at
risk in this fracture pattern. Ankle-arm indices
should be measured in all patients with high-
energy plateau fractures and patients with
gross residual displacement in the emergency
department. This simple technique is a use-
ful screening tool for occult and gross arte-
rial injury.19 A value of less than 0.90 after
traction and closed reduction of the fracture
should prompt vascular surgical consultation
and probable surgical intervention.
Type V and VI Fractures
The treatment of high-energy Schatzker
type IV, V, and VI fractures can be divided
182 MILLS & NORK

Submeniscal
incision

Figure 4. A, The anterolateral approach to the proximal tibial articular surface. An important
feature of this approach includes preservation of the tibial capsular attachments before per-
forming a submeniscal arthrotomy to allow for later closure (Courtesy of Kate Sweeney).
B, A femoral distractor allows for improved visualization of the lateral plateau articular
surface.
 OPEN REDUCTION AND INTERNAL FIXATION OF HIGH-ENERGY TIBIAL PLATEAU FRACTURES 183

Figure 5. A raft of screws may be placed closer to the subchondral bone.

This allows for effective compression of the lateral plateau combined with
support of the articular reduction. (Courtesy of Kate Sweeney).

into 2 categories: (1) treatment of the soft
tissue injury and (2) treatment of the skele-
tal injury. The treatment of both must occur
concurrently.
Treatment of the Soft Tissue Injury
When high-energy plateau injuries are
closed, signicant contusion and degloving of
the periarticular tissues can occur, rendering
early surgical incisions harmful to the in-
tegrity of the soft tissue envelope. The authors
routinely treat closed, comminuted bicondylar
plateau fractures with temporary knee span-
ning external xation with a mild distraction
force across the knee to improve the resting
position of fracture fragments by available lig-
amentotaxis (Fig. 7). This approach minimizes
the embarrassment to the soft tissue envelope
from displaced fragments and helps restore
the sagittal and coronal alignment to allow for
soft tissue recovery during the 2 to 3 weeks
before ORIF. When applying the frame, care
should be taken to keep the distal femoral
Shanz pin proximal to the suprapatellar pouch
and the proximal of the tibial pins distal to the
expected extent of eventual plate application.
A tibial Shanz pin placed too proximally in the
eventual surgical zone risks deep infection at
the time of ORIF.
Schatzker type V and VI fractures may be
open injuries with marked soft tissue contu-
sion, frank soft tissue loss, or tissue necro-
sis. Although emergent operative treatment
of these open injuries, including debridement
and stabilization (ORIF), is recommended by
some,2 the placement of surgical incisions or
extensions of traumatic wounds must be con-
sidered carefully. Frequently, rotational ap
coverage or free tissue transfer is required in
this setting.
Reduction of the Articular Surface and
Maintenance of Axial Alignment
Anatomic or near-anatomic restoration of
the articular surface remains a goal of the trau-
matologist, as does restoration of the sagit-
tal and coronal alignment of the proximal
tibia.5, 29, 36 Anatomic reduction of the meta-
physis is not necessary and may increase
surgical morbidity. The goal of xation is
to span severe comminution with bridging
plates, avoiding unnecessary dissection, while
providing alignment and adequate stability,
allowing early range of motion.
Management of Open Bicondylar
High-Energy Fractures of the
Tibial Plateau
A treatment protocol for the acute de-
bridement and stabilization of open type V
and VI fractures has been proposed by
Benirschke et al.2 These authors emphasized
early stable articular surface restoration and
184 MILLS & NORK

A B C

D E F

Figure 6. A and B, This 48-year-old man sustained multiple injuries after a high-speed motor vehi-
cle crash. The articular injury consisted of separation of the entire medial plateau with rotation into
varus and exion. C, CT scan axial view. D, Coronal reformation. E and F, Fixation was accomplished
through a posteromedial approach with placement of the plate to resist inferior translation and exion
of the articular fragment.
OPEN REDUCTION AND INTERNAL FIXATION OF HIGH-ENERGY TIBIAL PLATEAU FRACTURES 185

A B C

D E F

Figure 7. A and B, AP and lateral radiographs of a typical bicondylar tibial plateau fracture with metadi-
aphyseal separation in a 72-year-old woman involved in a high speed motor vehicle crash. The antero-
posterior view demonstrates the condylar widening and signicant shortening. The lateral view clearly
shows the coronal fracture line of the medial tibial plateau. C and D, After application of a temporary
knee spanning anterior external xator, length is re-established, and the condylar width is improved
through ligamentotaxis. The soft tissue injury improved over a period of 3 weeks, allowing operative
xation through two incisions. E and F, Follow-up radiographs at 6 months demonstrate maintenance
of the articular reduction, limb axis, and condylar width.
186 MILLS & NORK

joint coverage. Their protocol included deni-
tive internal xation at the time of initial
debridement. Bone grafting of metaphyseal
defects created after elevation and restoration
of the articular surface is performed at the
time of delayed primary closure, skin graft, or
ap coverage. Surgical incisions for fracture
exposure and soft tissue debridement are
designed to limit the creation of large aps,
and standardized incisions are not prede-
termined. Fixation schemes are planned to
yield maximal bony stability, while limiting
further soft tissue stripping or further wound
compromise. By following this protocol, the
authors were able to accomplish immediate
rigid internal xation without deep infec-
tion in 14 patients with type II and III open
bicondylar tibial plateau fractures. This treat-
ment protocol continues to be employed with
minor modications for open high-energy
plateau fractures. Alternatively, these open
fractures may be treated with debridement,
antibiotic bead placement as necessary, knee
spanning external xation, and delayed or
staged ORIF. Figure 8 Shows the steps in
management of such a high-grade open type
VI plateau fracture.
Dual Plating
Although newer xed angle plate and screw
designs, such as the less invasive stabilization
system (see later) may obviate the need for
dual plating of many bicondylar plateau frac-
tures, this is evolving technology not available
to all surgeons and not applicable to all frac-
tures. Medial and lateral plate application re-
mains a common treatment for high-energy,
complex, bicondylar tibial plateau fractures at
the authors institution.
Many authors have reported remarkably
high complication rates with dual plating of
high-energy tibial plateau fractures. In most
such reports, wide stripping of the proximal
tibia is reported and implicated in the rates of

A B

Figure 8. This-27-year old woman sustained this high-energy Type IIIB open proximal tibial frac-
ture with associated articular involvement, bone loss, and contamination. Initial management con-
sisted of debridement,
application of a spanning external xator, and placement of antibiotic im-
pregnated beads. A, Soft tissue coverage consisted of a latssimus free ap at 72 hours followed
by eventual frame removal and ORIF. Delayed antibiotic bead removal and bone grafting of the
large defect was performed at 4 weeks. B, Three-month follow-up radiographs.
 OPEN REDUCTION AND INTERNAL FIXATION OF HIGH-ENERGY TIBIAL PLATEAU FRACTURES
infection seen. Moore et al30 reported a 23%
infection rate with dual plating of bicondy-
lar fractures but used an anterior Mercedes
incision to approach the injury. Young and
Barrack47 reported an 87.5% deep infection
rate and 100% complication rate with dual
plating for comminuted or bicondylar plateau
fractures. Although not specically describ-
ing their surgical approach, they do describe
devascularization of the proximal tibia with
the approach, and postoperative radiographs
suggest the plates were applied through a
single midline incision. Veri et al44 reported
a matched cohort series comparing internal
xation with ring xator methods for high-
grade tibial plateau fractures. These authors
found 44% of the fractures treated with open
methods had an infection requiring intra-
venous antibiotics or operative debridement
or both compared with 12% in the ring xator
group. Mallik et al26 described an 80% deep
infection rate in a few patients with bicondylar
plateau fractures treated with ORIF but also
described large amounts of soft-tissue strip-
ping and the use of dual plates. To minimize
the rate of deep infection in these high-energy
bicondylar fractures, many authors have
recommended minimally invasive, limited
incision reduction techniques for joint surface
restoration combined with standard, hybrid or
ne-wire xation and spanning of the metadi-
aphyseal fracture.11, 12, 27, 38, 43 This is a common
and efcient means of treatment of types V
and VI fractures. It is as technique and sur-
geon dependent as ORIF, however, and in the
authors experience frequently suboptimally
performed. Satisfactory reduction of commin-
uted articular surfaces with limited incision
techniques or indirect reduction maneuvers
may be difcult and can result in malreduc-
tion. Incorrect placement of intra-articular
half-pins or ne wires can lead to compli-
cations of septic arthritis17 and prolonged
external xation pin or wire placement to
osteomyelitis (Fig. 9). Anatomic studies have
improved understanding of safe extracapsular
wire placement.10, 18
Dual plating through a midline extensile
incision carries a relatively high risk of soft
tissue complications and deep infection as a
result of medial and lateral soft tissue strip-
ping. It is intuitive, especially in the patient
with direct anterior force application and re-
sulting fracture with anterior open wounds,
closed degloving, or signicant contusion, that
straight anterior surgical incisions should be
avoided. If used, dual plate application can be
187
achieved with minimal soft tissue disruption.
Two plates frequently are necessary to stabi-
lize some bicondylar fractures optimally, espe-
cially those with posteromedial displacement
of the medial plateau fracture.
Combined Anterolateral and
Posteromedial Plate Application
(Dual Plating Technique)
The patient is positioned supine when
using a dual plate construct is anticipated.
Generally, the medial column is approached
rst, although occasionally one can work
through medial and lateral incisions to op-
timize the metaphyseal reduction. If so, the
lateral approach is that described for type I
through III fractures. In these high-energy
fractures with signicant metaphyseal com-
minution, one should consider using larger
(4.5 mm) metaphyseal spanning plates for
the lateral column to compensate for the
absence of cortical support. No thigh or
buttock bumps are placed initially to allow
improved access to the posteromedial border
of the tibia. Delayed placement of a lateral
bump under the buttock enhances the lateral
approach.
The medial incision is made approximately
1 cm posterior to the posteromedial border
of the tibia metaphysis (Fig. 10). The saphe-
nous vein and nerve are retracted anteriorly.
Deep dissection proceeds to the pes anseri-
nus, which is mobilized proximally and dis-
tally but not detached. The underlying me-
dial collateral ligament is protected, the fascia
overlying the medial head of the gastrocne-
mius incised longitudinally, and the postero-
medial margin of the tibial metaphysis visual-
ized. Subperiosteal dissection is limited to the
fracture margins and the region of anticipated
plate application. Disruption of anteromedial
soft tissues is avoided. This deep exposure
through a more anterior skin incision has been
described but with detachment and retrac-
tion of the pes tendons.30 In general, mobiliza-
tion of the proximal and distal border of the
pes tendons allows adequate retraction and
fracture visualization and reduction. Two pat-
terns of medial plateau injury are recognized:
(1) The entire medial plateau may separate as
a single condylar segment (Fig. 11); (2) more
commonly the medial plateau injury consists
of separation and rotation of a posterome-
dial fragment (Fig. 12). After provisional frac-
ture reduction and stabilization, a plate can be
Text continued on page 194
188 MILLS & NORK

A B

C D

Figure 9. A, This 38-year-old man sustained a closed Type VI tibial plateau fracture in a motor ve-
hicle accident. Initial treatment consisted of a limited approach to the lateral plateau articular injury
with percutaneous large fragment subchondral screw stabilization. B, The meta-diaphyseal separa-
tion was narrowly spanned with a hybrid external xator. C, The patient eventually developed septic
arthritis, requiring multiple joint debridements
and proximal tibial osteomyelitis with a draining sinus.
Antibiotic beads were placed after an extensive debridement
of the proximal tibia. Gastrocnemius
rotational myoplasty was used to cover the antibiotic beads and the associated soft tissue defect.
D, The healed proximal tibia following large volume cancellous bone grafting. While his infection is
controlled, he has a signicant varus malunion of the articular surface and proximal tibia.
OPEN REDUCTION AND INTERNAL FIXATION OF HIGH-ENERGY TIBIAL PLATEAU FRACTURES 189

Figure 10. The posteromedial approach to the tibial

plateau and proximal tibia. The incision is posterior to the
palpable border of the tibia. The gastrocnemius fascia is
dissected off the posteromedial tibia and retracted pos-
teriorly. The pes anserinus tendons are retracted anteri-
orly (arrow ) for reduction and plate xation. The soft tis-
sue attachments at the anteromedial tibial surface are left
undisturbed.
190 MILLS & NORK

A B

Figure 11. Radiographs demonstrating the medial plateau component of a bicondylar injury (A).
Note the complete separation of the medial plateau with posterior displacement of the articu-
lar segment (B). The axial (C) and coronal (D) CT scans demonstrate the medial injury and the
intercondylar split. The medial plateau is stabilized with a posterior antiglide plate and transxa-
tion from the lateral implant (E and F ).
Illustration continued on opposite page
OPEN REDUCTION AND INTERNAL FIXATION OF HIGH-ENERGY TIBIAL PLATEAU FRACTURES 191

E F

Figure 11 (Continued ).
192 MILLS & NORK

A B

Figure 12. In this patient, the medial plateau injury (A) consists of an additional coronal split that is
best visualized on the lateral view (B). The CT scan (C and D) further denes the medial plateau artic-
ular separation, which is best visualized in the sagittal reformation (D). Fixation can be accomplished
with an antiglide plate and lag screws placed from anterior to posterior (E and F ).
Illustration continued on opposite page
OPEN REDUCTION AND INTERNAL FIXATION OF HIGH-ENERGY TIBIAL PLATEAU FRACTURES 193

E F

Figure 12. (Continued ).

194 MILLS & NORK
applied to the posteromedial aspect of the
tibia. This can be a difcult plate to contour if
one chooses the rigidity of a 3.5 dynamic
compression (DC) or limited contact dynamic
compression (LCDC) plate. A one third or one
fourth tubular plate can be an effective but-
tress and much easier to contour. This dual
plate scheme allows for a wide anterior skin
bridge if the described lateral incision and
posteromedial incision are used (Fig. 13). Im-
proper plate placement limits the effective-
ness of the 2-plate construct. Effective control
of posteromedial displacement requires poste-
rior plate application. When soft tissue con-
cerns limit additional surgical dissection, a
unilateral medial half-pin external xator may
be used as an alternative to medial plate appli-
cation. This xator can be used to avoid varus
malalignment and generally is removed 8 to
12 weeks postoperatively when consolidation
of the metaphyseal fracture is evident.
An alternative to external xation and ORIF
has been introduced for high-energy bicondy-
lar tibial plateau fractures. The less invasive
skeletal stabilization system provides precon-
toured plates with a locking screw-plate inter-
face providing a xed angled implant. Advan-
Figure 13. Intraoperative clinical image of the incisions
for xation of a bicondylar tibial plateau fracture. Note the
skin bridge, which is left intact over the anteromedial tibial
surface (arrow ).
tages include (1) submuscular, extra-periosteal
plate application through relatively small in-
cisions; (2) percutaneous screw placements
through a guide, limiting additional expo-
sure; and (3) the xed angled nature of the
plate, potentially obviating the need for me-
dial xation (Fig. 14). Plate lengths are avail-
able to span the metadiaphysis. Limitations
are the need for adequate exposure allow-
ing articular reduction and the inability of
the plate to reduce or buttress posteromedial
displacement.
REHABILITATION
Recovering range of motion is a challenge
in the multiply-injured patient who (1) can-
not participate actively in rehabilitation and
(2) may have soft tissue injuries precluding
immediate range of motion. Knee exion con-
tracture is a commonly reported problem.22
Recognizing the potential disability of chronic
exion contracture, the authors place patients
in a hinged knee brace locked in extension
postoperatively. A padded bump under the
heel is used in the hospital bed and at home
after discharge to maximize knee extension.
Motion is held until surgical and traumatic
wounds are dry. Continuous passive motion
begins when wounds are dry; the goal is
full extension and 90 of exion within 5 to
7 days. If other injuries allow, the patient
is mobilized with a hinged brace locked in
extension for 6 weeks. Nonweight-bearing
precautions generally continue for 12 weeks.
Active exion and passive extension is en-
couraged for 6 weeks, then active knee ex-
tension is begun. Active knee extension is de-
layed if ORIF of a tibial tubercle avulsion was
required.
SUMMARY
High-energy bicondylar tibial plateau frac-
tures are a treatment challenge for the ortho-
pedic traumatologist. Although alternative
methods for treating these injuries have
yielded satisfactory results, ORIF remains a
safe technique if performed correctly (Fig. 15).
Although the soft tissues often present the
greatest treatment challenge, stabilization and
reconstruction of the osseous anatomy is
possible.
OPEN REDUCTION AND INTERNAL FIXATION OF HIGH-ENERGY TIBIAL PLATEAU FRACTURES 195

A B

C D

Figure 14. A and B, High-energy open tibial plateau fracture in a 32-year-old man after
a high-speed motor vehicle crash. Note the signicant metaphyseal and diaphyseal in-
volvement. C and D, Stabilization consisted of reduction of the articular surface and bio-
logic plating of the tibia with a xed-angled device.
196 MILLS & NORK

A B

C D

Figure 15. A and B, This bicondylar tibial plateau fracture is characterized by condylar widening,
shortening, severe lateral comminution, and a displaced coronal fracture of the medial plateau. Initial
management consisted of spanning external xation followed by operative stabilization of the medial
plateau (10 days) and the lateral plateau (22 days). Lateral and medial meniscus tears were identi-
ed and repaired. C and D, The patient was allowed to bear weight at 12 weeks, and healing occurred
uneventfully.
 OPEN REDUCTION AND INTERNAL FIXATION OF HIGH-ENERGY TIBIAL PLATEAU FRACTURES
ACKNOWLEDGMENTS
The authors wish to acknowledge David Barei, MD,
Carlo Bellabarba, MD, and Stephen Benirschke, MD for
their contributions to this article.
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Address reprint requests to
William J. Mills, MD
Department of Orthopedic Surgery
Harborview Medical Center
Box 359798
325 Ninth Avenue
Seattle, WA 98104
e-mail: wjmills@uwashington.edu
TREATMENT OF COMPLEX FRACTURES 00305898/02 $15.00 + .00

HYBRID EXTERNAL FIXATION FOR

TIBIAL PLATEAU FRACTURES
Clinical and Biomechanical Correlation

J. Tracy Watson, MD, Steve Ripple, MD, Susan J. Hoshaw, PhD,

and David Fyhrie, PhD

INDICATIONS diametaphyseal comminution and signi-

For most tibial plateau fractures, especially
those caused by a low-energy mechanism
of injury, contemporary internal xation
techniques using cannulated screws; low-
prole, precontoured, periarticular plates;
and arthroscopic-assisted reduction, with or
without limited incisional approaches have
demonstrated excellent clinical outcomes with
few severe complications; however, for those
fractures that are a result of a higher-energy
mechanism, typically the Schatzker type 5
and type 6 injury patterns, these fractures
have been associated with a high incidence
of severe complications when treated with
traditional internal xation techniques. The
concept of hybrid external xation has
gained wide approval as the severity of the
soft tissue injury has increased, and many
of the factors that preclude even a limited
exposure and plating are present.
Other indications for this methodology
include those fractures with signicant meta-
physeal and subchondral comminution with
resultant periarticular fragmentation that
would preclude routine plate and screw sta-
bilization. Plateau fractures that present with
cant extension into the shaft region are best
treated with this technique. Those complex
fracture patterns with additional soft tissue
compromise (e.g., associated compartment
syndrome), open fractures with soft tissue
loss, and fractures in association with the mul-
tiply injured patient are relative indications for
this technique.
The specic denition of hybrid xation is
quite ambiguous. The term hybrid xation de-
notes no single or universally accepted treat-
ment strategy or device. As commonly ap-
plied, the method uses an external xator to
provide a ligamentotaxis reduction force and
maintains this reduction as a neutralization
device. Percutaneous or limited open incisions
may be used to reduce displaced metaphyseal
and articular fragments in conjunction with
lag screws or small plates.4, 6, 15, 16, 21
Periarticular small diameter tensioned wires
are used to achieve articular stabilization and
are then connected to a proximal ring at the
level of the proximal tibia. The proximal peri-
articular ring then is attached to the shaft be-
low the distal extent of the fracture using a va-
riety of Schanz pin orientations. Despite the
variety of hybrid frames available, specic

From the Division of Orthopaedic Traumatology, Department of Orthopedic Surgery, Wayne State University School
of Medicine ( JTW); the Detroit Receiving Hospital, Detroit Medical Center ( JTW); Phoenix Orthopaedic Consul-
tants, Glendale, Arizona (SR); Dow Corning Corporation, Midland, Michigan (SJH); and the Section of Biomechanics,
Breech Research Laboratory, Henry Ford Hospital Musculo Skeletal Research Laboratory, Detroit, Michigan (DF)

ORTHOPEDIC CLINICS OF NORTH AMERICA

VOLUME 33 NUMBER 1 JANUARY 2002 199

200 WATSON et al
biomechanical principles must be adhered to.
It is currently accepted that dual plating pro-
vides the gold standard of fracture stabiliza-
tion for the treatment of complex tibial plateau
fractures. Many investigators have described
various xation methodologies for the man-
agement of Schatzker type 5 and 6 fracture
patterns as well as those fracture patterns that
may present with solitary intra-articular frac-
ture lines in association with diametaphyseal
comminution and shaft dissociation. Fixation
strategies have included medial and lateral
buttress plating for Schatzker 5 injuries, and
lateral dynamic compession (DC) plating with
medial buttress plating for Schatzki 6 injuries.
In an effort to avoid the soft tissue compli-
cations that can result from the extensile expo-
sures required to facilitate these xation strate-
gies, the use of small tensioned wire hybrid
xators has become an accepted treatment
option. The use of these devices has become
quite liberal despite the fact that little, if any,
biomechanical data are available to support
the use of these small wire techniques.
FRACTURE MODEL
A biomechanical model of a complex proxi-
mal plateau fracture was developed to evalu-
ate the stability of various tensioned wire con-
gurations and compare them to the currently
accepted gold standard of dual plating.19
Composite material tibial bone models
(Sawbones, Pacic Research, Vaston, WA;
Figure 1. A template was used to produce consistent condylar frac-
ture lines using a thin saw blade. A Schatzker Type VI pattern was
fashioned in the testing bones.
designed to reproduce the normal working
and biomechanical characteristics of normal
bone) were cut using templates to produce a
Schatzki 6 injury (Fig. 1).
The simulated fracture was then stabilized
using one of the following hybrid wire cong-
urations or plating strategies.
A. Two counteropposed olive wires, each
tensioned to 90 kg and attached to a
proximal xation ring. Each wire was
positioned centrally in the midportion
of each condylar fragment to act in a
lag fashion and provide intercondylar
compression.
B. Two counteropposed olive wires placed
as previously described and a solitary
6.5-mm cancellous lag screw was in-
serted from the lateral condyle into the
medial fragment in an effort to pro-
vide intracondylar compression. (This is
the conguration commonly shown by
many hybrid manufacturers in product
information brochures.)
C. Four counteropposed olive wires with
a 6.5-mm cancellous intracondylar lag
screw. The additional olive wires are
placed inferiorly on each condylar frag-
ment near its apex to function in an
antiglide fashion. Each hybrid congu-
ration used two rings, with distal ring
xation composed of three 5-mm Schanz
pins oriented 60 to each other. The rings
are connected with four threaded rods to
provide 360 stability of the rings (Fig. 2).
 HYBRID EXTERNAL FIXATION FOR TIBIAL PLATEAU FRACTURES 201

Figure 2. A two-ring frame was mounted onto the testing bone using
four connecting rods to connect the distal and proximal rings. The dis-
tal ring was attached to the shaft using three schantz pins, all placed
out of plane to each other to increase the pin spread, and thus, shaft
stability.

This ring conguration was selected to

alleviate the cantilever loading effects
that can occur with solitary monolateral
bar to ring hybrid adaptations.
D. The contemporary low-prole internal
xation strategy used a lateral 4.5-mm
buttress plate and a medial 3.5-mm
DC plate (Fig. 3).

Mechanical Testing

For each repaired tibial model, both fracture

lines were instrumented using two linear mo-
tion potentiometers, and the entire construct
was mounted on an Instron 8501 machine (In-
stron, Cantron) (Figs. 4 and 5). Each model
was then cyclically loaded to 300 N at stan-
dard loading rates to simulate a normal gait
pattern. Stressstrain curves were measured
from both condylar potentiometers to evalu-
ate stability of the individual condyles and
from the MTS actuator to evaluate the stabil-
ity of the entire construct. Five bone models
were tested for each condylar xation method-
ology, and each model underwent three test-
ing sequences, for a total of 15 tests per bone Figure 3. Dual-plating conguration using a 4.5-mm lat-
eral buttress plate and a medial 3.5-mm DC plate. Note
model. With 75 mechanical tests per xation that each condylar fracture line has been instrumented
technique, multiple data points were sufcient with a linear motion potentiometer to determine the de-
to achieve statistical signicance. gree of condylar displacements that occur with loading.
202 WATSON et al

Figure 4. Two counter-opposed olive wire xation with the potentiome-

ters mounted on both of the condylar fragments.

Figure 5. Test setup demonstrating the xation construct mount-

ed on the Instron machine.
 HYBRID EXTERNAL FIXATION FOR TIBIAL PLATEAU FRACTURES 203

Results pression slightly but did not signicantly en-

Actuator data revealed the most stable
construct to be the hybrid frame with four
counteropposing olive wires and cannulated
screw. The dual plating construct was next
in rigidity (Fig. 6). The potentiometer results
demonstrated that the highest displacements
occurred at the medial condylar fragment,
regardless of the xation methodology. Sta-
tistical analysis of each construct for condylar
stability revealed signicant superiority of the
four wires plus screw conguration (C) with
respect to two wires only (A), and to two
wires plus cannulated screw (B). Dual plating
(D) was shown to be similar in preventing
condylar displacement to four wires plus
screw (C), with no signicant differences
between the two (Table 1).
These data support the use of multiple
tensioned wires to stabilize complex plateau
fractures that incorporate a bicondylar frac-
ture pattern. Fixation with four counterop-
posed olive wires is comparable to the stability
achieved with dual plating congurations.
The commonly shown xation with only
two wires is inadequate, and the addition of
cannulated screws increased condylar com-
hance the overall stability of the construct and
should not be used instead of additional wire
xation elements.19
Frame Conguration
Using the previous data, proximal articular
xation must consist of at least three tensioned
wires. Contrary to what many manufactures
illustrate in their sales brochures, if an inad-
equate number of wires are used (only two
wires) and they are placed with a minimal di-
vergent angle of less than 60 , the proximal
periarticular segment will have a tendency to
translate along the mediolateral axis as if a
solitary wire or axle were present.3, 7, 8
Clinical and mechanical studies have shown
the inadequacies of a two-wire-only construct;
therefore, at least three or more out-of-plane
wires are recommended to avoid this transla-
tional effect.3, 7, 8, 13, 1618, 20
Full ring stabilization is preferable to mono-
lateral shaft stabilization because of the can-
tilever loading that is accentuated when a
proximal ring is attached to a solitary dia-
physeal bar (Fig. 7). This frame conguration

0.16

0.14

0.12

0.10

0.08

0.06
um/N

0.04

0.02

0
2 Wires 2 Wires + screw 4 Wires + screw 2 Plates
-0.02

Figure 6. Load versus displacement, illustrating the relative instability of the two-wire con-
gurations. The actuator data trendlines show that the four-wire and two-plate constructs
are similar in the stability that they afford. Open bar = lateral condyle, shaded bar = medial
condyle. P = 0.0001.
204 WATSON et al

Table 1. CONDYLAR STABILITY VERSUS FIXATION METHODOLOGY

Medial Condyle Lateral Condyle
(potentiometer (potentiometer
Fixation Construct Test Count displacement [mean] m/N) displacement [mean] m/N)
A (2 wires) 75 53.462 33.656
B (2 wires + screw) 75 46.998 15.834
C (4 wires + screw) 75 6.601 1.926
D (2 plates) 75 5.362 4.192

Two wires were compared with all other methodologies. This revealed no signicant improvement to 2 wires + screw (P = 0.6988);
however, superior stability was seen when comparing 4 wires to 2 wires (P < 0.0001), and 2 plates to 2 wires, (P < 0.0001). (ANOVA
and Fishers PLSD.) (Signicance achieved with P = 0.005.)

functions similar to a diving board, produc- Clinical Applications

ing tremendous loads at the metadiaphyseal
junction with associated development of non-
or malunions at this location. Thus, if mono-
lateral adaptations are to be used, it is
recommended that at least three divergent
connecting bars be used to attach the intact
distal diaphyseal segment to the periarticular
ring. The bars should be oriented to achieve
270 of bar to ring attachment to alleviate this
problem of cantilever loading. The additional
disadvantage of this monolateral type of
construct is the inability to easily dynamize
this xator. In addition, if adjustments for
alignment or dynamic gradual compression
or lengthening is required, this frame cong-
uration is generally unsatisfactory for these
complex maneuvers and thus should not be
used for these situations.
The advantages of using a circular, ten-
sioned small wire, external xator in these
situations are numerous.29, 1113, 1618, 21 The ar-
ticular wires are placed percutaneously with
minimal additional devitalization of the bone
and its periosteal and endosteal blood sup-
plies. Small tensioned wires allow for the
capture of very small metaphyseal and sub-
chondral fragments. Therefore, this type of
xation is especially useful in comminuted pe-
riarticular injuries. For Schatzker 5 and 6 frac-
tures, olive wires can compress the condy-
lar fracture lines, much as lag screws are
used.
A mechanically stable and adjustable hybrid
ring xator can span across a fracture gap in
cases of comminution or minimal bone loss,

Figure 7. A complex open plateau fracture treated with a circular hybrid. Note the
multiple proximal wires, as well as the full circular connections between proximal and
distal xation. The large areas between connection rods allow for ease of secondary
procedures. In this case, multiple debridements and the use of an antibiotic bead
pouch facilitated early ap closure.
 HYBRID EXTERNAL FIXATION FOR TIBIAL PLATEAU FRACTURES
similar to an internal neutralization plate.
Compression can be directed across the site
of bone loss or fracture gap that occurs in
type 6 injuries when comminution is found
at the diaphysealmetaphyseal region. The
xator can be used to compress fracture gaps
to achieve bone-on-bone contact without
additional bone grafting. Patient performing
self-adjustments of the frame can continually
modify the maintenance of the mechanical
axis. Rotational and translational deformi-
ties also can be corrected as consolidation
progresses. In addition, small tensioned wire
xators allow for early partial weight-bearing
and range of motion of the knee. At the time
of early consolidation, the frame should allow
for dynamization to decrease pinbone inter-
face stress and facilitate fracture consolidation.
During the treatment of these complex
injuries, secondary procedures are often re-
quired (e.g., to achieve soft tissue coverage
or to perform delayed bone grafting). These
circular frames can be modied easily by tem-
porarily removing any obstructing connecting
bars, performing the additional procedure,
and then replacing the struts. The authors
have found it problematic to drape the xator
out of the operative eld and additionally
maintain this usually small area as sterile
throughout an entire procedure. It has been
shown that, following a standardized protocol
of precleansing the ex-x frame, followed by
alcohol wash, sequential povidoneiodine
prep, paint, and spray, with air drying fol-
lowed by draping the extremity and xator
directly into the operative eld, one can
safely perform the additional surgery without
the increased risk for postoperative wound
infection.15, 16, 18
SURGICAL TECHNIQUE FOR HYBRID
FIXATION OF PLATEAU FRACTURES
The technique of hybrid application relies
heavily of the principles of ligamentotaxis to
achieve a metaphyseal reduction. These tech-
niques usually will not reduce the impacted
articular surfaces. Simply pulling on it is not
indicated in cases in which large areas of artic-
ular depression and comminution are present.
These areas must be addressed through lim-
ited incisions using uoroscopic or arthro-
scopic guidance to reestablish congruent artic-
ular surfaces.
The application of a circular or hybrid
external xator may involve positioning of
the patient on a fracture or radiolucent table
205
with calcaneal pin or distal tibial pin traction.
Alternatively, femoral distractors or tempo-
rary spanning external xators can be used
to obtain preliminary ligamentotaxis and
reduction. Additional closed reduction of the
condylar components is achieved by the use
of large, percutaneously placed reduction for-
ceps. Percutaneous Kirschner wires also can
function as joysticks and aid in the manipula-
tion of these large condylar fragments. After
reduction of the condyles, olive wires (1.8-mm
Kirschner wires with a 4-mm bead located
eccentrically on the wire) are used to achieve
interfragmentary compression of the condylar
articular surface. If necessary, limited incisions
are used to elevate depressed fragments and
bone graft defects through submetaphyseal
cortical windows.
Careful preoperative planning using CT
scan data is of tremendous value. The ability
to maintain the condylar reduction depends
on the presence of compressive forces on
either side of the fracture lines; this is accom-
plished by placing counteropposed olive wires
through the fragments coming from opposite
sides of the major condylar fracture line. One
can also substitute cannulated screws for olive
wires if the metaphyseal fragments are large
enough and not extensively comminuted.
Placement and direction of periarticu-
lar olive wires and cannulated screws is
performed with the aid of uoroscopy, fol-
lowing the surgical plan as determined by
the preoperative CT scan (Fig. 8). Three or
four olive wires are usually required for sta-
bilization of the condylar and metaphyseal
fragments. These wires should be applied in
such a way that they cross perpendicular to
the major fracture lines, much as one would
place a lag screw. This is done to achieve
maximal condylar compression. If this wire
orientation cannot be placed to achieve inter-
fragmentary compression because of anatomic
constraints (i.e., front-to-back transxion
wires), cannulated screws will accomplish this
without the risk for neurovascular compro-
mise. Great care should be taken to avoid the
proximal tibial capsular reection. Olive wires
should not transx this region so as to avoid
secondary seeding of the joint with resulting
joint sepsis. To avoid articular penetration, the
wires should be placed at least 14 mm from the
subchondral line of the joint.14
Following articular reduction, a preassem-
bled frame consisting of three or four appro-
priately sized rings is placed around the limb.
The proximal ring is temporarily placed at the
level of the bular head, and the wires are
206 WATSON et al

Figure 8. A, Proximal plateau fracture with overlap of fracture fragments and inability to determine the
fracture pattern. B, A traction lm that demonstrates an excellent reduction, as well as the ability to de-
termine the fracture pattern. Early distraction is a crucial portion of this treatment option. C, A traction
CT scan of this fracture reveals near anatomic reduction of the condyles, which will allow a percuta-
neous stabilization to be performed using a stable wire and ring pattern.

attached and tensioned to the proximal ring.
The distal aspect of the frame is attached to
the bone using 5-mm half-pins or, in some
cases of extensive shaft comminution, transx-
ion wires. The proximal and distal rings are
connected to each other with fully adjustable
components to allow for the appropriate cor-
rection and alignment of the overall mechani-
cal axis (see Fig. 7).
As this technique has developed, many in-
vestigators have found it necessary to use
additional small plates for xation of heav-
ily comminuted metaphyseal fragments (cor-
tical substitution) or for those fracture pat-
tern that preclude small wire xation because
of anatomic constraints and wire corridors
that orient wires in a front-to-back orienta-
tion4, 16 (Fig. 9).
 HYBRID EXTERNAL FIXATION FOR TIBIAL PLATEAU FRACTURES 207

Figure 9. A, Complex proximal plateau fracture with dissociation of the tibial tubercle fragment, as
well as severe impaction of the articular surface requiring a limited open approach. B, Intraoperative
ouroscopy view demonstrating anterior hook plate used to achieve xation of the tubercle fragment.
Bone graft substitute was placed through a cannula to provide support for the reduced articular sur-
faces. C and D, AP and lateral views demonstrating the hybrid xation construct consisting of a three-
ring frame using four proximal wires with additional cannulated screw augmentation.
Illustration continued on following page
208 WATSON et al
E F
Figure 9 (Continued ). E and F, Two year follow-up radiographs showed the preservation of the lateral
joint surfaces and the overall preservation of the mechanical axis.
In some instances, with acute fractures, the
tibial tubercle is fractured as a separate frag-
ment in conjunction with posterior cortical
comminution. Because of the anatomic con-
straints and inherent dangers of placing front-
to-back transxion wires, the stabilization of
this tubercle fragment is accomplished with an
anterior hook plate (Fig. 9), allowing for rigid
xation of the tubercle fragment with distally
directed screws, which are able to purchase
intact posterior cortex at a site distal to the tu-
bercle fragment.16
Serial radiographs should be observed for
any deviation of the mechanical axis while
in the external xator. If needed, adjustments
may be made gradually to realign the extrem-
ity and to add compression to small areas
of bony comminution. This maneuver allows
one to gain bone on bone contact and thus
a more stable fracture conguration. As frac-
ture consolidation progresses, these frames do
allow full, unrestricted weight-bearing. After
consolidation is complete, the connections be-
tween the proximal and distal rings are loos-
ened (frame dynamization) so that the pin
bone stresses are decreased and the weight-
bearing forces are transmitted by the bone
instead of the external xator.
Before frame removal, the authors allow pa-
tients unrestricted activity for approximately
10 days after frame dynamization in the hope
of preventing late deformity. If a patient has
an increase in pain or subtle changes are
visualized on radiography after the frame
is dynamized, it can be assumed that frac-
ture healing is incomplete. If so, the frame
is retightened to allow forfurther consolida-
tion before its removal, and bone grafting is
considered.
SUMMARY
The biomechanical data support the use of
tensioned wire xation to stabilize complex
fractures of the proximal tibia. The authors
have shown that the stability of a four-wire
construct is comparable to the gold standard
 HYBRID EXTERNAL FIXATION FOR TIBIAL PLATEAU FRACTURES
of dual plating internal xation techniques.
Using these techniques many recent investi-
gators have demonstrated improved clinical
results, with average knee scores (Knee Soci-
ety Rating System) for most patients ranging
from 85 to 90. More important is that these
studies continue to show decreases in the rates
of major wound complications or residual os-
teomyelitis; these decreases had occurred with
traditional ORIF techniques despite the fact
that approximately one third of cases in these
series were open injuries.1, 10, 15, 20, 21 With these
data available, small wire hybrid xation po-
sitioned in a stable frame conguration is an
additional tool that should be considered for
complex proximal tibial injury.
References
1. Blake R, Watson JT, Morandi M, et al: Treatment
of complex tibial plateau fractures with the Ilizarov
external xator. J Orthop Trauma 7:167168, 1993
2. Catagni M: Fractures of the leg (tibia). In Maioccki
AB, Aronson J (eds): Operative Principles of Ilizarov.
Baltimore, Williams & Wilkins, 1991, pp 91124
3. Calhoun JH, Li F, Ledbetter BR, et al: Biomechanics of
the Ilizarov xator for fracture xation. Clin Orthop
280:1523, 1992
4. Dendrinos GK, Kontos S, Katsenis D, et al: Treatment
of high-energy tibial plateau fractures by the Ilizarov
circular xator. J Bone Joint Surg Br 78:710717, 1996
5. Frankel VH, Green SA, Paley D, et al: Sympo-
sium: Current applications for the Ilizarov technique.
Contemp Orthop 28:5171, 1994
6. Gaudinez RF, Mallik AR, Szporn M: Hybrid external
xation of comminuted tibial plateau fractures. Clin
Orthop 328:203210, 1996
7. Ilizarov GA: The treatment of fractures: Theoretical
considerations, experimental studies and clinical ap-
plication of the apparatus. In Ilizarov GA, Green SA
(eds): Transosseous Osteosynthesis: Theoretical and
Clinical Aspects of the Regeneration and Growth of
Tissue. Berlin, Springer-Verlag, 1992, pp 369452
209
8. Kummer FJ: Biomechanics of the Ilizarov external
xator. Clin Orthop 280:1115, 1992
9. Mallik AR, Coval DJ, Whitelaw GP: Internal versus
external xation of bicondylar tibial plateau fractures.
Orthop Rev 21:14331436, 1992
10. Marsh JL, Smith ST, Do TT: External xation and lim-
ited internal xation for complex fractures of the tib-
ial plateau. J Bone Joint Surg Am 77:661673, 1995
11. Mikulak SA, Gold SM, Zinar DM: Small wire external
xation of high energy tibial plateau fractures. Clin
Orthop 356:230238, 1998
12. Murphy CP, DAmbrosia R, Dabezies ET: The small
pin circular xator for proximal tibial fractures
with soft tissue compromise. Orthopedics 14:273280,
1991
13. Paley D: Biomechanics of the Ilizarov external xa-
tor. In Bianchi-Miocchi A, Aronson J (eds): Operative
Principles of Ilizarov. Baltimore, Williams & Wilkins,
1991
14. Reid JS, Vanslyke M, Moulton MJR, et al: Safe place-
ment of proximal tibial transxation wires with re-
spect to intracapsular penetration. In Orthopaedic
Transactions. Presented at the 10th Annual Meeting
of the Orthopaedic Trauma Association. Tampa, 1995
15. Watson JT: High energy fractures of the tibial plateau.
Orthop Clin North Am 25:728752, 1994
16. Watson JT, Coufal C: Treatment of complex lat-
eral plateau fractures using Ilizarov techniques. Clin
Orthop 353:97106, 1998
17. Watson JT: Tibial pilon fractures. Techniques Orthop
11:150159, 1996
18. Watson JT, Moed BR, Karges DE, et al: Pilon fractures:
Treatment protocol based on severity of soft-tissue
injury. Clin Orthop 375:7890, 2000
19. Watson JT, Fhyrie D, Ripple S, et al: Biomechani-
cal analysis of tibial plateau fracture xation using
tensioned wire constructs [abstract]. In Program and
Abstracts of the 6th Annual Meeting of the Associa-
tion for the Study and Application of the Methods of
Ilizarov (ASAMI-NA). Atlanta, 1996, p 25
20. Weiner LS, Kelley M, Yang E, et al: The use of com-
bination internal xation and hybrid external xation
in severe proximal tibia fractures. J Orthop Trauma
9:244250, 1995
21. Zecher SB, Danziger MB, Segal D, et al: Treat-
ment of high-energy proximal tibial fractures using
the Monticelli-Spinelli external xator: A preliminary
report. Am J Orthop 25:4954, 1996
Address reprint requests to
J. Tracy Watson, MD
University Health Center 7-C
Department of Orthopaedic Surgery
4201 St. Antoine Boulevard
Detroit, MI 48201
e-mail: jwatson@med.wayne.edu
TREATMENT OF COMPLEX FRACTURES
Bruce French, MD, and Paul Tornetta, III, MD
Skeletal xation of tibia fractures resulting
from high-energy trauma has undergone a
number of fundamental changes over the past
few decades. These changes are because, in
part, of a better understanding of the intimate
association between the disruption of the soft
tissue envelope of the tibia and the osseous in-
jury, increased implant choices, and the devel-
opment of protocol-driven studies to evaluate
treatment options. Current xation principles
of open fractures are based on Gustilo and
Andersons classication scheme, originally
published in 1976 and modied in 1984.42, 43
Soft tissue injuries found in association with
closed tibia fractures, as classied by Tscherne
and Gotzen, have also been shown to have
clinical and therapeutic signicance.78 These
soft tissue classication schemes represented
a major step forward in the treatment of tibia
fractures, and they facilitated a description
of the injury, which was then used to guide
treatment protocols and evaluate outcomes.
Results of the treatment of tibia fractures
before these schemes must be viewed with
skepticism as increasingly poor prognosis is
associated with higher grades of soft tissue
disruption. The development of aggressive
and emergent protocol-driven management
of soft tissue injuries in association with tibia
fractures has markedly improved outcomes,
regardless of the xation method. In open
fractures, these principles involve emergent
debridement of contaminated, nonviable
soft tissues and bone, pulse lavage irriga-
From Orthopaedic Trauma and Reconstructive Surgery, Columbus, Ohio (BF); and the Department of Orthopaedic
Surgery, Boston Medical Center, Boston, Massachusetts
ORTHOPEDIC CLINICS OF NORTH AMERICA
VOLUME 33 NUMBER 1 JANUARY 2002
00305898/02 $15.00 + .00
HIGH-ENERGY TIBIAL
SHAFT FRACTURES
tion, prophylactic antibiotics, and skeletal
stabilization.19 Scheduled, repeat debride-
ments, interim obliteration of dead space with
antibiotic-laden methylmethacrylate beads,
early, tension-free vascularized soft tissue
coverage, and prophylactic bone grafting have
also decreased complications and improved
results in patients with open fractures. Modi-
cation of the external xation frame constructs
based on sound biomechanical testing has
made their application more uniform (hence,
reproducible) and user friendly, while decreas-
ing complication rates. Frame dynamization
also has been recently introduced as a means
to diminish healing times. The emergence of
interlocking tibia nails, inserted with either
reamed or unreamed technique, has stimu-
lated debate as to the optimal treatment of
these fractures. Recent emphasis on more care-
ful study design has helped to better delineate
indications for one mode of xation versus an-
other, although many questions still remain to
be answered. The following is a review of the
current treatment principles, with particular
attention to skeletal xation of high-energy
tibia fractures in the multi-trauma patient.
ENERGY ABSORPTION AND SOFT
TISSUE INJURY
Soft tissue and osseous injury associated
with trauma to the leg is dependent on the
energy absorbed by the limb at the time of
211
212 FRENCH & TORNETTA
impact. The amount of energy transferred to
the limb during, for example, a bumper injury
is directly proportional to the mass of the ve-
hicle and the squared value of the velocity. Al-
though a fall from the curb may result in the
transfer of 100 ft/lb of energy, a high velocity
gun shot results in the transfer of 2000 ft/lb,
and a typical bumper injury at 20 miles per
hour in the transfer of 100,000 ft/lb.24 This en-
ergy transfer is responsible not only for os-
seous disruption but also soft tissue damage,
such as periosteal stripping, muscle crush,
closed degloving, and loss of skin intergrity.
As the energy absorbed by the limb increases,
the fracture pattern and associated soft tis-
sue damage also increases. Unlike the frac-
ture, which is visualized by radiographs, the
amount of soft tissue damage is harder to
dene.
Oestern and Tscherne78 have proposed a
classication of soft tissue injury in association
with closed fractures (Table 1). Closed type 0
and 1 injuries imply a low energy mechanism
of injury with intact soft tissues and simple
fracture patterns. Grade 2 and 3 closed injuries
imply a great deal of energy absorption by
the limb with signicant osseous and soft tis-
sue disruption. Treatment of these injuries re-
quires urgent care to prevent long-term ad-
verse sequelae. The successful treatment of
these higher-grade injuries is more difcult. In
an animal study, Edwards34 demonstrated that
the addition of a crush injury to the soft tissues
in association with a tibia fracture resulted
Table 1. CLASSIFICATION OF CLOSED FRACTURES
Grade 0 Soft tissue damage absent or negligible;
fracture is the result of indirect forces and
has a simple conguration
Grade 1 Supercial abrasion or contusion caused by
fragment pressure from within; fracture
conguration more severe
Grade 2 Deep contaminated abrasion associated with
localized skin or muscle contusion from
direct trauma; impending compartment
syndrome included in this category;
generally direct violence has produced the
injury
Grade 3 Skin is extensively contused or crushed;
muscle damage may be severe; other
criteria for this category are subcutaneous
avulsions, decompensated compartment
syndrome, and rupture of a major blood
vessel; fracture conguration is severely
comminuted
From Oestern HJ, Tscherne H: Pathophysiology and clas-
sication of soft tissue injuries associated with fractures. In
Tscherne H, Gotzen L (eds): Fractures with Soft Tissue Injuries.
Berlin, Springer-Verlag, 1984, pp 19; with permission.
in prolonged union times and increased risk
for skin necrosis after cast immobilization, as
compared with animals with a tibia fracture
without additional crush injury. Clinical series
involving closed and open treatment of tibia
fractures have documented increased compli-
cation rates and prolonged union times asso-
ciated with high-energy injuries.51, 55, 79 Gaston
et al39 found the Tscherne grade to be a signif-
icant predictor of time to union and functional
outcome after intramedullary nailing.
Open fracture classication generally is
by the scheme initially published in 1976 by
Gustilo and Anderson42 and later modied in
1984 by Gustilo et al43 (Table 2). This classica-
tion has gained widespread support because
it has prognostic signicance. Regardless of
treatment, modality, increased complication
rates and prolonged union times are associ-
ated with the high-grade open fractures. In
one series of open fractures treated with plate
xation, the infection rate was 5.4% for low-
energy fractures compared with nearly 50%
for high-grade open injuries.25 Of particular
concern is the open fracture with inadequate
soft tissue coverage (type 3B) or signicant
vascular injury (type 3C). Brumback and
Jones18 surveyed orthopedic surgeons to
assess the interobserver reliability associated
with this classication system. Even among
orthopedic surgeons experienced in the treat-
ment of these injuries the interobserver agree-
ment was only 60%.
TREATMENT OPTIONS
Cast
Cast immobilization, particularly with early
conversion to a functional brace orthotic or
cast, is the mainstay of treatment of lower-
energy tibia fractures with minimal (Tscherne
0 or 1) soft tissue disruption, provided re-
duction of the osseous deformity is accept-
able. Fractures resulting from more violent
energy transfer generally have more signi-
cant osseous and soft tissue disruption, mak-
ing closed reduction difcult to obtain and
maintain.1 Hooper et al,51 in a randomized-
prospective study comparing casting with in-
tramedullary nailing in displaced closed and
type 1 open tibia fractures, reported a sig-
nicant decrease in malunion rates and time
to union after nailing compared with casting.
Conversion from casting to nailing was re-
quired in 20% of the cases secondary to loss

Table 2. CLASSIFICATION OF OPEN FRACTURES
Grade 1 Skin opening of 1 cm or less; most like
an inside out mechanism; minimal
muscle contusion; simple transverse
or short oblique fracture pattern
Grade 2 Skin laceration greater than 1 cm, with
extensive soft tissue damage, aps or
avulsion; minimal to moderate
crushing component; simple
transverse or short oblique fracture
pattern with minimal comminution
Grade 3 Extensive soft tissue damage including
muscle skin and neurovascular
structures; often a high-velocity
injury with severe crushing
component
3A Extensive soft tissue laceration (10 cm),
adequate bone coverage; includes
segmental fractures and gunshot
wounds
3B Extensive soft tissue injury with
periosteal stripping and bone
exposure; typically associated with
massive contamination; inadequate
soft tissue coverage requires ap
advancement or free ap
3C Vascular injury requiring repair
From Gustilo RB, Mendoza RM, Williams DN: Problems in the
management of type III (severe) open fractures: A new classi-
cation of type III open fractures. J Trauma 24:742746, 1984; with
permission.
of reduction. Puno et al79 also reported in-
creased rates of malunion and failure to main-
tain reduction with casting compared with
intramedullary nailing of displaced closed-
and low-grade open fractures. Sarmiento88 has
written extensively on the effectiveness of
functional bracing of tibia fractures. This treat-
ment method is associated with high union
rates and minimal morbidity, provided adher-
ence to proper indications. This method of
treatment is acceptable for reduced transverse
fractures and axially unstable fractures with
less than 12 mm of initial shortening with ac-
ceptable angular and rotational reduction. An
intact ipsilateral bula predisposes the frac-
tured tibia to fall into varus and is therefore
a relative contraindication to functional brac-
ing. Furthermore, closed treatment does not
allow for ongoing soft tissue evaluation and
treatment, an essential component of the suc-
cessful management of high-energy injuries.
Union times become prolonged as the injury
severity increases with a subsequent increased
immobilization time and resultant limb dys-
function, including muscle atrophy and joint
stiffness. For these reasons, functional bracing
is thought to be a poor choice of skeletal stabi-
lization for tibia fractures resulting from high-
energy mechanisms.
HIGH-ENERGY TIBIAL SHAFT FRACTURES 213
Plate Fixation
Plate xation has fallen into disfavor for
the treatment of these injuries. Traditional
plating techniques require extensive soft
tissue dissection, further devitalizing soft
tissue and bone. Bach and Hansen,6 in a
prospective-randomized study comparing
external xation with open reduction and plat-
ing of type 2 and 3 open fractures, reported
infections in 35% after plating versus 19% after
external xation. Osteomyelitis developed in
13% of patients with plated tibias compared
with 3% of patients with external xation
patients. Burwell20 reported a nonunion rate
of 27% and a deep infection rate of 14% in a
subset of patients with severe tibia fractures
who underwent open reduction and plating.
Ruedi et al86 reported a complication rate of
30% after open reduction and plating of open
tibia fractures compared with less than 1% in
closed fractures. Johner and Wruhs55 also saw
complication rates increase from 13% to 32%
after plating of open tibia fractures compared
with closed. At this time, open reduction and
internal xation of high-energy tibia fractures
with a standard plating techniques is not
recommended.
Percutaneous plating, featuring small inci-
sions, limited periosteal stripping and indirect
reduction techniques, is a biologic benecial
alternative to traditional plating techniques.
Collinge et al27 reported on a small series of
patients with high-energy open and closed
tibia fractures with metaphyseal extension
thought not to be amenable to intramedullary
nailing. Although technically challenging,
acceptable reduction and stable xation was
achieved in all the patients. Deep infection
occurred in only one patient. This technique,
though promising, particularly in periarticular
fractures, has yet to be evaluated in large
study cohorts or in a randomized prospective
fashion.
External Fixation
Based on high complication rates seen
with available treatment modalities, exter-
nal xation emerged as the treatment of
choice for high-energy closed and open tibia
fractures (Fig. 1). Based on biomechanical
studies, bulky external xation frames and
transxion pins have largely been supplanted
with anteriorly-applied, unilateral-uniplanar
constructs. These frames are easy and safe
214 FRENCH & TORNETTA
A B
Figure 1. A and B, Radiographs of a Tscherne 3 injury in an 18-year-old female pedestrian. C and
D, The canal size measured only 6 mm, and the patient was treated with standard anterior external
xation.
to apply, allow sufcient access for wound
care and secondary procedures, and provide
sufcient mechanical xation for patient
mobilization and bone healing.8 The further
benet of cyclical motion (dynamization) in
fracture healing has also been demonstrated
recently by a number of authors in test sub-
jects as well as clinical series.61, 62, 69 Results
of external xation of open fractures using
current open fracture protocols and simple
frame constructs have yielded acceptable
union and complication rates. Marsh et al 69 re-
ported a 98% union rate in 101 open fractures
treated with acute application of a dynamic,
unilateral-uniplanar external xation frame.
Union occurred at an average of 25 weeks. The
deep wound infection rate was 6%, and the
malunion rate was low (95% of the fractures
united with less than 10 malalignment). A
union rate of 93% with a deep infection rate
of 15% was reported by Edwards et al35 in
a series of 176 type 3 open fractures treated
with external xation. Of note, 33% of the
C D
fractures required greater than 1 year to unite.
The deep infection rate was 21% in the rst
half of the study and only 9% in the second.
This decreased rate was attributed to more
aggressive soft tissue debridement and early
soft tissue coverage. Prolonged union times
have been demonstrated when comparing
external xation in type 3A compared with
type 3B open fractures, with a difference of
nearly 4 months.31 Table 3 demonstrates union
times and deep infection rates in a recent
series of open fractures treated with external
xation. In general, union times range from
6 to 9 months with deep infection rates in the
range of 5% to 20%.31, 35, 69, 75, 104
External xation, for all its advantages,
is associated with a relatively high rate of
hardware complications, which ultimately
limit the durability of the frame construct.
Pin tract infectious complications, resulting
in recalcitrant infection or loosening, are the
most common cause for failure of the external
xation device. Limiting cortical necrosis

Table 3. RESULTS OF EXTERNAL FIXATION OPEN TIBIA FRACTURES
Open Unions,
Study # Fractures, n Grade wk
Edwards35 202 3 36
Marsh69 101 2,3 25
Melendez75 38 2,3 23
Court-Brown31 51 3 37
Behrens8 26 2,3 26
during half pin insertion and meticulous soft
tissue care are essential to prolong the life span
of the half pins. Pins should be placed after
predrilling to diminish the amount of necro-
sis and posterior cortical injury. Regardless,
most half pins loosen between 3 to 6 months
after their application. The incidence of pin
tract complications increases as the time in
the external xation device increases. Table 3
demonstrates rates of pin tract infectious com-
plications. The prolonged union times seen in
the higher-grade open fractures push the lim-
its of frame durability. A number of strategies
are employed to decrease the time spent in
the external xation frame, thereby decreasing
the rate of pin tract infections. Early frame
removal with cast application, once the soft
tissues have healed, has not met with uni-
formly successful results. Loss of reduction
has been the primary problem associated with
removal of the external xation frame prior
to union, with reported rates ranging from
10% to 30%.8, 25, 31 Most authors recommend
continuation of the external xation device
until clinical and radiographic union. In one
study, refracture after frame removal did not
occur if the instrumented bending stiffness at
the fracture site was above 15 Nm/deg. These
authors conclude that a bending stiffness
greater than or equal to 15 Nm/deg is me-
chanically equivalent to clinical union.62 Early
prophylactic bone grafting at 6 to 8 weeks is
a well-accepted mode to increase the rate of
union and to diminish the time in the frame.
Bone grafting is generally performed through
a posterolateral approach, creating a synosto-
sis between the bula and the tibia. Although
the bone defect is typically located antero-
medially, the posterolateral approach has a
number of advantages over anteromedial
graftingavoidance of compromised antero-
medial soft tissues, placement of the graft in a
well vascularized area for rapid graft incorpo-
ration, and ability to place a large amount of
graft. Blick et al13 demonstrated a statistically
signicant (12 weeks) decrease in union times
HIGH-ENERGY TIBIAL SHAFT FRACTURES 215
Deep Bone Pin Tract
Infection, % Graft, % Infection, %
15 28 29
6 NA 29
3 58 17
18 70 35
0 45 25
when prophylactic bone grafting at 10 weeks
was compared with bone grafting for delayed
union at 20 weeks. Comparing prophylactic
with delayed bone grafting in a cohort of
patients with type 3B open fractures, Trabulsy
et al103 also reported a statistically signicant
decreased time to union of 9 weeks. The re-
ported rate for prophylactic bone grafting
after external xation of open fractures ranges
from 20% to 50%. More recently, a number of
authors have reported successful prophylactic
bone grafting of type 3B open fractures under
a mature ap.49, 57, 81 Interim obliteration of
the dead space under the ap with antibiotic-
impregnated, methylmethacrylate beads is
recommended. This simplies the procedure
and also has shown to decrease deep infection
rates.49, 57
Dynamization of the external xation frame
has a benecial effect on union rates. Dy-
namization, an imprecise term, is generally
brought about by some modication of the
external xation frame that allows for some
axial motion and loading at the fracture site.
Kenwright and Goodship,61 in a sheep fracture
model, demonstrated a signicantly increased
rate of callus formation and mineralization
as stability of the external xation frame was
decreased by increasing the offset between
the frame and the bone. Motion of 0.5 mm
was more benecial than 2 mm of motion.
In a randomized-prospective study compar-
ing dynamic external xation (1 mm) versus
static external xation, Kenwright et al62
demonstrated more rapid achievement of
clinical and radiographic union. Marsh et al69
demonstrated no loss of reduction with good
union rates in a large group of patients treated
with a commercially-available, spring-loaded
dynamic external xation frame and early
weight bearing. Aro et al5 demonstrated that
frame dynamization does not alter xation
rigidity in either torsion or bending. In their
animal osteotomy model, these authors found
increased callus formation and decreased
times to union with dynamized versus static
216 FRENCH & TORNETTA
frames. Early frame dynamization is a safe
and effective method to positively alter the
local mechanical environment at the fracture
site and, thereby, produce improved union
times compared with a rigid frame construct.
Precise control of the amount of axial motion is
provided by commercially available frames or
can be achieved by decreasing the stiffness of
the external xation frame.
The nal solution to prevention of exter-
nal xation failure is conversion of the exter-
nal xation to an intramedullary nail. Early,
anecdotal reports concerning conversion ex-
ternal xation to a reamed intramedullary nail
featured high secondary infection rates. In a
series of 47 nonunions, treated initially by a
variety of methods followed by reamed in-
tramedullary nailing, the deep infection rate
was 13%.108 Even with a prolonged period
of casting between frame removal and nail-
ing, 85% of these infections occurred after ini-
tial treatment with external xation. Maurer70
reported a deep infection rate of 25% when
reamed intramedullary nailing followed exter-
nal xation. Pin-tract infection was found to
be a signicant predictor of deep infection,
with 71% of the patients with a previous pin-
tract infection developing deep infection af-
ter reamed intramedullary nailing. Other au-
thors have reported this association between
previous pin-tract infections and deep infec-
tion after intramedullary nailing for delayed
or nonunion.72 Fischer reported a 47% deep in-
fection rate in type 3B open fractures treated
with delayed reamed nailing after initial ex-
ternal xation.38 Risk of deep infection was
associated with a history of pin-tract infec-
tions, current pin-tract infections, or persistent
wound drainage. Open fractures with a his-
tory of supercial wound infection also were
found to have high rates of deep infection with
a delayed nailing procedure. As a reconstruc-
tive procedure, reamed intramedullary nailing
after primary external xation has not been a
successful procedure. This technique is partic-
ularly contraindicated in the presence of active
infection of the bone, wound or pin, ring or
halo sequestrum, poor soft tissue coverage, or
open half-pin tracts.
Sequential conversion of an external xa-
tion device to a reamed intramedullary nail
relatively early in the treatment course, gen-
erally after initial soft tissue stabilization, has
received better results. Blachut11 reviewed a
sequential nailing protocol in 39 patients with
open fractures. Patients were in the external
xation frame for an average of 17 days.
Reamed nailing was undertaken at an av-
erage of 9 days after removal of the frame
(26 days from the injury) when the pin tracts
had healed. Union was achieved in 92% of the
patients with a deep infection rate of 5%. Inter-
estingly, the two patients with a history of pin-
tract infections did not develop deep infection
after the nailing procedure. In a prospective-
randomized study of sequential nailing or
casting after 4 weeks of primary external x-
ation of open fractures, patients undergoing
nailing demonstrated increased union rates
and decreased malunion rates.4 The deep in-
fection rate after nailing was 6% (one pa-
tient). Cole et al,26 with the use of temporary
spanning femoral-calcaneal external xation
or splinting and early conversion to a reamed
nail after soft tissue coverage in a cohort of
46 open fractures, reported a 98% union rate
with only one deep infection (2%). Of the
46 patients, 25 underwent primary external
xation followed by either reamed nailing
(metaphyseal fractures) or nonreamed nailing
(diaphyseal fractures). Henry 48 presented the
results of a prospective protocol for conver-
sion of external xation to a reamed nail. A
group of patients with short-term xation and
no history of pin-tract infections underwent si-
multaneous frame removal and nailing. A sec-
ond group of patients with prolonged frame
xation (average of 146 days) and a history
of pin-tract infections underwent a sequen-
tial protocol involving frame removal, irriga-
tion and debridement of the pin tracts, and
reaming of the canal with placement of antibi-
otic impregnated beads. Nailing was accom-
plished when the pin tracts had healed and
the canal cultures were negative. The infection
rate was 0% with an 84% union rate. Sequen-
tial, reamed intramedullary nailing after tem-
porary external xation and wound stabiliza-
tion appears to be a safe procedure. Exchange
nailing should be performed within 14 days
of injury, when possible, if the soft tissues
allow.
Intramedullary Nailing
Kuntscher and Maatz66 introduced inser-
tion of a locked intramedullary nail after
reaming of the tibia in the 1940s, during the
same time femoral nailing was being in-
troduced. Unlike the femur, however, the
tibia was thought to be ill suited for reamed

nailing secondary to its relatively precarious
blood supply. Alternatively, small diameter,
nonlocked intramedullary devices, partic-
ularly those of Lotte and Ender, were more
commonly used in order to protect the blood
supply of the tibia. Based on the success of
reamed intramedullary nailing of the femur
and dissatisfaction with the stability provided
by these small diameter, unlocked tibial in-
tramedullary devices, reamed intramedullary
nailing of unstable tibia fractures became
more popular. Puno et al79 reviewed 200 dis-
placed closed- and low-energy tibial fractures
treated with either casting or a reamed locked
intramedullary nail. Intramedullary nailing
resulted in a union rate of 98%, infection
rate of 3.3% with no malunions compared
with 90%, 1.4% and 4.3%, respectively, for
the casted cohort. The casting group had a
13% failure rate, treated with conversion to
an intramedullary nail. Bone and Johnson,15
also in 1986, reported on a diverse group of
tibia fractures treated with intramedullary
nailing. Although the union rate was 98%
for the acute fractures, the infection rate in
type 2 and 3 open fractures was 25%, com-
pared with 2.9% in the closed or type 1 open
fractures. Wiss and Stetson109 reported on
a cohort of 134 patients with high-energy,
unstable tibia fractures treated with acute
reamed nailing. The union rate was high in
open and closed fractures, with an overall
deep infection rate of 9%. The infection rate,
however, was ve times higher in the open
fractures, compared with the closed fractures.
These early studies suggested that reamed
nailing is a safe and effective mode for the
treatment of lower-grade open fractures.
However increased infection rates made this
technique less effective for the management of
the high-energy open fracture. Studies specif-
ically limiting reamed intramedullary nailing
to closed- and lower-grade open fractures
have validated these early conclusions. Court-
Brown et al28 reported on 125 acute, displaced
closed and type 1 open fractures after reamed
nailing. The union rate was 98% at an aver-
age of 17 weeks. The deep infection rate was
1.6% with a malunion rate of 2.4%. The most
common complication was anterior knee pain,
occurring in 40% of the patients. This similar
problem has been noted in other studies.60
A 98% union rate and 3% infection rate was
reported by Williams et al107 in another large
group of closed fractures treated with acute
reamed nailing. Success of this procedure
HIGH-ENERGY TIBIAL SHAFT FRACTURES 217
has led to routine use of reamed nailing for
displaced closed and type 1 open fractures,
particularly after failed closed reduction or in
unstable patterns.
POTENTIAL IATROGENIC
COMPLICATIONS OF
INTRAMEDULLARY NAILING
Elevation of Compartment Pressures
Use of the reamed intramedullary nail in
the high-energy closed- and open-fracture,
however, continues to raise a number of is-
sues surrounding potential iatrogenic com-
plications. Of particular concern is the de-
velopment of compartment syndrome as a
result of the nailing procedure. Another con-
cern surrounds damage to the blood supply
of the cortical bone as a result of the ream-
ing procedure and the potential effects this
would have on union and infection rates.
These concerns have lead to a recent surge
in clinical and laboratory studies about the
reaming process as well as the development of
a locked unreamed intramedullary device for
the treatment of these injuries. Compartment
syndrome has a well-recognized associa-
tion with high-energy tibia fractures. As the
amount of energy absorbed by the extremity
increases, so does the possibility of an associ-
ated compartment syndrome. Compartment
syndrome incidence after major trauma to the
tibia, regardless of the soft tissue injury, varies
between 0% to 48% (Fig. 2).13, 19, 110 Several au-
thors have anecdotally reported an apparent
association between delayed development of
a compartment syndrome and acute, reamed
intramedullary nailing.71, 98 As early as 1971,
Hamza et al45 reported ve neuromuscular
complications after reamed nailing of 50 acute
tibia fractures. By description, these com-
plications can be inferred to have been the
result of untreated elevated compartment
pressures. Koval et al64 found nearly one third
of the patients treated with delayed reamed
nailing of the tibia using a fracture table and
90/90 traction had some neurologic decit
postoperatively. Primary neural injury or in-
jury from the traction post could be partially
responsible. The cause of these decits, how-
ever, was likely multifactorialbleeding into
the compartments, reaming of the canal with
expulsion of intramedullary contents into
the closed compartments, vascular congestion
218 FRENCH & TORNETTA

A B C D

Figure 2. A 38-year-old man with a Tscherne 3 closed fracture and compartment syndrome that was
treated with emergent fasciotomy through a lateral approach and unreamed intramedullary nail (A). AP
(B ), and lateral (C ) radiographs. The patient developed excellent callus by 12 weeks (D ).
Illustration continued on opposite page

secondary to the traction post, and soft tissue
swelling. The factors, together, may have
resulted in increased pressure in the compart-
ment and resultant neurologic compromise.
McQueen et al74 conducted a prospective
study of compartment pressures associated
with reamed nailing of acute tibia fractures.
These authors found signicant pressure
increases during the surgical procedure,
particularly during traction and reaming,
which were frequently greater than 30 mm
Hg. After nail insertion and during the ensu-
ing 24 to 36 hours these pressures decreased
to acceptable levels. Tornetta and French101
found similar but much shorter lived pressure
increases during unreamed intramedullary
nailing without the use of a fracture table.
Pressures peaked during the nailing pro-
cedure (reduction and nail insertion) but
returned to baseline at the termination of
the procedure. Transient pressures greater
than 40 mm Hg were recorded in almost half
the patients. Of the 56 patients in the study,
none developed clinical sequelae of a missed
compartment syndrome.
A number of factors associated with the
nailing process may be responsible for these
increased pressures. Moed and Strom74 found
that the reaming procedure itself raised com-
partment pressures in an animal fracture
model. Similarly, Wozasek et al111 reported
that intramedullary pressure increases by a
factor of 10 during reaming. This pressuriza-
tion causes extrusion of blood and marrow
products through the fracture site into the
compartments. The use of 90/90 positioning
with a posterior distal femoral/popliteal post
can cause vascular congestion by impeding
venous outow and may impede arterial in-
ow, decreasing the perfusion pressure of the
limb. Possibly the most important factor is the
use of traction. Shakespeare and Henderson93
 HIGH-ENERGY TIBIAL SHAFT FRACTURES 219

E F

Figure 2 (Continued ). At 1 year, the patient had excellent function

with complete restoration of bony continuity and functioning of the
lower extremity (EG ).

demonstrated an increase in posterior com- transient elevations of compartment pressures

partment pressure of 5.7% per kilogram of
weight applied during calcaneal traction.
Finally, tourniquet use decreases perfusion to
the limb and promotes vascular congestion;
therefore, it has also been implicated in this
problem.
Ultimately, it can be conclude that the intra-
medullary nailing process, whether reamed or
unreamed, can be expected to lead to at least
in the lower extremity. In a patient at high risk
for developing a compartment syndrome,
effort should be made to avoid factors that
may potentiate this problem, including: 90/90
positioning, continuous traction, tourniquets,
and reaming. A number of these factors may
be avoided by not using the fracture table
for the nailing procedure. In a recent study
prospectively comparing patients nailed with
220 FRENCH & TORNETTA
and without use of the fracture table, the
fracture table cohort demonstrated a signif-
icant increase in set-up time and decreased
ability of the surgeon to perform concomi-
tant procedures.73 The time for the nailing
procedure, number of assistants, and overall
reduction quality were similar in the two
groups, suggesting that the use of a fracture
table is not necessary in the multitrauma
patient and may increase the complexity of
the patients care. The possibility of a delayed
compartment syndrome, developing after
nailing of the tibia, must be appreciated by
the operating surgeon. Frequent postoperative
pressure monitoring may be required in the
obtunded or uncooperative patient.
Disturbance of Cortical
Bone Circulation
The effect of reaming and nailing on the
blood ow to the lower extremity, particu-
larly the cortex of the tibia, has been the
subject of many studies. Rinelander80 has de-
ned the three basic components of the arte-
rial blood supply to the long bones: nutrient
artery, metaphyseal arteries, and periosteal ar-
teries. In the normal long bone, blood ow
is centrifugal, from the medullary cavity to
the periosteum. Periosteal arteries supply the
outer 30% of the cortex, and medullary arter-
ies supply full thickness of the cortex. All ve-
nous drainage is to the periosteal surface. Dur-
ing fracture repair, surrounding soft tissues
provide a new vascular component to the area
of bone repair, termed the extraosseous blood
supply. This blood supply can effectively re-
verse the normal centrifugal blood ow. Early
animal studies concerning reaming of the fe-
mur have demonstrated complete obliteration
of the medullary blood supply, rendering the
inner 70% of the cortex ischemic.63 Blood sup-
ply to the callus was found to come predom-
inantly from the extraosseous blood supply.
The concern, then, was that intramedullary
reaming, combined with periosteal stripping
and soft tissue loss, as seen with high-grade
open tibia fractures, would render the cortex
of the tibia avascular, resulting in increased in-
fections and delayed healing. Unreamed nail-
ing has also been shown to have a signi-
cant negative effect on the medullary blood
supply, rendering approximately 30% of the
inner cortex avascular, compared with 70% af-
ter reamed nailing of closed fractures in an ex-
perimental setting.91 Cortical bone perfusion
was found to be greater in the unreamed nail
group at 2 and 6 weeks after the nailing pro-
cedure but not at 12 weeks, as compared with
the reamed group. Comparison of loose tting
and tight tting unreamed nails suggests that
the amount of cortical perfusion decit is pro-
portional to the amount of cortical contact be-
tween the nail and the endosteum.54 Nutrient
artery blood ow is nearly completely oblit-
erated after standard intramedullary nailing,
whether reamed or unreamed. However, at
2 weeks it was found to return to baseline af-
ter unreamed nailing and only to 25% of base-
line after reamed nailing.17 Perhaps somewhat
paradoxically, reamed nailing was found to re-
sult in increased muscle perfusion surround-
ing the fracture at the conclusion of the ream-
ing process, and unreamed nailing lead to a
decrease in muscle perfusion.52 Although the
perfusion of the muscles surrounding the frac-
ture site had returned to baseline at 11 weeks
after unreamed nailing, there was still found
to be a statistically signicant increase in the
muscle perfusion in the reamed group. In an-
other closed fracture model, the amount of
callus formed after reamed and unreamed
nailing was similar; however, the porosity of
the fracture callus was greater in the reamed
group, suggesting a more active and advanced
bone repair process.92 Thus, the nailing pro-
cess does signicantly interfere with the blood
ow to the diaphysis of long bones. This dis-
ruption is dependent on the amount of contact
between the endosteal surface and the nail as
well as the amount of reaming.53 This process
is reversible with a more rapid return of cor-
tical and nutrient artery blood ow after un-
reamed than reamed nailing. Finally, there is a
paradoxical increase in muscle perfusion sur-
rounding the fracture site, even above base-
line, after reamed nailing that is not present
after unreamed nailing, which produces a de-
crease in muscle perfusion.
Thermal Injury to Cortical Bone
Further injury to the tibia and soft tissues
during the reaming process is created by heat
generation. Case reports of thermal necrosis
involving bone and soft tissue after ream-
ing of long bone fractures can be found.68, 77
Henry et al50 demonstrated mean intrame-
dullary temperatures of 52 C and mean ex-
tramedullary temperatures of 46 C with ream-
ing of cadaveric tibia.50 Increased heat was
generated with increased reamer diameter.

Osteocyte necrosis is seen with temperatures
of 50 C.9 Eriksson et al36 found delayed osteo-
cyte death after elevation of bone temperature
to 47 C for 1 minute. In an elegant theoretical
model, Baumgart7 concluded that the essential
factor in temperature increases with reaming
is friction between the reamer and the bone.
This heat generation is directly proportional to
the rotational speed of the reamer, the reaming
time, and the axial force applied during the
reaming procedure. Temperature increases are
inversely proportional to the reamer diameter.
Reaming without advancing can rapidly ele-
vate temperatures. With blunt reamers, even
under optimal conditions, a reaming time of
30 seconds produces local temperature in-
creases of at least 6 to 8 C above body temper-
ature. Under unfavorable circumstances (e.g.,
high reamer speeds, high axial forces, high
friction), temperature increases to 80 C may be
seen in as little as 30 seconds. Sharp reamers
are the most important prerequisite for limi-
tation of heat generation. Reamer size should
be increased in 0.5 mm increments rather than
1 mm increments in order to decrease fric-
tion. Reamers should be cleaned during the
reaming process to prevent clogging and con-
gealing of the cutting utes. Reaming time
should be minimized and never should be in
one spot without advancing. Axial forced ap-
plied during the reaming process should be
minimized. Additionally, tourniquet use in-
hibits convective heat transfer from the bone
to the soft tissue by limiting blood ow to
the limb and is contraindicated. Each succes-
sive larger reamer causes expansion of the
devascularized zone of bone on either side of
the fracture, not only because of vascular in-
sult, but also by heat generation. In extreme
cases this heat generation may cause necro-
sis of the bone, periosteum, and skin, limit-
ing the regenerative ability of the adjacent soft
tissues.
SOFT TISSUE COVERAGE
In experimental canine studies, the type
of soft tissue coverage has a profound ef-
fect in the healing response of an avascu-
lar bone segment. Richards et al83, 84 created
a 2 cm avascular zone of tibia, disrupting
the medullary and periosteal blood supply.
The segment was then internally xed with a
laterally applied plate. Medially, the avascu-
lar bone was covered with either skin alone
or a rotational muscle ap. Vascular penetra-
HIGH-ENERGY TIBIAL SHAFT FRACTURES 221
tion of the devascularized cortical segment
was primarily the result of peripheral osteo-
clastic resorption and vascular inltration not
via medullary arterial revascularization. Skin
coverage alone of the avascular segment re-
sulted in minimal callus formation of low
porosity. Muscle coverage of the defect re-
sulted in a threefold increase in the amount
of callus formed and sixfold increase in the
cortical porosity of the callus compared with
the skin coverage group. Increased porosity is
thought to be the result of increased osteoclas-
tic activity. In the bone repair process, osteo-
clastic activity precedes osteoblastic activity.
A small amount of endosteal callus was ob-
served. Muscle has a higher resting blood ow
than either skin or bone. In a follow-up study,
Richards et al82 demonstrated that muscle ap
coverage resulted in a statistically signicant
increase in the early strength of union com-
pared with skin coverage. Likewise, 12 weeks
after the osteotomy the maximum bending
load was signicantly greater in the muscle
coverage group. The energy absorbed to fail-
ure at 12 weeks was three times greater when
the defect was covered by muscle than by skin.
Interestingly, two animals in the skin cover-
age group were dropped from the study sec-
ondary to deep infections. None of the animals
in the muscle coverage group had infections.
Muscular aps have been shown to have a
greater resistance to bacterial inoculation than
random pattern aps.23 It appears that dis-
ruption of the medullary and periosteal blood
supply results in a fracture repair process ini-
tiated by the soft tissue envelope. The qual-
ity of the soft tissue envelope, in terms of
blood supply, profoundly affects the healing
process.
This concept of early, well-vascularized soft
tissue coverage of avascular tibial segments
of the tibia has been shown to have clinical
merit. In a series of high-energy tibia fractures
with soft tissue loss, Byrd et al21 demonstrated
increased rates of complications in fractures
after delayed coverage compared with early
coverage. Osteomyelitis was ve times more
prevalent, and nonunion was three times
more prevalent in the delayed compared
with the acute coverage group. Similarly,
Caudle and Stern22 also found signicant
increases in nonunion and infection in a group
of patients with type 3B open fractures who
either had late ap coverage or whose wounds
were allowed to close by secondary intention
compared with patients with acute ap cover-
age. Flap coverage within 2 weeks of a type 3B
222 FRENCH & TORNETTA
fracture was shown to result in decreased
infection rates, hospital stay, and number of
secondary procedures compared with ap
coverage accomplished after 2 weeks.43
Soft tissue coverage prior to osseous recon-
struction has been advocated by a number of
authors. Fisher et al38 demonstrated that early
ap coverage followed by delayed, prophy-
lactic bone grafting after wound maturation
lead to a signicant (9 weeks) decrease in time
to union than acute bone grafting before soft
tissue stabilization. Trabulsy et al103 evaluated
early ap coverage within 7 days, prophylactic
bone grafting at 8 to 12 weeks, and early skele-
tal stabilization (nonrandom external xation
or unreamed nail) in 45 type 3B fractures. Only
6% of the patients developed infection, with
4% developing chronic osteomyelitis. Union
was achieved in 98% of the fractures at an av-
erage of 55 weeks. Prophylactic bone graft-
ing at 8 to 12 weeks was found to decrease
the time to union by 9 weeks compared with
bone grafting at 12 weeks or greater (aver-
age 8 months) for delayed union. No dif-
ferences were seen in union rates compar-
ing external xation to unreamed nailing. Fix
and ap techniques, which feature soft tis-
sue coverage concurrent with the rst or sec-
ond debridement, have also been advocated.
Sinclair et al94 reported on 17 patients with
type 3B open tibia fractures, who underwent
free ap coverage of within 72 hours of their
injury. No ap failures occurred. There was
one deep infection. Cole et al26 reported on
the extensive use of local fasciocutaneous aps
for wound coverage with the initial debride-
ment of patients with open tibia fractures. In-
tramedullary nailing was accomplished on a
delayed basis. No ap failures or deep in-
fections were reported. Gopal et al40 reported
on 57 patients with type 3B open tibia frac-
tures. Nearly 50% of these patients had acute
ap coverage with the initial debridement.
The ap failure rate was 3.6%. The deep in-
fection rate was 9%, with three of ve infec-
tions occurring when ap coverage was de-
layed greater than 1 week. These studies stress
the importance of the initial debridement fol-
lowed by early, well-vascularized soft tissue
coverage and by prophylactic bone grafting
when the soft tissue envelope has matured, re-
gardless of the method of xation.
Based on these studies, the standard treat-
ment of tibia fractures with soft tissue and
bone loss involves early, vascular soft tis-
sue coverage and delayed, prophylactic
bone grafting of osseous defects. The animal
laboratory studies concerning reamed or un-
reamed nailing have not lead to as denitive
conclusions. One school of thought is that
unreamed nailing produces less damage to
the cortex and more rapid regeneration of the
medullary blood supply. Therefore, this nail
should be used in high-energy open fractures
with an already compromised blood supply
to prevent infection and promote healing.
The other school of thought is that calus
formation after disruption of the medullary
and periosteal blood supply depends on ex-
traosseuos blood supply derived from the
surrounding soft tissues. Medullary callus
formation is not pronounced, even with plate
xation. Theoretically, then, early soft tissue
coverage combined with the reaming process
(which appears to stimulate muscular blood
ow) may stimulate more rapid bone union
and increased bacterial clearance. Infectious
complications are not a product of the ream-
ing process but secondary to inadequate
debridement and soft tissue coverage.
UNREAMED TIBIAL NAILING
Unreamed locked intramedullary nailing
has been evaluated in a number of clinical
studies, particularly involving high-energy
tibia fractures, to better evaluate the effect
of not reaming the canal. In a group of mul-
titrauma patients undergoing unreamed
nailing, the overall union rate was 93%.3 The
closed fracture union rate was 100%, and 86%
of the open fractures went on to timely union.
There were no infections in the closed frac-
tures and one infection (6%) in the open group.
In another group of polytrauma patients with
mixed open and closed fractures, even with
40% of the patients undergoing early inter-
vention procedures to promote union, Riemer
et al85 reported a 35% delayed/nonunion
rate. Comparison of closed and type 1 and
2 open fractures with grade 3 open fractures
revealed that there were similar times to union
and reoperation rates. Fractures with less
comminution (Winquist 1 or 2) healed at an
average of 29 weeks with a 24% reoperation
rate, and fractures with more comminution
(Winquist 3 or 4) required an average of
35 weeks to unite with a 53% reoperation rate.
Static locking of the nail was found to be a
signicant predictor of reoperation and lead
to statistically signicant increases in union

times, even when adjusting for Winquist
classication. Only two infections were re-
ported in this cohort, which included 29 type 3
open fractures.
Studies specically addressing unreamed
nailing of closed, high-energy tibia fractures
have demonstrated its clinical efcacy. Gre-
gory and Sanders41 prospectively evaluated
the use of unreamed nailing in Winquist 3 and
4 fractures as the result of high-energy trauma.
Only 87% of the fractures healed within
26 weeks, and 5% and 8% of the fractures were
classied as having delayed or nonunion,
respectively. Acute infectious complications
did not occur. Krettek et al65 reported on un-
reamed nailing in patients with acute fractures
classied as having severe soft tissue injury. A
100% union rate, at a mean time of 44 weeks,
was achieved. Almost 25% of the patients,
however, required a secondary procedure
to achieve union. Both studies reported that
approximately 15% of the cross-locking bolts
failed. Both authors concluded that unreamed
nailing provides safe and effective tibia sta-
bilization in the acute multitrauma patient.
Union times, hardware failure rates, and sec-
ondary procedures, however, appear to be
increased compared with previous studies of
reamed nailing.
Prospective-randomized studies comparing
reamed with unreamed nailing of closed tibia
fractures conrm what was suggested in these
studies. In one study, Blachut et al12 found
the reoperation rate to achieve union was
twofold greater after unreamed compared
with reamed nailing. There was a trend to-
wards increased rates of nonunion of the
tibia affter unreamed (11%) compared with
the reamed (4%) nailing. Court-Brown et al32
found a statistically signicant increase in time
to union after unreamed (22 weeks) compared
with reamed (15 weeks) nailing with no dif-
ference in infection rates. There was a consid-
Table 4. NONREAMED NAILING OPEN TIBIA FRACTURES
Open Union at
Study Fractures, n Grade 6 mo, %
Bonatus14 72 IIII 68
Bone16 29 IIIIA 51
Sanders87 46 IIII 66
Singer95 43 IIII 98
Tornetta102 143 IIII 53
Whittle105 50 IIII 46
Stegemann96 41 IIIIA
HIGH-ENERGY TIBIAL SHAFT FRACTURES 223
erably higher rate of secondary reamed intra-
medullary nailing in the unreamed group to
promote union. Based on these prospective-
randomized studies there appears to be
little justication for the routine use of the
unreamed nailing technique in closed tibia
fractures undergoing operative stabilization,
regardless of the soft tissue injury. The un-
reamed technique appears to lead to longer
time to union, increased need for secondary
procedures, and increased rates of hardware
failure. These studies, however, were per-
formed using nails with small cross-locking
bolts by surgeons with extensive experience in
the reamed technique using the fracture table
and not with unreamed nailing. The technical
aspects of the nailing, including the presence
of a fracture gap, was not examined. Infection
rates in closed fractures after nailing do not
seem to be appreciably altered by the presence
or absence of reaming.
Evaluation of unreamed nailing of open
tibia fractures has been undertaken by a
number of authors (Table 4).14, 16, 87, 95, 96, 102, 105
Generally, the union rates are high, how-
ever, the time to union is prolonged. In a
prospective study with follow up on 143 open
fractures, Tornetta and McConnell102 found
only 53% of the fractures to have united at
6 months. Ultimately, the vast majority of
the fractures united without the need for
secondary procedures. Overall, 25 proce-
dures were performed in 16 fractures (11%)
to achieve union. The deep infection rate was
2.8%. Evaluation of these studies concerning
unreamed nailing of open tibia fractures leads
to a number of conclusions. Prolonged union
times can be expected, particularly as the
grade of the fracture is more severe. Secondary
procedures to achieve union are frequently
necessary. Aggressive early debridement
and soft tissue coverage combined with un-
reamed nailing produces low rates of deep
Deep Secondary Hardware
Infection, % Procedures, % Failure, %
4 30 <1
7 50 0
13 24 20
12 47 41
2.8 11 <1
8 36 10
2 37 7.3
224 FRENCH & TORNETTA
infection. High rates of hardware failure are
seen compared with reamed nailing but only if
small diameter locking screws are used. Most
cases of hardware failure were associated
with delayed union and frequently did not
lead to a loss of reduction. Many authors
have referred to this late cross-locking bolt
failure as self-dynamizationa potentially
benecial complication. Fractures at the meta-
physeal/diaphyseal junction, particularly in
the setting of a delayed union, are more prone
to nail breakage.106 Use of a titanium alloy nail
and attempts to achieve cortical contact are
benecial in prevention of hardware failure.
Tornetta and McConnell102 reported a screw
failure rate of only 0.3% and no nail failures
in the largest reported series of open fractures
treated with unreamed nailing. They attribute
this to the use of a nail with larger locking
screws for all sizes from 8 mm and up. It
clearly has been demonstrated that interlock-
ing screw and nail failure is independent of
placement technique (reamed or unreamed)
and related to union and the mechanical
strength of the implant.
REAMED TIBIAL NAILING
Alternatively, reamed nailing has also
been investigated for use in open fractures,
although more sparingly than unreamed
nailing (Table 5). In a prospective study in-
volving reamed nailing of 41 acute type 2
and 3 open fractures, Court-Brown30 reported
good results in the type 2 and 3A fractures but
increased complication rates in the type 3B
fractures. Type 2 and 3A fractures united at
an average of 24 and 27 weeks, respectively,
with only one deep infection (3.5%). Ap-
proximately one fth of the type 2 and 3A
fractures required a secondary procedure to
obtain union. Conversely, the infection rate
in type 3B fractures was 23% with an average
union time of 50 weeks. Secondary procedures
Table 5. REAMED INTRAMEDULLARY NAILING OPEN FRACTURES
Union
Study # I II
Court-Brown30 41 24
Keating59 110 29 32
Keating57 53 28
Robinson81 30
Keating56 57
to obtain union were much more prevalent,
with 50% of the patients requiring bone graft
procedures. Keating et al59 assessed results in
110 open fractures treated with acute, reamed
nailing. Average union times and number of
delayed unions progressed steadily with in-
creasing severity of fracture grade. Overall,
the infection rate was 5%, with 11% of the
type 3B fractures having a deep infection. The
most common complication was anterior knee
pain, occurring in 57% of the patients. The au-
thors attributed their success to aggressive
soft tissue and bone debridement followed by
early soft tissue coverage. Henry49 found the
addition of interim dead space management
with antibiotic impregnated methylmethacry-
late beads prior to soft tissue coverage to
signicantly decrease infection rates from 16%
to 4% in a large series of patients undergo-
ing reamed nailing of open tibia fractures.
Robinson et al81 reported on the use of reamed
nailing in 30 acute type 3B open fractures
associated with signicant bone loss. All but
one fracture united at an average of 53 weeks.
The deep infection rate was 20%; however,
85% (5/6) of the infections developed in pa-
tients who initially had split thickness skin
graft coverage of the soft tissue defect. Serial
irrigation and debridement combined with
ap coverage resulted in stabilization of the
infection and osseous union in 85% of the
infections. Poor soft tissue management, not
the reaming process, was thought to be re-
sponsible for the high infection rate. Keating
et al56 recently presented results of a group of
55 patients with 57 type 3B open fractures who
underwent acute reamed intramedullary nail-
ing. These authors reported a 17.5% infection
rate. Of these infections, 40% were considered
supercial and resolved with local irrigation
and debridement with retention of the hard-
ware. The mean time to union was 43 weeks
with 26% of the fractures requiring bone graft
and 23% revision nailing. The average nail
diameter was 11 mm.
Deep Infection
IIIA IIIB I II IIIA IIIB
27 50 7 23
34 39 10 11
31 30 4 8
53 20
43 17.5

COMPARISON STUDIES OF TIBIAL
FRACTURE FIXATION
Prospective, randomized studies of skele-
tal xation methods in open fractures are rel-
atively lacking. External xation compared
with unreamed nailing of open fractures in
a prospective-randomized fashion has been
published in only two reports.46, 100 Tornetta
et al,100 in a cohort of 29 patients with type 3B
open fractures, found a similar time to union,
ankle and knee range of motion, and the
number of secondary procedures needed to be
similar in the two groups. Prophylactic bone
grafting was performed in approximately two
out of three of the patients, regardless of the
mode of xation. Deep infection rates were
also similar one in each group), however, 21%
of the patients with external xation had pin-
tract infection problems. The second study, by
Henley et al46 included 174 type 2 and type 3A
and B open fractures. Again, no signicant dif-
ferences were noted in the time to union or
deep infection rates. These parameters were
more closely associated with the grade of open
fracture, rather than the mode of xation. Loss
of alignment and hardware infection com-
plications were signicantly increased in the
external xation group, with a signicant in-
crease in the rate of secondary procedures per-
formed per fracture in the external xation
group. Nonrandomized studies mirror these
results (Table 6).47, 89, 90 Schendelmaier et al89 re-
ported decreased time to full weight bearing,
better function, and decreased need for sec-
ondary procedures after unreamed nailing in
a nonrandomized comparison with external
xation. Signicant decreases in the need for
secondary procedures after unreamed nailing
compared with external xation has been re-
ported in a number of studies. A meta-analysis
of recent literature concerning the use of un-
reamed nailing or external xation of type 3B
Table 6. EXTERNAL FIXATION VS NONREAMED INTRAMEDULLARY NAILING OF OPEN TIBIA FRACTURES
Study # Grade Union, wk
Tornetta100 29 3B 23
Henley46 174 II 46
3A3B
Schandelmaier90 179 closed & 26
open
Schandelmaier89 32 3B 31
Prospective randomized.
HIGH-ENERGY TIBIAL SHAFT FRACTURES 225
open fractures was unable to generate enough
data to denitively support one method of x-
ation over the other.33 There was found to be
reduced time to union (4 weeks) and a re-
duced need for intravenous antibiotics follow-
ing unreamed nailing compared with external
xation. Union rates were similar in the two
groups. Although there was a trend toward
decreased rates of malunion and supercial
sepsis after nailing, the numbers did not reach
statistical signicance.
Studies comparing reamed to unreamed
nailing of open fractures of the tibia are also
lacking.2, 37, 58 In a prospective-randomized
study comparing these two techniques in
closed and open fractures, excluding type
3B injuries, reamed nailing of closed frac-
tures was found to yield higher union rates
at 4 months but not at 6 or 12 months.37 Un-
reamed nailings of closed fractures resulted
in a signicant increase in cross locking screw
failure and a trend towards increased rate of
secondary procedures performed in order to
achieve union. Reamed nailing of the open
fractures was not found to lead to more rapid
union or increased infection rates. Keating
et al58 reported on 94 open fractures treated
in a prospective-randomized fashion with a
reamed or unreamed nail. With regards to the
technical aspects of the operative procedure
and the rate of early complications, there were
no signicant differences between the two
groups. No signicant differences were found
in the time to union or rates of nonunion
and infection between the two groups; how-
ever, the unreamed group healed faster for
types 1 through 3A, and there were twice as
many infections in the reamed group. The
limited number of patients in each subgroup
of open fractures decreased the power of
the study to detect meaningful differences.
Functional outcomes were also similar. The
only signicant difference reported in the
Nail External Fixation
Bone Bone
Deep Infection, % Graft % Union, wk Infection, % Graft, %
6.6 60 28 7 70
13 14 50 21 36
3 23 26 2 30
5 18 37 10 53
226 FRENCH & TORNETTA
study was the rate of screw failure, occurring
in 29% of the unreamed compared with 9%
in the reamed cohort. Although certainly an
important study, the limited number of frac-
tures limited the ability of the study to detect
subtle differences in outcome and complica-
tions. A meta-analysis of reamed compared
with unreamed nailing of lower extremity
long bone fractures was unable to demon-
strate signicant differences in the rates of
malunion, infection, pulmonary embolus, or
compartment syndrome based on the method
of xation.10 Within the tibia fracture subset,
the authors reported a pooled nonunion rate
of 14% after unreamed nailing. As expected, a
signicant increased risk of screw failure was
associated with unreamed nailing with small
diameter cross-locking bolts. Published stud-
ies prospectively comparing reamed nailing to
external xation in high-grade open fractures
are currently lacking in the literature.
SUMMARY
Optimal skeletal stabilization of high-
energy tibia fractures, particularly with an
open wound, remains controversial. Optimal
treatment of the injured limb, however, is
far less controversial. As a rst step, acute,
aggressive debridement of the soft and os-
seous tissues combined with high pressure
pulsatile lavage is essential. Repeat, sched-
uled debridements followed by early, well
vascularized coverage of soft tissue defects
decreases complication rates, regardless of
the skeletal stabilization method chosen. The
importance of these steps to the outcome of
the injury is of paramount importance. Devi-
ation from this protocol will invariably raise
complication rates despite adequate skeletal
stabilization. When reviewing large series of
open tibia fractures reported from trauma
centers, the skill, judgement, experience of the
orthopedic traumatologist, and the quality of
the support services involved in the patients
care can not be underestimated in terms of
the potential positive aspect on the outcome.
These intangible factors, which certainly have
signicant impact on outcomes, must be taken
into consideration in the decision of the treat-
ment of these injuries because little margin for
error.
Reamed intramedullary nailing is the
treatment of choice for the vast majority of
high-energy unstable closed tibia diaphysis
fractures, regardless of the soft tissue in-
jury. Hemodynamic instability and elevated
compartment pressures or impending com-
partment syndrome may be indications for
an alternative mode of treatment, at least
initially. In the setting of a hemodynamically
unstable patient, an external xation device
can be more rapidly applied. In the setting
of elevated compartment pressures, reaming
may potentiate the problem. An unreamed
nail or external xation device may be more
appropriate in this situation.44 Unreamed
nailing as the rst choice in the treatment of
this injury has shown to lead to increased rates
of delayed/nonunion and hardware failure if
small diameter interlocking bolts are used.
Skeletal stabilization of open fractures of the
tibia, despite numerous studies, has no one
optimal solution. External xation emerged
as the gold standard for treatment of these
injuries. More recently, the unreamed, locked
tibial nail seems to have largely supplanted
this device, particularly at trauma centers
treating large numbers of these injuries.
Although union and deep infection rates ap-
pear to be similar, unreamed nailing avoids
the Achilles heel of the external xation
devicethe half pin/bone interface. Failure
of the half pin, either through aseptic or septic
loosening, invariably limits the duration of
the external xation device. Problems associ-
ated with delayed reconstruction of the mal-
or nonunited tibia after failed external xa-
tion have been outlined earlier. Conversely,
reamed exchange intramedullary nailing after
initial stabilization with a reamed or un-
reamed nail has shown to be an extremely
effective method to bring about union of the
tibia with low complication rates (Table 7).29, 97
The ease of reconstructive procedures after
unreamed nailing compared with that with
external xation has largely been responsible
for the decrease in routine use of the external
xation device in open tibia fractures. The
external xation device, however, remains an
important tool in the armamentarium of the
orthopedic surgeon. The intramedullary nail
limits secondary debridement, particularly of
the canal and soft tissues opposite the open
wound. Thus, in extremely contaminated
fractures, or in injuries with questionable soft
tissue viability, an external xation device
offers stabilization without compromising fu-
ture debridements. Again, the hemodynami-
cally unstable patient benets from rapid
frame placement, rather than nailing, which
typically requires more time. Instances of
compromised or questionable limb viability

Table 7. RESULTS REAMED EXCHANGE NAILING AFTER INITIAL NONREAMED INTRAMEDULLARY NAIL
Time to Exchange
Study N Type
Templeman97 28 Closed/open
Riemer85 12 Closed/open
Gregory41 4 Closed
Bonatus14 4 Open
Sanders87 5 Open
Singer95 11 Open
Tornetta102 12 Open
or function, such as prolonged warm ischemia
with a major vascular disruption or tibial
nerve disruption, may be better initially man-
aged with rapid frame application. More
denitive reconstruction or amputation can
then be evaluated in a more controlled setting.
Finally, intramedullary nailing, particularly
small diameter nailing, can be a demanding
procedure. The widened proximal and distal
aspects of the tibia do not allow for intimate
contact between the nail and the endosteum.
Reduction, therefore, can be challenging. High
rates of malunion have been reported after
nailing of proximal fractures.67 A number of
techniques have been described to success-
fully nail proximal tibia fractures.99 These
variations include: variation of the portal
placement, nailing with the knee extended,
use of poller or blocking screws, and appli-
cation of an anterior unicortical push plate.
Successful use of an intramedullary nail, par-
ticularly a small diameter nail in the extremes
of the tibia, requires a thorough knowl-
edge of the techniques in order to prevent
malreduction.
Reamed intramedullary nailing of lower-
grade open fractures has been successful. Use
of this technique in high-grade open frac-
tures has been reported by some authors, but
concern still exists surrounding the vascular
and cortical damage incurred by the reaming
process and resultant risk of deep infection.
The debate of reamed or unreamed nailing of
open tibia fractures has not come to a con-
clusion. Ultimately, the goal should be to ob-
tain adequate skeletal stabilization while min-
imizing the iatrogenic damage to the blood
supply and cortex. Transition from an 8 mm
or 9 mm diameter nail to a 10 mm diame-
ter nail, in most systems, allows for placement
of larger cross-locking bolts. Although some
intramedullary canals may be wide enough
to accept this nail without reaming, smaller
canals may require some reaming to accept
a nail of this size. It is unclear if the benet
HIGH-ENERGY TIBIAL SHAFT FRACTURES 227
Nail, wk Union, % Infection, %
24 93 11
24 100 0
> 26 100 0
> 24 100 0
> 24 91 0
NA 91 0
NA 100 0
of the larger diameter nail exceeds the risk of
minimal reaming. On the other hand, sequen-
tial increases in reamer diameter result in in-
cremental damage to the vascular supply of
the cortex and in increased potential for cor-
tical necrosis. In a patient with an open tibia
fracture and with a large intramedullary tibia
diameter, the risks of reaming to place a large
diameter tibia nail (e.g., 11 mm or greater di-
ameter) probably outweigh the benets and
should be avoided. Thus, the decision to place
an intramedullary nail with or without ream-
ing should be dependent on the size of the pa-
tients intramedullary canal and the severity of
the soft tissue damage. Rather than represent-
ing a true dichotomy (to ream or not to ream),
the real issue should center on achieving an
optimal environment for fracture healing by
obtaining adequate stabilization with mini-
mal damage to the soft and osseous tissues.
As experience and available data increase ad-
vocates of reamed and unreamed techniques
have converged. Reamed nailing is now per-
formed after minimal increases in the inner
canal size and unreamed nailing is performed
with implants large enough to have good me-
chanical characteristics. At this point, the size
of unreamed and reamed nailing differs by
only 1 mm to 1.5 mm. Finally, complete and
expeditious irrigation and debridement com-
bined with early well-vascularized soft tissue
coverage of traumatic defects is of paramount
importance in the successful treatment of open
tibia fractures, regardless of the mode of skele-
tal xation.
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83. Richards RR, Orsini EC, Mahoney JL, et al: The in-
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84. Richards RR, Schemitsch EH: Effect of muscle ap
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85. Riemer B, DiChristina D, Cooper A, et al: Unreamed
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the tibial shaft. Injury 7:252257, 1976
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Address reprint requests to
Bruce French, MD
Orthopaedic Trauma and Reconstructive Surgery
340 East Town Street, Suite 10200
Columbus, OH 43215
TREATMENT OF COMPLEX FRACTURES
Complex intra-articular fractures of the tibial
plafond (pilon fractures) have been studied for
some time.8 Because of the severity of some of
these fractures, several previous investigators
have referred to them as explosion fractures
of the distal tibia.17, 32 The most challenging of
these fractures are those that result from high-
energy trauma, including falls, motor vehicle
crashes, and industrial accidents. Pilon frac-
tures resulting from high-energy trauma typ-
ically have multiple metaphyseal fragments
and displaced articular fragments associated
with signicant soft tissue injury. Another sub-
set of these fractures is the result of low-energy
trauma. These fractures are characterized by a
spiral fracture of the metaphysis of the tibia
and minimal or no displacement of the articu-
lar surface.
Treatment of pilon fractures has evolved
over the last 100 years. Because of the limited
implants available and poor outcomes associ-
ated with surgical intervention in the past, con-
servative means of treatment was commonly
advocated.16 In an effort to improve patient
outcomes while decreasing the amount of time
in a cast, Leach et al18 advocated open reduc-
tion and internal xation (ORIF) of the bula
and nonoperative management of the tibia.
Rouff et al32 subsequently advocated ORIF of
the bula and limited internal xation of
the tibial fragments. In the late 1950s and
early 1960s, the Arbeitsgemeinschaft fur Oste-
osynthesefragen/Orthopaedic Trauma Associ-
ation (AO/OTA) group developed general
From the Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri
ORTHOPEDIC CLINICS OF NORTH AMERICA
VOLUME 33 NUMBER 1 JANUARY 2002
00305898/01 $15.00 + .00
PILON FRACTURES
Assessment and Treatment
Joseph Borrelli, Jr, MD, and Erik Ellis, MD
guidelines for the treatment of intra-articular
distal tibia fractures.29 These recommendations
included ORIF of the bula, anatomical re-
duction and internal xation of the articular
fragments, iliac crest bone graft placed within
the metaphysis to support the articular reduc-
tion, and medial tibial buttress plating of the
distal tibia to stabilize the tibia and prevent
varus deformity. Successful treatment of these
injuries was expected when these recommen-
dations were followed particularly in cases
where the pilon fracture was the result of low-
energy trauma.17, 21, 29, 30, 31 Unfortunately, simi-
lar results were not realized when these same
principles were applied to high-energy frac-
tures with signicant soft tissue injury.22, 27, 34 As
a result of this early experience, in particular
the high complication rate associated with op-
erative treatment of the injuries, the need for
the development of more effective treatment
regimens became obvious.
A review of the literature shows that for the
best outcome operative treatment of these in-
juries should be tailored to the fracture pat-
tern (i.e., personality of the fracture), degree
of soft tissue injury, patients demands and ex-
pectations, and the surgeons experience and
training. Currently, surgeons have a variety of
surgical options and implants in their arma-
mentarium for the treatment of these injuries.
These options include external xation, exter-
nal xation with limited internal xation, and
traditional ORIF. Newer techniques and im-
plants are on the horizon and include newly
231
232 BORRELLI & ELLIS
designed plates, which can be placed along
the medial tibia through small incisions with
percutaneously placed screws. Regardless of
which technique is used, the goals of opera-
tive intervention include the preservation of
soft tissue attachments to the fracture frag-
ments, anatomical reduction of the articular
fragments, and realignment of the limb. This
review assesses these complex injuries, the var-
ious treatment options, and their outcomes.
ANATOMY
The relatively thick-walled cortical bone of
the tibial diaphysis ares distally at the tran-
sition of the diaphysis to metaphysis. The cor-
tex is much thinner here and the metaphysis
is lled with trabecular bone. The anterome-
dial surface of the distal metaphysis is concave
with a radius of curvature of approximately
20 cm and internally rotated 25 with respect
to the posterior tibia.21 This torsion is more ex-
treme proximally than distally and is more pro-
nounced anteriorly than posteriorly. Restora-
tion of limb alignment and rotation depends
on a thorough understanding of this complex
anatomy.
The lateral aspect of the distal tibia forms a
triangular notch for articulation with the bula.
The tibia and bula are joined by a series of
strong ligaments attached to each of these bony
prominences and the interosseous membrane,
which extends the length of the leg. Either of
these prominences can be fractured during in-
jury and subsequent repositioning and stabi-
lization are necessary to restore stability of the
ankle and to assist in the reconstruction of the
distal tibia.
The articular surface of the distal tibia, the
tibial plafond, is quadriangularly shaped and
articulates with the dome of the talus. This sur-
face is wider anteriorly and is concave in the
coronal and sagittal planes. This articular sur-
face is continuous with the medial malleolar
articular surface, which lies approximately 90
to the tibial plafond and extends about 1.5 cm
distal to it. The bula also articulates with the
lateral aspect of the talus to complete the ankle
mortise.
The blood supply of the soft tissues cover-
ing the distal aspect of the tibia is provided
by perforating arteries that originate from the
dorsalis pedis, posterior tibial, and the per-
oneal arteries.35 The supercial venous system
of the leg includes the greater saphenous vein
that travels with the saphenous nerve anterior
to the medial malleolus and along the medial
surface of the tibia to reach the knee. The lesser
saphenous vein and nerve and the sural nerve
pass posterior to the lateral malleolus and prox-
imally to the center of the posterior aspect of
the leg between the medial and lateral heads
of the gastrocnemius muscle. Disruption of the
veins at the time of injury or surgery can cause
subsequent venous stasis changes of the skin,
chronic swelling, and potential ulceration.
MECHANISM OF INJURY
Fractures of the tibial plafond are believed
to result from either axial compression or tor-
sion of the leg. Fractures resulting from axial
compression are often the result of high-energy
trauma and often have several displaced ar-
ticular fragments, comminution of the meta-
physeal bone, and soft tissue injury. In these
types of injuries, it is common that the bula
is also fractured. These injuries commonly oc-
cur when individuals fall from a height, are in-
volved in a motor vehicle crash, or during an
industrial accident.
Low-energy fractures of the distal tibia typ-
ically are spiral in nature with little comminu-
tion of the metaphysis and few articular frag-
ments. These fractures commonly occur during
sporting activities (e.g., skiing or roller blad-
ing), and because they are of low-energy na-
ture, there is typically less soft tissue swelling
and the bula may or may not be fractured.
Assessment
Assessment of patients with fractures of the
distal tibia should be carried out in a systematic
fashion to assure full evaluation and so other
injuries are not overlooked. Particular attention
must be paid to the contralateral lower extrem-
ity and the lumbar and thoracic spines, partic-
ularly when these injuries occur as a result of a
fall or motor vehicle accident.
Considerable swelling of the foot and an-
kle often develops shortly after the injury and
care must be taken to assure that the skin is
intact. Open tibial plafond fractures typically
present with traumatic wounds of the medial
aspect of the distal tibia or at the level of the
bular fracture (Fig. 1). Closed but widely dis-
placed fractures of the distal tibia may cause
the overlying skin to be tented and jeopar-
dize its blood supply. The skin, therefore, must
be thoroughly examined to recognize the pres-
ence of an impending open fracture. If recog-
nized, the patient should be sedated and the

Figure 1. Anteroposterior (A), lateral (B ), and mortice (C ) radiographs of an open, high-energy, distal
tibia and bula fracture. Open wounds were present medially (grade IIIB) and laterally at the level of the
bula fracture.
fracture reduced to prevent further skin necro-
sis and subsequent fracture contamination.
Assessment of the neurovascular status of
the limb must also be made at the time of pre-
sentation and the ndings documented. Serial
physical examinations should be performed,
and the results documented to help identify
the development of compartment syndrome.
Surgeons must remain vigilant for the devel-
opment of compartment syndrome, particu-
larly in the setting of a high-energy distal tibia
fracture.
In many cases, patients with high-energy
tibial plafond fractures are transferred to re-
ferral centers for denitive treatment. Despite
closed reduction and splinting, this often
allows time for considerable swelling and frac-
ture blister formation. Two types of fracture
blisters have been described in the literature
and appear to represent different degrees of
skin involvement.11, 12, 13, 43 Blisters lled with
relatively clear uid represent supercial
epidermal injury, and blisters lled with blood
represent full thickness dermal injury. The size,
characteristics, and position of these fracture
blisters may ultimately inuence the deni-
tive treatment of the fracture.28 In general, the
PILON FRACTURES 233
blisters should be left intact and covered with a
sterile dressing before application of the splint.
The radiographic evaluation of tibial pla-
fond fractures typically begins with plain
radiographs. Anteroposterior (AP), mortice,
and lateral views of the ankle allow the
surgeon to develop a good understanding of
the fracture pattern (see Fig. 1). Full length
radiographs of the tibia and bula do not
allow as accurate assessment of the fracture
because the radiograph beam is centered on
the diaphysis and not the ankle joint. Plain
radiographs, of the ipsilateral knee (joint
above) however, should be obtained to rule
out the presence of an associated fracture.
Radiographic evaluation of the lumbosacral
spine should also be considered, particularly
when the fracture is the result of a fall, if the
patient has signs or symptoms consistent with
a spinal injury, or if the patient is unconscious.
Plain radiographs of the contralateral ankle
will provide a template for preoperative plan-
ning and rule out the presence of an associated
and perhaps less symptomatic fracture.
Computerized tomography (CT) of the tibial
plafond is helpful in gaining a better under-
standing of the fracture pattern, demonstrating
234 BORRELLI & ELLIS
the number of articular fragments, the de-
gree of fracture displacement (step, gap),
and the presence of articular cartilage im-
paction (Fig. 2). Occasionally, sagittal and
coronal reconstructions are obtained for frac-
tures that are more complex. CT scans have
been shown to be superior to plain radio-
graphs in assessing fracture fragment dis-
placement and can be used during pre-
operative planning and to guide operative
treatment.37
FRACTURE CLASSIFICATION
Effective fracture classication schemes im-
prove communication among treating physi-
cians, provide insight into injury prognosis,
and help guide treatment. The classica-
29, 30, 31
tion proposed by Ruedi and Allgower
30 years ago is still widely used today. This
classication system separates the fractures
into three types depending upon the amount
of articular fracture displacement. Type A frac-
tures are simple cleavage type fractures with
little or no articular displacement, type B frac-
tures have displacement of the articular surface
without comminution, and type C fractures
Figure 2. CT scans clearly demonstrating the presence of four displaced articular
fragments of the distal tibia.
have intra-articular displacement with marked
comminution.
Recently, the AO/OTA23, 24 has developed
and published a comprehensive classication
for long bone fractures (Fig. 3). This classica-
tion scheme divides metaphyseal/epiphyseal
fractures into three separate groups. Type A
fractures are extra-articular fractures, which
may be simple (A1), comminuted (A2), and
severely comminuted (A3). Type B fractures are
fractures that involve only a portion of the ar-
ticular surface including a portion of the col-
umn (B1), the entire column (B2), or with the
primary fracture line in the coronal plane creat-
ing a posterior malleolar fragment (B3). Type C
fractures, presumably the result of the greatest
amount of energy, are fractures that involve the
both metaphysis and the articular surface with-
out comminution (C1), with metaphyseal com-
minution and a simple articular fracture (C2),
and fractures with metaphyseal and articu-
lar surface comminution (C3). Although, occa-
sionally cumbersome to use, particularly when
attempting to subclassify these fractures, this
classication scheme provides a more detailed
description of the fracture pattern in a uniform
fashion, allowing a more direct comparison of
fractures and easier computer documentation.

Figure 3. Fracture classication as proposed by the AO/ASIF.
Dirschl et al9 investigated three factors
that may inuence the reliability of fracture
classication systems using tibial plafond
fractures as a model. They studied the quality
of radiographs, the ability of the observer to
identify the fracture fragments, and the use
of binary decision making. No differences in
interobserver reliability were found among
the Ruedi/
Allgower
and binary classication
systems. Interobserver agreement on the
adequacy of the radiographs was less than
agreement on the classication of the fractures
themselves. They concluded that classication
systems, such as proposed by Ruedi/
Allgower,
PILON FRACTURES 235
may inherently perform poorly on reliability
analyses because of observer difculty in
reliably identifying the number and displace-
ment of articular fracture fragments on plain
radiographs.
OPERATIVE INDICATIONS
The primary indications for surgical inter-
vention of fractures of the tibial plafond are ar-
ticular fracture fragment displacement of more
than 2 mm, joint instability resulting from the
fracture, unacceptable axial alignment of the
236 BORRELLI & ELLIS
limb, and an open fracture. The presence of a
vascular injury necessitating repair to maintain
viability of the foot is also an indication for op-
erative stabilization of the fracture. The bene-
ts of operative stabilization include anatomic
reconstruction of the articular surface with
restoration of normal weight-bearing charac-
teristics of the joint. Early motion of the joint
allowed after operative stabilization improves
articular cartilage nutrition and facilitates sur-
gical wound and ligament healing. Early mo-
tion also aides in minimizing arthrobrosis and
muscle atrophy, and in most cases, obviates the
need for external immobilization in the form of
casts or splints.38, 39, 40, 41
Surgical Timing
The extent of soft tissue injury associated
with these fractures is highly dependent upon
the amount of energy absorbed and the pa-
tients innate physiologic response to injury.
One way to decrease the risk for soft tissue com-
plications following ORIF is to determine the
proper time for surgical intervention. Inappro-
priate surgical timing can result in an inability
to close the incisions at the conclusion of the
procedure, closure of the incisions under ten-
sion, or the need for multiple relaxing incisions
to relieve tension on the incision.19 All of these
situations increase the risk for wound compli-
cations and long-term complications.15, 22, 27, 34
Although external xation with or without
limited internal xation may be safely ac-
complished soon after injury, formal ORIF
should be delayed until the soft tissue injury
has resolved. It is not uncommon to delay
surgery for 2 to 3 weeks from the time of in-
jury while waiting for soft tissue swelling to
resolve.26, 42
TREATMENT OPTIONS
There are several treatment options for tib-
ial plafond fractures that include hybrid ex-
ternal xation, limited internal xation with
external xation, percutaneous plating (gen-
erally reserved for extra-articular fractures or
these with minimal intra-articular involve-
ment), and external xation. The method
where temporary external xation is per-
formed and followed by formal ORIF is gaining
in popularity.26, 42
Hybrid external xation of pilon fractures
has been advocated recently.1, 10, 36, 44 Indica-
tions for the use of the hybrid external xator
includes those fractures with large articular
fragments that reduce with ligamentotaxis as-
sociated with signicant metaphyseal com-
minution. Contaminated open fractures are
relative indications for the use of a hybrid x-
ator. With hybrid external xators, it is possi-
ble to stabilize the fracture soon after injury
when soft tissues swelling would otherwise
prevent formal ORIF. The stability afforded
by the hybrid is sufcient to allow early an-
kle range of motion, and complications associ-
ated with large incisions and soft tissue strip-
ping, such as wound dehiscence, infection, and
osteomyelitis, may be avoided. The hybrid
external xator acts in place of the plate to
neutralize deforming forces while maintaining
length, alignment, and rotation. Whether or not
plate xation of the bula should be carried
out in this setting is the topic of considerable
debate. Williams et al44 evaluated 53 patients
with pilon fractures and associated bula frac-
tures; 22 patients underwent ORIF of the bula.
Although no statistical difference in the com-
plication rate was realized between the two
groups, there was a trend towards increased
complications when the bula was plated. It is
hypothesized that plating of the bula in the
presence of a comminuted tibia fracture may
delay healing by holding the tibia out to length
and not allow contact among the tibial frac-
ture fragments thereby encouraging the devel-
opment of a nonunion.
To apply the hybrid frame external xator,
the patient is placed supine on a radiolucent ta-
ble with a bump under the ipsilateral buttock,
and a pneumatic tourniquet is placed around
the proximal thigh. The limb is exsanguinated
with an Esmarchs bandage and the tourniquet
elevated to 300 mm Hg. Restoration of the ar-
ticular surface is performed by manipulation of
the fracture fragments. Once these fragments
are reduced, they can be lagged together with
lag screws. Application of the xator proceeds
by passing a wire through the articular block
from posterolateral to anteromedial. This wire
may be placed just anterior to the bula, or if
the bula is not plated, this wire may be placed
through the bula. This wire should not be
placed posterior to the bula where the per-
oneal tendons and sural nerve are at risk. A
second wire is placed from posteromedial to
anterolateral, beginning on the posterior aspect
of the tibia and exiting anterior to the bula.
Care should be taken to not pass the wire pos-
terior to the tibia to avoid the neurovascular
bundle and exor tendons. These wires should
be passed 10 mm proximal to the joint to assure

extra-articular placement. Olive wires may be
used and can serve two separate functions.
These wires may help to reduce the fracture
fragment and may prevent the distal tibia frag-
ment from translating relative to the proximal
fragment. A 5/8ths ring is then attached on the
proximal side of the two wires. This serves
to keep the ring further from the foot and
allows more ankle dorsiexion. Two 5.0-mm
Schanz screws are placed proximal to the frac-
ture from anterior to posterior in the sagit-
tal plane and a carbon ber rod is applied
to connect the ring to the Schanz screws.
A second rod is often placed between the
Schanz screws and the ring to further in-
crease stability (Fig. 4). Fluoroscopic guidance
is used to assist in passing the wires and dur-
ing fracture reduction. The pin to bar clamps
are tightened to ensure that the reduction is
maintained.
The use of limited internal xation in con-
junction with hybrid external xation has
Figure 4. A typical hybrid external xator for treatment of
a distal tibia fracture.
PILON FRACTURES 237
been described previously in this review.3, 36
Percutaneously placed screws with washers
using a standard lag screw technique or par-
tially threaded cancellous screws can be used
to augment hybrid external xation. The use
of limited-open reduction, combined with hy-
brid external xation, limits the amount of soft
tissue dissection necessary for the placement
of large plates with the increased risk for skin
slough and deep infection. This method is ben-
ecial in the treatment of open fractures where
plates would not have adequate soft tissue cov-
erage and for severely comminuted fractures
where screw xation of the articular fragments
is only possible.
Another technique that has been used in the
treatment of distal tibia fractures is the use
of minimally invasive plating. This is a rela-
tively new method of treatment and is well
suited in the treatment of those pilon fractures
that have less comminution and reduce well
with ligamentotaxis. These patients are treated
with a two-staged protocol designed to allow
soft tissue recovery prior to denitive xation
of the plafond. The rst stage, performed as
soon as possible after the patient is fully as-
sessed, includes ORIF of the bula and appli-
cation of a triangular external xator spanning
the ankle joint (Fig. 5). Reduction and stabi-
lization of the bula restores the length of the
lateral column and assists in the reduction of
the anterolateral fragment of the distal tibia
(Chaput fragment) and the posterior malleo-
lus fragment (Wagstaffes fragment). Restora-
tion of bula length also helps avoid valgus de-
formity of the tibial plafond. The incision used
for xation of the bula should be positioned
slightly posterior to the lateral aspects of the
bula to maximize the width of the potential
skin bridge if formal plating is planned for the
tibia.15 The temporary spanning external xa-
tor is applied by placing two Schanz screws
into the tibia proximal to the fracture. These
screws are placed approximately one half n-
ger breadth medial to the tibial crest in the
midsagittal plane to assure bicortical purchase.
The spanning external xator is completed by
the placement of a centrally threaded trans-
xation pin (5.0 mm) placed from medial to
lateral through the calcaneal tuberosity. This
pin must be placed well posterior and infe-
rior to avoid injury to the neurovascular bun-
dle medially and to avoid the sural nerve as
it exits laterally. The half-pins and transxa-
tion pin are then connected with carbon-ber
rods with the maximal distraction obtainable
across the ankle joint and fracture site using
238 BORRELLI & ELLIS

Figure 5. A and B, Temporary spanning external xator applied with a single calcaneal trans-
xation pin (5.0 mm) and two half-pins in the tibia. This xator applies ligamentotaxis to the
fracture fragments while allowing the soft tissues to recover. It also provides portable traction
and allows the patient to ambulate comfortably with crutches.

manual traction. Application of this frame in
the acute setting helps reapproximate the frac-
ture fragments through ligamentotaxis, mak-
ing subsequent reconstruction of the articular
surface easier (Fig. 6). Stabilization of the frac-
ture fragments increases patient comfort, as-
sists in prevention of further soft tissue injury,
and encourages soft tissue recovery. Creation
of this portable traction allows the patient to be
mobilized (thus avoiding the complications as-
sociated with prolonged recumbency) and to
be discharged from the hospital. The patient
can then be followed as an outpatient until soft
tissue recovery is nearly complete (1421 days).
For minimally invasive plate osteosynthesis
of pilon fractures, the patient is placed supine
on a radiolucent table with a bump under the
ipsilateral buttock and a tourniquet is applied
to the proximal thigh. The articular fragments
are reduced percutaneously with the aid of u-
oroscopy and reduction forceps or with small
incisions made over the fractures. Internal
xation can be achieved with a attened semi-
tubular plate or one of the newer low-prole
plates available. Once the appropriate length
plate has been chosen, a longitudinal incision
(23 cm) is made over the anteromedial sur-
face of the tibia proximal to the fracture. A sub-
cutaneous tunnel is created beneath the skin
distally with a Kelly clamp, if necessary, to al-
low the plate to be passed. The plate is passed
and its position conrmed with uoroscopy.
Screws are placed from distal to proximal and
an indirectly reduction of the distal metaph-
ysis is obtained. Interfragmentary compression
screws are placed as needed to create interfrag-
mentary compression and to increase the stabil-
ity of the construct. The incisions are irrigated
and closed, and the permanent radiographs are
taken prior to application of a short leg splint.
Preferred Treatment Method
Currently, a two-staged protocol designed
to allow soft tissue recovery prior to denitive
 PILON FRACTURES 239

Figure 6. Anteroposterior (A), mortice (B ), and lateral (C ), radiographs of an open Pilon fracture after
open reduction and internal xation (ORIF) of the bula and application of the temporary external xator.
Ligamentotaxis has realigned the articular fragments, while ORIF of the bula has restored the length
of the limb. Antibiotic impregnated beads have been placed temporarily in the medial soft tissue defect.

xation is being used in numerous trauma
centers.26, 42 The rst stage, performed soon
after the injury, includes open reduction and
internal xation of the bula and the applica-
tion of a triangular external xation spanning
the ankle joint (see Fig. 2). Reduction and op-
erative stabilization of the bula restores the
length and alignment of the bula and assists
in the reduction of the anterolateral fragment
of the distal tibia (Chaput fragment) and the
posterior tibia fragment. The incision for xa-
tion of the bula should be positioned slightly
posterior to the lateral aspect of the bula in
order to maximize the width of the skin bridge
across the anterior leg created during ORIF of
the tibial plafond.
The spanning external xator is created as
described previously with 5.0 mm Schanz
screws and a centrally threaded transxation
pin. The pins are connected with carbon ber
rods and distraction is applied by pulling down
on the transxation pin and maintained by
tightening the pin to bar connectors.
Once soft tissue swelling has decreased,
open reduction and internal xation of the
distal tibia can be performed. Typically soft tis-
sue recovery is heralded by a decrease in the
swelling of the foot and ankle, healing of frac-
ture blisters, and wrinkling of the skin on the
dorsum of the foot, anterior aspect of the ankle,
and base of the toes.
With the patient supine on a radiolucent
table, routine prepping of the thigh, leg, and
ankle is performed after application of a pneu-
matic tourniquet and placement of a bump
beneath the ipsilateral buttock. A tourniquet
is used to minimize blood loss and to pro-
vide a bloodless eld. Maintaining at least a
7-cm skin bridge between the bular and tibial
incisions is important. The distal tibia is ap-
proached through an extensile anteromedial
incision. This incision begins one-half nger-
breath lateral to the tibial crest and is carried
distally, parallel to the path of the anterior tib-
ialis tendon. The incision is brought across the
front of the tibia, at the level of the distal meta-
physis, and extended to the level of the talonav-
icular joint. Deep dissection is carried out me-
dial to the anterior tibialis tendon and care is
taken to maintain the periosteal attachments to
240 BORRELLI & ELLIS
the fracture fragments. An arthrotomy is per-
formed, and visualization of the tibial plafond
is achieved by distraction of the talus using the
previously applied external xator or a femoral
distractor.
Reconstruction of the distal tibia begins with
an anatomic reduction of the articular surface,
typically beginning with the least displaced
fractures rst. It is essential to begin with the
reduction of the articular surface rst and not
the metaphyseal portion because small malre-
ductions at the level of the metaphysis will
create unacceptable displacements at the artic-
ular surface. The reduced articular fragments
can then be temporarily stabilized with smooth
wires (1.6 mm) or pointed reduction forceps.
Denitive stabilization of these fragments is
achieved with small fragment cortical screws
placed using the lag screw technique or par-
tially threaded cancellous screws. The meta-
physeal fragments are then reapproximated or
anatomically reduced if this can be performed
without sacricing their soft tissue attach-
ments. Persistent bony defects present after re-
duction of the articular surface should be lled
with autologous bone graft, which can be aug-
Figure 7. Anteroposterior (A), mortice (B ), and lateral (C ), radiographs at 1-year follow-up demonstrates
complete healing of the fractures and an anatomically reduced articular surface.
mented with synthetic bone graft substitutes. A
small fragment low-prole plate placed along
the medial aspect of the tibia is used to neutral-
ize rotation forces, resist varus deformity, and
to reattach the articular block to the diaphysis.
In the past, large fragment plates were used on
the anterior aspect of the tibia; however, these
bulky implants are no longer recommended in
order to avoid closing the surgical incision un-
der tension and the realization that these meta-
physeal fractures heal relatively quickly and
do not require rigid stabilization. Smaller im-
plants (cloverleaf, one-third tubular, distal ra-
dial T plates, and even mini-fragment plates)
are now preferentially used to obtain stable
xation and minimize soft tissue compromise
(Fig. 7). Occasionally, because of the fracture
pattern, it is necessary to supplement this xa-
tion with more than one plate, with the second
plate placed anteriorly. The soft tissues are han-
dled carefully during the procedure and the in-
cision is meticulously closed using absorbable
suture for the deep tissues (20 Vicryl) and 30
nylon for the skin. The skin incision should be
closed with the Allgowers
modication of the
Donati stitch, with the knots placed along the

lateral edge of the wound in an effort to avoid
wound necrosis.
Upon completion, the external xator (if not
already removed) is removed and the pin
sites debrided and irrigated. Pin sites are left
open and are dressed, as are the surgical inci-
sions, with a povidone-iodine impregnated
occlusion dressing. A well-padded short leg
splint is applied with the ankle held in neutral
dorsiexion.
Postoperative Course
Patients are maintained toe touch weight
bearing (TTWB) and discharged home when
comfortable. The incisions are inspected post-
operatively at 6 to 8 days. At this time, the
splint is discarded, and the patient is placed
in a removable walking boot. Active range of
motion of the ankle is allowed at this time
if the incisions are healing without complica-
tions. Sutures are removed at approximately
2 to 3 weeks when the incisions have healed
thoroughly. Active range of motion (AROM)
and active-assistive range of motion (AAROM)
of the ankle midfoot and forefoot is encour-
aged while maintaining TTWB. Plain radio-
graphs are typically taken at the time of suture
removal to assure no change in the articu-
lar reduction, alignment, or position of the
implants. Further evaluation is performed in
1 month (67 weeks postoperatively) when an-
other set of plain radiographs is taken. If there
is evidence of early osseous healing, as deter-
mined by blurring of the fracture planes, par-
tial weight bearing (PWB, 50 lb) is initiated,
and formal physical therapy is begun. Physical
therapy includes AAROM muscle strengthen-
ing, proprioception training, and edema con-
trol. Typically the patient is seen 4 to 6 weeks
later (1013 weeks postoperatively) when an-
other set of plain radiographs are made, and
the patient is advanced to full weight bearing
(FWB; see Fig. 4).
Complications
The incidence of severe complications
following ORIF of the tibial plafond ranges
from 10% to 55%.22, 25, 34 These complications
typically involve the soft tissues and range
from supercial skin necrosis at the suture
line to full-thickness skin loss and deep
infection. Supercial wound breakdown can
be successfully treated with oral antibiotics,
local wound care (dressing changes), and
PILON FRACTURES 241
delay in ankle motion; however, full-thickness
wound complications can progress to deep
infection, including osteomyelitis requiring
debridement, long-term antibiotics, and soft
tissue coverage. Teeny et al34 reported that the
development of supercial wound problems
increased the risk for deep infection sixfold.
The degree of initial soft tissue injury appears
to play a role in the development of these se-
rious complications, as well as the timing and
methods of operative stabilization. Using the
protocol of immediate application of a span-
ning external xator of the tibia followed by
delayed ORIF, two recent studies have reported
a rate of deep infection of 0% and 6%.14, 26, 42
Nonunions of the distal tibia are believed
to be the result of traumatic devasculariza-
tion of the fracture fragments, excessive soft
tissue stripping at the time of surgery, and
distraction or instability of the fracture site.
Bourne et al5 reported a 25% nonunion rate
in Reudi/
Allgower Classication type C frac-
tures treated with ORIF, and Sirkin et al re-
ported a 100% union rate in 40 type C frac-
tures. Treatment of these nonunions typically
includes autologous bone grafting and repeat
skeletal stabilization.6, 7, 41, 42
Malunions involving the metaphysis or the
articular surface occur as a result of insuf-
cient fracture reduction xation or loss of
xation. Inadequate xation or implant fail-
ure allows the distal tibia to drift into varus
resulting in an oblique alignment of the weight-
bearing surface of the tibia. This varus align-
ment will cause the weight bearing forces to be
applied to the lateral aspect of the foot caus-
ing alterations in foot mechanics, pain, abnor-
mal shoe wear, and may accelerate degener-
ation of the ankle joint cartilage. The rate of
malunion has been reported in some series to
be as high as 42%.27 Correction of a signicant
malalignment can be accomplished by a supra
malleolar, opening wedge osteotomy, and bone
grafting. Rapid healing of the osteotomy is
expected because of the compression applied
across the osteotomy by the contracted soft
tissues.
Articular malunions, particularly those with
signicant step deformities, should be avoided.
These malreductions lead to nonuniform dis-
tribution of the weight bearing forces on the
articular cartilage and can accelerate the devel-
opment of post-traumatic arthritis. Therefore,
treatment methods designed to assure articu-
lar reduction without soft tissue compromise
are theoretically better at avoiding articular
malunions than other methods. Intra-articular
242 BORRELLI & ELLIS
osteotomies and revision of the xation are nec-
essary if a signicant malunion is present.
Some loss of ankle motion is expected af-
ter healing of pilon fractures because of asso-
ciated injuries to the surrounding soft-tissues,
arthrobrosis, muscle contracture, and scar-
ring. Fracture xation protocols, which allow
for and encourage early range of motion, may
improve nal ankle motion and functional out-
come. Limited ORIF and external xation has
been shown to result in a greater decrease in
ankle range of motion (ROM) when compared
with delayed ORIF.22, 27 Babis et al2 reported
better ankle ROM in patients treated with de-
layed ORIF than in those treated with minimal
osteosynthesis and external xation.
Post-traumatic arthrosis following pilon
fractures may result from cartilage damage
sustained at the time of injury, avascular
necrosis of the subchondral bone, and resid-
ual articular incongruity.30 Several studies
have determined that the nal functional re-
sult correlates strongly with the accuracy of
articular reduction.6, 7, 26, 33, 36, 42 In one study,
post-traumatic arthrosis was found in 100%
of patients with an unsatisfactory articular
reduction.27 It should, however, be noted that
an anatomic reduction of the articular frag-
ments does not necessarily prevent the devel-
opment of posttraumatic arthrosis.26 Conser-
vative treatment of ankle arthritis begins with
bracing, activity modication, nonsteroidal
anti-inammatory medications, and may ult-
imately include the use of a solid ankle foot
oethosis (AFO). Typically, shoe modications,
including a cushioned heel and rocker bot-
tom sole, are necessary in an attempt to
minimize weight-bearing forces and motion
across the ankle. Once other means of con-
servative management have been exhausted,
surgical treatment, including ankle osteophyte
resection or tibiotalar arthrodesis, may be nec-
essary for pain relief.
Results
The results of surgical management have
been shown to be affected by the type of frac-
ture, the quality of articular reduction achieved
at surgery, and the specic procedure by which
the fracture is managed.2 Based on the review
of 28 patients with Reudi/ Allgower
type B
and C fractures treated over a 10-year period,
Rommers et al28 concluded that standardize
protocols should be developed to success-
fully treat patients with severe pilon fractures
associated with severe soft tissue injury. They
advocated a step-wise reconstruction of the
pilon, including primary bridging of the tibia
with an external xator and secondary recon-
struction of the tibia after the soft tissues had
recovered.
Results of External Fixation
Versus ORIF
Comminuted pilon fractures have been
treated with external xation, with or with-
out limited internal xation, for several years.
These techniques are commonly advocated in
an effort to avoid the high complication rates
that have been associated with ORIF. Bonar
et al4 reported results with the use of a uni-
lateral external xator for the treatment of se-
vere pilon fractures. This retrospective review
of 21 patients included two distinct treatment
groups. The rst group (n = 5) was patients
who underwent only external xation with-
out attempted articular reduction. The second
group (n = 16) included patients who under-
went limited internal xation combined with
external xation. Four of the ve patients in
the rst group went on to an arthrodesis, while
the fth received a late amputation. Each of the
fractures in the second group healed without
evidence of wound infection, skin slough, or
osteomyelitis. Reecting on the results of the
patients in the second group, the authors con-
cluded that less extensive tissue dissection, in
an area prone to wound complications, may
have accounted for the low rate of infection,
wound complication, and nonunions.
Marsh et al20 have subsequently reported
results of a prospective multicenter study of
48 patients, treated with an articulated exter-
nal xator for displaced pilon fractures. At an
average follow-up of 30 months (n = 30), 21 pa-
tients where found to have little or no evidence
of osteoarthrosis, and nine patients had mild
to severe joint space narrowing, some with
subchondral collapse. One patient underwent
early ankle arthrodesis. All fractures healed,
one after a delayed bone grafting, and no in-
fections in any of the operative or traumatic
wounds over the tibia developed. Eight pa-
tients were treated for pin-site infections with
two patients requiring debridement of a pin-
site after removal of the xator. The authors
concluded that the prevalence of early com-
plications, associated with severe fractures of
the tibial plafond and their treatment, could
be decreased with the use of an articulated

external xator combined with limited internal
xation. [K1]
Wyrsch et al45 reported a randomized,
prospective trial of 39 patients with pilon frac-
tures. Group one (n = 9) were treated with ORIF
of the tibia and bula through separate inci-
sions, and group two (n = 20) were treated with
hybrid external xation, with or without lim-
ited internal xation. Group one had 15 com-
plications, all but four of which were infection
or wound dehiscence. Only four patients in
group two had complications. Complications
in group one tended to be more severe, and
three patients in this group eventually had be-
low knee amputations. At a minimum follow-
up of 2 years, the investigators found no signif-
icant difference in posttraumatic arthritis and
concluded that external xation was a satis-
factory method of treatment of pilon fractures
and was associated with fewer complications.
It is important to note that group one patients
underwent ORIF of the tibia on an average of
5 days after injury (range, 3 hours to 17 days).
This relatively short time between injury and
surgery could account for the reported high
complication rate associated with ORIF of the
tibia.
Barbieri et al3 reported on 37 patients treated
with hybrid external xation for displaced pi-
lon fractures. Fifteen patients also had limited
internal xation, eleven fractures were open.
With a follow-up of 15 months, 12 patients
had an excellent result, nine good, seven fair,
and six poor. Complications occurred in 12 pa-
tients (35%) and included one skin slough, ve
pin-tract infections, three deep infections, three
nonunions, and three loss of reductions, which
required frame revision. These investigators
concluded that hybrid external xation with
or without internal xation provide compara-
ble results with other treatments with fewer
complications.
Although improvement in operative tech-
niques apparently has lead to decreased com-
plications, true functional outcome following
up a pilon fracture has not been widely eval-
uated. Sands et al33 published their results
of a retrospective study of 64 patients, 30 of
whom completed the Short Form-36 health sta-
tus questionnaire. They then compared these
results with age matched, uninjured controls
and patients with other injuries. Not surpris-
ing the study group had signicant differences
in general health perception, physical function,
physical role function, emotional role function,
social and mental function, and pain and en-
ergy levels when compared with age matched
PILON FRACTURES 243
population data and patients with other in-
juries. Because of these ndings, investigators
are now advocating an increased use of health
status questionnaires in place of traditional
clinical analysis to clearly understand func-
tional outcome following these and other com-
plex fractures.
Sirkin et al,42 using a standard treatment pro-
tocol, reported results of 56 high-energy pi-
lon fractures (AO types 43AC). There were 34
closed fractures (group I) and 21 open fractures
(group II, three type I, six type II, eight type
IIIA, and ve type IIIB). The treatment proto-
col included immediate (< 24 hours) ORIF of
the bula and application of an external xa-
tor spanning the ankle joint followed by ORIF
of the tibia with plates and screws. Open re-
duction and internal xation was performed
on a range of 12.7 days post injury in group
I, and 14 days post injury in group II. With
follow-up available on 97% of the group I pa-
tients, all the wounds had healed, and there
was no wound dehiscence or full thickness
tissue necrosis requiring secondary soft tis-
sue coverage; however, ve patients (17%) did
have partial thickness skin necrosis. Each was
treated with local wound care and oral an-
tibiotics and healed uneventfully. One patient
(3%) developed a chronic draining sinus sec-
ondary to osteomyelitis, but after wound de-
bridement, implant removal, and intravenous
(IV) antibiotics the patient was healed. Follow-
up was available on 86% of group II patients;
two patients (8%) developed a partial thick-
ness wound necrosis that resolved with local
wound care and antibiotics. Two patients (8%)
developed deep infections following a type I
open fracture in one patient and a type IIIA
open fracture in the other. The patient with the
type I open fracture eventually healed, and the
patient with the type IIIA ultimately received a
below knee amputation because of osteomyeli-
tis of the tibia and calcaneus. Based on their
data, the authors hypothesized that the histor-
ically high rates of infection associated with
ORIF of these fractures was likely caused by at-
tempts at poor surgical timing and technique.42
Patterson and Cole26 also reported experi-
ence using this two-staged protocol for the
treatment of severe (AO/OTA classication
type A and C) pilon fractures. Twenty-one
consecutive patients with twenty-two fractures
were treated. All patients underwent immedi-
ate bular xation and placement of a medially
applied spanning external xator. On an av-
erage of 24 days, patients underwent removal
of the external xator and formal ORIF of the
244 BORRELLI & ELLIS
tibia. At follow-up of 22 months, all fractures
had healed with an average ankle ROM of 7 of
dorsiexion, 33 of plantar exion, 17 of ever-
sion, and 11 of inversion. Based on subjective
and objective measurements, the investigators
reported 77% good or excellent results, 14% fair
results, and 9% poor results. No infections or
soft tissue complications were reported in any
of the patients. The authors concluded that this
two-staged approach offered acceptable results
for the treatment of severe pilon fractures while
minimizing soft tissue complications and im-
proved articular reconstruction.26
SUMMARY
The treatment of high-energy intra-articular
fractures of the tibial plafond involves many
potential complications. A protocol, which in-
cludes immediate ORIF of the fractured bula
and the application of a spanning external x-
ator followed by delayed ORIF of the tibia, has
been developed. This protocol recognizes the
importance of the surrounding soft tissues and
is based on sound principles and thorough clin-
ical experience. This protocol allows the soft
tissues to recover before denitive xation of
the tibia is undertaken and permits early mo-
bilization of the ankle joint during the healing
process. This protocol avoids prolonged use of
the external xation, therefore minimizing the
risks of pin-site infection and joint stiffness. The
use of this protocol appears more widely ac-
cepted for treatment of pilon fractures as treat-
ment now turns towards ORIF and away from
the use of external xators.
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Address reprint requests to
Joseph Borrelli, Jr, MD
One Barnes Jewish Hospital Plaza, Suite 11300
St. Louis, MO 63110
TREATMENT OF COMPLEX FRACTURES
FRACTURES OF THE TALAR NECK
Michael Archdeacon, MD, MSE, and Roger Wilber, MD
Fractures of the talus have been described
for 400 years. The rst recorded account was
from Fibricius of Hilden in 1608.15 He wrote:
the Reverend Master Woolfbrand of Duis-
burg, a man strong and eshy, in jumping
from a bank three feet high so twisted and
broke his right foot that the whole of the os tali
was not only displaced, but the ligaments by
which it is bound to the other bones, being
broken, it burst through the skin and hung
out.13, 15, 19
Other surgeons in history described the in-
jury, including Cooper.11 He described the
injury and its treatment and the complica-
tion of infection and its subsequent treatment:
Mr. Downes, on the 24th of July had the mis-
fortune to dislocate the astragalus by falling
from his horse. . . . I would not operate . . . that
the skin might give way and the bone become
exposed, when we would be justied in re-
moving it. . . . Great discharge of pus and the
astragalus became loose . . . Finding the astra-
galus very loose, I removed it. . . . The patient
had a slight motion which was gradually in-
creasing. From these early accounts, it is ob-
vious that injuries to the talus were vexing and
created a high degree of apprehension because
of the potential complications.
Anderson et al4 reported the rst series of
talar neck fractures in 1919. Based on the ob-
servation that World War I pilots sustained the
injury as they forcefully applied pressure to
the rudder during airplane crashes, he coined
the term aviators astragalus. In 1952, Coltart9
From the Department of Orthopaedic Surgery, University of Cincinnati, Cincinnati (MA); and Department of
Orthopaedic Surgery, University Hospitals of Cleveland, MetroHealth Medical Center, Cleveland, Ohio (RW)
ORTHOPEDIC CLINICS OF NORTH AMERICA
VOLUME 33 NUMBER 1 JANUARY 2002
00305898/02 $15.00 + .00
described a series of talus fractures based
on his observation of 25,000 fractures during
World War II. This series of 106 fractures or
dislocations of the talus was the largest series
to date; Coltart9 attempted to classify the in-
juries and determine treatment modalities.
The landmark article for fractures of the
talar neck is attributed to Hawkins.18 In 1970,
he presented a classication system for frac-
tures of the talar neck and determined the risk
of osteonecrosis of the talar dome based on
the pattern of injury and its disruption of the
blood supply to the talus. Canale and Kelly 8
expanded the classication system and fur-
ther emphasized its prognostic value in their
1978 article. Canale also is credited with the
development of a specic radiographic tech-
nique for visualizing fractures of the talus.
Modern treatment of talar neck fractures cen-
ters on early diagnosis with appropriate imag-
ing technique and anatomic reduction and x-
ation with the goal of minimizing damage to
the talar blood supply.
ANATOMY
Bony Anatomy
Kleiger and Ahmed22 described the bony
anatomy of the talus. It is the second largest
tarsal bone. It is wedge shaped, widest an-
teriorly, with a curved lateral wall and a
straight medial wall. It typically is described
247
248 ARCHDEACON & WILBER
in 3 segments: the head, the neck, and the
body. Sixty percent to 70% of the talus is
covered with articular cartilage. The head of
the talus articulates with the navicular bone
at the talonavicular joint. The posterior and
anterior facets articulate with the calcaneus in
the subtalar joint. The dome of the talar body
articulates with the distal tibia and bula in
the talocrural joint or tibiotalar joint. There
are no muscular attachments to the talus. It
is constrained by ligaments in the ankle mor-
tise. The subtalar joint and the talonavicular
joints are maintained by joint capsules and the
interosseous ligaments. These ligamentous
constraints provide stability yet allow mobil-
ity in the tibiotalar and subtalar joints (Fig. 1).
Vascular Anatomy
Understanding of the blood supply in the
talus has been enhanced greatly by numerous
authors.8, 17, 20, 23, 29, 31 The extensive extraosseus
anastomotic network, which is the source of
the intraosseus blood supply, is composed of
3 main vessels and their branches. The poste-
rior tibial artery is the most signicant of these
3 vessels, contributing most of the intraosseus
blood supply. Contributions from the ante-
rior tibial and the perforating peroneal arter-
ies complete the supply. A branch of the per-
forating peroneal artery subsequently forms
the artery of the tarsal sinus. The posterior
tibial artery branches and forms the artery of
the tarsal canal, which subsequently anasto-
moses with the artery of the tarsal sinus within
the canal. This artery provides the main blood
supply to the talus, especially that of the tarsal
body. The head and neck of the talus receive
Figure 1. Lateral view of the talus and calcaneus bony
anatomy with congruous subtalar joint.
additional blood supply from branches of the
dorsalis pedis artery on its dorsal surface and
from a branch of the artery of the tarsal sinus.
A perforating branch from the tarsal canal
through the deltoid ligament supplies the me-
dial aspect of the talar dome. This artery is
a branch of the tarsal canal artery. The pos-
terior portion of the talus, through its tuber-
cle, receives a small branch from the posterior
tibial artery. This extraosseus network forms
a complex weblike intraosseus blood supply.
Most of this network can be seen receiving its
blood supply from the anastomotic artery of
the tarsal canal.
The region of the talus that has the most ten-
uous blood supply is the anterolateral surface
of the dome of the talus. Damage to the exten-
sive vascular network in various fracture pat-
terns is responsible for the complication of os-
teonecrosis in the talar dome.2, 3 In his classic
article, Hawkins18 provided an explanation for
the predictable rates of osteonecrosis based on
the fracture pattern and displacements.
MECHANISM OF INJURY
The deforming forces resulting in fracture
of the neck were described by Anderson et al.4
As the foot is positioned in extreme plantar
flexion, a dorsiflexion load is applied to the
forefoot, causing fracture of the neck of the
talus. This mechanism often is encountered in
automobile crashes during forceful braking
followed by sudden impact. The sequence of
injury has been explained further by Penny
and Davis.30 There are four stages of injury.
Stage I consists of excessive dorsiexion of
the ankle and foot causing rupture of the pos-
terior capsule of the subtalar joint. Stage II is
encountered as the neck of the talus impacts
the anterior rim of the distal tibia between
the middle and posterior facets. Stage III is
marked by the initiation of fracture between
the middle and posterior facets as the dor-
siexion force continues. Stage IV occurs as
the body of the talus subluxates. The position
of the hindfoot determines the direction of
subluxation or dislocation. If the foot is in-
verted, the foot subluxates medially, and if it
is everted, it subluxates laterally. The pull of
the Achilles tendon forces the body of the talus
into equinus, and the fractured neck comes to
rest on the body of the calcaneus. If continued
dorsiexion occurs, the tibiotalar joint capsule
ruptures posteriorly, causing subluxation of
the talobular joint. As the force continues,

the body of the talus can dislocate completely
from the ankle joint, rotating around an intact
deltoid ligament and allowing the fractured
surface of the neck to face laterally and supe-
riorly between the medial malleolus and the
Achilles tendon.
EXAMINATION
Examination begins with inspection, look-
ing for ecchymosis, edema, and deformity. The
status of the soft tissue envelope surrounding
the fractures is important (Fig. 2). Second,
the vascular examination must be performed,
looking specically for cyanosis or pallor and
assessing capillary rell. A meticulous exami-
nation of the dorsalis pedis and posterior tib-
ial pulses is mandatory in the traumatically
injured foot. If the pulses are not palpable,
a Doppler examination is appropriate. Next,
gentle palpation provides insight into local-
izing the point of injury through tenderness
and crepitance. Active and passive range of
motion should be examined. Finally, a neu-
rologic examination is performed and docu-
mented thoroughly. This examination includes
an assessment of sensation in the distributions
of the supercial and deep peroneal nerves,
the sural, saphenous, and tibial nerves. Motor
examination includes grading motor function
of the major peripheral nerves of the foot by
assessing ankle dorsiexion and plantar ex-
ion, inversion and eversion, hallux extension,
Figure 2. Lateral view of a patient with a Hawkins-type III talar neck fracture and
posterior medial displacement of the body of the talus. The exed hallux is indica-
tive of tension of the exor hallucis longus tendon.
FRACTURES OF THE TALAR NECK 249
and toe exion. It should be noted if a pa-
tient is unable to perform the motor examina-
tion secondary to pain. A high level of concern
for the development of a compartment syn-
drome in the foot, especially in high-energy in-
juries, must be present. The most sensitive test
for compartment syndrome is pain with pas-
sive stretch and pain out of proportion for the
known injuries. If uncertainty arises, measure-
ment of compartment pressures is indicated.
RADIOGRAPHIC EVALUATION
Canale View
Standard radiographs of the ankle, includ-
ing the anteroposterior, lateral, and mortise
views, typically show the fracture. Generally,
the lateral radiograph provides the most in-
sight with respect to the extent of the frac-
ture and the subluxation of the involved joints
(Fig. 3). Canale and Kelly 8 described a mod-
ied radiographic technique used for assess-
ing fractures of the talar neck. The technique
is performed with the cassette under the foot.
The ankle is placed in maximal equinus facil-
itated by exion of the hip and knee. The foot
is pronated approximately 15 , while the x-ray
tube is directed cephalad at a 75 angle from
the horizontal table top. This view shows the
lateral prole of the talus without superim-
posed osseous structures and the fracture and
its reduction (Fig. 4).
250 ARCHDEACON & WILBER

Hawkins article was the association of prog-

nosis with injury type.

Hawkins I

Type I fractures occur as a nondisplaced ver-

Figure 3. Normal ankle radiograph in which the two
domes of the talar body overlap. A true lateral radiograph
is important for determining displacement of the talar neck
as well as the congruity of the subtalar and tibiotalar
joints.
tical fracture of the talar neck. The fracture
enters the subtalar joint between the middle
and posterior facets. Only the vessels enter-
ing the neck of the talus and ascending to-
ward the body are interrupted. The fracture
is not displaced in the subtalar or tibiotalar
joints, and the incidence of osteonecrosis is
low. Hawkins18 reported a 0% incidence of os-
teonecrosis in his series.

CLASSIFICATION Hawkins II

In this classic article, Hawkins18 described a
series of 57 fractures of the neck of the talus
and outlined a classication system. The clas-
sication system prognosticated the incidence
of posttraumatic osteonecrosis and identied a
relationship to the initial displacement of the
fracture. Hawkins18 noted a 26% incidence of
concomitant medial malleolar fractures associ-
ated with talar neck fractures. Of the fractures,
96% were sustained by a mechanism of forced
dorsiexion. The most notable contribution of
Type II fractures consist of a vertical frac-
ture of the talar neck, displaced in the subta-
lar joint with either subluxation or dislocation.
The ankle joint remains located. As the subta-
lar joint subluxates, the body of the talus as-
sumes an equinus position (Fig. 5). Two vascu-
lar sources for the talar body are interrupted in
type II fractures. The vessels proceeding from
the neck toward the body and the vessels en-
tering the foramina in the sinus tarsi and tarsal
canal are injured traumatically. The vessels

A B

Figure 4. A, The angle of the x-ray beam should be directed 75 from the horizontal position. B,
Frontal view of the foot with a 15 inclination for obtaining the Canale view. The combination of these
two angles isolates the talar neck from the underlying osseus structures, allowing better visualization.

Figure 5. Lateral radiograph of a Hawkins II talar neck
fracture with malalignment of the subtalar joint.
entering the foramina on the medial surface of
the body generally are not disturbed. The inci-
dence of osteonecrosis is higher in type II frac-
tures, with a reported 42% incidence.18
Hawkins III
Type III fractures are characterized by verti-
cal fracture of the neck and an accompanying
subluxation or dislocation of the tibiotalar and
subtalar joints. The body of the talus often
is extruded posteromedially and is rotated
within the ankle mortise, becoming wedged
in various positions between the tibia and the
calcaneus (Fig. 6). The incidence of osteonecro-
sis is much higher in this fracture pattern
because the 3 main vascular sources for
the talar body have been disrupted. In the
Hawkins series, 91% of these injuries devel-
oped osteonecrosis.18
Hawkins IV (Canale)
In follow-up to Hawkins original paper,18
Canale and Kelly 8 modied the classication
and commented on a prognostic radiographic
indicator, the Hawkins sign. In 71 fractures of
the talar neck, they noted 3 patients who sus-
tained a talar neck fracture not previously
described by Hawkins. The fracture was as-
sociated with dislocation of the body from
the ankle or subtalar joint and a dislocation
or subluxation of the head of the talus from
the talonavicular joint. This rare combina-
tion of injuries has been termed the type IV
fracture.
FRACTURES OF THE TALAR NECK 251
Prognosis and Osteonecrosis
The Hawkins classication provides a rea-
sonable guide for preoperative counseling.18
Type I fractures have a low incidence of os-
teonecrosis. Type III fractures with associated
dislocation of the subtalar and tibiotalar joints
have a high incidence of osteonecrosis, ap-
proximately 90%. Most patients with these in-
juries can expect this outcome. Approximately
40% to 50% of type II fractures develop os-
teonecrosis, and these are more difcult to
predict. In the absence of osteonecrosis, good
counseling can be provided for the patient that
fusion will not be required and that eventual
healing will lead to a good to excellent out-
come. In the patient with osteonecrosis, fu-
sion may be needed later, however. Canale
and Kelly 8 noted that their results compared
closely with those of Hawkins in regard to the
incidence of osteonecrosis. The poorest results
occurred in patients with the most severe in-
jury types. Type IV fractures had a reported
avascular necrosis rate of 100%.8
TREATMENT
Historical Perspective
Historically the spectrum of treatment
methods has been advocated for fractures
of the talar neck. Cooper11 described a frac-
ture-dislocation of the talus and chose non-
operative management for fear of wound
complications. As infection became apparent,
a great discharge of pus and the astragalus
Figure 6. Lateral radiograph of a typical Hawkins III talar
neck fracture. Displacement of the talar body posteriorly
and medially, and loss of the normal subtalar and tibiota-
lar articulations.
252 ARCHDEACON & WILBER
became loose, Cooper11 chose operative inter-
vention, nding the astragalus very loose, I
removed it. In the early 1900s, talectomy was
the favored treatment. This technique subse-
quently was abandoned. Boyd and Knight7
advocated nonoperative, nonweight-bearing
treatment for talus fractures. Blair6 recom-
mended partial talectomy with arthrodesis of
the remaining head and neck fragment to the
tibia. Kleiger and Ahmed22 and McKeever26
recommended primary subtalar arthrodesis.
Hawkins18 and Canale and Kelly 8 advised
open reduction and internal xation for
displaced, unstable fractures.
Modern treatment centers on prompt reduc-
tion and operative stabilization for displaced
talar neck fractures. This section outlines treat-
ment for the various fracture types.
Rationale for Open Reduction
and Internal Fixation
Reduction Maneuver
Most displaced fractures of the talar neck
require open reduction and internal xation.
These fractures should be treated urgently
because of compromise to the circulation of
the talus and the potential for posttraumatic
osteonecrosis.10, 16, 35 The reduction is crucial
and must be anatomic to reduce the incidence
of osteonecrosis and posttraumatic arthrosis.
In displaced talar neck fractures, the body
and neck frequently are plantar exed. The
forefoot requires plantar exion to align the
head and neck fragments. By manipulating
the heel into varus or valgus, the subtalar joint
is reduced. For type III fractures with asso-
ciated tibiotalar subluxation or dislocation, a
calcaneal traction pin often is needed for ma-
nipulation. Dorsiexion followed by plantar
exion and eversion of the hindfoot opens
the subtalar and ankle joints. Pressure is ap-
plied through the body using the thumb in a
posterior-to-anterior direction allowing for re-
duction of the talar body within the ankle mor-
tise and subtalar joint. Further direct pressure
to the calcaneus laterally completes reduction
of the subtalar joint. 5
Varus Malalignment
Adelaar3 stated that rupture of the talocal-
caneal ligament occurs with dorsal displace-
ment of the distal fragment. Comminution
most often involves the medial side, most
likely secondary to a supination-type mecha-
nism in which the talar neck impacts the me-
dial malleolus. During reduction, it is crucial
to obtain anatomic alignment of the neck. The
resulting supination or varus deformity with
comminution is difcult to reduce and main-
tain with closed management. If more than
3 mm of displacement or 5 of varus exist,
open reduction is recommended.1
Sangeorzan et al33 performed a cadaver
study to evaluate the contact characteristics
of the subtalar joint in instances of varus
malalignment. With 2 mm of varus displace-
ment, the posterior facet showed no signicant
change in loading characteristics, but a more
focused region of contact was noted in the
malaligned tali. Hypothetically the altered
loading mechanics and increased pressure
gradients could lead to premature arthrosis.
In the anterior and middle facets, contact
area and high-pressure loading decreased
with displacement. This relative unloading
of the subtalar joint theoretically increased
the talonavicular joint loading, which in the
patient may predispose to arthrosis. Although
the subsequent development of arthrosis is
hypothetical, an anatomic restoration of the
joints and loading characteristics appears to be
the most intuitive approach.
To study the effect of varus malalignment on
foot position and motion, Daniels et al12 per-
formed an in vitro cadaver study on 12 spec-
imens, creating a varus malunion model of
the talar neck. By removing a medially based
wedge of bone, they created varus malalign-
ment of approximately 17 . Subtalar motion
and foot position were measured, and a di-
rect linear correlation was identied between
the degree of varus malalignment, foot po-
sition, and subtalar motion. The limitation
of motion was characterized as an inability
to evert the foot. Inversion was not limited,
however.
Surgical Approach for Open
Reduction and Internal Fixation
Approach
To reduce the fracture fragments anatomi-
cally and to prevent varus malalignment, most
authors advocate anteromedial and antero-
lateral incisions to address comminution and
 FRACTURES OF THE TALAR NECK 253

rotational malalignment (Fig. 7). If a posterior
approach is employed, it is imperative to
use an anteromedial approach to inspect the
quality of the reduction because image in-
tensication and plain lms frequently are
inadequate.1
Sangeorzan et al33 advocated a medial ap-
proach for visualizing fracture reduction. It is
performed through the interval between the
tibialis anterior and tibialis posterior tendons
and can be extended by a medial malleolar
osteotomy in cases in which the fracture ex-
tends into the body of the talus. The osteotomy
theoretically protects the blood supply from
the deltoid ligament, enhances the exposure of
the medial neck, and provides access to the
body of the talus. The anterolateral approach
is used as an adjunct for the placement of in-
ternal xation. This incision provides access to
the thickened cortical bone on the lateral, plan-
tar aspect of the talus in the region of the si-
nus tarsi for the placement of xation. Addi-
tionally the exposure allows for inspection of
the quality of reduction. A posterolateral ap-
proach has been advocated for screw place-
ment from posterolateral to anteromedial.24, 36
This approach avoids disruption of the blood
supply at the sinus tarsi and around the talar
neck and allows perpendicular placement of
lag screws across the fracture line. It does not

Figure 7. The two-incision approach for talar neck fractures. A, Frontal view of
two-incision approach. B, Lateral view of lateral incision with exposed exten-
sor digitorum brevis. C, Dorsal view of medial and lateral incisions.
254 ARCHDEACON & WILBER
provide direct visualization of the reduction,
however.
Fixation Method and Biomechanics
of Fixation
After obtaining anatomic reduction, the
fracture must be internally stabilized. A va-
riety of techniques have been described for
the internal xation of talar neck fractures
including Kirschner wires, various screw sizes
and congurations, and small neutralization
plates. Swanson et al34 performed an anatomic
in vitro analysis of xation of talar neck frac-
tures with 40 cadaver specimens in an attempt
to clarify the ideal xation method. Four
groups of xation constructs were tested to
failure. The rst group was xated with 2-mm,
crossed Kirschner wires placed anterior to
posterior. The second group was treated with
dual, 4-mm cancellous screws placed anterior
to posterior. The third group had internal xa-
tion with dual, 4-mm cancellous screws placed
posterior to anterior. The nal group was xed
with a single 6.5-mm cancellous screw and
an additional 2-mm Kirschner wire to control
rotation. The specimens were tested to failure.
The posterior-to-anterior screw provided a
mechanically superior construct in terms of
failure and yield loads.
Primary Arthrodesis
Morris et al28 described a modied Blair fu-
sion for treatment of fracture-dislocations of
the talar neck and osteonecrosis of the talar
body. Before excising the body of the talus, an
anterior tibial sliding graft was positioned in
a slot in the talar neck. The construct was se-
cured with a single screw and a Steinmann
pin placed through the calcaneus into the tibia.
Morris et al28 reported 8 fracture cases and
2 cases of osteonecrosis, followed for 1 to
16 years. Solid fusion was attained in all an-
kles with an active range of motion from 10
of dorsiexion to 20 of plantar exion. Subta-
lar motion was evaluated to be approximately
50% of normal. They advocated primary, mod-
ied Blair arthrodesis for complete extrusion
of the body of the talus because of the 90% in-
cidence of posttraumatic osteonecrosis. Morris
et al28 stated this procedure had advantages
over tibial calcaneal arthrodesis because it pre-
served the anatomy of the foot, prevented
shortening, and allowed motion of the talon-
avicular and subtalar joints.
Fracture-Specic Treatment
Type I
Undisplaced fractures associated with
a low-energy mechanism may be treated
nonoperatively. The patient must remain non
weight bearing in a short leg cast with close
clinical and radiographic follow-up. If loss of
reduction or any degree of malalignment is
noted, prompt open reduction and xation
is recommended. An additional option for
the nondisplaced type I fracture involves
percutaneous xation with 1 or 2 lag screws
placed posterior to anterior from the body
of the talus into the neck. This option may
be advisable when compliance with strict
nonweight bearing is a concern. With either
treatment modality, nonweight bearing is
essential for 6 to 10 weeks. The advantage
of the percutaneous xation method is the
allowance of early range of motion. It is not
advisable, however, to begin weight bear-
ing until trabeculation across the fracture is
seen.
Type II
In type II fracture patterns, closed reduc-
tion is more difcult because of the disrup-
tion of the talocalcaneal ligament. Open re-
duction through the anteromedial approach
is necessary to obtain reduction because this
is the region of malalignment, malrotation,
and comminution (Fig. 8). An accessory an-
terolateral approach can be used for reduc-
tion and xation in a region of thicker cortical
bone along the lateral sinus tarsi. Two crossed,
fully threaded 3.5-mm neutralization screws
or 2 terminally threaded 4.0-mm lag screws
are placed across the fracture from anterior
to posterior (Fig. 9). If the screws originate
in the articular cartilage, they must be coun-
tersunk so that they do not impinge during
talonavicular motion. Alternatively a postero-
lateral approach can be combined with the an-
teromedial approach for posterior-to-anterior
xation. Reduction is performed through the
anterior incision, and xation is performed
through the posterior incision. Two parallel,
terminally threaded 4.0-mm lag screws or a
single 6.5-mm cancellous lag screw and an an-
tirotation 2-mm Kirschner wire can be placed
across the fracture line. These screws should
originate at the posterolateral tubercle and be
directed across the fracture and into the head
of the talus.3 Cannulated screws allow this
 FRACTURES OF THE TALAR NECK 255

Figure 8. Sixteen-year-old girl with multiple injuries, including a frac-

ture of the talar neck and an associated calcaneus fracture. CT scan
reconstruction of the lateral view and the anterior view, revealing marked
comminution of the subtalar joint. The patient had an intramedullary rod
placed for the treatment of the tibia fracture and open reduction internal
xation of the talar neck fracture on admission. The open treatment of the
calcaneus fracture and primary fusion of the subtalar joint were performed
at approximately 10 days postinjury.

technique to be done percutaneously from the

posterior incision just lateral to the Achilles
tendon. Usually, 8 to 12 weeks is required be-
fore evidence of fracture healing is observed
on plain radiographs.34

Figure 9. The typical placement of screws in the talus
from both the medial and lateral sides. The lateral screw
obtains purchase in the stronger cortical bone. The me-
dial screw is counter-sunk into the articular surface of the
talar head.
Type III
Dislocation or subluxation of the subtalar
joint and the ankle joint make the type III
injury more difcult to reduce. Of type III in-
juries, 50% are open fractures.1 Either open
or closed, the dislocated talar body may ap-
ply considerable pressure on the medial skin.
This situation can lead to skin necrosis and
further complications if not reduced promptly.
The dislocated body of the talus may com-
promise the medial neurovascular structures,
increasing further the risk for osteonecrosis.
256 ARCHDEACON & WILBER
These injuries should be treated emergently
to reduce the incidence of posttraumatic os-
teonecrosis and to reduce the complications
associated with skin loss and open wounds of
the hindfoot.
To facilitate this difcult reduction, a
Schantz pin may be placed in the tuberosity
of the calcaneus to distract and manipulate
the hindfoot into an equinus position (Fig. 10).
A medial malleolar osteotomy may facilitate
exposure of the dislocated talus and spare fur-
ther trauma to the remaining vessels entering
the medial talus. Temporary xation of the
ankle and subtalar joints with a transarticular
2-mm Kirschner wire placed through the cal-
caneus into the talus and continuing into the
plafond of the tibia may assist in holding the
reduction until denitive xation is obtained.
This xation can be accomplished in a manner
similar to the xation of type II fractures.
Because open medial wounds frequently are
associated with these high-energy injuries,
anterior-to-posterior xation is often more
convenient (Fig. 11). Type III fractures are
treated in a nonweight-bearing cast for 8 to
12 weeks and progressed, as fracture healing
is evident on plain radiographs. Close radio-
graphic follow-up is necessary to identify
early signs of osteonecrosis, specically the
Hawkins sign.8
Type IV
Type IV injuries occur rarely, but they are
treated in a similar fashion to type III frac-
tures if reduction is obtained promptly. An
additional 2-mm smooth Kirschner wire can
be used as a joystick in the talar head frag-
ment to reduce the talonavicular dislocation.
Figure 10. Use of the large femoral distractor for Hawkins
III talar neck fractures with displacement of the body pos-
teriorly. Alternatively, an isolated Schanz pin in the calca-
neus allows for exion and extension of the foot, which
may be necessary for reduction of the body.
The talonavicular joint can be pinned in a
transarticular manner either as an intraoper-
ative aid or denitively if the joint is unsta-
ble. The talonavicular transarticular pin can
be pulled at 4 to 8 weeks. These injuries have
a high incidence of post-traumatic osteonecro-
sis, with reported incidence of 100%. Consid-
eration should be given to partial talectomy
and wound treatment followed by early Blair
arthrodesis, tibiocalcaneal arthrodesis, or an-
kle arthrodesis.16 The management of post-
traumatic osteonecrosis is discussed further in
the section on complications.
OUTCOMES
Historical Results
Hawkins18 described a series of 57 frac-
tures of the neck of the talus in 55 patients.
The most notable contribution was the cor-
relation between fracture displacement and
posttraumatic osteonecrosis of the talar dome.
Hawkins determined that osteonecrosis could
be identied based on the anteroposterior ra-
diograph between 6 and 8 weeks after injury.
Subchondral atrophy in the dome of the talus
signied a viable talus, whereas the lack of at-
rophy or an increase in radiodensity was con-
sistent with osteonecrosis. This relative radi-
olucency in the subchondral bone has been
coined the Hawkins sign (Fig. 12). Hawkins18
showed this to be a useful objective prognostic
indicator. Canale and Kelly8 also commented
on the subchondral radiolucency. They inter-
preted this radiographic nding to be indica-
tive of disuse osteopenia with vascular con-
gestion suggesting continuity of the blood
supply and evidence of vascularity to the body
of the talus. This nding classically is seen
beginning in the medial subchondral bone
of the dome and progressing laterally. This
progression most likely is due to blood sup-
ply reestablishing from the medial side of the
dome through the deltoid ligament.8, 18
In follow-up to Hawkins, Canale and Kelly8
reported 71 fractures through the talar neck
with an average follow-up of approximately
12.7 years. Good to excellent results were
noted in 59% of the patients according to
the criteria of Hawkins. Patients initially were
treated with closed reduction. If the fracture
was displaced 5 or more mm or rotated 5
or more, an open reduction with or without
internal xation was performed. Surgical
wounds were left open and closed secondarily.

Figure 11. Talar neck fracture and an associated talar head fracture with treatment by
way of two-incision approach and open reduction internal xation.
Canale and Kelly 8 reported osteonecrosis
in 52% of their patients. Specically, type I
fractures were immobilized for 6 to 12 weeks
in a nonweight-bearing cast, and 10 were
treated by open reduction and internal xa-
tion, 2 of which obtained a primary subtalar
fusion. Posttraumatic osteonecrosis occurred
in approximately 50% of type II fractures, and
Figure 12. AP radiograph of the ankle, revealing the sub-
chondral lucency indicative of relative osteopenia sec-
ondary to bony resorption and an intact blood supply. The
Hawkins sign typically progresses from medial to lateral.
FRACTURES OF THE TALAR NECK 257
poor results were correlated with an inade-
quate reduction. Four patients with type II
fractures underwent triple arthrodesis for a
painful malunion, and 1 patient underwent
a tibiocalcaneal arthrodesis. All 5 of these
patients eventually had a good result. Twenty-
three patients with type III fractures were
treated; 15 were treated with open reduction,
of which 11 had internal xation. Two patients
underwent primary Blair arthrodesis, and
1 patient underwent primary talectomy. The
remaining 5 patients had closed reductions.
Of the type III fractures, 84% showed changes
consistent with osteonecrosis. Three patients
were identied as having type IV injuries. All
of these fractures were open, and the results
were poor in 1 patient and fair in 2 patients.
Posttraumatic osteonecrosis developed in
approximately 10% of the type I injuries, 50%
of type II fractures, 85% of type III fractures,
and 100% of the rare type IV variants.8
Modern Results
Several authors have published results simi-
lar to Hawkins. There is some evidence, how-
ever, that prompt (within 6 to 8 hours) open
258 ARCHDEACON & WILBER
reduction and internal xation of any dis-
placed fracture results in a lower incidence of
posttraumatic osteonecrosis.10, 16 Closed treat-
ment generally is reserved for a few patients
with nondisplaced, stable, type I fractures in
compliant patients.
Szyszkowitz et al35 reviewed 89 fractures
of the talus, 71 of which were central frac-
tures or Hawkins-type injuries. Nonoperative
cast treatment was chosen for stable, nondis-
placed, or easily reduced fractures. Fractures
with displacement were treated emergently
with closed or open reduction through an
anteromedial approach to reduce the risk of
vascular insult to the talus. Internal xation
with either anterior-to-posterior or posterior-
to-anterior xation was performed based on
traumatic wounds. Implants included a sin-
gle 6.5-mm cancellous screw or 2 crossed,
4.0-mm cancellous screws. In the displaced or
dislocated fracture groups, a weight-relieving
caliper was used to protect the talus during
healing at around 2 weeks postoperatively.
Late results for 60 of the displaced or dis-
located fractures were reviewed at approxi-
mately 7 years. Approximately 43% of these
patients had ankle joint arthrosis, and 62% had
subtalar arthrosis radiographically, but 82%
had good or very good clinical results. The
rate of osteonecrosis was not reported, but
Szyszkowitz et al35 stated it was surprising to
see many revascularized talus bodies.
Comfort et al10 described 36 talar neck frac-
tures with approximately 7-year follow-up. Of
the fractures, 28 were treated with open reduc-
tion and anterior-to-posterior internal xation
within 12 hours of injury. They used a medial
malleolar osteotomy to improve exposure
on the medial side. Patients who developed
osteonecrosis were treated with a patellar-
tendon bearing orthosis for protected non
weight bearing. Of the patients, 33% had
evidence of osteonecrosis, but only 17%
had complete involvement of the dome.
Osteonecrosis correlated with the degree of
displacement of the fracture. One patient
required a subtalar arthrodesis, 1 patient
required a triple arthrodesis, and 2 patients
developed spontaneous subtalar fusion, for
a total arthrodesis rate of approximately
15%. According to Hawkins18 criteria, there
were 96% good or excellent results. Comfort
et al10 recommended prompt open reduction
and internal xation, medial malleolar os-
teotomy when necessary to provide adequate
exposure, and protected weight bearing for
selective cases in the face of osteonecrosis.
Grob et al16 described a series of 41 oper-
atively treated talus fractures, approximately
70% of which were treated within 8 hours
of injury. Twenty-ve patients were reeval-
uated at an average of 9.8 years, and 16%
were noted to have osteonecrosis. The 4 pa-
tients who developed osteonecrosis had par-
tial or complete talar body dislocation. Of the
patients, 32% developed ankle arthrosis, and
37% developed subtalar arthrosis. Seven cases
required an arthrodesis procedure for necrosis
with collapse (29%) or painful arthrosis (71%).
Grob et al16 recommended that complete talar
fracture-dislocations be treated with immedi-
ate ankle arthrodesis. They suggested fusion
may be a more appropriate management strat-
egy in these severe injuries because it allows
for revascularization and preserves subtalar
motion.
OPEN INJURIES
In the series of Canale and Kelly,8 5 frac-
tures were complicated by infection and
osteomyelitis. Four of the 5 fractures were
open injuries. Adelaar1 stated that 50% of type
III fractures are open injuries. Because of the
disruption of the vascular supply to the talus
and the tenuous nature of the soft tissues in
the region, these injuries are difcult to treat
without wound complications or infection.
Adelaar3 advocated external xation and
wound management, followed by Blair-type
arthrodesis or tibiocalcaneal arthrodesis.
Sanders et al32 retrospectively reviewed
11 patients with severe grade IIIB open an-
kle or open talus fractures. Three of these
patients had type II or type III talar neck
fractures, all of which were treated with a
standardized regimen of repeated irrigation
and debridement, temporary placement of
antibiotic beads in the dead space, appropriate
soft tissue coverage with free tissue transfer,
and intravenous antibiotics until the wound
was free of necrotic tissue. The three open
talar fractures underwent an arthrodesis of the
ankle and the subtalar joint with autogenous
iliac crest bone grafting and internal xation
with plates. Sanders et al32 reported 100%
success rate with fusion and muscle ap cov-
erage; however, all patients had a signicant
disability. They recommended considering
early amputation in severe open injuries; even
though all patients eventually healed and the
limb was salvaged, the reconstruction was not
functional.
 FRACTURES OF THE TALAR NECK 259

Marsh et al25 reported on 18 open talar
fracture-dislocations or total dislocations of
the talus. They treated the patients with exter-
nal xation to maintain hindfoot position, re-
peated irrigation and debridement, followed
by a modied Blair fusion or a tibiocalcaneal
arthrodesis. The incidence of infection was
38% and was associated with extrusion of the
talar body through an open wound. Marsh
et al25 attributed infection in these injuries to
the tenuous soft tissue envelope and to the
delicate blood supply of the talus. For 13 pa-
tients at an average of 7 years, the results
were good to excellent in 6, fair in 2, and com-
plete failure in 6. These data suggest a higher
failure rate in open fractures complicated by
infection.
COMPLICATIONS
General Complications
The frequency of complications is higher
in injury patterns of greater severity. This
fact has been noted since the earliest obser-
vations on fractures of the talus. McKeever26
described early and late complications. The
most notable early complications were skin
necrosis and infection. These often are asso-
ciated with fracture-dislocations in which the
skin was tented or the fracture was open. Late
complications included malunion and post-
traumatic subtalar arthrosis. Arthrosis was at-
tributed to prolonged immobilization required
for successful fracture healing and to articu-
lar damage sustained in severe fractures or
dislocations. Multiple authors have written
about their experience with postfracture com-
plications. Specic recommendations concern-
ing osteonecrosis, arthrosis, and malunion are
addressed.
satisfactory results. In cases of complete loss
of the talar body or osteonecrosis with col-
lapse, Adelaar2 recommended a Blair-type
tibiotalar arthrodesis from the distal tibia to
the remaining viable talar head and neck. He
recommended external xation to maintain
hindfoot height and to preserve subtalar
motion (Fig. 13).
Dennis and Tulus14 reported a series of
7 patients who underwent tibiotalar arthrode-
sis for treatment of osteonecrosis. They per-
formed a modied Blair arthrodesis through
an anterior approach in which the body of
the talus was removed. A rectangular graft
was formulated from the anterior aspect of the
tibia and translated in a sliding fashion dis-
tally into a slot cut in the head and neck of the
talus. The construct was internally xed with
a single screw. At 4-year follow-up, Dennis
and Tulus14 reported good results in 5 patients,
fair in 1 patient, and poor in 1 patient. Post-
traumatic osteonecrosis rates seem to have
declined in light of modern treatment with
emergent or urgent open reduction and in-
ternal xation of displaced and unstable talar
neck fractures. A percentage of patients de-
velop this complication to some degree, how-
ever. Conservative treatment seems warranted
until the patient shows a permanent disability,
at which time a modied Blair-type arthrode-
sis or tibiotalar arthrodesis21 should provide a
reasonable result.

Osteonecrosis
The watershed theory of osteonecrosis
within the talus generally is accepted. Given
adequate time, McKeever26 believed that
revascularization of the talar dome would
occur, and collapse could be avoided. Canale
and Kelly 8 stated most poor results were
secondary to posttraumatic osteonecrosis.
Their results compared closely with those of
Hawkins,18 especially in regard to osteonecro-
sis, which generally was associated with a
severe disability. If the patient could remain Figure 13. Severe avascular necrosis and subsequent
nonweight bearing until revascularization, degenerative arthrosis of the tibiotalar joint secondary to
however, a high percentage could expect a Hawkins III talar neck fracture.
260 ARCHDEACON & WILBER

Arthrosis
Canale and Kelly8 addressed posttraumatic
arthrosis. Approximately 50% of their patients
who did not undergo primary fusion showed
evidence of subtalar arthrosis, a third of whom
had a malunion. Canale and Kelly8 empha-
sized that before arthrodesis for degenerative
joint disease, the ankle and the subtalar joints
need thorough examination and evaluation.
Currently a computed tomography scan is the
best method for evaluating subtalar arthro-
sis. In their hands, severe subtalar arthrosis
was managed best with a subtalar fusion or
triple arthrodesis. Complete talectomy did not
prove to be a benecial procedure.
McKeever26 stated that the ankylosed or
compromised tibiotalar joint is well tolerated
in the face of a normal subtalar joint and
exible foot, and, conversely, arthrodesis of
the subtalar joint and the talonavicular joint
is well tolerated in the face of a normal ankle Figure 15. Malunion and shortening of the talar neck sec-
joint. Adelaar1 recommended a tibiocalcaneal ondary to comminution of the dorsal medial bone. The pa-
tient subsequently developed tibiotalar impingement ante-
arthrodesis for subtalar arthrosis. Mainte- riorly and subluxation of the talonavicular joint.
nance of adequate heel height helps to prevent
anterior ankle impingement (Fig. 14).
Kitaoka and Patzer21 evaluated the results
of arthrodesis for arthrosis of the ankle and performed in 16 patients using external xa-
osteonecrosis of the talus in 19 patients at a tion in 13, internal xation in 4, and no xation
mean of 6 years. A subtalar arthrodesis was in 2 patients. Supplemental iliac crest bone
graft was used in 74% of the patients, and lo-
cal bone graft was used in 25%. The clinical re-
sult was good-to-excellent in 68% and fair-to-
poor in 32%. The use of rigid xation and bone
grafting had an arthrodesis rate similar to that
for patients who do not have osteonecrosis.

Figure 14. Loosening and collapse of an attempted sub-
talar joint fusion with loss of normal heel height and sub-
sequent impingement of the talar neck on the anterior dis-
tal aspect of the tibia.
Malunion
Malunion generally is dorsal or varus and
occurs most commonly in type II fractures.
These patients are more likely to develop
posttraumatic arthrosis (Fig. 15).8 Monroe and
Manoli27 described a patient with a malunion
of a type II talar neck fracture initially treated
nonoperatively. Rigid varus deformity of the
forefoot was a source of severe pain and dis-
ability. The patient underwent osteotomy of
the talar neck with insertion of a tricortical il-
iac crest bone graft to correct the deformity. At
56 months, the patient had consistent relief of
pain and was employed at his preinjury job
performing heavy labor. Radiographs showed
maintenance of the position of the osteotomy
and no evidence of osteonecrosis in the talar
body. The most acceptable treatment for malu-
nion is to prevent its occurrence; however, if

a malunion develops and the patient is not
ready for arthrodesis, an osteotomy is a rea-
sonable alternative.
SUMMARY
Fractures of the talar neck have been well
described, and a broad spectrum of treatment
alternatives has been attempted. Hawkins18
and Canale and Kelly 8 have contributed sig-
nicantly to understanding of this injury.
Their work has dened a classication sys-
tem that identies the severity of the injury
based on displacement, outlined treatment
rationale, and allowed some prognostica-
tion. More recent publications have outlined
treatment rationales that include prompt
recognition of the injury, anatomic reduction,
and stabilization with internal xation for all
but completely nondisplaced, stable type I
fractures. It seems that the incidence of post-
traumatic osteonecrosis can be reduced with
emergent treatment of displaced fractures.
If osteonecrosis develops, a modied Blair
arthrodesis or tibiotalar arthrodesis has had
reasonable success. In the case of post-
traumatic arthrosis, ankle arthrodesis or
subtalar arthrodesis should provide accept-
able pain relief and function, if planned and
executed carefully.
References
1. Adelaar RS: Complex fractures of the talus. Instr
Course Lect 46:323338, 1997
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23. Larson RL, Sullivan CR, Manes JM: Trauma surgery
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25. Marsh JL, Saltzman CL, Iverson M, et al: Major open
injuries of the talus. J Orthop Trauma 9:371376, 1995
26. McKeever FM: Treatment of the complications of frac-
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27. Monroe MT, Manoli A: Osteotomy for malunion of
a talar neck fracture: A case report. Foot Ankle Int
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28. Morris HD, Han WL, Dunn AW: Modied Blair fu-
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29. Mulnger GL, Trueta J: The blood supply of the talus.
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30. Penny JN, Davis LA: Fractures and fracture-
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31. Peterson L, Goldie IF, Lindell D: The arterial supply
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35. Szyszkowitz R, Reschauer R, Seggl W: Eighty-ve
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1970

Address reprint requests to

Michael Archdeacon, MD, MSE
Department of Orthopaedic Surgery
University of Cincinnati
PO Box 670212
231 Albert Sabin Way
Cincinnati, OH 45267-0212

e-mail: archdemt@ucmail.uc.edu
TREATMENT OF COMPLEX FRACTURES
FRACTURES OF THE CALCANEUS
David P. Barei, MD, FRCS(C), Carlo Bellabarba, MD,
Bruce J. Sangeorzan, MD, and Stephen K. Benirschke, MD
Fractures of the calcaneus account for ap-
proximately 60% of tarsal injuries and usually
are the result of a fall from a height. Of those
injured, 80% to 90% are men in their prime
working years.21, 40, 73, 93, 94, 101 Other injuries to
the appendicular and axial skeleton occur fre-
quently and should be sought. Despite the
relative prevalence of this injury, denitive
management is controversial. Historically the
closed treatment of these injuries had been
unsatisfactory, leading Cotton and Wilson23
to write in 1916, the man who breaks his
heel bone is done. Conn22 reiterated this pes-
simistic view, reporting calcaneus fractures
are serious and disabling injuries in which the
end results continue to be incredibly bad.
Later, Bankart5 similarly reported his experi-
ence: the results of crush fractures of the os
calcis are rotten.
Because the bony architecture is com-
plex and the soft tissue envelope tenuous,
open reduction is challenging and fraught
with potential morbidity. Historically, open
treatment failed to show improved out-
come over non-operative care and in some
circumstances resulted in a worse out-
come.31, 32, 47, 52, 58, 71, 73, 82, 94, 105 Modern techniques
allow a better appreciation of the complex
fracture and bony anatomy. Open reduction
with rigid internal xation is the standard
for displaced intra-articular fractures in other
weight-bearing joints. Unfortunately, the re-
sults of contemporary open treatment have
not been as satisfactory in the calcaneus
as in other intra-articular fractures. Current
From the Department of Orthopaedic Surgery, University of Washington, Harborview Medical Center, Seattle,
Washington
ORTHOPEDIC CLINICS OF NORTH AMERICA
VOLUME 33 NUMBER 1 JANUARY 2002
00305898/02 $15.00 + .00
techniques of radiographic imaging, xation
methods, rehabilitation, and outcome assess-
ments suggest that an improved result can be
achieved.72, 80, 98, 102
ANATOMY
The calcaneus is a three-dimensionally com-
plex bone with ve clinically signicant as-
pects of the bony anatomy (Fig. 1) (1) The
superior surface has three articular facets sup-
ported by a complex corticocancellous bony
structure. The large posterior facet and the
smaller middle and anterior facets function
as a single articulation with the talus and to-
gether compose the inferior portion of the sub-
talar joint. Changes in the relationships among
the facets affect subtalar joint mechanics and
are analogous to an intra-articular fracture
even when the fracture line does not traverse
a cartilage surface. A shallow oblique groove
that represents the oor of the tarsal canal sep-
arates the posterior facet from the anterior and
middle facets. Laterally the tarsal canal opens
into a recessed area anterior to the posterior
facet known as the sinus tarsi. The relation-
ship among the articular surfaces dees sim-
ple description. (2) The middle and anterior
facets frequently are contiguous and, although
smaller than the posterior facet, bear more
weight per unit area.103 The dense bone of the
sustentaculum tali supports the lesser facets
and provides an optimal site for rigid screw
xation. (3) The medial wall is sharply sloped
263
264 BAREI et al

Figure 1. See legend on opposite page

 FRACTURES OF THE CALCANEUS 265

and is in close proximity to the medial neu-
rovascular structures and exor group of ten-
dons. It is less surgically accessible and more
vulnerable to neurovascular injury. (4) The lat-
eral wall of the calcaneus is relatively at and
is covered primarily by skin and subcutaneous
tissue; this allows easier surgical access and fa-
cilitates placement of xation devices. The lat-
eral aspect of the calcaneus is subject to soft
tissue complications. (5) Distally the anterior
portion of the calcaneus articulates with the
cuboid creating a mobile joint. Secondary frac-
ture lines that involve this distal facet occur
frequently and when displaced result in artic-
ular incongruity.
The calcaneus functions as a major verti-
cal support, or foundation, during weight-
bearing activities and as a fulcrum allowing
effective function of the calf musculature. In
the intact calcaneus, the superior facets act
together to allow an oblique rotation of the
hindfoot that accounts for most of the inver-
sion and eversion of the foot.103 Simplistically,
subtalar inversion locks the midtarsal joints,
allowing the foot to function as a rigid plat-
form for push-off. Conversely, subtalar ever-
sion creates relative motion at the midtarsal
joints allowing the foot to absorb energy dur-
ing heel-strike. An effective gait is achieved by
maintenance of lateral column length and heel
height coupled with smooth, adequate subta-
lar joint motion. Given this intricate relation-
ship, a truly anatomic fracture reduction is
difcult.
FRACTURE ANATOMY
Calcaneal fractures typically result from ax-
ial loading mechanisms. On impact, the talus
continues the downward descent into the rel-
atively stationary calcaneus. The inferior mid-
coronal portion of the talus, including the
lateral process, acts as a fulcrum, or wedge,
fracturing the calcaneus. The ultimate fracture
pattern depends on numerous variables, in-
cluding the lateral position of the calcaneus
beneath the talus,85 the changing position of
the foot at impact, the quality of bone, and
the direction and magnitude of the resultant
force. Despite the innite potential congura-
tions, certain consistent fracture patterns have
been observed (Fig. 2).17
Although its position varies, a primary frac-
ture line or separation fracture is common to
most intra-articular fractures of the calca-
neus.6, 8, 17, 19 This primary fracture line begins
in the sinus tarsi near the lateral wall and
propagates obliquely across the posterior facet
to the medial wall. The anterolateral exit point
is at the angle of Gissane but may extend an-
teriorly as far as the calcaneocuboid joint.14,28
The posteromedial exit point is posterior to
the sustentaculum. The primary fracture line
divides the calcaneus into posterolateral and
anteromedial fragments. The posterolateral
segment consists of the tuberosity and lateral
wall with a variable portion of the posterior
facet. The anteromedial segment comprises
the remaining posterior facet and the susten-
tacular fragment with the middle and anterior
facets. The posterolateral tuberosity fragment
typically is driven anteriorly and laterally
along the primary fracture line, assuming a
position beneath the bula. The anteromedial
sustentacular fragment may rotate downward
away from the talus, particularly in high-
energy injuries, and locks into the posterior
facet fragment.64 Disimpaction of the tuberos-
ity allows the sustentacular fragment to rotate
back to its native position secondary to its
strong soft tissue attachments.
Additional secondary fracture lines invari-
ably occur. These include a medial fracture
extension that divides the middle facet from
the posterior facet and an anterior fracture ex-
tension that divides the anterior process, pro-
ducing a common anterolateral fragment.18, 53
Secondary fracture lines in the body of the
calcaneus further affect the posterior facet
fragment. The morphology of the lateral pos-
terior facet fragment depends on the exit point

Figure 1. A, Lateral view of the normal talocalcaneal relationship. B, Lateral view of the calcaneus
with the talus removed. The posterior facet (PF), middle facet (MF), and distal articular facet (CC) are
demonstrated. The distal articular facet is the calcaneal portion of the calcaneocuboid joint. C and D,
The superior aspect of the calcaneus demonstrates the posterior facet ( gray arrow ) and the conu-
ent anterior and middle facets ( black arrow ). These facets constitute the inferior portion of the subtalar
joint and articulate with corresponding areas on the inferior surface of the talus. E, This posterior view
of the calcaneus demonstrates the relationship of the posterior facet ( white arrow ) to the sustentacu-
lum tali ( black arrow ) and the sloping medial wall. F, Relationship of the posterior facet (PF), middle
facet (MF), and distal facet (CC) to each other and to the tuberosity as viewed from the distal aspect of
the calcaneus.
266 BAREI et al

Figure 2. A, Primary ( black arrow ) and secondary anterior ( gray arrows ) fracture lines,
viewed from the superior aspect of the calcaneus. Note the creation of the posterolateral
and anteromedial fragments by the primary fracture line. B, This axial CT image demon-
strates the primary fracture line ( white arrow ). The tuberosity segment is displaced later-
ally and distally along the primary fracture line, thus shortening and widening the heel. A
portion of the posterior facet (PF) remains attached to the sustentaculum tali (ST). C and
D, The direction of the primary fracture line on the lateral view is typically vertical. When
a secondary posterior fracture line is transversely oriented and exits the tuberosity on its
posterior surface, a separate tongue fragment is created. This fragment is composed of
a portion of the posterior facet and the tuberosity. Understanding this relationship facili-
tates reduction of the posterior facet in tongue-type fracture patterns. E and F, When the
secondary fracture line exits on the superior aspect of the tuberosity, a joint depression
fragment is created. Typically, this fragment is depressed and rotated into the body of the
calcaneus. Unlike the tongue-type fracture, manipulation of the tuberosity does not re-
duce the posterior facet in a joint depression fracture.
Illustration continued on opposite page
 FRACTURES OF THE CALCANEUS 267

Figure 2 (Continued ).
268 BAREI et al
of this fracture line relative to the calcaneal
body and tuberosity. Two common patterns
have been identied. A fracture line that
travels in a transverse plane and exits the
calcaneal tuberosity on the upper posterior
surface results in a tongue-type fragment. The
relationship of the lateral posterior facet and
the superior aspect of the tuberosity remains
intact. Joint depression fractures are those in
which the secondary fracture line separates
the lateral posterior facet from the body and
tuberosity of the calcaneus. This fragment
is rotated or depressed into the body. The
relationship between the depressed fragment
and the tuberosity is altered.
Continued impaction of the lateral edge of
the talus into the calcaneus results in addi-
tional comminution of the posterior facet, cre-
ating extreme lateral posterior facet fractures
and multiple chondral and osteochondral frac-
ture fragments. Comminution and impaction
of the posterior facet drives the lateral wall
fragments further laterally and exacerbates
subbular impingement.
Conceptually the primary fracture line is a
reproducible part of a stellate fracture pattern
centered in the sinus tarsi. The nal defor-
Figure 3. A and B, Severe anterior process comminution ( black arrow ) may preclude satisfactory
screw purchase. Distal facet comminution and anterolateral fragments can also be seen. In these situ-
ations, xation may be extended to the intact cuboid.
mity reects the predictable displacements of
the major fracture fragments relative to each
other. The calcaneal length and height are di-
minished. The heel is widened secondary to
the displacement of the posterolateral tuberos-
ity fragment and the associated lateral wall
blowout. The posterior facet is incongruent and
potentially multifragmented. The relationship
of the 3 superior facets necessarily is altered.
Anterior process fractures may result in cal-
caneocuboid incongruity, which, if extensive,
jeopardizes distal screw purchase (Fig. 3). Loss
of Bohlers angle results in a more horizon-
tal attitude of the talus and affects tibiotalar
and talonavicular mechanics. Loss of normal
talonavicular and calcaneocuboid interaction
affects midtarsal mobility.
CLASSIFICATION
Several fracture classications have been
proposed, none of which is accepted uni-
versally or has shown reproducible prognos-
tic potential.20, 24, 26, 50, 84 The major, more recent
classication systems are based on 3 fracture
characteristics: displacement, the presence of
 FRACTURES OF THE CALCANEUS 269

posterior facet involvement, and the sever-
ity of posterior facet involvement. Only com-
puted tomography (CT) can assess this last
feature accurately.
Descriptive classications use basic fracture
terminology, such as nondisplaced or dis-
placed and intra-articular or extra-articular. The
amount of comminution, the presence of open
wounds, and the relationship of the posterior
facet relative to the tuberosity (Bohlers angle)
(Fig. 4) describe the fracture further.8 Early for-
mal classications were based on plain radio-
graphs, particularly the lateral image.31, 82, 104
The difference between extra-articular and
intra-articular fractures was emphasized by
Essex-Lopresti31, 32 and reects the general im-
pression that extra-articular fractures tend to
have better outcomes than fractures involving
the subtalar joint. Essex-Lopresti31 identied
two distinct intra-articular fracture patterns:
the joint depression fracture and the tongue-type
fracture (see Fig. 2CF). As described previ-
ously, the difference between these two frac-
ture types depends on associated secondary
fracture lines relative to the tuberosity frag-
ment. Theoretically, the differences between
the two types should be easily discerned. In
the more common complex fracture patterns,
however, the distinction may not always be
obvious. The Essex-Lopresti system is simple
to use and relies on readily available radio-
graphs, but the category joint depression is
not detailed enough to facilitate prognosis or
communication between orthopedists.
CT improves the ability to assess articular
and nonarticular comminution. Several CT-
based classication systems have been created
that focus on the articular injury, particularly

Figure 4. A, Bohlers angle, the complement of the angle subtended by the

two lines demonstrated, decreases with depression of the posterior facet or
shortening of the heel. B, The angle of Gissane is densely corticated and is
a common exit point of the primary fracture line along the lateral aspect of the
calcaneus.
270 BAREI et al

articular injury to the posterior facet.19, 24, 84 The
CT classication system of Sanders et al84 is
used widely and is based on the number and
location of calcaneal posterior facet fracture
lines relative to the widest portion of the pos-
terior facet of the talus (Fig. 5).84 Although the
ability of treating physicians to assess these
parameters has never been validated, it is
likely that the greater the comminution, the
greater the energy, with worse prognosis.76, 79
The lack of matched, nonoperatively treated
patients complicates the ability to draw strong
prognostic conclusions from all proposed
classications.
Although the subtalar joint has three facets
that function as a single complex articular
surface, none of the current classications con-
siders displacement that disturbs the relation-
ships between the three facets. This indepen-
dent variable may account for discrepancies in
the reliability of the classication systems. Al-
terations in the size and shape of the calca-
neus, involvement of the calcaneocuboid joint
or the anterior and middle facets, and associ-
ated soft tissue injury also may affect outcome.
These factors further hinder an effective and
comprehensive classication system.
IMAGING
The acutely traumatized foot (Figs. 6 and 7)
is imaged initially with dorsoplantar, lateral,
and oblique plain radiographs. The diagnosis
of most calcaneal fractures is made on these
initial images, particularly the lateral view.
The addition of the axial view generally com-
pletes the plain radiographic investigation.
The dorsoplantar view shows involvement of
the calcaneocuboid joint and lateral wall dis-
placement. The lateral view allows assessment
of posterior facet position and loss of calcaneal
height (Bohlers angle) and gives a general
impression of overall comminution. The axial
view is informative and shows the direction
and displacement of the tuberosity along the
primary fracture line. Widening of the heel,
varus angulation, lateral wall displacement,
and bular abutment also typically are seen.
Posterior facet incongruity and its relation-
ship to the sustentacular fragment are visual-
ized, provided that the radiographic technique
is satisfactory. Comparative lateral and axial
views of the contralateral uninjured calcaneus
facilitate the assessment of displacement and
help guide fracture reduction. Multiple hind-
foot oblique views may be obtained to image
the posterior facet further.10 These views are
obtained by placing the cassette behind the
heel and distal tibia with the foot in varying
degrees of rotation. The x-ray beam is aimed
cephalad and brought through a 0 to 40 arc in
10 increments. Each image shows a different
portion of the posterior facet. Although these
views largely have been replaced by CT scan-
ning, they may be helpful intraoperatively.

Figure 5. Sanders classication emphasizes posterior facet comminution. A, A two-part frac-

ture pattern is visualized on the coronal CT image. Lateral wall (LW) displacement is noted
beneath the bula, B, A severer three-part fracture is demonstrated on this CT coronal
reconstruction. The relationship of the fracture lines to the talus (T) further describes the frac-
ture pattern. Bony debris is again noted in the subbular area.
 FRACTURES OF THE CALCANEUS 271

Figure 6. This gentleman was injured after falling from a ladder. A, The preoperative lateral image
demonstrates a tongue-type fracture pattern with loss of Bohlers angle and a double density corre-
sponding to displacement of the posterior facet. B, The axial radiograph demonstrates heel widening,
and lateral wall displacement beneath the bula. C and D, The postoperative radiographs reveal satis-
factory restoration of heel height, width, and posterior facet congruency.

CT facilitates the preoperative plan and
shows previously unrecognized fracture com-
minution. Surrounding soft tissue injury, par-
ticularly of the peroneal tendons, is occa-
sionally observed.9, 30, 81 CT scanning should
include 2 planes: a transverse plane that paral-
lels the plantar surface of the foot and a semi-
coronal plane perpendicular to the posterior
facet.87, 88 The transverse plane images show
secondary fracture lines traversing the sus-
tentacular segment and anterior process and
calcaneocuboid joint involvement. Sagittal
and coronal reconstructions further enhance
comprehension of the complex fracture and
bony anatomy. Modern computer software
programs minimize radiation exposure and
scan time by creating these reconstructions
with reformatting techniques. The quality of
the reformatted images depends on excellent
initial CT scans. Three-dimensional CT recon-
structions may improve conceptualization of
the injury further but are not obtained rou-
tinely. Magnetic resonance imaging has been
used experimentally to evaluate the status of
272 BAREI et al

Figure 7. This comminuted calcaneal fracture was the result of a high-speed motor vehicle colli-
sion. The patient was polytraumatized. AE, The preoperative plain radiographs and CT images re-
veal signicant injury to the posterior facet, widening of the heel, and loss of calcaneal height. The
horizontal attitude of the talus is noted. The primary fracture line (PFL) can be seen on the axial
radiograph. F and G, The postoperative images show satisfactory reduction of the key elements of the
fracture. AP = anterior process, CC = calcaneocuboid joint; Cu = cuboid; LW = lateral wall; PF = pos-
terior facet; ST = sustentaculum tali; T = tuberosity; TH = talar head.
Illustration continued on opposite page

the plantar fat pad after calcaneal fracture but
is used rarely in the acute setting.56
TREATMENT
The management of displaced intra-
articular calcaneal fractures is controversial.
Treatment should attempt to improve on
the natural history of the injury. The ideal
prospective natural history study has not been
performed. Long-term retrospective data of
intra-articular calcaneal fractures managed
nonoperatively showed that most patients
have long-term symptoms.51, 58, 60 Other au-
thors have reported relatively satisfactory
long-term results in severely displaced frac-
tures managed conservatively.60, 79, 83
Closed Treatment
The principles of closed functional treat-
ment are acute pain relief, control of swelling,
and early motion. Rest, ice, compression,
and elevation are emphasized initially. Early
motion aids functional recovery and seems to
be more important than maintaining position
with immobiliztion.32, 58 If closed treatment

Figure 7 (Continued ).
is selected, the injured foot and lower leg are
placed in a compression dressing followed
by a removable splint or commercially avail-
able boot. The patient should be nonweight
bearing on the affected extremity. Early
splinting prevents the occurrence of equinus
contracture and minimizes discomfort. Range-
of-motion exercises are instituted as soon
as the swelling and pain are under control.
Progressive weight bearing is started when
the fracture is healed, generally between 6 and
12 weeks. Then graduated stretching and
strengthening exercises are begun. Custom
orthoses may improve standing and walking
tolerance. A good-to-excellent outcome occurs
less than half the time with this treatment.51
Closed manipulative reduction also has
been recommended.4, 8, 31 The goal of this treat-
ment is to restore the overall shape of the cal-
caneus, with emphasis on restoring Bohlers
angle, obtaining posterior facet congruency,
and reestablishing normal heel width. This
FRACTURES OF THE CALCANEUS 273
operation requires relaxation of the gastrocne-
mius muscle by knee exion and some form of
traction on the heel.21, 58 A well-molded plaster
cast usually is necessary to maintain the re-
duction. These techniques may be impressive
in restoration of heel height and normalizing
width, but except in unique circumstances,
they are not particularly effective in obtaining
posterior facet congruity.31, 38, 89 This method
has limited indications but may be useful in
managing patients who are not candidates for
open treatment. The principles of manipula-
tive reduction, particularly of the calcaneal
tuberosity, frequently are used during formal
open reductions.
Indications and Rationale
for Surgical Treatment
Virtually every aspect of the surgical man-
agement of complex calcaneal fractures is
a source of debate. Basic concepts, such as
274 BAREI et al
the method and need for extra-articular and
intra-articular reduction, the choice of surgical
approach, bone graft requirements, patient
position, implant selection, and outcome as-
sessment, all are controversial issues.91 The
inability to show signicantly superior out-
comes after surgical management fuels this
controversy further.
The principles of bony reconstruction, par-
ticularly in weight-bearing joints, include
anatomic reduction and rigid xation of intra-
articular fractures and accurate restoration of
coronal, sagittal, and transverse mechanical
axes. Adherence to these principles maxi-
mizes the chance for optimal outcome, but
application of these principles to the cal-
caneus has been slow. Complex bony and
fracture anatomy, a tenuous soft tissue enve-
lope, and the difculty of achieving anatomic
reduction and rigid xation are important
complicating issues. Although clinical expe-
rience suggests that there are some instances
in which open management is superior to
closed management, exact indications are
elusive. Long-term symptoms occur in most
patients with displaced calcaneal fractures
treated nonoperatively.51, 58 The severity of
these symptoms is related to the initial frac-
ture pattern and subsequent widened heel;
shortened lateral column; and incongruent,
stiff subtalar joint. Degenerative changes in
the tibiotalar joint are caused by the altered
position of the talus during weight-bearing
activities. Hindfoot pain and swelling are the
major manifestations.19, 52, 58, 76, 79 Early surgi-
cal attempts at improving the outcome after
calcaneal fractures met with a signicant inci-
dence of wound complications, particularly
sepsis. In these situations, the results of
operative treatment have led to worsened
outcomes than the natural history of the initial
injury58 and are supportive of nonoperative
management.
The ideal method of determining treat-
ment for any disease process is rst to study
prospectively the natural history, then to
compare this with the outcomes obtained in
a group of patients assigned randomly to a
specic treatment. The randomized controlled
trial, although ideal in theory, has several
problems when used in surgical situations. A
few of these problems include factors related
to the technical performance of the surgical
procedure, the learning curve,84 standardiza-
tion of the technique, anticipation of special
situations, and the experience of the partici-
pating surgeons. Specic problems related to
advanced trials of calcaneal fractures include
the lengthy follow-up needed, the ability to
generalize the results to the orthopedic com-
munity, obtaining statistical power, and the
validity of the outcome measurement tools. A
Canadian multicenter randomized controlled
clinical trial comparing operatively versus
nonoperatively managed displaced calcaneal
fractures is ongoing. Despite the problems
inherent to large randomized surgical tri-
als, these results should help substantially
in dening the indications and results of
operative treatment. As in most orthope-
dic literature, retrospective studies form
most opinions regarding calcaneal fracture
management. These include retrospective
cohort-matched studies,12 studies using CT to
classify the acute injury,24, 61, 84 CT assessment
after open treatment,43, 46, 90 and biomechan-
ical studies.3 The value of the prospective
studies that have been performed to date has
been limited by the small study populations,
surgeon-randomized allocations, relatively
short follow-up, and suboptimal postopera-
tive radiographic evaluation.74, 98 Variations in
surgical technique and other treatment param-
eters also make direct comparisons between
studies difcult.78
Together, these studies suggest several con-
cepts. Displaced fractures seem to have a
worse outcome than nondisplaced fractures.24
Increasing numbers of fracture lines and dis-
placement of the posterior facet typically are
the result of high-energy forces, and these frac-
tures have worse outcomes than those with
less involvement of the posterior facet.46, 76, 84
Anatomic restoration of the posterior facet
correlates with, but does not guarantee, a
good result.84 Obtaining an anatomic posterior
facet reduction becomes more difcult with
increased articular comminution. Posterior
facet incongruity and degeneration, as mea-
sured by CT scan, have been correlated with a
loss of subtalar motion and are strong predic-
tors of a poor clinical outcome.46 The clinical
importance of posterior facet congruity is
supported by biomechanical data. Specically,
articular incongruity alters contact stress pat-
terns across the posterior facet,3, 67 presumably
affecting cartilage wear and predisposing
to posterior facet arthrosis. The alteration in
subtalar mechanics with simulated injury to
the lesser facets has not been evaluated.
Other factors associated with long-term
patient dissatisfaction or painful sequelae
include calcaneobular abutment, peroneal
tendon irritation, sural nerve entrapment, heel

pad dysfunction, generalized swelling, and
hindfoot stiffness.44, 45, 58, 63 Maneuvers that
allow improved gait correlate with improved
clinical and functional scores.20, 51 Although
small numbers and multiple categories make
the conclusions more empirical than sci-
entic, these predominantly retrospective
studies suggest that treatments that diminish
swelling, improve posterior facet congruency
and subtalar motion, and decompress the
subbular area (narrow the heel) are likely to
lead to the best clinical outcome. In all studies,
however, only 15% to 20% of patients were
completely pain-free. This small percentage
suggests a need to identify sources of long-
term discomfort to improve the outcome of
this injury.46, 58, 61, 76, 79, 84, 85
Based on this historical information, indi-
cations for surgical treatment are an incon-
gruous subtalar joint with more than 2 mm
displacement; gross displacement of the heel,
particularly with subbular impingement; de-
pression of the talus into a horizontal posi-
tion; or bony pressure points likely to ulcer-
ate or give mechanical pain. The status of the
surrounding soft tissue envelope and the pa-
tients lifestyle and expectations further mod-
ify the decision-making process.
Contraindications to surgical treatment in-
clude peripheral vascular disease, peripheral
neuropathy, advanced age, sedentary lifestyle,
inadequate soft tissue envelope, and patient
unwillingness to proceed with unproven treat-
ment. All but the last of these items are relative
contraindications. Threatened soft tissues sec-
ondary to prominent displaced fracture frag-
ments may force intervention in patients with
peripheral neuropathy or vascular disease.
Under these circumstances, reduction may
salvage the signicantly jeopardized soft
tissue envelope. Age, sedentary lifestyle, and
occupation are relative criteria that should
be balanced against the degree of deformity
and likelihood of poor outcome from closed
treatment.
Surgical treatment logically addresses the
anatomic causes of patient dissatisfaction.
Restoring calcaneal height improves the tibio-
talar position and may diminish long-term
degeneration in the ankle. Reestablishment
of heel length may improve shoe comfort,
midtarsal mechanics, and the lever arm of the
gastrocnemius-soleus complex. Normalizing
calcaneal height and length necessarily nar-
rows the heel as the tuberosity is brought back
along the primary fracture line beneath and
posterior to the posterior facet.44 Reducing the
FRACTURES OF THE CALCANEUS 275
lateral wall blowout completes the subbular
decompression. Reduction of the articular
facet surfaces and accurate reestablishment
of the geometric relationships between the
3 superior calcaneal facets should minimize
the subtalar pain associated with the develop-
ment of arthrosis and stiffness. In situations
in which marked comminution of the poste-
rior facet precludes a satisfactory reduction,
restoration of extra-articular anatomy fol-
lowed by acute subtalar arthrodesis has been
advocated. Several authors have reported rea-
sonable success with this technique in limited
numbers.11, 37, 42, 70 Signicant controversy ex-
ists as to the most effective means of achieving
satisfactory patient outcomes after sustaining
a displaced, intra-articular calcaneal fracture.
Timing
Most calcaneal fractures are repaired sur-
gically in a delayed fashion to allow for the
initial swelling to resolve.85 Acute intervention
through the signicantly traumatized zone
has resulted in early wound breakdown and
complications.39 Most denitive interventions
can be performed between 7 and 10 days.
Injuries with associated marked edema and
fracture blisters may require delays of 2 to
3 weeks. In these situations, the application
of a foot pump has been shown to expedite
edema resolution and is well tolerated by
the patient.96 Reduction maneuvers become
increasingly difcult with the increased delay.
Delayed surgery in fractures with marked
shortening may decrease signicantly the
pliability of the anticipated lateral skin ap.
Particular attention to closure of this ap is
required.
Surgical Approach
Several surgical methods are available for
calcaneal fracture surgery, including mini-
mally invasive and open techniques. Modern
percutaneous reduction and screw xation
techniques are an extension of closed manipu-
lative reductions described by Essex-Lopresti
and are successful in properly chosen fracture
patterns (Fig. 8).99, 100 Minimal open proce-
dures combined with circular ring external
xation also have been described.75 These
techniques and others, such as the use of
bioabsorbable implants,49 currently are being
investigated.
Open calcaneal fracture surgery can be
performed using medial, lateral, or combined
276 BAREI et al

Figure 8. AF, This fracture was managed acutely with percutaneous techniques. Note that the ar-
ticular surface of the posterior facet is virtually intact. Strategic screw placement secures the major
fracture lines and early management facilitates reduction because of increased fracture mobility. AP =
anterior process; PF = posterior facet.
Illustration continued on opposite page

approaches.6, 14, 54, 64, 77, 92, 93 The medial ap-
proach described by McReynolds has the most
historical support.1316 The lateral approach
currently is the most popular. The advantage
of the medial approach is direct visualization
of the posteromedial extent of the primary
fracture line. The medial aspect of the cal-
caneus generally fails under shear forces,
producing less comminution than is found
laterally. Relatively sharp cortical margins
allow anatomic reduction of the tuberosity
to the sustentacular fragment, effectively
narrowing the heel. Visualization and reduc-
tion of depressed posterior facet fragments
cannot be performed from this vantage point.
Because of the slope of the medial wall and
its close relationship to the medial tendi-
nous and neurovascular stuctures, applica-
tion of rigid implants along this surface is dif-
cult (see Fig. 1E). The lateral approach allows
direct examination of the posterior, middle,
and calcaneocuboid joint surfaces, however.
Depressed fragments are accessed and el-
evated under direct vision, and the lateral
surface is suited best for application of rigid
xation. Satisfactory relationship between
the sustentacular and tuberosity fragments
is conrmed radiographically. Most complex

Figure 8 (Continued ).
calcaneal fractures can be addressed entirely
using the lateral approach.
The patient is given a satisfactory, usually
general, anesthetic and positioned in the true
lateral position with the operative side up.
Bony prominences are protected, and an ax-
illary roll is placed. The ipsilateral iliac crest
can be prepared and isolated in the event that
bone graft is needed. The table beneath the op-
erative limb is padded strategically to provide
a at, stable platform for the operation and for
obtaining intraoperative radiographs. A prox-
imal thigh tourniquet commonly is used, pro-
vided that no contraindications exist.
A lateral extensile exposure, popularized
by Benirschke and Sangeorzan6 and similar
to that suggested by Gould,36 is employed.
It differs from the classic lateral approach77
in that it has an acute curve distally instead
of following the peroneal tendons (Fig. 9).6,36
The vertical limb parallels the Achilles ten-
don and is posterior to the sural nerve. At the
transition between the lateral foot skin and
the specialized, thicker plantar skin, the in-
cision curves sharply, paralleling the plantar
surface of the calcaneus and extending across
the calcaneocuboid joint. At the apex of the
ap, the incision is carried directly to bone,
keeping a full-thickness ap of skin, subcu-
taneous tissue, and periosteum. The peroneal
FRACTURES OF THE CALCANEUS 277
tendons, sural nerve, and calcaneobular lig-
ament are left undisturbed and are reected
en masse in the ap. Subperiosteal elevation
is continued until the subtalar joint is seen.
Distally the calcaneocuboid joint is exposed.
When the calcaneus is exposed fully, gen-
tle retraction of the ap is performed by a
skilled assistant or, as an alternative, by insert-
ing Kirschner wires into the talus. The vas-
cularity of the ap is based on the peroneal
artery blood supply, which remains protected
within the substance of the ap.35 Some au-
thors recommend that the vertical limb should
run almost in the midline posteriorly to avoid
injury to the sural nerve and the terminal
branches of the peroneal artery. Clinical series
and anatomic dissections have supported this
recommendation.27, 35
Reduction
The thin lateral wall is reected outward,
exposing the comminuted posterior facet.
The anterior and lateral displacement of the
tuberosity fragment crowds the central por-
tion of the calcaneus, hampering attempts
at reducing the posterior facet. Accurate
reduction of the tuberosity relative to the sus-
tentacular fragment decompresses the central
278 BAREI et al

Figure 9. The classic (A) and lateral extensile (B) incisions are demon-
strated. Note that the classic incision follows the course of the peroneal
tendons beneath the bula (Fib). The lateral extensile incision has a
much sharper angle at the apex and the distal limb extends toward
the base of the fourth metatarsal. The vertical limb is placed near the
Achilles tendon to minimize complications with ap vascularity.

part of the calcaneus allowing the potential
space for posterior facet reduction. In a simple
fracture pattern in which there is no fracture
line separating the middle facet from the me-
dial part of the posterior facet, the tuberosity
initially is directed plantarward, medially
and out of varus. Posterior translation and
restoration of calcaneal pitch completes the
decompression. A 4.0-mm Schanz pin inserted
into the tuberosity provides direct control for
this reduction maneuver. After satisfactory re-
duction of the tuberosity fragment, 2 or more
0.062 inch Kirschner wires are placed from
the posterior plantar aspect of the tuberosity
into the anteromedial sustentacular fragment.
The direction of these Kirschner wires is from
posterior plantar to anterior dorsal with a
slight lateral-to-medial orientation. In more
comminuted fractures, the middle facet may
be separated from the medial part of the poste-
rior facet. This medial posterior facet fragment
may be driven beneath the middle facet and
remainder of the sustentaculum tali. This frac-
ture should be reduced rst and provisionally
held with Kirschner wires. The medial part of
the posterior facet is elevated until it is aligned
with the middle facet. This reduction requires
satisfactory visualization, which is difcult
without a headlamp and adequate retraction.
Anterior process fractures, particularly those
involving the calcaneocuboid joint, are re-
duced and provisionally held under direct
vision. Intraoperative axial and lateral views
are used to assess reduction of the tuberosity
and anterior process. Then the posterior facet
is reconstructed, typically by reducing the
central and lateral fragments to the stable me-
dial portion. Satisfactory reduction is ensured
under direct vision and by palpation using
a semicurved instrument, such as a small
periosteal elevator. Provisional Kirschner wire
xation is performed strategically in anticipa-
tion of denitive plate and screw placement.
A second set of intraoperative lateral and
axial radiographs conrms the adequacy of all
elements of reduction.
Several areas are available for optimal screw
xation (see Fig. 6C and D). These areas in-
clude the dense bone in the sustentaculum
tali, the thickened trabecular or thalamic bone
beneath the posterior facet, the cancellous
bone deep to the heel cord insertion, and the
bone of the dorsal half of the anterior process
near the calcaneocuboid joint. Numerous
implants are available for application along
the lateral calcaneal wall, including locking
screw/plate devices and multilimbed plates.
A pelvic reconstruction plate contoured into
a gentle arc, with the concavity plantarward,
is frequently sufcient. It is kept straight in
the sagittal plane creating a tensioned implant
that resists the inherent varus tendency of
the tuberosity. The most distal screw should
course just proximal to the calcaneocuboid

joint and be directed slightly cephalad to take
advantage of the thickened bone beneath the
anterior process. The most posterior screws
should be inserted into the tuberosity. The
posterior facet itself is secured with multiple
cortical lag screws directed slightly anteri-
orly toward the middle facet. Strategic and
safe screw placement has been described in
a laboratory model.48 Empowered posterior
facet xation is obtained with screws inserted
through the plate.57 Fixation with additional
screws, Kirschner wires, or plates may be
required in highly comminuted fractures
(see Fig. 7F and G). Fractures with multiple
small posterior facet fragments may be assem-
bled extracorporeally, held with 0.045-inch
Kirschner wires, then reduced to the remain-
ing intact articular surface. Multiple smaller
implants frequently are required to secure
these comminuted injuries denitively.
The indications for using bone graft are
controversial.85 Bone grafting commonly is
used in other periarticular injuries, particu-
larly those involving the tibial plafond and
tibial plateau. Its purpose is to act as an ad-
junctive supportive structure preventing col-
lapse of the elevated articular segments. As
with other articular fractures, the bone graft
should be used when the area beneath the
posterior facet is vacant and nonsupportive
or whenever enough bone is missing or im-
pacted that a buttress is needed.77 This situa-
tion is most likely to occur in high-energy in-
juries and in patients with poor bone density.
Despite the intuitive advantages, there has
been virtually no scientic support for the use
of bone graft in displaced intra-articular cal-
caneal fractures. Tufescu and Buckley102 com-
pared patients treated with and without sup-
plemental bone graft and, similar to other
authors,84 were unable to show any objec-
tive radiographic or functional benet to its
use in the open management of these frac-
tures. Injectable bone graft substitutes im-
prove the initial compressive strength of the
posterior facet reconstruction97 and may expe-
dite weight bearing86 ; whether this translates
into superior outcomes is unknown. The so-
called neutral triangle, an area beneath the an-
terior part of the posterior facet with minimal
bone density, experiences limited mechanical
strains and does not need bone grafting.
A small closed-suction drain is placed deep
to the ap and brought out anteriorly. Clo-
sure of the incision is performed in 2 layers to
decrease the incidence of wound dehiscence.1
The initial deep interrupted absorbable su-
ture should grasp periosteal tissue, giving a
FRACTURES OF THE CALCANEUS 279
secure closure when tied. Interrupted sutures
are placed beginning at the ends of the wound
and working toward the apex, advancing the
ap slightly with each stitch. Ultimately, this
technique minimizes tension at the apex of the
wound and distributes the tension in the ap
along the vertical and transverse limbs of the
incision. Then the skin is closed with a nylon
ap stitch.
Postoperative Management
Postoperatively the limb is splinted and el-
evated with the foot and ankle in the neu-
tral position for 72 hours. Drains are removed
24 to 48 hours after the operation. The pa-
tient may be up for limited periods for tri-
als of crutch walking. Range of motion of
the toes is encouraged. The detrimental effects
of cigarette smoking on wound and fracture
healing are reinforced.
Active range-of-motion exercises of the
foot and ankle are begun when the surgi-
cal incision is secure, typically within 3 to
5 days. The patient initially is supplied with
a removable, well-padded splint to minimize
gastrocnemius-soleus contracture and for
comfort. Sutures are removed 2 to 3 weeks
after surgery. Patients are tted with support
stockings as needed to control foot and ankle
edema and are encouraged to wear them for
at least 6 months after the operation. In gen-
eral, narcotic analgesics are discontinued 3 to
4 weeks after surgery.
Weight bearing on the affected extremity is
delayed for 8 to 12 weeks, depending on the
fracture pattern, degree of comminution, and
rigidity of xation. When the fracture is simple
and the fragments can be compressed with lag
screws, walking may be started earlier than
in fractures that depend on buttress plates to
maintain the reduced position. Active range-
of-motion exercises of the ankle and subtalar
joints are continued during this nonweight-
bearing period. Patients should perform much
of their physical therapy outside of supervised
therapy sessions. Patients with bilateral frac-
tures are conned to bed-to-chair activities for
12 weeks. Weight bearing is resumed accord-
ing to patient tolerance, and the patient usu-
ally is transitioned from a removable cast boot
to supportive cushioned shoes. The use of
ambulation aids is discontinued by 16 weeks.
After healing, patients are encouraged to use
shoes with a cushioned or shock-absorbing
sole. A custom orthotic insert also may be of
value.
280 BAREI et al
RESULTS
Assessing the results of displaced intra-
articular calcaneal fractures is difcult because
of the lack of standardized fracture classica-
tions, varying surgical techniques, differences
in radiographic measurements, and the
use of assorted validated and nonvalidated
outcome parameters. The data before the
common usage of CT scanning are particularly
ambiguous.85 A meta-analysis showed a ten-
dency toward return to previous employment,
lower risk of experiencing signicant foot
pain, and generally better overall outcomes
with operative management.80 Only 6 suitable
studies for analysis were identied in the
authors extensive literature search, empha-
sizing further the need for a large randomized
clinical trial to clarify the surgical care of these
fractures.
Accurate clinical assessment of subtalar mo-
tion is difcult, but motion is diminished
in most patients. Most studies describe an
approximate 50% decrease in subtalar range
of motion in operatively managed calcaneal
fractures.12, 43, 74 Of patients who worked at the
time of injury, 40% to 85% return to work
within 9 months. Individuals who work in
sedentary occupations seem to return to work
much sooner. Patients with bilateral calcaneal
fractures or other signicant injuries and pa-
tients who do heavy labor may take longer
to return to work and often change jobs. The
variability in timing and eventual return to
work depends in part on regional social, eco-
nomic, and cultural differences.
Numerous authors have attempted to
correlate clinical and radiographic param-
eters with outcomes. Data have suggested
that men, patients with multiple injuries,
and heavy laborers may have improved
outcomes with operative management.102
OFarrell et al74 found that operative xation
improved walking tolerance, improved sub-
talar motion, and returned patients to work
earlier. Good outcomes seem to be associated
with anatomic reduction, particularly of the
posterior facet.43, 46, 76, 84, 90, 98 Paley and Hall76
reported that subtalar incongruity, talonavic-
ular or ankle arthrosis, increased heel width,
Figure 10. This calcaneal fracture was the result of a motor vehicle collision. The hindfoot was grossly
distorted and an open wound with visible bone was present on its medial aspect. AC, Radiographic
investigations, particularly the axial plain and CT images, identify the sustentacular (ST) fragment and
its distal extent ( white arrows ) as the cause. D and E, Irrigation and debridement followed by delayed
denitive reduction and xation demonstrate adequate restoration of the anatomy, and also allow heal-
ing of the medial traumatic wound.
and bulocalcaneal impingement are associ-
ated with a poor outcome. In this same study,
heel height, heel pad height, and a shortened
gastrocnemius-soleus lever arm were not
related to outcome. Many authors believe that
restoration of Bohlers angle correlates with
a better outcome.21, 41, 51, 58, 59, 76, 85 Others have
not found this correlation.43, 46 Tongue-type
fractures may have a better outcome than joint
depression injuries.72 Laboratory studies indi-
cate that there may be an anatomic rationale
for this.29
Most patients either return to previous shoe
wear or use a shoe with a shock-absorbing
sole. Thirty percent of patients signicantly
modify their activity and change to a more
sedentary occupation. Recreational pursuits
often are modied. Patients followed for more
than 2 years noted continued improvement
in subtalar symptoms and seemed to have
durable results.55, 65 A subgroup of patients,
presumed to be those with severely injured
subtalar joints, may not experience this im-
provement and have continued pain.
COMPLICATIONS
Compartmental syndromes are reported to
occur in 10% of displaced calcaneal fractures.68
Prompt diagnosis and surgical release, partic-
ularly of the quadratus plantae compartment,
located on the plantar-medial aspect of the
foot, minimize the sequelae of clawed toes and
painful nerve dysfunction.62, 66, 68 Open frac-
tures secondary to blunt trauma are infre-
quent. In these situations, the open wounds
are typically on the medial aspect of the foot
and are invariably the result of penetration
from the sustentacular fragment. Treatment
consists of wound debridement and irriga-
tion, followed by provisional closed or percu-
taneous reduction to restore general alignment
and remove soft tissue tension on the injured
medial soft tissue envelope. Denitive xation
can proceed in the usual fashion when the
overall swelling has decreased (Fig. 10).
Major and minor complications attributable
to open reduction and internal xation
through a lateral approach are found in
Figure 10. See legend on opposite page
281
282 BAREI et al
10% to 20% of patients. These include infec-
tion, wound healing problems, sural nerve
symptoms, and failure to achieve reduction.
Using the standard lateral approach, the
reported infection rate is 2% to 3%.7, 72 In most
cases, the infection can be controlled with
suppressive antibiotics until fracture union.
Removal of xation and bony debridement
are performed when union is ensured. Wound
complications, particularly delayed healing
and marginal skin ap necrosis, occur in 8%
to 9%. When calcaneal length and height are
restored during surgery, increased tension
at the apex of the incision may contribute to
these wound complications. The number of
wounds that develop marginal skin loss at
the apex of the incision has diminished since
the more gently curving classic approach has
been modied to include a sharper curve; this
is presumably because tension is avoided at
the corner of the wound, and undermining
of the skin is not needed when applying the
plate through the modied incision. Further
understanding of the vascular supply of the
ap also may contribute to the decreased
wound complications. Smoking, diabetes, and
open fractures all are independent risk fac-
tors for wound complications after open re-
duction and have a cumulative effect.1, 34
Patients with one or more of these risk factors
should be counseled regarding their increased
relative risk of wound complications, and the
decision regarding operative versus nonoper-
ative management should be reassessed.
Sural nerve symptoms occur in a few pa-
tients and resolve within a few months in
most. The incidence of sural nerve symptoms
seems to have lessened with the use of the ex-
tended lateral incision.25 Patients who present
with neurapraxia of the tibial nerve usually
have return of nerve function by 8 months.
Most mild nerve symptoms resolve soon after
surgery when the shape of the foot is restored.
Long-term tibial nerve symptoms may per-
sist and require tarsal tunnel release and tib-
ial nerve exploration.69 Care should be taken
to exclude regional pain syndromes. Pain sec-
ondary to posterior facet arthrosis responds
well to subtalar arthrodesis.2, 33, 70, 95 Correction
of residual malalignment optimizes the end
result.
SUMMARY
The ideal treatment for calcaneal fractures
is unknown. The natural history of displaced
calcaneal fractures is unfavorable. Compared
with other intra-articular fractures of the
lower extremity treated by contemporary
techniques, the results are not nearly as pre-
dictable. For fractures with signicant intra-
articular displacement, subbular abutment,
anterior ankle impingement, pressure points,
or difculty in shoe tting, open reduction
may be appropriate. A careful lateral extensile
approach allows reduction and xation of
all of the key elements of the fracture with
sufcient rigidity to allow early motion. The
morbidity of open calcaneal treatment when
performed by experienced fracture surgeons is
comparable to that of other complex fractures.
ACKNOWLEDGMENT
The authors gratefully acknowledge the invaluable
contributions of Ms. Jane Younge in preparing the gures
for this article.
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Address reprint requests to
David P. Barei, MD, FRCS(C)
Department of Orthopaedic Surgery
Harborview Medical Center
Box 359798
325 Ninth Avenue
Seattle, WA 98104