Multidisciplinary Approach to Trauma 9781685079154, 1685079156

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Emergency and Intensive Care Medicine

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Mehmet Cenk Turgut, MD and Asli Turgut, MD Editors

Multidisciplinary Approach to Trauma

Copyright © 2022 by Nova Science Publishers, Inc. DOI: https://doi.org/10.52305/INJJ1614 All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. We have partnered with Copyright Clearance Center to make it easy for you to obtain permissions to reuse content from this publication. Simply navigate to this publication’s page on Nova’s website and locate the “Get Permission” button below the title description. This button is linked directly to the title’s permission page on copyright.com. Alternatively, you can visit copyright.com and search by title, ISBN, or ISSN. For further questions about using the service on copyright.com, please contact: Copyright Clearance Center Phone: +1-(978) 750-8400 Fax: +1-(978) 750-4470

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NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the Publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Additional color graphics may be available in the e-book version of this book.

Library of Congress Cataloging-in-Publication Data

ISBN: H%RRN

Published by Nova Science Publishers, Inc. † New York

Contents

Preface

...................................................................................................................... ix

Chapter 1

Clavicle Fractures, Scapula Fractures and Acromioclavicular Joint Injuries ........................................................ 1 Erdem Sahin

Chapter 2

Glenoid Fractures and Shoulder Dislocation .......................................... 11 Mehmed Nuri Tütüncü

Chapter 3

Proximal Humerus Fractures ................................................................... 23 Halit Cengiz

Chapter 4

Humeral Shaft Fractures .......................................................................... 33 M. Fatih Uzun

Chapter 5

Distal Radius Fractures ............................................................................. 43 Özkan Öztürk

Chapter 6

Forearm Fractures ..................................................................................... 55 Nasuhi Altay

Chapter 7

Hand Fractures (Carpal, Metacarpal and Phalanx Fractures) ............. 63 Ali İhsan Tuğrul

Chapter 8

Distal Humerus Fractures ......................................................................... 81 Orkun Halaç

Chapter 9

Proximal Radius and Ulna Fractures....................................................... 93 Oktay Polat

Chapter 10

Supracondylar Humerus Fractures in Children ................................... 101 Ferhan Bozkurt

Chapter 11

Acetabular Fractures ............................................................................... 113 Alperen Zeynel and Mehmet Cenk Turgut

Chapter 12

Femoral Neck Fractures .......................................................................... 121 Mustafa Caner Okkaoglu

Chapter 13

Femur Shaft Fractures ............................................................................ 137 Eyüp Şenocak

Chapter 14

Patella Fracture........................................................................................ 145 Anar Alakbarov

vi

Contents

Chapter 15

Tibial Plateau Fractures .......................................................................... 165 Tural Khalilov

Chapter 16

Tibial Shaft Fractures.............................................................................. 173 Khalid Bunyatov

Chapter 17

Tibial Pilon Fractures .............................................................................. 181 Ahmed Heydar

Chapter 18

Ankle Fractures........................................................................................ 193 Serdar Toy

Chapter 19

Fractures and Dislocations of the Foot................................................... 201 Mehmet Demir

Chapter 20

Lisfranc Injury ......................................................................................... 211 Samir Ilgaroğlu Zeynalov

Chapter 21

Calcaneus Fractures ................................................................................ 225 Ahmed Arif Uzun

Chapter 22

Antibiotic Prophylaxia in Orthopedic Trauma ..................................... 237 Esmeray Mutlu Yilmaz

Chapter 23

Traumatic Brain Injury: Epidemiology, Classification and Pathophysiology .............................. 247 Burcu Bulut Okay

Chapter 24

Approach to Ocular Traumas................................................................. 251 Mehmet Tahir Eski

Chapter 25

Damage Control Surgery ........................................................................ 267 Ahmet Burak Çiftci

Chapter 26

Are Some Trauma-Related Findings Actually Signs of Genetic Diseases? ................................................................................. 275 Çiğdem Yüce Kahraman

Chapter 27

Animal Bites ............................................................................................. 281 Abdulkerim Olgun

Chapter 28

Diagnosis and Treatment of Pathological Femur Fractures ................ 291 Natig Valiyev

Chapter 29

Diagnosis and Treatment of Pathological Humerus Fractures ............ 305 Ali Erkan Yenigül

Chapter 30

Peripheral Nerve Traumas...................................................................... 313 Gülay Soykök

Chapter 31

Trauma Radiology (Radiography and Ultrasound).............................. 323 Vusala Garayeva

Chapter 32

Pediatric Forearm Fractures .................................................................. 345 Kayahan Karaytug and Natig Valiyev

Contents

vii

Chapter 33

Electromyography in Peripheral Nerve Injuries .................................. 355 Suna Dagli Atalay

Chapter 34

Approach to Burn Trauma ..................................................................... 365 Ahmet Sarac

Chapter 35

Nasal Fractures ........................................................................................ 375 Asude Ünal, Dursun Mehmet Mehel and Ayşe Çeçen

Chapter 36

Temporal Bone Fractures and Treatment ............................................. 383 Ayşe Çeçen, Dursun Mehmet Mehel and Asude Ünal

Chapter 37

Chest Traumas in Pediatric Patients ...................................................... 393 Serap Samut Bülbül

Editors’ Contact Information ............................................................................................ 401 Index

................................................................................................................... 403

Preface

Trauma is a health problem that causes death or serious disability worldwide and is the leading cause of death in healthy young adults aged 1-44 years. The most common causes of trauma are traffic accidents, falls from height, and gunshot wounds. Approximately 50% of deaths in accidents occur within seconds and minutes. During this period, deaths occur due to laceration of the brain, brain stem, spinal cord, heart, aorta and great vessels. About 30% of deaths occur within minutes and the first few hours (the golden hour) after injury. Deaths occur during this period due to epidural or subdural hemorrhages, hemopneumothorax, splenic rupture, liver laceration, pelvic fractures, or other injuries that cause significant blood loss. The hours when the health personnel working in the emergency departments or ambulances can be most helpful to the patients are those who are brought in during the golden hour. For this reason, it is essential to know the approach to trauma as holistic and to conduct research on this subject.

Chapter 1

Clavicle Fractures, Scapula Fractures and Acromioclavicular Joint Injuries Erdem Sahin, MD Department of Orthopedics and Traumatology, Health Sciences University Erzurum Regional Training and Research Hospital, Erzurum, Turkey

Abstract Clavicle fractures, scapula fractures and acromioclavicular joint injuries occur as a result of low or high energy traumas. Treatments can be conservative or surgical. After treatment, patients generally continue their lives without any sequelae.

Clavicle Fractures Introduction The clavicle is an “S” shaped bone between the sternum and acromion, connecting the upper extremity to the trunk. The clavicle transfers all the force on the upper extremity to the whole body because it connects the two. Clavicle fractures are common due to both the above mechanism and its subcutaneous location in the anterior of the body. Therefore, it is directly exposed to trauma. Anatomically, the clavicle consists of three parts: medial, middle, and lateral. The medial part is broad and protects the underlying neurovascular structures, such as the subclavian artery and vein and the brachial plexus. The middle part acts as a bridge between the medial and lateral parts. The lateral part has various ligament complexes that carry the shoulder and contribute to the stability of the shoulder joint.



Corresponding Author’s Email: [email protected].

In: Multidisciplinary Approach to Trauma Editors: Mehmet Cenk Turgut and Asli Turgut ISBN: 978-1-68507-761-7 © 2022 Nova Science Publishers, Inc.

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Epidemiology Clavicle fractures are most common in the younger population. They account for 2-4% of adult fractures and 35% of shoulder circumference fractures (Canadian Orthopedic Trauma Society, 2007). The middle, lateral, and medial fractures account for 69%-81%, 28%, and 2-3% of all clavicle fractures, respectively (Robinson, 1998).

Etiology Clavicle fractures may be due to low-energy traumas (e.g., simple falls) or high-energy traumas (e.g., car accidents). They may also occur as a result of shoulder dystocia, instrument use, or specialized maneuvering in newborns.

Diagnosis Anterior-posterior (AP) radiography is the first-line imaging method and often sufficient for diagnosis. However, in the case of lateral fractures, physicians should request 20 cephalic angle imaging in addition to AP X-ray in order to figure out the fracture displacement. The “Serendipity” view (40 cephalic angle) provides more information about fracture fixation and displacement in medial fractures. Computed tomography (CT) imaging is the best diagnostic tool for evaluating joint involvement in medial and lateral fractures.

Fracture Classification The classification of a clavicle fracture depends on its anatomical location. According to Allman’s classification (1967), Type I fractures are middle third clavicle fractures between the coracoclavicular ligament and the sternocleidomastoid muscle; Type II fractures are one-third fractures lateral to the coracoclavicular ligament; and Type III fractures involve the one-third clavicle medial to the sternocleidomastoid muscle. The lateral one-third fractures have a high rate of nonunion. Therefore, Neer classifies fractures according to the degree of ligament injury and displacement of the fracture in that region (Neer, 1963).

Treatment Conservative treatment is the first option for childhood clavicle fractures. The conservative option for a newborn clavicle fracture is either no treatment (if the infant is not restless) or pinning the infant’s sleeve of the affected arm to the front of their clothing for 2-3 weeks (if the infant is restless). Conservative treatment is often the option for middle third clavicle fractures. The Figure8 bandaging technique or shoulder-arm slings applied for 1-4 weeks are generally the treatment of choice for non-displaced fractures. A tight Figure-8 bandage can cause skin lesions, thrombosis, and temporary paralysis of the brachial plexus (Lenza et al., 2014).

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Research in recent years has reported a nonunion rate of 5.9% and 15% in non-displaced and displaced fractures, respectively (van der Meijden et al., 2012). A shortening of more than 1.5-2 cm or a displacement of more than 100% results in unsatisfactory clinical outcomes in patients undergoing conservative treatment (McKee et al., 2012). Comminuted and displaced fractures and tobacco use are associated with a high nonunion rate (Robinson et al., 2004). Surgical treatment has become popular in recent years because it results in an early return to work in the active population, high union rates in shaft fractures, and better functional outcomes in the short term (Woltz et al., 2017). Table 1. Indications for surgical treatment in middle third clavicle fractures Fracture specific Slipping and/or shortening > 2 cm Number of shatters > 3 Segmentary fractures Fractures threatening the open or soft tissue Marked malposition and winging of the scapula on initial examination Malunion or nonunion resulting in clinical findings Fracture-related injuries Vascular injuries requiring repair Progressive neurological deficit Ipsilateral upper extremity fractures Multiple ipsilateral rib fractures Floating shoulder Bilateral clavicle fractures Patient-related factors Multiple injuries requiring weight-bearing and early use of the arm The patient’s desire to return to previous activity

Figure 1. Preoperative (1) and postoperative (2) views of a patient operated with plate-screw osteosynthesis for a middle third clavicle fracture.

Plate-screw osteosynthesis and intramedullary fixation have become the most popular surgical options in recent years (Frima, 2019). Plate-screw osteosynthesis is the most common surgical treatment for middle third clavicle fractures with the best clinical outcomes. Plate-

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screw osteosynthesis provides a more stable fixation and prevents shortening and rotation in comminuted fractures better than an intramedullary rod. However, plate-screw osteosynthesis may cause infections, nonunion, implant failure, and cosmetic problems (Delvaque et al., 2019). Intramedullary nailing is applied in different forms, ranging from Kirschner wire to elastic stable intramedullary nailing (ESIN) (Zlowodzki et al., 2005). These forms are more suitable for short oblique and transverse fractures. They may cause implant failure, skin problems due to implant prominence at the entry site, and nail displacement (van der Meijden et al., 2015). Conservative treatment is the standard option for medial third clavicle fractures because most of them are non-displaced (Salipas et al., 2016). The prevalence of nonunion among nondisplaced and displaced fractures after treatment is 7% and 14-20%, respectively. The surgical treatment indications are the degree of fracture displacement greater than the width of the shaft, open fractures, displaced intra-articular fractures, and neurovascular injury accompanying the fracture. Of lateral clavicle fractures, stable fractures (Neer Type-1 and Type-3) and non-displaced fractures medial to the coracoclavicular (CC) ligament are treated conservatively. Surgical treatment is recommended for Neer Type-2a, Type-2b, and Type-5 unstable fractures (Oh et al., 2011). Plate-screw systems are recommended for fractures with sufficient lateral bone stock, whereas CC fixation methods (e.g., cortical buttons) are recommended for comminuted fractures with insufficient bone stock. After the patient undergoes surgical treatment for a clavicle fracture, the physician places the arm in the shoulder-arm sling and allows the patient to make pendulum movements. The physician removes the shoulder-arm sling in the second week. The patient starts active exercises in such a way that the shoulder elevation does not exceed 90 degrees. If the patient shows clinical and radiological improvement at the end of the sixth week, she starts performing strengthening exercises. The physician allows the patient to return to sports after four to six months (Wiesel et al., 2018).

Scapula Fractures Introduction The scapula is a triangle-like bone that contains glenoid, acromion, and coracoid structures. It connects the upper extremity to the axial skeleton (Bartoníček, 2015). Scapula fractures are rare because strong muscle structures protect the scapula. Extra-articular scapular fractures are scapular neck and shaft, spina scapula, acromion, and coracoid process fractures. The most common extra-articular fractures are neck and shaft fractures (Herscovici et al., 2006).

Epidemiology Scapula fractures are uncommon injuries that account for less than 1% of total fractures and about 3-5% of all shoulder girdle fractures (Cole, 2002). Scapula fractures generally occur due

Clavicle Fractures, Scapula Fractures and Acromioclavicular Joint Injuries

5

to high-energy traumas. Therefore, they are sometimes accompanied by ipsilateral extremity injuries, thoracic injuries, head injuries, and spinal fractures (Cole et al., 2012).

Etiology Scapula fractures often occur due to high-energy traumas (car accidents, falling from a height, etc.). Glenoid or acromion fractures may also occur indirectly when the humeral head hits the glenoid or acromion due to falling on the flexed elbow. Sudden contractions of the long head of the triceps attached to the lower edge of the glenoid and the short head of the biceps attached to the coracoid may also cause avulsion fractures in those regions.

Diagnosis A thorax anteroposterior view is the first imaging option for the diagnosis of scapula fractures. In addition to thorax AP views, physicians can use scapula Y-ray, axillary views (glenoid fractures), or Stryker notch views (coracoid fractures) to make a more detailed examination. Computed tomography (CT) imaging also helps physicians to examine fractures and detect accompanying pathologies.

Fracture Classification The classification of scapula fractures depends on their anatomical location. They are classified as shaft fractures, spina fractures, glenoid fractures, acromion fractures, and coracoid fractures. Scapula shaft fractures are the most common, followed by neck fractures and coracoid fractures.

Figure 2. Preoperative (1) and postoperative (2) views of a patient operated with plate-screw osteosynthesis for a scapula fracture.

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Erdem Sahin

Treatment Scapula fractures are generally treated conservatively. The physician fixes the fracture for 3-4 weeks with a Velpeau bandage or shoulder-arm sling. Then, the patient begins to perform exercises to maintain the range of motion of the shoulder joint. The surgical treatment indications are accompanying ipsilateral clavicle fractures, displaced coracoid fractures, open fractures, neurovascular injuries, scapulothoracic dissociation, glenoid lip fractures causing shoulder subluxation or instability, and glenoid cavity fractures with a displacement of more than 5 mm. A patient with a scapula fracture uses a shoulder-arm sling for three weeks after surgical treatment. She starts performing active finger, wrist, and elbow movements as soon as the pain subsides. She performs passive shoulder movements in the second week and active movement and strengthening exercises in the sixth week.

Acromioclavicular Joint Injuries Introduction The acromioclavicular joint (AC) contributes to the wide range of motion of the shoulder joint. The joint capsule, AC ligaments, and coracoclavicular (CC) ligaments provide AC joint stability (Mazzocca et al., 2007).

Epidemiology Physicians sometimes overlook AC joint dislocations, which account for 12% of all shoulder girdle dislocations (Li et al., 2014).

Etiology Acromioclavicular joint injuries are often caused by falling on the shoulder while the arm is adducted (Fukuda et al., 1986). The force applied to the shoulder as a result of direct trauma pushes the acromion medially and downward. If a fracture does not occur, the force first stretches the AC ligaments and then results in a tear. The continuing force stretches the CC ligaments, causing the tearing of the deltoid and trapezius muscles and eventually tearing the CC ligaments.

Diagnosis Physical examination reveals deformity, often with swelling, tenderness, and sometimes crepitation of the AC joint. Acromioclavicular joint injuries are diagnosed clinically.

Clavicle Fractures, Scapula Fractures and Acromioclavicular Joint Injuries

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The acromioclavicular joint is generally intertwined. Therefore, physicians may sometimes overlook minor fractures on shoulder X-rays. As a standard, the Zanca view with a 15° cephalic angle is sufficient for imaging the AC joint (Zanca, 1971). Physicians prefer stress viewing less because it is painful and has little prognostic value (Bossart et al., 1988).

Classification of AC Joint Injuries Rockwood improved Tossy et al.’s original classification and made it popular (Williams et al., 1989). Table 2. Rockwood classification of acromioclavicular joint injuries Type 1: Sprain of the AC joint capsule. No radiological finding. Type 2: Rupture of the AC joint capsule with a possible sprain of the CC ligaments. Minimal dissociation radiologically. Type 3: Complete rupture of the joint capsule and the CC ligaments. Less than 100% dislocation at CC distance. Type 4: Tear in the deltotrapezial fascia with the AC and CC ligaments. Clavicle displaced posteriorly into or over the trapezius muscle. Type 5: All soft tissues torn in the distal clavicle. Dislocation of > 100% at CC distance. Type 6: The distal clavicle projects towards the subcoracoid and subacromial regions.

Treatment The treatment of Type 1 and 2 injuries involves resting, ice compression, analgesics, fixation, and early joint exercises. The treatment of Type 3 injuries is a moot point. Some recommend surgical treatment, while others recommend conservative treatment. However, both approaches have good clinical outcomes. Type 4, 5, and 6 injuries require surgical repair.

Figure 3. Comparative shoulder view (1), shoulder AP view (2), and post-fixation (button technique) view (3) of a patient with a Type 5 AC joint injury according to the Rockwood classification.

Patients treated conservatively for AC joint injuries use shoulder-arm slings for 1-2 weeks, depending on the severity of the injury. Afterward, they undergo an early and progressive rehabilitation program. They should avoid doing contact sports and lifting heavy weights for 2-3 months before the ligaments fully heal (Mazzocca et al., 2007).

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Surgical treatment includes AC fixation, CC fixation, and CC ligament reconstruction. Patients treated surgically for AC joint injuries use shoulder-arm slings for six weeks after surgery. They start making joint movements gradually and reach a full range of motion by the end of the third month. They then move on to strengthening exercises. They can do sports or heavy work at the end of the 6th month (Cook J.B., Krul K.P., 2018).

Conclusion Clavicle fractures, scapula fractures and acromioclavicular joint injuries occur as a result of low- or high-energy traumas. Treatments can be conservative or surgical. Individual treatment protocols should be applied for the patient. After treatment, patients generally continue their lives without any sequelae.

References Allman F. L., Jr (1967). Fractures and ligamentous injuries of the clavicle and its articulation. The Journal of bone and joint surgery. American volume, 49(4), 774–784. Bartoníček, J., Tuček, M., & Naňka, O. (2015). Zlomeniny lopatky [Scapular fractures]. Rozhledy v chirurgii: mesicnik Ceskoslovenske chirurgicke spolecnosti, 94(10), 393–404. Bossart, P. J., Joyce, S. M., Manaster, B. J., & Packer, S. M. (1988). Lack of efficacy of ‘weighted’ radiographs in diagnosing acute acromioclavicular separation. Annals of emergency medicine, 17(1), 20–24. https://doi.org/10.1016/s0196-0644(88)80497-9. Canadian Orthopaedic Trauma Society (2007). Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. The Journal of bone and joint surgery. American volume, 89(1), 1–10. https://doi.org/10.2106/JBJS.F.00020. Cole P. A. (2002). Scapula fractures. The Orthopedic clinics of North America, 33(1), 1–vii. https://doi.org/ 10.1016/s0030-5898(03)00069-5. Cole, P. A., Gauger, E. M., & Schroder, L. K. (2012). Management of scapular fractures. The Journal of the American Academy of Orthopaedic Surgeons, 20(3), 130–141. https://doi.org/10.5435/JAAOS-20-03130. Cook, J. B., & Krul, K. P. (2018). Challenges in Treating Acromioclavicular Separations: Current Concepts. The Journal of the American Academy of Orthopaedic Surgeons, 26(19), 669–677. https://doi.org/ 10.5435/JAAOS-D-16-00776. Delvaque, J. G., Bégué, T., Villain, B., Mebtouche, N., & Aurégan, J. C. (2019). Surgical treatment of midshaft clavicle fractures by minimally invasive internal fixation facilitated by intra-operative external fixation: A preliminary study. Orthopaedics & traumatology, surgery & research : OTSR, 105(5), 847– 852. https://doi.org/10.1016/j.otsr.2019.01.022. Frima, H., van Heijl, M., Michelitsch, C., van der Meijden, O., Beeres, F., Houwert, R. M., & Sommer, C. (2020). Clavicle fractures in adults; current concepts. European journal of trauma and emergency surgery: official publication of the European Trauma Society, 46(3), 519–529. https://doi.org/10.1007/s00068-01901122-4. Fukuda, K., Craig, E. V., An, K. N., Cofield, R. H., & Chao, E. Y. (1986). Biomechanical study of the ligamentous system of the acromioclavicular joint. The Journal of bone and joint surgery. American volume, 68(3), 434–440. Herscovici, D., Jr, & Roberts, C. S. (2006). Scapula fractures: to fix or not to fix? Journal of orthopaedic trauma, 20(3), 227–229. https://doi.org/10.1097/00005131-200603000-00012.

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Lenza, M., Belloti, J. C., Andriolo, R. B., & Faloppa, F. (2014). Conservative interventions for treating middle third clavicle fractures in adolescents and adults. The Cochrane database of systematic reviews, (5), CD007121. https://doi.org/10.1002/14651858.CD007121.pub3. Li, X., Ma, R., Bedi, A., Dines, D. M., Altchek, D. W., & Dines, J. S. (2014). Management of acromioclavicular joint injuries. The Journal of bone and joint surgery. American volume, 96(1), 73–84. https://doi.org/ 10.2106/JBJS.L.00734. Mazzocca, A. D., Arciero, R. A., & Bicos, J. (2007). Evaluation and treatment of acromioclavicular joint injuries. The American journal of sports medicine, 35(2), 316–329. https://doi.org/10.1177/03635 46506298022 McKee R. C., Whelan D. B., Schemitsch E. H., McKee M. D. Operative versus nonoperative care of displaced midshaft clavicular fractures: A meta-analysis of randomized clinical trials. J. Bone Joint Surg. Am. 2012;94:675-684. Neer C. S., 2nd (1963). Fracture of the distal clavicle with detachment of the coracoclavicular ligaments in adults. The Journal of trauma, 3, 99–110. https://doi.org/10.1097/00005373-196303000-00001. Oh, J. H., Kim, S. H., Lee, J. H., Shin, S. H., & Gong, H. S. (2011). Treatment of distal clavicle fracture: a systematic review of treatment modalities in 425 fractures. Archives of orthopaedic and trauma surgery, 131(4), 525–533. https://doi.org/10.1007/s00402-010-1196-y. Robinson C. M. (1998). Fractures of the clavicle in the adult. Epidemiology and classification. The Journal of bone and joint surgery. British volume, 80(3), 476–484. https://doi.org/10.1302/0301-620x.80b3.8079. Robinson, C. M., Court-Brown, C. M., McQueen, M. M., & Wakefield, A. E. (2004). Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. The Journal of bone and joint surgery. American volume, 86(7), 1359–1365. https://doi.org/10.2106/00004623-200407000-00002. Salipas, A., Kimmel, L. A., Edwards, E. R., Rakhra, S., & Moaveni, A. K. (2016). Natural history of medial clavicle fractures. Injury, 47(10), 2235–2239. https://doi.org/10.1016/j.injury.2016.06.011. van der Meijden, O. A., Gaskill, T. R., & Millett, P. J. (2012). Treatment of clavicle fractures: current concepts review. Journal of shoulder and elbow surgery, 21(3), 423–429. https://doi.org/10.1016/j.jse.2011.08.053. van der Meijden, O. A., Houwert, R. M., Hulsmans, M., Wijdicks, F. J., Dijkgraaf, M. G., Meylaerts, S. A., Hammacher, E. R., Verhofstad, M. H., & Verleisdonk, E. J. (2015). Operative treatment of dislocated midshaft clavicular fractures: plate or intramedullary nail fixation? A randomized controlled trial. The Journal of bone and joint surgery. American volume, 97(8), 613–619. https://doi.org/10.2106/JBJS. N.00449. Wiesel, B., Nagda, S., Mehta, S., & Churchill, R. (2018). Management of Midshaft Clavicle Fractures in Adults. The Journal of the American Academy of Orthopaedic Surgeons, 26(22), e468–e476. https://doi.org/10.5435/JAAOS-D-17-00442. Williams G, Nguyen V, Rockwood C. (1989) Classification and radiographic analysis of acromioclavicular dislocations. Appl Radiol, 18:29-34. Woltz, S., Krijnen, P., & Schipper, I. B. (2017). Plate Fixation Versus Nonoperative Treatment for Displaced Midshaft Clavicular Fractures: A Meta-Analysis of Randomized Controlled Trials. The Journal of bone and joint surgery. American volume, 99(12), 1051–1057. https://doi.org/10.2106/JBJS.16.01068. Zanca P. (1971). Shoulder pain: involvement of the acromioclavicular joint. (Analysis of 1,000 cases). The American journal of roentgenology, radium therapy, and nuclear medicine, 112(3), 493–506. https://doi.org/10.2214/ajr.112.3.493.

Chapter 2

Glenoid Fractures and Shoulder Dislocation Mehmed Nuri Tütüncü, MD Department of Orthopedics and Traumatology, Kars Harakani State Hospital, Kars, Turkey

Abstract Glenoid fractures are generally considered to be rare fractures with a reported frequency of less than 1%. Glenoid rim fractures and avulsion fractures are more commonly encountered after shoulder dislocations, while glenoid fossa fractures generally occur with high-energy trauma. In addition to plain radiography, computed tomography should also be included in radiological examination. The degree of fracture displacement, the presence of instability, and the size of the fracture fragment are important parameters to be considered for surgical treatment options. Ideberg and AO/OTA systems are frequently used for the classification of glenoid fractures. Surgical treatment outcomes are successful, especially with carefully selected patient groups. The shoulder joint is the most commonly dislocated structure in the whole body, shoulder dislocations roughly constituting 45% of all dislocations. Trauma is the most common etiology for dislocation, however, 4% of shoulder dislocations may develop following atraumatic events. The recommended treatment modality is immediate reduction, nevertheless, additional injuries may be detected afterward. A thorough neurovascular assessment should be completed before and after the reduction. The development of instability after a shoulder dislocation is a frequent problem. The patient’s age at the time of the first dislocation, additional injuries, and athletic activity are important factors leading to development of instability. Choice of treatment is still controversial. Surgery may be preferred following the first dislocation in young adults who participate in contact sports, while conservative treatment is favored in sedentary patients over 40 years of age.

Introduction Upper extremity function relies on shoulder joint movement, and in this respect, maintaining many vital activities such as nutrition, personal care, and gross / fine motor activities requires 

Corresponding Author’s Email: [email protected].

In: Multidisciplinary Approach to Trauma Editors: Mehmet Cenk Turgut and Asli Turgut ISBN: 978-1-68507-761-7 © 2022 Nova Science Publishers, Inc.

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a healthy shoulder movement. The shoulder joint is the most mobile joint; therefore, the risk of injury and instability is also quite high (Habermeyer et al., 1999). Shoulder dislocations account for 45% of all dislocations (Kirkley et al., 2005). The glenohumeral joint is a ball-and-socket type of joint located between the humeral head and the glenoid on the lateral surface of the scapula. The humeral head is approximately 30 degrees retroverted relative to the trans-epicondylar line. The superior inclination of the humeral head relative to the humeral diaphysis is 130-150 degrees (Boileau and Walch, 1997). The glenoid cavity which is the scapular structure that articulates with the humerus, is pearshaped and has 5 degrees of retroversion relative to the scapular axis. However, the normal glenoid version has been reported to vary between 10 degrees of anteversion and 7 degrees of retroversion. The glenoid also has a superior inclination of 5-15 degrees (Gregory et al., 2005). For the shoulder to function ideally, a balance between stability and mobility must be achieved. Dynamic and static stabilizers of the glenohumeral joint maintain this balance. The glenoid version, intra-articular negative pressure, labrum, and glenohumeral ligaments can be listed as static stabilizers. Periscapular muscles such as rotator cuff muscles, levator scapula, trapezius, rhomboids, serratus anterior, and biceps are considered as dynamic stabilizers (Witney-Lagen and Hunter, 2019). Glenoid fractures, similar to other scapular fractures, are rare (Owens and Goss, 2004). High-energy trauma and shoulder dislocations are the main causes of glenoid fracture. While high-energy traumas lead to glenoid fossa, neck, and accompanying scapular fractures; shoulder dislocations generally account for glenoid rim fractures (Kelly et al., 2019).

Glenoid Fractures Epidemiology While glenoid fractures constitute approximately 20% of scapular fractures, they account for less than 1% of all fractures (van Oostveen et al., 2014). Glenoid rim and avulsion fractures— usually encountered following shoulder dislocations—are more common than glenoid fossa fractures. Falls and sports activities are mostly responsible (Schandelmaier et al., 2002). Anterior rim and avulsion fractures are more frequently seen since shoulder dislocations mostly occur in the anterior direction. Glenoid posterior rim fractures are rarely seen. They accompany posterior shoulder dislocations usually occurring after an epileptic seizure or an electric shock (Goebel and Seebauer, 2008). Glenoid fossa fractures may present with scapular fractures following high-energy traumas such as traffic accidents and falls (Gilbert et al., 2018).

Imaging In concordance with general orthopedic practice, conventional plain radiographs should be requested first in glenoid fracture cases. The shoulder anteroposterior (AP) view, the true shoulder AP (Grashey) view, and axillary view should be evaluated (McAdams et al., 2009). However, radiographs alone are not sufficient to determine the treatment plan. Especially if non-displaced fractures are suspected, computed tomography (CT) can be very useful. A CT

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examination may reveal important factors such as the degree of displacement and intra-articular extension which can affect the treatment plans (Armitage et al., 2009).

Figure 1. Glenoid fracture. Shoulder AP and true shoulder AP views.

Figure 2. Glenoid fracture. CT scan views.

Classification The first and, later widely accepted, glenoid fracture classification was introduced by Ideberg in 1984 (Ideberg et al., 1995). Subsequently, Goss modified this classification to include six types of intra-articular fractures; Type Ia: anterior rim fracture, Type Ib: posterior rim fracture, Type II-V: glenoid fossa fractures with intra-articular extension, and Type VI: comminuted intra-articular glenoid fractures (Goss, 1992). Type Ia, also as known as “bony Bankart,” is the most common type, usually seen after anterior shoulder dislocation. The Ideberg classification being a conventional radiography-based classification system has very limited prognostic value (van Oostveen et al., 2014). In addition, the Ideberg classification provides inadequate information in terms of the degree of displacement and the need for surgery which necessitated the constitution of a new classification system.

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In 2013, the AO Foundation and the Orthopedic Trauma Association (OTA) defined a new classification system based on CT evaluation. Accordingly, 3 main fracture types were determined; F0: extra-articular glenoid fractures, F1: simple pattern intra-articular glenoid fractures, and F2: multifragmentary intra-articular glenoid fractures. The AO/OTA classification of glenoid fractures has proven to be reliable when used by competent shoulder surgeons (Jaeger et al., 2013).

Treatment The success of glenoid fracture treatment depends on various factors and continues to be a subject of debate. The treatment algorithm is generally determined according to the fragment size, degree of displacement, and instability. Glenoid fractures require surgery more frequently when compared to scapula fractures, which are mostly treated conservatively (Frich and Larsen, 2017). Small, minimally displaced fractures that do not cause instability can be followed conservatively with a sling (Lewis et al., 2013). Early mobilization should be initiated after two weeks, and the sling should not be used for more than six weeks (Maquieira et al., 2007). Surgical indications include intra-articular glenoid fractures that cause instability, displacement of more than 5 mm, fractures involving more than 21% of the anterior articular surface and more than 33% of the posterior articular surface, fractures where the humeral head cannot be concentrically reduced, and fractures with an articular step off greater than 2 mm (Brag et al., 2021). In addition, extra-articular glenoid fractures with more than 40 degrees of angulation and more than 1 cm of translation require surgical treatment (Cole et al., 2012). Numerous methods have been introduced for the treatment of glenoid fractures, such as open surgery, arthroscopically-assisted open surgery, and full arthroscopic surgery. The posterior Judet approach is used for the posterior and inferior fractures, whereas the deltopectoral approach is preferred for the anterior and superior fractures (van Oostveen et al., 2014). Recently, the use of arthroscopy in glenoid fractures has become widespread due to a decreased frequency of complications. Arthroscopically-assisted percutaneous screw fixation and the use of arthroscopic suture anchors are among the preferred methods (Bauer et al., 2006). In chronic cases, anterior bone block grafting such as Bristow-Laterjet or Eden-Hybinette techniques can be used (Seidl and Joyce, 2020). Complications of the surgically treated glenoid fractures include infection, heterotopic ossification, brachial plexus injury, and implant-related problems. Limited range of motion, early osteoarthritis, and residual pain are problems that can be seen both conservatively and surgically treated patient groups (Frich and Larsen, 2017).

Figure 3. Glenoid fracture. Perioperative images of the arthroscopic suture anchor fixation.

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Figure 4. Glenoid fracture. Postoperative plain radiographs of the arthroscopic suture anchor fixation.

Rehabilitation For two weeks following the surgical or conservative treatment of the intra-articular glenoid fractures a sling should be used; at the same time, weight-bearing activities and active mobilization should be avoided (Kraus et al., 2010). Patients with rigid fixations should start pendulum exercises and passive range of motion (ROM) exercises promptly after the operation (Schandelmaier et al., 2002). Active-assisted ROM exercises can be introduced 4 weeks after the operation while strengthening exercises should be started 8 weeks after the operation. After 3 months, patients can resume their daily activities (Owens and Goss, 2004, Maquieira et al., 2007). Patients who are treated conservatively should undergo radiographic evaluation every week or 2 weeks for the first month, in order to assess fracture displacement (Theivendran et al., 2008). It may take up to one year for patients to fully regain function and to return to sports (Goss, 1992).

Shoulder Dislocation Epidemiology The glenohumeral joint is the most frequently dislocated joint in the body, accounting for 45% of all dislocations (Kirkley et al., 2005). The incidence of traumatic shoulder dislocations has been reported to be 1.7% (Howell et al., 1988). Approximately 95% of traumatic dislocations are anterior dislocations (Boffano et al., 2017). Regardless of the direction of the dislocation, the most common etiological factor is trauma, however other factors such as epilepsy and electric shock can be blamed in posterior dislocations. The male/female ratio has been reported to be 2.5-3/1 (Zacchilli et al., 2010). Anterior traumatic dislocations are most commonly seen in young males (Shiedls et al., 2018).

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Clinical Diagnosis During rotation, when the loads on the shoulder exceed the strength of the structures that provide shoulder stability, the humeral head slides out of the glenoid fossa. Clinical manifestation includes intense pain and a prominent deformity. Factors such as the type of trauma, the position of the arm, previous history of dislocation (time and number of dislocations, treatment methods), age, level of activity, and occupation should be thoroughly questioned. Neurovascular assessment of the upper extremity before and after the reduction should be performed and findings should be recorded (Kowalsky and Levine, 2008).

Figure 5. Anterior shoulder dislocation. Shoulder AP and axillary views.

Anterior dislocations usually occur during abduction, external rotation, and extension. The humeral head can be palpated anteriorly and a corresponding gap may occur laterally. The acromion becomes more prominent due to the dislocation and forms the “epaulet sign.” Patients usually present to the emergency department holding their dislocated arm in abduction and external rotation (Dala-Ali et al., 2012). In posterior dislocations, however, the humeral head can be palpated posteriorly, the arm may be locked in an internally rotated position, and external rotation may be limited. It should be noted that posterior dislocations can often be missed in the emergency department, and the history and physical examination should be diligently evaluated in these patients (Rouleau et al., 2014).

Accompanying Injuries The structures that stabilize the shoulder joint can be impaired with dislocation. The anterior inferior glenohumeral ligament (AIGHL), inferior capsule, and anterior inferior labrum are the most important structures that prevent the forward translation of the shoulder. Following anterior shoulder dislocation, the anterior inferior labrum separates from the glenoid and forms Bankart’s lesion, the incidence of which is 90%. Moreover, soft tissue pathologies such as SLAP lesion (superior labrum anterior-posterior), HAGL (humeral avulsion of the glenohumeral ligament), ALPSA (anterior labroligamentous periosteal sleeve avulsion), and rotator cuff tears especially in the elderly population can also be encountered. On the other hand, bony lesions seen with dislocation are glenoid rim fracture (bony Bankart), Hill-Sachs lesion (humeral head impaction fracture), humeral neck, and greater tuberosity fracture (Hasebroock et al., 2019).

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Figure 6. A. Classic Bankart lesion (red arrow). T2 weighted magnetic resonance imaging (MRI) in the axial plane. B. Bony Bankart lesion (yellow arrow). CT image in the axial plane.

A complete neurological assessment should be executed before and after the reduction. The reported rate of neurological complications after dislocation varies between 5.4% and 55% (Robinson et al., 2012). The most common type of injury is neuropraxia; and the most commonly affected nerves are the axillary nerve, suprascapular nerve, and radial nerve. Although rare, brachial plexus palsy may be observed. The risk of nerve injury is greater in high-energy traumas. (Atef et al., 2016). Vascular pathologies after shoulder dislocation are uncommon. Axillary artery injuries have been rarely observed in the elderly population. When vascular pathologies are suspected, vascular surgery consultation should be requested immediately (Eyler et al., 2018).

Imaging For the traumatic shoulder dislocations, plain radiographs should be the first imaging modality to be requested. The shoulder AP view is usually sufficient to diagnose the dislocation. Transthoracic and axillary lateral views may also be requested to determine the direction of the dislocation. Shoulder dislocation is often accompanied by additional injuries. CT can be quite useful especially for the detection of accompanying bone pathologies. In the chronic period, magnetic resonance imaging (MRI) can be used to assess both bony and soft tissue pathologies (Bushnell et al., 2008).

Treatment The primary treatment for acute traumatic glenohumeral dislocation is reduction. Before the intervention, the direction of the dislocation and possible additional bone pathologies should be determined and neurovascular examination should be performed. Numerous maneuvers have been described for shoulder reduction, including the historically important Hippocrates method, the frequently used traction-counter traction maneuver, and the Milch, Kocher, and Stimson methods. Patients should be given adequate sedoanalgesia and maneuvers should be performed gently in order not to cause additional injuries during reduction. After the intervention, the reduction should be confirmed via plain radiography, and neurovascular examination should be repeated (Hovelius, 1999).

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If conservative treatment is deemed appropriate for the patient following reduction, immobilization with a sling for an average of 3-6 weeks is recommended. No significant correlation was found between the duration of immobilization and the risk of recurring instability (Kuhn, 2006). Classical practice is to immobilize the shoulder in internal rotation which is probably preferred due to the ease of application. However, novel studies are reporting that immobilization in external rotation diminishes the risk of recurrent dislocation (Shinagawa et al., 2020). Nevertheless, no consensus on the subject has been reached yet (Liavaag et al., 2011). Hand, wrist, and elbow ROM exercises should be performed starting from the immobilization period. After the immobilization period, a rehabilitation program including periscapular muscle strengthening should be implemented. Conservative treatment is generally preferred in patients who have shoulder dislocation for the first time. Patients who are below the age of 20 at the time of the first dislocation, are at risk for the development of recurrent shoulder dislocation. It has been reported that the rate of re-dislocation within 2 years in young patients who were followed conservatively after the first dislocation was 87% (Rowe and Sakellarides, 1961). Therefore, several authors favored surgical treatment following the first dislocation especially in young patients (Sachs et al., 2007). However, remission rates of up to 43% following conservative treatment have also been reported, and accordingly, immediate surgery following the first dislocation has been described as “overtreatment” (Hovelius, 1999). On the other hand, surgery may be recommended in young adults participating in contact sports and overhead activities, to avoid recurrent dislocation and to facilitate an early return to sports. The risk of re-dislocation decreases in patients over 40 years of age and with limited activity levels. Conservative treatment should be preferred in this patient group. Clinicians should also be cautious about the development of rotator cuff tears in this population (Zacchilli et al., 2010). Numerous surgical methods have been described for instability that developed following shoulder dislocation. Open or arthroscopic methods employed for the repair of Bankart’s lesion—which plays a vital role in the anterior shoulder instability—were not significantly superior to each other in reducing the risk of recurrent dislocation. However, better functional results were reported after arthroscopic surgery. Arthroscopic surgery has many advantages such as intraoperative detection of additional pathologies, a shorter hospital stay, significantly less blood loss, and preservation of the subscapularis muscle (Cole and Warner, 2000). Nonetheless, a Bankart repair alone is not sufficient in terms of instability in bony Bankart lesions covering more than 25% of the glenoid and in large Hill-Sachs lesions. Additional surgical interventions such as anterior bone block procedures (Laterjet or Eden-Hybinette) or remplissage may be required (Arner et al., 2020). Rotator cuff tears are commonly seen following shoulder dislocations over the age of 40, and have been reported to exist in 80% of the patients who are 60 years or older (Rumian et al., 2011). It should be noted that subscapularis insufficiency may be the underlying reason for anterior shoulder instability, especially in revision surgeries (Aydin et al., 2020).

Conclusion Glenoid fractures are rare. Computed tomography use in diagnosis and treatment is highly recommended. Due to low incidence rates, studies regarding glenoid fractures are mainly case series and the scientific evidence level is considered to be low. Classification and treatment

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options remain controversial. Regardless of the method used, the outcomes are generally favorable in selected patient groups. Shoulder dislocation is the most commonly detected dislocation in the body and a frequent orthopedic emergency. A thorough neurovascular assessment should be executed before and after the reduction. Computed tomography and magnetic resonance imaging are highly useful in detecting additional injuries. Management of the first dislocation is still a subject of debate in young patients, and there are numerous authors recommending surgery.

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Goebel, M., & Seebauer, L. (2008). Behandlungskonzepte zur Versorgung akuter Glenoidfrakturen nach vorderer oder hinterer Luxation [Open operative treatment of acute glenoid fractures following anterior and posterior shoulder dislocation]. Operative Orthopadie und Traumatologie, 20(3), 228–238. https://doi.org/10.1007/s00064-008-1305-z. Goss T. P. (1992). Fractures of the glenoid cavity. The Journal of bone and joint surgery. American volume, 74(2), 299–305. Gregory HS, Bain I, Itoi E, Giacomo GD (2015). Normal and Pathological Anatomy of the Sh. Habermeyer, P., Gleyze, P., & Rickert, M. (1999). Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: a prospective study. Journal of shoulder and elbow surgery, 8(1), 66–74. https://doi.org/10.1016/s1058-2746(99)90058-7. Hasebroock, A. W., Brinkman, J., Foster, L., & Bowens, J. P. (2019). Management of primary anterior shoulder dislocations: a narrative review. Sports medicine - open, 5(1), 31. https://doi.org/10. 1186/s40798-0190203-2. Hovelius L. (1999). The natural history of primary anterior dislocation of the shoulder in the young. Journal of orthopaedic science: official journal of the Japanese Orthopaedic Association, 4(4), 307–317. https://doi.org/10.1007/s007760050109 oulder, 94. Hovelius, L., Olofsson, A., Sandström, B., Augustini, B. G., Krantz, L., Fredin, H., Tillander, B., Skoglund, U., Salomonsson, B., Nowak, J., & Sennerby, U. (2008). Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. a prospective twenty-five-year follow-up. The Journal of bone and joint surgery. American volume, 90(5), 945–952. https://doi.org/10. 2106/JBJS.G.00070. Howell, S. M., Galinat, B. J., Renzi, A. J., & Marone, P. J. (1988). Normal and abnormal mechanics of the glenohumeral joint in the horizontal plane. The Journal of bone and joint surgery. American volume, 70(2), 227–232. Ideberg, R., Grevsten, S., & Larsson, S. (1995). Epidemiology of scapular fractures. Incidence and classification of 338 fractures. Acta orthopaedica Scandinavica, 66(5), 395–397. https://doi.org/ 10.3109/1745367950899557. Jaeger, M., Lambert, S., Südkamp, N. P., Kellam, J. F., Madsen, J. E., Babst, R., Andermahr, J., Li, W., & Audigé, L. (2013). The AO Foundation and Orthopaedic Trauma Association (AO/OTA) scapula fracture classification system: focus on glenoid fossa involvement. Journal of shoulder and elbow surgery, 22(4), 512–520. https://doi.org/10.1016/j.jse.2012.08.003. Kelly, M. J., Holton, A. E., Cassar-Gheiti, A. J., Hanna, S. A., Quinlan, J. F., & Molony, D. C. (2019). The aetiology of posterior glenohumeral dislocations and occurrence of associated injuries: a systematic review. The bone & joint journal, 101-B(1), 15–21. https://doi.org/10.1302/0301-620X.101B1.BJJ-20180984.R1. Kirkley, A., Werstine, R., Ratjek, A., & Griffin, S. (2005). Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder: long-term evaluation. Arthroscopy: the journal of arthroscopic & related surgery: official publication of the Arthroscopy Association of North America and the International Arthroscopy Association, 21(1), 55–63. https://doi.org/10.1016/j.arthro. 2004.09.018. Kowalsky, M. S., & Levine, W. N. (2008). Traumatic posterior glenohumeral dislocation: classification, pathoanatomy, diagnosis, and treatment. The Orthopedic clinics of North America, 39(4), 519–viii. https://doi.org/10.1016/j.ocl.2008.05.008. Kraus, N., Gerhardt, C., Haas, N., & Scheibel, M. (2010). Konservative Therapie anteroinferiorer Glenoidfrakturen [Conservative therapy of antero-inferior glenoid fractures]. Der Unfallchirurg, 113(6), 469–475. https://doi.org/10.1007/s00113-010-1754-3. Lewis, S., Argintar, E., Jahn, R., Zusmanovich, M., Itamura, J., & Rick Hatch, G. F. (2013). Intra-articular scapular fractures: Outcomes after internal fixation. Journal of orthopaedics, 10(4), 188–192. https://doi.org/10.1016/j.jor.2013.09.002. Liavaag, S., Brox, J. I., Pripp, A. H., Enger, M., Soldal, L. A., & Svenningsen, S. (2011). Immobilization in external rotation after primary shoulder dislocation did not reduce the risk of recurrence: a randomized controlled trial. The Journal of bone and joint surgery. American volume, 93(10), 897–904. https://doi.org/10.2106/JBJS.J.00416.

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Maquieira, G. J., Espinosa, N., Gerber, C., & Eid, K. (2007). Non-operative treatment of large anterior glenoid rim fractures after traumatic anterior dislocation of the shoulder. The Journal of bone and joint surgery. British volume, 89(10), 1347–1351. https://doi.org/10.1302/0301-620X.89B10.19273. McAdams, T. R., Blevins, F. T., Martin, T. P., & DeCoster, T. A. (2002). The role of plain films and computed tomography in the evaluation of scapular neck fractures. Journal of orthopaedic trauma, 16(1), 7–11. https://doi.org/10.1097/00005131-200201000-00002. Owens Bp, Goss Tp (2004). surgical approaches for glenoid fractures. Techniques in shoulder & elbow surgery. 5, 103-115. Robinson, C. M., Shur, N., Sharpe, T., Ray, A., & Murray, I. R. (2012). Injuries associated with traumatic anterior glenohumeral dislocations. The Journal of bone and joint surgery. American volume, 94(1), 18– 26. https://doi.org/10.2106/JBJS.J.01795. Rouleau, D. M., Hebert-Davies, J., & Robinson, C. M. (2014). Acute traumatic posterior shoulder dislocation. The Journal of the American Academy of Orthopaedic Surgeons, 22(3), 145–152. https://doi.org/10.5435/ JAAOS-22-03-145. Rowe, C. R., & Sakellarides, H. T. (1961). Factors related to recurrences of anterior dislocations of the shoulder. Clinical orthopaedics, 20, 40–48. Rumian A, Coffey D, Fogerty S, Hackney R. (2011). Acute first-time shoulder dislocation. Orthop Trauma, 25,363–368. Sachs, R. A., Lin, D., Stone, M. L., Paxton, E., & Kuney, M. (2007). Can the need for future surgery for acute traumatic anterior shoulder dislocation be predicted?. The Journal of bone and joint surgery. American volume, 89(8), 1665–1674. https://doi.org/10.2106/JBJS.F.00261. Schandelmaier, P., Blauth, M., Schneider, C., & Krettek, C. (2002). Fractures of the glenoid treated by operation. A 5- to 23-year follow-up of 22 cases. The Journal of bone and joint surgery. British volume, 84(2), 173–177. https://doi.org/10.1302/0301-620x.84b2.12357. Seidl, A. J., & Joyce, C. D. (2020). Acute Fractures of the Glenoid. The Journal of the American Academy of Orthopaedic Surgeons, 28(22), e978–e987. https://doi.org/10.5435/JAAOS-D-20-00252. Shields, D. W., Jefferies, J. G., Brooksbank, A. J., Millar, N., & Jenkins, P. J. (2018). Epidemiology of glenohumeral dislocation and subsequent instability in an urban population. Journal of shoulder and elbow surgery, 27(2), 189–195. https://doi.org/10.1016/j.jse.2017.09.006. Shinagawa, K., Sugawara, Y., Hatta, T., Yamamoto, N., Tsuji, I., & Itoi, E. (2020). Immobilization in External Rotation Reduces the Risk of Recurrence after Primary Anterior Shoulder Dislocation: A Meta-analysis. Orthopaedic journal of sports medicine, 8(6), 2325967120925694. https://doi.org/10.1177/23259671209 25694. Theivendran, K., McBryde, C. W., & Massoud, S. N. (2008). Scapula fractures: A review. Trauma, 10(1), 25– 33. https://doi.org/10.1177/1460408607088442. van Oostveen, D. P., Temmerman, O. P., Burger, B. J., van Noort, A., & Robinson, M. (2014). Glenoid fractures: a review of pathology, classification, treatment and results. Acta orthopaedica Belgica, 80(1), 88–98. Witney-Lagen, C., & Hunter, A. (2019). Diagnosis and management of shoulder instability. British journal of hospital medicine (London, England: 2005), 80(3), C34–C38. https://doi.org/10.12968/hmed.2019. 80.3.C34. Zacchilli, M. A., & Owens, B. D. (2010). Epidemiology of shoulder dislocations presenting to emergency departments in the United States. The Journal of bone and joint surgery. American volume, 92(3), 542– 549. https://doi.org/10.2106/JBJS.I.00450.

Chapter 3

Proximal Humerus Fractures Halit Cengiz Department of Orthopaedics and Traumatology, Keçiören Training and Research Hospital, Ankara, Turkey

Abstract The functionality of the shoulder joint, one of the joints having the widest range of motion of the human body, is extremely crucial for the individual to be able to move in a healthy way. Proximal humerus fractures are among the important fractures leading to loss of function in the shoulder joint. Proximal humerus fractures are classified differently depending on the displacement between fragments of the humerus or fragments of the fracture. As a treatment approach, surgical and conservative treatments are administered in these fractures. The treatment approach differs depending on factors related to the patient, fracture, and surgeon.

Introduction The shoulder joint is one of the functionally active joints with a wide range of motion in the human body. Therefore, functional recovery after injury is highly important (Erasmo et al., 2014). Proximal humerus fractures (PHFs) are frequently observed in the young and elderly population. Despite different opinions on treatment approaches in PHFs, a common consensus has not been developed yet (Garrigues et al., 2012). In this chapter, the classification, symptoms and findings, and treatment approaches of PHFs are discussed in line with the literature.

Anatomy The humerus is the biggest bone of the upper extremity. The most important structure in the proximal humerus is the ellipsoidal humeral head that articulates with the glenoid. The narrow part down the humeral head is called the anatomical neck. There are tuberculae on the outer 

Corresponding Author’s Email: [email protected].

In: Multidisciplinary Approach to Trauma Editors: Mehmet Cenk Turgut and Asli Turgut ISBN: 978-1-68507-761-7 © 2022 Nova Science Publishers, Inc.

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side of the humeral head. The posterior large part is called the tuberculum majus, and the anterior small part is called the tuberculum minus. The m. subscapularis is attached to the tuberculum minus, and the m. supraspinatus, m. infraspinatus, and m. teres minor are attached to the tuberculum majus. The tuberculum majus extends distally as the crista tuberculi majoris, and the tuberculum minus extends as the crista tuberculi minoris. The groove formed between these two protrusions is called the sulcus intertubercularis, and its proximal side is covered with cartilage for the sliding of the tendon structure passing through it. An average angle of 130 degrees exists between the caput humeri and the corpus humeri, and the opening faces inward and downward. The part just below the tubercles is called the collum chirurgicum. The structure of the caput humeri has a trabecula system and alveoli. This system extends in trabeculae from the humeral head to the articular surface. Parallel trabeculae are added to this surface to ensure a smooth geometric structure, and the trabeculae are vertical at the level of the greater tubercle (Hoyen & Papendrea, 2014; Brorson, 2011; Handoll & Brorson, 2015). It has been revealed that these trabeculae extend from the attachment points of the muscles to the anatomical neck of the upper ones by opening gradually, and the lower ones extend toward the external cortical structure in line with the vertical system, which results from the pulling effect of the muscles (Freislederer et al., 2021).

Classification According to the classification made by Codman and based on the relation between four main parts, proximal humerus fractures are divided into three: the tuberculum majus, tuberculum minus, and humeral head and diaphysis (Figure 1).

Figure 1. Fragments defined by Codman.

While Codman paid attention to the fracture lines between the humeral fragments in his classification, Neer made his classification according to the significance of the displacement between the fragments. According to Neer, fractures must be displaced more than 1 cm or more than 45 degrees compared to other parts for them to be considered different parts. He divides fractures into four parts as non-displaced, two-part fractures, three-part fractures, and four-part fractures. Moreover, valgus impacted fractures have been defined as a special type of four-part

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fracture today (Figure 2). These fractures are described as a special type of fracture in which circulation is better preserved than in other comminuted fractures, and good clinical results are achieved when conservatively treated (Brorson, 2011; Handoll & Brorson, 2015).

Figure 2. The Neer classification.

According to the AO classification, fractures are divided into 11-A extra-articular unifocal fractures, 11-B extra-articular bifocal fractures and 11-C joint-related fractures. Each fracture has subgroups based on impaction and dislocation.

Clinical Findings In proximal humerus fractures, the most significant symptom is the patient’s presentation by holding the affected extremity with the other extremity, as well as swelling and hematoma, particularly in elderly patients. A neurovascular evaluation of the patient should be carefully

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conducted, and findings should be recorded. The axillary nerve examination is important. To evaluate the axillary nerve, the examiner’s palm is placed on the deltoid muscle on the affected side of the patient, and the patient is requested to perform a gentle abduction movement (Campochiaro et al., 2015).

Radiological Evaluation Shoulder injuries are evaluated with anteroposterior shoulder radiography, lateral scapular radiography, and axillary view. Axillary radiography is not used so often today since the patient has a lot of pain and it does not change the treatment decision so much. The routine use of computed tomography (CT) has come into prominence because it is difficult to only classify PHFs with radiographs. Especially the 3D reconstructed CT imaging method facilitates planning, particularly in the preoperative period, since it gives more accurate information about the form of the fracture (Berkes et al., 2014).

Figure 3. Positioning of trauma series radiographs.

In addition to showing occult greater tubercle and anatomical neck fractures, MR imaging can also help to evaluate the accompanying rotator cuff injuries. However, it is not recommended to use it in the acute period (Wu et al., 2019; Rouleau et al., 2016).

Indications and Treatment Two-Part Fractures Anatomical Neck Fractures These generally require surgical treatment.

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Surgical Neck Fractures Conservative treatment is rarely administered, apart from in elderly patients from whom there is a low recovery expectation after the surgical treatment. In young patients, the preferred treatment method is ORIF with locking plates or locking nails. Arthroplasty can also be considered in elderly and osteoporotic patients.

Greater Tubercle Fractures As subacromial impingement and nonunion are commonly observed in displaced fractures greater than 5 mm, surgical treatment is indicated. It is possible to fix large parts with locking plates or treat them with the tension band method with screws or K-wires.

Three-Part Fractures Closed reduction can be applied to three-part fractures, but they usually require surgical treatment as reduction cannot be maintained. A conservative treatment method can be used in elderly comorbid patients with a low probability of recovery through surgical treatment. Options of surgical treatment include locking plates, locking nails, hemiarthroplasty, and reverse shoulder prosthesis.

Four-Part Fractures Surgical treatment is necessary for these fractures, except for elderly patients who have valgusimpacted fractures and a low possibility of recovery with surgical treatment. Options of surgical treatment include locking plates, locking nails, hemiarthroplasty, and reverse shoulder prosthesis. In valgus-impacted fractures, circulation is good. Therefore, conservative treatment yields better results.

Conservative Treatment In the literature, no standard treatment algorithms for the treatment of PHFs have been formed yet. Factors such as patient characteristics, the formation of fractures in different ways, implant diversity, and the surgeon’s experience cause a change in treatment methods. Only 20% of proximal humerus fractures require surgical treatment (Popescu et al., 2009). Less displaced or non-displaced fractures are treated with non-surgical methods. Immobilization with a Velpeau bandage or shoulder arm straps is recommended for 2-3 weeks. Thereafter, pendulum exercises and passive range of motion exercises are initiated. Moreover, cold therapy and the use of analgesics are also recommended for patients. For the evaluation of fracture stabilization, patients should have radiographs taken on a weekly basis. As of the sixth week, active range of motion exercises are initiated.

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In elderly patients, conservative treatment provides quite good results for non-displaced fractures. Of abduction and flexion, 80% is regained in valgus-impacted fractures. It is stressed that surgical treatment does not improve patient outcomes in elderly patients with two-, three-, and four-part fractures (Launonen et al., 2015; Leighton, 2012; Wassenaar et al., 2021). Nonsurgical treatment methods can be used even in complex fractures in elderly patients with a low possibility of recovery with surgical treatment. However, the number of studies on the subject is limited in the literature (Huri, 2017). Young patients, who expect to return to work and sports activities earlier, have difficulty in accepting the limitations of treatment methods apart from surgical treatment. Still, nonsurgical treatment should be taken into account for one-part and some two-part fractures (Trail et al., 2019).

Surgical Treatment Open Reduction-Internal Fixation (ORIF): Displaced two-, three-, and four-part fractures are the most important indications. The most suitable patients for the ORIF method are those who are physiologically young, have active good bone stock, and can adapt to rehabilitation in the postoperative period. Locking plates: Locking plates are today the most common implant option in the treatment of PHFs. Fixed angles between plates and screws ensure the stability of the implant. Screws locked to the plate prevent screws from returning and fragments from slipping. Plates and screws comprising a single whole help with resistance against rotational and bending forces. Intramedullary nails: Nails used in two-part neck fractures in past years have also started to be used in comminuted fractures in recent years, and successful results have been reported (Trail et al., 2019; Giannoudis et al., 2012). It has been highlighted that angular-stable locking intramedullary nails, which have been used recently, can enhance stability, particularly in osteoporotic patients (Giannoudis et al., 2012). In a study, locking plates and nails were compared biomechanically in cadaver models, and locking plates were reported to provide a more stable fixation in valgus loading and similar results against other forces (Foruria et al., 2010). In a study conducted by Gracitelli et al., the nail and plate groups were found to be similar radiologically and clinically, but the complication rate was observed to be higher in the nail group (Gracitelli et al., 2017). Arthroplasty: Arthroplasty is indicated in patients who are thought to have an impaired vascular structure in radiological evaluation (Hertel’s criteria), who possibly develop avascular necrosis, are old and have four-part fractures not suitable for stable fixation, and have osteoporotic three- and four-part fractures. Arthroplasty can be applied as hemiarthroplasty and reverse shoulder prosthesis. Hemiarthroplasty: Good functional outcomes can be obtained if anatomical relations can be restored properly in cases in which the rotator cuff is not affected. Reverse shoulder prosthesis: Primary reverse shoulder prosthesis is a treatment option with increasing use in elderly osteoporotic patients. Lower revision rates and better clinical outcomes have been reported compared to hemiarthroplasty.

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Surgical Approaches In surgical treatment, the deltopectoral and deltoid split approaches are used most frequently. These are regarded as advantageous since the deltopectoral approach can easily be extended distally and provides good access to the humeral head, and the deltoid split approach provides good access to the tuberculum majus and minus and easier plate placement. However, the risk of iatrogenic damage to the axillary nerve has been reported to be higher in the deltoid split approach.

Complications Shoulder stiffness: The most common complication in PHFs is shoulder stiffness. In highenergy traumas, it is more common in patients whose immobilization is prolonged and who do not comply with rehabilitation. Poor union: Especially the union of the tuberculum majus in more than 5 mm of the superior part causes patients to develop impingement. In severe poor unions, osteotomy or arthroplasty should be planned. Nonunion: Nonunion is rare. It is observed especially in elderly patients with displaced fractures for whom non-surgical treatment methods are used. Patients with significant pain, deformity, and functional loss resulting from nonunion are treated surgically with ORIF or arthroplasty. Osteonecrosis: This occurs especially in multi-part fractures and in patients who have undergone excessive soft tissue dissection during surgery. It appears with pain in patients with collapse after necrosis. MRI can be used for early diagnosis. Patients without collapse can be treated with non-surgical techniques. However, arthroplasty should be considered in symptomatic patients with collapse. Infection: Infection rarely takes place after surgical treatment of the PHF. Patients who develop infections are treated in compliance with orthopedic infection principles. Nerve injury: Although nerve injury has been reported by 45% in electrophysiological studies evaluating PHFs and shoulder dislocations treated surgically or conservatively, no adequate studies on its clinical importance have been encountered in the literature.

Conclusion There are no standard treatment methods available to treat proximal humerus fractures, but the treatment option differs depending on factors such as the patient, the type of fracture, and the surgeon’s experience. For this reason, the patient and fracture should be carefully evaluated, a treatment option that suits the patient and the fracture should be preferred, and complications should be closely monitored. Our treatment choice is open reduction-internal fixation with locking plates in displaced fractures in young patients, whereas we prefer conservative treatment or primary reverse shoulder prosthesis in elderly patients with advanced osteoporosis in whom stable fixation cannot be achieved.

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References Berkes, M. B., Dines, J. S., Little, M. T., Garner, M. R., Shifflett, G. D., Lazaro, L. E., Wellman, D. S., Dines, D. M., & Lorich, D. G. (2014). The Impact of Three-Dimensional CT Imaging on Intraobserver and Interobserver Reliability of Proximal Humeral Fracture Classifications and Treatment Recommendations. The Journal of bone and joint surgery. American volume, 96(15), 1281–1286. https://doi.org/10.2106/ JBJS.M.00199. Boileau, P., d'Ollonne, T., Bessière, C., Wilson, A., Clavert, P., Hatzidakis, A. M., & Chelli, M. (2019). Displaced humeral surgical neck fractures: classification and results of third-generation percutaneous intramedullary nailing. Journal of shoulder and elbow surgery, 28(2), 276–287. https://doi.org/10.1016/ j.jse.2018.07.010. Brorson, S. (2011). Management of proximal humeral fractures in the nineteenth century: an historical review of preradiographic sources. Clin. Orthop. Relat. Res., 469(4):1197-1206. doi: 10.1007/s11999- 010-17078. Campochiaro, G., Rebuzzi, M., Baudi, P., & Catani, F. (2015). Complex proximal humerus fractures: Hertel's criteria reliability to predict head necrosis. Musculoskeletal surgery, 99 Suppl 1, S9–S15. https://doi.org/10.1007/s12306-015-0358-z. Erasmo, R., Guerra, G., & Guerra, L. (2014). Fractures and fracture-dislocations of the proximal humerus: A retrospective analysis of 82 cases treated with the Philos(®) locking plate. Injury, 45 Suppl 6, S43–S48. https://doi.org/10.1016/j.injury.2014.10.022. Freislederer, F., Bensler, S., Specht, T., Magerkurth, O., & Eid, K. (2021). Plate Fixation for Irreducible Proximal Humeral Fractures in Children and Adolescents-A Single-Center Case Series of Six Patients. Children (Basel, Switzerland), 8(8), 635. https://doi.org/10.3390/children8080635. Foruria, A. M., Carrascal, M. T., Revilla, C., Munuera, L., & Sanchez-Sotelo, J. (2010). Proximal humerus fracture rotational stability after fixation using a locking plate or a fixed-angle locked nail: the role of implant stiffness. Clinical biomechanics (Bristol, Avon), 25(4), 307–311. https://doi.org/10.1016/ j.clinbiomech.2010.01.009. Garrigues, G.E., Johnston, P.S., Pepe, M.D., Tucker, B.S., Ramsey, M.L., & Austin, L.S. (2012). Hemiarthroplasty versus reverse total shoulder arthroplasty for acute proximal humerus fractures in elderly patients. Orthopedics. 35(5), e703-8. doi: 10.3928/01477447-20120426-25. Giannoudis, P. V., Xypnitos, F. N., Dimitriou, R., Manidakis, N., & Hackney, R. (2012). "Internal fixation of proximal humeral fractures using the Polarus intramedullary nail: our institutional experience and review of the literature". Journal of orthopaedic surgery and research, 7, 39. https://doi.org/10.1186/1749-799X7-39. Gracitelli, M., Malavolta, E. A., Assunção, J. H., Ferreira Neto, A. A., Silva, J. S., & Hernandez, A. J. (2017). Locking intramedullary nails versus locking plates for the treatment of proximal humerus fractures. Expert review of medical devices, 14(9), 733–739. https://doi.org/10.1080/17434440.2017.1364624. Handoll, H.H., & Brorson, S. (2015). Interventions for treating proximal humeral fractures in adults. The Cochrane database of systematic reviews, (11), CD000434. https://doi.org/10.1002/14651858.CD00 0434.pub4. Hoyen, H., & Papendrea, R. (2014). Exposures of the shoulder and upper humerus. Hand clinics, 30(4), 391– v. https://doi.org/10.1016/j.hcl.2014.08.003. Huri, G. (2017). Orthopaedic Study Guide Series The shoulder (I) Springer. Launonen, A.P., Lepola, V., Flinkkilä, T., Laitinen, M., Paavola, M., & Malmivaara, A. (2015). Treatment of proximal humerus fractures in the elderly: a systemic review of 409 patients. Acta orthopaedica, 86(3), 280–285. https://doi.org/10.3109/17453674.2014.999299. Leighton, R. (2012). Internal fixation with a locking plate was not more effective than nonoperative treatment in older patients with three-part proximal humeral fractures. The Journal of bone and joint surgery. American volume, 94(4), 367. https://doi.org/10.2106/JBJS.9404.ebo205. Popescu, D., Fernandez-Valencia, J. A., Rios, M., Cuñé, J., Domingo, A., & Prat, S. (2009). Internal fixation of proximal humerus fractures using the T2-proximal humeral nail. Archives of orthopaedic and trauma surgery, 129(9), 1239–1244. https://doi.org/10.1007/s00402-008-0789-1. Rouleau, D. M., Laflamme, G. Y., & Mutch, J. (2016). Fractures of the greater tuberosity of the humerus: a study of associated rotator cuff injury and atrophy. Shoulder & elbow, 8(4), 242–249. https://doi.org/10.1177/1758573216647896. Trail, Ian A., et al., (2019).eds. Textbook of shoulder surgery. Springer.

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Wu, J., Han, Z., Wang, Q., & Wu, X. (2019). Inferior displacement of greater tuberosity fracture suggests an occult humeral neck fracture: a retrospective single-centre study. International orthopaedics, 43(6), 1429– 1434. https://doi.org/10.1007/s00264-019-04294-1. Wassenaar, D., Busch, A., Wegner, A., & Jäger, M. (2021). Schulterendoprothetik [Shoulder arthroplasty]. Der Orthopade, 50(3), 245–256. https://doi.org/10.1007/s00132-020-04065-6.

Chapter 4

Humeral Shaft Fractures M. Fatih Uzun, MD Erciyes University, Faculty of Medicine, Kayseri, Turkey

Abstract Although humeral fractures are rare, their incidence has been increasing in recent years. The humerus is a bone on which surgery is rarely performed compared to other extremity bones, and important neurovascular structures travel close to the bone. As a result of increasing frequency, these fractures pose a problem for the healthcare system and patients. Most humeral shaft fractures can be treated with conservative methods. These methods are a functional brace, hanging cast, coaptation splint, Velpeau bandage, shoulder spica cast, and functional device. Surgical treatments are open reduction internal fixation (plating), intramedullary nailing, closed reduction and external fixation.

Introduction The frequency of humeral shaft fractures is approximately 1% among all fractures. They are characteristically caused by direct trauma and can also result from competitive sports such as baseball and arm wrestling (DiCicco et al., 1993). Although most of the fractures are suitable for conservative treatment methods, a small number of them are treated successfully with surgical treatment (McKee & Larsson, 2010). The wide range of motion of the elbow and shoulder joints and the ability to tolerate small shortnesses result in less functional limitation (Sarmiento et al., 2000). It shows a bimodal distribution resulting from high-energy traumas in the 3rd decade in men and simple falls in the 8th decade in women. While 5% of the fractures are open fractures, 63% are classified as simple fractures (Tytherleigh-Strong et al., 1998).



Corresponding Author’s Email: [email protected].

In: Multidisciplinary Approach to Trauma Editors: Mehmet Cenk Turgut and Asli Turgut ISBN: 978-1-68507-761-7 © 2022 Nova Science Publishers, Inc.

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Anatomy The humeral shaft is the bony part that covers the distal part of the surgical neck proximally and the proximal part of the epicondyles distally (Klenerman, 1966). For a safe surgical approach, it is necessary to know the complex neurovascular anatomy of the arm. The anatomical structures to be considered during the approach to the humeral shaft are the axillary nerve and brachial artery proximally and the median, ulnar, and radial nerves distally (Zlotolow et al., n.d.). The humeral shaft is cylindrical in its proximal half, flattens distally and takes the form of a triangle. The anatomical structures of surgical importance are the deltoid process and the radial groove. The deltoid process is an elevation near the middle of the anterolateral part of the attachment of the deltoid muscle. The radial groove begins distal to the insertion site posterior to the lateral head of the triceps muscle and runs downward anterolaterally. The radial nerve and the profunda brachii artery are located in this groove (Updegrove et al., 2018). The humeral shaft has three surfaces: anterolateral, anteromedial, and posterior (Lambert, 2016). The radial nerve passes through the radial groove 101 to 148 mm proximal to the lateral epicondyle (Guse & Ostrum, 1995).

Figure 1. Neurovascular anatomy of the arm (McKee & Larsson, 2010).

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Physical Examination-Imaging While high-energy direct injuries such as motor vehicle injury, falling from a height, hand wrestling, and gunshot wounds play a role in young patients, humeral shaft fractures occur as a result of simple falls to the ground in elderly patients (McKee & Larsson, 2010). It is very important to take a detailed history and perform a detailed neurovascular examination. There is a risk of radial nerve involvement in the distal third and middle shaft fractures of the humeral shaft. It should be examined for bruising, open fractures, soft tissue injuries and angulation and malpositions that may occur in the arm. The neurovascular examination is essential before the reduction maneuver to be applied (Pollock et al., 1981). In patients with excessive swelling, care should be taken in terms of compartment syndrome, and intracompartmental pressure should be measured if necessary. There is a marked increase in the incidence of forearm compartment syndrome in patients with a forearm fracture (floating elbow) with ipsilateral humeral shaft fracture, especially in pediatric patients (Ring et al., 2001). The examination of adjacent joints should also be performed. As the imaging method, it is essential to take anteroposterior and transthoracic lateral radiographs at 90-degree angles. Adjacent joints should definitely be included in the examination area. While taking the lateral radiograph, the patient should turn sideways, if the arm is turned sideways, only the distal fracture part will be turned sideways by turning the broken limb sideways. Additional imaging methods are rarely required. These conditions include angiography in vascular injuries associated with shaft fracture and computed tomography in fractures involving the distal and proximal joint, respectively (McKee & Larsson, 2010). Magnetic resonance images, bone scans, and computed tomography may be necessary in cases where a pathological fracture is suspected (Egol, 2015).

Classification The classification that is accepted in the case of humeral shaft fractures and correlates with the prognosis is a combination of the Orthopedic Trauma Association (OTA)/Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification derived from the Müller AO long bone fracture classification (Marsh et al., 2007). Three main types were identified: simple, wedge type, and complex fractures. Afterward, these types are divided into subtypes. After the classification process of humeral shaft fractures, it was accepted by different orthopedic surgeons and important authorities (Mahabier et al., 2017) (Figure 2). Two classifications were defined for periprosthetic fractures after shoulder arthropathy. These are the Wright and Cofield classification system, which shows the relationship between the tip of the humeral stem and the fracture location, and the classification system created by Campbell et al., Williams and Iannotti, based on where the fracture occurs in the humerus.

Treatment Conservative More than 90% of humeral shaft fractures can be treated by non-surgical treatment methods (Egol, 2015). The acceptable criteria for conservative treatment include varus up to 20-30

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degrees, 3 cm shortness, and sagittal angulation of 20 degrees (Clifford R., 2008). A coaptation splint, Velpeau bandage, suspending cast, arm sling, shoulder spica cast, and functional splinting are conservative treatment methods. Although the outcomes of the mentioned treatment methods are good, functional splinting became the gold standard in conservative treatment due to its easy application, allowing shoulder and elbow movements, and being inexpensive (McKee & Larsson, 2010). Non-surgical treatments are performed in the following patient groups: • • • • • •

Adaptive, preferably active patients, Patients who can stand upright, Patients who meet the reduction criteria, Patients having a surgeon performing the treatment with a good command of the postural and muscular strengths, Patients with an extremity with nerve integrity (e.g., brachial nerve), Patients having close follow-up and observation (Egol, 2015).

Figure 2. Orthopedic Trauma Association (OTA)/Arbeitsgemeinschaft für Osteosynthesefragen (AO) diaphyseal fracture classification. Copyright by AO Foundation, Switzerland.

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Surgical The main conditions that determine the surgical indications for humeral shaft fracture may vary according to the shape of the fracture, patient age, compliance with the treatment and associated injuries. Surgical indications can be divided into absolute and relative indications. Absolute surgical indications: • • • • • • • • • •

No acceptable alignment with functional splinting, Severe soft tissue damage, High-energy gunshot wound, Open fractures with major soft tissue damage, Association with vascular injury, Pathological fracture, Brachial plexus injury, Concomitant intra-articular fracture, Radial nerve involvement after reduction, Floating elbow or shoulder.

Relative surgical indications: • • • • • • • •

Multiple trauma, Low-energy gunshot wound, Comminuted fractures, Open fracture, Bilateral humerus fracture, Segmental fracture, Obesity, Primary radial nerve involvement (Updegrove et al., 2018).

Surgical Approaches Although many approaches to the humeral shaft have been described, the one most commonly used is the anterolateral and posterior approach. Furthermore, there are direct lateral and medial approaches preferred for different fracture patterns and conditions (McKee & Larsson, 2010). •

Posterior Approach

This approach is preferred for fractures involving the elbow joint or distal third humeral shaft fractures where exploration is required for radial nerve involvement (McKee & Larsson, 2010). The patient position is lateral decubitus or prone. The medial head should be separated by entering the interval between the long head and the lateral head of the triceps muscle, and the radial nerve should be found in the spiral groove and explored (Egol, 2015). The benefit of this approach is the ability to overlook the distal articular surface, lateral and medial columns,

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direct visualization of the radial nerve, and a suitable bone base for plate fixation (McKee & Larsson, 2010). •

Anterolateral Approach

The humeral shaft is used in the detection of proximal third and middle shaft fractures. The patient can be in the supine position or the beach chair position. An incision can be made on the fractured area along the lateral edge of the biceps muscle and extended to the coracoid process proximally and the lateral supracondylar region distally. In the humeral shaft, the opening is continued between the biceps muscle and the triceps, the brachialis muscle splint is separated, and the bone is reached. The radial nerve should be located and protected distally (McKee & Larsson, 2010). •

Medial Approach

Although this is required to be used rarely, it can be preferred in cases where the anterior and lateral soft tissues are injured and there is vascular injury (Rommens & McCormark, 2007). This approach can also be preferred in obese patients and nonunions.

Surgical Techniques Open Reduction and Plate Fixation In open reduction and internal fixation with the plate, minimal damage should be done to the soft tissues, and the periosteal blood supply should be preserved by placing the plate on the periosteum (Rommens & McCormark, 2007). Plates can be used according to the fracture configuration in the form of direct compression fracture fixation, bridging, and neutralization after interfragmentary fixation with a lag screw (Updegrove et al., 2018). With the plate fixation of humeral shaft fractures, union rates of up to 96% were reported, and complication rates are infection (2-5% in open fractures, 1-2% in closed fractures), 1% re-fracture, and 2-5% radial nerve palsy (McKee & Larsson, 2010). If a compression screw is used for plate fixation, at least 3 screws (6 through the cortex) should be applied in the proximal fragment, and 3 screws (6 through the cortex) should be applied in the distal fragment, and if a compression screw is not applied, 4 screws (8 through the cortex) should be applied in the proximal and distal fragments. Locking plate systems should be used in osteoporotic or osteopenic patients to minimize failure due to fixation materials (McKee & Larsson, 2010). Intramedullary Nail Fixation Indications: • • • • •

Segmental fractures requiring extensive soft tissue dissection, Pathological fractures, Fractures of overweight patients, Osteoporotic patients with poor bone quality (McKee & Larsson, 2010).

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Locking intramedullary humeral nails provide axial and rotational stability with distal and proximal locking screws. In the antegrade intramedullary nailing of the humeral shaft fracture, the proximal locking screws should not extend beyond the medial cortex. Screws passing through the medial cortex may damage the axillary nerve (Egol, 2015). The radial nerve is at risk in lateral to medial locking (Bono et al., 2000). Distal locking should be done from anterior to posterior or posterior to anterior (Egol, 2015). Care should be taken when performing the distal locking from lateral to medial. A mini-open incision is required to minimize iatrogenic radial nerve injury. The nail size should be well adjusted. While the long nail is being placed, an opening may occur at the distal fracture line, which may cause delayed union or nonunion. Furthermore, a long nail selected may cause impingement in the acromion (McKee & Larsson, 2010).

External Fixation External fixation is an inexpensive technique with relatively high complication rates, which is preferred in patients with high complication rates in whom intramedullary fixation and plate fixation cannot be performed (Rich et al., 1971) (Kamhin et al., 1978). Indications: • • • •

Situations in which rapid fixation is required and the patient’s condition does not allow for final treatment, Temporary fixation due to soft tissue problems (open fractures, etc.), Infected fractures (McKee & Larsson, 2010).

Complications Radial Nerve Palsy Radial nerve involvement in humeral shaft fractures is the most common nerve complication of long bone fractures (Shao et al., 2005). Various studies show that the rate of radial nerve injury related to humeral shaft fracture varies between 2% and 17% (Chang & Ilyas, 2018). Most nerve injuries heal completely (McKee & Larsson, 2010). The most common cause of secondary nerve involvement is closed approaches with or without manipulation (Shah & Bhatti, 1983). Although the treatment is controversial, if there is an open soft tissue injury (open fracture, vascular injury) and a condition requiring surgical intervention in the ipsilateral extremity, an exploration should be performed (McKee & Larsson, 2010). Furthermore, if the damage to the nerve is caused by a foreign body and broken ends, the repair will be beneficial (Foster et al., 1985). In treatment, the spontaneous recovery of primary radial nerve injury was found to be 70%, and there was no significant difference between the early surgical approach and observation (Shao et al., 2005). If there are no signs of recovery in electrophysiological studies performed within 3-4 months with observation, a delayed surgical approach is recommended (Egol, 2015). Contracture development is prevented by applying a dynamic splint to the patient after radial nerve injury (McKee & Larsson, 2010).

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Nonunion Risk factors for nonunion in humeral shaft fractures • • • • •

Intrusion of soft tissue between the fracture ends, Distraction of fracture ends, Wrong implant use, Patient’s factors (osteopenia), Infection (McKee & Larsson, 2010).

Good outcomes were reported with treatment using open reduction of the fracture and autogenic grafting after internal fixation (Ring et al., 2000).

Infection Infection after surgery of humeral shaft fractures is extremely rare. The most important reason for this is the soft tissue cover and good blood supply. For the treatment of infection, debridement should be performed if necessary, culture should be taken and appropriate antibiotic treatment should be initiated, implants should be removed if necessary and external fixation and antibiotic-impregnated materials should be used (McKee & Larsson, 2010).

Conclusion Humerus shaft fractures are not rare. Although most of the treatment consists of conservative methods, the tendency toward surgery has been increasing in recent years. Before treatment, a careful neurovascular examination should be performed. Good functional results can be obtained with appropriate diagnosis and correct treatment.

References Bono, C. M., Grossman, M. G., Hochwald, N., & Tornetta, P. 3rd. (2000). Radial and axillary nerves. Anatomic considerations for humeral fixation. Clinical Orthopaedics and Related Research, 373, 259–264. Chang, G., & Ilyas, A. M. (2018). Radial Nerve Palsy After Humeral Shaft Fractures: The Case for Early Exploration and a New Classification to Guide Treatment and Prognosis. Hand Clinics, 34(1), 105–112. https://doi.org/10.1016/j.hcl.2017.09.011. Clifford R. (2008). Humeral Shaft Fracture: Wheeless’ Textbook of Orthopaedics. Wheeless’ Textbook of Orthopaedics Www.Wheelessonline.Com. https://www.wheelessonline.com/bones/humerus/humeralshaft-fracture/. DiCicco, J. D., Mehlman, C. T., & Urse, J. S. (1993). Fracture of the shaft of the humerus secondary to muscular violence. Journal of Orthopaedic Trauma, 7(1), 90–93. https://doi.org/10.1097/00005131-19930200000017. Egol, K. A. (2015). humerus shaft fractures. In M. Themi Protopsaltis (Ed.), Handbook of fractures (5th ed., Issue 16, pp. 195–206). Wolters Kluwer Health. Foster, R. J., Dixon, G. L. J., Bach, A. W., Appleyard, R. W., & Green, T. M. (1985). Internal fixation of fractures and non-unions of the humeral shaft. Indications and results in a multi-center study. The Journal of Bone and Joint Surgery. American Volume, 67(6), 857–864.

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Gregory, P. R. (1997). Fractures in Adults. In Journal of Orthopaedic Trauma (Vol. 11, Issue 2). https://doi.org/10.1097/00005131-199702000-00017. Guse, T. R., & Ostrum, R. F. (1995). The surgical anatomy of the radial nerve around the humerus. Clinical Orthopaedics and Related Research, 320, 149–153. Jupiter, J. B. (1990). Complex non-union of the humeral diaphysis. Treatment with a medial approach, an anterior plate, and a vascularized fibular graft. The Journal of Bone and Joint Surgery. American Volume, 72(5), 701–707. Kamhin, M., Michaelson, M., & Waisbrod, H. (1978). The use of external skeletal fixation in the treatment of fractures of the humeral shaft. Injury, 9(3), 245–248. https://doi.org/10.1016/0020-1383(78)90016-5. Klenerman, L. (1966). Fractures of the shaft of the humerus. The Journal of Bone and Joint Surgery. British Volume, 48(1), 105–111. Lambert, S. (2016). Gray’s Anatomy. In S. Standring (Ed.), Gray’s anatomy (pp. 797-836.e1). Elsevier Limited. https://www.elsevier.com/books/grays-anatomy/standring/978-0-7020-5230-9. Mahabier, K. C., Van Lieshout, E. M. M., Van Der Schaaf, B. C., Roukema, G. R., Punt, B. J., Verhofstad, M. H. J., Den Hartog, D., Bolhuis, H. W., Bos, P. K., Bronkhorst, M. W. G. A., Bruijninckx, M. M. M., Den Hoed, P. T., Dwars, B. J., Goslings, J. C., Haverlag, R., Heetveld, M. J., Kerver, A. J. H., Kolkman, K. A., Leenhouts, P. A., … Zuidema, W. P. (2017). Reliability and Reproducibility of the OTA/AO Classification for Humeral Shaft Fractures. Journal of Orthopaedic Trauma, 31(3), e75–e80. https://doi.org/10.1097/BOT.0000000000000738. Marsh, J. L., Slongo, T. F., Agel, J., Broderick, J. S., Creevey, W., DeCoster, T. A., Prokuski, L., Sirkin, M. S., Ziran, B., Henley, B., & Audigé, L. (2007). Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. Journal of Orthopaedic Trauma, 21(10 Suppl), S1-133. https://doi.org/10.1097/00005131-200711101-00001. McKee, M. D., & Larsson, S. (2010). HUMERUS SHAFT FRACTURE. In P. Bucholz, Robert W.; Heckman, James D.; Court-Brown, Charles M.; Tornetta (Ed.), Rockwood And Green’s Fractures In Adults, 7th Edition (7th ed., pp. 999–1038). Lippincott Williams & Wilkins. Pollock, F. H., Drake, D., Bovill, E. G., Day, L., & Trafton, P. G. (1981). Treatment of radial neuropathy associated with fractures of the humerus. The Journal of Bone and Joint Surgery. American Volume, 63(2), 239–243. Rich, N. M., Metz, C. W. J., Hutton, J. E. J., Baugh, J. H., & Hughes, C. W. (1971). Internal versus external fixation of fractures with concomitant vascular injuries in Vietnam. The Journal of Trauma, 11(6), 463– 473. https://doi.org/10.1097/00005373-197106000-00003. Ring, D., Jupiter, J. B., Quintero, J., Sanders, R. A., & Marti, R. K. (2000). Atrophic ununited diaphyseal fractures of the humerus with a bony defect: treatment by wave-plate osteosynthesis. The Journal of Bone and Joint Surgery. British Volume, 82(6), 867–871. https://doi.org/10.1302/0301-620x.82b6.10124. Ring, D., Waters, P. M., Hotchkiss, R. N., & Kasser, J. R. (2001). Pediatric floating elbow. Journal of Pediatric Orthopedics, 21(4), 456–459. Rommens, P. M., & McCormark, R. (2007). humerus, shaft. In T. P. Rüedi (Ed.), AO principles of fracture management: Volume 1. Principles. Volume 2. Specific fractures. (pp. 595–607). Thieme Verlag. Sarmiento, A., Zagorski, J. B., Zych, G. A., Latta, L. L., & Capps, C. A. (2000). Functional bracing for the treatment of fractures of the humeral diaphysis. The Journal of Bone and Joint Surgery. American Volume, 82(4), 478–486. https://doi.org/10.2106/00004623-200004000-00003. Shah, J. J., & Bhatti, N. A. (1983). Radial nerve paralysis associated with fractures of the humerus. A review of 62 cases. Clinical Orthopaedics and Related Research, 172, 171–176. Shao, Y. C., Harwood, P., Grotz, M. R. W., Limb, D., & Giannoudis, P. V. (2005). Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. The Journal of Bone and Joint Surgery. British Volume, 87(12), 1647–1652. https://doi.org/10.1302/0301-620X.87B12.16132. Tytherleigh-Strong, G., Walls, N., & McQueen, M. M. (1998). The epidemiology of humeral shaft fractures. The Journal of Bone and Joint Surgery. British Volume, 80(2), 249–253. https://doi.org/10.1302/0301620x.80b2.8113.

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Updegrove, G. F., Mourad, W., & Abboud, J. A. (2018). Humeral shaft fractures. Journal of Shoulder and Elbow Surgery, 27(4), e87–e97. https://doi.org/10.1016/j.jse.2017.10.028. Zlotolow, D. A., Iii, L. W. C., Barron, O. A., & Glickel, S. Z. (n.d.). Surgical Exposures of the Humerus. Journal of the American Academy of Orthopaedic Surgeons, 14(13), 754–765.

Chapter 5

Distal Radius Fractures Özkan Öztürk* Department of Orthopedics and Traumatology, Erzurum City Hospital, Erzurum, Turkey

Abstract Distal radius fractures are the most common fractures of adults. These fractures are mostly treated conservatively. Assessment of stability is crucial, and “open reduction internal fixation” (ORIF) is a reasonable treatment option for unstable fractures. Good clinical results may be achieved in conservatively treated, minimally displaced fractures. Prolonged conservative treatment is abandoned day by day. If treated inappropriately, these fractures can result in acute carpal tunnel syndrome, tendon ruptures, radiocarpal arthritis, and complex regional pain syndrome, which can end in permanent disability.

Introduction Distal radius fractures (DRFs) are the most common fractures of adults (Bonafede et al., 2013). Approximately one-sixth of all bone fractures are DRFs (Kilgore et al., 2009). The mean cost of one DRF patient to the American healthcare system is $5707 (Bonafede et al., 2013). Traditionally, DRFs are treated conservatively. On the other hand, unstable fracture patterns are associated with more complications after conservative treatment (Kvernmo & Krukhaug, 2013). The patient’s age, trauma pattern, and overall health status are considered for the treatment. The ideal treatment is still controversial (Wu et al., 2020). This chapter will deal with the diagnosis and treatment of DRFs.

Epidemiology The DRF is the most common long bone fracture (Bonafede et al., 2013; MacIntyre & Dewan, 2016), and accounts for 17.5% of all adult fractures (Kilgore et al., 2009). *

Corresponding Author’s Email: [email protected].

In: Multidisciplinary Approach to Trauma Editors: Mehmet Cenk Turgut and Asli Turgut ISBN: 978-1-68507-761-7 © 2022 Nova Science Publishers, Inc.

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The DRF shows a bimodal age distribution (MacIntyre & Dewan, 2016). The first peak incidence is seen in childhood, and the second peak is seen in the elderly. Women suffer two (Stirling et al., 2018) to five times more than men (Diamantopoulos et al., 2012). DRFs are seen more often in winter (Diamantopoulos et al., 2012; Rundgren et al., 2020). Living in rural areas (Diamantopoulos et al., 2012) is shown to be a risk factor for highenergy traumas. The most critical risk factor is poor bone quality (Diamantopoulos et al., 2012; Øyen et al., 2010; Seeley et al., 1991).

Diagnosis A thorough medical history is crucial to identify the coexisting injuries. The energy of the trauma must also be questioned. DRFs after low-energy traumas may be the first sign of osteoporosis (Shah et al., 2020). Swelling around the wrist, pathological joint movements, and tenderness are the clinical signs. The angulation after displaced fractures may be visible. The neurological examination must be thoroughly done. Acute carpal tunnel syndrome is seen in 5.4% to 8.6% of the patients (Pope & Tang, 2018). Dysesthesias, severe pain in the area innervated by the median nerve, and weakness in the hypothenar muscles must alert the physician toward acute carpal tunnel syndrome. The primary diagnostic tool is conventional radiography of the wrist. At least posteroanterior and lateral views must be acquired. A beneficial posteroanterior view is acquired when the elbow and the shoulder are flexed to 90°, and the forearm is neutrally rotated. The pisiform should be superimposed on the distal pole of the scaphoid in a well-shot lateral view (Henry, 2008).

Posteroanterior View Assessment Radial Length Radial length shows the shortening of the radius after a DRF. Two perpendicular lines to the radial axis are drawn, one passing from the tip of the radial styloid, the other passing from the ulnar border of the distal articular surface (Figure 1). The radial length is the distance between these two lines, and it must be around 12 mm (Porrino et al., 2014). Radial Inclination Radial inclination is the angle between the line perpendicular to the central axis of the radius and the line passing from the ulnar and radial endpoints of the articular surface of the distal radius (Figure 1). This angle is typically 23°(13°-30°) (Porrino et al., 2014). A DRF alters this angle (Henry, 2008). Ulnar Variance Ulnar variance is the vertical distance between two perpendicular lines to the central axis, one passing from the radial sigmoid notch, and the other passing from the lateral cortical margin of the distal ulna (Figure 1).

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Articular Step-Off Articular step-off is acceptable up to 2 mm (Figure 1). The radial translation ratio, the ratio of the distal radioulnar gap to the radioulnar width of the proximal fracture fragment, is an independent risk factor for the instability of the distal radioulnar joint (Fujitani et al., 2011). The cutoff value is 15% (Fujitani et al., 2011).

Lateral View Assessment Volar Tilt The volar tilt is the angle between the line perpendicular to the central axis of the radius and the line connecting the volar and dorsal tips of the articular surface of the distal radius (Figure 1). The standard value of volar tilt is around 11°. CT is helpful to inspect joint congruency, and MRI is helpful to evaluate the triangular fibrocartilage complex (TFCC) and periarticular ligaments.

Figure 1. Several measurement parameters of distal radius fractures. Taken from (Blakeney, 2010).

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Treatment Some classification systems were traditionally used to classify DRFs. Frykman, Fernandes, Malone, and AO are the most famous classification systems for DRFs. On the other hand, these were neither reliable nor reproducible (Flikkilä et al., 1998; Kural et al., 2010; Küçük et al., 2013; Jayakumar et al., 2017; Yinjie et al., 2020; Bergvall et al., 2021). These classification systems are based on the involvement of radiocarpal and distal radioulnar joints, the coexistence of ulnar styloid fractures, the comminution of the fracture, and the mechanism of the trauma. These systems do not address age and bone density, which are both critical factors for prognosis. Since these systems have minor reproducibility and little prognostic value, we will not give the details. The concept of stability is essential to understand the basics of the treatment. In 1989, LaFontaine et al. suggested a dorsal angulation of more than 20°, dorsal comminution, intraarticular fracture, age older than 60, and associated ulnar injury as factors of instability (Lafontaine et al., 1989). LaFontaine claimed that the presence of three of these five criteria predicts secondary displacement, and these patients are candidates for surgery (Lafontaine et al., 1989). Other studies separately evaluated these criteria. According to Nesbitt et al., only age is associated with the risk of secondary displacement (Nesbitt et al., 2004). Wadsten et al. showed that cortical comminution is an important factor of instability (Wadsten et al., 2014). Restoring the volar cortical continuity is shown to be an important predictor of possible secondary displacement (LaMartina et al., 2015). Ulnar variance and volar tilt were found to be important radiological parameters for good functional outcomes after conservative treatment (Dario et al., 2014). According to a systemic review, age, female gender, and dorsal comminution are the risk factors, while associated ulna fracture or intra-articular involvement is not (Walenkamp et al., 2016). The severity of ulnar variance (Jianda et al., 2019; Kodama et al., 2014), radial height (Cai et al., 2015), and volar tilt (Cai et al., 2015; Kodama et al., 2014) are associated with poor outcomes after conservative treatment. Older men have a worse prognosis after DRF (Egund et al., 2020). Preexisting carpal or carpometacarpal joint arthritis is not associated with worse outcomes (Davies et al., 2017). Carpal malalignment is found to be related to the worst outcomes (Batra et al., 2008; Gupta et al., 2002). According to the American Academy of Orthopedic Surgeons Guideline in 2010, the indications for surgery are (Lichtman et al., 2010): 1. Fractures with post-reduction radial shortening >3 mm, 2. Dorsal tilt >10 degrees, 3. Intra-articular displacement or step-off >2 mm.

Conservative Treatment Closed reduction is done with a three-step procedure. In the first step, the fracture is disimpacted by increasing the initial deformity. The second step is the reduction done with the opposite maneuver. The final maneuver is locking the reduction by taking the patient’s forearm

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into pronation. This technique, also called the manipulation technique, requires an assistant for traction. If a DRF is dorsally angulated, then the first maneuver is forcing the wrist dorsally, the second is manipulating the distal fragment into the volar and ulnar position. After the reduction, the forearm is taken into pronation (Fernandez, 2005). There is wide agreement on the necessity of casting after closed reduction, but the method of casting is a controversial issue. In the conservative treatment of dorsally-angulated DRFs, the volar flexion and ulnar deviation cast (VFUDC), which was first described by Cotton in 1910 (Raittio et al., 2020), was found to be less successful than the functional cast position, characterized by 0-20° of dorsal flexion (Raittio et al., 2020). Casting in dorsiflexion may be superior to neutral and palmar flexion (Baruah et al., 2015). However, the difference is not big enough to affect the patients’ daily lives (van Delft et al., 2021). Functional bracing in supination was found to be superior to dorsal splinting in terms of redislocation and clinical outcome scores (Bünger et al., 1984; Sarmiento et al., 1980; Sarmiento & Latta, 2014), but some authors claimed that the supine position is associated with more redislocation (Wahlström, 1982). Short arm casts are as effective as long arm casts in terms of preventing redislocation (Gamba et al., 2017; Maluta et al., 2019; Okamura et al., 2021; Park et al., 2017). Duration of treatment is another issue. Minimally-displaced fractures tend to be stable, and most of the loss of reduction occurs in the first two weeks after the fracture (Solgaard, 1986). Christensen et al. reported that casting for three weeks is equal to casting for five weeks in the minimally-displaced DRF patients (Christensen et al., 1995). Bentohami et al. also reported similar findings (Bentohami et al., 2019). On the other hand, casting for ten days instead of one month in displaced and reduced DRFs is discouraged (Christersson et al., 2018). We can conclude that three weeks for nondisplaced fractures and four weeks for displaced and reduced fractures are enough.

Surgical Treatment Closed reduction and percutaneous pinning (CRPP), open reduction and internal fixation (ORIF), and external fixation are surgical options. CRPP may be arthroscopy-assisted (the Rayhack technique). Dorsal or volar plates may be used in ORIF. ORIF yields better surgical outcomes than external fixation (Wang et al., 2013; Wei et al., 2012; Xie et al., 2013), but better grip strength is achieved with external fixation (Wei et al., 2012). ORIF is associated with fewer complications than external fixation (Wei et al., 2012; Xie et al., 2013). ORIF is also associated with a more rapid recovery (Xie et al., 2013). ORIF yields better clinical results and fewer infections compared to CRPP (Zong et al., 2015), but these better results may not be clinically important (Chaudhry et al., 2015). On the other hand, CRPP is shown to be a viable surgical option, and ORIF is suggested for complex fractures (Brennan et al., 2016). The conflicting literature was assessed in a systemic review of overlapping meta-analyses, and the authors concluded that ORIF is superior to CRPP and external fixation (Zhang et al., 2016).

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Surgical Technique The author performs the surgery under regional block and tourniquet. The skin is dissected along with the radial border of the flexor carpi radialis tendon. After the skin incision, the tendon is retracted to the ulnar side. Care is taken to protect the radial artery and the palmar branch of the median nerve while deepening the incision between the flexor pollucis longus tendon and the radial artery. Then the pronator quadratus muscle is elevated from the radial border, and after that the distal radius is exposed. The fracture line is disimpacted by traction and with a periosteal elevator if needed. Releasing the brachioradialis muscle from its insertion helps reduction. A Kirchner wire is temporarily inserted from the tip of the radial styloid. After that, a volar locking plate is placed appropriately. Its distal end must be on the watershed line of the distal radius. A cortical screw is inserted from the oblong hole and tightened after confirming the plate’s position with fluoroscopy. At least three distal and three proximal screws must be inserted. The joint line must be checked with fluoroscopy for the potential penetration of the joint. The wound is appropriately closed.

Postoperative Care The patient is encouraged to mobilize the fingers, elbow, and shoulder immediately. One week may be enough for the dissolution of edema and initiating active movement. Active wrist and forearm motion is initiated when the patient is comfortable. After the sixth week, movements against resistance are initiated.

Complications Carpal tunnel syndrome may be observed immediately after the trauma or may emerge after weeks. Acute carpal tunnel syndrome was reported in 5.4% to 8.6% of the distal radius fractures (Niver & Ilyas, 2012). This complication may be associated with malunion, chronic edema, or prolonged immobilization in the Cotton-Loder position (Niver & Ilyas, 2012). The treatment is immediate surgical release (Schnetzler, 2008). Extensor pollucis longus tendon rupture is seen in 5% of the patients (Roth et al., 2012) and mostly seen after conservative treatment (Jupiter & Fernandez, 2002). The preferred treatment is extensor indicis proprius tendon transfer to the extensor longus tendon (Magnussen et al., 1990). Flexor pollucis longus tendon rupture may be seen after very distal volar plate positioning (Kitay et al., 2013). Dorsal angulation, joint incongruity, positive ulnar variance, and increased radial inclination are associated with radiocarpal arthritis (Lameijer et al., 2017). Its prevalence is reported as 37% (Lameijer et al., 2017). Malunion and nonunion are other complications. They can alter the biomechanical balance of the wrist (Nishiwaki et al., 2014), and are treated with an osteotomy (Schurko et al., 2020). Complex regional pain syndrome is a frequently seen complication after conservative or surgical treatment of DRFs. Its incidence is reported as 15% (Farzad et al., 2018). Anxiety

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(Dilek et al., 2012), high energy injuries (Roh et al., 2014), female gender (Roh et al., 2014), fibromyalgia (Lipman et al., 2019) and low levels of serum Vitamin D (Lee et al., 2020) are some of the risk factors. Low-dose prednisolone is effective in treatment (Atalay et al., 2014; Kalita et al., 2006). Calcium channel blockers, α-blockers, pregabalin, gabapentin, and some antiepileptics are other treatment options (Li et al., 2010). Stellate ganglion blockade is another option for the treatment (Yucel et al., 2009). 500 mg/day oral vitamin C uptake for fifty days can prevent the complex regional pain syndrome after DRFs (Zollinger et al., 2007).

Conclusion Distal radius fractures are seen daily by emergency physicians, orthopedic surgeons, and family physicians. This frequently seen fracture must be carefully managed. If the fracture is thought to be unstable or associated with joint incongruity, then it must be surgically treated. Daily vitamin C uptake may prevent complex regional pain syndrome. Physicians and surgeons must be careful about the complications of the conservative or surgical treatment.

References Atalay, N. S., Ercidogan, O., Akkaya, N., & Sahin, F. (2014). Prednisolone in complex regional pain syndrome. Pain Physician, 17(2), 179–185. Baruah, R. K., Islam, M., & Haque, R. (2015). Immobilisation of extra-articular distal radius fractures (Colles type) in dorsiflexion. The functional and anatomical outcome. Journal of Clinical Orthopaedics and Trauma, 6(3), 167–172. https://doi.org/10.1016/j.jcot.2015.03.006. Batra, S., Debnath, U., & Kanvinde, R. (2008). Can carpal malalignment predict early and late instability in nonoperatively managed distal radius fractures? International Orthopaedics, 32(5), 685–691. https://doi.org/10.1007/s00264-007-0386-x. Bentohami, A., van Delft, E. A. K., Vermeulen, J., Sosef, N. L., de Korte, N., Bijlsma, T. S., Goslings, J. C., & Schep, N. W. L. (2019). Non- or Minimally Displaced Distal Radial Fractures in Adult Patients: Three Weeks versus Five Weeks of Cast Immobilization-A Randomized Controlled Trial. Journal of Wrist Surgery, 8(1), 43–48. https://doi.org/10.1055/s-0038-1668155. Bergvall, M., Bergdahl, C., Ekholm, C., & Wennergren, D. (2021). Validity of classification of distal radial fractures in the Swedish fracture register. BMC Musculoskeletal Disorders, 22(1), 587. https://doi.org/ 10.1186/s12891-021-04473-5. Blakeney, W. (2010). Stabilization and treatment of Colles’ fractures in elderly patients. Clinical Interventions in Aging, 5, 337–344. https://doi.org/10.2147/CIA.S10042. Bonafede, M., Espindle, D., & Bower, A. G. (2013). The direct and indirect costs of long bone fractures in a working age US population. Journal of Medical Economics, 16(1), 169–178. https://doi.org/10.3111/ 13696998.2012.737391. Brennan, S. A., Kiernan, C., Beecher, S., O’Reilly, R. T., Devitt, B. M., Kearns, S. R., & O’Sullivan, M. E. (2016). Volar plate versus k-wire fixation of distal radius fractures. Injury, 47(2), 372–376. https://doi.org/10.1016/j.injury.2015.08.040. Bünger, C., Sølund, K., & Rasmussen, P. (1984). Early results after Colles’ fracture: functional bracing in supination vs dorsal plaster immobilization. Archives of Orthopaedic and Traumatic Surgery. Archiv Fur Orthopadische Und Unfall-Chirurgie, 103(4), 251–256. https://doi.org/10.1007/BF00387330. Cai, L., Zhu, S., Du, S., Lin, W., Wang, T., Lu, D., & Chen, H. (2015). The relationship between radiographic parameters and clinical outcome of distal radius fractures in elderly patients. Orthopaedics & Traumatology, Surgery & Research : OTSR, 101(7), 827–831. https://doi.org/10.1016/ j.otsr.2015.04.011.

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Chaudhry, H., Kleinlugtenbelt, Y. V, Mundi, R., Ristevski, B., Goslings, J. C., & Bhandari, M. (2015). Are Volar Locking Plates Superior to Percutaneous K-wires for Distal Radius Fractures? A Meta-analysis. Clinical Orthopaedics and Related Research, 473(9), 3017–3027. https://doi.org/10.1007/s11999-0154347-1. Christensen, O. M., Christiansen, T. G., Krasheninnikoff, M., & Hansen, F. F. (1995). Length of immobilisation after fractures of the distal radius. International Orthopaedics, 19(1), 26–29. https://doi.org/10.1007/ BF00184910. Christersson, A., Larsson, S., & Sandén, B. (2018). Clinical Outcome after Plaster Cast Fixation for 10 Days Versus 1 Month in Reduced Distal Radius Fractures: A Prospective Randomized Study. Scandinavian Journal of Surgery : SJS : Official Organ for the Finnish Surgical Society and the Scandinavian Surgical Society, 107(1), 82–90. https://doi.org/10.1177/1457496917731184. Dario, P., Matteo, G., Carolina, C., Marco, G., Cristina, D., Daniele, F., & Andrea, F. (2014). Is it really necessary to restore radial anatomic parameters after distal radius fractures? Injury, 45 Suppl 6, S21-6. https://doi.org/10.1016/j.injury.2014.10.018. Davies, J. H., Centomo, H., Leduc, S., Beaumont, P., Laflamme, G.-Y., & Rouleau, D. M. (2017). Preexisting Carpal and Carpometacarpal Osteoarthritis Has No Impact on Function after Distal Radius Fractures. Journal of Wrist Surgery, 6(4), 301–306. https://doi.org/10.1055/s-0037-1602800. Diamantopoulos, A. P., Rohde, G., Johnsrud, I., Skoie, I. M., Hochberg, M., & Haugeberg, G. (2012). The epidemiology of low- and high-energy distal radius fracture in middle-aged and elderly men and women in Southern Norway. PloS One, 7(8), e43367. https://doi.org/10.1371/journal.pone.0043367. Dilek, B., Yemez, B., Kizil, R., Kartal, E., Gulbahar, S., Sari, O., & Akalin, E. (2012). Anxious personality is a risk factor for developing complex regional pain syndrome type I. Rheumatology International, 32(4), 915–920. https://doi.org/10.1007/s00296-010-1714-9. Egund, L., McGuigan, F. E., Egund, N., Besjakov, J., & Åkesson, K. E. (2020). Patient-related outcome, fracture displacement and bone mineral density following distal radius fracture in young and older men. BMC Musculoskeletal Disorders, 21(1), 816. https://doi.org/10.1186/s12891-020-03843-9. Farzad, M., Layeghi, F., Hosseini, A., Dianat, A., Ahrari, N., Rassafiani, M., & Mirzaei, H. (2018). Investigate the Effect of Psychological Factors in Development of Complex Regional Pain Syndrome Type I in Patients with Fracture of the Distal Radius: A Prospective Study. The Journal of Hand Surgery AsianPacific Volume, 23(4), 554–561. https://doi.org/10.1142/S2424835518500571. Fernandez, D. L. (2005). Closed manipulation and casting of distal radius fractures. Hand Clinics, 21(3), 307– 316. https://doi.org/10.1016/j.hcl.2005.02.004. Flikkilä, T., Nikkola-Sihto, A., Kaarela, O., Pääkkö, E., & Raatikainen, T. (1998). Poor interobserver reliability of AO classification of fractures of the distal radius. Additional computed tomography is of minor value. The Journal of Bone and Joint Surgery. British Volume, 80(4), 670–672. https://doi.org/10.1302/0301620x.80b4.8511. Fujitani, R., Omokawa, S., Akahane, M., Iida, A., Ono, H., & Tanaka, Y. (2011). Predictors of distal radioulnar joint instability in distal radius fractures. The Journal of Hand Surgery, 36(12), 1919–1925. https://doi. org/10.1016/j.jhsa.2011.09.004. Gamba, C., Fernandez, F. A. M., Llavall, M. C., Diez, X. L., & Perez, F. S. (2017). Which immobilization is better for distal radius fracture? A prospective randomized trial. International Orthopaedics, 41(9), 1723– 1727. https://doi.org/10.1007/s00264-017-3518-y. Gupta, A., Batra, S., Jain, P., & Sharma, S. K. (2002). Carpal alignment in distal radial fractures. BMC Musculoskeletal Disorders, 3(1), 14. https://doi.org/10.1186/1471-2474-3-14. Henry, M. H. (2008). Distal radius fractures: current concepts. The Journal of Hand Surgery, 33(7), 1215– 1227. https://doi.org/10.1016/j.jhsa.2008.07.013. Jayakumar, P., Teunis, T., Giménez, B. B., Verstreken, F., Di Mascio, L., & Jupiter, J. B. (2017). AO Distal Radius Fracture Classification: Global Perspective on Observer Agreement. Journal of Wrist Surgery, 6(1), 46–53. https://doi.org/10.1055/s-0036-1587316. Jianda, X., Qu, Y., Huan, L., Chen, Q., Zheng, C., Bin, W., & Pengfei, S. (2019). The severity of ulnar variance compared with contralateral hand: its significance on postoperative wrist function in patients with distal radius fracture. Scientific Reports, 9(1), 2226. https://doi.org/10.1038/s41598-018-36616-5.

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Seeley, D. G., Browner, W. S., Nevitt, M. C., Genant, H. K., Scott, J. C., & Cummings, S. R. (1991). Which Fractures Are Associated with Low Appendicular Bone Mass in Elderly Women? Annals of Internal Medicine, 115(11), 837–842. https://doi.org/10.7326/0003-4819-115-11-837. Shah, G. M., Gong, H. S., Chae, Y. J., Kim, Y. S., Kim, J., & Baek, G. H. (2020). Evaluation and Management of Osteoporosis and Sarcopenia in Patients with Distal Radius Fractures. Clinics in Orthopedic Surgery, 12(1), 9–21. https://doi.org/10.4055/cios.2020.12.1.9. Solgaard, S. (1986). Early displacement of distal radius fracture. Acta Orthopaedica Scandinavica, 57(3), 229– 231. https://doi.org/10.3109/17453678608994383. Stirling, E. R. B., Johnson, N. A., & Dias, J. J. (2018). Epidemiology of distal radius fractures in a geographically defined adult population. The Journal of Hand Surgery, European Volume, 43(9), 974– 982. https://doi.org/10.1177/1753193418786378. van Delft, E. A. K., van Gelder, T. G., Vermeulen, J., Schep, N. W. L., & Bloemers, F. W. (2021). Does position of the wrist during cast immobilisation in patients with distal radius fractures affect outcome? European Journal of Trauma and Emergency Surgery : Official Publication of the European Trauma Society. https://doi.org/10.1007/s00068-021-01751-8. Wadsten, M. Å., Sayed-Noor, A. S., Englund, E., Buttazzoni, G. G., & Sjödén, G. O. (2014). Cortical comminution in distal radial fractures can predict the radiological outcome. The Bone & Joint Journal, 96-B(7), 978–983. https://doi.org/10.1302/0301-620X.96B7.32728. Wahlström, O. (1982). Treatment of Colles’ fracture. A prospective comparison of three different positions of immobilization. Acta Orthopaedica Scandinavica, 53(2), 225–228. https://doi.org/10.3109/174536782 08992206. Walenkamp, M. M. J., Aydin, S., Mulders, M. A. M., Goslings, J. C., & Schep, N. W. L. (2016). Predictors of unstable distal radius fractures: a systematic review and meta-analysis. The Journal of Hand Surgery, European Volume, 41(5), 501–515. https://doi.org/10.1177/1753193415604795. Wang, J., Yang, Y., Ma, J., Xing, D., Zhu, S., Ma, B., Chen, Y., & Ma, X. (2013). Open reduction and internal fixation versus external fixation for unstable distal radial fractures: a meta-analysis. Orthopaedics & Traumatology, Surgery & Research : OTSR, 99(3), 321–331. https://doi.org/10.1016/ j.otsr.2012.11.018. Wei, D. H., Poolman, R. W., Bhandari, M., Wolfe, V. M., & Rosenwasser, M. P. (2012). External fixation versus internal fixation for unstable distal radius fractures: a systematic review and meta-analysis of comparative clinical trials. Journal of Orthopaedic Trauma, 26(7), 386–394. https://doi.org/10.1097/ BOT.0b013e318225f63c. Wu, M., Li, X., Li, J., & Chen, Y. (2020). Operative vs conservative treatment in distal radius fractures: A protocol. Medicine, 99(29), e21250. https://doi.org/10.1097/MD.0000000000021250. Xie, X., Xie, X., Qin, H., Shen, L., & Zhang, C. (2013). Comparison of internal and external fixation of distal radius fractures. Acta Orthopaedica, 84(3), 286–291. https://doi.org/10.3109/17453674.2013.792029. Yinjie, Y., Gen, W., Hongbo, W., Chongqing, X., Fan, Z., Yanqi, F., Xuequn, W., & Wen, M. (2020). A retrospective evaluation of reliability and reproducibility of Arbeitsgemeinschaftfür Osteosynthesefragen classification and Fernandez classification for distal radius fracture. Medicine, 99(2), e18508. https://doi.org/10.1097/MD.0000000000018508. Yucel, I., Demiraran, Y., Ozturan, K., & Degirmenci, E. (2009). Complex regional pain syndrome type I: efficacy of stellate ganglion blockade. Journal of Orthopaedics and Traumatology, 10(4), 179–183. https://doi.org/10.1007/s10195-009-0071-5. Zhang, Q., Liu, F., Xiao, Z., Li, Z., Wang, B., Dong, J., Han, Y., Zhou, D., & Li, J. (2016). Internal Versus External Fixation for the Treatment of Distal Radial Fractures: A Systematic Review of Overlapping Meta-Analyses. Medicine, 95(9), e2945. https://doi.org/10.1097/MD.0000000000002945. Zollinger, P. E., Tuinebreijer, W. E., Breederveld, R. S., & Kreis, R. W. (2007). Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter doseresponse study. The Journal of Bone and Joint Surgery. American Volume, 89(7), 1424–1431. https://doi.org/10.2106/JBJS.F.01147. Zong, S.-L., Kan, S.-L., Su, L.-X., & Wang, B. (2015). Meta-analysis for dorsally displaced distal radius fracture fixation: volar locking plate versus percutaneous Kirschner wires. Journal of Orthopaedic Surgery and Research, 10, 108. https://doi.org/10.1186/s13018-015-0252-2.

Chapter 6

Forearm Fractures Nasuhi Altay, MD Department of Orthopedics and Traumatology, University of Health Sciences Erzurum Region Education and Research Hospital, Erzurum, Turkey

Abstract In this chapter, we will talk about forearm fractures, which are the most common injuries in the population. Forearm fractures account for approximately 1% of all fractures. Forearm injuries are usually caused by falls, sports injuries, and motor vehicle accidents. The forearm has a complex structure, and the deterioration of this anatomical structure significantly affects the functions of the hand and elbow joints. The diagnosis of forearm fractures can be easily made in the presence of findings such as pain, deformity, and loss of function. X-ray and tomography are often used for diagnosis. While conservative treatment is preferred in the treatment of pediatric forearm fractures, surgical treatment is preferred in the treatment of adult forearm fractures. In conservative treatment, closed reduction and casting in a neutral position are performed. Even if adequate reduction is achieved in the conservative treatment of adult forearm fractures, it is difficult to maintain stabilization with the pulling effect of strong muscle groups. Since a high rate of nonunion and limitation of movement develops with conservative treatment, surgical treatment is usually required. Anatomic reduction and absolute stabilization are required because angular and malunion of the radius and ulna can cause functional deficiencies. Intramedullary nailing and plate screw osteosynthesis methods can be used in surgical treatment. Nailing is a more non-invasive method preferred in segmental comminuted fractures. Fixation with a plate screw provides an excellent fixation in terms of anatomical reduction and stability and is considered as the gold standard method due to its high union rates. Surgical treatment includes complications such as compartment syndrome, infection, nonunion, malunion and refracture. Today, open reduction and plate fixation give satisfactory results in terms of union and functional adequacy of forearm fractures.



Corresponding Author’s Email: [email protected].

In: Multidisciplinary Approach to Trauma Editors: Mehmet Cenk Turgut and Asli Turgut ISBN: 978-1-68507-761-7 © 2022 Nova Science Publishers, Inc.

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Introduction Forearm (radius and ulna) fractures are some of the most common orthopedic injuries. The treatment of shaft fractures of the forearm, which is the attachment site of many muscles and tendons, is important because these fractures may cause limitation of flexion, extension, and rotation. The anatomical structure of the radius and ulna allows pronation and supination movements of the forearm. For this reason, any deformity in the anatomical structure of the radius and ulna can cause significant limitation in the movements of the wrist and elbow (Matthews, Kaufer, & Garver, 1982). The distortion or angulation of the normal inclination of the radius can cause decreased rotation of the forearm, arthrosis, and instability in the distal radioulnar joint (Schemitsch & Richards, 1992). The radius and ulna articulate with the humerus on the proximal side and the carpal bones on the distal side (Weiss & Hastings, 1992). Therefore, in the case of a fracture of any of the forearm bones, the proximal radioulnar and distal radioulnar joints should be evaluated (Arias & Varacallo, 2020).

Etiology Forearm fractures can occur by many different mechanisms, with direct trauma being the most common. They usually occur because of an impact that is perpendicular to the axis of the forearm or direct impact. High-energy trauma is the most common cause in young adult patients with high bone quality. Falls from height, sports injuries and traffic accidents are the most common causes of forearm fractures. Traffic accidents are often accompanied by open fractures and soft tissue injuries. Firearm injuries are other high-energy traumas in which bone and soft tissue loss, open comminuted bone fractures and neurovascular injury are seen (Osterhoff, Morgan, & Shefelbine, 2016). Low bone quality due to osteoporosis is the most common cause of forearm fractures in low-energy traumas such as falling from a height in elderly patients. In addition, pathological bone diseases and metastatic tumors can also cause forearm fractures in elderly patients (Drake, 2013).

Evaluation Pain, deformity, edema, and loss of function in the wrist and forearm can be observed clinically in forearm fractures. The wrist and elbow joints should also be evaluated in forearm traumas. Comprehensive neurovascular examination of the entire extremity should be performed. The circulation of the fingers (capillary refill) and the presence of radial and ulnar pulses should be evaluated and followed for compartment syndrome in the presence of excessive edema. Sensory and motor function of the fingers should be evaluated in the neurological examination. Care should be taken in terms of neurovascular injury and infection in firearm wounds and open fractures (Duckworth et al., 2012).

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Standard AP (anteroposterior) and lateral radiographs should be taken in the radiological evaluation of forearm fractures. CT examination can be performed in the presence of comminuted or intra-articular fractures.

(A)

(B)

Figure 1. Lateral (A) and AP (B) x-rays of the forearm showing a diaphyseal ulna fracture (Operative Orthopedics of the Upper Extremity, 2014).

Treatment Forearm fractures can be treated conservatively and surgically. The main goal of treatment is to restore the pronation and supination of the forearm by protecting the radioulnar joint and providing its length. The treatment of the fracture is decided depending on the age of the patient, the type of fracture, the presence of soft tissue damage and neurovascular injury. Non-operative treatment is the most preferred method in pediatric forearm fractures and successful results can be obtained. Contrary to this, surgical treatment is recommended in the treatment of adult forearm fractures since the success rate of non-operative treatment is low. Surgical fixation is often required in forearm double fractures in adults since angulation and shortness of the forearm can develop even in minimally displaced fractures of the radius and ulna (Crenshaw & Perez, 2003). Although nonsurgical treatment of forearm fractures in adults is rare, isolated nondisplaced ulna shaft fractures or minimally displaced fractures can be treated conservatively with a cast. However, absolute surgical fixation is required in isolated radius shaft fractures to provide radial inclination and avoid a rotation defect. The AO classification is frequently used in forearm fractures (Müler, 1990). Type A fractures include simple fractures of the ulna, radius, or both; A1 describes an isolated fracture of the ulna and A2 describes an isolated fracture of the radius. In both groups,

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.1, .2 and .3 are used for oblique fractures, transverse fractures, and fractures with dislocations, respectively (A1.3 describes a Monteggia fracture and A2.3 describes a Galeazzi fracture). Type B fractures are those with butterfly fragments. Likewise, B1 describes an isolated fracture of the ulna, B2 describes an isolated fracture of the radius and B3 describes a fracture including both the ulna and radius. Similarly, .1, .2 and .3 define intact fragment, comminuted fragment and fracture with dislocation, respectively. Type C fractures are complex fractures. C1 describes an isolated fracture of the ulna, C2 describes an isolated fracture of the radius and C3 describes a fracture including both the ulna and radius. C1.1 defines an isolated segmental ulna fracture, C1.2 defines an accompanying radius fracture and C1.3 defines a comminuted ulna fracture. C2.1, C2.2, and C2.3 define an isolated segmental radius fracture, an accompanying ulna fracture, and a comminuted radius fracture, respectively. C3.1, C3.2 and C3.3 indicate the presence of segmented fractures in both bones, a segmental fracture in one bone and a comminuted fracture in the other, and an irregular comminuted fracture of two bones, respectively. Since adult forearm fractures require surgical treatment, immobilization should be applied before surgical intervention. A splint with the patient’s elbow in 90 degrees of flexion and the forearm in a neutral position will be suitable for immobilization. Open fractures should be reduced before splinting, the wound should be thoroughly irrigated, antibiotics should be started, and temporary fixation should be made with an external fixator if necessary. The timing of surgical treatment is determined by factors such as the type of fracture (open-closed), neurovascular injury due to fracture, and compartment syndrome. Forearm fractures in boys over 12 years old and girls over 10 years old, whose bone maturation is nearly completed, are also treated just like in adults. In the presence of almost complete anatomical reduction in elderly patients, follow up with cast treatment can be used. Although the surgical treatment of isolated ulna shaft fractures is controversial, surgical treatment is preferred in cases of more than 10 degrees of angulation and more than 50% bone apposition.

Figure 2. AP x-ray of the both-bone forearm fracture (Operative Orthopedics of the Upper Extremity, 2014).

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Intramedullary nailing and open reduction-internal fixation techniques are used in the surgical treatment of forearm fractures (Zhao et al., 2017). Although a short surgery duration and fewer wound site problems are advantages of the intramedullary nailing technique, the absence of radial bowing and rotation can be counted among the disadvantages. Open reduction-internal fixation treatment of forearm fractures is the gold standard method because of minimal radial bowing and rotational defects (Iacobellis & Biz, 2014). External fixators can be used in the treatment of open fractures of the forearm with severe soft tissue damage or bone loss. They can also be preferred in patients with multiple traumas for short-term temporary fixation. In addition to being a minimally invasive technique, intramedullary nailing has important advantages in being used in forearm segmental fractures, pathological fractures and refracture after plate removal. However, they are not preferred due to their high malunion rate, nonunion rate at around 20%, and poor functional results (Lee et al., 2008). Open reduction-internal fixation is the most used technique because of the reduction of fractured parts, good anatomical alignment, early initiation of motion, and better functional results. It gives near perfect results with a union rate of around 90% (Goldfarb et al., 2005). The surgical approach of ulna shaft fractures is performed by plate fixation from the dorsal or volar face between the extensor carpi ulnaris and the flexor carpi ulnaris. Plate fixation is applied to radial shaft fractures with the volar Henry approach.

Accompanying Injuries Galeazzi Fracture This is a type of fracture in which a radius distal one-third shaft fracture is accompanied by distal radioulnar joint dislocation. Closed reduction and cast application are not appropriate treatment methods. The distal radioulnar joint is reduced by open reduction and plate fixation of the radius shaft fracture.

(A)

(B)

Figure 3. Lateral (A) and AP (B) x-ray of the forearm showing a Galeazzi fracture (Operative Techniques Orthopedic Trauma Surgery, 2020).

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(A)

(B)

Figure 4. AP (A) and lateral (B) x-rays of the forearm show a Monteggia fracture (Atlas of Upper Extremity Trauma, 2018).

Monteggia Fracture This is a type of forearm fracture in which an ulna fracture and radial head dislocation occur together. While it can be treated with closed reduction and cast fixation in children, surgical treatment is required in adults. It occurs due to reasons such as a direct impact to the forearm from the ulnar side, falling in a hyperextension or hyper pronation position, and the protrusion of the radial head by the biceps in supination. Monteggia fractures are classified into 4 types by Bado. Bado classification: • • • •

Type I, fracture of the ulnar shaft and anterior dislocation of the radial head, Type II, fracture of the ulnar shaft and posterior dislocation of the radial head, Type III, fracture of the ulnar shaft and lateral dislocation of the radial head, Type IV fracture of the ulnar shaft and fractured dislocation of the radial head.

Radial head dislocation in Monteggia fractures is usually reduced by anatomical fixation of the ulna fracture. Persistent and recurrent subluxation of the radial head appears because of the non-anatomical fixation of the ulna fracture.

Prognosis Since the osteosynthesis with a plate of forearm bone fractures provides a rigid fixation, movement starts in the elbow and wrist joints, usually within the first week after the operation. There may be a slight decrease in joint range of motion and muscle strength (Chapman, Gordon, & Zissimos, 1989). However, the prognosis of forearm fractures is generally good, as union occurs within approximately two months after surgical fixation (Droll et al., 2007).

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Complications Complications such as bleeding, infection, nonunion, malunion, compartment syndrome, radioulnar synostosis and neurovascular injury may occur after the surgical treatment of forearm double fractures (Ring et al., 2004, Bauer, Arand, & Mutschler, 1991). Pre- and postoperative blood and wound follow-up, antibiotic therapy, and circulation follow-up can be used to prevent complications in open fractures. Compartment syndrome is a serious complication and fasciotomy should be performed urgently if it is diagnosed before or after the operation. Bone graft can be used to reduce the rate of nonunion in comminuted or segmental bone fractures. Limitation of forearm functions and pronation-supination can be seen in malunion cases. Elbow and wrist injuries that may accompany forearm fractures and possible complications should be considered before surgery (Ayzenberg et al., 2016, Kim et al., 2015).

Conclusion Forearm double fractures are among the most common fractures in children and adults. They can be treated with closed reduction and cast in uncomplicated cases during childhood. Forearm fractures in adults often require surgical treatment. In open fractures, early wound irrigation should be performed, and antibiotic therapy should be started. Detailed soft tissue and neurovascular examination should be performed. Precautions should be taken against surgical complications, especially against compartment syndrome. Intramedullary nailing is a good treatment modality in patients with segmental, comminuted fractures and soft tissue damage, except for the possibility of forearm rotation defect and nonunion. Today, the most used method, accepted as the gold standard for the surgical treatment of forearm fractures, is plate and screw fixation. It has advantages such as an almost complete anatomical reduction, high union rates, and early initiation of movement. The importance of postoperative physical therapy, exercise and compliance with follow-up should be explained in detail to the patients for returning to pre-surgical physical activities.

References Arias, D. G., Varacallo, M. (2020). Anatomy, Shoulder and Upper Limb, Distal Radio-Ulnar Joint. Ayzenberg, M., Tiedeken, N. C., Arango, D. E., Raphael, J. (2016). Acute Both Bone Fracture in a Chronic Contracted Forearm. J. Orthop. Case Rep. 6(5), 55-58. Bauer, G., Arand, M., Mutschler, W. (1991). Post-traumatic radioulnar synostosis after forearm fracture osteosynthesis. Arch. Orthop. Trauma Surg. 110(3), 142-5. Chapman, M. W., Gordon, J. E., Zissimos, A. G. (1989). Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna. J. Bone Joint Surg. Am. 71(2), 159 69. Crenshaw, A. H., Perez, E. A. (2003). Fractures of the shoulder, arm, and forearm. Campbell’s Operative Orthopaedics. 3, 3371-460. Drake, M. T. (2013). Osteoporosis and cancer. Curr. Osteoporos. Rep. 11(3), 163-70. Droll, K. P., Perna, P., Potter, J., Harniman, E., Schemitsch, E. H., McKee, M. D. (2007). Outcomes following plate fixation of fractures of both bones of the forearm in adults. J. Bone Joint Surg. Am. 89(12), 261924.

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Duckworth, A. D., Mitchell, S. E., Molyneux, S. G., White, T. O., Court-Brown, C. M., McQueen, M. M. (2012). Acute compartment syndrome of the forearm. J. Bone Joint Surg. Am. 94(10), e63. Edwards, P. H., & Grana, W. A. (2001). Anterior cruciate ligament reconstruction in the immature athlete: longterm results of intra-articular reconstruction. Am. J. Knee Surg. 14(4), 232-237. Goldfarb, G. A. et al. (2005). Fuctional outcome after fracture of both bones of the forearm, JBJS. 3, 374-9. Iacobellis, C., Biz, C. (2014). Plating in diaphyseal fractures of the forearm. Acta Biomed. 84(3), 202-11. Kim, S. B., Heo, Y. M., Yi, J. W., Lee, J. B., Lim, B. G. (2015). Shaft Fractures of Both Forearm Bones: The Outcomes of Surgical Treatment with Plating Only and Combined Plating and Intramedullary Nailing. Clin. Orthop. Surg. 7(3), 282-90. Lee et al. (2008). Interlocking contoured intramedullary nail fixation for selected diaphyseal fractures of the forearm in adults. JBJS. 90(9), 1891-8. Matthews, L. S., Kaufer, H., Garver, D. F., Sonstegard, D. A. (1982). The effect on supination-pronation of angular malalignment of fractures of both bones of the forearm. J. Bone Joint Surg. Am. 64(1), 14-7. Müler, M. E. (1990). The comprehensive classification of fractures of long bones. Berlin: Springer-Verlag. Osterhoff, G., Morgan, E. F., Shefelbine, S. J., Karim, L., McNamara, L. M., Augat, P. (2016). Bone mechanical properties and changes with osteoporosis. Injury. 2, S11-20. Ring, D., Allende, C., Jafarnia, K., Allende, B. T., Jupiter, J. B. (2004). Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bone-grafting. J. Bone Joint Surg. Am. 86(11), 2440-5. Schemitsch, E. H., Richards, R. R. (1992). The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults. J. Bone Joint Surg. Am. 74, 1068-1078. Weiss, A. P., Hastings, H. (1992). The anatomy of the proximal radioulnar joint. J. Shoulder Elbow Surg. 1(4), 193-9. Zhao, L., Wang, B., Bai, X., Liu, Z., Gao, H., Li, Y. (2017). Plate Fixation Versus Intramedullary Nailing for Both-Bone Forearm Fractures: A Meta-analysis of Randomized Controlled Trials and Cohort Studies. World J. Surg. 41(3), 722-733.

Chapter 7

Hand Fractures (Carpal, Metacarpal and Phalanx Fractures) Ali İhsan Tuğrul* Department of Orthopedics and Traumatology, Beyhekim Training and Research Hospital, Konya, Turkey

Abstract Hand fractures (metacarpus, phalanx and carpal fractures) are conditions that are frequently encountered. The fracture mechanism can be associated with a fall, crush-twist injuries, or direct contact during sports. In these fractures, symptoms can be stated as swelling, bruising, tenderness, pain, deformity, and limitation of movement. The tendons and adjacent bones of the hand should also be evaluated during the physical examination. For a definitive diagnosis of the fracture, diverse methods such as x-ray (PA, lateral, oblique, carpal tunnel radiography), CT, MRI, and, if required, bone scintigraphy can be used. For treatment, conservative methods are usually used without considering surgery. For a while, a cast, splint or buddy-taping of a finger can be used, depending on the type and location of the fracture. On the other hand, surgery may be required in unstable fractures.

Introduction The structures that form the wrist are the distal radioulnar, radiocarpal, and ulnocarpal joints, eight carpal bones and their joints and ligaments. The eight carpal bones consist of the scaphoid, lunate, triquetrum, and pisiform in a proximal order and the trapezium, trapezoid, capitate, and hamate in a distal order (Figure 1). The extraosseous blood supply to the carpal bones is ensured through three dorsal and three palmar transverse arterial arches. The carpal bones can be named as the scaphoid, triquetrum, trapezium, lunate, capitate, hamate, pisiform, and trapezoid according to the frequency of fractures. The most frequent mechanism of carpal injury involves falling on an extended hand in hyperextension with the hand open. In carpal injury, localized tenderness during the physical examination is the most typical finding. X-ray, MRI, and CT can be used for radiological evaluation. The treatment aims to provide a proper anatomical *

Corresponding Author’s Email: [email protected].

In: Multidisciplinary Approach to Trauma Editors: Mehmet Cenk Turgut and Asli Turgut ISBN: 978-1-68507-761-7 © 2022 Nova Science Publishers, Inc.

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alignment, or poor functional outcomes may emerge. In unstable displaced fractures and fractures for which conservative treatment is not successful, surgical treatment is considered. As the treatment approach to each carpal bone can be different, each is discussed respectively.

Figure 1. Normal anatomy of carpal bones.

Metacarpal fractures account for approximately 10% of all fractures, and most of these fractures occur in work accidents. Work machines used in the industrial environment lead to osseous injuries as well as soft tissue damage through mechanisms such as crushing, shearing, and twisting. Therefore, in this type of injury, the fracture is mostly accompanied by tendon, vein, nerve, and ligament injuries. At the end of the treatment, the function of the hand is important. Metacarpi shape the transverse and longitudinal slopes of the hand. Four dorsal and three palmar interosseous muscles come out of the bodies of the metacarpi and flex the metacarpophalangeal joints. These muscles typically flex the fracture line in metacarpal fractures. The apex of the fracture is angulated dorsally. In traumas accompanied by soft tissue injuries, the treatment primarily aims to reduce the bone and comprise the skeletal framework. For treatment, external fixation and on-site rehabilitation are planned in stable fractures, whereas surgery and early mobilization are primarily considered in unstable fractures. Among surgical methods, there are percutaneous bracing, open reduction and internal fixation, as well as external fixators used in bone loss and complex soft tissue damages. Concerning the range of motion in the carpometacarpal joints during the opposition movement, the range of motion is 15-20 degrees in the first metacarpal joint, 20-30 degrees in the fourth and fifth metacarpal joints, and the second and third metacarpal joints are immobile. Metacarpal fractures are divided into 4: head, neck, shaft, and base. In terms of location, injury is mostly seen in the fifth metacarpal bone, followed by the first metacarpal bone. The first metacarpal base fracture, on the other hand, is the most common type of metacarpal fracture (Van Onselen et al., 2003; Varis et al., 2003). The rotational deformity is significant in the treatment of metacarpal fractures. To see rotational deformity, the fingertips should face the scaphoid, and the nail beds should be parallel to each other when fingers are flexed during the hand examination (Figure 2). An angulation less than 10 degrees is necessary for shaft fractures on the coronal and sagittal planes for conservative treatment. A sagittal angulation less than 20

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degrees is accepted in second and fourth metacarpal metaphyseal fractures, and a sagittal angulation of less than 45 is accepted in fifth metacarpal metaphyseal fractures. Phalanx fractures are the most common hand fractures. Phalanx fractures are common hand injuries involving the proximal, middle, and distal phalanx. The majority of the patients who present to the emergency department due to trauma have metacarpal and phalanx fractures. These are the most observed fractures of the skeletal system. The diagnosis is confirmed by radiographs. Treatment involves immobilization or surgical fixation, depending on the location, severity, and alignment of the injury (Barton, 1984). Phalanx fractures account for 10% of all fractures and are observed in men more often. Among phalanx fractures, distal phalanx fractures are the most common, and they are respectively followed by middle and proximal phalanx fractures (Stern, 2005). Mostly, sports injuries in the young age group, work accidents in the middle age group, and falls in the advanced age group lead to phalanx fractures. Tenderness, swelling, crepitus, and, if available, open wound are evaluated during the physical examination. Limitation of movement and shearing of the fingers (Figure 3) should be taken seriously. Numbness in the digital nerve stimulation area should be assessed. If required, Doppler ultrasound can be used to evaluate an arterial injury. AP, lateral, and oblique radiographs are used for diagnosis. Treatment is divided into two as conservative and surgical. Conservative treatment is adequate in general. In conservative treatment, the wrist should be neutral, the MCP joints should be in flexion of 7090 degrees, and the IP joints should be in extension (Figure 4). Acceptable reduction for conservative treatment is shortness less than 6 mm, an angulation of less than 15 degrees, and 0 rotation (Snead and Retting, 2001). The first choice in fractures that do not fulfill these criteria is surgery.

Figure 2. Rotational deformity after hand fractures.

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Figure 3. Shearing fingers.

Figure 4. The “Safe Position” for the hand.

Carpal Bone Fractures Scaphoid They are the most common fractures of the carpal bones. They are encountered in men more often and account for approximately 11% of hand fractures and 60% of carpal fractures (Beris and Soucacos, 2002). Diagnosis is often delayed. Delay in diagnosis and treatment may influence the prognosis of the fracture. These fractures usually occur upon falling on an open hand. In some patients, other pathologies involving the wrist are also observed. The scaphoid bone has 5 different articular surfaces. It articulates with the lunate, capitate, trapezium, trapezoid, and distal radius. Having multiple articular surfaces increases the risk of developing pseudoarthrosis and nonunion due to fractures. The forces that result in fracture owing to the moment on the scaphoid generate a tensile force in the dorsal cortex and a compressive force

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in the volar cortex. This leads to the extension of the proximal part and flexion of the distal part in 1/3 fractures, and angular deformity develops, with the apex facing dorsally. The blood supply to the scaphoid is critical; it is fed by three arterial groups, namely volar, lateral, distal, and dorsal (Figure 5). The circulation of the proximal region is weak compared to the distal region and needs intraosseous blood circulation. Tenderness is felt in the wrist, especially in the area anatomically called snuffbox, during the physical examination. PA, lateral, and oblique radiographs help with diagnosis. USG, scintigraphy, CT and MRI are other diagnostic methods. When a scaphoid fracture is suspected clinically, but the fracture is not identified on the radiographs, the wrist is immobilized for 2 weeks. If there is a fracture at the end of 2 weeks, the diagnosis can be established easily as the resorption of the fracture line will be seen. US helps with the diagnosis but does exclude the fracture (Dias et al., 1990; Herneth et al., 2001). Forty-eight hours must elapse to establish a diagnosis in scintigraphy (Tiel-van Buul et al., 1993). The sensitivity and specificity of MRI in diagnosis are high (Amadio and Moran, 2005). The stability of the fracture and whether it is displaced are significant in the treatment of scaphoid fractures. Classifications were made, including the Mayo classification based on the localization of scaphoid fractures, the Russe classification based on the fracture line, and the Herbert classification based on the anatomy, stability, and chronicity of the fracture.

Figure 5. Blood supply of the scaphoid bone.

Table 1. Herbert classification Type A Stable Acute Fractures Type B Unstable Acute Fractures

Type C Delayed Union Type D Nonunion

a.1 Tubercle fractures a.2 Incomplete fractures of the waist b.1 Distal oblique fractures b.2 Fractures of the waist b.3 Proximal pole fractures b.4 Transscaphoid perilunate dislocation fractures d.1 Stable (fibrous) nonunion d.2 Unstable (displaced) nonunion

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Table 2. Russe classification 1. Horizontal fractures 2. Vertical oblique fractures 3. Transverse fractures

Table 3. Mayo classification 1. Tubercle fractures 2. Distal articular surface fractures 3. Distal 1/3 fractures 4. Middle 1/3 fractures 5. Proximal pole fractures

In acute nondisplaced stable fractures, conservative treatment is generally adequate if there is no additional injury or the child is sick. Early diagnosis is good for the prognosis of treatment. If the cast stays for 10-12 weeks, the success rate is 90-95%. Fractures in the middle or distal region of the scaphoid are expected to heal faster than those in the proximal region. In the case of angulation or collapse in the fractured parts during follow-up, surgical treatment is required. The prognosis is poor in fractures diagnosed late. However, as the initial treatment, a long part of the arm is cast with the support of the thumb for 6 weeks. If no union is seen despite immobilization for 20 weeks, surgical treatment will be considered. Surgical treatment may be considered primarily in some patient groups (athletes and musicians) because muscle atrophy, joint stiffness, and inability to use the hand may occur as a result of prolonged casting (Amadio and Moran, 2005). In cases when the inter-fragmentary step-off is more than 1 mm, the lunocapitate angulation is more than 15 degrees, or the scapholunate angulation is more than 45 degrees in the lateral view, and in cases of carpal instability resulting from the fracture, displaced, unstable fractures are considered. An infrascaphoid angulation larger than 45 degrees on the lateral radiograph and less than 35 degrees on the PA radiograph are signs of displacement (Amadio and Moran, 2005). If radial reduction is tried and successful at the initial stage, pinning can be done percutaneously. For reduction, radial compression and longitudinal traction maneuvers are applied. When closed reduction is not successful, open reduction and internal fixation are applied. The method the surgeon has the best experience in is the best fixation method. K-wire, staple, AO cannulated screws, fully threaded cannulated screws, and Herbert screws can be used. Herbert screws are a widely used method, but there is a risk of scapholunate joint injury, STT arthritis (Beris and Soucacos, 2002; Tumilty and Squire, 1996; Canllanan et al., 1996). Therefore, limited percutaneous screw (Acutrak) placement has been used more often recently. Recent studies have emphasized that the proper placement of screws is more important than the fixation material applied (Toby et al., 1997). Due to the risk of nonunion and avascular necrosis in proximal fractures, surgical treatments are more preferred than long-term cast treatment (Amadio and Moran, 2005). In cases of nonunion despite cast treatment for more than 6 months and the proximal part smaller than 1/3, vascularized bone grafting can be performed (Fernandez and Eggli, 1995).

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Figure 6. OS Lunatum.

Lunate These fractures are rare. The lunate is attached to the scaphoid and triquetrum via interosseous ligaments, and it is distally in relation to the capitate (Figure 6). It enables blood circulation through the proximal carpal tunnel, and the vessels attach to the bone from the volar section. Fractures are divided into 5 different groups: palmar pole fractures, osteochondral fractures of the proximal articular surface, dorsal pole fractures, transverse fractures of the shaft, and transarticular frontal fractures of the shaft. Nondisplaced fractures are usually monitored conservatively, and surgical treatment is considered for the occurrence of vascular anastomosis in displaced fractures (Teisen and Hjarback, 1988).

Triquetrum The triquetrum is the second most frequently fractured carpal bone after the scaphoid. Most triquetrum fractures are in connection with ligament injuries. The most common trauma mechanism involves the impaction of the dorsal triquetrum by the ulnar styloid as a result of falling on the wrist while the hand is open. Fractures are divided into 3: dorsal, shaft, and volar fractures (Amadio and Moran, 2005). Immobilization for 6 weeks is adequate in stable fractures, whereas surgical treatment is considered in case of carpal instability.

Pisiform They are rare fractures. They occur with a direct impact on the hypothenar region on the volar side of the wrist or a fall on the wrist of an open hand. These fractures may not be clearly seen on routine direct radiographs. Diagnosis is established with lateral radiographs taken in forearm supination (20-45 degrees) or with carpal tunnel radiographs. In these fractures, ulnar nerve injuries should be excluded owing to the proximity of the pisiform bone to Guyon’s canal. Treatment is mostly conservative, and fragment excision may be required in displaced fractures.

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Trapezium Of all carpal bone fractures, 3-5% are trapezium fractures. They can be observed in connection with radial fracture dislocations. Shaft fractures are divided into 3 types: marginal trapeziometacarpal fractures and back fractures. Most fractures are shaft fractures. They may occur as a result of axial loading on the first finger in abduction or direct trauma of the palmar arch. Standard radiographs are generally adequate for diagnosis. Nondisplaced fractures are treated with 4-week cast treatments involving the thumb, whereas displaced fractures are fixed with K-wire or screws (Freeland and Finley, 1984). Post-traumatic osteoarthritis is the most common complication. In some cases, there may be a need for excisional arthroplasty.

Trapezoid The trapezoid has a protected structure due to the capitate, trapezium, and second metacarpal bone surrounding it. It is often fractured indirectly as a result of axial loading from the second metacarpal bone. Its fractures can also be seen with dorsal dislocations. The bone is also sometimes fractured by direct trauma. Fractures may be overlooked on direct radiographs since the fracture fragments are superimposed on other capitate and trapezoidal bones. CT plays a significant role in diagnosis. While stable fractures are treated with immobilization for 6 weeks, unstable fractures are treated with open reduction and internal fixation. Post-traumatic osteoarthritis may develop in cases of inadequate joint restoration.

Capitate Isolated fractures of the capitate are rare due to its position protected by the bones around. If isolated fractures develop, then they will be unstable. The blood supply is not good proximally. Therefore, there is a risk of nonunion or avascular necrosis in shaft fractures (Kimmel and O’brien, 1982). In the presence of dorsiflexion of the wrist, axial loading increases the dorsiflexion of the wrist. In this case, the scaphoid is fractured first, and the capitate is also fractured with the compression caused by the radius dorsal on the capitate. This situation is called naviculocapitate fracture syndrome. If dorsiflexion continues, the head of the capitate rotates 90 degrees. When the hand is positioned neutrally, the proximal part of the capitate is flexed 180 degrees. This injury may be observed together with dorsal perilunate dislocation or fracture of the distal end of the radius. Open reduction is required to fix the rotation of the fractured fragment in the capitate. While this fragment is excised by some surgeons, it is internally fixed with scaphoid and capitate fractures by others. Treatment will be conservative if there is no displacement. Midcarpal arthritis and osteonecrosis are complications likely to occur after capitate fractures.

Hamate They are divided into 2 types: body and hook fractures. They can be fractured separately or simultaneously. Body fractures generally occur due to impacts or direct trauma of the hand.

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While PA radiographs are mostly adequate for diagnosis, CT can be performed in some cases. Accompanying fractures in the fourth or fifth metacarpal bones can be observed together with conditions such as ulnar nerve damage and axial carpal instability. Conservative treatment is usually applied in stable, isolated fractures. However, open reduction and internal fixation are applied in displaced fractures (Ogunro, 1983). In hook fractures of the hamate, ulnar artery bleeding into Guyon’s canal may occur. In such cases, median and ulnar nerve symptoms are observed. They often arise when a hard object hits the palm. Stress fractures may develop as a result of repetitive traumas in those engaged in sports such as golf and baseball. For diagnosis, carpal tunnel radiographs can be used. CT may be necessary in cases that cannot be clarified with direct radiographs. Nonunion, ulnar, or median neuropathy, and 5th finger flexor tendon rupture are among the complications of hamate fractures.

Metacarpal Fractures Head In general, these are intra-articular fractures. The 5th metacarpal head is fractured the most. The Brewerton view may be helpful in diagnosis (Lane, 1977). Most fractures require anatomical reduction to re-enable joint alignment and minimize post-traumatic arthrosis. To control the distal part in metacarpal reduction, intervention should be performed when the proximal interphalangeal joint is in extension and the metacarpophalangeal joint is in flexion (Figure 7).

Figure 7. Management of metacarpal fractures.

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Neck Metacarpal neck fractures are seen with direct traumas. Usually, closed reduction can be performed. The special name given to the 5th metacarpal neck fracture is boxer’s fracture. While an angulation of 50-60 degrees in the 5th metacarpal bone is accepted, an angulation of 30-40 degrees in the 4th metacarpal bone, and 10 degrees in the 2nd and 3rd metacarpal bones can be accepted (Sennett, 1997; Amadio et al., 1991; Smith and Peimer, 1977). Unstable fractures require surgical intervention with percutaneous pins and plate fixation.

Shaft Metacarpal shaft fractures are mostly observed in the 4th and then in the 5th metacarpal bones. Surgical treatment is considered in case of an angulation of more than 30 degrees in the 5th metacarpal bone, 20 degrees in the 4th metacarpal bone, and 10 degrees in the 2nd and 3rd metacarpal bones (Sennett, 1997; Smith and Peimer, 1977; Opgrande and Westphal, 1983). Rotational healing is not accepted in metacarpal fractures (Sennett, 1997). Among the surgical criteria, there are shortness of more than 3 mm, rotational deformity, angular displacement, and shaft displacement of more than 50%. As surgical treatment options, closed reductionpercutaneous fixation, open reduction-internal fixation or, in cases with bone loss, external fixation can be preferred (Dona et al., 2004; Roth and Auerbach, 2005).

Base They occur as a result of crush traumas. Base fractures between the second and fifth metacarpal bones may be associated with carpometacarpal fracture-dislocations. Not only PA and lateral radiographs but also lateral view in 30 degrees of pronation is also significant for diagnosis (Bora and Didizian, 1974). Avulsion fractures may occur owing to the traction of ECRL and ECRB. Extra-articular fractures are usually stable and treated conservatively. 1. metacarpal base fracture: It occurs with the traction of the abductor pollicis longus (APL) and adductor pollicis (AP). It is divided into 4 types according to Green’s classification (Green and O’brien, 1972): (a) Bennett’s fracture-dislocation: After the fracture, the radial part of the joint shifts radially. The fracture line separates the main part of the metacarpus from the volar lip and leads to articular separation at the first carpometacarpal joint. The first metacarpal bone is pulled proximally by the APL. The medial metacarpal base of the thumb, to which the volar oblique ligament is connected, stays in its place (Figure 8). Intra-articular step-off up to 1-3 mm does not affect joint stability and does not prevent union. During reduction, the thumb is abducted, and the base of the thumb is compressed. Following reduction, external fixation should be done. If no reduction is achieved, internal fixation is done (Bollag and Lemberger, 1976).

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Figure 8. Bennett’s fracture.

(b) Rolando’s intra-articular fracture: It is a multiple fracture of the metacarpal base. Unlike Bennett’s fracture-dislocation, there is no dislocation. They are T-Y-type fractures involving the metacarpal base of the thumb without diaphyseal displacement. Complete reduction is significant for the prevention of posttraumatic arthritis. Following reduction, external fixation should be done. If no reduction is achieved, internal fixation is done (Rolando, 1996). (c) Extra-articular fractures: They are mostly transverse, less often oblique fractures. Treatment is generally conservative. Reduction is usually done with traction in extension and abduction, and cast treatment is applied for 3-4 weeks. (d) Epiphyseal injuries: These are Salter type 2 fractures. Direct fixation is usually adequate as the reduction loss will not be much. Surgery is performed in unstable cases. Fracture of the 5th metacarpal base: It is called a reverse Bennett fracture. It refers to the fracture-dislocation of the fifth metacarpal/hamate base. The proximal metacarpal part is displaced proximally by the traction of the extensor carpi ulnaris. In case of displacement, open reduction-internal fixation or closed reduction-internal fixation is applied (Bruske et al., 2001).

Complications Malunion, nonunion, infection, metacarpophalangeal joint extension contracture, loss of motion, and post-traumatic osteoarthritis are the most common complications (Sennett, 1997; Margles, 1988). Early movement and on-site rehabilitation interventions are effective in

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avoiding complications (Margles, 1988). Mostly rotational and angular deformities in the 2nd and 3rd metacarpal bones can cause cosmetic and functional disorders. As a result of open injuries, contaminated open fractures, or injuries accompanied by bone loss, nonunion is seen, but rarely. When appropriate debridement or antibiotherapy cannot be administered after such injuries, infection may arise. Splinting in an inappropriate position may lead to metacarpophalangeal joint extension contracture. Tendon adhesions occurring after surgery can often result in loss of motion in the proximal interphalangeal joint. Failures in joint restoration may induce post-traumatic arthritis (Prokop et al., 2002a; Prokop et al., 2002b).

Phalanx Fractures Distal Phalanx Fractures Distal phalanx fractures are the most common phalangeal fractures. The first and third fingers of the hand are the most injured fingers because they are more distal during daily activities (Thomine, 1985).

Classification Tuft Fractures The mechanism usually involves a crush injury. The dorsal cortex, nail matrix, and nail bed of the distal phalanx are in close relation with each other (Figure 9). When such injuries are not treated, they can result in nail growth disorders. The resulting subungual hematomas are painful and should be drained with the help of a needle. These injuries are divided into 2 types as simple and comminuted. Immobilization is adequate for simple fractures, whereas surgery may be required for comminuted fractures (Pan et al., 1989). Shaft Fractures Shaft fractures are divided into 2 as transverse and longitudinal. Transverse fractures also consist of 2 types: stable and unstable. Treatment of stable fractures is conservative, and immobilization is adequate. In unstable fractures, closed reduction is tried first. In the case of failure in closed reduction, open reduction and internal fixation are applied (Pan et al., 1989).

Figure 9. Anatomy of the nail.

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Fractures Involving the Joint These are divided into 3 types: volar, dorsal, and epiphyseal. The FDP tendon attaches to the distal phalanx shaft. In volar fractures, surgery is required if FDP tendon avulsion occurs. Fractures that occur at the attachment site of the extensor tendon due to tendon tension in dorsal articular surface fractures are called Mallet fractures (Pan et al., 1989). Extra-articular physeal separation taking place during this tension is called a Seymour fracture (Henry, 2001). A Seymour fracture fits SH1 or SH2 in terms of type. In fractures involving the dorsal articular surface, an extension splint is given if the fragment is smaller than 50% of the articular surface. If the fragment is larger, an extension splint is given after closed reduction, and the fracture is monitored closely. If loss of reduction occurs during follow-up, surgical methods are applied. Surgically, techniques such as reduction with K-wires, extension block technique or pull-out are used (Pan et al., 1989).

Middle and Proximal Phalanx Fractures These fractures are divided into 2 as fractures involving the joint and fractures not involving the joint.

Fractures Involving the Joint Fractures involving the joint include condylar (unicondylar, bicondylar), comminuted, base (dorsal, volar, lateral), fracture-dislocation, and shaft fractures extending to the joint. Extraarticular fractures consist of neck, shaft, and base fractures. While the apex of a proximal phalanx fracture tends toward a palmar angulation, the apex of a middle phalanx fracture tends toward a dorsal angulation proximally and a palmar angulation distally. Torsional forces lead to spiral fractures, whereas shear forces result in short oblique fractures. Treatment outcomes in intra-articular fractures are poorer than treatment outcomes in extra-articular fractures. While fractures that do not tend to shift are treated with bandaging (Figure 10), unstable fractures that can be fixed in a closed manner or fractures that cannot be fixed in a closed manner are treated surgically.

Figure 10. Finger bandaging.

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Figure 11. Extension block splint.

Condylar fractures are divided into two as unicondylar and bicondylar. They require anatomical reduction. As it is difficult to evaluate the continuity of reduction in a splint or cast, CRIF is considered for nondisplaced fractures. When CRIF fails, ORIF is considered. In comminuted intra-articular fractures, there is also a need for the reconstruction of the articular surface. Comminuted fractures which cannot be reconstructed can be treated in a closed manner with early preserved mobilization. Dorsal base fractures refer to central extensor tendon avulsion fracture or volar fracture-dislocation. If the ruptured fragment is small, no dislocation has occurred and continuity of the extensor tendon is observed, an extension block splint can be used (Figure 11). Lateral base fractures are usually treated conservatively if there is no collateral avulsion. Volar base fractures require surgical treatment if the fragment is larger than 20% (Pan et al., 1989; Henry, 2001; Mc Cue et al., 1970; Blazar et al., 2001). Dorsal fracturedislocations have a controversial treatment. While those with an articular displacement of less than 30% are mostly monitored conservatively, surgical treatment comes to the fore in cases of articular displacement of 40% and higher. Volar fracture-dislocations are the result of central slip avulsion. Those with displacements below 1 mm are monitored conservatively. However, those with displacements above 1 mm are monitored surgically. Shaft fractures involving the joint are treated surgically if they cause step-off in the joint.

Fractures not Involving the Joint These are shaft fractures. CRIF or ORIF is considered in displaced or unstable fractures. They are divided into two types as neck fractures and shaft fractures. Neck fractures are rare in adults; they are rather observed in children. While the apex of a fracture in the neck of the middle phalanx tends toward volar angulation, the apex of a fracture in the base tends toward dorsal angulation. Shaft fractures can be of different types (transverse, oblique, spiral, comminuted). Transverse fractures are common in the middle phalanx, whereas spiral and oblique fractures are common in the proximal phalanx. In nondisplaced fractures, conservative treatment and early movement are preferred. In displaced fractures, on the other hand, percutaneous pinning and splinting are performed. The immobilization period is 21-28 days. Among the surgical treatment methods, there are closed reduction and K-wire fixation, closed reduction hollow screw fixation, open reduction and plate/screw fixation, and open

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reduction and wire stretching/cerclage fixation. External fixators can also be used in comminuted, infected fractures with bone loss. Attention should be paid to the following points while making a decision on treatment in phalanx fractures: Type of fracture (transverse fractures may lead to angular deformity, oblique fractures may lead to rotational deformity and shortness, comminuted fractures may lead to angular and rotational deformity), stability (shortness ?, angular deformity ?, rotational deformity ?), the presence of accompanying injuries (neurovascular, tendon, soft tissue), whether there is an open fracture, and whether the fracture involves the joint.

Complications Limitation of movement is the most common complication (Page and Stern, 1998). Joint contracture and tendon adhesion are the main causes. Prolonged immobilization, poor surgical fixation, and open fractures are among the causes. Infection occurs after open fractures. It is rare after closed fractures (Pan et al., 1989). Following open fractures, necessary debridement during the surgical intervention and the use of antibiotics in the postoperative 24 hours are preventive. Malunion appears as shortness, rotational deformity, and angular deformity. It is corrected surgically. Nonunion is rare. In the case of nonunion of fractures for 4 months, nonunion is considered. It is generally observed after neurovascular injury, bone loss, and open fractures.

Conclusion The carpal region is the area between the wrist, hand, and forearm. This region is comprised of 8 carpal bones and ligaments that are in close relation with each other. They ensure circulation through the dorsal and palmar transverse arterial arches. Stability during wrist movements and interrelated movements is associated with the capsuloligamentous integrity and indentations in the contact surfaces of the carpal bones. The capitate is at the center of rotation in most wrist movements. A good medical history should be taken, and a detailed physical examination should be performed for diagnosis in wrist problems. In addition to circulatory, sensory, and motor examination, the presence of additional pathologies (ligament, capsule, joint, bone, tendon sheath, tendon) should be questioned. The diagnosis is then established with an appropriate radiological evaluation. While conservative treatment is generally considered for stable fractures, surgical treatment is considered for unstable displaced fractures. A vast majority of metacarpal fractures result from work accidents. As a result of accidents induced by heavy machinery, bone injuries are accompanied by soft tissue damages. An effective approach is crucial in the treatment of tendon, vessel, nerve, and ligament injuries occurring along with fractures. The treatment aims to gain a functional hand. Conservative and surgical approaches are available for treatment. While external fixation and on-site rehabilitation are planned in stable fractures, surgery and early mobilization are primarily considered in unstable fractures. Among the surgical methods, there are percutaneous bracing,

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open reduction and internal fixation, as well as external fixators used in bone loss and complex soft tissue damages. Phalanx fractures are the most common hand fractures. They correspond to 10% of all fractures. They involve the proximal, middle, and distal phalanges. Although the mechanism of trauma varies according to the age group, these fractures usually take place as a result of sports injuries in young people, work accidents in adults, and falls and simple traumas in the elderly. Physical examination and radiological imaging help with diagnosis. Attention should be paid to nerve and vascular injuries in addition to the bone, especially in work accidents. Surgical treatment is preferred in fractures that do not meet the criteria of conservative treatment. The complication rate is high in phalanx fractures (Tan et al., 2005; Botte et al., 1992). In the case of malunion, a rotational osteotomy can be performed (Trumple and Gilbert, 1998; Weckesser, 1965). If nonunion develops, surgical treatment and grafting are performed (Jupiter et al., 1985). Limitation of movement is the most common complication (Duncan et al., 1993).

References Amadio P.C., Beckenbaugh R.D., Bishop A.T., et al. (1991). Fractures of the hand and wrist, in Flynn’s Hand. Baltimore: MD, Williams & Wilkins:122-85. Amadio P.C., Moran S.L. Fractures of carpal bones. In D.P. Green, W.C. Pederson, R.N. Hotchkiss & S.W. Wolfe (Eds.), Green’s Operative Hand Surgery (15th ed., pp. 711-68). Philadelphia: Elsevier Inc. Barton N.J. (1984). Fractures of the hand. J Bone Joint Surg, 66B: 159-67. Beris A.E., Soucacos P.N. Recent scaphoid fractures. In J. Duparc (Ed.), Surgical tecniques in Orthopaedics and Traumatology (Wrist and Hand) (1st ed., 55-280-D-10): pp. 1-6). Paris: Elsevier. Blazar P.E., Robbe R., Lawton J.N. (2001). Treatment of dorsal fracture/dislocations of the proximal interphalangeal jointby volar plate arthroplasty. Tech Hand Up Extrem Surg, 5: 148-52. Bollag H.R., Lemberger U. (1976). Late results following Bennet’s fractures. Helv Chir Acta, 43: 793-6. Bora F.W. Jr., Didizian N.H. (1974). The treatment of injuries to the carpometacarpal joint of the little finger. J Bone Joint Surg (Am), 56: 1459-63. Botte M.J., Davis J.L.W., Rose B.A. et al. (1992). Complications of smooth pin fixation of fractures and dislocations in the hand and wrist. Clinical orthopaedics and Related Research, 276: 194-201. Bruske J., Bednarski M., Niedzwiedz Z., Zyluk A., Grzeszewski S. (2001). The results of operative treatment of fractures of the thumb metacarpal base. Açta Orthop Belg, 67: 368-73. Canllanan I., Lahoti O., McElwain J.P. (1996). Herbert screw insertion in the scaphotrapezial joint: A cause of degenerative change. J Hand Surg (Br), 21: 775-7. Dias J.J., Thompson J., Barton N.J., Gregg P.J. (1990). Suspected scaphoid fractures. The value of radiographs. J Bone Joint Surg Br, 72: 98-101. Dona E., Gillies R.M., Gianoutsos M.P., Walsh W.R. (2004). Plating of metacarpal fractures: unicortical or biocortical screws. J Hand Surg (Br), 29: 218-21. Duncan R.W., Freeland A.E., Jabaley M.E., Meydrech E.F. (1993). Open hand fractures: Analysis of the recovery of active motion and of complications. J Hand Surg, 18A: 387-94. Fernandez D.L., Eggli S. (1995). Nonunion of the scaphoid: revascularization of the proximal pole with implantation of a vascular bundle and bone grafting. J Bone Joint Surg (Am), 6: 883-93. Freeland A.E., Finley J.S. (1984). Displaced vertical fracture of the trapezium treated with a small cancellous lag screw. J Hand Surg (Am), 9: 843-5. Green D.P., O’Brien E.T. (1972). Fractures of the thumb metacarpal. South Med J, 65: 807-14. Henry M. (2001). Fractures and dislocations of the hand. In R.W. Bucholz & J.D. Heckman (Eds.), Rockwood and Green’s Fractures in adults (5th ed., pp. 655-748). Philadelphia: Lippncott Williams & Wilkins.

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Herneth A.M., Siegmeth A., Bader T.R, et al. (2001). Scaphoid fractures: evaluation with high-spatialresolution US initial results. Radiology, 220: 231-5. Jupiter J.B., Koniuch M.P., Smith R.J. (1985). The management of delayed union and nonunion of the metacarpals and phalanges. J Hand Surg, 10A: 457-66. Kimmel R.B., O’Brien E.T. (1982). Surgical treatment of avascular necrosis of the proximal pole of the capitate – case report. J Hand Surg (Am), 7: 284-6. Lane C.S. (1977). Detecting occult fractures of the metacarpal head: the Brewerton view. J Hand Surg (Am), 2: 131-3. Margles S.W. (1988). Intra-articular fractures of the metacarpophalangeal and proximal interphalangeal joints. Hand Clin, 4: 67-74. Mc Cue F.C., Honner R., Johnson M.C., Gieck J.H. (1970). Athletic injuries of the proximal interphalangeal joint requiring surgical treatment. J Bone Joint Surg, 52A: 937-56. Ogunro O. (1983). Fracture of the body of the hamate bone. J Hand Surg (Am), 8: 353-5. Opgrande J.D., Westphal S.A. (1983). Fractures of the hand. Orthop Clin North Am, 14: 779-92. Page S.M., Stern P.J. (1998). Complications and range of motion fallowing plate fixation of metacarpal and phalangeal fractures. J Hand Surg, 23A: 827-32. Pan W.K., Chow S.P., Luk K.D.K. et al. (1989). A prospective study on 248 digital fractures of the hand. J Hand Surg, 14A: 474-81. Prokop A., Helling H.J., Kulus S., Rehm K.E. (2002a). Conservative treatment of metacarpal fracture. Kongressbd Dtsch Ges Chir Kongr, 119: 532-5. Prokop A., Jubel A., Helling H.J., Kulus S., Rehm K.E. (2002b). Treatment of metacarpal fractures. Handchir Mikrochir Plast Chir, 34: 328-31. Rolando S. (1996). Fracture of the base of the first metacarpal and the variation that has not yet been described. 1910. Clin Orthop Relat Res, 327: 4-8. Roth J.J., Auerbach D.M. (2005). Fixation of hand fractures with biocortical screws. J Hand Surg (Am), 30: 151-3. Sennett B.J. (1997). Operative treatment of metacarpal fractures of the hand (Excluding thumb metacarpal fractures). Op Tech Orthop, 7: 127-33. Smith R.J., Peimer C.A. (1977). Injuries to the metacarpal bones and joints. Adv Surg, 11: 341-74. Snead D., Retting A.C. (2001). Hand and wrist fractures in athletes. Curr Opin Orthop, 12: 160-6. Stern P.J. (2005). Fractures of the metacarpals and phalanges. In D.P. Green, R.N. Hotchkiss, W.C. Pederson & S.W. Wolfe (Eds.), Operative Hand Surgery (5th ed., pp. 301-41). Philadelphia: Elsevier Churchill Livingstone. Tan V., Beredjiklian P.K., Weiland A.J. (2005). Intra-articular fractures of the hand: treatment by open reduction and internal fixation. J Orthop Trauma, 19: 518-23. Teisen H., Hjarback J. (1988). Classification of fresh fractures of the lunate. J Hand Surg (Br), 13: 458-62. Thomine J.M. (1985). The management of recent fractures of the phalanges and metacarpals. In R. Tubiana (Ed.), The Hand (1st ed., pp. 763-820). Philadelphia: WB Saunders Company. Tiel-van Buul M.M., Vab Beek E.J.R., Borm J.J.J., et al. (1993). The value of radiographs and bone scintigraphy in suspected scaphoid fracture, a statistical analysis. J Hand Surg (Br), 18: 403-6. Toby E.B., Butler T.E., McCormack T.J., Jayaraman G. (1997). A comparison of fixation screws for the scaphoid during application of cyclical bending loads. J Bone Joint Surg (Am), 79: 1190-7. Trumple T., Gilbert M.G. (1998). In situ osteotomy for extra-articular malunion of the proximal phalanx. J Hand Surg, 23A: 821-6. Tumilty J.A., Squire D.S. (1996). Unrecognized chondral penetration by a Herbert screw in the scaphoid. J Hand Surg (Am), 21: 66-8. Van Onselen E.B., Karim R.B., Hage J.J., Ritt M.J. (2003). Prevalence and distribution of hand fractures. J Hand Surg (Br), 28: 491-5. Waris E., Ashammakhi N., Happonen H., et al. (2003). Bioabsorbable miniplating versus metallic fixation for metacarpal fractures. Clin Orthop Relat Res, 410: 310-9. Weckesser E.C. (1965). Rotational osteotomy of the metacarpal for overlapping finger. J Bone Joint Surg, 47A: 751-6.

Chapter 8

Distal Humerus Fractures Orkun Halaç, MD Department of Orthopedics and Traumatology, Ağrı Training and Research Hospital, Ağrı, Turkey

Abstract Distal humerus fractures are rare injuries. Since the distal humerus forms the elbow joint and its geometry is different, its treatment requires experience. According to age distribution, it is observed in young patients together with high-energy traumas such as gunshot wounds and traffic accidents, while it is often observed after simple falls in elderly patients. Distal humerus fractures were often treated conservatively before the use of locking anatomical plates. Nonunion, malunion, and joint stiffness are common after conservative treatment. The use of conservative treatment has become limited due to the development of implants that allow compression between the fractured parts, which are anatomically compatible with the medial and lateral columns, and the understanding of the three-dimensional anatomical structure of the distal humerus. Studies on surgical treatment have reported successful outcomes in both parallel (180) and orthogonal (90-90) plate fixation in double plate applications. The main goal in surgical treatment is to initiate early elbow movements with stable fixation. Revision surgery after unstable fixation is always more difficult than the first surgery. Surgical treatment includes major complications such as elbow joint stiffness, mechanical failure, ulnar neuropathy, nonunion, heterotrophic ossification, nonunion of olecranon osteotomy, and wound problems.

Introduction Distal humerus fractures are rare in adults. They constitute approximately 2-6% of adult fractures and 33% of humerus fractures. Distal humerus fractures show a bimodal age distribution. While they are frequently observed after high-energy trauma in young male patients, they occur as a result of low-energy trauma on the basis of osteoporosis in elderly female patients. The incidence of distal humerus fractures in adults is 5.7/100,000 (Robinson et al., 2003). 

Corresponding Author’s Email: [email protected].

In: Multidisciplinary Approach to Trauma Editors: Mehmet Cenk Turgut and Asli Turgut ISBN: 978-1-68507-761-7 © 2022 Nova Science Publishers, Inc.

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Anatomy The distal humerus, together with the radius and ulna, forms the elbow joint. The radiocapitellar joint and proximal radioulnar joint are trochoidal joints. The ulna-humeral joint is a ginglymus (hinge) type joint. The humerus terminates distally as the medial and lateral columns. Most of the medial column terminates as the medial epicondyle, which does not contain articular surfaces. The trochlea forms the articular part of the medial column. The distal part of the lateral column consists of the lateral condyle and the capitellum, which makes up most of it. The trochlea forms a bridge called the 'tie arch' between the medial epicondyle and the capitellum. In the upper part of the trochlea, there is the olecranon fossa in the posterior part between the medial and lateral columns and the coronoid fossa in the anterior part. The humeral intramedullary canal terminates 2-3 cm proximal to the olecranon fossa. The capitellum and trochlea are angled 40-45 degrees anteriorly with respect to the distal humerus. On the coronal plane, the trochlea is positioned more distally to the capitellum, and the distal humeral articular surface is at 4-8 degrees valgus with respect to the humeral shaft axis. On the axial plane, the articular surface of the distal humerus is externally rotated 3-8 degrees with respect to the intercondylar axis between the medial and lateral condyles. Ligament structures are as important as bone structures in elbow joint stability. On the radial side of the elbow joint, there is the lateral collateral ligament complex consisting of the radial collateral ligament (RCL), the lateral ulnar collateral ligament (LUCL), the accessory collateral ligament, and the annular ligament. The lateral collateral ligament complex is an important constraint to varus and posterolateral rotatory instability (Duning et al., 2001; Imatani et al., 1999). On the medial side of the elbow joint, there is the ulnar collateral ligament, which consists of the anterior bundle, the posterior bundle, and the transverse ligament. The ulnar collateral ligament is an important limitation against valgus and posteromedial rotatory instability (Armstrong et al., 2002; O’Driscoll et al., 1992). Damage to ligamentous structures during surgical dissection adversely affects elbow stability.

Clinical Evaluation Patients are often first evaluated in the emergency department. The patient often presents to the emergency department with complaints of pain, edema, limitation of movement, or deformity in the affected elbow. In the patient's anamnesis, the age of the patient and the way the trauma has occurred should be questioned. In the first evaluation of the patient, the condition of soft tissues, skin integrity and an upper extremity neurovascular examination should be made and noted. In cases where skin integrity is compromised and fractured bone ends or fracture hematoma come into contact with the external environment, the fracture should be considered as an open fracture. Radial and ulnar artery pulses should be checked. In the presence of vascular injury, extremity revascularization should be performed before fracture stabilization. Although radial nerve injury is the most common after distal humerus fractures, ulnar and median nerve injuries can also be observed. In the patient presenting with elbow trauma, landmark points (olecranon, medial condyle, lateral condyle) around the elbow should be palpated and evaluated for crepitation or instability. Gentle movements should be made during

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palpation of landmarks around the elbow. Adjacent neurovascular structures around the distal humerus may be damaged during palpation. Pain radiating to the extremity with passive flexion of the fingers in the affected extremity is a warning for compartment syndrome.

Radiological Evaluation After a detailed physical examination, direct anteroposterior and lateral radiographs should be obtained. Depending on the type and shape of the fracture, oblique radiographs and traction radiographs can be obtained. Oblique radiographs and traction radiographs are important in terms of defining the fracture structure and preoperative planning. In cases where there is doubt in the evaluation of the anatomical structure, radiographs of the contralateral side can be obtained. In extremity fractures, radiographs of the affected joint should be obtained for other accompanying fractures. In intra-articular fractures of the elbow, intra-articular hematoma may facilitate the diagnosis by causing the joint capsule to displace the fatty tissues in the anterior and posterior elbows. The displacement in the surrounding fatty tissues due to subperiosteal hematoma in non-displaced fractures and hemarthrosis in intra-articular fractures is called the “fad pad sign.” In the lateral radiographs of the elbow, the line drawn on the anterior humeral cortex and the line drawn on the long axis of the radius intersect at the center of the capitellum. Frequently, direct radiographs are sufficient for the diagnosis of fracture. In cases where the fracture extends to the joint, computed tomography (CT) can be used to provide a 3D evaluation of the fracture. Computed tomography is helpful in determining the amount of displacement and preoperative planning in non-displaced fractures that cannot be diagnosed and in fractures extending to the joint (Doornberg et al., 2006; Brouwer et al., 2012). After fractures of the lower end of the humerus, neurovascular structures around the elbow may be injured due to sharp fracture ends or by being trapped between the fracture ends at the time of the trauma. A vascular injury should be suspected in cases where the radial and ulnar pulse in the distal part of the fracture cannot be obtained and the distal capillary filling is slowed down. Doppler USG or contrast-enhanced computed tomography examination should be performed.

Classification Distal humerus fractures can be classified as supracondylar, transcondylar, intercondylar, medial condyle, lateral condyle, capitellum and trochlea fractures according to the anatomical location (Clarke and Amirfeyz, 2012). Although many classifications were defined for distal humerus fractures, the classification defined by the AO-OTA (Association Osteosynthesis Orthopaedic Trauma Association) is used nowadays (Figure 1). Distal humerus fractures define fractures within the square formed by the epicondyle distance on the anterior-posterior radiograph according to the AO-OTA (Figure 1).

Figure 1. AO-OTA (Association Osteosynthesis Orthopaedic Trauma Association) classification (Meinberg, E.G., Agel, J. M.A., Roberts, C.S., Karam, M.D., & Kellam, J.F. (2018). Fracture and dislocation compendium 2018 Orthopaedic Trauma Association Classification, database and outcomes committee. J Orthop Trauma, 32, 11-20).

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Treatment The aim of the treatment we choose is to obtain an uncomplicated, moving, stable and functional joint during the treatment. As a result of the more detailed understanding of the fracture structure over time and the advancement of implant technology, surgical treatment is often preferred in distal humerus fractures.

Conservative Conservative treatment of distal humerus fractures is indicated for non-displaced fractures and patients who cannot be operated on due to comorbid diseases (advanced age, dementia, cerebrovascular accident) (Desloges et al., 2015). Cast-splint and functional bracing can be used as conservative treatment. Cast-splint fixation is performed with the forearm in a neutral position and the elbow in a 90-degree flexion position. Frequent radiological evaluation is required for early detection in case of loss of fracture reduction in conservative treatment. In the second week of the follow-up with a cast-splint, there should be a switch to functional braces that allow passive elbow movement, and passive and active movement that can be tolerated should be initiated. Prolonged immobilization of the elbow joint can result in joint stiffness (Aitken et al., 2015). With conservative treatment, the brace is terminated after the radiological union is achieved in X-ray in 6-8 weeks. In cases with excessive soft tissue edema, olecranon skeletal traction provides gradual fracture reduction, minimizing the movement of the fracture ends. After the soft tissue edema regresses, a cast-splint or functional brace can be used. Treatment with skeletal traction is limited due to the long hospital stay and the advancing implant technology (Athwall, 2014).

Surgical Surgical treatment of distal humerus fractures is preferred for open fractures, unstable fractures, and displaced fractures. The aim of surgical treatment is anatomical joint reduction, stable internal fixation of the articular surface with the humeral metaphysis, and early movement of the elbow joint. Surgery should be performed as an emergency in patients with open fractures, neurovascular injury, and compartment syndrome. Surgery is also recommended for fractures of the distal humerus that do not show intraarticular extension (AO-OTA A2-A3). Percutaneous crossed Kirschner wire can be used in adult patients as in the pediatric age group. In adults, 3.5 and 4.5 cannulated screws can be used instead of crossed Kirscher wire if there is sufficient bone stock in the distal fracture. During cross-fixation, care should be taken not to allow implants to pass into the olecranon fossa and coronoid fossa. When the elbow is in extension, the olecranon is in harmony with the olecranon fossa, and when the elbow is in flexion, the coronoid is in harmony with the coronoid fossa. The implant in the olecranon fossa or coronoid fossa will restrict elbow joint movement. Fixation after percutaneous fixation is not rigid enough to allow early movement. Fixation should be supported with a splint. Early movement is important to avoid joint stiffness, but fracture displacement should be considered. With the presence of anatomically shaped locking

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plates that provide stable fixation, open reduction internal plate fixation is recommended instead of fixation with Kirschner wire or cannulated screw in adult AO-OTA A2-A3 fractures (Lauder, 2020). Stable fixation and internal fixation are required in AO-OTA Type B and Type C fractures that show intra-articular extension and fragmentation of the distal humerus. Stable fixation can be achieved with anatomically shaped locking screw plate systems. During internal fixation, they can be placed parallel to each other in both columns or posteriorly on the epicondyle on the medial side, in the lateral column of the distal humerus, as the posterior part of the capitellum does not contain the articular surface, so as not to restrict the elbow extension movement. Early movement can be initiated by providing stable fixation with double plate application. Despite using a double plate in which the articular surface contains multiple parts, rigid fixation that will provide early movement may not be achieved. In these cases, the important thing is not the early movement but the anatomical restoration of the joint. Elbow arthroplasty may also be a treatment option for AO-OTA type B and C fractures in osteoporotic elderly patients with advanced arthrosis.

Surgical Treatment Approaches Posterior Surgical Interventions Posterior surgical interventions can be classified into four types: Olecranon osteotomy (chevron, reverse chevron), paratricipital (triceps-on), Bryan-Morrey (triceps reflecting), and Campbell (triceps splinting). For posterior intervention, the patient is often operated upon in the prone position. The posterior intervention method is selected according to the amount and shape of the patient's intra-articular fracture, the necessity of exposing the joint, and other accompanying traumas (olecranon fracture triceps incision). In all posterior interventions, the ulnar nerve should be dissected and preserved at the posterior medial epicondyle. Olecranon osteotomy is the best method to reach the distal articular surface (Wilkinson and Stanley, 2001). However, it requires additional osteotomy and fixation. While osteotomy is performed with a cutting motor, the last part of the osteotomy should be completed with an osteotome so as not to damage the olecranon cartilage. In the paratricipital (triceps-on) approach, the triceps olecranon is not separated from the attachment site and the triceps medial and lateral apertures are opened, providing limited access to the joint. If adequate reduction from the articular surface cannot be achieved, an olecranon osteotomy can be added to the paratricipital (tricepson) approach. The paratricipital approach allows early movement by preserving triceps integrity. It also excludes complications such as nonunion in olecranon fixation and subcutaneous palpation of the implants used in olecranon fixation. In the Campbell approach, the triceps enters from the midline, providing access to the medial and lateral columns. To reach the elbow joint surface, the elbow should be placed in a flexion position. Access to the articular surface is limited. The advantage of the Campbell approach is that it is technically easy compared to other approaches. The Bryan-Morrey (triceps reflecting) approach is often used in elbow arthroplasty. In the Bryan-Morrey approach, the triceps is tipped from the ulnar periosteum from medial to lateral by the anconeus muscle.

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Lateral Surgical Interventions Elbow lateral interventions can be performed as Kocher, Kaplan and extensor digitorum splint interventions. Lateral interventions can be extended proximally to reach the lateral column. Lateral interventions are often preferred for the internal fixation of capitellum and radial head fractures.

Post-Surgical Complications Distal humerus fractures are open to complications due to their complex anatomical structure, fractures often involving the joint, and comminuted fractures. The occurrence of distal humerus fractures with high-energy trauma increases the frequency of complications due to the presence of other accompanying traumas in the young population and comorbid diseases and osteoporosis in the elderly population.

Elbow Stiffness Elbow joint stiffness is the most common complication after open reduction and internal fixation (Sanchez et al., 2008). Reduction in the joint range of motion can be caused by nonunion, malunion, capsular adhesion, heterotrophic ossification, prolonged immobilization time, and implants (Green, 2009).

Ulnar Neuropathy Ulnar neuropathy can be encountered in the preoperative and postoperative periods. Although the ulnar nerve-related problem after fracture is not exactly known, the ulnar nerve involvement ranged from 0% to 51% in studies, and it was found to be 13% on average. These studies do not include information about ulnar neuropathy during trauma, perioperative or postoperative periods (Chen et al., 2010). Vazquez et al. reported postoperative ulnar nerve injury and dysfunction as 10% in a study including 69 patients without preoperative ulnar nerve dysfunction (Vazquez et al., 2010).

Mechanical Failure Mechanical failure is observed in 7-27% of distal humerus fractures (Kraiser et al., 2011; Pereles et al., 1997). Stable internal fixation may not be possible due to the comminuted fracture and osteoporosis in elderly patients. Stable internal fixation may not be achieved, especially in elderly patients with poor bone quality. In cases where internal fixation is planned for elderly osteoporotic patients, preparation for total elbow arthroplasty should also be performed (Hausman and Panozzo, 2004; Obert et al., 2013).

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Nonunion The rates of union of distal humerus fractures after open reduction and internal fixation are between 2% and 10% (Helfet et al., 2003). In recent studies, union rates after double plate applications have been reported as between 89% and 100% (Theivendran et al., 2010; Pajarinen and Bjorkenheim, 2002). High-energy trauma, comminuted fracture, and articular or metaphyseal bone defect pose a risk for union in geriatric patients. In geriatric patients, union is more important than early movement. Fixation should be supported with a cast or brace. In the study conducted by Shin et al., in which the plate configurations (parallelorthogonal) were compared, 17 patients who underwent osteosynthesis with a perpendicular (orthogonal) plate and 18 patients who underwent osteosynthesis with a parallel plate were compared. Nonunion was detected in 2 patients in the perpendicular (orthogonal) plate group. No nonunion was observed in the parallel plate group. However, there was no statistically significant difference between the two groups. Two patients with nonunion were revised with autogenous graft and parallel plating. After the revision, union was achieved in 2 patients. As a result, it was emphasized that both parallel plating and orthogonal plating provided sufficient stability and fracture reconstruction in distal humerus fractures (Shin et al., 2010). The use of parallel plates allows the use of more screws and longer screws in the lateral column compared to orthogonal plating. In this way, parallel plating provides an increase in stability in the humeral metaphyseal area (O’Driscoll, 2005).

Malunion The most common complication in the conservative treatment of distal humerus fractures is malunion. It occurs in about one in three cases (Kinaci et al., 2016; McKee et al., 1994). As the use of implants becomes widespread, its frequency is gradually decreasing.

Nonunion of Olecranon Osteotomy Olecranon osteotomy provides the widest junction to reach the distal humeral articular surface. Fixation is required after olecranon osteotomy (McKee et al., 2000). This may result in implant irritation in the skin due to nonunion, malunion, or poor soft tissue coverage of the proximal part of the ulna. In cases of nonunion of the humerus after comminuted distal humerus fractures, olecranon osteotomy creates additional problems in revision with total elbow arthroplasty (Coles et al., 2006; Hewins et al., 2007). In a study comparing the fixation methods of olecranon osteotomy, nonunion was found to be higher in fixation with the tension band method than plate fixation (Woods et al., 2015). In the study conducted by Coles et al., no nonunion was observed in 70 olecranon osteotomies performed with a screw, tension band or plate osteosynthesis after olecranon osteotomy. However, 8% of patients required the removal of the implant due to symptomatic skin irritation (Coles et al., 2006).

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Heterotrophic Ossification The incidence of heterotrophic ossification after open reduction internal fixation of distal humerus fracture is observed in a wide range of 0%-49% (Huang et al., 2005). In the literature, risk factors such as the presence of head trauma accompanying elbow trauma, delayed surgical treatment, use of bone grafts, prolonged postoperative immobilization, and the position and number of plates used in fixation were shown (Douglas et al., 2012). Indomethacin prophylaxis or prophylactic low-dose radiotherapy was found to be effective for heterotrophic ossification. There is insufficient evidence for routine prophylaxis against heterotrophic ossification in distal humerus fractures.

Complications Related to Infection and Wound Site Wound site infection after distal humerus fractures is associated with increased morbidity. It often progresses with swelling in the posterior elbow, discharge and nonunion at the wound site. In the early postoperative wound infection, successive debridement and antibiotherapy should be applied. Open fractures, comminuted fractures, patients using grafts due to bone defects, advanced age and accompanying systemic diseases increase the susceptibility to infection.

Conclusion Open reduction, parallel two-column plating or orthogonal (90-90) plating is considered to be the gold standard treatment method in distal humerus fractures. Good functional outcomes can be obtained after postoperative rehabilitation by providing early joint movement after stable internal fixation. Unstable fixation, poor bone quality and comminuted fractures are risk factors for mechanical failure. There is insufficient evidence for routine ulnar anterior transposition during plate osteosynthesis for ulnar neuropathy. More studies are needed for the routine use of indomethacin and low-dose radiotherapy identified to prevent heterotrophic ossification. Nonunion, malunion, wound site, and olecranon osteotomy nonunion problems are rarely observed. Stable fixation should be provided to prevent joint stiffness, and early mobilization should be provided after fixation.

References Aitken, S. A., Jenkins, P. J., & Rymaszewski, L. (2015). Revisiting the “bag of bones”: functional outcome after the conservative management of a fracture of the distal humerus. Bone Joint J, 97–B, 1132–1138. Amstrong, A. D., Dunning, C. E., Faber, K. J., et al. (2002). Single-strand ligament reconstriction of the medial collateral ligament restores valgus elbow stability. J Shoulder Elbow Surg, 11(1), 65-71. Athwall, G. S. Fractures of the distal humerus. In: Rockwood, C. A., Bucholz, R. W., Court-Brown, C. M., Heckman, J. D., & Tornetta III, P. (Eds.). (2014). Rockwood and Green's fractures in adults. Vol 1. (7th ed.). Lippincott & Williams

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Brouwer, K. M., Lindenhovius, A. L., Dyer, G. S., Zurakowski, D., Mudgal, C. S., & Ring, D. (2012). Diagnostic accuracy of 2- and 3-dimensional imaging and modeling of distal humerus fractures. J Shoulder Elbow Surg, 21(6), 772–6. Chen, R. C., Harris, D. J., Leduc, S., Borrelli, J. J. Jr., Tornetta, P., & Ricci, W. M. (2010). Is ulnar nerve transposition beneficial during open reduction internal fixation of distal humerus fractures? J Orthop Trauma 24, 391–394. Clarke, A. M., & Amirfeyz, R. (2012). Distal humerus fractures – where are we now? Orthopaedics and Trauma, 26(5), 303–309. Coles, C. P., Barei, D. P., Nork, S. E., Taitsman, L. A., Hanel, D. P., & Bradford Henley, M. (2006). The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus. J Orthop Trauma, 20, 164–171. Desloges, W., Faber, K. J., King, G. J., & Athwal, G. S. (2015). Functional outcomes of distal humeral fractures managed nonoperatively in medically unwell and lower-demand elderly patients. J Shoulder Elbow Surg, 24(8), 1187–1196. Doornberg, J., Lindenhoivius, A., Kloen, P., Van Dijk, C. N., Zurakowski, D., & Ring, D. (2006). Two and three-dimensional computed tomography for the classification and management of distal humeral fractures. Evaluation of reliability and diagnostic accuracy. J Bone Joint Surg Am, 88(8), 1795–801. Douglas, K., Cannada, L. K., Archer, K. R., et al. (2012). Incidence and risk factors of heterotopic ossification following major elbow trauma. Orthopedics, 35, 815–822. Dunning, C. E., Zarzour, Z. D., Petterson, S. D., et al. (2001). Ligamentous stabilizers against posterolateral rotatory instability of the elbow. J Bone Joint Surg Am, 83-A(12), 1823-1828. Green, A. (2009). Postoperative management after open reduction and internal fixation of distal humeral fractures. Instr Course Lect, 58, 535–539. Hausman, M., & Panozzo, A. (2004). Treatment of distal humerus fractures in the elderly. Clin Orthop Relat Res 425, 55–63. Helfet, D. L., Kloen, P., Anand, N., & Rosen, H. S. (2003). Open reduction and internal fixation of delayed unions and nonunions of fractures of the distal part of the humerus. J Bone Joint Surg [Am], 85-a, 33–40. Hewins, E. A., Gofton, W. T., Dubberly, J., MacDermid, J. C., Faber, K. J., & King, G. J. (2007). Plate fixation of olecranon osteotomies. J Orthop Trauma, 21, 58–62. Huang, T. L., Chiu, F. Y., Chuang, T. Y., & Chen, T. H. (2005). The results of open reduction and internal fixation in elderly patients with severe fractures of the distal humerus: a critical analysis of the results. J Trauma, 58, 62–69. Imatani, J., Ogura, T., Morito, Y., et al. (1999). Anatomic and histologic studies of lateral collateral ligament complex of the elbow joint. J Shoulder Elbow Surg, 8(6), 625-627. Kaiser, T., Brunner, A., Hohendorff, B., Ulmar, B., & Babst, R. (2011). Treatment of supra and intra-articular fractures of the distal humerus with the LCP Distal Humerus Plate: a 2-year follow-up. J Shoulder Elbow Surg, 20, 206–212. Kinaci, A., Buijze, G. A., Leeuwen, D. H., Jupiter, J. B., Marti, R. K., & Kloen, P. (2016). Corrective osteotomy for intra-articular distal humerus malunion. Arch Bone Jt Surg, 4, 161–165. Lauder, A., & Richard, M. J. (2020). Management of distal humerus fractures. Eur J Orthop Surg Traumatol, 30(5), 745-762. McKee, M., Jupiter, J., Toh, C. L., Wilson, L., Colton, C., & Karras, K. K. (1994). Reconstruction after malunion and nonunion of intra-articular fractures of the distal humerus. Methods and results in 13 adults. J Bone Joint Surg Br, 76, 614–621. McKee, M. D., Wilson, T. L., Winston, L., Schemitsch, E. H., & Richards, R. R. (2000). Functional outcome following surgical treatment of intra-articular distal humeral fractures through a posterior approach. J Bone Joint Surg [Am], 82-a, 1701–1707. Meinberg, E. G., Agel, J. M. A., Roberts, C. S., Karam, M. D., & Kellam, J. F. (2018). Fracture and dislocation compedium-2018 Orthopaedic Trauma Association Classification, database and outcomes committee. J Orthop Trauma, 32, 11-20. O’Driscoll, S. W. (2005). Optimizing stability in distal humeral fracture fixation. J Shoulder Elbow Surg, 14(suppl S), 186–194.

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O’Driscoll, S. W., Morrey, B. F., Korinek, S., & An, K. N. (1992). Elbow subluxation and dislocation. A spectrum of instability. Clin Orthop Relat Res, Jul(280), 186-197. Obert, L., Ferrier, M., Jacquot, A., et al. (2013). Distal humerus fractures in patients over 65 complications. OTSR, 99, 909–913. Pajarinen, J., & Bjorkenheim, J. M. (2002). Operative treatment of type C intercondylar fractures of the distal humerus: Results after a mean follow-up of 2 years in a series of 18 patients. J Shoulder Elbow Surg, 11, 48–52. Pereles, T. R., Koval, K. J., Gallagher, & M., Rosen, H. (1997). Open reduction and internal fixation of the distal humerus: functional outcome in the elderly. J Trauma, 43, 578–584. Robinson, C. M., Hill, R. M., Jacobs, N., Dall, G., & Court-Brown, C. M. (2003). Adult distal humeral metaphyseal fractures, epidemiology and results of treatment. J Orthop Trauma, 17(1), 38–47. Sanchez-Sotelo, J., Torchia, M. E., & O’Driscoll, S. W. (2008). Complex distal humeral fractures: internal fixation with a principle-based parallel-plate technique. J Bone Joint Surg Am, 90(suppl 2 Pt 1), 31–46. Shin, S. J., Sohn, H. S., & Do, N. H. (2010). A clinical comparison of two different double plating methods for intraarticular distal humerus fractures. J Shoulder Elbow Surg, 19, 2–9. Theivendran, K., Duggan, P. J., & Deshmukh, S. C. (2010). Surgical treatment of complex distal humeral fractures: functional outcome after internal fixation using precontoured anatomic plates. J Shoulder Elbow Surg, 19, 524–532. Vazquez, O., Rutgers, M., Ring, D. C., Walsh, M., & Egol, K. A. (2010). Fate of the ulnar nerve after operative fixation of distal humerus fractures. J Orthop Trauma, 24(7), 395–399. Wilkinson, J. M., & Stanley, D. (2001). Posterior surgical approaches to the elbow: a comparative anatomic study. J Shoulder ElbowSurg, 10, 380–382. Woods, B. I., Rosario, B. L., Siska, P. A., Gruen, G. S., Tarkin, I. S., & Evans, A. R. (2015). Determining the efficacy of screw and washer fixation as a method for securing olecranon osteotomies used in the surgical management of intraarticular distal humerus fractures. J Orthop Trauma, 29, 44–49.

Chapter 9

Proximal Radius and Ulna Fractures Oktay Polat*, MD Department of Orthopedics and Traumatology, Ağrı Training and Research Hospital, Ağrı, Turkey

Abstract Elbow trauma is a common condition. These injuries involve a wide range of injury patterns, including mild soft tissue injuries and contusions as well as complex osseoligamentous injury patterns and terrible triad injuries. Complex fractures of the elbow make reduction and subsequent fixation difficult, posing a real challenge for orthopedic surgeons. The majority of complex elbow dislocations cause elbow instability and require surgical treatment. The main objective of surgery is the restoration of adequate stability to the critical anatomy for the purpose of initiating an early range of motion, which has been indicated as a key to successful outcomes.

Proximal Radius Fractures Introduction Proximal radius fractures constitute one-third of elbow fractures (Karlsson et al., 2010). The clinical and radiological examination allows the establishment of an appropriate treatment plan with an accurate diagnosis. Minimally displaced fractures of the radius are treated nonsurgically, and good outcomes are achieved. Open reduction internal fixation is applied in radial head fractures exceeding 2 mm. A radial head prosthesis is used in complex comminuted fractures (Yoon, Athwal, Faber, & King, 2012). Joint stiffness is the complication that is observed most frequently in proximal radius fractures. Early aggressive elbow movements should be initiated to avoid it (Swensen et al., 2019).

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Corresponding Author’s Email: [email protected].

In: Multidisciplinary Approach to Trauma Editors: Mehmet Cenk Turgut and Asli Turgut ISBN: 978-1-68507-761-7 © 2022 Nova Science Publishers, Inc.

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Anatomy The radial head has an elliptical structure in cadaver studies. The concave side of the radius articulates with the capitellum. The non-articulating 80 degrees remaining in the radial head’s posterolateral region has usually been considered the “safe zone” for screw fixation after displaced fractures. The radial artery and interosseous branches supply the radial head. The posterior interosseous nerve courses around the radial neck and near the radial head (EssexLopresti, 1951; King, Zarzour, Patterson, & Johnson, 2001).

Clinical Manifestation The majority of radial head fractures take place because of a fall onto an outstretched hand. Patients can present with a limited elbow or forearm range of motion and pain. Swelling and ecchymosis are frequently observed along the forearm, and medial and lateral elbow in the examination. With the aim of determining whether the reduced range of motion originates from pain or mechanical block, arthrocentesis may be applied with a direct lateral approach for the removal of the hemarthrosis and intra-articular injection of lidocaine. It is also necessary to confirm elbow stability as a result of testing valgus-varus laxity and conducting the pivot-shift test for the purpose of assessing posterolateral rotatory instability. Anteroposterior, lateral and oblique (Greenspan) images are acquired in these fractures. The special Greenspan image is obtained by placing the forearm in the neutral position and centering the X-ray beam on the radiocapitellar joint. Computed tomography can also be performed for preoperative evaluation (Swensen et al., 2019). While the rate of other injuries is 20% in nondisplaced radial head fractures, it increases to 80% in comminuted fractures. Yüzük et al. reported 5 common injuries in these fractures. These are radial head fracture and rupture of the interosseous ligament of the forearm (EssexLopresti), rupture of the MCL or capitellar ligament, elbow posterior dislocation, terrible triad injuries (posterior dislocation of the elbow with fractures of the radial head and coronoid process), and posterior olecranon fracture dislocations (posterior Monteggia pattern injuries) (Ring, 2008).

Classification The Mason classification system is employed for radial head fractures. It considers nondisplaced fractures (type I), displaced fractures (type II), and fractures displaced by comminution (type III). Johnston considered radial head fractures related to elbow dislocation as type IV. Then, he added joint displacement (2 mm) and an area (>30%) including the articular surface with the aim of differentiating Mason I and II (Burkhart, Wegmann, Müller, & Gohlke, 2015; Johnston, 1962; Mason, 1954).

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Treatment Conservative Conservative treatment is applied to Mason type I fractures. In the acute state, if the joint is very painful and swollen, hemarthrosis can be aspirated with local anesthetic injection. In Mason type I fractures, a long arm cast is used when the elbow is at 90 degrees of flexion. If symptoms do not improve significantly in the first 7-14 days and patients also report pain or congestion in the wrist, and there are instabilities, an MRI scan is required. Surgical treatment may be required if there are signs of instability and/or loose articular bodies (Harbrecht et al., 2021). Surgical Osteosynthesis: This is used for Mason type II and also Mason type III fractures. There are two processes to treat fractures adequately, which are the Kaplan and Kocher techniques (Barnes, Lombardi, Gardner, Strauch, & Rosenwasser, 2019). It is necessary to place the plate screw in the safe range with the aim of avoiding interaction with the proximal radioulnar joint, which is 110 degrees lateral in the neutral pronation-supination of the elbow (Harbrecht et al., 2021). Arthroplasty: There should always be a prosthetic option for the surgical treatment of multi-fragmented fractures. A radial head prosthesis is utilized if it is impossible to achieve anatomical reduction and stable fixation (Harbrecht et al., 2021). Radial head resection: This form of treatment must be used only in exceptional cases when ligament injuries can be safely excluded. It is a treatment option in elderly patients who have low functional requirements (Harbrecht et al., 2021). Complications: Radial nerve lesion, elbow stiffness, radius head necrosis and pseudarthrosis.

Proximal Ulna Fractures Introduction Proximal ulna fractures represent frequently observed injuries that constitute 10% of all fractures in the upper extremity (Rommens, Küchle, Schneider, & Reuter, 2004). These fractures, which are classified as “olecranon fractures” from time to time, are usually complex and may involve various injury patterns, including the coronoid, radial head, or collateral ligaments. Predicting the outcomes is more challenging because of difficulties in the fragment fixation of comminuted lesions and the quick onset of elbow joint stiffness, particularly when the complete fracture cannot be exactly diagnosed (Niéto et al., 2015).

Olecranon Fractures Anatomy The olecranon represents the ulna’s proximal articular portion. The olecranon and coronoid processes form the greater sigmoid notch. An area of the articular surface without hyaline

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cartilage, which is usually named the “bare spot,” separates the olecranon and coronoid processes. The proximal ulna has a mean varus angulation of 14 degrees, which is significant since it is particularly related to implant selection with preformed locking plates (Brolin & Throckmorton, 2015).

Clinical Manifestation Patients usually present with elbow swelling and pain after falling. In the case of a displaced fracture, a marked deformity with a palpable gap at the elbow can be observed. Patients cannot perform active elbow extension. The ulnar nerve has the highest risk because of its superficial location on the elbow’s medial side. The initial assessment made with the elbow’s anteroposterior (AP) and lateral radiographs is adequate for determining the fracture pattern for most fractures. Computed tomography may be performed for preoperative planning (Sullivan, Herron, & Hayat, 2020).

Classification The Mayo classification is the most common classification. There are three types, each of which is divided into types a and b, respectively, as non-comminuted and comminuted. Type I fractures are not displaced. Type II fractures are displaced by a minimum of 3 mm. Nevertheless, the ulnohumeral articulation is preserved and indicates intact collateral ligaments. In type III injuries, there is the displaced fracture and the unstable ulnohumeral joint. The said injury is a fracture dislocation, and collateral ligaments can be insufficient and may lead to instability (Morrey, 2009).

Treatment Conservative It is possible to treat undisplaced olecranon fractures with early progressive active range of motion exercises, with the elbow flexed at 45-90 degrees, by staying in the long arm splint followed by the avoidance of active extension. Conservative treatment of type 2 displaced fractures may be considered in people over 70 years of age (Putnam, Christophersen, & Adams, 2017; Sullivan et al., 2020). Surgical The tension band technique is used for Mayo type 2A fractures. This technique requires an intact dorsal cortex. Plate screw fixation is recommended in comminuted fractures such as Mayo type 2B and Mayo type 3. Excision and triceps advancement are performed in elderly patients in whom the fragment is of a very small size for fixation or in the case of involving less than 50% of the articular surface (Sullivan et al., 2020; Wiegand, Bernstein, & Ahn, 2012).

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Coronoid Fractures Anatomy The ulna coronoid process is very important for elbow stability. Together with the olecranon, it forms the ulna’s greater sigmoid notch. On average, 60% of the anteromedial aspect of the coronoid process is not supported by the proximal ulnar metaphysis, making it prone to fracture with varus stress (Steinmann, 2008).

Clinical Manifestation A coronoid tip fracture is usually observed together with an elbow dislocation and a radial head fracture, an injury pattern commonly called the “terrible triad.” The progressive valgus force pushes the coronoid under the trochlea and is fractured at the tip of the coronoid process. In the anteromedial coronoid fracture, the injury mechanism is opposite that of the tip fracture. A varus and posteromedial rotational force in the forearm leads to the rupture of the lateral collateral ligament (LCL) from the humeral origin. As the LCL gives way, the medial coronoid process is forced against and under the medial trochlea. Due to the shape of the medial coronoid process, this movement will lead to the fracture of the process, which mainly includes the anteromedial portion (Steinmann, 2008). Regan and Morrey established a classification of coronoid process fractures into three types on the basis of the lateral radiographic view: type 1 includes the avulsion of the tip of the process, type 2 includes the portion containing ≤50% of the coronoid, and type 3 includes the portion containing >50% of the coronoid.

Treatment The purpose of treatment is restoring and maintaining joint alignment during the healing of the ligaments. It is possible to treat some terrible triad and anteromedial facet coronoid fractures non-surgically. Likewise, it is possible to consider the non-surgical treatment of anteromedial facet fractures in the case of excluding subluxation and the presence of only a small, minimally displaced fracture. The elbow stability, not the dimensions of the coronoid fragment, should be primarily considered for surgical fixation. Fixation strategies and surgical approaches differ according to the properties of the fracture and associated injuries. The direct anterior approach is required for the anterior support of large coronoid fragments. The posterior approach is recommended with other elbow injuries. In small coronoid fragments, osteosynthesis is achieved by suturing through a transosseous tunnel that opens posterior to anterior along the proximal ulna. The remaining internal fixation options involve internal fixation using a small plate or retrograde screw and screw fixation (Feng et al., 2018; Garrigues, Wray III, Lindenhovius, Ring, & Ruch, 2011; Ring & Horst, 2015).

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Conclusion It is important to know that proximal ulna and radius fractures may be related to neurovascular problems. The conservative management of undisplaced fractures is applied. However, all displaced fractures require surgery. In some cases, limited range of motion and pain may remain permanent even if healing has been completed.

References Barnes, L. F., Lombardi, J., Gardner, T. R., Strauch, R. J., & Rosenwasser, M. P. (2019). Comparison of exposure in the Kaplan versus the Kocher approach in the treatment of radial head fractures. Hand, 14(2), 253-258. Brolin, T. J., & Throckmorton, T. (2015). Olecranon fractures. Hand Clin., 31(4), 581-590. Burkhart, K. J., Wegmann, K., Müller, L. P., & Gohlke, F. E. (2015). Fractures of the radial head. Hand Clin., 31(4), 533-546. Essex-Lopresti, P. (1951). Fractures of the radial head with distal radio-ulnar dislocation. J. Bone Joint Surg. Br., 33(2), 244-247. Feng, D., Zhang, X., Jiang, Y., Zhu, Y., Wang, H., Wu, S., Zhang, J. (2018). Plate fixation through an anterior approach for coronoid process fractures: A retrospective case series and a literature review. Medicine (Baltimore). 97(36). Garrigues, G. E., Wray III, W. H., Lindenhovius, A. L., Ring, D. C., & Ruch, D. S. (2011). Fixation of the coronoid process in elbow fracture-dislocations. J. Bone Joint Surg. Am., 93(20), 1873-1881. Harbrecht, A., Ott, N., Hackl, M., Leschinger, T., Wegmann, K., & Müller, L. (2021). Radial head fractures: Epidemiology, diagnosis, treatment and outcome. Der Unfallchirurg [The trauma surgeon]. Johnston, G. (1962). A follow-up of one hundred cases of fracture of the head of the radius with a review of the literature. Ulster. Med. J., 31(1), 51. Karlsson, M. K., Herbertsson, P., Nordqvist, A., Besjakov, J., Josefsson, P. O., & Hasserius, R. (2010). Comminuted fractures of the radial head: Favorable outcome after 15-25 years of follow-up in 19 patients. Acta Orthop., 81(2), 224-227. King, G. J., Zarzour, Z. D., Patterson, S. D., & Johnson, J. A. (2001). An anthropometric study of the radial head: implications in the design of a prosthesis. J. Arthroplasty., 16(1), 112-116. Mason, M. L. (1954). Some observations on fractures of the head of the radius with a review of one hundred cases. Br. J. Surg., 42(172), 123-132. Morrey, B. (2009). Current concepts in the management of complex elbow trauma. Surgeon, 7(3), 151-161. Niéto, H., Billaud, A., Rochet, S., Lavoinne, N., Loubignac, F., Pietu, G., Fabre, T. (2015). Proximal ulnar fractures in adults: a review of 163 cases. Injury, 46, S18-S23. Putnam, M. D., Christophersen, C. M., & Adams, J. E. (2017). Pilot report: non-operative treatment of Mayo Type II olecranon fractures in any-age adult patient. Shoulder Elbow, 9(4), 285-291. Ring, D. (2008). Displaced, unstable fractures of the radial head: fixation vs. replacement - what is the evidence? Injury, 39(12), 1329-1337. Ring, D., & Horst, T. A. (2015). Coronoid fractures. J. Orthop. Trauma, 29(10), 437-440. Rommens, P., Küchle, R., Schneider, R., & Reuter, M. (2004). Olecranon fractures in adults: factors influencing outcome. Injury, 35(11), 1149-1157. Steinmann, S. P. (2008). Coronoid process fracture. J. Am. Acad. Orthop. Surg., 16(8), 519-529. Sullivan, C. W., Herron, T., & Hayat, Z. (2020). Olecranon Fracture: StatPearls Publishing, Treasure Island (FL). Swensen, S. J., Tyagi, V., Uquillas, C., Shakked, R. J., Yoon, R. S., & Liporace, F. A. (2019). Maximizing outcomes in the treatment of radial head fractures. J. Orthop. Traumatol., 20(1), 1-9.

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Wiegand, L., Bernstein, J., & Ahn, J. (2012). Fractures in brief: olecranon fractures. Clin. Orthop. Relat. Res., 470(12), 3637-3641. Yoon, A., Athwal, G. S., Faber, K. J., & King, G. J. (2012). Radial head fractures. J. Hand Surg., 37(12), 26262634.

Chapter 10

Supracondylar Humerus Fractures in Children Ferhan Bozkurt*, MD Department of Orthopedics and Traumatology, Keçiören Training and Research Hospital, Ankara, Turkey

Abstract Supracondylar humerus fractures (SCHFs) are fractures of the elbow region that are most common in play-age children and the riskiest due to the neurovascular anatomical structures close to the fracture site. Therefore, they are fractures that should be carefully focused on by emergency department and traumatology doctors, require close follow-up and are open to complications. In this chapter, SCHFs, which are common in children, and their treatment approaches will be examined based on the current scientific knowledge.

Introduction These are fractures that have the potential to develop a neurovascular injury, compartment syndrome, and malunion and require experience in management. The American Academy of Orthopedic Surgeons (AAOS, September 2011) prepared clinical guidelines to help decisionmaking in the treatment and care of these specific fractures. Likewise, the British Orthopaedic Association published the Standard of Trauma 11 (BOASTs 11, October 2020) guidelines. The complication rates have decreased depending on the modern treatment approaches in the last decade.

Epidemiology and Risk Factors An SCHF generally occurs after falling on outstretched arm. The non-dominant arm is frequently affected. The peak age is 5-7 years. It is necessary to suspect child abuse in physeal fractures and supracondylar humerus fractures of children younger than 2 years old. They constitute 3.3% of all pediatric fractures (Otsuka & Kasser, 1997). Distal radius fractures are *

Corresponding Author’s Email: [email protected].

In: Multidisciplinary Approach to Trauma Editors: Mehmet Cenk Turgut and Asli Turgut ISBN: 978-1-68507-761-7 © 2022 Nova Science Publishers, Inc.

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the most common accompanying additional skeletal system injury. In displaced fractures, the rate of neurovascular injury is 20-40% (Waters& Bae, 2012). Elbow joint hyperextension and ligamentous hyperlaxity are accused in etiology. The mechanism of fracture occurs when the trochlea-olecranon-joint capsule complex of the elbow in extension transmits the loaded trauma energy to the thin and weak supracondylar region of the humerus in the anterior-posterior plane. Of SCHFs, 97% are extension type fractures formed in this way, and the remaining 3% are flexion type fractures (Mahan et al., 2007). It is possible to define SCHF cases with forearm fracture as floating elbow, and these cases have an increased risk for compartment syndrome (Waters& Bae, 2012). An SCHF observed in adolescents is mainly associated with sports, and its treatment is open reduction + internal fixation similar to that in adults (Figure 3 C, D, E).

Clinical Evaluation Physical Examination An SCHF may also appear as a major deformity in the elbow joint, starting with simple symptoms of pain, swelling, and movement restriction. It is necessary to examine the upper and lower joints adjacent to the elbow joint and take x-rays in suspicious cases. In the physical examination, ecchymosis, the pucker sign can be observed in the antecubital region. The pucker sign shows that the proximal ends of the fracture pass through the brachialis muscle and progress up to the subcutaneous tissue. The brachialis muscle has a role of protecting the brachial artery, and the risk of brachial artery injury increases in cases with the pucker sign. It is absolutely necessary to note the neurovascular condition of the patient during the first admission to the emergency department and before the surgery. Skin temperature, radial pulse, digital capillary refill time, tenderness in forearm compartments, and radial nerve, median nerve (including anterior interosseous nerve examination), and ulnar nerve examinations should be involved in this evaluation. The passive extension and flexion of fingers may indicate elevated compartment pressure. Soft tissue injury in the affected limb is the key factor that determines the urgency of the operation. In the control of circulation, the color and temperature of the hand are first checked. A pale hand and a hot pink hand indicate a serious problem and good circulation, respectively. Then, the capillary refill time is checked, and the fact that it is shorter than 3 seconds indicates good circulation. A swollen, stretched, pale, cold, and pulseless hand indicates the development of compartment syndrome. The pain does not respond to analgesics in these cases. A forearm compartment pressure above 30 mm Hg leads to the diagnosis of compartment syndrome. Median nerve injury may conceal the signs of compartment syndrome.

Radiological Evaluation In pediatric patients who have a history of elbow trauma, standard AP and lateral x-rays are taken in the case of pain, swelling, and an inability to use the joint. It is necessary not to take a true lateral radiograph at the external rotation. Contralateral elbow radiographs are problematic, and may only be requested if the diagnosis is not clear. Baumann's (carrying) angle is evaluated

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on the true AP radiograph (Figure 1B). In the radiological evaluation of fracture reduction, the anterior humeral line should pass through the middle third of the capitellum on the lateral x-ray radiograph (Figure 1A). In children younger than 4 years of age, the anterior humeral line passes through the anterior third of the capitellum (Herman et al., 2009). In extension type 2-3 fractures, the “hourglass” view observed on the lateral radiograph is impaired, and the capitellum remains posterior to the anterior humeral line in these fractures. On the lateral radiograph of the elbow, the anterior fat pad shadow is mostly normal; however, the posterior fat pad sign is frequently the supportive sign of a nondisplaced SCHF (Skaggs and Mirzayan, 1999). In a normal elbow, the physeal line is wider posteriorly than anteriorly on a lateral radiograph. The lateral capitellar angle is approximately 30 degrees (Figure 1C).

Figure 1. (A) Anterior humeral line, (B) Baumann’s angle, (C) Capitellar angle.

Baumann's angle is defined as being between a line drawn perpendicular to the humeral axis and the lateral condyle physis line on a true AP radiograph. Its normal values are 9-26 degrees, and it is 17 degrees on average. As a general rule, Baumann's angle is regarded to be at least 10 degrees. Table 1. Modified Gartland fracture classification Type 1 Type 2 Type 3A, posteromedial Type 3B, posterolateral Type 4 (Leitch et al.) Medial comminution (Skaggs et al.)

Non-displaced Displaced one plane, posterior intact cortex and periosteum Displaced two plane, medial periosteum intact Displaced two plane, lateral periosteum intact Displaced, complete periosteal disruption Collapse of the medial column, loss of Baumann's angle

Fat pad sign Deformity is seen in the lateral x-ray view Deformity is seen in the lateral and AP view Deformity is seen in the lateral and AP view Instability in flexion and extension, diagnosed with examination under anesthesia Cause of cubitus varus deformity, gunstock deformity, cubitus rectus

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Fracture Classification On radiological x-rays, fractures are classified based on the direction of the fracture and the degree of displacement. While 97% of cases are extension-type fractures, 3% of them are flexion-type fractures. Nowadays, the modified Gartland classification is the most frequently used extension type SCHF classification (Table 1).

Type 1 These are stable fractures with 2 mm and less displacement. On a direct roentgenogram, the anterior humeral line is not disrupted, and the posterior fat pad sign may be the sole radiological sign. All periostea are intact. Type 2 These are fractures with more than 2 mm of displacement. The posterior cortex and periosteum are intact. The anterior humeral line is observed anterior to the capitellum. The anterior periosteum is injured (Figure 2A). Wilkins classified Type 2 fractures into two types: stable 2A and unstable type B with rotation (Wilkins, 1984). Type 3 Displaced fractures refer to fractures in which cortical contact is lost at the ends of the fracture, accompanied by damage to the medial or lateral periosteum with the anterior periosteum. Injury to the soft tissues and neurovascular structures is frequently observed. The direction of displacement is important and indicates which soft tissue is at risk by the proximal end of the fracture. In Type 3A fractures, the medial periosteum remains mostly intact and helps fracture reduction in posteromedial fractures (Figure 2B). In Type 3B fractures, the lateral periosteum remains intact in posterolateral fractures (Figure 2C). The radial nerve in type 3A fractures and the median nerve and brachial artery in type 3B fractures are at risk of injury on the displaced fracture line. Type 4 These are the fractures in which the medial and lateral periostea are accompanied by multidirectional instability and the posterior periosteum is damaged all around the fracture line (Figure 2E). The fracture is unstable in every direction. They are diagnosed by performing an examination under anesthesia. The capitellum, which is placed anterior to the anterior humeral line in flexion, is placed posteriorly in extension (Leitch et al., 2006).

Medial Comminution This is a thin and incomplete fracture line observed in the medial supracondylar region on direct radiographs. Baumann's angle is disrupted and decreases. It leads to cubitus varus and rectus if it is not sufficiently evaluated and treated properly (Skaggs et al., 2006). This group of fractures is defined as “Tweeners Type 1.5,” and deformity is likely to occur in their treatment in the cast (Waters& Bae, 2012).

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The usage area of computed tomography is limited. It can be used in cases of suspected Ttype condylar fractures, and magnetic resonance imaging can be used mostly in cases of suspected physeal and cartilage fractures.

Figure 2. (A) Type 2 fracture, (B) Type 3A fracture, (C) Type 3B fracture, (D) Flexion type fracture, (E) Type 4 fracture.

Clinical Treatment It is necessary to splint the extremity depending on the type of fracture in the emergency department. In displaced fractures that require reduction, neurovascular evaluation should be performed and recorded, and then, they need to be splinted by attempting gentle reduction. It is necessary to perform neurovascular evaluation again and again after splinting. It is necessary to provide a splint position at an elbow flexion of 40-50 degrees to avoid compartment syndrome, and excessive extension and flexion should be avoided. In cases with a surgical decision, soft tissue damage and condition mainly determine the urgency of surgery. It is necessary not to delay surgical treatment in the presence of circulatory disorder, ipsilateral additional trauma, open fracture, the pucker sign, and very noticeable swelling. Apart from the presence of these conditions, no significant clinical difference exists between the surgical outcomes of performing fracture fixation within and out of working hours

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and the surgical outcomes of performing it within the first 12 hours and within 12-24 hours (Okkaoğlu et al., 2021). In cases with good preoperative distal tissue perfusion, perioperative brachial artery exploration is not needed regardless of the radial pulse (BOASTs, October 2020). There is an indication for fasciotomy in cases with a compartment pressure higher than 30 mmHg. Generally, post-traumatic nerve injury occurs due to neuropraxia. Exploration is not needed during surgery in these cases. The anterior interosseous nerve is the most injured nerve and usually heals within 3 months.

Fracture Treatment Type 1 Fractures with no displacement are treated by immobilization for 3-4 weeks. While a long arm posterior splint is applied in the presence of swelling, a long arm cast can be applied in the absence of swelling. Immobilization is performed when the elbow is positioned at 60-90 degrees of flexion. This treatment can also be performed in fractures with an anterior displacement of less than 2 mm, and an increase in normal elbow extension degrees and a decrease in flexion degrees are expected after healing in these fractures. In the presence of medial communication and in cases when the capitellar angle decreases below 20 degrees, immobilization is applied by correcting the appropriate Baumann's and capitellar angles with reduction under anesthesia. Type 2 Nowadays, many surgeons prefer closed reduction and percutaneous pinning under anesthesia, although the treatment of type 2A fractures is controversial. Patients treated with closed reduction and plaster cast need to be followed up closely for the loss of reduction. Varus and valgus deformities in the coronal plane have no remodeling capacity. However, remodeling capacity is limited in deformities in the AP plane. Due to the presence of rotational deformity in Type 2B fractures, percutaneous pinning is required after closed reduction. Type 3 These fractures differ from other types of fractures in terms of being unstable, an increased risk of neurovascular injury, difficulty in the reduction technique, increased swelling, and the complication rate. In these cases, cortical contact is completely disrupted, and the periosteum is torn. It is possible to avoid compartment syndrome by performing a gentle reduction and temporary splinting at 30 degrees of flexion in the emergency department. Closed/open reduction + percutaneous pinning is the best method. In the operating room, an attempt is made to prevent neurovascular structures from entering the fracture line by applying traction for one minute with the elbow at 20 degrees of flexion before reduction. In cases with the pucker sign, the “milking maneuver” is performed proximal to the distal (Peters, 1995). By checking the varus-valgus alignment, the fracture is reduced with anterior pressure over the olecranon. In a successful reduction, the child's fingers touch the shoulder joint. By checking the varus and valgus alignment through fluoroscopy, the fracture is fixed by pins. Open reduction is performed in cases with suspected neurovascular injury.

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Figure 3. (A, B) Operated type 3A fracture AP and lateral view, (C) 13-year-old boy type 3A fracture, (D, E) postoperative 3. Mouth AP and lateral view.

In Type 3A fractures with posteromedial displacement, the pronation of the forearm during reduction is mostly helpful for reduction. Likewise, the supination of the forearm is mostly helpful for reduction in posterolateral Type 3B fractures.

Type 4 These are the fractures that are severely unstable in every direction. Open reduction may be needed in their treatment. It is possible to achieve closed reduction with the reduction technique defined by Leitch (Leitch, 2006). In an unreduced fracture, while 2 K-wires applied over the lateral epicondyle are placed on the distal fragment and then a surgeon fixes the fracture by reducing the fracture in the coronal and sagittal planes, the other surgeon advances the pins along the fracture line, and the fracture is fixed.

Pin Configuration Two cortex-involved lateral entry divergent/parallel and medial, lateral entry crossed fracture fixation methods have been defined. Stability is evaluated after the application of two lateral entry pins, one of which passes through the olecranon fossa, and a third lateral pin or a medial pin can be applied if sufficient stabilization cannot be achieved. In biomechanical analyses, it was demonstrated that the use of medial and lateral entry crossed pins ensured more stable fracture fixation. However, it was demonstrated that the use of three lateral entry pins also ensured sufficient fracture fixation in many cases (Braurer et al., 2007). Lateral divergent pins are more stable compared to parallel pins (Lee et al., 2002). Despite the presence of an increased

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risk of iatrogenic ulnar nerve injury in the use of medial pins, the risk can be minimized with a small incision over the medial epicondyle (Yen et al., 2008). The medial pin is applied more horizontally to avoid medial pin ulnar nerve injury (Özçelik et al., 2006). In Type 3 fractures whose closed reduction cannot be achieved by conventional methods, reduction can be facilitated using a temporary pin applied from the posterior (Yu et al., 2004).

Open Reduction Open reduction and exploration are applied in cases of a circulatory disorder in the extremity, open fractures, and failure to achieve the desired reduction with closed methods. Anterior, posterior, medial, and lateral approaches can be applied. It is preferably recommended to use an approach from the side with periosteal injury. Neurovascular injury and irreducibility are most frequently observed in posterolateral Type 3b fractures, and the anterior approach for the anterior and medial periosteum is the most appropriate approach for these fractures. The transverse incision is made over the fracture line, and it is possible to extend the incision superiorly and inferiorly when needed. Neurovascular structures are clearly evaluated and provide rapid access to the fracture line (Waters& Bae, 2012). The anterior approach requires a learning curve and close observation of the surgical site in the first few cases (Ersan et al., 2012). During the approach, neurovascular structures can be found immediately in the subcutaneous tissue due to damage to the brachialis muscle.

Complications Avascular Limb The avascular limb due to SCHF requires emergency intervention without any delay. For any angiographic examination, it is necessary to reduce the fracture without loss of time. After the gentle closed reduction of the fracture, the distal peripheral arterial circulation mostly starts again (Schoenecker et al., 1996). The routine fracture treatment procedure is applied if the hand is pink and warm, pulses are taken, and capillary filling is observed. The patient is hospitalized for observation if the hand is pink, the capillary filling is good, but the pulses cannot be taken. The absence of the radial pulse is not in itself an indication for emergency surgical exploration. Emergency surgical exploration is required if the hand is not pink, capillary filling is weak or absent, and pulses cannot be taken. Arterial capillary filling alone may be misleading, and venous reflux may occur. In addition to the temperature, turgor, and color of the hand, pulses should be checked repeatedly. Capillary arterial filling should be examined comparatively with the intact side, and it should not be longer than 3-5 seconds compared to the intact side. In case of artery injury, vascular surgery and repair with a non-tensioned vein graft may be required, and it is always recommended to apply prophylactic fasciotomy in these cases. In patients undergoing closed reduction + pinning, it may take 10-15 minutes to feel intraoperative distal pulses due to arterial vasospasm. After intraoperative fracture fixation, it is necessary to check arterial pulses before the case is terminated. If distal pulses cannot be taken during the process, the risk of compartment syndrome is high, and there is an indication

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for exploration. If the pulse is lost after pinning in a case with a pulse, it is necessary to remove the pins and perform arterial exploration. If the pulses cannot be taken after the decompression of neurovascular structures and fracture fixation, it is necessary to wait for 15 minutes, and vascular reconstruction is required if the pulses still cannot be taken and distal tissue perfusion is poor. The need for vascular reconstruction is controversial if tissue perfusion is achieved sufficiently, although the pulses cannot be taken.

Compartment Syndrome This is the clinical picture in which pain, pulselessness, paresthesia, pallor, and paralysis symptoms known as the 5P symptoms are observed and extremity circulation is impaired. It is observed by 0.1-0.5% in SCH fractures (Bashyal et al., 2009). Other symptoms of compartment syndrome are pain on finger extension, increased analgesic requirement, and increased swelling. Median nerve injury may conceal the signs of compartment syndrome. The presence of a radial artery pulse does not eliminate compartment syndrome. The risk of development increases in the presence of high-energy trauma, the presence of additional fractures in the forearm bones, brachial artery rupture, and increased time until the first intervention after trauma.

Neurological Deficit Neural injury is observed by 13%. It mostly occurs in the form of neuropraxia. The anterior interosseous nerve is the most frequently affected nerve by 5%, followed by the radial nerve by 4%. The anterior interosseous nerve innervates the flexor pollicis longus, pronator quadratus, and radial half flexor digitorum profundus (2nd and 3rd digits) muscles. While thumb IP joint flexion indicates the intact anterior interosseous nerve, the flexion of the PIF joints indicates the intact median nerve, MCP joint extension indicates the intact radial nerve, and the flexion of the 5th finger DIF joint indicates the examination of the intact ulnar nerve. Ulnar nerve lesion is most frequently observed in flexion type SCHF (Babal et al., 2010). The presence of a neurological deficit does not constitute an indication for exploration, and it is followed up to 6 months (Kasser & Beaty, 2006). The improvement is usually observed in the 3rd month (Culp et al., 1990). Iatrogenic ulnar nerve injury is not caused by the direct penetration of the pin, and it is mostly caused by the soft tissue wrapping of the pin as it turns during application. Another reason is that excessive flexion is applied to the elbow to preserve the reduction. Therefore, it is recommended to first apply two lateral entry pins and then use a medial pin by reducing elbow flexion below 90 degrees in the guidelines. The removal of pins and exploration are not routinely recommended in postoperative iatrogenic ulnar nerve injuries. The ulnar nerve generally heals within 3-4 months.

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Pin Tract Infection and Pin Migration Pin tract infections are rarely observed. They can be prevented by regular dressing in patients with poor sanitation. It is possible to use oral antibiotics for their treatment. They should be followed up for deep tissue infection and septic arthritis development. Pin migration is observed in cases when less than 1 cm is left on the skin. It needs to be removed. Bending the pin by 90 degrees at a distance of 1 cm from the skin at the end of the operation prevents migration.

Elbow Stiffness Physical therapy is not required in most of the treated patients. ROM is provided by 90% within 39 days after the removal of pins (Wang et al., 2009). This ratio is 98% at the end of 52 weeks (Zionts et al., 2010). Malunion, nonunion, and trochlear avascular necrosis are other complications that can be observed in other SCH fractures and treatments.

Flexion-Type Supracondylar Humerus Fracture This constitutes 2% of all supracondylar humerus fractures. It occurs by falling on the flexed elbow. The posterior periosteum is torn (Figure 2D). Ulnar nerve injury is more frequently observed. The fracture classification is Type 1: non-displaced, Type 2: minimum angulation with cortical contact, and Type 3: unstable displaced without cortical contact. Although the reduction maneuver is reversed in the treatment, the main fixation rules are applied in extension-type fractures. Flynn's criteria for the grading outcome are used in the evaluation of the treatment of all SCH fractures (Table 2). Table 2. Flynn's criteria for grading outcome Result

Rating

Satisfactory

Excellent Good Fair Poor

Unsatisfactory

Cosmetic factor (carrying angle loss in degrees) ‹5 5-10 11-15 15‹

Functional factor (loss of motion in degrees) 5 5-10 11-15 15‹

Conclusion SCHFs are common childhood fractures with a high risk of complications. The neurovascular injury requires close follow-up since it is associated with the risk of compartment syndrome development. The primary goal of treatment is to ensure the continuity of the distal vascular circulation and then fix the fracture. It is necessary to gently reduce displaced fractures as soon

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as they appear to preserve the distal vascular circulation. The condition and perfusion of soft tissues determine the urgency of the surgery. The goal of fracture fixation is to ensure the normal mechanical axis of the elbow. The anterior humeral line, capitellum relationship, and Baumann’s angle should be restored. Baumann’s angle is considered to be a minimum of 10 degrees and an average of 17 degrees. The anterior humeral line should pass through the middle third of the capitellum. The medial and lateral columns should appear intact on oblique radiographs. It is necessary to try open reduction if the desired restoration cannot be achieved by closed reduction. It is an obligation to achieve anatomical reduction as much as possible to avoid cubitus varus and loss of elbow flexion and extension. When the growth of the humerus is considered, it is observed that it grows from the distal epiphyses by 20% and the proximal epiphyses by 80%. Our remodeling capacity in SCHFs is relatively low. We have no remodeling capacity in varus and valgus deformities, and the capacity for flexion and extension is very limited. In this case, the restoration of Baumann’s angle is essential. Since the remodeling capacity of adolescent SCHFs is very low, the treatment management is open reduction + internal fixation as in adults.

References Abzug JM, Herman MJ. (2012). Management of supracondylar humerus fractures in children: Current concepts. J Am Acad Orthop Surg, 20(2):69-77. Babal JC, Melhman CT, Klein G. (2010). Nerve injuries associated with pediatric supracondylar humerus fractures: a meta-analysis, J Pediatr Orthop. 30:253-63. Bashyal RK, Chu JY, Schoenecker PL, Dobbs MB, Luhmann SJ, Gordon JE. (2009). Complications after pinning of supracondylar distal humerus fractures. J Pediatr Orthop. 29(7):704-708. Brauer CA, Lee BM, Bae DS. Waters PM, Kocher MS. (2007). A systematic review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus. J Pediatr Orthop. 27:181– 186. 63. British Orthopaedics Association Standard for Trauma and Orthopaedics (BOASTs), Supracondylar fractures in the humerus in Children, updated October (2020). Culp RW, Osterman AL, Davidson RS, (1990). Neural injuries associated with supracondylar fractures of the humerus in children. J Bone Joint Surg Am. 72(8):1211–1215. Ersan Ö, Gönen E, İlhan RD, Boysan E, Ateş Y. (2012). Comparation anterior and lateral approaches in the treatment of extension -type supracondylar humerus fractures in children. J Pediatric Orthop B. 21(2):121-6. Flynn JM, Skaggs D, Waters PM. (2015). Wolters Kluwer Rockwood and Wilkins Fractures in Children 8. Edition Chapter 16. Herman MJ, Boardman MJ, Hoover JR, Chafetz RS. (2009). Relationship of the anterior humeral line to the capitellar ossific nucleus: Variability with age. J Bone Joint Surg Am. 91(9):2188–2193. Kasser JR, Beaty JH. (2006) Rockwood and Wilkins’ Fractures in Children. 6th edt. Lippincott Williams & Wilkins. pp:543–589. Lee SS, Mahar AT, Miesen D. Newton PO. (2002). Displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop. 22:440–443. Leitch KK, Kay RM, Femino JD, Tolo VT, Storer SK, Skaggs DL. (2006). Treatment of multidirectionally unstable supracondylar humeral fractures in children. A modified Gartland type-IV fracture. J Bone Joint Surg Am. 88:980-5. Mahan ST, May CD, Kocher MS. (2007) Operative management of displaced flexion supracondylar humerus fractures in the children. J Pediatr Orthop 27:551-6.

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Okkaoğlu MC, Özdemir FE, Özdemir E, Ateş A, Altay M. (2021). Is there an optimal timing for surgical treatment of pediatric supracondylar humerus fractures in the first 24 hours? J Orthop Surg Res10;16(1)484. Otsuka NY, Kasser JR. (1997). Supracondylar fractures of the humerus in children. J Am Acad Orthop Surg. 5:19–26. Ozcelik A, Tekcan A, Omeroglu H. (2006). Correlation between iatrogenic ulnar nerve injury and angular insertion of the medial pin in supracondylar humerus fractures. J Pediatr Orthop B. 15:58–61. Peters CL, Scott SM, Stevens PM. (1995). Closed reduction and percutaneous pinning of displaced supracondylar humerus fractures in children: Description of a new closed reduction technique for fractures with brachialis muscle entrapment. J Orthop Trauma. 9(5):430-434. Schoenecker PL, Delgado E, Rotman M. Mitchell SG, Capelli AM. (1996). Pulseless arm in association with totally displaced supracondylar fracture. J Orthop Trauma. 10:410–415. Skaggs DL, Mirzayan R. (1999). The posterior fatpadsign in association with occult fracture of the elbow in children. J Bone Joint Surg Am. 81:1429–1433. Skaggs DL, Flynn JM. (2006) Staying out of trouble in pediatric orthopaedics. Lippincott, Williams and Wilkins. Wang Y-L, Chang WN, Hsu CJ, Chien JH, Shu FS (2009). The recovery of elbow range of motion after treatment of supracondylar and lateral condylar fractures of the distal humerus in children. J Orthop Trauma. 2009;23(2):120–125. Waters PM. Bae DS. (2012) Pediatric Hand ve Upper Limb Surgery, A practical Guide. Chapter 27. Wolters Kluwer, Lippincott, Willams, Wilkins. Wilkins KE. King RE. (1984) Fractures and dislocations of the elbow region. Rocwood Fractures in children. Lippincott, pp 363–450. Yen YM, Kocher MS. (2008). Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children. Surgical technique. J Bone Joint Surg Am. 90 Suppl 2 Pt 1:20–30. Yu SW, Su JY, Kao FC. Ma CH. Yen CY. Tu YK. (2004). The use of the 3-mm K-wire to supplement reduction of humeral supracondylar fractures in children, J Trauma 57(5):1038–1042, 2004. Zionts LE, Woodson CJ, Manjra N, Zalavras C. (2009) Time of return of elbow motion after percutaneous pinning of pediatric supracondylar humerus fractures. Clin Orthop Relat Res. 467(8):2007–2010.

Chapter 11

Acetabular Fractures Alperen Zeynel1,, MD and Mehmet Cenk Turgut2, MD 1Department

of Orthopedics and Traumatology, Erzurum City Hospital, Erzurum, Turkey 2Department of Orthopedics and Traumatology, Erzurum Regional Training and Research Hospital, Erzurum, Turkey

Abstract Nowadays, the increase in the frequency of accidents also increases the incidence of highenergy acetabular fractures. Additional systemic injuries are frequently observed since they are high-energy injuries. Their rare occurrence, poor surgical background and experience, and complex anatomy complicate surgical interventions in these fractures and reduce the desired levels of success. Conservative treatment increases the incidence of post-fracture osteoarthritis. Effective studies of Judet and Letournel formed the basis of the modern literature. Furthermore, the three-dimensional structure of the acetabulum has been better understood with the developing imaging methods, and there has been an increase in the tendency toward surgery. Anatomical reduction and early rehabilitation should be the goal in acetabular fractures, as in all intra-articular fractures.

Introduction Acetabular fractures are complex injuries that commonly occur as a result of high-energy traumas (Giannoudis, Grotz, Papakostidis, & Dinopoulos, 2005). Thus, accompanying systemic injuries are common. In elderly patients, they may also occur as a result of low-energy traumas. The fracture pattern depends on the bone quality, the direction of the incoming vector, and the position of the femoral head during the accident. Their incidence is approximately three per hundred thousand (Negrin & Seligson, 2017). Acetabular fractures were usually treated by conservative methods until the 1960s. These methods caused patients to have severe hip and low back pain, gait and posture disorders, and neurological problems (Matta, 2011). In Judet and Letournel’s studies on the acetabulum and



Corresponding Author’s Email: [email protected].

In: Multidisciplinary Approach to Trauma Editors: Mehmet Cenk Turgut and Asli Turgut ISBN: 978-1-68507-761-7 © 2022 Nova Science Publishers, Inc.

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pelvis, fundamental principles were identified, and new classification systems and surgical approaches were revealed (Giannoudis et al., 2005). It is possible to use conservative treatment options for nondisplaced fractures. However, anatomical open reduction and internal fixation are needed to decrease the risk of osteoarthritis in displaced fractures. Apart from acetabular fractures with open fractures and irreducible hip dislocations, it is essential not to consider emergency surgery and to have good planning skills.

Anatomy It is possible to define the acetabulum as a semispherical structure with a cotyloid fossa and a horseshoe-shaped articular surface. Its mean lateral inclination is between 40 and 48 degrees. Its anteversion is between 18 and 21 degrees. It is necessary to know the column theory with regard to surgical approaches. The acetabulum is composed of two columns. The anterior column is composed of the anterior iliac wing, the anterior half of the acetabulum, and the superior pubic ramus. The posterior column is composed of the posterior half of the acetabulum, the ischial tubercle, and sciatic notch. The acetabular roof is the portion that supports the femoral head and bears the main load. The quadrilateral surface, which comprises the lateral surface of the true pelvis, is the flat bony area. This structure constitutes the neighborhood of the medial wall of the acetabulum. The iliopectineal eminence extends above the acetabular roof and the femoral head. In posterior fractures, the sciatic nerve passing under the piriformis muscle at the greater sciatic notch is at risk. Furthermore, in fractures that reach the upper part of the sciatic notch, it is necessary not to ignore the injuries of the superior gluteal artery passing through this region. Anastomosis called corona mortis exists between the epigastric branch of the external iliac artery and the obturator artery. It may lead to difficult-to-control bleeding, particularly in ilioinguinal approaches.

Classification The Judet and Letournel classification is the most widely used classification system, and its reliability has been proven by many studies (Ohashi, El-Khoury, Abu-Zahra, & Berbaum, 2006; Petrisor et al., 2003). This system is classified into two groups, including 5 simple fractures and 5 combined fractures (Judet, Judet, & Letournel, 1964). This classification was combined in more detail with the Müller AO Classification (M Tile, Helfet, & Kellam, 1995). Table 1. Letournel classification Simple fxs • Ant. wall • Post. wall • Ant. column • Post. column • Transverse-fxs

Combined fxs • Post. column + wall • T type fractures • Transverse + post. wall • Fractures of both columns • post. hemitransverse + ant. column or wall

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The posterior wall fracture is encountered most frequently (Baumgaertner, 1999; Letournel, 2007). Anterior wall fractures are the least common among acetabular fractures (Ochs et al., 2010). Transverse fractures are included in simple fractures since they are related to only one plane, although they are involved in both columns.

Patient Management The initial examination and clinical evaluation are of vital importance since acetabular fractures are high-energy traumas. Priority should be given to the detection and treatment of lifethreatening conditions. Excessive fluid volume loss, prolonged shock, and the need for too many transfusions are the most common causes of death in patients. It is therefore very important to evaluate hemodynamic stability. The perineal and rectal examination should certainly be performed, and bleeding in the urethral meatus should certainly be checked. It is necessary to avoid examinations that will increase the risk of bleeding, and imaging methods should be employed quickly after the first interventions. AP, obturator oblique, and iliac oblique radiographs are the recommended imaging methods. Obturator oblique radiography is important for evaluating the anterior column + posterior wall. The iliac oblique radiograph is important for evaluating the posterior column + anterior wall. There are radiographic landmarks of the acetabulum on these radiographs. Letournel’s six basic radiographic landmarks are the posterior wall of the acetabulum, the anterior wall of the acetabulum, the roof, tear, ilioischial line, and iliopectineal line. While the iliopectineal line is important for evaluating anterior column fractures, the ilioischial line is important for evaluating posterior column fractures. Furthermore, the distance between the femoral head and tear drop is important for evaluating the hip dislocations in traumatic and atraumatic hips. Except for the landmarks, there are certain special findings that can be evaluated on radiographs. In posterior wall fractures, the “gull sign” is observed on the iliac oblique radiographs. The “spur sign” is seen on the obturator oblique radiographs. Matta et al. developed the “roof-arc” system to evaluate the acetabular roof after fractures. They advocated the need for surgery if any of the three radiographs had 40 years and associated with femoral head trauma (Ensrud, 2013). There are studies indicating that osteoarthritis occurs at a rate of 8% even with excellent reduction, although its incidence decreases due to anatomical reduction (Ragnarsson & Mjöberg, 1992). HTO is a common complication (Meena, Tripathy, Sen, Aggarwal, & Behera, 2013). It has the lowest incidence with the anterior ilioinguinal approach and the highest incidence with the extensile approach (Kumar et al., 2021). Male gender and head trauma are the factors that increase the risk, and treatment with 25 mg of indomethacin three times a day for 4 to 6 weeks starting from the day of surgery was recommended for prophylaxis (Moed & Maxey, 1993). There are also studies arguing that low-dose radiation decreases the risk and severity of HTO (Freije, Kushdilian, Burney, Zang, & Saito, 2021). In the literature, the incidence of avascular necrosis of the femoral head following the surgical treatment of acetabular fractures is 10-15% (Magu et al., 2014). Most of the patients are associated with hip dislocation and posterior wall fracture (Ziran, Soles, & Matta, 2019). The incidence of infection is 4-5% and higher than in the extended approaches (Giannoudis et al., 2005; Wright et al., 1994). In a meta-analysis carried out by Kelly et al., iatrogenic nerve injury was found to be 6.5%. The lateral femoral cutaneous nerve was the most frequently injured nerve. Sciatic nerve injury is observed especially after posterior fracture dislocations. It was concluded

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that there was a decrease in sciatic nerve injury over time with the acetabular surgery (Kelly, Ladurner, & Rickman, 2020).

Conclusion In the treatment of acetabular fractures, it is aimed to achieve a stable, compatible, and functional hip and prevent the occurrence of post-traumatic arthritis. It is necessary to perform the preoperative systemic assessment of patients in detail since acetabular fractures are highenergy fractures. Patients’ increased functional expectations, advancing implant technologies, and the results of current studies direct the treatment option in these fractures to surgery. Due to their complex structures, these fractures should be treated by surgeons who have a good knowledge of anatomy and the current literature.

References Baumgaertner, M. R. (1999). Fractures of the posterior wall of the acetabulum. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 7(1), 54-65. Borrelli Jr, J., Goldfarb, C., Catalano, L., & Evanoff, B. A. (2002). Assessment of articular fragment displacement in acetabular fractures: a comparison of computerized tomography and plain radiographs. Journal of orthopaedic trauma, 16(7), 449-456. Ensrud, K. E. (2013). Epidemiology of fracture risk with advancing age. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences, 68(10), 1236-1242. Freije, S. L., Kushdilian, M. V., Burney, H. N., Zang, Y., & Saito, N. G. (2021). A retrospective analysis of 287 patients undergoing prophylactic radiation therapy for the prevention of heterotopic ossification. Advances in Radiation Oncology, 6(3), 100625. Geerts, W. H., Pineo, G. F., Heit, J. A., Bergqvist, D., Lassen, M. R., Colwell, C. W., & Ray, J. G. (2004). Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, 126(3), 338S-400S. Giannoudis, P., Grotz, M., Papakostidis, C., & Dinopoulos, H. (2005). Operative treatment of displaced fractures of the acetabulum: a meta-analysis. The Journal of bone and joint surgery. British volume, 87(1), 2-9. Hustedt, J. W., Blizzard, D. J., Baumgaertner, M. R., Leslie, M. P., & Grauer, J. N. (2012). Is it possible to train patients to limit weight bearing on a lower extremity? Orthopedics, 35(1), e31-e37. Judet, R., Judet, J., & Letournel, E. (1964). Fractures of the acetabulum: classification and surgical approaches for open reduction: preliminary report. JBJS, 46(8), 1615-1675. Kelly, J., Ladurner, A., & Rickman, M. (2020). Surgical management of acetabular fractures–a contemporary literature review. Injury, 51(10), 2267-2277. Kumar, D., Kushwaha, N. S., Tiwari, P. G., Sharma, Y., Srivastava, R., & Sharma, V. (2021). Outcome of acetabulum fractures treated with open reduction and internal fixation through Kocher-Langenbeck Approach: A retrospective study. Journal of Clinical Orthopaedics and Trauma, 101599. Letournel, E. (2007). Acetabulum fractures: classification and management. Orthopedic Trauma Directions, 5(05), 27-33. Letournel, E., & Judet, R. (2012). Fractures of the acetabulum: Springer Science & Business Media. Magu, N. K., Gogna, P., Singh, A., Singla, R., Rohilla, R., Batra, A., & Mukhopadhyay, R. (2014). Long term results after surgical management of posterior wall acetabular fractures. Journal of Orthopaedics and Traumatology, 15(3), 173-179. Matta, J. M. (2011). Fracture of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. Orthopedic Trauma Directions, 9(02), 31-36.

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Meena, U., Tripathy, S., Sen, R., Aggarwal, S., & Behera, P. (2013). Predictors of postoperative outcome for acetabular fractures. Orthopaedics & Traumatology: Surgery & Research, 99(8), 929-935. Moed, B. R., & Maxey, J. W. (1993). The effect of indomethacin on heterotopic ossification following acetabular fracture surgery. Journal of orthopaedic trauma, 7(1), 33-38. Negrin, L. L., & Seligson, D. (2017). Results of 167 consecutive cases of acetabular fractures using the KocherLangenbeck approach: a case series. Journal of orthopaedic surgery and research, 12(1), 1-8. Ochs, B. G., Marintschev, I., Hoyer, H., Rolauffs, B., Culemann, U., Pohlemann, T., & Stuby, F. M. (2010). Changes in the treatment of acetabular fractures over 15 years: analysis of 1266 cases treated by the German Pelvic Multicentre Study Group (DAO/DGU). Injury, 41(8), 839-851. Ohashi, K., El-Khoury, G. Y., Abu-Zahra, K. W., & Berbaum, K. S. (2006). Interobserver agreement for Letournel acetabular fracture classification with multidetector CT: are standard Judet radiographs necessary? Radiology, 241(2), 386-391. Petrisor, B. A., Bhandari, M., Orr, R. D., Mandel, S., Kwok, D. C., & Schemitsch, E. H. (2003). Improving reliability in the classification of fractures of the acetabulum. Archives of orthopaedic and trauma surgery, 123(5), 228-233. Petsatodis, G., Antonarakos, P., Chalidis, B., Papadopoulos, P., Christoforidis, J., & Pournaras, J. (2007). Surgically treated acetabular fractures via a single posterior approach with a follow-up of 2–10 years. Injury, 38(3), 334-343. Ragnarsson, B., & Mjöberg, B. (1992). Arthrosis after surgically treated acetabular fractures: a retrospective study of 60 cases. Acta Orthopaedica Scandinavica, 63(5), 511-514. Romness, D. W., & Lewallen, D. G. (1990). Total hip arthroplasty after fracture of the acetabulum. Long-term results. The Journal of bone and joint surgery. British volume, 72(5), 761-764. Schmidt, A. H., & Teague, D. C. (2011). Orthopaedic Knowledge Update 4: Trauma: American Academy of Orthopaedic Surgeons. Tile, M., Helfet, D., & Kellam, J. (1995). Comprehensive Classification of Fractures in the Pelvis and Acetabulum. Berne: Maurice E. Muller Foundation. Tile, M., Helfet, D. L., Kellam, J. F., & Vrahas, M. (1995). Fractures of the pelvis and acetabulum: Williams & Wilkins Baltimore. Tornetta III, P. (1999). Non-operative management of acetabular fractures: the use of dynamic stress views. The Journal of bone and joint surgery. British volume, 81(1), 67-70. Wright, R., Barrett, K., Christie, M. J., & Johnson, K. D. (1994). Acetabular fractures: long-term follow-up of open reduction and internal fixation. Journal of orthopaedic trauma, 8(5), 397-403. Ziran, N., Soles, G. L., & Matta, J. M. (2019). Outcomes after surgical treatment of acetabular fractures: a review. Patient safety in surgery, 13(1), 1-19.

Chapter 12

Femoral Neck Fractures Mustafa Caner Okkaoglu, MD Department of Orthopedics and Traumatology, Health Sciences University, Kecioren Training and Research Hospital, Ankara, Turkey

Abstract Hip fractures are one of the most common fractures, and may occur with high-energy trauma in young people and low-energy trauma such as simple falls in the elderly. Femoral neck fractures constitute approximately half of these fractures. It is estimated that their numbers will increase even more, especially with the aging population. While the diagnosis of these fractures can be easily made with X-rays, magnetic resonance imaging is an important diagnostic tool in occult or stress fractures. The treatment is shaped by considering the patient's age, comorbidities and activity level. While fixation is the first choice in young patients, arthroplasty may be the first choice in elderly patients. Femoral neck fractures are a type of fracture open to complications. While avascular necrosis, nonunion, malunion, and complications are common after internal fixation, prosthetic dislocations and periprosthetic infections are complications that may develop due to arthroplasty. Especially in elderly patients, femoral neck fracture is an important mortality risk factor. The treatment modality decision and treatment application processes of these common fractures are very important. Predicting the complications that may occur and considering the risks specific to the patient while making the treatment decision will guide us in the success of the treatment.

Introduction Hip fractures are one of the most common fractures, and may occur with high-energy trauma in young people and low-energy trauma such as simple falls in the elderly. Hip fractures in the elderly are increasing rapidly, especially with the aging population, and it is expected that there will be approximately 300,000 hip fracture cases annually in the USA in 2030 (Brox et al., 2015). 

Corresponding Author’s Email: [email protected].

In: Multidisciplinary Approach to Trauma Editors: Mehmet Cenk Turgut and Asli Turgut ISBN: 978-1-68507-761-7 © 2022 Nova Science Publishers, Inc.

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Approximately 70% of hip fractures occur in women, and the incidence increases with age (Koval and Zukerman, 1994). Hip fractures consist of fractures in 4 different regions of the proximal femur. These are: femoral head fractures, femoral neck fractures, trochanteric fractures and subtrochanteric fractures. Femoral head and neck fractures are grouped as intracapsular fractures, and trochanteric and subtrochanteric fractures are grouped as extracapsular fractures. Among these, femoral neck fractures constitute 53% of these fractures (Thorngren et al., 2002). Three of these fractures are seen in women (Holmberg and Thorngren, 1987). One of the most important features that distinguishes femoral neck fractures from other hip fractures is that these fractures are intracapsular fractures. Because of this feature, there is a high probability of avascular necrosis of the femoral head after damage to its vascular support during fracture. In an adult, the most important vascular structure feeding the femoral head is the medial femoral circumflex artery. This arterial structure can be damaged especially in displaced femoral neck fractures, which can lead to nonunion and avascular necrosis (Barney et al., 2021).

Presentation Patients can apply to the hospital without describing any trauma or with a very low-energy trauma, or they can apply after a very high-energy traffic accident. Generally, young patients present with high-energy trauma, and older patients with lower-energy trauma such as a simple fall (Protzman and Burkhalter, 1976). The pain conditions of the patients at the time of admission can also be at very different levels. For example, a patient with a non-displaced valgus impacted femoral neck fracture comes to the hospital complaining of pain only when the affected hip is weight bearing, while the patient with a completely displaced femoral neck fracture has severe pain in the hip with the leg in external rotation, and is usually brought to the hospital by ambulance. When these patients are admitted to the hospital, a detailed examination should be performed, especially in low-energy trauma, an evaluation for syncope or another neurological disorder. In high-energy trauma, the necessary resuscitation procedures should be applied to the patient, examination and emergency treatment of other vital organs and systems should be performed, and other bone fracture examinations such as femur shaft, pelvis, calcaneus, and vertebra should be done meticulously.

Radiology In patients with femoral neck fractures, as in all fractured patients, the primary diagnostic tool is X-ray. Anteroposterior (AP) radiographs can be easily taken in patients with femoral neck fractures. However, lateral radiographs cannot be taken because the patient feels pain. Therefore, although the diagnosis of the fracture can mostly be made by AP X-ray, it is important to understand the configuration of the fracture in planning the treatment strategy. In these cases, a direct hip lateral radiograph or figure four radiograph is recommended if possible. However, if there is a possibility of displacement of a non-displaced fracture while these radiographs are being taken, the patient's hip should not be forced into extreme positions.

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Although 98% of femoral neck fractures can be diagnosed with XR X-rays, technetium bone scintigraphy can enable us to make a diagnosis in the remaining 2% in the case of high suspicion (Fairclough et al., 1987). Computed tomography (CT), especially in patients with femoral neck fractures that we cannot position, will provide 3D vision, and will be beneficial both for detecting difficult-to-see fractures and for understanding the fracture configuration. Another diagnostic tool is magnetic resonance imaging (MRI), which is not usually used in the acute phase, but allows us to detect occult fractures or stress fractures. MRI has been shown to be more sensitive than scintigraphy in detecting occult fractures (Rizzo et al., 1993).

Classifications Many classification types have been previously described for femoral neck fractures. One of the most important factors that these classification systems draw the most attention to and determine the fracture type is the amount of fracture displacement. There are three most commonly used classifications in the literature. These are the Garden, Pauwels and AO/OTA classifications.

Garden Classification (Garden 1961) The Garden classification primarily divides femoral neck fractures into 2 main parts. These are nondisplaced (Types 1 and 2) fractures and displaced (Types 3 and 4) fractures. These are again divided into 2, defining 4 types of fractures in total (Figure 1). • • • •

Type I: Incomplete fracture––valgus impacted-non displaced, Type II: Complete fracture––nondisplaced, Type III: Complete fracture––partial displaced, Type IV: Complete fracture––fully displaced.

Figure 1. Garden classification of femoral neck fractures (Van Embden et al., 2012).

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The Garden classification is the most commonly used classification in the literature on femoral neck fractures (Zlowodski et al., 2005).

Pauwels Classification (Pauwels 1935) Pauwels defined femoral neck fractures as vertical, oblique or transverse types. He classified the type of fracture according to the angle between the fracture line and the horizontal line (Figure 2). He thought that with this classification, the type of fracture could affect the stability and predict the nonunion condition. • • •

Type 1: Transverse fractures forming an angle of less than 30 degrees with the horizontal line, Type 2: Oblique fractures forming an angle of 30-50 degrees with the horizontal line, Type 3: Vertical fractures forming an angle of more than 50 degrees with the horizontal line.

Figure 2. Pauwels classification of femoral neck fractures (Ye et al., 2015).

AO/OTA Classification This classification categorizes fractures based on the name of the bone, the place on the bone, and the morphology of the fracture. Femoral neck fractures are classified as 31B according to this classification system. The femur refers to 3, femoral proximal to 1 and the femoral neck part to B (Figure 3). • • •

B1: Nondisplaced femoral neck fracture, B2: Transcervical displaced femoral neck fracture, B3: Subcapital femoral neck fracture.

This classification is not often used because it does not provide much information about prognosis compared to the other two classifications, except for non-displaced or displaced fractures.

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Figure 3. AO/OTA classification of femoral neck fractures (Blundell et al., 1998).

Apart from these classifications, surgeons agree with each other as to whether the fracture is intracapsular or extracapsular, or whether it is displaced or non-displaced.

Anatomy of the Femoral Neck The hip is a ball-socket type joint. The femoral neck transmits the mechanical load on the spherical femoral head with an anteversion angle of 10-25 degrees to the femoral transcondylar axis and a varus angle of 130-135 degrees to the femoral shaft. Ward described a trabecular mesh geometry in the femoral head, neck and trochanteric region (Ward, 1830). According to this geometry, stress lines pass through certain regions that the Singh index also references (Singh, 1970) (Figure 4). The thickest of these stress lines starts from the calcar region and spreads to the lower part of the femoral head. The calcar region starts from the posteromedial shaft below the trochanter minor and reaches the trochanter major, and is the strongest bony region that supports the femoral neck posteromedially (Griffin, 1982).

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Figure 4. Singh index and trabecular lines of the femoral head and neck (Okkaoglu et al., 2021).

Figure 5. Femoral head and neck arterial supply (Baig and Baig, 2018).

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One of the most important complications of femoral neck fractures is avascular necrosis and nonunion cases. Basically, the most important reason for this is the blood supply of the femoral neck and head. It is supplied from 3 arteries: the ligamentum teres artery, capsular vessels (mostly originating from the medial, but also the medial and lateral femoral circumflex artery), and the intramedullary blood supply (Figure 5). The most important vascular structure in the blood supply of the femoral head in adults is the deep branch of the medial femoral circumflex artery (Tucker, 1949). Capsular vessels, which mostly branch from this artery, are damaged in displaced femoral neck fractures, disrupting the blood flow to the femoral head and may cause avascular necrosis (Garden, 1971). Another difference of the femoral neck anatomy from other bones is the absence of a cambial layer that will participate in the formation of the callus in the capsular part of the femoral neck. This causes the healing of this fracture to be forced to endosteal healing, and accordingly, prolonged union times (Keating, 2010).

Treatment Options Nondisplaced Femoral Neck Fractures Non-Surgical Treatment When 14-55% of nondisplaced femoral neck fractures are followed up without surgery, they are displaced within 2-3 years, and 14% go to osteonecrosis. At the same time, the mobility scores of these patients decrease significantly and their mortality increases (Xu et al., 2017). Therefore, this option should be reserved for patients with advanced co-morbidities who cannot be ambulated before fracture (Rashidifard et al., 2017).

Surgical Treatment Internal Fixation Today, surgery is the first choice in the treatment of non-displaced femoral neck fractures, and the two most commonly used methods are cannulated screws or dynamic hip nails. Fixation with Cannulated Screw In this fixation method, the unaffected hip is flexed and abducted while the patient is lying in the supine position. Then, with a minimal incision of 4-5 cm opened laterally, the layers are passed. The lateral aspect of the proximal femur is reached. After sending 3 guide wires, often in the form of an inverted triangle, to the reduced femoral neck fracture from this region, fixation is provided with a cannulated screw. For optimal fixation in cannulated screw fixation methods, there are many different views on the number of cannulated screws and the orientation of the cannulated screws. In a very recent study, 5 configurations were examined: the alpha configuration with 4 cannulated screws, 1 buttress plate with 3 cannulated screws, the rhomboid configuration with 4 cannulated screws, fixation with 3 cannulated screws with an inverted triangle shape, and fixation with 3 cannulated screws with a straight triangle shape. According to this study, the alpha configuration with 4 cannulated screws has been shown to be the most reliable and biomechanically effective configuration, especially in young vertical fractures with

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a higher risk of nonunion and instability (Jiang et al., 2021) (Figure 6). However, the inverted triangle configuration with 3 cannulated screws is the most preferred method, especially in more stable fractures with low verticality.

Figure 6. Fixation methods with cannulated screws (Jiang et al., 2021).

Dynamic Hip Screw Dynamic hip screws (DHSs) are among the most commonly used implants after cannulated screws in femoral neck fractures (Figure 7). In a meta-analysis study, 25 studies comparing the DHS and cannulated screw in femoral neck fractures were examined, and their superiority to each other could not be demonstrated. However, cannulated screws cause smaller incisions, and less bleeding and pain, making cannulated screws the first choice.

Figure 7. 55-year-old man with valgus impacted femoral neck fracture (pre-operative and post-operative x rays).

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As a result, these two methods are frequently used in nondisplaced femoral neck fractures. Especially when compared with displaced femoral neck fractures, most of the patients can return to their former lives with minimal or no morbidity (Tidermark et al., 2003).

Displaced Femoral Neck Fractures The reason for the treatment of displaced femoral neck fractures and non-displaced femoral neck fractures being explained separately in this section is that displacement is one of the most important criteria determining the prognosis in these fractures. Surgical options for treatment are therefore not as clear-cut as in non-displaced femur fractures. Different types of treatment can be preferred in the elderly and young people. In patients under 60 years of age, regardless of the type of implant, open reduction internal fixation is generally preferred, while arthroplasty is the first choice for those over 80 years of age. If the patient is between the ages of 60 and 80, the decision should be made by considering the physical activity level and expectations of the patient (Bandhari et al., 2005). As noted above, it is important to preserve the patient's bone in young patients and every effort should be made to achieve open reduction internal fixation whenever possible. As in nondisplaced fractures, cannulated screws and DHSs are the first options if internal fixation is considered in displaced fractures (Figure 8). Before implant selection, anatomical reduction is very important in femoral neck fractures. In this type of fracture where nonunion or avascular necrosis is seen with high rates, there are acceptable limits up to minimal valgus and 20 degrees posterior angulation in fractures where anatomical reduction cannot be achieved or fracture comminution is present (Arnold, 1984; Barnes and Donovan, 1987). However, the risk of avascular necrosis increases if reduction is far from the anatomical reduction.

Figure 8. 56-year-old man with displaced femoral neck fracture (pre-operative and post-operative x rays).

DHSs and cannulated screws are frequently used in displaced fractures and nondisplaced fractures. Another fixation method in recent years is medial calcar plating (Kunapuli et al., 2015). This method can be used alone or in combination with the other 2 methods. This method

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has been claimed to be biomechanically stronger in some studies (Kunapuli et al., 2015). However, as stated above, according to the latest study, cannulated screw fixation with the alpha configuration is considered to be the strongest fixation (Jiang et al., 2021). Mobilization of these patients in the post-operative period should not be avoided. However, patient communication should be provided optimally. The patient should be allowed to walk without any weight bearing by pressing on the tip of the toe. Their union will take longer than nondisplaced femoral neck fractures. Follow-up should be done at frequent intervals. While the rates of nonunion of these fractures are between 6.5 and 31.8% in the literature, the rates of avascular necrosis are between 3.7% and 32.7% (Asnis et al., 1994, Stappaerts and Broos, 1987, Bjorgul and Reikeras, 2007). These high rates of avascular necrosis and nonunion observed after femoral neck fracture fixation have led to the emergence of many controversial issues about what we should pay attention to when performing internal fixation. Some of these are as follows:

Surgical Timing In a study, no difference was found in terms of nonunion and avascular necrosis rates between immediate surgery and surgery up to 7 days after the injury in a patient presenting with a femoral neck fracture (Barnes et al., 1976). However, in another study, 0% avascular necrosis developed in patients taken in the first 12 hours, while 16% avascular necrosis developed in the group taken after 12 hours (Jain et al., 2002). Chang et al. showed less osteonecrosis and better reduction qualities in patients who were operated upon in the first 6 hours in their study (Chang et al., 2020). According to Gümüstas et al., on the other hand, they did not show a difference in taking the patient to surgery in the first 24 hours and later on, and argued that the factor affecting the actual results was fracture displacement (Gümüstas et al., 2018). In conclusion, the effect of surgical timing on avascular necrosis and nonunion in femoral neck fractures is controversial, but still, femoral neck fractures should be operated on as soon as possible, especially in young patients. While the timing of surgery may affect reduction, nonunion and avascular necrosis in young patients and patients undergoing fixation, it is important in terms of mortality in elderly patients and patients undergoing arthroplasty. Fu et al. showed that fewer fatal medical complications developed in elderly patients who underwent surgery in the first 24 hours after a femoral neck fracture (Fu et al., 2017). Closed or Open Reduction In a study comparing closed reduction with open reduction, no significant difference was found in terms of fracture reduction quality, nonunion, or osteonecrosis (Upadhyay, 2002). The important thing here is that the reduction can be achieved anatomically, if this can be achieved with closed reduction, open reduction is not necessary. Should Fracture-Related Hemarthrosis Be Drained? According to Maruenda et al. and Melberg et al. in their studies, they showed that fracturerelated hemarthrosis increases intracapsular pressure (Maruenda et al., 1997, Melberg et al., 1986). They argued that this may increase the rate of avascular necrosis. However, there is still no strong study showing that it has a clinically significant effect.

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Arthroplasty Apart from fixation methods, the other treatment method is arthroplasty. Arthroplasty or fracture fixation has been widely discussed in the literature. In a systematic review, it was shown that fixation is safer in some entities, such as blood loss and infection rate (Parker et al., 2006). However, the advantage of arthroplasty over fixation is that it has lower revision rates, does not have problems such as avascular necrosis or nonunion, and has an earlier recovery period. In another study, it was shown that fixation in femoral neck fractures had more major complications and there were more minor complications when arthroplasty was performed (Sathiyakumar et al., 2015). When we decide to choose arthroplasty, it is also controversial whether total hip arthroplasty or hemiarthroplasty should be preferred. Ekhtiari et al., in their published metaanalysis, showed a similar revision rate, functional outcome, mortality, periprosthetic fracture and dislocation rates at 5-year follow-ups in these two types of treatment. Patients with total hip arthroplasty have been shown to have a slightly better health-related quality of life, while patients with hemiarthroplasty have shown shorter operative times, but this is not clinically significant (Ekhtiari et al., 2020). Hemiarthroplasty Today, although the use of unipolar, monolithic prostheses (Austin Moore, Thompson prosthesis) has decreased significantly in developed countries, these types of prostheses are still used in some parts of the world. It can be said that there is no big difference in complications and functional results between bipolar hemiarthroplasty prostheses and unipolar prostheses used in developed and developing countries (Keating, 2010).

Figure 9. 84-year-old woman with subcapital femoral neck fracture (pre-operative and post-operative x rays).

Bipolar hemiarthroplasty, which has been used frequently in recent years, is the most commonly used treatment method, especially in femoral neck fractures over 80 years of age (Figure 9). There are different types in which the femoral stem is placed either cemented or

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uncemented. The advantage of bipolar hemiarthroplasty over unipolar arthroplasty is the presence of a bipolar cup as another mobile component on the femoral head, which allows dual mobility in the femoral head. This cup is thought to provide greater range of motion. The prosthetic survival of hemiarthroplasty is extremely high, with a 10-year survival rate of 93.6% (Haidukewych et al., 2002). Again, according to the same study, the dislocation rate is 1.9%, the revision rate is 4.7%, and the protrusion acetabuli rate is 0.5% in patients with hemiarthroplasty. Another dilemma is related to the use of cement in the application of these prostheses. There was no significant difference between the clinical outcomes of modern type cementless prostheses and cemented prostheses (Santini et al., 2005).

Total Hip Arthroplasty Total hip arthroplasty is a more complex surgery than hemiarthroplasty and a riskier treatment option considering that the target population with a traumatized hip and hip fracture is generally elderly patients who may have cognitive impairment. It has been shown to have a higher rate of dislocation, especially when compared to hemiarthroplasty (Gregory et al., 1992). But it is thought to have longer-term survival. Apart from surgeon preference in femoral neck fractures, the main indication for total hip arthroplasty is elderly femoral neck fractures in which the acetabulum is arthritic. However, it may also be a good option instead of fixation in young patients under the age of 60 who have a high probability of nonunion when fixation is performed, steroids are used, and there are alcoholism and osteoporosis issues (Keating, 2010). In this surgical option, the technique is similar to hemiarthroplasty. There is also a cemented or uncemented femoral stem, a ceramic or metal head attached to it, and an acetabular cup articulating with it. In this technique, special attention should be paid to the fact that the acetabulum is not sclerotic during the preparation of the place for the acetabular cup, unlike TKA for arthrosis, and that excessive medialization and even protrusion should be considered during reamerization. Another difference is that, again, due to the high risk of hip dislocation in fracture patients, the capsulectomy procedure applied in THA due to arthrosis is not performed here; on the contrary, the capsule is preserved and re-sutured at the end of the case. In addition, attention should be paid to the anteversion and alignment of the acetabulum and femur. In order to have less hip dislocation, it should be aimed to achieve a high head-to-neck ratio. Although there are many studies advocating THA in the literature, the most demonstrative study was by Lee et al., who provided very encouraging information about prosthesis survival in fracture patients. In this study, 10-year survival was 94% and 20-year survival was 84% in patients with cemented total hip arthroplasty performed after femoral neck fracture (Lee et al., 1998). In a randomized controlled study comparing these 3 treatment methods used in femoral neck fractures, i.e., fixation, hemiarthroplasty and total hip arthroplasty, it was found that THA has a minimally higher dislocation rate, a much lower revision surgery rate than internal fixation, and the lowest mortality rate. Considering the long survival of TKA, it is undoubtedly a good choice for femoral neck fractures (Figure 10).

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Figure 10. 54-year-old woman with femoral neck fracture (pre-operative and post-operative x rays).

Complications The most common complications after the detection of femoral neck fractures are late union, nonunion, malunion, and avascular necrosis. Blomfeld et al., in a 4-year follow-up, reported a 42% complication rate in patients who underwent internal fixation after femoral neck fracture (Blomfeld et al., 2005). Stappaerts defined the two most important risk factors for malunion or loss of fixation as age and poor reduction (Stappaerts, 1985). In a recent study, patients with femoral neck fractures followed up with fixation had a 4-fold higher rate of reoperation compared to arthroplasty, with worse functional outcomes, and quality of life scores. The rate of nonunion or osteonecrosis was found to be 39-43% (Marais and Ferreira 2013). Dislocations are more common in patients treated with arthroplasty. For example, hip dislocation is seen 5 times more in post-fracture total hip arthroplasty compared to total hip arthroplasty due to arthrosis. Again, in the same study, it was shown that dislocations are 2-3 times more common in THA than in hemiarthroplasty (Zagarov et al., 2018). In recent years, dual mobility cups have been used to reduce this complication and this has reduced dislocation rates (De Martino et al., 2017). Another problem in patients undergoing arthroplasty is prosthesis infections. Especially in post-fracture arthroplasty, prosthetic infections are more common than in arthroplasty performed in arthrosis patients (Guren et al., 2017). Thromboembolism seen in patients who underwent arthroplasty after fracture is an important problem too. Asymptomatic deep vein thrombosis is seen in 50% of these patients, and fatal pulmonary embolism is seen in 0.6%. Therefore, it should be kept in mind that mechanical and medical thromboembolism prophylaxis should be given to all patients with femoral neck fractures, especially those undergoing arthroplasty.

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Conclusion Femoral neck fractures are very common in the aging population and will continue to be a public health problem for the society in the future. The most important feature that distinguishes femoral neck fractures from other fractures is the weak and insufficient arterial nutrition, and especially in the patients we treat with internal fixation, they may present with a high rate of complications. For this reason, it is important to be careful about the complications that may occur and make the right decision, while keeping in mind the patient's expectations, additional morbidities, and functional and cognitive capacities in the treatment selection of these fractures.

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Pauwels F. Der Schenkelhalsbruch: Ein mechanisches problem [The femoral neck fracture: a mechanical problem]. Stuttgart: Ferdinand Enke Verlag, 1935. Protzman R. R., Burkhalter W. E. (1976) Femoral-neck fractures in young adults. J Bone Joint Surg Am. Jul;58(5):689-95. Rashidifard C. H., Romeo N. M., Muccino P., Richardson M., DiPasquale T. G . (2017) Palliative management of nonoperative femoral neck fractures with continuous peripheral pain catheters: 20 patient case series. Geriatr Orthop Surg Rehabil 8:34–38. Rizzo, P. F., Gould, E. S., Lyden, J. P., &Asnis, S. E. (1993). Diagnosis of occult fractures about the hip. Magnetic resonance imaging compared with bone-scanning. The Journal of bone and joint surgery. American volume, 75(3), 395–401. Santini S., Rebeccato A., Bolgan I., Turi G. (2005) Hip fractures in elderly patients treated with bipolar hemiarthroplasty: comparison between cemented and cementless implants. J Orthopaed Traumatol 6:80– 87. Sathiyakumar V., Greenberg S. E., Molina C. S., et al. (2015) Hip fractures are risky business: an analysis of the NSQIP data. Injury 46:703. Singh, M., Nagrath, A. R., & Maini, P. S. (1970). Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis. The Journal of bone and joint surgery. American volume, 52(3), 457–467. Stappaerts KH. Early fixation failure in displaced femoral neck fractures. Arch Orthop Trauma Surg. 1985. 104(5):314-8. Stappaerts, K. H., & Broos, P. L. (1987). Internal fixation of femoral neck fractures. A follow-up study of 118 cases. Acta chirurgica Belgica, 87(4), 247–251. Thorngren, K. G., Hommel, A., Norrman, P. O., Thorngren, J., &Wingstrand, H. (2002). Epidemiology of femoral neck fractures. Injury, 33 Suppl 3, C1–C7. Tidermark, J., Ponzer, S., Svensson, O., Söderqvist, A., &Törnkvist, H. (2003). Internal fixation compared with total hip replacement for displaced femoral neck fractures in the elderly. A randomised, controlled trial. The Journal of bone and joint surgery. British volume, 85(3), 380–388. https://doi.org/10.1302/0301620x.85b3.13609. Tucker F. R. (1949). Arterial supply to the femoral head and its clinical importance. The Journal of bone and joint surgery. British volume, 31B(1), 82–93. Upadhyay, A., Jain, P., Mishra, P., Maini, L., Gautum, V. K., & Dhaon, B. K. (2004). Delayed internal fixation of fractures of the neck of the femur in young adults. A prospective, randomised study comparing closed and open reduction. The Journal of bone and joint surgery. British volume, 86(7), 1035–1040. Van Embden, D., Rhemrev, S. J., Genelin, F., Meylaerts, S. A., &Roukema, G. R. (2012). Thereliability of a simplifiedGardenclassificationforintracapsularhipfractures. Orthopaedics & traumatology, surgery & research: OTSR, 98(4), 405–408. Ward F. O. Human Anatomy. London. Renshaw. 1830. Xu D. F, Bi F. G., Ma C. Y., Wen Z. F., Cai X. Z . (2017) A systematic review of undisplaced femoral neck fracture treatments for patients over 65 years of age, with a focus on union rates and avascular necrosis. J Orthop Surg Res;12:28. Ye, Y., Hao, J., Mauffrey, C., Hammerberg, E. M., Stahel, P. F., & Hak, D. J. (2015). Optimizing Stability in Femoral Neck Fracture Fixation. Orthopedics, 38(10), 625–630. Zagorov M., Mihov K., Dobrilov S., Tabakov A., Gospodinov A., Nenova G . (2018) Dual mobility cups reduce dislocation rate in total hip arthroplasty for displaced femoral neck fractures. Annual Proceeding 24:2077– 2081. Zlowodzki, M., Bhandari, M., Keel, M., Hanson, B. P., & Schemitsch, E. (2005). Perception of Garden's classification for femoral neck fractures: an international survey of 298 orthopaedic trauma surgeons. Archives of orthopaedic and trauma surgery, 125(7), 503–505.

Chapter 13

Femur Shaft Fractures Eyüp Şenocak, MD Department of Orthopedics and Traumatology, University of Health Sciences Erzurum Education and Research Hospital, Erzurum, Turkey

Abstract In this chapter, we discussed femoral shaft fractures commonly seen as a result of highenergy trauma. The incidence of femoral shaft fractures in the general population is between 8.5 and 18 per 100,000 annually. In general, direct radiography is sufficient for diagnosis. However, CT may be required in shaft fractures showing joint extension. The treatment is almost entirely surgical for the adult, and surgical options include osteosynthesis with plate and screw, fixation with external fixator, retrograde intramedullary nailing and antegrade intramedullary nailing. Among these treatment options, which have distinct advantages and weaknesses compared to each other, the appropriate treatment option is determined and applied according to the patient’s age, activity level and fracture pattern. Alternative treatment modalities have variable complication potentials. The risk of complications such as neck fracture risk in antegrade nailing, knee joint pathologies in retrograde nailing, nonunion in plate and screw fixation, and malalignment in fixation with external fixator isincreased. For this reason, it is necessary to approach the appropriate fracture and the appropriate patient with the appropriate treatment.

Inroduction Today, there has been a significant increase in general trauma with increasing work accidents, traffic accidents and firearm injuries. This increase in general trauma has also caused an increase in femoral shaft fractures. Femoral shaft fractures show a bimodal distribution according to age and gender. They are frequently seen in young men as a result of high-energy trauma and in older women as a result of falling down. Since femoral shaft fractures are usually 

Corresponding Author’s Email: [email protected].

In: Multidisciplinary Approach to Trauma Editors: Mehmet Cenk Turgut and Asli Turgut ISBN: 978-1-68507-761-7 © 2022 Nova Science Publishers, Inc.

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the result of high-energy trauma, they are a type of trauma with a high probability of comorbid disease or complications.

Anatomy The femur is the widest and longest bone of the human body. It has a large area protected by big muscles and a good blood supply. The average length of the femur in humans is one-quarter of the body length. The axis of the femur is from top to bottom and from outside to inside. The shaft of the femur shows a posterior-facing curvature and the distal end is positioned more posteriorly than the proximal (Leung et al., 1991). The medullary cavity of the femoral diaphysis is a large compact cylinder. Toward the proximal and distal ends, this compact structure thins and widens for increasing the trabecular bone ratio of the cavity (Helfet et al., 1992). The femur is basically evaluated in three parts: the proximal metaphyseal region, the diaphysis and the distal metaphyseal region. The proximal femur consists of the head, neck, trochanter major, trochanter minor, and subtrochanteric regions. The femoral head articulates with the acetabulum. The ligamentum capitis femoris attaches here. The femoral neck is the part that connects the head to the neck. The average angle between the femoral neck and the shaft is 126 degrees in adults and anteversion of the femoral head is between 12 and 14 degrees (Kuran, 1983). The distal femur consists of the medial and lateral condyles, the epicondyles, and the articular surface. In addition to being an anatomical structure to which muscles attach, the linea aspera also acts as a support in the concave structure of the femur and separates the trochanter major and minor. Knowing the origin and insertion of the muscles and tendons in the femur is very helpful in understanding the shape of the deformity during the interventions. The attachment sites in the proximal femur are insertions of the abductor muscles of the trochanter major, the short external rotators, the gluteus maximus and iliopsoas on the lateral femur. The intermedius muscle attaches along its shaft to the anterolateral aspect of the femur. The deformity that occurs in femur fractures is almost entirely caused by the resting tone of the muscles surrounding the bone. In femur proximal segment fractures, the hip is in flexion, abduction and external rotation with the effect of abductor flexors and external rotators. In distal segment fractures, extension deformity develops with the effect of the gastrocnemius attaching to the posterior. The thigh region is divided into 3 main compartments by lateral, medial and posterior intermuscular septums. Quadriceps femoris, sartorius, psoas, iliacus and pectineal muscles constitute the anterior compartment. The muscle structures that make up the posterior compartment are the biceps femoris, semitendinosus and semimembranosus, and the distal part of the adductor magnus. The medial compartment muscles consist of the adductor longus, adductor brevis, most of the adductor magnus, and the gracilis muscle.

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Treatment Conservative treatment has no place in the treatment of femoral shaft fractures in adult patients, except for patients in poor general condition, those who are immobile and without mobilization potential. Surgical treatment options include fixation with plate and screw, treatment with external fixator, retrograde intramedullary nailing and antegrade intramedullary nailing.

Plate and Screw Fixation Fracture fixation with plate and screw tends to decrease after the widespread use of intramedullary nailing. Disadvantages include the need for excessive muscle and periosteal scraping in classical practice, causing excessive blood loss, and it being a more invasive procedure compared to closed techniques. However, plate screw osteosynthesis, performed without opening the fracture line with the bridge plating technique, is a less invasive technique, although not as much as nailing techniques, with relatively less bleeding and requiring less dissection (Gates et al.,1985). Disadvantages include the inability to bear weight early, the risk of refracture with plaque removal after healing, the development of osteoporosis in the area where the plate is used, and a higher risk of postoperative infection compared to other surgical methods (Wiss 1991).

Indication After the increase in popularity of intramedullary nailing, the indications for primary platescrew fixation have narrowed considerably. Plate-screw osteosynthesis may be preferred to nailing according to clinical and patient-specific situations. Osteosynthesis with a plate-screw is indicated for patients with severe narrowing of the medullary canal either structurally or secondary to a previous operation, the presence of an ipsilateral femoral neck fracture, the presence of an associated vessel or nerve cut that requires intervention since it is necessary to make a wide incision, a proximally or distally extending metaphyseal fracture, or a new segment fracture adjacent to malunion or nonunion (Whittle, 1998). Technique The patient is operated in the supine position and on a radiolucent table that allows fluoroscopy. By placing a thick pad below the hip on the fractured side, internal rotation of the extremity is achieved, thus facilitating the surgical procedure. The height placed under the thigh also provides a clearer side view in fluoroscopy. The open technique which is characterized by opening the fracture line or bridge plating may be preferred depending on the shape of the fracture. However, extensive soft tissue and periosteal dissection should be avoided in both techniques. The plate length and width area controversial issue in femur fractures. However, the general opinion is that it is best to use a plate with at least 10 holes, preferably 4.5 mm, even for the simplest femur fractures. However, the important thing here is the length of the plate rather than the number of screws used (Stoffel et al., 2004). If bridge plating is going to be preferred, 3 screws per fragment are considered to be biomechanically sufficient (Stoffel et al., 2004).

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Fixation with an External Fixator Although the treatment of femoral shaft fractures with an external fixator is a definite indication, the area of use is quite narrow. Although it is preferred to use a specially designed semicircular external fixator together with single plan unilateral fixators, patient tolerance is very low with this kind of treatment. The most important advantage is that it is a less invasive technique and can be applied very quickly. It is the most suitable method of fixation especially for patients whose general condition is unstable and for whom rapid intervention is required. The most important advantages are providing the opportunity to correct the reduction losses in the postoperative period, allowing dynamization and allowing early mobilization (Alonso et al., 1989). Since it is less invasive, it is widely indicated in patients with open fractures with vascular damage. The most common complications of external fixator application include angled union, pin site infection, restriction of the knee joint and shortening of the limb (Nowotarski et al., 2000).

Indication While external fixation was considered as an absolute indication for highly fragmented open femur fractures, external fixator indications have been limited with the development of medullary fixations. Despite this fact, the external fixator continues to be widely used. The most common indications for external fixator application are femoral fractures with bruised muscle requiring secondary extensive debridement, the presence of contamination in the medulla, temporary stabilization during situations requiring vessel-nerve repair, and a femoral fracture with soft tissue injury that has extensive contamination and temporary fixation during multiple trauma. Its important advantages are that it can be applied in open fractures and is easy to apply. Technique The aim of temporary external fixator fixation should be to align the femoral segments, increase patient comfort as much as possible, and reduce soft tissue damage. The external fixator can be placed anteriorly, anterolaterally and laterally. However, lateral placement is ideal and pins must be placed along the iliotibial band. Making the incision parallel to the iliotibial band reduces the joint limitation of motion in the knee. The pin diameter in the adult patient should be at least 5mm. Pin application should be as close to the fracture line as possible, but outside the predicted fracture hematoma site.

Retrograde Intramedullary Nailing The retrograde intramedullary femoral nail, designed as an alternative to plate and screw fixation, is used in distal femur fractures where standard antegrade nails are difficult to reach and especially in patients with a high probability of osteopenia-related failure. The retrograde nail can be used in the open or closed technique as intra-articular or extra-articular in distal femur fractures extending approximately 20 cm above the knee joint, when the medial and lateral epicondylar cortices are strong enough to provide the bicortical involvement of at least

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two distal screws. Allowing weight-bearing in the early postoperative period is an advantage over fixation with plate and screw or external fixator. On the other hand disadvantages include the requirement of arthrotomy due to potential arthritic changes and septic arthritis.

Indication Retrograde nailing is indicated for morbidly obese patients in whom intervention from the proximal femoral region is difficult, patients with bilateral femoral fractures, andthe presence of distal metaphyseal fracture requiring additional fixation with antegrade nailing. Retrograde intramedullary femoral nailing is indicated for femoral shaft fracture in pregnancy due to its distance fromthe abdomen, ipsilateral femoral neck fracture and ipsilateral acetabulum fracture.It is indicated in the presence of femoral shaft fracture and tibial fracture as it allows the fixation of two fractures with a single incision.

Figure 1. Preoperative and postoperative late radiographic images of a 36-year-old male patient treated with a retrograde intramedullary nail.

Retrograde nailing is relatively contraindicated in the presence of severely arthritic and restricted knees, as a certain amount of knee flexion is required in retrograde nailing. Retrograde nailing is relatively contraindicated in the presence of patella baja because there may not be a space for the nail to enter the flexed knee. Retrograde nailing is also relatively contraindicated in the presence of a subtrochanteric fracture.

Technique The patient is operated on in the supine position and on the radiolucent table. A pillow is placed below the knee and under the ipsilateral hip in order to provide an average of 45 degrees of flexion and to prevent external rotation of the thigh, relatively. Covering is done widely to include the proximal hip. The fluoroscopy is placed perpendicular to the patient’s long axis. Pharmacological relaxation is absolutely necessary to overcome the tonus of the thigh muscles if the reduction is going to be applied manually (Carmack et al., 2003). The incision is made for approximately 5 cm starting from the inferior patella to the tibial tubercle. The patellar tendon can be split into two parts after cutting or can remain medial to the patellar tendon. After the patellar tendon is passed, it is entered 6.2-12 mm anterior of the

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posterior cruciate ligament at the intercondylar notch with a K-wire and scopy control is performed in the AP and lateral plane (Krupp et al., 2003). If the K-wire is in the appropriate position, the entry point is opened over this wire and a retrograde femoral nail is applied with or without reaming. During these procedures, the joint surfaces of the patella and condyle are protected, preventing damage. The ideal nail size is up to the trochanter minor level. If reaming is going to be applied, it should be carved 1 mm more than the desired nail diameter. While the distal locking is performed with the nail apparatus, the proximal locking can be performed with or without a guide depending on the nail design. However, in the case of locking without a guide, excessive proximal muscle mass may cause problems in locking.

Antegrade Intramedullary Nailing An antegrade intramedullary femoral nail had become a better anatomical fixation method with the development of implant technology. Its superiority over non-intramedullary techniques can be summarized as early movement, early weight-bearing, a shorter hospital stay and higher union potential. Successful results of locked intramedullary nailing have been reported in many large-scale studies (Brumback et al., 1992). Today, the expected union rate of these fractures with intramedullary nailing varies between 95 and 99% and the infection rate is less than 1%. Malunion after intramedullary nailing is very rare in femoral shaft fractures. Besides, the addition of locking nails to modern nailing systems has expanded the indications for this procedure, including severe separated fractures, and distal and proximal shaft fractures (Brumback et al., 1988). In terms of biomechanics, intramedullary nails have a load-sharing structure rather than a load-bearing one; therefore, they act as an internal splint in the union of the fracture and provide the appropriate amount of load to the bone. In this way, the fracture heals with a large callus tissue, in other words with a secondary union. Loading the bone during union ensures a higher callus quality, so the risk of developing a fracture after removal of the implant is very low (Clawson et al., 1971).

Figure 2. Preoperative and postoperative late radiographic images of a 43-year-old male patient treated with an antegrade locked intramedullary nail.

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Indication Indications are for all femoral shaft fractures that allow stable proximal and distal locking except pertrochanteric comminuted femur fractures and comminuted femoral fractures involving the distal joint. However, in patients who are morbidly obese and where proximal access may be difficult, the relative indication may shift to retrograde nailing. Technique There are basically 2 methods in the fixation of fractures with an antegrade locking nail: a. Static locking b. Dynamic locking. Static locking basically refers to the type of nailing with proximal and distal locking which is generally used in fractures with little cortical contact and comminuted fractures such as Winquist-Hansen type III and IV fractures. Since the fixation of static locked intramedullary nails to the bone is rigid, it does not allow the implant to slip, thereby controlling axial shortening and malrotation. A femur fixed with static locking can only reach 75-80% of the solid femoral bending rigidity. Therefore, weight-bearing in static-locked intramedullary nails is delayed until fracture consolidation occurs. In this case, the strength and thickness of the locking nails become important (Russel et al., 1991). Dynamic locking is defined as the placement of only one of the proximal or distal locking nails. It is indicated for stable and isthmus fractures such as Winquist-Hansen Types I and II. In dynamic locking, the nail is allowed to slide in the bone. Dynamic locking allows early weight-bearing because it does not cause nail breakage. Nailing from the proximal side is preferred in dynamic locking nails because it is easier to place surgically and requires less surgical time. The radiological placement of distal nails under fluoroscopy is more difficult (Claiborne, 1998). The insertion site is also important in an antegrade locked or unlocked intramedullary femoral nail, and although it varies depending on the nail design, Küntscher and AO groups suggest the top of the trochanter major (Brumback et al.,1999). There is consensus on the fact that entry points more medial to the trochanter major may impede blood flow to the femoral head and cause femoral neck fracture. If the insertion site is located more in the anterior, it may cause a cleft in the anterior femoral cortex and an increased risk of femoral neck fracture (Tencer et al.,1985). There are many studies about nailing with or without reaming in antegrade nailing. Some authors have argued that the potential for embolism is increased due to increased medullary pressure during nailing with reaming. On the other hand, some authors stated in their study that it is possible to use thicker nails in nailing with reaming which increases the potential for union with a more rigid fixation. As a result, both techniques are usable and their obvious superiority to each other has not been demonstrated (Shewring and Meggit 1992).

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Conclusion Basically, every surgeon can use all of the techniques mentioned in femoral shaft fractures; however, we believe that the technique with the most surgical experience should be used, without going beyond the indications, in accordance with the patient’s condition and resources.

References Alonso, J., Geissler, W., Hughes, J. L. (1989). External fixation of femoral fractures. Indications and limitations. Clin Orthop., 241(241):83-88. Brumback, R.J., Ellison, T.S., Poka, A., et al., (1992). Intramedullary nailing of femoral shaft fractures. Part III: Long-term effects of static interlocking fixation. J Bone Joint Surg [Am], 74(1):106-112. Brumback. R. J., Uwagie-Ero, S., Lakatos, R. P., et al., (1988). Intramedullary nailing of femoral shaft fractures. Part II; Fracture-healing with static interlocking fixation. J Bone Joint Surg [Am] 70(10):14531462. Brumback, R. J., Toal, T. R. Jr., Murphy-Zane, M. S., Novak, V. P., Belkoff, S.M. (1999). Immediate weightbearing after treatment of a comminuted fracture of the femoral shaft with a statically locked intramedullary nail. J Bone Joint Surg Am., 81(11): 1538–44. Carmack, D.B., Moed, B.R., Kingston, C., et al., (2003). Identification of the optimal intercondylar starting point for rterograde femoral nailing: an anatomic study. J Trauma, 55(4):692-695. Claiborne, A. C. (1998). General principles of fracture treatment, Campbell’s Operative Orthopaedics, Willis C. Campbell, S. T. Canale, James H. Beaty (eds), 9th. Ed., Vol.3, pp: 2042, Mosby. Clawson, K., Smith, R., Hansen, S., (1971). Closed intramedullary nailing of the femur. J Bone Joint Surg, 53A: 681–692. Gates, D. J., Alms, M., Cruz, M. M, (1985). Hinged cast and roller traction for fractured femur. A system of treatment fort the Third World. J Bone Joint Surg Br, 67(5):750-756. Helfet, D. L., Browner, B. D., Jupiter, J. B., Levine, A. M., Trafton, P. G. (1992). Fracture of the distal femur, Skeletal trauma, 2nd edition, Philadelphia: WB Saunders Comp, pp:1643-83. Krupp, R. J, Malkani, A. L., Goodin, R. A., et al., (2003). Optimal entry point for retrograde femoral nailing. J Orthop Trauma, 17(2):100-105. Kuran, O. (1983). Femoral Anatomy; Systemic Anatomy. İstanbul: Filiz Kitabevi, pp:76-79. Leung, K. S., Shen, W. Y., So W. S., Mui, L. T., Grosse, A. (1991). Interlocking intramedullary nailing for supracondylar and intercondylar fractures of the distal part of the femur. J Bone Joint Surg, 73-A: 33240. Nowotarski PJ, Turen CH, Brumback RJ, et all, 2000, Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am 82(6):781-788. Russell, T. A., Taylor, J. C., LaVelle, D. G., Beals, N. B., Brumfield, D. L., Durham, A. G (1991). Mechanical characterization of femoral interlocking intramedullary nailing systems. J. Orthop Trauma, 5: 332–340. Shewring, D. J., Meggit B. F. (1992). Fractures of the distal femur treated with the AO dynamic condylar screw. J. Bone and Joint Surg., 74-B:122-125. Stoffel, K., Stachowiak, G., Forster, T., et al. (2004). Oblique screws at the plate ends increase the fixation strength in synthetic bone test medium. J Orthop Trauma, 18(9):611-616. Tencer, A. F., Sherman, M. C., Johnson, K. D. (1985). Biomechanical factors affecting fracture stability and femoral bursting in closed intramedullary rod fixation of femur fractures. J. Biomech. Eng. 107: 104–111. Whittle, A. P. (1998). Fractures of the lower extremity. Canale ST (Ed). Campbell’s operative orthopaedics, 9th edition, Vol: 3, St. Louis: Mosby-YearBook Inc, pp: 2042-179. Wiss, D. A., Rockwood, C. A., Green, D. P., Bucholz, R. W. (1991). Supracondylar and intercondylar fractures of the femur, Fracture in adults, 3rd edition, Vol: 2, Philadelphia: J. B. Lippincott Comp, pp: 1778-97.

Chapter 14

Patella Fracture Anar Alakbarov* Department of Orthopedics and Traumatology, Medipol University Hospital İstanbul, Turkey

Abstract The patella is the largest and biomechanically most important sesamoid bone of the human body. It is located on the anterior portion of the knee with attached quadriceps and patellar tendons. Due to its location, the patella can easily traumatize because of direct contact or impact on the knee. In the literature, the patella fracture prevalence is reported as about 1% of all bone fractures. On the physical examination, the physician may detect knee pain, a gap on the patella, swelling, ecchymosis, and knee joint limitation resulting from the extensor mechanism injury. After physical and radiological examination, the physician should decide the form of treatment. The indication for conservative treatment is an interfragmental gap of less than 3 mm and articular stepping of less than 2 mm. Conservative treatments, including cast or splint implementation and immobilizer or brace usage, can be chosen according to the patient’s medical condition. If surgery is needed, the technique chosen for the surgical treatment depends on the surgeon’s preference and experience. After conservative treatment, rehabilitation of the knee can begin when the bone healing is approved with an x-ray. Additionally, after surgical treatment, physical rehabilitation can begin with quadriceps isometric exercises on postoperative day one and can continue for up to 6 months with some rehabilitation modalities to improve the range of motion and strength for preventing stiffness and weakness. Despite appropriate treatment and intensive physical therapy, complications may develop in the knee. Possible complications include infection, stiffness, weakness, implant failure, arthritis, nonunion, delayed wound healing, reduction loss, etc. A complication may also occur in experienced hands, but a specialist knows how to manage and solve it. However, it has been shown in the literature that the success of treatment after patella fractures is high, and the complication rates are low.

*

Corresponding Author’s Email: [email protected].

In: Multidisciplinary Approach to Trauma Editors: Mehmet Cenk Turgut and Asli Turgut ISBN: 978-1-68507-761-7 © 2022 Nova Science Publishers, Inc.

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Introduction Embryology-Anatomy The patella has a triangular shape and the location of this largest sesamoid bone of the human body is the anterior of the knee. It is one of the few bones without a periosteal surrounding (Alice et al., 2012). Just after femoral and tibial articular - end chondrification, the patella is visible as a continuous fibrous band on the anterior surface of the knee joint (Andersen et al., 1961; Hall et al., 2007). The patella develops from the longitudinally arranged cluster of cells within this fibrous band near to the distal end of the femur (Gardner et al., 1980). The patella becomes chondrified close to the ninth week of gestation primarily by forming a hyaline cartilage mass and after the fourteenth week of gestation it becomes fully cartilaginous (MéridaVelasco et al., 1997). At 2 to 3 years of age the patella is radiographically seen as a small focus and primary ossification occurs at 5 to 6 years of age (Gray et al., 1950; Walmsley et al., 1940). Ossification of the bone begins within the mass of epiphyseal cartilage and progressively expands from the center of the patella to the margins (Callaghan et al., 2003; Alice et al., 2012).

Figure 1. Anterior and posterior surfaces of the human left real patella. Note the two surfaces of the real human patella: anterior (dorsal) cribriform––the roughened surface contains multiple vascular orifices and the posterior (volar) surface contains bright articular cartilage (reproduced and re-illustrated from www.opo-7.xyz/ProductDetail.aspx?iid=53797795&pr=32.99).

The patella is a roughly ovoid and flat bone. Also, the anteroinferior margin of the patella known as the apex is slightly rounded. The patellar tendon is attached to the apex of the patella. The proximal edge of the patella is called the base and it is the attachment site of the rectus femoris and vastus intermedius. The patella has two surfaces: anterior and posterior, and three borders: superior, medial, and lateral. The medial and lateral borders are the attachment site of the vastus medialis and lateralis muscles. The anterior patellar surface consists of multiple roughened vertical ridges produced by the quadriceps tendon fibers. The gross, posterior

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surface of the patella has a smooth oval facet covered with articular cartilage (Matthews et al., 1953). This articular (hyaline) cartilage is the thickest cartilage in the human body and its center has a 4- to 5-mm thickness (Reider et al., 1981; Draper et al., 2006) (Figure 1).

Vascular/Neuroanatomy The vascular supply of the patella comes from the dorsal plexus of blood vessels separated into both an extraosseous and an intraosseous vascular system (Shim et al., 1986; Bucholz et al., 2009). The supreme genicular, lateral superior genicular, medial superior genicular, lateral inferior genicular, medial inferior genicular, and anterior tibial recurrent arteries create a vascular anastomotic ring surrounding the patella which supplies blood for the extraosseous system (Crock et al., 1962). The intraosseous blood supply can be divided into two main systems: midpatellar vessels and polar vessels (Scapinelli et al., 1967; Malek et al., 2001) (Figure 2). The innervation of the anteromedial part of the knee is supplied by genitofemoral, femoral, obturator and saphenous nerves. The innervation of the anterolateral side is supplied by the lateral femoral and lateral sural cutaneous nerves (Horner et al., 1994). The knee joint (or within the patella or the sulcus of the femur) does not contain nerve root endings (Scuderi et al., 1995).

Figure 2. The schematic drawing of patellar arterial blood vessels: the patellar rete composed of; (A) the descending genicular artery and medial superior genicular artery, (B) the medial superior genicular artery, (C) the medial inferior genicular artery, (D) the anterior final recurrent artery and lateral inferior genicular artery, (E) the lateral superior genicular artery (reproduced and re-illustrated from Kirschner et al. (1997)).

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Ligamentous Insertions The medial patellofemoral ligament (MPFL) originates on the adductor tubercle located at the medial side of the knee and inserts into the superomedial portion of the patella. It mainly resists the lateral displacement of the patella and prevents dislocation of the knee cap. The lateral patellofemoral ligament (LPFL) is located on the lateral side of the knee and originates on the proximal lateral epicondyle and inserts into the superolateral portion of the patella. It resists the sliding of the patella towards medial dislocation. The vastus intermedius (VI) is the deep layer of the aponeurosis which has its origin on the anterior surface of the femur and the superior pole of the patella is the insertion site of the vastus intermedius. The other parts of the quadriceps (rectus femoris––RF, vastus lateralis––VL, vastus medialis––VM, vastus medialis––VMO, and the vastus lateralis obliques––VLO) are superficial to the vastus intermedius and terminate in an aponeurosis that merges into the anterior third of the joint capsule. This aponeuro-tendinous tissue which is called the quadriceps tendon continues towards the tuberositas tibia and is renamed the patellar tendon (Figure 3).

Figure 3. Illustration of knee and patella ligaments (reproduced and re-illustrated from https://www.jpaget.nhs.uk/ media/ 367767/PH-40- Medial- Patella- Femoral- LigamentReconstruction-llt-v1-web.pdf).

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Biomechanic According to some 20th century prominent orthopedists, the patella is an insignificant and useless bone but now it is clear that the patella has an important biomechanical function (Grelsamer et al., 2001). Kaufer’s study established that quadriceps muscles effect the knee extension enhanced by the patella. Indeed, the moment arm of the quadriceps is increased by the patella, especially in the earlier degrees of flexion. However, the patella is more than a simple lever (Kaufer et al., 1971; Grelsamer et al., 1994). Contrary to simple levers, the fulcrum of the extensor mechanism is shifting constantly as the knee flexes and extends (Grelsamer et al., 2001; Grelsamer et al., 1994). While performing this function, it withstands extremely high forces even in daily activities. For instance, the forces of patellofemoral compression increase 3.3 times the body weight while climbing stairs and 7.6 times the body weight while squatting (Reilly et al., 1984).

History and Physical Examination The prevalence of patella fracture is reported in the literature to be about 0.7% to 1% of all bone fractures of the human body (Melvin et al., 2011). It is most prevalent in 20-50-year-olds and is twice as common in males. A fall from a height and a direct blow to the patella (for example, in cases of dashboard injury) or a combination of these mechanisms is a common reason for hospital admission. Especially in cases of dashboard injury and high-velocity trauma, fractures of the proximal tibia and distal femur, ruptures of the posterior cruciate ligament, knee dislocations, and acetabular fractures may accompany patella fracture and should be kept in mind. The patellofemoral joint contact area changes between flexion and extension; higher flexion angles create more proximal patellar pole fractures and lower flexion angles cause more distal fractures during impact. The physical examination should begin with an inspection of the whole lower extremity for an evaluation of skin contusions, abrasions, and blisters, and the presence of an open fracture. Also, gentle palpation and examination of the hip, thigh, leg, and ankle should be carried out to rule out a concomitant fracture. A careful neurovascular examination of lower leg compartments should be documented. In the physical examination, patellar fragments displaced more than 2 to 3 cm will reveal a visible or palpable defect between the fragments (Figure 4). Hemarthrosis is significant and develops after the fracture. Detection of a patellar bony defect or displacement with little or no effusion may be a sign of a retinacular tear. An excessive hemarthrosis will make the examination of the knee extremely painful for the patient. Arthrocentesis with an aspiration of hemarthrosis and the injection of lidocaine or bupivacaine into the joint can be helpful. In the case of an intact patellar retinaculum, the patient can extend the knee and this does not rule out a patella fracture. However, the inability to extend the knee, suggests a disconnexion in the extensor mechanism (Bostrom et al., 1972).

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Figure 4. Demonstrates a patellar fracture with clinical and radiological images. (A) Gap of patellar fragments (reproduced from Ricci and Ostrum (2016)). (B) Roentgenography of the patella fracture. (C) Represents a large gap between the bone fragment––a clinical photo modified with x-ray by the author.

Differential Diagnosis If the cause of a patella fracture is trauma the differential diagnosis must be a traumatic lesion. Any trauma affecting the knee extensor system is included in the differential diagnosis of a patella fracture. The main injuries are rupture of the patellar or quadricipital tendon and an avulsion fracture of the tuberositas tibia (Figure 5). Also, any traumatic or pathological tibial plateau or distal femur fracture, articular cartilage injury, and cruciate or collateral ligament injury may diagnostically imitate or be confused with a patella fracture in the clinical examination (Steinmetz et al., 2020).

Figure 5. A computed tomography image of an avulsion fracture of the patellar tendon (avulsion of the tibial tubercle). The asterisks indicate an intact and undulated patellar tendon (yellow arrow).

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In the radiological examination, a bipartite patella caused by a lack of fusion of ossification centered especially on the superolateral edge of the patella may be misdiagnosed as a patella fracture (Figure 6). A bipartite patella is a congenital condition and reported as bilateral in 50% of cases. Based on the position of the accessory center, it can be classified into three groups: Type I (5% of patients)––at the inferior pole, Type II (20% of patients)––at the lateral margin, and Type III (75% of patients)––at the superolateral pole (Atesok et al., 2008).

Imaging Modalities Fractures of the patella following a trauma may be evaluated and diagnosed with several imaging modalities. Radiography (x-rays) is the major and primary imaging technique for the evaluation of the patella and the knee joint (Figure 7). There are three essential views in standard radiography: anteroposterior (AP), lateral, and tangential-Merchant (notch) projections. Plain radiographs are mostly useful in determining the type and degree of patellar injury (Figure 8). For the subtle injuries of the extensor mechanism, computed tomography or magnetic resonance imaging may be useful and helpful (Larsen et al., 2016). Computed tomography (CT) should not be the first radiological examination technique. In patients with osteopenia and hemarthrosis, CT may be used to identify stress fractures. CT scans have a 71% detection rate of a subtle fracture. CT scans may be used for the evaluation of malunion or nonunion, and patellofemoral alignment disorders. Magnetic resonance imaging (MRI) can be used for the evaluation of soft tissue damage especially in a quadriceps tendon injury and patellar tendon injury, and the state of tissue in post patellar dislocation. Even after a fracture or relocation of a dislocated patella, a set of concomitant injuries is often present (for example, contusion of the lateral femoral condyle, a tear of the medial retinaculum, and a joint effusion) (Frank et al., 2013).

Figure 6. X-ray of the bipartite patella. Note the sclerotic margin of the fragment.

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Figure 7. The standard radiographic lateral view of the knee (displaced patella fracture).

Figure 8. Plain radiographs of the knee, lateral view––anteroposterior view––tangential (Merchant) view (reproduced from Park et al. (2016)).

Figure 9. Schematic drawing of the patellar fracture classification according to the configuration of a fracture (reproduced and re-illustrated from Cramer and Moed (1997)).

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Figure 10. AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification of the patella fractures (reproduced and re-illustrated from https://surgeryreference.aofoundation.org/orthopedic-trauma/ adulttrauma/patella).

Classification The classification of a patella fracture is based on comminution, displacement, and the fracture pattern. The classification, especially according to its pattern (transverse, vertical, stellate, apical, marginal, osteochondral), the surrounding soft tissue condition and the patient’s functional capacity provide information to the orthopedic surgeon and guide the appropriate treatment. There is more than one classification of patella fracture in the literature. Among these classifications, the most frequently used and guiding one is the AO classification (Figure 10). The fracture types of the patella are classified as following: A (A1-A2), extra-articular; B (B1-B2-B3), partial articular (vertical); and C (C1-C2-C3), complete articular (nonvertical). The subclassification of patella fractures is done based on location (proximal vs. distal and medial vs. lateral) and the degree of the comminution according to the AO. The patella is labeled 34 in the AO classification. A type A fracture requires reattachment of the extensor mechanism to the adjacent patella. It is often associated with a rupture of the retinaculum that needs to be repaired. A type B fracture does not involve injury to the extensor mechanism. The purpose of repairing this type of fracture is to anatomically reduce the articular surface of the patella to

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minimize the risk of patellofemoral joint arthrosis. As this type of fracture is typically oriented vertically it must be differentiated from the bipartite patella. A type C fracture is a disruption of the extensor mechanism combined with a disturbance of the articular surface. More fragments mean greater articular surface deformation and breakdown that need to be accurately fixed.

Treatment of Patella Fracture Conservative Treatment Non-displaced and closed patellar fracture can be treated conservatively with a cast, splint, or immobilizer (Galla et al., 2005) (Figure 11). Non-displacement criteria include less than 3 mm of fracture displacement and articular steps less than 2 mm (Cramer et al., 1997). Vertical, stellate and transverse fractures of the patella often spare the medial and lateral retinaculum, maintaining knee extension (Bostro et al., 1972; Griswold et al., 1954). The patella fracture in a transverse pattern can be present with 4 to 5 mm of significant displacements. However, active leg extension may rule out the retinaculum tear and can be managed conservatively (Bostro et al., 1972). Also, because the distal portion of the patella is extra-articular, fracture of the inferior pole of the patella can also be managed conservatively (Kakazu et al., 2016). Conservative treatment usually includes weight-bearing-as-tolerated (WBAT) mobilization with knee support. The patient can begin passive (PROM) range of motion from 0 to 30 degrees after 2 weeks and the arc of motion can be increased by 15 degrees per week. After 8 weeks nearly a full PROM may be achieved (Kakazu et al., 2016). Conservative treatment for non-displaced patella fracture has good outcomes, with no weakness, chronic pain, or arthrosis and a full range of motion (Scott et al., 1949; Sorensen et al., 1964). Bostro reported 422 patellar fractures, of which 219 were treated nonoperatively and 98% exhibited good or excellent results (Bostro et al., 1972).

Surgical Treatment An operative intervention has been indicated in open patellar fractures, with more than a 3-mm fracture gap, and more than 2 mm of incongruity of the articular surface, or extensor mechanism dysfunction. The primary goals of operative treatment are to preserve extensor function and restore the congruency of the articular surface. The major principles are anatomic reduction with the step-free reconstruction of the articular surface and the stable fixation of fracture fragments. A supine position should be used. Tourniquet usage is up to the surgeon’s preference. It has to be applied as proximal as possible and should be inflated with the full knee flexed to avoid entrapment of the quadriceps femoris muscle, which could otherwise prevent reduction. Some surgeons prefer a transverse, pure median, or lateral parapatellar approach but an anterior longitudinal midline skin incision and medial parapatellar approach to the knee joint are recommended. In our opinion, these will be helpful for potential revision surgery (for example, total knee arthroplasty).

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Timing of Surgery In the patient with a patella fracture, the timing of surgery varies depending on associated injuries and the patient’s medical condition. In terms of surgical timing, the approach to an open fracture is different from that of a closed fracture. Open fractures require tetanus prophylaxis (within 72 hours), intravenous antibiotics (within 3 hours and recommended firstgeneration cephalosporin + aminoglycoside), and debridement of nonviable tissues followed by thorough irrigation (Patzakis et al., 1989; Wilkins et al., 1991). In a closed fracture, a long leg splint may be applied first and surgery may be delayed until other limbs or life-threatening conditions have been fixed. For both open and closed patellar fractures, the status of the soft tissue envelope is the major determiner for the surgery timing. The compromised soft tissue prevents a surgical operation and a delay in the surgery is warranted to minimize the risk of infection. If the soft tissues are good and available for intervention, the surgery may be performed within the first week following an injury. Applying early surgery allows an earlier mobilization of the limb that minimizes the potential for knee joint stiffness. Also, a prolonged delay can result in more proximal migration of the patellar fragments. The result of migration is to shorten the extensor mechanism due to quadriceps muscle spasm and this makes reduction and fixation more difficult (Smith et al., 1997).

Figure 11. Treatment algorithm for patella fractures. ROM: Range of motion (reproduced and redrawn from Attarian (2007)).

Figure 12. Preoperative and postoperative (tension band technique) x-rays of patella fracture.

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Open Reduction and Internal Fixation (Orif) There are several surgical technique options for patella fracture such as just a tension band with wire, just cannulated screw fixation, a K-wire assisted tension band, a cannulated screw assisted tension band, a closed-proximal fragment to tibial tubercle wiring, plate-screw fixation, wires placed 1 cm apart passed perpendicular to the fracture line and a tension band (cerclage) cinctured in the shape of a figure eight, total or partial patellectomy, etc. But the modified tension band wiring with K-wire or cannulated screw (according to AO principles) is the most accepted, reliable, and widely used technique (Figure 12). Although stainless steel wires are mainly used for tension band wiring, braided, non-absorbable polyester sutures (for example, Ethibond) can also be used (Gosal et al., 2001). Biomechanical studies have shown that braided suture materials have no significant disadvantages and account for comparable results to steel wires (Schwabe et al., 2010). Furthermore, secondary hardware removal is the disadvantage of classic stainless-steel wires, and an application of a braided suture is much easier than that of a steel wire (Gosal et al., 2001).

Surgical Setting Before beginning an operation for patella fracture, the surgeon should check the following instruments and issues. • • • • • • • • • • • • • • • • • • • • • • •

Patient position and knee-leg supports Belt for patient’s stabilization Tourniquet (to prevent bleeding) Esmarch bandage Marker pen and ruler Cautery (bipolar and monopolar) Fluoroscopy (active) Aspirator and irrigation syringe (50 ml) Sterile drape and loban drape Mersilene tape and/or fiberwire suture Bone graft (if necessary) Suture and wire passer (for example, 14-gauge angiocatheter) Stainless steel wire (16 to 20 gauge) for cerclage Wire tightening device or wire holder Wire cutter and K-wire bender Kirchner wires (K-wire) size 1,25 to 2.0 mm Double-ended 1,6 mm K-wire Large, medium, and small pointed reduction clamps Small and mini-fragment screws (1,5 to 3.5 mm) Forceps, needle holder, scissors, curette Scalpel (nos. 11, 15, and 20) Retractors (superficial and deep tissue) Skin and subcutaneous sutures (prolene or monocryl and vicryl)

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Elastic and roll bandage, gauze, plaster, cotton Immobilizer or knee splint/a knee ankle foot orthosis (KAFO).

Surgical Procedures Steps of cannulated screw and K-wire fixation with supplemental wiring: 1. Use a scalpel to incise the skin and the bursa for a midline longitudinal incision. 2. Clean the fracture lines with a curette and irrigate the joint as much as possible for debris removal. 3. In a retrograde direction pass the K-wire through to the proximal fragment (from the fracture line towards the solid edge), roughly 5 mm away from the articular surface, and send proximally until flush with the fracture edge. 4. Send the second K-wire, placed 1 cm apart from and in a similar fashion parallel to the first K-wire. 5. Reduce and stabilize the fracture fragments with reduction clamps. 6. Send and pass across K-wires from the fracture line and out through the patellar tendon. 7. For the K-wire assisted tension band technique, after the previous step, pass through the steel cerclage wire (an 18-gauge wire) deeper than the K-wire and obtain a figure of eight shape then tighten the cerclage till the fracture line is fully closed. After cerclage tightening, bend and cut the remaining K-wire with a wire cutter. 8. For the cannulated screw assisted technique, use a cannulated drill to drill over the Kwires and place 3.5- or 4.0-mm cannulated screws. 9. Then, pass an 18-gauge wire through one cannulated screw, and after passing the wire through an 18-gauge angiocatheter and through the patellar tendon, pass the wire through the other screw in the opposite direction and then pass the wire through the quadriceps tendon. After passing the quadriceps tendon tighten the edge till the surface of the fracture line is fully closed and cut on the dorsal surface of the patella. 10. Examine an articular surface and the reduction with the knee extension and controlled flexion by fluoroscopy (Kakazu et al., 2016) (Figure 13).

Figure 13. Postoperative (cannulated screw assisted tension band technique) x-rays of patella fracture.

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Patellectomy This surgical technique has been used since the 1960s and has limited usage. The partial patellectomy indications are severe comminution, significant cartilage loss, or fracture of the internal or external lateral margins. More than 60% of bone excision in the patellectomy should be avoided, as it leads to horizontal rocking (LeBrun et al., 2012). The total patellectomy is used for uncontrolled sepsis and severe-extensive comminution not amenable to salvage, however it should be avoided because the consequence is 50% strength loss of the extensor mechanism (Appel et al., 1993).

Open Patella Fracture The treatment algorithm of the open patella fracture is the same as open long bone fracture care (Schwabe et al., 2010). Following the algorithm, open patellar fractures require urgent intervention to prevent septic arthritis and osteomyelitis. Wide debridement, plenteous irrigation, appropriate antibiotics, and stable fixation are the main principles of the treatment. The first goal of treatment should be to achieve a sufficient and closed soft tissue envelope so, vacuum-assisted closure techniques can be used if necessary. After the reduction of infection risk, patellar fragments can be fixed (Anand et al., 2008).

Contraindication There is no exact contraindication for patella fracture but relative contraindications are medically frail patients whose surgical risk is high because of comorbidity, fracture of the nonambulatory patient, pathological fracture of the patella in a patient with low survival expectation due to multiple metastases, wide and severe soft tissue injuries around the knee and uncontrollable infection of the extremity.

Pediatric Patella Fracture This most commonly occurs between 8 and 12 years of age as a patellar sleeve fracture. The “sleeve of cartilage” is mostly avulsed from the remainder of the patella due to eccentric loading of the extensor mechanism. The patient comes to the orthopedic emergency room with knee pain, swelling, and an inability to bear weight or perform a straight leg rise. The radiographic examination may detect patella alta or baja and an ossified fragment may or may not accompany the avulsion. If an extensor mechanism is intact and the fracture is non-displaced the patient may be treated nonoperatively with a cast or splint immobilization. It is clear that displaced and open fractures require open reduction and internal fixation.

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Figure 14. The pediatric patella fracture (sleeve of cartilage avulsion) (reproduced from Wheatley and D’Alleyrand (2020)).

Postoperative Care and Rehabilitation Boström et al. reported good outcomes after patella fracture especially conservative treatment, as there was no arthrosis, weakness, pain, and range of motion limitation. Other studies also support these findings and surgical treatments also have satisfactory outcomes (Scott et al., 1949; Sorensen et al., 1964). The main factors influencing the outcome are the clinical condition of the patient, the severity of the trauma and the degree of an injury, the success of the surgical technique, and post-operative care. As physicians, we cannot change the patient’s medical history and trauma factors, and the success of the surgery depends on experience, but postoperative care and physical therapy play a critical role in patella fracture surgery and physicians should focus on this factor. Following surgery––ORIF––(on the operation day), the patient should rest with full knee extension, apply an ice pack, elevate the leg and take an analgesic. Isometric quadriceps exercises are allowed to begin after the postoperative first day. If a drain is applied and drainage is reduced, the drain may be removed on the postoperative second day. The operated leg can then be placed in a removable knee brace locked in extension and for the physical therapy it may be unlocked and allowed movement till targeting the flexion angle. After 3 days, the continuous passive motion (CPM) machine can be used if it is thought that fixation is strong enough or the fracture is stable; however, caution is recommended to prevent the failure of fixation. Sterile wound dressing should be continued every 3 days for 2 weeks and then stitches should be removed if a nonabsorbable suture is applied. In two or three weeks following surgery, the wound is expected to be completely healed and then professional physical therapy may begin. At 4 to 6 weeks, if the healing sign on the radiography is verified, progressive resistance exercises are introduced. Gradually, the brace is weaned and can be finished at 3 months when the radiologic and clinic confirmation of the fracture healing is obtained. If necessary, the physical therapy may be continued up to postoperative 6 months. After bone healing confirmation, weight-bearing in full extension and flexion is permitted. Also, aggressive physical therapy is permitted to improve the range of motion and strength for preventing stiffness and weakness (Kakuzu et al., 2016).

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Complications After operative and nonoperative treatment, stiffness is a common complication that has not shown length of immobilization to be a significant factor. Srinivasulu et al. reported more than 20 degrees of restriction of movements in their 10.5% of cases (Srinivasulu et al., 1986). Weakness of the quadriceps muscle is the permanent complaint and includes both straightening (extension) and bending (flexion). It is more common with partial or total patellectomy. Another common problem is an implant-related complication due to the subcutaneous position of the patella. Implant-related complications include wire-cerclage breakage or migration and Kirschner’s wire failure. A complication with Kirschner’s wire fixation is more common than with cannulated screws. In their 27-patient case series, LeBrun et al. reported an approximate 52% hardware removal rate after 6.5 years of follow-up (LeBrun et al., 2012). Anterior knee pain is another major complication in most patients due to patellofemoral arthritis. It is possibly the result of iatrogenic damage to the articular surface or the initial injury, or secondary to inadequate articular reduction. Nonunion has a rate of 12.5% of cases in the literature. Nonunion often occurs as an asymptomatic fibrous nonunion, has a higher incidence with open fractures, and typically does not require additional surgical treatment (Sassoon et al., 2013). The nonunion-related complication of osteonecrosis (especially proximal fragment) is thought to be due to excessive initial fracture displacement and may be followed nonoperatively.

Figure 15. Failure of K-wire assisted tension band reconstruction as a complication after patella fracture surgery (reproduced from Sassoon et al. (2013)).

An infection has been reported in the literature in 2 to 10% of cases and with delayed wound healing, this rate may be as high as 12% and the severity of the soft-tissue injury increases the rate. Hoshino et al. has reported 3.6% of infection incidence in their series of 448 low open fractures, in a retrospective study (Hoshino et al., 2013). Therewith, superficial infections can be successfully treated with local wound care and oral antibiotics, whereas deep

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infections require hospitalization, a period of intravenous antibiotics and deep tissue debridement with the retention of hardware until fracture union (Catalano et al., 1995; Sassoon et al., 2013). Loss of reduction is another annoying complication that may occur in 20 to 45% of fractures treated operatively. Bostman et al. reported that less than 2 mm of fracture displacement does not affect the patellofemoral function and does not produce symptomatic impairment (Bostman et al., 1982). Reasons for loss of reduction include morbid obesity, an inappropriate rehabilitation protocol, unrecognized comminution, an improper fixation technique, and patient noncompliance.

Conclusion Patella fracture is an injury that can lead to serious problems which limit the patient’s life if not treated appropriately. The trauma that causes patella fracture in the patient is usually highenergy trauma. This trauma, which breaks the knee cap, can damage the soft tissues around the knee. Ignoring the condition of this soft tissue during treatment may lead to unsuccessful treatment or irreversible medicolegal problems in the knee. As an outcome, whether surgical or conservative, it has been shown in the literature that treatment success and patient satisfaction are high after patella fracture treatment.

References Alice, J. S. F., Florian W., Scott A. R. (2012). The Basic Science of the Patella: Structure, Composition, and Function. J Knee Surg, 25:127–142. http://dx.doi.org/10.1055/s-0032-1313741. ISSN 1538-8506. Anand, S., Hahnel J. C., Giannoudis P. V. (2008). Open patellar fractures: high energy injuries with a poor outcome? Injury, 39(4):480–484. http://dx.doi.org/10.1016/j.injury.2007.10.032. Andersen, H. (1961). Histochemical studies on the histogenesis of the knee joint and superior tibio-fibular joint in human foetuses. Acta Anat (Basel), 46:279–303. Appel, M. H., Seigel, H. (1993). Treatment of transverse fractures of the patella by arthroscopic percutaneous pinning. Arthroscopy, 9(1):119–21. http://dx.doi.org/10.1016/S0749-8063(05)80357-3. Atesok, K., Doral, M. N., Lowe, J., Finsterbush, A. (2008). Symptomatic bipartite patella: treatment alternatives. J Am Acad Orthop Surg. 16(8):455–61. http://dx.doi.org/10.5435/00124635-20080800000004. Bostman, O., Kivilusto, O. and Nirhamo, J. (1982). Comminuted displaced fractures of the patella. Injury, 13: 196. Bostro¨m, A. (1972). Fracture of the patella. A study of 422 patellar fractures. Acta Orthop Scand Suppl., 143:1–80. Bucholz, R. W., Court-Brown, C., Heckman, J. D. (2009). Rockwood and Green's Fractures in Adults, 4th ed. Philadelphia: Lippincott Williams & Wilkins. Callaghan, J. J. (2003). The Adult Knee. Baltimore: Lippincott Williams & Wilkins. Catalano, J. B., Iannacone, W. M., Marczyk, S., et al. (1995). Open fractures of the patella: long-term functional outcome. J Trauma, 39(3): 439–444. Cramer, K.E,, Moed, B.R. (1997). Patellar Fractures: Contemporary Approach to Treatment. J Am Acad Orthop Surg., 5(6):323–331. Crock, H.V. (1962). The arterial supply and venous drainage of the bones of the human knee joint. Anat Rec, 144:199–217.

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Draper, C. E, Besier, T. F., Gold, G.E., et al. (2006). Is cartilage thickness different in young subjects with and without patellofemoral pain? Osteoarthritis Cartilage,14(9):931–937. Frank A., Liporace, Joshua R. Langford, George J. Haidukewych (2013). Fractures of the Patella / chapter 82. https://musculoskeletalkey.com/fractures-of-the-patella/#bib4 Galla, M., Lobenhoffer, P. (2005). Patella fractures. Chirurg, 76(10):987–97. Gardner, E., O'Rahilly, R. (1980). The early development of the knee joint in staged human embryos. J Anat, (102):289–299. Gosal, H. S., Singh, P., Field, R. E. (2001). Clinical experience of patellar fracture fixation using metal wire or non-absorbable polyester--a study of 37 cases. Injury, 32(2):129–135. http://dx.doi.org/10.1016/S00201383(00)00170-4. Gray, D. J, Gardner E. (1950). Prenatal development of the human knee and superior tibiofibular joints. Am J Anat, 86(2):235–287. Grelsamer, R. P., Proctor, C. S., Bazos, A.N. (1994). Evaluation of patellar shape in the sagittal plane: A clinical analysis. Am J Sports Med, 22:61–66. Grelsamer, R. P. & Weinstein, C. H. (2001). Applied Biomechanics of the Patella. Clinical Orthopaedics and Related Research, 389: 9–14. doi:10.1097/00003086-200108000-00003 Griswold, A. S. (1954). Fractures of the patella. Clin Orthop, 4:44–56. Hall, B. K. (2007). Fins into Limbs: Evolution, Development and Transformation. Chicago, IL: University of Chicago Press. Horner, G., Dellon, A. L. (1994). Innervation of the human knee joint and implications for surgery. Clin Orthop Relat Res., (301): 221–226. Hoshino, C. M, Tran W., Tiberi J. V, et al. (2013). Complications following tension-band fixation of patellar fractures with cannulated screws compared with Kirschner wires. J Bone Joint Surg Am., 95(7):653–659. Kakazu, R., & Archdeacon, M. T. (2016). Surgical Management of Patellar Fractures. Orthopedic Clinics of North America, 47(1): 77–83. doi:10.1016/j.ocl.2015.08.010 Kaufer, H. (1971). Mechanical function of the patella. J Bone Joint Surg, 53:1551–60. Larsen, P., Court-Brown, C. M., Vedel, J. O., Vistrup, S., & Elsoe, R. (2016). Incidence and Epidemiology of Patellar Fractures. Orthopedics, 39(6): e1154–e1158. doi:10.3928/01477447-20160811-01. LeBrun, C. T., Langford J. R., Sagi, H. C. (2012). Functional outcomes after operatively treated patella fractures. J Orthop Trauma., 26(7):422–6. http://dx.doi.org/10.1097/BOT.0b013e318228c1a1 LeBrun, C. T, Langford, J. R., Sagi, H.C (2012). Functional outcomes after operatively treated patella fractures. J Orthop Trauma, 26:422–426. Malek, M. M. (2001). Knee Surgery: Complications, Pitfalls, and Salvage. New York: Springer. Matthews, B. F. (1953). Composition of articular cartilage in osteoarthritis; changes in collagen/chondroitinsulphate ratio. BMJ, 2(4837):660–661 Melvin, J. S., Mehta S. (2011). Patellar fractures in adults. J Am Acad Orthop Surg. 19(4):198-207. Mérida-Velasco, J. A., Sánchez-Montesinos, I., Espín-Ferra, J., Mérida Velasco, J. R., Rodríguez-Vázquez, J. F, Jiménez-Collado, J. (1997). Development of the human knee joint ligaments. Anat Rec, 248(2):259– 268. Patzakis, M. J., Wilkins, J. (1989). Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res, 36. Reider, B., Marshall, J.L., Koslin, B., Ring, B., Girgis, F.G. (1981). The anterior aspect of the knee joint. J Bone Joint Surg Am., 63(3): 351–356 Reilly, D. T., Martens M. (1972). Experimental analysis of the quadriceps muscle force and patello-femoral joint reaction force for various activities. Acta Orthop Scand., 43:126–137. Sassoon, A., Langford, J., & Petrie, J. (2013). Complications of Patellar Fracture Repair: Treatment and Results. Journal of Knee Surgery, 26(05): 309–312. doi:10.1055/s-0033-1353990 Scapinelli, R. (1967). Blood supply of the human patella. Its relation to ischaemic necrosis after fracture. J Bone Joint Surg Br, 49(3):563–570 Schwabe, P., Haas, N. P., Schaser, K. D. (2010). Extremitätenfrakturen mit schwerem offenem Weichteilschaden. Initiales Management und rekonstruktive Versorgungsstrategien. [Fractures of the extremities with severe open soft tissue damage. Initial management and reconstructive treatment

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strategies]. Unfallchirurg. 113(8):647–670. doi: 10.1007/s00113-010-1801-0. (Ger). Available from: http://dx.doi.org/10.1007/s00113-010-1801-0. Scott J. C. (1949). Fractures of the patella. J Bone Joint Surg Br., 31B(1):76–81. Scuderi, G.R., Kibiuk, L. V, Insall, J.N. (1995). The Patella. New York: Springer Verlag. Shim, S. S., Leung, G. (1986). Blood supply of the knee joint. A microangiographic study in children and adults. Clin Orthop Relat Res, (208):119–125. Smith, S. T., Cramer, K. E., Karges, D. E., Watson J. T., Moed B. R. (1997). Early complications in the operative treatment of patella fractures. J Orthop Trauma, 11(3):183-7. doi: 10.1097/00005131199704000-00008. Sorensen, K.H. (1964). The late prognosis after fracture of the patella. Acta Orthop Scand, 34:198–212. Srinivasulu K., Marya R.S., Bhan S., Dave, P.K. (1986). Results of surgical treatment of patellar fractures. Ind. J. Orthop. 20: 158. Steinmetz, S., Brügger, A., Chauveau, J., Chevalley, F., Borens, O., Thein E. (2020). Practical guidelines for the treatment of patellar fractures in adults. Swiss Med Wkly. 15: 150: w20165. doi: 10.4414/smw. 2020.20165. Walmsley, R. (1940). The development of the patella. J Anat, 74 (Pt 3):360–368. Wilkins, J., Patzakis, M. J. (1991). Choice and duration of antibiotics in open fractures. Orthop Clin North Am. 22(3):433-7. PMID: 1852421

Chapter 15

Tibial Plateau Fractures Tural Khalilov, MD Department of Orthopedic and Traumatology, Private Tuzla Mercan Hospital, Istanbul, Turkey

Abstract Tibial plateau fractures are periarticular fractures of the proximal tibia, often accompanied by soft tissue injury. Tibial plateau fractures constitute approximately 1% of all fractures and 8% of fractures in people over the age of 55. Tibial plateau fractures show bimodal distribution. The character of the fracture depends on the mechanism of injury. The tibial plateau is a portion of the proximal tibia that includes the articular surface. It is divided into the medial and lateral tibial plateau by the intercondylar eminence. There are various classifications of tibial plateau fracture. The Schatzker and treecolumn classifications are commonly used. A new way of thinking also informs us about the 3D morphology of the fracture, the mechanism of injury and which surgical approach to choose for the fracture. Radiological imaging is important in the evaluation of injury and in preoperative planning (x-ray, CT, MRI). Depending on the severity of the injury, treatment of the fracture ranges from conservative to surgical. Our goal in treatment is the preservation of soft tissue, reconstruction of the joint, reconstruction of the mechanical axis and early functional movement. The biomechanics of fixation, localization of the displaced joint fragment and soft tissue status must be considered when deciding on the surgical treatment approach. There are various complications due to being late and early stage. This chapter considers the definition, epidemiology, anatomy, diagnosis and treatment strategies of tibial plateau fractures.

Introduction Tibial plateau fractures are periarticular fractures of the proximal tibia, often accompanied by soft tissue injury. Tibial plateau fractures constitute approximately 1% of all fractures and 8% of fractures in people over the age of 55. Tibial plateau fractures show bimodal distribution. 

Corresponding Author’s Email: [email protected].

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The character of the fracture depends on the mechanism of injury. This chapter considers the definition, epidemiology, anatomy, diagnosis and treatment strategies of tibial plateau fractures.

Epidemiology Tibial plateau fractures constitute approximately 1% of all fractures and 8% of fractures in people over the age of 55. Tibial plateau fractures show bimodal distribution. They are caused by high-energy trauma in males in their 40s and by falling in females in their 70s. When we look at the frequency of tibial plateau fractures, the lateral tibial plateau is 55-70%, the medial is 10-20% and the bicondylar is 10-30%.

Mechanism of Injury These fractures are usually caused by varus/valgus loading with or without axial loading. Associated injuries are meniscal tear (a lateral meniscal tear is more common than a medial one), ACL injuries, compartment syndrome, and vascular injury.

Anatomy of Tibial Plateau The tibial plateau is a portion of the proximal tibia that includes the articular surface. It is divided into the medial and lateral tibial plateau by the intercondylar eminence. The lateral tibial plateau is convex proximal to the medial plateau. The medial tibial plateau is concave and distal to the lateral tibial plateau. According to the column concept, the tibial plateau consists of three (medial, lateral and posterior) columns anatomically. The posterior column also consists of medial and lateral parts.

Classification of Tibial Plateau Fractures There are various classifications of tibial plateau fracture. The Schatzker classification is commonly used (Figure 1).

Figure 1. Schatzker classification of tibial plateau fractures (Rudran, 2020).

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Type I––Split fracture of the lateral tibial plateau, Type II––Split and depression of the lateral plateau, Type III––Pure depression fracture of the lateral tibial plateau, Type IV–– Medial tibial plateau fracture, Type V––Bicondylar fracture (intact metaphysis and diaphysis), Type VI––Tibial plateau fracture with metaphyseal-diaphyseal disassociation. Another classification used today is the tree-column classification concept (Figure 2).

Figure 2. Tree-column concept (Luo, 2010).

According to the column concept, the tibial plateau is divided into three columns––medial, lateral and posterior. Just as there are fractures involving a single column, fractures involving 2 and 3 columns are also encountered. A new way of thinking also gives us information about the 3D morphology and injury mechanism (Figure 3). In addition, this classification helps us choose the surgical approach for the fracture.

Figure 3. 3D morphology and injury mechanism (Luo, 2010).

Physical Examination A circumferential look is required to exclude an open injury with inspection. Compartment syndrome should be considered when compartments are tight and incompressible when

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assessed by palpation. Instability is evaluated with the varus-valgus stress test (often not possible due to pain). A neurovascular examination should evaluate whether there is any difference in the pulse examination between the extremities.

Radiological Imaging Radiological imaging is important in the evaluation of injury and preoperative planning. Anteroposterior, lateral, and oblique knee radiographs should be obtained in all patients with suspected tibial plateau fractures. A CT scan (including three-dimensional reconstruction) is important to identify articular depression, comminution, fracture fragment orientation and surgical planning. MRI is useful to determine meniscal and ligamentous pathology.

Management of Tibial Plateau Fractures Goals of Treatment • • • • •

soft tissue preservation and decompression joint reconstruction reconstruction of mechanical axis stable osteosynthesis early functional movement.

Conservative Management Indications: • • • • •

non-displaced Schatzker type I fractures axial stable fractures severe osteoporosis local or general contraindications for surgery elderly patients with low expectations.

In conservative treatment, the hinge knee brace and long leg cast, 6-8 weeks of non-weightbearing and physiotherapy are used.

Surgical Management Surgical treatment principles: • •

the least traumatic option must be chosen depending on the condition of the soft tissue direct reduction of the joint

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the articular surface must be observed directly by arthrotomy or arthroscopy indirect reduction can be chosen in simple partial intra-articular fractures. Indications: a lateral plateau fracture with >3 mm articular step-off, >5 mm condylar widening or varus or valgus instability all medial tibial plateau fractures all bicondylar tibial plateau fractures neurovascular injury open fracture.

Emergency surgery indications: • • • • •

vascular injury compartment syndrome open fracture floating knee polytrauma.

Surgical treatment options: • • • • •

open reduction-internal fixation screws (simple split fractures) plate fixation (non-locked and locked plates) external fixation (temporary) arthroplasty (in patients > 65-years-old with osteoporotic bone).

The biomechanics of fixation, localization of the displaced joint fragment and soft tissue status must be considered when deciding on the surgical treatment approach (Figure 4). Surgical approaches: • • • • • • •

lateral (most common) medial posteromedial posterior mini open arthroscopic combined.

During open reduction-internal fixation, ligament and meniscus structures are exposed, then the articular surface is anatomically reduced and intrafragmentary compression is performed.

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Figure 4. Different surgical approaches according to the location of the fracture in the tibial plateau (the green area is the articular surface). The lines show the ten-segment classification of the tibial plateau. The tibial footprint of the anterior cruciate ligament (ACL). The tibial footprint of the posterior cruciate ligament (PCL) (Krause, 2019).

Complications • • • • • • • • •

early DVT 5-10% infection 2,8-80% compartment syndrome. late malunion joint stiffness myositis ossificans post-traumatic arthritis.

Conclusion Tibial plateau fractures can either occur as fragility fractures or as a result of high-energy impact. We need to analyze the fracture mechanism and accompanying injuries in tibial plateau fractures. Radiological imaging is important in the evaluation of injury and preoperative planning (x-ray, CT-3D, MRI). The correct timing and planning are important in treatment. Our goal in treatment is preservation of the soft tissue, reconstruction of the joint, reconstruction of the mechanical axis and early functional movement. Good results are obtained when the anatomy and stability of the tibial plateau are restored.

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References Berkson E M, Virkus W W. (2006). High-energy tibial plateau fractures. J. Am. Acad. Orthop. Surg. 14(1): 20– 31. Cong-Feng Luo, Hui Sun, Bo Zhang, Bing-Fang Zeng. (2010). Three-column fixation for complex tibial plateau fractures. J. Orthop. Trauma, 24(11):683-92. Kfuri M, Schatzker J. (2018). Revisiting the Schatzker classification of tibial plateau fractures. Injury, 49(12): 2252–2263. Krause M, Preiss A, Muller G et al., (2016). Intra-articular tibial plateau fracture characteristics according to the ‘Ten segment classification’. Injury, 47(11): 2551–2557. Markus Rossmann, Florian Fensky, Ann-Kathrin Ozga, Johannes M Rueger, Sven Märdian, Gabriele Russow, Ulf Brunnemer, Gerhard Schmidmaier, Alexander Hofmann, Philipp Herlyn, Thomas Mittlmeier, Ahmed Amer, Thomas Gösling, Lars G Grossterlinden (2020). Tibial plateau fracture: does fracture classification influence the choice of surgical approach? A retrospective multicenter analysis. Eur J Trauma Emerg Surg. DOI:10.1007/s00068-020-01388-z. Matthias Krause, Sebastian. (2019). How can the articular surface of the tibial plateau be best exposed? A comparison of specific surgical approaches. Arch. Orthop. Trauma Surg. 139(10):1369-1377. Molenaars, Rik J. BSc, Mellema, Jos J. MD, Doornberg, Job N. MD, PhD, Kloen, Peter MD, PhD. (2015). Tibial Plateau Fracture Characteristics: Computed Tomography Mapping of Lateral, Medial, and Bicondylar Fractures, The Journal of Bone and Joint Surgery, 97(18): 1512-1520. Rudran B, Little C, Wiik A, Logishetty K. (2020). Tibial Plateau Fracture: Anatomy, Diagnosis and Management. Br J Hosp Med (Lond), 81(10): 1-9. doi: 10.12968/hmed.2020.0339. Epub 2020 Oct 30. PMID: 33135915. Three-Column Classification System for Tibial Plateau Fractures: What the Orthopedic Surgeon Wants to Know.(2021). Wesley N Bryson, Eric J Fischer, Jack W Jennings, Travis J Hillen, Michael V Friedman, Jonathan C Baker. Radiographics. 41(1): 144-155.

Chapter 16

Tibial Shaft Fractures Khalid Bunyatov, MD Department of Orthopaedics and Traumatology, Sultanbeyli Ersoy Hospital, Istanbul, Turkey

Abstract Tibial diaphysis fractures are among the most common long bone fractures nowadays. Although high-energy traumas are the main cause of fracture formation in young individuals, low-energy traumas also cause fracture development in elderly osteoporotic patients. Patients present to emergency departments with pain, an inability to bear weight, deformity, and sometimes an open fracture in the affected extremity. Treatment should be planned after obtaining a detailed medical history and physical examination. In the treatment, plans should be made by considering the age and mobilization status of patients and the shape of the fracture. In open fractures, a secondary treatment plan should be made after primary debridement and washing in the emergency department. In open fractures, tetanus prophylaxis should be questioned, and prophylactic antibiotic treatment should be initiated. The aim of treatment is to provide early mobilization and an early return to work, daily activities and sports.

Keywords: tibial diaphysis fractures

Introduction Tibial diaphysis fractures are defined as body fractures that occur distal to the tibial plateau and 4-5cm proximal to the tibial plafond. Tibial diaphysis fractures are among the most common long bone fractures. They are more common in males than females. Another reason that makes tibial diaphysis fractures different from other long bone fractures is that compartment syndrome is more frequently observed after these fractures. It is caused by high-energy traumas in the young population and mostly by low-energy traumas in the elderly population. In pediatric polytrauma, the tibial shaft is the third most common long bone fracture after femur and humerus fractures (Buckley et al., 1994). 

Corresponding Author’s Email: [email protected].

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In play-age children, torsional forces in plantar flexion of the ankle cause spiral-shaped nondisplaced fractures of the tibial shaft (toddler's fracture). Tibial fractures are usually accompanied by fibular fractures and are more common in the distal third diaphysis (C.M. Court-Brown & Caesar, 2006). Approximately 23% of tibial diaphysis fractures are open fractures (C. Court-Brown, Keating, Christie, & McQueen, 1995).

Classification There are different classification systems for fractures concerning the tibial diaphysis. In closed fractures, the tibial diaphysis is defined as 4 2 in the AO classification system. Group A fractures are called simple fractures, and there is full contact between the proximal and distal fragments. In group B fractures, there is a medial butterfly fragment with full contact. In group C fractures, while the butterfly fragment is present, there is no contact between the proximal and distal fragments (Meinberg, Agel, Roberts, Karam, & Kellam, 2018) (Table 1 OTA classification). Table 1. OTA classification

There are also the Tscherne and Gustilo-Anderson classification systems created by considering the condition of soft tissues in tibial diaphyseal fractures (Table 2 and Table 3). Table 2. Tscherne classification GRADE 0 -No or minimal soft tissue damage -No or minimal soft tissue damage Simple fractures

GRADE 1 -Superficial skin abrasion or contusion -Moderate fracture pattern

GRADE 2 -Skin and muscle contusion -Deep abrasion -Severe fracture pattern

GRADE 3 -Severe skin contusion or crush injury -Severe damage to the muscles -Compartment syndrome -Degloving injuries

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Table 3. Gustilo-Anderson classification Type 1 -Clean wound (1 cm) -more severe trauma

Type 3 A -significant soft tissue injury (>10 cm) -contaminated wound -complex unstable fracture pattern -no flap required

Type 3 B -significant periosteal stripping -severely contaminated wound -severe soft tissue injury -requires flap

Type 3 C -vascular injury requiring repair

Clinical Evaluation Patients usually present to the clinic with severe leg pain, an inability to bear weight on the affected side, acute deformity in the leg, pathological movement, swelling in the leg and an open wound. Since tibial shaft fractures usually occur as a result of high-energy trauma, the inspection and examination of the patient should be performed properly, and concomitant injuries, skin problems, open wounds, and deformity should be evaluated and noted. Among the peripheral nerves, the tibial nerve, deep and superficial peroneal nerve, sural nerve, and saphenous nerve should be examined, accompanying compartment syndrome should be evaluated, and peripheral pulses should be checked. Hand Doppler and pulse oximeters can be used in the circulatory examination. If there is a suspected vascular injury, the ankle-brachial index should be examined and compared with the contralateral extremity, and further examinations and vascular surgery consultation should be requested in cases of increased suspicion. After the careful physical examination of the patient, open and contaminated injuries should be debrided and irrigated, the fracture should be stabilized, and prophylactic antibiotics should be initiated (Kumar & Narayan, 2014). In the presence of open fractures, after the first debridement and irrigation, a secondary debridement should be planned for the patient in the operating room. The patient's tetanus prophylaxis should be questioned. Apart from these, it should be considered that acute injuries of the knee and ankle joints adjacent to tibial shaft fractures may accompany tibial shaft fractures and should be carefully examined. Considering high-energy tibial shaft fracture in the pediatric population, the first step is to evaluate the ATLS (advanced trauma life support) score and take a careful anamnesis(Raducha, Swarup, Schachne, Cruz Jr, & Fabricant, 2019).

Radiological Evaluation After the patient's clinical anamnesis, examination and emergency intervention are performed, and direct radiographs are the first radiological evaluation to be made for the evaluation of the fracture. Anteroposterior and lateral imaging of the tibia and fibula should be considered on direct radiographs. Moreover, knee and ankle radiographs should also be examined. In tibial shaft fractures that extend into the joint, a three-dimensional evaluation of the joint with computed tomography is the preferred radiological imaging method in addition to direct

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radiography. Scintigraphy and magnetic resonance imaging may be preferred in fractures caused by pathological bone lesions that are not apparent on direct radiography.

Figure 1. Tibial shaft fracture anterior-posterior view, B: Tibial shaft fracture lateral view (from the author's own archive).

Treatment The treatment of tibial shaft fractures is addressed under two headings, conservative and surgical treatments. While conservative treatment includes a cast and braces, surgical treatment includes external fixators, plate screw fixation, and intramedullary nails. Factors such as the patient's age, the shape of the fracture, the soft tissue condition, and the general condition of the patient should be considered while deciding on treatment. The aim is to restore alignment and ensure early mobilization of the patient (Louwerens & Bentley, 2014).

Indications for Conservative Treatment • • • • • • •

A variant are also at higher risk (van Stralen et al., 2008; Varga & Kujovich, 2012). Thrombophilia is a coagulation or fibrinolytic system abnormality which leads to hypercoagulopathy. In this situation arterial or venous thrombosis risk increases. There are genetic and acquired causes of thrombophilia. Genetic causes include mutations of factor II (prothrombin), factor V Leiden and deficiency of anticoagulant proteins; protein C, protein S or antithrombin III (AT III). Also, hyperhomocysteinemia, dysfibrinogenemia, elevated factor VIII, factors IX and XI, and high lipoprotein-a are rare genetic causes. Acquired causes include trauma, surgery, immobilization, pregnancy, hormone replacement therapy, oral contraceptive use, paroxysmal nocturnal hemoglobinuria, and heparin-induced thrombocytopenia (Dautaj et al., 2019) Hereditary thrombophilias are associated with deep venous thrombosis and/or VTE. Genetic testing for hereditary thrombophilia in VTE patients is not recommended as it will not change treatment and clinical management in most cases (Connors, 2017). Young-aged VTE with weak provoking factors (minor surgery, combination oral contraceptives, or immobility), VTE with a strong family history and recurrent VTE are the situations to consider genetic testing. However, the use of hereditary thrombophilia tests is much more common (Connors, 2017). People with a first-degree relative having a history of thrombosis have a 2-3-fold increased risk of VTE. The risk is more than 4 times if it has been seen in at least one other family member before the age of 50. If an individual with a positive family history has factor V Leiden or the prothrombin 20210G>A mutation, the risk of VTE increases 3-4 times. The risk increases 5 times in factor V Leiden carriers who have a relative who has had VTE before the age of 50, and 13 times in those who have more than one affected relative. Environmental factors shared in these families and additional genetic factors also contribute to the process (Eikelboom & Weitz, 2011; Varga & Kujovich, 2012). While performing post-traumatic VTE prophylaxis, family history, age of the patient, and previous VTE history should be carefully evaluated and if necessary, they should be referred

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to hematology and medical genetic units. Knowing the genetic predisposition is valuable for prophylaxis in subsequent hypercoagulated conditions.

Osteogenesis Imperfecta Osteogenesis imperfecta (OI) is a genetic disease with bone fragility and deformity. Most of the cases are due to mutations in COL1A1/2 genes which encode collagen type 1. The incidence of OI is about 1 in 10,000 (Pepin & Byers, 2015). The clinical features and severity are variable. Craniofacial and dental abnormalities, hearing loss, muscle weakness, and respiratory and cardiovascular complications may accompany the phenotype (Marom et al., 2020). Recurrent, atypically located, low trauma fractures are seen in OI due to bone fragility and osteopenia. OI type 1 is the common and milder clinical type. It is more common in the pediatric group and its incidence decreases with age (Marom et al., 2020). Classic non-deforming osteogenesis imperfecta (OI) (type 1), perinatally lethal OI (type 2), progressively deforming OI (type 3), and common variable OI (type 4) are common types of OI. Findings suggesting the diagnosis of OI (Steiner & Basel, 2020) are: • • • • • • •

Fractures with or without minimal trauma (after the exclusion of non-accidental trauma (NAT) or other bone-disrupting diseases) Bone deformity and short stature Blue/gray sclera Dentinogenesis imperfecta (DI; with opalescent or yellow-brown enamel) Progressive, postpubertal hearing loss Signs of connective tissue abnormalities and ligamentous laxity Family history compatible with autosomal dominant inheritance.

Suggested radiographic features are; fractures, particularly in long bones, codfish vertebra, wormian bones, protrusio acetabuli, low bone mass or osteoporosis. A skeletal survey is essential for differential diagnosis. If clinical and radiographic findings suggest OI, the diagnosis is confirmed by molecular genetic tests. First of all, COL1A1 and COL1A2, which are responsible for approximately 85% of OI, can be screened and then multigenic panels related to other genes can be screened (Marini et al., 2017; Steiner & Basel, 2020). Fracture cases first apply to the emergency department and anamnesis, physical examination and radiological findings should be evaluated together. Evaluation and differential diagnosis are of vital importance, especially in the pediatric group. Non-accidental trauma is also a probable diagnosis to keep in mind. Cases of physical abuse far outnumber cases of OI and may rarely occur in a child with OI. Overlapping clinical findings include; fractures discordant with the trauma history, multiple and recurrent fractures, and fracture findings at different ages and at different healing stages (Steiner & Basel, 2020). Besides, posterior rib fractures, transverse fractures of fingers, metacarpal or metatarsal and metaphyseal chip fractures are suggestive of non-accidental trauma (Pepin & Byers, 2015). However, OI cases with a mild clinical course may be misdiagnosed as child abuse, and in this case, the child and family may be adversely affected sociologically and psychologically. If a clear distinction

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cannot be made at this stage, it is important to refer to medical genetics for molecular genetic testing (Pepin & Byers, 2015). In addition, genetic counseling should be obtained in the case of an OI diagnosis. After the diagnosis of OI, it is necessary to screen other family members, to evaluate the risk of transmission to future generations, and to inform the family about prenatal diagnosis and preimplantation genetic diagnosis. Prenatal diagnosis, if positive, gives the family the choice of termination of the pregnancy. The preimplantation genetic diagnosis, is the procedure of genetic testing of embryos for the known genetic disease and implanting the healthy embryos into the uterus of the mother (Steiner & Basel, 2020).

Inherited Bleeding Disorders Hemophilias and von Willebrand Disease Hemophilia A and B are X-linked recessive bleeding disorders caused by mutations in the genes encoding coagulation factors VIII and IX, respectively. Prevalence is about 1 in 10,000 worldwide. Hemophilia A is more common among hemophilias with a rate of 80-85%. Hemophilias are classified as severe (30% burned TBSA due to the risk of intestinal ileus. In cases such as concomitant head trauma or extremity fracture, it is appropriate for the doctors of the relevant department to evaluate the patient first, and then follow up in the burn unit/center. However, if the accompanying trauma is life-threatening, it is more appropriate to hospitalize the patient in the surgical intensive care unit and perform the burn treatment there (Yastı et al., 2015). While only the burned area is affected in mild burns, systemic events also develop in severe burns. The release of histamine, prostaglandin and cytokines, which are inflammatory and vasoactive mediators, causes blood plasma to leak out of the capillaries and cause edema. Fluid losses mostly occur in the first 24 hours and peak six to eight hours after burn trauma (Schaefer and Nunez Lopez, 2021). This response of the body to the burn leads to a decrease in cardiac output. Insufficient fluid resuscitation in the first 24 hours increases hypovolemia, while excessive fluid resuscitation increases tissue edema and causes the burn to deepen (Lam et al., 2018).

Fluid Therapy Burns exceeding 20% in adults and 10% in children require fluid resuscitation (Yastı et al., 2015). In burn fluid replacement, Parkland and Modified Brook formulas are mostly preferred in adult patients and the Galveston formula is preferred in children (Jeschke and Herndon, 2014; Yastı et al., 2015; Vivó et al., 2016; Hollén et al., 2017; Pham et al., 2019) (Table 4). Half of the calculated amount of fluid should be given in the first 8 hours, and the remaining half in the next 16 hours. The liquid that should be preferred in the first 24 hours is Ringer’s Lactate solution, which is the closest to body fluid (Latenser, 2009). Whatever formula is used to calculate the fluid deficit, it can give insufficient or misleading results, especially in deep second- and third-degree burns (Jeschke and Herndon, 2014). For this reason, it is important to monitor the patient’s urine output (0.5 cc/kg or 30-50 cc/hour in adults, 1-2 cc/kg/hour in children), blood pressure measurement, prevention of hypothermia, and consciousness status together with fluid replacement (Schaefer and Nunez Lopez, 2021). The fluid requirement is higher than calculated in cases of accompanying additional trauma, inhalation and electrical burns (Yastı et al., 2015). Table 4. The most commonly used formulas in fluid resuscitation Parkland formula Modified Brook formula Galveston formula

4 mL/kg/burned TBSA 2 mL/kg/burned TBSA 2000 mL/m2BSA + 5000 mL/m2 burned TBSA

Giving excess fluid is called over creep (Saffle, 2007). Overhydration causes fluid accumulation in the interstitial space (pulmonary edema, pleural and pericardial effusion), compartment syndrome, and edema, further increasing the depth of the burn wound (Latenser, 2009; Jeschke and Herndon, 2014; Strang et al., 2014). There are studies showing that adding high-dose vitamin C to the treatment reduces the amount of fluid resuscitation, edema and mortality (Matsuda et al., 1991; Rizzo et al., 2016; Nakajima et al., 2019).

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Burn Follow-Up and Treatment It is difficult to assess the degree of the burn at first sight. It is easy to identify a very superficial or very deep burn. The first 1-2 days are important to understand whether a deep burn is second degree or third degree. If the edema zone in the burn accompanies necrosis in the follow-up of the patient, a second-degree deep burn turns into a third-degree burn (Monstrey et al., 2008). In addition to clinical observation, thermography, video angiography, video microscopy, biopsy and laser Doppler imaging system methods have also been described to evaluate the depth of the burn (Monstrey et al., 2008; Zuo et al., 2017). Cleaning necrotic tissues, preventing infection and providing a moist environment for epithelization development are important in burn wound care (Partain, Fabia et al., 2020). Superficial burns heal spontaneously without scarring with conservative treatment. Recovery is faster with escharotomy, escharectomy, early surgical excision and grafting in very deep burns, and hypertrophic scar development is less in the long term compared to the conservative approach (Zuo et al., 2017). Scar development is not expected in burns that heal in 2 weeks. However, if the healing exceeds 3 weeks, the possibility of hypertrophic scar development is quite high (Monstrey et al., 2008).

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Figure 1. (A) Second-degree superficial burn (B) second-degree deep burn.

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Figure 2. (A) Third-degree burn (B) split thickness skin graft (3.5/1 meshed).

Second-degree superficial burns heal in 10-15 days with daily dressings without leaving any scars. Vaseline-impregnated gases, Bactigras, silver sulfadiazine, Biobrane (Smith & Nephew), and Opsite (Smith & Nephew) are used as dressing materials (Wasiak et al., 2008).

Approach to Burn Trauma

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Daily dressings, escharotomy, escharectomy and split thickness skin graft (STSG) placement are the most common treatment options for second-degree deep and third-degree burns. Biological (allograft, xenograft, amniotic membrane) and synthetic derm equivalents (dermal substitutes), cultured epithelial autografts, and autologous skin cell suspensions are used in third-degree burns (Lineen and Namias, 2008; Partain et al., 2020). The risk of wound contraction following epithelialization is higher in second-degree deep and third-degree burns. Early escharotomy, escharectomy and STSG are preferred for burns that do not have a chance to heal within 14-21 days. Since the necrotic tissue is removed in the early period, the risk of infection decreases, the length of hospital stay is shortened, and the treatment costs decrease (Xiao-Wu et al., 2002; Barret and Herndon, 2003). Early grafting causes less contraction and less hypertrophic scarring in the post-burn period. A fourth-degree burn is a burn in which all layers are burned. In fourth-degree burns due to electrical burns, there is a risk of amputation of the extremity, although escharotomy and fasciotomy are performed in the early period (Bartley et al., 2019). Their treatment is complex surgical reconstructions.

Use of Antibiotics in Burns Fever after burn trauma is one of the body’s responses to trauma. An infection is not expected to develop immediately after a burn. Although it is an incorrect treatment, antibiotics are usually started from the moment of the burn due to fever and high leukocyte levels. In fact, antibiotics should be started after the presence of infection is detected. It is difficult to detect the actual infection because of the systemic inflammatory syndrome that develops in the burn patient (Greenhalgh et al., 2007). Therefore, many parameters have been proposed; some of these being high heart rate, low blood pressure, base deficit