Trauma and orthopedic surgery

Fractures are common complications of trauma and often require surgical treatment. Orthopedic surgery aims to restore or preserve as much limb function as possible. Fracture care comprises the repositioning of the broken pieces of bone (reduction) and their immobilization and stabilization (fixation) in proper union until they have healed. Surgical fracture management permits more precise measures, a greater degree of stability, and better anatomical reduction than conservative fracture management, resulting in quicker immobilization. These advantages should always be weighed against the possible complications of surgery (e.g., wound infections, blood clot formation, blood loss, and compartment syndrome). Conservative treatment (e.g., closed reduction internal fixation) is indicated for most fractures in children because pediatric bones have greater remodeling capacity than adult bones. Osteosynthetic procedures are chosen on the basis of fracture type, fracture location, and the patient's general condition. If there is advanced joint damage, arthroplasty may be necessary to restore function. Follow-up treatment may involve orthopedic rehabilitation. In patients with bone misalignment (e.g., hip dysplasia), osteotomy may be necessary. Amputation may be indicated if the injured structure or its function cannot be restored and/or if there is a risk of complications (e.g., gangrene).

• Definition: Osteosynthesis is the fixation (stabilization and immobilization) of bone fractures using mechanical devices (e.g., screws, plates, nails, and wires) placed inside the body (internal fixation) or outside (external fixation).
• Indications
  • Displaced intraarticular fractures < 2 mm
  • Unstable fractures at risk of further damage (e.g., from a fracture reduction)
  • Multifragmentary fractures
  • Conservative reduction
• Contraindications
  • Systemic infection
  • Local infection
  • Osteomyelitis
• Complications
  • Wound infection
  • Neurological and vascular injury (e.g., bleeding, hematoma, seroma)
  • Avascular necrosis
  • Posttraumatic osteoarthritis
  • Nonunion
  • Secondary dislocation
  • Compartment syndrome
  • For further information, see “Complications” in “General principles of fractures.”

Internal fixation is a surgical method to fixate fractures and/or dislocations using rods, nails, plates, and/or screws placed inside the body.

Closed reduction internal fixation

• Definition: a procedure to repair a fracture and/or dislocation with physical manipulation (e.g., via traction) followed by percutaneous fixation with mechanical devices (e.g., Kirschner wires)
• Indications
  • Stable fractures
  • Preferred treatment for pediatric fractures

Open reduction internal fixation

• Definition: a surgical procedure to repair a fracture and/or dislocation through operative (open) repositioning (reduction), followed by fixation with rods, nails, plates, and/or screws.
• Indications
  • Failed closed reduction
  • Multiple trauma
  • Open fractures
  • Fractures with vascular injuries
  • Nonunion

Lag screw fixation

• Definition: the fixation of a fracture using lag screws either on their own or in combination with other devices (e.g., plates)
• Indications: : most types of fractures (e.g., articular fractures, slipped capital femoral epiphysis)
• Principles: fixation and compression of the fracture gap
• Types of hardware involved
  • Cortical screws: fixation of the fracture gap
  • Cancellous screws: compression and fixation of the fracture gap

Plate fixation

• Definition: a surgical procedure in which stainless steel or titanium plates are used in combination with screws for the fixation of a fracture
• Indications: comminuted fractures (e.g., unstable articular fractures, osteoporotic fractures)
• Principles: neutralization and stabilization of the malposition for quicker postoperative functional rehabilitation
• Types of hardware involved
  • Buttress (antiglide) plates: compensate for shear forces
  • Compression plates: compress the fracture gap
  • Neutralization plates: neutralize bending, torsional, and shear forces
  • Tension-band plates: convert tensile forces into compression forces
  • Bridge plates: connect the intact bone ends of comminuted fractures or bony defects, bypassing the intermediate fracture zone

Dynamic hip screw fixation ^[1]

• Definition: a surgical procedure for the fixation of certain types of hip fracture using an orthopedic implant consisting of a sliding lag screw, a stabilizing side plate with a barrel, and cortical screws
• Indications: fractures in the trochanter region
• Principle: When the patient places weight on the affected leg, the sliding lag screw moves through the barrel and enables fracture compression.
• Types of hardware involved
  • Sliding lag screw: compression of the fracture gap
  • Side plate: stabilization and fixation of the fracture gap
  • Cortical screws: fixation of the side plate to the bone

Intramedullary nail fixation

• Definition: a surgical procedure in which a metal rod is inserted into the medullary cavity of a bone to internally fix a fracture
• Indication
  • Diaphyseal fractures of the long bones (e.g., tibial shaft, distal femur, humerus shaft)
  • Metaphyseal fractures
• Principle
  • Stabilization of the bone
  • Preservation of bone length
  • Limitation of rotation

Kirschner wire fixation

• Definition: a surgical procedure that uses a wire for the fixation of bone fragments
• Indications
  • Fractures of small bones
  • Fragment repositioning in multifragmentary fractures
  • Epiphyseal and/or metaphyseal fractures
  • Provisional fixation
  • Support of fractures that have been fixed with screws and/or plates
• Principle: fixation of the fracture without compression

Tension-band wiring

• Definition: a surgical procedure using Kirschner wires and a tension band to internally fixate and compress fractures
• Indications
  • Greater tuberosity fractures
  • Olecranon fractures
  • Greater trochanter fractures
  • Patella fractures
  • Lateral malleolus fractures
• Principle: intrafragmentary compression of a bending fracture
  • Application of two Kirschner wires placed parallel to one another and perpendicular to the fracture line.
  • Application of a tension band in a figure-eight loop around Kirschner wires

• Definition: a surgical method for the fixation of a fracture using metal devices (e.g., pins, screws, plates) that are secured outside of the skin ^[2]
• Indications
  • Temporary fixation
  • Open fractures with soft tissue loss
  • Fractures with significant bone loss
  • Comminuted long bone fractures
  • Unstable fractures (e.g., extremity fractures, pelvic fractures)
• Principle: fixation and compression of the fracture gap through an externally fixed mechanical device (fixator) rooted in the bone with the screws fixed proximally and distally from the fracture

General

• Definition: a surgical procedure to replace and/or remodel a damaged musculoskeletal joint in order to restore joint function
• Indication: : severe joint damage (e.g., trauma, osteoarthritis) most commonly of the knee, hip, and shoulder
• Complications
  • Prosthetic joint infection: See “Subtypes and variants” in “Septic arthritis.”
  • Prosthetic loosening: the loosening of an endoprosthesis, which can result in diminished or lost joint function ^[3]
    • Clinical features include:
      • Aseptic prosthetic loosening (gradual process): local pain, decreased function
      • Septic prosthetic loosening (rapid and acute process): local pain, swelling, redness, pus, loss of function, and possible consequent systemic symptoms (e.g., fever, malaise, fatigue)
    • Treatment: prosthetic replacement
  • For general complications see “Complications” in “Osteosynthetic procedures” above.

Total arthroplasty ^[4]

Total arthroplasty is a surgical procedure in which a damaged musculoskeletal joint is entirely removed and replaced with an endoprosthesis.

Hemiarthroplasty ^[4]

Hemiarthroplasty is a surgical procedure in which the damaged portion of a musculoskeletal joint is removed and replaced with an endoprosthesis (e.g., hip hemiarthroplasty).

Resection arthroplasty

• Definition: a surgical procedure in which a damaged joint is partially or completed removed to preserve as much function as possible
• Indications
  • Unsuccessful arthroplasty
  • Destruction of the joint (e.g., due to trauma, inflammation)

Complications after osteosynthesis/arthroplasty ^[5][6]

• Early postoperative complications
  • Infection
  • Injury to surrounding structures (tendons, nerves, vessels)
  • Venous thromboembolism
  • Hemorrhage
  • Compartment syndrome
• Late postoperative complications
  • Posttraumatic osteoarthritis
  • Malalignment/dysfunction
  • Nonunion
  • Material fracture, periprosthetic fracture
  • Loosening of prostheses
  • Persistent pain
  • Joint stiffness

Corrective osteotomy

• Definition: a surgical procedure to correct bone misalignment by transecting the bone and realigning and fixing it in a normal position
• Indications: posttraumatic malunions, congenital or acquired valgus and varus deformities with the risk of osteoarthritis (e.g., severe hallux valgus or genu varum)

Hip osteotomy

• Definition: a surgical procedure to improve hip joint coverage that involves cutting the femur and/or pelvis and repositioning the acetabulum and/or femur
• Indications: hip dysplasia, Legg-Calvé-Perthes disease
• Types
  • Children aged 2–10 years: Salter osteotomy (complete transection and repositioning of the iliac bone for better coverage of the femoral head)
  • Children aged < 10 years: triple innominate osteotomy (repositioning the acetabulum by cutting through the ilium, ischium, and pubis without disrupting the triradiate cartilage)
  • Adults: periacetabular osteotomy (repositioning the acetabulum by cutting through the ilium, ischium, and pubis)