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Technique Spotlight: Allograft Stabilization of the Sternoclavicular Joint

Authors’ Preferred Surgical Technique: Figure-of-Eight Sternoclavicular Joint Reconstruction Using Autograft Tendon Rationale As described in the previous chapter, a variety of techniques have been described to treat the unstable sternoclavicular joint (SCJ). The figure-of-eight technique was developed after biomechanical testing determined that the posterior capsule was the primary restraint to posterior translation of the SCJ and the posterior capsule and anterior capsule were restraints to anterior…

Professionalism and the Economics of Orthopaedic Trauma Care

Introduction The practice of medicine is fundamentally and historically based in service; whether service to patients, service to communities, service to society, or service to one's partners and colleagues, the professional lives of physicians are linked to service. The professional lives of those doing orthopaedic fracture care are even more closely aligned to service, as the individuals treated have sustained painful injuries that cannot be scheduled…

Outcome Assessment in Orthopaedic Traumatology

Introduction The last century has brought remarkable advances in the field of orthopaedic traumatology. The creation and dissemination of this new knowledge could not have been possible without the ability of surgeon scientists to measure and communicate their patient outcomes. Just as the delivery of skeletal trauma care has evolved through the decades, so have the techniques used to quantitate and report these advances. Outcomes Research—Assessment…

Physical Impairment Ratings for Fractures

Fractures account for only about 10% of all musculoskeletal traumatic injuries, but they cause a disproportionate amount of medical impairment. The costs of fracture care, including lost productivity, medical expenses, and disability payments, make this class of injury a significant burden both to employers and to society in general. The role of physicians in the medical care of fractures is well established, but their job does…

Surgical Site Infection Prevention

Surgical site infection (SSI) is one of the most common and devastating complications of orthopaedic surgical procedures. The Centers for Disease Control and Prevention (CDC) estimates that 22% of all healthcare-associated infections are SSIs. More than 290,000 SSIs occur annually in the United States, resulting in $1 billion to $10 billion in direct and indirect medical costs. In 2002, there were more than 43 million procedures…

Medical Management of the Orthopaedic Trauma Patient

Acute Pain Management, Regional Anesthesia Techniques, and Management of Complex Regional Pain Syndrome In 1995, the president of the American Pain Society, Dr. James Campbell, argued that pain was the “fifth vital sign” and suggested that to provide effective care, a patient's pain should be quantified and treated. In 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO; now The Joint Commission) recognized that “unrelieved…

Occupational Hazards in the Treatment of Orthopaedic Trauma

Optimal and Safe Use of C-Arm X-Ray Fluoroscopy Units Introduction The use of fluoroscopic imaging procedures allows healthcare professionals to view the examination and procedure of the patient in real time. Modern fluoroscopic devices are greatly improved from the darkened room imaging conducted in the mid-twentieth century. The imaging system or image intensifier assembly is the fundamental component for the production of the patient image. It…

The History of Fracture Treatment

Early Splinting Techniques Humans have never been immune from injury, and doubtless the practice of bonesetting was not unfamiliar to our most primitive forebears. Indeed, given the known skills of Neolithic humans at trepanning the skull, it would be surprising if techniques of similar sophistication had not been brought to bear in the care of injuries. However, no evidence of this remains. The earliest examples of…

Articular Cartilage Reconstruction Using Osteochondral Allografts

Introduction Background Symptomatic cartilage defect in a young patient is a difficult problem to treat. Several options for biologic treatment have been described, but each of them has its own limitations. For example, the use of cylindrical allograft transplants (single plug, snowman technique), which is a well-established technique for focal chondral defects, has shown good results in carefully selected patients. However, it is restricted to small-size…

Amputations in Trauma

General Principles History Amputation is no longer only the result of traumatic amputation or the real or perceived failure of limb salvage. Rather, amputation is now considered a viable and reasonable treatment option for extensively injured extremities and as such should be considered a reconstructive, rather than ablative, procedure. Amputation surgery has developed extensively since it was first recorded in Neolithic times, when the procedure was…

Limb Salvage and Reconstruction

The management of traumatic limb-threatening injuries, especially to the lower extremity, remains a controversial topic in the orthopaedic literature. During recent years, there have been tremendous technical developments in protective gear for the head and chest, improvements in prehospital care and medical evacuation, and organized regional trauma care and improved critical care within those trauma centers. As a result, orthopaedic surgeons are now challenged by severe…

Principles of Deformity Correction

Lower Limb Alignment and Joint Orientation Bones, joints, and bone and joint segments can be two-dimensionally characterized using axis lines. A mechanical axis line connects the center of a proximal joint to the center of a distal joint ( Fig. 70.1 ). An anatomic axis line is the middiaphyseal line (see Fig. 70.1 ). Whereas the anatomic axis is used in the frontal and sagittal planes,…

Periprosthetic Fractures of the Lower Extremity

Introduction Periprosthetic fractures are defined as fractures involving joint replacements. In general, periprosthetic fractures can occur intraoperatively (primary periprosthetic fracture) or in the postoperative course (secondary periprosthetic fracture). In the lower extremity, periprosthetic fractures could be divided depending on the anatomic site into periprosthetic fractures around hip arthroplasty (acetabulum, proximal femur) and periprosthetic fractures around knee arthroplasty (distal femur, proximal tibia, patella). Key Points: General Information…

Posttraumatic Reconstruction of the Foot and Ankle

Residuals of trauma to the foot and ankle are a major cause of pain and disability for the affected patients. Trauma involving the joints of the ankle and foot is the most common cause of symptoms leading to the need for ankle and foot reconstruction requiring soft tissue balancing, osteotomies, and/or fusion. The reasons include inadequate assessment and treatment at the time of initial trauma leading…

Foot Injuries

Be sure you put your feet in the right place, then stand firm. —ABRAHAM LINCOLN As Homo sapiens, our evolutionary ancestors evolved to bipedality several million years ago. During this transition, the foot underwent multiple structural alterations. Many theories exist, aside from our hominid ancestors simply descending from the trees, on the evolutionary forces that have led to these structural changes. Regardless, the foot has evolved…

Malleolar Fractures and Soft Tissue Injuries of the Ankle

This chapter discusses malleolar fractures, related ligament injuries, and other soft tissue injuries sustained with ankle trauma. Pilon fractures are discussed in Chapter 65 . Talar injuries are reviewed in Chapter 67 . Introduction The ankle is a complex hinge in which both bones and ligaments play an equally important role in its stability. As a weight-bearing joint, the ankle is exposed to forces that transiently…

Fractures of the Tibial Pilon

The defining characteristic of a pilon fracture is the involvement of the distal tibial metaphysis and articular block extending 5 cm proximal to the tibiotalar joint. The nature and complexity of these fractures range from simple patterns (e.g., boot-top ski injuries) to complex, high-energy injuries with significant soft tissue stripping, fracture comminution, articular impaction, and bone loss. At least half are due to motor vehicle collisions. Therefore…

Tibial Shaft Fractures

Introduction Fractures of the tibial shaft are defined as occurring 5 cm proximal to the tibial plafond and distal to the tibial plateau. The subcutaneous location of the tibia makes it a common site for open fractures and perioperative wound complications. Tibial shaft fractures are more commonly associated with compartment syndrome than any other fracture. Fractures in the proximal and distal thirds of the tibia are commonly…

Malunions and Nonunions About the Knee

Introduction The diagnosis and treatment of a malunion or nonunion about the knee should be approached systematically. A malunion is defined as a fully healed fracture resulting in a deformity of the bone. To identify a malunion about the knee requires the accurate measurement of limb alignment and joint orientation. This includes the alignment of the femur and tibia, the articular congruency of the distal femur…

Tibial Plateau Fractures

Introduction Tibial plateau fractures, inclusive of articular fractures of the proximal tibia and adjacent metaphysis, accounted for 1.2% of the fractures treated in Edinburgh's population of more than 500,000 during the year 2000, ranking 16th of the 27 reported anatomic fracture locations. This rank is approximately in line with fractures of the calcaneus and humeral shaft. The age distribution of tibial plateau fractures follows a bimodal…