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Principles of Internal Fixation

Introduction Conservative management of fractures has limitations. Traction, splintage, and casting are limited in their capacity to restore form and function. The fundamental purpose of the skeleton is to provide structure to the body and create attachment points for muscles, tendons, and ligaments, thereby enabling joints to move. When the form of the skeleton is disrupted, the function of the skeleton is affected. In the mid-1900s,…

Principles and Complications of External Skeletal Fixation

Historical Background Early Fixators The external fixator was invented 12 years before the plaster cast. In 1846 Jean Francois Malgaigne devised an ingenious mechanism consisting of a clamp that approximated four transcutaneous metal prongs to reduce and maintain patellar fractures ( Fig. 8.1 ). In the 170 years since Malgaigne's invention, many other external fixation systems have been introduced. Among the best known are the Parkhill…

Closed Fracture Management

Introduction Nonoperative management of fractures is presumably as old as humankind. One would therefore anticipate that as part of the evolutionary biology of humans there would be an intrinsic ability for fractures to heal without surgical interference. Over centuries this has been demonstrated to be the case; fractures, left to their own devices, will heal, and, even more important, this healing process is expedited by active…

Biomechanics of Fractures

Introduction Understanding biomechanics is essential for an orthopaedic surgeon. Orthopaedic surgeons are architectural engineers of the human skeleton, and their job in trauma is to repair the skeletal structure if it is fractured or diseased so that it can resume its function. Doing so requires knowledge of the forces that caused the fracture and understanding of the destabilizing forces with the potential to prevent healing. Effective…

Biology and Enhancement of Skeletal Repair

Introduction The rapid development of contemporary fracture fixation devices has occurred as the concepts of minimally invasive surgical techniques have advanced. Percutaneous instrumentation, the refinement of insertion portals, and the development of blocking screw techniques have expanded the range of intramedullary (IM) nailing from midshaft injuries to the articular margins. Locking plates have extended the role for periarticular fracture fixation using minimalistic exposures. Fully implantable limb…

Vascularity and Stability: The Pillars of Fracture Healing

Introduction Fracture healing is a complex process influenced by biologic and biomechanical factors. Understanding the biology of a healing bone is critical when utilizing implants that will affect this process. Although many of the principles taught in fracture surgery have implications on a cellular level, these effects are not routinely considered by surgeons. This chapter focuses on how orthopaedic implants interact with the body's native physiology…

The Challenges of Orthopaedic Trauma Care in the Developing World

Introduction This chapter proposes an overview of the challenges in meeting the increasing needs for trauma care in low- and middle-income countries (LMICs). The epidemiologic aspects of the burden of injuries are discussed elsewhere in this book (see Chapter 2 ), as is the nonsurgical management of fractures (see Chapter 7 ), so a special effort was made to keep overlaps to a minimum. Topics addressed…

Global Burden of Musculoskeletal Injuries

Injuries are a leading cause of death and disability around the world. In 2016 injuries killed 4.6 million people globally, corresponding to a rate of 64.4 per 100,000 people. Fig. 2.1A shows the relative distribution of global deaths, from communicable diseases (Group A, in red ), noncommunicable diseases (Group B, in blue ), and injuries (Group C, in green ) in 2016. The area each box…

The History of Trauma Care

The views expressed are those of the author and do not reflect the official position of the Uniformed Services University, the Department of Defense, or the United States Government. Introduction Trauma derives from the Greek word τραῦµα, literally meaning “wound.” The history of trauma is thus the history of wounds and their management over time. Wounds provide an unusually pellucid window into the science, society, and…

Future directions in shoulder arthroplasty

Shoulder arthroplasty has advanced immeasurably since the first shoulder replacement was implanted by Péan in 1893. Implant designs continue to evolve and improve, as do the materials from which these designs are constructed. The reverse prosthesis has gained widespread use in the United States since 2004 and continues to evolve, with design changes introduced by many companies that manufacture a version of this semiconstrained device. One…

Rehabilitation after shoulder arthroplasty

The goal of rehabilitation after shoulder arthroplasty is restoration of functional shoulder mobility in a timely fashion. Biologic factors impose limitations in achieving mobility after shoulder arthroplasty. Histologically, collagenous connective tissues in the shoulder (tendons, ligaments, capsule) contract after shoulder arthroplasty. These connective tissues are subject to the biomechanical properties and limitations of collagen, including plasticity, stretching, and temperature sensitivity. The plasticity of collagen allows connective…

Results and complications

The results of revision shoulder arthroplasty are as variable as the indications for which it is performed. In general, outcomes after revision shoulder arthroplasty are less satisfactory than those after primary shoulder arthroplasty. Because of the paucity of results of revision shoulder arthroplasty reported in the literature, this chapter reports the results of revision shoulder arthroplasty by drawing from our own experience. In addition, the most…

Glenoid component

Problems with the glenoid are a common indication for revision arthroplasty. Such problems include failure of previously implanted glenoid components from total shoulder arthroplasty and osseous glenoid erosion after hemiarthroplasty. Frequently, glenoid problems involve substantial osseous compromise and require complex reconstruction. The ability to deal with these glenoid problems is necessary to successfully treat many cases of failed shoulder arthroplasty. Treatment of the various types of…

Humeral component

Reconstruction of the proximal humerus can be a very difficult aspect of revision shoulder arthroplasty. During extraction of the previous humeral stem, every effort should be made to preserve as much native proximal humeral bone as possible (see Chapter 38 ). The overall condition of the proximal humerus and rotator cuff plays a significant role in determining the type of implant to be used in revision…

Humeral stem removal and glenoid exposure

Humeral stem removal can be simple or one of the most difficult and time-consuming aspects of revision shoulder arthroplasty. Preoperative planning becomes very important in facilitating removal of the humeral stem during revision shoulder arthroplasty. Although relatively smooth press fit humeral stems may be easy to remove, extensively porous-coated stems can be especially difficult to extract, particularly when they have been inserted with bone cement. Identification…

Preoperative planning, imaging, and special tests

Revision shoulder arthroplasty is more challenging overall than primary shoulder arthroplasty. Preoperative planning for a revision arthroplasty case is critically important and is initiated as soon as revision arthroplasty is being considered; it should never be an afterthought the morning of surgery. Preoperative planning for revision shoulder arthroplasty is similar to, albeit more complex than, planning for primary shoulder arthroplasty and consists of reviewing the patient's…

Indications and contraindications

Just as with hip and knee arthroplasty, as the volume of shoulder arthroplasties performed each year increases, so will the number of patients requiring revision shoulder arthroplasty. Indications for performing revision shoulder arthroplasty are variable and numerous and can include problems related to the glenoid, problems related to the humerus, and problems related to the soft tissues (rotator cuff, instability). Rarely, infection, either early postoperative or…

Biologic alternatives to shoulder arthroplasty

In our practice, few situations exist in which biologic surface replacement of the humeral head is more advantageous than conventional humeral head replacement with a stemmed or new stemless implant. In addition, use of biologic replacement hinders glenoid exposure and thus prevents implantation of a prosthetic glenoid implant in many cases. However, there are some indications for biologic humeral resurfacing for focal loss of humeral head…