Планирование и техника вправления в хирургии переломов

Planning and
Reduction Technique
in Fracture Surgery
J.Mast R.Jakob R.Ganz
Planning and
Reduction Technique
in Fracture Surgery
Foreword by H. Willenegger
With 130 Figures in 782 Separate Illustrations
~ Springer
Jeffrey Mast, MD, Associate Clinical Professor
Department of Orthopedic Surgery
Wayne State University, Hutzel Hospital
4707 St. Antoine Blvd., Detroit, MI 48201, USA
Roland Jakob, MD
Department of Orthopedic Surgery
University of Berne, Inselspital
CH-3010 Berne, Switzerland
Reinhold Ganz, MD, Professor
Director, Department of Orthopedic Surgery
University of Berne, Inselspital
CH-3010 Berne, Switzerland
Illustrations by Jan Piet Imken
Illustrator, Laboratory for Experimental Surgery
CH-7270 Davos Platz, Switzerland
ISBN-13: 978-3-642-64784-0
DOl: 10.1007/978-3-642-61306-7
e-ISBN-13: 978-3-642-61306-7
Library of Congress Cataloging-in-Publication Data
Mast, J. (Jeffrey) 1940- Planning and reduction technique in fracture surgery / J.Mast,
R.Jakob, R.Ganz. Bibliography: p. Includes index.
1. Fractures-Surgery. I. Jakob, Roland. II. Ganz, R. III. Title. [DNLM: 1. Fractures-surgery.
WE 175 M423p) RD101.M365 1989 61T.15-dc19 DNLM/DLC 88-24958
This work is subject to copyright. All rights are reserved, whether the whole or part of the material
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The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
© Springer-Verlag Berlin: Heidelberg 1989
Softcover reprint of the hardcover 1st edition 1989
Printed on acid-free paper
"I get by with a little help from my friends"
"The Beatles" (by John Lennon and Paul McCartney, 1967)
VII
Foreword
During the past 30 years, the Study Group for the Problems of Osteosynthesis (AO) has made decisive contributions to the development of osteosynthesis as a surgical method. Through close cooperation among specialists in the fields of orthopedic and general surgery, basis research,
metallurgy, and technical engineering, with consistently thorough followup, it was possible to establish a solid scientific background for osteosynthesis and to standardize this operative method, not only for the more obvious applications in fracture treatment, but also in selective orthopedics
where hardly any problems relating to bone, such as those with osteotomies can be solved without surgical stabilization. Besides the objective
aim, the AO was additionally stimulated by a spirit of open-minded
friendship; each member of the group was recruited according to his professional background and position, his skills, and his talent for improvisation.
Against this backdrop without even mentioning the schooling program
well known throughout the world I should like to add some personal and
general comments.
This book is written for clinicians, instructing them how to perform osteosynthesis with special reference to plating in all its varieties and in strict
accordance with the biomechanical and biological aspects and facts.
From this point of view, the chapter on preoperative planning merits particular emphasis. Not only is it conductive to optimal surgery, it will also
contribute to self-education and may found a school. Preoperative planning thus appears as a leitmotif throughout the whole book. The theme is
illustrated with a number of fascinating details and suggestions concerning
fracture repair and the different kinds of osteotomies, always closely
linked with further fundamental concepts: minimal disturbance of blood
flow, minimal hardware, optimal stability.
I perused with special interest the chapter on plate fixation. All plates
(straight and angled) were implanted with the patient on a conventional
operating table without X-ray control, even in the case of a segmental fracture, shortening, or comminution. For such cases, the AO distractor is the
instrument of choice; the reduction can be achieved without external traction, avoiding the need for both the traction table and the technically demanding insertion of an interlocking nail. Following the precepts outlined,
the results are convincing, provided that the specific problems of the plate,
which is in eccentric position, are taken into consideration. The AO distractor simplifies the reduction of a fracture to be treated by intramedullary nailing. In certain cases, the plate itself can be used as a reduction instrument, for instance by applying the plate first at the proximal part of
VIII
the fractured bone. This simple and effective procedure is demonstrated in
different situations and will be stimulating for anyone familiar with the art
of plating.
The great importance of any simplification of osteosynthesis should not be
underestimated, as it is not only in developing countries that operating
rooms may not be adequately equipped. Having discovered this for myself
in the course of my travels in various countries, I always carry the AO distractor in my luggage and have often found it useful.
In addition to discussing external fixation and the minidistractor, the remaining chapters refer to a number of combinations of internal and external fixation. Finally, the authors describe a remarkable selection of tricks
used to adapt the classical AO implants to many different purposes. Every
devotee of the art of surgery will especially like this well-illustrated closing
chapter.
This expertly written and stimulating book is a valuable addition to the orthopedic literature and merits the widest possible distribution.
Berne, October 1988
Prof Hans Willenegger, M. D. hon., D. V. M. hon.
IX
Preface
This book is the product of an AO fellowship awarded to one of us (JM)
in 1979. This invitation to study in Switzerland allowed the three of us to
meet and subsequently become friends.
Over the ensuing years the very positive contact between us stimulated the
development of a surgical approach based on the classical tenets of AO
surgical philosophy but altered by the realization that the anatomic repair
of certain high-energy injuries to bone and soft tissue requires excellent
judgement and a few reliable tricks.
The acceptance of the interlocking intramedullary nail has highlighted the
fact, well appreciated in the classical orthopedic literature, that living bone
will heal. Healing of viable bone occurs by means of callus formation, gap
healing, or "soudure autogene", depending on the circumstances of contact
and stability. In the case of the interlocking nail, given the right starting
point, correct alignment in the frontal and sagittal planes is restored because of the location of the implant in the intramedullary canal of the
proximal and distal main fragments. Realignment of the fracture in the
horizontal plane (rotation) and correction of any residual displacement
(shortening and lengthening) must be the concern of the surgeon at the
time of the operation; the implant itself does not bring about the restoration of these relationships. The anatomic reduction of intercalary displaced diaphyseal fragments, however, is not so important as long as they
do not interfere with function. These fragments remain viable by virtue of
their connections to the adjacent soft tissue, and healing of the bone may
be expected to occur with "functional aftercare". In contrast, regardless of
the state of reduction or contact, dead bone heals only when the time necessary for revascularization of the necrotic fragments has passed and when
infection has not intervened.
We have observed that the same outcome can be achieved by plate
fixation of a comminuted fracture. The plate, however, must be applied in such a way as to minimize the disruption of blood flow in the
fracture zone and to maximize mechanical stability. We have used on
many occasions a technique which can be described, simply, as the
"interlocking plate" method. Thus, when internal fixation of bone is indicated, a prime consideration must be to preserve the remaining vascularity.
On the other hand, as we have learned, healing of a fracture in a position
compromising function, or in association with contractures or dystrophies
that compromise use, is also unacceptable. Therefore it is not enough to be
the guardian of the vitality of the fracture zone; one must also be concerned with the axial relationships of the extremity and the early restora-
x
tion of movement. Stable fixation with a reduction restoring normal spatial relationships is also a goal.
How to accomplish these objectives simultaneously is the central concern
of this book. We have pushed one another along through clinical application of the methods that are described. Problems, results, and novel applications of the principles have been shared informally, and some early reports on success of the methods in the clinical setting have been generated.
In the end, it was accepted that a book on the subject should be written.
For purposes of expedience one of us (JM) became the writer and the other two provided criticism, ideas, and illustrative cases. Thus, although the
result is a composite product, it is expressed in one person's style. In some
instances this approach is a compromise, as like orthopedic surgeons in
general we differ in our preferences, our special interests, and our general
approach.
Nevertheless, we have tried to set out clearly the methods by which we
treat certain fractures. We hope that the techniques discussed will be fully
understood and also applied, with the end result of satisfaction for both
patient and surgeon.
We would like to thank the following individuals for their help with the
preparation of the manuscript and the many illustrations: David Roseveare, our copyeditor at Springer-Verlag, for refining the crude extracts
that he received; Jan Piet Imken for patiently revising and re-revising illustrations to ensure clarity and accuracy; Slobodan Tepic for his technical
assistance; Theres Kiser, Gerold Huber, and Lottie Schwendener from
Switzerland and Ronnie Constantino from Melbourne, Florida for their
exceptional photographic work; Polly Barnes from Mainstream Studio for
her proofreading and typing skills; Fellow surgeons Brett Bolhofner, Keith
Mayo, Joel Matta, Raymond White, Philip Anson, Christian Gerber, Diego Fernandez, Balz Isler, Peter Ballmer, Fred Baumgartel, Hans Jaberg,
Hans Ueli Staubli, Stephan von Gumpenberg, and other friends and colleagues for cases and support. Lastly, the writer thanks the staff at Melbourne Orthopedic Clinic, Florida, including Dan King and Glenn Bryan,
for allowing him a little time for this project. We are also grateful to Phillip
G. Spiegel for his support and encouragement.
Berne and Detroit, October 1988
Jeffrey Mast
Roland Jakob
Reinhold Ganz
XI
Contents
Chapter 1: Rationale . . . . . . . . . . . . . . . . . . . . . . . . . ..
1
Chapter 2: Anticipation (Preoperative Planning)
11
Fractures and Post-traumatic Residuals .
Osteotomies . . . . . . . . . . . . . . . .
The Goals of Planning . . . . . . . . . .
Preoperative Planning by Direct Overlay Technique:
The Making of a Jigsaw Puzzle . . . . . . . . . . . .
Preoperative Planning of an Acute Fracture Using the Sound Side:
Solving the Jigsaw Puzzle. . . . . . . . . . . . . . . . . . . . . . . ..
11
12
15
Chapter 3: Reduction with Plates
48
.....
16
16
Using a Straight Plate as a Reduction Aid . . . . . . . . .
Reduction of a Distal Third Oblique Fracture of the Tibia by Means
of an Antiglide Plate .
Fractures of the Fibula
Forearm Fractures ..
Acetabular Fractures .
Using the Angled Blade Plate as a Reduction Tool.
Proximal Femur .
Summary . . . . . . . . . . . . . . . . .
50
Chapter 4: Reduction with Distraction .
130
The Femoral Distractor . . . . . . . . .
The External Fixator in Reduction and Internal Fixation
of Os Calcis Fractures
The Minidistractor
Summary . . . . . . . .
131
Chapter 5: Substitution . . . . . . . . . . .
201
Combined Internal and External Fixation
Composite Fixation .
Summary . . . . . . . . . . . . . . . . . . .
201
203
51
53
54
54
56
57
57
139
141
143
205
XII
Chapter 6: Tricks
228
Tricks with Instruments .
Tricks with Implants
228
230
References . . .
251
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
XIII
Glossary
Absolute stability: In a fracture treated by internal fixation with physiologic activity there should be no motion between fracture fragments until
healing has occurred. This is best achieved through the use of interfragmentary compression.
Antiglide plate: A plate used to reduce an oblique fracture indirectly
through interference between the plate and the undisplaced main fragment.
Buttress plate: A plate employed to support the fractured bone in the area
of the metaphysis, usually used in conjunction with lag screws.
Direct reduction: The repositioning of bone fragments individually under
direct vision with an instrument.
Dynamic compression: The fracture fragments are not only compressed by
the prestress of the implant, but also subjected to additional compression
which results from harnessing forces generated at the level of the fracture
when the skeleton comes under physiologic load.
Indirect reduction: The blind repositioning of bone fragments through distraction accomplished with an instrument (distractor) or an implant.
Instability: Movement between fracture fragments at any time resulting
from the application of fixation which leads to a loss of reduction.
Interference reduction: A forced repositioning of a bone fragment or fragments achieved by means of conflict between the bone and an anatomically contoured implant.
Interfragmentary compression: Prestressing an implant increases friction
between the fracture fragments and this improves the stability of the internal fixation.
Neutralization plate: A plate used to protect lag screw fixation from torsional and bending movements.
Preload (prestress): This is achieved by tensioning an implant and reciprocally compressing the bone or fracture surfaces, before the patient actively
subjects the implant to load or stress.
Relative stability: In a fracture treated by internal fixation with physiologic
activity there is motion between the fracture fragments although the reduction is maintained throughout, until healing has occurred.
Static interfragmentary compression: The tension applied to an implant results in compression at the fracture interface.
Tension band: An implant loaded in tension against the bone, which is under reciprocal compression load.
1
Chapter 1: Rationale
This book is written with the purpose of sharing with you various techniques that will facilitate your efforts to obtain a successful result in the
operative treatment of difficult extremity fractures. The primary objective
in these challenging operations is to apply the basic principles of stable
fixation with the least possible disturbance of the soft tissues.
Unquestionably, the correct application of the AOI ASIF techniques has
benefited thousands of patients. In mUltiple international conferences, orthopedic surgeons have learned the practical aspects of the use of compression, neutralization, and splintage in fracture surgery. These basic
principles outlined in the AO manual [25] remain the foundation for the
successful application of the methods to be discussed. Satisfaction of this
prerequisite, allied with a better knowledge of the instrumentation and a
desire to maintain the viability of the surgical zone, gives us the ability to
enhance our results.
Logically, then, functional treatment can be extended to fractures with severe comminution, emphasizing the biologic rather than the purely mechanical principles. This book will discuss the means of achieving fracture
reduction with the least motor input and the least devitalization of a living
tissue - bone - and yet produce an internal fixation that is mechanically
sound and conservatively applied.
The postoperative X-ray is the visual statement of the surgical intervention. By analyzing the results of our prior cases we can follow the evolution of the sophistication of our technique, a direct expression of increased
understanding and improved skills. Similarly, it is interesting to compare
the editions of the Manual of Internal Fixation [25] from 1963 to 1979.
Comparing the reduction and fixation montages for various fracture types
the different editions, the reader sees the evolution of the system. This development was assisted by critical review of the results of fixation; in AO
clinics, in courses, and in review of the materials in the AO Documentation Center (Bern, Switzerland).
What are the requisites for reduction? In general, these depend on the specific bone and on the anatomic location of the fracture in that bone. In the
diaphysis, we must be faithful to the axis of extremity by restoring the
bony shaft so as not to leave residual angulations in the frontal or sagittal
planes. In the horizontal plane, rotational alignment must be correct. In
young adults or active individuals, we should avoid shaft displacements
and shortening or lengthening, particularly in the lower extremities. However, the anatomic reduction of each fracture surface is not critical, nor
should it be the absolute goal in this region, especially if the trade-off for
anatomicity is the devitalization of the fracture zone [2, 9, 12].
2
Fig. 1.1, pages 5-7
Fig. 1.2, page 8
In the metaphysis the same principles hold true. However, we often must
introduce bone or a suitable substitute into metaphyseal areas which have
lost substance due to the impaction of cancellous bone by axial forces
transmitted from the articular surface.
In the epiphysis, anatomic reduction requirements are more severe. The
articular surface and its subchondral supporting system demand accurate
repositioning of displaced fragments so that the joint surfaces remain
smooth and congruent.
Likewise, the distribution of the soft tissue that corresponds to the anatomic segments of bone influences the surgical approaches and tactics
used to obtain a reduction. For example, indirect reductions in diaphyseal
femur fractures are logical because of the extensive muscular envelope
which surrounds the bone. If a plate is to be used, the surgical approach
must be conservative, taking care to preserve soft tissue attachments to all
of the fragments. Obviously, this favors traction reduction and intramedullary fixation in this area as only one end of the bone is exposed. In contrast, in fractures involving the joint surface, the bone is more easily accessible because of the relatively thin soft tissue envelopes surrounding it (the
exceptions being the acetabulum and the glenoid), and a direct reduction
followed by internal fixation may be possible.
Nevertheless, reduction and stable fixation of fractures remains a difficult
task. Knowledge of all the tricks in the fracture surgeon's repertoire is necessary. The variations in technique presented in this book will hopefully
offer alternative and useful solutions for problem fractures.
The bone surgeon develops, with time and experience, a sense of balance,
a sense of the relationship of implants to the fracture pattern. The end result of a successful procedure is immediate satisfaction with a fixation
complex which is correct. In this context, "correct" implies an economy of
foreign material which satisfies the mechanical demands of the fracture.
The fixation montage will vary depending on the fracture configuration,
i. e., torsional fractures versus bending fractures, the presence of absence
of osteoporosis, and the presence or absence of preload. However, in the
end, each screw used should have a specific function. This may be to provide interfragmentary compression, fixation of the main implant, or both
(Figs. 1.1, 1.2).
Anticipation and sequential stabilization are two helpful principles in fracture surgery that are discussed in this volume. By "anticipation" we mean
preoperative planning. Using drawings, the surgeon can arrive at the best
methodes) of solving a difficult problem. The surgery is performed on paper prior to being carried out in the operating room. In this manner, the
surgeon can better grasp the entirety of the problem and devise appropriate solutions. The methods described should allow the surgeon to get a
feel for the kinetics of the surgical procedure. This sense of dynamics
comes from "playing" with the tracings, superimposing one on the other,
lengthening or shortening, angulating or displacing. If, as occasionally
occurs, drawings cannot be made from the fracture and the operation
cannot be planned (i. e., when there is too much comminution of bone),
modification of the usual approach is necessary, perhaps aiming for primary fusion in an articular fracture or indirect splinting in a diaphyseal
fracture. In the case of a different or unusual approach, preoperative sim-
3
ulation of surgery saves operative time and energy and avoids subsequent
problems.
The careful development of an operative plan allows more sophisticated
methods of indirect reduction to be carried out. This in turn leads directly
to maintaining viability of the bone fragments by limiting the amount of
dissection necessary to carry out the internal fixation.
Sequential stabilization means that each step in the operative procedure
increases the stability of the fractured bone. This is not a new concept. The
fracture table used by most orthopedic surgeons is a means of obtaining
relative control of unstable bone fragments. The problem is, however, that
traction is exerted indirectly on the entire limb, including the fractured
bone. Additionally, because the joints are not free to move, the fracture
table may be a hindrance. Also, the table is cumbersome outside of the operative field, necessitating communication with an "unscrubbed surgeon"
who may be unfamiliar with basic orthopedic jargon. We have all experienced the difficulties posed by a comminuted subtrochanteric fracture in
which the fracture table has been employed as an adjunct to operative fixation. Visibility is compromised without doing extensive soft tissue stripping, and in extension, for example, the lesser trochanter is displaced by
its attachment to the iliopsoas, which can make reduction of the proximal
medial fragments all but impossible without being able to move the hip
freely.
New instruments such as the femoral distractor and the articulating tension device provide, through localized distraction, ways of obtaining a reduction and at the same time increasing stability. The traction effect can
be obtained without sacrificing the mobility of the adjacent joints, and the
force is exerted directly on the bone in need of the traction. The use of
these instruments has allowed us to do many of the indirect reductions
that will be described.
"Dialing a reduction" with the femoral distractor gives the surgeon the
security afforded by a reduction accomplished with minimal energy, as
well as the knowledge that the maneuver can be repeated if necessary. This
approach replaces the suspense of the old approach: "pull hard and we
will see if we can get a clamp around it". The decision is now how and
where to insert a set of connecting belts so that the fracture will reduce
when the distraction is applied. Because the femoral distractor essentially
acts like an external fixator when we connect it, we have increased the stability of the fracture zone, which makes further steps easier to perform.
Fracture surgeons share the instability problems of the mountain climber.
The mountaineer has been schooled in basic techniques, has learned from
past experience, and approaches his task tactically. He has an array of
simple but effective devices - ropes, pitons, chucks, etc. - to keep his instability relatively limited. He remains thoughtful, calm, and organized. In
tackling the problems of his climb, he protects himself with the knowledge
of how to use the equipment at his disposal. In principle, his plan is based
on controlling instability at each point along the way. The fracture surgeon's task is in a way similar. In the relative security of our operating
rooms we as well must deal with instability. The operative fixation of fractures is a controlled conversion of instability to stability.
This is best accomplished when our approach has been thought out be-
4
Fig. 1.3, page 9
forehand so that each step along the way is a secure one, permitting us to
reach our goals of maximum patient safety and a minimum of anxiety for
the surgeon. We too can move stepwise toward the eventual solution of the
problem confident that our result has restored the relationships of the
bone and left nature minimally scarred (Fig. 1.3).
Fig.l.l. a A closed comminuted fracture
of the femur in a 22-year-old male. b The
operative treatment consisted of plate fixation of the femur. This case illustrates a
problem produced by a deficient understanding of both the mechanics and the
biology involved in the selected treatment. The postoperative X-rays are seen
at approximately 6 weeks after the operation. In what appears to have been a difficult procedure a varus reduction has been
accomplished piece by piece with severe
stripping of the periosteum. The stripping
is implied by the fact that the screws were
inserted at positions in the fracture zone
circumferentially around the bone. The
use of the two plates means that, al-
though seventeen screws have been in- ~
serted, they have not been incorporated
into a stable fixation complex. There is
inadequate fixation proximal, between
and distal to the segmental fracture lines.
c The combination of these errors produces a predictable failure, seen at
14 weeks. Biologic and mechanical factors interact in the failure. The decreased
vascularity due to the extent of the exposure increased the healing time of the
fracture and therefore placed greater demands on the mechanical fixation, which
was also inadequate, being too short and
not adequately spanning the fracture
zone.
5
6
o
o
o
d The attempted repair was poorly conceived and again a failure because the mechanics of the plate were not considered. In this intervention a bone graft was added. The avascular zone was bypassed but the
plate was "too long" for the segment of bone fixed (see diagram: note
abutment of end of plate against greater trochanter). There is a varus deformity and no preload exists. The femur is unstable. e Fixation fails in
14 weeks with irritation callus and loose screws. f The final, successful
procedure illustrates better principles. Bone grafting was carried out,
along with the application of the angled blade plate. The varus deformity has been corrected. The plate has been preloaded and there is only
minimal intervention at the site of the nonunion, where some revascularization has already occurred. g The result is seen 3 years later. Unfortunately, because of the previous mistakes in technique, the lateral cortex
of the femur has been destroyed, necessitating further procedures to reconstruct it and return the bone to normal so that it can stand alone
without the plate
7
8
Fig.1.2. a In contrast to the case illustrated in Fig.1.1 is this case
of a 70-year-old male involved in a motor vehicle accident. He
sustained a closed segmental femur fracture as his only injury.
b Treatment consisted of open reduction and internal fixation
1 day later, using a 20-hole 95° angled blade plate to accomplish
the reduction. The plate was applied with axial preload followed
by the application of lag screws. Only 12 screws were required using this sequence of reduction and fixation. The medial cortex
was not visualized and no bone graft was added. c The fracture
9
healing is visualized at approximately 9 weeks after operation. There is a softening of the fracture lines, each
one of them slowly fading away. A sclerotic fragment is
seen along the medial cortex of the distal fragment
which probably represents some avascularity due to the
original accident. This area is being successfully bridged
by new bone formation along the most medial aspect of
the fracture. d At 1 year and 2 months there is complete
healing and the fractured bone is well into the period of
remodeling. This patient was actually found to be fully
Fig.t.3. "Are you sure it's a femur?
I'm experiencing tension on this side too".
weight-bearing 1 day after his original surgery, testimony to the stability achieved. In contrast to the case illustrated in Fig. 1.1, the surgical procedure was carried
out in a biological way by using the implant as a reduction aid. Perfect mechanics were ensured by obtaining
axial compression by means of tensioning the plate, enhanced by interfragmentary compression. The result
was a healed fracture of the femur with a functionally
perfect extremity
10
From: Moser H (1965) Heitere Medizin. Ein medizinisches Rilderbuch, 4th edn.
NebelspaIter-Verlag. Rorschach/Switzerland. (Reproduction with kind permission)
11
Chapter 2: Anticipation
(Preoperative Planning)
Fractures and Post-traumatic Residuals
Successful operative reduction and internal fixation necessitates a thorough understanding of all phases of the procedure, the approach, and the
mechanics of the fracture. This goal is easier to achieve when the operation is planned beforehand. As with all major construction, which is centered on a blueprint or plan, "the drawing board" is where the problem in
construction is best solved. In the orthopedic training programs of the
1960s and 1970s minimal time was devoted to preoperative planning. The
major emphasis was on the indications for various procedures - intramedullary nailing, plating, etc. - and how to perform them. During this
formative time, a lot of surgeons developed an intuitive sense of how the
operation would actually unfold, and as a result many pride themselves on
their ability to "eyeball" a correction. Although some do indeed have this
talent, for the majority this approach leads to less than desirable results.
The method of preoperative planning most frequently taught during this
period was the use of "cutouts" made with X-ray copies. When an osteotomy was to be performed, cutouts of the X-ray were made, taped together
in their new position, and the procedure planned. A problem with cutouts
was that the reference, i. e., the normal side of the patient, was not considered. Cutouts also enticed the surgeon to be prematurely definitive. They
were difficult to use more than once, and therefore the planner lost the
benefit of considering all the possible solutions to the problem. The first
solution or the most common type of correction may not always be the
best answer to the individual deformity.
Preoperative planning should also extend to complex fracture fixations.
Tracing fractures from X-rays in various planes forces the surgeon to focus
intently on the X-ray, sometimes finding much more than is apparent originally. Additionally, seeing the same fragment in different planes improves
the surgeon's spatial perception, an important asset with immediate practical application. With time and experience, the average dimensions of frequently fractured bones, as well as their unique contours and appearances,
become an intuitive part of the surgeon's general knowledge. With this
ability as the foundation, the surgeon further learns how a specific implant
must be contoured for a specific part of a bone. Together, these learned
skills permit the surgeon to use such techniques as the precontoured plate
to reduce as well as fix the fracture.
Accurate manipulation of fragments at the time of surgery results in fracture reduction. Displacements and angulations are usually due to loss of
length, the effect of the elastic musculature attached to the fragments. If
12
the soft tissues are intact, restoration of length and rotation results in almost complete reduction of the associated fragments. By tracing the fracture fragments the surgeon can visualize what will happen when the procedure is actually carried out, getting a sense of the "kinetics" of the
operation, the play-by-play scenario from start to successful conclusion. In
pseudarthrosis or malunion, partial or complete healing has occurred. In
these cases, the surgeon must discover the best way to correct the deformities. Ideally, such reconstructive surgery should be planned to be carried
out in a manner which allows for total correction of the deformity. All angulations, malrotations, and displacements should be considered and an
osteotomy designed, when possible, that will correct all aspects of the
problem.
Planning from X-rays is possible provided one realizes the limitations of
the system [26]. Since torsional displacements are not well visualized in the
standard views there will always be a "built-in" source of error, especially
since internal rotation (varus) and external rotation (valgus) may express
themselves to modify the shadows projected in the frontal or sagittal
plane. Because of this one must sometimes utilize other techniques of
imaging, - axial views, CT scans, etc. - to appreciate how the rotation will
influence the outcome. In the end the clinical apprecation of the limb orientation before and during the operation is the best way to minimize the
mistakes inherent in a approach that cannot eliminate this influence during the planning stage.
Because X-rays represent a two-dimensional shadow of three-dimensional
structures, the following points must be kept in mind:
Fig. 2.1, page 20
Fig. 2.2, page 21
Fig. 2.3, page 22
(1) There will always be magnification.
(2) If the deformity appears in both the AP and the lateral view, the X-ray
beam is not being directed in the plane of the deformity. That is to say,
the deformity is actually greater than is appreciated on either the AP
or lateral view and exists somewhere between the two. The plane of
the deformity and the actual magnitude of its angulation may be determined by a simple geometric figure (Figs.2.1-2.3).
(3) As has been mentioned, plain X-rays will not give a good indication of
rotational or torsional deformities; these must be determined by CT
scan and/or clinical examination.
Osteotomies
As Milch [22] has instructed, there are in principle relatively few types of
osteotomy. Those most commonly used include the transverse and oblique
osteotomies. He writes that, every long bone may be classified as either
straight or bent, depending on the relations between its mechanical and
anatomic axes. Since the mechanical axis is invariably straight, it is possible to define a straight bone as one in which the mechanical axis is collinear with the anatomic axis. In the radius, ulna, tibia, and fibula the two
axes are so nearly the same that they may easily be recognized as straight
bones. In the humerus the head is eccentrically placed at the end of a short
anatomic neck, and as a result its proximal and distal articulations deter-
13
mine a mechanical axis which lies slightly medial to the anatomic axis;
nevertheless, the divergence between these two axes is so minimal that the
humerus too may be considered as clinically straight.
Dysfunction in straight bones is the result of displacement of the mechanical axis caused by a deformity of the anatomic axis and includes clinical
entities such as mal unions and some forms of genu valgus. It should be
kept in mind that the changes are characterized by a change in direction of
the mechanical axis, and whether this arises in consequence of rotation,
angulation, transposition, or relative disproportion in length, the deformity
is essentially of a directional nature. Cure or improvement may be effected
through surgical procedures designed to correct deformity and to re-establish normal axial alignment. Such osteotomies are called directional osteotomies.
A bent bone may be defined as one in which the mechanical axis diverges
from the anatomical axis. The femur is a bent bone, as its long neck leads
to an axial divergence that is typical of the form and vital to the function
of the bone. The importance of the differentiation between the two bone
forms becomes clear when the femur is considered as the derivative of an
antecedent straight bone in which the upper end has been angulated. The
bending down of this upper portion to form the femoral neck has produced a medial displacement of the mechanical axis and a decrease in the
effective length of the bone. Because the limb has a specific orientation the
formation of a femoral neck leads to a multitude of clinical variations
which may be affected by the level, degree, and direction of angulation of
the neck. Dysfunction is the result of pathologic displacement of the mechanical axis, there being no disturbance in the direction of the anatomic
axis. Disability may arise from instability of the hip joint as a result of loss
or impairment of the normal anatomical fulcrum. Osteotomies of a bent
bone are more complex, giving rise to secondary effects that may be more
than solely directional.
In planning an operation these factors must be taken into account, and
with the drawings made the surgeon will be able to see what can be corrected with which osteotomy, along with the effect the osteotomy will have
on congruency of the joint, overall length of the limb, and alignment.
Osteotomies may be employed to change length (lineal osteotomy), rotation (torsional osteotomy), displacement (translational osteotomy), or angulation (angular osteotomies). Most often more than one effect is desired
and a complex osteotomy must be performed.
Closing Wedge Osteotomy with Transverse Cuts Made Perpendicular to the
Shaft Axis: This osteotomy will shorten the extremity by half the length of
the base of the wedge that is taken [3]. As an advantage the osteotomy
leaves surfaces perpendicular to the shaft axis, allowing for correction of
rotational malalignments. Prior to surgery, the exact plane of the deformity
should be resolved radiographically or geometrically, and the surgical correction is best carried out at the predetermined location.
Closing Wedge Osteotomy with Limbs Oblique to the Shaft Axis: With this
osteotomy, corrections may be made in one plane of reference, and the
other planes may be corrected to a moderate degree by passively sliding
14
the bones on their cut surfaces, thereby correcting a small amount of angulation. Lengthening may be carried out by sliding the bones along one another. If rotation is to be corrected, this must be anticipated and the limb
oriented before the wedge is cut from the fragment to be corrected [7]. If
this is not done, it will be necessary to leave an opening in the osteotomy
surfaces which may require bone grafting.
The advantages of an oblique osteotomy are
(1) the possibility of lengthening,
(2) the intrinsic rotational stability in the matching cut surfaces, and
(3) the ability to fix the osteotomy with a lag screw crossing the obliquity,
giving excellent compression of the surfaces. The osteotomy then may
be further neutralized with a plate.
Opening Wedge Osteotomy with a Transverse Limb Aimed at the Apex of the
Deformity: Generally speaking, with an opening wedge type of osteotomy,
one can correct all three planes and lengthen at the same time. When contact is to be maintained between the two fragments the lengthening in the
diaphysis is restricted to half the length of the base of the opening wedge.
Opening Wedge Osteotomy Oblique to the Shaft Axis: This osteotomy allows for the same corrections as above; however, additional lengthening
may be carried out without loss of contact between the two major fragments. Because of the oblique surfaces a lag screw can be used to fix the
interpositional graft securely.
Step Cut Osteotomy: A step cut osteotomy is extremely effective when
there has been significant displacement as well as angulation. Essentially,
the osteotomy separates two major fragments with osteotomy surfaces perpendicular to the shaft axis, therefore allowing the restoration of length
and correction in all three planes. In the end it may be stabilized in most
cases by an intramedullary nail.
Fig. 2.4, pages 23, 24
Fig. 2.5, pages 25, 26
Barrel Vault or Arcuate Osteotomy: This osteotomy, described by Maquet
[16], allows angular corrections in one plane and correction of a displacement at 90° to the plane in which the angular correction has been made. It
has been popularized by Maquet in the proximal tibia.
Other forms of osteotomy that are popular by reason of their enhancement
of the geometry of the cuts to provide stability or to facilitate lengthening
are the V-shaped, mortise and tenon, and Z-shaped procedures.
Modifications of the simple cuts described are frequently used to enhance
one or another feature as required. These modifications may vary from
fractional wedge corrrections (Y-shaped osteotomies) to cuts designed to
allow a fragment to remain attached to its soft tissues, such as may benefit
a lengthening procedure, or cuts with slightly unusual geometry to enhance postcorrectional stability (Fig.2.4), for example the V-shaped, mortise and tenon, and Z-shaped osteotomies.
Sometimes there is more than one site of deformity or other conditions
that should be corrected simultaneously. In these cases more than one
osteotomy may be needed in order to fully correct all angulations and displacements. Such complex problems may be solved by using various combinations of osteotomies (Fig. 2.5).
15
The preoperative plan should display the features of these osteotomies
proposed to accomplish a specific effect. The surgeon must then ask himself five basic questions. First, is the proposed osteotomy site surgically accessible through standard exposures? Second, can the plan be carried out
using Kirschner wires as guides? Third, is the location of the cuts biologically reasonable? (Has infection been absent in the area? (Is the cut being
made through live bone in an area that should heal without complications?) Fourth, can the corrections be stably fixed with plates and screws,
medullary nails, or other means? And fifth, can the soft tissues withstand
the degree of skeletal anticipated alterations (e. g., lengthening, shortening,
or straightening)?
If these questions can be answered affirmatively, the planned procedure
should be successful.
Our ability to plan is rapidly expanding because of the improvements in
imaging and the advances in computerized "spatial graphics." The technology is now available for instant fabrication of models of specific deformities as an extension of the capabilities of modern CT scanners. Likewise
software is becoming available for planning of operative procedures.
However, preoperative plans made from X-rays have proven satisfactory
and represent the least expensive alternative.
Preoperative planning is the dress rehearsal for the problem-solving
aspects of surgery. Where possible, it should be removed from the busy environment of the emergency room or office to a quiet place equipped with
an X-ray viewing box, goniometer, colored felt-tip pens and high-quality
tracing paper or transparent plastic sheets.
The Goals of Planning
Different approaches may be used to attain the two goals of planning,
which are
(1) a tracing of the desired end result and
(2) a tracing of the "surgical tactic" [24].
The surgical tactic is the outline of the sequential steps in the operating
room which will lead to the desired result.
For the purposes of this chapter we will deal with three possibilities:
(1) the direct overlay technique,
(2) working from a tracing of the sound side, and
(3) working from a tracing of the anatomical axes of the injured side.
When the sound side has no pre-existing deformity, all these methods
achieve the same final result.
Since preoperative planning is based on X-rays, the first step is to obtain
quality AP and lateral views of both the injured and the uninjured extremity. This is not an easy task in the acutely injured patient. However, it is
possible to obtain these films if the surgeon is willing to take the time to
help position the extremity for the X-ray, inspect the result of the study,
and repeat it in another projection if necessary.
16
If the cathode is a standard 1 m from the X-ray, the resultant magnification will be in the order of 10%. The distance should remain constant since
the sound side will be used as a template for the injured side. The magnification should be consistent so that the bony contours will match and
changes in dimension will remain in proportion. Nevertheless, tracings of
reconstructions from X-rays may yield a femur much larger than the actual bone and may need to be scaled down.
Briefly, the steps of planning are as follows:
(1) The sound side or the "normal axes" of the fractured extremity are
traced.
(2) The fractures are traced and "reduced" within the contours of the
sound side tracing, or around the axes of the appropriate joint.
(3) A transparent sheet with the outline of the appropriate implant is then
placed over the outline of the "reduced" fracture, which is then also
traced onto its proper location. This tracing represents the desired end
result.
(4) Lastly, one works backward through the steps which allowed the tracing of the desired end result. This becomes the surgical tactic for the
given case.
Preoperative Planning by Direct Overlay Technique:
The Making of a Jigsaw Puzzle
The direct overlay technique is simple and may be quickly accomplished,
but its application tends to be limited to straight bones. The fracture as it
appears on the AP X-ray is traced on a sheet of tracing paper. Each of the
major fragments is then retraced on a separate piece of paper. A straight
line is drawn as a reference axis for a straight bone and the individual
fragments are reduced around this axis, fitting the fracture geometry together as well a possible. A similar drawing may be made, if desired, from
the lateral view. If there is a problem, e. g., a major fragment is rotated out
of recognizable alignment, one should proceed to the technique using the
normal side for tracing (see below). If the tracing of the fracture has been
reduced successfully, then the implant template is used as the next step,
overlaying it onto the proper location in the montage. A "final result"
drawing is then made by tracing the entire construct on a fresh piece of
tracing paper.
The derivation of the surgical tactic is as given in the following sections
describing the other two methods of planning.
Preoperative Planning of an Acute Fracture Using the Sound Side:
Solving the Jigsaw Puzzle
On an appropriately sized piece of tracing paper, the bony contours of the
sound side are traced in the plane of the reference. This plane of reference
is selected by looking at the AP and lateral projections of the injured side
17
and deciding in which view the fracture displacement predominates and
which view will be the most useful from the standpoint of orientation and
reconstruction. Other factors to be considered are: In which view is the
key or major fragment(s) best visualized, and/or in which view is the orientation of the desired implant for fixation best understood? In most
cases, the frontal plane will be used, because there is less overlay of osseous anatomy and the normal axes are more familiar. In a malunion, the
view is selected in which the deformity has the greatest angulation. If AP
and lateral views are very close in value, an attempt must be made to get
X-rays in the plane in which the deformity actually exists and another
view at 90° to this plane.
The X-ray of the injured extremity in the chosen reference plane is placed
on the viewing box, and the fractured bone is then traced on a separate
piece of tracing paper. The tracing of the sound side is then turned over so
that it matches the orientation of the tracing of the fracture side when superimposed on it. The outline of the sound side is moved around over the
tracings of the fractured bone, starting at either end. Where one starts is
mainly a function of which part of the fracture is most reliably projected
and recongnized as an anatomic contour that can be trusted. For example,
in an intertrochanteric fracture whose proximal frament is flexed, abducted, and externally rotated, it may be better to start with the distal side
where the fragment is more truly projected.
This decision as to where to start can easily be determined by cross-reference to the lateral projection. The tracing of the fracture begins by aligning
the major contours of the fractured bone with the external contours of the
sound side. To aid in this step, the fractures in the involved bone may be
"expanded" by tracing each of the major fracture fragments on a separate
piece of tracing paper. The contours at the same respective locations are
overlaid sequentially, tracing the fracture lines into the normal outline,
much as a jigsaw puzzle is solved. Occasionally an informed approximation must be made. As more and more identifiable fragments are traced into their appropriate reduced position, the solution of the remaining pieces
becomes easier, until only one or two fragments are left. Since these fragments represent the spaces that are left in the construct, it is less important
to fit them in directly. Their shape and size are implied by the blank spaces
that remain in the drawing. the "jigsaw puzzle" is nearing completion!
It can be anticipated that a few fragments may be spun out of their normal
planar orientation, so that their shadows on the X-ray may not represent
their true size or shape in either the AP or lateral views. However, this is
rarely the case for all the fragments. Fragments are frequently displaced,
but this is not a problem, as they may be identified and traced into a reduced position. Major fragments which are grossly malrotated seem to be
infrequent in practice. If no major fragments are recognizable, then a significant problem exists; that is, too much comminution may be present. If
the surgeon cannot draw it, then he/she will have great difficulty in reducing and stabilizing the fracture. The solution may reside in "bypassing" the
fracture zone and splinting it with a "locked" plate or nail. If a "dry bone"
or plastic model of the involved bone is available, reference to it may help
solve problems for which no clear answers are discernible from the X-rays
alone. This is particularly true in fractures of the acetabulum.
18
Fig. 2.6, pages 27-29
Fig. 2.7, pages 30-32
Once the entire fracture pattern has been drawn with the help of the outline of the normal side, an overlay of the appropriate implant for fixation
is placed in its proper position and traced onto the fracture drawing. The
best-sized implant and the correct position of the screws can be determined at this point. The desired number of screws are drawn in their correct locations at measured distances from bony landmarks such as tubercles, epicondyles, joint lines, etc., all of which can be found by palpation
at surgery. A proper screw for a specific function, e. g., a lag screw, can be
planned, as well as the securing of the implant by a proper number of fixation screws required as dictated by the drawing of the fracture. This tracing then represents the desired end result.
The surgical tactic must then be developed, determining the order of reductions and their sequence [17], to facilitate the solution of the technical
problems at surgery. For example, it may be decided to reduce only the
joint and then introduce the implant, or to reduce the entire bone and only
then introduce the implant. Each step along the way is clearly marked on
the drawing, which can be used as a guide to help the surgical team understand and anticipate all the steps in the procedure (Fig. 2.6, 2.7).
Planning from the Axes
Fig. 2.8, page 33
Fig. 2.9, pages 34, 35
An alternative method which is useful for lower extremity fractures in the
vicinity of the joints is to use the lower extremity limb axes, as illustrated
in Fig.2.8. The diagram, based on the physiological axes of the lower extremity, is helpful in the planning of an operative procedure in the coronal
plane, such as supracondylar fractures of the femur. When using the limb
axes, the articular segment of the distal femur is traced, with individual
fractures in a reduced position. The axes - the anatomic axes of the femoral shaft and the tibial shaft and the mechanical axis of the knee joint - are
traced on a separate piece of paper. The relationship of these lines is such
that the femoral shaft axis subtends an angle of 99° medial with the mechanical axis of the knee. The tibial shaft axis subtends an angle of 87°
medial with the same line.
When planning repair of a distal femur fracture from the axes, the first
step is to trace the articular fragments in a reduced relationship. If the articular fragment is not fractured as in our example (Fig.2.9), the joint segment, which has been traced on a separate piece of paper, is placed on the
axes. Similarly, the metaphyseal fractures are traced and reduced along the
axes of the femoral shaft. At this point, using an implant template, the
proper-sized 95° angled blade plate is selected and traced into the desired
location, along with the screws that will secure the implant to the bone.
Care must be taken to ensure that the blade length is correct, i. e., 1 cm
shorter than the silhouette of the distal femur in the frontal plane (usually
a 60-mm blade is enough). The drawing will now show the desired end result.
The surgical tactic is then developed by backtracking. The steps that were
made to obtain the tracing of the desired end result are reconstructed - reduction of the articular segment, fixation of the distal fragment with
screws, positioning of the Kirschner wires for proper introduction of the
19
seating chisel, insertion of the seating chisel at the proper location and to
the proper depth, introduction of the plate of the proper size, application
of the articulating tensioner, distraction of the fracture, reduction of the
plate to the diaphyseal fragment, reduction of the metaphyseal fragments,
compression of the fracture fragments, and, finally, application of the
screws through and, if necessary, outside the plate. This is the plan - the
tactic - the surgeon will follow step by step in executing the operation.
Depending on the time available and the difficulty of the fracture to be
treated, planning can be detailed or brief. A brief plan in a case to be treated with a condylar blade plate may encompass only the tracing of the articular fragments in their reduced position, onto which is traced in proper
position the outline of the blade of the plate to be used. This is the critical
step: since the angle of the plate is known, if the blade is precisely introduced in known relationship to the fragments relative to the axis, then
bringing the plate to the bone with an appropriate clamp will restore the
angular relationships of the bone, and only rotation is left to contend with.
In this manner the plate itself will act as a splint around which the fracture
may be accurately reduced. The tracing of this critical step, however, must
inform the surgeon of the exact level of the window for introducing the
seating chisel, the direction the seating chisel must take in the bone in order to obtain the correct axes, and the depth to which it must be introduced.
With the AO condylar blade plate, proper insertion of the blade in the distal femur results in anatomic reduction of the distal femur when the plate
is placed under tension. Under these circumstances, the normal anatomic
axis of the femur is restored as the blade of the plate is at an angle of 95°
approximating the normal average anatomic axis of the femur, which is
98° in males and 100° in females. That is why this plate is so valuable in
the handling of supracondylar fractures of the femur and in cases where
supracondylar osteotomies must be carried out to correct old traumatic residual deformities (Fig. 2.10). Figures 2.10-2.14 are illustrations of planning of fractures and osteotomies utilizing the principles discussed in this
chapter.
Fig. 2.10, page 36
Fig.2.11, pages 36-40
Fig.2.12, pages 40-42
Fig. 2.13, pages 43, 44
Fig. 2.14, pages 45-47
20
a
Fig.2.ia, b. Appreciating the deformity on X-ray. The
case illustrated is an arbitrary one without a rotational
component showing a deformity as it would appear on
an X-ray of the mid-distal junction of the tibia. a The
deformity seen in the AP view is a varus deformity.
b
b On the lateral view the same deformity is seen as posterior apical angulation. There are not two deformities
present; rather, the X-ray is centered away from the
plane of the actual deformity. The actual degree of the
deformity and its location can be determined using the
simple diagram shown in Fig. 2.2
21
!
I
---.- .
...::::::" X
..-'
"-'- -'-.
\
Fig. 2.2. The coordinates of the X-ray in Fig.2.1 have
been placed in a diagram at 90 0 to each other. They are
marked A-P (anterior-posterior) and M-L (medial-lateral). Since the point at which the deformity occurs does
not change, the shadow of the deformity can be constructed in the corner of the coordinates with the actual
value of the angulation and the direction of its displacement appreciated on the AP view. This angle can be
called AP (a). Because the deformity occurs at the same
level, the angulation and direction of displacement seen
on the lateral view can be constructed starting at the
identical point in the corner of the drawing and subtending an angle lateral (a') equal to that seen from the
shadow of the deformity on the lateral X-ray. The actual
plane of the deformity is somewhere between the planes
of the AP and the lateral views, and the angle (X) of the
deformity will be larger than is seen in either view. We
would like to ascertain this angulation, and also the exact plane of the deformity relative to the AP and lateral
projections. These values can be obtained if we rotate
the shadowed triangular projections about the A-P and
M-L axes placing them in the plane of these axes. If perpendiculars are constructed from the acute angle end of
the bases of these triangles, in the A-P-M-L plane, their
intersection (point P) defines the acute angle end of the
deformity (right triangle whose opposite angle is X).
Construction of this right triangle with long leg equal to
the long legs of the other two triangles in the A-P-M-L
plane provides the angle X which can be measured with
a goniometer (or protractor).
An alternative trigonometric solution which can be obtained with an inexpensive pocket calculator requires
solving the equation.
X = arctan ytan 2a + tan 2a'
Y = arctan (tan a/tana')
Example
= 20 0 tan 20 0 = 0.364 tan 2 20° = 0.132
=10° tan 100 =0.176tan 2 100 =0.031
tan 2 20° = tan 2 10° = 0.163
X=arctan YO.163 = 21.98° = 22 0
Y = arctan (0.364/0.176) = 64.20
The location of the plane of the deformity relative to the
A-P and M-L coordinates can then be obtained by measuring the angle between the A-P coordinate and the
long leg of the deformity, and an X-ray beam oriented
along this line will show the deformity at its greatest angulation. Likewise, the complement of this angle will
show no deformity, as the X-ray beam will pass tangential to the deformity and therefore we will see no significant shadow
22
p
[>[>
M
L
X 1122
=
A
a
0
A
A
p
M
[>[>L
-
x.2ao
A
b
A
A
Fig. 2.3. a An example of the use of the method illustrated in Fig.2.2 to calculate the true angulation and
plane of a deformity of the tibia in which 10° varus is
seen on the AP view and 20° posteroapical angulation
(recurvatum) is seen on the lateral view. An arbitrary location can be taken along the AP axis, and for this example we have selected 5 cm. The projection of the deformity on the AP view is drawn with a 10° angulation
displacement medialward. Likewise, in the mediolateral
axis at 5 cm from the intersection of the coordinates a
20° deformity is drawn with its displacement anteriorly.
Where the hypotenuses cross the coordinat~s, a rightangled projection is constructed running anterior from
the AP view and medial from the lateral view. From the
point at which these two projections intersect, a line is
drawn to the intersection of the coordinates. A right
angle to this line is then constructed with the length of
5 cm. Connecting the line between the long leg and the
short leg gives us a hypotenuse and the angle X, which
is then measured using a goniometer and found to be
24°. The AP and lateral views are off the axis of the
plane of the deformity. If we want to see the deformity
in its maximal degree, we must go 60° lateral from
where the AP X-ray was taken. If we want to see no deformity on the AP view we must swing 30° medial.
From a practical standpoint these simple calculations allow us to locate and appreciate the deformity and to
have an idea of how much of an error there will be in
preoperative planning of the correction of the deformity
from only one view. b The calculation is drawn for a
deformity displaying 20° varus in the AP projection and
20° recurvatum in the lateral projection. In this example
it is seen that the deformity exists in a plane halfway between the AP and lateral projections, with X being 28° .
It would not be optimal to plan an operative correction
from the standard views
23
c
'
hl
"-,.,
c"
Fig.2.4a-c, legend see page 24
r'
.. ~ -'>-
'
24
Fig. 2.4. a Old malunion of an intertrochanteric-subtrochanteric fracture of the right femur. The patient was short 2 cm
on the right side, had an external rotation deformity, and
complained of pain in the right hip and knee. b Tracing of
the malunion of the right femur alone and with the left femur
turned and superimposed. This shows the 2 cm shortening as
well as the varus position of the femoral neck. The lateral
view shows the loss of normal femoral antetorsion. c Preoperative plans drawn to explore the possibilities of the corrections. The first centers on a 120° double-angled blade plate,
and employing a transverse opening wedge osteotomy results
in correction of the deformity. However, the stability is precarious; a medial defect will be present if full length is regained. The second version shows an osteotomy based on the
90° osteotomy plate. Here, if a special chevron-shaped cut is
made to separate the two major fragments a medial buttress
may be created which will give immediate stability to the
osteotomy. A bone graft may be obtained from the proximal
lateral cortex and placed into the central defect (arrow, bottom right). Length may be completely restored as well as the
proper neck-shaft axis. The planning allowed the surgeon to
see the best way to solve the patient's problem. d Postoperative radiographic control. e The postoperative result after
1 year. All aspects of the deformity have been corrected, and
planning has allowed the creation of a medial buttress, giving
the patient more security in the immediate postoperative period
25
Fig. 2.5. a, b A 29-year-old male with a longstanding pseudarthrosis of the femur. He had 11 cm of shortening and
has had seven operations, including an attempted free fibular graft. He has pain in the hip, the knee and in the midthigh area. X-rays show a moderately reactive pseudoar-
throsis with a loose intramedullary nail in place
along with an implanted electrical stimulation device. c Scanogram showing t 1 cm of shortening.
26
d, e Planned repair of pseudarthrosis to include lengthening of the femur. Two osteotomies are envisioned: 1 A 30° valgus osteotomy which will regain length as well as
unload the lateral aspect of the joint space of
the hip, which is narrowed. This will provide
an additional piece of bone to use as a graft
for repair of the pseudarthrosis. 2 An oblique osteotomy in a distal third of the femur
which, by sliding it distally, and medially,
will allow an additional lengthening to occur. Further length will be obtained by reducing the pseudarthritic area of the femur,
realigning the femoral shaft axes. 3 The desired end result includes 7 cm of lengthening. Bone grafts obtained from the wedge removed at the time of the valgus osteotomy
are stippled. f Post-operative control.
g Scanogram showing S cm residual leg
length discrepancy. h, i Result at SY2 months.
The patient was lost to follow-up and returned at 13 months with a broken plate and
a nonunion at the location of the previous
pseudarthrosis. This was treated by implant
removal, additional 1.S cm lengthening, decortication, and bone grafting. j, k Final result showing healing of the nonunion
27
~
~J
f\
j
Y~j)
1
\
I
~ I
I
I
6
Fig.2.6a-h, legend see page 2R
J
i
fIn ;/\\
,i II
i.~
i
.
28
Fig. 2.6. a Planning from the sound side. Comminuted
segmental fracture of the femur with pertrochanteric extension. "Solving the jigsaw puzzle." b Tracing of the
fracture. Solid lines are posterior, dotted lines anterior.
c Tracing of the uninjured side. d Retracing with fragments separated so as to fully appreciate their size and
extent. e Tracing of the sound side with fracture lines
included by superimposition of the sound side over the
fractured side. f An implant has been traced over the reduced fracture. This allows one to determine the length
of the blade and plate which will be necessary, along
with the proper location of both lag and fixation screws,
which have been drawn in. This drawing represents the
desired final result. g, h The surgical tactic in this case:
I Lateral approach to the proximal femur with anterior
caps ulotomy. 2 Reduction of the trochanteric fragment
with temporary fixation. 3 Insertion of the seating chisel
from a point 1 cm below the tip of the trochanter into
the inferior quadrant of the femoral head. The seating
chisel can be driven in to a depth of 80 mm. 4 Insertion
of an 80-mm 20-hole 95° angled blade and reduction of
the proximal femur to the plate. 5 Insertion of a connecting bolt into the second plate hole perpendicular to
the plate. 6 Insertion of a connecting bolt into the femoral metaphysis at right angles to the femoral shaft axis.
For this the remainder of the lateral approach to the
femur must be executed. 7 Distraction. 8 Reduction of
the distal femur to the plate with a Verbrugge clamp.
9 Tensioning of the plate. 10 Insertion of lag screws.
II Insertion of fixation screws through the plate. i, j AP
and lateral views of the femur 3 weeks postoperatively,
showing the final result. Although there is a large posterior medial defect, the medial aspect of the fracture was
not seen and the soft tissues remain intact. The plate
could be preloaded because of the anterior reduction.
The lag screws and fixation screws have been inserted as
planned. k, I Fracture healing at 9 weeks. Because of a
viable fracture zone, we see early signs of healing with
softening of the fracture lines and filling in of the fracture gaps. m, n At 53 weeks the fracture is completely
healed and early remodeling is occurring along the diaphysis. 0 Final X-ray after metal removal at 134 weeks.
Traces of previous internal fixation are still evident. This
patient had a subsequent trauma with a tension fracture
of the lateral femoral cortex. This problem was treated
by closed nailing
29
30
Fig. 2.7. a, b AP and oblique views of a closed comminuted femoral shaft fracture associated with a tibial plateau fracture. The femoral shaft fracture extends down
into the intercondylar notch with displacement of the
lateral condyle. c, d Tracing of the fracture in the frontal and sagittal planes. e Tracing of the normal femur in
the frontal plane. f Superimposition of the normal femur outline on the fractured femur outline. This is the
best method to trace the fractures into their correct location. The fractures from the original tracing have been
separated to allow more definitive identification.
g, h The fractured femur reconstructed in the frontal
plane, using the method described. The lateral plane has
also been reconstructed. One can see a posterior medial
gap caused by the comminution seen in the original xray. i A template of a 95° angled blade plate is used.
This is oriented along the lateral side of the distal femur
with the blade parallel to the end of the femur in the
frontal plane 1.5 cm off the end of the joint. Final result
with the angled blade plate in place along with leg and
fixation screws. j Surgical tactic to achieve this result:
1 Reduction and fixation of the lateral condylar fragment with a lag screw. 2 Placement of the Kirschner
wires to guide the introduction of the seating chisel.
3 Insertion of the seating chisel 1.5 em from the joint
line parallel to the Kirschner wire and insertion of the
angled blade plate, which was planned to be 22 holes
e
~J
31
long. 4 Insertion of a fixation screw, holding the angled
blade plate, into the distal fragment. 5 Careful cerclage
wiring of the main butterfly fragment to the proximal
fragment. 6 Control of the relationship of the proximal
fragment to the blade plate by means of a Verbrugge
clamp. 7 Placement of the articulating tension device
and distraction off the end of the plate. 8 Reduction of
the proximal fragment to the plate by means of a Verbrugge clamp. 9 Axial tensioning of the angled blade
plate with the Verbrugge clamp and the cerclage in
place. 10 Insertion of lag screws. 11 Insertion of fixation
screws. In this case bone graft was obtained at the time
of surgery from the greater trochanter. k Intraoperative
photo showing the articulating tensioner under compression at the end of and cerclage wires. I Postoperative result showing internal fixation of both the proximal tibia and the distal femur. m, n Postoperative
control 7 months after the injury. Union with full range
of motion of the hip and knee. 0, p Final views 2lh years
following the accident. Knee motion is full although arthritic changes are present
8
,....,oII-t--l0
h
32
33
\.
\
.
I
\
\
\.
\
Fig.2.S. The axes of the lower extremity. The femoral
shaft axis meets the mechanical axis of the knee joint at
99° medially. The tibial shaft axis is a continuation of
the mechanical axis of the lower extremity and has a relationship of 6° valgus to the anatomic axis of the femur
above. The mechanical axis has a relationship of 3° to
the vertical axis of the body. These relationships are extremely valuable in planning operative surgery of the
lower extremity. (Redrawn from Muller [23])
34
a
<
35
b
o
o
o
o
o
o
o
o
o
o
Fig. 2.9. a Closed fracture of the distal femur with a
large medial butterfly fragment. In this particular example the drawing has been broken down to its component
parts. The anatomic axis of the femur and tibia is included, along with the mechanical axis of the knee joint.
Transparencies of the fracture components and the axes
are provided in the pocket inside the back cover of the
book. The fragments can be cut out and reassembled in
a reduced position around the axes. The reader can also
"play" with the effects caused by different positions of
the blade of the plate relative to the distal femur fragment. This will show the varus and valgus effect caused
by blade placement. This is exactly the method that
would be used in planning such a reduction in the frontal plane. Because at either end of the femur there is
usually an angular displacement in the sagittal plane
(flexion relative to the fragment itself), the length as
seen on the AP view must be considered together with
what one sees in the lateral view. If the amount of flexion (or rarely, extension) is great, the length of the fragment must be taken from the lateral view and extrapolated to the AP. In our example, there is only slight
flexion of the distal fragment. Therefore this extrapolation is unnecessary. With this in mind, one can see that
there are two ways to proceed. First, the fracture may be
reduced about the axes and the implant then applied
along the lateral border with the blade parallel to the
joint. Second, the blade may be placed into the distal
fragment parallel to the joint and then, using the plate
as a handle, the reduction made against the proximal
femoral metaphysis. Because of the soft tissues, if slight
distraction is carried out by placing the articulating tension device off the end of the plate and opening it, the
medial butterfly will be pulled into the defect along with
the medial pillar. One can also see that variations in the
blade of the plate relative to the distal articular fragment
will result in a change of primary contact, medial or lateral with reduction to the diaphysis. Thus, one can see
that correct application of the seating chisel parallel to
the joint will result in preload of the bone implant complex or primary contact medially. The remainder of the
planning consists of drawing in the important lag screw
fixation for the medial butterfly along with the screws
necessary to fix the plate to the proximal and distal fragment. b The fragments have also been created in the lateral view. The critical factor here is to know the distance
from the anterior and posterior margins of the distal
fragment to the midaxis of the plate, so that the plate
may be used as a handle to reduce the fracture in the
sagittal plane as well. With experience, this relationship
is not difficult and is found at surgery by following the
anterior cortex proximally as a guide
36
Fig. 2.10. The angle between the blade and the plate
portion of the condylar blade plate is 95° . The most important step in using this device is the exact placement
of the blade parallel to the end of the femur in the frontal and sagittal planes. It can be then used as an instrument for reduction regardless of the fracture configuration in the metaphysis or diaphysis
37
•• •
•
I
• I
);
.~•
f
Fig. 2.11. a A 40-year-old female who was struck by a car while crossing the
street. Initial X-ray shows a comminuted proximal femur fracture with a
neck, trochanteric, and proximal femur component. The fracture was open.
She was treated by irrigation debridement and placed in balanced skeletal
traction. She was then transferred to our facility. b, c AP and very dark lateral views of the same fracture with traction and internal rotation: note how
the X-ray is markedly improved. The fracture would like to reduce with the
restoration of length and rotation. This is an indication that an indirect reduction should be successful. d Tracing of the fracture from the X-ray taken in traction. e Tracing of the normal femur. f By overlaying the normal
on the fractured side the fracture lines may be drawn into the outline of the
normal side. g By overlaying the template of the condylar plate series one
can see the proper relationship of the blade to the proximal fragment that
will allow the plate to be used for a splint for reduction of the fracture. This
has been traced into the drawing.
38
\
k
h Another procedure (the method actually used in this particular case) is illustrated in the following. The head fragment is traced on a single piece of
tracing paper. i On a separate piece of tracing paper the trochanter is outlined. j, k The two fragments are now placed together as they appear on
the X-ray and are manipulated so that they are reduced. (We know that the
tip of the trochanter should point to the center of rotation of the femoral
head.) I Since to proceed in this way parallels the actual sequence of events
in surgery, the template for the 95° blade plate is next overlaid onto the two
fragments in its correct location.
39
o
m, n The proximal shaft fragments are
also traced on separate pieces of tracing
paper. 0 With the blade plate traced into the proximal fragments, the shaft
fragments are manipulated until they
come into axial alignment with the
plate portion of the blade plate. The
crosses mark the location of the critical
lag screw fixation. The trochanteric
fragment must be fixed to the reduced
neck fragment. The blade must enter
the inferior medial quadrant of the
head (70 mm). In this portion of the
bone the fracture lines are torsional and
especially fortuitous because the stem
of the distal main fragment extends
proximally and medial. Planning from
the sound side (see above) brings one to
this step when the template for the
angled blade plate is added to the montage, the only difference being that in
planning from the injured side the sequence of events is that which will be
followed in surgery and one gets a better sense of the "kinetics" of the operation. p, q AP and lateral X-rays of the
postoperative result.
40
r Final postoperative., result with
the final drawing superimposed.
Because of the torsioned fracture
line and the medial spike, secure
fixation with lag screws has been
possible. The plate, however, was
preloaded before their insertion, as
will be described. s Result at
7 months after operation, showing
remodeling of the healed fracture
zone. The medial cortex of the
bone was never visualized
41
Fig. 2.12. a, b A 44-year-old female 1 year after a subtrochanteric fracture with peritrochanteric extension,
initially treated with an angled blade plate with a varus
reduction. Over the year after operation, the patient developed progressive subluxation of the hip with resorption at the base of the neck, further varus migration, and
nonunion. She was short 2.5 cm, walked with a limp,
and had pain in the right hip. Abduction and adduction
films show motion of the fixation and subluxation of
the femoral head. c, d Tracing of the pseudarthrosis in
which the head-neck-shaft relationship demonstrates a
varus of 90°. There has been resorption of the neck and
lateral luxation of the femoral head. If the implant selected were again a 95° angled blade plate, a 50° placement of the seating chisel relative to the tract of the old
angled blade plate would result in valgization of 50°.
This implant was chosen in this particular case, as it allowed lateralization of the distal fragment, restoring the
correct relationships at the knee, and a final head-neckshaft relationship of 140°. The tactic is as follows: 1 A
lateral incision over the proximal femur with an anterior
capsulotomy with removal of the old hardware. 2 Placement of a screw at 50° to the old tract of the angled
blade plate, ensuring that relationships at the pseudarthrosis will be maintained during insertion of the seating
chisel. 3 Insertion of a Kirschner wire parallel to the
axis of the femoral neck in the horizontal plane and at
50° to the old tract of the angled blade plate. Insertion
of the seating chisel to 70 mm. Loosening of the seating
chisel. 4 Cutting of the existing lateral cortex of the
proximal fragment 1 cm. Below the window of the old
seating chisel parallel to the new direction of seating
chisel. 5 Removal of a lateral-based wedge through a
transverse osteotomy cut at the intertrochanteric level at
90° to the shaft axis and intersecting at the point of the
old femoral neck. Completion of this cut medially with
an osteotome curving in an upward direction. 6 Insertion of a 70-mm 95° angled blade plate, seven holes
long. 7 Insertion of a screw into the proximal fragment.
8 Application of a Verbrugge clamp to the distal fragment, reducing it to the angled blade plate. 9 Slight distraction to facilitate lateralization of the shaft using the
articulating tension device. 10 Compression of the osteotomy by means of the articulating tension device.
11 Screw fixation of the plate to the shaft. e Superimposition of the old position of the femoral head and neck
with dotted lines over the new position following a valgization of 50°. Note the increase in the length of the leg
and the improvement of all the axes.
11
42
f Result at 4 months after the operation. g, h, i At
2Y2 years there has been slow obliteration of the osteotomy line. The femoral head remains congruent in the acetabulum with a good joint space. The patient has a full
range of motion with no pain or limp. This case illus-
trates how planning may be based on the use of one of
the angled blade plates in which the fixed angle of the
plate provides a means of controlling the degree of correction required. The final reduction of the osteotomy is
facilitated by using the plate as a reduction aid
43
c
Fig.2.13a-h. A 62-year-old man who had sustained a comminuted intertrochanteric fracture of the right hip approximately 1 year earlier.
The fracture had been treated with a compression hip screw and side
plate. His leg was short, externally rotated, and painful. a, b AP and
lateral views of the nonunion, which involved the trochanter as well as
the neck of the femur and the proximal femoral shaft. c, d Preoperative plan of the case predicated on the careful removal of the existing
implant and broken screws and the carrying out of a tOO abduction
osteotomy accompanied by lateralization of the femoral shaft and correction of rotation. Using a chevron-shaped osteotomy, medial buttressing and compression of the nonunion is assured. Rotation may be
corrected through the nonunion, which is transverse in shape, before
the oblique cuts of the abduction osteotomy are made. 1 Placement of
a Kirschner wire at 90° to the shaft axis. 2 Insertion of another Kirschner wire 15° varus to wire 1. 2A A Kirschner wire marking the old
track of the hip screw which was centered in the femoral neck axis.
3 Placement of a wire parallel to wire 2 and parallel to the axis of the
femoral neck in the horizontal plane. 4 One centimeter down from the
tip of the trochanter and parallel to wire 3, the seating chisel is inserted
80 mm. 5 The seating chisel is then loosened. 6 An osteotomy cut is
made 30° upwards relative to guide wire 1 starting at a point 2 cm
proximal to the most proximal screw hole. This separates a fragment
of metaphysis which will go with the femoral neck fragment. 7 A chevron-shaped osteotomy, the wedge aspect of which is on the oblique cut
and subtends an angular segment based laterally 10° determined by
cutting upward at an angle ot 40° to guide wire 1. 8 A 70-mm blade
plate is inserted, impacting it so as to compress the old trochanteric
malunion. 9 Insertion of screw into the metaphyseal fragment, again
compressing the trochanteric nonunion. 10 Application of a Verbrugge
clamp to the plate, reducing the distal fragment and lateralizing it.
11 Distraction with the articulating tension desire off the end of the
plate, facilitating lateralization of the distal fragment. 12 Compression
of the osteotomy and tensioning of the plate. 13 Insertion of final fixation screws.
Jf
IZ II
d
44
e, f X-ray 4 months after surgery: consolidation of the
nonunion and a good joint space. The patient was ambulating without external support and had no pain.
g, h An additional lag screw was added at the time of
surgery high in the trochanter to hold it in place during
insertion of the seating chisel. One year after surgery.
Although the patient has no pain the upper screw penetrates the subchondral bone. Healing has taken place
45
c
d
Fig. 2.14. a, b A 32-year-old man who suffered a gunshot wound to the distal femur, with
an open comminuted fracture in the area. The patient had been treated by initial irrigation
and debridement followed by skeletal traction, and later a cast brace. He presented with
6\12 cm shortening, 15° varus, and 10° antecurvatum. He complained of a short extremity
and difficulty in ambulation. He had near-normal knee motion. His X-rays and AP and
lateral projection are presented. c, d Tracing of the deformed side superimposed on the
normal side. Shortening and varus are evident in the AP projection. The lateral shows a
10° anteroapical angulation associated with a full shaft displacement.
.
.•
.-.,..
-..)..
...: .1
-......... .
-.:... ...... .:
46
13
10 --YoII.aJ16
12
II
e
9
f
o
13
/
18-
I,
h
e This case is selected as an example because it shows the virtues of the angled blade plate as a means of monitoring a corrective osteotomy of the distal femur. Because of the fixed angle
between the blade and the plate, it has the additional advantage
of preserving the axial relationships when lengthening is carried
out. The planning in this case is carried out in the frontal plane.
The final correction in the sagittal plane is made by an opening
osteotomy, which will give the opportunity, if necessary, to correct rotation. From a review of the patient's X-rays, trying various types of osteotomies, it was found that a truncated segmental osteotomy would correct all aspects of the deformity. The
stem of this segment must be displaced medially at the time of
distraction in order to regain the length and give a medial buttress. It is important in such a procedure that the segment not be
stripped of its soft tissue during the process of cutting it free.
Therefore the planning becomes even more important, as the
cuts can be made following outer contours and using Kirschner
wires as guides along with dimensions measured from the Xray. f The desired end result is drawn based on the creation of a
truncated segment. g-j The deformity viewed in the coronal
plane. The blade plate will play an important role in the lengthening and reduction of the osteotomy; therefore, the first step is
to plan its insertion: 1 A lateral approach to the distal femur is
made. 2 A summation Kirschner wire parallels a Kirschner wire
placed through the joint along the end of the distal femur and
another placed across the face of the distal femoral condyles indicating the correct torsion. 3 The seating chisel is inserted
about 1.5 cm off the joint line parallel to summation Kirschner
47
wire 2 and then loosened so that it may be easily extracted once the osteotomy is
cut. The seating chisel will then act as a guide to the placement of subsequent
Kirschner wires. 4 A Kirschner wire is inserted at 45° to the seating chisel, giving
the direction of the oblique cut and the distal femur. 5 A Kirschner wire is
placed at 30° from the seating chisel and gives the direction of the cut to remove
the wedge which will correct the varus deformity seen on the X-ray. 6 Mter these
wires have been placed, the osteotomy is cut obliquely parallel to Kirschner
wire 4 four-fifths across the bone anteriorly or to a depth of about 6 cm. A second cut is then made parallel with Kirschner wire 5 and terminated where it
meets the previous cut. The wedge removed represents the corrective wedge of
15° based laterally. 7 The proximal extent of the callus is determined and then
an obliquely oriented 4-cm-Iong saw cut is made parallel to the lateral cortex.
8· A transverse and longitudinal cut with a length of 3 cm is made through the
bone. 9 Completion of the osteotomy of the medial cortex. 10 A second cut is
made in the proximal fragment removing a block of bone equal to the width of
the callus and oriented obliquely to the horizontal plane. Its length is equal to
the amount of proposed lengthening. There is some flexibility to the final length,
given the trade off between medialization of the segmental fragment and the distal oblique osteotomy. 11 Insertion of the angled blade plate with a blade length
of 60 mm. 12 Reduction of the plate to the proximal shaft of the Verbrugge
clamp. 13 Distraction of the osteotomized distal femur. The articulating tensioner is drawn in exaggerated fashion in order to show the displacement mechanics
clearly. 14 Correction of rotation between the distal and proximal fragment with
a standard reduction forceps (not shown in drawing). 15 Compression of the
osteotomy surfaces after reduction of the segmental block. 16, 17 Insertion of
the critical lag screws fixing the segmental osteotomy block into the montage after axial compression has been exerted. 18 Insertion of the fixation screws.
k, I Postoperative AP and lateral X-rays of the case illustrating the following:
correction of the varus, lengthening of the extremity in a fixation montage identical to the preoperative plan save for one anteroposterior lag screw. m, n Final
X-rays after plate removal showing healing of the osteotomy. The patient has regained full knee motion. Cosmetically, his leg appears anatomic in regard to the
axis; however, he is still 1 cm short
48
Chapter 3: Reduction with Plates
Ideally, an implant should contribute to the reduction of a fracture as well
as stabilizing it. This is one of the advantages of a reamed intramedullary
nail. In the simple fractures the intramedullary nail fills the canal and produces stability by an interference fit in the region of the isthmus of the
femur. The nail partially fills the canal, and as long as rotation is correct as
the nail passes through the fracture, reduction in the coronal and sagittal
planes is forced to occur. With contemporary prebent nails shaped like the
femur, the reduction is then anatomic. A straight plate, when applied to a
straight bone from the proper side of a displacement, may also interfere
with this displacement and cause the bone to reduce. When the plate is
properly contoured to the area of the bone being stabilized, this reduction
too is quite anatomic.
The orthodox approach to plate fixation is to first expose and reduce the
fracture, preliminarily fixing it with lag screws. When the fractured bone
has been reduced and provisionally fixed, an implant can be contoured to
the bone. Templates are available for this purpose. The problem is how to
reduce the fracture without excessive stripping of the soft tissues, hold the
reduction so as to be able to correctly contour a plate, and then apply the
plate. The clamps seem to be always in the way. Moreover, the use of multiple large-jawed reduction clamps frequently results in soft tissue stripping and interference with the osseous blood supply. However, if the implant to be used to stabilize the fracture is attached to one end of the bone
and used as the means of reduction, then stripping is much less extensive,
and-the use of clamps, at least on one side of the fracture, is minimized.
In the orthodox direct approach to plating fractures, reduction of the fragments is followed by fixation with lag screws. Using a strip of soft aluminum, a template is formed by pressing the strip against the external contours of the bone. Care is then taken in contouring the plate to match the
aluminum template. The contoured plate is then fixed to the bone, forming a stable fixation complex. The plate is, in this situation, used for neutralization and provides enough stability in combination with lag screws to
allow functional after-treatment. Plate contouring in this situation is critical because the lag screws have already exerted their effect.
Although seemingly straightforward, the method is difficult to use. Frequently, though a perfect reduction has been obtained and lag screws inserted without difficulty, when applying the plate and tightening the
screws that fix it to the bone, a small amount of displacement occurs in the
fracture. When the displacement is very slight one accepts the situation
rather than repeating the procedure with the chance of running into further complications such as loss of the holding power of the screws, further
49
devitalization of the soft tissues, and/or unfavorable prolongation of the
time the wound is open. The surgeon must, however, ask what has really
happened to the fixation. Has the plate negated a little of the interfragmentary compression exerted by the screws, or has it caused the fracture
gap to open ever so slightly, producing a potentially dangerous situation,
as described by Perren [27]. In addition, in other fractures which have a favorable configuration, it is optimal to privide maximal "preload" with the
plate. If lag screws have already been placed across the fracture fragments,
then preloading the plate may produce only shear forces in the screw fixation rather than allowing axial compression forces to be generated in the
bone. The full benefit of axial preload cannot in these situations be realized, a factor which may make the difference between success or failure.
When plate application precedes reduction, the plate may be utilized as a
reduction aid. The plate acts as a splint to restore the alignment. Through
distraction of the fracture zone, comminuted fractures, by virtue of their
soft tissue attachments, approximate themselves and may be "teased" into
final reduction with a small instrument. The fragments stay biologically
active because of intact soft tissues. Following the distraction phase and
reduction, axial compression may be applied, and in most cases stability is
achieved before the application of the definitive lag and plate screws. This
means that with only a clamp (such as a Verbrugge forceps) holding the
plate to the bone and/or a pointed reduction forceps holding the bone
fragments, preload may be applied. Using the articulating tension device
on the femur, upward of 100 kp axial preload is possible. In the ideal situation after loading of the bone has been accomplished, all the clamps can
be removed save the one that holds the plate to the proximal fragment.
The clamps used for provisional stability do not prevent longitudinal impaction of the bone fragments as lag screws might. Given this fact, if the
surgeon can load the fracture with a plate, this constitutes evidence that
bone is being impacted into bone in the longitudinal axis. Ideally, when
preloading has been properly applied, the impaction is on the medial side.
This, however, is not always possible, depending on the fracture pattern.
In some cases the contact area may be anterior, posterior, or, occasionally
in the worst circumstances, lateral under the plate. Impaction, which is almost always possible in simple fracture patterns, generates an energy circuit between the implant and the bone (Fig. 3.1). This represents the ideal
situation mechanically for a plate, as only when there is a completely restored buttress of bone can plates be loaded and maintain the load. The
plate in this instance is in tension. It is a load-sharing rather than a pure
load-bearing device. Once the lag screws have been inserted into this prestressed montage, transaxial compression is also added, producing a very
high degree of stability. Essentially, the lag screws are placed in the locations previously occupied by the clamps which held the fracture together
during the axial compression. Proceeding in this order in simple fractures,
or in fractures without too much comminution, optimum plate mechanics
and optimum biological activity of the fracture zone may be obtained.
In some situations, because of too much comminution this ideal cannot be
realized. In such circumstances the plate is merely fixed to the proximal
and distal main fragments, bypassing the zone of comminution. The plate
in these circumstances acts simply as a splint, supporting the fracture in
Fig.3.1, page 59
50
buttress, but the fragments spanned by the plate are viable and capable of
rapid consolidation.
In such cases the early application of the plate allows it to be used as a
stable scaffolding to enable the manipulation of displaced fragments to be
carried out with improved leverage and less force.
Using a Straight Plate as a Reduction Aid
Any relatively straight portion of any bone may be reduced by the application of a straight plate. The principle is that previously described with the
intermeduallary nail, although a difference is that now the interference reduction is occurring along the external surfaces, not in the intramedullary
canal. The most simple and elegant demonstration of this is the "antiglide
plate" described by B. G. Weber in his book, Special Techniques of Internal
Fixation [33]. The antiglide reduction is elegant because it in addition automatically places the plate in the optimum position for further axial loading. Reduction is obtained by the screws pulling the bone fragment down
an inclined plane; then, when the reduction is complete, the axilla is located in the best position to apply axial compression to the bone by tensioning the plate, by means of either the articulating tensioning device or the
DC holes.
Fractures of the Distal Tibia: General Considerations
Fig. 3.2, page 60
The surgeon must contour the plate for this area of the tibia before reduction of the fracture, bearing in mind the normal contours of the bone
(Fig. 3.2). Consider the shape of the lower half of the tibia. The surface
most convenient and conservative for plating is the medial face. This is a
subcutaneous border, and therefore surgical intervention causes little disturbance of the musculature or the blood supply of the tibia. Obviously,
great care must be taken in handling the soft tissues, as any loss of skin
will definitely result in problems, that require sophisticated procedures to
resolve. If attention is paid to this important detail, problems rarely occur.
The surgical approach is made parallel and one finger lateral to the crest
of the tibia, crossing in a gentle curve from lateral to medial as the tibial
metaphysis is reached and then distally along the border of the anterior
pillar of the medial malleolus. A description of this surgical approach may
be found in the book Surgical Approaches for Internal Fixation by Th. Riiedi and colleagues [29]. When swelling of the limb with loss of mobility of
the skin is anticipated, the incision may be made 2-3 cm lateral to the
crest. Placing the incision more laterally has a relaxing effect on the soft
tissues which may be valuable at the time of closure. The skin, subcutaneous tissues, and fascia of the anterior compartment are cut vertically as
one unit in line with the incision. Lifting the medial fascia of the compartment anteriorly and medially, the dissection is carried out by separating
the muscle from the fascia of the anterior compartment until the crest of
the tibia is reached. The periosteum in this area, if not stripped by the fracture itself, is elevated only to the degree necessary for exposure. On clo-
51
sure in circumstances of soft tissue swelling, the medial flap, composed of
skin, subcutaneous tissue, and periosteum, is sewn to the muscular edge of
tibialis anterior, with the lateral wound edge left free. The resultant wound
with a base of muscle may be closed 3-5 days later with split-thickness
skin graft, usually meshed 1.5: 1, or, occasionally, closed using delayed primary suture techniques.
Reduction of a Distal Third Oblique Fracture of the Tibia
by Means of an Antiglide Plate
The reduction of a distal third oblique fracture with an antiglide plate is illustrated in Fig.3.3. Figure 3.4 shows the application of this principle in a
fresh tibia fracture with an intact fibula. The patient is a 40-year-old man.
The injury was closed. Figure 3.5 illustrates application of the same principle at 8 weeks in another case.
If a lot of shortening is present, or if the fracture is old or comminuted, the
preceding technique may be modified by utilizing the articulating device
off the end of the plate. With this device, distraction or compression, depending on the circumstances, can be exerted on a fracture through a plate
attached to the bone. These effects may be enhanced by inlaying the plate,
as with the standard DCP or by fashioning hooks or blades from the end
hole, as with a one-half tubular plate. (Fig.3.6), techniques which will be
discussed later (see Figs. 3.16, 3.17).
The articulating tensioner, first used in 1972, evolved from the original
plate-tensioning "outrigger" adapted from the plates of Danis [4]. Collaboration between surgeons and instrument makers led to the development of
the new tensioner, which has a rotatable hook on one leg and a foot on the
other which takes a 4.5-mm cortical screw. The limbs are jointed to allow
the tensioner to function across angulations. The upper portion consists of
a strain gauge which is color-coded in yellow, green, and red to give a
rough indication of how much tension is being generated in the plate. The
addition of this instrument has allowed many innovations in the handling
of fractures with plates (Figs. 3.7 -3.9). Other fracture patterns besides the
oblique and spiral may be approached in a similar way. However, the articulating tensioner is almost always needed for distraction so that the fragment ends clear one another and a reduction in alignment can occur
(Fig. 3.10). The plate is attached by a single screw to the shaft fragment
that is displaced to the side away from where the plate will eventually be
attached. In cases where there is no room distally or proximally for the articulating tension device, an alternative is to place a single screw approximately 1 cm off the end of the plate, proximally or distally. The bone
spreader (Fig. 3.11) is then used, placing one foot against the screwhead
and the other against the end of the plate. When the handles of the bone
spreader are squeezed together, the feet separate, pushing the plate and
distracting the fracture. In this instance, as with the articulating tension device, the plate is controlled on its proximal side by means of a Verbrugge
clamp (Fig.3.12) and fixed by one or two screws to the distal fragment.
When distraction is complete, the Verbrugge clamp is tightened and the
laminar spreader is removed. A no. 0 or no. 1 Verbrugge clamp can then be
Fig.3.3, pages 61,62
Fig. 3.4, page 63
Fig. 3.5, page 64
Fig. 3.6, pages 65, 66
Fig. 3.7, page 67
Fig. 3.8, page 68
Fig. 3.9, page 69
Fig. 3.10, pages 70, 71
Fig.3.11, page 72
Fig.3.12, page 72
52
placed such that its broad plate - holding end embraces the screwhead
and the pointed end is placed in the distal hole of the plate. By closing the
clamp the fractures can be coapted. The compression is then achieved by
the usual method by means of the DC holes or by eccentric loading of a
one-half or one-third tubular plate.
When the distraction load is high, i. e., in internal fixation of a 4- to
6-week-old fracture, the plate may deform somewhat during distraction.
This usually does not constitute a problem, since this slight bending of the
plate will result in a little concavity against the relatively straight shaft portion of the bone as distraction is applied. This concavity will straighten after reduction once tension is applied to the plate.
Fractures of the Tibial Pilon
Fig. 3.13, pages 73, 74
Fig.3.14, pages 75-77
Fig.3.15, pages 78, 79
Fig.3.16, page 80
A similar application of the plate as a reduction aid is seen with a pilon
fracture. The classical operative approach to the tibial pilon fracture is to
start on the lateral side and anatomically reduce and stabilize the fibula
[1]. The reason for this is that gaining fibular length restores tibial length
by ligamentotaxis through the intact syndesmotic ligaments and the anterolateral tibial fragment (the Chaput-Tillaux tubercle). This is also an example of indirect reduction.
This fibular fixation facilitates the operative reduction of the tibia. However, in a small percentage of pilon fractures, the fibula is not broken [19].
Usually a small fragment of the Chaput tubercle stays in its normal relationship to the fibula because of the intact syndesmotic ligaments, while
the remainder of the joint surface is displaced upward with the talus; the
ligamentous injury in these cases is usually confined to the lateral collateral ligament system. When there are large joint pieces, it is helpful to apply
the plate to the distal tibial fragment containing the medial malleolus and
to reposition it and the attached portion of the articular surface in a manner similar to that described for the distal third of the tibia (Figs. 3.9, 3.13).
A distractor may also be used for this purpose, as will be described in the
next chapter (Figs. 3.10, 3.11). Clinical examples of this technique are
shown in Figs. 3.14 and 3.15).
B. G. Weber, at an advanced AO course session, made a suggestion that is
useful in certain plate fixations of the distal tibial pilon. In a patient with
good bone stock who has a very low fracture of the tibia, or a tibial pilon
fracture with a large medial tibial articular fragment, it is helpful to "inlay" the plate. A straight DC plate on the distal tibia may be quite bulky,
making skin closure difficult. It is also too prominent under the skin on
the medial side of the ankle after skin closure. To avoid this, the plate may
be inlaid into the distal fragment after contouring it as descirbed in the
preceding section. When the plate is inlaid it is actually far more effective
as a distraction device, with the end of the plate directly pushing the distal
malleolar fragment (Fig. 3.16). In this situation a decreased moment is exerted on the screws during distraction. Care must be exercised in performing this technique so as not to create an instability that will compromise
the buttressing function of the plate. In general, if only the thin metaphyseal cortex is involved it is suitable to use a one-half tubular plate in this
53
location. This plate may be flattened out in its distal aspect and contoured
very nicely to achieve an excellent buttress effect against the distal tibia.
Once flattened it has a very low profile which matches very nicely the
thickness of the cortex of the bone which it is substituting.
Fractures of the Fibula
Indirect reduction techniques have frequent application in fractures of the
fibula. Regaining fibular length is an important part of the reduction of
most types of fractures that involve the ankle joint. Frequently, the comminution in the region of the distal shaft of the fibula consists of very
small fragments connected to shreds of ligament and interosseous membrane. The size of the fragments and their number would defy individual
repositioning and fixation. A plate, or small distractor, may be employed
to overcome this shortening and bypass the comminution.
One of two anatomic sites is usually employed for plate fixation of the distal fibula. The site used most often is the posterior lateral surface of the
fibula, the other, the posterior border of the fibula. The AO one-third tubular plate is the most convenient implant to use in either location. The
implant is not bulky, is easily contoured, and in fresh fractures is strong
enough to withstand the forces in this area (Fig. 3.17). When dealing with a
malunion of the fibula, i. e., in a lengthening osteotomy of the fibula, when
distraction forces will be high because of adaptive changes in the soft tissues, the 3.5-mm DCP may be preferable [35]. Depending on its location,
the plate must be contoured to the characteristic shape of the bone
(Fig.3.18). Clinical examples of the use of this technique are seen in cases
illustrated in Figs.3.9 and 3.15). In both cases illustrated, the fibular fracture is associated with an intra-articular distal tibial fracture. The length of
the fibula must be regained. The fibular fracture in Fig. 3.9 is comminuted
and long. A ten-hole one-third tubular plate was attached to the distal
aspect of the fibula with a single screw. After achieving alignment in the
sagittal plane relative to the distal fragment the second screw was added.
Using a laminar spreader off the end of the plate against a "push-pull"
screw, the plate was used to regain length and to allow the reduction of the
comminuted fibula fragments by their soft-tissue attachments. The final
clinical photograph shows the fibula healed 10 months post injury. In this
case an attempt was made to place a single lag screw across two of the major fragments in the comminuted area.
In Fig.3.15 also a pilon fracture, reduction of the fibula by plate application was the first step. Note in the intraoperative film the presence of the
push-pull screw which was removed before the final radiographs in the series. The fibular fracture here was less comminuted than in the previous
example but had a medial butterfly fragment. It was also "old". In both
of these examples the plate was applied to the posterior surface of the
fibula.
The fibular plate in the posterior position is favored by Weber, particularly
in type B ankle fractures. The application of the plate and the rationale behind it are described in the book already mentioned above [33]. The reader
is referred to his account of the use of the plate in this circumstance, the
Fig.3.17, page 81
Fig.3.18, pages 82-84
54
classic description of the antiglide mechanism and a prime example of an
indirect reduction maneuver.
When comminution is present a posterior position of the plate may also be
advantageous. This is because the posterior surface of the fibula is straight,
a straight plate may be applied, and the steps outlined can be followed to
obtain a reduction. Additionally, the screws in the distal fragment can be
longer, usually in the vicinity of 24 mm, and therefore gain an extremely
good hold in the bone. In the case of posterior displacement of a crushed
lateral malleolus, a one-third tubular plate modified to provide hooks distally can be applied. This both reduces and buttresses the crushed malleolus without the need for screws. The disadvantages of the posterior approach are the difficulty of surgical access for drilling, tapping, and
screwing and the presence of an implant in a relationship to the peroneal
tendons; in practice, however, this has not been a problem.
Forearm Fractures
Fig. 3.19, page 85
Fig. 3.20, pages 86-88
Fig.3.21, page 89
Fig. 3.22, page 90
The radius and ulna are relatively small bones with proportionate musculature, so that manual reduction techniques are more successful. In our experience, however, indirect reduction techniques have als~ been very useful in the forearm. Because of the easy access and the relatively simple
anatomy, segmental fractures and comminuted fractures of the ulna adapt
easily to this technique (Fig. 3.19). Although because of the "outcropping"
muscles the radius is a little less accessible, the technique is quite easily
applied and equally successful (Figs. 3.20-3.22).
Acetabular Fractures
In certain instances in the operative treatment of acetabular fractures, the
plate functions as a reduction aid as well as a fixation implant.
Three examples will be described:
(1) fractures of the anterior wall or low anterior column,
(2) those associated with a comminuted quadrilateral plate, and
(3) fractures of the posterior column.
Fractures of the anterior column frequently occur in the middle or articular segment. In this region the bone is relatively thin and overlies the joint.
Additionally, there is often comminution extending into the quadrilateral
plate surface. The area is less accessible because of the overlying iliopsoas
muscle and obturator internus muscle. As a result, reduction with provisional stabilization is frequently difficult to obtain.
Precurved plates simplify the maneuver to be described because less contouring is needed than is the case with a straight 3.5-mm reconstruction
plate. These plates are available with a 100 mm radius. Emile Letournel
has two plates with radii of 88 mm and 108 mm. According to his investigations, these two sizes represent the two most common radii found in the
human pelvis. He uses the 88-mm plate for small pelves, and the 108-mm
plate for large pelves [14]. They are stiffer and plate contouring must be
exact as they do not deform under pressure from screw insertion.
55
Once the iliac wing has been reconstructed in high anterior column fractures, or in low or very low anterior column fractures, early plate application helps to reduce the fracture. A very slight concavity is fashioned in
the middle third of the selected curved plate to accommodate the mild elevation associated with the iliopectineal eminence and a slight twist is imparted to the posterior portion of the implant, clockwise for a right acetabulum and anticlockwise for a left acetabulum. Through the ilioinguinal
approach, the plate is slid underneath the musculature of the iliopsoas and
the femoral vessels. It is then attached to the body of the pubis with a single screw and rotated along the superior pubic ramus and the pelvic inlet
around the screw until it sits congruently on the iliopectineal line and pelvic brim.
If necessary, slight distraction may then be effected by means of a pushpull screw placed off the end of the plate in conjunction with an appropriately sized bone spreader, as described for straight plates (see p. 82-90).
The wall or column fracture may then be aligned beneath the plate with an
instrument, after which the distraction force is removed. The plate is secured posteriorly to the dense bone of the sciatic buttress with one or two
screws, and then screws are placed sequentially on alternating sides of the
fracture. As this is accomplished, the plate is pressed downward into the
bone. The curvature and length of the anterior column are restored and
the plate pushes the fracture in the articular segment down and into reduction. Finally, screws may be placed so that they are angulated medially,
penetrating the quadrilateral plate surface and securing the plate to the
bone over the reduced articular segment. The most posterior screws may
be quite long and may be lagged to fix posterior column fracture lines.
The feature of the bone that makes this possible is the fact that the pubic
tubercle and the posteriormost swelling of the sciatic buttress lie about on
the same level as the top of the iliopectineal eminence. Because of this, a
slight gap is left underneath the plate on both sides of this prominence.
With a malleable plate, such as the 3.5-mm reconstruction plate, or to a
lesser degree, the new AO 3.5-mm precurved pelvic reconstruction plate,
the screws will mold the plate to the bone as they are inserted, squeezing
the iliopectineal eminence downward (Fig. 3.23).
When a severe degree of comminution exists in the area of the quadrilateral surface of the medial wall of the pelvis, a reduction as well as buttressing of the area may be effected by the use of a one-third tubular plate. The
plate is first flattened and then bent in an oblique fashion such that the
long bent limb projects anteriorly to the short limb. The bend should be
made at least 90°. This plate then may be used in conjunction with the
curved reconstruction plate by slipping the long end into the pelvis against
the quadrilateral plate and sliding the short end 'underneath the reconstruction plate. The bent one-third tubular plate is then forced to open
against the quadrilateral surface by placing a large reduction forceps
against it at the apex of the bend. This pushes it against the quadrilateral
plate surface and slides it back over the pelvic brim under the reconstruction plate. The reconstruction plate is then seated by tightening the
screws previously placed in it, bringing it flush against the pelvic brim and
trapping the one-third tubular plate underneath. The one-third tubular
plate is sprung against the medial wall, reducing and buttressing it simulta-
Fig. 3.23, page 91
56
Fig. 3.24, pages 92, 93
Fig. 3.25, page 94
Fig.3.26, pages 95, 96
Fig. 3.27, pages 96,97
Fig. 3.28, page 98
Fig. 3.29, page 99
neously. The end screw-hole in the one-third tubular plate, projecting into
the internal iliac fossa, may be filled with a single screw to tag the plate in
position. The plate functions as a spring plate, which is of value at other
sites as well for both reducing and buttressing a fracture line (Fig. 3.24).
Clinical examples of this technique are illustrated in Figs.3.25 and 3.26.
In transverse fractures the ischiopubic segment is displaced inward along
a vertical axis through the pubic symphysis and the pelvic brim tilted inward along a horizontal axis extending from the symphysis to the fracture.
A plate attached to the distal fragment may be extended by a clamp and
used to close the fracture gap once rotation is correct. The plate used in
this manner should be a flexible one, such as the 3.5 mm AO reconstruction plate. The flexibility of this plate allows it to be stretched across
the fracture and then contoured as the screws are applied by their bite into
the bone. Dana Mears of Pittsburgh has described using the plate in this
manner [20]. He feels that it has been helpful to him in fracture lines which
cross low on the retroacetabular surface. We use this technique frequently
(Fig. 3.27). Figure 3.28 shows a variation of the technique in which the
plate has been placed obliquely such that the plate itself can be utilized to
derotate the ischiopubic segment. The technique illustrated in Fig. 3.27
may be followed employing the Kocher-Langenbeck approach, while that
in Fig.3.28 would require an extended iliofemoral or triradiate approach.
In the case illustrated in Fig. 3.29, the technical aspects of the surgery were
complicated by the fact that the patient was extremely obese. In such a
case, this method of reduction and fixation is a great help.
Using the Angled Blade Plate as a Reduction Tool
Fig. 3.30,
pages 100-107
Fig.3.31, page 108
Having discussed indirect reduction technique using the standard plates
which sometimes need to be pre contoured, we would like now to discuss
the use of the condylar blade plate in indirect reductions of the femur. For
those who use a 95° angled blade plate regularly, it becomes an "ideal implant". The exact insertion of the seating chisel in the distal end of the
femur or in the precise locations in the proximal femur, determined by a
preoperative plan, leads to reduction of the fracture with the insertion and
fixation of the plate to the distal or proximal fragment. Let us first discuss
the use of the condylar blade plate in the distal femur (Figs. 3.30,3.31).
Reduction of a Comminuted Fracture of the Distal Femur
Occasionally a fracture of the femur will be present which involves the full
extent of the distal end with severe comminution. As a result, piece-bypiece anatomic reduction is impractical; in fact carrying out such a reduction severely compromises the remaining blood supply. Additionally, a
fracture extending into the joint should have an exact articular reduction
that will be stable, congruous, and allow for early motion. In such a case,
after direct articular reconstruction, the condylar plate may be used as a
reduction aid and an internal splint in a buttress mode proximal and distal
to the comminuted area, skipping the fracture zone [21]. The soft tissue
57
stripping required is minimal, limited to a small amount along the lateral
cortex, where the plate itself will come in contact with the proximal and
distal main fragments. The value this approach is that the entire area of
comminution may be bypassed and left undissected. These fragments,
therefore, remain attached to the soft tissues. The plate then acts as a
stable splint, allowing for the mobilization of the patient and the institution of physical therapy. Reduction is defined in terms of length and limb
orientation in the three planes. The fracture fragments themselves are approximated by means of their soft tissue attachments but may not be anatomically reduced except at the level of the joint. However, because of the
viability of the comminuted area, it predictably undergoes consolidation
quite rapidly, usually in about 6-8 weeks (Figs. 3.32, 3.33). To employ this
technique, one must have a distal femur fracture which is not broken in
the coronal plane, the so-called "Hoffa extension." If there is a coronal
fracture, the only device that can be used with any reliability is the condylar buttress plate. The problem with this plate is that the screws passing
through the distal holes do not have a fixed relationship to the plate, so
that as the plate is used in distraction or compression with the articulating
tension device, the shaft of the screws may shift relative to the plate, producing a varus deformity with distraction or a valgus deformity with compression. The condylar buttress plate, unlike the blade plate, can be used
safely only as a buttress plate. In indirect reduction it is normally used in
conjunction with the femoral distractor, which is inserted in such a way so
as to result in the proper axial relationships of the knee joint on reduction.
Proximal Femur
The principles are similar in the proximal femur and are frequently applied in intertrochanteric/subtrochanteric fractures. Depending on the
fracture pattern, the articulating tensioner is used as described by Weber
[32] in this region, or, in the case of more comminution, the femoral distractor may be used. However, in both instances, the plate is applied before reduction and used as an aid to obtain reduction (Figs. 3.34-3.38).
Summary
This chapter has dealt with the reduction of fractures by plates. We have
seen that in many cases the principles are the same, i. e., the reduction occurs either through interference, as in the case of an antiglide mechanism,
or by distraction, which by increasing the tension in the soft tissues tends
to recentralize the fragments, causing them to approximate their previous
location in the fractured bone. The instruments which are helpful in accomplishing these technical maneuvers are the articulating tension device,
the bone spreader, the Verbrugge and standard reduction clamps, and the
large pointed reduction forceps. The surgeon must be careful to spare the
soft tissue connections to the fragments of the bone and keep bone exposure to the absolute minimum. For this reason a favorite instrument is the
"dental pick." Detailed attention must be focused at all times on the skin
Fig. 3.32,
pages 109-113
Fig. 3.33, page 114
Fig. 3.34,
pages 115-121
Fig. 3.35,
pages 122-124
Fig. 3.36, pages 125,
126
Fig. 3.37, pages 127,
128
Fig. 3.38, page 129
58
edges and the muscle and care must be taken to avoid unrecognized injury
to the soft tissue coverings by retractors. When the reduction has been obtained, in most fracture patterns an attempt should be made to preload the
fractured area, impacting the bone longitudinally so that all fracture gaps
are overcome. Having accomplished this, lag screw should be inserted
where the clamps held the reduction during loading with the articulating
tension device. Finally, the minimum number of screws necessary to secure the implant to the bone should be applied. This approach increases
the healing potential of the bone in plate fixation by limiting devascularization to the area immediately underneath the implant. By virtue of improved biomechanics, the plate becomes a load-sharing rather than a loadbearing device. Only the exact number of screws demanded by the
fracture configuration are used in the plate. This will decrease future morbidity, as following implant removal every screwhole is a potential site for
refracture.
In some instances, because of comminution, it is impossible to improve on
the mechanics of the plate beyond providing a buttress function. This
should be recognized beforehand because of preoperative planning and
during surgery every effort should be made not to "get into" the fracture.
The plate acts as a scaffold to help to obtain axial realignment and to correct rotations, angulations, and displacements. The fracture zone is splinted by the plate and should be left undisturbed and viable. Autogenous
,cancellous bone grafting is another means of extending the biological potential of the approach but needs to be used only when bone substance is
missing or when, because of devascularization, prolonged healing is anticipated. Care must be taken in inserting the bone graft to avoid further devitalization of the soft tissue attachments to the bone fragments. Additional protection of the plate in these circumstances may be achieved by
utilizing one of the technique discussed in Chap.5.
Once the surgeon has begun to understand the use of the implant in reduction as well as fixation, many more applications will be appreciated. As a
consquence, the results of such surgical interventions will be better than
they have been in the past.
59
G
11
11
11
u
Fig.3.t. Theoretical diagram of a distal femur fracture
with a medial butterfly fragment. Because the normal
angulation between the shaft and the end of the joint in
the frontal plane of the distal femur is greater than that
of the angled blade plate by several degrees, exact application of the seating chisel followed by introduction of
the plate results in a preload along the medial cortex. If
longitudinal or axial compression is exerted while
clamps maintain the reduction, the bone fragments are
free to impact fully, one on the other. Because under
these circumstances there is complete bone-to-bone contact, indeed impaction, tension in the plate and compression in the bone are directly linked. At this point in
a clinical case it is usually possible to remove the clamp
holding the medial butterfly fragment in place and find
that it is absolutely stable before the application of the
lag screw. After achieving this, the introduction of lag
screws, providing trans axial compression, further enhances the fixation
60
r =:t 20 em
a
Fig.3.2. a The medial aspect of the lower tibia as it progresses proximally from the medial malleolus upward to
the midpoint presents a concave curved surface forming
an arc of a circle with a radius of approximately 20 cm.
Depending on the length of the tibia, the curvature extends from 8-12 cm from the buttress of the medial
malleolus. The medial border of the bone then straightens and progresses approximately to the midportion,
where there is a slight convex curve. b From the medial
face of the tibia in the mid portion of the bone to the nat
internal surface of the medial malleolus in the midportion there is an internal torsion which is more extreme
proximally than it is distally immediately above the
malleolus. Because of the lipping of the anterior crest in
the midportion, this torsion is also greater as one progresses anteriorly on the bone. This torsion of the medial face of the tibia is about 25 0 with respect to the posterior half of the bone surface. These figures, though
approximate, are accurate enough to allow application
of the plate to the bone in this region. The most important consideration of the curvature of the concavity of
the distal end of the medial tibia is that the plate is not
overcontoured. What is actually required is to bend the
plate into a curve representing an arc of a circle somewhat more than the curvature of the medial face of the
distal tibia. This allows a certain amount of preload to
be applied when the plate is finally screwed to the bone.
Of the two factors, the degree of torsion is much more
important to the final reduction than is the degree of
concavity, as long as too much concavity is not present.
As a general rule, the stiffer the implant, the more precise the plate contouring must be. If a very small error
has been made in torsion a little compensation may be
obtained by slightly angulating the plate in the long
axis, anteriorly if the plate has been overtorqued, or toward the posterior border if the plate has less twist
61
Fig.3.3a-e. Reduction of a distal third oblique fracture
using an anti glide plate. a Following surgical exposure,
a seven- to ten-hole plate, depending on the fracture, is
selected. It is first twisted so that there is a torsion in the
plate of approximately 25°, then it is placed in a bending press and a mild concavity is pressed into its distal
two-thirds. This may be checked at surgery by using a
marking pencil and a 20-cm length of suture thread to
draw an arc on a flat surface against which the curve of
the plate can be checked. The curvature may also be ascertained by a comparison AP X-ray of the opposite
side. b The plate is then fixed to the distal fragment at
the level of the buttress of the medial malleolus with one
screw. Care must be taken not to enter the joint with the
screw because it is so low and because the curve of the
plate has the natural tendency to direct the screw into
the joint. Therefore the normal 3.2-mm drill guide is
used and a screw is inserted parallel with the joint. The
screw is snugged but not definitively tightened. The
plate is then rotated around the distal screw until its ori-
entation to the distal fragment is correct in the sagittal
plane. The fit of the plate against the proximal fragment
will be a little tight at this point. To accommodate this,
the distal screw may need to be loosened slightly. The
tightness of the proximal end of the plate against the
proximal fragment represents the plate-bone interference that in the end will reduce the fracture. With only
the distal screw in place, the alignment of the fractures
will be improved. At this time rotation should be corrected by gently twisting the patient's foot, and therefore
the distal fragment, in the appropriate direction.
c When little or no shortening is present, the next screw
hole is drilled through the plate with a neutral drill
guide. The screw length, which will be a little greater because the plate is not yet positioned snug against the
bone, is measured and the screw is tapped and inserted.
The distal screw and the second screw are then tightened together, but not definitively. The distal fragment
of the fractured bone will be drawn in toward the plate.
62
?
d If the level of the fracture permits, the next screw is inserted before the previous two are completely seated,
and, as a last step distally, all three screws are tightened
together. Because of the correct approximation of the
fractured bone and the plate in the distal fragment, the
antiglide mechanism is observed as the screw pulls the
bone to the plate, and the plate contacts the opposite
fragment. This slides the fragments against each other,
regaining the length. This exerts strain on the distal
screws biting into the bone of the· distal fragment. For
this reason, the quality of the bone stock should be good
if this technique is to be used. Additionally, as can be
seen, because of the correct approximation of the fractured bone and the plate in the distal fragment, tension
may be placed on the plate by loading the screw in the
proximal fragment with a load guide or with the external tensioning device. An oblique fracture should also
be crossed by a lag screw; this may be facilitated by
placing the plate in the best position for this as determined by the preoperative plan. e This illustration
merely shows that if the plate is fixed first to the proximal fragment it will have no effect on the reduction. If,
following fixation of the plate to the proximal fragment,
the screws are placed in the distal fragment, a large
amount of compression will be generated between the
fracture surfaces as the bone tries to elongate and cannot, because the distance between the screws is then
fixed. This technique for obtaining compression is
sometimes used in oblique osteotomy in the intertrochanteric area of the hip
63
Fig. 3.4. a, b A closed oblique fracture of the distal tibia with an intact fibula:
AP and lateral projections. There is 1 cm of shortening. There is no tenderness of the ankle or around the knee joint. c, d The fracture was treated with
an antiglide plate applied medially. The lateral side (muscular compartment)
was not entered. Healing of the fracture is seen on the follow-up X-ray at
10 weeks. Note the hole remaining off the end of the plate proximally where
the articulating tension device has been used to aid in regaining length, and
for additional control in tensioning the implant. Note the lag screw. A small
amount of callus is present posterior medially where the distal fragment had
been displaced. (Case courtesy of Dr. Brett Bolhofner of St. Petersburg, Florida, USA)
64
Fig. 3.5. a, b A distal tibia-fibula fracture that was operated at 8 weeks. The patient had been treated with "pins
and plaster" between the tibia and the calcaneus. c The
fibula was first approached and fixed by a technique
that will be described. The plate was precontoured and,
after an anteromedial approach to the distal tibia, applied to the distal fragment. By means of inserting the
screws in the distal fragment of the tibia, the translation
was overcome, the comminuted fracture was never seen,
and only the medial face of the tibia was ever surgically
exposed. The postoperative fixation montage is seen.
d, e The fracture viewed 4 months later after healing had
taken place. The patient had regained most of his motion but, because of the original prolonged period of
time in a plaster cast, displayed decreased dorsiflexion:
this has since improved. There is a slight valgus tilt of
the distal fragment
65
Fig. 3.6. a When there is more shortening present, or
there is a butterfly fragment on the opposite side but
the oblique major fracture line is recognized, the
same technique may be used with the exception of
applying the articulating tensioner off the proximal
end of the plate. In this illustration we see that the
fracture line is basically short and oblique, but with
a butterfly fragment. The same approach can be
used if the fracture is shortened or old. The plate is
precontoured as was the case in Fig.3.3. b The plate
is then applied to the distal fragment with a single
screw. It is aligned to the distal fragment in the sagittal place and rotation is corrected. c A very small
opening is made laterally through the soft tissues of
the proximal fragment and a no.2 Verbrugge clamp
is placed against the plate, holding it to the midportion of the bone of the proximal fragment. The articulating tension device is placed 1-2 cm off the end
of the plate, depending on the amount of shortening
present. At this point a second screw may be placed
distally in the plate, although it should not be
snugged. Before its insertion, the alignment of the
plate to the distal fragment in the sagittal plane
should be checked and the Verbrugge clamp is tightened after the plate is brought into the proper relationship with the proximal fragments. d Distraction
is then carried out. The plate will slide underneath
the Verbrugge clamp. At this point, if it has not been
done already, a second screw will be placed through
the plate into the distal fragment. It may be tightened. As the distraction is carried out, the butterfly
66
e
fragment, by virtue of its soft tissue attachments, will tend to approximate itself into reduction. This may be assisted with a fine instrument such as a dental pick. e A soft-tissue-sparing clamp such as the pointed reduction forceps is then used to secure the butterfly fragment in its reduced position. The Verbrugge clamp is tightened to maintain
the distraction. The articulating tension device is then loosened and the tab slipped out
from the end of the plate. f The articulating tension device is then placed in the end
hold of the plate and compression is applied. The pointed reduction forceps are tightened to hold the butterfly fragment in its reduced position. Care is taken to apply the
correct amount of tension to the plate in the tibia. This should be in the vicinity of
60 kp, or in the green zone on the collar of the articulating tensioner. Rarely, the Verbrugge clamp must be loosened just a little to allow this to occur. Too much tension in
the plate may result in a valgus reduction with this combination of plates and screws.
Alternately, the DC holes may be used and the load guide set eccentric in the second
hole from the end of the plate. g With the plate tensioned and with the plate dynamics
correct, the butterfly fragment may actually be stable without use of the pointed reduction forceps. This may easily be checked at this time. However, the pointed reduction
forceps should be in place when the definitive lag screws are inserted, in this case
through the plate into the butterfly fragment. The remaining screws are then inserted
through the plate, the number used depending on the quality of the bone and the mechanics achieved with the plate. It has been our clinical experience that if a compression fixation has been accomplished fewer screws are needed
67
Fig. 3.7. The articulating tension device pictured here
has joints which allow the device to function across angulations, a rotatable hook on one leg, and a foot on the
other which takes a 4.5-mm cortical screw. The rotatable
hook fits against the end of the plate or in the end hole
and allows the device to work by either pushing (distraction) or pulling (tensioning). It has a built-in strain
gauge that tells the surgeon the amount of tension that is
being applied. The total excursion possible on the standard model is 40 mm. When a greater distance of shortening is to be overcome, or when the forces acting in the
fracture are very high, the articulating tension device
must be walked along the bone or the femoral distractor
utilized. The femoral distractor will be discussed in the
next chapter
68
Fig. 3.8. a, b A 56-year-old retired college professor was
struck by an automobile while riding his bicycle and
sustained a grade 2 open tibia fracture. After irrigation
and debridement a precontoured plate was attached to
the bone distally, and on the proximal main fragment
distraction with the articulating tension device was carried out. The reduction was made with soft-tissue-sparing clamps, and finally the application of a small antiglide plate proximally to fine-tune the reduction followed
by lag and plate-fixation screws completed the initial
surgery. c, d The postoperative result. Note the tenuous
fixation proximally: there are only two screws clearly
fixing the proximal end of this fracture. This was a mistake in planning, as the fracture was not fully visualized
at the time of surgery and the plate was originally fixed
too distal and thus was a little short proximally. The fibula was fixed because of suspicion of an ankle injury
which proved to be erroneous. e, f The final control
(13 months later) after fracture union had taken place.
The proximal fracture lines initially showed irritation
callus, which later became fixation callus. The patient
was treated with immediate active joint rehabilitation
and with the onset of irritation callus was placed in a
cylinder cast for 1 month. In this case the viability of the
fractures played a bigger role in the final outcome than
did the mechanical stabilization. The fibula healed despite the distal fixation
69
Fig. 3.9. a, b Closed comminuted fracture of the tibia with
distal intra-articular extension and anterior joint impaction
treated by the methods illustrated in Fig.3.5, X -rays taken
before surgery. c, d AP and lateral views of the postoperative
result. The fibula was first approached and fixed by indirect
reduction and fixation utilizing a one-third tubular plate.
Next, a narrow 4.5-cm DCP was precontoured and applied
to the distal fragment by means of two screws. The articulating tension device was then applied to the proximal
end of the plate and length was regained. Bone graft was inserted during the distraction stage, after which'mild compression was exerted to coapt the fragments. Reductions were
therefore achieved indirectly. Following this, lag screw fixation was carried out. e, f On control at 8 months, bony union
had occurred. The patient had no complaints relative to the
tibia and full function of the foot, ankle, and knee
70
Fig.3.10a- f. The distraction technique (Fig.3.S) may be
used in fracture with transverse or piral fracture lines,
or in tho e displaying a large amount of comminution,
in which case the articulating ten ion device is used off
the end of the plate. a The plate is attached to the fragment which is displaced away from the side that will be
definitively plated. The articulating ten ion device is
placed on the end of the plate and di traction i carried
out. b The plate is aligned to the di tal fragment and a
second crew is placed through one of the holes. A Verbrugge clamp is carefully placed by minimally opening
the lateral compartment uch that it secures the plate
again t the proximal fragment. Distraction is carried
out. c Comminution i reduced with a fine instrument
and held with a pointed clamp which i not shown in
this illustration.
71
\
\
d The plate is preloaded and lag and fixation snews are
inserted. Caution must be used with the amount of preload applied - 60 kg is optimal for the tibia. More may
result in varus angulation. e If the proximal fragment is
displaced laterally relative to the distal fragment and definitive plating will be on the medial surface, preliminary fixation with a single screw attaching the plate to
the proximal fragment will cause reduction to occur.
This is opposite to the situation seen in the previous illustration. r With a Verbrugge clamp carefully centering
the plate on the distal fragment, distraction is carried
out. Because the tibial shaft is relatively straight along
the medial face in its midportion, a plate shaped just
slightly concave may be applied to this area of the bone.
The concave contour will give the plate a little preload
as it is screwed to the bone after reduction has been obtained
72
Fig. 3.11. Bone spreaders. The AO bone spreader is a
valuable adjunct to fracture reduction., It may be used
like the articulating tension device as a distraction device. In this case it is placed off the end of a plate and
against a screw that is placed free in the proximal fragment approximating 1 cm from the end of the plate and
is used as a push screw. Opening of the bone spreader
between the screw and the end of the plate provides a
distraction force
Fig. 3.12. Verbrugge clamp. This clamp is used in many
circumstances to hold the plate to the bone and comes
in various sizes from 0 to 3. The proper size should be
selected in harmony with the size of the bone fragment
with which one is dealing. The pointed end of the
clamps may also be used in the end hole of the plate,
and the broad end around the free screw to pull the
plate therefore coapting the fragments
73
I
o
o
o
o
c
Fig. 3.13. a A tibial pilon fracture in which the fibula
has not been fractured but there is an associated
short oblique fracture of the distal tibia. The plate
must be precontoured in a manner similar to that described in Fig.3.5. The surgical exposure is the same
as described earlier, extended further distally to end
slightly inferior to the medial extensor retinaculum,
and by subperiosteal extension the dissection is carried laterally so that the anterior tibial tubercle can
be visualized along with its joint fragment. A limited
anterior capsulotomy of the ankle joint is carried out
so that the articular surface can be controlled. b A
precontoured plate is then attached to the midportion of the medial malleolar fragment by a single
screw, usually 20 mm in length. The incision may
need to be lengthened at this time in order to allow
access to the distal tibia proximal to the end of the
plate. c A Verbrugge clamp is carefully inserted into
the anterior compartment, taking care not to strip
any more soft tissue than necessary. The plate is centered on the proximal fragment slightly posterior to
its midportion. d The articulating tension device is
then placed approximately 2 em off the end of the
plate with a single cortical screw. It is placed in the
distraction mode and the tab inserted into the little
slot underneath the plate. Careful distraction is carried out. As the distraction occurs, the plate usually
aligns itself to the center of the distal fragment. Occasionally the alignment may need to be adjusted using a standard reduction forceps. A second short
screw can be placed in the second hole if the fracture pattern allows it at this point, fixing the plate in
a reduced position in the sagittal plane. Slight over-
d
o
o
o
74
e
distraction is carried out and the joint line is controlled directly through the anterior capsulotomy.
When the medial malleolar fragment and the fragment of the anterior tibial tubercle are at the same
level, small anterior articular fragments may be
placed into their reduced position with a dental pick
and held by means of a pointed reduction forceps.
At this juncture Kirschner wire fixation of the articular surface is carried out, and once more the articular
reduction is controlled by looking directly into the
joint. If there has been impaction into the metaphysis of the articular surface, bone grafting is carried
out through the defect. e With provisional fixation
and bone grafting accomplished, the distraction
force is removed. The most distal provisional screw
is removed and the proximal portion of the hole
overdrilled with the 4.5-mm drill. The drill sleeve is
inserted and the 3.2-mm drill is used to perforate the
anterior tibial tubercle. A 4.5-mm cortical screw may
then be inserted as a lag screw. A 6.5-mm cancellous
screw may be used instead. Following the replacing
of the first screw, the second screw is similarly removed and replaced. f In fractures that extend into
the diaphysis, following the firm fixation and bone
grafting of the distal portion of the fracture, a small
amount of compression may be applied to the plate
by turning the articulating tension device around
and putting it into compression mode. This is only
rarely indicated. g The remainder of the screws are
inserted, making sure to place at least one lag screw
across the diaphyseal extension of the fracture
75
,,'jg.3.14a-d. legend see page 76
76
Fig. 3.14. a, b AP and lateral views of a pilon
fracture with an intact fibula. Note how Chaput's tubercle has remained at length with the
intact fibula while the articular fragments are
impacted upward. There is articular comminution as well as comminution in the metaphysis; however, the medial malleolar fragment is
large. There is usually a lesion in the lateral
collateral system and the syndesmotic ligaments are generally intact. c Intraoperative
photo showing the articulating tension device
in "distraction mode", pushing the plate and
therefore the distal fragment to which it is at-
tached into reduction. d Keying in a diaphyseal fragment. e Postoperative X-ray of the reconstruction. The articular segment has been
perfectly reconstructed; however, in the absence of lateral dissection, the butterfly fragment in the posterolateral side was never seen
and remains displaced. Biology was favored
over a perfect X-ray : rather than devitalize the
fragment it was left to heal. f Control at
8 weeks. g, h AP and lateral views at 1 year.
i, j After implant removal 1 Y2 years later. The
patient is functioning normally
77
78
79
Fig. 3.15. a, b AP and lateral views of a fracture
of the tibial pilon. In the AP view, the medial
malleolar fragment cannot be well appreciated;
however, it is quite large. In this case, the fibula
is broken. c The swelling was too great to operate on the night of admission, so the patient was
placed on a Bohler-Braun frame in calcaneal
traction. The fracture wants to reduce! This is excellent evidence that indirect reduction will be
possible. d Intraoperative X-ray showing the reconstructed fibula and the tibia with the articulating tension device providing distraction on the
medial malleolar fragment. The plate was origi-
nally fixed to the medial malleolar fragment by a
single screw and length of the joint was regained.
It was then fixed with a Kirschner wire and later
with a 6.5-mm cancellous screw. Bone grafting
was subsequently carried out. The screw just
proximal to the fibular plate is a witness to the
indirect reduction carried out on the bone. This
will be described in a later portion of this chapter (p. 82-84). e, f Follow-up X-rays at 6 weeks
show the reduction of the joint obtained by this
method along with early consolidation of the
fracture. The patient unfortunately never came
back and could not be found
80
a
Fig.3.16a-c. Inlaying a plate. A 2- to 3-mm-deep depression may be cut into the distal fragment in the optimal location for plate application. The width should
match the width of the plate. After preparing grooves
matching the outline of the plate, the thin metaphyseal
cortex is impacted inward 2-3 mm to accept the plate.
This allows one effectively to debulk the plate, preventing it from being so prominent under the skin. The impaction should be made with great care and good judgment should be exercised when deciding to use this
technique, as it could be problematic in osteoporotic
bone or in highly comminuted fractures. One must be
careful not to create a situation that compromises the
proximal edge of the fracture, destroying the buttressing
effect of the plate. a The grooves are cut. b The precut
metaphyseal cortex is impacted inward 1-2 mm. c The
plate is settled into the groove prepared for it and will
therefore be less prominent underneath the skin. Inlaying the plate allows distraction forces to be transmitted
directly to the bone. The screw is relieved of bending
stress and only holds the plate to the bone
81
Fig. 3.17. a The osseous anatomy of the distal fibula. From the distal tip of the lateral malleolus
proximally there is first a slight pronounced concavity. The concavity ends at a point 8-9 cm
from the tip of the lateral malleolus where the crista fibularis crosses the posterolateral surface as
an oblique linear swell. This crest also imparts a slight external rotation to the shaft of the fibula
as viewed distally to proximally. It continues until just below the midportion of the bone.
b When contouring the plate that will lie on this surface of the bone, these observations must be
considered. Speaking in terms of the surface of the plate that will come in contact with the bone,
we must first flatten the plate in its distal aspect, usually the terminal two holes, with a mallet.
This will make the plate less bulky beneath the skin. Then we should twist the plate so that the
nonflattened end is externally rotated compared to the flattened or distal end. A slight short concavity is created at the distal end, followed by a convexity that is approximately 6 cm long and
starts in the region of the second-to-last hole of the plate. We are assuming here the use of an
eight-hole plate, which is usually required when dealing with the type of fracture necessitating
this special technique. c In special circumstances, e. g., osteoporosis, a short distal fragment, or
buttressing with the plate alone and no screws, a short blade may be constructed by flattening
the end of the plate as described above and bending it at a right angle at the distal hole. Similarly, hooks or fixation spikes may be fashioned by sacrificing the end hole, cutting it out to
leave two sharp spikes after having bent the flat portion to 90°. Depending on what has been
fashioned from the distal portion of the plate, two small drill holes or a slot may be made with
the small osteotome to enhance the seating of this fixation device. Because the blade or hooks
are embedded in the bone, the screw exerts its force only to hold the plate to the bone. As distraction or compression is carried out, the tendency towards valgus or varus deformation is minimized
c
82
83
c
Fig. 3.18. a, b When the plate has been contoured, it is
attached to the lateral malleolar fragment with a single
screw. Depending on how the end of the plate has been
used, the screw will normally go in the second hole, as
there it will have a better buttress effect to resist the
forces of distraction. The screw is usually 18 mm in
length. Care is taken not to penetrate the distal talofibular joint. A second screw is then placed proximal to the
plate about 2 cm from the end and free in the midportion of the bone. A small-fragment Verbrugge clamp is
used to fix the plate to the proximal fragment in the
midportion of the bone. A small bone spreader is then
placed so that one foot is under the end of the plate, the
other against the free screw. Distraction of the plate is
effected by opening the laminar spreader. c When the
length is regained, determined at first by the resistance
within the laminar spreader, the small intermediary fragments may be squeezed into reduction with a dental
pick. Their reduction in length ultimately determines the
true length, and the tension may be reduced within the
laminar spreader until the fragments are slightly compressed by the elastic effect of the soft tissues.
84
o
d If the fracture pattern lends it elf to further compre sion, this may be accompli hed at thi point by placing a
small Verbrugge clamp at the end of the plate so that the
pointed end i in the proximal hole and the broader
plate-holding end i around the free screw-head. Closing the clamp will then apply tension to the plate, further stabilizing the fracture. e If the fragments lend
themselve to it, crew fixation , generally with sma ll fragment or mini-fragment screws, may be carried out.
Usually no tension is applied to the plate and the fragment are too small for crews. The plate then act in
pure buttres mode
85
oc-=~(~-.-L) --:J
a
7______------------~
b
Fig. 3.19 a, b. The ulna is more or less straight along its
dorsal surface, which is the surface most amenable to
plate fixation. From the olecranon distally it presents a
slight concavity, then it is straight or gently bowed dorsally until the distalmost portion just proximal to the
styloid process. Here again a slight concavity is present.
A straight 3.S-cm mini-DCP is compatible with most ulnas. Occasionally, in a large man, the standard DCP
should be used. In cases in which indirect reduction is
carried out, the ulnar plate is first contoured to provide
a very slight amount of concavity to the bone surface of
the plate, sufficient to arch the plate away from the
straight surface by about 2-3 mm at the apex (b). This
technique is most useful where a segmental fracture or a
large amount of comminution is present. The plate to be
used is usually long : 12-16 holes or longer for the
3.S-mm DCP, 8-12 holes for the standard DCP. A very
small amount of convexity in its distal most portion
should be imparted to the bone surface of the plate if it
extends to the level of the base of the ulnar styloid
86
Fig. 3.20. a The technique is illustrated graphically on a
segmental fracture of the ulna associated with a midshaft fracture of the radius. To avoid redundancy, only
the technique for the segmental fracture of the ulna will
be described, although a similar approach is used for
the radius. The basic principles are the same as those
described for the tibia, although the instruments used
are smaller. The no.O Verbrugge clamp and the medium
reduction forceps, along with the small-fragment pointed reduction forceps, are suitable auxiliary aids in the
reduction of the average-sized ulna. The dental pick is
always helpful. b The plate is attached to the distal fragment with one screw, great care being taken to drill the
hole in the midportion of the bone. If the distalmost
hole in the plate is used, more compensation in angulation of the plate is available subsequently. The screw is
snugged but not definitively tightened. c In large bones
the articulating tension device is used similarly to the
methods previously described. In smaller bones, or
when exposure is limited, the medium bone spreader
may be used instead. It is used between a free screwhead, usually of a 3.5-mm cortical type, and the end of
the plate. Axial deviation of the plate is controlled by
the use of the medium Verbrugge clamp and the small
repositioning forceps. The fracture is then reduced by
distraction. When the fragments have been reduced, the
clamps are tightened and the tension is reduced in the
bone spreader.
c
87
d If further coaptation of the
fracture lines is de ired, the
no.O or no.1 Verbrugge clamp
is placed 0 that its broad foot
is centered around the far side
of the screw. Its small end will
then fit into the end hole in the
plate. By then squeezing the
clamp tension can be applied
to the plate, closing any remaining gaps in the fracture. The
load guides may then be used to
tensi on the plate in the u ual
manner. e The plate is then angulated to occupy the midportion of the proximal fragment
and held there with a no.O Verbrugge clamp.
e
o
o
f A "push-pull" screw is placed off the proximal end of
the plate at a distance of 1 cm from the end of the plate.
A medium bone spreader is placed between the pushpull screw head and the end of the plate. Distraction of
the plate is carried out. Because of the intact soft tissues
the segmental fracture tends to reduce into the gap between the proximal and distal main fragments. The reduction is "fine-tuned" with the dental pick and held in
place with the small pointed reduction forceps.
88
g
h
[)
g The proximal Verbrugge clamp is tightened. The
spreader is removed and a no.O Verbrugge clamps is
placed with its foot around the push-pull screw and its
pointed end in the terminal hole of the plate. Because
the distal screw has not been tightened definitely, during
this action it seeks the "load" position of the plate hole.
The proximal fracture line may also be controlled with a
small pointed reduction forceps. h With the Verbrugge
clamp coapting the fractures and the pointed reduction
forceps stabilizing them, the screws are inserted as
shown. Interfragmentary compression is applied across
all the fracture lines. i Finally, lag screws are inserted
"outside" of the plate, ensuring both axial and trans axial compression. The radius may then be fixed in a similar manner
89
Fig. 3.21. a, b AP and lateral X-rays of a 27-year-old male
with a Monteggia fracture dislocation of the elbow associated with a segmental fracture of the ulna and fracture of
the radius. c, d AP and lateral views at 8 weeks after surgery. One fracture line is still healing. e, f AP and lateral
views of the elbow and forearm 5 years later. The patient
has full function. His postoperative mobilization started
10 days after surgery. He is back working full-time in construction
90
Fig. 3.22 a-h. A closed, comminuted
left forearm fracture in an 80-yearold female. She was polytraumatized
in a motor vehicle accident. a, b AP
and lateral views before operation.
c, d AP and lateral views immediately after operation. Note the screw in
the distal radius, against which distraction with a laminar spreader was
carried out. The small butterfly fragment in the posterior aspect of the
ulna was subsequently fixed with a
small 2.7-mm lag screw. e, f Six
weeks later. Note the early healing of
both ulna and radius. We have frequently observed that when indirect
methods are used for reducing the
fracture and stable fixation is
achieved, the bone heals extremely
rapidly. g, h The same fracture at
3 months. Full function of the forearm is present and the patient is
back to normal activities
91
Fig.3.23a-c. The use of a cUlVed reconstruction
plate for reduction of a comminuted anterior
wall or column fracture. a The preculVed reconstruction plate is slipped underneath the
iliopsoas muscle, usually from the posterior
aspect of the surgical exposure. It is attached to
the pubic ramus and the area of the pubic tubercle by a single screw. It may then be rotated until it is well aligned with the pelvic brim.
b, c The plate which has been pre contoured
with a slight concavity in its middle thlrd is then
screwed to the intact bone anterior and posterior to the fractured anterior wall. Because of the
shape of the bone in the area of the pelvic brim,
there will be a slight gap on both sides of the iliopectineal eminence which will be eliminated
when the screws pull the plate to the bone. This
will cause compression to be exerted on the anterior wall fragments, pressing them downward
or inferiorly and into reduction. The compression forces also contribute to stability, which
may be augmented by the careful placement of
lag screws through the quadrilateral surface or
into the dense bone posteriorly
92
[© © ©
a
© © <0 ©I
(
Fig. 3.24 a-f. Buttressing the medial wall with a onethird tubular plate. a A seven-hole one-third tubular
plate is usually selected. Two holes will go outside, one
under a reconstruction plate and the other free. The five
holes that go inside will buttress the quadrilateral surface. The plate is flattened along its entire length and
then bent obliquely at the end of the second hole. b The
oblique bend in the plate allows the five holes that will
rest against the quadrilateral surface to be flexed anteriorly 15 _20 The oblique bend is dependent on whether one is operating on a right or left acetabulum.
c, d This plate, now shaped like a number 7, is slipped
inside the pelvis with the long portion against the quadrilateral surface and held with a clamp. A AO "KingTongs" pelvic reduction forceps is placed against the
plate and the short end fed underneath the reconstruction plate that has been applied to the pelvic brim.
To accomplish this, the reconstruction plate should not
be definitively tightened. The one-third tubular plate is
then pressed against the quadrilateral surface and
slipped underneath the reconstruction plate with the reduction forceps. The screws in the reconstruction plate,
resting on the pelvic brim, are then tightened. e Illustration of the orientation of the buttress plate seen from the
inside. f The free screw-hole in the short end of the
plate which rests in the bottom of the iliac fossa is filled
with a single 3.5-mm cortical screw. This method provides an effective buttress of the quadrilateral surface
0
b
0
•
_ _ _ _ _~93
94
Fig. 3.25 a-f. A 46-year-old female who sustained
a fracture of both columns of the acetabulum in a
motor vehicle accident. a, b, c AP view of the
pelvis and right and left 45° oblique views. Note
the medial wall comminution associated with the
anterior column fractures. d, e, f One-year result.
The surgery was carried out through the anterior
ilioinguinal approach. The modified one-third tubular plate hugs the quadrilateral surface and is
underneath the pelvic brim plate. The support of
the intrapelvic plate is concentrated on the quadrilateral surface
95
Fig.3.26a-g. A 44-year-old male with an anterior column posterior hemitransverse acetabular fracture.
a, b, c Preoperative AP pelvic and right and left 45 °
oblique views. Again medial wall comminution is present. d Postoperative result. Note location of the buttress plate on the medial quadrilateral surface.
e, f, g Final result at 6 months showing a congruent
hip joint
96
Fig.3.27a-c. A reconstruction plate can be
used to reduce the posterior column in some
instances. This technique is used by Dana
Mears of Pittsburgh and is described in his
book Fractures of the Acetabulum and Pelvis
(Mears 1986). a The plate is first contoured
to fit the ischium and the subcotyloid groove
of the ischium. The soft 3.5-cm AO reconstruction plate is used. The plate is attached
to the distal fragment by two or three screws
starting at the tuberosity of the ischium and
crossing the subcotyloid groove. The large
pointed reduction forceps, or alternatively a
Verbrugge clamp, is then placed in the open
position, one end in the terminal hole of the
plate and the other either in a hole drilled in
the iliac wing or against the head of a screw
inserted in the iliac wing. If a Verbrugge
clamp is used, the pointed end is placed in
the terminal hole of the plate and the broad
or plate-holding end is placed around the
head of a screw inserted in the iliac wing.
The clamp is then closed as rotation is controlled.
97
b As the clamp is closed, the plate lifts the displaced
fragment into the appropriate reduction. Final reduction
may be obtained by further manipulation with a large
pointed reduction forceps once the fracture surfaces are
opposed. Correct rotation of the column is verified by
digital palpation of the quadrilateral surface of the
bone. Additional compression is then added by forcibly
closing the pointed reduction forceps or the Verbrugge
clamp on the distal hole in the plate. c The screws are
then inserted in the proximal fragment, starting as close
to the fracture surface as the relationship of the plate
holes to the location of the joint will allow and proceeding proximally. Insertion of the screws in a direction
away from the fracture serves a dual purpose: they more
easily avoid penetrating the joint and also serve to produce tension in the plate whil~ contouring it to the surface of the retroacetabular portion of the proximal fragment. Finally, the pointed reduction or Verbrugge clamp
may be removed and the remaining screws inserted in
the posterior iliac wing
98
Fig.3.28a-c. This technique is similar to that described
in Fig. 3.27; however, the plate has been placed in an
oblique position such that derotation of the ischiopubic
segment may be carried out as the fracture surfaces are
opposed. a The plate is gently contoured in a slight
concavity and attached to the inferior aspect of the retroacetabular surface. By placing the plate in this position one sacrifices the long screws afforded by fixation
into the tuberosity. However, the plate in this position
may be used to derotate the inferior fragment directly.
b The pointed reduction forceps is placed such that one
end is in the end hole of the plate and the other on the
inferior iliac spine, and then closed. Rotation must be
checked by digital palpation of the quadrilateral surface
at this time. c When the reduction is complete the
screws are inserted away from the joint, further tensioning the plate
99
Fig. 3.29 a, b. A transverse posterior wall
fracture in an extremely obese, short female. a Before operation. b Through an
iliofemoral approach the fracture was reduced and fixed utilizing the technique described in Fig. 3.27. Because of the patient's
obesity exposure was difficult, and the reconstruction plate was extremely helpful.
Note the straightening of the plate due to
tensioning it along the retroacetabular surface. The anterior column was fixed with a
single 4.5-mm lag screw
100
d
Fig.3.30a-t. A supracondylar femur fracture consisting of two main
articular fragments and a medial butterfly. The patient is operated in
the supine position with a bolster under the knee such that the knee
may be flexed to 60°. A lateral approach to the femur is utilized, carefully opening the joint so that the end of the femur in both frontal and
horizontal planes may be directly visualized. The approach is well described in the book Surgical Approaches for Internal Fixation [23].
a Exposure of the lateral articular fragment and the articular surface of
the distal femur by opening the joint. b Mter exposure, we favor as an
initial step the creation of the window that will receive the seating chisel. c To review, the window for the seating chisel is in the middle third
of the anterior half of the distal femur 1.5 cm above the joint line.
d The location of the window does not change in relationship to the
101
size of the distal fragment, but is constant, and making
the window early helps to orient the surgeon as to where
to place the other implants for fixation such that they do
not come into conflict with the eventual location of the
blade plate. e The most difficult aspect of this preliminary location of the window is to attain good orientation as to the location of the proper axis for the plate in
the sagittal plane. Three steps may be carried out to attempt to confirm the correct orientation at surgery. The
first is to imagine a perpendicular from the greatest
transverse diameter of the distal articular fragment that
was used to locate the middle third of the anterior half
of the bone (see c). Second, the window should be parallel to and prolonged from the anterior flange of the metaphysis on the lateral fragment as it extends off the articular segment of the trochlear notch. The third helpful
ploy is to visualize the inside of the joint with a mind to
the orientation of the distal femur in the frontal plane:
the plate portion of the blade plate should be placed so
that the femur is in its normal weight-bearing position.
This latter observation is best carried out after articular
reconstruction. Although these determinations are difficult, they are supported by a good preoperative plan
and at this step are not critical to the final position, as
the seating chisel can be steered somewhat to correct the
orientation with the slotted hammer at the time of its insertion. f, g The illustrations depict front and side views
of the articular reconstruction and fixation with Kirsch-
ner wires or definitive lag screws. This reduction may
sometimes be difficult. Insertion of a Schanz screw, with
a T-handle chuck attached, into the medial condylar
fragment through a stab wound in a safe location affords a direct handle on the medial condylar fragment
that may be used to correct varus-valgus or flexion-extension orientation. Reduction may then be maintained
with a large pointed reduction forceps used intra-articularly or a new circle-pointed reduction forceps which
may be used percutaneously on the medial side and in
the wound on the lateral side. Temporary fixation may
then be carried out with Kirschner wires. The reduction
is inspected and then definitive lag screw fixation with
6.5-mm cancellous screws placed in a relationship to the
window such that they will not come into conflict with
any part of the condylar blade plate. Kirschner wires are
then placed intra-articularly on the end of the distal
femur in line with the window in the coronal plane and
on the anterior aspect of the distal femur in line with the
window in the horizontal plane. h, i A summation
Kirschner wire is then drilled into the bone 5 mm from
the joint surface. It is parallel both to the Kirschner wire
that has been placed through the joint along the end of
the distal femur in the coronal plane and to the Kirschner wire that has been placed along the anterior surface
of the distal femur in the horizontal plane. This summation wire will serve as a directional guide for the insertion of the seating chisel.
102
j The intra-articular Kirschner wires may
be removed, checking once more at this
juncture the parallel relationships to the
summation Kirschner wire. At this point
the reduction of the articular fragment to
the shaft has not yet been made. k, I The
seating chisel is then introduced into the
window and driven in approximately
1 cm. Its parallel relationship with the directional Kirschner wire is checked in
both planes. If the relationship is correct,
the seating chisel guide is set onto the
seating chisel and the sagittal plane
checked as well. Using the slotted hammer as a steering mechanism, the seating
chisel is driven in with a mallet, controlling these relationships closely.
103
n
m Guided by the preoperative plan, the seating chisel is
driven into a depth of 60 mm or occasionally 70 mm.
The illustration views the progress of the seating chisel
in the horizontal plane. n The seating chisel is then
loosened and removed, the plate introducer is set parallel to the blade of the plate, and the plate itself is inserted along the track previously made by the seating chisel. 0 With the fracture still unreduced, the plate is
brought to the proximal shaft and attached there with a
no.3 Verbrugge clamp, taking care that the clamp does
not disrupt too much of the soft tissue on the medial
side of the bone. At this point, should it be necessary, a
little (less than 5°) mal alignment of the plate in the sagittal plane may be corrected using the standard reduction clamp against the plate and the posterior lateral
cortex of the articular fragment or the anterior lateral articular fragment, depending on the nature of the malalignment. Following these small corrections, the screw
may be inserted in the second hole of the plate in order
to preserve the corrected alignment in the sagittal plane.
The Verbrugge clamp is fastened snug, but not tight, to
the proximal fragment and gentle traction is applied in
the direction of the long axis of the leg. This will minimize the shortening before the application of the articulating tensioner off the end of the plate.
104
p Following this preliminary gain in length the no.3 Verbrugge clamp is tightened maximally. The articulating
tension device is then inserted at the proximal end of
the plate. The location of the drill hole that will connect
the articulating tension device to the bone is determined
by the amount of residual shortening to be overcome.
Usually the distance of the drill hole for the articulating
tension device from the end portion of the plate will be
about 1-2 cm. This will leave 2-3 em in the device for
further distraction of the fracture. Ahole for anchoring
the articulating tension device is made through one or
two cortices proximal to the plate, depending on the
quality of the bone. In nonosteoporotic bone, it may
suffice to penetrate only one cortex. Following the application of the tensioning device, the hook on its distal
end is turned into a position which will allow it to push
on the proximal end of the plate. The tightened Verbrugge clamp maintains the correct proximal alignment
of the plate in the sagittal plane. With a standard reduction clamp the rotation of the fracture may be controlled
by placing one jaw of the clamp on the plate and the
other against the proximal fragment. The tendency of
the plate to angulate as distraction is increased may likewise to controlled by this method. In order to prevent
straightening of the normal anterior curvatum of the
femur the distraction is carried out over a bolster which
is placed behind the thigh and kept there during the
distraction process. When slight overdistraction is
achieved, the butterfly fragment may be teased into reduction by the use of the dental pick, small bone hook,
or large pointed reduction forceps. The butterfly fragment should be in a position of approximate reduction
from the distraction process alone as it is usually connected to the soft tissues that will be elongated during
the distraction.
105
q A large pointed reduction forceps is then placed on
the butterfly fragment and tightened to impact it into the
defect on the medial aspect of the femur. This instrument is preferred as it is extremely sparing to the soft
tissues, slipping through them rather than pushing them
away. The butterfly fragment mayor may not slip immediately into a completely anatomic reduction; however,
it should be possible to jam it into the defect such that
with the aid of the pointed reduction clamp it is stable
in that position. The object here is to maintain the complete viability of the medial butterfly and yet at the same
time orient it such that it is impacted between the two
major fragments and therefore capable of taking load.
With this accomplished, the distraction exerted by the
articulating tension device is removed. When the device
is loose, its hook is placed in compression mode and
tension is applied to the plate. Depending on the quality
of the bone and the fracture morphology, maximal preload is then applied. In healthy non porotic bone, tension to the end of the red zone on the device may normally be applied safely.
106
r As an optional step, when the fracture configuration
appears suitable, stability of the medial butterfly fragment can be checked by the effect of axial compression
alone. This is not necessary but will demonstrate that
the preload obtained by axial compression is well distributed. In our experience, because of the stability obtained through axial compression, with simple fracture
patterns the limb may be actually taken through a vigorous range of motion even at this stage, with complete
stability of the fractures before the insertion of a single
screw. The beneficial feature of the angled blade plate is
that since the angle between the blade plate and the
plate is 95° , application of it in perfect alignment to the
anatomic axis of the femur in the frontal plane should
automatically result in significant preload once the plate
is reduced to the proximal fragment. It is this preload
that allows the butterlly fragment, once reduced, to be
stabilized by the introduction of axial compression. This
would not be the case if the compression forces were located exclusively underneath the plate, as would occur
in a valgus reduction of the fracture. Because as yet no
screws have been inserted in the fracture zone, the bone
fragments are free to impact, eliminating significant
fracture gaps and producing a true medial buttress. This
sets up the tension-compression cycle in the plate-bone
construct. Lag screw fixation through the plate, which is
possible under these circumstances, or outside the plate
is carried out in the usual manner. A general rule of
thumb is that lag screws may be inserted successfully in
the areas previously occupied by the clamps which have
effectively temporarily stabilized the fracture.
107
s, t The remainder of the plate screws are then added
according to the preoperative plan and the articulating
tensioner is removed. When one accomplishes the fixation in this order, one knows that a buttress of bone has
been restored, as only in its presence may the axial preload with the tensioner be applied and maintained. This
cannot always be determined when lag screw fixation
precedes plate application. Proper application of the
angled blade plate further suggests that the impaction of
bone has occurred on the side opposite the plate, which
is mechanically optimal. A further advantage of this approach is that the reduction is carried out by means of
the soft tissue attachments, not in spite of them. Finally,
the reduction maneuvers are mechanically effective and
smooth, without the usual struggle attendant on manual
reduction
108
os
Fig. 3.31 a-g. A clinical case
showing the application of
the principles discussed in
Fig. 3.30. a, b Fractured
femur with medial butterfly
fragment in a 16-year-old
male. c Intraoperative X-ray
at the stage in which axial
compression has been applied and all clamps stabilizing the medial butterfly have
been removed. At this point
it was possible to put the
patient's knee through a fullrange of motion with no displacement of the butterfly,
the bone was under longitudinal compression (axial),
and the butterfly was stable
without a single screw.
d, e Final fixation montage
showing the use of three lag
screws (counting from the
bottom, screws 3, 6, and 7)
and fixation screws. f, g Final healing with the implants
removed. The patient had
uncompromised function of
his extremity
109
Fig. 3.32 a-o. A comminuted fracture of the
mid- to distal femur with an intra-articular extension may be treated successfully utilizing an
angled blade plate and spanning the fracture
zone. Preoperative assessment will allow the
surgeon to know the amount of shortening present. This can be accomplished by comparing
the comminuted segment, from the joint proximal, with the normal side. a The illustrated segment covers 12 cm. b To minimize blood loss
and cut down on the amount of time the wound
is exposed, only the distal portion of the wound
is needed at first. The lateral approach is selected. The joint is opened so as to be able to inspect the femoral condyles under direct vision,
and the window is made as discussed in the previous example. c Articular reconstruction is carried out, provisional and definitive fixation being accomplished.
c
110
e
d
o
g
d Kirschner wires are inserted in the same areas in the
joint as shown in Fig. 3.30. e A summation Kirschner
wire is then inserted parallel to the Kirschner wires in
the frontal and horizontal planes to act as a definitive
guide for the insertion of the seating chisel, which is
then carried out.. f, g The lateral approach is then extended proximally, taking care to bypass the fractured
area, dissecting to bone only proximal to the fracture on
the lateral side. The area of the fracture will usually
have some disruption of the musculature which will require only a small amount of further development in order to allow the plate to come underneath the vastus lateralis. A nO.3 Verbrugge clamp is then placed carefully
on the proximal fragment and tightened to hold the
plate to the shaft.
111
h, i The articulating tension device is then placed as
close as possible to the end of the plate and the tab
turned to the distraction mode. The device is fastened to
the bone by means of a uni- or bicortical screw, depending on the quality of the bone. Distraction is then carried out according to how much elongation of the segment is needed, determined in the preoperative plan. If
the fracture morphology allows, the Verbrugge clamp
may be tightened, the articulating tension device turned
into compression mode, and an attempt made to load
the fracture. It may be surprising, but using pointed reduction clamps in a couple of key places a comminuted
fracture can be impacted and preloaded so that
both mechanical stability and biological viability are
achieved. Lag screws are inserted in the location previously occuppied by clamps. However, in highly comminuted fractures this will be impossible and a pure buttress function of the plate is all that can be realized.
112
j The plate is then fixed to the proximal fragment with
k
m
fixation screws. The articulating tensioner is removed.
Suction drains are used, the posterior border of the vastus lateralis is left free, and the fascia lata is closed along
with the other layers of the wound in anatomic sequence. k If the angled blade plate to be used is long,
that is over nine holes, as is frequently the case when
dealing with highly comminuted fractures in this area,
then a slightly more posterior angulation of the flange of
the seating chisel guide is required relative to the midline of the distal femur in the sagittal plane. This is to
compensate for the anterior bow of the femur. This is
not a more posterior position of the plate, but merely a
slight posterior angulation of the plate relative to the
shaft. This will place the plate portion of the angled
blade plate on the lateral aspect of the femoral shaft
over its entire length and not off anteriorly in the proximal portion. I, m, n Some fracture configurations present an antiglide situation. If the proximal and distal
fragments of the supracondylar fracture have an obliquity from superior medial to inferior lateral, it may be
better to leave final impaction of the plate into the distal
fragment until after the rotational correction is made.
When the plate forms an acute angle with the distal
fragment, final reduction may be blocked because the
space between the plate and the opposing medial flange
of the distal fragment may be so small as not to allow
113
,
t
o
the flange of the proximal fragment to be interdigitated.
In fact, one of the most difficult fractures to reduce is
one in which there is a long spiral fracture without comminution of the supracondylar or subtrochanteric regions, for these reasons. Having the plate not fully seated until after reduction is made presents no real
problem. In fact, seating the blade and plate in this sequence causes the plate to exhibit an "antiglide effect"
which will secure the reduction of the fracture and give
a variable amount of compression across the oblique
fracture surfaces. 0 Some fractures, because they are
oblique and because the shearing surfaces are smooth
without interdigitations, may actually be more stable
slightly out of, rather than in anatomic reduction. With
compression load, the fracture shortens. However, when
there is a slight malrotation of the butterfly fragment it
is impacted proximally and distally by its offset into the
intermedullary canal and therefore accepts a load, becoming wedged, as it were, between the two major fragments. This situation frequently occurs in an indirect reduction of a comminuted fracture when load is applied
after distraction and after reduction forceps are carefully placed on comminutions to bring them into the fracture gap. It is surprising under these circumstances how
many of these fractures may actually accept load
114
Fig. 3.33. a, b A 19-year-old male with polytrauma from
a motorcycle accident. The patient sustained an open
grade 1 comminuted femoral fracture along with injuries to his right ankle, pancreas, kidney and spleen. The
patient also had a pneumothorax and a cardiac contusion. c, d Open reduction and internal fixation was carried out with a condylar blade plate. Several fragments
were without soft tissue, and therefore a cancellous
bone graft was applied. The condylar plate was used to
reduce the fracture and to act as a splint for the comminuted fracture zone. e, f At 8 weeks the patient began
full weight bearing. The X-ray at 16 weeks shows consolidation of new bone along the medial cortex. g, h Xrays at 1 year show healing and remodeling of the fracture zone. The patient has normal function of his knee
joint and is working full time
115
Tracing of fracture side
c
a
Tracing of good side
Fig.3.34a-w. Drawings of a typical case of intertrochanteric fracture with pertrochanteric and subtrochanteric extension. The critical steps are determined in the preoperative plan and carried out at
surgery, using an exposure that allows direct visualization of the
head, neck, and trochanteric region of the proximal femur. The
procedure is carried out on a regular operating table with the involved leg prepared and draped free. The steps of preoperative
planning are reproduced here. a, b AP and lateral appearance of
fracture. c Tracing of the fractured hip in the frontal plane. d Tracing of the normal hip in the frontal plane.
d
116
'frocing of good s1de
Tracing of fracture side
2'racin
g or good side
f
Tracing of fracture aide
'f rscing of good side
9
e Superimposition of the normal side over the fractured
side, tracing in the outlines of the fracture of the lesser
trochanter. In this case, because the distal fragments are
more extended than the proximal, it is better to start
there as there is less distortion. The proximal fragments
is flexed and externally rotated. f The tracing after this
step. g Superimposition of f over the fractured side to
draw in the major fracture through the lateral cortex.
h The tracing after this step. i Superimposition of the
proximal fragments. We must match the diameters on
the two drawings distally and place the trochanters at
the same level. The "trochanteric extension" fracture
line is drawn. j The tracing after this step. k Since plate
application will precede reduction, the proximal fragments are traced as a separate block. When this has
been accomplished, the template for the condylar plate
is overlaid on the proximal fragment until the tip of the
blade lies in the inferior quadrant of the femoral head
medially and, laterally, penetrates the lateral cortex at a
level 1.5-2.0 cm below the tip of the trochanter, usually
just above the vastus tubercle of the great trochanter.
With the blade in this position, the proper length of the
plate is determined and the blade plate is traced onto
the proximal fragment. With a subtrochanteric fracture
the length of the blade is not so critical, a shorter blade
being selected. With a pertrochanteric or intertrochanteric fracture the blade length is usually longer, with
70 mm or sometimes 80 mm blade length needed.
117
Tracing of
side
Tracing of good side
h
Tracing of good side
Tracing of good side,
proximal femur ,
and implant template
k
118
Tracing of distal fragment
I On a second sheet of tracing paper the distal fragments
are traced as a separate block. m The illustrations are
then manipulated so as to reduce the plate portion of
the blade plate to the lateral cortex of the distal fragment tracing. One can see at this point whether the reduction with a 95° implant in the position selected results in an anatomic valgus or varus position. If it results
in too much valgus or varus, a second tracing may be
made, changing the orientation of the blade in the proximal fragment. The final drawing in the coronal plane
should tell the surgeon the following: first, the location
of the entry point from the tip of the trochanteric or the
vastus tubercle; second, the direction of the end of the
blade to direct it toward the inferior quadrant of the
femoral head; third, the length of the blade. All of these
~racing
ot X-ray,
femoral head, and implant
points are definable at surgery from a lateral approach
to the hip. With an anterior capsulotomy, the neck of
the femur will be fully exposed safely and the inferior
quadrant of the head directly visualized with no endangering of the blood supply to the femoral head. One
Hohmann retractor will be placed on the anterior rim of
the acetabulum and one along the inferior neck, and a
wide Hohmann posterior to the greater trochanter. With
these retractors in place, the point of entry for the seating chisel and the depth at which it is to be introduced
are seen directly at surgery and can be measured with a
ruler from the landmarks previously described. These
may be correlated with the values obtained from the
drawing.
119
n
n The knowledge that the proximal fragment of such an
intertrochanteric or subtrochanteric fracture is usually
flexed, externally rotated, and abducted facilitates the
placement of the seating chisel in the horizontal and
sagittal planes. At surgery the anterior neck of the proximal femur is exposed and a Kirschner wire is placed
along the anterior surface of the neck and tapped into
the femoral head. This gives the orientation of the seating chisel in the horizontal plane. Placement of the chisel in the sagittal plane is usually quite simple unless the
proximal fragment is exceedingly short - a small spike
of bone extending distally from the neck on the lateral
or medial side will indicate the position. The coronal
plane is known from the preoperative plan. The window
for the introduction of the seating chisel will be located
at a given distance, for example 2.0 cm, from the tip of
the trochanter and in the middle portion of the anterior
half of the trochanter, and the blade will be directed toward the inferior quadrant of the femoral head. 0 A
summation pin may be inserted above the window for
the seating chisel containing the information of the torsion of the neck and the direction from the window to
the inferior quadrant of the femoral head. This may be
checked with the condylar plate guide. All three planes
are now known, and the seating chisel may be inserted.
Once it has been inserted to the appropriate depth, the
seating chisel is extracted and the plate is introduced.
All the guide wires may now be removed. By placing a
standard reduction forceps on the edge of the plate anteriorly or posteriorly against the edge of the trochanter,
slight adjustments in the sagittal plane can be made before the insertion of the first screw in the plate into the
calcar. Once this screw has been inserted, the plate may
be used to reduce the fracture. p The plate is brought to
the lateral cortex of the distal fragment by flexing and
p
abducting the leg. The plate is aligned along the long
axis of the distal fragment in the sagittal plane and a
Verbrugge clamp is affixed to the plate, holding it in approximation to the distal fragment.
120
q
s
r
q The amount of shortening may be assessed, and the
articulating tensioner is applied distal to the end of the
plate, usually 1-2 cm from it. In the proximal femur
both cortices should be penetrated with this screw because of the forces involved. The hook of the articulating tension device is placed in distraction mode and
fixed in the slot on the underside of the plate. A standard reduction forceps is placed at the fracture
obliquely between the proximal and distal fragments, or
sometimes merely straddling the plate, the jaws on the
anterior and posterior cortex respectively just distal to
the fracture. Once this arrangement has been achieved
distraction is carried out. r Usually a slight amount of
overdistraction is created at first. The hip may need to
be flexed and externally rotated in order to facilitate the
reduction of the lesser trochanteric fragment, which may
then be teased into reduction with a small instrument
such as a dental pick. Other medial comminutions may
also be reduced at this time. s These fragments are held
with a pointed reduction forceps.
121
u
t
t The articulating tension device is altered to compression mode and the plate is tensioned. In good bone the
tension should be increased until the red colJar disappears from sight. After a little time has elapsed the tension may be tightened again, as settling of the medial
buttress usualJy dissipates some of the compression obtained. When optimal compression is obtained, the
clamps should be tightened to the maximum, the hip
flexed, and clinical rotation verified. u Lag screw fixation of the comminuted fracture fragments should then
be carried out. v, w The remainder of the plate screws
are then added as per the preoperative plan and the fixation complex is complete
v
w
122
b
00. 23/'~
123
e
d
4
Fig. 3.35 a-i. A comminuted intertrochanteric fracture
associated with a transforaminal fracture in a 30-yearold man. a, b, c Preoperative X-rays: AP and lateral
views of the hip, AP view of the pelvis. d, e Preoperative drawings: 1 fractured side; 2 the fractures drawn into the outline of the sound side with the seating chisel in
place; 3 perspective drawing of where the seating chisel
will be placed relative to the original displacement of
the fracture; 4 drawing of the plate in the proximal frag-
ment; 5 the fractures distracted for reduction of the
comminuted metaphysis; 6 with compression applied to
the articular block. f, g The immediate postoperative Xrays. Note the small amount of flexion residual in the
proximal fragment. This occurred because the amount
of flexion of the proximal fragment was not fully appreciated. It creates a mild extension osteotomy. h, i The final X-rays after 55 weeks
124
125
Fig.3.36a-f. A 27-year-old male with a subtrochanteric fracture with trochanteric and
proximal shaft components. a, b, c AP and
lateral films of the original fracture. d, e The
postoperative montage. In this case, the se-
quence of operative events was as described in
Fig. 3.34, the plate being used as a means of reduction. The articulating tensioner was used
just in distraction and then in compression.
f Healing of the fracture at 26 weeks
126
127
Fig. 3.37 a-d, legend see page 128
128
Fig. 3.37. a A 16-year-old Caucasian female who was
struck by the propeller of a motorboat when she feel into the water. She sustained open iliac wing, SI joint, intertrochanteric, subtrochanteric, and proximal femoral
shaft fractures on the right. The sciatic nerve was lacerated at the level of the tendon of the internal obdurator
muscle. b Initial treatment consisted of irrigation and
debridement of the fractures followed by internal fixation of the pelvis and femur. The femur was reduced indirectly as has been described. The sciatic nerve was repaired and the wounds were closed secondarily at
5 days. Because of the nerve repair the patient was
placed in a spica cast with the hip in extension for
6 weeks. c, d Radiographic control at 8 weeks. Already
we see a "softening" of the fracture lines indicative of
early healing of stable, vascular fracture fragments. The
blade was inserted without a capsulotomy of the hip because of the open fractures. The blade is just out anteriorly. e 6 months post injury all fractures are healed. The
patient has return of sciatic nerve function to the level of
the knee joint. f Montage at 9 months
129
Fig. 3.38. a A 24-year-old male
who fell while working on a
bridge. AP X-ray showing comminuted subtrochanteric fracture with extension into the trochanteric mass and proximal
femur. b Treatment with the
method described and an
angled blade plate. c X-ray at
1 month shows softening of
fracture lines and healing of living bone. d, e AP and lateral Xrays at 7 months demonstrate
healing
130
Chapter 4: Reduction with Distraction
Fig.4.1, page 145
Fig.4.2, page 145
Comminuted fractures, especially those involving joints, pose several
problems. The first is the loss of intrinsic stability. Small comminuted fragments cannot by themselves be reduced and held in a stable state by compression. Secondly, a deforming force is still partially present in the form
of the intact extremity proximal to the fracture. This force interacts with
the elastic musculature that traverses the fracture zone and inserts on the
distal fragment. Most residual displacements of fractures are a result of
shortening, the weight of the extremity, and the pull of the elastic musculature surrounding the fractured extremity. Mechanical failures of the musculoskeletal system are usually either through bone or through ligament,
and less frequently through both in the same location. In comminuted
fractures there is usually some critical soft tissue, i. e., ligaments, capsule,
or periosteum, that remains intact.
The principles we use in the technique of distraction to obtain reduction
can be seen in everyday life. A sail, for example, has no intrinsic stability.
However, when it is attached to a mast and boom by means of the couplings to the riggings, tension may be applied to the riggings and the form
of the sail established and maintained. The stability is so good, indeed,
that load can be applied and therefore functional benefit derived (Fig.4.1).
Another principle of distraction is the removal of the deforming force and
temporary static arrest of instability. We employ this when we use a bumper jack to change a flat tire. Imagine the difficulties that would be encountered without one! However, we can accomplish that task with relative ease when the jack removes the deforming forces by lifting the car off
the tire (Fig.4.2). In orthopedic surgery these two principles may be applied to the operative repair of comminuted fractures. The biological jacks
are the fracture table, the distractors, and the articulating tensioners. Reduction of a comminuted fracture is achieved through ligamentotaxis. This
term was coined in 1979 by J. Vidal [31], who introduced the concept in order to extend the indications of external fixation to comminuted intra-articular fractures. He described the reduction of small comminuted metaphyseal and epiphyseal fragments by restoration of tension in the capsuloligamentous structures that connected to the fracture fragments. Vidal used
this system with the external fixator for definitive treatment. We use it to
obtain a reduction and to provide temporary stability while definitive and
stable internal fixation is carried out. This approach has been utilized to
great advantage in many areas, particularly in fractures of the femur, tibial
plateau, tibial pilon, os cal cis, and wrist.
131
The Femoral Distractor
The femoral distractor (Fig.4.3), first modified in 1969 by~. E. Muller
(personal communication, 1988) from the distractor used in spinal surgery
by Harrington [8], is still undergoing evolution at the time of writing. The
current model consists of two arms that may be connected to the proximal
and distal fragments of a fracture by bolts or Schanz screws. These arms
are connected to a threaded spindle; one arm is fixed, and the other is
moved along the spindle by means of two collar screws and a carriage. An
excursion of up to 27 cm is built into the device, and an additional 3 cm is
possible if the compression collar screw is removed. Even more excursion
is possible; however, kinking of the threaded spindle within the sleeve may
cause angular malposition of the end of the device and loss of mobility in
distraction or compression.
The connecting bolts are designed to permit fixation to the bone through
either one or two cortices. The drill bit used with the connecting bolts has
a diameter of 4.5 mm. Sometimes, when high forces are to be overcome or
the distractor will be placed well away from the bone, 6.0-mm Schanz
screws are preferable, as they are more rigid and resist bending. They may
be inserted with the same drill bit.
When applying the connecting bolts to the bone, it is useful to drill the
hole perpendicular to the shaft axis. This is facilitated by the use of the
90° angle guide which is found in the angled blade plate set of instruments. The femoral distractor has a swivel in the socket which holds the
connecting bolt in the fixed arm, thereby allowing certain corrections to be
carried out in rotation.
In the future additional distractors will become available, such as the extra-long one seen in Fig.4.4. Some of these will allow corrections not possible with the current models. For example, currently there is no adjustment with the device in the frontal plane; placing the connecting bolts or
Schanz screws parallel to one another is a relative necessity. In some cases,
correction of the deformity in the frontal plane is accomplished by placing
the connecting bolts at such an angle to one another that they become parallel after the deformity is corrected. Attachments of various types for the
distractor are being developed by AD and will be useful to all of us.
Fractures of the Femoral Shaft
The use of the femoral distractor in femoral shaft fractures is well covered
in the Manual of Internal Fixation [25]. Although we will address it briefly
here, the reader is referred to this original description.
Through the appropriate incision, the fracture of the femur is exposed. In
most cases, there will have been considerable dissection of the deep layers
secondary to the injury itself. Initially, the major fragment ends are
cleaned of interposed soft tissue, granulation tissue, or, if the fracture is
old, callus. If nailing is to be carried out, reaming of the bone ends from
the fracture site retrograde for a short distance allows for better control of
the centralization of the reaming. Similarly, if plating is to be carried out
and lag screw fixation performed, the opportunity afforded by the relaxed
Fig.4.3, page 146
Fig.4.4, page 146
132
Fig.4.5, page 147
Fig. 4.6, page 148
Fig.4.7, page 149
Fig.4.8, page 150
Fig.4.9, page 151
Fig. 4.1 0, page 152
soft tissues in their state before reduction should be taken to anticipate fixation by setting up inside-outside gliding or threaded holes. These can be
utilized for fixation once reduction and axial compression have been accomplished.
Following this, the linea aspera is identified on the proximal and distal
fragments. Using this structure as a guide to correct axial alignment, the
location for the connecting bolts (which may be planned beforehand with
the tracing) is found. The connecting bolts should be proximal and distal
enough from the fracture to allow an appropriate implant to be placed in
between, in front of them or behind them (Fig. 4.5).
With the two connecting bolts in position, the femoral distractor is applied
and, using the collar screw on the inside of the arm, distraction is carried
out. As with distraction-reduction using plates, there is a tendency with
distraction to straighten out the normal anterior bow of the femur. This
must be anticipated, as loss of the normal contour of the femur results not
only in a gap posteriorly in the reduction, but also a thigh that appears
conical, less muscular, and cosmetically abnormal (Fig.4.6 a- b).
Distracting the major fragments facilitates the incorporation of the comminuted bone fragments into the reduction. They are then stabilized with reduction forceps, and following this the distraction force is removed by reversing the screw collar on the inside. Further impaction and compression
of the bone fragments may be accomplished by turning the screw collar
tight on the outside. A contoured plate may be applied at this point. This
plate may be employed as a definitive fixation of the femoral fracture, if
that is the plan, or as a temporary splint to allow antegrade reaming and
open intramedullary nailing of the fracture to be carried out once the femoral distractor has been removed. In this case, the plate may be much
shorter (Fig.4.7). If the plating is to be definitve, compression from the
femoral distractor is not enough (Fig.4.8), and the articulating tension device should be applied to tension the implant as the fixation is accomplished. A clinical example is given in Fig. 4.9 with sequential films, showing the radiographic appearance of fracture healing under these conditions. Fig.4.10 illustrates the problem of a femoral neck fracture combined
with a comminuted shaft fracture.
Closed Intramedullary Nailing of the Femur
The long femoral distractor can be used to advantage in closed nailing
procedures. Long connecting bolts which fit into sleeves that are mounted
on the carriage attachment allow the spindle to distract from a distance
away from the soft tissues of the thigh. These modifications decrease the
bending moment exerted on the bolts and increase the effectiveness of the
distraction process.
The advantage of this system is that a fracture table is not needed. The
patient may be placed on a regular operating room table that has been extended by a "cardiac pacemaker board", or a translucent operating table
designed for use with image intensification.
133
The operation may be carried out with the patient in the supine or the lateral postion. When possible, the lateral position is used, as it affords easier
access to the trochanter, less interference with the soft tissues, and better
deployment of the image intensifier.
Knee rolls or bolsters are needed to support the operated leg during the
procedure. The upper trunk is stabilized by means of a total hip bean bag,
or built-in table supports. The image intensifier is situated so that AP and
lateral control of the fracture zone is possible. Monitoring of the trochanteric area is quite easily accomplished by swinging the arm obliquely.
Depending on the forces of distraction required, various combinations of
proximal control may be obtained, but normally one or two unicortical
connecting bolts are sufficient. These are inserted under the image intensifier control through a short 25-mm incision overlying the thickened portion of the proximal lateral femoral cortex. With the intensifier positioned
to give an AP view, a 2.0-mm Kirschner wire is used as a probe to feel the
sagittal diameter of the bone beneath. Next, a 4.5-mm drill sleeve with a
trocar is inserted at the desired location and checked to be at right angles
to the lateral femoral cortex. The trocar is removed and a hole is drilled
through a single cortex with a 4.5-mm drill. Without removing the guide, a
2.0-mm Kirschner wire is placed into the drill sleeve and into the hole as a
marker. This Kirschner wire is removed and the connecting bolt is inserted
into the hole with a T-handled chuck. If necessary, a second unicortical
connecting bolt may be inserted in a similar fashion, using the carriage
clamp as a guide (Fig. 4.4).
The distal connection is likewise placed through a 25-mm incision. This is
located over the lateral femoral condyle and based on a 2.0-mm Kirschner
wire that is placed transversely to the femoral shaft axis. Again verifying
with the image intensifier, the 4.5-mm drill hole is made at as close as possible to right angles with the shaft of the distal femur, or approximately 5°
varus in relation to the Kirschner wire placed across the end of the distal
femur through the joint. A 6.0-mm Schanz screw is then inserted in the
hole following use of a marker in the same manner as at the proximal end.
The position of the Schanz screw is shown in Fig.4.17 j.
The long femoral distractor is then placed over the connecting bolt proximally and the Schanz screw distally. Using the inside collar screw, distraction is carried out. Rotation can be adjusted at the distal end by means of
the set screw, and when the alignment is correct the other set screws are
tightened as well. Alignment in the coronal plane may be facilitated by the
use of bolsters, as has been mentioned above. Manipulation in the sagittal
plane is possible, and the correction achieved may be fixed somewhat by
the addition of a second connecting bolt proximally. If there is more resistance' this correction may be delayed until the actual procedure has begun,
the reduction in this plane being controlled by means of a 9-mm nail inserted into the proximal fragment after initial reaming. This nail serves as
a lever arm for manipulating the proximal fragment. When this method is
used, the approach is made, the proximal fragment is reamed to 10 mm,
and the 9-mm nail is inserted. For the purpose of gaining more leverage,
the nail may be lengthened by adding the proper-sized conical bolt and
the ram guide. Usually the proximal fragment needs to be manipulated into extension, and this is easily accomplished with the improved leverage
134
Fig.4.11,
pages 153-155
Fig.4.12, page 156
afforded by the nail. When the reduction is obtained a 3-mm ball-tipped
guide wire is passed across the fracture into the distal fragment.
The intramedullary nailing procedure may progress to conclusion with only a few precautions. The first is that the initial reaming should proceed
with image control as the reamer passes the unicortical connecting bolts.
In some cases, these will need to be adjusted to allow the reamer to pass
without interference. The second precaution, applicable to all closed nailing procedures, is that the manipulation maneuver which reduced the deformity should be repeated exactly when the reaming head passes the fracture site so as to avoid eccentric reaming of the fragments.
Because the femoral distractor connects directly into the proximal and distal fragments, control of the reduction in the coronal plane is much more
reliable than on a fracture table. Additionally, in simple fracture patterns,
once the reduction is achieved, the femoral distractor may be placed in
compression, stabilizing the reduction in both planes (Fig. 4.11).
A new model of the extra-long femoral distractor will soon be available. It
has been modified from the original design by the AO Technical Commission and connects to the femur distally in the frontal plane and proximally
in the sagittal or frontal planes. It is inserted by means of guides that protect the soft tissue structures in the anterior proximal thigh. No temporary
medullary nail need be inserted to manipulate the proximal fragments, as
the proximal end has an alignment jig that aids in manipulation of the
proximal fragment as well as serving as a guide for interlocking the proximal end of the nail (Fig. 4.12).
Fractures of the Proximal Femur
Fig.4.13,
pages 157 -159
Fig. 4.14, pages 160, 161
The femoral distractor is exceedingly useful in the proximal femur, as fractures at this site are frequently comminuted and the forces working against
reduction are great. In this instance, the femoral distractor is a helpful adjunct to plate fixation, and far more versatile than a fracture table. The
techniques recommended in difficult fractures are the same as described
for plate application before reduction (p. 115) except that the femoral distractor instead of the articulating tension device is used for the definitive
reduction (Figs.4.13, 4.14).
Supracondylar Fractures of the Femur
Fig.4.15,
pages 162-164
Fig.4.16, page 165
Fig. 4.17, pages 166, 167
In most distal femur fractures the articulating tension device may be used
to regain length. In fractures comminuted over a large segment or in the
presence of osteoporotic bone, the distractor is perhaps more suitable. The
distractor is also exceedingly useful in fractures which must be treated
with a condylar buttress plate. Because of the amount of communition associated with these fractures and the lack of a fixed relationship of the distal portion of the condylar buttress plate to the bone, the distractor with
connecting bolts proximal and distal controls the reduction more reliably
than the articulating tension device, as has been described in Chap. 3
(Figs.4.15-4.17). The femoral distractor may be employed to achieve reduction with the proper anatomic axis of the femur restored as well.
135
Comminuted Fractures of the Tibial Plateau
Comminuted fractures of the tibial plateau can present a very difficult
technical problem. All too often, the first hour of surgery only sees the situation getting worse. As the fracture is exposed, the problem becomes
more complex. Free central fragments are exposed and, because of instability, may even be removed to avoid their falling out of the wound. It is
during this stage that the surgeon may have real doubts as to the wisdom
of the decision to operate upon such a fracture. The final result in these
fractures may also be disappointing. Complication rates are high, particularly those of skin slough, infection, and late settling of the reduced fracture [11].
We have found the femoral distractor to be of great value in this group of
fractures. The reduction is achieved by ligamentotaxis and provisionally
stabilized by the tension applied to the soft tissues connected to the major
fragments. In an atmosphere of control, fragments not reduced by the distraction may be reduced with a small instrument and held in place with
provisional Kirschner wires or supported by bone graft placed underneath
them. When necessary, X-rays may be obtained to assess the progress of
the case. Using distractors, less soft tissue dissection is required; in fact
such dissection is counterproductive, as the reduction is effected through
the intact soft tissues. As a result, operating time is effectively shortened
and the blood supply to the bone is preserved.
The femoral distractor is used like a jack on the same side as the fracture. It is
applied with concern for the anatomic axes of the extremities, so that when
the distraction-reduction is complete the axes are correct. The deforming
force of the femoral condyle is removed from the fractured tibial plateau.
This enables one to reconstruct the plateau with accuracy and, perhaps more
importantly, introduces relative stability in correct alignment, which allows
the surgery to be carried out in a more controlled fashion.
In lateral plateau fractures the distractor is placed on the lateral side and in
medial plateau fractures it is applied medially. In a bicondylar plateau fracture it is best to use two distractors, one medially and one laterally, as it has
been found that distraction on only one side of a bicondylar fracture produces a deformity in the opposite direction. With two distractors, knee flexion and extension may be obtained during the procedure if necessary.
Using a single anterior distractor is a possibility and is indeed the preferred method of two of us; however, with this arrangement the knee cannot be flexed or extended as needed. Two distractors used simultaneously
allow the impacted joint surfaces to be disimpacted and reduced while the
physiologic alignment of the limb is maintained. The proximal Schanz
screws are placed just in front of the respective epicondyles of the femur,
with their orientation in the coronal plane controlled by a transarticular
guide wire. The connecting bolts are inserted perpendicular to the tibial
shaft axis, using the 90° angled template. Their distal location should be
far enough away so as not to conflict with the plate that will be used to
buttress the fractured bone when definitive fixation is applied. With this
arrangement the knee may be flexed or extended 60° or so without difficulty during the procedure. This facilitates the reduction and, in some
cases, increases the surgical exposure of the articular surface.
136
Fractures of the Lateral Tibial Plateau
Fig.4.18, pages 168,
169
Fig. 4.19, page 170
The surgical approach is straight lateral, extending approximately 20 cm.
The iliotibial tract is mobilized by peeling it away from the tubercle and
the the incision is continued distally into the anterior fascia. Approximately 5 mm of adventitial fringe is left connected to the meniscus for later
reattachment. The coronary ligaments is incised to allow upward retraction of the meniscus so that the articular surface can be directly visualized.
This exposure will allow the surgeon to identify the vertical or oblique
fracture line extending from the joint surface distally into the proximal tibial metaphysis and in some cases into the diaphysis.
Further exposure is best carried out through the fracture, hinging the lateral fragment or fragments laterally to expose the depressed central plateau
fragment. When the intra-articular damage has been visualized, the femoral distractor is applied laterally (Fig.4.18).
Following reduction and bone grafting, a plate acting as'a buttress may
now be applied to the distal side of the fracture. It is contoured so that its
curve is slightly less than that of the lateral plateau metaphysis. In this
manner, when the plate is applied distally with screws, its proximal end
will spring against the mismatched contour of the metaphysis of the proximal tibia and buttress the fractured bone by pushing it upward and inward
against the unfractured medial plateau. An L-buttress, a standard narrow
DCP, or a shaped one-half tubular plate may be used, depending on the
individual fracture. Because the cortex of the tibial metaphysis is really
quite thin, when the fracture is confined to this area we choose a plate that
is also thin. Theoretically, after reduction we would like to support the articular segment with an "artifical cortex" in the region of the fractured
metaphysis; for this reason our preference has been a shaped one-half tubular plate for this purpose. One should keep in mind that this system of
reduction is carried out with relative stability afforded by the production
of tension in the soft tissues around the knee. Therefore a fixation complex that is mechanically effective and yet not bulky may be applied. Soft
tissues need only be dissected along the edges of the fracture lines. The result is stable yet economical fixation. In addition, this approach is increasingly helpful as the fracture problem becomes more difficult because of
comminution. Once fixation has been achieved and all the screws have
been tightened, the fixator and the Schanz screws may be removed
(Fig. 4.19).
Fractures of the Medial Tibial Plateau
The technique used in the operative reduction and fixation of medial plateau fractures is similar to that for lateral plateau fractures, with the following exceptions:
The medial surgical approach may be a straight and parapatellar or may
be of the "hockey stick" type, in which case the transverse limb runs parallel to the joint line. This latter approach has the advantage of proximal extension, if necessary posteromedially, to obtain a better view of the posterior medial joint line.
137
Close attention should again be paid to the soft tissues medially. The osseous insertion of the medial ligament attachment allows little if any soft tissue stripping. It is preferable to place the plate over the medial collateral
ligament instead of deep to it (Fig. 4.20).
Fig. 4.20, page 171
Bicondylar Fractures of the Tibial Plateau
In bicondylar fractures of the plateau, reduction is difficult and fixation
using two plates is suggested. This large amount of hardware is bulky,
making the soft tissues more difficult to manage. Partly because of this
and partly because of the exposure necessary, skin slough, leading to deep
infection, is a too frequent occurance. Occasionally, the infrapatellar tendon is left exposed in the wound and may become infected and require excision. For this reason, we try to avoid using two plates, one medial and
one lateral. Usually the medial side can be buttressed by a simple medial
external fixator, using one pin proximally and one pin distally. This fixator
is applied after joint reconstruction and lateral buttress plating.
With these fractures reduction through ligamentotaxis is sometimes quite
dramatic. Two femoral distractors are used, one medially and one laterally.
Distraction of both sides is carried out simultaneously. This provides control, so that a varus or valgus deformity from the distractor may be
avoided. The use of two distractors placed as described also allows the
joint to be flexed and/or extended, which may facilitate the reduction or
enable the fixation to be more easily applied.
We favor a straight lateral approach with a medial counterincision, the
length of which is determined by what must be accomplished medially.
Sometimes a straight midline approach may be used. This is perhaps indicated in older patients who may require a subsequent total knee replacement. The patellar tendon may (if necessary) be mobilized by displacing it
with its fragment if it is part of the fracture. It may also be mobilized by
osteotomizing the anterior tibial tubercle if the posterior cortex of the tibia
is not fractured in such a way as to jeopardize its reinsertion through
screw fixation. Probably the best approach is that the patellar tendon be
tendonotomized in "Z" fashion. Most frequently, however, it is not necessary to do anything special with the tendon insertion, and in this case it
should obviously be left attached to the tubercle.
Incision of the coronary ligament allows upward retraction of the meniscus, which permits control of the articular surface (Fig.4.21).
An alternative to using two distractors is seen in Fig. 4.22, and is preferred
by the Bernese authors. There is no conflict with the implants when the
distractor is applied in such an manner (Fig. 4.23).
Special Circumstances in Fractures of the Tibial Plateau
There are times when patients present with fractures of such a nature that
conventional approaches are doomed to failure. These are usually highenergy fractures with severe comminution, extensive soft tissue injury, or
lacerations of the skin overlying ligamentous or tendinous structures. In
Fig.4.21, pages 172,
173
Fig.4.22, page 174
Fig.4.23, page 175
138
Fig.4.24, page 176
Fig.4.25, page 177
these circumstances creative approaches founded on basic principles but
tailored to the individual case are needed. These creative applications of
established principles usually involve substituting an implant or explant
for what the bone lacks in a given area, a subject to be discussed in the
next chapter. Sometimes a cortical patch may be formed from a lightweight plate to provide continuity in a crushed metaphysis, at other times
an external fixator may be used as a temporary medial cortex on the side
opposite a plate. In some devastating injuries the goals can only be articular reconstruction and provisional stability through external fixation until
the healing of the tissues is achieved. The initial plan is based on the premise that the early solution is to gain coverage and wound healing. The
initial construction will be modified when soft tissue healing is complete.
More stability will be added so that physiologic motion can occur in the
involved joints.
In these circumstances the knee joints may need to be bridged initially by
external fixation frames. On other occasions the situation may demand internal fixation on one side of the plateau with an external fixator used to
buttress the other side. By this means, one may play the implant against
the external fixator to obtain the effect of having a medial buttress
(Figs. 4.24, 4.25).
Fractures of the Tibial Shaft
Fig. 4.26, page 178
Fig. 4.27, page 179
In the tibia, as in diaphyseal fractures of the femur (see p.131), the femoral
distractor acts as an indirect reduction aid, allowing simultaneous realignment of the tibial shaft and the restoration of length in an atraumatic way.
The distractor has been particularly helpful in the reduction and fixation
of comminuted shaft fractures (Figs. 4.26, 4.27). It may be used acutely or
to correct longstanding malunion or nonunion. It is equally helpful in
plate fixation and in cases suited for intramedullary nail fixation. In the
latter, application of the distractor in the proper manner may allow closed
nailing to be carried out (Figs.4.26, 4.27).
Open and Closed Nailing: The steps in using the distractor as an aid to intramedullary nailing of the tibia are essentially the same as described for
the femur (p.132), with a few exceptions. The distractor may be applied
medially or laterally, depending on the dominant displacement of the fracture. It must be applied in the metaphyseal bone far away from the fracture. Because of this, Schanz screws should be used and their position controlled by placing them parallel to the knee and ankle joint axis in the
coronal plane. This is assured by placing 2.0-mm Kirschner wires transcutaneously through the joint of the knee and the ankle. The exact location,
if in doubt, may be verified with the use of the image intensifier. The
6.0-mm Schanz screws are then inserted 1-2 cm below the joint proximally
and above the joint distally, parallel to these guide wires. It is important
that in the proximal tibia the Schanz screw is inserted in the posterior half
of the metaphysis close to the joint, enabling it to be used for distraction
and temporary stabilization without conflicting with the reaming or definitive nailing of the tibia.
139
With fractures of the tibial shaft, the advantage of the femoral distractor
over a fracture table as a reduction aid is that the knee may be flexed to
120°, which facilitates the reaming and the nail insertion by lessening the
chances of conflict with the posterior tibial cortex during the procedure.
The joints are free to move, and the leg itself is free on the operating
table.
Distraction is then carried out until the fracture is stabilized by the increased soft tissue tensions. Manual manipulation may be required to reduce the fracture in the sagittal plane, and when flexing the knee assistance may be required to pull backward on the proximal portion of the leg
to counteract the tendency for the proximal fragment to extend because of
the pull of the quadriceps as the knee is flexed.
The "pacemaker board" is utilized in order that the image intensifier may
be used as needed during operation. The AP view is obtained by extending the knee during surgery and placing the leg on the table; the lateral
view may also be obtained in this position by changing the orientation of
the C-arm. The lateral view can be monitored during surgery if the C-arm
is elevated in a horizontal orientation and focused on the fracture site as
reaming or nailing is carried out. This, however, is sometimes difficult and
requires an experienced radiology technician, and represents one of the
few compromises made in utilizing the technique (Fig.4.28).
Fig. 4.28, pages 180,
181
Fractures of the Tibial Pilon
Pilon fractures, like fractures of the tibial plateau, may be treated with
greater ease if the distractor is employed as a means of regaining tibial
length [18, 19].
The basic principles of the operative treatment of these fractures remain
unchanged: fibular reduction and fixation, articular reconstruction, bone
grafting of the resultant metaphyseal defect, and stabilization with a medial buttress plate [25]. The femoral distractor is helpful in the second and
third steps of the procedure, particulary in those cases where the fibula is
not involved with the fracture (Figs.4.29, 4.30).
The External Fixator in Reduction and Internal Fixation
of Os Calcis Fractures
A Special construct utilizing either the minifixator or the normal external
fixator has been extremely useful in the successful reduction and internal
fixation of intra-articular fractures of the os calcis. It has been employed
successfully in both central depression and tongue type fractures. However, all os calcis fractures must be scrutinized carefully, evaluating the appropriate views and, in may cases, CT scans, to understand the fracture
pattern. The goal is to identify those cases that will benefit from surgical
treatment [28].
In general, these fractures of the os calcis will have in common a "medial
separation fragment" [5, 15] which will aid in reduction orientation and
provide good cancellous bone for fixation that will be directed from lateral to medial.
Fig.4.29, pages 182,
183
Fig.4.30, page 184
140
Fig.4.31,
pages 185-188
The lateral surgical approach has been utilized for the following reasons:
First, there is a pronation deformity of the os calcis which can be dealt
with more easily from the lateral side. Second, the "separation fragment",
the sustentaculum tali, usually stays reduced to the talus because of its
strong intraosseous ligamentous connections. Most commonly the main
fracture dislocation takes place in the dorsolateral part of the posterior
facet of the os calcis. Third, the lateral approach is technically easier with
no need to deal directly with the neurovascular bundle.
The incision is liberal and curvilinear, one finger breadth distal to the inferior tip of the lateral malleolus, parallel to the peroneal tendons proximally, and extending to the base of the cuboid distally. The peroneal tendon
sheath is incised longitudinally along with its distal retinaculum. The fibulocalcaneal ligament, which forms the medial wall of the tunnel for the
peroneal tendons, is opened if necessary to deal with the fracture, if it is
not already ruptured. All of the structures are loosely repaired at the time
of wound closure (Fig. 4.31).
In addition to the adjustment of the frame to regain the external appearance of a normal heel, an intraoperative X-ray may be made to assess the
progress of the overall reduction.
The fixation of the Steinmann pin in the tuberosity of the os calcis may be
compromised because of extra-articular extensions of the fracture into this
area; surprisingly, however, even small fragments suffice to achieve
enough stability to allow the Steinmann pin to fulfill its function of regaining the length of the body of the os ca1cis and rotating the posterior tuberosity downward.
In central depression fractures, after the subtalar area is inspected, the lateral wall of the os calcis is checked along with the calcaneocuboid articulation. In the easiest type of case, the lateral half of the subtalar articular
surface is impacted. In more difficult cases, a third or even a fourth central
fragment may be present. Usually we are dealing with sagittal, longitudinal fracture lines which, when reduced, maintain the convexity of the posterior subtalar facet. The articular fragments are disimpacted and lifted up
against the intact joint surface belonging to the talus. They may be held
with a small elevator and fixed with Kirschner wires to the medial separation fragment of the sustentaculum tali, which, as has been mentioned, is
in its proper reduced position. If comminution is present and central articular fragments must be fixed, they are elevated and transfixed with small
subchondral Kirschner wires to the sustentaculum. These wires are driven
through the sustentaculum, emerging through the skin on the medial side.
They are next retrieved with a drill on the medial side and withdrawn until
they are flush with the fracture surface on the lateral side. Only now is the
lateral articular comminution (usually in conjunction with the exploded
lateral cortex) united, thus completing the reduction of the subtalar joint.
The Kirschner wires are now driven back from the medial side into the reduced lateral fragment. This completes the temporary fixation.
When the lateral wall fragment is significant, its reduction usually obviates
the need for cancellous bone grafts, as the residual defects are insignificant. This has been the experience of ourselves and others. In rare cases,
cancellous bone grafts may be required to support the reduced articular
surface.
141
Defintive fixation is carried out with screws buttressing the lateral wall
across the area of comminuted joint to the good-quality bone of the medial separation fragment. Generally, small 3.S-mm cortical screws, placed
subchondrally, are used. When comminution of the lateral cortex of the os
calcis is present, small-fragment plates, such as the AO 3.S-mm reconstruction plates or the 3.S-mm Y plate of Letournel, are used to buttress
the fractured cortex. Additionally, when comminution is significant, these
plates are needed to maintain length with regard to the tuberosity fragment and the fragment of the anterior articular process.
In tongue type fractures a similar approach is employed. The technique
differs somewhat in that when constructing the triangular frame, care must
be taken to avoid transfixing the articular fragment which extends posteriorly into the posterior os calcis, as this would prevent its later manipulation. This could conceivably happen if the pin through the tuberosity was
placed in the tongue fragment itself. The reduction of the tongue fracture
is facilitated by using a small Hohmann retractor or a periosteal elevator
as a lever.
When the os calcis is multifragmented, reconstruction of the joint between
the os calcis and the cuboid may prove to be difficult. In these circumstances small Kirschner wires inserted from posterior through the tuberosity and thus through the anterior process, transfixing the cuboid, help to
maintain the reduction. These Kirschner wires may be removed 3-4 weeks
after surgery.
After removal of the external fixation frame, stability and mobility of the
joint is verified and final X-rays are obtained. To the extent possible, the
dissected soft tissue structures are sutured. Loose closure of the peroneal
tendon sheath and the skin is carried out over small suction-drainage
tubes. A soft compression dressing is added. The leg and foot are elevated
for 72 h. Active and passive exercises are begun after 24 h. If stability is
not assured at surgery, a removable posterior split is used. The foot, however, is removed from the splint several times a day for the same exercises.
Partial weight bearing to 10 kg is instituted following the period of elevation to help prevent post-traumatic osteoporosis and Sudek's atrophy.
Although this technique has been used since 1983, no formal reports on its
long-term effectiveness have yet been published. It is our opinion that the
shape of the hindfoot can be restored to normal and maintained. Although
some motion is preserved, loss of greater than SO% of the mobility of the
subtalar joint is to be expected (Figs. 4.32-4.34).
Fig.4.32, page 189
Fig. 4.33, page 190
Fig. 4.34, pages 191,
192
The Minidistractor
The minidistractor belongs to the small fragment set of instruments. The
standard model has an excursion of 4 cm and is connected to the bone by
means of 2.S-mm Schanz screws or Kirschner wires. There are numerous
applications of the minidistractor in comminuted fractures of the small
bones (Fig.4.3S).
Fig.4.35, page 193
142
Comminuted Fractures of the Fibula
Fig. 4.36, page 194
When employing the minidistractor, it is important to realize two things.
First, excursion of the standard model is approximately 4 cm, and second,
the pins must be inserted at right angles to the shaft axis of the bone, as
there are no corrections to be made with the device itself in the frontal
plane.
The minidistractor is connected to the proximal and distal major fragments with 2.5-mm Schanz screws which are drilled directly into the bone.
Following this, utilizing the turn buckle, the spindle is lengthened. Fragments in the lateral cortex will usually serve as a guide to length, as when
the intermediate fragments will fit in the fracture gaps so produced, the
proper length has been reached. A slight amount of overdistraction is carried out and the comminuted fractures are reduced in the defect produced
and aligned to the axis of the fibula (Fig.4.36). Plating with the one-third
tubular plate may then be carried out.
Other Applications
Fig.4.37,
pages 195-197
Fig.4.38, page 198
Fig.4.39, page 199
Similarly, the minidistractor may be extremely helpful in fractures of the
hand, the olecranon, and the distal radius and comminuted fractures of
the distal humerus. The principles are similar to those discussed above for
fractures of the fibula, so only the salient points will be mentioned here.
When dealing with severe comminution of the distal humerus or olecranon, the technique may help to salvage a difficult open reduction and internal fixation. For example, a fracture of the proximal ulna with an extremely short olecranon fragment, split in the sagittal plane, associated
with fragmentation of the proximal metaphysis extending into the diaphysis may be solved using a special minidistractor with an excursion of 8 cm
(a special order item which may be obtained from Synthes). With the patient in the lateral or semi prone position, the exposure is posterior, swinging lateral to the olecranon bursa. If there is any question as to its whereabouts, the ulnar nerve may be identified proximally and proteced distally
in the region of the fracture (Fig.4.37).
The minidistractor has uses in fractures of the wrist, hand, and the foot to
overcome problems of shortening in both acute and old fractures of the
distal radius, carpals, metacarpals, tarsals, and metatarsals, and to maintain length in shattered phalanges. Figure 4.38 illustrates a method of application of the minidistractor in a comminuted distal radius fracture. Figure 4.39 is a clinical example of its application in a severe injury to the
foot.
The Minifixator as a Distractor
The minifixator, discussed in the section on the os calcis above is frequently applicable to injuries of the wrist joint. This method is described in detail elsewhere [10] and will therefore be alluded to only briefly here. The
method is based once more on reduction by ligamentotaxis of the distal
143
radius and ulna. This technique is effective in this area because of the
strong capsular ligaments, and is indicated in unstable fractures of the distal radius with comminution and impaction. The standard technique employs distraction over the wrist joint with the wrist in a neutral position, although montages may sometimes be made which do not span the wrist
joint. The fixation is made with 2.5-mm terminally threaded Schanz pins,
employed together with universal clamps which have holding sleeves for
the 4.0-mm bars and the 2.S-mm pins. In addition there are "bar-to-bar"
4.0-mm clamps with spring-loaded nuts. The connecting bars are 4.0 mm
in diameter and range from 60 to 200 mm in length. The technique in the
usual situation is to make 5-mm incisions in the skin overlying safe areas
for insertion of the pins. The 2.S-mm threaded wires are then inserted with
a small air drill using a 3.S-mm tissue sleeve to protect the soft tissues. Two
threaded Schanz screws are inserted proximal to the fracture in the radius
and two are inserted distally in the shaft of the second metacarpal. Maintaining the forearm and hand in neutral rotation, the wires are inserted at
an angle of 4So to both the transverse and the sagittal plane, avoiding the
extensor tendons. In the forearm the first wire is placed proximal to the
palpable wad of the extensor pollicis brevis muscle. The distal wire is inserted between the tendons of the abductor pollicis longus and extensor
carpi radialis brevis and longus muscles. When inserting the wires in the
metacarpal, the metacarpophalangeal joint is flexed to a right angle to
avoid the extensor hood. The thumb is held in abduction to avoid the first
web space. In the metacarpal the two Kirschner wires must be inserted
converging at an angle of Soo -60° in the bone, the points not touching
each other. This allows a longer passage in the bone and thus more stable
fixation. The two outer wires are drilled first and the connecting rod is
temporarily fixed. Placement of the two inner wires is then facilitated by
using the two inner clamps as aiming devices. After the rod is attached to
the pins and adjacent to the bone, the two distal metacarpal clamps are
fixed. Pulling on the fingers directly or by use of "chinese finger traps"
provides distraction. If reduction under the image intensifier is satisfactory, the proximal clamps with the spring-loaded nuts are tightened manually. During this phase any desired change of position can easily be accomplished. When adequate distraction and manipulation have resulted in the
desired reduction and maintenance of the fracture, a second rod is applied
2-3 em further along the threaded wires, to increase stability. Finally, the
special proximal manual clamps can be replaced by the definitve clamps.
The advantages of this method are a simple frame, easy application, economical use of materials, and stable fixation. A clinical example can be
seen in Fig. 4.40.
Summary
The distractors compose a helpful adjunctive set of instruments in trauma
and reconstructive surgery of the skeleton. They not only aid in obtaining
a reduction through the principle of ligamentotaxis, but as they do so, increase the stability of the fractured part and remove the deforming force.
By slight overdistraction, irregularly shaped fragments may be reduced
Fig. 4.40, page 200
144
and held in their place by tissue sparing forceps. Fragments that profit
from slight "over-reduction", such as central tibial plateau fractures, can
be managed more easily.
Regardless of whether or not the definitive implant for fixation of the fracture is a nail, plate, or a lag screw, it is best to plan where and how to
mount the distractor. In this way, conflicts between distractor and implant
or unforeseen problems of angulation caused by the distractor can be anticipated and therefore eliminated.
At present there are two distractors, the so-called femoral distractor which
was specifically designed for the femur and the minidistractor designed
for the hand and foot. There are also prototypes of models with modifications in length, clamp adjustability, and size. As the use of these instruments increases, other models will surely appear with further developments that will make them even more valuable.
This chapter has described only some of the situations in which the distractors are useful; there are many other occasions on which they have
been of service. The purpose here has been to acquaint the reader with the
principles of their use and their major applications. Having done that,
when those other occasions arise, the distractor will be available on the
back table.
145
Fig.4.1. A sail has no intrinsic stability; however, because of its attachments to the riggings, tension may be
applied to the sheets and the form of the sail restored.
Indeed, as long as the tension is maintained the sail is
able to withstand load and the functional shape of the
sail maintained
Fig.4.2a, b. The jack allows us to work on a
tire with the deforming force of the car removed. We can employ the same principle in
orthopedic surgery, with clear benefit in
many circumstances
b
146
Fig.4.3. The standard femoral distractor allows an excursion of 27 cm easily, although there are adjustments for
rotation, parallel relationship of connecting bolts is mandatory, as in these
models no adjustments can be made
in the frontal plane. A forthcoming
new distractor with increased length
and increased versatility by virtue of
adjustable bolt holders is shown in
Fig. 4.4
Fig. 4.4. A prototype extra-long femoral distractor. This model allows distraction of the tibia and femur for
closed intramedullary nailing and
comes with extra-long connecting
bolts and carriage holders which can
take more than one connecting bolt
147
o
Fig. 4.5. The placement of the connecting bolts should
be such that they are out of the way of the definitive implant to be used. In an open femoral nailing, unicortical
connecting bolts may allow the maintenance of reduction while reaming is carried out. In a plate fixation,
connecting bolts should be placed wide enough apart to
allow the plate to be placed inside of them, or anterior
or posterior enough so that the plates can be placed behind or in front of them. The 4.5-mm drill hole is then
made with the help of the right-angled template guides
so that it will run perpendicular to the femoral shaft
axis. The right-angled guides are found in the angled
o
blade plate set. If one has correctly assessed the relationship of the linea aspera along the general shape of
the bone (the pronounced curve of the femur along its
anterior lateral border), there will be only minor, if any,
rotational corrections to make once the distractor is applied. If the patient is osteoporotic or if a lot of distraction is to be carried out, it is best to penetrate both cortices with the connecting bolts. This tends to minimize
the deformity produced when tension is increased in the
soft tissues by distraction (with a lateral application a
varus deformity occurs). Penetrating both cortices with
the connecting bolts also helps to prevent pullout
148
a
b
c
149
<II Fig.4.6.
a As the forces in distraction become higher
there is a tendency to straighten out the femur at the
fracture site. This will lead to a less than pleasing appearance of the thigh and also leave a posterior gap at
the fracture site. There are two ways in which the normal anterior bow of the femur may be preserved during
distraction. b The first and preferable way is to place a
bolster posterior to the thigh during distraction, allowing gravity to produce a slight anterior angulation while
distraction is carried out. c The second way is less acceptable as it requires more dissection. When forces are
high, however, such as in the lengthening of an old frac-
Fig. 4.7. The use of a one-halftubular plate as a temporary splint to
hold fracture reduction while interrnedullary nailing is carried out.
A one-half tubular plate is particularly well suited to this purpose, as
its edges will bite into the cortex of
the femur. Therefore, when pressure is exerted on the plate with the
Verbrugge clamps, the edges bite
into the bone, creating some additional rotational stability. Although
this is an effective technique, it requires more bone exposure and
therefore it is more advisable to use
the unicortical connections for the
bolts and the femoral distractor itself to maintain the reduction
ture malunion, it is sometimes necessary. Using the
bending press, a concavity is produced in a narrow 8- to
10-hole DCP with a curve distributed along its entire
length. With careful dissection, the plate is slid onto the
anterior surface of the femur and held in place proximally and distally with large self-centering Verbrugge
clamps. Distraction is then carried out. The plate in this
case acts as a tract along which the fragments glide as
the distraction forces are applied, and the anterior bow
of the femur is preserved. Obviously, the price for such a
tactic is high as more soft tissue dissection is required
150
a
Fig. 4.8. a If plating is to be definitive, and the fracture
pattern is simple, compression from the femoral distractor is not enough. The bone fragments may be compressed in this circumstance, but the implant has not
been preloaded. Fixation of the plate should be obtained by means of a screw or screws to one side of the
fracture, and the articulating tensioner should be applied to the other end of the fracture 2-3 cm from the
end of the plate. The adjustable hook in the device is
then placed into compression mode and tension is
placed on the plate until appropriate load (in or beyond
the red zone in the femur) has been reached. Before this
is accomplished, the femoral distractor should have
been removed, or if it is still in situ it should be maximally compressing the reduced fracture so that it is taking no load. The plate is maximally tensioned with the
tensioner, and lag screws and plate screws may be inserted. A lag screw across a fracture is extremely important to increase stability. b In this case the fourth screw
hole from the left has been used for a lag screw to cross
the fracture. If there has been bone loss opposite the
plate or a significant devitalization of the fracture zone
from the original injury or surgical technique has been
faulty, a cancellous bone graft should be added. It may
be applied to the opposite side through the fracture during the distraction stage
151
Fig.4.9. a A 25-year-old female with a severely comminuted femoral fracture sustained in a motorcycle accident. At the present time this type of injury would best be handled by an interlocking nail. b Immediate postoperative X-rays showing internal fixation of this difficult fracture with a plate
and lag screws. The medial aspect of the femur was not visualized, bone
graft was not used, and reposition of the fracture fragments along the medial cortex was accomplished indirectly by use of the femoral distractor. c Six
weeks later. Note the radiographic appearance of a softening of the bone in
the region of the comminution. This is a sign of vascularity, evidence that
the fragments are alive. The patient at this time was with 10 kg weight bearing on the left lower extremity. d Approximately 5 months post fracture.
There is a slow washing out of the previously sharp fracture lines and osseous welds are noted in the area of the viable comminutions. e Eight months
post injury. The fracture is healed and undergoing remodeling. f The fracture, almost 2 years old, is in late remodeling. The cortices are once more
established. g Two years eight months, after metal removal. The screw
holes have all but filled in. This case demonstrates the principles of indirect
reduction with maintenance of viability of the medial cortical fracture zone
and healing without a bone graft secondary to preservation of the vascularity of the medial aspect of the femur
lY Ul Ule;; llle;;Uldl d~Vt:l.'l UI Ule;; le;;lllUl
152
Fig. 4.10 a-e. A 27-year-old female involved in a motor vehicle accident. a, b Complex injury to left femur including a
transcervical fracture and comminuted segmental fracture of
mid shaft. The fractures were
closed. c Open reduction and
screw fixation of the femoral
neck followed by indirect reduction with the femoral distractor and plate fixation. Again
the medial aspect of the fracture
was not seen. No bone graft
was used. The distractor was
applied anterolaterally. d Mter
8 months the fracture lines have
consolidated, and are slowly
fading away. e Follow-up at
1Vz years: bony union has taken
place
153
Fig.4.lla-d, legend ~cc page 154
154
Fig.4.11a-o. A segmental femoral fracture in a 13-year-old boy.
He was treated for 2 weeks in traction but an acceptable position
could not be obtained and he was transferred to our hospital. We
chose to perform intramedullary nailing. a, b AP and lateral views
before operation. c Here the extra-long femoral distractor is seen.
Note the new carriage holders and the extra-long connecting bolts.
Lateral position on the table with bolsters such that good AP and
lateral control with image intensification may be carried out. d This
is a different case, showing that the old femoral distractor can likewise be used; however, its length precludes distracting from one
end of the femur to the other. e Clinical photo at the time of passing the guide rod. Note the inside collar screw, which is tightened
in distraction, and the addition of counterpressure anteriorly by
means of a mallet. The fracture focus is being viewed with the image intensifier. f First graphic image: the point in the operation depicted by the previous clinical photo. g A view of the distal Schanz
screw showing it at right angles to the femoral shaft axis and above
the physis. h A view of the proximal connecting bolt as the 9-mm
end-cutting reamer passes down the 3-mm guide rod. Note that the
bolt projects too far into the intermedullary canal and has impinged
on the reamer. i The connecting bolt has been backed out so that it
is no longer making contact. Reaming can now be carried out.
j, k AP and lateral views of the femur a month post procedure
showing early callus formation. I, m Healed fracture with nail in situ. n, 0 Final AP and lateral X-rays showing healed femur with nail
removed and no abnormality at the femoral neck
155
156
Fig. 4.12. The current model of the femoral distractor.
This new prototype will allow distraction, interlocking,
and manipulation of the proximal and distal fragment
of the femur in all planes
Fig. 4.13. a Drawing of a comminuted fracture of the
subtrochanter region of the femur, extension into the
proximal shaft. b A tracing of the good side. c The
good side with the fracture lines drawn in. This was accomplished in the same manner illustrated in Fig. 3.34.
d The drawing must include the reduced head, neck,
and trochanteric aspects of the proximal fragment. The
implant overlay is then adjusted such that the entry
point is on the surface of the lateral aspect of the greater
trochanter about 1.5 cm from the tip and the blade is directed into the inferior quadrant of the head. The second hole of the plate will be used for the insertion of the
connecting bolt or Schanz screw in order to attach the
femoral distractor. This is drawn in place with the
Schanz screw perpendicular to the long axis of the
plate. e The distal fragment is also drawn, with the connecting bolt at right angles to the femoral shaft and well
away from the fracture focus so that the plate can be at-
tached to the shaft and "tensioned" proximal to the dis- ~
tal connecting bolt. f The proximal fragment and the
distal fragment are then adjusted in length in the same
way as would occur with the femoral distractor during
surgery. At this time incorporation of the comminution
of the segment may be carried out. Because the femoral
distractor is being used, the level of the second hole of
the plate should be scrutinized closely to see if there is
good bone opposite it. The second screw-hole of the
plate is the ideal location for the connecting bolt, as the
first screw-hole then remains open for a fixation screw.
The first screw is a very important screw that engages
the calcar in the proximal fragment. If the proximal
fragment is too short medially, however, the first screwhole in the plate may be the only possible place to fix
the proximal connecting bolt. If that is the case, a new
direction of the fixation screw or 6.5-mm cancellous
screw will be needed. When a 6.5-mm cancellous screw
157
Tracing of good side - - Tracing of good aide
rracing of fractures - - - -
I
"
1\
II
I
, ; , .... __ -
I
I ,
"
J
'
\
\I
I
I
I
I
I,
"
I \
-
a
d
is inserted in the hole after the femoral distractor is removed, good fixation can still be obtained in the calcar.
It is reiterated that during planning, if, in reducing the
plate portion of the blade plate to the shaft, varus or too
much valgus appears in the drawing in the frontal plane,
then the step for location of the seating chisel must be
b
"i..' ...1, \
c
e
redrawn until the final position is satisfactory. This new
data must be incorporated. The case itself differs from
the description in the previous chapter (Fig.3.34) only
insofar as the distractor is used as the reduction instrument.
158
g The fracture is exposed and an anterior caps ulotomy
of the hip is carried out, exposing the femoral head and
neck. The seating chisel is inserted, guided as usual by
Kirschner wires. Control of the three planes of reference
is obtained as has been described earlier (Fig. 3.34). The
95° condylar plate is then introduced, and, using the
drill guide, a 4.5-mm drill hole is made in the lateral cortex at right angles to the second hole of the plate. The
connecting bolt is inserted. If it is too short, a 5.0-mm or
6.0-mm Schanz screw may be substituted. Usually, because of the forces required, both cortices are engaged,
although this is not always necessary. The full extent of
the lateral mailbox approach is then developed to allow
the plate portion of the blade plate to be brought along
the lateral cortex of the unreduced fracture and applied
to the main distal fragment. The distal hole for the connecting bolt is next made in the location determined by
the preoperative plan. The bolt is inserted and the distractor attached. h A large Verbrugge clamp is placed
on the plate, making a small opening in the medial soft
tissues for the bone-holding arm of the clamp. The
broader plate-holding portion is placed on the plate and
the clamp is snugged up until it is stable. Depending on
the length of the fracture, one or more extra clamps may
be necessary and are inserted in a smiliar manner. At the
level of the subtrochanteric fracture, it is usually helpful
to place a standard reduction clamp straddling the plate,
with one jaw on the anterior surface of the femur and
one on the posterior cortex. This clamp may be adjusted
as distraction is carried out by placing one of the jaws
on the edge of the plate and the other against the respective anterior or posterior cortex. This allows a little
adjustment of rotation as reduction is carried out with
distraction. The rotation can then be fixed by the wing
nut on the femoral distractor. When the fragments have
been inserted and the rotation is correct, a pointed reduction clamp is carefully inserted through the soft tissue and closed against the medial fragment. The clamps
are fully tightened to restore and maintain the alignment. The plate in this case acts as a splint to restore the
alignment in the frontal and sagittal planes. The distraction is slowly released by spinning the collar screw in
the reverse direction. When it is loose the col\ar screw
on the other side may be tightened to compress the bone
fragments together. As this is accomplished, the comminuted fragments previously reduced are impinged upon
159
the other fragments, compressed, and stabilized. If the
clamps cannot control these fragments at this point, the
fracture may be redistracted, reduction regained, and
cerclage wires placed very carefully around the plate
and comminuted fragments in the area where clamps
were previously unsuccessful. The compression stage is
once more carried out and, as noted earlier, the external
tensioner is placed off the end of the plate. Preload is
then added to the plate. The femoral distractor must remain in compression during this time so that it allows
the load to be taken by the bone and does not itself
share the load. It is our experience in fractures of the
i Fixation montage as a buttress plate. j Fixation
montage if axial load has been generated and
maintained. If the plate is used as a tension band
plate, lag screws are inserted in the location previously occupied by the pointed reduction forceps
femur that in the normal case enough preload should be
applied to allow the red ring to be completely covered
by the collar, i.e., over 100 kp of load. A little time
should be allowed to pass while general wound care is
attended to. This will show whether the force generated
by tensioning will dissipate. If it does, the compression
should be regained with an open-end wrench until it is
maintained over a period of time. If it is impossible to
preload the plate, this indicates that the deficiency exists
in the bone buttress and the plate can only be used as a
buttress plate. In this instance success depends on the
viability of the fragments.
160
z
"co
I
cr
QI)
o
161
NK 5-28-81
Fig. 4.14. a, b Preoperative X-rays of a closed comminuted subtrochanteric femoral fracture with trochanteric
extension in a 28-year-old Caucasian male. The fracture
was operated on very shortly after admission. The femoral distractor was used along with the plate as a reduc-
tion aid. c, d Postoperative control at 6 months showing
all fractures healed. Note use of 6.5-mm screw in site occupied by connecting bolt. e, f The patient subsequently
had his plate removed and returned to his previous employment as a laborer
162
Fig. 4.15. a A severely comminuted fracture of the distal
femoral shaft extending into the supracondylar and intracondylar area. The articular segment has been reconstructed and fixed. The blade plate has been inserted as
described in Fig. 3.32. The connecting bolt has been
placed in the first hole of the plate, and the femoral dis-
tractor has spanned the comminuted area and portion
of the femoral shaft to be plated. The plate is attached
to the proximal fragment by means of a Verbrugge
clamp. b Using a small instrument, such as a dental
pick, comminuted fragments with their soft tissues attached are gently teased into approximate reduction.
163
c As the comminutions are brought into the plate, they
are fixed by means of a large pointed reduction forceps .
Rotation of the plate is controlled by a standard reconstruction clamp as shown. d As the fragments are assembled using the plate as a scaffolding, a decision must
be made as to whether or not the fracture pattern will al-
low the application of preload. If the pattern is such that
preload may be applied, the articulating tension device
must next be attached to the end of the plate and tensioning of the plate carried out. Following this, lag
screws may be inserted.
164
e The final montage for a case in which axial preload
was not possible because of too much comminution. In
some cases preload may be quite impossible and the
plate should be used in the pure buttress mode. f The
final montage for a case in which axial preload was possible. Lag screws are inserted at the location previously
occupied by clamps
165
Fig. 4.16 a-f. A highly comminuted diaphyseal metaphyseal fracture of the left
femur in a 27-year-old male.
a Preoperative X-ray in frontal plane showing extensive
comminution extending to
the low medial metaphysis.
b, c AP and lateral views
shortly after operation. The
fracture has been fixed with
an angled blade plate which
was applied utilizing the
femoral distractor. The comminuted area has been bypassed, although a careful
bone graft was carried out at
the time of the original surgery. d, e At 6 weeks, early
consolidation is seen. This
patient was mobilized from
the first postoperative day.
f At 1 year, full constitution
of the medial cortex has occurred and remodeling is
taking place
166
167
Fig. 4.17 a - j. A severely comminuted supracondylarlintracondylar fracture in an 80-year-old Caucasian female. a, b The fracture was a grade 2 open injury. There
was a coronal split in the condyles, as can be seen in the
lateral view. c Intraoperative X-ray showing the use of
the femoral distractor proximal and distal to the condylar buttress plate. The distal Schanz screw is inserted in
the subchrondral bone at the distal aspect of the joint in
the notch of the buttress plate. A proximal connecting
bolt is inserted in the shaft away from the intended implant. Reconstruction has been carried out with cerclage
wires because of the extensive "barrel staving" type of
fracture lines. Despite the use of cerclage, the medial
aspect of the fracture was not visualized. No bone grafting was carried out. d, e Immediate postoperative result. f, g X-rays at a little over 6 weeks show a softening
of the fracture zone with early callus formation along
the medial buttress. There is no evidence of loosening of
the fixation. h, i The fracture seen at 8V2 months. There
is complete healing of the comminuted area with preservation of knee function and overall good alignment of
the patient's lower extremity. j The artist's illustration of
the use of the femoral distractor in combination with the
condylar buttress plate. In order to avoid axial malalignment of the distal articular fragment the distal Schanz
screw is placed perpendicular to the femoral shaft axis
or at 5° varus to the end of the distal femur (in the
joint), relative to the frontal plane. Early application of
the condylar buttress plate allows it to substitute for the
broken lateral cortex
168
Fig. 4.18. a The placement of the femoral distractor on
the lateral side of the femur for a lateral plateau fracture. It is placed approximately a finger breadth in front
of the lateral epicondyle on the distal femur and anywhere below the implant and the midline of the sagittal
plane at right angles to the tibial shaft. Proximally, a
2.0-mm guide wire is placed intra-articularly so that it
rests against the ends of the femoral condyles in the
frontal plane. Using this as a guide and reference, a
4.5-mm drill hole is made just anterior to the lateral
femoral epicondyle. b Using the T-handled chuck from
the external fixator set, a 6.0-mm Schanz screw is inserted into the lateral femoral epiphysis. The more porotic
the bone, the deeper into the condyle the screw must be
inserted. The Schanz screw is checked manually for sta-
bility. Distally, a point on the lateral surface of the tibial
diaphysis is selected that is sufficiently beyond the distalmost aspect of the fracture to allow the definitive implant to be applied without fear of conflict. A rightangled guide is oriented to the surface of the bone and a
drill hole of 4.5 mm is made through the cortex. In most
cases, the drill hole need not be continued completely
through the opposite cortex, but should be made such
that the end of the Schanz screw will have a fixation
point on the intramedullary surface of the internal tibial
cortex. It is helpful when placing the Schanz screws to
keep them as parallel as possible in the horizontal plane,
as less correction in rotation will then be needed. If the
bone stock is good, a connecting bolt through only one
cortex is used.
169
c A distractor is then applied, sliding its connectors over
the Schanz screws or connecting bolts. Next the inner
collar is turned along the threaded part of the spindle,
thus providing a distraction force. Since the force is situated laterally, the effect will be to lift the lateral femoral
condyle out of the fracture plateau, simultaneously correcting the malalignment by setting the joint on its medial side and approximating the major plateau fragments
with ligamentotaxis. With the distractor so positioned,
the articular surface may be inspected. At this point it
may be helpful to flex the patient's knee to facilitate the
view into the posterior portion of the joint. The joint
fragments may be elevated and reduced with a small instrument. They may be held in their respective positions
by a supporting sub condylar Kirschner wires. Usually
as a next step bone graft is obtained and placed in the
defect beneath the elevated plateau. It should be impacted so as to provide a dense support that will prevent
late settling. The lateral fragment that had been swung
open to provide access to the central portion of the joint
is next closed, checking once more the articular reduction. At this time it may be desirable to remove a little of
the distraction force so that the lateral hinge fragment
can be reduced to the central articular fragments
c
170
Fig. 4.19. a Four views of the knee joint showing a lateral tibial
plateau fracture with central articular impaction. The injury was
sustained while skiing. b Surgery was carried out the same day.
Through a lateral approach the fracture was exposed and a
femoral distractor applied. This intraoperative view shows distraction on the lateral side of the joint. The articular reduction
has been carried out and provisionally fixed with a Kirschner
wire. I will be supported by bone graft and buttressed by a
plate. c Immediate postoperative X-ray illustrating the reduction obtained. The fracture is buttressed by a one-half tubular
plate. d X-ray control 1'l1 years later show maintenance of the
reduction along with an excellent joint space. The patient's recovery has been complete and she functions normally
171
c
Fig. 4.20. a This illustration shows the location for the
distraction bolts as seen from the medial side. The proximal Schanz screw is placed just anterior to the medial
epicondyle and parallel to the end of the distal femur.
The distal bolt is placed at right angles to the tibial axis.
b Distraction is carried out, reducing the femur upward
and onto the intact plateau. c The distractor may be
used intermittently during the procedure to aid in both
reduction and visualization of the articular surface
172
Fig.4.21. a With bicondylar tibial plateau fractures two distractors are used, applied as shown
in the preceding figures, one lateral and one medial. Simultaneous distraction frequentl y results
in reduction and avoids producing a deformity
in the opposite direction, which would occur if
only one distractor were used. The use of two
distractors greatly facilitates the reduction of the
usual bicondylar fracture pattern; however, posterior fragments are the exception: these are aJways troublesome as they are not easily controlled by direct vision except with prohibitive
soft tissue stripping. Such fragments are best
handled indirectly by distraction accompanied
by proper positioning of the knee in flexion or
extension. b Approximation of the reduction is
carried out through distraction. Final reduction
173
o
e
is carried out by means of reduction forceps and a small
instrument. Provisional fixation of Kirschner wires may
be helpful in order to sequentially stabilize the comminuted joint surface. c Undercontouring of a half-tubular
plate allows its application inferiorly on the distal fragment as shown in the drawing. It can be seen that the
plate functions purely as a buttress, helping to stabilize
the joint surfaces. A figure 8 tension band wire over the
anterior tibial tubercle fragment and the distal tibial
metaphysis is frequently helpful in order to counteract
the extension moment produced by the quadriceps tendon on this fragment. This has been a mechanically effective yet economical way to increase the stability of
the fixation. d The provisional Kirschner wire fixation
is replaced by definitive stable internal fixation by
means of lag and plate screws. Recently we have attempted more and more often to replace a buttress plate
on the medial side of the fracture with an external fixator: shown here is a three-hole one-half tubular plate
substituting for the broken medial cortex. We try to
avoid the use of bulky implants on both sides of the
proximal tibia. e The fixator located on the medial side
has the advantage of providing a buttress without impinging on the medial ligamentous structures. In a few
cases it may be applied without a formal medial exposure. It is placed in the subcondylar bone proximally
and at right angles to the shaft distally. The fixator itself
is locked in buttress mode
174
a
b
Fig. 4.22 a, b. Alternative anterior method of montage of
the femoral distractor in bicondylar tibial plateau fractures. A proximal Schanz screw is placed in the midline
in the distal femur proximal to the patella. Distally the
connecting bolt is placed at right angles to the tibial
shaft axis away from the fracture. Distraction is then uti-
lized to reduce the fracture, which may be approached
medially or laterally as demanded by the circumstances.
This montage allows distraction without the production
of a varus or valgus deformity; however, the knee obviously cannot be flexed during the procedure, which is
sometimes a disadvantage
175
Fig.4.23 a-f. A 44-year-old man involved in a motorcycle accident sustaining bilateral tibial injuries. That on
the right was a bicondylar tibial plateau fracture,
closed. a, b Before operation. c Intraoperative control
with two distractors and a Kirschner wire across the
joint. Note that regaining the correct length reduced the
fracture. The underbent one-half tubular plate is in a
load position. d Intraoperative control with definitive
fixation. e, f Follow-up 18 months later. Full use of extremity with full motion
176
a
b
Fig. 4.24. a An example of a type of injury requiring a
special approach because of compromised bone and
soft tissues. It is a comminuted proximal tibial plateau
fracture extending into the tibial diaphysis. b, c The approach is one of articular reconstruction and fixation
with a simple lag screw followed by spanning the knee
with moderate distraction provided by an anterior unilateral frame in order to stabilize the soft tissues by Jigamentotaxis. Half-pins are utilized away from the tibial
c
fracture focus, so as not to limit possible more definitive
fixation in the future. An additional advantage of such a
construct is to allow elevation of the limb, as the frame
may be utilized to support the injured extremity in a position higher than chest level. When the soft tissues have
healed, in 2-3 weeks, either the frame may be broken
down and reapplied beneath the knee joint so as to allow motion, or internal fixation may be employed as a
delayed secondary procedure
177
Fig.4.25a-j. A 26-year-old man with an open grade 2
comminuted tibial plateau fracture with extension distally into the diaphysis. a, b Before operation. c, d The
initial treatment consisted of irrigation and debridement
of the open wounds, articular reduction, and fixation
with two lag screws and a Kirschner wire, followed by
the application of a half pin frame external fixator anteriorly. e, f At 6 weeks the patient was taken back to surgery, where the anterior frame was disassembled and the
patient had a lateral plate fixation with a medial exter-
nal fixator as a buttress. He was then started on physical
therapy with an active knee range of motion exercises.
g, h At 4 months the medial fixator has been removed,
the patient's range of knee motion is 130° to full extension, and there is consolidation of the comminuted
fracture area. i, j Final radiographs at approximately
1112 years after the accident. Healing in complete knee
motion is full
178
Fig. 4.26. a Example of a comminuted diaphyseal fracture of the tibia with displacement and shortening. In
such a comminuted fracture the distractor is extremely
helpful. b The connecting bolts are inserted proximal
and distal to the fracture, or to the fracture zone when
comminution is present. The bolts are placed into the
shaft at right angles to the shaft axis with the help of the
right-angled guide. Rotation is controlled with an attempt to make the connecting bolts as parallel as possible in a horizontal plane. Although correction of rotation is possible with the distractor after the bolts have
been inserted, major corrections demand that the distractor become skewed, which make it a little more difficult to work around during the subsequent reduction
and fixation steps. The distractor is best applied medially, anteromedially, or anteriorly, thereby circumventing
penetration of the muscle compartments. Displacement
of the fracture, choice of surgical approach, and method
of fixation all playa role in deciding the best location
for the distraction bolts. As described an extra-long femoral distractor is available which allows one to insert the
connecting bolts with a greater span between them.
General principles for distraction, reduction, and plate
fixation are similar to those presented in discussing the
application of the distractor in fractures of the femur
(Figs. 4.3 -4.9) except that the distraction need not be
carried out over a bolster as the tibia is a straight bone.
These steps will not be reiterated here. Medial application of the plate is desirable, as no important blood vessels enter the medial face of the tibia along its subcutaneous border and the anteromedial counter of the
tibia is much more accessible and easier to fit with a
plate. However, the condition of the soft tissues and the
nature of the fracture pattern and displacement also
playa role in this decision. Only those screws necessary
for interfragmentary fixation or implant fixation should
be utilized
179
Fig.4.27a-f. A 38-year-old Caucasian male with a grade 2
open tibial fracture associated with polytrauma and fractures
of the ipsilateral femur and femoral neck. All fractures were
treated by the methods described in this book. a, b AP and
lateral views of the left lower extremity fracture before operation. c, d Postoperative control of the fracture a year later.
The patient has full weight bearing on this extremity and full
motion of his knee and ankle, and has returned to work.
Looking closely one can see the holes proximally and distally
where the distractor was applied. e, f Control at 2 years. The
patient at this time elected not to have his implants removed
180
\
Fig. 4.28. a, b Front and side views of a tibia in which
the femoral distractor is applied to regain length in a reduction. Note that the Schanz screws are placed at right
angles to the tibial shaft axis and proximally in the midportion of the bone. The operation is performed on a radiotranslucent table with "pacemaker" extension, monitoring the procedure with image intensification.
c, d Length and alignment are restored by use of the
femoral distractor in the sagittal plane. Pressure on the
proximal fragment is exerted by the assistant to over-
come its tendency to extend with knee flexion. Note that
the proximal position of the pin allows medullary reaming and subsequent nailing to be carried out without interference. Distally the Schanz screw must be removed
before final impaction of the nail. e Completed nailing
is illustrated. The advantage of this approach is the increased knee flexion that may be obtained when using
the distractor. The disadvantage is that image intensification control is difficult to obtain in the lateral view
181
e
182
a
b
Fig. 4.29. a Front and side views of a comminuted pilon
fracture in which the fibula is intact. b The connecting
bolt is applied proximal to the fracture in a location
where it will not interfere with the definitive fixation.
An attempt is made to place it at right angles to the tibial shaft axis utilizing the right-angled template from the
angled blade plate set. It may be placed through one or
two cortices, depending on the situation. Distally, after
the standard operative approach is extended 1 cm and
taking care to protect the posterior tibial tendon and the
neurovascular bundle, a careful anterior capsulotomy of
the ankle joint is performed so that the talus at the end
of the distal tibia is visualizable. Just behind the rim of
cartilage that extends medially from the articular surface
of the talus and just in front of the medial malleolus and
slightly proximal to the neurovascular bundle, a 4.S-mm
drill hole is made in the talus parallel to its articular surface. The drill hole is made to the other side of the talus
but not through the opposite cortex. Into this drill hole
the long end of the connecting bolt or S.D-mm Schanz
screw is inserted. The distractor is then connected and
distraction is carried out. Usually it is best to place the
leg on a bolster so that the distal tibia is supported up to
the prominence of the heel. c, d The talus is distracted
below the exposed articular surface, which may then be
explored from below as well as from above, proceeding
through the fracture gaps. Distraction is obtained or released as needed so that in the end the articular reduc-
183
d
e
tion may be obtained and temporarily maintained with
Kirschner wires. Use of the large as well as the circular
pointed reduction forceps facilitates the repositioning of
these articular fragments. e With preliminary Kirschner
wire fixation holding the fracture, the distraction force
can be increased so that the articular reconstruction can
be viewed directly, fracture faults being probed for stepoffs with a dental pick. If the reduction is less than desirable, the distraction may be released and an attempt
made to improve the situation, using the top of the talus
as a template. These steps may be repeated as necessary. f Once the articular reconstruction is correct, de-
finitive fixation may be carried out after cancellous
bone grafting of the defect. Because of the intact soft tissues in the area of the metaphysis, a relatively light medial buttress plate is being used by us more and more as
an "artificial cortex" to support a comminuted area of
the metaphysis. Depending on how far the fracture lines
extend proximally from the metaphysis, a cloverleaf
plate or a one-third or one-half tubular plate flattened in
its distal aspect has been used with good success. If
there is a significant diaphyseal extension with short oblique or transverse fracture lines, the 4.5-mm narrow
DCP, as described earlier (Figs. 3.2-3.5), is indicated
184
Fig. 4.30 a-g. A distal intra-articular tibial fracture in a
28-year-old metal worker who fell while at work.
a-c AP, oblique, and lateral views before operation.
Note the proximal extension of the fracture lines from
the tibial crest to the articular surface. d, e AP and lateral views following reduction and fixation of the fracture.
The femoral distractor was utilized and a one-half tubular plate extending proximally was employed as the de-
finitive implant. This implant was chosen because the
upper portion of the fracture consisted of a torsional
fracture line amenable to leg screw fixation, while the
crushing of the metaphysis would be well supported by
an implant of this dimension. f, g The fracture a little
more than 1Vz years after the accident. The patient has
occasional lateral ankle pain, but motion is excellent
185
Fig. 4.31. a A central depression fracture of the os calcis
with loss of joint congruency and Bohler's angle. b The
goal will be to reestablish the three poles of the os calcis,
as described by Emile Letournel, and Bohler's angle by
use of a triangular frame. c Illustration of the foot and
ankle from the lateral side. The incision is liberal and
curvilinear one finger breadth distal to the inferior tip of
the lateral malleolus, parallel to the peroneal tendons,
and extending to the base of the fifth metacarpal. The
sural nerve is protected. The peroneal tendon sheath is
incised longitudinally along with its distal retinaculum
and the tendons subluxed anteriorly. The fibular calcaneal ligament which forms a medial wall of the tunnel
for the peroneal tendons is incised and tagged, if it is
not already ruptured. The fat pad is dissected from the
sinus tarsi, hinging it anteriorly along with the short toe
extensors so that the anterior process and calcaneocuboid joint can be visualized. All of the structures are
loosely repaired at the time of wound closure. The authors have used two types of frames over the evolution
of this technique; however, the principles of their effectiveness are similar. d An external fixator is mounted in
a triangular configuration. This illustration shows a
standard external fixator which is available in most hospitals.
186
f
e One of the authors prefers the mini external fixator in
an "L" configuration because it uses 4.0-mm pins and is
less bulky. f The triangular or L-shaped frame accomplishes several things. First, by connecting the transfixion pins to the tubes or bars of the frame, proper orientation of the fragments is obtained (varus and pronation
of the tuberosity fragment is corrected). Second, by
lengthening the legs of the triangle, proper length is regained. Third, by increasing the distraction laterally the
subtalar joint may be opened a little to allow visualization from the lateral side of the medially reduced sustentaculum tali fragment. This fragment remains reduced in most cases because of its strong intraosseous
ligaments and capsular attachment to the talus. Fourth,
this configuration of the fixator allows for a preliminary
fixation of the fracture fragments with good visibility.
Finally, effective definitive internal fixation, which can
be minimal in amount, is applied. During the procedure
the distraction force is applied and released as needed.
At the end of the case the frame is removed. g Three
4.5-mm Steinmann pins are inserted, the first two
through stab wounds in the skin and the third under direct vision into the cuboid at the distal end of the
wound. The first Steinmann pin is placed at right angles
to the tibial shaft axis approximately 10 cm proximal to
the ankle joint. The stab wound is made and, if using a
standard external fixator a 4.5-mm drill bit and its corresponding drill sleeve is employed. The Steinmann pins
are then placed in the T-handle chuck and inserted into
the bone. After careful inspection of the area of the posterior distal portion of the os calcis, the second Steinmann pin is inserted perpendicular to the long axis of
the posterior fragment through the tuberosity. In practice this may be determined by palpation of the heel
fragment. The drill hole is made with a 4.5-mm drill and
drill guide, being careful to pass through an area of cancellous bone posterior and distal enough in the tuberosity to ensure avoidance of the medial neuro-vascular
bundle and to stay out of a tongue extension if there is
one. The third 4.5-mm pin is inserted after drilling a
hole under direct vision through the cuboid, passing as
horizontal as possible yet of necessity upward medial
187
through the navicular and exiting superior to the neurovascular bundle. Two adjustable clamps are placed on
each pin, and matching bars of the appropriate length
are passed through each of the tube-holding ends of the
clamps. The clamps are snugged but not tightened. By
manual traction or, if a standard external fixator is used,
with the tension device, each of the limbs of the triangular structure is lengthened and the triangle is made symmetrical. When length has been regained, the assistant
tightens the clamps definitively. At this stage, the procedure usually restores two poles of the os calcis. A disturbing disorganization of fracture fragments becomes
recognizable with almost normal anatomic landmarks
except for the hole underneath the talus. The subtalar
region will still need reduction, as centrally the articular
surface is markedly impacted into the underlying bone
below the posterior facet of the talus. Before reducing
this by digging it out of its impacted position, it is good
to check on the location of the sustentaculum tali fragment, which will be the medialmost fragment in the region and, as the joint is further distracted, will move
with the underlying joint surface of the opposing facet
of the talus. This is the important landmark to which
other fragments must be reduced.
h
anterior
facet
middle
facet
.......--initial
Fx-line
b : blo ws-out
lateral wall
posterior
facet
h In this view we look down the axis of the lower leg at
the os calcis. We see a "schematic" central depression
fracture with the initial fracture line, the primary fracture line, the joint depression fracture line, and the subtalar depression fragment that causes the lateral wall
blowout. i The fractures as they are displaced. The depression of the subtalar joint cannot be shown well on
this view. j Placing the pins, viewing the heel from
above the long axis of the os calcis aligns to the junction
of the 3rd and 4th metatarsals. Rotation is not appreciated in the drawing; however, it can be appreciated
clinically, and the tuberosity pin is placed by reference
to the plantar surface of the heel.
joint depression
Fx-line
188
k
k Aligning the pins in the frame and lengthening the
axis of the triangle corrects the alignment and reestablishes length. The third pole of the os calcis (thalamic
pole) is reduced by elevating the depressed subtalar
fragment. In this drawing the subtalar fragment and the
lateral wall fragment are still displaced. One observes
that looking from lateral over the depressed thalamic
portion of the bone it is easy to see the sustentacular
fragment. 1, m After elevating the subtalar articular surface, the lateral wall fragment is closed and definitive
fixation is carried out. The small Y plate of Letoumel is
perfect for such a fracture, but in this case with a large
medial separation fragment (sustentaculum tali fragment) a 3.5-mm reconstruction plate is used
Fig. 4.32 a-g. A comminuted, central, depression type
os calcis fracture in a 30-year-old man. a-e AP, lateral,
oblique, and axial views before operation. The fracture
involves the lateral half of the subtalar joint with the primary fracture line continuing through the anterior process to the calcaneocuboid joint. There is loss of
Bohler's angle, as depicted in Fig.4.31 a. There is also ~
comminution of the lateral wall and a fracture into the
anterior process. The fracture of the tuberosity is more
extensive in this actual case than in the diagrammatic illustration (Fig.4.31).
189
f, g Postoperative X-rays showing the reconstruction of the subtalar joint and
lengthening of the os calcis with fixation by
means of subchondral lag screws and
maintenance of length by a 3.5-mm reconstruction plate. Bohler's angle and congruency of the subtalar joint have been restored. There is a step-off at the calcaneocuboid joint. Unfortunately this patient
was lost to follow-up. The case is presented
to show the potential for restoration of the
normal shape of the bone afforded by the
system
190
e
Fig.4.33a-k. A 48-year-old man sustained an interesting twopart fracture of the os calcis with lateral extrusion of the posterior fragment and comminution of the fibula. a-d AP, oblique,
lateral, and axial views of the ankle and foot before operation.
Notice the medial separation fracture line. It runs through the
posterior facet and leaves the sustentaculum intact for both reduction and fixation. The fibula has been crushed by the extended calcaneal fragment. e This illustration shows the indirect reduction of the comminuted fibula fracture done from
anterior with a spring plate. As noted earlier (Fig.3.17, p.81
and Fig.6.15, p.244) if necessary the distalmost hole may be
fashioned into small hooks, and in this case additional tension
band fixation was carried out. A little concavity, just enough to
start the deformation, is bent into the plate before its application to the fracture. f-h AP, lateral, and axial views of the foot
and ankle postoperatively, showing restoration of the os calcis,
including the subtalar joint, the length of the os calcis, and the
calcaneocuboid joint. i-k X-rays 2 years after the accident.
Subtalar motion is slightly limited
191
0910" BH
27.4.14
091068 BH
13.7.87
Fig. 4.34 a-m. Bilateral closed os calcis fractures in a
24-year-old farmer who fell 6 m onto a concrete floor.
The patient had surgery on the day of the accident.
a Lateral and axial views of the left heel demonstrate a
joint depression fracture. b Surgery was carried out
via a lateral approach using the minifixator in a trian-
gular configuration as a reduction aid. In these intraoperative views we see the reduction with preliminary fixation with Kirschner wires. These were subsequently replaced by screws. c Lateral and axial views
the day following surgery. The joint has been restored
along with Boehler's angle.
192
d The right heel was fractured as well. Lateral and axial views show
a similar joint depression fracture with a fracture line extending into the tuberosity of the os caIcis. e A similar lateral approach was
employed on the right side. Illustrated is the preliminary reduction
and fixation. f One day after the operation, the reduction and fixation of the right side is seen. g, h Final radiographic results seen in
lateral and axial views at a little over 3 years. The joint spaces are
well maintained. The trabecular pattern of the bone has been restored. i-I Clinical photographs of the left and right feet. The patient is working full time as a farmer. He has full ankle motion, but
the left subtalar motion is decreased. He can walk 10 km but complains of some heel pain afterwards. m Footprints taken at the time
of the 3-year follow-up
193
Fig. 4.35. The minidistractor from the small fragment set of instruments. The pin-holders are fixed
to a small threaded spindle with a central knurled
collar. The standard model has excursions of 4 cm,
but a model with longer excursions to 8 cm may be
obtained through special order. The connection is
at right angles to the spindle, and no corrections
can be made with the pin-holders that are mounted
on the carriage
194
a
b
c
Fig. 4.36. a A comminuted fracture of the fibula in the
transitional cortex between metaphysis and diaphysis
associated with a fracture of the medial malleolus and
ankle instability. b Application of the minidistractor to
the proximal and distal fragments with 2.S-mm terminally threaded Schanz screws. c Slight overdistraction is
d
created, allowing the intermediary fragments to be reduced. d The reduction of the intermediary fragments
then ensues or is "fine-tuned" with a dental pick, followed by application of a one-third tubular plate to the
posterior or posterolateral surface and removal of the
tracti(;n force on the minidistractor (not shown)
195
a
Fig. 4.37 a-g. Reduction of a comminuted proximal olecranon fracture. a The patient is placed
in the lateral position with the elbow flexed 90°
over a bolster. A posterior approach is carried
out with preservation of the periosteal and muscular attachments to the fragments. the ulnar
nerve should be identified. Next the short proximal articular fragment is identified. If it is split
in the sagittal plane, it is reduced and held with
small pointed reduction forceps while it is fixed
with a small-fragment lag screw. A reduction of
the short olecranon fragment is made to the distal humerus with the fragment oriented to the
distal humeral articulation such that it is congruent with the trochlea in a position of 90° of
flexion. In this position, a 2.5-mm Kirschner
wire is inserted at right angles to the short fragment so that it enters the joint and penetrates
the trochlea, providing fixation of this fragment
to the distal humerus. A 2.5-mm Schanz screw is
then inserted at right angles to the ulnar shaft
axis at a point in the midline of the bone near
the fracture and in the distal fragment. A minidistractor with 8 cm excursion is used. b Distraction is carried out, leaving reduction of the
posterior cortex until after an attempt to reduce
the more anterior fragments (coronoid fragment) has been made. This may be difficult, but
will be rendered easier by the reduced stabilized
proximal joint and 90° of flexion of the elbow.
A gliding hole of 3.5 mm is made in the olecranon fragment.
b
196
c The best time to reduce the anterior fractures is prior to "closing the door" by reducing the posterior cortex. First, temporary
stabilization may be accomplished by means
of a Kirschner wire followed by lag screw
fixation of the anterior articular fragment.
Drilling the gliding hole before the reduction, as shown, allows all the threads to be
placed confidently in the distal fragment.
d, e With the distractor the anterior and posterior transitional fragments are next reduced and fixed using with transaxial lag
screws.
197
f Final fixation may be accomplished using a hook plate made from a one-half or
one-third tubular plate acting as a tension
band, which may be tensioned according
to the principles discussed in Figs.3.18d
and 3.20d, utilizing a Verbrugge clamp
and a push-pull screw off the end of the
plate. g Alternatively, classical tension
band fixation may be used in certain fractures, with long intramedullary Kirschner
wires incorporated into the composite to
act as splintage for the comminuted area.
Because of their inability to provide secure fixation against shortening, the final
montage may need to be buttressed by
means of a mini external fixator to maintain length
198
a
b
c
e
Fig. 4.38. a Illustration of a comminuted
fracture of the distal end of the radius: AP
view. b The first 2.5·mm Schanz screw is inserted at 15° from the plane of the distal radiocarpal joint determined by image intensification or through a Kirschner wire inserted
into the joint space at surgery. The second
Schanz screw is placed at right angles to the
shaft of the radius proximal to the fracture.
c The minidistractor is applied and distraction is carried out. As length is regained on
the fragment containing the radial styloid the
distal most pin is driven across the epiphyseal
fragment. This may be accomplished simply
by loosening the knurled pin collar sleeve.
d Reduction carried out with "tissue-sparing" pointed reduction forceps. e Buttressing of the fracture zone with a smaIl-fragment T plate. f The lateral view of such a
plate with volar displacement will exert an
excellent buttress effect and can be made
more stable by the insertion of screws
through the distal holes in the plate
199
Fig. 4.39. a An AP view of the foot showing a crush
injury to the forefoot associated with fractures of the
metatarsal necks as well as a Lisfranc dislocation.
The cuboid is also comminuted and shortened.
b The first metatarsal cuneiform fracture dislocation
along with the base of the second metacarpal has
been reduced and fixed with a Kirschner wire. The
fractured metatarsal necks have been stabilized with
Kirschner wires placed from distal to proximal in the
intramedullary canal. The lateral border of the foot
has been brought to its proper length through ligamentotaxis, using the minidistractor between the os
calcis and the fifth metatarsal. c The foot in comparison to the opposite side 2 years later. The patient's
function is now nearly perfect. The minidistractor
was used to regain and maintain the lateral pillar of
the foot through the healing period
200
Fig. 4.40 a-h. A comminuted fracture of the distal radius in a 48-year-old man. a, b Note the intra-articular extension of the metaphyseal fracture along with a separate dorsoulnar fragment which still bears a loose
relationship to the ulnar styloid. c, d The problem has
been solved by combining ligamentotaxis for reduction
with internal fixation by means of lag screws and
Kirschner wires. The minifixator in this case has been
used both to gain reduction and to maintain length of
the comminuted distal radius. Fracture reduction from
proximal to distal using 3.5 mm lag screws for fixation.
Articular reduction and fixation with Kirschner wires is
followed by supplementary autogenous bone graft. A
transfixing Kirschner wire temporarily maintains the
distal radioulnar relationship. e, f The Kirschner wire
through the distal radioulnar joint has been removed
and early consolidation of the fracture is seen 7 weeks
post operation. g, h Six-month follow-up showing
union of the distal radius, maintenance of the relationship between the distal radius and ulna, and restoration
of a healthy trabecular pattern. Functionally, this patient
has only minor limitations of pronation and supination
201
Chapter 5: Substitution
We have coined the term "substitution" to describe situations in which an
external fixator or an implant is used to compensate for some deficiency
in the bone following fracture or disease. This substitution is required for
success to be achieved with a given fixation method. In fractures, because of
the potential for bone regeneration, what ever is lacking is usually absent
only temporarily. Thus it is possible, in a situation where a plate has been
used on a fracture that has no contralateral medial buttress, to compensate
this deficiency by applying an opposing simple external fixator. This provides a temporary medial buttress giving the unviolated comminuted fragments time to consolidate and repair their supportive function.
Another variation on the same idea is to influence the mechanics of the
primary implant by the secondary fixation. For example, if we take a plate
and place it on one side of the fractured bone and place an external fixator on the other side, what we do with the fixator influences the function
of the plate. For example, in a simple fracture, if we tension the fixator the
plate becomes a tension band plate, or if we place the fixator in a small
amount of distraction, then both plate and fixator act in buttress mode
and the bending moments on the plate may be expected to decrease
(Figs. 5.1, 5.2).
Fig. 5.1, pages 206,
207
Fig. 5.2, page 207
Combined Internal and External Fixation
The combined techniques of osteosynthesis have evoloved from the difficulties encountered in attempting stabilization of fractures in the vicinity
of a joint. Their biological and mechanical advantages and the ease of application have since been recognized. The range of indications for their
use has yet to be fully defined.
One of the authors applied this technique for the first time when dealing
with a difficult adult distal intra-articular humerus fracture, where instead
of plating the posterior surface and the medial column of the elbow at
right angles, a posterior plate was used in combination with a lateral miniexternal fixator to neutralize the bending moments on the plate
(Fig. 5.3).
This combined internal and external fixation is not the old concept of
"minimal internal fixation plus external fixation" popularized by many in
the 1980s [30], but is based rather on what has been observed by others in
closed fracture care.
If a fracture treated in a cast angulates, over time there is callus formation
on the concave side. Once this callous bridge has developed it may be uti-
Fig. 5.3, pages 208,
209
202
Fig. 5.4, page 210
Fig. 5.5, pages 211,
212
Fig. 5.6, page 213
lized as a hinge by manipulating the fracture in the opposite direction.
This transforms the callus into a tension band. This principle is used in the
treatment of pseudoarthrosis (Fig. 5.4) [34].
The plate applied to one side of the bone acts as a hinge (artificial callus)
that can be placed under tension by opposing it with a fixator used in tension. This makes the plate stay in a tension mode as long as the external
fixator remains tensioned. In bone without a pure tension side, it may alter
the local loading mechanics in a favorable way.
As mentioned above, if the fixator is given a support function, i.e., buttress, then it acts to protects the plate from cyclic bending moments. If the
plate and external fixator are both mounted on the tension side of an eccentrically loaded bone, tensioning of the fixator can reduce the bending
moments in the plate. These observations may have application when plating is used with an unreliable patient or in circumstances where loads on
the bone are particularly high, such as in fixation of a comminuted femoral fracture or in a leg lengthening procedure fixed with a plate.
In principle, the plate can have smaller dimensions when combined with a
fixator. It is important to replace a relatively noncompliant implant with a
more elastic one in this approach. Accordingly, the high degree of rigidity
resulting from the introduction of every screw into the plate should be
avoided and only those screws demanded by the fracture should be used.
The clamps which have been applied effectively in provisional reduction
of a fracture serve as a guide to the location of critical screws. By using no
more screws than necessary, a more elastic system is created.
The method enables the alteration of local mechanics postoperatively by
changing the fixator from tension to compression. In addition it offers the
possibility of correcting an axis deviation such as a varus or valgus at a later date.
It is self-evident that although a minimum of hardware is used, this type of
system can be very stable. The reason for this is the long lever arm of the
external fixator. Fatigue fractures of the plate should be rare.
The cardinal advantage of combined internal and external fixation is the
fact that tissue vitality can be preserved and surgical violation of tissues
kept to a minimum. These factors influence the outcome particularly of
comminuted fractures, as they are almost always associated with a high
degree of soft tissue injury. Subsequently, bone healing can be achieved as
rapidly as nature allows (Fig. 5.5).
Finally, the advantages of easy application should be mentioned. The
plate is chosen as a function of the bone involved (a broad plate in the
femur, a one-half tubular plate in the metaphysis of the tibia, a narrow
DCP in the diaphysis of the tibia) and is applied to the biologically favorable side of the bone. So-called key fragments are fixed with as few screws
as possible. The biologically unfavorable side which is compromised by
emminent soft tissue and/or osseous necrosis is stabilized by the external
fixator. As a rule, one Schanz screw per main fragment is sufficient. Depending on the fracture pattern, the external fixator should be used to influence the function of the plate by placing it under tension or compression. In cases where there is no medial buttress the external fixator should
probably be used as a buttress placing the fixator under compression,
thereby achieving good stability (Fig. 5.6).
203
During the postoperative period the fracture can be influenced by changing the amount of flexibility in the system by increasing of decreasing the
amount of tension or compression in the fixator. At the appropriate time,
usually at 6-12 weeks, the fixator may be removed completely. Occasionally a loose pin will have to be removed and replaced during the course of
treatment, although this has been a relatively rare occurence.
Fresh fractures by type, and the tibial metaphysis by location, constitute
our main areas of application. Because of the high incidence of infection
and soft tissue problems found in the treatment of bicondylar tibial plateau fractures by double plate fixation [11], in Bern all types of these severe fractures are treated nowadays with the methods described.
An excellent situation for the application of these principles is a highly
comminuted meta-epiphyseal tibial fracture which, beyond emergency
measures such as irrigation and debridement of open wounds on day 1, is
treated by reduction and screw fixation of the joint while the residual fractures are immobilized using an anterior fixator frame which may span the
joint. The definitive treatment incorporating, the use of "substitution" (or
internal! external fixation as described) is accomplished subsequent to repair and healing of the soft tissues (Fig. 5.7).
In principle the combination of internal fixation and an external fixator
has broad potential for application. It has been used for several years now
in the treatment of pelvic ring injuries, in which the posterior ring is fixed
with a plate and screws and the anterior ring stabilized with an external
fixator frame [20]. In our hands it has proven effective in comminuted
shaft fractures of femur and tibia, in the distal tibia, distal femur, distal radius and distal humerus, as mentioned above (Figs. 5.8, 5.9).
We have also used this concept of subsitution in combination with unreamed intramedullary nails. In most of these instances the fixator was
used to prevent shortening and rotational deformities from occurring in
tibia fractures treated with Ender nails. The C-shaped Ender nail was inserted in the usual location laterally, and a simple external fixator with one
pin above and one pin below was placed medially. The fixator was tensioned against the bend of the Ender nail. This combination has met with
early success in the few cases in which it has been applied.
In the area of reconstructive surgery and secondary surgery, the methods
described have an increasing range of indications. Biologically and mechanically comparable principles are involved. An example of such an application comes with a Wagner type lengthening of the femur with conventional plate fixation after lengthening has been carried out. The forces on
the plate under these circumstances are very high, with a great tendency to
deform in varus because of the lateral plate. The stability of such a construction may be enhanced by an ipsilateral fixator the long arms of which
are "tensioned."
Composite Fixation
Another area considered under substitution is composite fixation, which
can be illustrated by the creation of an artificial medial cortex by the use
of an endosteal plate in combination with an standard plate. When there is
Fig. 5.7, pages 214,
215
Fig. 5.8, pages 216,
217
Fig. 5.9, page 218
204
no medial buttress because of severe comminution or pathologic bone, the
Fig.5olO, page 219 use of an endosteal medial plate can solve an otherwise insoluble problem
Fig. 5.11, page 220
Fig. 5.12, pages 221,
222
Fig. 5.13, page 223
Fig. 5.14, page 224
(Figs. 5.10-5.13). The technique of placing a plate into the intramedullary
canal is well known and widely employed in the fixation of pathological
fractures [6]. It increases the stability of the fixation by substituting for the
medial cortex.
It has been frequently used in pertrochanteric pathological fractures where
the intraosseous plate substitutes for the calcar. In combination with an
angled blade plate, the proximal portion of the intraosseous plate is abutted against the blade and pushed as far medial as possible with a screw
that threads the lateral cortex and impinges on the plate. Tightening this
screw pushes the plate medially. The other screws fixing the blade plate to
the shaft pass through the intraosseous plate and continue into the medial
cortex. The assembling of this montage is facilitated through an anterior
window. In the case of a pathological fracture such a window may exist
because of the destructive activity of the tumor; otherwise it can be created by the surgeon. Following the positioning of the screws they may be
loosened, bone cement introduced, and, following hardening of the cement, definitively tightened (Fig. 5.14).
This montage is stable enough to allow immediate weight bearing and has
consistently scored high in rigidity and resistance to fatigue in laboratory
experiments [13]. It is an alternative we favor to the insertion of a megaprosthesis, which sacrifices a healthy joint because of a metaphyseal problem.
The same technique in the distal femur can be used with the 95° condylar
plate or with the condylar buttress plate. The endosteal plate may be the
broad or narrow 4.5-mm DCP depending on the circumstances. Using
matching plates outside and inside makes lining up the screw holes easier,
but in practice using a broad plate laterally and an endosteal narrow plate
medially presents no real problem.
The holes may be found in two ways. In pathologic fractures where methyl
methacrylate is being used, an anterior window is made; the drilling and
insertion of the screws in such a case is under direct vision (Manual of Internal Fixation 1979). When the plate is used without a window, as in osteoporotic bone or severely comminuted fractures, the drill hole is first made
through the plate hole in the lateral cortex of the femur, then a small
Kirschner wire is inserted through the drill hole and manipulated to locate
the hole in the intramedullary plate. The drill is then once more advanced
in this direction and through the medial plate hole, continuing through the
medial cortex. Frequently there is a conflict in inserting the screw through
the medial plate hole and it must be threaded through both the endosteal
plate hole and the medial cortex. Actually this is desirable, as it ensures
the blocking fuction of the plate (buttressing), which is the situation wanted. One or two screws should be used abutting the plate, threading only
the lateral cortex to allow the screw to push the plate medially against the
medial cortex.
In certain conditions one of the authors, R. G., has used a dual extra-/intraosseous plate to advantage. Its indication has been found in aneurysmal
bone cysts and giant cell tumors that have destroyed bone, creating large
defects in the epi-/metaphyseal bone above a joint. In such cases the
205
plate, usually contoured to the shape of a "bishop's staff," takes over the
support function of the subchondral bone. The plate is used to buttress the
very thin contours of the remaining uninvolved cartilage surface. The associated defect is filled with autogenous cancellous bone. Removal of such
an implant is possible with an small curved chisel that is used to undercut
the bone around the plate (Fig. 5.15).
A 3.5-mm reconstruction plate may be used to substitute for the bony attachments of important muscles. In such cases, for instance when part of
the body of the scapula or the iliac wing must be resected, the reconstruction plate can be fixed to either end of the remaining bone after contouring to allow the reattachment of the muscles in near-anatomic locations (serratus anterior and subscapularis on the scapula, gluteus medius
and minimus on the iliac wing). In both locations the frame provided by
the reconstruction plate substitutes for the bony attachments, and after
scar tissue formation has taken place almost normal function can be expected.
Summary
By "substitution" we mean the use of an implant or an external fixator in
such a way as to contribute to stability by carrying out the function of
some part of the structure of the bone that has been temporarily lost
through injury, or permanently lost through malignancy; the employment
of a secondary implant or external fixator to create a force that modifies
and controls the function of the primary implant, leading to increased stability of the fracture zone.
Our experience to date with the various montages described has been encouraging: they are sparing of the soft tissue, allowing one to use fewer
implants and yet achieve enhanced stability, which enables the patient to
realize the benefits of "functional" after-treatment. In addition, the approach is extremely versatile and the montage can be altered in the postoperative period: changes may be made as necessary in axial alignment or
in implant function.
The methods described have application in fresh fractures particularly in
the tibial metaphysis, but have been used in other locations as well.
In composite fixation an endosteal implant may be used to compensate
for the lack of a medial cortex. The indications for such a technique are
few and usually concern pathologic fractures, severe osteoporosis in an
elderly patient, or severe comminution of bone.
In the cases where such techniques are indicated because of fractures, the
substitution may be only for a temporary period until healing has taken
place.
Pathologic fractures or tumor surgery, on the other hand, may require that
substitutions are permanent, or last as long as the patient remains functionally active.
Fig.5.15,
pages 225-227
206
Fig. 5.1. a "Substitution" using plate fixation
and an external fixator is indicated in severely
comminuted fractures such as that in the tibia
illustrated. Hypothetically speaking the soft
tissue injuries of the leg consist of a grade 2
open wound with a 6 cm laceration on the medial aspect of the leg. b A lateral plate is applied using the methods discussed in Chap. 3
(Figs. 3.6-3.10). Extreme care must be exercised with the soft tissues and the deep exposure of the bone must be limited to the region
of the intact proximal and distal main fragments. In this way the comminuted fragments
remain attached to soft tissue. Using the plate,
which must be "contoured" for the lateral side
of the bone (this task may be facilitated preoperatively by using a bone model and exploiting
the fact that the comminuted segment is
straight) in combination with the articulating
tension device, reduction is carried out. c As
an alternative, the external fixator applied as a
femoral distractor may be used for reduction
and maintained afterward (Figs. 4.26, 4.27).
The fracture is reduced. Pointed reduction
forceps applied through the soft tissues may
be used to improve the reduction (not shown).
d Along with proximal and distal fixation
screws, lag screws are inserted in the areas previously occupied by clamps. If reduction was
made with the plate, Schanz screws are inserted proximally and distally on the medial side
of the tibia perpendicular to the tibial shaft
axis. A simple meoial frame is then construct·
ed with the tubular fixator system.
207
e If the external fixator
was used, preload is
applied by tensioning the
fixator, which also
tensions the plate
Fig. 5.2. If the fracture is such that there is no way to insure a medial buttress, the fixator is applied in compression, using both plate and fixator in a buttress mode.
Frequently the decision as to how to use the fixator depends on what has been achieved after the plate fixation. In some cases the fixator may be used to modify
the function of the plate in one segment of the fracture
in buttress mode, and by placing an intermediary pin,
the plate over another segment of the fracture may be
placed in tension. This combination is seen in the case
presented in Fig.5.7
208
209
9
Fig.5.3a-j. Original case in which a posterior plate was
paired with a lateral fixator to decrease the bending
fragments on the plate. A graft was anticipated because
of loss of bone stock. a, b AP and lateral X-rays of an
open fracture of the elbow 6 weeks after initial treatment. The fracture was being treated in traction. The injury was to the dominant arm of a 42-year-old gynecologist. c-e The operative plan, based on a posterior
approach with reduction of the humerus with the minifixator. Fixation of the fracture with the Y plate, bone
graft of the defect. Use of the minifixator to decrease
bending moments on the plate so that active motion can
commence immediately postoperatively. f Postoperative
X-ray showing combined internal-external fixation of
the right elbow 6 weeks after surgery. g, h Clinical photo showing fixation montage, with patient performing
active flexion and extension. i, j Result after 60 months.
The patient regained functional motion of the elbow
and was able to resume his favorite sport of tennis,
which he still plays
210
Fig.5.4a-g. A 6-week-old humerus fracture in a
patient with a closed head injury and polytrauma.
The humerus had been treated conservatively with
a sling and swathe. a AP X-ray showing varus angulation of the distal humerus with a medial butterfly fragment and early callus. b, c Four weeks after
applying a minidistractor laterally against the early
medial callus bridge which acts like a tension band.
Note rapid development of callus. d, e Seven
weeks after application of external fixator: time of
removal. C, g Healed fracture. There is a full shaft
displacement of the humerus which is now completely healed with a callus bridge
211
Fig.5.5a-f,
legend see
page 212
212
Fig. 5.5. a, b A 28-year-old male who had a motor vehicle accident and sustained a grade 2 open fracture of the
tibia. The wound, 4 cm long, was located medialIy.
c, d The plate was applied lateralIy as described in
Fig.5.2 and a medial fixator was placed in tension.
e, f The bone and montage at 10 days. At this time delayed primary closure had been carried out. g, h A
2\1 months the fixator was removed. i, j The treated
fracture is viewed at approximately 6 months post injury
213
Fig.5.6a-e. A 22-year-old male with polytrauma including open fractures of both tibia, a closed fractured femur, left humerus fracture, and a closed head
injury. a, b AP and lateral views of the comminuted
left tibia fracture: the fibula is fractured in the midshaft. The open wound was made up of multiple
2 cm lacerations to bone along the medial subcutaneous border of the leg. The wounds were irrigated and
debrided. c Application of the lateral plate and medial external fixator. This was an early case of this
form of treatment and the plate was tensioned, creating a mild varus deformity, but the montage was extremely stable. Bone graft and delayed closure of the
wounds were carried out at 5 days. d, e Six-month
follow-up. The fracture has healed. The fixator was
used in tension throughout the postoperative course
214
215
Fig.5.7a-m. Another example of a tibial plateau fracture with distal extension
into the diaphysis as a segmental fracture. This case illustrates the versatility of
the external fixator. The fracture was associated with a grade 2 soft tissue
wound. a Before operation. b, c Initial treatment consisted of irrigation and debridement, articular reduction, and fixation by a single lag screw followed by application of a transarticular anterior half-frame fixator with carbon fiber tubes.
d, e At 6 weeks, lateral plating with a long T plate associated with medial external fixation. Note that in the proximal highly comminuted segment the fixator
has been placed in buttress mode, with distraction between the first two pins,
and that in the lower portion of the fracture, where stability through interfragmentary compression was possible, the fixator has been placed in tension
against the lateral plate, changing its function to a tension band plate. f, g AP
and lateral X-rays 4 months after application of the lateral plate and medial fixator show consolidation of the comminuted metaphyseal fractures along with
healing of the distal fractures. At this point the fixator was removed. h, i AP and
lateral views 2 months later with full healing of the tibia from the joint distally.
The knee motion was full, the alignment anatomic. j, k AP and lateral views at
13 months show complete healing. I, m AP and lateral views following metal removal almost 2Vz years after injury. Function is normal
216
217
Fig.5.8a-n. A 24-year-old right-handed female was involved in a high-speed motor vehicle accident. She sustained a "side-swipe" injury to her right arm. a-d AP and
lateral radiographs of the elbow and wrist show high-energy fractures. The associated soft tissue injuries consisted of
avulsion of the volar-radial musculature, including a I~ra­
tion of the radial nerve, and a gaping volar skin defect of
the elbow region. There was also a third-degree soft tissue
injury of the wrist which included laceration of the flexor
profundus tendons to the long and ring fingers. e-h Initial
surgical treatment on admission consisted of thorough debridement of elbow and forearm wounds with combined
internal and external fixation of both fracture levels. The
nerve and tendon injuries were repaired at the same time,
and coverage of the large soft tissue defect was obtained by
a rotational transsubcutaneous latissimus dorsi flap combined with split-thickness skin grafts of the muscle and of
the wound of the distal forearm. Radiographs taken 1 week
postoperatively of the distal humerus and wrist are show.
The distal ulna was devoid of soft tissue and was removed.
Primary bone grafting of the distal humerus and distal radius was carried out. i-I Follow-up X-rays at approximately
6 weeks after the accident show early consolidation of all
the fractures. All external immobilization was discontinued
at 3 weeks and the patient was encouraged to exercise all of
the joints fully. The fixators were removed shortly after
these X-rays were taken. m, n Follow-up X-rays at
6 months. The patient required no surgical interventions
following her initial care. There were no complications and
elbow and wrist motion are unrestricted. At the time of
these X-rays, there was visible recovery of the sutured radial nerve, which has subsequently improved further. The
case demonstrates the use of combined internal-external
fixation. The external fixator is applied classically on the
wrist fracture and as a substitute for a second plate on the
distal humerus
218
Fig.5.9a-h. A 23-year-old male was the only survivor
of a high-speed automobile accident. The patient was
polytraumatized including a closed head injury, a comminuted femur fracture and ipsilateral open tibia fracture, an ipsilateral forearm fracture and a contralateral
open ankle fracture. a, b AP and lateral views of the left
femur fracture. Certainly using a plate fixation in this
circumstance has its advantages to the patient during
the initial surgical procedure, as its ease of application
in the supine position and its independence from image
intensification allow all injuries to be handled simultaneously in a speedy and efficient way. c, d The postoperative montage is illustrated in AP and lateral projections. The fracture was reduced indirectly by the use of
the articulating tension device proximally after the plate
was fixed to the distal fragment. The lateral cortex of
219
... the bone proximal and distal to the fracture zone was all
that was directly visualized. An external fixator was then
mounted through open plate holes proximally and distally and loaded in tension, "protecting" the plate from
cyclic loading until the viable medial cortical comminution consolidates. The correct axis of the shaft along
with the correct length has been achieved, but individual
diaphyseal fragments are not anatomically reduced.
Fig. 5.10. The use of DCP as a medial
buttress, combined with a 95° angled
blade plate. The 95° angled blade plate
may be used either with the articulating
tension device or with the femoral distractor to distract the fracture. While the
fracture is distracted a gouge and curette
are used to make a trough in the distal
metaphysis on the medial aspect to allow
the intramedullary plate to be seated
against the blade. The plate is fed into the
intramedullary canal retrograde and then,
using the curved impactor, driven into the
prepared trough to abut against the blade.
The fracture is now reduced by diminishing the distraction force and allowing the
fracture surfaces to oppose. Two or three
screws should thread the lateral cortex
only and impact against the plate, push-
e, f Five weeks post injury there is softening of the fracture lines with some early bone formation in welds seen
proximally and distally. The fixator has been removed.
g, h The healed fracture 4 months later. In this case the
lateral fixator in combination with a lateral plate provided a solution to a difficult fracture that was both biologically and mechanically sound
ing it medial. The other screws are inserted through the holes in both plates. To
accomplish this, a 3.2-mm drill is used to
drill the lateral cortex with the appropriate drill guide. A 1.6-mm Kirschner wire
is then passed through the hole and used
to feel the hole of the medullary plate.
When the direction is known, the drill is
directed in the same path toward the medial cortex, which is penetrated. Insertion
of these screws is frequently skewed so
that the screws actually thread the hole in
the plate as they pass into the medial cortex. This ensures the blocking action of
the plate. In the drawing the fifth screw
from the top would have this effect. The
medial plate is thus locked between the
blade and the screws
220
Fig. 5.11 a-h. A 74-year-old chronic alcoholic was
struck by a car. He sustained a grade II open fracture of the left distal femur. Emergency surgery
consisting of irrigation and debridement followed
by internal fixation. a, b Preoperative radiographs.
The fracture is difficult because of metaphyseal
comminution. c, d Postoperative AP and lateral Xrays showing the use of an angled blade plate in
conjunction with an endosteal narrow DCP. The
fourth and eighth screws push the plate medial.
The second, third, fifth, sixth and seventh screws
traverse the endosteal plate holes. e, f At 4 months
almost complete consolidation of the medial cortex
is seen, although two screws are visibly loose.
g, h At 1 year after operation the AP and lateral radiographs show healing of the fracture with normal
axis. The loosening of the screws has not progressed since the X-rays at 4 months
221
Fig. 5.12 a-f. An illustration of a highly comminuted supracondylar intracondylar fracture in a patient with a total
knee prosthesis and osteoporosis. a The femoral distractor connecting bolts are inserted at right angles to the
shaft of the proximal femur and parallel with the tibial
plateau component of the prosthesis in the proximal tibia. b A narrow DCP is shaped to approximate the contours of the internal medial surface of the distal femur. A
broad DCP may be used but has the disadvantage of being stiffer and more difficult to contour. c The distractor
is placed into the distraction mode and through the fracture itself the plate is fed proximally into the intermedul\ary canal. d Utilizing the curved impactor from the
bone-grafting set of the AO, the intermedullary implant is
impacted distally until it buttresses the femoral component. The distractor is then utilized to gain reduction, in
the proper length relationships, of the distal femur.
g
~
g
\\
g
g
g
g
g
()
o
o
()
o
o
a
a
c
b
d
222
e, f A check is made to ensure that the intramedullary
plate is buttressed against the femoral components and
then a condylar buttress plate is utilized laterally in such a
way that the screws inserted in the plate on the lateral surface penetrate the lateral cortex and cross through some
of the holes of the intramedullary plate to penetrate the
medial cortex. One or two of the screws inserted through
the lateral plate may abut against the intramedullary
plate, trapping it against the medial cortex and creating
an artificial medial buttress. The advantage gained is similar to that yielded by an interlocking nail. Application of
the plate endosteally also has the advantage of leaving the
soft tissues attached to the medial fragments. The medial
buttress obtained in such a way may be temporary, until
bone healing is complete, or can be made permanent, allowing limb salvage in a patient with a terminal malignancy, by adding methyl methacrylate to the composite
223
.'ig.5.13a-h. A 90-year-old female was involved in a
motor vehicle accident. She sustained bilateral, highly
comminuted condylar and supracondylar femoral fractures above bilateral total knee prostheses. She was originally treated in traction and transferred to our facility
10 days after the accident. The patient was uncontrollable in traction - hysterical and unable to tolerate this
form of treatment. a-d Preoperative AP and lateral
views note the comminution existing in both of these
fractures. There was no evidence of loosening of the
prosthetic components. e-h X-rays of the patient's
composite fixations approximately 1 week post surgery. With this fixation the patient's distal femurs
were stable and she could be mobilized. Unfortunately, the patient died of a stroke 2 months later in a
nursing home
224
Fig. 5.14. a A 45-year-old female with breast
carcinoma metastasis to the proximal femur of
the right leg. b Treatment consisted of a 95°
condylar plate combined with a narrow DCP on
the endosteal surface of the medial cortex. Note
the third screw from the top that pushes the
plate medialward. The entire tumorous defect
was injected with bone cement which extends
from the blade of the condylar plate distally.
The screws are prepared, then the cement is applied and after it hardens the screws are definitively tightened. The screws traverse the holes
of the intraosseous plate. c, d The 4Yz-year follow-up. The patient is functioning fully in all regards. e At 7 years the patient was walking
without a limp and carrying out all normal activities. She died a further year later of her primary disease. Note the proximal migration of
the implant over the years
225
Fig. 5.15 a-o. A 21-year-old salesgirl presented with a pathologic
fracture of the lateral condyle of
the right femur. A complete workup provided the diagnosis of giant
cell tumor. a, b AP and lateral Xrays showing a lytic lesion of the
lateral femoral condyle with destruction of the lateral cortex and a
pathologic fracture involving the
joint surface. c A lateral tomogram
showing the extent of the defect
and fracture. A biopsy revealed the
tumor to be a grade II lesion.
d, e Surgery consisted of careful
curettage of the lesion, support of
the joint surface with an extra-intraosseous buttress plate, and fixation of the subchondral fracture
with a screw. These operative photographs show the one-half tubular
plate in position with temporary
fixation of the fracture with
Kirschner wires.
~
226
227
n
o
~ f, g The cavity was then filled with au-
togenous cancellous bone and the
wound was closed. h, i The postoperative AP and lateral views show the
joint contours to be restored and buttressed by the one-half tubular plate
used in this manner. The subchondral
screw fixes the fracture seen on the
joint in the clinical photos. j, k Radiographs at 8 weeks. There is no loss of
reduction of the reconstructed joint
surface. I, m Radiographs at 5 years:
no recurrence, improved trabecular
structure of the bone. n, 0 The right
knee lacks 10° of flexion, but otherwise is stable and painless
228
Chapter 6: Tricks
Generally, fracture patterns in the skeletal system tend to repeat; however,
the individual variations and combinations are endless. The corrrect reaction to a given situation requires experience, but to have the reduction
"fall into place" on the first attempt requires a little luck as well. We are
guided by the basic principles of anatomic reduction, stable internal fixation, and atraumatic surgical technique which are applied so as to allow
active, painfree mobilization of the muscles and joints. These principles,
once learned, are put into practice to the benefit of many patients.
With assimilation of the principles, innovations or unorthodox applications evolve to deal with the difficult or complex fracture situations which
are encountered. If these innovations stand the test of time and reproducibility, they become the "tricks of the trade."
Many surgeons have contributed ideas to this chapter. Many ideas have
emerged at the "hints and kinks" sessions on the advanced AO courses.
Other "tricks" recorded here are already used routinely by certain surgeons, but are described so that they may be tried by others. Where possible the surgeons generally thought of as "innovators" of the tricks have
been identified.
Tricks with Instruments
Fig.6.t, page 232
The AO have two models of wire tighteners. One, the "torpedo" wire tightener, makes a cerclage loop which is controlled like a: lasso and maintains
the tension very well after the end is crimped and cut. The other wire tightener has two arms which hold the wire and may be spread to tension it.
Maintaining the tension and spinning the device results in a secure twist in
the wire. This wire tightener is extremely useful in reducing a butterfly
fracture. The wire is carefully placed around the fragments and the tension
in the wire loop controlled while the fragments are manipulated. The important step is to make sure that the wire passes at the intersection of the
proximal and distal main fragments and butterfly. With correction of rotation and alignment by gentle manipulation of the extremity, the wire is
tensioned with the arms and twisted until snug. Final adjustments are
made and the wire is tightened definitively. Because the wire encircles portions of all three fragments, tightening effects the reduction (Fig. 6.1) (AlIgower and Riiedi).
The bone spreader is always an important instrument to have on the back
table. Besides being useful off the end of a plate in the "push-pull" screw
229
technique, it is helpful in restoring displaced articular fragments. Sometimes this may be accomplished through a very small wound, as is illustrated in Fig. 6.2.
The Hohmann retractor and the standard reduction forceps are both important devices for making the small adjustments necessary to reduce a
fracture that has residual shortening. In both instances, the instrument is
selected that matches the size of the bone with which one is working. The
Hohmann retractor is used as a bone lever. The tip is inserted into the fracture, with the wider part of the blade used against one side and the smaller
pointed end levered against the other. The curve of the tip makes it handy
as a lever (Fig. 6.3). The standard reduction forceps may be rotated on the
points of its jaws to lengthen an oblique fracture (Fig. 6.4).
The pelvic reduction forceps is extremely useful in manipulating the large
fragments associated with acetabular fractures. Its use depends on placing
two screws, one in each fragment, and positioning the shoes of the clamp
around them. The clamp may then be manipulated so that distraction, displacement, and compression of the two fragments can be accomplished.
The clamp is also valuable in reducing a translation of the major fragments in the pelvis. First, one foot is fastened solidly with the screw to the
fragment that is in proper alignment. The clamp is then opened, and
through the other foot a hole is drilled in the fragment that is translated.
A long screw is inserted into the hole until it has a good bite on the far
fragment and then the clamp is opened further, producing distraction of
the fracture surface. The clamp is supported by the hands, and, tightening
the long screw, the translated fragment is threaded back to the foot of the
clamp, reducing the translation. The clamp is then closed after matching
of the fracture surfaces, compressing them together in a reduced position
(Fig. 6.5). The clamp also has a spindle lock on the handle with collar nuts
that allow distraction or compression to be applied in a more controlled
manner.
These clamps have been used to advantage by some surgeons (Hansen) in
manipulative reductions of long bones. Essentially they are connected to
each fragment by means of the screws and manipulated to reduce a tibia
or a femur as described for the pelvis.
Many surgeons have avoided using an awl to gain entry to the intramedullary canal by substituting the first stage of the Synthes "DHS" reamer and
its 2.7-mm guide pin. It is particularly helpful in the supine position,
where the soft tissue of the buttock makes it difficult to use the awl (Day
and Comfort). This technique is employed via the standard surgical approach. The piriform fossa is identified, and the 2.7-mm guide wire in the
proximal femur must be verified with the image intensifier. This is easily
accomplished in the AP projection, but the confirmatory lateral view must
be a little oblique in a cross-table lateral projection. The first stage of the
reamer is then drilled over the guide pin, opening a pathway into the proximal end of the medullary canal. Both reamer and guide pin are then removed and the 3-mm guide wire for intramedullary nailing is inserted into
the proximal fragment of the femur (Fig. 6.6).
The centrally cannulated T-handled chuck from the AO external fixation
set serves many functions besides the insertion of Schanz screws or Steinmann pins. In intramedullary nailing, for example, it may be slid over the
Fig. 6.2, page 233
Fig. 6.3, page 234
Fig. 6.4, page 235
Fig. 6.5, page 236
Fig. 6.6, page 237
230
Fig. 6.7, page 237
Fig. 6.8, page 238
Fig. 6.9, page 239
3-mm guide wire to act as a handle to manipulate the guide wire across
fracture fragments (Fig. 6.7). The same instrument is also valuable in combination with a Schanz screw to provide increased leverage for rotating
fragments into reduction, as in a posterior approach to a transverse or posterior column fracture (Letournel). In such a case it is placed into the ischium and with the handle the ischium is rotated in order to reduce the ischiopubic fragment (Fig. 6.8).
A similar ploy may advantageous in a T type supracondylar fracture of the
distal femur. In the case of difficulty in reducing the medial condyle
through the lateral approach, a small stab wound is made medially over
the fractured medial condyle. A 6.0-mm Schanz screw is inserted into the
medial fragment through a 4.S-mm drill hole made in the side of the fragment. With a handle on the medial condyle, rotation and varus/valgus
maneuvers can be carried out while the intra-articular reduction is viewed
through the lateral operative incision (Fig. 6.9).
The aiming device from the external fixator set may also be of value beyond its recognized role. The pointed end of the device may be used for
lag screw fixation of small fragments in the vicinity of a joint or of larger
fragments in, for example, the femoral neck, or in certain instances for lag
screw fixation in the pelvis and acetabulum.
Tricks with Implants
Fig. 6.10, page 240
Fig. 6.11, page 241
An important principle to remember with open reduction and internal fixation using a plate and screws is that the best opportunity to set up the
critical aspects to the fixation comes before the reduction is made. This
makes sense for a number of reasons, of which the foremost is that with an
excellent reduction, the fracture lines become lost in the soft tissue attachments and the chance of drilling into a fracture line or obtaining a suboptimal location for the lag screw is great. Before the reduction not only are
the fractures obvious, but the planes of the fractures can be seen. Because
of this the emphasis has been more on "inside-outside" techniques of lag
screw fixation.
This approach is very applicable to articular fractures, where one is accustomed to making a reduction of the articular surface and then fixing it
provisionally with Kirschner wires before definitive fixation with 6.S-mm
cancellous screws. There is frequently dilemma, because we have only two
thread lengths, one giving us too much thread for our situation and therefore no lag effect, and the other too little purchase in the far fragment. A
cortical screw used low, just in the subchondral bone, will have excellent
purchase, as the trabeculae are dense in this region, and if the gliding hole
is prepared before reduction, the screw will have the maximum possible
number of threads in the far fragment (Fig. 6.10).
A helpful ploy with a fracture exhibiting a butterfly fragment on the side
away from the operative field is to use the 4.S-mm tap as a handle. By this
means it is possible to manipulate the butterfly fragment into reduction
leaving its soft tissues attached (Fig. 6.11) (Allgower and Riiedi).
Two or three screws can be placed so that when a wire is brought around
under the screw heads a pulley is formed. The pulley effect may be used to
231
obtain reduction and provide temporary fixation until more definitive
measures are applied. Sometimes this ploy is used in combination with a
bone spreader when dislodging a fracture which is impacted, e. g., a fracture through the iliac wing in the region of the sciatic buttress in which the
wing fragment is entrapped on the side away from the operative field. In
these situations there is little room for a clamp, and it is difficult to use one
because the surface of the bone is smooth and rounded. An example of
this application is seen with a sacroiliac dislocation approached anteriorly
(Fig. 6.12).
There are several ways to use plates that have not been mentioned. The
short one-third tubular plate may be used to fine-tune reductions, and is
most helpful in the flat bones, for example in the pelvis, to reduce translations (Fig. 6.13). In addition, these plates may be used as small antiglide
strips on the slopes of oblique fracture lines [34] or as buttresses substituting for comminuted areas of cortex (Fig. 6.14). They can also be fashioned
into little spring plates that have a strong buttressing effect when used over
comminuted surfaces such as the posterior wall of the acetabulum
(Fig. 6.15, 6.16).
Like the one-third tubular plate, the one-half tubular plate has a number
of applications. A hook can be fashioned from an end hole after flattening
the terminal portion of the plate and this modified plate used in stabilizing
osteotomies (Feiler 1985). Some surgeons flatten the end and bend the
plate sharply so that it may be driven into the bone to stabilize high tibial
osteotomies [35]. The free end of the plate deforms as the screws thread
the distal fragment of the osteotomy surfaces (Fig.6.17).
More cumbersome, although at times helpful, a 4.5-mm narrow DCP may
be bent over the course of a few days into a right angle. The bone may be
slotted to receive the bent end and the plate impacted into the slot (J.Alonzo). This technique is rarely indicated, but it helps the screws resist loosening, because a portion of the plate is driven into the bone and this relieves the screws from bending moments. It has been used in the case of
very short epiphyseal segments with loss of bone that need stabilization.
Occasionally it is possible to place a screw from the side of the plate
through its end, thereby locking the plate (Fig. 6.18).
The preceding represent some helpful surgical tricks compiled over the
last several years from a multitude of sources. They represent variations of
standard techniques that have been tried in certain situations and have
proven to be helpful. Many are quite simple, and the only reason they are
not used by many more surgeons is lack of exposure.
To illustrate this point we include as a final example, a very simple modification of one of the most basic of techniques, taught by Maurice Mtiller,
who is not only one of the world's masters of surgical tricks, but a master
magician as well, and one of the finest of all surgical technicians. This
technique, based on a square knot, is exceedingly helpful, especially when
one is working alone, in approximating the tissues gently during wound
closure. The primary two throws of a square knot are made, leaving a little
more tail on the free end than normal (from this point the free tail is not
grasped until the knot has been slid into the desired position and the soft
tissue approximated). The held end is lifted slightly to obtain a straight
pull and is then pulled with a steady tension. The throws change their
Fig.6.12, page 242
Fig. 6.13, page 243
Fig. 6.14, page 243
Fig.6.15, page 244
Fig. 6.16, pages 245,
246
Fig. 6.17, page 247
Fig. 6.18, pages 248,
249
232
shape from a square knot into half-hitches and slide along the tensioned
Fig. 6.19, page 250
end, slipping on the loop and approximating the soft tissues. It may help
to slide the half-hitches along with the tip of the needle holder. When the
desired approximation is reached, the free end is grasped and firmly tensioned. This squares the knot once more. A final throw is then made to
lock the knot (Fig. 6.19).
Fig. 6.1. a A comminuted tibial fracture with two main
fragments in the butterfly may be controlled effectively
by a cerclage wire passed prior to reduction at the point
of junction of three components of the fracture, i. e., the
butterfly and the proximal and distal main fragments.
b By spreading the tip of the wire tightener and aligning
the leg as shown, the wire tightener may be spun, twisting the wire and effecting a reduction
a
b
233
Fig.6.2a-k. A valgus-impacted
proximal humeral fracture with involvement of the greater tuberosity. a, b AP and axillary views before operation. c, d Via a small
deltoid splitting incision, a periosteal elevator is introduced through
the fracture cleft in the greater tuberosity. Through the same small
incision a bone spreader is inserted
in the opening made by the elevator and opened, disimpacting and
correcting the valgus position of
the articular component. Control at
this point in the procedure is obtained with image intensification.
e, f With the components in a reduced position. A terminally
threaded Schanz screw is utilized
for final reduction and fixation, definitively backed up by a second.
g, h Following metal removal approximately 4 months after operation. i-k Final result almost
2Yz years post injury showing full
restoration of the anatomy of the
proximal humerus. The patient has
absolutely full function
234
b
c
Fig.6.3a-c. The Hohmann retractor has not been widely
utilized as a reduction aid, although mentioned in the
Manual of Internal Fixation for reduction of the femur.
a The gains entrance between the two cortices of a diaphyseal fracture. b With the tip introduced, the instrument is turned. c The curve of the tip provides a good
lever for regaining length
235
2
---'-L____
Fig. 6.4. The standard reduction forceps can be used to
obtain length in an oblique fracture. The points are
placed on each main fragment straight up and down, or
slightly cocked if the obliquity of the fracture line is
long. Maintaining pressure, the handle is rotated with
the hand reversing the relative position of the clamp
jaws and lengthening the fracture
\
"
236
Fig. 6.5 a-d. The reduction of translation of a flat bone.
a The pelvic reduction forceps is first placed securely on
one fragment with a screw. Using the 3.2-mm drill a
hole is made in the bone in alignment with the screwholding end of the forceps. b An extra-long screw is inserted through the hole in the clamp and into the bone.
c By tightening the screw the translation is overcome.
The clamp should be opened such that interference between the two fragments is eliminated. Further turning
of the screw will then completely eliminate the translation. d The forceps is closed and the reduction may be
provisionally stabilized by closing the collar nut on the
spindle
237
lfig.6.6. A 2.7-mm guide pin from the AO
DHS set is inserted into the piriform fo : a and controlled with an AP and oblique
'or lateral view using the image intensifier.
'When it has been ascertained that the ori-
entation is correct the third stage of the
DHS reamer is used to open up the cortex and ream the cancellous bone to
make a passage for the 3-mm guide wire
Fig. 6.7. The T-handJed chuck from the external fixator set is centrally cannulated. This allows it to be used
with the 3-mm guide wire as a handle to negotiate the
guide wire across the fracture fragments
238
Fig. 6.8 a, b. The T-handled chuck
attached to a S.O-mm Schanz screw
is also an important instrument to reduce acetabular fractures when operating from a posterior approach. It
is normally placed in the ischium
just below the subcotyloid gutter, as
illustrated. It is used to derotate the
posterior column fracture, or the ischiopubic fragment in the case of a
transverse fracture. The reduction is
controlled with a finger which palpates the quadrilateral plate surface
239
Fig. 6.9. The same instrument also is of value in an intercondylar, supracondylar fracture of the distal femur.
Here it is inserted through a small stab wound made
over the medial condyle, placed in the medial condylar
fragment, and used to derotate and control the reduction of a supracondylar fracture with split, displaced
condyles
240
a
Fig.6.10a-c. The technique and advantage of setting up gliding holes before reduction. a The figure illustrates
a distal tibia fracture with a large posterior malleolus comprising over half
the articular surface. It is approached
surgically, and before reduction a
4.5-mm gliding hole is made just proximal to the joint line. Through the exposure frequently the drill may be
seen coming out of the cancellous separation of the fracture fragments.
b Next, the drill sleeve is placed in the
4.5-mm gliding hole and the reduction
is carried out in the usual manner and
held provisionally, either with Kirschner wires or with reduction forceps as
shown. Through the drill sleeve the
3.2-mm drill is inserted and the
threaded hole is drilled. The surgeon
may gain an appreciation of how good
the lag screw will be by how long the
3.2-mm drill stays in bone before it
reaches the other cortex and goes
through. c With the reduction maintained by the reduction forceps, the
hole is tapped, measured, and the appropriately sized 4.5-mm cortical
screw is inserted as a lag screw. By
carrying out the steps of lag screw fixation in this order it is certain that the
threads exist only in the far fragment
and that the maximal lag effect is
therefore achieved
241
a
b
I
Fig. 6.11. a Illustration of a fracture in the
diaphysis with a butterfly fragment on the
far side. Such a fracture may be manipulated without much interference with the soft
tissue envelope by drilling with a 3.2-mm
drill in the center of the fragment prior to
reduction. b The tap for a lag screw is then
inserted into the hole that has been made
and the fracture fragment may be manipulated into a reduced position and held
there with a tissue-sparing forceps such as
a pointed reduction clamp not shown. c As
an additional advantage a pointed drill
guide can then be placed in the hole in the
butterfly and the opposite cortex overdrilled using the 4.S-mm drill sleeve and
the pointed reduction guide. In this manner a lag screw may be placed in order to
maintain the reduction
242
a
c
b
Fig. 6.12 a-c. Screws and wires are useful for temporary
fixation when the location is inaccessible to standard
clamps. This technique is helpful in the anterior fixation
of the sacroiliac joint or with large incarcerated bone
fragments, sometimes in conjunction with a bone
spreader. a A place is selected on the sacral ala and a
hole may be drilled to the depth of 30-40 mm. A
4.5-mm screw of 32-34 mm in length is inserted and left
proud. A similar screw is inserted in the posterior thickening of the iliac bone next to the joint and in an appropriate position in relation to the screw in the sacrum.
The head of this screw is also left proud and a 1.2-mm
wire is placed around the two screws. b, c By twisting
the wire or by using the standard AO wire tightener, the
two plates of bone are brought together. Sometimes it is
necessary to place a second set of similar screws slightly
more proximal (or distal) to give a second point of reduction. In this way rotation may be eliminated as well.
Tightening the wires on the two sets of screws stepwise
shares the load so that neither set is overloaded. In addition, on the concave side of the sacroiliac joint, the
straight pull of the wires between the two screws helps
to hold the rotational alignment of the ilium relative to
the sacrum. With the two screws then held in approximation by tightened wire the reduction is temporarily
fixed. Final fixation is then accomplished with an anterior plate or plates. Alternatively, the screw fixation set
up prior to reduction may be employed for definitive
fixation. In such a case the screw is inserted through a
stab wound from the outside through the iliac wing into
the ala of the sacrum or the body
243
Fig. 6.13. An example of the use of a one-third tubular plate to overcome a translation. The plate is simply applied to the side of translation
by means.of screws. As the screws are tightened, the plate comes into an
interference relationship with the other fragment and the fracture is
forced into reduction. This technique is sometimes helpful on the iliac
wing. Screws can then be placed in the other side of the plate as needed
Fig.6.14a-e. The same principle may be used in the
proximal tibia in conjunction with a femoral distractor
when a proximal articular tibial plateau fragment resists
reduction in the sagittal plane. a The femoral distractor
is used in distraction mode and the small four- or fivehole one-third tubular plate is applied to the distal fragment on the crest of the tibia. b As the screws are inserted the plate impinges upon the proximal fragment,
reducing the translation. c With the translation reduced,
the proximal screws may be inserted which fixes this
proximal transverse fracture more securely; an anterior
plate tends to block the deforming force of the quadri-
ceps. With the screws tensioning the plate, it acts as a
tension band. d The same principle may be exploited
with less of an implant. For example, the wire shown in
this illustration crosses over the tip of the proximal fragment and as the wire is tightened the translation may be
overcome. e This figure-of-eight wire acts as well as a
tension band wire, as it neutralizes very well the effect
of the quadriceps on the proximal fragment, yet is a very
economical implant. It is also of value used in the same
manner to secure stability in the sagittal plane when a
high tibial osteotomy is carried out
244
~
1/3 tubular plate
(\
1/2 tubular plate
10 0 0 0 1
1000 01
lo ooC:
a
Fig. 6.15. a A "spring plate" is helpful to stabilize thin
fragments of an articular surface such as seen frequently
in fractures of the posterior wall of the acetabulum. For
this technique a three-hole one-third tubular plate is
usually selected. It is flattened and the end hole is cut
out, leaving two sharp spikes projecting. These spikes
are then bent at 90° to the flattened plate. A spring effect which pushes the prongs into the underlining shales
of bone, stabilizing them securely, can be produced in a
number of ways: by applying the plate over a concavity
or hollow in the bone, or by bending the plate into a
slight concavity as viewed from the bone surface and inserting screws through the holes into the bone, as seen
here, or by sliding the plate underneath a previously applied buttress plate, as seen in Fig.3.24a-f. b Illustration of the principle of a hooked spring plate, using the
example of the posterior inferior wall of the acetabulum
in the region of the tuberosity. Frequently in this loca-
b
tion there is a small shale fracture of a thin but important portion of the articular surface of the back of the
acetabulum. Because of its peripheral location it is difficult to fix with screws. The technique shown here has
been of value at this location and others where there are
small shale fractures of the posterior wall. The end hole
of the plate is filled with a screw and the prongs are rotated over the unstable shale fragment. Placement of the
second screw is such that this malleable plate is forced
into the concavity of the bone springs the plate against
the shale fracture, which is stabilized by the prongs. The
small plate can also be contoured into a concavity and
placed underneath the buttress plate running up to the
posterior retroacetabular surface. Tightening of the buttress plate pushes the hooked spring plate into the shale
fractures or comminuted fractures of the posterior rim,
stabilizing them securely
245
Fig.6.16a-h. Use of the plate described in Fig.6.15 in a
transverse and posterior wall acetabular fracture in
which the posterior wall was comminuted and the fragments peripheral and thin. a-d Preoperative X-rays.
e CT scan. f-h Postoperative X-rays of the internal fixation. Note the small hooked spring plate stabilizing the
posterior inferior wall, which was thin and in which no
screw could be placed
246
247
Fig.6.17a-e. A 65-year-old university
professor had pain in the right knee,
along the medial compartment, for
1 year. a Standing AP new of the right
knee. Note the loss of physiologic valgus and of the medial joint space.
b, c AP and lateral views of knee immediately postoperatively. The one-half tubular plate has been driven into the tibial metaphysis parallel with the joint
line. The osteotomy is done behind the
anterior tibial tubercle. Fixation is secured with a lag screw through the plate
and across the osteotomy, and a second
screw through the plate into the distal
fragment. This results in stable fixation
of the osteotomy, allowing "functional"
aftercare immediately in the postoperative period. d, e The osteotomy is
healed at 8 weeks. The patient has not
lost any knee motion. Full recuperation
will occur by 3-6 months
248
249
.... Fig.6.18a-k. A 15-year-old girl involved in a motor vehicle accident sustained a grade III open tibia and fibula fracture. a AP view of the involved right leg. Note the
severe soft tissue injury apparent on this plain X-ray.
b Although the middle segment of the fracture was completely stripped of its soft tissue an attempt was made to
use it. After thorough irrigation and debridement minimal internal-external fixation was attempted. c The patient became infected and was transferred to the care of
Dr. Thomas Greene, a microvascular hand surgeon. The
avascular segmented fragment had sequestrated and
was removed. The clinical photograph shows the condition of the leg at this point in time. d The Hoffmann apparatus was removed and the leg kept at length with calcaneal pin traction. The wound was serially debrided.
Drainage ceased. e, r Internal stabilization was
achieved by fixing the fibula with a 3.5-mm DCP and a
one-third tubular hook plate with a tension band; and
the tibia with a narrow 4.5-mm DCP bent to a right
angle and inserted directly into the distal fragment,
which was extremely short and porotic. The defect in
the tibia was filled with PMMA and gentamycin beads.
In the same session of surgery a free vascularized trapezius muscle flap was transferred into the large defect
and grafted with split-thickness skin. g Clinical photograph showing the condition of the soft tissue after this
intervention. There was no drainage. The soft tissue
sleeve of the tibia had been reconstructed. h, i At
21;2 months post accident and 19 days post stabilization,
another free graft was carried out, this time of the fibula
from the opposite side (shown above). It was fixed with
screws passing through the small plate. Note that there
has been early consolidation of the fibula. j At
3V2 months post free fibula transfer. All fracture interphases have healed, and a synostosis between the tibia
and fibula has developed. k Just short of 11;2 years post
accident the leg is healed. There is no shortening. The
function of the knee and ankle are excellent. The transferred fibula is hypertrophic
250
4
j
r
6
"-.- 1"";
~
I
Fig. 6.19. The Maurice Muller controlled square knot.
The suture is inserted in the usual manner. 1 The first
throw is accomplished. 2 The second throw is made to
form a loose square knot. 3 The held end is then pulled
while the free end is not set. 4 This changes the shape of
the knot to half-hitches which slide easily along the
pulled portion. 5 The desired approximation is
achieved. 6 The free end is then pulled, which resquares
the knot. 7 Finally, a further throw is made to lock the
square knot
251
References
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H (1979) Manual of internal fixation, 2nd edn.
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253
Subject Index
acetabulum, fractures 54, 91-99
-, reconstruction plates 54, 91-99
-, reduction techniques 55,91-99
-, spring plate 55, 92-95, 231
angled blade plate as a reduction tool 56, 100
- - - in comminuted supracondylar femur fractures
56,109-112
- - - in intertrochanteric fractures 57,115-129
- - - in planning 18
- - - in supracondylar femur fractures 100-108
articulating tension device 51
axes, lower extremity 33
olecranon fracture, reduction with minidistractor
195-197
os calcis fracture, reduction with external fixator
139-141, 185-192
- - -, - with minifixator 139-141, 191, 192
- - -, surgical approach 140
osteotomy, arcuate 14
-, oblique, closing wedge 13
-, -, opening wedge 14
-, step cut 14
-, transverse, closing wedge 13
-, -, opening wedge 14
bone, bent 13
-, straight 12
bone spreader as a reduction aid 224
- - used in distraction 51
bone tap as reduction aid 230
pelvic reduction forceps as a reduction aid 224
plate, antiglide 50
-, buttress 50
-, inlay of 52, 231
-, neutralization 48
-, tensioning 49
preoperative planning, cutouts 11
- -, direct overlay technique 16
- -, goals 15
- -, methods 15
- -, using the axes 18
- -, - the sound side 16
push-pull screw 51, 81-83, 87 -88
callus used as a tension band 202, 210
composite fixation, use in fresh fractures 203-205
- -, - in pathological fractures 204-205, 224-227
controlled square knot 231, 250
distractor, use in closed medullary nailing, femur 132,
148,149,153-154
Ender nails, use with external fixator 203
external fixation, use in substitution 201, 203, 206,
207,218
femoral distractor 131, 146
femur, proximal reduction with distractor 134
-, shaft reduction with distractor 131, 147-152
-, supracondylar, reduction with distractor 134,
162-167
fibula fracture, plate contouring 53, 81
- -, reduction with minidistractor 142
- -, - with one-third tubular plate 53, 82, 83
forearm fracture 54,85,86,87,88,89,90
- -, reduction with plates 87-90
hip reamer as aid to intramedullary nailing 237
Hohmann retractor as a reduction aid 225
lag screw, inside, outside technique 230
ligamentotaxis 130
minidistractor 141, 193
radius, distal fracture, reduction with minidistractor
198
-, - -, - with mini-external fixator 142, 143, 200
reduction, fracture 11
-, indirect 3, 49
-, interference 48
- requisites 1
spring plate, use in fibula reduction 190
T-handled chuck as a reduction aid 230
- - in intramedullary nailing 224
tibia, closed intramedullary nailing with distractor
180-181
- fractures 50
- -, pilon 52, 73-80
- -, plate contouring 50, 60, 68-71
-, pilon fracture reduction with distractor 139,
182-184
-, reduction with straight plate 50, 61-66
254
tibia, shaft reduction with distractor 138, 178
tibial plateau, reduction with distractor 135-138,
168-177
Verbrugge clamp as a plate tensioner 51
wire tighteners, use in reduction
X-rays, appreciating deformity 20
-, errors in planning 12
-, magnification 16
225