Skeletal Trauma: Basic Science, Management, and Reconstruction, 2-Volume Set 6th Edition

Description

Offering expert, comprehensive guidance on the basic science, diagnosis, and treatment of acute musculoskeletal injuries and post-traumatic reconstructive problems, Skeletal Trauma, 6th Edition, brings you fully up to date with current approaches in this challenging specialty. This revised edition is designed to meet the needs of orthopaedic surgeons, residents, fellows, and traumatologists, as well as emergency physicians who treat patients with musculoskeletal trauma. International thought leaders incorporate the latest peer-reviewed literature, technological advances, and practical advice with the goal of optimizing patient outcomes for the full range of traumatic musculoskeletal injuries. Offers complete coverage of relevant anatomy and biomechanics, mechanisms of injury, diagnostic approaches, treatment options, and associated complications. Includes eight new chapters dedicated to advances in technology and addressing key problems and procedures, such as Initial Evaluation of the Spine in Trauma Patients, Management of Perioperative Pain Associated with Trauma and Surgery, Chronic Pain Management (fully addressing the opioid epidemic), Understanding and Treating Chronic Osteomyelitis, and more. Features a complimentary one-year subscription to OrthoEvidence, a global online platform that provides high-quality, peer-reviewed and timely orthopaedic evidence-based summaries of the latest and most relevant literature. Contains unique, critical information on mass casualty incidents and war injuries, with contributions from active duty military surgeons and physicians in collaboration with civilian authors to address injuries caused by road traffic, armed conflict, civil wars, and insurgencies throughout the world. Features important call out boxes summarizing key points, pearls and pitfalls, and outcomes. Provides access to nearly 130 instructional videos that demonstrate principles of care and outline detailed surgical procedures. Contains a wealth of high-quality illustrations, full-color photographs, and diagnostic images. Enhanced eBook version included with purchase. Your enhanced eBook allows you to access all of the text, figures, and references from the book on a variety of devices. Skeletal Trauma Copyright Page Dedication Contributors Foreword Preface Acknowledgments Video Contents Vol1_Endsheet 4_VuMedi ad 1 The History of Trauma Care Introduction The Ancient World Ancient Egypt Ancient Greece Ancient Rome The Middle Ages The Early Modern Era (ca. 1450–ca. 1800) Trauma Management in the 19th Century Napoleonic Wars Mid 19th Century American Civil War Late 19th Century Trauma Management in the 20th Century World War I Interwar Years World War II Mid-Century Developments From the Korean War Through the War in Vietnam Post-Vietnam Trauma Care in the United States and the Creation of an American Trauma System Modern Trauma Physiology and Damage Control Surgery Education and Systems War on Terror Conclusion References 2 Global Burden of Musculoskeletal Injuries Causes of Injury Geographic and Demographic Distribution of Injury Burden Estimating the Burden of Musculoskeletal Injury Focus on Military Injuries References 3 The Challenges of Orthopaedic Trauma Care in the Developing World Introduction Improving Trauma Care Systemwide Globally: the World Health Organization’s Guidelines for Trauma System Development Background Case Studies of Individual Institutions Global Efforts to Improve Trauma Care The Role of the WHO: the World Health Assembly Resolutions on Trauma and Emergency Care Services and on Essential Surgical Care Barriers to Access Education Pediatric Trauma (Management of Common Injuries) Adult Trauma Spinal Injuries Cervical Spine Thoracolumbar Spine Pelvic and Acetabular Fractures Pelvic Ring Injuries Acetabular Fractures Lower Extremity Injuries Hip Dislocations Hip Fractures Femoral Shaft Fractures Knee Injuries Tibia–Fibula Fractures Foot and Ankle Injuries Upper Extremity Injuries Shoulder Injuries Humeral Shaft Fractures Elbow Injuries Forearm Injuries Hand and Wrist Amputations Avenues for Orthopaedic Volunteerism Service Provision Teaching and Training Disaster Relief The SIGN Intramedullary Nail System Background Design Features Innovation Outcomes The SIGN Database Surgical Technique Interlocking Screw Placement Fin Nail Tibial Nail Technique Design Features Incision and Bone Entrance Reduction Reaming Nail Insertion Placement of Interlocking Screws Femoral Nail Technique Introduction Reduction Antegrade Nail Technique Retrograde Nail Technique Pediatric Femoral Fractures Hip Fractures Background SIGN Hip Construct Technique Subtrochanteric Fractures Femoral Neck Fractures References 4 Vascularity and Stability Introduction Strain and Vascularity “Teams” Of Cells Provide Solutions Two Methods of Ossification Primary Bone Healing—Low Strain, Sufficient Vascularity Secondary Bone Healing—Moderate Strain, Moderate Vascularity Vascularity in Healing Fractures Fracture Fixation Plating Nails Conclusion References 5 Biology and Enhancement of Skeletal Repair Introduction Biology of Graft Substitutes Graft Osteogenesis Graft Osteoconduction Graft Osteoinduction Growth Factors Growth Factor Effects on the Phases of Fracture Healing Factors Influencing the Inflammatory Phase Arachidonic Acid Metabolism and the Action of Nonsteroidal Antiinflammatory Drugs Wnt Pathway Factors Affecting the Early Callus Phase Remodeling Phase Factors Affecting the Remodeling Phase: New Venues for Effective Pharmacologic Intervention Graft Incorporation and Healing of Fractures Stages of Bone Graft Incorporation Autogenous Iliac Crest Bone Graft Osteoconductive Graft Substitutes Calcium Sulfate Substitutes Calcium Phosphate Substitutes Hydroxyapatite Tricalcium Phosphate Demineralized Bone Matrix Conclusion Patient-Derived Cellular Therapies Marrow Aspirate Historical Perspective Current Methodology Preclinical Substantiation Clinical Application of Marrow Elements Iliac Crest Marrow Aspiration Technique Clinical Results Conclusion Allograft Stem Cell Preparations Platelet-Rich Plasma Platelet-Derived Growth Factor Transforming Growth Factor–β Platelet-Rich Plasma Augmentation of Graft Materials Preclinical Studies Platelet-Rich Plasma Preparation Clinical Evidence Bone Applications Soft Tissue Applications Recombinant Human Platelet-Derived Growth Factor Inductive Substrates (Bone Morphogenetic Proteins) BMP-7 BMP-2 Fibroblast Growth Factor Off-Label Use and Complications Bone Morphogenetic Protein Interactions Future Directions: Timing of Delivery Future Directions: Mode of Delivery Economic Impact Summary Conclusion References 6 Biomechanics of Fractures Introduction Basics of Mechanics Movement and/or Displacement Stress/Strain Stress-Strain and Other Diagrams Properties of Materials (Young’s or Elastic Modulus, Yield and Failure, Energy/Toughness) Other Material Properties (Viscoelasticity, Anisotropy, Creep and Relaxation, Fatigue, S-N Curve) Finite Element Analysis Primer Bone Properties and Fracture Risk Bone Mechanical Properties Cortical Bone Properties and Microstructure Trabecular Bone Properties and Microstructure Age-Related Bone Property Changes Osteoporosis Structural Properties and Loading Modes Definition (Area Moment of Inertia) Cylinder (Long Bone, Intramedullary Nail, Screw) Rectangle (Plate) and Optimization (I Beam, External Fixator) Loading Modes Tension/Compression and Shear Bending Torsion Loading Experienced by the Skeleton Clinical Examples of Combined Loading Fracture Severity Quantification Fractures Associated With Particular Diseases and Conditions Osteoporosis and Age-Related Fractures Defects in Bone Caused by Malignancy and Benign Conditions Implant-Related Bone Fracture: Periprosthetic and Interprosthetic Fractures Stress Shielding Fracture Healing Healing by Callus Formation: Biomechanical Considerations Biomechanical Stages of Fracture Healing Biomechanics of Fracture Fixation Nonoperative Treatment, Casting and Splinting, Traction Surgical Fixation: Biomechanical Considerations Intramedullary Rods Plate Fixation External Fixation Summary References 7 Closed Fracture Management Introduction Basic Principles Fracture Reduction and Maintenance of Reduction Manipulative Reduction Types of Anesthesia Timing of Reduction Radiographic Examination of Fractures External Support of Fractures Plaster of Paris Management of Acute Fractures Application of Three-Point Loading Techniques Postreduction Management of Acute Fractures Wedging of Casts Walking Casts Scaphoid Fractures Incidence and Demographics Clinical Examination Radiologic Examination Classification and Fracture Incidence Treatment Options Operation Versus Conservative Treatment Minimally Displaced and Undisplaced Cast Treatment Conclusion Distal Radius Fractures Demographics Clinical Assessment Radiologic Assessment Normal Parameters How Much Deformity Is Acceptable in Adults Radial Length Dorsal Angulation Radial Inclination and Intraarticular Displacement Treatment Young Patients Elderly Patients Humeral Shaft Fractures Clinical Considerations Treatment: Functional Bracing Technique Potential Options Strategy Exercise Outcomes Union Versus Nonunion Other Studies Summary Controversies Conclusion Proximal Humerus Fractures Impact Challenges Diagnosis Treatment Initial Immobilization Rehabilitation Timing of Rehabilitation Proximal Fracture of the Humerus Evaluation by Randomization (Profher) Trial Nonoperative Treatment Outcomes Valgus Impacted Fractures One- and Two-Part Fractures Three- and Four-Part Fractures Conclusion Ankle Fracture Epidemiology and Risk Factors Clinical Evaluation Assessment Radiographic Evaluation Classification Systems Determining Stability Smokers Diabetes Elderly Patients Treatment General Special Techniques Long Term Conclusion Tibial Fractures Pathophysiology of Fracture Healing Vascularity and Fracture Healing The Role of the Hematoma Shortening Angulation Soft Tissue Compression Representative Examples Technique Acute Management The Short Functional Cast The Functional Brace Brace Removal and Follow-Up Prognostic Correlations and Considerations Factors Influencing Healing Time Longer Than 30 Weeks Factors Influencing Nonunion Factors Influencing Final Shortening More Than 20 mm Factors Influencing Brace Discontinuance Factors Influencing Final Coronal Angulation (Varus/Valgus) Factors Influencing Final Sagittal Angulation (Anterior/Posterior) Pearls and Pitfalls Traction Indications for Traction Types of Traction Skin Traction Skeletal Traction Treating Femoral Fractures Buck’s Traction Thomas Splint Neufeld Traction Perkins’ Traction Posttraction Assessment References 8 Principles and Complications of External Skeletal Fixation Historical Background Early Fixators Fixators for Limb Lengthening Circular Fixators Fixators for Severe Trauma Computerized Correction Combined Internal and External Fixation Fixator-Assisted Nailing External Skeletal Fixation in the Future Fixator Terminology Frame Configuration Prefabricated Fixators Improvised Fixators Problems, Obstacles, and Complications Nerve and Vessel Injury Vessel Injuries Compartment Syndrome Nerve Injuries Implant Placement to Avoid Neurovascular Injury Technique of Identifying Landmarks Pin Tract Infection Pathophysiology of Pin- or Wire-Site Sepsis Fluid Secretion Abscess Formation Skin Necrosis Heat Injury Deep Soft Tissue Necrosis Bone Necrosis Motion The Pin–Skin Interface The Pin–Bone Interface Strategies to Reduce Implant-Site Sepsis Fixator Selection Pin Selection Pin and Wire Insertion Considerations Fracture Alignment Predrilling Pin Insertion Inserting Transfixion Wires Implant–Skin Interface Management Frame Assembly Pin Care Routine Ambulatory Aids Dealing With Pinhole Problems Fixator-Associated Problems Pressure Necrosis Broken Components Disruption of Lifestyle Pain Postoperative Pain Pain While the Fixator Is in Place Pain on Pin Removal Persistent Pain After Fixator Removal Bone Pain Neurogenic Pain Pain Associated With Fracture Healing Psychological Problems Principles Unique to the Ilizarov Method Treatment Principles for Nonunions and Malunions Segmental Skeletal Defects Joint Mobility Stretching Contractures Limb Positioning Functional Limb Use Regenerate Healing and Maturation Post-Ilizarov Management External Fixators as Nonunion Machines External Fixators for Damage Control Orthopaedics The Temporary Fixator Military Applications When Fluoroscopy Is Not Available The Drill Sleeve Conversion to Permanent External Fixation Choice of Implants Reducing Costs From Inventory Control Implant Depth Using the Atlas for Damage Control Orthopaedics Danger Regions for Percutaneous Pins Inserted Without Fluoroscopy Femur Tibia Humerus Forearm References 9 Principles of Internal Fixation Introduction Plan of Attack and How to Use This Chapter Fracture Pattern Fracture Pattern = Law of Conservation of Energy Fracture Pattern Reveals the Intrinsic Stability of the Bone After Reduction Fracture Pattern Characterizes the Unbalanced Forces That Create Displacement and Subsequent Deformity Fracture Pattern Predicts Expected Soft Tissue Damage Fracture Pattern Defines Expected Mode of Healing Soft Tissue Pattern Recognize the Severity of the Soft Tissue Injury Preoperatively Modify Surgical Plans Based on Soft Tissue Injury Pattern Familiarize Yourself With the Concept of Angiosomes Empower Fracture Fixation Constructs Area Involved Articular Surface Metaphysis and Diaphysis Desired Stability Spectrum of Stability Absolute Stability Compression Summary of Absolute Stability Relative Stability Strain Theory of Perren Stress Distribution Versus Stress Concentration Summary of Relative Stability Approach Intraoperative Positioning and Patient Safety Supine Position Prone Position Lateral Decubitus Position Special Considerations: Hemilithotomy, Perineal Post, and Tourniquet Use Hemilithotomy Position Perineal Post Tourniquets Surgical Exposure Reduction: Direct Versus Indirect Quality of Reduction Method of Reduction AO Philosophy and Inherent Conflict Direct Reduction: Instruments and Techniques Indirect Reduction: Instruments and Techniques Direct and Indirect Reduction: Summary Fixation Wires and Pins Screws Screw Functions Screw Parts: Head Screw Parts: Inner Diameter Screw Parts: Outer Diameter Screw Parts: Tip Screw Types Screw Function Revisited Drill Bits and Taps Screwdrivers Plate Mechanical Function Neutralization Plating Compression Plating Tension Band Plating Buttress Plating Bridge Plating Locked Internal Fixator Specific Design Features Intramedullary Nail or Rod Mechanical Form of Stability General Design Features Proximal End Central Portion Distal End Cross-Sectional Shape Diameter Cannulation Steps of Intramedullary Rodding Starting Point and Entrance Angle Into the Proximal Segment Reduction of the Fracture Reaming (if Chosen) Entrance Angle Into and Ending Point in the Distal Segment Interlocking Screw Insertion Working Length Revisited Construct Stability Construct Failure Injury Factors Patient Factors Surgeon Factors Proactive Failure Analysis Loosening of Screws in a Conventional Plating Construct Screw Fracture in a Conventional Plating Construct Plate Fracture in a Conventional or Locking Construct Bone–Screw Interface Failure in a Locking Construct Interlocking Screw Fracture in an Intramedullary Rod Construct Interlocking Screw Backout and Bone–Screw Interface Failure in an Intramedullary Rod Construct Preoperative Planning The Desired End Result The Surgical Tactic The Operation Logistics Summary References 10 Evaluation and Treatment of the Multi-Injured Trauma Patient Introduction Trauma Systems Prehospital Evaluation and Care Prehospital Personnel Prehospital Care: Airway Control Prehospital Care: Resuscitation Hospital Evaluation and Care Trauma Team Hospital Resuscitation Primary Survey Airway Hemorrhage Control Breathing Circulation Disability Exposure and Environmental Control Damage-Control Surgery Secondary Survey Trauma to the Cranium Neck Injury Thoracic Injury Abdominal Injury Retroperitoneal Injuries Genitourinary Injuries Musculoskeletal Injuries Tertiary Survey The Future of Trauma Care Summary References 11 Initial Evaluation of the Spine in Trauma Patients Introduction Initial Evaluation and Stabilization Advanced Trauma Life Support Classification of Neurologic Injury Radiographic Assessment Cervical Spine Clearance Patient Classification Alert and Asymptomatic Patients Short-Term Cognitive Impairment Patients Symptomatic Patients Long-Term Cognitive Impairment Patients Conclusion: Cervical Spine Clearance Thoracolumbar Spine Clearance Geriatric Spine Trauma Conclusion Acknowledgment References 12 Damage Control Orthopaedic Surgery: A Strategy for the Orthopaedic Care of the Critically Injured Patient Introduction History Early Total Care Damage-Control Orthopaedics Early Appropriate Care Initial Treatment of the Multiply Injured Patient Resuscitation The Basic Characteristics of Shock The Basic Principles of Resuscitation Achieving Hemostasis Endpoints to the Acute Resuscitation and Avoiding Pulmonary Complications The Decision for DCO Assessment Implementing the Principles of DCO Management Goals Surgical Timing and the Titration of Care External Fixation Pelvic Stabilization and Hemodynamic Control Managing Other Musculoskeletal Injuries Conversion to Definitive Fixation Clinical Experience Patients With Thoracic Injury The Effect of Timing The Effect of Reaming The Effect of the Fracture Treatment Recommendations Patients With Fat Embolism Syndrome Patients With Bilateral Femur Fractures Patients With Head Injury Patients With Unstable Pelvic Ring Injuries Conclusion References 13 Disaster Management Introduction Disaster Planning Disaster Classification Disaster Management Barriers to Effective Disaster Response Disaster Response Organization: Incident Command System Natural and Manmade Disasters Nuclear and Radiologic Events Biologic Events Chemical Events Blast Events Blast Injury Pathophysiology Primary Blast Injury Secondary Blast Injury Tertiary and Quaternary Blast Injury Mass Shootings Medical Management of Disaster Casualties Triage: Concept and Principles The Challenge of Individual Triage Global Triage Accuracy Decontamination Evacuation Evacuation and Echelons Echelon I Echelon II Echelon III Echelon IV Echelon V Hospital Care Blast Injury Disaster Education Initiatives Looking to the Future Project Zero: National Academy of Science, Engineering, and Medicine Summary References 14 The Management of Acute and Perioperative Pain Associated With Trauma and Surgery Introduction The Opioid Crisis and Orthopaedic Trauma Surgery Relevance to Orthopaedic Trauma Surgery The National Response to the Opioid Crisis Physiology of Pain Peripheral Nociception Transduction Transmission Central Processing Modulation Perception Sensory and Affective Aspects of Pain Assessment of Acute Pain Verbal Rating Scales Visual Analog Scales Numerical Rating Scales Picture or Face Scales Behavioral Measurements Treatment of Acute Pain Pharmacologic Opioids Effect of Opioids on Cardiac Function Cognitive Effects and Sedation Opioid-Induced Constipation or Opioid Bowel Dysfunction Opioid-Related Endocrinopathy Opioid-Induced Hyperalgesia Nonsteroidal Antiinflammatory Drugs Basic Pharmacology Adverse Effects Acetaminophen Basic Pharmacology Adverse Effects Ketamine and Other N-Methyl-d- Aspartate Inhibitors Basic Pharmacology Adverse Effects Local Anesthetic Agents Basic Pharmacology Adverse Effects and Contraindications Steroids and Other Pharmacologic Agents Basic Pharmacology Adverse Effects Regional Anesthesia Neuraxial Blockade Subarachnoid Block Single-Injection and Continuous Spinal Anesthesia. Brief History of Single-Injection and Continuous Spinal Anesthesia. Catheter Placement for Continuous Spinal Anesthesia. Epidural Anesthesia and Analgesia Epidural Analgesia. Indications. Contraindications. Mechanism of Action. Local Anesthetics, Opioids, and Mode of Delivery. Single-Injection and Continuous Peripheral Nerve Blocks Ultrasound Guidance The Four Basic Requirements for Successful Regional Anesthesia Informed Consent for Nerve Blocks Important “New” Anatomy Currently Shaping Regional Anesthesia The Circumneurium. The Crossover of the Fibers of the Anterior and Middle Scalene Muscles. Three Important “Old” Anatomic, Physics, and Physiologic Concepts Hilton’s Law of Anatomy. Fick’s Second Law of Diffusion. Arthrogenic Muscle Inhibition Ambulatory Continuous Peripheral Nerve Blocks Controversial Issues in Acute Pain Medicine The Controversy of Regional Anesthesia and Acute Compartment Syndrome Diagnosis Monitoring Treatment What about Regional Anesthesia and Acute Compartment Syndrome? Liposomal Bupivacaine in Fracture Surgery Role in Orthopaedic Surgery Role in Fractures and Fracture Surgery Role in Peripheral Nerve Blocks Some Practical Considerations for Collaboration Between Orthopaedic Surgeons and Acute and Chronic Pain Specialists Conclusion Acknowledgments References 15 Chronic Pain Management Introduction Chronification of Pain After Trauma Incidence of Chronic Pain After Trauma Etiology of Chronic Pain After Trauma Pathophysiology of Chronic Pain After Trauma Risk Factors and Mitigation Strategies for Chronic Pain After Trauma Demographic and Social Factors Traumatic Brain and Spinal Cord Injury Traumatic Amputation Nerve Injuries Periarticular Fractures/Combination Injuries and Development of Posttraumatic Arthritis Surgical Factors Preexisting Conditions Presurgical Pain Postsurgical Pain Genetic Factors Rehabilitation Psychological Factors Treatment Overview of Chronic Pain After Trauma Pharmacologic Approaches Nonsteroidal Antiinflammatory Drugs Acetaminophen Opioids Adjuvant Analgesic Drugs (Gabapentinoids/Neuropathic Pain Medications, Antidepressants, Muscle Relaxants, Topical Agents) Nonpharmacologic Approaches Psychological Interventions Rehabilitation and Physical Therapy Social Support and Disability Interventional Pain Medicine Options Hot Topics Preemptive and Preventive Analgesia Preventive Analgesia Preemptive Analgesia Which Approach Should Practitioners Take Given the Conflicting Results? Complex Regional Pain Syndrome Three Stages of CRPS Stage 1 (Acute Stage: 0 to 3 Months) Stage 2 (Dystrophic Stage: 3 to 9 Months) Stage 3 (Atrophic Stage: 9 to 18 Months) Incidence of CRPS Etiology Natural Course of CRPS Diagnosis Tests Used to Support the Diagnosis of CRPS Prevention Treatment Overview Conclusion Neuromodulation for Chronic Pain After Trauma Spinal Cord Stimulation and Dorsal Root Ganglion Stimulation References 16 Evaluation and Treatment of Vascular Injuries Introduction Epidemiology and Outcomes of Vascular Injury in Orthopaedic Trauma History and Physical Examination Signs of Vascular Injury Hard Signs Soft Signs Hemorrhage Extremity Hemorrhage Manual Pressure and Hemostatic Dressings Tourniquets Tourniquet Conversion Junctional Hemorrhage Ischemia High-Risk Findings Diagnosis Arterial Pressure Index Duplex Ultrasonography Computed Tomography Angiography Invasive Angiography Nonoperative Management Management of Vascular Injury Communication and Planning Preparation of the Operating Room Patient Preparation Surgical Exposures Damage Control Ligation Temporary Vascular Shunt Definitive Repair Venous Repair Fasciotomy Sequencing of Repairs Postoperative Care References 17 Compartment Syndromes Introduction History Pathophysiology Diagnosis: Clinical Assessment Crush Syndrome Compartment Syndrome in Combat Measurement Techniques Needle Manometer Arterial Line Catheter Stryker Stic Catheter System Microporous Catheter New Technologies Fasciotomy Techniques Compartment Syndrome of the Hand Compartment Syndrome of the Forearm Volar (Henry) Approach Volar Ulnar Approach Dorsal Approach Compartment Syndrome of the Upper Arm Compartment Syndrome of the Leg Fibulectomy One-Incision (Perifibular) Fasciotomy Double-Incision Technique Compartment Syndrome of the Thigh Compartment Syndrome of the Foot Closure and Aftercare of Fasciotomy Wounds Chronic Exertional Compartment Syndrome Future Direction Acknowledgments References 18 Open Fractures Introduction Mechanism Direct Blow Crush Injury Explosion and Blast Injury Pathophysiology: Infection Classification Gustilo and Anderson Other Open Fracture Classifications OTA/AO Open Fracture Classification Basic Principles of Open Fracture Management in the Emergent Setting Initial Trauma Assessment Prompt Diagnosis Control Bleeding Injury Assessment Integument Contamination Vascular Muscle Integrity and Function Bone Loss Splinting Wound Infections and Antibiotics Specific Antibiotics Length of Antibiotic Treatment Basic Principles of Open Fracture Management in the Operating Suite Skin Preparation Débridement Irrigation Tips and Tricks Landmark Study: FLOW Open Fractures With Compartmental Syndrome Osseous Stabilization Internal Fixation Intramedullary Nailing External Fixation Wound Management Primary Closure Tips and Tricks: Ankle Fractures Delayed Primary Closure Vacuum-Assisted Closure, Negative-Pressure Wound Management Local Antibiotics Comparison of Different Options for Initial Wound Management Immediate Shortening Future Developments Bacteria Identification Using Molecular Platform Antimicrobial Implants Local Antibiotic-Delivery Devices Antibiofilm Agents Dual-Purpose Bone Grafts Tissue Engineering and Regenerative Medicine Approaches Conclusion References 19 Soft Tissue Reconstruction Introduction and General Principles Introduction Reconstructive Ladder and Elevator Initial Evaluation Wound Preparation for Soft Tissue Coverage Negative-Pressure Wound Therapy Wound Coverage Types Skin Grafts Full-Thickness Skin Graft Split-Thickness Skin Graft Dermal Substitutes Random-Pattern Flaps Axial-Pattern Flaps Island-Pattern Flaps Perforator Flap Free Flap Soft Tissue Reconstruction of the Upper Extremity Surgical Planning The Shoulder Scapular and Parascapular Flap The Brachium and Arm Pedicled Latissimus Dorsi Muscle Flap Pedicled Pectoralis Muscle Flap The Elbow Radial Forearm Flap Anconeus Muscle Flap Pedicled Latissimus Dorsi Muscle Flap Forearm Anterolateral Thigh Flap Lateral Arm Flap Scapular and Parascapular Flap Omental Flap Wrist and Hand Reverse Radial Forearm Flap Posterior Interosseous Artery Flap Groin Flap First Dorsal Metacarpal Artery Flap Lower Extremity Soft Tissue Reconstruction Introduction Surgical Planning Hip and Thigh Lower Thigh, Knee, and Proximal Third of the Leg Gastrocnemius Muscle Flap Vastus Lateralis Muscle Flap Saphenous Artery Fasciocutaneous Flap Sural Artery Fasciocutaneous Perforator Flap Popliteal-Based Posterior Thigh Fasciocutaneous Flap Superior Lateral Genicular Artery Fasciocutaneous Flap Middle Third of the Leg Soleus Flap Lower Third of the Leg and Ankle Propeller Flaps Reverse Sural Artery Flap The Foot Distally Based Sural Artery Flap Dorsalis Pedis Flap Medial Plantar Flap Free Flap Special Situations Osteocutaneous Flaps for Limb Salvage Reconstruction Soft Tissue Coverage for High-Velocity Missile Injuries and Blast Trauma Rehabilitation and Outcomes Outcome Studies References 20 Gunshot Wounds and Blast Injuries Introduction Ballistics Diagnosis General Treatment Principles Antibiotic Usage Wound Assessment Upper Extremity Proximal Humerus and Shoulder Joint Vessel and Nerve Injury Fracture Humeral Shaft and Arm Vessel and Nerve Injury Fracture Elbow Distal Humerus Ulna Forearm Gunshot Fractures of the Hand and Wrist Introduction Initial Treatment Surgical Treatment Soft Tissue Management Fracture Treatment Lower Extremity Pelvis Imaging Studies Intraarticular Bullets Intestinal Contamination Fracture Management Femur History and Physical Examination Imaging Initial Treatment Definitive Treatment Diaphyseal and Subtrochanteric Fractures Distal Femoral Fractures Tibia Intraarticular Fractures Foot Orthopaedic Management in the Blast Trauma Patient Blast Trauma Mechanisms of Injury Lessons Learned Conclusion References 21 Pathologic Fractures Introduction Metastatic Bone Lesions Prognosis Biology of Bone Metastases Evaluation Examination: Clinical Features and Presentation Diagnosis Diagnostic Evaluation Imaging Biopsy Management Impending Fractures Pathologic Fractures Goals Nonoperative Treatment Surgical Treatment Upper Extremity Lower Extremity Pelvis and Acetabulum Spine Complications Special Considerations Metastatic Sarcoma to Bone Renal Cell Carcinomas Radiation-Induced Fractures Bisphosphonate-Associated Fractures Conclusion References 22 Osteoporotic Fragility Fractures Demographics of Osteoporotic Fragility Fractures Trends of Fragility Fractures Results of Fragility Fractures Socioeconomic Implications of Fragility Fractures Is the Medical System Prepared for This Change? Secondary Fracture Prevention: Dietary Supplementations and Medical Therapies Vitamin D and Calcium Bisphosphonate Therapy Selective Estrogen Receptor Modulators Calcitonin Antiresorptive Monoclonal Antibodies Denosumab Anabolic Agents Teriparatide Abaloparatide Prevention of Falls Comprehensive Falls Assessment Modification of the Home Exercise Programs Smoking Cessation Medical and Surgical Interventions Unsuccessful Interventions Implementing Secondary Fracture Prevention as a System: the Fracture Nurse Liaison Model Obtaining Dual-Energy X-Ray Absorptiometry Scans Intradisciplinary Team Communication Initiation of Medical Management Medical Therapy Compliance The Role of a Metabolic Bone Clinic Recent National Efforts to Improve Fragility Fracture Care in the United States Summary References 23 Surgical Site Infection Prevention Introduction Defining Surgical Site Infections Preoperative Interventions Smoking Obesity Rheumatoid Arthritis Human Immunodeficiency Virus Staphylococcus Aureus Screening and Decolonization Diabetes Mellitus Malnutrition Anemia Dental Health Prophylactic Antibiotics Timing of Administration Antimicrobial Choices Dosing Duration Intraoperative Means of Reducing Infection The Operating Room Environment The Surgical Team The Surgical Site Conclusion References 24 Diagnosis and Treatment of Complications Systemic Complications Fat Embolism Syndrome Etiology Prevention and Treatment Thromboembolic Disorders Pathogenesis Diagnosis Venous Thromboembolism Protection in Orthopaedic Trauma Polytrauma Patient Hip Fracture Patient Isolated Lower Leg Injury Patient: Distal to the Knee Spinal Cord Injury Patient Treatment of Existing Deep Venous Thrombosis and Pulmonary Embolism Summary Multiple Organ System Dysfunction and Failure Orthopaedic Management Local Complications of Fractures Soft Tissue and Vascular Problems Proximal Humerus Fractures Tibial Pilon Fractures Posttraumatic Arthrosis Joint Incongruity Articular Cartilage Damage Malalignment Malorientation Repetitive Loading Injury Summary Peripheral Nerve Injuries Classification of Nerve Injury Evaluation of Peripheral Nerve Injuries Electromyography and Electrodiagnostics Basic Science of Electrodiagnostics. Characteristic Electromyography Patterns. Nerve Conduction Studies Somatosensory-Evoked Potentials Prognosis Specific Fractures: Humerus Fractures and Radial Nerve Palsy Distal Radius Fractures and Carpal Tunnel Syndrome Summary Management of Complications Risk Management Missed Injuries Documentation of Complications Summary References 25 Understanding and Treating Chronic Osteomyelitis History Epidemiology Epidemiology of Hematogenous Osteomyelitis Epidemiology of Osteomyelitis Secondary to Vascular Insufficiency and Systemic Disorders Epidemiology of Posttraumatic and Postoperative Osteomyelitis Pathogenesis Causative Organisms Role of Fungal and Other Pathogens Development of a Biofilm and Role of a Biofilm in Osteomyelitis Types and Classification of Osteomyelitis Diagnostics Appropriate Tests Role of Inflammatory Indices Value of Cultures DNA Analysis Imaging Studies and Nuclear Medicine Studies Planning and Treatment of Chronic Osteomyelitis Amputation for Treatment Antibiotic Suppression Therapy Tips and Pearls in Treatment Role of Systemic Antibiotics in the Treatment of Chronic Osteomyelitis References 26 Nonunions Introduction Definitions Fracture Repair Healing via Callus Direct Bone (Osteonal) Healing Indirect Bone Healing Etiology of Nonunions Predisposing Factors—Instability, Inadequate Vascularity, Poor Contact Instability Inadequate Vascularity Poor Bone Contact Other Contributing Factors Infection Nicotine and Cigarette Smoking Certain Medications Additional Contributing Factors Evaluation of Nonunions Patient History Physical Examination Radiologic Examination Plain Radiographs Anatomic Location Healing Effort and Bone Quality Surface Characteristics Status of Previously Implanted Hardware Deformities Computed Tomographic Scanning and Tomography Nuclear Imaging Other Radiologic Studies Laboratory Studies Consultations Treatment Objectives Strategies Nonunion Type Hypertrophic Nonunions Oligotrophic Nonunions Atrophic Nonunions Infected Nonunions Active Purulent Drainage Active Nondraining Quiescent Synovial Pseudarthrosis Treatment Modifiers Anatomic Location Epiphyseal Nonunions Metaphyseal Nonunions Diaphyseal Nonunions Nonunions Traversing More Than One Anatomic Region Segmental Bone Defects Static Treatment Methods Acute Compression Methods Gradual Compression Methods Prior Failed Treatments Deformities Surface Characteristics Pain and Function Osteopenia Mobility of the Nonunion Status of Hardware Motor and Sensory Dysfunction Patient Health and Age Problems at Adjacent Joints Soft Tissue Problems Metabolic and Endocrine Abnormalities Treatment Methods Mechanical Methods Weight Bearing External Supportive Devices Dynamization Excision of Bone Screws Cables and Wires Plate-and-Screw Fixation Intramedullary Nail Fixation Osteotomy External Fixation Biologic Methods Nonstructural Bone Grafts Autogenous Cancellous Graft. Allogeneic Cancellous Graft. Bone Marrow Injection Bone Graft Substitutes Growth Factors Decortication Electromagnetic, Ultrasound, and Shock-Wave Stimulation Methods That Are Both Mechanical and Biologic Structural Bone Grafts Mesh Cage Bone Graft Constructs Exchange Nailing Technique. Modes of Healing. Other Issues Bone Contact. Deformity. Infection. Literature Review for Exchange Nailing. Summary. Synostosis Techniques Ilizarov Method Arthroplasty Arthrodesis Amputation Summary Acknowledgments References 27 Motorized Intramedullary Lengthening Nail for Limb Reconstruction Introduction Fundamental Principles Antegrade Femur Lengthening Indications and Preoperative Planning Surgical Technique Postoperative Regimen Retrograde Femur Lengthening Indications Preoperative Planning Surgical Technique Postoperative Regimen Tibial Lengthening Indications and Preoperative Planning Surgical Technique Postoperative Regimen Nonunion Compression Indications Preoperative Planning Surgical Technique Postoperative Regimen Outcomes Summary References 28 Psychological, Social, and Functional Manifestations of Orthopaedic Trauma and Traumatic Brain Injury* Introduction Biomedical Versus Biopsychosocial Model of Medicine Anxiety Disorders and Posttraumatic Stress Generalized Anxiety Disorder and Panic Disorder Posttraumatic Stress Disorder Traumatic Brain Injury and Posttraumatic Stress Disorder Traumatic Brain Injury and Suicide Depression Impact of Psychological Comorbidities on Disability and Family Function Effect on Family Members and Relationships Prevention and Management of Psychological Comorbidities Treatment of Posttraumatic Stress Disorder Treatment of Depression Role of the Orthopaedic Surgeon Communication, Education, and Resources Peer Support Self-Management Family Involvement Conclusion and Future Directions References 29 Pathophysiology and Early Management of Spinal Cord Injury Introduction Pathophysiology of Spinal Cord Injury Primary Injury Secondary Injury Concepts of Neuroprotection Pharmacologic Therapies Riluzole Methylprednisolone Sodium Succinate Minocycline Magnesium Sulfate Monosialotetrahexosylganglioside (GM-1) Nimodipine Thyrotropin-Releasing Hormone Gacyclidine (GK-11) Opioid Antagonism Nonpharmacologic Therapies Therapeutic Hypothermia Principles of Early Management Early Patient Stabilization Hemodynamic Resuscitation Fracture Reduction Traction Early Versus Delayed Surgery Thoracic Spinal Cord Injury Conclusion References 30 Craniocervical Injuries Introduction Anatomy of the Craniocervical Junction Occiput Atlas Axis Ligamentous Anatomy Kinematics Physical Examination Diagnostic Imaging Plain Radiographs Computed Tomography Magnetic Resonance Imaging Dynamic Fluoroscopy Craniocervical Dissociations Mechanism of Injury Classification Imaging Nonoperative Management Operative Management Outcomes and Associated Injuries Occipital Condyle Fracture Mechanism of Injury Classification and Management Imaging Nonoperative Management Operative Management Outcomes and Associated Injuries Atlas Fractures and Transverse Atlantal Ligament Injuries Mechanism Classification Imaging Nonoperative Management Operative Management Outcome and Associated Injuries Atlantoaxial Injuries Mechanism Classification Imaging Nonoperative Management Operative Management Outcome and Associated Injuries Surgical Fixation of Craniocervical Injuries Anesthetic Principles Positioning Neuromonitoring Approach and Technique Occipital Plating C1 Screw Options C2 Screw Options Wiring Options Conclusion References 31 Craniocervical Injuries Introduction Mechanism of Injury, Biomechanics, and Anatomy Bony Anatomy Vertebral Artery Ligamentous Anatomy Mechanism of Injury Evaluation Clinical Assessment Imaging Diagnosis and Classification Odontoid Fracture Traumatic Spondylolisthesis (Hangman’s Fracture) C2 Corpus Fractures Management Odontoid Fractures Treatment Options Type I Odontoid Fractures Type II Odontoid Fracture Risk Factors for Nonunion. Nonoperative Care. Odontoid Screw Advantages and Disadvantages. Indications and Contraindications. Posterior C1–C2 Fusion Advantages and Disadvantages. Indications and Contraindications. Type III Odontoid Fracture Geriatric Odontoid Fractures Odontoid Fractures in Children Outcomes of Odontoid Fractures Type I Type II Nonoperative Care. Internal Fixation. Traumatic Spondylolisthesis/ Hangman’s Fracture Treatment of Type I Injuries Treatment of Type II and Type IIA Nonoperative Treatment Operative Treatment Treatment of Type III Outcome of Treatment of Hangman’s Fractures Treatment of C2 Corpus Fractures Surgical Treatment Positioning Techniques Anterior Procedures. Posterior Procedures. Surgical Approach Anterior Approach to C2. Posterior Approach. Other Approaches. Reduction and Fixation Techniques Anterior Screw Fixation of the Dens. Anterior Transarticular C1–C2 Screw Fixation. Anterior Discectomy and Fusion. Posterior C2 Pedicle Screw Fixation (“Judet”). Posterior C1–C2 Screw–Rod Fixation (“Harms Construct”). Posterior Transarticular C1–C2 Screw Fixation (“Magerl”). Meta-Analyses and Systematic Reviews Guidelines Cost-Effectiveness Conclusion References 32 Subaxial Cervical Spine Trauma Introduction Anatomy Osseous Structures Nonosseous Structures Biomechanics The Concept of Biomechanical Stability of the Cervical Spine Quantifying Instability Classification Systems Aospine Subaxial Cervical Spine Injury Classification System Type A: Compression Injuries Type B: Tension Band Injuries Type C: Translation Injuries Type F: Facet Injuries Neurologic Status Modifier Case-Specific Modifiers M1: Posterior Capsuloligamentous Complex Injury Without Complete Disruption M2: Critical Disc Herniation M3: Stiffening/Metabolic Bone Disease M4: Vertebral Artery Abnormality Management General Considerations Principles of Nonoperative Management Principles of Operative Management Decision Making: Management of Injuries Injury-Specific Treatment Recommendations Compression and Burst Fractures Anterior Tension Band Injuries Treatment Recommendations for Anterior Distraction in the Nonankylosed Spine (Type B3) Treatment Recommendations for Anterior Distraction Injuries of the Ankylosed Spine (Types B3, M3) Translation (Type C) Flexion Compression or Teardrop Injury Unilateral Facet Fracture-Dislocation Bilateral Facet Fracture-Dislocations Floating Lateral Mass Fractures (Type F3) Techniques Closed Reduction of a Cervical Facet Dislocation Contraindications Positioning Pin Insertion Traction Weight Surgical Techniques Approach Surgical Anatomy The Lateral Mass. Cervical Pedicles. Vertebral Body. Vertebral Artery. Surgical Stabilization Anterior Cervical Discectomy and/or Corpectomy and Fusion. Posterior Stabilization. Summary References 33 Thoracolumbar Trauma Classification Anatomy of Thoracolumbar Region Mechanisms of Injury Preoperative Physical Examination and Radiographic Evaluation General Assessment Physical Examination Imaging in Thoracolumbar Fractures Classification of Injury Evolution of Thoracolumbar Classification Systems The Thoracolumbar Injury Classification System The Aospine Thoracolumbar Spine Injury Classification System Conclusion Treatment of Burst Fractures Anatomy Burst Fractures in Thoracolumbar Fracture Classification Patient Assessment Physical Examination Imaging Treatment Nonoperative Treatment Bracing Indications for Nonoperative Treatment Versus Operative Treatment Principles of Nonoperative Treatment Fragility Fracture Considerations Surgical Treatment of Burst Fractures Surgical Indications Posterior Instrumentation With or Without Fusion Anterior Thoracolumbar Approach: Corpectomy and Instrumentation Surgical Indications, Advantages, and Limitations Positioning Landmark, Incision, and Approach Corpectomy and Decompression Instrumentation and Fusion Closure and Postoperative Course Complications From Anterior Thoracolumbar Approach Posterior Thoracolumbar Approach: Corpectomy and Instrumentation Outcomes Nonoperative Treatment Versus Operative Treatment for Thoracolumbar Fractures Without Neurologic Deficit Anterior Versus Posterior Fusion Outcomes Conclusion Flexion-Distraction and Fracture-Dislocation Injuries Mechanism of Injury Flexion Injuries Flexion-Distraction Injuries Lateral Shear Injuries Flexion-Rotation Injuries Fracture-Dislocation Injuries Treatment Treatment Considerations Principles of Nonoperative Treatment Treatment of Chance and Flexion-Distraction Injuries Distraction Injuries Fracture-Dislocations Lateral Shear or Slice Injuries Operative Treatment Extent of Fusion/Instrumentation (Short Segment/Long Segment) Role of Decompression Timing of Surgery Role of Anterior Plus Posterior Surgery Minimally Invasive Surgery Versus Open Surgery Surgical Technique Anesthetic Considerations Positioning Exposure Fracture Reduction Instrumentation Fusion Wound Closure Complications Intra-Abdominal Injuries Dural Tears Neurologic Complications Postoperative Infections Implant Complications Skin Ulceration Chronic Pain Outcomes Conclusion Low-Lumbar Fractures Biomechanics/Anatomy Fracture Classification Treatment General Assessment Nonsurgical Treatment Compression Fractures Burst Fractures Without Neurologic Injury Surgical Treatment Burst Fractures With Neurologic Injury Flexion-Distraction Injuries Chance-Type Fractures Fracture-Dislocation Injuries Surgical Technique: Posterior Instrumentation of the Low-Lumbar Spine Anesthesia Positioning Exposure Decompression Reduction Pedicle Screw Instrumentation Closure Surgical Technique of Anterior Decompression of the Low-Lumbar Spine Approaches Positioning Incision Closure Complications Treatment Outcomes Conclusion New Concepts in Management of Thoracolumbar Fractures Fusionless Spine Trauma Care Indications for Percutaneous Instrumentation Fractures in Ankylosed Spines Flexion-Distraction and Chance-Type Fractures Burst Fractures Multilevel Spine Fractures Adjunct to Anterior Decompression and Fusion Otherwise Stable Fractures in a Polytrauma Setting Fractures and Dislocations With Complete Neurologic Injury Complex Sacral Fractures and Spinopelvic Dissociation Patterns Disadvantages of Fusionless Spine Care Surgical Technique: Minimally Invasive Stabilization With Percutaneous Instrumentation Patient Positioning Imaging Choice—Fluoroscopy Versus Intraoperative CT Navigation Fracture Reduction Wound Closure Follow-Up Instrumentation Removal Surgical Technique: Percutaneous Instrumentation Using Fluoroscopy Imaging Setup—Fluoroscopy Screw Starting Point—Fluoroscopy Screw Pathway Establishment—Pedicle Cannulation With Fluoroscopy Screw Insertion—Fluoroscopy Cement Augmentation of Pedicle Screws Iliac Screw Insertion—Fluoroscopy Rod Insertion—Fluoroscopy Facet Joint Fusion—Fluoroscopy Surgical Technique: Percutaneous Instrumentation Using Intraoperative CT Navigation Imaging Setup—CT Navigation Screw Starting Point—CT Navigation Screw Pathway Establishment—CT Navigation Screw Insertion—CT Navigation Cement Augmentation of Pedicle Screws— CT Navigation Rod Insertion—CT Navigation Facet Joint Fusion—CT Navigation Complications of Percutaneous Instrumentation Damage-Control Spine Surgery Lateral Approach for Thoracolumbar Burst Fractures Indications—Lateral Approach for Thoracolumbar Burst Fractures Surgical Technique: Lateral Approach for Trauma Thoracoscopic Approach for Thoracolumbar Junction Burst Fractures Conclusion References 34 Fractures in the Ankylosed Spine Introduction Global Epidemiologic Trends in Ankylotic Spinal Disorders Biomechanical Modifications and Altered Fracture Mechanisms of the Ankylosed Spine Prehospital Care for Patients With Fractures of the Ankylosed Spine In-Hospital Diagnosis and Classification of Fractures of the Ankylosed Spine Considerations for the Optimal Treatment of Ankylosed Spine Fractures Long-Term Outcome and Possible Ways to Improve Care References 35 Osteoporotic Spinal Fractures Introduction Epidemiology Mechanism of Injury and Biomechanics Evaluation Diagnosis and Classification Management Cement Augmentation: Vertebroplasty and Kyphoplasty Indications Patient Selection Vertebroplasty Technique Anesthesia and Patient Positioning Pedicle Insertion Cement Application Postoperative Care Kyphoplasty Technique Modifications of Cement Augmentation Cement Formulations Expansion Devices Biopsy Cement Augmentation in Spinal Metastasis Surgical Intervention Complications Cement Augmentation Clinical Outcomes Vertebroplasty and Kyphoplasty Surgical Intervention Meta-Analysis and Systematic Reviews Guidelines Cost-Effectiveness Conclusion References 36 Avoiding Complications in Spine Trauma Patients Introduction Preoperative Considerations Preoperative Evaluation and Decision Making Complications With Preoperative Cervical Collar Management Preoperative Timing Steroids in Spinal Cord Injury: Indications and Potential Complications Blunt Cerebrovascular Injury Preoperative Nutritional Status Obesity Prognostic Implications of Diagnosis Pulmonary Complications Intraoperative Management Preoperative and Intraoperative Imaging Intraoperative Blood Loss Incidental Durotomy/Dural Tears From Spine Trauma Recombinant Human Bone Morphogenetic Protein-2 Postoperative Considerations Surgical Site Infection Catheter-Associated Urinary Tract Infections Acute Deep Venous Thrombosis Metabolic Bone Disease Failure of Fixation/Pseudoarthrosis Neurologic Deterioration Decubitus Ulcer Controversy in Characterizing Spinal Cord Complications Conclusion References 37 Principles of Orthotic Management Introduction Cervical Orthoses Extrication Collars Cervical Traction and Halo Ring Halo Vest Soft Cervical Collar Hard Cervical Collar Cervicothoracic Orthosis Figure-of-Eight Brace Thoracolumbar Orthoses Thoracolumbar Sacral Orthoses Lumbosacral Orthoses Other Types of Special Orthoses Thigh Extension Hyperextension Braces Cervicothoracic Lumbosacral Orthoses Illustrative Case: Hangman’s Fracture General Principles of Orthotic Use Outcome of Bracing After Spinal Trauma Complications of Bracing Summary References 38 Pelvic Ring Injuries Introduction Anatomy Pelvic Stability and Biomechanics Trauma Mechanism and Pathomechanics of Pelvic Injuries Trauma Mechanism Motor Vehicle Accident Fall From a Height Osteoporotic Pelvic Fractures of the Elderly Pathomechanics of Pelvic Injuries Anterior-Posterior Force Pattern Lateral Compression Force Pattern External Rotation-Abduction Force Pattern Shear Force Pattern Radiologic Diagnostics in Pelvic Injuries Plain Radiographs Anterior-Posterior Radiograph Inlet Radiograph (Pennal I) Outlet Radiograph (Pennal II) Computed Tomography Magnetic Resonance Imaging Scintigraphy Special Imaging of the Symphysis Classification of Pelvic Injuries Anatomical Classification Mechanical Classification Young and Burgess Classification AO Classification (Modified Pennal and Tile Classification) Fractures With Proper Names Osteoporotic Pelvic Ring Fracture Classification Sacral Fracture Classification Denis Classification Roy-Camille Classification Isler Classification Lumbosacral Injury Classification Acute Management Prehospital Management Diagnostics Treatment Emergency Management Diagnostics Associated Injuries Damage Control Orthopaedics Pelvic Circumferential Compression Device External Fixation Anterior External Fixation Surgical Technique: Supraacetabular Fixator. Pelvic C-Clamp Surgical Technique: Pelvic C-Clamp. Resuscitative Endovascular Balloon Occlusion of the Aorta Surgical Technique: REBOA Preperitoneal Pelvic Packing Surgical Technique: Pelvic Packing Transcatheter Arterial Embolization Definitive Management History Physical Examination Decision Making Surgical Approaches Anterior Approaches Pfannenstiel Approach Surgical Technique: Pfannenstiel Approach. Stoppa Approach Surgical Technique: Stoppa Approach. Anterolateral Approach Surgical Technique: Anterolateral Approach. Lateral Approach Surgical Technique: Lateral Approach. Posterior Approaches Surgical Technique: Paramedian Approach Surgical Treatment External Fixation Sacroiliac Fixation Anterior Pelvic Ring Fixation Anterior Fixators Surgical Technique: Subcutaneous Anterior Internal Fixation. Symphyseal Plating Surgical Technique: Symphyseal Plating. Pubic Ramus Fixation Surgical Technique: Superior Ramus Screw. Posterior Pelvic Ring Fixation Sacroiliac Plating Surgical Technique: SI Joint Plating. Sacroiliac Screw Fixation Surgical Technique: Open Iliosacral Screw Fixation. Percutaneous Sacroiliac Screw Fixation Surgical Technique: Percutaneous Sacroiliac Screw Fixation. Transiliac-Transsacral Screw Fixation Surgical Technique: Transiliac-Transsacral Screw Fixation. Posterior Pelvic Ring Plating Surgical Technique: Posterior Pelvic Ring Plating. Isolated Iliac Wing Fractures Sacral Fractures With Spinopelvic Instability Neural Decompression Surgical Stabilization Techniques Direct Sacral Osteosynthesis. Surgical Technique: Direct Osteosynthesis of the Sacrum. Percutaneous Posterior Pelvic Fixation. Spinopelvic Fixation. Surgical Technique: Lumbopelvic Stabilization. Conservative Treatment of Pelvic Ring Fractures Postoperative Treatment Complications Early Complications Infection Loss of Fixation Neurologic Injury Thromboembolism Late Complications Pain Malunion Nonunion Genitourinary Injuries Assessment Management Open Pelvic Fractures Assessment Management Outcome References 39 Surgical Treatment of Acetabular Fractures Epidemiology Osteology Radiology Radiographs Imaging Technique Computed Tomography Angiography Magnetic Resonance Imaging Classification Posterior Wall Acetabular Fractures Posterior Column Acetabular Fractures Anterior Wall Acetabular Fractures Anterior Column Acetabular Fractures Transverse Acetabular Fractures Transverse Fractures With Associated Posterior Wall Involvement Posterior Column Fracture With Associated Posterior Wall Involvement Anterior Column Fracture With Associated Posterior Hemitransverse Injury T-Type Acetabular Fracture Both-Column Acetabular Fracture Variant Patterns Decision Making Radiographic Parameters Closed Treatment Surgery Biomechanic Stability Bone Quality and Special Considerations Operative Timing Initial Management Surgical Exposures Kocher–Langenbeck Ilioinguinal Exposure Lateral Window Medial Window Middle Window Extended Iliofemoral Exposure Combined Anterior and Posterior Exposures Other Exposures Smith–Petersen Pararectus Approach Manipulative Reduction and Percutaneous Fixation Exposure, Reduction, and Fixation by Fracture Pattern Posterior Wall Posterior Column Anterior Wall Anterior Column Transverse Transverse Fracture With Associated Posterior Wall Involvement Posterior Column Fracture With Associated Posterior Wall Involvement Anterior Column Fracture With Associated Posterior Hemitransverse Involvement T-Type Associated Both-Column Fracture Operative Management of A Transverse Fracture With Associated Posterior Wall Acetabular Component Using A Kocher–Langenbeck Exposure and the Patient Positioned Prone Application of an Intrapelvic Plate to Support the Quadrilateral Surface Fracture Component Acetabular Osseus Pathways for Screw Fixation Anterior Column Pathway Midpelvic Pathway: Anterior Inferior Iliac Spine to Posterior Ilium Iliac Crest Pathways Posterior Acetabular Column Pathway Aftercare Complications Malreduction Nerve Injury Deep Venous Thrombosis Infection Ectopic Bone Formation Aseptic Necrosis of the Femoral Head Arthritis Fixation Error Nonunion Summary References 40 Fractures and Dislocations of the Hand The Thumb Ray Intraarticular Carpometacarpal Fractures of the Thumb Metacarpal Regional Anatomy Examination Indications Surgical Exposures and Fixation Techniques Outcomes Sequelae Future Directions Extraarticular Fractures of the Thumb Metacarpal Ligamentous Injuries Carpometacarpal Joint Examination Indications Surgical Exposures and Technique Outcomes Sequelae Future Directions Thumb Metacarpophalangeal Collateral Ligament Injuries Regional Anatomy Examination Indications Surgical Exposures and Repair Techniques Acute Ulnar Collateral Ligament Repairs Chronic Ulnar Collateral Ligament Reconstructions Acute Radial Collateral Ligament Repairs Chronic Radial Collateral Ligament Reconstructions Open Reduction and Internal Fixation of Collateral Ligament Avulsion Fracture Outcomes Ulnar Collateral Ligament Radial Collateral Ligament Future Directions Thumb Metacarpal-Phalangeal Joint Dislocations Metacarpal Fractures (Excluding the Thumb) Regional Anatomy Examination Metacarpal Base and Carpometacarpal Fractures of the Digits Indications Surgical Exposures and Fixation Techniques Outcomes Sequelae Future Directions Metacarpal Shaft Fractures Indications Nonoperative Treatment Surgical Exposures and Fixation Techniques Closed Reduction and Percutaneous Techniques Transmetacarpal Pinning. Retrograde Techniques Retrograde Longitudinal Intramedullary Fixation. Retrograde Crossed Pinning. Retrograde Limited-Open Intramedullary Headless Screw Fixation. Antegrade Techniques Open Reduction and Internal Fixation Oblique and Spiral Fractures Simple Transverse Diaphyseal Fractures Sequelae Future Directions Metacarpal Neck Fractures Indications Nonoperative Treatment and Outcomes Surgical Exposures and Fixation Techniques Retrograde Limited-Open Intramedullary Headless Screw Fixation Open Reduction and Internal Fixation Surgical Outcomes Future Directions Fixed-Angle Implants Open Reduction and Internal Fixation in Special Circumstances Metacarpal Head Fractures Indications Nonoperative Treatment Surgical Exposures and Fixation Techniques Outcomes Complications of Metacarpal Fractures Metacarpophalangeal Joint Ligamentous Injuries Regional Anatomy Dislocations Collateral Ligament Injuries Metacarpophalangeal Collateral Ligament Avulsion Fractures Phalangeal Fractures and Interphalangeal Joint Injuries Phalangeal Fractures Fractures of the Distal Phalanx Complications Fractures of the Middle and Proximal Phalanges Articular Phalangeal Fractures Condylar Fractures Classification. Examination. Surgical Exposure and Fixation Techniques. Phalangeal Base Fractures Dorsal Base Fractures Volar Lateral Fractures Plateau Fractures Volar Central Fracture-Dislocations Extension Block Splinting Extension Block Pinning Closed Reduction and Percutaneous Fixation Open Reduction and Internal Fixation External Fixation Volar Plate Arthroplasty Hemi-Hamate Arthroplasty Nonarticular Fractures of the Phalanges Phalangeal Neck Fractures Phalangeal Shaft Fractures Closed Reduction and Immobilization Closed Reduction and Percutaneous Pinning Open Reduction and Internal Fixation Open Reduction and Wire Fixation Screw Fixation Plate Fixation External Fixation References 41 Fractures and Dislocations of the Carpus Fractures of the Scaphoid Introduction Mechanism of Injury and Biomechanics Evaluation Examination Imaging Diagnosis and Classification Duration Location Orientation Displacement Comminution Associated Injuries Patient Factors Management Disorder or Injury Emergent Treatment Indications for Definitive Care Nonoperative Treatment Nondisplaced Fractures Surgical Treatment Nondisplaced Fractures Percutaneous Scaphoid Fixation Volar Percutaneous Scaphoid Fixation Technique (Fig. 41.6). Dorsal Percutaneous Scaphoid Fixation. Displaced or Unstable Fractures Open Volar Approach (Fig. 41.8 and see Video 41.1) Open Dorsal Approach Pitfalls and Avoidance of Complications Postoperative Care and Rehabilitation Complications Surgical Delayed Union Nonunion Operative Treatment Operative Treatment (see Videos 41.1 Through 41.16) Bone Grafting Vascularized Bone Grafts. Modified Matti-Russe Technique (see Video 41.1). Fisk-Fernandez Technique (Fig. 41.12). Internal Fixation. Special Situations Proximal Pole Fractures. Distal Pole Fractures. Salvage Procedures. Radial Styloidectomy. Proximal Row Carpectomy. Arthrodesis. Technique: Complete Arthrodesis. Other Salvage Procedures Distal Scaphoid Resection Arthroplasty. Outcome Meta-Analysis and Systematic Reviews Guidelines Authors’ Preferred Approach Cost-Effectiveness Other Carpal Fractures Lunate Fractures Mechanism of Injury and Biomechanics Trauma Kienböck Disease Evaluation Examination Imaging Diagnosis and Classification Trauma Kienböck Disease Management Trauma Kienböck Disease Radial Shortening Technique: Total Intercarpal Arthrodesis. Complications Trauma Kienböck Disease Outcome Meta-Analysis and Systematic Reviews Fractures of the Capitate Fractures of the Hamate Technique Fractures of the Triquetrum Fractures of the Trapezium Fractures of the Pisiform Fractures of the Trapezoid Dislocation of the Carpus Introduction Wrist Motion Theories Wrist Ligament Anatomy Wrist Kinematics Mechanism of Injury and Biomechanics Evaluation Examination Stress Tests Imaging Routine Views Supplemental Views Other Studies Cineradiography. Magnetic Resonance Imaging. Computed Tomography. Arthroscopy. Perilunate Dislocations and Fracture-Dislocations Diagnosis Treatment Outcome Closed Reduction Technique. Open Reduction Internal Fixation Technique. Transscaphoid Perilunate Dislocation Technique: Dorsal Approach Technique: Volar Approach for Scaphoid Fixation Transtriquetral Perilunate Fracture-Dislocation Capitate–Hamate Diastasis Scapholunate Dissociation Diagnosis Treatment Acute Scapholunate Dissociation. Closed Reduction and Percutaneous Pinning Technique. Authors’ Preferred Method. Chronic Scapholunate Dissociation. Soft Tissue Methods. Direct Ligamentous Repair. Dorsal Capsulodesis. Tendon Grafts. Bone–Ligament–Bone Grafts. Intercarpal Arthrodesis. Scapholunate Arthrodesis. Scapholunate–Capitate Arthrodesis. Scaphoid Excision and Four-Corner Arthrodesis. Scapho–Trapezial–Trapezoid Arthrodesis. Reduction Association of the Scapholunate Joint (RASL). Lunotriquetral Dissociation Diagnosis Treatment Authors’ Preferred Method. Midcarpal Instability Authors’ Preferred Approach Secondary (Adaptive) Midcarpal Instability References 42 Fractures of the Distal Radius Functional Anatomy Classification Extraarticular Fractures Intraarticular Fractures Diagnostic Imaging Determination of Stability Relation of Anatomy to Function Treatment Patient Considerations Options Treatment of Extraarticular Fractures Stable Fractures Unstable Fractures Percutaneous Pins External Skeletal Fixation Open Reduction Comparison of Fixation Techniques Treatment of Intraarticular Fractures Stable Fractures Unstable Fractures Two-Part Radiocarpal Fractures Two-Part Impacted Fractures Two-Part Radial Styloid Fractures Three-Part Intraarticular Fractures Four-Part Intraarticular Fractures Intraarticular Fractures With Five or More Parts Associated Injuries Ulnar Styloid Fractures Ligamentous Injuries and Carpal Fractures Complications Nerve Injuries Hand Stiffness and Tendon Dysfunction Malunion Nonunion Evaluation of Outcome Future Considerations Bone Replacement Materials Alternative Fixation Options Arthroscopically Guided Reduction Summary References 43 Diaphyseal Fractures of the Forearm Functional Anatomy Proximal Radioulnar Joint Distal Radioulnar Joint Interosseous Membrane Muscles Supinators Pronators Nerves and Vessels Classification of Diaphyseal Forearm Fractures Arbeitsgemeinschaft Für Osteosynthesefragen/Orthopaedic Trauma Association Classification Monteggia Fracture Galeazzi Fracture Essex-Lopresti Lesion Classification of Associated Soft Tissue Trauma Diagnosis Anamnesis Clinical Examination Radiologic Examination Magnetic Resonance Imaging Examination Ultrasonography Treatment Simple Ulna Fracture, Radius Intact Simple Fracture of the Radius, Ulna Intact Simple Fracture of the Radius and the Ulna Wedge Fracture of the Ulna, Radius Intact Wedge Fracture of the Radius, Ulna Intact One Bone Wedge Fracture, the Other Simple or Wedge Complex Fracture of the Ulna, Radius Simple or Wedge Complex Fracture of the Radius, Ulna Simple or Wedge Complex Fracture of the Radius and the Ulna Essex-Lopresti Lesion Aggravating Cofactors Open Fracture Peri-Implant Fractures Periprosthetic Fractures Osteoporosis and Osteomalacia Osteogenesis Imperfecta Spastic Palsy and Epilepsy Nicotine Abuse Immune Suppression and Diabetes Complications Compartment Syndrome of the Forearm Wound Infection and Osteomyelitis Delayed Bone Healing and Nonunion Malunion and Bridging Callus Concomitant Soft Tissue Injury Traumatic Forearm Amputation Implant Removal Outcome Conclusion References 44 Trauma to the Adult Elbow Introduction Mechanism of Injury and Biomechanics Evaluation Examination Imaging Diagnosis and Classification Management Disorder or Injury: Radial Head Fractures Emergent Treatment Indications for Definitive Care Nonoperative Treatment Surgical Treatment Surgical Anatomy Positioning Techniques Surgical Approach Reduction and Fixation Techniques Pitfalls and Avoidance of Complications Radial Head Excision. Radial Head Replacement. Radial Head ORIF. Management of Intraoperative Problems Postoperative Care and Rehabilitation Complications Outcome Disorder or Injury: Olecranon Fractures Emergent Treatment Indications for Definitive Care Nonoperative Treatment Surgical Treatment Surgical Anatomy Positioning Techniques Surgical Approach Reduction Techniques Fixation Techniques Fragment Excision. Open Reduction and Internal Fixation. Tension-Band Wiring. Plating. Pitfalls and Avoidance of Complications Management of Intraoperative Problems Postoperative Care and Rehabilitation Complications Outcome Disorder or Injury: Coronoid Fractures Emergent Treatment Indications for Definitive Care Nonoperative Treatment Surgical Treatment Surgical Anatomy Positioning Techniques Surgical Approach and Fracture Reduction and Fixation Surgical Approach to Anterolateral or Tip Fractures. Anteromedial Fractures. Basal Fractures. Pitfalls and Avoidance of Complications Management of Intraoperative Problems Postoperative Care and Rehabilitation Complications Outcome Disorder or Injury: Elbow Dislocations Emergent Treatment Indications for Definitive Care Nonoperative Treatment Surgical Treatment Surgical Anatomy Positioning Surgical Approach and Reduction and Fixation Pitfalls and Avoidance of Complications Management of Intraoperative Problems Postoperative Care and Rehabilitation Complications Outcome Meta-Analyses and Systematic Reviews Conclusion References 45 Fractures of the Distal Humerus Introduction Epidemiology Functional Anatomy Surgical Anatomy Blood Supply Evaluation Examination Imaging Classification Management A- and C-Type Fractures Emergent Treatment Nonoperative Treatment Surgical Treatment Surgical Approach Paratricipital (Triceps-Sparing) Approach. Triceps-Splitting Approach. Olecranon Osteotomy Reduction Techniques Fixation Techniques Postoperative Care and Rehabilitation Coronal Fractures (B Type) Initial Treatment Nonoperative Treatment Surgical Treatment Positioning Techniques Surgical Approach Reduction Techniques Fixation Techniques Arthroscopic-Assisted Fixation. Postoperative Care and Rehabilitation Open Fractures of the Distal Humerus Total Elbow Arthroplasty Complications Ulnar Nerve Heterotopic Ossification Nonunion and Fixation Failure Elbow Stiffness Outcome Meta-Analyses and Systematic Reviews Conclusion References 46 Fractures of the Humeral Shaft Introduction Relevant Anatomy Mechanism of Injury/Biomechanics Evaluation Examination Imaging Diagnosis and Classification Management Disorder and Injury Emergent Treatment Indications for Definitive Care Pathologic Fractures Nonoperative Treatment Surgical Treatment Surgical Anatomy Patient Positioning Surgical Options Intramedullary Nailing. Retrograde Humerus Nailing. Antegrade Humerus Nailing. External Fixator. Plate Osteosynthesis. Approaches for Plate Osteosynthesis Anterior Approach. Posterior Approach. Medial Approach. Anterolateral and Anterior Minimally Invasive Approach. Reduction Techniques Fixation Techniques Pitfalls/Avoidance of Complications Management of Intraoperative Problems Postoperative Care and Rehabilitation Complications Radial Nerve Palsy Delayed Union and Nonunion Outcome Meta-Analyses and Systematic Reviews Nonoperative Versus Operative Therapy Open Reduction and Internal Fixation Versus Minimally Invasive Osteosynthesis Plate Fixation Versus Intramedullary Nailing Antegrade Versus Retrograde Nailing Guidelines Cost-Effectiveness Conclusion References 47 Proximal Humeral Fractures and Glenohumeral Dislocations Essential Principles for Treatment of Proximal Humeral Fractures and Glenohumeral Dislocations Relevant Anatomy and Biomechanics Joint Anatomy Neurovascular Anatomy Biomechanics Evaluation of an Acutely Injured Shoulder History Physical Examination Imaging Trauma Series (Three Views) Rotational Anteroposterior Views (Two Views) Computed Tomography Magnetic Resonance Imaging Ultrasonography Radiograph Image Intensifier Differential Diagnosis Surgical Treatment of Proximal Humeral and Glenohumeral Injuries Anesthetic Considerations Intraoperative Imaging Intraoperative Patient Positioning Surgical Approaches Deltopectoral Approach Superior Approach With or Without Anterior Acromioplasty Posterior Approach Outcome Evaluation Proximal Humeral Fractures and Fracture-Dislocations Introduction Scope and Instruction for the Clinical Use of This Section Epidemiology Mechanism of Injury Associated Injuries Polytrauma Patient Ipsilateral Upper Extremity Fracture Rotator Cuff Tear Nerve Injuries Vascular Injuries Seizures Pathologic Fractures Evaluation Clinical Examination Imaging Classification The Neer Classification AO/ASIF Classification System Hertel’s Predictors of Humeral Head Ischemia Role and Reliability of Classifications Authors’ Preferences and Fractures With Special Interest Two-Part Greater Tuberosity Fracture The Valgus Impacted Three- and Four-Part Fractures Fracture-Dislocations Management Emergent Treatment Evaluation of Osteoporosis Nonoperative Treatment: Indications and Outcome Nonoperative Treatment in Young Patients Nonoperative Treatment Algorithm Complications After Nonoperative Treatment Surgical Treatment Surgical Approaches Open Reduction of Specific Fracture Types Two-Part Greater Tuberosity Fractures. Two-Part Lesser Tuberosity Fractures. Two-Part Fracture-Dislocations of the Tuberosities With Undisplaced Fractures of the Surgical or Anatomic Neck. Two-Part Surgical Neck Fractures. Three-Part and Four-Part Fractures. Intramedullary Rodding. Closed Reduction and Percutaneous Fixation. Positioning Techniques and Surgical Approach. Reduction and Fixation Techniques. Pitfalls and Avoidance of Complications. Management of Intraoperative Complications. Complications. Outcome. Open Reduction and Internal Fixation: Conventional Plate. Positioning Techniques and Surgical Approach. Reduction and Fixation Techniques. Pitfalls and Avoidance of Complications. Management of Intraoperative Complications. Complications. Outcome. Open Reduction and Internal Fixation: Locking Plate. Positioning Techniques and Surgical Approach. Reduction and Fixation Techniques. Pitfalls and Avoidance of Complications. Management of Intraoperative Complications. Complications. Outcome. Primary Hemiarthroplasty. Positioning Techniques and Surgical Approach. Reduction and Fixation Techniques. Pitfalls and Avoidance of Complications. Management of Intraoperative Complications. Complications. Outcome. Primary Reverse Total Shoulder Arthroplasty. Positioning Techniques and Surgical Approach. Reduction and Fixation Techniques. Pitfalls and Avoidance of Complications. Management of Intraoperative Complications. Complications. Outcome. The Role of Arthroscopy for Fracture Treatment. Complications and Outcome. Comparison of Surgical Treatments Conventional Versus Locking Plate Open Reduction and Internal Fixation Primary Hemiarthroplasty Versus Open Reduction and Internal Fixation Primary Reverse Total Shoulder Arthroplasty Versus Primary Hemiarthroplasty Postoperative Rehabilitation Algorithm Authors’ Preferred Treatment Primary Clinical Results After Using the Treatment Algorithm for Proximal Humerus Fractures Fractures in Young and Active Patients Fractures in Elderly Patients Conclusion Glenohumeral Dislocations Introduction Direction of Dislocation Anterior Dislocation Inferior Dislocation Posterior Dislocation Findings After Glenohumeral Dislocations The “Essential Lesion” Glenohumeral Ligaments Hill-Sachs Lesions Associated Injuries and Complications Fractures Greater Tuberosity Fracture. Glenoid Fracture. Coracoid Process Fractures. Rotator Cuff Tears Nerve Injuries Vascular Injuries Evaluation Examination and Imaging Patient History Physical Examination Rotator Cuff Testing. Imaging Testing Diagnosis and Classification Classification Management and Treatment Closed Reduction Recurrence Age and Gender Postreduction Management Immobilization in Internal Rotation Immobilization in External Rotation Instability Repair Indication Capsulolabral Repair Bone Block Procedures Treatment of Glenoid Rim Fractures Surgical Treatment Rotator Cuff Repair Authors’ Preferred Treatment Posterior Dislocation Introduction Characteristics of Posterior Dislocation Etiology Directions of Posterior Dislocations Associated Fractures Diagnosis Associated Injuries Classification Recurrence Treatment Closed Reduction Open Reduction Outcome Authors’ Preferred Treatment Treatment of Fracture Sequelae of the Proximal Humerus Biomechanics Evaluation Examination Imaging Diagnosis and Classification Management Nonunion Management Greater Tuberosity Nonunion Surgical Neck Nonunion Malunion Management Two-Part Fracture Malunion Tuberosity Malunion. Surgical Neck Malunion. Three- and Four-Part Fracture Malunions Technique of Arthroplasty Technique of Standard Shoulder Replacement Technique of Reverse Total Shoulder Replacement Summary References 48 Fractures and Dislocations of the Clavicle Anatomy Sternoclavicular Joint Dislocation Shoulder Suspensory Complex Acromioclavicular Joint Dislocation Decision Making Operative Treatment Fractures of the Clavicle Classification Epidemiology Mechanism Evaluation Radiographic Evaluation Management of Specific Injuries Birth Fractures Midclavicular Fractures Nonoperative Treatment Operative Treatment Authors’ Preferred Technique. Intramedullary Nailing. Postoperative Care. Results. Pitfalls Plating Implantation Through Minimally Invasive Approach Patient Positioning. Surgical Approach (Minimally Invasive). Fracture Reduction. Plate Insertion and Position. Confirmation of Reduction and Fixation. Open Plating. Patient Positioning. Surgical Approach. Fracture Reduction and Fixation. Postoperative Care. Distal Clavicular Fractures Floating Shoulder Medial Clavicular Fractures Complications Nonunion and Malunion Neurovascular Complications Refracture Complications of Operative Treatment References 49 Scapula Fractures Introduction Mechanism of Injury and Biomechanics Evaluation Examination Imaging Diagnosis and Classification Management of Scapula Fracture Emergent Treatment Indications for Definitive Care Nonoperative Treatment Surgical Treatment Choosing the Surgical Approach Surgical Anatomy Positioning Techniques Positioning for Anterior Approaches Positioning for Posterior Approaches Surgical Approach Posterior Approach Options Exposure Options. Wound Closure. Minimally Invasive Approach Anterior Approach Reduction Techniques Fixation Techniques Pitfalls and Avoidance of Complications Neurovascular Complications Management of Intraoperative Problems Mobilization of Fracture Fragments. Postsurgical Manipulation. Postoperative Care and Rehabilitation Complications Nonoperative Complications Missed or Delayed Diagnosis Deformity and Malunion Pain Nonunion Operative Complications Infection Neurovasular Injury Hematoma Hardware-Related Complications Malunion Nonunion Shoulder Stiffness Outcome Isolated Extraarticular Fracture Double Lesions of the Superior Shoulder Suspensory Complex Isolated Process Fractures Intraarticular Glenoid Fractures Meta-Analyses and Systematic Reviews Conclusion References 50 Chest Wall Trauma Introduction Rib Fractures Mechanism of Injury and Pathophysiology Evaluation Examination Imaging and Diagnosis Classification Management Emergent Treatment Ventilatory Support Nonoperative Treatment Indications for Operative Management Operative Management Surgical Anatomy Patient Setup and Positioning Surgical Approaches Reduction Techniques Fixation Techniques Selection of Ribs for Fixation Pitfalls Traumatic Lung Hernia Postoperative Care and Rehabilitation Outcomes Morbidity and Mortality Outcomes of Nonoperative Management Outcomes of Operative Management Nonunions and Malunions Meta-Analyses and Systematic Reviews Conclusion Sternum Fractures Evaluation of Sternal Fractures Surgical Management of Sternal Fractures Surgical Technique for Sternum Fixation References 51 Replantation Introduction Indications and Contraindications Indications Contraindications Preoperative Evaluation and Transport Preoperative Considerations Management Technique of Replantation Bone Fixation Tendon Repair Arterial Repair Nerve Repair Vein Repair Skin Closure Postoperative Management Expectations After Replantation Special Circumstances References 52 Hip Dislocations Introduction Pathology Relevant Anatomy and Biomechanics of the Uninjured Hip Mechanisms of Injury Commonly Associated Injuries Diagnosis Classification Posterior Hip Dislocations Anterior Hip Dislocations Patient History and Physical Examination Initial Radiographic Evaluation Plain Film Analysis Computed Tomography Magnetic Resonance Imaging Isotope Imaging Treatment Emergent Treatment—Initial Management Special Considerations in the Multiply-Injured Patient Algorithm for Initial Management Management After Reduction Algorithm for Postreduction Management Management of Specific Types of Hip Dislocations Levin Type I (Closed Reduction Successful) Levin Type II (Closed Reduction Unsuccessful) Levin Type III (Closed Reduction Unsuccessful or Not Concentric) Levin Type IV (Significant Associated Acetabular Fractures Requiring Reconstruction) Levin Type V (Associated Femoral Head or Neck Injury) Surgical Treatment Surgical Anatomy Positioning Techniques and Surgical Approaches Posterior Approach Extension of Posterior Approach, With Digastric Trochanteric Osteotomy and Surgical Dislocation of the Hip Anterior Approach Direct Lateral and Anterolateral Approach Arthroscopic Approaches Surgical Complications Infection Sciatic Nerve Injury Late Sciatic Nerve Palsy Heterotopic Ossification Thromboembolism Outcomes Assessment of Results Posttraumatic Arthritis Avascular Necrosis Recurrent Dislocation Missed and Delayed Diagnoses Sciatic Nerve Injury Effects on Outcome of Other Associated Injuries Meta-Analyses and Systematic Reviews Cost-Effectiveness Conclusion References 53 Medical Management of the Patient With Hip Fracture Outcome Variables Mortality Recovery of Function Medical Complications Preoperative Assessment Cardiovascular Assessment Congestive Heart Failure Valvular Disease Hypertension Atrial Fibrillation Anticoagulation Preoperative Antiplatelet Therapy Pulmonary Assessment Renal Assessment Hepatic Assessment Mental and Functional Status Assessment Laboratory Assessment Perioperative Management Delirium Diabetic Management Glucocorticoid Replacement Therapy Pain Management Surgical-Site Infection Prophylaxis Deep Vein Thrombosis Prophylaxis Nutritional Optimization Bladder Management Blood Management Postoperative Fever Osteoporosis Diagnosis Management Options Timing of Treatment Fracture Liaison Service Hip Protectors Summary Sample Fragility Fracture Service References 54 Intracapsular Hip Fractures Femoral Head Fractures Relevant Anatomy Articular Cartilage Osseous Anatomy Mechanism of Injury Consequences of Injury Degenerative Joint Disease Avascular Necrosis Limited Motion (Heterotopic Ossification) Associated Injuries Diagnosis and Evaluation History Physical Examination Radiographic Imaging Other Studies Classification Management Emergent Treatment Special Considerations for Patients With Polytrauma Indications for Definitive Care Nonoperative Treatment Surgical Treatment Fragment Excision Open Reduction and Internal Fixation Prosthetic Replacement Open Reduction and Internal Fixation of Associated Acetabular Fractures Surgical Approaches Anterior Approach: Smith-Petersen Surgical Anatomy. Positioning Techniques. Surgical Approach (see Fig. 54.7). Posterior Approach: Kocher-Langenbeck Surgical Anatomy. Positioning Techniques. Surgical Approach. Posterior Approach Using Surgical Hip Dislocation Surgical Anatomy. Positioning Techniques. Surgical Approach Reduction Techniques Fixation Techniques Postoperative Care and Rehabilitation Follow-Up Care and Rehabilitation Complications Chronic Instability. Wound Infection. Heterotopic Ossification (Fig. 54.11). Sciatic Nerve Palsy. Avascular Necrosis. Degenerative Arthritis. Outcome Assessment of Results Pipkin I Conservative Versus Fragment Excision Versus ORIF ORIF: Anterior Versus Posterior Approaches Posterior Approach With and Without Surgical HIP Dislocation Meta-Analyses and Systematic Reviews Conclusion Femoral Neck Fractures Relevant Anatomy Osseous Anatomy Vascular Anatomy and Physiology Effect of Femoral Neck Fracture on Vascular Supply Incidence Mechanism of Injury and Prevention Bone Density Consequences of Injury Nonunion Avascular Necrosis Pain Limited Motion Impaired Mobility Medical Complications Mortality Commonly Associated Injuries Diagnosis Clinical Suspicion History Physical Examination Imaging Plain Films Search for Occult Fractures Computed Tomography Radionuclide Studies Magnetic Resonance Imaging Ultrasonographic Venography Nutritional Assessment Essential Studies Differential Diagnosis Evolution of Classification Systems Current Classification Nondisplaced Femoral Neck Fractures Displaced Femoral Neck Fractures Fatigue Fractures of the Femoral Neck Transverse (Tension) Fractures Compression Fractures Pathologic Femoral Neck Fracture Femoral Neck Fractures in Young Adults Special Cases Rheumatoid Arthritis. Renal Failure. Basilar Neck Fracture Management Current Algorithm for Treatment of Femoral Neck Fracture Initial Treatment Undisplaced Femoral Neck Fractures Displaced Femoral Neck Fracture Treatment of Fatigue or Stress Fractures Pathologic Femoral Neck Fractures Patients With Multiple Injuries Indications for Operative Intervention Controversial Topics Timing of Surgery Fixation Methods Pauwels Type III Femoral Neck Fracture Role of Capsulotomy Open Reduction and Internal Fixation Versus Arthroplasty: Principles of Management and Treatment Algorithm Hemiarthroplasty versus Total Hip Arthroplasty Nonoperative Management Surgical Treatment for Nondisplaced Fractures In Situ Fixation Preoperative Planning and Positioning Techniques Surgical Approach Pitfalls and Avoidance of Complications Intraoperative Complications Displacement of the Fracture. Intraarticular Pin Placement. Surgical Treatment for Displaced Fractures Positioning Techniques (Free-Leg Style) Surgical Anatomy and Approach Open Reduction Through the Watson-Jones Approach. Open Reduction Through the Smith-Petersen Approach. Reduction Techniques Fixation Techniques Fixation Bone Substitute or Adjuvant Postoperative Care and Rehabilitation Surgical Treatment With Hemiarthroplasty Indications Historical Implant Choices and Designs Timing of Surgery Preoperative Planning Surgical Anatomy and Approach Anesthesia and Positioning Technique Surgical Technique (First-Generation Endoprostheses: Historical Purpose) Current-Generation Endoprostheses Cement Insertion. Management of Intraoperative Problems Femoral Shaft Fracture. Incorrect Sizing of the Outer Bearing. Poor Implant Position. Postoperative Restriction, Activity, and Plan Total HIP Arthroplasty Postoperative Care and Rehabilitation Immobilization Mobilization Physical Therapy Rehabilitation Units Duration and Extent of Disability Assistance and Living Arrangements Assessment of Results Protocols for Associated Injuries Femoral Shaft Fractures Femoral Neck and Head Fractures Femoral Neck and Acetabular Fractures Complications: Identification and Treatment Avascular Necrosis Fixation Failure Nonunion Failed Arthroplasty Subtrochanteric Fracture Below Screws Pressure Sores Outcome Open Reduction and Internal Fixation Versus Arthroplasty (Hemi or Total) Meta-Analyses and Systematic Reviews FAITH Trial Cost-Effectiveness Conclusion References 55 Intertrochanteric Hip Fractures Introduction Incidence and Epidemiology Anatomy of the Intertrochanteric Region Bony Anatomy Muscular and Neurovascular Anatomy Diagnosis Radiographic Assessment Computed Tomography or Magnetic Resonance Imaging for Negative Radiographs Classification of Intertrochanteric Femur Fractures Evans Classification AO/OTA Classification Assessment of the Patient Management Nonoperative Management Operative Management High-Energy Fractures Fragility Intertrochanteric Fractures Timing of Surgery Surgical Intervention Patient Positioning Fluoroscopic Imaging Fracture Reduction Stable Fractures Unstable Fractures Medial Displacement Osteotomy. Open Reduction Surgical Stabilization Surgical Technique for Sliding Hip Screw and Side Plate Adjuncts to Plate Fixation. Wound Closure. Axial Dynamic Compression Plating Intramedullary Sliding Hip Screws Guide-Pin Placement Proximal Femoral Preparation and Nail Insertion Lag Screw Insertion Distal Interlocking Proximal Femoral Locking Plate Hip Arthroplasty Special Fracture Situations Reverse Obliquity Fractures High-Energy and Combined Intertrochanteric–Diaphyseal Fractures Pathologic and Impending Fractures Fracture of the Greater Trochanter Summary of Fixation of Intertrochanteric Femur Fracture Postoperative Management and Discharge Planning Complications Loss of Fixation Nonunion Secondary Fracture Displacement Patient Outcome Summary References 56 Posttraumatic Reconstruction of the Hip Joint Primary Reconstruction Hemiarthroplasty Uni- Versus Bipolar Hemiarthroplasty Total Hip Arthroplasty Decision Making: Hemiarthroplasty Versus Total Hip Arthroplasty Technical Considerations for Primary Arthroplasty in the Setting of Acute Femoral Neck Fracture Reconstruction After Failed Internal Fixation Preoperative Evaluation Hip Salvage in the Young Patient Preoperative Evaluation Failed Femoral Neck Fixation Valgus-Producing Osteotomy: Overview and Historical Results Valgus-Producing Osteotomy: Author’s Preferred Technique Intertrochanteric Fixation Failure: Revision Fixation Conversion Arthroplasty in Setting of Failed Fixation Technical Considerations for Conversion Arthroplasty in the Setting of Failed Femoral Neck Fixation Failed Intertrochanteric Fixation Technical Considerations for Conversion Arthroplasty in the Setting of Failed Intertrochanteric Fixation Published Outcomes Failed Acetabular Fixation Technical Considerations for Failed Acetabular Fixation Published Outcomes Conclusion References 57 Subtrochanteric Fractures of the Femur Anatomy Biomechanics Incidence and Mechanism of Injury Physical Examination Radiographic Studies Classification Management Evolution of Treatment and Implants Current Treatment Algorithm Description of Individual Procedures Traction and Nonoperative Treatment Temporary Stabilization Before Definitive Fixation Plate Fixation, Including Minimally Invasive Percutaneous Plate Osteosynthesis of Subtrochanteric Fractures Background Indications Technique and General Principles of Plating Subtrochanteric Fractures Results 95-Degree Angled Blade Plate Dynamic Condylar Screw Proximal Femoral Locking Plate Sliding Hip Screw Intramedullary Nailing of Subtrochanteric Fractures History and Introduction Preoperative Planning Patient Positioning Reduction Maneuvers Antegrade Locked Nailing Piriformis Entry Cephalomedullary (Reconstruction) Interlocked Nailing Clinical Results. Trochanteric Entry Cephalomedullary Interlocked Nailing Clinical Results. Rehabilitation, Weight Bearing, and Follow-Up Care Special Considerations Polytrauma and Multiply Injured Patients: Timing of Provisional and Definitive Fixation Open Subtrochanteric Fractures Proximal fracture extension and intramedullary nailing Indications for Bone Grafting Comminution, Associated Fracture Patterns, Significant Osteopenia, and Atypical Fractures Obese Patients Complications Loss of Fixation and Implant Failure Nonunion Malunion Salvage Hip Joint Replacement Tips and Tricks Blocking Screws Cerclage Wiring Clamp-Assisted Reduction and Percutaneous Nailing Reduction Tips Establishment of Correct Rotation Plate Length Lateral Decubitus Position Starting Point for Intramedullary Nailing Acknowledgments References 58 Femoral Shaft Fractures Introduction Epidemiology Anatomic Considerations Bony Structures Musculature of the Femur Region Pathophysiology: Polytrauma Considerations History of Surgical Treatment Surgical Strategies and Timing Patient Assessment and Initial Management Diagnostic and Preoperative Treatment Management of Soft Tissue Injuries Fracture Classification Principles of Management of Diaphyseal Femoral Fractures General Aspects Nonoperative Treatment Technical Aspects of Femoral Traction Operative Treatment External Fixation Open Reduction and Internal Fixation: Plate Osteosynthesis Intramedullary Nailing History and General Aspects Role of Reaming Role of Locking Antegrade Nailing Entry Point for Antegrade Nailing. Technique of Antegrade Nailing. Retrograde Nailing Technique of Retrograde Nailing. Antegrade or Retrograde Nailing Poller Screws Conversion From External Fixation to Intramedullary Nailing Complications of Nailing Intramedullary Nailing: Postoperative Care Implant Removal Special Situations Concomitant Ipsilateral Injuries Ipsilateral Femoral Neck Fracture/Intertrochanteric Fracture Bilateral Femoral Fractures Femoral Shaft Fractures With Acetabular Fractures Floating-Knee Injuries Pathologic Femoral Fractures Fatigue (Stress) Fractures Bone Loss and Nonunion in Femoral Fractures Nonunion Aseptic Nonunion: Management Options Septic Nonunion Hardware Failure Summary References 59 Fractures of the Distal Femur Pathology Relevant Anatomy Bone, Muscles, and Tendons Alignment Anatomic and Functional Consequences of the Injury Incidence of Fractures Commonly Associated Injuries Soft Tissue Injuries Vascular Injuries Complex Trauma of the Knee Diagnosis Classification Patient History and Physical Examination Radiographic Evaluation Treatment History Traction and Cast Early Attempts of Open Reduction and Internal Fixation Arbeitsgemeinschaft für Osteosynthesefragen Compression Plating Techniques Antegrade Intramedullary Nailing Retrograde Intramedullary Nailing Dynamic Compression Screw Double Plating (Lateral and Medial Plates) Bone Cement and Medial Bone Grafts Minimally Invasive Plating Bridge Plating Locking Plates Dynamic Locking Screw External Fixation With Taylor Spatial Frame Decision Making Assessment for Surgery: Patient, Fracture, and Surgeon Factors Indications for Surgery Extraarticular Fractures (Type A) Unicondylar and Hoffa Fractures (Type B) Bicondylar Fractures (Type C) Special Circumstances Open Fractures. Associated Vascular Compromise. Ipsilateral Fractures of the Tibial Shaft. Ipsilateral Fractures of the Tibial Plateau. Bilateral Femoral Fractures. Polytraumatized Patients and Burns. Pathologic Fractures. Fractures in Myelopathic, Nonambulatory Patients. Associated Ligamentous Disruptions of the Knee Joint. Management Principles of Surgical Treatment Preoperative Planning Planning With Pen, Paper, Templates, and Light Box Planning With Digital Planning Systems Preoperative Planning in the Presence of Preexisting Deformity Timing of Surgery Orthopaedic Damage Control: Staged Stabilization Delayed Definitive Surgery Acute Definitive Fixation Nonoperative Treatment Traction Cast Bracing Operative Treatment Temporary External Fixation Surgical Approaches Positioning. Conventional Lateral Approach. Tibia Tubercle Osteotomy. Infrapatellar Tenotomy. Medial Approach. Minimally Invasive Techniques. Transarticular Approach and Retrograde Plate Osteosynthesis With a Lateral Parapatellar Arthrotomy. Approach for Minimally Invasive Percutaneous Plate Osteosynthesis. Retrograde Nailing Approach. Implants With Plate Components 95-Degree Condylar Blade Plate. Dynamic Condylar Screw and Side Plate “Conventional” Technique. Condylar Buttress Plate, Standard Technique. Locking Plates. Implant Concept. Mechanical Studies. Preoperative Planning Approach Minimally Invasive Plate Osteosynthesis Positioning of the Patient. Alignment Control. Torsion. Length. Frontal-Plane Alignment. Sagittal-Plane Alignment. Computer Navigation in Distal Femur Fractures. Reduction and Fixation Techniques. Instruments. Locking Plate Instruments. Minimally Invasive Percutaneous Plate Osteosynthesis Locking Plate: Tips and Tricks Intramedullary Nail Fixation Antegrade Nailing. Retrograde Intramedullary Nailing. Planning. Technique. Alignment Tips and Tricks: Avoiding and Correcting Recurvatum Deformity. Alignment Tips and Tricks: Avoiding and Correcting Varus or Valgus Deformity. Arthroplasty Tips for Specific Fracture Patterns Type A (Extraarticular). Type B (Unicondylar, Hoffa Type). Type B1 and B2 Fractures. Type B3 Fractures (Hoffa Fracture). Osteochondral Fractures. Type C (Bicondylar) Fractures. Type C1 and C2 Fractures. Type C3 Fractures. Intraarticular Defects. Extraarticular Defects. Bilateral Comminution. Floating Knee and Ipsilateral Multisegmental Fractures. Periprosthetic Fractures Above Total Knee Arthroplasty. Fractures Between Total Hip and Total Knee Prosthesis (Interprosthetic Fractures). Bone Grafting Adjunctive Fixation Techniques in Osteoporotic Bone Bone Cement (Liquid Injection). Bone Cement (Dough Insertion Technique). Surface Enlargement. Cerclage Wires. Postoperative Treatment Implant Removal Complications Infection Nonunion Risk Factors Treatment Malunion and Malalignment Loss of Fixation Contractures and Decreased Knee Motion References 60 Patella Fractures and Extensor Mechanism Injuries Anatomy Biomechanics Patient’s History and Physical Examination Radiographic Evaluation Injuries Patella Fractures Treatment Postoperative Management Complications Extensor Mechanism Soft Tissue Injuries Treatment Repair or Reconstruction of Quadriceps Tendon Ruptures Repair or Reconstruction of Patellar Tendon Ruptures Postoperative Management Patellar Dislocation Treatment Medial Patellofemoral Ligament Repair or Reconstruction Transfer of the Tibial Tuberosity Postoperative Management Patella Fractures and Extensor Mechanism Injuries Associated With Bone–Patellar Tendon–Bone Autograft Injuries of the Extensor Mechanism After Total Knee Arthroplasty Complete Deficiency of the Extensor Apparatus Malunion and Nonunion of Patellar Fractures Acknowledgment References 61 Dislocations and Soft Tissue Injuries of the Knee Pathology Relevant Anatomy Bone, Muscles, and Tendons Functional Anatomy Anterior Cruciate Ligament Posterior Cruciate Ligament Anterolateral Complex Lateral and Posterolateral Stabilizers Medial Stabilizing Structures Anatomic and Functional Consequences of the Injury Incidence of Knee Dislocations Commonly Associated Injuries Vascular Damage Incidence of Nerve and Meniscus Lesions Fractures, Soft Tissue Injury, and Complex Knee Injury Compartment Syndrome Outcome Prognostic Factors Diagnosis Classification Arbeitsgemeinschaft Für Osteosynthesefragen Schatzker Moore Schenck Suggested Classification System Soft Tissue Associated Injuries Patient History and Physical Examination Radiographic Evaluation Treatment Principles Arterial Injuries and First Line of Treatment Ligament Repair Ligament Bracing Posterior Cruciate Ligament Anterior Cruciate Ligament Medial Structures Lateral and Posterolateral Structures Ligament Reconstruction Autografts Allografts Fixation Devices Mechanical Properties Posterior Cruciate Ligament Anterior Cruciate Ligament Lateral and Posterolateral Structures Medial Collateral Ligament Decision Making Assessment for Surgery: Patient, Injury, and Comorbidity Indications for Surgery Special Circumstances Open Fracture-Dislocations and Soft Tissue Injuries Associated Vascular Compromise Polytraumatized Patients and Burns Principles of Surgical Treatment Orthopaedic Damage Control: Staged Stabilization Nonoperative Treatment Cast or Splint Brace Operative Treatment Acute Knee Reconstruction External Fixation Surgical Approaches Positioning. Anteromedial Approach. Tibial Tubercle Osteotomy. Anterolateral Approach. Lateral Approach. Posteromedial Approach. Dorsal Approach. Minimally Invasive Techniques. Arterial Reconstruction Nerve Reconstruction Ligament Refixation Ligament Reconstruction Positioning of the Patient Intraoperative Control of Tunnel Placement Tips and Tricks Meniscus Refixation. Cartilage Refixation. Osteochondral Refixation. Soft Tissue Management. Delayed Knee Reconstruction Surgical Approaches Treatment of Neurovascular Sequelae Ligament Reconstruction Meniscus Regeneration and Transplantation Cartilage Regeneration Osteochondral Reconstruction and Regeneration Soft Tissue Conditioning Arthroplasty and Arthrodesis Tips for Specific Injury Patterns Posterolateral Injuries. Anteromedial Instability. Intraarticular Defects. Extraarticular Defects. Defects of the Extensor Mechanism. Postoperative Treatment Complications Infection Chronic Instability Joint Degeneration Contractures and Decreased Knee Motion References 62 Tibial Plateau Fractures Introduction Biomechanics and Mechanism of Injury Biomechanics Basic Science Consequences of Injury Evaluation and Examination History Physical Examination Associated Injuries Skeletal Injuries Proximal Fibular Fractures Tibial Tubercle Fractures Intercondylar Eminence Fractures Soft Tissue Injuries Meniscal Injuries Collateral Ligament Injuries Cruciate Ligament Injuries Posterolateral Corner Injuries Neurovascular Injury Fracture-Dislocations Compartment Syndrome Imaging Radiographs Computed Tomography Scanning Magnetic Resonance Imaging Duplex Ultrasonography and Arteriography Classification General Concepts Fracture Management History Emergent and Urgent Stabilization External Frames Vascular Injury Open Fractures Polytrauma External Fixation Technique Indications for Operative Management Articular Incongruity Axial Malalignment and Instability Personality of the Injury Nonoperative Treatment Surgical Treatment Surgical Anatomy Skeletal Cartilage and Menisci Ligaments Muscle Attachments Popliteal Fossa Preoperative Planning Surgical Timing Surgical Tactic C-Arm, Universal Distractor, and Headlamp Fracture Reduction Instruments Surgical Approches Anterolateral Posteromedial Posterolateral With Fibular Osteotomy Posterolateral Without Fibular Osteotomy Posterior Anterior Anterolateral and Posteromedial Posterolateral and Posteromedial Reduction Techniques Articular Reduction Intraoperative Assessment of Alignment Bone Graft and Bone Graft Substitutes Fixation Techniques Conventional Implants Precontoured Plates Angular-Stable (Locking) Implants Hybrid Plates and Variable-Angle Screws Techniques for Specific Schatzker Types Type I Type II Type III Type IV Types V and VI Posterior Shear Fractures Tibial Eminence Fractures Arthroscopically Assisted Treatment Operating Room Setup Articular Reduction Intercondylar Eminence Reduction Definitive External Fixation Ring Fixators Supplementary Uniplanar External Fixation Surgical Technique for External Fixation of Plateau Fractures Postoperative Care and Rehabilitation Early Range of Motion Time to Weight Bearing Postoperative Bracing Complications Infection Nonunion Contractures Posttraumatic Osteoarthritis Outcomes Randomized Prospective Studies Return to Sports Tibial Plateau Fractures in Elderly Adults Meta-Analyses and Systematic Reviews Conclusion References 63 Malunions and Nonunions About the Knee Introduction General Principles Basic Biomechanics Frontal Alignment and Knee Joint Line Angulation Sagittal Alignment and Soft Tissue Contractures Patella-Femoral Tracking and Rotational Deformities Nonunion Classification Intraarticular Versus Extraarticular Osteotomies Limb Length Discrepancy Charcot Neuroarthropathy Surgical Considerations Distraction Osteogenesis Internal Versus External Fixation Monolateral Versus Circular External Fixation Arthroscopy-Assisted Surgery Fixator-Assisted Surgery Total Knee Replacement After Trauma Authors’ Preferred Treatment Method Distal Femur Nonunion and Malunion Diagnosis Surgical Timing Surgical Technique: Mobile Knee Joint Surgical Technique: Stiff Knee Joint Postoperative Care Surgical Alternatives Nonunions and Malunions of the Proximal Tibia Diagnosis Surgical Treatment Postoperative Care Surgical Alternatives References 64 Tibial Shaft Fractures Introduction Relevant Surgical Anatomy Compartmental Anatomy Mechanism of Injury and Biomechanics Diagnosis History Examination Imaging Classification Management Evolution of Treatment Emergent Treatment Initial Care: Immobilization Tibial Shaft Fractures With Associated Arterial Injury Acute Compartment Syndrome of the Leg The Polytrauma Patient and Damage-Control Orthopaedics Mangled Extremity Closed Tibial Shaft Fractures Indications for Definitive Care (Surgical Versus Nonoperative Care) Nonoperative Treatment Tibial Cast Application Functional Cast or Brace Surgical Treatment Surgical Anatomy Intramedullary Nailing of Closed Tibia Shaft Fractures Positioning. Surgical Approach Nail Insertion With the Knee Flexed. Insertion With the Knee Extended. Reduction Techniques. Nail Insertion and Fixation Technique. Reamed Versus Unreamed Nailing. Intramedullary Nailing After External Fixation. Plating of Closed Tibia Shaft Fractures Surgical Approaches. Minimally Invasive Approaches. Reduction Techniques. Fixation Technique. Plate Length and Screw Density. External Fixation. Pitfalls and Avoidance of Complications. Postoperative Care and Rehabilitation After Plating. Assessment of Healing. Postoperative Care Weight Bearing. Outpatient Care. Nail Removal. Rehabilitation After Plating. Plate Removal. Closed Proximal Third Tibial Fractures Emergent Treatment Indications for Definitive Care (Surgical Versus Nonoperative Care) Nonoperative Treatment Surgical Treatment Surgical Anatomy Intramedullary Nailing of Proximal Tibia Shaft Fracture Nailing Proximal Tibial Fractures in a Semi-Extended Position. Reduction Techniques External Fixation Assisted Nailing. Plating-Assisted Nailing. Poller (Blocking) Screws. Nailing Proximal Tibial Fractures With Articular Involvement. Pitfalls and Avoidance of Complications in Proximal Tibia Nailing. Postoperative Care and Rehabilitation. Plating of Proximal Tibia Shaft Fractures Reduction Techniques in Plating of Proximal Tibia Fractures. Pitfalls and Avoidance of Complications in Proximal Tibia Plating. Postoperative Care and Rehabilitation. External Fixation of Proximal Tibia Shaft Fracture Closed Distal Third Tibial Fractures Emergent Treatment Indications for Definitive Care (Surgical Versus Nonoperative Care) Nonoperative Treatment Surgical Treatment Surgical Anatomy Nailing Distal Tibial Fractures Reduction Techniques in Nailing of Distal Tibia Fractures. Distal Fixation With Intramedullary Nailing. Nailing Distal Tibial Fractures With Articular Involvement Plating of Distal Tibial Fractures Positioning. Surgical Approach. Reduction Techniques With Plating of a Distal Tibia Fracture. Pitfalls and Avoidance of Complications in Managing Distal Tibia Fractures Management of Intraoperative Problems Postoperative Care and Rehabilitation Open Tibia Fractures Emergent Treatment Indications for Definitive Care Débridement Reduction and Provisional Fixation Techniques Fixation Techniques External Fixation Definitive External Fixation for Open Tibia Fractures Emergency External Fixation for Open Tibia Fractures Technique for Applying “Emergency” Tibial External Fixator Pin Insertion. Frame Construction. Pin Care. Removal of the External Fixator After Fracture Union Nailing of Open Fractures Plating of Open Fractures Bone Grafting of Open Tibia Fractures Management of Bone Defects in Open Tibia Fractures Pitfalls and Avoidance of Complications in Open Tibia Fractures Management of Intraoperative Problems Postoperative Care and Rehabilitation Fibula Fractures Fibula Fractures Associated With Tibia Shaft Fractures Isolated Fibula Fractures Treatment Complications Injuries to the Proximal Tibiofibular Joint Diagnosis Treatment Nonoperative Operative Outcomes Stress Fractures of the Tibia Diagnosis Treatment Nonoperative Operative Outcomes Complications Infection Acute Infection Risk Factors Management Chronic Infection (Osteomyelitis) Management Fixation Failure Diagnosis Management Prevention Delayed Union and Nonunion Incidence Diagnosis Management Nonsurgical Treatment of Tibia Shaft Fracture Nonunion Intramedullary Nailing for Tibial Fracture Nonunion Dynamization of Tibia Nails for Delayed Union of Tibia Shaft Fractures Exchange Nailing for Tibia Shaft Nonunion Plate Fixation for Tibial Shaft Nonunion External Fixation for Tibial Shaft Nonunion Bone Grafting for Tibial Shaft Nonunion or Critical Bone Defects Biological Therapies (Osteobiologics) for Tibia Shaft Nonunion Occult Infection at the Nonunion Site Malunion (Residual Deformity) Indications for Surgery Refracture Stiffness Complications Related to Intramedullary Nailing Technical Problems Compartment Syndrome Acute Surgical Infection Knee Pain Broken Hardware During Nail Removal Outcomes of Tibia Shaft Fractures Tibial Fracture Outcome Scores Short Form-36 Short Musculoskeletal Function Assessment Foot Function Index Musculoskeletal Function Assessment Radiographic Union Score for Tibial Fractures Outcomes After Brace (Nonoperative) Treatment of Tibial Shaft Fractures Outcomes After Nailing of Tibial Fractures Outcomes After Plating of Tibial Fractures Outcomes After External Fixation of Tibial Fractures Outcomes of Tibia Shaft Nonunion Randomized Controlled Trials Distal Tibia Shaft Fractures Proximal Tibia Shaft Fractures Low-Intensity Pulsed Ultrasound in Treatment of Tibial Fractures (TRUST Trial) Electrical Stimulation Weight Bearing Meta-Analyses and Systematic Reviews Cost-Effectiveness Acknowledgment References 65 Fractures of the Tibial Pilon Mechanism of Injury Classification Radiographic Evaluation Initial Treatment Treatment Options Closed Treatment Traction Surgical Management Timing of Surgery and Staged Protocol Treatment Timing of Surgery Soft Tissue Management Staged Protocols Surgical Approaches Anteromedial Exposure Direct Anterior Exposure Anterolateral and Extended Lateral Exposures Posterolateral Exposure Posteromedial Exposure Technique of Open Reduction and Internal Fixation Restoration of Length (Step 1) Fibular Fixation Other Means of Obtaining Length Reconstruction of the Metaphyseal Shell (Step 2) Bone Grafting of Metaphyseal Defects (Step 3) Reattachment of the Metaphysis to the Diaphysis (Step 4) Plate Fixation Minimally Invasive Plate Osteosynthesis Technique External Fixation Joint-Spanning Frames Articulating Joint-Spanning External Fixator Tensioned-Wire External Fixation Tensioned-Wire Technique Wound Closure Open Fractures Flap Coverage Postoperative Care Obesity and Diabetes Nonreconstructible Pilon Fractures Complications Early Complications Late Complications Nonunion and Malunion Posttraumatic Arthrosis Chronic Osteomyelitis Clinical Outcomes Prognosis Summary References 66 Malleolar Fractures and Soft Tissue Injuries of the Ankle Introduction Incidence Anatomy and Biomechanics Bony Anatomy Ligamentous Anatomy Syndesmosis Syndesmosis Importance Deltoid Ligament Lateral Ankle Ligaments Relevant Tendinous Anatomy Biomechanics Ankle Joint Mechanics Patient Presentation, History, and Physical Examination Patient Presentation: Polytrauma History Physical Examination Radiographic Imaging Routine Imaging Ligamentous Assessment and Preoperative External Rotation Stress Radiographs Other Studies Classification Lauge-Hansen Supination-Adduction Supination–External Rotation Pronation-Abduction Pronation–External Rotation Danis-Weber Arbeitsgemeinschaft Für Osteosynthesefragen–Orthopaedic Trauma Association Initial and Definitive Management of Ankle Fractures Initial Management of Fractures Presenting to the Emergency Department Isolated Nondisplaced Malleolar Fractures Operative Treatment of Ankle Fractures Choice of Fixation Operating Room Setup and Patient Positioning Lateral Malleolus Fracture Reduction and Fixation Posterior Malleolus Fracture Reduction and Fixation Medial Malleolar Fracture Fixation and Ligamentous Injuries Arthroscopy Wound Closure and Postoperative Care Outcome for Malleolar Fracture Complications Wound Problems Infection Malunion Late Syndesmotic Instability Tibiofibular Synostosis Nonunion Fractures in Special Treatment Groups Osteopenia Diabetic Patients Elderly Patients Management of Soft Tissue Injuries: Syndesmosis and Deltoid Ligaments Syndesmosis Syndesmosis Injury Diagnosis Syndesmosis Reduction Syndesmotic Fixation Deltoid Ligament Ankle Dislocations Ankle Dislocation Without Fracture Acknowledgments References 67 Foot Injuries General Principles of Care Evaluation and Initial Management Fractures of the Talus Anatomy Blood Supply Imaging Talar Neck Fractures Evaluation and Initial Management of Talar Neck Fractures Classifications Nonoperative or Closed Treatment Minimally Invasive Techniques Operative Treatment Postoperative Care and Rehabilitation Outcomes Complications Posttraumatic Arthrosis Avascular Necrosis Nonunion and Malunion Arthrofibrosis Salvage Talar Body Fractures Treatment Overview Surgical Approaches Operative Treatment Postoperative Care and Rehabilitation Outcomes Talar Head Fractures Treatment Nonoperative or Closed Treatment Operative Treatment Postoperative Care and Rehabilitation Outcomes Posterior and Lateral Talus Process Fractures Posterior Talar Process Fractures Treatment and Outcomes Lateral Talar Process Fractures Diagnosis Treatment Nonoperative or Closed Treatment. Operative Treatment. Outcomes Osteochondral Fractures of the Talar Dome Tarsal Dislocations Peritalar and Subtalar Dislocations Treatment Nonoperative or Closed Treatment Operative Treatment Postoperative Care and Rehabilitation Complications Outcomes Total Talar Dislocation Chopart or Transverse Tarsal Dislocation Classifications Evaluation and Initial Management Treatment Nonoperative or Closed Treatment Operative Treatment Postoperative Care and Rehabilitation Outcomes Isolated Tarsal Dislocations Calcaneus Navicular and Talonavicular Joint Cuboid and Calcaneocuboid Joint Cuneiforms Hindfoot Sprain Calcaneal Fractures Intraarticular Calcaneus Fracture Historical Perspective Anatomy Injury Mechanism and Fracture Patterns Evaluation and Initial Management Radiographic Anatomy Classifications Patient Factors Influencing Treatment Comparison of Operative Versus Nonoperative Treatment Nonoperative or Closed Treatment Operative Treatment Open Reduction and Internal Fixation of Intraarticular Calcaneus Fractures Timing of Surgery. Surgical Approaches. Intraoperative Patient Positioning. Surgical Technique: Extensile Lateral Approach. Surgical Technique: Sinus Tarsi Approach. Postoperative Care and Rehabilitation. Use of Bone Graft and Substitutes. Implants Minimally Invasive Techniques Surgical Technique: Westhues/Essex-Lopresti Maneuver. Surgical Technique: Modified Westhues/Essex-Lopresti Maneuver. Arthroscopically Assisted Calcaneus Open Reduction and Internal Fixation. Primary Subtalar Arthrodesis Outcomes Complications Wound Healing and Infection Arthrofibrosis Issues of Implanted Hardware Posttraumatic Arthrosis Compartment Syndrome Nerve Injury Malunion Nonunion Ankle and Subfibular Impingement Peroneal Tendon Instability Open Fractures of the Calcaneus Classifications Evaluation and Initial Management Outcomes Extraarticular Calcaneus Fractures Anterior Calcaneal Process Fractures Posterior Tuberosity Calcaneus Fractures Sustentacular Fractures Navicular Fractures Anatomy Blood Supply Evaluation and Initial Management Classifications Navicular Avulsion Fractures Navicular Body Fractures Tuberosity and Accessory Navicular Fractures Indications for Operative Treatment Surgical Approaches Treatment Dorsal Navicular Avulsion Fractures Navicular Body Fractures Tuberosity Avulsion Fractures Management of Severe Comminution Postoperative Care and Rehabilitation Outcomes Complications Posttraumatic Arthrosis Avascular Necrosis Nonunion Arthrofibrosis Hindfoot Varus Tarsometatarsal (Lisfranc) Injuries Anatomy Mechanism of Injury Diagnosis Classifications Treatment Evaluation and Initial Management Nonoperative or Closed Treatment Operative Treatment Timing of Operative Treatment Surgical Approaches Surgical Technique: Two-Dorsal-Incision Technique Minimally Invasive Techniques Associated Pathology Associated Midfoot Sprains Associated Intertarsal Instability Associated Metatarsal Fractures Associated Cuboid Fractures Postoperative Care and Rehabilitation Outcomes Complications Wound Healing and Infection Compartment Syndrome Posttraumatic Arthrosis Malunion Issues of Implanted Hardware Cuboid Fractures Treatment Cuneiform Fractures Metatarsal Fractures Anatomy Evaluation and Initial Management Classifications Indications for Treatment Nonoperative or Closed Treatment Operative Treatment of Metatarsal Fractures First Metatarsal Second, Third, and Fourth Metatarsals Postoperative Care and Rehabilitation Complications Outcomes Fifth Metatarsal Fractures Anatomy Mechanism of Injury Classifications Fifth Metatarsal Avulsion Fractures Treatment Outcomes Fifth Metatarsal Metadiaphyseal (Jones) Fractures Treatment Outcomes Fifth Metatarsal Proximal Diaphyseal Fractures (Stress Fractures) Treatment Outcomes Fifth Metatarsal Shaft Fractures Injury to the Metatarsophalangeal Joints First Metatarsophalangeal Joint Injuries Anatomy Mechanism of Injury Initial Evaluation and Management Turf Toe Treatment Metatarsophalangeal Dislocation Treatment Lesser Metatarsophalangeal Joints Anatomy Treatment Injury to the Proximal Phalanx and Interphalangeal Joint of the Hallux Dislocation Injury to the Lesser Phalanges and Interphalangeal Joints Dislocation Distal Phalanx and Nail Bed Injuries Nail Bed Injuries Sesamoid Fractures Anatomy Evaluation and Initial Management Sesamoidectomy Sesamoid Open Reduction and Internal Fixation With Bone Grafting Foot Compartment Syndrome Anatomy Evaluation and Initial Management Pressure Measurement Operative Decompression Outcomes Mutilating Injuries: the Mangled Foot Crush Injuries Thermal Injury Burns Frostbite Gunshot Wounds Heel Pad Injury Traumatic Tendon Injury Anterior Tibial Tendon Injury Peroneal Tendon Injury Flexor Hallucis Longus Tendon Injury Flexor Digitorum Longus Tendon Injury Extensor Hallucis Longus Tendon Injury Extensor Digitorum Longus Tendon Injury Puncture Wounds Animal Bites and Marine Wounds Neuropathic Foot Fracture Advanced Imaging Modalities for Foot Trauma Weight-Bearing Computed Tomography Intraoperative Three-Dimensional Imaging Acknowledgment References 68 Posttraumatic Reconstruction of the Foot and Ankle Principles of Reconstructive Surgery of the Foot and Ankle Physical Examination Imaging Studies Ankle and Pilon Malunions and Nonunions Analysis of the Problem Supramalleolar Osteotomy Malleolar Osteotomies Intraarticular Osteotomies Surgical Treatment of End-Stage Ankle Arthrosis Arthrodesis Versus Ankle Arthroplasty Arthrodesis Techniques Total Ankle Arthroplasty Techniques Talar Malunion and Nonunion Analysis of the Problem Techniques of Joint-Preserving Corrections Salvage Options Calcaneal Malunion and Nonunion Analysis of the Problem Planning Correction Surgical Approaches Joint-Preserving Corrections Correction With Arthrodesis of the Subtalar Joint Type I: Subtalar Arthritis (Without Deformity) Type II: Additional Varus/Valgus Deformity Type III: Additional Loss of Height Type IV: Malunited Fracture-Dislocations Type V: Complex Malunions With Additional Talar Tilt Postoperative Rehabilitation and Results Chopart Joint Malunions and Nonunions Etiology and Pathomechanism Analysis of the Deformity Surgical Planning Surgical Approaches Techniques of Correction Type I: Solid Malunion Navicular and Talar Head Malunions. Cuboid and Anterior Calcaneal Process Malunions. Type II: Nonunion Type III: Deformity With Arthritis of the Calcaneocuboid Joint Type IV: Deformity With Arthritis of the Talonavicular Joint Type V: Complex Deformities With Talonavicular and Calcaneocuboid Arthritis Aftercare and Results Lisfranc Joint Malunion and Instability Analysis of the Deformity Lisfranc Joint Arthrosis Corrective Fusion of the First to Third Tarsometatarsal Joints Aftercare and Results Cuboid–Metatarsal Fourth and Fifth Joint Arthrosis Chronic Instability After Subtle Lisfranc Injuries Metatarsal Nonunions and Malunions Analysis of the Deformity Correction Phalangeal Malunions and Nonunions Bony Deformities Chronic Instability Sesamoid Nonunion and Necrosis Soft Tissue Balancing: Tendon Lengthening and Transfer Residuals of Compartment Syndrome, Postischemic Syndrome, or Traumatic Nerve Injury Definitions Sequelae of Anterior Compartment Syndrome Sequelae of Superficial Posterior Compartment Syndrome Old, Deep Posterior Compartment Syndrome Sequelae of Central Plantar Foot Compartment Syndrome Osteotomies and Fusions Aftercare and Results Ischemic or Traumatic Damage to the Peroneal Muscles and Tendons Chronic Achilles Tendon Rupture References 69 Periprosthetic Fractures of the Lower Extremity Introduction Epidemiology Periprosthetic Fractures Around Hip Arthroplasty Periprosthetic Fractures of the Acetabulum Periprosthetic Fractures of the Proximal Femur Periprosthetic Fractures Around Knee Arthroplasty Periprosthetic Fractures of the Distal Femur Periprosthetic Fractures of the Proximal Tibia Periprosthetic Fractures of the Patella Periprosthetic Fractures Around Unicompartmental Knee Arthroplasty Risk Factors Patient-Related Risk Factors Implant-Related Risk Factors Periprosthetic Fractures Around UKA Diagnostics Clinical Examination Laboratory Examination Radiologic Examination Classification Unified Classification System Periprosthetic Fractures Around Hip Arthroplasty Periprosthetic Fractures of the Acetabulum Periprosthetic Fractures of the Proximal Femur Periprosthetic Fractures Around Knee Arthroplasty Periprosthetic Fractures of the Distal Femur Periprosthetic Fractures of the Proximal Tibia Periprosthetic Fractures of the Patella Management Periprosthetic Fractures Around Hip Arthroplasty Periprosthetic Fractures of the Acetabulum Intraoperative Fractures Postoperative Fractures Periprosthetic Fractures of the Proximal Femur Intraoperative Fractures Postoperative Fractures Type A Periprosthetic Femoral Fractures. Type B1 Periprosthetic Femoral Fractures. Type B2 Periprosthetic Femoral Fractures. Type B3 Periprosthetic Femoral Fractures. Type C Periprosthetic Femoral Fractures. Bone Grafting Periprosthetic Fractures Around Knee Arthroplasty Periprosthetic Fractures of the Distal Femur Intraoperative Fractures Postoperative Fractures Type IA Fractures. Type IB Fractures. Type II Fractures. Type III Fractures. Periprosthetic Fractures of the Proximal Tibia Type I Fractures. Type II Fractures. Type III Fractures. Type IV Fractures. Periprosthetic Fractures of the Patella Outcome and Complications Periprosthetic Fractures Around Hip Arthroplasty Periprosthetic Fractures Around Knee Arthroplasty Periprosthetic Fractures Around Unicompartmental Knee Arthroplasty Interprosthetic Femoral Fractures Risk Factors Classification Management Outcome and Complications Management of Femoral Nonunion Prevention of Periprosthetic Fractures References 70 Principles of Deformity Correction Lower Limb Alignment and Joint Orientation Characteristics of Deformity Level of Angulation Osteotomy Rules Focal Dome Osteotomy Plane of Angulation Multiapical Angulation Translation Deformity Angulation and Translation Rotational Deformity Length Deformity Joint Considerations for Correction of Deformity Improvements in Deformity Correction: Development and Application References 71 Limb Salvage and Reconstruction Do the Limbs Matter? Why so Many Extremity Injuries? Initial Management: Think Physiology, Not Anatomy Common Factors Addressed With Initial Decision Making Scoring Systems Nerve Injury and Plantar Sensation Peripheral Nerve Injury Vascular Injury Limb Salvage Limb Salvage: Surgical Reconstruction Modern Intramedullary Interlocking Nails External Fixation Special Considerations Bone Loss Soft Tissue Loss Rehabilitation Costs Outcomes References 72 Amputations in Trauma General Principles History Initial Management Principles Upper Extremity Amputations Amputation Versus Limb Salvage and Replantation in the Upper Extremity Length Selection and Preservation Nerve and Muscle Management Partial Hand Amputation and Amputations Through the Carpus Wrist Disarticulation Transradial Amputation Elbow Disarticulation and Distal Transhumeral Amputations Proximal Transhumeral Amputation, Shoulder Disarticulations, and Forequarter Amputations Outcomes of Upper Extremity Amputations Pain Management in the Upper Extremity Amputation Lower Extremity Amputations Transpelvic Amputation (Hemipelvectomy, Hip Disarticulation) Transfemoral Amputation Knee Disarticulation Transtibial Amputation Ankle Disarticulation Hindfoot Amputations Midfoot Amputations Forefoot Amputations Special Considerations Pediatric Amputations Extremity Replant Onsite Amputation General Prosthetic Considerations and Rehabilitation Upper Extremity Prosthetic Considerations Lower Extremity Prosthetic Considerations Prosthetic Advances Rehabilitation Concerns Future Directions Targeted Muscle Reinnervation Osseointegrated Percutaneous Prosthetic Systems Vascularized Composite Tissue Allotransplantation (Hand Transplantation) Complications Infection Soft Tissue Complications Bursitis Neuromas and (Phantom) Pain Heterotopic Ossification Contractures Other Complications References 73 Articular Cartilage Reconstruction Using Osteochondral Allografts Introduction Background Limitations of Cartilage Healing Quality of Life After Cartilage Defect Regenerative Therapy Options Joint Replacement in Young Patients Free Allogenic Osteochondral Transplants Vascularized Allogenic Osteochondral Transplants Autologous Osteochondral Transplantation Transplantation of Allogenic Osteochondral Tissue Fresh Large Osteochondral Shell Allograft Transplantation Challenges of and Obstacles to the Use of Fresh Osteochondral Allograft Legal Basis Tissue Donation Graft Storage Cartilage Vitality Chondral Long-Term Cell Survival Osseous Integration Immunologic Aspects of Allogenic Articular Transplants Cartilage Immunogenicity Immunogenicity of Bones Immunogenicity of Meniscal Tissue Chimerism Diagnosis Indications Surgical Planning Transplant and Defect Geometry Transplantation Techniques Single-Plane Resurfacing (Uniplanar Technique) With Fresh Large-Size Osteochondral Transplant Bone Layer Thickness Surface Treatment Impact and Dehydration Fixation Multiplanar FLOCSAT and Multipolar FLOCSAT Bipolar FLOCSAT Tripolar FLOCSAT FLOCSAT in Combination With Meniscus and/or Ligaments Additional Pathologies Bone Defect and Nonunion Malalignment Ligamentous Injuries Meniscus Damage Rehabilitation Complications Conclusion References 74 The History of Fracture Treatment Early Splinting Techniques Precursors of the Plaster Bandage The Plaster Bandage and Its Derivatives Traction Functional Bracing Open Fractures Early Fracture Surgery Wire Fixation Screw Fixation Plate Fixation External Fixation Intramedullary Fixation Robert Danis and the Development of the AO Group Gavriil A. Ilizarov and the Discovery of Distraction Osteogenesis Stuart A. Green Emile Letournel and the Surgery of Pelvic and Acetabular Fractures Joel M. Matta Klaus Klemm and Interlocking Nailing and Local Antibiotic Bead Chain Therapy David Seligson Maurice Edmond Müller, Internal Fixation Techniques and Hip Prostheses Joseph Schatzker Martin Allgöwer, Internal Fixation and Fracture Management Marvin Tile Summary Christopher L. Colton References 75 Occupational Hazards in the Treatment of Orthopaedic Trauma Optimal and Safe Use of C-Arm X-Ray Fluoroscopy Units Introduction Features Reduction of Radiation Dose During C-Arm Operation In Summary: to Operate a C-Arm and Reduce the Radiation Exposure Protection From Radiation of C-Arm Equipment When in Operation Annual Inspection of C-Arm Equipment Prevention of Occupationally Acquired Bloodborne Pathogens Hepatitis B Virus Acute Infection Chronic Disease Treatment Prevention Before and After Occupational Exposure Hepatitis C Virus Screening Human Immunodeficiency Virus Management of Occupational Exposure to HIV Strategies to Prevent Occupational Transmission of Bloodborne Pathogens Screening for Bloodborne Pathogens Human Immunodeficiency Virus Hepatitis C Virus Management of Bloodborne Pathogen Infected Healthcare Workers Personal Protective Equipment Gloves Gowns Masks, Eye Protection, and Face Shields Other Personal Protective Equipment Work Practices and Engineering Controls Setting Expectations Needles and Sharps Hands-Free Technique Blunted Surgical Needles Regulated Medical Waste Summary References 76 Medical Management of the Orthopaedic Trauma Patient Acute Pain Management, Regional Anesthesia Techniques, and Management of Complex Regional Pain Syndrome Neurophysiology of Pain Processing Nociceptors and Primary Afferents Central Nervous System Relay and Processing Treatment Options Opioids Patient-Controlled Analgesia Assessment Pharmacotherapy Nonsteroidal Antiinflammatory Drugs Acetaminophen Opioids Selection of Opioids Appropriate and Inappropriate Use of Opioids Diagnosis and Differential Informed Consent Abuse Addiction Physical Dependence Tolerance Withdrawal (Abstinence) Opioid Agreements Initiation and Assessment of Therapy Analgesia Activity Adverse Effects Aberrant Behavior Neuraxial Delivery Systems: Subarachnoid Injections Neuraxial Delivery Systems: Continuous Epidural Catheters Peripheral Nerve Blocks Upper Extremity Blocks Interscalene Block Supraclavicular Infraclavicular Axillary Lower Extremity Blocks Lumbar Plexus Blocks (Psoas Compartment Block) Femoral Adductor Canal Block Parasacral Block Sciatic Nerve Block Popliteal Block Complex Regional Pain Syndrome Risk Factors Pathophysiology Symptomatology Imaging and Testing Treatment Medical Therapies Conclusion Perioperative Assessment Introduction to Perioperative Medicine Preoperative Cardiac Risk Assessment Pulmonary Risk Assessment Medications β-Blockers Hyperglycemic Medications Glucocorticoids Antihypertensive Medications Anticoagulation Medications Herbal Supplements Other Medications Ordering Tests Diabetes Mellitus Obstructive Sleep Apnea Liver Disease Preventing Complications Delirium Acute Renal Failure Postoperative Fever Other Conclusion Management of the Pregnant Woman Introduction Assessment Physiologic Changes in Pregnancy Diagnostic Imaging in Pregnancy X-Ray Computed Tomography Magnetic Resonance Imaging Nuclear Imaging Common Musculoskeletal Complaints in Pregnancy Fetal Monitoring During Nonobstetric Surgery Anesthesia During Pregnancy Preterm Labor Trauma in Pregnancy Medications for Use in Musculoskeletal Injuries or Complaints in Pregnancy Perimortem Cesarean Delivery Substance Abuse Syndromes: Recognition, Prevention, and Treatment Introduction Definitions Recognition—Estimating Risk Alcohol Opiates Cocaine Benzodiazepines Recognition—Early Identification of Signs and Symptoms Alcohol Opiates Cocaine Benzodiazepines Management—Prophylaxis/Treatment General Medical Considerations Alcohol Benzodiazepine Administration Benzodiazepine Protocol Alcohol Replacement Ethanol Replacement Protocol Additional Considerations for Implementation of Alcohol Replacement Therapy Opiates Cocaine Benzodiazepines Discharge Plans Summary References 77 Surgical Site Infection Prevention Defining Surgical Site Infections Preoperative Interventions Prophylactic Antibiotics Timing of Administration Antimicrobial Choices Dosing Duration Intraoperative Means of Reducing Infection The Operating Room Environment The Surgical Team The Surgical Site Conclusion References 78 Physical Impairment Ratings for Fractures Generic Issues of Disability and Impairment Definitions Role of the Physician Third-Party Payers and the Workers’ Compensation System Work Restrictions Types of Disability Temporary Total Disability Temporary Partial Disability Permanent Partial Disability Epidemiology of Fractures in the United States Guides for Impairment Determination Historical Perspective How to Perform an Impairment Evaluation Example 1 Impairment Rating. Example 2 Impairment Rating. Example 3 Impairment Rating. Impairment and Fractures Preexisting Conditions and Apportionment Neurologic Injuries Spine Fractures Summary References 79 Outcome Assessment in Orthopaedic Traumatology Introduction Outcomes Research—Assessment of Clinical Outcomes Region-Specific Outcome Measures Patient-Reported Outcome Measures Patient-Reported Outcome Measurement Information System Economic Outcome Measures Choosing an Outcome Measurement Tool Quality Improvement in Healthcare An Example of Change in Healthcare: Venous Thromboembolism Reporting Moving Toward High Reliability in Healthcare Delivery Providing Value in the Delivery of Healthcare Surgeon Leadership Conclusion References 80 Professionalism and the Economics of Orthopaedic Trauma Care Introduction The “On-Call” Controversy Emergency Medical Treatment and Active Labor Act Economics of Orthopaedic Trauma Care References