About This Course
The UCSF Ortho Trauma Core provides educational content related to orthopaedic surgery for trauma specialty. The course is organized by anatomic region and matches the core curriculum topics for the UCSF Orthopaedic Surgery residency. The course is in development and content will be continually added.
Requirements
The UCSF Ortho Trauma Core is meant to be an educational resource for orthopaedic trainees. Learners should be practicing surgeons or surgeons in training.
Course Staff
Faculty Contributors:
Dr. Paul Toogood and Dr. Dave Shearer
Open Fractures
Learning Objectives
- State the basic evaluation and treatment of open fractures in the emergency room
- State the fundamentals of open fracture management in the operating room
- Understand what evidence we have to guide treatment currently
Recorded Lecture
Clavicle Fractures
Learning Objectives
- Understand relevant anatomy
- Initial evaluation and management
- Nonoperative versus operative indications
- Review findings from landmark studies
Clavicle Fractures - Dr. Tangtiphaiboontana
- Additional Reading
-
Additional Reading
Articles:
1. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial. Journal of Bone and Joint Surgery. 2007;89(1):1-10. doi:10.2106/JBJS.F.00020
2. Robinson CM, Goudie EB, Murray IR, et al. Open Reduction and Plate Fixation Versus Nonoperative Treatment for Displaced Midshaft Clavicular Fractures: A Multicenter, Randomized, Controlled Trial. Journal of Bone and Joint Surgery. 2013;95(17):1576-1584. doi:10.2106/JBJS.L.00307
3. Woltz S, Stegeman SA, Krijnen P, et al. Plate Fixation Compared with Nonoperative Treatment for Displaced Midshaft Clavicular Fractures: A Multi-Center Randomized Controlled Trial. Journal of Bone and Joint Surgery. 2017;99(2):106-112. doi: 10.2106/JBJS.15.01394
4. McKnight B, Heckmann N, Hill JR, et al. Surgical management of midshaft clavicle nonunions is associated with a higher rate of short-term complications compared with acute fractures. Journal of Shoulder and Elbow Surgery. 2016;25(9):1412-1417. doi:10.1016/j.jse.2016.01.028
5. Tamaoki MJS, Matsunaga FT, Costa ARF da, Netto NA, Matsumoto MH, Belloti JC. Treatment of Displaced Midshaft Clavicle Fractures: Figure-of-Eight Harness Versus Anterior Plate Osteosynthesis. Journal of Bone and Joint Surgery. 2017;99)14):1159-1165. doi: 10.2106/JBJS.16.01184
Scapula Fractures
Learning Objectives
- Understand relevant anatomy
- Initial evaluation and management
- Nonoperative versus operative indications
- Approaches and important NV structures
Recorded Lecture
Scapula Fractures - Dr. Tangtiphaiboontana
- Additional Reading
-
Additional Reading
Classic Articles:
1. Jones CB, Cornelius JP, Sietsema DL, Ringler JR, Endres TJ. Modified Judet approach and minifragment fixation of scapular body and glenoid neck fractures. Journal of orthopaedic trauma. 2009;23(8):558–564.
Significance:
Review Articles:
1. Cole PA, Gauger EM, Schroder LK. Management of scapular fractures. Journal of the American Academy of Orthopaedic Surgeons. 2012;20(3):130–141.
Significance:
3. Nork SE, Barei DP, Gardner MJ, Schildhauer TA, Mayo KA, Benirschke SK. Surgical exposure and fixation of displaced type IV, V, and VI glenoid fractures. Journal of orthopaedic trauma. 2008;22(7):487–493.
Significance:
2. Armitage BM, Wijdicks CA, Tarkin IS, et al. Mapping of Scapular Fractures with Three-Dimensional Computed Tomography: The Journal of Bone and Joint Surgery-American Volume. 2009;91(9):2222-2228. doi:10.2106/JBJS.H.00881
Significance:
New Articles:
1. Harvey E, Audigé L, Herscovici Jr D, et al. Development and validation of the new international classification for scapula fractures. Journal of orthopaedic trauma. 2012;26(6):364–369.
Significance:
4. Zlowodzki M, Bhandari M, Zelle BA, Kregor PJ, Cole PA. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. J Orthop Trauma. 2006;20(3):230-233.
Significance:
3. Herscovici D, Fiennes AG, Allgöwer M, Rüedi TP. The floating shoulder: ipsilateral clavicle and scapular neck fractures. J Bone Joint Surg Br. 1992;74(3):362-364.
Significance:
2. Anavian J, Gauger EM, Schroder LK, Wijdicks CA, Cole PA. Surgical and Functional Outcomes After Operative Management of Complex and Displaced Intra-Articular Glenoid Fractures: The Journal of Bone and Joint Surgery-American Volume. 2012;94(7):645-653. doi:10.2106/JBJS.J.00896
Significance:
Proximal Humerus Fractures
Recorded Lecture
Proximal Humerus - Dr. Anthony Ding
- Additional Reading
-
Additional Reading
Classic Articles:
1. Neer CS. Displaced Proximal Humeral Fractures: Part I. Classification and Evaluation. 1970. Clin Orthop Relat Res. 1970;442:77-82.
2. Neer CS. Displaced Proximal Humeral Fractures: Part II. Treatment of Three-Part and Four-Part Displacement. Journal of Bone and Joint Surgery. 1970;52(6):1090–1103.
3. Rangan A, Handoll H, Brealey S, et al. Surgical vs Nonsurgical Treatment of Adults With Displaced Fractures of the Proximal Humerus: The PROFHER Randomized Clinical Trial. Journal of the American Medical Association. 2015;313(10):1037. doi:10.1001/jama.2015.1629
4. Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of Humeral Head Ischemia after Intracapsular Fracture of the Proximal Humerus. Journal of Shoulder and Elbow Surgery. 2004;13(4):427-433. doi:10.1016/j.jse.2004.01.034
Review Article:
1. Maier D, Jaeger M, Izadpanah K, Strohm PC, Suedkamp NP. Proximal Humeral Fracture Treatment in Adults. Journal of Bone and Joint Surgery. 2014;96(3):251-261. doi:10.2106/JBJS.L.01293
Distal Humerus Fractures
Recorded Lecture
Distal Humerus - Dr. Anthony Ding
- Additional Reading
-
Additional Reading
Classic Articles:
1. Helfet DL, Hotchkiss RN. Internal fixation of the distal humerus: a biomechanical comparison of methods. J Orthop Trauma. 1990;4(3):260-264.
2. Henley MB, Bone LB, Parker B. Operative management of intra-articular fractures of the distal humerus. J Orthop Trauma. 1987;1(1):24-35.
3. Jupiter JB, Neff URS, Holzach P, Allgöwer M. Intercondylar fractures of the humerus. An operative approach. JBJS. 1985;67(2):226–239.
4. McKee MD, Veillette CJH, Hall JA, et al. A multicenter, prospective, randomized, controlled trial of open reduction—internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. Journal of Shoulder and Elbow Surgery. 2009;18(1):3-12. doi:10.1016/j.jse.2008.06.005
Review Articles:
1. Galano GJ, Ahmad CS, Levine WN. Current treatment strategies for bicolumnar distal humerus fractures. Journal of the American Academy of Orthopaedic Surgeons. 2010;18(1):20–30.
2. Nauth A, McKee MD, Ristevski B, Hall J, Schemitsch EH. Distal Humeral Fractures in Adults: The Journal of Bone and Joint Surgery-American Volume. 2011;93(7):686-700. doi:10.2106/JBJS.J.00845
Proximal Radius and Ulna
Learning Objectives
- Understand the anatomy of the elbow
- Recognize common injury patterns around the elbow
- Describe an approach to common patterns
Recorded Lecture
Elbow Trauma - Dr. Kandemir
Pelvic Fractures
Learning Objectives
- Recite the life saving interventions critical to management of high-energy pelvic ring injuries
- Review the common pelvic ring injury patterns
- Know the surgical indications for each pattern
Recorded Lecture
Pelvic Ring Evaluation and Management - Dr. Morshed
- Additional Reading
-
Additional Reading
Articles:
1. Tile M. Pelvic ring fractures: should they be fixed? Bone and Joint Journal. 1988;70(1):1–12.
2. Day AC, Kinmont C, Bircher MD, Kumar S. Crescent fracture-dislocation of the sacroiliac joint: A functional classification. Journal of Bone and Joint Surgery. 2007;89(5):651-658.
Review Articles:
1. Bishop JA, Routt ML (Chip). Osseous fixation pathways in pelvic and acetabular fracture surgery: Osteology, radiology, and clinical applications. Journal of Trauma and Acute Care Surgery. 2012;72(6):1502-1509. doi:10.1097/TA.0b013e318246efe5
2. Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic fractures: part 1. Evaluation, classification, and resuscitation. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2013;21(8):448-457.
3. Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic fractures: part 2. Contemporary indications for definitive surgical management. Journal of the American Academy of Orthopaedic Surgeons. 2013;21(8):458-468.
Acetabular Fractures
Learning Objectives
- Understand anatomy allows radiographic evaluation of injury
- Consider indications for operative repair based on instability and displacement
Recorded Lecture
Acetabulum Essentials - Dr. Morshed
- Additional Reading
-
Additional Reading
Articles:
1. Letournel E. Acetabulum fractures: classification and management. Clinical Orthopaedics and Related Research. 1980;151:81–106.
2. Matta JM, Anderson LM, Epstein HC, Hendricks P. Fractures of the Acetabulum: A Retrospective Analysis. Clinical Orthopaedics and Related Research. 1986;205:230–240.
3. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. Journal of Bone and Joint Surgery. 1996;78(11):1632-1645.
4. Sagi HC, Afsari A, Dziadosz D. The anterior intra-pelvic (modified rives-stoppa) approach for fixation of acetabular fractures. Journal of Orthopaedic Trauma. 2010;24(5):263-270.
Surgical Approaches
Kocher Langenbach Approach
Femoral Neck Fractures
Learning Objectives
- Classify all types of hip fractures
- Identify the key management decision
- Describe the best treatment
Recorded Lecture #1
Femoral Neck Fractures - Dr. Marmor
Recorded Lecture #2
Young Femoral Neck Fracture - Dr. Morshed
- Additional Reading
-
Additional Reading
Classic Articles:
1. Haidukewych GJ, Rothwell WS, Jacofsky DJ, Torchia ME, Berry DJ. Operative Treatment of Femoral Neck Fractures in Patients between the Ages of Fifteen and Fifty Years. Journal of Bone and Joint Surgery. 2004;86(8);1711-1716.
Significance:
Review Articles:
1. Haidukewych GJ, Berry DJ. Salvage of Failed Treatment of Hip Fractures: Journal of the American Academy of Orthopaedic Surgeons. 2005;13(2):101-109. doi:10.5435/00124635-200503000-00003
2. Mayo K, Kuldjanov D. Generic Preoperative Planning for Proximal Femoral Osteotomy in the Treatment of Nonunion of the Femoral Neck: Journal of Orthopaedic Trauma. 2018;32:S46-S54. doi:10.1097/BOT.0000000000001087
3. Slobogean GP, Stockton DJ, Zeng B, Wang D, Ma B, Pollak AN. Femoral Neck Fractures in Adults Treated With Internal Fixation: A Prospective Multicenter Chinese Cohort. Journal of the American Academy of Orthopaedic Surgeons. 2017;25(4):297-303. doi:10.5435/JAAOS-D-15-00661
7. Slobogean GP, Sprague SA, Scott T, Bhandari M. Complications Following Young Femoral Neck Fractures. Injury. 2015;46(3):484-491. doi:10.1016/j.injury.2014.10.010
Significance:
6. Reina N, Bonnevialle P, Rubens Duval B, et al. Internal Fixation of Intra-Capsular Proximal Femoral Fractures in Patients Older than 80 Years: Still Relevant? Multivariate Analysis of a Prospective Multicentre Cohort. Orthopaedics and Traumatology: Surgery & Research. Published online December 2016. doi:10.1016/j.otsr.2016.10.013
Significance:
5. Oakey JW, Stover MD, Summers HD, Sartori M, Havey RM, Patwardhan AG. Does Screw Configuration Affect Subtrochanteric Fracture after Femoral Neck Fixation?: Clinical Orthopaedics and Related Research. 2006;443(:):302-306. doi:10.1097/01.blo.0000188557.65387.fc
Significance:
4. Damany DS, Parker MJ, Chojnowski A. Complications after Intracapsular Hip Fractures in Young Adults: A Meta-Analysis of 18 Published Studies involving 564 Fractures. Injury. 2005;36(1):131–141.
Significance:
3. Christal AA, Taitsman LA, Dunbar Jr RP, Krieg JC, Nork SE. Fluoroscopically Guided Hip Capsulotomy: Effective or Not? A Cadaveric Study. Journal of Orthopaedic Trauma. 2011;25(4):214–217.
Significance:
2. Baitner AC, Maurer SG, Hickey DG, et al. Vertical Shear Fractures of the Femoral Neck. A Biomechanical Study. Clin Orthop Relat Res. 1999;(367):300-305.
Significance:
New Articles:
1. Angelini M, McKee MD, Waddell JP, Haidukewych G, Schemitsch EH. Salvage of Failed Hip Fracture Fixation: Journal of Orthopaedic Trauma. 2009;23(6):471-478. doi:10.1097/BOT.0b013e3181acfc8c
Significance:
5. Zielinski SM, Keijsers NL, Praet SFE, et al. Functional Outcome After Successful Internal Fixation Versus Salvage Arthroplasty of Patients With a Femoral Neck Fracture: Journal of Orthopaedic Trauma. 2014;28(12):e273-e280. doi:10.1097/BOT.0000000000000123
Significance:
4. Swiontkowski MF, Winquist RA, Hansen ST. Fractures of the Femoral Neck in Patients between the Ages of Twelve and Forty-Nine Years. Journal of Bone and Joint Surgery. 1984;66:837–846.
Significance:
3. Molnar RB, others. Open Reduction of Intracapsular Hip Fractures using a Modified Smith-Petersen Surgical Exposure. Journal of Orthopaedic Trauma. 2007;21(7):490–494.
Significance:
2. Hartford JM, Patel A, Powell J. Intertrochanteric Osteotomy Using a Dynamic Hip Screw for Femoral Neck Nonunion. Journal of Orthopaedic Trauma. 2005;19(5):5.
Significance:
Intertrochanteric Fractures
Learning Objectives
- Classify all types of hip fractures
- Identify the key management decision
- Describe the best treatment
Recorded Lecture
Intertrochanteric Fractures - Dr. Marmor
- Additional Reading
-
Additional Reading
Articles:
1. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The Value of the Tip-Apex Distance in Predicting Failure of Fixation of Peritrochanteric Fractures of the Hip. Journal of Bone and Joint Surgery. 1995;77(7):1058–1064.
2. Haidukewych GJ, Israel TA, Berry DJ. Reverse Obliquity Fractures of the Intertrochanteric Region of the Femur. Journal of Bone and Joint Surgery. 2001;83(5):643–650.
3. Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P, Hip Fracture Study Group. Integrity of the Lateral Femoral Wall in Intertrochanteric Hip Fractures: An Important Predictor of a Reoperation. Journal of Bone and Joint Surgery. 2007;89(3):470-475. doi:10.2106/JBJS.F.00679
4. Hsu C-E, Shih C-M, Wang C-C, Huang K-C. Lateral femoral wall thickness. A reliable predictor of post-operative lateral wall fracture in intertrochanteric fractures. Bone Joint J. 2013;95-B(8):1134-1138. doi:10.1302/0301-620X.95B8.31495
Subtrochanteric Fractures
Learning Objectives
- Classify all types of hip fractures
- Identify the key management decision
- Describe the best treatment
Recorded Lecture
Subtroch - Dr. Marmor
Femoral Shaft
Learning Objectives
- Understand the anatomy of the proximal and distal femur
- Understand the indications for surgical intervention of femur fractures
- Understand the goals of surgery
- Understand the technical details of performing the surgical fixation of femur fractures
- Understand how to check and verify the length and alignment of femoral fracture fixation
- Understand the common complications of femur fracture treatment
Recorded Lecture
Femoral Shaft - Dr. Matityahu
Distal Femur
Learning Objectives
- Understand the anatomy of the distal femur
- Understand the indications for surgical intervention of supracondylar femur fractures
- Understand the goals of surgery
- Understand the technical details of performing the surgical fixation of supracondylar femur fractures
- Understand how to check and verify the length and alignment of supracondylar femoral fracture fixation
- Understand the common complications of supracondylar femur fracture treatment
Recorded Lecture
Distal Femur Fractures - Dr. Matityahu
Patella Fractures
Recorded Lecture
Patella Fractures - Dr. Lim
- Additional Reading
-
Additional Reading
Articles:
1. Bonnaig NS, Casstevens C, Archdeacon MT, et al. Fix It or Discard It? A Retrospective Analysis of Functional Outcomes after Surgically Treated Patella Fractures Comparing ORIF with Partial Patellectomy. Journal of Orthopaedic Trauma. 2015;29(2):80-84. doi:10.1097/BOT.0000000000000201
2. Lazaro LE, Wellman DS, Sauro G, et al. Outcomes After Operative Fixation of Complete Articular Patellar Fractures: Assessment of Functional Impairment. Journal of Bone and Joint Surgery. 2013;95(14):e96 1. doi:10.2106/JBJS.L.00012
3. Lorich DG, Warner SJ, Schottel PC, Shaffer AD, Lazaro LE, Helfet DL. Multiplanar Fixation for Patella Fractures Using a Low-Profile Mesh Plate. Journal of Orthopaedic Trauma. 2015;29(12):e504–e510.
4. Melvin SJ, Mehta S. Patellar Fractures in Adults. Journal of the American Academy of Orthopaedic Surgeons. 2011;19(4):198.
Tibial Plateau Fractures
Recorded Lecture
Tibial Plateau - Dr. Lim
- Additional Reading
-
Additional Reading
Article:
1. Fakler JKM, Ryzewicz M, Hartshorn C, Morgan SJ, Stahel PF, Smith WR. Optimizing the Management of Moore Type I Postero-Medial Split Fracture Dislocations of the Tibial Head: Description of the Lobenhoffer Approach: Journal of Orthopaedic Trauma. 2007;21(5):330-336. doi:10.1097/BOT.0b013e318055603c
Significance:
Surgical Approaches
Anterior Lateral Approach
Tibial Shaft Fractures
Learning Objectives
- Describe the initial evaluation of tibial shaft fractures
- Review key aspects of initial ER management
- State the treatment options for tibial shaft fractures and the pros and cons of each
Recorded Lecture
Tibial Shaft Fractures - Dr. Toogood
- Additional Reading
-
Additional Reading
Classic Articles:
1.
Hooper GJ, Keddell RG, Penny ID. Conservative management or closed nailing for tibial shaft fractures. A randomised prospective trial. Bone & Joint Journal. 1991;73(1):83–85.
Significance: This RCT demonstrated the benefits of intramedullary nailing for closed tibial shaft fractures compared to conservative treatment, including faster recovery and less risk of malunion and shortening. Operatively treated patients also had significantly less outpatient visits and x-rays post-operatively.
2.
Bhandari M, Guyatt G, Walter SD, Tornetta P, Schemitsch EH, Swiontkowski M, Sanders D. Randomized Trial of Reamed and Unreamed Intramedullary Nailing of Tibial Shaft Fractures: By the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) Investigators*. The Journal of Bone and Joint Surgery-American Volume. 2008 Dec;90(12):2567–2578.
Significance: The SPRINT trial was the largest multicenter clinical trial in orthopaedic trauma at the time of its publication. It demonstrated a lower risk of nonunion for reamed compared to unreamed nailing for tibial shaft fractures. The beneficial effect of reaming was significant for closed but not open fractures.
Other Articles:
1.
Weinberg DS, Park PJ, Liu RW. Association Between Tibial Malunion Deformity Parameters and Degenerative Hip and Knee Disease: Journal of Orthopaedic Trauma. 2016 Sep;30(9):510–515.
Significance: This study evaluated nearly 3000 cadaveric skeletons to assess the association between tibial malunion and osteoarthritis of the hip and knee. The authors found increased rates of knee arthritis with coronal deformities > 5 degrees and axial plane deformities > 10 degrees. Tibial malalignment was not associated with hip osteoarthritis but shortening >1cm was associated with hip arthritis.
Tibial Plafond Fractures
Learning Objectives
- Recognize the importance of staging and soft-tissue handling in tibial plafond fractures
- Know the definition and significance of B-type versus C-type pilon fractures and direction of failure (varus vs. valgus)
- Understand a framework for selecting the surgical approach and reduction sequence
- State the three most common modes of failure for tibial plafond fractures
Recorded Lecture #1
Intro to Tibial Plafond - Dr. Paul Toogood
Recorded Lecture #2
Avoiding Failures in Tibial Plafond Fractures - Dr. Shearer
Approach videos
Anterolateral Approach to the Ankle
Anteromedial Approach to the Ankle
- Additional Reading
-
Additional Reading
Classic Articles:
1. Rüedi TP, Allgöwer M. The operative treatment of intra-articular fractures of the lower end of the tibia. Clin Orthop Relat Res. 1979 Feb;(138):105–110.
Significance: This landmark article describes the approach to open reduction and internal fixation for tibial plafond fractures that forms the foundation of modern treatment. Notably, the results of early single-stage treatment were likely biased by a relatively low-energy population (ski injuries). Nonetheless, the principles of definitive fixation remain highly relevant to modern treatment.
Review Article:
1. Hebert-Davies J, Kleweno CP, Nork SE. Contemporary Strategies in Pilon Fixation: Journal of Orthopaedic Trauma. 2020 Feb;34(Supplement 1):S14–S20.
3. Patterson MJ, Cole JD. Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma. 1999 Feb;13(2).
- Significance: After a period of increasing fear of internal fixation for pilon fractures due to high rates of wound healing complications and infection, the Sirkin and Patterson articles established the modern protocol of staged treatment for high-energy tibial plafond fractures.
2. Sirkin M, Sanders R, DiPasquale T, Herscovici Jr D. A staged protocol for soft tissue management in the treatment of complex pilon fractures. Journal of orthopaedic trauma. 1999;13(2):78–84.
- Significance: After Ruedi and Allgower's results were not reproduced in North America, there was a large pendulum swing toward external fixation as definitive treatment. This was largely attributed to the higher energy injuries reported in US series attempting to replicate their results. This article by Sirkin as well as the article below by Patterson and Cole showed improved results with a staged approach beginning with temporizing external fixation, followed by definitive ORIF at a later date. Their improved results led to a return to the application of the principles outlined by Ruedi and Allgower for ORIF applied in staged fashion.
Ankle Fractures
Learning Objectives
- Identify the determinants of stability in the ankle
- Recite the two major fracture classifications: Weber and Lauge-Hansen
- Know techniques to detect occult instability
- Understand how fracture pattern dictates fixation strategy
Recorded Lecture
Ankle Fractures - Dr. Shearer
- Additional Reading
-
Additional Reading
Classic Article:
1. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am. 1976;58(3):356–357.
Significance: This article established the importance of small amounts of talar shift in increasing contact forces in the tibiotalar joint. Based on this article we generally assume that any degree of talar shift will predispose patients to post-traumatic ankle arthritis. Therefore, a major goal of our management is to identify patients with instability that will lead to talar shift and prevent it through appropriate treatment.
2. Solari J, Benjamin J, Wilson J, Lee R, Pitt M. Ankle mortise stability in Weber C fractures: indications for syndesmotic fixation. J Orthop Trauma. 1991;5(2):190–195.
Significance:
Calcaneal Fractures
Learning Objectives
- Know the key parameters for radiographic evaluation calcaneus fractures (height, width, varus)
- Differentiate tongue and joint depression fractures and treatment considerations
- State the major treatment options for calcaneus fractures and the pros and cons of each
Recorded Lecture
Calcaneus Fractures - Dr. Shearer
- Additional Reading
-
Additional Reading
1. Attinger CE, Evans KK, Bulan E, et al. Angiosomes of the Foot and Ankle and Clinical Implications for Limb Salvage: Reconstruction, Incisions, and Revascularization: Plastic and Reconstructive Surgery. 2006 Jun;117(SUPPLEMENT):261S-293S.
Significance: This article discusses the angiosomes of the foot and ankle which critical to understanding the approaches to the calcaneus. Specifically, the peroneal angiosome and its relationship to the extensile lateral approach.
4. Sanders R, Fortin P, DiPasquale T, et al. Operative treatment in 120 displaced intraarticular calcaneal fractures Results using a prognostic computed tomography scan classification. Clinical orthopaedics and related research. 1993;290:87–95.
Significance: This study used CT scans to classify calcaneal fractures based on the degree of comminution of the posterior facet, now known as the Sanders Classification. The study correlated the degree of comminution with clinical outcomes. The authors noted particularly poor outcomes in Sanders 4 fractures. The results emphasized the importance of achieving an anatomic reduction for good results and described improved results with increased experience.
3. Buckley R, Tough S, McCormack R, et al. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures. J Bone Joint Surg Am. 2002;84(10):1733–1744.
Significance: This multicenter RCT is the highest quality clinical trial comparing operative and non-operative treatment for calcaneal fractures. The authors randomized 424 patients and did not show a significant difference in SF-36 score between the two groups at minimum 2 years follow up. The study did identify several variables that favor surgical treatment, including younger age, female gender, light duty work, non-smokers, moderate injury severity, and anatomic reduction. Unlike the Benirschke study, these results likely represent a "average" result rather than a "ceiling".
2. Benirschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. Journal of orthopaedic trauma. 2004;18(1):1–6.
Significance: Dr. Benirschke, who was among the pioneers of the extensile lateral approach for calcaneal fractures, reported a serious infection rate (requiring more than oral antibiotics) of just 1.8% for closed fractures in a series of almost 400 cases operated in a 5 year period. This is lower than almost any other series and likely represents a ceiling for how good the approach can be rather than an expected outcome. This highlights the importance of volume and expertise in treating these injuries.
Talus Fractures
Learning Objectives
- Know the blood supply of the talus
- Recite the Hawkin's classification and its influence on risk of osteonecrosis
- State the most important aspects of emergency and operative treatment in reducing the risk of osteonecrosis and post-traumatic arthritis
Recorded Lecture
Talus Fractures - Dr. Shearer
- Additional Reading
-
Additional Reading
Classic Articles:
1. Hawkins LG. Fractures of the neck of the talus. The Journal of Bone and Joint Surgery. American Volume. 1970 Jul;52(5):991–1002.
Significance: Hawkins original series of 57 talar neck fractures formed the foundation of the now ubiquitous Hawkin's classification system. He demonstrated good outcomes with ORIF and anatomic reduction as long as AVN did not occur. He also demonstrated that AVN risk was correlated with the classification system.
2. Canale ST, Kelly FB. Fractures of the neck of the talus. Long-term evaluation of seventy-one cases. The Journal of Bone and Joint Surgery. American Volume. 1978 Mar;60(2):143–156.
Significance: Canale reported a series of 71 patients with nearly 13-year-follow up and again showed fair results with ORIF provided AVN did not occur. He also add a modification of the original classification by adding a 4th type involving dislocation of the talar head from the talonavicular joint (in addition to dislocation of the talar body from the subtalar and tibiotalar joints).
3. Vallier HA, Nork SE, Barei DP, et al. Talar neck fractures: results and outcomes. J Bone Joint Surg Am. 2004;86(8):1616–1624.
Significance: This is among the largest series of talar neck fractures in the published literature. The authors showed that post-traumatic arthritis and AVN were the most common complications and correlated with injury severity based on the Hawkin's classification. In addition, they showed that time to surgery was not correlated with AVN as long as the associated joint dislocation were promptly reduced. Open fractures and comminution were associated with poor outcome.
New Articles:
1. Vallier HA, Reichard SG, Boyd AJ, et al. A New Look at the Hawkins Classification for Talar Neck Fractures: Which Features of Injury and Treatment Are Predictive of Osteonecrosis? The Journal of Bone & Joint Surgery. 2014 Feb 5;96(3):192–197.
Significance: This series of 81 talar neck and body fractures largely reinforced previous studies. The most important contribution was a sub-classification of Type 2 fractures into Type 2A (subtalar subluxation) and Type 2B (subtalar dislocation). The results suggest the Type 2A injuries have a risk of osteonecrosis equivalent to a type 1 fracture, while Type 2B fractures were much higher risk and equivalent to type 3 fractures.
Review Article:
1. Shakked RJ, Tejwani NC. Surgical Treatment of Talus Fractures. Orthopedic Clinics of North America. 2013 Oct;44(4):521–528.
Lisfranc Injuries
Learning Objectives
- Describe the relevant anatomy and biomechanics of the midfoot
- Recognize key radiographic features on plain radiographs
- Understand diagnostic algorithm for the subtle Lisfranc
- Review the techniques for provisional and definitive management
Recorded Lecture
Lisfranc Injuries - Dr. Shearer
- Additional Reading
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Additional Reading
Classic Articles:
Faciszewski T, Burks RT, Manaster BJ. Subtle injuries of the Lisfranc joint. The Journal of Bone & Joint Surgery. 1990;72(10):1519–1522.
Review Article:
Benirschke SK, Meinberg E, Anderson SA, et al. Fractures and dislocations of the midfoot: Lisfranc and Chopart injuries. J Bone Joint Surg Am. 2012;94(14):1325–1337.
2. Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. J Bone Joint Surg Am. 2006;88(3):514–520.
Significance: In this clinical trial in Canada 41 patients with purely ligamentous Lisfranc injuries were randomized to either ORIF or fusion of the medial column. The authors found improved functional outcomes and lower rates of reoperation with fusion up to 2 year follow up. Significance: The authors discuss the subtle injury of the Lisfranc joint, defined as a diastasis between the medial cuneiform and the 2nd metatarsal base of 2-5mm without disruption of the first tarsometatarsal joint. The authors demonstrated that clinical outcome corresponds to maintenance of the alignment of the foot rather than the degree of diastasis. They emphasize the importance of weight bearing radiographs in predicting final outcome.
