Trauma 101: Orthopedics Study Tool

Indication

Low-energy closed isolated fractures with acceptable alignment and length, especially spiral patterns in a compliant patient, and most paediatric fractures.

Implant design notes

No implant. Above-knee cast initially, converted to a patellar tendon-bearing cast or a functional brace as swelling settles and the fracture becomes sticky.

Approach

Non-operative with close alignment surveillance.

Steps overview

1. Assess compartments carefully and give explicit written warning signs before applying any cast
2. Reduce under anaesthesia if displaced and apply a split above-knee cast
3. Elevate and observe for compartment syndrome in the first days
4. Radiograph at one and two weeks; loss of alignment early is common
5. Convert to a below-knee weight-bearing cast or brace once early union is evident
6. Progress weight bearing and monitor to union; expect three to four months

Notes

A circumferential cast can mask compartment syndrome — split it and document the instructions given. Shortening and malalignment developing in cast are indications to convert to fixation.

Indication

Most displaced closed diaphyseal fractures and the majority of open fractures after adequate debridement.

Implant design notes

Load-sharing locked nail permitting early weight bearing with minimal additional soft tissue insult, inserted through a suprapatellar or infrapatellar entry. Multiplanar interlocking is needed for short segments near the ends of the bone, where the canal no longer controls alignment.

Approach

Infrapatellar transtendinous or parapatellar entry with the knee flexed, or a suprapatellar approach with the knee semi-extended, which aids control of proximal fractures.

Steps overview

1. Assess and document compartments before and after surgery
2. Debride and irrigate thoroughly first if the fracture is open, following open fracture principles
3. Position for the chosen entry and confirm the start point on both views
4. Open the canal in line with the axis; malposition of the entry causes malalignment, especially proximally
5. Reduce the fracture and pass the guide wire centrally in both planes
6. Ream to the planned diameter and insert the nail to the correct depth
7. Interlock proximally and distally, using multiple planes for short segments
8. Confirm alignment and rotation, close, and begin early weight bearing as the pattern allows

Notes

Proximal third fractures tend to drift into valgus and apex-anterior angulation with an infrapatellar entry; a semi-extended technique and blocking screws counter this. Anterior knee pain is the commonest long-term complaint.

Indication

Severe open injury with contamination or bone loss, fractures extending into the metaphysis or physis, and damage control in the unstable patient.

Implant design notes

Monolateral or circular frame allowing wound access and gradual correction, or a minimally invasive plate for metaphyseal extension where a nail cannot control alignment. Circular frames additionally permit bone transport for segmental defects.

Approach

Percutaneous pin or wire placement, or a minimally invasive submuscular plate tunnel avoiding the compromised skin.

Steps overview

1. Debride and stabilise according to open fracture principles with early antibiotics and tetanus cover
2. Place pins or wires away from the zone of injury and from planned flaps
3. Restore length, alignment and rotation and lock the construct
4. Plan definitive soft tissue cover with plastic surgery input early
5. Monitor pin sites and plan conversion or definitive frame treatment
6. Address bone defects by transport, grafting or staged induced-membrane technique

Notes

Coordinate skeletal stabilisation and soft tissue cover as a single plan; delayed cover raises deep infection risk substantially.