Case of the Month

Complex Midfoot Injury

2012-02-01T21:21:00.000-08:00

A 24 year old fell awkwardly at a Fourth of July celebration, injuring her left foot. She presented to a local community hospital, where X-rays and a CT scan were obtained.
The plain X-rays showed evidence of a non-displaced fracture in one of the cuneiform bones.

The CT scan confirmed a fracture in the middle cuneiform, along with several small bone fragments suggestive of ligament injuries in the dorsal midfoot. A small about of subluxation is seen in the talonavicular joint.

She was placed in a boot type orthotic and instructed to keep her weight off of it. During the course of her follow-up, there was increasing displacement. Nine weeks after her fall, she was referred to the Orthopaedic Trauma Clinic at Harborview Medical Center, where the X-rays showed collapse of the midfoot.

At this point she was diagnosed with dislocation of the navicular at both the talo-navicualr and navicular-cuneiform joints. In contrast to the navicular-cuneiform joints, which are very stable joints without motion, the talo-navicular joint is a mobile joint, known in the foot as an “essential joint”. The architecture of this part of the foot, as well as the motion in the essential joints, contributes to the painless function of the foot. Surgery was indicated to restore the anatomic relationships of the midfoot, and to provide for normal motion in the talonavicular joint.

She underwent an open reduction of the navicular-cuneiform joints, which realigned the talo-navicular joint.

In addition, a stress X-ray was taken in the operating room, and demonstrated significant instability at the first tarso-metatarsal joint, a normally stable articulation. It is important when treating midfoot injuries to identify all sites of instability, some of which may not be immediately apparent. Stress X-rays are helpful in identifiying unstable joints, which may be injured but not significantly displaced. These are typically treated so that displacement will not occur once normal activity is resumed.

The Xrays after surgery show that the stable midfoot joints, the navicular-cuneiform, and tarso-metatarsal, have been reduced and stabilized with several plates, multiple screws, and Kirschner wires. At the same time, the talonavicular joint has been reduced and will stay reduced as long as the stable joints remain reduced.

Nine months after her surgery, she is walking unlimited distances with minimal pain. Once the stable joints have healed more completely, the hardware can be removed if desired.

Midfoot injuries can be challenging to diagnose. Once diagnosed, the goals of treatment are to restore and maintain the normal relationships of the bones. Stable joints must heal solidly, and essential joints must have motion spared in order to optimize the functional outcome.

Authored By: James Krieg, MD

Minimally Invasive Screw Fixation of Symptomatic Pubic Ramus Nonunions

2012-01-04T10:09:00.000-08:00

A 46 years old female had incidental trauma related to her equestrian activities. She noted some left groin pain but did not seek medical treatment initially. Several weeks later her left groin pain persisted and she consulted her local physician.

She had a slight antalgic gait and mild tenderness to palpation of her pubis. She had no other relevant findings on physical examination an anteroposterior pelvic plain radiograph revealed no fracture or other abnormailty.

Her pain worsened over the subsequent months and she was seen again and noted to have a more notable limp due to pain and persistent pubic tenderness.

Another plain pelvic film identified left sided peripheral superior and mid-inferior pubic ramus fractures.

Pelvic computed tomography confirmed the diagnosis and detailed the well-aligned hypertrophic nonunion sites. There were no other areas of fracture or instability seen on these imaging studies.

She was not able to work or participate in her routine activities due to her left inguinal-pubic pain. A complete medical evaluation ruled out any form of metabolic bone diseases. She was counseled regarding the variety of operative and non-operative treatment options, and she chose percutaneous stabilization of the symptomatic pubic ramus nonunion sites.

At surgery, medullary screws were inserted through small stab wounds under fluoroscopic guidance to stabilize the nonunion sites. First the superior ramus site was fixed with an antegrade superior ramus medullary lag screw. The inferior ramus site was then secured using a large cortical lag screw.

Immediately after surgery, she noted good relief from her prior symptoms. She used crutches for 6 weeks thereafter limiting her weight bearing to light pressure only during the stance phase of gait. During weeks 7-12 after surgery, she progressed from partial weight bearing to full weight bearing along with light strengthening exercises.

Four months after surgery, she had radiographic union at the nonunion sites, no pain complaints, and had returned to her previous job and recreational impact activities.

Authored By: M.L. Chip Routt, Jr., M.D.

Unstable Pubic Ramus and Y-Shaped Sacral Fractures

2011-12-06T14:08:00.000-08:00

A 72 years old female with a history of inflammatory bowel disease was injured while on vacation with her family. She fell down 4-5 steps onto a grassy lawn and noted immediate anterior and posterior pelvic pain. She was taken to a local emergency room where physical examination and plain pelvic radiographs revealed no abnormalities.

She was unable to ambulate without significant assistance and returned home. One week after injury, she consulted her primary physician and complained of worsening pelvic pain. She had no bowel or bladder symptoms.

She was referred to our clinic on that same day. On physical exam, she had pelvic mechanical instability. She had diminished strength of the hip area and lower extremity muscles bilaterally due to pain.

Her detailed neurological examination was otherwise normal. Pelvic plain radiographs and a computed tomography scan identified a right-sided displaced pubic ramus fracture and a displaced Y-shaped sacral fracture. On the anteroposterior image, she had a paradoxical inlet appearance of the sacrum.

The sagittal sacral CT scan images best demonstrated the displacement of the upper sacrum through the fracture’s transverse component.

She opted for surgical treatment of he unstable and displaced pelvic fractures. She underwent surgery the next day. After being anesthetized, she was positioned supine on a radiolucent table and elevated on a soft lumbosacral support. Manual compression of the pelvis under fluoroscopy identified the pubic ramus displacement due to instability.

Manipulative reduction using manual distraction at the iliac crests reduced the pubic fracture. Medullary fixation was performed percutaneously using a retrograde superior pubic ramus screw. The Y-shaped sacral fracture was stabilized percutaneously using two trans-iliac, trans-sacral iliosacral screws located safely within the upper sacral segment.

She had dramatic pain relief immediately after surgery. A licensed physical therapist monitored her rehabilitation for the next 3 months. For the initial six weeks after operation, light resistance strengthening exercises were selected along with right-sided protected weight bearing using a walker. Between weeks 7-12, progressive partial weight bearing and more vigorous strength training was performed. Four months after injury, she had returned to her normal activities without pain. Her plain pelvic radiographs demonstrated fracture union.

U, Y, and H-shaped sacral fractures are unusual and are often delayed diagnoses. The AP pelvic plain film may demonstrate a paradoxical inlet of the sacrum when the upper sacral component is displaced and kyphotic. Mid-sagittal sacral CT imaging better defines the fracture details. Percutaneous pelvic fixation is used when the fracture fragments and therefore osseus fixation pathways are adequately reduced/realigned.

Authored By: M.L. Chip Routt, Jr., M.D.

Complex Monteggia Fracture Dislocation

2011-11-02T10:54:00.000-07:00

A 25 year old male was involved in a severe motor vehicle collision in which his car collided with a transport truck. He sustained an isolated open fracture dislocation of his dominant elbow. On physical examination he had multiple small open wounds over the posterior aspect of his elbow and forearm. He had a normal neurologic and vascular examination.

Radiographs were performed which demonstrated an extremely comminuted fracture dislocation of his elbow. He had complete disruption of his proximal radioulnar joint with anterior dislocation of the radial head representing a Type I Monteggia injury variant.

The patient was brought emergently to the operating room for irrigation and debridement of his open wounds as well as open reduction and internal fixation of his fracture. He had massive disruption of the deep soft tissues and musculature around the elbow.

The joint was meticulously reduced and repaired and the ulnar shaft component was held with clamps. However, the radial head was not reduced indicating that length had not been completely restored to the comminuted ulnar shaft. Length was then added and held with a minifragment plate on the shaft of the ulna and the radial head was then reduced. A plate spanning the joint and ulnar shaft components was then placed to hold the reduction. The plate was a 3.5 mm LCDC thickness plate.

The elbow was then brought through a full range of motion and the radial head remained reduced and stable throughout the full arc of flexion and extension in full pronation and supination.

Postoperatively, the patient was started on a rehabilitation program of elbow range of motion exercises 48 hours after surgery. He was able to regain excellent motion and return to his full time manual job within six months of injury. Final radiographs demonstrated a healed ulna with a concentrically reduced joint.

Type I (anterior) Monteggia injuries are fracture dislocations of the elbow in which the ulna is fractured and the proximal radioulnar joint is disrupted. The radial head dislocates anteriorly in this type of injury. In adults, these injuries typically result from high energy mechanisms and can have a high incidence of nerve or vascular injury. The key to restoring elbow stability is anatomic reduction and length restoration of the ulnar shaft.

Most cases do not involve such an extensive fracture of the joint as was seen in this patient. However, like other Monteggia injuries, anatomic ulnar alignment was the key to restoration of elbow joint stability in this case. This patient had an excellent result which was only possible by accurately restoring his anatomy and placing sufficient sized implants to ensure a rigid and stable construct that allowed for early range of motion and elbow rehabilitation.

Authored By: Daphne Beingessner, M.D.

Anterior Column

2011-10-04T13:39:00.000-07:00

A 54 years old male fell approximately four feet from a ladder onto the ground. He complained of left hip pain and was unable to stand. On presentation to the emergency department, he was awake and alert, and only complained of severe left hip pain.

He was hemodynamically stable and his physical examination confirmed left hip pain with any attempted passive movement. There was no obvious limb deformity or abnormal other findings. The injured lower extremity’s neurological and vascular examinations were within normal limits, yet the muscle power evaluation was limited due to pain.

Pelvic radiographs and a computed tomography scan demonstrated a displaced left anterior column acetabular fracture. The axial CT images demonstrated the details including the dome involvement. Three-dimensional surface rendered images further defined the osseus anatomy of the fracture.

The fracture line extended from the posterior aspect of the iliac crest, through the iliac fossa, along the pelvic brim, and divided both the acetabular dome and anterior acetabular wall regions in half. Skeletal traction was used to protect the femoral head and acetabular fracture surfaces, relax muscle spasm, provide comfort, and alert the ancillary staff to the injury before surgery.

One day after injury, the patient underwent open reduction and internal fixation of the fracture using an ilioinguinal surgical exposure. The fracture surfaces were cleansed and then the fragments manipulated and clamped. The clamp was applied onto the pelvic brim and quadrilateral surface using the Stoppa interval of the ilioinguinal exposure.

A malleable plate and interfragmentary lag screws were used to definitively stabilize the fracture. The plate was secured initially onto the stable iliac bone and located just lateral to the sacroiliac joint. Then lag screws were inserted through the plate and between the tables of the iliac crest bone.

The antegrade medullary superior pubic ramus lag screw was inserted percutaneously safely within the osseus fixation pathway using fluoroscopic biplanar imaging. On the postoperative anteroposterior pelvic image, the surgical staples indicate the ilioinguinal skin incision.

On the first postoperative day, the patient began his rehabilitation program with passive range of hip motion and isometric muscle strengthening exercises. He used crutches to protect and unload the hip repair during ambulation for 6 weeks after surgery. During weeks 7-12, a routine conditioning and strengthening program was used along with progressive weight bearing.

At his follow up evaluation 3 months after surgery, he had no complaints nor limp, his hip range of motion was symmetrical with his uninjured side, and his hip and lower extremity strength had returned to normal. He returned to his regular job four months after surgery as a laborer.

Authored By: M.L. Chip Routt, Jr., M.D.

Distal Humerus Fracture

2011-09-11T15:01:00.000-07:00

43 year old female fell on the ice sustaining an intraarticular distal humerus fracture. This is a complex break of the end of the humerus thus involving the elbow joint. The elbow joint was in several pieces. The patient is an active, healthy female who is right hand dominant. Radiographs demonstrate a comminuted (multifragment) fracture of the distal humerus.

Standard radiographs are challenging to interpret, so additional xrays are taken with gentle traction applied to the arm. This helps delineate the fracture fragments.

A posterior approach was utilized to access the elbow. Given the severity of the fracture, including the multiple articular (joint) pieces, an olecranon osteotomy was performed to allow for visualization of the joint. The olecranon is the proximal part of the ulna. Posteriorly, it covers and contains the distal humerus, forming part of the hinge of the elbow joint. An olecranon osteotomy is a surgical procedure in which the olecranon (proximal ulna) is broken in a controlled manner and repaired at the end of the operation. With the olecranon osteotomy complete, the multiple pieces of the distal humerus fracture are fixed anatomically and secured with plates and screws.

Once the distal humerus is repaired, the final part of the operation involves fixing the olecranon osteotomy with a plate and screws.

At one year, the patient is pain free with near full range of motion. She lacks the last 5 degrees of extension and flexes to 135 degrees. She has full pronation and supination. She is back to her usual activities.

Distal humerus fractures are complex injuries which are challenging to fix and can result in significant functional limitations. When dealing with these injuries, it is important to properly identify the complexity of the fracture and adhere to good surgical principles and techniques to maximize patient outcomes.

Authored By: Lisa A. Taitsman, M.D.

Geriatric Hip Fracture

2011-08-02T17:09:00.000-07:00

An active 89 year old female presented to our Emergency Department following a fall complaining of left hip pain and an inability to walk. Radiographs revealed an intertrochanteric hip fracture.

She was admitted to the hospital and evaluated by the internal medicine team. She was cleared for surgery and on the following day she was taken to the operating room for closed reduction and internal fixation with a Dynamic Hip Screw (DHS).

Following the surgery, she was allowed to put weight on her leg as she tolerated. Her immediate postoperative course was uncomplicated. Her xrays at six weeks demonstrate good alignment and evidence of early healing.

Unfortunately, just before her three month follow up appointment, she fell again and sustained a right hip fracture.

Again, the patient was evaluated and co-managed by the medical team. This fracture was treated with a closed reduction and stabilized with a medullary hip screw. We chose to use this implant due to concerns that the fracture extended distally. For fractures that extend into the subtrochanteric region, a medullary implant is preferred over the DHS. At 2 months, the following xrays were obtained.

The patient is now almost 3 years out from her second surgery and is doing well. She uses a walker to ambulate and lives in an assisted living community. When caring for geriatric patients with hip fractures it is important to provide a quality operation, but also a team approach as to optimize patient outcome.

Authored By: Lisa A. Taitsman, M.D.

Complex Tibia Fracture

2011-07-08T22:25:00.000-07:00

This 55 year old female sustained an injury to her right leg after a fall from a ladder. The patient sustained an intraarticular fracture of the distal tibia combined with a non-contiguous fracture of the distal tibial shaft. Both injuries were closed. The short oblique fracture of the tibial shaft is shown in the injury radiographs (a, b). Further, at the ankle joint, there is a significant fracture intraarticular injury of the distal tibia which is characterized by a spiral fracture that separates a large posterior articular segment (c, d, e). There is a small piece of cortical comminution proximally at the posterior aspect of the fracture.


(a)	(b)


(c)	(d)	(e)

The CT scan help to further characterize the articular injury pattern. The axial images demonstrate the posterior articular segment that comprises the vast majority of the articular surface. The plane of the fracture at the joint line is largely coronally oriented with a medial cortical exit point that extends from the medial malleolus distally (a, b). The sagittal and coronal CT reformations further demonstrate the fractures and confirm the lack of significant impaction or comminution (c, d, e). These CT scans demonstrate that the medial malleolar fracture from the AP plain radiographs is actually a large articular fracture of the posterior aspect of the medial distal tibia.


(a)	(b)


(c)	(d)	(e)

The shaft fracture, if in isolation, would certainly be optimally managed with an intramedullary nail. The displaced articular injury, if in isolation, would be optimally managed with open reduction and internal fixation. However, the leg was initially quite swollen and open reduction of the articular surface at the initial operative intervention was felt to be risky. Further, it was felt that primary stabilization of the shaft fracture with a nail would potentially block an accurate reduction of the articular injuiry. For that reason, it was elected to fix the fibular fracture and place a spanning external fixator that provided temporary stability of both the shaft fracture and the pilon injury. The fibular was plated through a posterolateral surgical exposure. The external fixator was placed from the proximal tibia (2 Schanz pins) to the foot (transcalcaneal pin with a medial pin at the cuneiforms) to span both fractures and to reasonably center the talus relative to the tibial shaft (a, b). The repeat CT scan adds very little information and was probably unnecessary. The fractures are and the orientation of the articular injury is confirmed (c, d, e).


(a)	(b)


(c)	(d)

(e)

The patient elevated the lower extremity for seven days to allow adequate resolution of the soft tissues at the distal tibia. As mentioned previously, the ideal operative plan combined open reduction and internal fixation of the articular injury combined with intramedullary nailing of the tibial shaft component. The articular injury was approached first to prioritize the joint reduction. The patient was positioned supine. Given the long medial cortical exit of the fracture, a posteromedial skin incision was used to allow exposure of the posteromedial proximal aspect of the fracture. Distally, a full thickness flap was used to allow exposure of the medial distal tibia. An incision directly over the medial face of the distal tibia was avoided to minimize potential wound healing issues. The fracture was cleaned from proximal to distal, allow visualization of the fracture line at the joint. Despite a thorough removal of all hematoma from the fracture and the presence of a well-corticated fracture read, the fracture could not be perfectly reduced as judged visually and radiographically. Therefore, an anterolateral surgical exposure was performed to allow for control and clamping at the opposite fracture exit point. This allowed for simulataneous clamp applications and improved control of the fracture. No identifiable block to reduction was found, however, improved fracture reduction was obtained with the additional approach. Fixation consisted of multiple independent 2.4 mm lag screws placed perpendicular to the fracture line, and additional lag screws placed through a 2.0 mm plate along the anterior distal tibia. The lag screws and plate were placed in a location that was felt to allow for placement of an intramedullary nail for the tibial fracture (a, b, c).


(a)	(b)

(c)

An attempted closed reduction of the shaft fracture was performed but regaining length was difficult. Given the proximity of the posteromedial approach which was used for the articular injury and the shaft fracture, this incision was simply extended proximally five additional centimeters to allow for reduction and clamp placement at the shaft fracture. No significant soft tissue dissection was performed (a, b). This allowed for atraumatic nail placement without vigorous manipulation of the reduced articular injury. The clamp was left in position distally to ensure that the distal fracture did not displace (c, d). A reamed nail was placed. The three distal interlocking screws (medial to lateral, anterior to posterior, anteromedial to posterolateral) were placed. An additional lag screw was then placed posterior to the nail to support the articular fracture reduction. A small lag screw was placed at the medial malleolus (e, f). Final radiographs demonstrate the reductions of the tibial shaft as well as the distal tibial articular injury (g, h).


(a)	(b)


(c)	(d)


(e)	(f)


(g)	(h)

Initially, unrestricted range of motion exercises of the ankle joint and subtalar joint was encouraged two weeks following the definitive articular reconstruction. Weight bearing was restricted until 12 weeks given the articular injury. Healing of both fractures progressed uneventfully as demonstrated in the radiographs at 6 months (a, b, c, d e).


(a)	(b)	(c)	(d)

(e)

Criticisms and Alternatives:
Alternatively, a short intramedullary nail could have been used to treat the shaft component of the fracture, followed by delayed open reduction and internal fixation of the articular injury. This would have a required an extremely short nail that would have terminated quite close to the proximal extent of the articular fracture posterior cortical extension. However, this approach would have allowed primary stabilization of the tibial fracture, combined with fibular fixation. An ankle joint spanning external fixator would still have been required. The shaft component of the injury pattern could have been treated with a plate at the time of reduction and internal fixation of the pilon fracture. This could have been accomplished with a direct open reduction, or with a minimally invasive technique.

Authored By: Sean E. Nork, M.D.

Open pilon fracture with bone loss

2011-05-30T17:34:00.000-07:00

This 24 year old male sustained an open right pilon fracture while skiing. The patient was initially seen at an outside hospital and was ultimately referred approximately 16 hours following the injury. There was a large posteromedial open wound approximately five centimeters above the ankle joint, and the proximal tibial shaft was still extruded through the open wound at presentation. Surprisingly, the patient had intact plantar sensation and a well perfused foot. There was obvious damage to the posterior musculature. The injury radiographs demonstrate significant shortening and the extrusion of the tibial shaft posteriorly.

A CT scan was obtained prior to transferring the patient. In most circumstances, the CT scan would be obtained after fibular fixation and spanning external fixation in cases where a staged approach is planned. The injury CT scan images demonstrate the three major articular segments. The posterior segment is large and includes the entire posterior and central portions of the articular surface, and extends to the medial shoulder of the joint. The anterolateral articular segment extends to the medial shoulder.

The patient underwent initial irrigation and debridement, fibular stabilization, and spanning external fixation shortly after arrival to the hospital. At the same time the intercalary cortical fragment was reduced and stabilized. A posteromedial approach was used given the location of the open wound, the presence of a tibial shaft extruded through the skin, and the perceived need for debridement in this location. The incision was extended over a distance of approximately ten centimeters and was located posterior to the palpable posteromedial border of the tibia. This allowed for access to the tibial shaft, and the associated soft tissue structures. A significant portion of the flexor hallucis longus muscle was debrided and free cortical fragments were removed. The large intercalary cortical segment could be accurately reduced to the tibial shaft. This was felt to be important to decrease the ongoing pressure on the soft tissues, to allow for wound closure, and to allow for the future reduction of the articular surface. A posterolateral approach was used for fibular stabilization to allow for future anterior approaches. An external fixator was placed using a transcalcaneal pin, a medial cuneiform pin, and two tibial pins placed well proximal to the anticipated future surgical approaches. Antibiotic beads were placed into the osseus defect of the distal tibial metaphysis.

The patient was sent home for elevation and to allow for resolution of the soft tissue swelling. Twenty days after injury, the patient underwent definitive fixation of the pilon fracture. The injury pattern is amenable to fixation through either an anteromedial or anterolateral approach. Similarly, a direct anterior approach could be used. An anteromedial approach would actually allow for the best visualization of the medial articular segment reduction to the posterior articular segment; as well as the reconstruction of the medial column through the cortical read between the medial malleolus and the medial cortical fragment. However, given the presence of an extensive and lengthy posteromedial approach which was used for the initial operative debridement of the open fracture, an anterolateral approach was felt to be safer. The anterolateral and posterior segments were first stabilized, followed by reduction of the remainder of the joint.

The entire articular block was then reduced relative to the tibial shaft and an anterolateral plate was placed in a submuscular fashion beneath the anterior compartment musculature through the anterolateral incision. In order prevent varus, a medial plate was slid along the subcutaneous anteromedial face of the distal tibia through a one centimeter incision over the medial malleolus Finally, antibiotic beads were placed into the osseus defect.

Approximately six weeks later, the patient was brought back to the operating room for a planned bone grafting of the large osseus defect. The anterolateral approach allowed for access to the defect, retrieval of the antibiotic beads, and placement of graft. Bone graft (approximately 30 cc) was obtained from the proximal tibia and combined with allograft and demineralized bone matrix (10 cc).

Initially, unrestricted range of motion exercises of the ankle joint and subtalar joint was encouraged two weeks following the definitive articular reconstruction, despite the presence of the large osseus defect. The implants were felt to be of sufficient strength and the patient was compliant. The patient was allowed to begin weight bearing at 12 weeks from his definitive articular reduction, which was 6 weeks following his bone grafting procedure. Weight bearing was initially restricted to a walking boot for 6 weeks given the presence of the grafted defect, followed by unrestricted weight bearing with regular shoe wear. Radiographs at 6 months from his articular reconstruction demonstrate maintenace of alignment and the presence of the bone graft.

Radiographs at one year show incorporation of the bone graft. The patient was full weight bearing without restrictions. Ankle range of motion was 15 degrees dorsiflexion and 30 degrees plantar flexion. The patient had some persistent discomfort and stiffness.

Authored By: Sean E. Nork, M.D.

Complex proximal humerus fracture dislocation

2011-05-16T08:59:00.000-07:00

A 25 year old female fell 12 feet from a ladder sustaining a complex fracture dislocation of her left shoulder. This fracture pattern carries a high risk of avascular necrosis of the humeral head which can lead to painful arthritis of the shoulder joint. Maintaining fixation to union can be challenging.

Radiographs revealed an anterior dislocation of the humeral head as well as a coracoid fracture.

Computed tomography confirmed the diagnosis and demonstrated a small amount of bone for fixation in the humeral head. Given the patient’s young age, hemiarthroplasty was not considered as a treatment option.

The humeral head was reduced after the fracture was exposed through a deltopectoral incision.

The fracture was then fixed with a periarticular locking proximal humerus plate and screw fixation of the coracoid.

At 18 month follow-up, the patient had maintained the vascularity of the humeral head and had healed the fracture. There was slight restriction of forward flexion compared to the opposite shoulder (10 degrees). The patient had minimal pain and had returned to all baseline activities.

Complex proximal humerus fracture dislocations in young adults are challenging injuries. We have extensive experience treating this injury at Harborview Medical Center and with adherence to sound surgical technique, good results are possible.

Authored By: Daphne M. Beingessner, M.D.

Infected Humeral Nonunion

2011-04-21T12:30:00.001-07:00

A sixty year old underwent attempted open reduction and internal fixation of a humeral shaft fracture. The fixation failed and was removed but resulted in an infected nonunion of the humerus with significant bone loss. Antibiotic beads had been placed and the patient had an open draining wound.

At this point, she presented to Harborview Medical Center for treatment of her complex nonunion.

She was treated with irrigation and debridement of the infection, stabilizing with a locked plate, insertion of antibiotic beads into the bone defect and bacteria-specific intravenous antibiotics.

After 10 weeks, she was brought to the operating room for bone grafting. An intramedullary fibular allograft as well as autograft from her ipsilateral femur were placed. Intraoperative cultures were negative for continued infection.

At seven month follow-up, she had successful healing of her humeral shaft fracture with no infection and no pain. She had returned to all baseline activities and was happy with her outcome.

Authored By: Daphne M. Beingessner, M.D.

Periprosthetic Fracture Nonunion

2011-04-21T11:24:00.000-07:00

85 year old healthy, independent man, trip and fall 5 years after a total hip arthroplasty and ipsilateral total knee arthroplasty. He did not have any previous hip pain.

Treated with internal fixation:

Construct failed at one month postoperatively:

Presented to Harborview 8 months after failure, now wheelchair bound. Nonunion was repaired with a locking condylar plate spanning the entire hip prosthesis with secure proximal fixation. At one year follow-up, patient was living independently and ambulating with a cane or walker as needed.

This case highlights the importance of appropriate proximal fixation and the importance of spanning the entire femur in the setting of a perprosthetic fracture.

We have successfully treated a series of these patients with this technique as published in the following article: Isolated locked compression plating for Vancouver Type B1 periprosthetic femoral fractures.

Bryant GK, Morshed S, Agel J, Henley MB, Barei DP, Taitsman LA, Nork SE. Injury. 2009 Nov;40(11):1180-6.

Authored By: Daphne M. Beingessner, M.D.