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Sebastian Siebenlist, Arne Buchholz, and Karl F. Braun

  • Fractures of the proximal ulna range from simple olecranon fractures to complex Monteggia fractures or Monteggia-like lesions involving damage to stabilizing key structures of the elbow (i.e. coronoid process, radial head, collateral ligament complex).

  • In complex fracture patterns a computerized tomography scan is essential to properly assess the injury severity.

  • Exact preoperative planning for the surgical approach is vital to adequately address all fracture parts (base coronoid fragments first).

  • The management of olecranon fractures primarily comprises tension-band wiring in simple fractures as a valid treatment option, but modern plate techniques, especially in comminuted or osteoporotic fracture types, can reduce implant failure and potential implant-related soft tissue irritation.

  • For Monteggia injuries, the accurate anatomical restoration of ulnar alignment and dimensions is crucial to adjust the radiocapitellar joint.

  • Caution is advised if the anteromedial facet (anatomical insertion of the medial collateral ligament) of the coronoid process is affected, to avoid posteromedial instability.

  • Radial head reconstruction or replacement is essential in Monteggia-like lesions to restore normal elbow function.

  • The postoperative rehabilitation programme should involve active elbow motion exercises without limitations as early as possible following surgery to avoid joint stiffness.

Cite this article: EFORT Open Rev 2019;4:1-9. DOI: 10.1302/2058-5241.4.180022.

Olga D. Savvidou, Frantzeska Zampeli, Panagiotis Koutsouradis, George D. Chloros, Aggelos Kaspiris, Savas Sourmelis, and Panayiotis J. Papagelopoulos

  • Treatment of distal humerus fractures is demanding. Surgery is the optimal treatment and preoperative planning is based on fracture type and degree of comminution.

  • Fixation with two precontoured anatomical locking plates at 90o:90o orthogonal or 180o parallel is the optimal treatment.

  • The main goal of surgical treatment is to obtain stable fixation to allow immediate postoperative elbow mobilization and prevent joint stiffness.

  • Despite evolution of plates and surgical techniques, complications such as mechanical failure, ulnar neuropathy, stiffness, heterotopic ossification, nonunion, malunion, infection, and complications from olecranon osteotomy are quite common.

  • Distal humerus fractures still present a significant technical challenge and need meticulous technique and experience to achieve optimal results.

Cite this article: EFORT Open Rev 2018;3:558-567. DOI: 10.1302/2058-5241.3.180009

Holger Keil, Nils Beisemann, Benedict Swartman, Sven Yves Vetter, Paul Alfred Grützner, and Jochen Franke

  • The reconstruction of anatomical joint surfaces, limb alignment and rotational orientation are crucial in the treatment of fractures in terms of preservation of function and range of motion. To assess reduction and implant position intra-operatively, mobile C-arms are mandatory to immediately and continuously control these parameters.

  • Usually, these devices are operated by OR staff or radiology technicians and assessed by the surgeon who is performing the procedure. Moreover, due to special objectives in the intra-operative setting, the situation cannot be compared with standard radiological image acquisition. Thus, surgeons need to be trained and educated to ensure correct technical conduct and interpretation of radiographs.

  • It is essential to know the standard views of the joints and long bones and how to position the patient and C-arm in order to acquire these views. Additionally, the operating field must remain sterile, and the radiation exposure of the patient and staff must be kept as low as possible.

  • In some situations, especially when reconstructing complex joint fractures or spinal injuries, complete evaluation of critical aspects of the surgical results is limited in two-dimensional views and fluoroscopy. Intra-operative three-dimensional imaging using special C-arms offers a valuable opportunity to improve intra-operative assessment and thus patient outcome.

  • In this article, common fracture situations in trauma surgery as well as special circumstances that the surgeon may encounter are addressed.

Cite this article: EFORT Open Rev 2018;3:541-549. DOI: 10.1302/2058-5241.3.170074

Simon M. Lambert

  • Interfragmental ischaemia is a prerequisite for the initiation of the inflammatory and immunological response to fracturing of bone.

  • Intrafragmental ischaemia is inevitable: the extent of the initial ischaemic insult does not, however, directly relate to the outcome for healing of the fracture zones and avascular necrosis of the humeral head. The survival of distal regions of fragments with critical perfusion may be the result of a type of inosculation (blood vessel contact), which establishes reperfusion before either revascularization or neo-angiogenesis has occurred.

  • Periosteum has a poorly defined role in fracture healing in the proximal humerus. The metaphyseal periosteal perfusion may have a profound effect, as yet undefined, on the healing of most metaphyseal fractures of the proximal humerus, and may be disturbed further by inadvertent surgical manipulation.

  • The metaphysis can be considered as a ‘torus’ or ring of bone, its surface covered by periosteum antero- and posterolaterally, through which the tuberosity segments gain perfusion and capsular reflections antero- and posteromedially, through which the humeral head (articular) fragment gains perfusion.

  • The torus is broken in relatively simple primary patterns: a fracture line at the upper surface of the torus is an anatomical ‘neck’ fracture; a fracture line at the lower surface of the torus is the surgical ‘neck’ fracture. Secondary fragmentation (through compression and/or distraction) of the torus itself creates complexity for analysis (classification), alters the capacity and outcome for healing (by variable interruption of the fragmental blood supply) and influences interfragmental stability.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.180005

Abdel Rahim Elniel and Peter V. Giannoudis

  • Open fractures of the lower extremity are the most common open long bone injuries, yet their management remains a topic of debate.

  • This article discusses the basic tenets of management and the subsequent impact on clinical outcome. These include the rationale for initial debridement, antimicrobial cover, addressing the soft-tissue injury and definitive skeletal management.

  • The classification of injury severity continues to be a useful tool in guiding treatment and predicting outcome and prognosis. The Gustilo-Anderson classification continues to be the mainstay, but the adoption of severity scores such as the Ganga Hospital score may provide additional predictive utility.

  • Recent literature has challenged the perceived need for rapid debridement within 6 hours and the rationale for prolonged antibiotic therapy in the open fracture. The choice of definitive treatment must be decided against known efficacy and injury severity/type.

  • Recent data demonstrate better outcomes with internal fixation methods in most open tibial fractures, but external fixation continues to be an appropriate choice in more severe injuries. The incidence of infection and non-union has decreased with new treatment approaches but continues to be a source of significant morbidity and mortality.

  • Assessment of functional outcome using various measures has been prevalent in the literature, but there is limited consensus regarding the best measures to be used.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170072

Pedro Cano-Luís, Miguel Ángel Giráldez-Sánchez, and Pablo Andrés-Cano

  • The most common cause of post-traumatic pelvic asymmetry is, by far, initial nonoperative treatment.

  • Open reduction and internal fixation of unstable pelvic fractures are recommended to avoid pelvic nonunion or subsequent structural deformities.

  • The most common symptom is pelvic pain. Pelvic instability is another symptom, as well as persistent urogenital problems and neurological sequelae.

  • Preoperative evaluation of these patients requires careful clinical and functional assessment, in addition to a complete radiological study.

  • Surgical treatment of pelvic fracture nonunions is technically demanding and has potentially serious complications.

  • We have developed a new classification that modifies and completes Mears and Velyvis’s classification in which we highlight two types of post-traumatic sequelae with different clinical conditions and whose basic differentiating element is whether pelvic deformity is present or not. Based on this classification, we have established our strategy of surgical treatment.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170069.

Horacio Caviglia, Adrian Mejail, Maria Eulalia Landro, and Nosratolah Vatani

  • The objective of surgery for acetabular fractures is to achieve precise reduction to restore joint congruence, fix internal bone fragments, avoid displacement of the fracture and allow rapid rehabilitation.

  • Open reduction and internal fixation is the benchmark method for displaced acetabular fractures, but open reductions can increase morbidity, causing neurovascular injury, blood loss, heterotopic bone formation, infection and poor wound healing.

  • An anatomical reduction with a gap of 2 mm or less is a predictor of good joint function and reduced risk of post-traumatic osteoarthritis.

  • The percutaneous approach is associated with fewer complications than open techniques, but acetabular geometry makes percutaneous screw insertion a challenging procedure.

  • The percutaneous technique is recommended for non-displaced or slightly displaced fractures, and in obese, osteoporotic and elderly patients who cannot receive total joint arthroplasty.

  • We recommend the use of intramedullary cannulated screws.

  • Fracture reductions are achieved by manual traction of the affected bones. If some fracture displacement remains, accessory windows can be used to introduce a ball spike pusher, a hook or a Steinmann pin which can be used as a joystick to rotate the fracture.

  • In this paper, we describe the accessory windows for the anterior column, the quadrilateral plate and the posterior column. We detail the position, direction and kind of screws used to stabilize the anterior and posterior columns.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170054

Philipp Schleicher, Andreas Pingel, and Frank Kandziora

  • Cervical spine injuries are frequent and often caused by a blunt trauma mechanism. They can have severe consequences, with a high mortality rate and a high rate of neurological lesions.

  • Diagnosis is a three-step process: 1) risk assessment according to the history and clinical features, guided by a clinical decision rule such as the Canadian C-Spine rule; 2) imaging if needed; 3) classification of the injury according to different classification systems in the different regions of the cervical spine.

  • The urgency of treatment is dependent on the presence of a neurological lesion and/or instability. The treatment strategy depends on the morphological criteria as defined by the classification.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170076

Vasileios Lampridis, Nikolaos Gougoulias, and Anthony Sakellariou

  • Medial column (deltoid ligament) integrity is of key importance when considering the stability of isolated lateral malleolus ankle fractures.

  • Weight-bearing radiographs are the best method of evaluating stability of isolated distal fibula fractures.

  • Computed tomography (CT) scanning is mandatory for the assessment of complex ankle fractures, especially those involving the posterior malleolus.

  • Most isolated trans-syndesmotic fibular fractures (Weber-B, SER, AO 44-B) are stable and can safely be treated non-operatively.

  • Posterior malleolus fractures, regardless of size, should be considered for surgical fixation to restore stability, reduce the need for syndesmosis fixation, and improve contact pressure distribution.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170057

Rafik Yassa, Mahdi Yacine Khalfaoui, Ihab Hujazi, Hannah Sevenoaks, and Paul Dunkow

  • Hip fractures are common and increasing with an ageing population. In the United Kingdom, the national guidelines recommend operative intervention within 36 hours of diagnosis. However, long-term anticoagulant treatment is frequently encountered in these patients which can delay surgical intervention. Despite this, there are no set national standards for management of drug-induced coagulopathy pre-operatively in the context of hip fractures.

  • The aim of this study was to evaluate the management protocols available in the current literature for the commonly encountered coagulopathy-inducing agents.

  • We reviewed the current literature, identified the reversal agents used in coagulopathy management and assessed the evidence to determine the optimal timing, doses and routes of administration.

  • Warfarin and other vitamin K antagonists (VKA) can be reversed effectively using vitamin K with a dose in the range of 2 mg to 10 mg intravenously to correct coagulopathy.

  • The role of fresh frozen plasma is not clear from the current evidence while prothrombin complex remains a reliable and safe method for immediate reversal of VKA-induced coagulopathy in hip fracture surgery or failed vitamin K treatment reversal.

  • The literature suggests that surgery should not be delayed in patients on classical antiplatelet medications (aspirin or clopidogrel), but spinal or regional anaesthetic methods should be avoided for the latter. However, evidence regarding the use of more novel antiplatelet medications (e.g. ticagrelor) and direct oral anticoagulants remains a largely unexplored area in the context of hip fracture surgery. We suggest treatment protocols based on best available evidence and guidance from allied specialties.

  • Hip fracture surgery presents a common management dilemma where semi-urgent surgery is required. In this article, we advocate an evidence-based algorithm as a guide for managing these anticoagulated patients.

Cite this article: EFORT Open Rev 2017;2:394–402. DOI: 10.1302/2058-5241.2.160083