Category: Trauma Review

Trauma orthopedic exam prep review questions and answers …

Management of Distal Femoral Fractures: Principles of Fixed-Angle Stable Fixation

High-Yield Summary

Distal femoral fractures require stable fixation that restores articular congruity and axial alignment while allowing early mobilization; fixed-angle devices are the gold standard for most displaced fractures.
Understanding the distal femur’s complex anatomy and load transmission is critical for implant positioning and achieving biomechanical stability.
Classification systems such as the AO/OTA guide surgical planning by defining fracture morphology and comminution, directly influencing implant choice and approach.
Operative management is indicated for displaced, intra-articularor unstable fractures; fixed-angle locking plates or retrograde intramedullary nails are preferred implants depending on fracture pattern and bone quality.
Surgical mastery hinges on meticulous reduction, preservation of soft tissueand avoiding malalignment; intraoperative fluoroscopy and careful screw placement are essential to prevent fixation failure.

Clinical Fundamentals

Anatomy and Biomechanics

The distal femur comprises the metaphyseal flare and the articular surface, including the medial and lateral condyles and the intercondylar notch. The supracondylar region transitions from diaphyseal cortical bone to metaphyseal cancellous bone, influencing fixation strategies. The distal femur transmits axial loads from the hip to the knee, with varus-valgus and rotational stresses concentrated at the condyles. The lateral column is typically more robust, while the medial column is critical for load sharing and stability.

Epidemiology

Distal femoral fractures account for approximately 0.4% of all fractures and 3-6% of femoral fractures. They occur bimodally: high-energy trauma in younger patients and low-energy osteoporotic fractures in the elderly. Comorbidities such as osteoporosis and polytrauma status affect fixation strategy and prognosis.

Classification & Diagnosis

Classification System	Description	Impact on Management
AO/OTA Classification	Types 33-A (extra-articular), 33-B (partial articular), 33-C (complete articular)	Dictates surgical approach, implant choiceand fixation strategy
Gustilo-Anderson (for open fractures)	Grades I-III based on soft tissue injury severity	Guides timing of surgery and antibiotic protocols
Radiographic Assessment	AP, lateraland oblique views; CT scan for articular involvement	Essential for accurate fracture mapping and surgical planning

Diagnostic Pearls:

CT imaging is mandatory for intra-articular fractures to delineate fragment size and displacement.
Beware of occult coronal plane fractures (Hoffa fractures) which may be missed on plain films.
Assess limb alignment and rotational profile clinically and radiographically to avoid malunion.

Decision-Making Algorithm

Criteria	Non-Operative Management	Operative Management
Fracture Displacement	Minimally displaced (<2 mm articular step, <5° angulation)	Displaced fractures with articular incongruity or instability
Patient Factors	Low-demand, medically unfit for surgery	Medically stable, active patients requiring early mobilization
Fracture Pattern	Stable extra-articular fractures without comminution	Intra-articular, comminutedor open fractures
Bone Quality	Good bone stock	Osteoporotic bone requiring fixed-angle devices for stability

Surgical Approach and Implant Choice:

Lateral parapatellar or minimally invasive approaches are preferred for exposure.
Fixed-angle locking plates provide angular stability, especially in osteoporotic bone or comminuted metaphyseal fractures.
Retrograde intramedullary nails are suitable for extra-articular or simple intra-articular fractures with intact distal bone stock.
Dual plating may be necessary for complex bicondylar fractures or medial column support.

Surgical Mastery & Pearls

Step-by-Step Conceptual Overview

Patient Positioning: Supine with a radiolucent table; knee flexed to 30° to relax posterior structures.
Exposure: Lateral parapatellar arthrotomy for articular visualization; preserve soft tissue envelope to maintain blood supply.
Reduction: Achieve anatomic articular reduction first using pointed reduction clamps or K-wires as joysticks; confirm with fluoroscopy.
Temporary Fixation: Use lag screws for intercondylar fragments to restore joint congruity.
Plate Application: Contour fixed-angle locking plate to lateral femur; ensure plate spans comminution zones adequately.
Screw Placement: Insert locking screws in distal fragment to maximize purchase; use bicortical screws proximally for stability.
Alignment Check: Confirm coronal, sagittaland rotational alignment fluoroscopically before final fixation.
Closure: Layered closure preserving periosteum and soft tissues.

Intraoperative Red Flags

Failure to restore articular congruity leads to post-traumatic arthritis.
Malrotation greater than 10° predisposes to functional impairment.
Inadequate plate length or screw density increases risk of fixation failure.
Overly aggressive soft tissue dissection compromises healing.

Evidence-Based Synthesis

Recent randomized controlled trials and meta-analyses have established fixed-angle locking plates as superior to conventional plating in osteoporotic distal femoral fractures, demonstrating reduced rates of nonunion and hardware failure. Retrograde intramedullary nailing offers comparable outcomes in select fracture patterns but may be limited by distal fragment size and comminution. The literature emphasizes early weight-bearing facilitated by stable fixation as a key determinant of functional recovery.

Controversy persists regarding the optimal implant for complex intra-articular fractures, with some studies advocating dual plating for enhanced medial support, while others caution against increased soft tissue disruption. Emerging evidence supports minimally invasive plate osteosynthesis (MIPO) techniques to preserve biology without compromising reduction quality.

Master Class Pro-Tip

Mastery in distal femoral fracture fixation lies in the nuanced balance between mechanical stability and biological preservation. Prioritize anatomic articular reduction and restore the medial column’s integrity through strategic screw placement or supplemental plating. Employ intraoperative 3D imaging or navigation when available to verify reduction and hardware positioning, especially in complex patterns. Recognize that fixed-angle constructs are not a substitute for meticulous technique-implant choice complements, but does not replace, surgical precision.

August 8, 2026/0 Comments/by OrthoNet AI

Trauma Review

Principles of Circular External Fixation in Complex Tibial Pilon Fractures

High-Yield Summary

Complex tibial pilon fractures involve articular comminution and metaphyseal-diaphyseal dissociation, requiring precise restoration of joint congruity and limb alignment to prevent post-traumatic arthritis.
Circular external fixation offers biomechanical advantages including multiplanar stability, load sharingand minimal soft tissue disruption, critical in high-energy, soft tissue-compromised injuries.
Staged management with initial spanning external fixation followed by definitive circular frame application optimizes soft tissue recovery and fracture biology.
Accurate frame assembly and tensioning, combined with strategic wire and pin placement, are essential to avoid neurovascular injury and ensure stable fixation.
Early weight-bearing and dynamization protocols facilitated by circular frames improve functional outcomes and reduce complications compared to traditional fixation methods.

Clinical Fundamentals

Relevant Anatomy

The distal tibia forms the plafond, articulating with the talus. The pilon region includes the distal metaphysis and articular surface, surrounded by thin soft tissue envelopes anteriorly and medially, increasing risk of soft tissue compromise. The anterior neurovascular bundle (anterior tibial artery and deep peroneal nerve) and posterior tibial neurovascular structures are at risk during fixation.

Biomechanics

The pilon transmits axial loads from the tibial shaft to the ankle joint. Fracture patterns disrupt the load transfer, causing instability. Circular external fixation provides multiplanar stability through tensioned wires and half-pins, converting shear forces into axial compression, promoting secondary bone healing via micromotion.

Epidemiology

High-energy axial loading (e.g., motor vehicle collisions, falls from height) predominantly causes pilon fractures. These injuries often present with severe soft tissue damage, complicating management and increasing risk of infection and nonunion.

Classification & Diagnosis

Classification System	Description	Impact on Management
Ruedi-Allgower	Type I: Non-displaced; Type II: Displaced with minimal comminution; Type III: Comminuted, displaced	Guides urgency and fixation complexity
AO/OTA (43C)	C1: Simple articular; C2: Multifragmentary articular; C3: Articular + metaphyseal comminution	Determines fixation strategy and need for staged approach
Gustilo-Anderson	For open fractures: Type I-III based on soft tissue injury severity	Dictates timing and method of fixation, antibiotic use

Diagnostic Pearls

CT scan with 3D reconstruction is mandatory for surgical planning to delineate articular fragments and metaphyseal comminution.
Assess soft tissue envelope meticulously; compartment syndrome and skin viability influence timing of fixation.
Beware of subtle posterior malleolar fragments that may require separate fixation.

Decision-Making Algorithm

Criteria	Non-Operative Management	Operative Management
Fracture Displacement	Minimally displaced, stable fractures	Displaced, unstable, comminuted fractures
Soft Tissue Condition	Intact soft tissues, low-energy injury	Severe soft tissue injury, open fractures (staged)
Patient Factors	Low-demand patients, significant comorbidities	Healthy patients, high functional demand
Fixation Choice Rationale	Casting or splinting to maintain alignment	Circular external fixation preferred for complex, high-energy injuries with soft tissue compromise

Why Circular External Fixation?

Minimizes soft tissue disruption compared to ORIF.
Allows early weight-bearing and dynamization.
Provides stable fixation in metaphyseal comminution.
Facilitates staged protocols with initial spanning frame.

Surgical Mastery & Pearls

Step-by-Step Conceptual Overview

Preoperative Planning

Review CT scans to identify articular fragments and plan wire trajectories.
Mark neurovascular landmarks and plan pin/wire insertion zones.

Initial Stabilization

Apply spanning external fixator to restore length and alignment, allowing soft tissue recovery.

Frame Assembly

Construct a multiplanar circular frame with at least two rings spanning the distal tibia and proximal metaphysis.
Use tensioned olive wires and half-pins to maximize stability.

Wire and Pin Placement

Insert wires perpendicular to the fracture plane and avoid neurovascular structures.
Tension wires to 110-130 kg to optimize stiffness.

Articular Reduction

Perform limited open reduction of articular fragments through small windows.
Use fine wires or screws for fragment fixation if necessary.

Postoperative Protocol

Initiate early weight-bearing as tolerated.
Dynamize frame progressively to stimulate healing.

Intraoperative Red Flags

Excessive wire tension causing neurovascular compromise.
Pin site placement through compromised soft tissue zones.
Failure to restore articular congruity leading to malalignment.
Over-tightening frame rings causing patient discomfort or skin necrosis.

Evidence-Based Synthesis

Recent randomized controlled trials and meta-analyses have demonstrated that circular external fixation reduces deep infection rates and wound complications compared to open reduction internal fixation (ORIF) in complex pilon fractures with severe soft tissue injury. The staged protocol-initial spanning external fixation followed by definitive circular frame application-has become the standard of care, balancing soft tissue preservation with mechanical stability.

Biomechanical studies confirm that tensioned wires in circular frames provide superior multiplanar stability and allow controlled micromotion, which enhances callus formation and reduces nonunion rates. However, some data suggest that in low-energy, minimally comminuted fractures, ORIF may yield faster functional recovery, highlighting the need for individualized treatment.

Controversy remains regarding the optimal timing for frame dynamization and weight-bearing initiation, with ongoing trials investigating the balance between mechanical stimulation and risk of loss of reduction.

Master Class Pro-Tip

Mastery in circular external fixation hinges on the nuanced understanding that frame construct is not static: dynamically adjust wire tension and frame configuration in response to fracture healing progression and patient biomechanics. Employ intraoperative fluoroscopy to confirm wire trajectories in multiple planesand do not hesitate to perform limited open reduction of articular fragments before frame application to ensure anatomical joint restoration. This proactive approach minimizes secondary procedures and optimizes long-term functional outcomes.

July 25, 2026/0 Comments/by OrthoNet AI

Trauma Review

Assessing and Managing Subtrochanteric Femur Fractures: Challenges in Reduction

High-Yield Summary

Subtrochanteric femur fractures occur in the proximal femur region extending 5 cm distal to the lesser trochanter, characterized by high biomechanical stress and deforming muscle forces complicating reduction.
Intramedullary nailing is the gold standard for fixation, offering biomechanical advantages and improved outcomes compared to extramedullary devices.
Achieving anatomic or near-anatomic reduction is critical; malreduction leads to nonunion, implant failureand poor functional outcomes.
Key deforming forces include proximal fragment flexion, abductionand external rotation; understanding these guides reduction maneuvers and implant choice.
Surgical mastery requires strategic use of adjuncts such as percutaneous clamps, cerclage wiresand provisional fixation to control fragments before nail insertion.

Clinical Fundamentals

Anatomy and Biomechanics

The subtrochanteric region spans from the lesser trochanter to approximately 5 cm distal. This zone endures high compressive and tensile forces during weight-bearing due to its proximity to the hip joint and lever arm mechanics. The cortical bone predominates here, resulting in a biomechanically demanding environment for fracture healing.

Muscle attachments create characteristic deforming forces:

Iliopsoas causes flexion and external rotation of the proximal fragment.

Gluteus medius and minimus abduct the proximal fragment.

Adductors pull the distal fragment medially and into varus.

These forces produce a typical fracture pattern with proximal fragment flexed, abductedand externally rotatedand distal fragment adducted and shortened.

Epidemiology

Subtrochanteric fractures represent 5-20% of proximal femur fractures, commonly seen in high-energy trauma in younger patients and low-energy osteoporotic fractures in the elderly. The fracture pattern and bone quality influence fixation strategy and prognosis.

Classification & Diagnosis

Classification System	Description	Impact on Management	Diagnostic Pearls	Common Pitfalls
Seinsheimer Classification	Categorizes based on fracture pattern and comminution (Types I-V)	Guides fixation complexity and implant choice	Use AP and lateral radiographs; CT may clarify comminution	Overreliance on plain films can underestimate fracture complexity
AO/OTA Classification (31A3)	Defines subtrochanteric fractures as 31A3, with subtypes based on fracture line and comminution	Influences nail selection and reduction strategy	Evaluate for extension into intertrochanteric or diaphyseal regions	Missing extension into shaft can lead to inadequate fixation
Gustilo-Anderson (Open Fractures)	Classifies open fractures by severity	Dictates timing and antibiotic protocol	Early recognition of open wounds critical	Underestimating soft tissue injury increases infection risk

Diagnostic pearls include careful assessment of limb length, rotational profileand soft tissue status. CT imaging is valuable for complex or comminuted fractures to plan reduction and fixation.

Decision-Making Algorithm

Non-Operative vs. Operative Management

Non-operative treatment is rarely indicated due to high risk of malunion, nonunionand functional impairment. Exceptions include non-ambulatory patients with prohibitive surgical risk or minimally displaced fractures in low-demand patients.

Operative management is standard, with intramedullary nailing preferred for its biomechanical superiority and minimally invasive approach. Plate fixation is reserved for select cases with specific indications such as very distal extension or failed nailing.

Implant Selection and Surgical Approach

Intramedullary nails (cephalomedullary nails) provide load-sharing fixation and control of proximal fragment deformity. Nail choice depends on fracture length, comminutionand patient anatomy.

Open reduction is often necessary for severely displaced or comminuted fractures. Minimally invasive techniques with percutaneous clamps and cerclage wires assist in achieving and maintaining reduction before nail insertion.

Surgical Mastery & Pearls

Step-by-Step Conceptual Overview

Patient Positioning: Supine on a fracture table with traction applied to restore length and aid reduction.

Reduction Strategy:

Apply traction to restore length.

Use percutaneous clamps or Schanz pins for controlling proximal fragment rotation and abduction.

Consider limited open approach for direct visualization and cerclage wiring if closed reduction fails.

Guidewire Insertion: Confirm correct entry point at the piriformis fossa or tip of the greater trochanter to avoid malalignment.

Reaming and Nail Insertion: Sequential reaming to accommodate nail diameter; avoid over-reaming to preserve bone stock.

Proximal and Distal Locking: Secure fixation with proximal lag screws and distal locking bolts; verify under fluoroscopy.

Intraoperative Red Flags:

Persistent varus malalignment despite traction and clamps.

Difficulty passing guidewire due to malreduction or cortical impingement.

Excessive soft tissue stripping during open reduction risking devascularization.

Technical Tips

Use a lateral starting point for the nail to prevent varus malreduction.

Employ cerclage wires judiciously to aid reduction without compromising periosteal blood supply.

Confirm rotational alignment clinically and fluoroscopically before locking.

Avoid excessive traction to prevent neurovascular injury.

Evidence-Based Synthesis

Landmark studies consistently demonstrate superior outcomes with intramedullary nailing compared to plating, including lower rates of nonunion and implant failure. Recent randomized controlled trials emphasize the importance of anatomic reduction in subtrochanteric fractures, correlating malreduction with increased mechanical complications.

Controversy persists regarding the optimal entry point for nails-piriformis fossa versus greater trochanter-with biomechanical data favoring the piriformis entry for alignment but greater trochanter entry offering easier access in obese or muscular patients. Clinical consensus is evolving, with surgeon experience and patient anatomy guiding choice.

Emerging literature supports the selective use of cerclage wiring to facilitate reduction without increasing nonunion risk, challenging prior dogma against circumferential wiring in subtrochanteric fractures.

Master Class Pro-Tip

Mastery in subtrochanteric fracture fixation hinges on transforming the deforming forces from adversaries into allies. Achieve this by preemptively controlling the proximal fragment with percutaneous clamps or Schanz pins before nail insertion, rather than relying solely on traction. This proactive reduction strategy minimizes malalignment, reduces operative timeand preserves biology. Remember, the perfect nail cannot compensate for a poorly reduced fracture-invest in reduction first, implant second.

July 10, 2026/0 Comments/by OrthoNet AI

Trauma Review

Management of Intertrochanteric Hip Fractures: Cephalomedullary Nails vs. Sliding Hip Screws

High-Yield Summary

Intertrochanteric fractures require stable fixation to restore early mobility and reduce morbidity; implant choice hinges on fracture stability and patient factors.
Sliding hip screws (SHS) remain effective for stable, non-comminuted fractures with intact lateral walls.
Cephalomedullary nails (CMN) offer biomechanical advantages in unstable patterns, reverse obliquityor lateral wall compromise, reducing varus collapse and implant failure.
Early weight-bearing is generally feasible with both implants but is more reliable with CMN in unstable fractures.
Surgical decision-making must integrate fracture classification, bone qualityand patient comorbidities to optimize outcomes.

Clinical Fundamentals

Relevant Anatomy

The intertrochanteric region lies between the greater and lesser trochanters, comprising cancellous bone with a rich vascular supply. The lateral femoral cortex, particularly the lateral wall, is critical for implant support and fracture stability. The calcar femorale provides a dense inferomedial buttress essential for load transmission.

Biomechanics

Intertrochanteric fractures disrupt the proximal femoral load-sharing mechanism. The medial cortex resists compressive forces, while the lateral wall counters tensile forces. Implant choice must restore this balance: SHS relies on lateral wall integrity for sliding compression, whereas CMN provides intramedullary load sharing, reducing bending moments and varus deformity risk.

Epidemiology

These fractures predominantly affect elderly osteoporotic patients after low-energy falls. Incidence rises with age and comorbidities, emphasizing the need for prompt fixation to minimize complications such as pneumonia, thromboembolismand decubitus ulcers.

Classification & Diagnosis

Classification System	Key Features	Impact on Management
AO/OTA Classification	Types 31-A1 (simple, two-part), 31-A2 (multi-fragmentary), 31-A3 (reverse obliquity, transverse)	Guides implant choice: SHS for A1, CMN preferred for A2 and A3 due to instability
Evans Classification	Stable vs. unstable based on posteromedial cortex and lateral wall integrity	Stable fractures suitable for SHS; unstable require CMN or alternative fixation
Lateral Wall Integrity	Intact vs. compromised lateral wall (>20.5 mm thickness considered intact)	Intact lateral wall favors SHS; compromised lateral wall mandates CMN to prevent collapse

Diagnostic Pearls

Obtain AP and lateral hip radiographs; consider CT for complex or ambiguous patterns.
Assess lateral wall thickness on AP view; <20.5 mm predicts instability.
Beware of underestimating comminution on plain films; intraoperative fluoroscopy aids real-time assessment.

Decision-Making Algorithm

Non-Operative vs. Operative Management

Non-operative treatment is reserved for non-ambulatory patients with prohibitive surgical risk or minimal displacement. Operative fixation is standard for ambulatory patients to restore function and reduce complications.

Implant Selection Criteria

Criteria	Sliding Hip Screw (SHS)	Cephalomedullary Nail (CMN)
Fracture Stability	Stable (AO 31-A1), intact lateral wall	Unstable (AO 31-A2, 31-A3), lateral wall compromise
Bone Quality	Moderate osteoporosis	Severe osteoporosis benefits from intramedullary support
Patient Factors	Low-demand, stable fracture	High-demand, unstable fractureor reverse obliquity
Surgical Considerations	Easier technique, shorter operative time	Biomechanical superiority in unstable patterns, less varus collapse

Surgical Mastery & Pearls

Sliding Hip Screw Technique

Position patient supine on fracture table; achieve anatomic or slight valgus reduction.
Confirm lateral wall integrity fluoroscopically.
Insert guidewire centrally in the femoral neck on AP and lateral views; maintain tip-apex distance <25 mm to reduce cut-out risk.
Ream and insert lag screw; attach side plate and secure to femoral shaft.
Allow controlled impaction via sliding mechanism; avoid over-compression to prevent shortening.

Cephalomedullary Nail Technique

Position patient supine; obtain fluoroscopic alignment.
Achieve reduction with traction and rotation; confirm with AP and lateral views.
Make a small incision at the tip of the greater trochanter; insert guidewire into femoral canal.
Ream canal to appropriate diameter; insert nail ensuring correct depth and rotation.
Place lag screw or helical blade centrally in femoral head with tip-apex distance <25 mm.
Lock distal screws as indicated; consider distal locking to prevent rotation or shortening in unstable fractures.

Intraoperative Red Flags

Varus malreduction increases failure risk; aim for slight valgus or neutral alignment.
Excessive reaming or cortical breach predisposes to iatrogenic fractures.
Avoid lateral wall fracture propagation during SHS insertion.
Monitor for lag screw cut-out or nail toggle during insertion.

Evidence-Based Synthesis

Landmark randomized controlled trials and meta-analyses have clarified implant selection nuances. Early studies favored SHS for stable fractures due to simplicity and cost-effectiveness. However, recent high-quality evidence demonstrates that CMN reduces mechanical complications, especially in unstable fractures with lateral wall compromise or reverse obliquity patterns.

The HEALTH trial and subsequent meta-analyses show no significant difference in mortality or functional outcomes between implants but highlight lower reoperation rates with CMN in unstable fractures. Contradictions persist regarding operative time and blood loss, with CMN sometimes associated with longer procedures but fewer failures.

Current consensus advocates for SHS in stable, non-comminuted fractures with intact lateral walls, reserving CMN for unstable patterns. The evolving literature underscores the importance of individualized treatment based on fracture morphology and patient factors rather than a one-size-fits-all approach.

Master Class Pro-Tip

Mastery in intertrochanteric fracture fixation lies in preoperative fracture pattern recognition and intraoperative reduction precision. When using a cephalomedullary nail, prioritize achieving a tip-apex distance under 20 mm and central lag screw placement in both planes to minimize cut-out risk. In unstable fractures, proactively protect or reconstruct the lateral wall-consider adjunctive cerclage or limited open techniques-to prevent secondary collapse. This nuanced approach, combining biomechanical principles with meticulous technique, distinguishes the expert surgeon from the competent.

June 26, 2026/0 Comments/by OrthoNet AI

Trauma Review

Understanding the Pipkin Classification of Femoral Head Fractures

High-Yield Summary

The Pipkin classification stratifies femoral head fractures by location and associated injuries, directly guiding surgical approach and fixation strategy.
Type I and II fractures involve the femoral head below or above the fovea capitis, respectively, with Type II often requiring more aggressive fixation due to weight-bearing surface involvement.
Type III combines femoral head fracture with femoral neck fracture, significantly increasing the risk of avascular necrosis and often necessitating urgent surgical intervention.
Type IV includes femoral head fracture with acetabular involvement, complicating reduction and fixation and often requiring combined surgical approaches.
Accurate imaging and early reduction are critical; delayed management correlates with poor outcomes including post-traumatic arthritis and osteonecrosis.

Clinical Fundamentals

Relevant Anatomy

The femoral head is a spherical structure articulating with the acetabulum, covered predominantly by hyaline cartilage except at the fovea capitis, where the ligamentum teres attaches. The vascular supply is primarily from the medial femoral circumflex artery, with limited collateral flow, making the femoral head vulnerable to ischemia after fracture or dislocation.

Biomechanics

The femoral head transmits axial loads through the hip joint; fractures involving the weight-bearing dome (superior to the fovea) compromise joint congruity and stability. The location of the fracture fragment relative to the fovea dictates the biomechanical impact and guides fixation necessity.

Epidemiology

Femoral head fractures are rare, typically resulting from high-energy trauma such as motor vehicle collisions. They frequently occur in conjunction with posterior hip dislocations, and the incidence of associated femoral neck or acetabular fractures increases complexity and morbidity.

Classification & Diagnosis

Pipkin Type	Description	Clinical Implication	Imaging Pearls
Type I	Fracture inferior to fovea capitis	Non-weight-bearing fragment; may be managed conservatively if stable	CT scan essential to delineate fragment size and displacement
Type II	Fracture superior to fovea capitis	Weight-bearing surface involved; usually requires surgical fixation	MRI can assess cartilage damage; CT for fragment characterization
Type III	Type I or II fracture plus femoral neck fracture	High risk of avascular necrosis; urgent fixation or arthroplasty considered	Prompt radiographs and CT; assess neck fracture displacement
Type IV	Type I or II fracture plus acetabular fracture	Complex injury; combined surgical approach often needed	CT with 3D reconstruction critical for operative planning

Diagnostic Pearls

Always obtain a CT scan after initial radiographs to assess fragment size, displacement, and associated injuries.
Beware of missed femoral neck fractures in Type III injuries, as they dramatically alter prognosis and management.
Early reduction of hip dislocation reduces ischemic time and improves outcomes.

Decision-Making Algorithm

Management Criteria	Non-Operative Indications	Operative Indications
Fragment size and displacement	Small, non-displaced Type I fractures	Displaced Type I or II fractures >2 mm
Involvement of weight-bearing surface	Stable, non-displaced fragments below fovea	Type II fractures involving superior dome
Associated injuries	Isolated femoral head fracture without instability	Type III (neck fracture) or Type IV (acetabular fracture)
Patient factors	Low-demand patients, contraindications to surgery	Young, active patients; open fractures; failed closed reduction

Surgical Approach Selection

Anterior (Smith-Petersen) approach offers direct visualization of the femoral head, ideal for Type I and II fractures.
Posterior (Kocher-Langenbeck) approach preferred for associated posterior acetabular fractures (Type IV) and posterior dislocations.
Combined approaches may be necessary for complex Type IV injuries.

Implant Choice

Headless compression screws or bioabsorbable pins for small fragments to minimize cartilage damage.
Mini-fragment plates or countersunk screws for larger fragments to restore articular congruity.
Consider arthroplasty in elderly patients with Type III fractures or comminution.

Surgical Mastery & Pearls

Step-by-Step Conceptual Overview

Preoperative Planning: Review CT scans meticulously to understand fragment size, displacement, and associated injuries. Plan approach accordingly.
Patient Positioning: Supine for anterior approach; lateral decubitus for posterior approach; ensure fluoroscopic access.
Exposure: Protect vascular supply by minimizing soft tissue stripping; identify and preserve the medial femoral circumflex artery when possible.
Reduction: Achieve anatomic reduction of fragments; use small elevators or K-wires for provisional fixation.
Fixation: Insert headless screws countersunk below cartilage; avoid hardware prominence to prevent joint damage.
Associated Injuries: Address femoral neck or acetabular fractures in the same setting if feasible.
Closure: Meticulous soft tissue repair to reduce risk of instability and heterotopic ossification.

Intraoperative Red Flags

Excessive bleeding near the medial femoral circumflex artery signals risk to femoral head perfusion.
Difficulty achieving anatomic reduction suggests unrecognized fragment or soft tissue interposition.
Hardware prominence on fluoroscopy mandates repositioning to avoid cartilage damage.

Evidence-Based Synthesis

Recent literature emphasizes early anatomic reduction and stable fixation as paramount to optimizing outcomes in femoral head fractures. Studies comparing surgical approaches show no definitive superiority but highlight the importance of approach selection based on fracture pattern and associated injuries. The risk of avascular necrosis remains highest in Type III fractures, with some evidence supporting early arthroplasty in elderly or severely comminuted cases.

Meta-analyses reveal that non-operative management of small, non-displaced Type I fractures yields acceptable outcomes, but displaced fractures benefit from surgical fixation to prevent post-traumatic arthritis. The role of arthroscopy is emerging for fragment excision and loose body removal but is not yet standard.

Controversy persists regarding the timing of surgery; however, consensus favors reduction within 6 hours to minimize ischemic insult. The literature also underscores the need for vigilant postoperative monitoring for osteonecrosis and heterotopic ossification, with prophylaxis protocols variably applied.

Master Class Pro-Tip

Prioritize preservation of the medial femoral circumflex artery during dissection-this single step distinguishes a competent surgeon from a master. Use intraoperative Doppler or fluorescein angiography when available to confirm femoral head perfusion before fixation. This vigilance reduces avascular necrosis risk and improves long-term joint survival, especially in complex Type III and IV injuries.

June 11, 2026/0 Comments/by OrthoNet AI

Trauma Review

Management of Distal Radius Fractures: A Guide to Volar Locking Plates

High-Yield Summary

Volar locking plates provide stable fixation for distal radius fractures, especially in osteoporotic bone and comminuted patterns, enabling early mobilization and improved functional outcomes.
Key surgical goals include restoration of volar tilt, radial height, and radial inclination to prevent long-term wrist dysfunction.
Indications for operative fixation include unstable fractures with displacement, intra-articular involvement, and failure of closed reduction.
Precise plate positioning and screw placement are critical to avoid complications such as flexor tendon irritation or rupture.
Postoperative rehabilitation protocols emphasizing early range of motion optimize recovery and minimize stiffness.

Clinical Fundamentals

Relevant Anatomy

The distal radius articulates with the scaphoid and lunate, forming the radiocarpal joint. The volar surface is concave and supports the carpal bones, while the dorsal surface is convex. The watershed line, a critical landmark on the volar radius, demarcates safe plate placement to avoid flexor tendon irritation. The pronator quadratus overlays the volar distal radius and is routinely elevated during surgery.

Biomechanics

The distal radius transmits axial loads from the hand to the forearm. Volar locking plates function as fixed-angle constructs, providing angular stability that resists collapse in osteoporotic or comminuted fractures. Restoration of radial height, volar tilt (normal ~11°), and radial inclination (normal ~22°) is essential to maintain wrist kinematics and load distribution.

Epidemiology

Distal radius fractures are among the most common upper extremity fractures, with a bimodal distribution: young patients sustain high-energy trauma, while elderly patients typically sustain low-energy osteoporotic fractures. The incidence is increasing with aging populations, emphasizing the need for reliable fixation methods.

Classification & Diagnosis

Classification System	Description	Impact on Management
AO/OTA Classification	Comprehensive system categorizing fracture by location, morphology, and complexity (Type A: extra-articular, B: partial articular, C: complete articular)	Guides surgical approach and fixation strategy
Fernandez Classification	Mechanism-based (Type I: bending, II: shearing, III: compression, IV: avulsion, V: combined)	Helps anticipate fracture pattern and soft tissue injury
Frykman Classification	Focuses on involvement of radiocarpal and distal radioulnar joints	Influences prognosis and need for anatomic reduction

Diagnostic Pearls

Obtain true PA and lateral wrist radiographs with the forearm in neutral rotation to accurately assess displacement.
CT scans are invaluable for complex intra-articular fractures to delineate articular step-offs and comminution.
Beware of underestimating volar tilt loss on lateral views; subtle dorsal angulation can be missed.
Assess for associated injuries such as distal radioulnar joint instability or median nerve compression.

Decision-Making Algorithm

Criteria	Non-Operative Management	Operative Management
Fracture Stability	Stable, minimally displaced fractures	Unstable fractures with displacement >2 mm
Articular Involvement	Extra-articular or minimal articular step-off (<2 mm)	Intra-articular fractures with step-off >2 mm
Alignment	Acceptable radial height, inclination, volar tilt	Loss of radial height >5 mm, dorsal tilt >10°, radial inclination loss >5°
Patient Factors	Low-demand, medically unfit for surgery	High-demand patients, open fractures, neurovascular compromise
Failure of Closed Reduction	N/A	Persistent displacement after closed reduction

Surgical Approach and Implant Choice

The volar Henry approach is the standard for volar locking plate placement, providing excellent exposure with minimal soft tissue disruption. Volar locking plates are preferred over dorsal plates due to lower tendon complication rates and superior biomechanical stability in osteoporotic bone. Plate selection depends on fracture pattern; variable-angle locking screws allow tailored fixation in multifragmentary fractures.

Surgical Mastery & Pearls

Step-by-Step Conceptual Overview

Patient Positioning and Exposure: Supine with arm on hand table; volar Henry approach with careful identification and protection of the radial artery and median nerve.
Fracture Reduction: Achieve anatomic reduction under fluoroscopy; provisional K-wire fixation may assist. Restore radial height, volar tilt, and inclination.
Plate Positioning: Place the plate proximal to the watershed line to avoid flexor tendon irritation; confirm with fluoroscopy in lateral and PA views.
Screw Placement: Insert locking screws into the distal fragment ensuring subchondral support without intra-articular penetration; use variable-angle screws for fragment-specific fixation.
Soft Tissue Management: Repair pronator quadratus over the plate to provide a barrier to tendons; meticulous hemostasis to reduce hematoma risk.
Intraoperative Red Flags: Avoid dorsal screw penetration which can cause extensor tendon injury; confirm screw length with fluoroscopy.
Closure and Immobilization: Close in layers; apply a volar splint or removable brace to allow early mobilization.

Evidence-Based Synthesis

Landmark randomized controlled trials and meta-analyses have established volar locking plates as the preferred fixation method for unstable distal radius fractures, particularly in elderly patients with osteoporotic bone. Studies demonstrate superior maintenance of reduction, earlier return of wrist motion, and improved patient-reported outcomes compared to external fixation or dorsal plating. However, recent data highlight that in select low-demand patients with minimally displaced fractures, non-operative management yields comparable long-term function, underscoring the importance of individualized treatment.

Controversy persists regarding the necessity of routine CT imaging preoperatively; while CT improves fracture characterization, its impact on altering surgical plans remains debated. Additionally, the optimal timing of surgery and rehabilitation protocols continue to evolve, with emerging evidence supporting early controlled motion to reduce stiffness without compromising fixation integrity.

Master Class Pro-Tip

Mastery in volar locking plate fixation hinges on respecting the watershed line and achieving subchondral screw purchase without joint penetration. Employ intraoperative 3D fluoroscopy or cone-beam CT when available to confirm screw placement in complex fractures. Meticulous soft tissue handling, including robust pronator quadratus repair, dramatically reduces flexor tendon complications. Finally, tailor postoperative rehabilitation to fracture stability and patient factors-early active motion within a protected range often yields superior functional recovery compared to prolonged immobilization.

May 28, 2026/0 Comments/by OrthoNet AI

Trauma Review

Principles of Reaming in Intramedullary Nailing: Biological and Mechanical Effects

High-Yield Summary

Reaming enlarges the medullary canal to accommodate a larger-diameter nail, enhancing mechanical stability and load sharing.
Controlled reaming preserves endosteal blood supply while stimulating periosteal blood flow and osteogenic activity.
Over-reaming or aggressive technique risks thermal necrosis, fat embolism, and delayed healing.
Reamed nails demonstrate superior union rates and lower implant failure compared to unreamed nails in diaphyseal fractures.
Surgical technique must balance mechanical benefits with biological preservation to optimize fracture healing.

Clinical Fundamentals

The intramedullary canal is lined by endosteum, a critical source of blood supply and osteoprogenitor cells. The cortical bone provides primary mechanical strength, while the medullary canal’s diameter and shape vary by bone and patient age. Reaming modifies the canal diameter, allowing insertion of a larger nail that improves mechanical stability through increased nail-to-cortex fit and load sharing.

Biomechanically, a larger nail diameter reduces bending stresses and micromotion at the fracture site, promoting union. However, reaming disrupts the endosteal blood supply transiently but induces a biological response that enhances periosteal circulation and stimulates mesenchymal stem cell recruitment. This dual effect is critical in fracture healing dynamics.

Epidemiologically, diaphyseal fractures of the femur and tibia are the most common indications for reamed intramedullary nailing. The balance between mechanical stability and biological preservation is paramount in these high-energy injuries, often complicated by soft tissue damage.

Classification & Diagnosis

Classification System	Clinical Relevance to Reaming and Nailing	Diagnostic Pearls and Pitfalls
Gustilo-Anderson (Open Fractures)	Guides timing and extent of reaming; severe soft tissue injury may contraindicate aggressive reaming due to infection risk	Avoid reaming in Grade IIIB/C open fractures until soft tissue coverage is adequate
AO/OTA Fracture Classification	Determines fracture pattern and stability; simple diaphyseal fractures tolerate reaming better than comminuted or segmental patterns	Comminution increases risk of thermal necrosis during reaming; use incremental reaming
Tscherne Classification (Closed Fractures)	Assesses soft tissue injury severity; higher grades require cautious reaming to preserve biology	High-grade closed injuries may have compromised periosteal circulation, necessitating gentle reaming
Radiographic Assessment	Essential to evaluate canal diameter, fracture morphology, and alignment preoperatively	Over-reliance on AP view alone may underestimate canal size; always obtain orthogonal views

Decision-Making Algorithm

Non-operative management is reserved for stable, non-displaced fractures with minimal soft tissue compromise and intact biological environment. Operative management with intramedullary nailing is indicated for displaced diaphyseal fractures requiring mechanical stabilization.

Reaming is preferred when:

The fracture pattern is simple or moderately comminuted, allowing for enhanced mechanical stability.
The soft tissue envelope is intact or minimally compromised.
The patient’s physiological status permits longer operative time and potential embolic risk.

Unreamed nailing is considered when:

There is severe soft tissue injury (e.g., Gustilo IIIB/C) where biological preservation outweighs mechanical advantage.
The patient is at high risk for fat embolism syndrome or cardiopulmonary compromise.
Canal anatomy is narrow or irregular, limiting safe reaming.

The choice of nail diameter and length is dictated by preoperative templating and intraoperative assessment, balancing canal fit with preservation of endosteal blood supply.

Surgical Mastery & Pearls

Preoperative Planning: Assess canal diameter and fracture morphology on orthogonal radiographs. Anticipate reamer sizes and nail diameter accordingly.

Reaming Technique: Begin with a small-diameter reamer, advancing incrementally by 0.5-1.0 mm steps. Maintain continuous irrigation or intermittent reamer withdrawal to dissipate heat.

Intraoperative Monitoring: Watch for increased resistance or sudden loss of resistance, which may indicate cortical breach or reamer jamming. Avoid forceful advancement.

Red Flags: Excessive bleeding from the canal may signal endosteal injury. Sudden drop in blood pressure or oxygen saturation suggests fat embolism; pause and stabilize patient.

Nail Insertion: Insert the largest nail that fits snugly without excessive force. Confirm alignment fluoroscopically before locking.

Postoperative Care: Monitor for compartment syndrome and embolic phenomena. Early weight-bearing is encouraged when stable fixation is achieved.

Evidence-Based Synthesis

Landmark randomized controlled trials (RCTs) such as the SPRINT trial demonstrated that reamed nailing reduces nonunion and implant failure rates compared to unreamed nailing in femoral shaft fractures. Meta-analyses confirm improved mechanical stability and union rates with reamed nails, particularly in closed fractures.

Conversely, studies in open tibial fractures reveal that aggressive reaming may increase infection risk and delay healing, especially in high-grade soft tissue injuries. Recent literature advocates a tailored approach: reaming when biological conditions permit, and unreamed or limited reaming in compromised soft tissue environments.

Emerging evidence highlights the biological benefits of reaming-induced periosteal hyperemia and stem cell activation, challenging the traditional view that reaming is purely destructive. However, consensus is lacking on optimal reaming diameter and speed, with ongoing trials investigating thermal injury mitigation strategies.

Master Class Pro-Tip

Mastery in reaming lies in the surgeon’s tactile feedback and intraoperative judgment: the ability to discern subtle changes in resistance and canal morphology allows precise reaming that maximizes mechanical advantage while preserving biological integrity. Employing pulsatile irrigation, incremental reaming, and real-time hemodynamic monitoring transforms a routine step into a strategic intervention that dictates fracture healing trajectory.

May 13, 2026/0 Comments/by OrthoNet AI

Trauma Review

Management of Lisfranc Injuries: Diagnosis and Fixation Strategies

High-Yield Summary

Lisfranc injuries involve disruption of the tarsometatarsal (TMT) joint complex, with subtle presentations requiring high clinical suspicion and weight-bearing radiographs for diagnosis.
The stability of the Lisfranc ligament complex dictates management; displacement >2 mm or joint incongruity mandates operative fixation.
Open reduction and internal fixation (ORIF) remains the gold standard for unstable injuries, with emerging evidence supporting primary arthrodesis in purely ligamentous injuries.
Accurate reduction of the TMT joint alignment is critical to prevent post-traumatic arthritis and chronic instability.
Postoperative protocols emphasize protected weight-bearing and close radiographic monitoring to detect loss of reduction.

Clinical Fundamentals

Relevant Anatomy

The Lisfranc joint complex comprises the articulation between the first, second, and third metatarsals and the three cuneiforms, plus the cuboid and fourth/fifth metatarsals. The Lisfranc ligament is a strong oblique interosseous ligament connecting the medial cuneiform to the base of the second metatarsal, providing primary stability. The second metatarsal base acts as a keystone, locked into a mortise formed by the cuneiforms, conferring inherent bony stability.

Biomechanics

The TMT joint complex transmits axial and rotational forces during gait. The second metatarsal base’s mortise configuration resists displacement, but ligamentous disruption compromises this stability, leading to abnormal joint mechanics and altered load distribution. Even minimal diastasis (>2 mm) can cause significant functional impairment.

Epidemiology

Lisfranc injuries are uncommon but often underdiagnosed, accounting for approximately 0.2% of fractures. They occur in high-energy trauma (motor vehicle collisions, falls) and low-energy mechanisms (sports injuries, twisting). Delayed diagnosis correlates with worse outcomes.

Classification & Diagnosis

Classification System	Description	Clinical Relevance
Hardcastle Classification	Type A: Total incongruity; Type B: Partial incongruity (medial or lateral displacement); Type C: Divergent displacement	Guides surgical approach and fixation strategy based on displacement pattern
Myerson Modification	Adds subtypes based on direction of displacement and comminution	Refines treatment planning, especially for partial injuries
Nunley and Vertullo	Graded by weight-bearing radiograph findings and diastasis	Helps decide operative vs. non-operative management

Diagnostic Pearls

Obtain weight-bearing AP, lateral, and oblique foot radiographs; non-weight-bearing films often miss subtle diastasis.
Look for >2 mm diastasis between the first and second metatarsal bases or malalignment of the medial cuneiform and second metatarsal.
CT scan is invaluable for assessing comminution and subtle fractures; MRI can delineate ligamentous injury when radiographs are inconclusive.
Beware of missed injuries in polytrauma or when initial swelling obscures clinical signs.

Decision-Making Algorithm

Criteria	Non-Operative Management	Operative Management
Displacement <2 mm, stable on weight-bearing	Indicated	Not indicated
Displacement >2 mm or joint incongruity	Contraindicated	Indicated
Purely ligamentous injury with instability	Controversial; often operative	Primary arthrodesis or ORIF
Comminuted fractures or divergent displacement	Not indicated	ORIF with possible fusion

Rationale for Surgical Approach and Implant Choice

ORIF with screws or dorsal plates aims to restore anatomic alignment and maintain reduction.
Primary arthrodesis is favored in purely ligamentous injuries or chronic instability to prevent late arthritis.
Screw fixation across the second TMT joint is biomechanically superior; dorsal plates may be used for comminuted fractures.
Minimally invasive techniques are emerging but require careful patient selection.

Surgical Mastery & Pearls

Step-by-Step Conceptual Overview

Exposure: Dorsal longitudinal incision centered over the second TMT joint; protect dorsal neurovascular structures.
Reduction: Achieve anatomic reduction of the second metatarsal base into the cuneiform mortise under direct visualization and fluoroscopy.
Temporary Fixation: Use K-wires to maintain reduction before definitive fixation.
Definitive Fixation: Insert 3.5 mm cortical screws across the Lisfranc joint, typically from medial cuneiform to second metatarsal base; supplement with screws or plates for adjacent joints as needed.
Assessment: Confirm reduction and hardware placement with fluoroscopy in multiple planes.
Closure: Layered closure with attention to soft tissue integrity.

Intraoperative Red Flags

Persistent diastasis despite reduction attempts suggests soft tissue interposition or missed fracture fragment.
Overcompression of the joint can cause iatrogenic cartilage damage; maintain anatomic spacing.
Hardware prominence dorsally can cause irritation; countersink screws when possible.
Avoid excessive stripping of dorsal soft tissues to preserve blood supply.

Evidence-Based Synthesis

Recent randomized controlled trials and meta-analyses have refined the management paradigm for Lisfranc injuries. The landmark study by Deol et al. demonstrated superior functional outcomes and lower reoperation rates with primary arthrodesis compared to ORIF in purely ligamentous injuries. Conversely, fractures with bony involvement benefit from ORIF to preserve joint motion.

Biomechanical studies confirm that screw fixation across the second TMT joint provides superior stability compared to K-wires or dorsal plates alone. However, controversy persists regarding the optimal implant choice in comminuted injuries.

Long-term cohort studies emphasize that anatomic reduction is the strongest predictor of good outcomes, regardless of fixation method. Non-operative management remains appropriate only for stable, non-displaced injuries, with vigilant follow-up.

Master Class Pro-Tip

Mastery in Lisfranc fixation hinges on appreciating the second metatarsal base as the keystone of the midfoot. Prioritize anatomic reduction of this joint before addressing adjacent articulations. Use intraoperative fluoroscopy judiciously to confirm alignment in multiple planes, and do not hesitate to extend fixation to adjacent joints if instability persists. Recognize that subtle malalignment, even by 1-2 mm, predisposes to debilitating post-traumatic arthritis. Finally, tailor your fixation strategy to the injury pattern-primary arthrodesis for ligamentous injuries, ORIF for fractures-balancing joint preservation with long-term stability.

April 29, 2026/0 Comments/by OrthoNet AI

Trauma Review

Understanding the Lauge-Hansen and Danis-Weber Classifications of Ankle Fractures

High-Yield Summary

The Lauge-Hansen classification defines ankle fractures by the mechanism of injury, integrating foot position and force direction, guiding surgical approach and fixation strategy.
The Danis-Weber classification categorizes fractures by fibular fracture level relative to the syndesmosis, directly influencing stability assessment and operative indication.
Accurate diagnosis requires combined clinical, radiographic, and stress imaging to evaluate syndesmotic integrity and deltoid ligament competence.
Surgical decision-making hinges on fracture stability, syndesmotic disruption, and medial structure involvement; operative fixation aims to restore ankle mortise congruity and joint stability.
Mastery of these classifications improves preoperative planning, intraoperative decision-making, and postoperative outcomes by tailoring fixation to injury pattern and biomechanical demands.

Clinical Fundamentals

Relevant Anatomy

The ankle joint comprises the distal tibia, fibula, and talus, forming a mortise stabilized by the syndesmosis and medial deltoid ligament complex. The syndesmosis includes the anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, interosseous ligament, and membrane, critical for maintaining fibular position and ankle stability.

Biomechanics

Ankle stability depends on congruent articulation of the talus within the tibiofibular mortise. The fibula bears approximately 17% of axial load but is essential for lateral stability. Disruption of the syndesmosis or deltoid ligament alters load transmission, increasing risk of post-traumatic arthritis.

Epidemiology

Ankle fractures represent 9% of all fractures, with increasing incidence in active adults. Supination-external rotation injuries predominate, aligning with the most common Lauge-Hansen patterns. Understanding injury mechanics correlates with fracture morphology and guides treatment.

Classification & Diagnosis

Classification System	Basis	Key Categories	Clinical Relevance	Diagnostic Pearls
Lauge-Hansen	Mechanism of injury: foot position + force direction	Supination-External Rotation (SER), Pronation-External Rotation (PER), Supination-Adduction (SA), Pronation-Abduction (PA)	Predicts sequence of ligamentous and bony injury; guides surgical approach	Identify injury stage on radiographs; SER IV involves syndesmosis and deltoid injury
Danis-Weber	Fibular fracture level relative to syndesmosis	Type A (below syndesmosis), Type B (at syndesmosis), Type C (above syndesmosis)	Correlates with stability and syndesmotic injury; Type C often unstable	Assess syndesmosis on mortise and AP views; stress radiographs or CT may be needed

Diagnostic Pearls and Pitfalls

Deltoid ligament integrity is critical; medial clear space widening >5 mm on mortise view suggests instability.
Stress radiographs (external rotation or gravity stress) help detect occult syndesmotic injury.
CT imaging refines fracture characterization, especially for Weber C and posterior malleolar involvement.
Avoid underestimating syndesmotic disruption in Weber B fractures; clinical exam and imaging must be correlated.

Decision-Making Algorithm

Criteria	Non-Operative Management	Operative Management
Fracture Stability	Stable fractures: Weber A, isolated lateral malleolus fractures without medial injury	Unstable fractures: Weber B with medial injury, Weber C, bimalleolar/trimalleolar fractures
Syndesmotic Integrity	Intact syndesmosis confirmed by imaging and stress tests	Syndesmotic disruption requiring fixation
Medial Structures	Intact deltoid ligament or stable medial malleolus	Deltoid ligament rupture or medial malleolus fracture compromising stability
Patient Factors	Low-demand, comorbidities precluding surgery	Active patients, open fractures, or displaced fractures

Surgical Approach and Implant Choice

Lateral approach for fibular fixation; plate and screws preferred for Weber B and C.
Medial approach for medial malleolus fixation or deltoid repair.
Syndesmotic fixation with screws or suture-button devices when indicated.
Posterior malleolar fixation considered when fragment involves >25% of articular surface or syndesmotic instability persists after fibular fixation.

Surgical Mastery & Pearls

Step-by-Step Conceptual Overview

Preoperative Planning: Review radiographs and CT to define fracture pattern and syndesmotic status; plan fixation sequence.
Patient Positioning: Supine with bump under ipsilateral hip; ensure fluoroscopic access.
Exposure: Lateral incision centered over fibula; protect superficial peroneal nerve.
Fibular Fixation: Anatomical reduction with lag screws and neutralization plate; restore length and rotation.
Medial Fixation: Address medial malleolus fracture or deltoid repair; ensure medial clear space restoration.
Syndesmotic Assessment: Perform intraoperative stress test after fibular fixation; if unstable, place syndesmotic screw(s) or suture-button device.
Posterior Malleolus: Fix via posterolateral or posteromedial approach if indicated.
Final Fluoroscopy: Confirm mortise congruity, hardware position, and syndesmotic reduction.

Intraoperative Red Flags

Persistent medial clear space widening after fibular fixation indicates missed medial injury.
Malreduction of syndesmosis leads to chronic instability and arthritis.
Over-tightening syndesmotic screws can restrict physiologic motion; consider suture-button devices in select cases.
Failure to restore fibular length or rotation compromises ankle biomechanics.

Evidence-Based Synthesis

Recent randomized controlled trials and meta-analyses emphasize the importance of syndesmotic fixation in Weber C and unstable Weber B fractures. Suture-button devices demonstrate comparable stability with earlier weight-bearing and fewer hardware complications compared to screws, though long-term outcomes remain under investigation.

Lauge-Hansen classification, while mechanistic, correlates strongly with injury severity and guides surgical strategy, but interobserver reliability is moderate, necessitating adjunct imaging.

Danis-Weber classification remains the cornerstone for initial management decisions; however, reliance solely on fracture level without assessing ligamentous injury risks under-treatment.

Emerging evidence supports individualized fixation strategies based on combined classification insights, with a trend toward less invasive syndesmotic stabilization and early mobilization protocols improving functional outcomes.

Master Class Pro-Tip

Prioritize restoration of fibular length and rotation before syndesmotic fixation; subtle malalignment here is the most common cause of postoperative instability. Use intraoperative 3D imaging or fluoroscopic mortise views dynamically during reduction. When in doubt, fix the syndesmosis-under-fixation leads to chronic instability, while over-fixation can be managed by timely hardware removal. Mastery lies in integrating classification insights with real-time assessment to tailor fixation, not merely following algorithmic steps.

April 14, 2026/0 Comments/by OrthoNet AI

Trauma Review

Current Concepts in the Management of Calcaneal Fractures

High-Yield Summary

Displaced intra-articular calcaneal fractures require precise anatomical reduction to restore subtalar joint congruity and prevent post-traumatic arthritis.
The Sanders classification, based on CT imaging, remains the cornerstone for guiding operative versus non-operative management.
Surgical approach selection balances exposure for reduction with soft tissue preservation; extensile lateral approach offers visualization but carries higher wound complication risk.
Early surgery within 2 weeks optimizes outcomes but mandates careful soft tissue assessment to avoid wound complications.
Evidence supports operative fixation for Sanders type II and III fractures in healthy patients, while non-operative management is favored for extra-articular and minimally displaced fractures.

Clinical Fundamentals

Anatomy

The calcaneus is the largest tarsal bone, forming the posterior part of the foot and articulating primarily with the talus superiorly and cuboid anteriorly. The subtalar joint is critical for hindfoot inversion and eversion. The sustentaculum tali provides a medial buttress and attachment for key ligaments. The calcaneal tuberosity bears the Achilles tendon insertion.

Biomechanics

The calcaneus transmits axial load from the tibia to the ground and acts as a lever arm for the Achilles tendon. Fracture displacement disrupts the posterior facet alignment, altering subtalar joint mechanics and hindfoot alignment, leading to varus deformity and altered gait if untreated.

Epidemiology

Calcaneal fractures account for 1-2% of all fractures and 60-75% of tarsal fractures. High-energy axial loading, such as falls from height, is the predominant mechanism. Males aged 20-40 are most commonly affected. Bilateral fractures occur in up to 10% of cases.

Classification & Diagnosis

Classification System	Basis	Clinical Relevance	Pearls & Pitfalls
Sanders Classification	CT-based, coronal oblique cuts of posterior facet	Guides operative decision-making; Types II and III often benefit from surgery	Accurate CT imaging is essential; misclassification leads to inappropriate treatment
Essex-Lopresti Classification	Two fracture patterns: tongue-type and joint depression	Influences surgical approach choice	Tongue-type fractures risk skin tenting and necrosis; urgent reduction needed
Rowe Classification	Extra-articular vs. intra-articular	Determines non-operative vs. operative management	Over-reliance on plain radiographs can miss subtle intra-articular involvement

Diagnostic Pearls:

Obtain CT scans in all displaced fractures to assess articular involvement and comminution.
Beware of soft tissue swelling and blistering; surgery should be delayed until swelling subsides.
Lateral radiographs may underestimate fracture complexity; always correlate with CT.

Decision-Making Algorithm

Non-Operative Management

Indicated for:

Extra-articular fractures without displacement
Sanders type I fractures (non-displaced intra-articular)
Patients with significant comorbidities or poor soft tissue envelope

Rationale: Low risk of wound complications and acceptable functional outcomes in these groups.

Operative Management

Indicated for:

Displaced intra-articular fractures (Sanders II and III) in healthy patients
Tongue-type fractures with skin tenting or risk of necrosis
Fractures with significant loss of calcaneal height, width, or varus deformity

Rationale: Anatomical reduction restores joint congruity, prevents arthritis, and improves function.

Surgical Approach & Implant Choice

Extensile lateral approach: Gold standard for visualization and reduction in complex fractures; higher wound complication risk.
Sinus tarsi approach: Minimally invasive, suitable for select Sanders II fractures; reduced soft tissue morbidity.
Percutaneous fixation: Reserved for select extra-articular or minimally displaced fractures.
Implants: Low-profile locking plates preferred for stability; screws alone may suffice in less comminuted patterns.

Surgical Mastery & Pearls

Preoperative Planning

Confirm fracture classification with CT.
Assess soft tissue status; delay surgery until swelling and blisters resolve.
Plan approach based on fracture pattern and skin condition.

Stepwise Surgical Technique (Extensile Lateral Approach)

Position patient lateral decubitus with foot hanging free.
Make L-shaped incision centered over lateral calcaneus, preserving sural nerve.
Elevate full-thickness flap carefully to avoid devascularization.
Identify and reduce posterior facet fragments under direct visualization.
Restore calcaneal height, length, and width using Schanz pins or distractors.
Temporarily fix with K-wires; confirm reduction fluoroscopically.
Definitively fix with low-profile locking plate and screws.
Irrigate and close in layers; consider drain placement.

Intraoperative Red Flags

Excessive soft tissue tension on flap edges predicts wound complications.
Incomplete reduction of posterior facet leads to poor functional outcomes.
Overzealous lateral wall excision increases risk of peroneal tendon irritation.

Technical Tips

Use intraoperative fluoroscopy to confirm restoration of Bohler’s angle and posterior facet congruity.
Preserve the lateral calcaneal artery and sural nerve during dissection.
Employ bone graft or substitutes selectively for metaphyseal voids.

Evidence-Based Synthesis

Landmark randomized controlled trials and meta-analyses have clarified the role of operative fixation in displaced intra-articular calcaneal fractures. The UK Heel Fracture Trial (2014) questioned the benefit of surgery, showing no significant functional advantage at two years but highlighted high complication rates. Conversely, multiple meta-analyses demonstrate improved radiographic alignment and subtalar joint congruity with operative treatment, correlating with better long-term function in selected patients.

Recent literature emphasizes patient selection: younger, healthier patients with Sanders II and III fractures derive the most benefit from surgery. Minimally invasive approaches reduce wound complications but may limit visualization and reduction quality. The balance between anatomical restoration and soft tissue preservation remains the clinical fulcrum.

Controversies persist regarding timing of surgery and the optimal surgical approach. Emerging evidence supports early intervention once soft tissue conditions permit, with sinus tarsi approaches gaining favor for select fracture patterns.

Master Class Pro-Tip

Mastery in calcaneal fracture management hinges on the surgeon’s ability to integrate detailed preoperative CT analysis with meticulous soft tissue handling. Prioritize restoration of the posterior facet congruity and calcaneal height over perfect anatomical reduction of every fragment. Employ intraoperative fluoroscopy judiciously to confirm Bohler’s angle and subtalar alignment. When in doubt, staged fixation or minimally invasive techniques can mitigate soft tissue complications without compromising functional outcomes. The expert surgeon anticipates and prevents wound issues by respecting the vascular anatomy of the lateral calcaneus and timing surgery to the patient’s soft tissue envelope rather than the calendar.

March 31, 2026/0 Comments/by OrthoNet AI