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Handbook of fractures(sổ tay chấn thương)

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Page i

FOURTH EDITION

Handbook of

Fractures


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Page ii


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FOURTH EDITION

Handbook of

Fractures
Kenneth A. Egol, MD

Professor and Vice Chairman
Department of Orthopaedic Surgery
NYU Hospital for Joint Diseases New York University Medical Center
New York, New York

Kenneth J. Koval, MD
Professor
Department of Orthopaedics
Dartmouth Hitchcock Medical Center
Lebanon, New Hampshire

Joseph D. Zuckerman, MD
Professor and Chairman
Department of Orthopaedic Surgery
NYU Hospital for Joint Diseases
New York University Medical Center
New York, New York


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Page iv

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Library of Congress Cataloging-in-Publication Data
Egol, Kenneth A., 1967Handbook of fractures/Kenneth A. Egol, Kenneth J. Koval, Joseph D. Zuckerman.
— 4th ed.
p. ; cm.
Rev. ed. of: Handbook of fractures/Kenneth J. Koval, Joseph D. Zuckerman.
Abridgement of Rockwood and Green's fractures in adults. 7th ed. c2010.
Includes bibliographical references and index.
ISBN 978-1-60547-760-2 (alk. paper)
1. Fractures--Handbooks, manuals, etc. 2. Dislocations--Handbooks, manuals, etc.
I. Koval, Kenneth J. II. Zuckerman, Joseph D. (Joseph David), 1952III. Koval, Kenneth J. Handbook of fractures. IV. Rockwood & Green's fractures in
adults. V. Title.
[DNLM: 1. Fractures, Bone—Handbooks. 2. Dislocations—Handbooks.
WE 39 E31h 2010]
RD101.K685 2010
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2009051161
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of the contents of the publication. Application of the information in a particular situation remains the professional responsibility of the practitioner.
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To my family, Lori, Alexander, Jonathan,
and Gabrielle, and to my mentors
KJK, JDZ, and MJB.
– Kenneth A. Egol
To all those people who have believed in me
and stood by me during adversity.
– Kenneth J. Koval
To the residents and faculty of the
NYU Hospital for Joint Diseases for all
their support in the past 25 years.
– Joseph D. Zuckerman


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CONTENTS

Preface
Acknowledgments

I. GENERAL CONSIDERATIONS
1 Closed Reduction, Casting, and Traction

xi
xii

1
3

2 Multiple Trauma

11

3 Open Fractures

25

4 Gunshot Wounds

36

5 Pathologic Fractures

41

6 Periprosthetic Fractures

50

7 Orthopaedic Analgesia

63

II. AXIAL SKELETON FRACTURES

77

8 General Spine

79

9 Cervical Spine

97

10 Thoracolumbar Spine

123

III. UPPER EXTREMITY FRACTURES AND DISLOCATIONS

141

11 Clavicle Fractures

143

12 Acromioclavicular and Sternoclavicular Joint Injuries

150

13 Scapula Fractures

162

14 Glenohumeral Dislocation

172

15 Proximal Humerus Fractures

193
vii


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Contents

16 Humeral Shaft Fractures

203

17 Distal Humerus

214

18 Elbow Dislocation

230

19 Olecranon

243

20 Radial Head

249

21 Radius and Ulna Shaft

257

22 Distal Radius

269

23 Wrist

281

24 Hand

305

IV. LOWER EXTREMITY FRACTURES AND DISLOCATIONS 325
25 Pelvis

327

26 Acetabulum

344

27 Hip Dislocations

360

28 Femoral Head

372

29 Femoral Neck Fractures

378

30 Intertrochanteric Fractures

388

31 Subtrochanteric Fractures

399

32 Femoral Shaft

408

33 Distal Femur

420

34 Knee Dislocation (Femorotibial)

429

35 Patella and Extensor Mechanism Injuries

439

36 Tibial Plateau

455

37 Tibia/Fibula Shaft

464

38 Injuries about the Ankle

476

39 Calcaneus Fractures

507


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Contents

ix

40 Talus

520

41 Fractures of the Midfoot and Forefoot

530

V. PEDIATRIC FRACTURES AND DISLOCATIONS

561

42 Pediatric Orthopaedic Surgery: General Principles

563

43 Pediatric Shoulder

572

44 Pediatric Elbow

598

45 Pediatric Forearm

645

46 Pediatric Wrist and Hand

660

47 Pediatric Hip

681

48 Pediatric Femoral Shaft

690

49 Pediatric Knee

698

50 Pediatric Tibia and Fibula

727

51 Pediatric Ankle

743

52 Pediatric Foot

752

Index

769


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PREFACE

This book represents the work of many physicians who trained at the
Hospital for Joint Diseases. Starting in the 1980s, the Department of
Orthopaedic Surgery initiated a weekly, didactic topic-related fracture
case conference. This conference consisted of a short lecture presented
by a senior resident on pertinent anatomy, fracture mechanism, radiographic and clinical evaluation, and classification and treatment options, followed by a series of cases that were used to further clarify the
options for fracture care. The senior resident was also responsible for
preparing a handout on the fracture topic, which was distributed prior
to the lecture.
Over time, it became apparent that these topic-related fracture
handouts were very useful as a reference for later study and were utilized by incoming residents as an aid in the Emergency Department.
This resulted in the original compilation of the “Hospital for Joint
Diseases Fracture Manual,” which was organized and prepared for publication “in-house,” by ourselves, two senior residents Scott Alpert and
Ari Ben-Yishay, and our editorial associate William Green. The
“Fracture Manual” became very popular, very quickly. Its popularity led
to the preparation and publication of the second edition. The third edition was designed, in part, to accompany Rockwood and Green’s textbook Fractures in Adults.
This fourth edition is a complete update of the “Fracture Manual.”
We have tried to keep it “pocket-size” despite the ever increasing expanse of material. Most importantly, we have tried to keep the “Fracture
Manual” true to its roots as a comprehensive, useful guide for the management of patients with fractures and associated injuries. We hope
that the users of this “Fracture Manual” find it helpful in their daily
practice of fracture care.
Kenneth A. Egol, MD
Kenneth J. Koval, MD
Joseph D. Zuckerman, MD

xi


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Part I Cerebrovascular Disease: Great Vessel, Carotid and Vertebral

ACKNOWLEDGMENTS

We would like to acknowledge the following people: James Slover, MD,
Timothy Rapp, MD, Ronald Moskovich, MD, Alan Strongwater, MD, and
Gail Chorney, MD, for their help in preparation of this book. In addition
we would like to acknowledge all of the residents and fellows, past, present, and future, at the NYU Hospital for Joint Diseases whose inquisitiveness compel us to continually update this text.

xii


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PART I
General
Considerations


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Closed Reduction, Casting,
and Traction

PRINCIPLES OF CLOSED REDUCTION











Displaced fractures, including those that will undergo internal fixation, should be reduced to minimize soft tissue trauma and
provide patient comfort.
Splints should respect the soft tissues.
Pad all bony prominences.
Allow for post injury swelling.
Adequate analgesia and muscle relaxation are critical for success.
Fractures are reduced using axial traction and reversal of the
mechanism of injury.
One should attempt to correct or restore length, rotation, and
angulation.
Reduction maneuvers are often specific for a particular location.
One should try to immobilize the joint above and below the injury.
Three-point contact and stabilization are necessary to maintain
most closed reductions.

COMMON SPLINTING TECHNIQUES










Splints may be prefabricated or custom made.
“Bulky” Jones
Lower extremity splint, commonly applied for foot and ankle
fractures and fractures about the knee, that uses fluffy cotton or
abundant cast padding to help with post injury swelling. The
splint is applied using a posterior slab and a U-shaped slab applied from medial to lateral around the malleoli. The extremity
should be padded well proximal and distal to the injury.
Sugar-tong splint
Upper extremity splint for distal forearm fractures that uses a
U-shaped slab applied to the volar and dorsal aspects of the forearm, encircling the elbow (Fig. 1.1).
Coaptation splint
Upper extremity splint for humerus fractures that uses a U-shaped
slab applied to the medial and lateral aspects of the arm, encircling
the elbow and overlapping the shoulder.
Ulnar gutter splint
Volar/dorsal hand splint
3


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Part I General Considerations

4

1








3

2

FIGURE 1.1 A sugar-tong plaster splint is
wrapped around the elbow and forearm and is
held using a circumferential gauze bandage.
It should extend from the dorsal surface of the
metacarpophalangeal joints to the volar surface
of the fracture site. (From Bucholz RW, Heckman
JD, Court-Brown C, eds. Rockwood and Green’s
Fractures in Adults. 6th ed. Philadelphia:
Lippincott Williams & Wilkins; 2006.)

Thumb spica splint
Posterior slab (ankle) with or without a U-shaped splint
Posterior slab (thigh)
Knee immobilizer
Cervical Collar
Pelvic binder

Visit the University of Ottawa web site for general casting techniques and specifics on placing specific splints and casts: www.med.
uottawa.ca/procedures/cast/

CASTING



The goal is semirigid immobilization with avoidance of pressure or
skin complications.
It may be a poor choice in the treatment of acute fractures owing to
swelling and soft tissue complications.
Padding: This is placed from distal to proximal with a 50%
overlap, a minimum of two layers, and extra padding for bony
prominences ( fibular head, malleoli, patella, and olecranon).
Plaster: Cold water will maximize the molding time. Hot water
may lead to burning the skin. Room temperature water is
preferred.
6-inch width for thigh
● 4- to 6-inch width for leg
● 4- to 6-inch width for arm
● 2- to 4-inch width for forearm
Fiberglass
● This is more difficult to mold but more resistant to moisture
and breakdown.


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Chapter 1 Closed Reduction, Casting, and Traction


5

Generally, it is two to three times stronger for any given
thickness.

Visit the University of Ottawa web site for general casting techniques and specifics on placing specific splints and casts: www.med.
uottawa.ca/procedures/cast/
Below Knee Cast (Short Leg Cast)






This should support the metatarsal heads.
The ankle should be placed in neutral; apply with the knee in
flexion.
Ensure freedom of the toes.
Build up the plantar surface for walking casts.
Fiberglass is preferred for durability.
Pad the fibula head and the plantar aspect of the foot.

Above Knee Cast (Long Leg Cast)





Apply below the knee first.
Maintain knee flexion at 5 to 20 degrees.
Mold the supracondylar femur for improved rotational stability.
Apply extra padding anterior to the patella.

Short and Long Arm Casts





The metacarpophalangeal (MCP) joints should be free.
Do not go past the proximal palmar crease.
The thumb should be free to the base of the metacarpal; opposition
to the fifth digit should be unobstructed.
Even pressure should be applied to achieve the best mold.
Avoid molding with anything but the heels of the palm, to avoid
pressure points.

COMPLICATIONS OF CASTS AND SPLINTS








Loss of reduction
Pressure necrosis, as early as 2 hours after cast/splint application
Tight cast or compartment syndrome
Univalving: 30% pressure drop
Bivalving: 60% pressure drop
Cutting of cast padding to further reduce pressure
Thermal injury
Avoid plaster thicker than 10 ply
Avoid water hotter than 24ЊC
Unusual with fiberglass
Cuts and burns during cast removal


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Part I General Considerations

FIGURE 1.2 Position of function for the MCP joint.

■ Thrombophlebitis or pulmonary embolus: increased with lower extrem-

ity fracture and immobilization but prophylaxis debated.
Joints should be left free when possible (i.e., thumb
MCP for short arm cast) and placed in position of function when
not possible to leave free.

■ Joint stiffness:

POSITIONS OF FUNCTION
■ Ankle: neutral dorsiflexion (no equinus)
■ Hand: MCP flexed (70 to 90 degrees),

interphalangeal joints in
extension (also called the intrinsic plus position) (Fig. 1.2)

TRACTION




This allows constant controlled force for initial stabilization
of long bone fractures and aids in reduction during operative
procedures.
The option for skeletal versus skin traction is case dependent.

Skin Traction





Limited force can be applied, generally not to exceed 10 lb.
This can cause soft tissue problems, especially in elderly patients
or those with or rheumatoid-type skin.
It is not as powerful when used during operative procedures for
both length and rotational control.
Bucks traction uses a soft dressing around the calf and foot
attached to a weight off the foot of the bed.


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Chapter 1 Closed Reduction, Casting, and Traction

7

FIGURE 1.3 Skeletal traction sites. Various sites for skeletal traction are
available. The techniques range from traction in the olecranon to skull
traction, as illustrated here. (Modified from Connolly J. Fractures and
Dislocations: Closed Management. Philadelphia: WB Saunders; 1995.)

This is an on option to provide temporary comfort in hip fractures and certain children’s fractures.
A maximum of 7 to 10 lb of traction should be used.
Watch closely for skin problems, especially in elderly or rheumatoid patients.
Skeletal Traction (Fig. 1.3)




This is more powerful, with greater fragment control, than skin
traction.
It permits pull up to 20% of body weight for the lower extremity.
It requires local anesthesia for pin insertion if the patient is awake.
The anesthesia should be infiltrated down to the sensitive
periosteum.


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Part I General Considerations



It is the preferred method of temporizing long bone, pelvic, and
acetabular fractures until operative treatment can be performed.
Choice of thin wire versus Steinmann pin
Thin wire is more difficult to insert with a hand drill and requires a tension traction bow. It requires use of a tension bow
(Kirschner).
The Steinmann pin may be either smooth or threaded.
● A smooth pin is stronger but it can slide through the skin.
● A threaded pin is weaker and bends more easily with increasing weights, but it will not slide and will advance more easily
during insertion.
● In general, the largest pin (5 to 6 mm) available is chosen,
especially if a threaded pin is selected.

Tibial Skeletal Traction







The pin is placed 2 cm posterior and 1 cm distal to the tibial
tubercle.
It may go more distal in osteopenic bone.
The pin is placed from lateral to medial to direct the pin away from
the common peroneal nerve.
The skin is released at the pin’s entrance and exit points.
One should try to stay out of the anterior compartment.
One should use a hemostat to push the muscle posteriorly.
A sterile dressing is applied next to the skin.

Femoral Skeletal Traction (Fig. 1.4)





This is the method of choice for pelvic, acetabular, and many femur
fractures (especially in ligamentously injured knees).
The pin is placed from medial to lateral (directed away from the
neurovascular bundle) at the adductor tubercle, slightly proximal
to the femoral epicondyle.
The location of this pin can be determined from the AP knee radiograph using the patella as a landmark.
One should spread through the soft tissue to bone to avoid injury
to the superficial femoral artery.

Calcaneal Skeletal Traction



This is most commonly used with a spanning external fixation for
“traveling traction,” or it may be used with a Bohler-Braun frame.
It is used for irreducible rotational ankle fractures, some pilon fractures and extremities with multiple ipsilateral long bone fractures.


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9

Chapter 1 Closed Reduction, Casting, and Traction

A

B

FIGURE 1.4 (A) Technique of inserting skeletal pins for femoral traction. A skeletal
traction pin is inserted in the distal femur from medial to lateral. Local anesthetic is
infiltrated down to the periosteum, and care is taken to avoid the neurovascular structures in the posteromedial aspect of the knee. A hand drill is used to insert the 3-mm
Steinmann pin, and care is taken to avoid pinching of the skin, which can be painful.
(B) The pin is padded, and a traction bow is attached. (Modified from Connolly J.
Fractures and Dislocations: Closed Management. Philadelphia: WB Saunders; 1995.)



The pin is placed from medial to lateral, directed away from the
neurovascular bundle, 2 to 2.5 cm posterior and inferior to the
medial malleolus.

Olecranon Traction





This is rarely used today.
A small to medium-sized pin is placed from medial to lateral in the
proximal olecranon; the bone is entered 1.5 cm from the tip of
the olecranon.
The forearm and wrist are supported with skin traction with the
elbow at 90 degrees of flexion.

Gardner Wells Tongs




This is used for cervical spine reduction and traction.
Pins are placed one fingerbreadth above the pinna, slightly posterior to the external auditory meatus.
Traction is applied starting with 5 lb and increasing in 5-lb increments with serial radiographs and clinical examination.


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Part I General Considerations

Halo





Indicated for certain cervical spine fractures as definitive treatment or supplementary protection to internal fixation.
Disadvantages
Pin problems
Respiratory compromise
Technique
Positioning of patient to maintain spine precautions
Fitting of halo ring
Preparation of pin sites
● Anterior: above the eyebrow, avoiding the supraorbital artery,
nerve, and sinus
● Posterior: superior and posterior to the ear
Tightening of pins to 6 to 8 ft-lb
Retightening if loose
● Pins only once at 24 hours after insertion
● Frame as needed

Spanning External Fixation





Concept of “Damage Control Orthopaedics” (DCO)
Allows for temporary stabilization of long bones.
Allows for transfer of patient in and out of bed.
Does not foster an elevation of compartment pressures in affected
extremities.
Performed in the operating room with fluoroscopy present.
Half pins can be placed into the ilium, femur, tibia, Calcaneus,
talus, and forefoot.
Connected by various clamps and bars.
Traction applied across affected long bones and joints.


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Multiple Trauma

High-velocity trauma is the number 1 cause of death in the 18- to
44-year age group worldwide.
Blunt trauma accounts for 80% of mortality in the Ͻ34-year age
group.
In the 1990s in the United States alone, income loss resulting from
death and disability secondary to high-velocity trauma totaled
75 billion dollars annually; despite this, trauma research received
Ͻ2% of the total national research budget.

The polytrauma patient is defined as follows:







Injury severity score Ͼ18
Hemodynamic instability
Coagulopathy
Closed head injury
Pulmonary injury
Abdominal injury

FIELD TRIAGE
Management Priorities








Assessment and establishment of airway and ventilation
Assessment of circulation and perfusion
Hemorrhage control
Patient extrication
Shock management
Fracture stabilization
Patient transport

TRAUMA DEATHS
Trauma deaths tend to occur in three phases:
1. Immediate: This is usually the result of severe brain injury or disrup-

tion of the heart, aorta, or large vessels. It is amenable to public
health measures and education, such as the use of safety helmets
and passenger restraints.
2. Early: This occurs minutes to a few hours after injury, usually as a result of intracranial bleeding, hemopneumothorax, splenic rupture,
11


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Part I General Considerations

liver laceration, or multiple injuries with significant blood loss. These
represent correctable injuries for which immediate, coordinated,
definitive care at a level I trauma center can be most beneficial.
3. Late: This occurs days to weeks after injury and is related to sepsis,
embolus, or multiple organ failure.
4. Mortality increases with increasing patient age (Fig. 2.1).

GOLDEN HOUR



Rapid transport of the severely injured patient to a trauma center
is essential for appropriate assessment and treatment.
The patient’s chance of survival diminishes rapidly after 1 hour,
with a threefold increase in mortality for every 30 minutes of
elapsed time without care in the severely, multiply injured patient.

THE TEAM




The orthopaedic surgeon plays a critical role in management of the
multiply injured patient.
The trauma team is headed by the trauma general surgeon, who
acts as the “captain of the ship” in directing patient care.
The orthopaedic consult is available to assess all musculoskeletal
injuries, provide initial bony stabilization, and work in concert
with the trauma surgeons to treat shock and hemorrhage.
Long bone IM nailing
Pelvic external or internal fixation
Management of open wounds
Splintage
Traction
DCO

RESUSCITATION
■ Follows ABCDE:

airway, breathing, circulation, disability, exposure.

AIRWAY CONTROL





The upper airway should be inspected to ensure patency.
Foreign objects should be removed, and secretions suctioned.
A nasal, endotracheal, or nasotracheal airway should be established as needed. A tracheostomy may be necessary.
The patient should be managed as if a cervical spine injury were
present. However, no patient should die from lack of an airway
because of concern over a possible cervical spine injury. Gentle
maneuvers, such as axial traction, are usually possible to allow for
safe intubation without neurologic compromise.


<40

40 – 65

FIGURE 2.1 Mortality rate increases with increasing age.

0%

10%

*

*

Age group

65 –75

*

75 – 85

>85

7:16 PM

20%

30%

40%

50%

60%

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Mortality

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