Cases for small group discussion Final case discussion (eg, polytrauma, complications, special fractures) Case collection for small group discussion Please note: Depending on the duration of the discussion session, the Course Chair needs to select an adequate number of cases. This collection provides you with a range of cases; it is not the purpose of this collection that you discuss all of them. As a rule of thumb, allow for 15–20 minutes discussion time for every case. Course chairs can also prepare their own cases. AOT Basic Principles Course

Table of contents Case 1: Closed tibial shaft fracture Case 2: Femoral and tibial fractures Case 3: Open fracture of the lower leg (Gustilo II) Case 4: Open fracture of the lower leg: Gustilo IIIA Case 5: Subtotal amputation of the left lower leg

Closed tibial shaft fracture Case for small group discussion: Polytrauma, complications, special fractures Discussion points: Fracture classification Indication for IM nail / external fixation / ORIF percutaneous plating Open or closed reduction Type of stability Patient positioning Entry point vs type of nail Bone healing Reamed vs unreamed (fat embolism) ETN Protect Compartment Syndrome Mikko Kirjavainen, FI AOT Basic Principles Course

Case description 42A1.(a) Day 0 30-year-old man involved in a car accident. Closed fracture. Discussion points: Soft-tissue injury Compartment syndrome Treatment options 42A1.(a) Day 0

Postoperative x-rays Discuss soft tissues and timing Quality of reduction Stability Implant chosen and nail length

6 months after primary surgery. No sign of bony consolidation 6 months after primary surgery. No sign of bony consolidation. Patient has daily pain and feels instability of his fracture. What are the reasons for nonunion? - Short nail resulting in poor stability. Malposition not primary problem! What are the treatment options?

Renailing with reaming the medullary canal in addition to osteotomy of the fibula. A compression option of the nail was used. Two blocking screws inserted proximally posterior to the nail. The first blocking screw did not provide sufficient support and the second blocking screw was used. Note adequate length and alignment with construct. Discuss: 1. Reduction 2. Role of blocking screws 3. Proximal locking options 4. Is fibula osteotomy needed? If yes, in which situation? Reference: Krettek C, Miclau T, Schandelmaier P, et al: The mechanical effect of blocking screws ("Poller screws") in stabilizing tibia fractures with short proximal or distal fragments after insertion of small-diameter intramedullary nails. J Orthop Trauma. 1999 Nov;13(8):550-3.

6 months after reoperation good bony healing and the patient was asymptomatic Discuss aftertreatment

Summary and take-home message The advent of nonunion may be related to poor mechanical stability and implant choice, as well as surgical technique. Revision procedure with longer and reaming improved the mechanical stability and stimulated the biology. React early to unfavorable result. Ask participants to summarize the case discussion.

Femoral and tibial fractures Case for small group discussion: Polytrauma, complications, special fractures AOT Basic Principles Course Case prepared for Davos Principles Course 2012. Used with kind permission.

35-year-old man, motorcycle accident How do you classify these fractures? 33C2.(j)- femur 42A3.(c)- tibia 4F1A -fibula

No neurovascular problems Compartments ok Closed fractures Soft tissues ok No neurovascular problems Compartments ok Discussion points: How to manage this problem? What are the key principles for treatment? IM nailing vs plate fixation – pros and cons Antegrade or retrograde – pros and cons 42A3 4F1A 33C2

Postoperative x-rays

Postoperative x-rays

Postoperative x-rays

4 months postoperative

4 months postoperative

4 months postoperative

Summary and take-home message Ipsilateral femoral and tibial fractures is an indication for retrograde femoral, and antegrade tibial nailing through one incision. Segmental fractures are well splinted by IM nailing. Early knee mobilization and weight bearing are key points. Ask participants to summarize the case discussion.

AOT Basic Principles Course Fracture of the right lower leg: Gustilo II open, AO/OTA 42B2 TIBIA & 4F2B FIBULA Case for small group discussion: Polytrauma, complications, special fractures Michael J Raschke, DE AOT Basic Principles Course

Case description 54-year-old man Fell down stairs Fracture of the lower leg: Gustilo II open fracture, AO/OTA 42B2 TIBIA & 4F2B FIBULA Compartment syndrome Additional case information: Date of accident:12.05.2011 Case history: fell down the stairs Diagnosis: fracture of the right lower leg : Gustilo II open, AO 42 C1, compartment syndrome Surgical treatment: 12.05.2011: Antibiotic Coated Nail (11x390), soft tissue treatment => fasciotomy 17./25.05.2011: wound revision => syspurderm change 01.06.2011: wound revision, secondary suture

Soft-tissue treatment => fasciotomy, plannning of surgical procedure Discussion points: Casting techniques Anticipation and assessment of soft-tissue damage Planning of operative procedure Day 0

Postop situation after Antibiotic Coated Nail (11x390) Discussion points: Assessment of soft-tissue damage Day 0

Days 5 and 13: debridements Day 20: debridement, secondary wound closure Discussion points: Vacuum dressing Timing Physical therapy Weight bearing

6 week follow-up: Partial weight bearing Moderate swelling Normal range of motion knee and ankle Discussion points: Bone healing progress

3 month follow-up: Full weight bearing Increasing consolidation

12 month follow-up: Full weight bearing Fracture consolidation Normal function Full range of motion knee and ankle

Summary and take-home message Preoperative management aids in avoiding complications. Assessing soft-tissue damage has priority over implant indication. Antibiotic coated nails help to lower risk of infection when using open procedures. Ask participants to summarize the case discussion.

Fracture of the right lower leg: Gustilo IIIA open fracture, 42B3 Case for small group discussion: Polytrauma, complications, special fractures Michael J Raschke, DE AOT Basic Principles Course

Case description 25-year-old man Crush injury Fracture of the right lower leg: Gustilo type IIIA open fracture, AO/OTA 42B3 Vascular injury subclavian Additional case information: Date of accident: 25.03.2011 Case history: severe contusion of the right lower leg by a hydraulic press Diagnosis: fracture of the right lower leg: Gustillo IIIA open AO 42 B1, perforating chest injury left side, A. subclavian dissection left side with thrombus Surgical treatment: 25.03.2011: external fixator right lower leg, soft tissue treatment , thoracotomy, partial pneumonectomy left side 11.04.2011: procedural change external to internal fixation, removal external fixator  Antibiotic Coated Nail (10x390), revision of hematoma

Day 0 – Initial management External fixator right lower leg, soft-tissue treatment, chest-injury management, partial pneumonectomy left side Discussion points: Fracture classification (42B3) Day 0 – Initial management

What is your plan for definitive treatment? Timing of definitive surgery? Next steps in the management of this patient? Case information: Surgical treatment day 17: procedural change external to internal fixation, removal external fixator  Antibiotic Coated Nail (10x390), revision of hematoma

Day 17 Pin tract debridement, change to internal fixation: Antibiotic Coated Nail (10x390) Discussion points: Sequence Stability following removal of external fixator Reduction aid Additional case information: Surgical treatment day 17: procedural change external to internal fixation, removal external fixator  Antibiotic Coated Nail (10x390), revision of hematoma Day 17

6 week follow-up Discussion points: Partial weight bearing / full weight bearing Further treatment goals Additional case information: Mild swelling at 6 weeks Sufficient mobility knee and ankle

6 month follow-up Full weight bearing Soft tissues healed Fracture healed Normal range of motion Back to work, full time

Take-home message Late change from external to internal fixation poses higher risk of infection. Pin tract debridement is essential. An antibiotic coated nail provides high concentration of antibiotic locally. Ask participants to summarize the case discussion.

Subtotal amputation of the left lower leg: Gustilo IIIC open, AO/OTA 42B3 tibia and 4F2B fibula Case for small group discussion: Polytrauma, complications, special fractures Michael J Raschke, DE AOT Basic Principles Course

Motor-scooter accident 17-year-old man Motor-scooter accident Subtotal amputation of the left lower leg: Gustilo IIIC open AO/OTA 42B3 tibia 4F2B fibula Sequence of steps in the management of this patient?

Day 0 External fixation, debridement Tibial shortening osteotomy (5.5 cm) Vascular and soft-tissue reconstruction Serial debridements and vacuum dressing Discussion points: Transfixation of ankle and foot Soft-tissue coverage Vacuum dressing Day 0

Removal of external fixator, change to antibiotic coated nail (UTN Protect 9x315 mm) Discussion points: Locking alternatives? Additional case information: C-reactive protein levels/leukocyte counts assessed before tibial nailing (2 days and 5 weeks postoperatively), were within normal range Day 23

Soft-tissue status 2 months post IM nail

5 months postinjury: Begin leg lengthening with Ilizarov Discussion points: Weight bearing Timing Additional case information: 5 months after accident: Ilizarov circular external fixator (2 carbon rings, 4 distractors) Lengthening performed by the patient (0.5–1 mm/day divided into 4 increments)

8 months after injury: Removal of external fixation Discussion points: Locking techniques

Complete bony consolidation at 13 months

Take-home message A fracture is a soft-tissue lesion which incidentally also has a fracture Soft-tissue management has priority External fixation plus bone resection serves soft-tissue management Availability of antibiotic coated nail makes different reconstruction techniques possible Ask participants to summarize the case discussion.