1. General principles and classification
Case collection for small group discussion: General principles, classification, concepts of stability, their influence on bone healing, and how to apply implants to achieve appropriate stability
Please note: There may not be enough time to discuss all cases in this document. Depending on the duration of the discussion session, the Course Chair needs to select an adequate number of cases. As a rule of thumb, allow for 15–20 minutes discussion time for every case.
Course chairs can also prepare their own cases.
AOTrauma Basic Principles Course

2. Table of contents Case 1: Diaphyseal femoral fracture
Case 2: Closed humeral shaft fracture
Case 3: Closed tibial shaft fracture
Case 4: Forearm fractures
Case 5: Open forearm fractures
Case 6: Open tibial and fibular fracture

3. Diaphyseal femoral fracture
Case for small group discussion: General principles, classification, concepts of stability, their influence on bone healing, and how to apply implants to achieve appropriate stability
A straightforward case of a simple diaphyseal femoral fracture treated according to the principle of relative stability (with a nail).
Learning outcomes:
Discuss when to ream or not to ream
Discuss indications for locking IM nails
Describe the type of stability provided by a medullary nail
Compare supine and lateral positions for nailing
Describe the type of healing anticipated with a nail
AOTrauma Basic Principles Course

4. 29-year-old woman, motorcycle crash
Retrograde amnesia
Closed femur fracture
No other injuries 3 2 B 2
How do you classify this injury?
Click after each answer to show results:
Which bone? – Femur (3)
Which segment? – diaphyseal segment (2)
Fracture type wedge fracture (B)
Which group Intact wedge B2 or fragmented wedge – (B3)
Classification: 32B3
Qualifications Subgroup proximal i/3rd - a, middle 1/3rd – b, Distal 1/3rd - c
Universal modifiers

5. Postoperative x-rays
The AFN (antegrade femur nail) has been used due to its lateral bend which can be inserted at the tip of the greater trochanter.
Is reduction satisfactory? - Yes, it appears that length, rotation, and alignment have been restored.
What type of stability is provided by this implant? - Relative stability
How does the implant function? - In this case it functions as a medullary splint.
Compare supine and lateral positioning of the patient
Discuss when to ream and when not to ream
What type of rehabilitation is called for? - Weight bearing as tolerated and active and passive ROM of all joints should be allowed.

6. 4 months postoperative No complaints Unrestricted walking
Discuss with participants:
At 4 months we see bridging callus which, combined with painless ambulation usually indicates advanced stages of healing and boney stability.
Breakage of the distal locking bolt might bother some, discuss its implications and treatment if any.

7. Works without restrictions or pain
1 year postoperative
Works without restrictions or pain
Discuss with participants:
Has the fracture healed? - Circumferential callus is present and the patient has no pain or restriction of activity. Clinically and radiographically this is healed.
Should the implant be removed? - Implant removal is not routinely recommended.

8. Summary and take-home messages
The treatment of choice for most femoral fractures is a reamed, locked intramedullary nail.
Interlocking is important for axial and rotational stability.
Early weight bearing is the goal.
Implant removal is not routinely recommended.
Ask participants to summarize the case discussion.

9. Closed humeral shaft fracture
Case for small group discussion: General principles, classification, concepts of stability, their influence on bone healing, and how to apply implants to achieve appropriate stability
This case is of a 24-year-old man with a 12-B2 closed fracture of the humerus.
Learning outcomes:
Describe the reduction goals for diaphyseal fractures
Correlate fracture configuration with type of reduction and stability possible in diaphyseal fractures
Associate type of implant chosen with type of stability produced
Recognize the type of bone healing associated with each type of stability
Describe bone healing in terms of clinical and radiographic criteria.
AOTrauma Basic Principles Course

10. 24-year-old man, motorcycle crash
Blunt thoracic trauma, otherwise stable,
Closed humerus fracture L radial nerve intact
Closed ankle fracture R
Are x-rays provided adequate? - No, you need to see the joint above and below the fracture in every case.
Goals of reduction? - If a plate is used, depending on how it is applied, the reduction and stability could be different.
What type of reduction is planned? - Closed, indirect reduction to restore length, rotation, and alignment.
What type of stability is desired? - Diaphyseal fractures will need only relative stability.
How would you decide which implant to use?

11. 24-year-old man, motorcycle crash1 2 B 2
How would you classify this fracture?
Click after each answer to show results:
Bone? - Humerus (1)
Segment: Proximal end segment (1), diaphyseal segment (2), or distal end segment (3)? - Diaphyseal (2)
Fracture type: Simple (A), wedge fracture (B), multifragmentary fracture(C)? - Wedge fracture (B).
Which group: Intact Wedge (B2)? multifragmentary wedge (B3)? – intact wedge (B2)
Classification: 12B2
Subgroup proximal i/3rd - a, middle 1/3rd – b, Distal 1/3rd -c
Qualifications
Universal modifier

12. Treatment goals Options Timing Patient positioning
Discuss indications for surgery.
What type of stability is desired? - Relative stability is best for diaphyseal fractures.
What is timing for surgery? - Surgery can be done any time, but the likelihood of obtaining a closed reduction is best if done early.

13. 4 days postoperative
What type of stability does this implant provide? - Relative stability
What type of healing do you anticipate? - Indirect healing with callus
What is the aftertreatment? - Functional ROM with load bearing is allowed.

14. Full range of motion of shoulder and elbow
95 days postoperative
No complaints
Full range of motion of shoulder and elbow
Is there any action to be taken?
How do you determine healing?
Clinically with:
Near circumferential bridging callus
No implant breakage or loosening
Painless range of motion

15. Summary and take-home message
Diaphyseal fractures require anatomical restoration of length, rotation, and alignment of the bone.
Relative stability is all that is required for diaphyseal fractures.
An intramedullary nail acts as a medullary splint to provide relative stability.
Indirect bone healing is anticipated with relative stability constructs.
Ask participants to summarize the case discussion.

16. Closed tibial shaft fracture
Cases for small group discussion: General principles, classification, concepts of stability, their influence on bone healing, and how to apply implants to achieve appropriate stability
Simple transverse midshaft tibial fracture (42-A3): In this case, attention to the soft tissue will be given, and relative stability as a treatment principle will be used.
Discussion points:
The discussion should center around absolute and relative stability as principle in general because specific fractures have not been discussed yet.
First start with a quick classification. Then focus on the associated soft-tissue injury and emergency management of the compartment syndrome.
AOTrauma Basic Principles Course

17. 37-year-old male pedestrian, struck by car bumper
GCS < 8
ABC stable
No other injuries
Classification:
What other information would you like to have?
What should the next step be in the assessment of this patient? - To observe the leg.
Stress the importance of clinical evaluation and observation.

18. 37-year-old male pedestrian, struck by car bumper4 2 A 3 4 F 2 B
How would you classify this fracture?
(Click after each answer to show results)
Bone? - Tibia (4)
Segment? – Diaphyseal segment 3
Type of fracture: simple A, wedge B, multifragmentary- C - Simple (A)
Which group: spiral (A1)? Oblique >30° (A2)?, transverse <30° (A3)? - Simple transverse <30° (A3)
Classification: 42A3
Qualification Subgroup proximal i/3rd - a, middle 1/3rd – b, Distal 1/3rd -c
Universal modifiers

19. 4 hours after trauma
Discuss the amount of soft-tissue trauma resulting from a car bumper injury.
Repeat importance of soft tissue for bone healing.
Discuss difficulties in assessment of soft tissues in closed fractures.
What would you be looking for in this clinical situation? - Answer: compartment syndrome
Discuss the cardinal symptoms of compartment syndrome:
Pain
Palor
Pulselessness
Pressure
Paresthesias
Which symptoms are most likely to develop?

20. 4 hours after trauma
Discuss the classification of soft-tissue injuries to get an appreciation of the spectrum of potential soft-tissue damage, even in a closed fracture.
What is the next step in the treatment of this patient?

21. Discuss the treatment options for compartment syndrome: diagnosis and indications for surgical treatment.
Stress the emergency nature of the condition.
How do you proceed? - Immediate 4-compartment fasciotomies, preferably through one incision.

22. 37-year-old male pedestrian, struck by car bumper
42-A3 closed fracture
Compartment syndrome
Discuss if and how the treatment options for the bony injury are influenced by the soft-tissue condition.
Does the treatment change? - In this case, probably not.
What are the options for the treatment of this fracture in light of the compartment syndrome?
Intramedullary nailing. Surgical stabilization of the bone with IM Nail would also help to stabilize the soft tissue.
Plate stabilization
External fixation
What type of stability will these types of treatment provide?

23. The fracture was stabilized with a reamed, interlocked intramedullary nail. What type of stability does this provide?

24. Summary and take-home message
Every injury has two components; a bony injury and a soft-tissue component.
The soft-tissue injury is just as important as the bony injury.
In complex injuries, it is important to prioritize the individual injuries.
Treatment of the compartment syndrome mandates the stabilization of the bony injury.
Ask participants to summarize the case discussion.

25. Forearm fractures
Case for small group discussion: General principles, classification, concepts of stability, their influence on bone healing, and how to apply implants to achieve appropriate stability
This case is of a 27-year-old man, polytrauma patient, with a closed forearm fracture (22-A2).
Learning outcomes:
Relate fracture type with the reduction needed and type of stability desired.
Discuss the goals of treatment for both bone fractures of the forearm.
Identify the function of the implants used and how they relate to reduction, stability and healing.
AOTrauma Basic Principles Course

26. 2 R 2 A 2 2 U 2 A 2 27-year-old man Polytrauma Closed injury
The emphasis in this case is the type of reduction and stability that can be achieved.
Classify this fracture 2R2A2 for radius 2U2A2 for ulna
Bone: Radius/ulna (2R/ 2U) Segment: Diaphyseal (2)
Fracture type: simple (A), wedge (B), or Multifragmentary (C)? - Simple (A)
Groups Spiral-1, Oblique -2 Transverse -3
Qualifications proximal i/3rd - a, middle 1/3rd – b, Distal 1/3rd -c
Primary or secondary bone healing?
How would you achieve your choice?
Which group?
A1: Ulna fractured, radius intact
A2: Radius fractured, ulna intact
A3: Radius and ulna fractured

27. 27-year-old man Polytrauma Closed injury
What type of reduction would you like to achieve? - Anatomical reduction
Does the forearm follow the principles of treatment of diaphyseal fractures? - Yes. The goal is to obtain anatomical restoration of the length, rotation, and alignment of both the forearm bones. The forearm is least forgiving of all diaphyseal fractures to reduction requirements.
What type of stability would you like to achieve for these fractures? - Absolute stability.
What implants are available to achieve this type of stability? – DCP, LC-DCP. With or without lag screw across the fracture (best stability).
What kind of bone healing would you expect with this type of fixation? - Direct bone healing with little to no callus.
Will this fixation allow early ROM? - That is the goal and can be achieved if done properly.

28. Fracture lines cannot be seen, implying anatomical reduction.
Can direct direct bone healing be expected in both these fractures? - Yes
How does the plate on the radius function? - Neutralization or protection plate.

29. Plate on the radius: The middle two screws are considered interfragmentary compression screws. The plate provides stability as a neutralization or protection plate to protect the lag screws.
Why is this called a “neutralization” plate. What is it neutralizing? - There are external forces on the forearm that include gravity, muscle contraction, range of motion of the joints and rotation of the forearm that could potentially overcome the stability of the lag screws. The plate “neutralizes” these forces and protects the integrity of the primary lag screw fixation.
Are you worried about periosteal stripping and bone vascularity?

30. Summary and take-home message
The fracture configuration will usually indicate the type of reduction that is possible and the type of fixation that is desired.
The goals of treatment of diaphyseal forearm fractures are anatomical restoration of:
Length
Rotation
Alignment
Each implant can function in several ways.
The method of application of the plate determines its function.
Ask participants to summarize the case discussion.

31. Open forearm fractures
Case for small group discussion: General principles, classification, concepts of stability, their influence on bone healing, and how to apply implants to achieve appropriate stability
This case is of a 32-year-old man, motorcycle accident, isolated open injury.
Learning outcomes:
Review the classification of forearm fractures
Understand the benefits / difficulties of direct (open) versus indirect (closed) reduction
Consider the optimal fixation for bone healing― absolute or relative stability
Discuss postoperative treatment
Case prepared for Davos Principles Course Used with kind permission.
AOTrauma Basic Principles Course

32. 32-year-old man Motorcycle accident Isolated injury Open
Classify this fracture 2R2B2 for radius 2U2B2 for ulna
Bone: Radius/ulna (2R/ 2U) Segment: Diaphyseal (2)
Fracture type: simple (A), wedge (B), or Multifragmentary (C)? - Simple (A)
Groups: Intact wedge-B2, Fragmented wedge –B3
Qualifications proximal i/3rd - a, middle 1/3rd – b, Distal 1/3rd -c
Primary or secondary bone healing?
How would you achieve your choice?

33. 2 R 2 B 2 2 U 2 B 2 How would you classify this fracture?
Click after each answer to show results:

34. 32-year-old man
How would you expect these fractures to heal?

35. 6 months
Absolute stability =
direct healing without callus
Bridge plate =
Relative stability =
indirect healing with callus

36. 6 months
Absolute stability =
direct healing without callus
Bridge plate =
Relative stability =
indirect healing with callus

37. Summary and take-home message
Forearm fractures, because of their low tolerance for any deformity, should be treated with the principles of articular fractures.
Preoperative planning is essential for better patient outcomes.
The importance of restoration of the anatomical limb axis is stressed.
The fracture configuration will usually determine the type of stability attainable and the type of implant to be used.
Ask participants to summarize the case discussion.
Module 3, case 4 (slide 8of 8)

38. Open diaphyseal tibial and fibular fracture
Case for small group discussion: General principles, classification, concepts of stability, their influence on bone healing, and how to apply implants to achieve appropriate stability
This case is of a 36-year-old male riding on his motorcycle who crashed into large post, isolated injury, NV intact (42-B3). This case emphasizes the dilemma of severe bone and soft-tissue injuries. Meticulous debridement and irrigation of the soft tissue wounds followed sequentially by stabilization of the boney injury and soft tissue coverage should proceed in a logical fashion determined by the extent of the injuries.
Learning outcomes:
Describe the initial management of open fractures.
Outline the definitive management of soft tissues and open fractures.
Consider shared care of severe soft-tissue wounds with plastic surgeons.
AOTrauma Basic Principles Course

39. 36-year-old man, motorcycle crashed into large post
Isolated injury
NV intact 4 2 B 3 4 F 2 B
How would you classify this fracture?
(Click after each answer to show results)
Bone? - Tibia (4)
Segment? – Diaphyseal segment 2
Type of fracture: simple A, wedge B, multifragmentary- C - Simple (A)
Which group: Intact Wedge B2, Fragmented wedge –B3
Classification: 42B3
Qualification Subgroup proximal i/3rd - a, middle 1/3rd – b, Distal 1/3rd -c
Universal modifiers

40. 42B3 tibia 4F2B fibula How would you classify the soft-tissue injury?
What Gustilo type? – Type III-B
What now?
When?

41. Postoperative x-ray
Provisional fracture stabilization has been achieved. What do staples indicate?
Definitive coverage of the wound with a musculocutaneous flap.
Discuss again the principle of viable soft tissue as a first concern followed by fracture stabilization.
Also talk about using the external fixator as reduction tool later.

42. Summary and take-home message
Accurate classification of the bone and soft-tissue injuries will help you understand the injury.
Often, classification of bone cannot be determined until after reduction.
Often, classification of the soft-tissue injury cannot be determined until after the first debridement.
Stabilization of the bone with an external fixator will allow better soft-tissue care.
Early soft-tissue coverage should be accomplished as soon as allowable.
Ask participants to summarize the case discussion.