1. 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

2. 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

3. 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

4. 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

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

6. 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?

7. 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 Nov;13(8):550-3.

8. 6 months after reoperation good bony healing and the patient was asymptomatic
Discuss aftertreatment

9. 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.

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

11. 35-year-old man, motorcycle accident
How do you classify these fractures?
33C2.(j)- femur
42A3.(c)- tibia
4F1A -fibula

12. 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

15. Postoperative
x-rays

16. Postoperative
x-rays

17. Postoperative x-rays

18. 4 months postoperative

19. 4 months postoperative

20. 4 months postoperative

21. 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.

22. 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

23. 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:
Case history: fell down the stairs
Diagnosis: fracture of the right lower leg : Gustilo II open, AO 42 C1, compartment syndrome
Surgical treatment:
: Antibiotic Coated Nail (11x390), soft tissue treatment => fasciotomy
17./ : wound revision => syspurderm change
: wound revision, secondary suture

24. 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

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

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

27. 6 week follow-up: Partial weight bearing Moderate swelling
Normal range of motion knee and ankle
Discussion points:
Bone healing progress

28. 3 month follow-up:
Full weight bearing
Increasing consolidation

29. 12 month follow-up: Full weight bearing Fracture consolidation
Normal function
Full range of motion knee and ankle

30. 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.

31. 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

32. 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:
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:
: external fixator right lower leg, soft tissue treatment , thoracotomy, partial pneumonectomy left side
: procedural change external to internal fixation, removal external fixator  Antibiotic Coated Nail (10x390), revision of hematoma

33. 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

34. 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

35. 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

36. 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

37. 6 month follow-up Full weight bearing Soft tissues healed
Fracture healed
Normal range of motion
Back to work, full time

38. 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.

39. 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

40. 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?

41. 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

42. 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

43. Soft-tissue status 2 months post IM nail

44. 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)

45. 8 months after injury: Removal of external fixation
Discussion points:
Locking techniques

46. Complete bony consolidation at 13 months

47. 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.