Copyright Š 2017 by ASOP Publishing
All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher except for the use of brief quotations in a book review. Printed in the United States of America First Printing, 2017 ISBN 978-1-64136-747-9 ASOP Publishing PO BOX 7440 Seminole, FL 33775 www.asop.org
ACKNOWLEDGEMENTS
O
ver the years, there has been considerable change in fracture management. The evidence-based approach to fracture care and the recent healthcare changes have certainly provided the impetus for a transition in contemporary orthopedics. However, there are those who have held steadfast in their approach to fracture management with select non-operative techniques. The American Society of Orthopedic Professionals (ASOP) would like to recognize the fine work of Drs. Gus Sarmiento, Loren Latta and Keith Vanic on this text that will further challenge the thought process and practice management of modern orthopedic procedures. ASOP has a long collaborative tradition in bringing the best approaches and techniques in the instruction of orthopedics and the evidence-based approach regarding current techniques in fracture management. This recent work “Objectivity in Fracture Care” will further test the collective thought for fracture management – particularly with our new millennial residents entering this ever changing and confusing healthcare arena. The orthopedic world needs those individuals that will persist and withstand the pressures of common practice. Undoubtedly, “Objectivity in Fracture Care” provides the salient features to transpose current supposition.
Charles Barocas, CO Executive Director
i
Table of Content
Contents ACKNOWLEDGEMENTS ............................................................................ i INTRODUCTION .......................................................................................... 1 ACROMIO-CLAVICULAR DISLOCATIONS .......................................... 7 CLAVICLE FRACTURES. ......................................................................... 27 HUMERAL SHAFT FRACTURES ............................................................ 61 COLLES FRACTURES ............................................................................... 83 EPILOGUE ................................................................................................... 97 REFERENCES ........................................................................................... 100
ii
INTRODUCTION
I
n the last few decades, the fracture management techniques have experienced profound changes. Within such areas, particularly those affecting long bones, the metamorphosis has been spectacular. Many fractures that were previously associated with serious complications or required prolonged hospitalization that frequently followed by death have rapidly become acceptable protocols for new treatment modalities. The revolution in fracture care ensued almost exclusively in the surgical arena. Similar progress in the non-surgical field was noticeably by comparison much smaller. . Initially, hip fractures and the femur appeared the benefit greatly from these new advancements. Surgical stabilization with metallic plates resulted in discontinuance of the previously required lengthy hospitalization and bed confinement. Despite the fact that there seemed to be the incidence of new complications, such as anesthesia administration and post-operative infections, these problems were gradually reduced by prophylactic methods, followed later by the invention of effective antibiotics and a better understanding of the mechanisms that favor contamination. As time and technique advanced, other fractures of long, as well as, short bones became surgical subjects with varying degrees of success. Eventually, every type of fracture scenario was considered to be appropriate for surgical methods. The surgical implant manufactures became major players seemingly overnight in the care of fractures and within a few years their newly acquired economic power became a dominant factor in patient care. The competition between these new and wealthy companies was overwhelming. Every hospital where surgery was performed became a customer.
1
A virtual orgy over the new and different implants dominated the spectrum of fracture care. Every company frequently brought forth modified implants hoping to gain additional prestige and wealth. Nonetheless, the fact remains that nature’s means of fracture healing in homo sapient as well as in the animal kingdom is the only true physiological mechanism that clearly illustrates the manner in which healing takes place. The sudden presence of a fracture is associated with bleeding and the subsequent invasion and appearance of capillaries. This latest phenomenon is the subsequent result of the inflammatory response and is further enhanced by the agreement that continued motion begets at the fracture site. When a fracture on a long bone is rigidly immobilized with an implant, the vascular picture does not transpire in the aforementioned manner. When rigid immobilization is not fashioned, the surrounding capillaries undergo metaplasia and their cells become bony structures. As such, this certainly fortifies the explanation why sequential radiographs of a healing diaphyseal fracture demonstrate final callus formation of greater diameter than the rest of the bone. Furthermore, this confirms the fact when comparing the force necessary to create a new fracture following removal of a plate with a similar fracture that had healed in the presence of physiological motion. As such, the latter overwhelmingly illustrates the greater strength of the bone. Following the removal of the plate the bone usually shows a thinner cortex and therefore a weaker bone. Such a mechanical environment explains why re-fractures are more likely to occur in bones previously treated with plates that were subsequently removed. Current trends emphasize the importance of anatomical reduction of fractures. Though the concept is medically sound, such techniques have become a mandate among an overwhelming percentage of orthopaedic surgeons. The presence of any deviation from the normal is considered to be unacceptable. In our ever growing litigious medical 2
society, there is an overpowering fear by orthopedic surgeons who feel obligated to follow such a mechanical manipulative “trend” of fracture management for fear of litigation. The current treatment philosophy is fast changing the orthopaedic discipline from a scientific profession into a series of surgical techniques and transforming the orthopaedist into a cosmetic surgeon of the skeleton. Furthermore, and of greater significance, is the easily identifiable loss of objectivity that has crept into the orthopedic profession. The obsession with the need to obtain anatomical reduction in all fractures, not infrequently results in damage to patients. Despite the fact that in contemporary orthopaedics, the surgical treatment has proven superior to the conservative approach in many instances, there are many instances when a non-surgical approach is the best method. Patients of advanced age suffering from cardiac or other debilitating conditions are a good example. The clinician should not morally justify subjecting those patients with fractures who may likely respond to simple non-surgical modalities to the risks of anesthesia and surgery. Additionally, such subjugation for the sole purpose of obtaining radiographs showing “perfect” reduction of their fractures even if an imperfect reduction has absolutely no clinical adverse consequence. Likewise, patients suffering from chronic diseases, such as significant diabetes, who provide a history of frequent infections, and those with degenerative conditions such as severe osteoporosis that may seriously compromise the maintenance of the fixation provided by the stiff plate. Nonetheless, there are many situations even in the presence of the above-mentioned problems when surgical intervention is justified.
3
Patients with fractures of long-bones in the upper and lower extremity who are treated nonsurgical and culminate into inconsequential deformities (i.e., a few degrees of angulation or malrotation), should not be subjected to surgery unless the indications and possible complications are carefully identified. We cannot think of a better argument to support assessment than to objectively observe the results from nonsurgical care of many fractures in poor countries where modern surgical treatments are not available. One would be astounded to appreciate how many patients with resulting anatomical deviations function virtually normally. This comment is not an endorsement or acceptance of such an unfair situation, which is begging for a solution, but simply a plea for objectivity. It is not at all difficult to fully appreciate the grounds for the rapid evolution of contemporary orthopaedics. The surgical approach to fracture care is most attractive to a large segment of medical students considering the choice of their perspective practice. In addition, and perhaps even more importantly, is the fact that they have learned that the personal financial reward from surgical care versus conservative management is quite substantial. This attitude has been strongly reinforced by the support of the attractive Orthopaedic Guidelines by virtually all political and academic organizations. The widely accepted fragmentation in orthopaedics provided the fertile grounds for the birth and growth of Orthopaedic Guidelines. The perception and grounded support was hastened by the rapid increase in the percentage of subspecialists. Such acceleration was creating difficulties in ensuring the definition of appropriate treatments, prevent abuses, and to establish a more desirable moral and ethical environment. Unintended consequences, however, began to emerge. 4
Guidelines, as structured are prepared by small groups of alleged unbiased individuals identified as specialists in the given areas. However, their impartiality and wisdom cannot be guaranteed. They are burdened with the same prejudices and biases that all humans share and are likely to make pronouncements they consider closest to ideal but subject to error. In doing so, they inadvertently deny the masses the right to freedom of speech and independent judgement that we so highly value in our society. The Guidelines are easily misunderstood as “mandates� to be obeyed. The fear of litigation when a complication occurs or the unanticipated clinical result by the patient can easily become a reality. The surgeon is accused of ignoring the Guidelines that represent best practice to the given orthopaedic problem. If this trend becomes widespread, progress is hindered and the enforced herd-mentality will demean the discipline. Rather than expecting orthopaedists to follow specific guidelines for every condition, they should be encouraged to take advantage of the readily available and robust educational opportunities: medical journals, post-graduate seminars and courses, conferences and other venues abound. Orthopaedic Guidelines will not be the answer to the current dilemma. An emergent effort by our orthopeadic representative organizations is more likely to have that needed effect to clearly appraise our current trend in fracture management and further realize the chronic manifestations it will have on our professional outlook. We as individuals should use our influence to support the project while reinforcing to the current and incoming classes the fact that Orthopaedic is a Profession and not strictly a business. For the remainder of this text, we chose four traumatic conditions common in the upper extremity. The authors strongly believe that we are qualified to discuss the subject matter because of a lifetime 5
commitment to patient care, research and teaching that afforded sufficient knowledge to justify rendering unselfish critical opinions. The future of our medical discipline is based on a serious restoration of the basic tenets that made Medicine one of the most respected and noble professions in the world. The exaggerated emphasis in profit and the unwise extreme involvement of “industry� within the field of medicine should be radically modified despite the fact that its involvement is essential.
6
ACROMIO-CLAVICULAR DISLOCATIONS
O
ver the years, open reduction internal fixation (ORIF) of the dislocated acromioclavicular joint has been a popular surgical procedure. However, the complication rate is quite high. The reduction is frequently unsuccessful and a re-dislocation most likely occurs. The mechanical stresses on the immobilized A-C joint continue despite the metallic fixation. Eventually, the patient may result in the development of an incongruous joint leading to osteoarthritis. At this point, the only viable option is resection of the distal end of the clavicle.
7
REPRESENTATIVE EXAMPLES OF CONSERVATIVE TREATMENT
T
he conservative treatment described in this text consists simply on the acceptance of the dislocation without any attempt to restore normal anatomy. Such an approach is based on the fact that considerable attempts in the restoration of anatomical reduction fails to provide a good patient result on most occasions. The reduction is difficult to maintain and a subluxation frequently develops which ultimately leads to osteoarthritis. On the other hand, in the complete absence of contact between the two involved bones most likely will preclude the development of such pathology. The pain that necessarily appears following the untreated joint disappears spontaneously. What has traditionally been a concern is the cosmetic implication of the dislocation resulting in an unsightly deformity. Conservative treatment is not being suggested as paramount but one treatment approach.. It is, however, a method to be considered since the culminating results are satisfactory in many instances as illustrated in this text. In addressing the overall issue of reduction versus no- reduction, the most important consideration is the ultimate function. If the deformity produced by the dislocation is obvious to the naked eye, surgery becomes a serious consideration. However, if the deviation from the normal cannot be detected by casual clinical observation but the function of the shoulder is painless and normal, surgery becomes questionable. Can one comfortably subject a patient to the risks of anesthesia, infection, additional surgery for removal of the implant, and other possible complications, simply to eliminate an inconsequential anatomical and merely cosmetic deviation?
8
CASE 1.
9
Radiograph of a dislocated clavicle with the patient demonstrating the painless function of his injured shoulder a few months after the initial accident. Only under close scrutiny can he “lump� be noticed. This example presents the questionable justification for surgery to correct a non-existing problem. Case 2.
10
Radiograph of a dislocated acromioclavicular joint. Patient demonstrates pain free range of motion of his shoulder a few months after the injury. The photos do not show any cosmetic deformity. The from-behind photograph illustrates the best view of the elevated distal clavicle. Case 3.
11
Radiograph of a dislocated acromioclavicular joint. The patient demonstrating pain free range of motion of his shoulders. The presence of the deformity is readily apparent. The question that arises is whether cosmetic surgery justified. Note the calcification of the surrounding ligaments.
12
Case 4.
Radiograph of a dislocated acromioclavicular joint. This older patient demonstrates shoulder range of motion several months after the injury. Some discomfort was still present but anecdotally improving. 13
CASE 5.
Acromioclavicular dislocation. The patient was polytraumatized and rendered wheelchair bound. He demonstrates shoulder function three months following initially injury.
14
Case 6.
Acromioclavicular dislocation. Patient demonstrated shoulder function approximately two and one half months later. The deformity is visible only when observed at a close proximity.
15
Case 7.
Acromioclavicular dislocation. Patient illustrates the function of his shoulders a few months after the initial accident.
16
CASE 8
17
Acromioclavicular dislocation. Patient demonstrates the function of his shoulders several months later. Case 9.
18
Acromioclavicular dislocation. Patient demonstrated pain free shoulder function a few months after the initial insult. A close view of her right shoulder makes the deformity more obvious. The question to be answered is whether a surgical scar would have been less noticeable?
19
CASE 10.
Acromioclavicular dislocation treated with a sling. Patient demonstrates the function of her shoulders approximately three months later. Her injured shoulder is still mildly symptomatic but gradually improving. 20
CASE 11.
21
Acromioclavicular dislocation treated conservatively. The patient illustrates shoulder range of motion several months after the injury. The “lump’ is recognizable particularly when adduction is performed. CASE 12.
22
Acromioclavicular dislocation treated conservatively. Patient demonstrates the asymptomatic function of his shoulder a few months after the initial injury. Case 13.
23
Dislocated acromioclavicular joint. The patient demonstrates the function of his shoulders approximately two months later. Case 14.
24
A dislocated acromioclavicular joint. Two months later the patient demonstrates shoulder function and is still experiencing some discomfort. The deformity is best recognized on the photo taken from behind.
25
Case 15.
Acromioclavicular dislocation. Patient demonstrates pain free shoulder function approximately three months after the initial injury. Can we say that surgical stabilization would have provided a better clinical result?
26
CLAVICLE FRACTURES. NON-SURGICAL TREATMENT
T
he non-surgical treatment of clavicular fractures is applicable to the vast majority of these orthopaedic cases. The surgical treatment has received a great deal of attention in recent years with obvious improvement in the management of difficult fractures. However, it appears that this particular technique has been abused to a great degree. Minor residual deformities that are produced by angulation are usually inconsequential. Non-unions can be treated when proven to be painful after a reasonable period of observation. Rushing into surgery because the callus does not appear early enough cannot be justified. In most instances, either the callus eventually becomes visible or its absence is inconsequential. The possibility exists that the observable absence of early bony callus in some instances may be due to the fact that the clavicle has centers of ossification different than other long bones. As such, this might explain the not infrequently observed delay in the formation of a bony bridge. A fracture that does not show bony bridging may be stable since fibrous cartilaginous tissues can provide all the necessary stability and without pain. The pace of osseous healing has not been clearly determined in the literature. Often such type of healing takes place outside the commonly accepted range. However, if in the absence of bony bridging, the fracture is painless and function is normal, can we justify surgery simply to obtain a radiograph showing “healing” even though the chances of complications are not significant”? In this chapter, we will illustrate several clinical examples of clavicular fractures that despite angular deformities the clinical results were very satisfactory. In other instances, the same was true even though bony bridges was not evident. 27
THE SLING:
The Clavicular sling is usually applied a few days after the injury occurs. The extremity is to be made gradually functional as the symptoms subside. Frequent adjustments should be made as the symptoms decrease.
28
CASE 1. A
B
29
a. Initial b. approximately two and one half month radiographs showing no evidence of early bony callus formation. Active shoulder motion was occasionally symptomatic but gradually improving. CASE 2.
30
a. Radiograph of displaced fracture. b. Last radiograph obtained two months later. No evidence of early callus observed. At that time the function of the asymptomatic shoulder is demonstrated. No further follow-up was available.
CASE 3. A
B
31
a. Initial radiograph. b. Radiograph obtained three months later. Minimal amount of callus formation observed. At that time the shoulder was asymptomatic and its range of motion virtually normal. CASE 4. A
B
32
a. Initial radiograph. b. Radiograph obtained two and one half month later. The shoulder is asymptomatic but some limitation of motion is evident. No evidence of bony callus is demonstrated. CASE 5 A
B
33
a. Initial Radiograph. b. Radiograph obtained three months later. The shoulder is asymptomatic and the film does not show evidence of bony union. CASE 6. A
B
34
Long oblique fracture showing the original shortening and the lack of radiologically visible callus three months later. We do not know if bony callus eventually appeared. This feature is inconsequential since the shoulder is clinically symptomatic.
35
Case 7. A
B
The radiographs of this clavicle fracture displays the initial displacement and the absence of visible bony callus approximately three months later. The shoulder is asymptomatic. It is not likely that surgical stabilization would have rendered a better clinical result.
36
CASE 8. A
B
Radiographs illustrate the initial displacement of the fragments and the presence of early callus approximately two and one-half months later. The shoulder was pain free at that time and likely to have remained subsequently asymptomatic.
37
CASE 9.
38
Radiographs showing the initial displacement and comminution of the fragments and the absence of visible callus three months later. The function of the shoulders is asymptomatic. CASE 10.
39
Radiographs illustrate a displaced fracture and the close approximation of the fragments three months later. The injured shoulder was asymptomatic. CASE 11.
40
Radiographs illustrate the clavicle fracture initially and approximately three months alter. No callus was visible but the function of the shoulder was virtually normal. CASE 12.
41
Initial and two and one half month old radiographs showing what appears to be early bridging callus. CASE 13.
Initial and four month old radiograph illustrate the improved alignment of the fragments and early bony bridge. Function was pain free.
42
CASE 14. A
B
43
Initial and approximately two- month old radiograph demonstrate the comminution of the fracture but no evidence of early bony callus. The function of the shoulder was almost normal and improving.
CASE 15. A
B
44
Initial and four month old radiographs showing the unchanged position of the fragments, but no clear evidence of callus formation. The function of the shoulder was pain free. CASE 16.
45
Initial and two and one half radiographs show the improved alignment of the fragments but no clear evidenced of bony callus. The function of the shoulder was only minimally symptomatic.
CASE 17. A
B
46
Initial and four month old radiograph illustrate what appears to be bony union. The function of the shoulder was asymptomatic.
CASE 18 A
B
47
Initial and three month old radiographs show the improved alignment of the fragments but no evidence of bony callus. The function of the shoulder was minimally symptomatic. The final deformity is difficult to recognize. CASE 19. A
B
48
C
Initial and one and two and one half month-old radiographs. Evidence of early bony callus observed. Range of motion of the shoulder is asymptomatic and the deformity difficult to visualize.
49
CASE 20.
50
Initial and approximately three month old distal fracture. No evidence of callus is observed but the shoulder is asymptomatic.
Case 21.
51
Radiographs showing mild overriding of the fragments. The fracture was treated conservatively. Patient demonstrates restricted shoulder abduction and external rotation.
CASE 22.
52
Initial and three month old radiographs. No evidence of callus is present. Active range of motion of the shoulder is asymptomatic. The deformity is easy to recognize. We doubt a surgical scar would have rendered a better clinical result. EXAMPLES OF PLATING
T
he following are examples of a successful as well as unsuccessful instance of clavicle fractures treated with plate fixation. CASE 1.
Radiographs of successfully plated clavicular fracture.
53
CASE 2.
Failed plated clavicular fracture. No details are available regarding the impetus for this particular scenario. CASE 3.
54
Mid-clavicular clavicle fracture stabilized with two plates. Approximately one year post-surgery the patient was involved in an automobile accident that yielded a new fracture at the stiffer plated and slightly flexible non-plated junction. The photograph illustrates the resulting surgical scar. CASE 4. A
B
55
C
D
Representative example of a failed plated clavicle. The plate came unattached during a bicycle accident nearly two years after the initial fracture. III INTRAMEDULLARY NAILING
T
he following are representative examples of successfully as well as unsuccessfully treated clavicular fractures with the use of an intramedullary nail. CASE 1.
Pre and post-operative radiographs of a nailed clavicle fracture. No further follow-up radiographs were available. 56
CASE 2. A
C
B
D
57
E
a. Sequential radiographs of clavicle treated with an intramedullary nail. b. Three months after surgery there was no evidence of bony callus. c. Five months later, and in the absence of healing, the nail was noticed to have bent. d. Two months later the nail broke and the fragments displaced. e. The nonunion was treated with an intramedullary nail and a bone graft held in place with circular wires. CASE 3. A
B
58
Clavicle fracture successfully treated with an intramedullary nail. Patient demonstrates shoulderrange of motion seven weeks after surgery. The scar is a very minimal. CASE 4.
59
Clavicle fracture treated with an intramedullary nail. Notice the migrating nail compromising the subcutaneous skin.
60
HUMERAL SHAFT FRACTURES FUNCTIONAL BRACING
A. Initial long-arm cast stabilizing the elbow at ninety (90) degrees of flexion. B. Functional brace and supportive sling usually applied a few days after the initial injury.
61
A soft sleeve is rolled over the upper arm.
The selected brace is placed over the injured upper arm The straps are tightened without applying excessive pressure. The shoulder should be relaxed during the process. A sling is then applied.
Passively, the elbow is extended. Once again, the elbow is flexed to ascertain that motion of the elbow will not be compromised. The sling is re-applied.
62
First with the sling in place, and gradually without it, pendulum exercises are performed several times throughout the day. As the swelling decreases, it is important to adjust the tightness of the brace in order to enhance its stabilizing effect. CASE 1.
63
Open fractures are more likely to experience subsequent complications. Healing time with open fractures is usually longer with the possibility of delayed unions and non-unions occurring. Nonetheless, functional bracing is often an appropriate treatment. CASE 2.
64
Obese patients are more likely to heal with residual angular deformities. However, the adipose tissues surrounding the angular deformity often prevents it from becoming noticeable with observation. Though the fracture was healed, this patient was still experiencing difficulties regaining full range of motion.
65
CASE 3.
Plating of humeral fractures is a proven and effective method of treatment and not infrequently the most appropriate one. Those with severe angular deformities not correctable by the application of a cast or brace, as well as some poly- traumatized patients are best treated in this manner. Fractures associated with nerve injury are usually best treated with plate fixation. When the plated fractures are close to the elbow joint, limitations with range of motion usually last longer. 66
CASE 4. A
B
67
Minimally displaced fracture with unremarkable healing and without any limitation of motion of the shoulders or elbows. CASE 5. A
B
Example of a failed plate fixation. It appears that the length of the plate and the number of screws stabilizing it were appropriate. We have no history of the events that led to the complication. 68
CASE 6.
69
Representative example of the relationship between radiological and clinical appearances. To surgically eliminate the bony deformity and to correct a virtually non-existent clinical problem is difficult to justify.
70
CASE 7. A
B
Quite often the initial overlapping deformity spontaneously improves following introduction of gravitation forces and the compression provided by the brace. The residual shortening of the humerus and the angular deformity are totally inconsequential since cosmetically and functionally they cannot be detected.
71
CASE 8. A
B
C
This type of comminution, despite the proximity of the shoulder joint and virtual exclusion of the fracture from the upper end of the brace, constitutes one of the best fractures for rapid fracture healing in good alignment. Minimal shoulder subluxation is visualized herein and disappears with the gradual increase of activity. CASE 9
72
Transverse, angulated fracture that united with excellent alignment and shortening. This reduction was carefully conducted under sedation and the alignment of the fresh fracture can be improved. Pressure on the lateral aspect of the fracture with counter pressure over the medial aspect of the elbow can in most instances will improve (minimize) the deformity. The subsequent use of the brace and the introduction of gravity further improved the alignment. CASE 10. A
C
B
D
73
Representative example of the correlation between radiologically evident angular deformity and the clinical reality. It is difficult to believe that a surgical correction would have provided better function in this polytraumatized patient who had become paraplegic. A
B
C
74
An oblique fracture that healed with excellent alignment as treated with a functional brace. The close proximity of the fracture to the shoulder joint does not preclude the successful use of the nonsurgical method of treatment. The residual shortening is inconsequential. A
B
75
Severely displaced segmental, comminuted fracture of the proximal end of the humerus and treated with a functional brace. (Borrowed from The Nonsurgical Treatment of fractures in Contemporary Orthopaedics. Jaypee. A. Sarmiento, M.D and Loren L. Latta, PhD. CASE 13.
76
Mid-third humeral fracture illustrating progressive healing. Notice that the angular deformity seen on the radiographs are not clinically detected.
77
CASE 14. A
B
78
Fracture of the left humerus sustained by this right upper extremity amputee. He had lost the arm following a severe injury that called for the ablation procedure several years earlier. Notice the function of his shoulder. CASE 15.
79
Comminuted fracture that healed with a varus deformity. In this instance, the clinical photograph shows the inconsequential deformity when the elbow is extended. Otherwise, the function of the shoulder is normal.
80
Transverse humeral fracture that healed with a varus deformity. At the time of radiographic examination, the patient is still in the brace. No photos were available after removal of the brace. CASE 17.
81
Fracture of the distal humerus that healed with varus and anteroposterior angulation. A delay in treatment with a functional brace was rendered five weeks after the initial insult. At such time the deformities were rather firm.
82
COLLES FRACTURES
M
ost fractures located on the distal metaphysis of the radius, with or without intraarticular involvement, are usually classified as Colles Fractures and until recently treated by non-surgical means. However, in more recent days, surgical management has gained a great deal of attention which has subsequently resulting in improved outcomes (particularly when dealing with severe intraarticular fractures). It must be kept in mind that traumatic disruption of articular surfaces of any joint may result in secondary osteoarthritic changes. The mechanism of injury also appears to be a factor with severe direct impaction being the most likely etiology. However and contrary to such premise, we suspect that the Colles fracture, despite the fact that virtually without exception is the product of severe vertical impaction, the incidence of wrist osteoarthritis may not be greater when compared to other major joints. At this point, the vast majority of Colles fractures may be successfully treated by manipulation, reduction, and immobilization in casts or braces. We have used this fracture to illustrate the fact that objectivity is needed when determining the choice of treatment. Subjecting all such patients to surgery in an effort to restore anatomical reduction and failing to keep in mind that acceptance of some malalignment does not preclude good asymptomatic function. Furthermore, surgery does not guaranty complete restoration of motion. Quite the contrary, surgery not infrequently is associated with greater limitation of motion when compared with nonsurgical treatment accompanying some deformity. This argument gains greater power when dealing with the elderly suffering with osteoporosis. Subjecting them to surgical interventions without realistic expectations must be questioned. Even though immobilization in forearm pronation and ulnar deviation is the commonly used method of treatment, we have come to the conclusion that the most logical position of immobilization is that of 83
supination of the forearm, and ulnar and volar deviation of the wrist. The aforementioned comes only after considerable clinical laboratory and scientific investigation. The above is based on the fact that since the brachioradialis muscle, which is attached to the dorsal-lateral aspect of the distal radial epiphyses of the radius, can displace the reduced fracture in a dorsalradial direction when it contracts. This is more readily discerned when the fracture is markedly oblique. Active flexion of the elbow or wrist triggers the contraction of the muscle and can recreate the original deformity. The pronation position of the forearm favors the contraction. On the other hand, supination silences the action of the muscle and in this manner eliminates the most important deforming force. The method of treatment in supination appeals to the application of the original cast with the elbow flexed at nine degrees, the forearm in supination and the wrist in volar and ulnar deviation. After a couple of weeks in this position, the cast is modified to allow limited motion of the elbow and flexion of the wrist - while still preventing radial deviation and extension of this joint. A new cast is molded around the elbow in a manner that allows full flexion, approximately 20 degrees of extension, as well as pronation/supination movements. The technique for functional, nonsurgical treatment is illustrated with a few representative clinical examples.
84
THE TECHNIQUE OF NON-SURGICAL TREATMENT
J
ust prior to the application of the cast, it is best to hold the arm in traction for a few minutes. This facilitates regaining length in some instances and reducing the radio-ulna dislocation. The procedure is carried out under local or general anesthesia
With the wrist in flexion and the forearm in pronation pressure is applied over the distal radius. After this stage is complete, the forearm is 85
rotated into supination while maintaining the volar and ulnar deviation of the wrist.
After wrapping the arm with a cotton bandage, plaster of Paris is used to cover the entire elbow, forearm, and wrist. The distal aspect of the upper arm is compressed in order to keep to a minimum any pronosupination.
86
The completed cast illustrating the final position of the various joints. If this modified cast is applied after the acute stage of healing had terminated and pain and marked swelling are no longer apparent, the cast is further modified. Otherwise, additional modifications are made at a later date. Those final modifications are aimed at not restricting the elbow and the wrist.
87
Notice the position of the elbow and wrist and the degree of possible extension of the elbow. THE FUNCTIONAL BRACE
T
he functional cast applied during the initial stage of care can be duplicated a few days later with a plastic brace that reproduces the technique just described. The material utilized is Orthoplast which is relatively stiff but becomes flexible as it is heated in water. In this new condition, the plastic is wrapped over the forearm, distal upper arm, and wrist.
88
Once the material is dry, the modifications are made to allow flexion of the elbow, limited extension and flexion of the wrist. Extension of the wrist is prevented as well as radial deviation. THE PRE-FABRICATED BRACE 89
T
he pre-fabricated braces come in different sizes and are easy to apply usually between the third and fourth post-injury weeks. The straps are tightened without excessive pressure. As the swelling decreases, adjustments are made.
90
REPRESENTATIVE EXAMPLES A SURGICAL EXAMPLE
91
Representative example of comminuted, intra-articular Colles fracture initially treated with multiple pins. The reduction failed and the pins and fragments displaced. Notice the resulting anatomical reduction of the fracture and the permanent loss of a few degrees of wrist flexion and extension of an inconsequential nature. This surgical example illustrates a chapter in the medical history of the senior author of this book since the injury occurred to him approximately fifteen years ago. The function of his wrist is limited in the last degrees of flexion and extension, a limitation that does not interfere with any of his activities.
92
NONSURGICAL EXAMPLES
Transverse extra-articular Colles fracture illustrating the dorsal-lateral displacement of the distal fragment.
Radiographs showing the reduction of the fragments and the equal degree of flexion of the two wrists.
93
Radiographs of displaced Colles fracture showing the initial picture and several months after the initial injury.
Initial radiograph of minimally intra-articular Colles fracture and three months after the initial insult.
94
Radiographs of intraarticular displaced fracture, following reduction and later stabilized in a brace.
95
a. Example of intr-aarticular displaced fracture b. post-reduction; and the final minimal limitation of wrist flexion.
96
EPILOGUE
O
ver the last decade in the United States, as well as in many other nations, Traumatology has undergone a profound metamorphosis which has begun the transition from being primarily a scientific discipline into a series of techniques primarily designed to provide cosmetic restoration of the skeleton. This perception led us to describe our recently graduated colleagues as “sophisticated skeletal cosmetologists.” In addition, rather than remaining the noble profession based on the traditional Hippocratic tenets of “first do no harm”, and “the welfare of the patient first”, has rapidly shifted in the heart and mind of an increasingly number of its practitioners towards a business-centered model where personal financial profit seems to guide practitioner decision making. At first glance, the genesis of change may not be as complicated as it seems relative to our professional judgement. The technical advances in surgery and anesthesia have provided healthy opportunities in the care of fractures. Such developments quickly demonstrated to be the complete or partial solution to conditions where conservative management was previously rendered with similar complications of various degrees. Fractures of the hip became a most rewarding area. Internal fixation of such fractures, which had previously required prolonged hospitalization frequently associate with death, yielded a dramatic and beneficial response. The results not only illustrated the improved prognosis for such fractures, but also proved to be financially rewarding to the treating physicians, since the payment for their services rapidly increased. As new musculoskeletal opportunities were created for surgery procedures in the care of hip fractures became obvious, techniques were developed for similar approaches to the treatment of femoral fractures with comparatively improved results. The surgical approach to fractures was rapidly extended to several other regions throughout the entire skeleton. 97
Physicians were not the only parties to benefit economically from the advanced approach to fracture care. The manufacturers of the metallic implants used for operative stabilization aggressively and effectively responded to the new and unexpected market opportunities. Virtually overnight, within the span of a few decades, the Implant Manufacturing Industry became a powerful giant. Every hospital in the country became a customer. The competition between the various companies resulted in a rapid proliferation of new implants and instrumentation. As is frequently the case, when business begins to dictate the course of medical procedure, some adverse developments will most likely arise. Historically, higher salaries always paralleled the potential consideration for entering medical school and as such become an obsessive contemplation. Surgical branches became the preferred subspecialization. Often, some communities became saturated with subspecialized surgeons which ultimately led to the performance of unnecessary surgeries. Some smaller communities have also confronted the same challenge. In the end, we are observing the care of many conditions, traditionally the exclusive domain of orthopaedists, being treated by others within the medicine as well as in the paramedical field. In this text, we chose to utilize select fractures in the upper extremity. Furthermore, we will attempt to illustrate the current trend where surgical treatment is becoming common practice, while ignoring the fact that functional nonsurgical approaches also have a rightful place in such fracture management. The logical balance in the treatment of virtually all musculoskeletal conditions is frequently dismissed. The conditions we have selected and illustrated with examples should have proven that rigid adherence to either surgical or nonsurgical approaches is not a healthy attitude and that objectivity should be considered when rendering quality and unselfish care to our patients.
98
W
e hope we have succeeded in presenting a framework that objectively addresses decisions to be made concerning the most desirable treatment modality for each individual circumstance. It is obvious that there are no treatments completely free of complications or less than satisfactory results. The strong current trend that urges physicians to manage virtually all fractures by surgical means has resulted in a rigidity that stymies progress and demeans the sophistication of a very historical profession. The myriad of social/political factors that the practice of medicine confronts today must mandate an honest but objective and rationale commitment when serving our trusted patient population.
99
REFERENCES
T
he literature is rich with the medical procedure regarding the four fractures discussed in this book and considerably more pages to outline than what is described in this medical review. Therefore, only those publications, based on personal and vicariously gained experiences by the authors are listed herein. 1. Sarmiento A: Subspecialization in Orthopaedics. Has it been all for the better?: J Bone and Joint Surg: 85-A: 369-373, 2003. 2. Sarmiento, A. Additional thoughts on Guidelines and the Joint Replacement Registry. American Journal of orthopaedics. 6-21- 2012 June 2013) 3. Sarmiento A. On Orthopaedic Guidelines- Relevance or doubleedge sword? Indian Orthopaedic Journal. May. Vol. 45:191-193. 2011. 4. Sarmiento A. Infringing on Freedom of Speech. JBJS Vol. 93-A. No.2 Jan 19, 2011 5. Sarmiento A. The rocky journey of Medicine. Avoiding major consequences. Tate Publishers. October 2013. 6. Sarmiento, A. The Brachioradialis as a Deforming Force in Colles' Fractures Clin. Orthop. Rel. Res. 38:86-92, 1965 7. Sarmiento, A., Pratt, G.W., Berry, N.C. and Sinclair, Wm. F. Colles' Fractures - Functional Bracing in Supination. J. Bone and Joint Surg. 57A:3,311-317, 1975 8. Sarmiento A., Latta L.L., Tarr R. R. The Effects of function in fracture healing and stability. Instructional Courses AAOS- Vol. XXV, 1976:83-106 ( (CHAPTER)
100
9. Sarmiento, A., Schaeffer, J.F., Beckerman, L., Latta, L.L. and Enis, J E. Fracture Healing in Rat Femora as Affected by Functional Weight Bearing. J. Bone and Joint Surg. 59A:3,369-375, 1977 10. Sarmiento, A., Kinman, P.B., Galvin, E.G., Schmitt, R.H. and Phillips, P.G Functional Bracing of Fractures of the Shaft of the Humerus. J. Bone and Joint Surg. 59A:5, 596-601, 1977 11. Sarmiento, A., Zagorski, J.B. and Sinclair, W.F. Functional Bracing of Colles' Fractures: A Prospective Study of Immobilization in Supination versus Pronation. Orthop. & Rel. Res. 146:175-187, 1980 12. Ross, S. D. K. and Sarmiento, M.D. Complications with Functional Fracture Bracing. Complications in Orthopaedics, Epps, C. (ed). J. B. Lippincott Co., 1983. (CHAPTER) 13. Tarr, R.R., Sew Hoy, A.L., Racette, W.L. and Sarmiento, A. The Evolution and Current Status of Functional Fracture Bracing. Report of 2800 Tibial, Humeral, Ulnar Fractures. Orthop. Rev. 13:1, 25-45, 1984 14. Llinas, A., McKellop, H., Marshall, J., Sharpe, F., Lu, B. Kirchen, M. and Sarmiento, A. Healing and Remodeling of Articular Incongruities in a Rabbit Fracture Model. J. Bone & Joint Surg. 75-A: N. 10, 1508-1523, October 1993 15. Latta. L.L. and Sarmiento, A. Principles of non-operative Fracture Treatment. SKELETAL TRAUMA. Browner, B. et al. Saunders Publishing. 1997 CHAPTER 16.Sarmiento A. The role of industry in orthopaedic education. J. Orthopaedics. Feb. 20(2) 100-102-3, 1997 17. Park, Sang-Hyun, O’Connor, K., McKellop, H. and Sarmiento, A. The Influence of active Shear or Compressive Motion on Fracture Healing. Jour. Bone and Joint Surg. Vol. 80A, No. 6; 868-878, June 101
1998 18. Sarmiento, A., Waddell, James P., Latta, Loren. Diaphyseal Humeral Fractures: treatment Options. An Instructional Course, AAOS J Bone and Joint Surg. Vol. 83-A, 10: 1566- 1579, 1999 19. Latta, L.L. Sarmiento, A. The Basic Sciences of fracture Healing in a nonsurgical environment. Editor: Bruce Browner. Lippincott, 2000 (CHAPTER) 20. Sarmiento A. Medicine and Industry: The Payer, the Piper and the Tune. Royal Canadian Annals of Medicine. Vol 33.No. 3, pp144-149, 2000 21. Sarmiento, A. Closed Treatment of Distal Radius Fractures. Techniques in Orthopaedics. Lippincott, Williams and Wilkins Editor: Bruce Browner. 2000)(CHAPTER
22. Sarmiento, A., Latta, L.L., Zagorski, J., Capps, C., Zych, G. Functional Bracing of Humeral Shaft Fractures. Journal of Bone and Joint Surgery. Vol. 82-A, No. 4 pp: 478- 486, 2000 23. Sarmiento, A. Closed Treatment of Distal Radius Fractures. Techniques in Orthopaedics. Lippincott, Williams and Wilkins Editor: Bruce Browner. 2000) (CHAPTER) 24, Sarmiento A, The impact of technological progress in Orthopaedics-Is it all for the better? Indian Orthopaedic Journal- 2001 25. Sarmiento, A. Waddell, J., Latta, L.L. Diaphyseal Humeral Fractures. AAOS Instructional Course Lectures. Vol. 51:257-269, February 2002 (CHAPTER 26. Sarmiento, A. The relationship between Orthopaedics and Industry 102
must be reformed. Clin. Orthop No. 412, pp: 38-44, 2003 27. Sarmiento A, Ethical consideration in the orthopaedists relationship with Industry. Acta Chirugiae Ortopedicae Czechosl. 73, 2007;p:159-61.
28. Sarmiento A and Latta L.L. Neglected trauma. Some Basic Concepts Regarding Bone Healing and fracture Care. Chapter in Prof. Jain’s Book. India. -pp:4-28.2010 CHAPTER. 29. Sarmiento A., Latta L.L. The nonsurgical treatment of Fractures in Contemporary Orthopaedics. . Jaype B. 2010. (BOOK ) 30. Sarmiento, A. Orthopaedics seeking a Balance. Jaypee Brothers. 2011. (BOOK 31. Sarmiento, A. The myth of the periosteum. Czechoslovakian Journal of orthopaedics 79: 9-10, 2012 32. Sarmiento, A. Reflections on acromioclavicular dislocations. Czech Journal. December 20 13:Vol. 80:373-376.
103
104
105