33C2.3   Complete articular fracture, simple articular, multifragmentary metaphyseal

Damage control

Indications

• Surgeon comfort with nailing techniques
• Need for patient mobilization
• Polytrauma including head injury

Contraindications

• Open knee wound precluding retrograde nailing or plating

Advantages

• Early mobilization

Disadvantages

• Hip pain
• Possible femoral nail removal

Operative options not available

Contraindications

• Safe definitive fixation possible

Advantages

• Easy to apply
• Minimally invasive and safe procedure

Disadvantages

• Pin loosening and track sepsis
• Pressure sores
• Knee stiffness
• Increased and prolonged patient discomfort and immobility
• Significant long-term muscle atrophy

Damage control

Further indication

• Associated neurovascular injury

Contraindication

• Existing prosthesis/implant conflicting with pin tracks

Advantages

• Minimally invasive
• Rapid procedure
• Provides time for more careful investigation

Disadvantages

• Potential knee stiffness
• Fixator pins may compromise sterility, future incisions, or definitive fixation

Treatment of choice

Indications

• All complete articular fracture with simple articular and fragmentary metaphyseal fracture types
• Closed and open fractures

Contraindications

• Patient in unstable condition or not medically fit for surgery

Advantages

• The articular surface can be reduced
• All simple complete articular injuries can be treated by this technique
• Fracture stabilization allows for early joint movement (but not full weight bearing)
• Can be used in cases of pulmonary compromise
• Reduced risk of osteoarthritis

Disadvantages

• Larger incisions
• Joint is mobilized but full weight bearing cannot be initiated
• More radiation

Simple articular injury with large fragments in good bone

Indications

• At least 6 cm of length of end segment for lag screw/blade fixation.
• Bilateral femur fractures
• Associated spine injury
• Selected closed and open fractures
• Obesity
• Floating knee” injury: can use same approach for ipsilateral tibial nail
• Pregnancy
• Fractures below stemmed hip prostheses

Contraindications

• Accompanying severe pulmonary trauma
• Local comminution at planned entry point in intraarticular fractures
• Prosthesis
• Patient in unstable condition, unfit for surgery
• Stiff knee joint which does not allow the flexion necessary for intramedullary nail insertion
• Local soft-tissue compromise

Advantages

• Fracture stabilization allows for early patient mobilization
• Allows indirect reduction
• Good biomechanical properties
• Minimizes secondary soft-tissue damage

Disadvantages

• Implant-related pain (particularly around distal interlocking screws)

Stability not guaranteed with single plate fixation

Indications

• Biomechanics of the fracture type (including body habitus challenges) with one side fixation predicting implant failure

Advantages

• May prevent biomechanical failure due to nonunion

Disadvantages

• Larger surgical intervention (time, soft tissue compromise due to two approaches, blood loss)

Severely osteoporotic bone in a medically frail patient

Contraindications

• Patient too sick to undergo large operation with large blood loss

Advantages

• Single operation with high success rate in medically frail patients

Disadvantages

• Higher infection rate
• Specialized surgical expertise required
• High cost and prosthesis rarely in stock