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Rockwood and Green’s Fractures in Adults

Volume 1

Tenth Edition

Editors Paul Tornetta III William M. Ricci Robert F. Ostrum Michael D. McKee Benjamin J. Ollivere Victor A. de Ridder

ROCKWOOD AND GREEN’S Fractures in Adults

TENTH EDITION

ROCKWOOD AND GREEN’S Fractures in Adults

TENTH EDITION

V olume 1

EDITORS

Paul Tornetta III, MD, PhD Professor and Chair

Michael D. McKee, MD, FRCS(C) Professor and Chairman Department of Orthopaedic Surgery University of Arizona—Phoenix Phoenix, Arizona Benjamin J. Ollivere, MBBS, MA, MD, FRCS(Tr & Orth) Professor of Orthopaedic Trauma Associate Pro-Vice Chancellor Faculty of Medicine and Health Sciences

Department of Orthopaedic Surgery Boston University School of Medicine Director of Orthopaedic Trauma

Boston Medical Center Boston, Massachusetts

William M. Ricci, MD Chief of Orthopedic Trauma Service Hospital for Special Surgery and NewYork Presbyterian Hospital Professor and Vice Chair of Orthopedic Surgery

Queens Medical Centre University of Nottingham Nottingham, United Kingdom

Weill Cornell Medical College Deputy Chief of Orthopaedics NewYork-Presbyterian Hospital New York, New York

VA de Ridder, MD, PhD, MBA, PhD BA LLB, FRCS Professor Emergency Care and Logistics, Trauma and Pediatric Trauma University of Utrecht Utrecht, The Netherlands

Robert F. Ostrum, MD Adjunct Professor of Orthopaedics University of North Carolina School of Medicine Chapel Hill, North Carolina

Acquisitions Editor: Tulie McKay Senior Development Editor: Stacey Sebring Editorial Coordinators: Sean Hanrahan and Janet Jayne

Editorial Assistant: Kristen Kardoley Marketing Manager: Kristen Watrud

Senior Production Project Manager: Catherine Ott Manager, Graphic Arts & Design: Stephen Druding Illustrator: Bernie Kida Manufacturing Coordinator: Lisa Bowling Prepress Vendor: Aptara, Inc.

10th edition.

Copyright © 2025 Wolters Kluwer.

Copyright © 2020 Wolters Kluwer. Copyright © 2015, Wolters Kluwer Health. Copyright © 2010, Wolters Kluwer Health/LWW. Copyright © 2008, 2004, 2000, Lippincott Williams & Wilkins. Copyright © 1996, Lippincott-Raven Publishers. Copyright © 1992, 1988, 1984, 1980, 1975, 1970, 1964, J.B. Lippincott Company. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at shop.lww.com (products and services).

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To my mother Phyllis, who found the best in people, had compassion for all, and whose insight, guidance, and love have always made me believe that anything is possible. PT3 To my wife Ann and my sons Michael and Luke. Thank you for your patience, love, and support. WMR

No man is an island. Thanks to my wife Joey, my sons Sam and Zach for your support,

although you’ll never open this book to see this, I have enjoyed all of our adventures together. RFO

To my children Sacha, Tyler, Robbin, Everett, Darya, Charlotte, and Juliette for enriching

my life every day. To my loving partner Niloofar, for all her support. And to the promise of a new generation, Mickey, Felix, Declan, Lincoln, and Bowie. MMcK

To my children Joshua, Grace, Harriet, and Finley and Katie my best friend and then wife, without whom none of it would be possible. BJO To my children Else and Fien for their love and keeping me curious about life. And the loving memory of my wife, Guusje. VAdR

CONTRIBUTORS

John D. Adams, Jr, MD Associate Professor Department of Orthopedic Surgery University of South Carolina School of Medicine, Greenville Greenville, South Carolina Jaimo Ahn, MD, PhD Gehring Research Professor of Orthopaedic Surgery and Biomedical Engineering Department of Orthopaedic Surgery Khalid Al-Hourani, MBBS, PhD Adult Reconstructive Surgery Fellow Department of Orthopaedic Surgery Massachusetts General Hospital Boston, Massachusetts Donald D. Anderson, PhD Professor and Vice Chair of Research, Orthopedics and Rehabilitation The University of Iowa Iowa City, Iowa Michael T. Archdeacon, MD, MSE CEO, UC Physicians Senior Associate Dean of Clinical Affairs University of Michigan Ann Arbor, Michigan

Jan Bartoníček, MD, DSc Professor Department of Orthopaedics First Faculty of Medicine Charles University and Central Military Hospital Prague, Czech Republic Claire Bastard, MD, MSc

Chef de Clinique des hôpitaux de Paris Department of Orthopaedic Surgery Sorbonne Université Paris, France Daphne M. Beingessner, BMath, BSc, MD, MSc, FRCSC Professor Department of Orthopaedic Surgery and Sports Medicine University of Washington Seattle, Washington Patrick F. Bergin, MD Professor Department of Orthopaedic Surgery University of Mississippi Medical Center Jackson, Mississippi Mitchell Bernstein, MD, FRCSC Associate Professor Department of Surgery McGill University

Peter J. Stern Professor and Chair Department of Orthopaedic Surgery University of Cincinnati College of Medicine Cincinnati, Ohio Nick Assink, MSc 3D Lab/Department of Trauma surgery University Medical Center Groningen Groningen, The Netherlands George S. Athwal, MD, FRCSC Professor Department of Surgery Roth|McFarlane Hand and Upper Limb Centre, St. Joseph’s Health Care Western University

Montreal, Quebec, Canada Mohit Bhandari, MD, PhD Professor and Chair Department of Surgery McMaster University Hamilton, Ontario Julius A. Bishop, MD Associate Professor

Department of Orthopaedic Surgery Stanford University School of Medicine Palo Alto, California Emily Boersma, MD, PhD Resident Department of Orthopedics Sint Maartenskliniek Nijmegen, The Netherlands

London, Ontario, Canada Chelsea Bahney, PhD Associate Professor

Department of Orthopaedic Surgery University of California San Francisco San Francisco, California

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Contributors

Yelena Bogdan, MD Associate Professor

Christen E. Chalmers, MD Orthopaedic Resident Department of Orthopaedic Surgery University of California, Irvine Orange, California Julien Chapleau, MD, MSc, FRCSC Associate Professor

Department of Orthopaedic Surgery Albert Einstein College of Medicine Bronx, New York Christopher M. Bono, MD Professor Department of Orthopaedic Surgery Massachusetts General Hospital Boston, Massachusetts Michael Bottlang, PhD Director Biomechanics Laboratory Legacy Health System Portland, Oregon Christina L. Boulton, MD Associate Professor Department of Orthopedic Surgery University of Arizona Tucson, Arizona Tejal S. Brahmbhatt, MD, FACS Assistant Professor of Surgery Department of Surgery Cedars Sinai Medical Center Los Angeles, California

Department of Surgery University of Montreal Montreal, Quebec, Canada

Lutz Claes, PhD Director Emeritus Institute of Orthopedic Research and Biomechanics Ulm, Germany Cory A. Collinge, MD Director of Orthopedic Trauma Harris Methodist Hospital Fort Worth Fort Worth, Texas Niloofar Dehghan, MD, MSc, FRCSC, FAAOS Assistant Professor University of Arizona College of Medicine—Phoenix Chief of Trauma—The CORE Institute Phoenix, Arizona Job N. Doornberg, MD, PhD Professor, Clinical Applications of Artificial Intelligence in Orthopaedic Trauma Surgery

Rocio Branes, MD Orthopedic Surgeon Department of Orthopaedic Surgery Hospital del Trabajador ACHS Santiago, Chile Mark R. Brinker, MD Director of Acute and Reconstructive Trauma Fondren Orthopedic Group Texas Orthopedic Hospital Houston, Texas Bennet Butler, MD Associate Professor Department of Orthopedic Surgery Northwestern University Chicago, Illinois John T. Capo, MD Chief of Hand Surgery Professor and Vice Chairman of Orthopaedics Residency Program Director Rutgers-RWJ Barnabas Health Jersey City Medical Center Jersey City, New Jersey Tom Carter, MD, FRCSEd (Tr&Orth) Consultant Orthopaedic Surgeon NHS Fife Kirkcaldy, United Kingdom

Department of Orthopaedic Surgery University Medical Center Groningen Groningen, The Netherlands Professor, Orthopaedic Trauma Flinders University, Flinders Medical Centre Adelaide, Australia Stephen A. Doxey, DO Postdoctoral Research Fellow Department of Orthopaedic Surgery

TRIA Orthopaedic Center Bloomington, Minnesota Andrew D. Duckworth, BSc(Hons), MBChB, MSc, FRCSEd(Tr&Orth), PhD Senior Clinical Lecturer and Honorary Consultant Orthopaedic Trauma Surgeon University of Edinburgh and Edinburgh Orthopaedics Edinburgh, United Kingdom Joseph Dynako, MD Resident Physician University of Mississippi Medical Center Department of Orthopaedic Surgery Jackson, Mississippi Owen Edwards, MS4/MD Medical Student SUNY Downstate School of Medicine Brooklyn, New York

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Contributors

Josef K. Eichinger, MD Professor of Orthopaedics and Rehabilitation Sports Medicine, Shoulder and Elbow Surgery Medical University of South Carolina Charleston, South Carolina Jamie Ferguson, MB, BCh, MEd, FRCS(Tr & Orth) Consultant in Trauma and Reconstruction Surgery Oxford University Hospitals Oxford, United Kingdom Reza Firoozabadi, MD, MA Associate Professor Orthopaedic Trauma Surgeon Harborview Medical Center/University of Washington Seattle, Washington Daniel C. Fitzpatrick, MS, MD Trauma Surgeon Center for Orthopedics & Sports Medicine Eugene, Oregon

Ryan Gao, MBChB, PhD, FRACS Orthopaedic Surgeon Department of Orthopaedic Surgery Northshore Hospital

Auckland, New Zealand Michael J. Gardner, MD Professor

Department of Orthopaedic Surgery Stanford University School of Medicine Palo Alto, California Joshua L. Gary, MD Chief of Orthopaedic Trauma Service Associate Professor and Clinical Scholar Department of Orthopaedic Surgery Keck School of Medicine of USC

Los Angeles, California Greg E. Gaski, MD Associate Professor University of Virginia School of Medicine—Inova Campus Department of Orthopaedic Surgery Inova Fairfax Medical Campus Falls Church, Virginia Peter V. Giannoudis, MD, PhD, FACS, FRCS, MBE Professor and Chairman Academic Department of Trauma & Orthopaedic Surgery School of Medicine, University of Leeds Leeds, United Kingdom L. Henry Goodnough, MD Assistant Professor

Christopher D. Flanagan, MD Staff Orthopaedic Trauma Surgeon Orthopaedic Trauma Service Florida Orthopaedic Institute Tampa, Florida Elvira R. Flikweert, MD, PhD Trauma Surgeon Department of Trauma Surgery Deventer Ziekenhuis

Deventer, The Netherlands Christopher Folau, DO Orthopaedic Trauma Surgeon Department of Orthopaedic Surgery Memorial Hospital, Beacon Health System South Bend, Indiana Antonio M. Foruria, MD, PhD Consultant and Associate Professor Chairman of the Division of Shoulder and Elbow Fundación Jim é nez D í az University Hospital Universidad Autónoma Madrid, Spain Jan Paul Frölke, MD, PhD Associate Professor Department of Surgery Radboudumc Nijmegen, The Netherlands Abhishek Ganta, MD, MPA Assistant Professor of Orthopedic Surgery Department of Orthopedic Surgery

Department of Orthopaedic Surgery Stanford University School of Medicine Palo Alto, California Michelle M. Gosselin, MD Assistant Professor Department of Orthopaedics Naval Medical Center San Diego San Diego, California Michael B. Gottschalk, MD

Vice Chair, Department of Orthopaedic Surgery Associate Professor, Hand and Upper Extremity Division Chief, Hand and Upper Extremity Surgery Fellowship Director, Hand and Upper Extremity Director, Clinical Research Emory Department of Orthopaedics Atlanta, Georgia Geertje Govaert, MD, PhD Trauma Surgeon Department of Trauma University Medical Centre Utrecht Utrecht, The Netherlands

NYU Langone Medical Center Jamaica Hospital Medical Center New York, New York

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Contributors

Caitlin Grant, MD Resident Department of Orthopedic Surgery University of Michigan Ann Arbor, Michigan Stuart A. Grant, MBChB, MMCI Professor

Brandi Hartley, MD Associate Professor Department of Orthopaedic Surgery University of Louisville School of Medicine Louisville, Kentucky Edward J. Harvey, MDCM, MSc, FRCSC Professor Department of Surgery McGill University Montreal, Quebec, Canada Jonah Hebert-Davies, MD, FRCSC Associate Professor

Department of Anesthesiology University of North Carolina Chapel Hill, North Carolina Matthew L. Graves, MD Hansjörg Wyss AO Medical Foundation Chair of Orthopaedic Trauma Professor and Chair Department of Orthopaedic Surgery University of Mississippi Medical Center Jackson, Mississippi Xavier L. Griffin, BMCh, PhD, FRCS (Trauma and Orthopaedics) Professor Bone and Joint Health, Barts and The London School of Medicine and Dentistry Queen Mary University of London London, United Kingdom Leonid S. Grossman, MD Orthopedic Trauma Surgeon Panorama Orthopedics and Spine Center Chair, Department of Surgery St. Anthony Hospital Golden/Lakewood, Colorado Melanie Haffner-Luntzer, PhD Adjunct Professor Institute of Orthopaedic Research and Biomechanics Ulm University Ulm, Germany Kurt D. Hankenson, DVM, PhD Henry Ruppenthal Family Professor of Orthopaedic Surgery and Biomedical Engineering Department of Orthopaedic Surgery

Department of Orthopedics and Sports Medicine University of Washington/Harborview Medical Center Seattle, Washington Martin J. Heetveld, MD, PhD Trauma Surgeon Department of Trauma Surgery Spaarne Gasthuis Haarlem, The Netherlands Carrie L. Heincelman, MD Clinical Instructor, Harvard Medical School Department of Orthopaedic Surgery Beth Israel Deaconess Medical Center Boston, Massachusetts Tim E. J. Hems, MA, DM, FRCS, FRCSEd(Orth) Consultant, Hand and Orthopaedic Surgeon Scottish National Brachial Plexus Injury Service Martin F. Hoffmann, MD, PhD Orthopaedic and Trauma Surgeon Department of General and Trauma Surgery BG University Hospital ‘Bergmannsheil Bochum’ Ruhr-University Bochum Bochum, Germany Daniel S. Horwitz, MD Professor Department of Orthopaedics Geisinger Health System Danville, Pennsylvania Brandon R. Hull, MD Assistant Professor Department of Orthopedic Surgery University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma Frank F. A. IJpma, MD, PhD Trauma Surgeon Department of Trauma surgery University Medical Center Groningen Groningen, The Netherlands Department of Orthopaedic Surgery Queen Elizabeth University Hospital Glasgow, United Kingdom

University of Michigan Ann Arbor, Michigan Derek G. Hansen, MD Assistant Professor of Orthopaedic Surgery Hospital for Special Surgery Weill Cornell/New York Presbyterian Hospital New York, New York Mitchel B. Harris, MD

Chief of Orthopaedic Surgery Massachusetts General Hospital Boston, Massachusetts

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Contributors

Clayton I. Inculet, MB, BCh, BAO, FRCSC, MESc Adjunct Professor Department of Orthopedics Western University London, Ontario, Canada Kaan Irgit, MD Associate Professor Department of Orthopedics and Traumatology Health & DNA Private Orthopedic Clinic Istanbul, Turkey Jaclyn M. Jankowski, DO Chief Quality and Patient Improvement Officer Division of Orthopaedic Trauma and Adult Reconstruction Department of Orthopaedic Surgery RWJBH Orthopaedics Cooperman Barnabas/Jersey City Medical Center Assistant Professor of Surgery and Perioperative Care Director of Value Based Health Care and Outcome Measurement Innovation The University of Texas at Austin, Dell Medical School Austin, Texas Kyle J. Jeray, MD Professor Department of Orthopedic Surgery University of South Carolina School of Medicine, Greenville Greenville, South Carolina John L. Johnson, MD Resident Department of Orthopaedic Surgery Georgetown University Hospital Washington, DC Noah M. Joseph, MD, MS Trauma Fellow Florida Orthopaedic Institute Tampa General Hospital Tampa, Florida Michael S. Kain, MD Associate Professor Department of Orthopaedic Surgery Boston University Chobanian & Avedisian School of Medicine Boston, Massachusetts Sanjeev Kakar, MD, CAQ, FAAOS Professor Department of Orthopaedic Surgery Mayo Clinic Rochester, Minnesota Michael B. Kelly, MBBS Consultant Orthopaedic Surgeon Department of Neurosciences and Musculoskeletal Medicine Livingston/Jersey City, New Jersey Prakash Jayakumar, MBBS, DPhil

Jon M. Kendrew, MBBS Honorary Consultant Department of Trauma Queen Elizabeth Hospital Birmingham West Midlands, United Kingdom Umraz Khan, MBBS Consultant Plastic Surgeon Department of Surgery North Bristol NHS Trust Bristol, United Kingdom Megan L. Killian, PhD Assistant Professor Department of Orthopaedic Surgery

University of Michigan Ann Arbor, Michigan Graham J. W. King, MD, MSc, FRCSC Professor Department of Surgery Western University London, Ontario, Canada Alex Kitto, MD Orthopedic Spine Surgery Fellow 2022–2023 Department of Orthopedic Surgery Boston University—Boston Medical Center Boston, Massachusetts Jennifer C. E. Lane, BM BCh, PhD, FRCS (Trauma and Orthopaedics) Clinical Lecturer Bone and Joint Health, Barts and The London School of Medicine and Dentistry Queen Mary University of London London, United Kingdom Hai V. Le, MD, MPH Associate Professor Department of Orthopaedic Surgery University of California, Davis Sacramento, California Valerae O. Lewis, MD John Murray Professor and Chair Department of Orthopaedic Oncology The University of Texas MD Anderson Cancer Center Houston, Texas Xinning Li, MD Professor BU Sports Medicine Fellowship Director

Department of Orthopaedic Surgery Sports Medicine and Shoulder Surgery Boston University School of Medicine Boston, Massachusetts Harry M. Lightsey, MD Orthopaedic Spine Surgery Fellow Rothman Orthopaedic Institute Philadelphia, Pennsylvania

North Bristol NHS Trust Bristol, United Kingdom

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Contributors

Philip K. Lim, MD Assistant Professor Department of Orthopaedic Surgery University of California, Irvine

James L. McVie, MBBS, FRCS(Tr&Orth) Orthopaedic Consultant Department of Trauma & Orthopaedic South Tees NHS Hospitals Foundation Trust Middlesbrough, Cleveland, United Kingdom Theodore Miclau, MD Professor and Vice Chairman Department of Orthopaedic Surgery University of California San Francisco San Francisco, California Anna Miller, MD Professor Department of Orthopaedic Surgery Washington University St. Louis, Missouri Hassan Mir, MD, MBA Professor Department of Orthopaedic Surgery University of South Florida Tampa, Florida Iain Moppett, BM Chir, PhD, FRCA Professor Academic Unit of Injury, Inflammation and Repair University of Nottingham Nottingham, United Kingdom John Morellato, MBBS (Hons), FRCSC Associate Professor Department of Orthopaedic Surgery University of Mississippi Medical Center Jackson, Mississippi Chad M. Myeroff, MD, FAAOS Shoulder and Elbow Surgeon Department of Orthopaedic Surgery TRIA Orthopaedic Center Woodbury, Minnesota Aaron Nauth, MD, MSc, FRCSC Assistant Professor Toronto, Ontario, Canada Daniel P. O’Connor, PhD Dean and Professor College of Liberal Arts and Social Sciences University of Houston Houston, Texas Eva O’Grady, MBBS University of Toronto St. Michael’s Hospital

Orange, California Richard Ma, MD Gregory L. and Ann L. Hummel Distinguished Professor

Director of Division of Sports Medicine Department of Orthopaedic Surgery University of Missouri School of Medicine Columbia, Missouri Tristan Maerz, PhD Assistant Professor Department of Orthopaedic Surgery University of Michigan Ann Arbor, Michigan Christiaan N. Mamczak, DO Associate Professor Department of Orthopaedic Surgery

University of South Florida Florida Orthopaedic Institute Tampa, Florida Hemil Maniar, MD Associate, Orthopaedics Department of Orthopaedics Lawrence Memorial Hospital Lawrence, Kansas Ralph Marcucio, PhD Professor

Department of Orthopaedic Surgery University of California San Francisco San Francisco, California Natalia Martinez-Catalan, MD, PhD Consultant Orthopedic Surgery Division of Shoulder and Elbow Fundación Jimenez Diaz University Hospital Madrid, Spain Michael D. McKee, MD, FRCS(C) Professor and Chairman Department of Orthopaedic Surgery University of Arizona—Phoenix Phoenix, Arizona

Louise McMenemy, MBBS, BSc (Hons), MRCS, PhD Trauma and Orthopaedic Registrar and Clinical Lecturer Royal Centre for Defence Medicine Birmingham, United Kingdom Martin McNally, MB, BCh, MD, FRSCEd, FRCS(Orth) Professor, Honorary Consultant in Limb Reconstruction The Bone Infection Unit

Locum Consultant Plastic Surgeon Swansea Bay University Health Board Swansea, United Kingdom

Nuffield Orthopaedic Centre Oxford University Hospitals Oxford, United Kingdom

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Contributors

Robert V. O’Toole, MD Professor Department of Orthopaedic Surgery University of Maryland School of Medicine Baltimore, Maryland Benjamin J. Ollivere, MBBS, MA, MD, FRCS(Tr & Orth) Professor of Orthopaedic Trauma Associate Pro-Vice Chancellor Faculty of Medicine and Health Sciences Nottingham, United Kingdom Nathan P. Olszewski, MD Associate Professor Department of Orthopaedic Surgery Boston University Boston, Massachusetts Robert F. Ostrum, MD Adjunct Professor of Orthopaedics University of North Carolina School of Medicine Chapel Hill, North Carolina Michalis Panteli, MD, FRCS (T&O), PhD Consultant Orthopaedic Surgeon Exeter Hip Unit, Princes Elizabeth Orthopaedic Centre, Exeter Honorary Lecturer in Trauma & Orthopaedic Surgery, University of Leeds Queens Medical Centre University of Nottingham Director of Shoulder Service Medical College of Georgia Augusta University Augusta, Georgia Jowan G. Penn-Barwell, FRCS (Tr & Orth), PhD Consultant Orthopaedic Trauma Surgeon Oxford Trauma Service Oxford University Hospitals Oxfordshire, United Kingdom Kevin D. Phelps, MD Assistant Professor Department of Orthopaedic Surgery Atrium Health and Wake Forest University School of Medicine Charlotte, North Carolina J. Whitcomb Pollock, MD, MSc, FRCSC Associate Professor Department of Surgery University of Ottawa Ottawa, Ontario, Canada Leeds, United Kingdom Stephen A. Parada, MD Professor

Jasper Prijs, MD Cotutelle PhD candidate Department of Surgery Department of Orthopaedics University Medical Centre Groningen

Groningen, The Netherlands Department of Orthopaedics Flinders University and Medical Centre Adelaide, Australia Stuart H. Ralston, MB ChB, MD, FRCP, FFPM (Hon), FMedSci, FRSE Professor Versus Arthritis Professor of Rheumatology Centre for Genomic and Experimental Medicine Institute of Genetics and Cancer University of Edinburgh Western General Hospital Edinburgh, United Kingdom Arul Ramasamy, MA, PhD, FFSEM, FRCS(Tr+Orth) Defence Professor of Trauma and Orthopaedics Imperial College London London, United Kingdom William M. Ricci, MD Chief of Orthopedic Trauma Service Hospital for Special Surgery and NewYork-Presbyterian Hospital Professor and Vice Chair of Orthopedic Surgery New York, New York Marc J. Richard, MD Associate Professor Director, Hand, Upper Extremity, and Microvascular Surgery Fellowship Department of Orthopaedic Surgery Duke University Weill Cornell Medical College Deputy Chief of Orthopaedics NewYork-Presbyterian Hospital

Durham, North Carolina Jarod A. Richards, MD Sports Medicine Orthopaedic Surgery Fellow Department of Orthopaedic Surgery University of Missouri Columbia, Missouri Cassandra Rickets, MD Trauma Fellow Florida Orthopaedic Institute Tampa General Hospital Tampa, Florida David Ring, MD, PhD

Associate Dean for Comprehensive Care Professor of Surgery and Perioperative Care Courtesy Professor of Psychiatry and Behavioral Sciences Courtesy Professor of Health Social Work Dell Medical School | The University of Texas at Austin Austin, Texas

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Contributors

Marco Rizzo, MD Professor Department of Orthopaedic Surgery Chair Division of Hand Surgery Mayo Clinic Rochester, Minnesota Craig Roberts, MD, MBA Emeritus Professor, Former Department Chair Department of Orthopaedic Surgery University of Louisville School of Medicine Louisville, Kentucky Dominique M. Rouleau, MD, MSc, FRCSC Associate Professor Orthopaedic Surgery Resident Brooke Army Medical Center San Antonio, Texas Tom K. Rowlands, FRCS, MB, BCh, BSc, Grad Dip Phys, L/RAMC Consultant Trauma and Orthopaedic Surgeon British Army Department of Trauma and Orthopaedic QMC Nottingham Nottingham, United Kingdom David S. Ruch, MD Virginia Flowers Baker Distinguished Professor of Orthopaedic Surgery Chief of Division of Hand & Microvascular Surgery Department of Orthopaedic Surgery Duke University Durham, North Carolina Shikha Sachdeva, MD Resident Department of Orthopaedic Surgery University of Louisville School of Medicine Louisville, Kentucky Joaquin Sanchez-Sotelo, MD, PhD Consultant and Professor of Orthopedic Surgery Chairman of the Division of Shoulder and Elbow Mayo Clinic Rochester, Minnesota David W. Sanders, MD, FRCSC Professor of Surgery Department of Orthopedics Western University London, Ontario, Canada Department of Surgery University of Montreal Montreal, Quebec, Canada Lydia G. Roward, MD

Roy W. Sanders, MD Professor and Chairman Department of Orthopaedic Surgery University of South Florida Tampa, Florida Ian D. Sargeant, MBBS, DAvMed, FRCSEd(Orth) Consultant Trauma and Orthopaedic Surgeon Queen Elizabeth Hospital Birmingham and Royal Centre for Defence Medicine West Midlands, United Kingdom Nathaniel E. Schaffer, MD, PhD Western Washington Medical Group Everett, Washington Thomas A. Schildhauer, MD, PhD Professor and Chairman Department of General and Trauma Surgery BG University Hospital ‘Bergmannsheil Bochum’ Ruhr-University Bochum Bochum, Germany Prism S. Schneider, MD, PhD, FRCSC Professor Department of Surgery and Department of Community Health Sciences University of Calgary Calgary, Alberta, Canada Andrew J. Schoenfeld, MD, MS Professor Department of Orthopaedic Surgery Brigham and Women’s Hospital Boston, Massachusetts John A. Scolaro, MD, MA Associate Professor Department of Orthopaedic Surgery University of California, Irvine Orange, California Hannah Seymour, BSc, MBBS, FRACP

Consultant Geriatrician Fiona Stanley Hospital Perth, Australia Jhase Sniderman, MD, FRCSC Orthopaedic Surgeon

Division of Orthopaedic Surgery Max Rady College of Medicine University of Manitoba Winnipeg, Manitoba, Canada James P. Stannard, MD Hansjorg Wyss Distinguished Chairman in Orthopaedic Surgery Medical Director of the Missouri Orthopaedic Institute Department of Orthopaedic Surgery University of Missouri Columbia, Missouri

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Contributors

Daniel J. Stinner, MD, PhD, FACS Associate Professor Department of Orthopaedic Surgery Vanderbilt University Medical Center Nashville, Tennessee Vincent M. A. Stirler, MD, PhD Military Surgeon Defence Health Organisation Kromhout Military Base Utrecht, The Netherlands Trauma Surgeon Radboud University Medical Center Nijmegen, The Netherlands Philipp N. Streubel, MD Staff Orthopedic Surgeon Levitetz Department of Orthopedic Surgery Cleveland Clinic Florida Weston, Florida Chadi Tannoury, MD, FAOA, FAAOS Associate Professor Department of Orthopedic Surgery Boston University—Boston Medical Center Boston, Massachusetts David C. Teague, MD Professor and Chair Department of Orthopedic Surgery University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma

Heather A. Vallier, MD Professor Department of Orthopaedic Surgery Case Western Reserve University School of Medicine Cleveland, Ohio Wyatt D. Vander Voort, MD Resident Physician Department of Orthopaedic Surgery University of California, Davis Sacramento, California Ana-Maria Vranceanu, PhD Associate Professor of Psychology Founding Director, Center for Health Outcomes and Interdisciplinary Research (CHOIR) David T. Rovee PhD and Joanne V. Rovee Endowed Chair in Psychiatry James and Elizabeth Gambles Endowed Chair Co-director, MassGeneral Neurosciences Massachusetts General Hospital Emory University Atlanta, Georgia Stephen J. Warner, MD, PhD Assistant Professor Department of Orthopaedic Surgery University of Texas Health Science Center at Houston Houston, Texas J. Tracy Watson, MD Professor Orthopaedic Surgery Department of Orthopaedic Surgery Saint Louis University School of Medicine St. Louis, Missouri Timothy O. White, MB ChB, BMedSci, MD, FRCS(Tr&Orth), FSTEd Consultant Orthopaedic Trauma Surgeon Department of Trauma and Orthopaedic Surgery Harvard Medical School Boston, Massachusetts Eric R. Wagner, MD, MS, CAQ, FAAOS Associate Professor Department of Orthopaedic Surgery

Nirmal C. Tejwani, MD, MPA Professor of Orthopedic Surgery Department of Orthopedic Surgery NYU Langone Medical Center Bellevue Hospital New York, New York Daniel G. Tobert, MD Assistant Professor Orthopaedic Spine Surgery Massachusetts General Hospital Department of Orthopaedic Surgery University of California San Francisco San Francisco, California Paul Tornetta III, MD, PhD Professor and Chair Department of Orthopaedic Surgery Boston University School of Medicine Director of Orthopaedic Trauma Boston, Massachusetts Paul A. Toogood, MD Associate Professor

Royal Infirmary of Edinburgh Edinburgh, United Kingdom Brandon G. Wilkinson, MD Trauma Surgeon Center for Orthopedics & Sports Medicine Eugene, Oregon Sarah Woltz, MD, PhD Trauma Surgeon Department of Surgery Spaarne Gasthuis Haarlem, The Netherlands

Boston Medical Center Boston, Massachusetts

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Contributors

John M. Yingling, DO Assistant Professor Department of Orthopedic Surgery University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma Richard S. Yoon, MD, FAAOS, FIOTA Fellowship Director, Orthopaedic Trauma & Adult Reconstruction Fellowship Director, Orthopaedic Research Division of Orthopaedic Trauma and Adult Reconstruction Department of Orthopaedic Surgery RWJBH Orthopaedics Cooperman Barnabas/Jersey City Medical Center Livingston/Jersey City, New Jersey

Zachary E. Zeller, MD Orthopaedic Surgery Resident Department of Orthopaedic Surgery Boston University Boston, Massachusetts

PREFACE

Since its first edition over 60 years ago, Rockwood and Green’s Fractures in Adults continues its legacy of excellence in this tenth edition. We have continued our work to make the chapters as easy to read and reference as possible without losing depth of coverage. Each of the clinical chapters is consistently formatted for ease of access to critical information, including checklists for preoperative planning and key surgical steps, tables of potential pitfalls and preventative measures. In addition, many chapters include annotated references for the key trials and studies in each area. The “Author’s Preferred Treatment,” which has been popular since its introduction, is presented succinctly with an algorithm for treatment based on the more in-depth information within the body of the chapter. The eBook that is a part of the purchase for most versions includes more than 70 procedural videos.

Expanded coverage includes two completely new chapters on Artificial Intelligence and 3D-Guided Surgery in Orthopae dic Trauma, and Regional Anesthesia for Fractures and Dislo cations. In addition, coverage of periprosthetic fractures of the up per extremity has been deepened—fractures of the olecranon, proximal radius, and radial head. Atypical femur fractures are also covered in more detail. We have worked to ensure that all topics are presented in a comprehensive, readable, beautifully illustrated review. We remain indebted to the experts who contribute their expertise and time to make this a resource that improves the care of orthopaedic trauma patients worldwide—that remains the goal for all of us. Paul Tornetta III, MD, PhD William M. Ricci, MD Robert F. Ostrum, MD Michael D. McKee, MD, FRCS(C) Benjamin J. Ollivere, MBBS, MA, MD, FRCS(Tr & Orth) VA de Ridder, MD, PhD, MBA, PhD BA LLB, FRCS

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CONTENTS

12 Principles and Biomechanics of Internal Fixation 396 Julius A. Bishop, L. Henry Goodnough, and Michael J. Gardner 13 Templating and Technical Tricks in Internal Fixation 426 Carrie L. Heincelman and Michael T. Archdeacon MANAGEMENT PRINCIPLES OF SPECIAL CIRCUMSTANCES 14 Management of the Multiply Injured Patient 467 Tejal S. Brahmbhatt and Heather A. Vallier 15 Gunshot and Wartime Injuries 497 Michelle M. Gosselin, Arul Ramasamy, Louise McMenemy, and Daniel J. Stinner 16 Classification and Initial Management of Open Fractures 518 Jamie Ferguson, Geertje Govaert, and Martin McNally 17 Acute Compartment Syndrome 572 Edward J. Harvey, Mitchell Bernstein, and Andrew D. Duckworth 18 Principles of Mangled Extremity Management 597 John L. Johnson and Greg E. Gaski 19 Soft Tissue Coverage for Injuries and Fractures 628 Umraz Khan, Michael B. Kelly, Eva O’Grady, and Khalid Al-Hourani 20 Principles of Nerve Injuries and Their Management 655 Tim E. J. Hems 21 Limb Amputation After Trauma 690 Jowan G. Penn-Barwell, Jon M. Kendrew, James L. McVie, Ian D. Sargeant, and Tom K. Rowlands 22 Psychosocial Aspects of Recovery After Trauma and Surgeon Wellness 705 Heather A. Vallier, David Ring, and Ana-Maria Vranceanu 23 Obesity and Diabetes in Orthopaedic Trauma 717

Contributors vii Preface xvii

Volume 1

SECTION ONE: GENERAL PRINCIPLES

BASICS 1 Biomechanics of Fractures and Fracture Fixation 1 Michael Bottlang, Daniel C. Fitzpatrick, Brandon G. Wilkinson, Lutz Claes, and Donald D. Anderson 2 Bone, Cartilage, and Tendon Healing 46 Nathaniel E. Schaffer, Megan L. Killian, Tristan Maerz, Kurt D. Hankenson, and Jaimo Ahn 3 Biologic and Biophysical Technologies for the Enhancement of Fracture Repair 65 Melanie Haffner-Luntzer, Chelsea Bahney, Ralph Marcucio, Paul A. Toogood, and Theodore Miclau 4 Osteoporosis and Metabolic Bone Disease 85 Derek G. Hansen and Stuart H. Ralston 5 Classification of Fractures 113 Shikha Sachdeva, Brandi Hartley, and Craig Roberts 6 The Epidemiology of Musculoskeletal Injury 131 Nathan P. Olszewski and Zachary E. Zeller 7 Imaging Considerations in Orthopaedic Trauma 189 Joseph Dynako, Noah M. Joseph, Cassandra Rickets, and Christiaan N. Mamczak 8 Outcome Studies in Trauma 234 Mohit Bhandari 9 Artificial Intelligence and 3D-Guided Surgery in Orthopaedic Trauma: Why, How, and What 258

Christopher Folau, John Morellato, Matthew L. Graves, and Patrick F. Bergin 24 Stress Fractures Brandon R. Hull, John M. Yingling, and David C. Teague 25 Pathologic Fractures

Job N. Doornberg, Frank F. A. IJpma, Prakash Jayakumar, Vincent M. A. Stirler, Nick Assink, and Jasper Prijs

744

PRINCIPLES AND BIOMECHANICS OF FRACTURE TEATMENTS 10 Principles of Nonoperative Management of Fractures

765

Valerae O. Lewis

COMPLICATIONS AND ADVERSE OUTCOMES 26 Venous Thromboembolism in Patients With Skeletal Trauma

282

Benjamin J. Ollivere and Andrew D. Duckworth

11 Principles of External Fixation

325

791

J. Tracy Watson

Prism S. Schneider

xix

xx

Contents

27 Complex Regional Pain Syndrome

817

Volume 2

Jan Paul Frölke and Emily Boersma 28 Perioperative Pain Management of Fractures Anna Miller, Christopher D. Flanagan, and Hassan Mir 29 Osteomyelitis and Other Orthopaedic Infections 835 Michalis Panteli and Peter V. Giannoudis 30 Principles of Nonunion and Bone Defect Treatment 873 William M. Ricci and Benjamin J. Ollivere 31 Principles of Malunion Treatment 926 Mark R. Brinker, Daniel P. O’Connor, and Stephen J. Warner 826

SECTION THREE: AXIAL SKELETON, PELVIS, AND ACETABULUM

46 Chest Wall Injuries

1851

Niloofar Dehghan 47 Principles of Spine Trauma Care

1884

Harry M. Lightsey, Mitchel B. Harris, and Daniel G. Tobert 48 Cervical Spine Fractures and Dislocations Hai V. Le, Andrew J. Schoenfeld, Wyatt D. Vander Voort, and Christopher M. Bono 49 Thoracolumbar Spine Fractures and Dislocations

1903

SECTION TWO: UPPER EXTREMITY

1986

32 Acromioclavicular and Sternoclavicular Joint Injuries Jonah Hebert-Davies, Jhase Sniderman, and Aaron Nauth 33 Scapular Fractures

Alex Kitto, Owen Edwards, and Chadi Tannoury

50 Pelvic Ring Injuries Reza Firoozabadi 51 Acetabulum Fractures

2052

959

2170

1013

Joshua L. Gary and Kevin D. Phelps

Jan Bartoníček 34 Clavicle Fractures

1049

SECTION FOUR: LOWER EXTREMITY

Sarah Woltz and Michael D. McKee 35 Glenohumeral Instability

1102

52 Hip Dislocations and Femoral Head Fractures 2275 Michael S. Kain and Paul Tornetta III 53 Femoral Neck Fractures 2325 Xavier L. Griffin, Jennifer C. E. Lane, Iain Moppett, and Hannah Seymour 54 Trochanteric Hip Fractures 2380 Martin J. Heetveld and Elvira R. Flikweert 55 Subtrochanteric Femur Fractures 2412 Jaclyn M. Jankowski and Richard S. Yoon 56 Atypical Femur Fractures 2435 Yelena Bogdan 57 Femoral Shaft Fractures 2452 John D. Adams, Jr, and Kyle J. Jeray 58 Distal Femur Fractures 2527 Cory A. Collinge and Lydia G. Roward 59 Lower Extremity Periprosthetic Fractures 2572 William M. Ricci 60 Patellar Fractures and Dislocations and Extensor Mechanism Injuries 2641 Philip K. Lim, Christen E. Chalmers, and John A. Scolaro 61 Knee Dislocations 2681 James P. Stannard and Jarod A. Richards 62 Tibial Plateau Fractures 2728 Hemil Maniar and Daniel S. Horwitz 63 Tibia and Fibula Shaft Fractures 2791 Bennet Butler, Christina L. Boulton, and Robert V. O’Toole

Xinning Li, Stephen A. Parada, Josef K. Eichinger, and Richard Ma

36 Proximal Humeral Fractures

1174

Antonio M. Foruria, Natalia Martinez-Catalan, and Joaquin Sanchez-Sotelo

37 Humeral Shaft Fractures

1278

Dominique M. Rouleau, Claire Bastard, Rocio Branes, and Julien Chapleau 38 Periprosthetic Fractures of the Upper Extremity 1338 Chad M. Myeroff, Stephen A. Doxey, and Michael D. McKee 39 Distal Humerus Fractures 1400 George S. Athwal and Ryan Gao 40 Elbow Dislocations and Terrible Triad Injuries 1472 Graham J. W. King, Daphne M. Beingessner, and J. Whitcomb Pollock 41 Fractures of the Proximal Forearm: Olecranon, Proximal Radius, and Radial Head 1529 Abhishek Ganta and Nirmal C. Tejwani 42 Diaphyseal Fractures of the Radius and Ulna 1565 Philipp N. Streubel and Leonid S. Grossman 43 Fractures of the Distal Radius and Ulna 1629 Marc J. Richard and David S. Ruch 44 Carpal Fractures and Dislocations 1663 Eric R. Wagner, Sanjeev Kakar, and Michael B. Gottschalk 45 Hand Fractures and Dislocations 1741 Michael B. Gottschalk, Philipp N. Streubel, Marco Rizzo, and John T. Capo

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Contents

64 Tibial Pilon Fractures

68 Fractures and Dislocations of the Midfoot and Forefoot Kaan Irgit, Thomas A. Schildhauer, Martin F. Hoffmann, and Robert F. Ostrum 69 Regional Anesthesia for Fractures and Dislocations

2853

3049

Roy W. Sanders and Christopher D. Flanagan

65 Ankle Fractures

2895

Timothy O. White and Tom Carter 66 Fractures and Dislocations of the Talus

2952

3150

David W. Sanders and Clayton I. Inculet

Caitlin Grant and Stuart A. Grant Index

67 Calcaneus Fractures

3008

I-1

Roy W. Sanders and Christopher D. Flanagan

SURGICAL PROCEDURE VIDEOS

UPPER EXTREMITY Shoulder/Upper Arm Exposures Upper/Deltopectoral Approach: Planning Exposures Upper/Deltopectoral Approach: Approach Exposures Upper/Deltopectoral Approach: Review Exposures Upper/Deltoid Split: Planning Exposures Upper/Deltoid Split: Approach Exposures Upper/Humerus—Posterior: Approaches to the Humerus Exposures Upper/Humerus—Posterior: Planning Exposures Upper/Humerus Distal with Olecranon Osteotomy: Planning Exposures Upper/Humerus Distal with Olecranon Osteotomy: Superficial Dissection Exposures Upper/Humerus Distal with Olecranon Osteotomy: Deep Dissection Exposures Upper Extremity: Humerus— Distal with Olecranon Osteotomy: Olecranon Osteotomy Exposures Upper/Humerus–Anterolateral: Planning Exposures Upper/Humerus–Anterolateral: Superficial Dissection Exposures Upper/Humerus–Anterolateral: Deep Dissection ORIF of the Clavicle Hemiarthroplasty for Proximal Humerus Fracture ORIF of the Humerus ORIF of a Two-Part Proximal Humerus Fracture Elbow/Forearm Exposures Upper/Fasciotomy: Pertinent Anatomy Exposures Upper/Fasciotomy: Planning Exposures Upper/Fasciotomy: Superficial Approach Exposures Upper/Fasciotomy: Deep Dissection Exposures Upper/Fasciotomy: Dorsal Approach

Smith-Petersen Approach to the Hip: Planning Smith-Petersen Approach to the Hip: Superficial Dissection Smith-Petersen Approach to the Hip: Deep Dissection Cephallomedullary Nail for Intertrochanteric Fracture LOWER EXTREMITY Thigh Exposures Lower/Distal Femur: Planning Exposures Lower/Distal Femur: Superficial Approach Exposures Lower/Distal Femur: Deep Dissection Percutaneous Plating of the Distal Femur ORIF of the Patella ORIF of the Posteromedial Tibial Plateau ORIF of the Lateral Tibial Plateau Lower Leg Exposure Lower/Posterolateral Approach to the Tibia: Pertinent Anatomy Exposure Lower/Posterolateral Approach to the Tibia: Planning Exposure Lower/Posterolateral Approach to the Tibia: Superficial Approach Exposure Lower/Posterolateral Approach to the Tibia: Deep Dissection Exposure Lower/Tibia Plateau: Alternative Approach IM Nail of the Tibia (Semiextended Technique) Foot and Ankle Approach to the Ankle: Anatomy Review ORIF of the Lateral Malleolus ORIF of the Tibial Plafond ORIF of the Calcaneus Trochanteric Nail of the Femur Retrograde Nail of the Femur Knee

Exposures Upper/Radial Shaft–Volar: Planning Exposures Upper/Radial Shaft–Volar: Superficial Approach Exposures Upper/Radial Shaft–Volar: Deep Dissection Exposures Upper/Distal Radius–Volar: Superficial Approach Exposures Upper/Distal Radius–Volar: Deep Dissection Exposures Upper/Distal Radius–Dorsal: Planning Exposures Upper/Distal Radius–Dorsal: Superficial Approach Exposures Upper/Distal Radius–Dorsal: Deep Dissection Exposures Upper/Deltopectoral Approach: Planning Exposures Upper/Deltopectoral Approach: Approach Exposures Upper/Deltopectoral Approach: Review Exposures Upper/Deltoid Split: Planning Exposures Upper/Deltoid Split: Approach Exposures Upper/Ulna: Planning Exposures Upper/Ulna: Exposure to the Ulna ORIF of the Distal Humerus Elbow: ORIF of the Olecranon ORIF of the Radial Head ORIF of the Radius and Ulna Hand and Wrist External Fixation of the Distal Radius Volar Locked Plating of the Distal Radius Hip/Pelvis Kocher–Langenbeck Approach to the Hip: Anatomy Review Kocher–Langenbeck Approach to the Hip: Planning Kocher–Langenbeck Approach to the Hip: Superficial Dissection Kocher–Langenbeck Approach to the Hip: Deep Dissection Smith-Petersen Approach to the Hip: Anatomy Review

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5

Classification of Fractures Shikha Sachdeva, Brandi Hartley, and Craig Roberts

recognized. Ideally, reliability is assessed, and categories or definitions are subsequently modified prior to adopting new classification schemes. The alpha numeric fracture code, orig inally developed by the Arbeitsgemeinschaft für Osteosynthe sefragen (AO) and expanded and refined by workgroups of the Orthopaedic Trauma Association (OTA) and AO, has made an international universal classification a near reality. Ultimately, the value of fracture classification lies in its application: imme diate application to clinical decision making (provided it can be applied efficiently and in real-time), and later application to outcomes research, artificial intelligence (AI), and predictive analytics. Previously a common topic of discussion both at scientific meetings and in orthopaedic journals, the analysis of fracture classification has decreased in popularity throughout the past several decades. In the 1990s, the journal Surgical Rounds for Orthopaedics had a regular column entitled “Fracture Eponym of the Month,” and full textbooks were dedicated to fracture eponyms, such as The Language of Fractures . 54 Conversely, now there are reference texts for orthopaedic traumatology that elect not to include a chapter specific to fracture classification. None theless, the 2018 OTA/AO Fracture Compendium 38 has resulted in a rekindling of interest and scientific publication on fracture classification. This chapter will describe how advanced imaging has changed and expanded fracture classification. It is also important to discuss the use of AI, which is likely to play an increasingly larger role in practice management and fracture classification as well. With advances in imaging and computer- based analysis, there will always be an important need to clas sify new knowledge through a well-defined scientifically valid process.

INTRODUCTION 113 BACKGROUND AND HISTORY 113 PURPOSE AND APPLICATION OF FRACTURE CLASSIFICATION 114 Common Language and Terminology 114 Treatment and Prognosis 115 Research 115 Education 115 LIMITATIONS AND CHALLENGES OF FRACTURE CLASSIFICATION SYSTEMS 116 Reliability 116 Validity 116 Measurement 116 Categorizing Continuous Variables 116 CURRENT STATE OF CLASSIFICATION OF FRACTURES 117 Fracture-Specific Classifications 117 OTA/AO 2018 Fracture Compendium Classification 120 Selected Recent Studies on the OTA/AO 2018 Fracture Compendium Classification 122 Soft Tissue Injuries Associated With Closed Fractures: Advent of MRI 124 OPEN FRACTURES 126 The Gustilo–Anderson Classification 126 Open Fractures and the OTA/AO Open Fracture Classification 126 ARTIFICIAL INTELLIGENCE AND MACHINE LEARNING 127 SUMMARY 128

INTRODUCTION

BACKGROUND AND HISTORY

Fracture classification serves many important purposes: com munication, research, education, and as a guide to treatment and prognosis. The scientific basis of modern classification has improved from the past, and most new classifications now result from a group consensus process directed by committees or task forces of major organizations. The need to optimize the reliability and validity of classification schemes is now well

Throughout much of the 19th and early 20th centuries, var ious fractures were named by the individuals who described them. For example, the term Colles’ fracture persists, describ ing dorsal displacement of the distal end of the radius with volar apex angulation in a “dinner fork” configuration. This

113

114

SECTION ONE • General Principles

PURPOSE AND APPLICATION OF FRACTURE CLASSIFICATION

Classification schemes should be considered a practical tool with applicable results, rather than a mental exercise, in order to help us treat fractures. Additionally, these systems continue to be fundamental to clinical research on fractures as it helps with grouping and descriptions. In short, it is important for fracture classification systems to provide a reproducible idea of what the fracture pattern entails, drive treatment options, provide information regarding prognosis, and/or be concise and easy to apply. The more of these characteristics a system can encompass, the more widespread its use is likely to be. The 2018 OTA/AO Fracture Compendium is a comprehensive, organized system developed with Delphi methodology. This alphanumeric frac ture system, originally developed by AO, was then expanded and refined by workgroups of the OTA and AO. Thus, an inter national universal classification has become a reality. Further advances in imaging modalities added information that was used as an aid to classify fractures. CT scanning is one such modality. Over the previous three decades, CT scans have become a routine part of assessment of many fractures. CT scans allowed clinicians to more fully appreciate the extent of an articular injury and have quickly become an important adjunct for preoperative planning. With the ability to reprocess CT-generated information to create three-dimensional represen tations of the fracture, the understanding of fracture anatomy and preoperative planning was further enhanced. CT gradually became incorporated into existing classifications, and in some areas, formal assessment by CT was recommended prior to assigning a classification category. AI may also provide the key to more accurate fracture cate gorization. Using AI, classification could occur as soon as imag ing data were uploaded and analyzed. Immediate treatment options, predictive analytics, and anticipated outcomes could conceivably be generated by the computer. In this hypotheti cal future, classification of fractures may become so rapid and instantaneous that it is no longer viewed as a process. This would allow cost-effectiveness, projected life-time costs of care, and disability to ultimately be linked to fracture classification in the future. COMMON LANGUAGE AND TERMINOLOGY Having an inclusive and universal system for classification of fractures provides a common language for healthcare provid ers and associated entities to discuss injuries. Broadly speaking, classifying fractures is a way to organize and transfer informa tion, discuss and guide treatment, link diagnosis with progno sis, and enhance learning and education. It helps clarify what to look for in characterizing a fracture, such as the important variables of displacement, the soft tissue anatomy and associ ated blood supply, and relevant biomechanics. Classification allows for a quick transition from the chaos of accidental injury to order, control, and rational decision mak ing. It provides categories and labels, making it easy to compare

Figure 5-1. Colles fracture. Note the dorsal angulation of the distal aspect of the radius.

injury, classified prior to the advent of radiographs, describes a unique fracture pattern and guided early treatment (Fig. 5-1). 8 Perhaps most importantly, the author really understood the fracture—without the benefit of radiographs—and fundamen tally appreciated its personality, biomechanics, and skeletal stability. Although most of us cannot conceive of the evaluation of fractures without radiographs, it was not until 1901 that William Conrad Roentgen was awarded the first Nobel Prize in physics for his work on x-ray imaging. In 1895, he discovered that the x-ray beam could pass through human tissue but was unable to pass through bone or metal, resulting in a method to project the images of bones on a film. 6 The impact that radio graphs have had on fracture care cannot be overstated. Radio graphs are still essential for determining management, whether it is an ankle fracture requiring a gravity stress view, a pelvic ring injury requiring inlet and outlet views, or an acetabular fracture requiring Judet views. 47 After the advent of radiography, fracture-specific classifica tions were described (and commonly named for their creators), many of which remain in usage today. For example, in 1961, Robert Symon Garden described the Garden classification of femoral neck fractures. 14,15 Joseph Schatzker’s description of tibial plateau fractures, based on a series of 94 radiographs, was published in 1979. 53 More recent classifications, such as the Sanders classification of calcaneus fractures, incorporate CT imaging findings in its criteria for classification. 52 Application of CT imaging is standard for evaluation of many articular frac tures and its indications continue to expand. Magnetic resonance imaging (MRI) can add additional infor mation about the concomitant state of adjacent soft tissue struc tures during the process of fracture classification. Application of MRI to fractures of the spine is well-known and has clear value for evaluation of the spinal cord, intervertebral discs, and the posterior longitudinal ligament. The role of MRI or other advanced imaging continues to evolve within fracture classifi cation and management due to technologic advancements and improved access, especially surrounding the elbow, knee, and posterior pelvis.