Grand Rounds : Journal of Orthopaedic Trauma

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​​​​​​​​​​​​​JOT Grand Rounds

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Ankle Fractures With Syndesmotic Injury Treated With Distal Fibula Plates and Syndesmotic Fixation Device: A Case Report

Hector J. Cerón, BS, Luis Guevara, DO, MPH, and Eildar Abyar, MD

Ankle fractures with concurrent syndesmotic injuries requiring stabilization are prevalent and require immediate care to avoid long-term complications. There are many surgical fixation options for syndesmotic disruption resulting in an ongoing search for the “gold standard." The present case report aimed to introduce a novel device for syndesmotic fixation and compare this technique with cortical screw and suture button fixation.

Publication support provided by DePuy Synthes​

Upper Extremity​​

Treatment of a High-Velocity Ballistic Humerus Fracture With Circular External Fixation and Polyacial Locking Struts: A Case Report

David J. Cinats, MD, MSc

Ballistic fractures of the extremities pose many challenges for orthopaedic surgeons because they can be associated with soft-tissue and neurovascular injuries. Fractures of the humerus comprise approximately 25% of ballistic upper extremity injuries. The fracture pattern tends to be diaphyseal, multifragmentary, and have a large zone of injury. This is a case of a 22-year-old man with a diaphyseal, multufragmentary, ballistic humeral shaft fracture with associated ballistic both bones forearm fracture, arm and forearm compartment syndrome, and antecubital fossa soft-tissue loss. The humerus fracture was treated in a closed manner with application of a circular external fixator and novel polyaxial locking struts. 

Publication provided by DePuy Synthes​​

Treatment of Chronic Radial Head Fracture/Dislocation With Radial Head Replacement​

Jennifer Blanda, MD, Mikhail Alexeev, MD, and Steven M. Kane, MD

Upper extremity elbow trauma is commonly encountered in clinical practice. Various treatment options exist for radial head fractures depending on how destabilizing the injury is to the elbow's mechanical function. The purpose of this case report is to demonstrate a surgical treatment option for comminuted radial head fractures requiring replacement using a new radial head replacement system.

Publication provided by DePuy Synthes

Use of the Femoral Neck System for the Treatment of a Femoral Neck Fracture in Active Middle-Aged Adults

Justin Kuether, MD, David Molho, MD, and Michael P. Leslie, DO

Femoral neck fractures in young and middle-aged patients are a challenging clinical scenario. They have a high complication rate and behave distinctly different than those found in an elderly population. Historically, there were limited fixation options for this age group; however, the recent introduction of the femoral neck system offers a new tool to manage these fractures. This system may have advantages over previously available methods, and the capabilities of this device may offer increased stability and improved outcomes for challenging femoral neck fractures.

Publication provided by DePuy Synthes 

Terrible Triad Elbow Fracture-Dislocation With a Significant Coronoid Fracture

Francisco Rubio, MD

​The terrible triad elbow fracture-dislocation injury pattern is challenging to treat. The goal of treatment is to restore alignment and stability to the elbow joint. Typically, significant coronoid fractures associated with this injury pattern require management by internal fixation to confer elbow stability. We present a case of a terrible triad injury with a significant coronoid fracture that did not require coronoid fixation to provide stability to the elbow because of the placement of the internal joint stabilizer-elbow (IJS-E) device.

Publication support provided by Skeletal Dynamics

Simple Elbow Dislocation in Patients With High Body Mass Index​

Deana Mercer, MD and Allicia O. Imada, MD

In patients with a body mass index (BMI) above 30, simple elbow dislocations can have associated soft-tissue stripping and severe instability not typically seen in patients who have lower BMIs. We describe a patient with a BMI above 30 who had a simple elbow

dislocation and a complex elbow injury with severe soft-tissue stripping. Treatment included open reduction of the elbow joint, repair of the lateral ulnar collateral ligament, and placement of an internal joint stabilizer. At 4-year follow-up, the patient has a painless joint without arthritis and full-range of motion without any deficit.

​Publication support by Skeletal Dynamics 

Managing a Terrible Triad With Concomitant Posteromedial Rotatory Instability: A Surgical Case Study​

Jorge L. Orbay, MD, Menar Wahood, DO, and Gabriel Pertierra, MS

Complex elbow injuries involving the anteromedial facet of the coronoid (AMF) may result in persistent posteromedial rotatory instability. Management of these injuries often results in poor outcome. An 86-year-old patient was treated with a posterior elbow dislocation and unstable anterior and medial coronoid facet fractures (O'Driscoll type 2–3) that proved unstable after closed reduction. In this case, an internal joint stabilizer applied from the lateral side was successful in restoring joint congruency, maintaining AMF reduction, and permitting early rehabilitation. The AMF was partially reduced by closed manipulation and healed in a position that provided stability.​

Publication support provided by Skeletal Dynamics​ ​​

Treatment of Chronic Unreduced Posterior Elbow Dislocation With an Internal Joint Stabilizer
Evan S. Fene, MD, Ishvinder S. Grewal, MBBS, John L. Eakin, MD, and Adam J. Starr, MD

Chronic unreduced elbow dislocations remain difficult to treat with a high rate of complications. This injury is rare in the United States; more often, it is seen in underdeveloped countries where many patients seek traditional treatment from

local bone setters before ever seeing an orthopaedic surgeon. The purpose of this report is to present successful surgical management of a patient with a chronic elbow dislocation treated with an internal joint stabilizer of the elbow.

Publication support provided by Skeletal Dynamics

Humeral Plate Augmentation of an Elbow Internal Joint Stabilizer

Kendrick Khoo, MD, Kamran Movassaghi, MD, MS, and Nathan Hoekzema, MD

We describe a unique case of a distal humerus fracture involving the capitellum with associated elbow dislocation. Preoperative computed tomography demonstrated avulsion fractures of the medial collateral ligament, triceps insertion, and lateral epicondyle indicative of significant elbow instability. The patient underwent capitellar fixation and internal joint stabilizer.  Because of the osseous compromise of the lateral distal humerus, the internal joint stabilizer was augmented with a precontoured lateral distal humeral plate to maintain the axis pin position.

Publication support provided bSkeletal Dynamics 

New-Generation Femoral Neck Fixation for the Treatment of a Nondisplaced Femoral Neck Fracture in an Elderly Patient

Eben A. Carroll, MD

Femoral neck fractures are challenging fractures to treat.  In the elderly with nondisplaced or stable valgus-impacted fracture patterns, success hinges on a construct's ability to maintain reduction. New-generation femoral neck fixation constructs may decrease failure rates by providing increased mechanical stability.  This case explores the use of a new-generation femoral neck fixation construct to stabilize a femoral neck fracture in an elderly patient.


Publication support provided by DePuy Synthes

Open Reduction and Internal Fixation of a Distal Radius Fracture With a Volar Locking Plate: A Case Report

John Wyrick, MD​

Fracture of the distal radius is the most common fracture of the upper extremity and one of the most common fractures treated by orthopedists. With th​e population continuing to age, the annual incidence of more than 600,000 is expected to increase as well. ​Over the past 10 years, a more aggressive treatment approach has been adopted by the orthopaedic community with a 2-fold increase in the number of patients treated with surgery from 1998 to 2008. This includes an even larger increase in the number of fractures treated with open reduction and internal fixation (ORIF) with volar locking plates. Publication support provided by Stryker Trauma & Extremities​

Precontoured Plate Fixation With Interfragmentary Lag Screw Use in a Middle Third Clavicle Fracture Fixation

Alireza Naderipour, MD and Michael D. McKee, MD, FRCS(C)

Middle third clavicle fractures are common injuries that need surgical fixation in a certain subset of patients. The use of precontoured clavicle plates facilitates intraoperative fixation
and can reduce soft tissue irritation and hardware removal rates.We report a 46-year-old patient with a mid-shaft right clavicle fracture who was treated with this technique, which resulted in an excellent clinical outcome.  Publication support provided by Stryker Trauma & Extremities

Talus Fracture Fixation With Headless Screws From a Posterior to Anterior Direction—A Case Report

Ravi Arvind Karia, MD and Animesh Agarwal, MD

Open reduction with internal fixation is the standard for most displaced talar neck fractures. The posterior to anterior screw direction allows for more perpendicular screw placement that has shown biomechanical advantages. This report demonstrates the use of headless compression screws for fixation of a displaced talus fracture after open reduction. Publication support provided by Acumed

Lauren M. Shapiro, MD and Robin N. Kamal, MD

Open reduction and internal fixation is the mainstay of treatment for most unstable, intra-articular distal radius fractures. Anatomical reduction and maintenance of the reduction can be challenging in the setting of injuries with multiple fracture
fragments and complex intra-articular fracture patterns. The aim of this report is to illustrate the use of the fragment-specific technique for intra-articular distal radius fracture fixation. Publication support provided by Acumed.

Michael Krantzow, DO

Carbon fiber–reinforced PEEK composite materials have recently begun to be used more widely in orthopaedic trauma surgery. Metallic implants for fracture fixation have been the most common method of fracture fixation, but not necessarily the best implant choice. In the current case series, the author demonstrates the utilization of carbon fiber–reinforced PEEK implants and its many benefits over metallic implants. Publication support provided by CarboFix & Invibio Biomaterial SolutionsTM.

Lower Extremity

Intramedullary Nailing With Angle Stable Locking Technique of an Intra-articular Distal Tibial Fracture and an Extra-articular Distal Tibial Shaft Fracture

Cade A. Morris, BS and Phillip M. Mitchell, MD

Evolution of distal interlocking technology with “angle stable" screws has improved fixation in the treatment of far distal tibia fractures in more osteoporotic patients. This report details the use

of a suprapatellar tibial IMN with angle stable locking screws in the treatment of an open distal tibial fracture with intra-articular extension in a 67-year-old man who fell off a ladder. ​

Publication provided by DePuy Synthes​​​

Treatment of a Multifragmentary Patella Fracture Using a Novel Anatomic Locking Plate​

Adeet Amin, MD, Patrick J. Kellam, MD, and Stephen J. Warner, MD, PhD

Multifragmentary patellar fractures present a challenge for orthopaedic surgeons regarding treatment options.  Presented in this care report is a 50-year-old active gentleman who presented with a closed multifragmentary patella fracture treated with open reduction internal fixation using a 2.7-mm variable angle locking patella plate. This plate allowed for multiplanar and interfragmentary screw fixation in each fragment with early range of motion postoperatively. The patient returned to full activities and range of motion at 6 months postoperatively. 

Publication provided by DePuy Synthes​​

Correction of Pediatric Distal Tibial Malunion With an Automated Hexapod External Fixator​

Christian Blough, MD, Abrianna Robles, BS, Kenneth D. Illingworth, MD, and Geoffrey S. Marecek, MD

Angular deformity and limb length discrepancy (LLD) are common sequelae of growth arrest after pediatric physeal fractures. This combination of skeletal deformity can be treated in a variety of ways. One such technique is the use of hexapod external fixation to simultaneously address the angular deformity and LLD in a gradual fashion. New technology, in the form of automated hexapod struts, facilitates such a correction and may provide several advantages for the surgeon and patient.

We present the case of an 11-year-old girl with marked distal tibial varus and LLD after an ankle fracture who was treated with angular and length correction using a hexapod external fixator with automated struts.​

Publication provided by DePuy Synthes​​

Limb Salvage Reconstruction of the Lower Leg with Automatic Hexapod Struts​

Austin T. Fragomen, MD

Circular frame external fixation is a mainstay in the treating surgeon's armamentarium for managing complex limb salvage cases. Automatic hexapod struts have revolutionized the patient experience by removing the burden of adjustments from the patient, but these novel struts have been available in limited quantities and have been employed judiciously. This case report reviews the use of automatic struts for a moderate tibial lengthening-bone transport case, highlighting the ease of use and excellent radiographic results.

Publication provided by DePuy Synthes​

Effective Medullary Debridement of Long Bone Osteomyelitis​

Brett D. Crist, MD

The case presented was a chronically infected open tibia fracture with a history of methicillin-resistant Staphylococcus aureus bacteremia and recurrent draining tibial wounds. Along with sinus tract excision, implant removal, extramedullary debridement, resorbable local antibiotic delivery, and culture-specific antibiotics, the second-generation Reamer Irrigator Aspirator (DePuy Synthes, West Chester, PA) was used for medullary canal debridement because of concern for medullary sepsis in the setting of chronic osteomyelitis and indwelling tibial intramedullary nail. Cultures were obtained using the graft filter to help direct culture-specific antibiotic therapy. The patient went on to resolve his infection and was asymptomatic 14 months after surgery.

Publication provided by DePuy Synthes​

Nailing of a Proximal Third Tibial Shaft Fractures Using Cortical Substitution Screws​

Melissa M. Gross, MD and Brian M. Weatherfod, MD

The proximal third tibial shaft continues to be a region fraught with fixation challenges. The deforming forces acting on the proximal tibia and the broad metaphyseal diameter in relation to the nail heavily influence the surgeon's ability to obtain reduction, maintain alignment, and achieve union while allowing for early range of motion and weight-bearing. Advances in nail design and refinement of surgical technique have led to increase utilization of nailing for proximal tibial metaphyseal fractures. This case outlines the use of threaded wires and interlocking screws both as intraoperative reduction aids and cortical substitution devices to restore the mechanical axis of the limb and prevent late loss of reduction.

Publication provided by DePuy Synthes​

Fixation of Distal Femoral Periprosthetic Fracture With a Retrograde Nail and Locking Attachment Washer Combination: A Case Report​

M. Kareen Shaath, MD and George J. Haidukewych, MD

Periprosthetic distal femoral fractures are challenging injuries to treat due to patients' poor bone quality and limited bone stock. The 2 main treatment strategies are laterally based locked plates and intramedullary nails. The authors present a case of a periprosthetic distal femoral fracture successfully treated with the new retrograde femoral nailing system. The novel attributes of this implant, the surgical technique, and our postoperative protocol are described.

Publication provided by DePuy Synthes​

Use of a Variable-Angle Locking Plate for the Treatment of a Comminuted Patella Fracture

Augustine M. Saiz, Jr, MD and Mark A. Lee, MD

Historically, patellectomy was considered the treatment of choice for highly comminuted or complex patella fractures, but resection shortens the extensor mechanism and that affects symptoms and function. Contemporary fixation strategies exist with the goals of (1) restoration of the functional integrity and strength of the extensor mechanism and (2) restoration of articular congruity. A meticulous surgical technique using basic fracture care principles coupled with the new variable-angle screw and plate technology may offer unique fixation advantages that translate to improved clinical outcomes in the most challenging fractures.

Publication provided by DePuy Synthes​

Complex Distal Femur Fracture: A New and Novel Technique to Maximize Fixation and Promote Early Wight-Bearing - A Case Report​​

Frank A. Liporace, MD, Luke G. Menken, DO, and Richard S. Yoon, MD

The authors present a new technique incorporating the concept of combining fixation options to enhance distal femur fragment stability with retrograde intramedullary nailing to allow for early weightbearing and decreased risk of fixation failure by combining retrograde nailing with a locking attachment washer.

Publication provided by DePuy Synthes​

Advancing the Treatment of Segmental Defects: Eliminating "Graft Escape" During the Second Stage of Masquelet Technique

Luke G. Menken, DO, Jaclyn M. Jankowski, DO, Frank A. Liporace, MD, and Richard S. Yoon, MD​

Segmental bone defects can arise from a variety of etiologies including trauma or malignancy, both with or without infection. One accepted treatment modality, the Masquelet technique, is a 2-staged procedure that involves bone grafting during the second stage. No matter the size of the defect, ensuring that the graft remains in the bony void in the desired configuration can be a difficult task; often, “graft escape" can occur, where even weight-bearing may cause the graft to move from its ideal position. The authors describe the use of a TRUMATCH(R) Graft Cage - Long Bone to eliminate “graft escape" and maintain ideal bone graft position within the void.

Publication provided by DePuy Synthes

Ankle Fractures With Syndesmosis Sprain Repaired With a Novel Screw-Suture Construct: A Report of 2 Cases

Babar Shafiq, MD and Davis Rogers, MD

Syndesmotic fixation remains a foundational operative technique in reconstructing ankle stability. Standard transsyndesmotic surgical options for the treatment of syndesmotic instability include screw fixation and/or fixation with a suture button. However, syndesmotic implants  frequently require removal; suture button tension consistency remains inconsistent; and certain complex ankle fractures increase the difficulty of inserting syndesmotic fixation without interfering with implants required to stabilize the bony fragments. Two cases are presented in which a new method of syndesmotic fixation is used and demonstrates restoration of the distal tibiofibular articulation via a modular system with which tension can be adjusted. 

Publication support provided by DePuy Synthes

Combined Open and Percutaneous Techniques in Complex Subtrochanteric Femur Fracture Nailing​

Greg M. Osgood, MD

Subtrochanteric femur fractures are challenging cases that every on-call orthopaedic surgeon may encounter. Fracture features and patient features complicate the execution of the surgery and also challenge optimal reduction for healing. Anatomical reduction can be achieved if these specific fracture characteristics are recognized, proper positioning and reduction tools are selected, and the surgeon uses the appropriate implant to its optimal biomechanical capabilities.

Publication support provided by DePuy Synthes 

Treatment of a Segmental Defect in the Humerus With Induced Membrane Technique

Clay A. Spitler, MD

Treatment of large long bone segmental defects is typically performed by bone transport or induced membrane technique. Although both methods are more frequently described in the lower extremity, descriptions and outcomes of upper extremity defects are less well described. The purpose of this case report is to describe the management of a segmental bone defect in the humerus using induced membrane technique with bone graft harvest from the ipsilateral femoral medullary canal.

Publication support provided by DePuy Synthes  ​

Use of Polymethyl Methacrylate Bone Cement to Augment the Salvaging of Failed Hip Fracture Fixation

Sarah Blumenthal, MD and Samir Mehta, MD

Cephalomedullary nails are frequently used for fixation of both stable and unstable hip fractures. Despite their many proven benefits, complications including fracture collapse and malunion remain a concern.  This case presents peri-implant failure after cephalomedullary nailing of an OTA/AO 31A2.2 left pertrochanteric hip fracture. The patient was successfully revised by treatment using a proximal femoral nailing system with polymethyl methacrylate augmentation. 

Publication support provided by DePuy Synthes 

Polymethylmethacrylate Augmentation in Revision of a Proximal Femur Fracture

Douglas W. Lundy, MD, MBA and Jennifer L. Bruggers, MD

Augmentation of fixation using polymethylmethacrylate is a reliable method to increase stability in complex proximal femoral fractures.  Salvage after cutout can be challenging because the bone stock of the proximal femur in elderly patients is often compromised by the cavitation defect created in the femoral head.  The bone loss after cutout can often be sufficient to make subsequent fixation technically difficult or impossible.  This report describes the use of polymethylmethacrylate (PMMA) to augment femoral head fixation in a patient with cutout after failed fixation of a subtrochanteric femoral fracture.

Publication support provided by DePuy Synthes

Lateral Malleolus Fixation With a Fibular Rod

Darryl A. Auston, MD, PhD

In the surgical treatment of fibula fractures, some patient populations may benefit from less invasive approaches and indirect reduction associated with fibular rods. The aim of this report is to demonstrate successful treatment of an unstable ankle injury in a geriatric patient with insulin-dependent diabetes using a fibular rod. Publication support provided by Acumed.

Krystin A. Hidden, MD, Marissa D. Jamieson, MD, and Adam T. Groth, MD

Comminuted medial malleolus fractures can be technically challenging injuries given the limited surface area of the small osseous fragment, and multiple fixation techniques have been described. The locking peg hook plate provides a reliable fixation option for medial malleolus fractures. The purpose of this case report is to discuss the use of a locking peg hook plate for a comminuted fracture of the medial malleolus. Publication support provided by Acumed.  

Brigham Au, MD

The treatment of unstable ankle fractures is a common problem for orthopedic surgeons. Anatomically contoured distal fibula plates offer the biomechanical advantage of polyaxial locked fixation with a lower profile than previous implants to mitigate concerns with wound complications.  This case demonstrates the use of a contoured distal fibula small fragment locking plate in the treatment of an unstable bimalleolar ankle fracture. Publication support provided by Smith & Nephew, Inc.

Fixation of Intertrochanteric Fractures of the Hip With a Carbon Fiber Intramedullary Implant

Fractures in the intertrochanteric region are among the most commonly treated operative orthopaedic injuries. Implant selection has gradually trended away from compression hip screws toward cephalomedullary nails. Carbon fiber–reinforced polyaryletheretherketone (PEEK) has been introduced as an alternative material in the construction of intramedullary nails and plates. The authors describe the use of a carbon fiber cephalomedullary nail to treat an intertrochanteric fracture, leading to uncomplicated fracture healing. Publication support provided by CarboFix & Invibio Biomaterial SolutionsTM

Erik Lund, MD and Hassan Mir, MD, MBA, FACS

Intraarticular distal tibia (pilon) fractures occur with limited frequency, but can present substantial morbidity to patients and clinical challenges to the treating orthopaedic surgeon. With the advent of modern surgical techniques and implants, open reduction and internal fixation is now the standard of care. This case demonstrates a pilon injury treated with a staged protocol. Fixation included low profile small fragment distal tibial and fibular plates with variable angle locking screws. This construct limited the dissection necessary to achieve the goals of anatomical joint reconstruction and rigid fixation, allowing for early motion. Publication support provided by Smith & Nephew

John D. Wyrick, MD

Several techniques are available in the treatment of large segmental bone defects. Bone transport is a very reliable method of reconstruction but is usually performed with the use of an external fixator, which can have significant drawbacks. This article describes a new method of bone transport using a magnetic internal lengthening nail combined with a plate to reconstruct a segmental bone defect in a distal femur. Sponsorship provided by NuVasive Specialized Orthopedics, Inc.

Unique Applications of Carbon Fiber–Reinforced Polyetheretherketone Nails in Tibia and Ankle Injuries

Gil R. Ortega, MD, MPH and Cody Pehrson, MD

Tibial shaft and distal tibial pilon fractures can be a clinical and surgical challenge for the orthopedic surgeon and the recovering patient. Despite advances in nonsurgical and surgical techniques, fracture fixation alternatives, and adjuncts to healing, tibial shaft, and distal tibia nonunions continue to occur. Another challenge in our athletic population is the treatment of tibial stress fractures. This article reviews the unique use of CFR-PEEK implants in a collegiate athlete with bilateral, symptomatic tibial shaft stress fractures that failed conservative management, and a patient who suffered an initial, open tibial shaft, and pilon fracture who was surgically treated initially, which then became a nonunion. Publication support provided by CarboFix Orthopedics & Invibio Biomaterial Solutions.

Use of Carbon Fiber–Reinforced PEEK for Treatment of Femur Fractures: A Small Step for Implants, a Large Step in Fracture Care​

Bruce H. Ziran, MD, FACS and Robert Harris, MD​

Composite carbon fiber–reinforced PEEK implants have now become cost-effective to use in fracture surgery. Since the use of metallic implants has dominated fracture treatment, there are sparse reports in the North American market regarding the efficacy of composite carbon fiber PEEK implants. The authors present a case report from their many applications to demonstrate the utility of such implants. Sponsorship provided by CarboFix Orthopedics​ & Invibio Biomaterial Solutions™​​​​

Fragment-Specific Fixation of Proximal Tibia Fractures: Case Report and Surgical Technique

Yelena Bogdan, MD and Paul Tornetta III, MD

Proximal tibia and plateau fractures are challenging cases with a high rate of soft-tissue complications. Although precontoured locking plates provide excellent results, they are not always ideally suited for fixation of additional or small fragments, and their prominence can lead to irritation and wound problems. This article illustrates the use of small-fragment plates in the fixation of a complex proximal tibia fracture. Sponsorship provided by Smith & Nephew, Inc​​

Atif Ahmed, MD, DMD and Edward Westrick, MD​

Fractures of the talus continue to be a challenging problem for the orthopaedic trauma surgeon. There are many attributes of the local anatomy and nature of the injury, which make this a complex situation. The authors present a case of a displaced Hawkins III talar neck fracture with a concomitant distal tibia fracture localized to the medial malleolus and articular surface.  This example demonstrates mini-fragment fixation to maintain reduction and lead to a favorable result in the setting of this potentially devastating and life-altering injury. Sponsorship provided by Smith & Nephew, Inc ​

Ipsilateral Ankle, Talus, and Calcaneus Fracture Dislocation: A Case Report

Erik Lund, MD and Hassan Mir, MD, MBA, FACS

Foot and ankle injuries can present with multiple fractures after high-energy trauma. The goal for complex combined injuries remains anatomic restoration of articular surfaces and overall alignment. Operative fixation may require a variety of plate and screw sizes for an optimal construct. This report demonstrates a case of a combined injury involving fractures of the ankle, talus, and calcaneus, where an assortment of mini-fragment implants were used. Sponsorship provided by Smith & Nephew, Inc           

John A. Scolaro, MD, MA

The concurrent use of plates and intramedullary nails has been described in the treatment of both acute and nonunited long bone fractures. This technique aids in the maintenance of reduction during nailing and if left in place, the plates can also serve to provide adjunctive fixation after nail placement. Read this case which demonstrates the use of mini-fragment plates and revision intramedullary nailing to successfully treat a complex segmental femoral malunion/nonunion. Sponsorship provided by Smith & Nephew, Inc. 


Fragment-Specific Pilon Fracture Fixation Using Mini Fragment Plates

Richard A. Lindtner, MD, PhD and Reza Firoozabadi, MD, MA

Surgical stabilization of pilon fractures is challenging and technically demanding. Anatomic reduction of the articular surface is often difficult to obtain and maintain. The objective of this article is to illustrate the successful use of mini fragment plates for fragment-specific pilon fracture fixation. Sponsorship provided by Smith & Nephew, Inc. 

High-Energy Pilon Fractures in the Elderly: A Case Report Highlighting Treatment Options and Strategies​

Michael T. Archdeacon, MD, MSE​

High-energy pilon fractures are complex injuries for which treatment recommendations have changed substantially over the past 4 decades.The appropriate treatment for a high-energy pilon fracture in an elderly patient has not been clearly established.  This report presents an open, complex intra-articular pilon fracture in an elderly patient who ultimately underwent uncomplicated ORIF and subsequent uneventful healing. Publication Support Provided by Stryker Trauma & Extremities​

Suprapatellar Nailing

​This video is narrated and features a surgical procedure completed by Dr. Joshua Langford at Orlando Regional Medical Center demonstrating the suprapatellar technique for tibial nail insertion using an insertion sleeve as part of the T2 Tibia Suprapatellar Instrument System.The demonstration includes patient positioning and incision as well as sleeve insertion and fixation into the tibia plateau, reaming and nail insertion.The video includes pre-nail and post-nail x-ray images demonstrating entry point, fracture reduction and final nail positioning. Publication support provided by Stryker Trauma and Extremities​

Daniel N. Segina MD and Ryan M. Wilson PA-C, MPAS

​The case demonstrates the utility of the suprapatellar nailing technique in the semi-extended position, particularly with the avoidance of vascular graft disturbance and prevention of malalignment. Publication Support Provided by Stryker Trauma & Extremities​.

Ginger Bryant MD

Treatment of tibial plateau fractures that involve the medial condyle can be challenging. The surgeon must determine if adequate fixation can be obtained, and more importantly maintained, from the commonly-used “lateral only” plate construct. This case presents a patient who sustained a medial tibial condyle fracture with lateral diaphyseal extension. Medial condyle reduction was obtained and the condylar fracture and the diaphyseal fracture extension were both treated with a medial locking plate only. Publication support provided by Stryker Trauma and Extremities​

A Missed Ipsilateral Femoral Neck Fracture in a Young Patient with a Femoral Shaft Fracture

Anthony V. Florschutz, MD, PhD,* Derek J. Donegan, MD,† George Haidukewych, MD et al.

Ipsilateral femoral neck-shaft fractures are uncommon but significant injuries that can present a diagnostic difficulty with respect to recognition of femoral neck component. Treating surgeons need to be attentive to the potential associated femoral neck fracture when managing femoral shaft fractures and consider its possibility even in the postoperative period. This case report describes a young male who was initially managed for an isolated femoral shaft fracture after a high-energy injury and was postoperatively diagnosed and treated for an ipsilateral femoral neck fracture. Publication support by Biomet, Inc.

Evaluation and Management of an Unstable Intertrochanteric Fracture of the Femur

Harish Kempegowda, MS; Akhil Tawari, MS; Michael Suk, MD JD MPH FACS; Daniel S. Horwitz, MD

Unstable intertrochanteric fracture of the femur is one of the most commonly encountered orthopaedic injuries in the United States. A 63-year-old female sustained a highly unstable intertrochanteric fracture of the femur (OTA 31-A 3.3) and she was treated with a long cephalomedullary nail. Four months later, a solid union occurred at the fracture site with minimal limb length discrepancy and the patient regained her pre-operative functional status. This case report highlights the important points which must be considered in the treatment of an unstable intertrochanteric fracture with emphasis on preoperative evaluation, intraoperative management and post-operative protocol for a good outcome. Publication support provided by Biomet, Inc. 

Fixator-Assisted Femoral Lengthening Following Intramedullary Exchange Nailing for Subtrochanteric Non-union

Frank A. Liporace, MD and Richard S. Yoon, MD

Non-unions in the femur can be a severely debilitating condition.  Here, we present a 36 year-old male who presented three years following a motor vehicle accident, complaining of severe left thigh pain and a short left lower extremity. Publication support provided by Biomet, Inc.

Intramedullary Nailing of Sequential Bilateral Atypical Subtrochanteric Fractures and the Management of Distal Femoral Intraoperative Fracture: Contemporary Issues on a Case Report

Theodoros H. Tosounidis, MD,  Kalliopi Lampropoulou-Adamidou, MD, Nikolaos K. Kanakaris, MD, 

Long antegrade cephalomedullary nailing is the standard of surgical care of atypical subtrochanteric fractures of the femur. This case discusses the management of sequential bilateral atypical subtrochanteric fractures in an elderly female patient and the technical issues pertaining to nailing of such fractures. Publication support provided by Biomet, Inc. 

Femoral Bone Transport With a Combined Method Using a PRECICE Nail and Cable Lengthening Technique

Stephen M. Quinnan, MD and Max Seiter, MD

Treatment of segmental bone loss in the femur can be very challenging.  This report presents a case of an open distal femur fracture with a 13-cm segmental bone defect, treated with a unique and previously undescribed use of an internal lengthening nail in conjunction with a cable bone transport. Sponsorship provided by NuVasive Specialized Orthopedics, Inc. 

Ravi Arvind Karia, MD

The purpose of this report is to demonstrate the use of a mini-fragment fixation construct in the treatment of a comminuted distal tibial plafond fracture. Internal fixation of displaced intra-articular distal tibia fractures remains the standard of care. Mini-fragment plating allows for more screw trajectory options and the ability to achieve multiplanar fixation with less bulk than with precontoured plating. Publication support provided by Smith & Nephew, Inc.

Pelvis Extremity

Isolated Anterior Intrapelvic Approach for Operative Reduction and Fixation of an Anterior Column Acetabulum Fracture With Superior Impaction

Matthew R. Garner, MD and H. Claude Sagi, MD​

Displaced fractures of the acetabulum in an aging population present unique challenges for the treating surgeon. Traditional extensile exposures and reduction techniques may be ill advised because of patient-related factors. This report presents operative reduction and fixation performed through an isolated anterior intrapelvic approach in an elderly patient with a displaced anterior column acetabulum fracture with superior dome impaction. Publication Support Provided by Stryker Trauma & Extremities​