OTA Specialty Day 2016 Practical Reduction Techniques: Diaphyseal Reduction Philip Wolinsky University of California at Davis Medical Center 8:55 am 9:55 am Tips and Tricks: Practical Reduction Techniques Moderators: Paul Tornetta, III, MD; Ronald Lindsey, MD 8:55 am 9:05 am Diaphyseal Reduction: Philip Wolinsky, MD 9:05 am 9:10 am Discussion 9:10 am 9:20 am Metaphyseal Fractures: Daniel Horwitz, MD 9:20 am 9:25 am Discussion 9:25 am 9:35 am Percutaneous Reduction: Christian Krettek, MD, FRACS 9:35 am 9:40 am Discussion 9:40 am 9:50 am Miniplates: How and When to Use Them: Paul Tornetta III, MD 9:50 am 9:55 am Discussion Diaphyseal Reduction Techniques for the Femur and Tibia Intramedullary Fixation Frequently used for stabilization of diaphyseal fractures of the femur and tibia The same reduction techniques can be used regardless of what type of implant you use: a plate or an IMN Starting point: When an IMN is used a correct starting site is critical to maintain your reduction whether you use an antegrade femur start side (piriformis fossa or greater trochanteric start site), a retrograde start site or standard or semi-extended technique for a tibial IMN. Piriformis Fossa Start Co-linear with shaft/ Posterior Advantage: In line with the axis of the femoral canal PF Disadvantage: Anterior displacement by more than 6 mm causes high hoop stresses that can cause bursting of the femoral cortex Lateral or medial displacement does not have as great an effect 1
Lateral Trochanteric Entry Useful for obese & muscular patients: faster and less radiation The tip of the GT or just medial to it is the best starting point: Best alignment regardless of the nail used Lateral start is the worst- always led to varus and gapping of the lateral cortex Retrograde Femoral Nailing Starting Point Just anterior to the ACL Junction of the anterior portion of the intercondylar notch and inferior posterior part of the patella femoral joint at Blumensaat s line Collinear with the canal on both views Before You Prep and Drape: Determining Length and Rotation Non-Comminuted Fractures Line up a radiographic key on imaging The width of the cortex should be similar on both sides of the fracture Comminuted Fractures No cortex(s) to line up Before you prep and drape: Know what length nail or plate you are going to use Know how to determine what the correct rotation is Using the good leg as a template Length: Use fluro to image the contra-lateral extremity Nail in the box or contralateral plate held over the leg Ruler Rotation: Clinical Assessment Femur Test hip IR and ER on the intact side prior to prepping and draping When the locks are in one end of the nail and one drill bit in in the other (rotationally stable but not committed) test hip ER and IR to see if it s close to the other side 2
Rotation X-ray Method Femur Perfect AP of the Knee Slide up to the hip and get an AP with the knee held in the same position Look at the shape of the GT and LT Rotational Malalignment after IMN of Femur Fractures 67 patients Fracture table/ antegrade nail CT scan post op 21 patients (28%) were off by 15 degrees or more 12 (16%) were off by >=20 degrees Torsional differences of < 10 are normal 10-14 is a grey area The hardest part of the case is getting and holding the reduction Reduction maneuvers: Escalating series of maneuvers A) All closed reduction with just traction: a. Fracture table b. Manual traction c. Traction pin with rope thrown off the end of the table/ traction bar attached to the foot of the table Traction alone typically gets things close but the reduction will need some fine tuning Escalation: When traction alone does not make it perfect Additional Reduction Tools: Divided into external and internal types B) All closed with traction and things to push with: Mallets, retractors, F tool Towel bumps Triangles: Specific fracture pattern: Distal third femur fractures Bump under distal thigh: Relaxes gastroc/ reduces typical apex posterior deformity Intramedullary reduction tool 3
C) Mini open via 1-2 cm incisions not at the fracture site: Bone/shoulder hooks to pull with Ball spikes to push with Sometimes need to Push one Fragment and Pull the other Half pins to steer/ rotate fragments External fixation frame/ distractor Non-Spanning Ex Fix ½ pins are harder to Place for an IMN than for a plate Can t block the entire canal where the IMN needs to go Femur: Proximal pin: proximal and medial near the LT medial to the IMN Distal femur where the canal flares out Tibia: Medially based frames (no fibula) Proximal pin goes posterior to where the IMN will sit Distal pin can go in the post malleolus posterior to where the IMN will sit, or at the level of the physeal scar if you don t need to push the IMN all the way distal to the physeal scar Reduction clamps applied remote from the fracture site to manipulate the fragments Blocking Screws : Concave side of the deformity in the mobile fragment Where you don t want the IMN to go Use blockers to Create a canal Push fragments with the IMN The IMN either needs to be centered and not eccentric in both fragments or eccentric the same way in the proximal and distal fragments D) Medium open: Reduction clamps at the fracture site: Spiral patterns particularly in the tibia = Clamps Mini-fragment plates to hold the reduction until the definitive hardware can be placed: Unicortical screws avoid the canal for IMN s Plating the fibula e) MAXXO 4
Large open approaches to do whatever is needed to obtain and obtain the reduction while still somehow trying your best to protect the biology and blood supply the best that you can F) Combinations of any of the above How can you tell of the fracture is reduced? Fluro: has a small field of view Clues: THE NAIL SHOULD BE CENTERED IN BOTH FRAGMENTS, NOT ECCENTRIC An eccentrically eccentric IMN= Mal-reduction A centered IMN or a symmetrical eccentric IMN = good reduction To center the IMN: Center the guide wire and the reamer The Nail Goes Where the Guide Wire is If you have an external fixator pins or a frame on: Use the ½ pins placed parallel to the joint the IMN should meet it at a right angle Distal Femur: The starting guide Wire should be about 90 degrees to a ½ pin placed parallel to the joint Bovie cord alignment: C arm shot of the cord centered over the femoral head Then centered over the ankle joint The wire should be centered over the knee joint of just medial to the center 5