Category Archives: Orthopedic Trauma

Orthopedic Trauma, Orthopedics, Print Release

PUBLISHED: Single-Incision Retrograde SIGN Nailing of the Femur and Antegrade SIGN Nailing of the Tibia for a Delayed-Presentation Floating Knee Injury

Single-Incision Retrograde SIGN Nailing of the Femur and Antegrade SIGN Nailing of the Tibia for a Delayed-Presentation Floating Knee Injury
Donald L. Fejfar, MD1; Samhita Kadiyala, BA1; Nikhil Gattu, MD1; Emily S. Powis, BS1; Elizabeth Rich, MD2; Ridwan M. Saeed, MD3; Hizkyas Kassaye, MD4; Pierre M. Woolley, MD5; Bitiel Banda, MD6; Kiran J. Agarwal-Harding, MD, MPH7
1Harvard Global Orthopaedics Collaborative, Boston, MA
2Walter Reed National Military Medical Center, Bethesda, MD
3Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
4Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia
5Hôpital Universitaire La Paix, Port au Prince, Haiti
6Mzuzu Central Hospital, Mzuzu, Malawi
7Beth Israel Deaconess Medical Center, Boston, MA

Floating knee injury, defined as ipsilateral femoral and tibial shaft fractures, is a high-energy traumatic injury frequently seen following road traffic accidents (RTAs), which disproportionately burden low- and middle-income countries. Definitive treatment of this complex injury typically involves internal fixation, and the commonly accepted preferred method is intramedullary nailing of both fractures. This video article describes the surgical technique for managing a floating knee using retrograde Surgical Implant Generation Network (SIGN) nailing of the femur and antegrade SIGN nailing of the tibia through a single infrapatellar incision in a single anesthesia event.

The case involves a 28-year-old female patient in rural Malawi with a floating knee injury sustained in a motorbike RTA, notable for her delayed presentation of three weeks. The key procedural steps, performed under spinal anesthesia, began with a single infrapatellar incision for the subsequent retrograde nailing of the midshaft femur. Due to delayed presentation (22 days from the date of injury to the first exam in the hospital, with 2 more days before surgery) and callus formation, intraoperative fracture fragment mobilization via a second lateral incision was required before securing the femoral nail. The same infrapatellar incision was then used to perform antegrade nailing of the proximal tibial shaft fracture, which was secured after a closed reduction. This single-incision approach provides a definitive, robust fixation solution appropriate for a resource-constrained setting where challenges include delayed patient presentation and limited imaging infrastructure.

Orthopedic Trauma, Orthopedics, Print Release

PUBLISHED: Debridement and External Fixation for Bilateral Neglected Open Tibial Shaft Fractures

Debridement and External Fixation for Bilateral Neglected Open Tibial Shaft Fractures
Donald L. Fejfar, MD1; Nikhil Gattu, MD1; Ridwan M. Saeed, MD2; Hizkyas Kassaye, MD3; Bitiel Banda, MD4; Pierre M. Woolley, MD5; Kiran J. Agarwal-Harding, MD, MPH1,6
1Harvard Global Orthopaedics Collaborative, Boston, MA
2Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
3Hawassa University Comprehensive Specialized Hospital, Hawassa, Ethiopia
4Mzuzu Central Hospital, Mzuzu, Malawi
5Hôpital Universitaire La Paix, Port au Prince, Haiti
6Beth Israel Deaconess Medical Center, Boston, MA

Open tibial shaft fractures represent a significant clinical challenge, particularly when presentation is delayed and wounds have become infected. This case demonstrates the surgical management of bilateral neglected open tibial shaft fractures in a young adult male who presented three weeks after initial injury from a motor vehicle collision in rural Malawi. He also suffered a bimalleolar fracture of the left ankle. The patient had grossly contaminated wounds with exposed bone and signs of infection bilaterally. The key procedural steps included aggressive irrigation and debridement of necrotic and infected tissue, skeletal stabilization with external fixation, local antibiotic therapy with gentamicin-impregnated collagen pellets, and soft tissue coverage with primary wound closure and a rotational subcutaneous flap on the left leg. External fixation is an essential treatment modality for open fractures with severe soft tissue injury when internal fracture fixation is not possible, especially in delayed cases with early signs of infection. This allows for staged management, repeated wound access, and preservation of blood supply while providing adequate stability for bone healing and soft tissue rest. This technique is particularly valuable in resource-limited settings where staged reconstruction and damage control orthopaedics are essential. The bilateral nature of these injuries, prolonged contamination period, immunocompromised status, and need for complex soft tissue reconstruction make this case unique and highlight the principles of managing neglected open fractures in challenging clinical circumstances.

Orthopedic Trauma, Orthopedics, Print Release

PUBLISHED: Left Tibia Pilon Open Fracture Open Reduction and Internal Fixation with External Fixator

Left Tibia Pilon Open Fracture Open Reduction and Internal Fixation with External Fixator
Nelson Merchan, MD1,2; Andrew M. Hresko, MD1,2; Edward Kenneth Rodriguez, MD, PhD2
1Harvard Combined Orthopaedic Surgery Residency Program
2Beth Israel Deaconess Medical Center

Tibial plafond or pilon fractures account for 5 to 10% of all lower extremity fractures and are associated with high energy trauma. These fractures have a high rate of non-union, mal-union, and wound healing issues due to weak metaphyseal bone, a lack of robust soft tissue coverage, and complex intra-articular extension. This manuscript and video demonstrates a tibial pilon fracture managed acutely with a hybrid fixation approach combining internal fixation with external fixation.

Orthopedic Trauma, Orthopedics, Print Release

PUBLISHED: Intramedullary Nail for Open Tibial Fracture

Intramedullary Nail for Open Tibial Fracture
Caleb P. Gottlich, MD, MS1; Michael J. Weaver, MD2
1Department of Orthopedic Surgery, Texas Tech University Health Science Center
2Brigham and Women’s Hospital

This article describes the stabilization of an open tibia shaft fracture using an intramedullary nail. After copious irrigation and debridement of the fracture site, a transpatellar tendon split is used to expose the nail entry point. This is followed by fracture reduction, sequential reaming, and nail insertion and locking. Finally, the technique for proximal tibia traction pin insertion is demonstrated on the contralateral tibia.

Orthopedic Trauma, Orthopedics, Print Release

PUBLISHED: Left Hip Hemiarthroplasty for Femoral Neck Fracture

Left Hip Hemiarthroplasty for Femoral Neck Fracture
Michael Akodu, MBBS; Elyse J. Berlinberg, MD; Miles Batty, MD; Michael McTague, MPH; Kiran J. Agarwal-Harding, MD, MPH
Beth Israel Deaconess Medical Center

Hip fractures are a major cause of morbidity and mortality, especially among older patients. They also account for a significant portion of healthcare spending and other non-medical costs. These fractures can be classified into various types based on the parts of the femoral head and neck affected, and fixation options are dependent on both patient and injury characteristics. In this video, Dr. Agarwal-Harding takes us through a hip hemiarthroplasty for a left femoral neck fracture, highlighting various guiding principles and surgical considerations.

Orthopedic Trauma, Orthopedics, Print Release

PUBLISHED: Closed Cephalomedullary Nailing of a Diaphyseal Femur Fracture on a Fracture Table

Closed Cephalomedullary Nailing of a Diaphyseal Femur Fracture on a Fracture Table
Sarita Jamil1; Michael J. Weaver, MD2
1University of Central Florida College of Medicine
2Brigham and Women’s Hospital

Femoral fractures typically occur in two major settings: high-energy mechanisms related to trauma and low-energy mechanisms in insufficiency fractures observed in elderly patients with osteopenia. Patients present with pain, swelling, and limited range of motion.

Intramedullary nailing is the definitive surgical treatment for femoral fractures to allow secondary healing of bone. Such a repair is performed here on a patient with a diaphyseal femoral fracture. Surgeon preference was to perform a closed cephalomedullary nailing with the patient supine on a radiolucent fracture table for traction.

Orthopedic Trauma, Orthopedics, Print Release

PUBLISHED: Bimalleolar Ankle Fracture Open Reduction and Internal Fixation

Bimalleolar Ankle Fracture Open Reduction and Internal Fixation
Kiran J. Agarwal-Harding, MD, MPH; Michael Akodu, MBBS; Miles Batty, MD; Elyse J. Berlinberg, MD; Michael McTague, MPH
Beth Israel Deaconess Medical Center

Ankle injuries are common, occurring most often among young males and older females. The ankle joint is crucial for stability and gait, making these injuries a significant source of disability.

Ankle injuries are usually treated operatively when there is loss of joint congruity and stability, and in this video, Dr. Agarwal-Harding takes us through the operative fixation of a bimalleolar ankle fracture. He talks about understanding why operative intervention is recommended, techniques involved, and other considerations.

Orthopedic Trauma, Orthopedics, Print Release

Right Distal Tibial Oblique Fracture Open Reduction and Internal Fixation (ORIF) with Medial Neutralization Non-locking Plate

Right Distal Tibial Oblique Fracture Open Reduction and Internal Fixation (ORIF) with Medial Neutralization Non-locking Plate
Andrew M. Hresko, MD; Edward Kenneth Rodriguez, MD, PhD
Beth Israel Deaconess Medical Center

Diaphyseal tibial fractures are common injuries that are most often treated with intramedullary nailing. However, certain patient factors may necessitate alternative treatment strategies such as open reduction internal fixation (ORIF) with plates and screws. Presence of a total knee arthroplasty (TKA) in the injured extremity is one such factor. TKA is a common operation that is only increasing in popularity, and management of tibia fractures distal to TKA may be a frequently encountered clinical scenario.

This video presents a technique for ORIF of a distal diaphyseal tibia fracture distal to a TKA that precludes intramedullary nail fixation. The fracture is fixed with lag screws and secured with an anatomically-contoured distal tibia locking-compression plate (LCP) in neutralization mode.

Orthopedic Trauma, Orthopedics, Print Release

PUBLISHED: Carbon Fiber Implant for Fixation of a Pathologic Subtrochanteric Fracture

Carbon Fiber Implant for Fixation of a Pathologic Subtrochanteric Fracture
Paul A. Rizk, MD; Joseph O. Werenski; Santiago A. Lozano-Calderon, MD, PhD
Massachusetts General Hospital

This case presents a patient with a pathologic subtrochanteric femur fracture secondary to an undiagnosed primary lung adenocarcinoma. The fracture, occurring in the context of persistent atraumatic thigh and knee pain, prompted swift identification of its pathological nature in the Emergency Department. The treatment plan involved open reduction and internal fixation utilizing a carbon fiber nail, considering the immediate need for stabilization and underlying oncologic factors.

This article highlights the strategic use of carbon fiber implants in managing pathologic fractures, offering advantages in postoperative imaging, disease monitoring, and precision in radiation therapy planning. The multidisciplinary approach underscores the importance of considering implant selection nuances, especially in metastatic bone disease, to optimize outcomes.

OMFS, Orthopedic Trauma, Orthopedics, Otolaryngology, Print Release

PUBLISHED: Open Reduction and Internal Fixation of Mandibular Body and Parasymphyseal Fractures with Maxillomandibular Fixation and Broken Tooth Extraction

Open Reduction and Internal Fixation of Mandibular Body and Parasymphyseal Fractures with Maxillomandibular Fixation and Broken Tooth Extraction
Derek Sheen, MD1; Cheryl Yu, MD2; Sarah Debs, MD2; Peter Kwak, MD2; Nima Vahidi, MD3; Daniel Hawkins, DDS2; Thomas Lee, MD, FACS2
1University of Texas Southwestern Medical Center
2Virginia Commonwealth University Medical Center
3Upstate Medical Center

This is a case discussing a 21-year-old male who suffered from both non-comminuted mandibular parasymphyseal and body fractures as a result of a motor vehicle accident, requiring open reduction internal fixation (ORIF) without postoperative maxillomandibular fixation (MMF). The fracture was complicated by a broken tooth root, which required extraction.

After intraoperative MMF, ORIF was performed. The parasymphyseal fracture was plated using two locking four-hole 2-mm thick miniplates utilizing two locking screws on either side of the fracture with one plate along the alveolar surface (monocortical screw) and one along the basal surface (bicortical screw). For the right body fracture, a three-dimensional locking ladder plate was used via a transbuccal trocar approach for additional exposure needed for proper screw placement. Once the hardware was secured, the patient was taken out of MMF and restoration of premorbid occlusion was confirmed. Lastly, watertight mucosal closure was performed using absorbable sutures and Dermabond (cyanoacrylate adhesive).