Rockwood and Green's fractures in adults 10th ed 2025

Cover Title Page Copyright Dedication Contributors Preface Contents SECTION ONE: GENERAL PRINCIPLES 1 Biomechanics of Fractures and Fracture Fixation INTRODUCTION BASIC MECHANICAL CONCEPTS Material Properties Structural Properties Load Transfer Through Joints and Fractures BIOMECHANICS OF FRACTURES Traumatic Loads Resulting in Fracture Physiologic Loads During Normal Activities Osteoporosis Stress Riser Fractures: Periprosthetic, Interprosthetic, and End Screw Fractures BIOMECHANICAL ASPECTS OF BONE HEALING Interplay Between Biology and Mechanics Natural Bone Healing Primary Bone Healing Delayed Union and Nonunion FRACTURE FIXATION STRATEGIES Targeting a Fracture-Healing Mode Fixation Strategies for Natural Bone Healing Fixation Strategies for Primary Bone Healing Creating a Durable Fixation Construct FIXATION CONSTRUCTS Biomechanical Characterization of Fixation Constructs Stiffness of Intramedullary Nail Constructs Stiffness of External Fixator Constructs Stiffness of Plate Constructs Construct Stiffness and Fracture Healing Strategies for Improvement of Fracture Fixation BIOMECHANICAL EVALUATION OF FIXATION CONSTRUCTS Benefits and Limitations of Biomechanical Studies Specimen Selection Loading Considerations Loading Modes Outcome Parameters Numerical Simulation SUMMARY 2 Bone, Cartilage, and Tendon Healing INTRODUCTION BONE HEALING Cellular Components Types of Bone Healing How Clinical Treatments Alter Healing Challenges and Emerging Therapeutics CARTILAGE Cartilage Healing Factors Influencing Cartilage Healing Response of Cartilage to Mechanical Injury Consequences of Cartilage Injury Modifiers of Cartilage Damage TENDON STRUCTURE, FUNCTION, AND CELL BIOLOGY Tendon Diseases and Injuries Emerging Therapies for the Treatment of Tendon Disorders CONCLUSION 3 Biologic and Biophysical Technologies for the Enhancement of Fracture Repair INTRODUCTION BONE GRAFT AND BONE GRAFT SUBSTITUTES Autograft Allograft Bone Graft Substitutes ENHANCEMENT OF FRACTURE HEALING USING CELL-BASED THERAPIES Mesenchymal Stem Cells Platelet Concentrates Bone Marrow Aspirates SYSTEMIC ENHANCEMENT OF FRACTURE HEALING Bone Morphogenetic Proteins Transforming Growth Factor β Wnt Fibroblast Growth Factor Vascular Endothelial Growth Factor Platelet-Derived Growth Factor Arachidonic Acid Metabolites Parathyroid Hormone Growth Hormone, Insulin-Like Growth Factors Other Pathways Statins PHYSICAL ENHANCEMENT OF SKELETAL REPAIR Electrical Stimulation Low-Intensity Pulsed Ultrasound Extracorporeal Shock Wave Therapy Low-Magnitude High-Frequency Vibration Therapy CONCLUSION 4 Osteoporosis and Metabolic Bone Disease INTRODUCTION ANATOMY AND PHYSIOLOGY Bone Anatomy Bone Modeling and Remodeling Molecular Regulators of Bone Remodeling OSTEOPOROSIS Epidemiology Pathophysiology Clinical Features Investigations Management Drug Treatments Treatment Effects and Complications AUTHORS’ PREFERRED TREATMENT OF ATYPICAL REACTION OF THE FEMUR Monitoring Response to Treatment Treatment Failure PAGET DISEASE OF BONE Epidemiology Pathophysiology Clinical Features Investigations and Diagnosis Management Duration of Treatment OSTEOMALACIA AND RICKETS Epidemiology Pathophysiology Clinical Features Investigations Management PRIMARY HYPERPARATHYROIDISM Epidemiology Pathophysiology Clinical Features Investigations Management FIBROUS DYSPLASIA OSTEOGENESIS IMPERFECTA Osteopetrosis 5 Classification of Fractures INTRODUCTION BACKGROUND AND HISTORY PURPOSE AND APPLICATION OF FRACTURE CLASSIFICATION Common Language and Terminology Treatment and Prognosis Research Education LIMITATIONS AND CHALLENGES OF FRACTURE CLASSIFICATION SYSTEMS Reliability Validity Measurement Categorizing Continuous Variables CURRENT STATE OF CLASSIFICATION OF FRACTURES Fracture-Specific Classifications OTA/AO2018 Fracture Compendium Classification Selected Recent Studies on the OTA/AO 2018 Fracture Compendium Classification Soft Tissue Injuries Associated With Closed Fractures: Advent of Mri OPEN FRACTURES The Gustilo–Anderson Classification Open Fractures and the OTA/AO Open Fracture Classification ARTIFICIAL INTELLIGENCE AND MACHINE LEARNING SUMMARY 6 The Epidemiology of Musculoskeletal Injury INTRODUCTION HISTORY FRACTURE INCIDENCE The Incidence of Fractures in Adults Gender and Age Social Deprivation Fracture Distribution Curves Changing Epidemiology Variation in Epidemiology Covid and Orthopaedic Trauma The Future Open Fractures Multiple Fractures Fragility Fractures Mortality Mode of Injury Specific Fracture Types Epidemiology of Adolescent Fractures THE EPIDEMIOLOGY OF DISLOCATIONS Shoulder Dislocations Sternoclavicular and Acromioclavicular Dislocations Elbow Dislocations Wrist and Hand Dislocations Hip Dislocations Knee Dislocations Ankle and Foot Dislocations THE EPIDEMIOLOGY OF TENDINOUS AND LIGAMENT INJURIES Hand and Forearm Injuries Knee Injuries Achilles Tendon Rupture Other Injuries 7 Imaging Considerations in Orthopaedic Trauma INTRODUCTION General Considerations Availability Image Resolution Invasiveness Cost-Effectiveness Patient Risk Surgeon Risk SPECIFIC IMAGING MODALITIES Radiography Fluoroscopy Computed Tomography Magnetic Resonance Imaging Arthrography Ultrasonography Nuclear Medicine Imaging Angiography MANAGEMENT OF IMAGING DATA Distribution of Imaging Information Picture Archive and Communications Systems Digital Imaging and Communications in Medicine Standards Teleradiology in Orthopaedics 8 Outcome Studies in Trauma INTRODUCTION EVIDENCE-BASED ORTHOPAEDICS The Hierarchy of Evidence The Impact of High-Quality Studies in Trauma Case Study: Trust Trial CLINICAL STUDY DESIGNS IN TRAUMA RESEARCH Randomized Trial Expertise-Based Randomized Trial Observational Study Prospective Cohort Study Case-Control Study Retrospective Case Series Case Study: The Faith Trial of Hip Fractures SYNTHESIZING EVIDENCE IN TRAUMA Systematic Review and Meta-Analysis Network Meta-Analysis Summarizing Evidence (The Grade Approach) Case Study: Open Fracture Network Meta-Analysis MEASURING VALUE IN TRAUMA FUNDAMENTALS OF STATISTICS IN TRAUMA OUTCOME STUDIES Hypothesis Testing, the p-Value, and Statistical Significance Descriptive Statistics: Measures of Central Tendency and Spread Reporting a Treatment Effect Common Statistical Approaches ISSUES IN THE DESIGN AND INTERPRETATION OF ORTHOPAEDIC STUDIES Type I (α) Error and Type Ii (β) Error Case Study: The Sprint Trial (Reamed vs. Unreamed Tibial Nails) When to Believe a Subgroup Analysis The Minimal Clinically Important Difference Study Power and Sample Size Calculation Fragility: A New Concept to Assess Validity of Results Case Study: Faith Subgroup Analyses When is a Study Truly Negative or Truly Positive? Guide to Interpretation of Results MEASURING PATIENT HEALTH AND FUNCTION Health-Related Quality of Life Floor and Ceiling Effects Common Outcome Instruments Used in Trauma THE ROAD AHEAD: THE AGE OF ARTIFICIAL INTELLIGENCE Gaps and Opportunities CONCLUSION 9 Artificial Intelligence and 3D-Guided Surgery in Orthopaedic Trauma: Why, How, and What Artificial Intelligence in Orthopaedic Trauma HYPE OR DISRUPTIVE INNOVATION? A BRIEF HISTORY OF AI WHY? To Alleviate the Health Care Burden to Society: Current Health Care Systems Are Not Sustainable Overcome Human Biases: Decrease Undesired Practice Variation, Improve Pattern Recognition, and Reduce Biased Decision Making HOW? GUIDING PRINCIPLES FOR AI MODEL DEVELOPMENT IN ORTHOPAEDIC TRAUMA Expanding Education: Training Our Peers Interdisciplinary Engagement: Bringing Computer Scientists and Engineers into Orthopaedic Trauma Care Data Integrity Appropriate Regulation: Enabling Responsible AI Through Robust Governance, Data Sharing, and Federated Learning WHAT? AI-Driven Image Analysis: Computer Vision Steps Toward Clinical Practice FUTURE PERSPECTIVE Large Language Models CONCLUSION 3D-Guided Surgery in Orthopaedic Trauma HYPE OR DISRUPTIVE INNOVATION? WHY? RATIONALE FOR USING 3D TECHNOLOGY HOW? IMPLEMENTATION OF 3D TECHNOLOGY WHAT? APPLICATIONS OF 3D TECHNOLOGY IN ORTHOPAEDIC TRAUMA SURGERY 3D Fracture Assessment 3D Virtual Surgical Planning 3D-Printed Surgical Guides Patient-Specific Implants CONCLUSION 10 Principles of Nonoperative Management of Fractures INTRODUCTION HISTORY OF NONOPERATIVE FRACTURE TREATMENT EPIDEMIOLOGY OF NONOPERATIVE FRACTURE TREATMENT The Effect of Age Fractures in the Elderly Fracture Severity TECHNIQUES OF NONOPERATIVE MANAGEMENT Traction Casts Braces Casts or Braces? Slings, Bandages, and Support Strapping Splints SPECIFIC FRACTURES Upper Limb Fractures Lower Limb Fractures SPECIFIC FRACTURE TYPES Periprosthetic Fractures Stress Fractures Pathologic Fractures THE FUTURE OF NONOPERATIVE FRACTURE TREATMENT 11 Principles of External Fixation INTRODUCTION HISTORICAL PERSPECTIVE Origins of Monolateral External Fixation World War II Use of External Fixation Contemporary Monolateral External Fixation Evolution Circular External Fixation FRAME TYPES, BIOMECHANICS, AND COMPONENTS Large Pin Fixation Simple Monolateral Frames Small-Wire Circular Frame Fixation Hybrid and Hexapod Fixators BIOLOGY OF EXTERNAL FIXATION AND DISTRACTION HISTOGENESIS Basic Biology Dynamization Fracture Healing With Limited ORIF Combined With External Fixation Biology of Distraction Osteogenesis CONTEMPORARY EXTERNAL FIXATOR APPLICATIONS Damage Control External Fixation Small Wire External Fixation Bone Transport Hexapod Fixators EXTERNAL FIXATOR FRAME MANAGEMENT Pin Insertion Technique Pin Care Frame Removal Frame Reuse FIXATOR-RELATED COMPLICATIONS Infection Premature Consolidation and Refracture Contractures CONCLUSION 12 Principles and Biomechanics of Internal Fixation PRINCIPLES OF INTERNAL FIXATION Principles of Intramedullary Nailing Principles of Plate and Screw Constructs BIOMECHANICS OF INTERNAL FIXATION General Biomechanical Principles Biomechanics of Intramedullary Nails Biomechanics of Plate–Screw Constructs Biomechanics of Multiple Implants MODES OF MECHANICAL FAILURE OF FIXATION DEVICES Screw Breakage During Insertion Screw–Bone Interface Failure 13 Templating and Technical Tricks in Internal Fixation INTRODUCTION TEMPLATING IN PREOPERATIVE PLANNING REDUCTION TECHNIQUES Fracture Compression Techniques Fracture Distraction and Lengthening Techniques Direct Fracture Manipulation Techniques Implant-Aided Reduction and Stabilization Techniques FUTURE DIRECTIONS: PATIENT-SPECIFIC IMPLANTS 14 Management of the Multiply Injured Patient PHILOSOPHY INITIAL ASSESSMENT OF THE TRAUMA PATIENT Primary Survey Secondary Survey Tertiary Survey Role of the Orthopaedic Surgeon CLINICAL PRESENTATION Shock CAUSES OF MORTALITY INJURY SCORING INITIAL MANAGEMENT Resuscitation Open Fractures Traumatic Arthrotomy Gunshot Wounds Fractures and Dislocations MANAGEMENT OF INJURIES TO OTHER SYSTEMS Head Injury Thoracic Injury Abdominal Injury Pelvic Injury TIMING OF MANAGEMENT OF ORTHOPAEDIC INJURY Benefits of Early Care Risks of Early Care Indications for Damage Control Techniques of Damage Control Principles of Early Definitive Management MANAGEMENT OF SPINAL INJURY Cervical Spine Thoracolumbar Spine CONTROVERSIES IN CARE Timing of Definitive Management Indications for Pelvis Angiography Fractures Associated With Severe Head Injury Fractures Associated With Vascular Injury Limb Salvage Versus Amputation PATIENT CHALLENGES IN CARE Obesity Diabetes Cardiovascular Disease Immunocompromise Elderly Patients Mental Illness Social Factors SYSTEM CHALLENGES TO CARE OPTIMIZING RECOVERY Nutrition Patient Engagement 15 Gunshot and Wartime Injuries Wartime Injuries INTRODUCTION TO WARTIME INJURIES PHYSICS OF EXPLOSION EFFECT OF BLAST ON THE MUSCULOSKELETAL SYSTEM Primary Orthopaedic Blast Injury Secondary Orthopaedic Blast Injury Combined Primary and Secondary Orthopaedic Injuries Tertiary Orthopaedic Injuries Quaternary Orthopaedic Blast Injury SPECIAL EFFECTS OF EXPLOSION Closed Explosion Versus Free Field Explosion MANAGEMENT OF BLAST INJURY Prehospital Care Hospital Care Damage Control Resuscitation Damage Control Surgery Acute Management of the Injured Extremity Gunshot Wounds INTRODUCTION TYPES OF GUNS Shotguns Handguns and Rifles AMMUNITION WOUND BALLISTICS Bullet–Tissue Interface EVALUATION AND MANAGEMENT OF GUNSHOT WOUNDS Initial Evaluation Management of Low-Velocity Gunshot Wounds Management of High-Velocity Gunshot Wounds SUMMARY 16 Classification and Initial Management of Open Fractures INTRODUCTION HISTORICAL PERSPECTIVE ETIOLOGY PATHOPHYSIOLOGY ASSESSMENT Prehospital Care Emergency Department Care Examination Role of Tissue Cultures in the Emergency Department Antibiotics and Tetanus Prophylaxis Radiographic Imaging and Other Diagnostic Studies Role of Biochemical Markers CLASSIFICATIONS AND SCORES FOR OPEN FRACTURES Classification Systems Open Fractures With Associated Vascular Injury Salvage or Amputation? TREATMENT Open Fracture Wound Excision Muscle Excision Degloving Local Antibiotics SKELETAL STABILIZATION Plaster Casts and Traction External Skeletal Fixation Primary Internal Fixation MANAGEMENT OF ACUTE BONE LOSS Upper Limb Defects Lower Limb Defects WOUND COVER Timing of Wound Cover Primary Closure of Wounds Delayed Soft Tissue Coverage The Timing of Soft Tissue Reconstruction Negative-Pressure Wound Therapy Type of Cover CONCLUSION 17 Acute Compartment Syndrome INTRODUCTION TO ACUTE COMPARTMENT SYNDROME HISTORY EPIDEMIOLOGY PRECLINICAL MODELING PATHOGENESIS Effects of Raised Tissue Pressure on Muscle Effects of Raised Tissue Pressure on Nerve Effects of Raised Tissue Pressure on Bone Reperfusion Injury DIAGNOSIS OF ACUTE COMPARTMENT SYNDROME Clinical Diagnosis Compartment Pressure Monitoring SURGICAL AND APPLIED ANATOMY Thigh Leg Foot Arm Forearm Hand TREATMENT OF ACUTE COMPARTMENT SYNDROME Fasciotomy Management of Associated Fractures AUTHORS’ PREFERRED TREATMENT FOR ACUTE COMPARTMENT SYNDROME COMPLICATIONS OF ACUTE COMPARTMENT SYNDROME Late Diagnosis FUTURE DIRECTIONS FOR RESEARCH 18 Principles of Mangled Extremity Management INTRODUCTION HISTORICAL BACKGROUND PRINCIPLES OF MANAGEMENT Initial Evaluation Vascular Assessment SALVAGE VERSUS AMPUTATION DECISION MAKING Survivability Plantar Sensation Decision-Making Protocols and Limb Salvage Scores ADDITIONAL IMPORTANT FACTORS Concomitant Foot and Ankle Injuries Mangled Foot Smoking Patient Characteristics MANAGEMENT Operative Debridement and Stabilization Skeletal Stabilization Hyperbaric Oxygen Soft Tissue Coverage REHABILITATION OF THE MANGLED EXTREMITY OUTCOMES: AMPUTATION VERSUS LIMB SALVAGE CLINICAL PRACTICE CONSIDERATIONS PSYCHOLOGICAL CONSIDERATIONS MILITARY TRAUMA CARE BONE-ANCHORED IMPLANT SYSTEMS FOR PROSTHETIC ATTACHMENT UPPER EXTREMITY SUMMARY 19 Soft Tissue Coverage for Injuries and Fractures INTRODUCTION TO SOFT TISSUE COVERAGE FOR INJURIES AND FRACTURES COMBINED CARE MODELS FOR ASSESSMENT AND TREATMENT INITIAL MANAGEMENT DECISION-MAKING CONSIDERATIONS RECONSTRUCTIVE LADDER Supportive Measures Direct Closure Skin Graft Local and Regional Flaps LOCAL/REGIONAL MUSCLE FLAPS Gastrocnemius Flap: Proximal Third of the Leg Soleus Flap: Middle and Distal Third of the Leg FREE TISSUE TRANSFER (FREE FLAP SURGERY) A Well-Prepared Patient Complete Surgical Plan Well-Equipped Operating Environment Safe Postoperative Environment Postoperative Care and Rehabilitation FREE FLAPS FOR LOWER LIMB RECONSTRUCTION Fasciocutaneous Free Flaps Muscle Free Flaps Vascularized Bone Flaps 20 Principles of Nerve Injuries and Their Management INTRODUCTION STRUCTURE OF PERIPHERAL NERVES Relevant Physiology and Microanatomy Relevant Surgical Anatomy NERVE REACTION TO INJURY, DEGENERATION, AND REGENERATION Compression Neuropathy Traumatic Injury Summary MECHANISM OF NERVE INJURY CLASSIFICATION OF NERVE INJURIES Neurapraxia Axonotmesis Neurotmesis Sunderland Classification Summary CLINICAL ASSESSMENT OF NERVE INJURIES Motor Function Sensory Function Autonomic Function Record Keeping INVESTIGATIONS Clinical Neurophysiology Magnetic Resonance Imaging Ultrasound Angiography PRINCIPLES OF MANAGEMENT OF NERVE INJURIES Open Injuries Closed Injuries Acute Nerve Compression Nerve Injuries Associated With Treatment Nontraumatic Causes of Peripheral Nerve Dysfunction NERVE EXPLORATION AND REPAIR Surgical Exposure Intraoperative Neurophysiology Direct Nerve Suture Nerve Tubes Nerve Grafting Nonneural Grafts Nerve Transfers Secondary Exploration and Repair of Nerves Neurolysis Secondary Repair With Nerve Grafts Postoperative Management Monitoring Recovery and Assessment of Outcome General Factors Influencing Recovery After Nerve Injury SECONDARY RECONSTRUCTION FOR NERVE INJURY Tendon Transfer Other Reconstructive Procedures NERVE INJURIES ASSOCIATED WITH SPECIFIC FRACTURES AND DISLOCATIONS Supraclavicular Brachial Plexus Infraclavicular Brachial Plexus, Shoulder Dislocation, and Proximal Humeral Fracture Radial Nerve Injury and Humeral Fractures Fractures and Dislocations of the Elbow Fractures of the Forearm and Wrist Open Injuries to the Hand and Wrist Pelvic Fractures Hip Dislocation and Acetabular Fractures Fractures and Dislocations of the Knee 21 Limb Amputation After Trauma INTRODUCTION TO LIMB AMPUTATION PRINCIPLES OF LIMB AMPUTATION Residual Limb Length Weight Bearing Muscle Balancing Amputation as Part of Damage Control Orthopaedics DECISION MAKING IN AMPUTATION Limb Amputation or Reconstruction Determining the Appropriate Amputation Level OUTCOMES AFTER LIMB AMPUTATION Outcome Measures for Amputation TECHNICAL CONSIDERATIONS OF LIMB AMPUTATION Myoplasty and Myodesis Neurovascular Transection Dressings and Drains AUTHORS’ PREFERRED METHOD FOR AMPUTATION DECISION MAKING MANAGEMENT OF EXPECTED ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS RELATED TO AMPUTATION SUMMARY, CONTROVERSIES, AND FUTURE DIRECTIONS RELATED TO AMPUTATION Osseointegration The Ertl Procedure 22 Psychosocial Aspects of Recovery After Trauma and Surgeon Wellness INTRODUCTION A THERAPEUTIC RELATIONSHIP PSYCHOSOCIAL ASPECTS OF RECOVERY SPECIFIC PSYCHOLOGICAL ISSUES Psychological Distress Isolation and Loneliness Depression and Anxiety Posttraumatic Stress Disorder Catastrophic Thinking Opioid Misuse STRESSFUL LIFE ALTERATIONS WITH INJURY ASSESSING THE EXPERIENCE OF INJURY: MENTAL HEALTH SURVEYS SURGEON STRATEGIES TO AMELIORATE THE PSYCHOSOCIAL ASPECTS OF INJURY DURING RECOVERY PROGRAMS AND RESOURCES TO ENHANCE RECOVERY FOLLOWING TRAUMA THE EFFECT OF TRAUMA ON THE SURGEON Burnout Moral Injury SUMMARY, CONTROVERSIES, AND FUTURE DIRECTIONS 23 Obesity and Diabetes in Orthopaedic Trauma Obesity SCOPE AND BURDEN FINANCIAL IMPLICATIONS BASIC SCIENCE OF OBESITY INITIAL EVALUATION AND MANAGEMENT Injury Patterns Initial Bony Stabilization Resuscitation Anesthesia Considerations Preoperative Imaging INTRAOPERATIVE CONSIDERATIONS Positioning Fracture-Specific Care POSTOPERATIVE CARE AND COMPLICATION PREVENTION Respiratory Failure Pharmacokinetics/Analgesia Renal Failure/Multiorgan Failure Thromboembolic Disease Medical Comanagement Mortality Delayed Recovery Diabetes Mellitus INTRODUCTION EPIDEMIOLOGY OF DIABETES MELLITUS DIAGNOSIS ORTHOPAEDIC PATHOPHYSIOLOGY Bone Metabolism/Fracture Healing Vasculopathy/Angiopathy Infection Fall Risk Peripheral Neuropathy Charcot Arthropathy GLUCOSE MANAGEMENT Evaluating Diabetic Control Perioperative Glucose Management 24 Stress Fractures HISTORICAL PERSPECTIVE PATHOPHYSIOLOGY RISK FACTORS Neuromuscular Hypothesis Caloric Insufficiency and the Female Triad Male Endurance Athletes and Decreased BMD Vitamin D Insufficiency STRESS FRACTURE VERSUS INSUFFICIENCY FRACTURE DIAGNOSIS Clinical Presentation Imaging Classification/Grading HIGH-RISK STRESS FRACTURES VERSUS LOW-RISK STRESS FRACTURES Management of High-Risk Stress Fractures Management of Low-Risk Stress Fractures UPPER EXTREMITY STRESS FRACTURES AUTHORS’ PREFERRED TREATMENT FOR STRESS INJURIES OF BONE VERTEBRAL STRESS FRACTURES PELVIC AND SACRAL STRESS FRACTURES LOWER EXTREMITY STRESS FRACTURES Femur Knee and Lower Leg Stress Fractures STRESS FRACTURES OF THE FOOT Calcaneus Tarsal Navicular Metatarsal Stress Fractures PREVENTION OF STRESS INJURIES BIOLOGIC MODALITIES AND FUTURE TREATMENT OPTIONS SUMMARY 25 Pathologic Fractures INTRODUCTION Demographics EVALUATION OF THE PATIENT WITH AN IMPENDING OR ACTUAL PATHOLOGIC FRACTURE Clinical Evaluation Imaging Studies Biopsy AUTHORS’ PREFERRED TREATMENT FOR PATHOLOGIC FRACTURES IMPENDING PATHOLOGIC FRACTURES Prophylactic Fixation TREATMENT OPTIONS FOR PATIENTS WITH METASTATIC OR SYSTEMIC DISEASE General Considerations Nonoperative Treatment Operative Treatment Complications Adjuvant Radiation and Medical Treatment Controversies and Future Directions TREATMENT OPTIONS FOR PATIENTS WITH PATHOLOGIC FRACTURES THROUGH PRIMARY BONE TUMORS Benign Bone Tumors Malignant Bone Tumors SUMMARY AND KEY POINTS 26 Venous Thromboembolism in Patients With Skeletal Trauma INTRODUCTION PATHOPHYSIOLOGY OF TRAUMA-INDUCED COAGULOPATHY Normal Hemostasis Trauma-Induced Coagulopathy RISK FACTORS FOR VENOUS THROMBOEMBOLISM Trauma-Related Risk Factors Patient-Related Risk Factors Risk Assessment Models VENOUS THROMBOPROPHYLAXIS IN ORTHOPAEDIC TRAUMA Pharmacologic Thromboprophylaxis Options Mechanical Thromboprophylaxis Options Inferior Vena Cava Filters CURRENT THROMBOPROPHYLAXIS RECOMMENDATIONS Timing of Thromboprophylaxis Initiation Patient Preference for Pharmacologic Thromboprophylaxis Summary of Thromboprophylaxis Recommendations AUTHOR’S PREFERRED THROMBOPROPHYLAXIS DIAGNOSIS OF VENOUS THROMBOEMBOLISM Assessing Pretest Probability of Vte Investigations for Deep Vein Thrombosis Investigations for Pulmonary Embolism Screening for Dvt TREATMENT OF VENOUS THROMBOEMBOLISM CONCLUSION 27 Complex Regional Pain Syndrome INTRODUCTION HISTORY INCIDENCE ETIOLOGY MAKING A DIAGNOSIS CLINICAL DIAGNOSIS Sensory Symptoms Vasomotor Instability Sudomotor/Edema Motor/Trophic Changes Diagnostic Tools Case Examples DIFFERENTIAL DIAGNOSIS MANAGEMENT CONCLUSION 28 Perioperative Pain Management of Fractures INTRODUCTION ASSESSMENT OF PAIN PAIN MEDICATION PREOPERATIVE IMPLICATIONS PERIOPERATIVE MANAGEMENT Peripheral Nerve Blockade Intravenous Pain Medications Oral Pain Medications AUTHORS’ PREFERRED METHOD OF PAIN MANAGEMENT Pain Management During Recovery Mental Health and Pain Management NEW AND FUTURE DIRECTIONS 29 Osteomyelitis and Other Orthopaedic Infections INTRODUCTION HISTORICAL PERSPECTIVE DEFINITIONS Orthopaedic-Related Infections Cellulitis Surgical Site Infections Septic Arthritis Periprosthetic Joint Infections Fracture-Related Infections Osteomyelitis CLASSIFICATION OF OSTEOMYELITIS EPIDEMIOLOGY OF OSTEOMYELITIS Predisposing Factors PATHOGENESIS OF OSTEOMYELITIS Initiation of Infection Role of Biofilm Propagation of Infection Common Pathogens Culture-Negative Infection CLINICAL PRESENTATION OF OSTEOMYELITIS DIAGNOSIS OF ORTHOPAEDIC INFECTION Choice of Radiologic Investigations Laboratory Diagnostic Tests Differential Diagnosis PRINCIPLES OF TREATMENT OF OSTEOMYELITIS Systemic Antibiotic Treatment Nonbiodegradable Antibiotic-Delivery Devices Biodegradable Antibiotic-Delivery Devices SURGICAL TREATMENT OF OSTEOMYELITIS Surgical Debridement Management of Critical Size Bone Defects Management of Dead Space Amputation Hyperbaric Oxygen Therapy COMPLICATIONS OF OSTEOMYELITIS SUMMARY, CONTROVERSIES, AND FUTURE DIRECTIONS RELATED TO OSTEOMYELITIS 30 Principles of Nonunion and Bone Defect Treatment INTRODUCTION TO NONUNIONS PATHOPHYSIOLOGY, ETIOLOGY, AND RISK FACTORS FOR NONUNION Fracture-Specific Factors Related to Nonunion Host Factors Related to Nonunion Treatment Factors Related to Nonunion Infection as a Factor Related to Development of Nonunion CLASSIFICATION OF NONUNION Atrophic Nonunion Hypertrophic Nonunion Oligotrophic Nonunion Pseudoarthrosis Bone Defects EVALUATION AND DIAGNOSIS OF NONUNION History and Physical Examination Related to Nonunion Radiographic Assessment of Nonunion Laboratory Studies for the Diagnosis of Nonunion Prediction of Nonunion NONUNION TREATMENT Objectives and General Principles of Nonunion Treatment Soft Tissue Management Associated With Nonunion Indications and Contraindications for Nonoperative and Operative Treatment Nonoperative Treatment of Nonunion Operative Treatment of Nonunion Long-Term Outcomes and Risk Factors for Nonunion Repair Failure BONE GRAFTS AND OTHER ADJUNCTS TO OPERATIVE NONUNION REPAIR Autogenous Bone Graft Bone Graft Substitutes and Other Modifiers of Bone Healing Graft Site Preparation AUTHORS’ PREFERRED TECHNIQUE FOR GRAFTING DEFECTS SPECIAL CIRCUMSTANCES IN THE TREATMENT OF NONUNIONS AND BONE DEFECTS Managing Articular Nonunion Managing Bone Defects and Segmental Bone Loss Management of Infected Nonunions Management of Soft Tissue Compromise Associated With Nonunion AUTHOR’S PREFERRED TREATMENT FOR NONUNIONS NONOPERATIVE NONUNION TREATMENT OPERATIVE TREATMENT OF NONUNION Septic Nonunions Aseptic Nonunions 31 Principles of Malunion Treatment EVALUATION Clinical Radiographic Evaluation of the Various Deformity Types TREATMENT Osteotomies Treatment by Deformity Type Treatment by Deformity Location Treatment by Method SECTION TWO: UPPER EXTREMITY 32 Acromioclavicular and Sternoclavicular Joint Injuries INTRODUCTION TO ACROMIOCLAVICULAR AND STERNOCLAVICULAR JOINT INJURIES ASSESSMENT OF ACROMIOCLAVICULAR AND STERNOCLAVICULAR JOINT INJURIES Mechanisms of Injury for Acromioclavicular and Sternoclavicular Joint Injuries Injuries Associated With Acromioclavicular and Sternoclavicular Joint Injuries Signs and Symptoms of Sternoclavicular and Acromioclavicular Joint Injuries Imaging and Other Diagnostic Studies for Acromioclavicular and Sternoclavicular Joint Injuries Classification of Acromioclavicular and Sternoclavicular Joint Injuries Outcome Measures for Acromioclavicular and Sternoclavicular Joint Injuries PATHOANATOMY AND APPLIED ANATOMY RELATING TO ACROMIOCLAVICULAR AND STERNOCLAVICULAR JOINT INJURIES Anatomy of the Acromioclavicular Joint Anatomy of the Sternoclavicular Joint TREATMENT OPTIONS FOR ACROMIOCLAVICULAR AND STERNOCLAVICULAR JOINT INJURIES Nonoperative Treatment of Acromioclavicular Joint Injuries Nonoperative Treatment of Sternoclavicular Joint Injuries Operative Treatment of Acromioclavicular Joint Injuries AUTHOR’S PREFERRED TREATMENT FOR ACROMIOCLAVICULAR JOINT INJURIES Operative Treatment of Sternoclavicular Joint Injuries AUTHOR’S PREFERRED TREATMENT FOR STERNOCLAVICULAR JOINT INJURIES MANAGEMENT OF EXPECTED ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS RELATED TO ACROMIOCLAVICULAR AND STERNOCLAVICULAR JOINT INJURIES 33 Scapular Fractures INTRODUCTION TO SCAPULAR FRACTURES APPLIED ANATOMY RELATING TO SCAPULAR FRACTURES Scapular Architecture Superior Shoulder Suspensory Complex Muscles of the Scapula Blood Vessels and Nerves of the Scapula ASSESSMENT OF SCAPULAR FRACTURES Mechanisms of Injury for Scapular Fractures Injuries Associated With Scapular Fractures Signs and Symptoms of Scapular Fractures Imaging and Other Diagnostic Studies for Scapular Fractures Classification of Scapular Fractures Outcome Measurements for Scapular Fractures TREATMENT OPTIONS FOR SCAPULAR FRACTURES Nonoperative Treatment of Scapular Fractures Operative Treatment of Scapular Fractures AUTHOR’S PREFERRED TREATMENT FOR SCAPULAR FRACTURES Glenoid Fractures Fractures of the Scapular Neck Fractures of the Scapular Body Process Fractures and Fractures of the Borders of the Scapular Body Complex Scapular Fractures ASSOCIATED INJURY PATTERNS Floating Shoulder Scapulothoracic Dissociation MANAGEMENT OF EXPECTED ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS RELATED TO SCAPULAR FRACTURES Nonoperative Complications of Scapular Fractures Operative Complications of Scapular Fractures SUMMARY, CONTROVERSIES, AND FUTURE DIRECTIONS IN SCAPULAR FRACTURES 34 Clavicle Fractures INTRODUCTION TO CLAVICLE FRACTURES ASSESSMENT OF CLAVICLE FRACTURES Mechanisms of Injury for Clavicle Fractures Injuries Associated With Clavicle Fractures Signs and Symptoms of Clavicle Fractures Imaging and Other Diagnostic Studies for Clavicle Fractures Classification of Clavicle Fractures Outcome Measures for Clavicle Fractures PATHOANATOMY AND APPLIED ANATOMY RELATING TO CLAVICLE FRACTURES Bony Anatomy of the Clavicle Ligamentous Anatomy of the Clavicle Muscular Anatomy of the Clavicle Neurovascular Anatomy of the Clavicle TREATMENT OPTIONS FOR MIDSHAFT CLAVICLE FRACTURES Nonoperative Treatment of Midshaft Clavicle Fractures Operative Treatment of Midshaft Clavicle Fractures AUTHOR’S PREFERRED TREATMENT FOR MIDSHAFT CLAVICLE FRACTURES TREATMENT OPTIONS FOR LATERAL CLAVICLE FRACTURES Nonoperative Treatment of Lateral Clavicle Fractures Operative Treatment of Lateral Clavicle Fractures TREATMENT OPTIONS FOR OTHER CLAVICLE INJURIES Treatment of Medial Clavicle Fractures “Floating Shoulder” Treatment of Associated Rib Fractures MANAGEMENT OF EXPECTED ADVERSE OUTCOMES AND UNEXPECTED COMPLICATIONS RELATED TO CLAVICLE FRACTURES Infection Nonunion Malunion Glenohumeral Arthritis Neurovascular Injury Hardware Failure Hardware Prominence Refracture Scapular Winging SUMMARY, CONTROVERSIES, AND FUTURE DIRECTIONS RELATED TO CLAVICLE FRACTURES Patient Selection for Operative Intervention Method of Fixation Timing of Surgical Intervention Summary 35 Glenohumeral Instability INTRODUCTION TO GLENOHUMERAL INSTABILITY ASSESSMENT OF GLENOHUMERAL INSTABILITY Mechanisms of Injury for Glenohumeral Instability Injuries Associated With Glenohumeral Instability Signs and Symptoms of Glenohumeral Instability Imaging and Other Diagnostic Studies for Glenohumeral Instability Classification of Glenohumeral Instability Outcome Measures for Glenohumeral Instability PATHOANATOMY AND APPLIED ANATOMY RELATED TO GLENOHUMERAL INSTABILITY Static Stabilizers Dynamic Stabilizers Deltoid Musculature Proprioception TREATMENT OPTIONS FOR GLENOHUMERAL INSTABILITY Nonoperative Treatment of Glenohumeral Instability Operative Treatment of Glenohumeral Instability Anterior Glenohumeral Instabili