The Rationale of Operative Fracture Care
2nd Edition
Published on 3. July 1996
Book
Hardback
XXIII, 633 pages
978-3-540-59388-1 (ISBN)
Description
T
he why, where, when and how of modern fracture treatment, written by two world-renowned experts. The first edition sold over 5,000 copies in the US alone and soon became a standard reference. This completely revised and enlarged second edition takes into account all the important advances that have taken place since. It is richly illustrated with clinical and radiological examples, and describes how to assess, diagnose and classify fractures, together with the relevant treatment in each case. Readers are offered advice on the daily practice of dealing with fractures, including the surgical approach, selection of the best implant, avoiding common pitfalls and the importance of post-operative care. Unparalleled in its coverage of the pelvis and acetabulum in addition to the upper and lower extremities.
Reviews / Votes
"This book must find its place in every traumatology surgeons library and be available to any training assistant" Eur. Jnl. Orthopaedic Surgery and TraumatologyMore details
Edition
2nd completely rev. and enlarged ed. Corr. 2nd printing
Language
English
Place of publication
Heidelberg
Germany
Publishing group
Springer Berlin
Target group
Professional and scholarly
Edition type
Revised edition
Illustrations
1910 figures, 30 tables
Dimensions
Height: 27 cm
Width: 19.3 cm
Weight
2220 gr
ISBN-13
978-3-540-59388-1 (9783540593881)
DOI
10.1007/978-3-642-88443-6
Schweitzer Classification
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Joseph Schatzker | Marvin Tile
The Rationale of Operative Fracture Care
Book
05/2005
3rd Edition
Springer
€341.33
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Previous edition
Joseph Schatzker | Marvin Tile
The Rationale of Operative Fracture Care
Book
11/1987
Springer
€85.59
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Content
I General Aspects of Internal Fixation.- 1 Principles of Stable Internal Fixation.- 1.1 Introduction.- 1.1.1 Mechanical Properties of Bone.- 1.1.2 Types of Load and Fracture Patterns.- 1.1.3 Classification of Fractures.- 1.1.4 Effects of Fracture.- 1.1.5 Soft Tissue Component and Classification of Soft Tissue Injuries.- 1.2 Aims of Treatment.- 1.3 Previous Experience with Internal Fixation.- 1.4 Rigidity and Stability.- 1.5 Methods of Stable Fixation.- 1.5.1 Lag Screw.- 1.5.2 Lag Screw, Neutralization, and Buttressing.- 1.5.3 Tension Band Plate.- 1.6 Methods of Relative Stability or Splinting.- 1.6.1 External Skeletal Fixation.- 1.6.2 Intramedullary Nailing.- 1.6.3 Bridge Plating.- 1.6.4 Methods of Reduction.- 1.7 Changes to the Early Concepts in Internal Fixation.- 1.7.1 Articular Fractures.- 1.7.2 Diaphyseal Fractures.- 1.8 Implant Failure and Bone Grafting.- 1.9 Implant Removal.- References.- 2 Intra-articular Fractures.- 2.1 Introduction.- 2.2 Clinical Aspects.- 2.2.1 Physical Examination.- 2.2.2 Radiological Evaluation.- 2.3 Surgery.- 2.3.1 Timing.- 2.3.2 Approach and Technique.- 2.4 Postoperative Care.- 2.5 Late Intra-articular Reconstructions.- References.- 3 Open Fractures.- 3.1 Introduction.- 3.2 Assessment of the Soft Tissue Wound.- 3.3 Classification.- 3.4 Management.- 3.4.1 Decision Making.- 3.4.2 Immediate Treatment.- 3.4.3 Operative Treatment.- 3.4.3.1 Limb Salvage.- 3.4.3.2 Cleansing.- 3.4.3.3 Débridement.- 3.4.3.4 Choice of Fixation.- 3.4.3.5 Implant Selection.- 3.4.3.6 Care of the Soft Tissue Wound.- 3.4.3.7 Secondary Fracture Care.- 3.4.3.8 Open Joint Injuries.- 3.5 Summary.- References.- II Fractures of the Upper Extremity.- 4 Fractures of the Proximal Humerus.- 4.1 Introduction.- 4.1.1 General Considerations.- 4.1.2 Anatomy.- 4.1.3 Vascular Anatomy.- 4.1.4 Four-Segment Classification.- 4.1.5 Stability.- 4.1.6 Surgical Difficulties.- 4.2 Classification.- 4.3 Natural History and Surgical Indications.- 4.3.1 Stable Fractures.- 4.3.2 Unstable Fractures.- 4.3.2.1 Minimal Displacement.- 4.3.2.2 Major Displacement.- 4.3.3 Articular Fractures.- 4.3.3.1 Impacted (Hill-Sachs).- 4.3.3.2 Humeral Head.- 4.3.3.3 Glenoid Labrum.- 4.4 Management.- 4.4.1 Assessment.- 4.4.1.1 Clinical.- 4.4.1.2 Radiological.- 4.4.1.3 Examination Under Anesthesia.- 4.4.2 Decision Making.- 4.4.2.1 Stable Fractures.- 4.4.2.2 Unstable Fractures.- 4.4.3 Surgical Technique.- 4.4.3.1 Timing.- 4.4.3.2 Approaches.- 4.4.3.3 Reduction.- 4.4.3.4 Methods of Internal Fixation.- 4.4.3.5 Wound Closure.- 4.4.3.6 Postoperative Care.- References.- 5 Fractures of the Humerus (12-A, B, and C).- 5.1 Introduction.- 5.2 Indications for Surgery.- 5.2.1 Failure to Obtain a Satisfactory Reduction.- 5.2.2 Failure to Maintain Reduction.- 5.2.3 Injuries to the Chest Wall.- 5.2.4 Bilateral Humeral Fractures.- 5.2.5 Multiple Injuries.- 5.2.6 Vascular Lesions.- 5.2.7 Neurological Lesions.- 5.2.8 Fractures of the Shaft Associated with Intra-articular Fractures or Articular Extensions of the Fracture.- 5.2.9 Open Fractures of the Humerus.- 5.2.10 Pathological Fractures of the Humerus.- 5.3 Surgical Approaches.- 5.4 Surgical Methods of Stable Fixation.- 5.4.1 Biomechanical Considerations.- 5.5 Postoperative Regimen.- 5.6 Removal of Internal Fixation.- References.- 6 Fractures of the Distal End of the Humerus (13-A, B, and C).- 6.1 Introduction.- 6.2 Fractures with a Good Prognosis.- 6.2.1 Fractures of the Epicondyles.- 6.2.1.1 Fractures of the Lateral Epicondyle (13-A 1.1).- 6.2.1.2 Fractures of the Medial Epicondyle (13-A1.2).- 6.2.1.3 Fractures of the Lateral Condyle (Bl).- 6.2.1.4 Fractures of the Capitellum (13-B3.1).- 6.3 Fractures with a Poor Prognosis: The Extra-Articular Group A2 and A3 and Complete Articular Type C.- 6.3.1 Supracondylar Fractures.- 6.3.1.1 Natural History.- 6.3.1.2 Factors Influencing Decisions in Treatment.- 6.3.1.3 Indications for Surgery.- 6.3.1.4 Surgical Treatment.- References.- 7 Fractures of the Olecranon (12-B1).- 7.1 Introduction.- 7.2 Methods of Evaluation and Guides to Treatment.- 7.3 Classification.- 7.3.1 Intra-articular Fractures.- 7.3.1.1 Transverse (21-B 1.1).- 7.3.1.2 Oblique (21-B 1.1).- 7.3.1.3 Comminuted Fractures and Associated Injuries.- 7.3.2 Extra-articular Fractures.- 7.4 Surgical Treatment.- 7.4.1 Positioning the Patient.- 7.4.2 Draping.- 7.4.3 Tourniquet.- 7.4.4 Surgical Exposure.- 7.4.5 Techniques of Reduction and Internal Fixation.- 7.4.5.1 Transverse Fractures.- 7.4.5.2 Transverse Fractures with Joint Depression.- 7.4.5.3 Oblique Fractures.- 7.4.5.4 Comminuted Fractures.- 7.5 Postoperative Care.- References.- 8 Fractures of the Radial Head (21-A2.2, 21-B2.1, 21-B2.2, and 21-B2.3).- 8.1 Introduction.- 8.2 Mechanism of Injury.- 8.3 Guides to Treatment.- 8.4 Surgical Treatment.- 8.4.1 Classification.- 8.4.2 Positioning and Draping the Patient.- 8.4.3 Surgical Exposure.- 8.4.4 Techniques of Reduction and Internal Fixation.- 8.4.4.1 Comminuted Fractures.- 8.4.4.2 Split-Wedge Fractures.- 8.4.4.3 Impaction Fractures.- 8.4.5 Postoperative Care.- References.- 9 Fractures of the Radius and Ulna.- 9.1 Introduction.- 9.2 Natural History.- 9.2.1 Closed Treatment.- 9.2.2 Open Treatment.- 9.2.3 AO/ASIF Techniques.- 9.3 Management.- 9.3.1 Principles.- 9.3.2 Indications for Surgery.- 9.3.2.1 Fractures of Both Bones.- 9.3.2.2 Fracture of One Bone.- 9.3.2.3 Open Fracture of the Forearm.- 9.3.3 Timing of Surgery.- 9.3.4 Surgical Technique.- 9.3.4.1 Preliminary Considerations.- 9.3.4.2 Surgical Approaches.- 9.3.4.3 Reduction Techniques.- 9.3.4.4 Technique of Fracture Fixation.- 9.4 Special Considerations.- 9.4.1 Fractures of Both Bones of the Forearm.- 9.4.2 Fractures of One Bone.- 9.4.2.1 Fractures of the Radius with Distal Radioulnar Subluxation (Galeazzi).- 9.4.2.2 Fractures of the Ulna.- 9.4.3 Fractures of the Forearm in Adolescents.- 9.4.4 Open Fractures of the Forearm.- 9.5 Complications.- 9.5.1 Radioulnar Synostosis.- 9.5.2 Stress Fracture.- 9.5.3 Refracture and Plate Removal.- References.- 10 Fractures of the Distal Radius.- 10.1 Distal Radius Fractures.- 10.1.1 Classification.- 10.1.2 Imaging.- 10.1.3 Closed Treatment.- 10.1.4 Management and Decision Making.- 10.1.4.1 Percutaneous Pinning.- 10.1.4.2 Pins and Plaster.- 10.1.4.3 External Skeletal Fixation.- 10.1.4.4 Limited Open Reduction.- 10.1.4.5 Open Reduction and Internal Fixation.- 10.1.4.6 Algorithm for Treatment.- 10.1.5 Surgical Technique.- 10.1.5.1 External Fixation Application.- 10.1.5.2 Limited Open Reduction.- 10.1.5.3 Open Reduction and Internal Fixation.- 10.2 The Distal Radioulnar Joint.- 10.3 Postoperative Care.- 10.4 Complications.- 10.4.1 Pin Site Infection.- 10.4.2 Median Nerve Compression.- 10.4.3 Reflex Sympathetic Dystrophy.- 10.5 Conclusions.- References.- III Fractures of the Spine, Pelvis, and Acetabulum.- 11 Fractures of the Spine.- 11.1 Introduction.- 11.2 History.- 11.2.1 Internal Fixation and Fusion.- 11.2.2 Distraction Rod Fixation.- 11.2.3 Segmental Sublaminar Wires.- 11.2.4 Short-Segment Fixation.- 11.3 Initial Assessment and Management.- 11.3.1 Physical Examination.- 11.3.1.1 Neurological Examination.- 11.3.1.2 Sacral Reflexes.- 11.3.1.3 Corticosteroids.- 11.3.2 Initial Radiological Assessment.- 11.3.2.1 Plain Films and Tomography.- 11.3.2.2 Computed Tomography Scan.- 11.3.2.3 Myelography.- 11.3.2.4 Magnetic Resonance Imaging.- 11.4 Classification.- 11.5 Operative Decision-Making with Neurological and Biomechanical Goals.- 11.5.1 Indications.- 11.5.1.1 Does the Patient Have a Neurological Deficit? If so, to What Degree?.- 11.5.1.2 Are the Anterior Elements Intact?.- 11.5.1.3 Are the Posterior Elements Intact?.- 11.5.1.4 What Information to Assess with Imaging?.- 11.5.1.5 Will the Patient Tolerate Operative or Nonoperative Treatment?.- 11.6 Preparation for Surgery.- 11.6.1 Timing of Surgery.- 11.6.2 Patient Positioning.- 11.6.3 Intraoperative Blood Loss.- 11.7 Anatomy as Related to Surgical Approaches.- 11.7.1 Posterior Approach.- 11.7.1.1 Cervical Spine Posterior Approach.- 11.7.1.2 Cervical Spine Decompression.- 11.7.1.3 Thoracic Spine Posterior Approach.- 11.7.1.4 Lumbosacral Junction Posterior Approach.- 11.7.2 Thoracolumbar and Lumbar Spine Decompression.- 11.7.3 Anterior Approach.- 11.7.3.1 Cervical Spine.- 11.7.3.2 Cervicothoracic Junction.- 11.7.3.3 Thoracic Spine.- 11.7.3.4 Thoracolumbar Junction.- 11.7.3.5 Lumbar Spine.- 11.7.3.6 Lumbosacral Junction.- 11.7.4 Decompression Anterior Approach.- 11.8 Fractures and Specific Management.- 11.8.1 Upper Cervical.- 11.8.1.1 Atlas Injury.- 11.8.1.2 Atlas and Odontoid Injury.- 11.8.1.3 Odontoid Injury.- 11.8.1.4 C2 Injury.- 11.8.2 Lower Cervical Spine.- 11.8.3 Thoracic Spine.- 11.8.4 Thoracolumbar Junction.- 11.8.4.1 Internal Fixation.- 11.8.5 Lumbar Spine.- 11.8.6 Sacral Fractures.- 11.9 Postoperative Care.- 11.9.1 Brace Wear.- 11.9.2 Mobilization.- 11.9.3 Complications and Their Prevention.- 11.9.4 Pedicle Screw Insertion.- 11.9.5 Thromboembolic Disease.- 11.9.6 Urinary Care.- 11.10 Outcomes of Treatment of Spinal Injury.- 11.11 Conclusion.- References.- 12 Fractures of the Pelvis.- 12.1 Introduction.- 12.2 Understanding the Injury.- 12.2.1 Ring Structure of the Pelvis.- 12.2.2 Anatomical Lesions.- 12.2.3 Stability of the Pelvis.- 12.2.3.1 Sacroiliac Complex.- 12.2.3.2 Pelvic Floor.- 12.2.4 Types of Injurious Forces Acting on the Pelvis.- 12.2.5 Effect of Forces on Soft Tissue.- 12.3 Classification.- 12.3.1 Type A Stable Fractures.- 12.3.2 Type B - Partially Stable Fractures.- 12.3.2.1 Open Book (Anteroposterior Compression) Fractures (B1, B3.1).- 12.3.2 Partially Stable Fractures (Type B2).- 12.3.2.1 Lateral Compression Fractures.- 12.3.3 Type C - Unstable Fractures - Complete Disruption of the Posterior Arch.- 12.3.4 Unusual Types of Fracture.- 12.4 Natural History.- 12.5 Management of the Pelvic Disruption.- 12.5.1 Assessment.- 12.5.1.1 General Assessment.- 12.5.1.2 Specific Musculoskeletal Assessment.- 12.5.1.3 Diagnosis of Pelvic Instability.- 12.5.2 Resuscitation.- 12.5.3 Provisional Stabilization.- 12.5.3.1 External Fixation or Pelvic Clamp.- 12.5.3.2 Skeletal Traction.- 12.5.3.3 Early Internal Fixation.- 12.5.4 Definitive Stabilization.- 12.5.4.1 Stable Fractures (Type A).- 12.5.4.3 Unstable Fractures (Type C).- 12.5.4.4 Surgical Techniques.- 12.5.4.5 Postoperative Care.- 12.5.4.6 Complications.- 12.6 Conclusions.- References.- 13 Fractures of the Acetabulum.- 13.1 Introduction.- 13.1.1 Natural History.- 13.1.2 Surgical Anatomy.- 13.1.3 Mechanism of Injury.- 13.2 Assessment.- 13.2.1 Clinical Assessment.- 13.2.2 Radiological Assessment.- 13.2.2.1 Special Radiographs of the Pelvis.- 13.2.2.2 Specific Acetabular Views.- 13.2.2.3 Tomography.- 13.2.2.4 Computed Tomography.- 13.3 Classification.- 13.4 Management.- 13.4.1 Indications.- 13.4.1.1 Fracture Factors.- 13.4.2 Patient Factors.- 13.4.3 Decision Making Algorithm.- 13.4.3.1 General Resuscitation.- 13.4.3.2 Fracture Personality Assessment.- 13.4.3.3 Significant Displacement or Dislocation.- 13.4.3.4 Urgent Open Reduction and Internal Fixation.- 13.4.3.5 Assessment of Congruity.- 13.4.3.6 Assessment of Operabilit.- 13.4.4 Surgical Considerations.- 13.4.4.1 General Considerations.- 13.4.4.2 Approaches.- 13.4.4.3 Reduction.- 13.4.4.4 Internal Fixation.- 13.4.4 Postoperative Care.- 13.5 Complications.- 13.6 Conclusions.- References.- IV Fractures of the Lower Extremity.- 14 Subcapital and Intertrochanteric Fractures.- 14.1 Anatomy and Blood Supply.- 14.1.1 Cross-Sectional Anatomy of the Head.- 14.1.1.1 Neck Shaft Angle.- 14.1.1.2 Greater Trochanter.- 14.1.2 Blood Supply.- 14.2 Classification.- 14.3 Subcapital Fractures.- 14.3.1 Classification.- 14.3.2 History and Physical Examination.- 14.3.3 Imaging Techniques.- 14.3.3.1 X-Rays.- 14.3.3.2 Bone Scan.- 14.3.3.3 Tomography.- 14.3.3.4 Magnetic Resonance Imaging.- 14.3.4 Surgical Treatment.- 14.3.4.1 Method of Reduction.- 14.3.4.2 Methods of Internal Fixation.- 14.3.4.3 Methods of Joint Replacement.- 14.3.5 Decision Making.- 14.3.5.1 Undisplaced Fractures.- 14.3.5.2 Displaced Fractures.- 14.3.5.3 Special Fracture Situations.- 14.3.6 Postoperative Management.- 14.3.7 Complications.- 14.3.7.1 Nonunion.- 14.3.7.2 Avascular Necrosis and Loss of Fixation.- 14.4 Intertrochanteric Fractures.- 14.4.1 Surgical Anatomy and Classification.- 14.4.2 History and Physical Examination.- 14.4.3 Surgical Treatment.- 14.4.3.1 Reduction.- 14.4.3.2 Internal Fixation.- 14.4.4 Postoperative Management.- 14.4.5 Common Early and Late Postoperative Complications.- References.- 15 Subtrochanteric Fractures of the Femur.- 15.1 Biomechanical Considerations.- 15.1.1 Mechanical Forces.- 15.1.2 Degree of Comminution.- 15.1.3 Level of the Fracture.- 15.1.4 Pattern of the Fracture.- 15.1.5 Deformity.- 15.2 Natural History.- 15.3 Indications for Open Reduction and Internal Fixation.- 15.4 Surgical Techniques.- 15.4.1 Diagnosis.- 15.4.2 Classification.- 15.4.3 Planning the Surgical Procedure.- 15.4.3.1 Implants.- 15.4.3.2 Preoperative Planning.- 15.4.4 Surgery.- 15.4.4.1 The Operating Table.- 15.4.4.2 Positioning the Patient.- 15.4.4.3 Surgical Approach for Plating.- 15.4.4.4 Technique of Open Reduction and Internal Fixation.- 15.4.4.5 Bone-Grafting.- 15.4.5 Postoperative Care.- 15.4.5.1 Signs of Instability.- 15.4.5.2 Infection.- References.- 16 Fractures of the Femur.- 16.1 Introduction.- 16.2 Factors Important in Evaluating the Mode of Treatment.- 16.3 Surgical Treatment.- 16.3.1 Timing of Surgery.- 16.3.1.1 Multiple System Injuries.- 16.3.1.2 Head Injury.- 16.3.1.3 Open Fractures.- 16.3.1.4 Vascular Injury.- 16.3.1.5 Ipsilateral Neck Fracture or Dislocation of the Hip.- 16.3.1.6 Ipsilateral Fracture of the Femoral Shaft and Ligamentous Disruption of the Knee.- 16.3.1.7 Floating Knee Syndrome.- 16.3.1.8 Isolated Fractures of the Femoral Shaft.- 16.3.2 Surgical Technique.- 16.3.2.1 Positioning the Patient, Skin Preparation, and Draping.- 16.3.2.2 Surgical Approach.- 16.3.2.3 Technique of Open Reduction.- 16.3.2.4 Technique of Fracture Fixation.- 16.3.2.5 Bone Grafting.- 16.3.2.6 Wound Closure.- 16.3.3 Postoperative Care.- 16.4 Special Considerations: Open Fractures of the Femur.- References.- 17 Supracondylar Fractures of the Femur (33-A,B, and C).- 17.1 Introduction.- 17.2 Guides to Treatment and Indications for Surgery.- 17.2.1 Absolute Indications.- 17.2.1.1 Intra-articular Fractures in Which Adequate Joint Congruity Cannot Be Restored by Manipulation.- 17.2.1.2 Open Intra-articular Fractures.- 17.2.1.3 Associated Neurovascular Injuries.- 17.2.1.4 Ipsilateral Fracture of the Tibial Plateau.- 17.2.1.5 Ipsilateral Fracture of the Tibia (The Floating Knee).- 17.2.1.6 Multiple Injuries.- 17.2.1.7 Pathological Fractures.- 17.2.2 Relative Indications.- 17.3 Surgical Treatment.- 17.3.1 Timing of Surgery.- 17.3.2 History and Physical Examination.- 17.3.3 Radiological Examination.- 17.3.4 Classification.- 17.3.5 Planning the Surgical Procedure.- 17.3.6 Surgical Anatomy of the Distal Femur.- 17.3.7 Positioning and Draping the Patient.- 17.3.8 Surgical Exposure.- 17.3.8.1 Lateral Exposure.- 17.3.8.2 Anterior Exposure.- 17.3.9 Techniques of Reduction and Internal Fixation.- 17.3.9.1 Type A Fractures.- 17.3.9.2 Type B Fractures.- 17.3.9.3 Type C Fractures.- 17.3.9.4 Supracondylar Fractures Above a Total Knee Replacement.- 17.3.9.5 The Open Supracondylar Fracture.- 17.3.10 Bone Grafting.- 17.3.11 Methyl Methacrylate.- 17.4 Postoperative Care.- 17.5 Complications.- 17.6 Conclusions.- References.- 18 Fractures of the Patella.- 18.1 Introduction.- 18.2 Methods of Evaluation and Guides to Treatment.- 18.3 Classification.- 18.3.1 Osteochondral Fractures.- 18.3.2 Stellate Fractures.- 18.3.3 Transverse Fractures.- 18.4 Surgical Treatment.- 18.4.1 Undisplaced Fractures.- 18.4.2 Displaced Fractures.- 18.4.2.1 Surgical Approaches.- 18.4.2.2 Biomechanical Considerations.- 18.4.2.3 Techniques of Internal Fixation.- 18.5 Postoperative Care.- Reference.- 19 Fractures of the Tibial Plateau.- 19.1 Introduction.- 19.2 Classification and Guides to Treatment.- 19.2.1 Type I (41-B1).- 19.2.2 Type II (41-B3.1).- 19.2.3 Type III (41-B.2).- 19.2.4 Type IV (41-B1, 41-B2, and 41-B3).- 19.2.5 Type V (41-C1).- 19.2.6 Type VI.- 19.2.7 Relationship of the Comprehensive Classification to the Six Fracture Types.- 19.2.8 Absolute Indications for Surgery.- 19.2.8.1 Open Fractures.- 19.2.8.2 Acute Compartment Syndrome.- 19.2.8.3 Associated Vascular or Neurological Injury.- 19.3 Methods of Assessment.- 19.3.1 History.- 19.3.2 Physical Examination.- 19.3.3 Radiological Examination.- 19.4 Surgical Treatment.- 19.4.1 Planning the Surgical Procedure.- 19.4.2 Approaches.- 19.4.3 Positioning the Patient.- 19.4.4 Timing the Surgical Procedure.- 19.4.5 Methods of Open Reduction and Internal Fixation.- 19.4.6 Internal Fixation of Different Fracture Types.- 19.4.6.1 Type I.- 19.4.6.2 Type II.- 19.4.6.3 Type III.- 19.4.6.4 Type IV.- 19.4.6.5 Type V.- 19.4.6.6 Type VI.- 19.4.7 Ligament and Meniscal Repair.- 19.4.8 Postoperative Care.- 19.5 Summary and Conclusions.- References.- 20 Fractures of the Tibia.- 20.1 Introduction.- 20.2 Natural History.- 20.2.1 Nonoperative School.- 20.2.2 Operative School.- 20.2.3 Plaster Disease.- 20.2.3.1 Compartment Syndromes.- 20.2.3.2 Reflex Sympathetic Dystrophy.- 20.2.3.3 Thromboembolic Disease.- 20.2.3.4 Severe Soft Tissue Injury.- 20.2.4 Factors Influencing the Natural History.- 20.2.4.1 Pathoanatomy of the Fracture.- 20.2.4.2 Soft Tissue Injury.- 20.2.4.3 Other Injuries to the Limb.- 20.2.4.4 Patient Factors.- 20.2.4.5 The Health Care Team.- 20.2.5 Summary.- 20.3 Assessment.- 20.3.1 Clinical Assessment.- 20.3.1.1 History.- 20.3.1.2 Physical Assessment.- 20.3.2 Radiological Assessment.- 20.4 Management.- 20.4.1 Decision Making.- 20.4.2 Nonoperative Treatment.- 20.4.3 Indications for Surgery.- 20.4.3.1 Primary Indications.- 20.4.3.2 Delayed Primary Indications.- 20.4.3.3 Secondary Indications.- 20.4.4 Role of Amputation in Severe Tibial Fractures.- 20.4.5 Timing of Surgery.- 20.4.6 Surgical Methods.- 20.4.6.1 Approaches.- 20.4.6.2 Reduction Techniques.- 20.4.6.3 Fixation.- 20.4.6.4 Wound Closure.- 20.4.6.5 Postoperative Course.- 20.5 Conclusions.- References.- 21 Fractures of the Distal Tibial Metaphysis Involving the Ankle Joint: The Pilon Fracture.- 21.1 Introduction.- 21.2 Natural History.- 21.2.1 Nature of the Injury.- 21.2.1.1 Axial Compression.- 21.2.1.2 Shear (Tension).- 21.2.1.3 Combined.- 21.2.2 State of the Bone.- 21.2.3 State of the Soft Tissues.- 21.2.4 Technical Difficulties.- 21.2.5 The Dilemma.- 21.2.6 Summary.- 21.3 Classification.- 21.3.1 Comprehensive Classification.- 21.3.2 Use of Classification in Decision Making.- 21.3.2.1 Fibula.- 21.3.2.2 Articular Surface of the Tibia.- 21.3.2.3 Distal Tibial Metaphysis.- 21.3.3 Personality of the Fracture.- 21.4 Assessment.- 21.4.1 Clinical.- 21.4.2 Radiological.- 21.5 Indications for Surgery.- 21.5.1 Minimal Displacement.- 21.5.2 Significant Displacement.- 21.5.2.1 Operable.- 21.5.2.2 Inoperable.- 21.6 Surgical Technique.- 21.6.1 Timing.- 21.6.2 Approach.- 21.6.2.1 Soft Tissue.- 21.6.2.2 Skeletal Tissue.- 21.6.3 Technique of Internal Fixation.- 21.6.3.1 Without Fibular Fracture.- 21.6.3.2 With Fibular Fracture.- 21.6.4 Fixation Techniques with Poor Skin and Soft Tissue (Grade 3).- 21.6.5 Wound Closure.- 21.6.6 Postoperative Care.- 21.6.6.1 Early.- 21.6.6.2 Late.- 21.7 Common Pitfalls of Treatment.- 21.7.1 Poor Decision Making.- 21.7.2 Operating Through Poor Skin.- 21.7.3 Technical Difficulties with the Fibula.- 21.7.4 Technical Difficulties with the Tibial Fracture.- 21.7.5 Poor Postoperative Care.- 21.8 Late Reconstruction: Supramalleolar Osteotomy.- References.- 22 Fractures of the Ankle.- 22.1 Introduction.- 22.1.1 Basic Principles.- 22.1.2 Anatomical Considerations.- 22.1.2.1 Stability.- 22.1.2.2 Congruity.- 22.1.2.3 Physiology.- 22.1.2.4 Pathoanatomy.- 22.1.3 Natural History.- 22.1.4 Mechanism of Injury.- 22.1.4.1 Supination - Adduction.- 22.1.4.2 Eversion - Abduction.- 22.2 Classification.- 22.2.1 Introduction.- 22.2.2 Comprehensive Classification.- 22.2.2.1 Type A.- 22.2.2.2 Type B.- 22.2.2.3 Type C.- 22.2.2.4 Isolated Medial Malleolus Fracture.- 22.3 Assessment of Stability.- 22.3.1 Clinical Assessment.- 22.3.1.1 History.- 22.3.1.2 Physical Examination.- 22.3.2 Radiological Assessment.- 22.3.2.1 Lateral Complex: Fibula and Tibiofibular Syndesmosis.- 22.3.2.2 Talus.- 22.3.2.3 Posterior Tibial Process.- 22.3.2.4 Medial Complex.- 22.4 Management.- 22.4.1 Decision Making.- 22.4.1.1 Type A.- 22.4.1.2 Types B and C.- 22.4.1.3 Isolated Medial Malleolar Fracture.- 22.4.2 Surgical Technique.- 22.4.2.1 Tourniquet.- 22.4.2.2 Timing.- 22.4.2.3 Incisions.- 22.4.2.4 Open Reduction and Internal Fixation.- 22.4.3 Wound Closure.- 22.4.4 Postoperative Program.- 22.4.4.1 Immediate Management.- 22.4.4.2 Early Motion.- 22.5 Special Problems in Ankle Fractures.- 22.5.1 Open Ankle Fractures.- 22.5.2 Ankle Fractures in the Elderly.- 22.5.3 Primary Ankle Arthrodesis.- 22.5.4 Fibular Lengthening for Malunion.- 22.5.5 Supramalleolar Osteotomy.- 22.5.6 Ankle Fractures in Adolescents.- References.- 23 Fractures of the Talus.- 23.1 Introduction.- 23.2 Anatomical Considerations.- 23.2.1 Vascular Anatomy.- 23.2.1.1 Extraosseous Arterial Supply.- 23.2.1.2 Intraosseous.- 23.2.1.3 Summary.- 23.2.2 Mechanism of Injury.- 23.2.2.1 Common Pattern.- 23.2.2.2 Atypical Patterns.- 23.2.2.3 Total Dislocation of the Talus.- 23.3 Classification and Natural History.- 23.3.1 Fractures of the Body of the Talus.- 23.3.2 Fractures of the Talar Neck.- 23.3.2.1 Type A: Undisplaced Fractures of the Talar Neck.- 23.3.2.2 Type B: Displaced Fractures of the Talar Neck with Subluxation of Subtalar Joint.- 23.3.2.3 Type C: Displaced Fractures of the Talar Neck with Posterior Dislocation of the Body.- 23.3.3 Subtalar Dislocation.- 23.3.4 Total Dislocation of the Talus.- 23.4 Management.- 23.4.1 Assessment.- 23.4.1.1 Clinical Assessment.- 23.4.1.2 Radiological Assessment.- 23.4.2 Decision Making.- 23.4.2.1 Fractures of the Body.- 23.4.2.2 Fractures of the Talar Neck.- 23.4.3 Surgical Technique.- 23.4.3.1 Timing.- 23.4.3.2 Antibiotics.- 23.4.3.3 Tourniquet.- 23.4.3.4 Skin Approaches.- 23.4.3.5 Stable Internal Fixation.- 23.4.3.6 Postoperative Care.- 23.4.4 Special Problems.- 23.4.4.1 Open Fractures and Fracture-Dislocations.- 23.4.4.2 Comminuted Fractures of the Talar Body.- References.- 24 Fractures of the Calcaneus.- 24.1 Introduction.- 24.2 Anatomy.- 24.3 Pathoanatomy (Mechanism of Injury).- 24.4 Classification.- 24.5 Assessment.- 24.5.1 Radiographic Assessment.- 24.6 Decision Making.- 24.6.1 Fracture Factors.- 24.6.2 Patient Factors.- 24.7 Treatment.- 24.7.1 Nonoperative Treatment.- 24.7.2 Operative Treatment.- 24.7.2.1 General Aspects.- 24.7.2.2 Specific Aspects.- 24.8 Postoperative Care.- 24.9 Prognosis and Results.- 24.10 Conclusions.- References.- 25 Injuries of the Midfoot and Forefoot.- 25.1 Fractures of the Navicular.- 25.1.1 Anatomy.- 25.1.2 Treatment.- 25.2 Fractures of the Cuboid.- 25.3 Fractures of the Metatarsals.- 25.3.1 Anatomy.- 25.3.2 Treatment.- 25.3.3 Fractures of the Proximal Fifth Metatarsal.- 25.4 Fractures of the Phalanges.- 25.5 Tarsometatarsal (Lisfranc) Fracture-Dislocations.- 25.5.1 Anatomy.- 25.5.2 Mechanism and Classification.- 25.5.3 Clinical and Radiological Diagnosis.- 25.5.4 Treatment.- 25.6 Compartment Syndromes of the Foot.- References.