Primary cemented bipolar radial head prostheses for acute elbow injuries with comminuted radial head fractures: mid-term results of 37 patients

BACKGROUND

Radial head arthroplasty represents a widely accepted treatment for elbow injuries with non-reconstructible radial head fractures. The aim of this retrospective multicenter study was to assess mid-term results of patients with clearly defined elbow injuries including type III fractures of the radial head according to Mason's classification type III after primary arthroplasty using a cemented bipolar design.

MATERIALS AND METHODS

In 45 cases a primary cemented bipolar arthroplasty of the radial head was implanted for elbow injuries combined with an acute Mason type III radial head fracture. In all patients associated fractures were detected with preoperative CT scans and ligamentous injuries were evaluated and both were addressed intraoperatively based on a standardized algorithm. Patients with associated injuries other than coronoid fractures and collateral ligament tears were excluded from this study to obtain a more homogenous sample. Clinical and radiological assessment was performed on thirty-seven patients at an average of 5.6 years postoperatively.

RESULTS

DASH Score, functional rating index of Broberg and Morrey, Mayo Elbow Performance Score, and Mayo Modified Wrist Score confirmed good-to-excellent results in most of the patients. Compared to the unaffected arm range of motion and grip strength were slightly reduced. No elbow instability or loosening of the prosthesis, and minor degenerative changes were detected in a few cases.

CONCLUSION

Primary cemented bipolar arthroplasty for type III fractures according to Mason's classification in an elbow injury pattern only including associated coronoid fractures and/or ligamentous tears resulted in good-to-excellent mid-term results. These results suggest that primary bipolar radial head arthroplasty combined with distinct treatment of all associated injuries provides good functional outcomes concerning range of motion, elbow stability, and strength in this cohort. However, the associated injuries may influence clinical and radiological outcome and need to be detected, classified, and treated carefully.

[Plate osteosynthesis of patellar fractures]

OBJECTIVE

Anatomic reconstruction of the retropatellar articular surface and repair of the extensor mechanism of the knee joint. The osteosynthesis should allow immediate mobilization as part of an early functional postoperative rehabilitation protocol.

INDICATIONS

Displaced fractures of the patella, especially multifragment and comminuted fractures with a retropatellar incongruity or dislocation of >2 mm.

CONTRAINDICATIONS

Critical local soft tissue because of the risk of postoperative infection.

SURGICAL TECHNIQUE

Median skin incision. For simple (transverse) fractures, preservation of the soft tissue and reduction control via the index finger. For complex fractures, lateral arthrotomy and eversion of the patella. Reconstruction of the articular surface from the joint side with optimal visibility. Temporary fixation with Kirschner wires, osteosynthesis with the fixed angle plate. If necessary, additional screws or wires.

POSTOPERATIVE MANAGEMENT

Immediate mobilization with full weightbearing in full extension with a knee brace. Extension/flexion 0/0/60° for 4 weeks, then 0/0/90° until the 7th week. Active extension after 6 weeks. Climbing stairs after 12 weeks.

RESULTS

Good functional results in combination with a low rate of complications and revisions.

Morphologic study of posterior articular depression in Schatzker IV fractures

The Schatzker classification of tibial plateau fractures is widely accepted. Type IV fractures are medial tibial plateau fractures that are either split off as a wedge fragment or depressed and comminuted. Posterior articular surface depression in Schatzker type IV tibial plateau fractures can be seen as a unique variant that increases the difficulty of reduction of the articular surface. Its morphologic characteristics have not been fully studied, and the incidence is sometimes underestimated. The goal of this study was to evaluate the morphologic characteristics of posterior articular depression in Schatzker type IV fractures based on computed tomography measurements. From January 2009 to December 2011, the medical records, including digital radiologic data, of all patients treated for tibial plateau fracture at the authors' institution were retrospectively analyzed. Articular surface depression deeper than 5 mm was the criterion for study inclusion. The depression depth, precise location of the articular depression center, surface area percentage, and distance of the fracture gap to the depression center were calculated. One hundred fifteen cases of Schatzker type IV fracture were retrieved, and a total of 47.83% (55 of 115) cases had posterior articular surface depression. The average depth of the depressed articular surface was 12.41 mm, the surface area percentage was 20.15% of the entire tibial plateau, and the gap distance from the medial direction was 41.40 mm, 2.8 times longer than that from the posterior direction, which was 14.91 mm. Posterior articular surface depression occurs in nearly half of Schatzker type IV fractures, and the posterior approach provides more direct access to the depression than the medial approach.

Assessment of changing patterns of Le fort fracture lines using computed tomography scan: an observational study

OBJECTIVES

To assess the changing mid-face fracture patterns using a computed tomography scan.

METHODOLOGY

Fifty patients with mid-face trauma requiring open reduction and fixation were studied using 1.6 mm axial, sagittal, coronal and 3D images. Images were evaluated clinically, intra-operatively and finally were compared with standard Le Fort lines. Results. The male population dominated the female at a ratio of 11.5:1. The majority of the mid-face fractures were seen in the age group of 21-30 years. Road traffic accident (78%) was the major etiological factor followed by work-related accidents (12%) and assaults (10%). The CT scan analysis included categorizing the patients into three groups: (1) Fracture patterns resembling Le Fort lines (24%); (2) Fracture patterns partially resembling Le Fort lines (56%); and (3) Fracture patterns that do not resemble Le Fort lines (20%).

CONCLUSION

With the change in the velocity of wounding object, there is a change in the mid-face fracture patterns. The majority of the cases present as a variant of classical Le Fort fractures. Computed tomography is a valuable diagnostic tool in assessing the fractures of the mid-face. 2D images are more sensitive than 3D images. However, both the images are required in delivery of an optimal treatment plan.

[Optimization of the diagnostics and treatment of the comminuted intraarticular fractures]

The diagnostic and treatment algorithm of the comminuted intraarticular fractures of the long tubular bones was worked out. It included laser Doppler flowmetry, thermography, artroscopy, osteoreplacing and external fixation methods. Bench tests of the innovated external fixation apparate proved the possibility of early postoperative rehabilitation of patients.

[Reliability of load-sharing classification in indications for anterior vertebral body replacement in thoracolumbar spine fractures]

INTRODUCTION

So far, the Load-Sharing Classification (LSC) has been the commonest method employed to identify indication for anterior replacement of vertebral bodies in thoracolumbar spine fractures. The aim of this study was to verify reliability of the LSC method in indications for anterior replacement surgery.

METHODS

Fractures were examined using x-ray, CT and MRI methods. The prospective study included only patients with type A3 comminuted fractures (AO classification) of the thoracolumbar vertebrae (Th11-L2), with MRI confirmed grade 3 or 4 intervertebral disc injuries (according to Oner) and with no concomitant nerve injuries. All fractures were treated using isolated posterior transpedicular (TP) fixation. 18 months after the procedure, angulation of the regional kyphosis, screw rupturing, Visual Analogue Scale (VAS) scores at rest and under loading, Pain Scale (PS) scores and Work Scale (WS) scores were assessed. The study group included 42 patients aged 27-72 years (the mean age was 51.55 y.o.a.), 28 subjects were males and 14 females. Using the LSC classification system, the study group was divided into two subgroups, one including patients with LSC up to grade 6 - Group A (18 subjects) and the other one including patients with LSC 7 to 9 - Group B (24 subjects).

RESULTS

Statistical assessment of clinical (PS, WS, VAS at rest and VAS after loading) and radiological findings (the degree of kyphotic changes) at month 18 identified no statistically significant correlations between the two subgroups. TP fixation failures (srews rupturing) occured only in Group A in two subjects.

DISCUSSION

Based on the LSC, Group B was expected to have inferior outcomes, however, this was not the case in our study group. Therefore, it can be concluded that LSC is not a reliable predictor of the final clinical and radiological findings in the type A3 fractures with grade 3 or 4 TH-L intervertebral disc injuries. The defined LSC 6- point threshold for indications for anterior vertebral body and disc replacements is arguable.

CONCLUSION

The authors do not consider the LSC method sufficiently reliable for determining indications for anterior replacements.

[Hawkins type III fracture: dislocation of the talus and fracture of the medial malleolus treated by distraction external fixation]

These injuries are extremely rare and severe. The literature describes only individual cases of such injuries. We report a case of a displaced fracture of the talar neck with a complete posterior dislocation and rotation of the body of the talus (Hawkins type III) associated with medial malleolus fracture, treated with the method of urgent open reduction and internal fixation of the talar neck and medial malleolus as well as with the method of distraction external fixation.A 26-year-old male was injured after a fall from a height of over 8 m and was admitted as an emergency to the University Orthopedic and Traumatology Clinic in Nis. Surgery was performed within 4 h postinjury. He was mobilized with crutches with non-weight bearing. The external fixator was removed 10 weeks postsurgery, when physical therapy was initiated. The follow-up was 3 years. There were neither early nor late postoperative complications. Three years postinjury, movements in the ankle joint were satisfactory (plantar flexion 35 degrees , dorsal flexion up to 10 degrees , moderately limited movements in the subtalar joint). There were no signs of avascular necrosis; the patient walked normally and went back to physical work 2 years postinjury. Urgent open reduction and internal fixation of the Hawkins type III fracture with dislocation of the talus and distraction external fixation can play an important role in the prevention of avascular necrosis of the talus and other complications which follow this injury.

Ostéosynthèse par plaque antérieure verrouillée des fractures complexes de l’extrémité distale du radius

PURPOSE OF THE STUDY

Maintaining radial length, likely to be the main challenge in the treatment of complex distal radius fractures, is necessary for complete grip-strength and pro-supination range recovery. In spite of frequent secondary displacements, bridging external-fixation has remained the reference method, either isolated or in association with additional percutaneous pins or volar plating. Also, there seems to be a relation between algodystrophy and the duration of traction applied on the radio-carpal joint. Fixed-angle volar plating offers the advantage of maintaining the reduction until fracture healing, without bridging the joint.

MATERIAL AND METHODS

In a prospective study, forty-three consecutive fractures of the distal radius with a positivated ulnar variance were treated with open reduction and fixed-angle volar plating. Results were assessed with special attention to the radial length and angulation obtained and maintained throughout treatment, based on repeated measurements of the ulnar variance and radial angulation in the first six months postoperatively.

RESULTS

The correction of the ulnar variance was maintained until complete recovery, independently of initial metaphyseal comminution, and of the amount of radial length gained at reduction. Only 3 patients lost more than 1 mm of radial length after reduction. The posterior tilt of the distal radial epiphysis was incompletely reduced in 13 cases, whereas reduction was partially lost in 6 elderly osteoporotic female patients. There was 8 articular malunions, all of them less than 2 mm. Secondary displacements were found to be related to a deficient locking technique. Eight patients developed an algodystropy. The risk factors for algodystrophy were articular malunion, associated posterior pining, and associated lesions of the ipsilateral upper limb.

CONCLUSION

Provided that the locking technique was correct, this type of fixation appeared efficient in maintaining the radial length in complex fractures of the distal radius. The main challenge remains the reduction of displaced articular fractures. Based on these results, it is not possible to conclude that this method is superior to external fixation.

A clinically applicable reporting system for the diagnosis of facial fractures

A clinically applicable, comprehensive reporting system for the diagnosis of facial fractures was developed with three guiding principles: (1) preservation of classical anatomical terminology and nomenclature, (2) facilitation of uniform interpretation of radiographs between radiologists and (3) non-redundant diagnostic descriptions of complex fractures, in a manner that correlates with treatment modality. Twenty-two fracture types (17 simple fracture types and 5 complex fracture types) are included in the system. Each patient's fracture pattern is described by listing the component fractures present. A short narrative (modifying description) is provided after each fracture listed. Simple fractures that help to comprise more complex fractures are not listed separately, but are described within the modifying description of the complex fracture they help to comprise. When components of multiple complex fractures are present, a hierarchy of complex fractures dictates which fracture is described first. Additional complex fractures are only described separately when they do not share common components. In all other cases, the second (lower order) complex fracture is best described by simply listing the component (simple or complex) fractures that are not accounted for in the higher order complex fracture. Adoption of this reporting system should improve communication between emergency medicine physicians, radiologists and surgeons.

Use of an External Fixation Combined with the Buttress-Maintain Pinning Method in Treating Comminuted Distal Radius Fractures in Osteoporotic Patients

BACKGROUND

It is difficult to keep the alignment of a distal radius fracture in patients with osteoporosis and prevent malunion. Therefore, we hoped to design better method to maintain alignment.

METHODS

Thirty-two patients over 65 years old with a displaced unstable distal radius fracture were treated by the external fixator combined with buttress-maintain pinning method and were compared with a group of 66 patients less than 60 years old treated by the same method.

RESULT

The radiologic results demonstrated that postoperative and final radial length and volar tilt were not statistically different between both groups. The functional result (excellent and good) in the elderly group was 87.5% and 89% to that of the control group. There was only one complication of pin tract infection in the elderly group.

CONCLUSIONS

External fixation for unstable distal radius fracture combined with buttress-maintain pinning method can be used in the osteoporotic bone of older adults with results similar to those for young adults at 18 months follow-up.

Quantifying comminution as a measurement of severity of articular injury

The severity of articular injury caused by a fracture of periarticular bone impacts patient prognosis. There currently are not good, objective methods for grading articular injury severity. Quantification of bone comminution from fracture image data, which has been possible in laboratory studies, may be a promising route. We show that tibial pilon fractures can be discriminated on the basis of de novo surface-apparent energy absorption.

Three-dimensional and two-dimensional computerized tomographic demonstration of calcaneus fractures

The objective of the study was to illustrate the diagnostic quality of three-dimensional computed tomography (3DCT) and to document its usefulness for detecting gross changes in articular surfaces of the calcaneus and posterior articular facet (PAF). Superior view 3DCT images of 51 calcanei in 39 different patients were reviewed based on bony fragments produced by primary fracture lines and involvement of the PAF. Of 49 intraarticular fractures examined, there were two severely comminuted and 47 comminuted fractures. Main characteristics of both groups were described. Important findings best seen on 3DCT images were the number and configuration of displaced PAF fragments, fracture lines separating the anterior process and the middle facet, and the extension of fracture lines into the calcaneocuboid facet. The double density sign seen in plain x-rays was identified as a double articular sign in 3DCT images.

Pilon-tibiale-Frakturen

In the AO classification, the distal tibia is 43 and A type injuries are extra-articular, B type partial articular and C type involve the whole of the articular surface with complete separation of the joint from the diaphysis. The term pilon fracture should be confined to B(3) and C type fractures. The injury mechanism of pilon fractures will vary from a simple fall to a high energy road traffic accident, leading to increasing fracture comminution and greater soft tissue injury with more open fractures. Plain radiographs and CT-scans are diagnostic prerequisites. A spanning external fixator, with or without fixing the fibula, is the initial method of choice. The goal is to span the zone of injury with the fixator, to align the limb, to reduce the articular surface through very limited approaches, and to minimize complications related to treatment to maintain length and provisionally align the fracture. When soft tissue swelling has subsided definitive stabilization is performed. Bone grafting of defects is rarely necessary.

Comminuted fracture of the ulnar sesamoid of the metacarpophalangeal joint of the thumb: an uncommon injury

Fracture of the ulnar sesamoid of the metacarpophalangeal joint of the thumb is rare. Injury may be caused as a result of hyperextension or, less frequently, direct trauma. A sesamoid may be incompletely ossified, making it difficult to diagnose the fracture on radiographs. Early recognition of this entity leads to appropriate management. The case of a 26-year-old man who sustained a hyperextension injury of the thumb is presented. Radiographs demonstrated a fracture of the ulnar sesamoid of the thumb metacarpophalangeal joint. The literature regarding this uncommon injury is discussed.

[Epidemiology, treatment and results of proximal humeral fractures: experience of a district hospital in a sports- and tourism area]

AIM OF THE STUDY

The epidemiology, therapy and results of proximal humeral fractures in a touristic area were investigated and our concept for treatment presented.

METHODS

Between 1.1.1999 and 30.04.2000 adult patients with proximal humeral fractures were included, the fractures classified (Codman/Neer and AO) and results determined after an average of 9 months.

RESULTS

62 adults were treated. 59 (95 %) had an accident during leisure time, mainly skiing accidents (52 %). 7 patients (11 %) had an associated luxation of the shoulder. 51 (82 %) were treated conservatively, 11 (18 %) operatively with a T-plate. The conservatively treated had to wear a Gilchrist-cast for an average of 29 (operatively 13) days, started passive movement after 20 (operatively 9) days, and active movement after 44 (operatively 45) days. The 32 employed (52 %) were not able to work for 46 days on average. Overall, 52 patients (84 %) were totally or mostly satisfied with the result. 5 among the 13 patients (38.5 %) with 3- or 4-part-fractures, and 4 among the 11 operated patients (36.4 %) were not satisfied with the result.

CONCLUSIONS

Proximal humeral fractures are common skiing injuries, they need a long and intensive treatment and are economically expensive. The Codman/Neer and AO-classifications are equal. The results for simple, mainly conservatively treated fractures (Codman/Neer 1, 2A, 2-part) are good. Complex, mainly operatively treated fractures (Codman/Neer 3- and 4-part) have a much poorer prognosis. Diagnostically the computed tomography with 3-D-reconstruction is recommended for a better representation of the fracture and a safer choice of the therapeutical strategy.

[Combined palmar and dorsal approach for complex distal radius fractures]

PURPOSE

The purpose of this paper was to describe our management of complex fractures of the distal radius using a combined dorsal and palmar approach and to evaluate the radiological and clinical outcome.

PATIENTS AND METHODS

Twenty out of 26 patients with complex fractures of the distal radius, which were operated on from 1996 to 2000 using a combined dorsal and palmar approach, were followed-up on an average of 28 months. According to AO fracture classification, there were one A3, two B3, three C1, two C2 and twelve C3 fractures. Six patients had associated injuries. The treatment was standardized: closed reduction on the day of injury; depending on the soft-tissue situation an external fixator or a forearm splint was applied; every patient underwent a computed tomography before the definitive surgical procedure, which was performed between one and 28 days after the injury when the swelling had subsided. According to the fracture patterns, the distal radius was stabilized using double plates (3), a palmar plate (11) or a dorsal plate (4), screws (1) or K-wires (1) combined with the initially applied external fixator (6). Follow-up included a radiological and clinical examination. The results were graded with use of the modified Mayo Wrist Score. Disability was assessed using the DASH score.

RESULTS

All fractures healed, some with minor malunion. Fourteen of the 20 patients had osteoarthrotic changes. Compared to the opposite wrist, range of motion for flexion/extension was reduced by 25 %, radial/ulnar deviation by 20 % and forearm rotation by 5 %. Grip strength averaged 15 % less than that of the opposite side. Modified Mayo Wrist Score revealed 65 % excellent, 30 % good and 5 % poor results. DASH score averaged 18 points.

[Treatment of proximal ulnar comminuted fractures--a challenge]

INTRODUCTION

Comminuted fractures of the proximal ulna are severe injuries often complicated by involvement of the elbow joint and damaged soft tissues. The treatment of these fractures is very demanding and the results often mediocre due to of ancillary injuries (Dislocation in the humero-ulnar joint and associated radial head fractures). We analyzed the results of the treatment of these fractures and investigated whether other factors than the severity of fracture type influenced the final outcome.

METHOD

Retrospective analysis of 18 patients with comminuted proximal ulna fractures. These comminuted ulna fractures included not only C-fractures according the the AO classification but also A1, A3, B1 and B3 fractures. Postoperative clinical and radiological examinations were routinely performed at 1/2-1 year intervals following treatment according to bone healing and work begin. This was done up to 48 months following treatment. Elbow function was recorded one year after the accident using the Morrey score.

RESULTS

According the the AO classification, of the total of 18 patients, four suffered from an A-fracture, four from a B-fracture and 10 from a C-fracture. Eight of the 18 patients had an open fracture. 10/18 of the patients also had a fractured radial head and 9/18 of the cases had a dislocation of the humero-ulnar joint. The average range of motion based on a postoperative examination after one year was extension/flexion 0 degree/20 degrees/120 degrees and pronation/supination 70 degrees/0 degree/70 degrees. The assessment based on the Morrey-score indicated excellent to good results for 10 patients, average results for four patients and poor results for four patients.

CONCLUSION

Despite correct diagnosis of the severity of injury and adequate treatment the results are only mediocre due to associated injuries (dislocation, radial head fractures). The goal is a stable anatomic reconstruction to allow early functional treatment.

[Fresh fractures of the radial head: results with the Judet prosthesis]

PURPOSE OF THE STUDY

Communitive fractures of the radial head are a therapeutic challenge when fixation is not possible. Secondary sequelae including ulnar valgus, ascension of the radius, osteoporosis of the humeral condyle and biomechanical impairment of the elbow cannot be avoided with resection or the Swanson prosthesis. The Judet prosthesis, with its floating cup, is a technically attractive solution, but the question is whether it can avoid the secondary effects observed with resection or the Swanson prosthesis.

MATERIAL AND METHODS

We have used the Judet prosthesis since August 1995 in 16 patients. These patients had Mason type IV (Johnston modification) lesions of the radial head in 14 cases and type III lesions in 2. Associated injuries included: Monteggia fracture in 2, open fracture-dislocation in 1, fracture of the radial neck associated with fracture of the lower radius in 1, and dislocation of the elbow in 2. Preoperatively, 7 of the 16 patients had an osteocartilaginous injury of the humeral condyle. The Judet prosthesis was implanted after resection in 3 patients, after osteosynthesis of the radial head in 3 others, and as the first line treatment in 10. Postoperatively, 13 of the 16 patients were given a unique 7 Gy radiation to prevent ossification as well as nonsteroidal antiinflammatory drugs (indometazin 50 mg b.i.d.) for 3 weeks. None of the patients were immobilized.

RESULTS

Mean follow-up for the 16 patients was 19 months (12-45). Deficient extension persisted in 5 patients (mean 5 degrees ). Average flexion was 128 degrees; two patients were limited to 100 degrees. Average pronation was 77 degrees, and average supination 79 degrees. Muscle force was 10% weaker than the healthy side. Sagittal and frontal stability in valgus was preserved in 14 patients. Two patients had a frontal instability with minimal valgus related to a minor insufficiency of the medial collateral ligament. According to the Radin and Riseborough classification, outcome was good in 7, fair in 6 and poor in 3. According to the Morrey classification, outcome was excellent in 2, good in 12, fair in 1 and poor in 1. Radiologically, there were no cases with ulnar valgus, humeral condyle osteoporosis, ascension of the radius, or subluxation of the distal radioulnar joint. The prosthesis loosened in one case without clinical expression.

DISCUSSION

Our results with the Judet prosthesis were much better than those reported in the literature for resection and Swanson prosthesis.

Orbital deformity after craniofacial fracture repair: avoidance and treatment

BACKGROUND AND OBJECTIVES

To achieve the optimal preoperative appearance following craniofacial fracture repair, the surgeon must be facile in the most sophisticated reconstructive techniques and able to determine their application. The purpose of this article is to describe the common deformities following such repairs, outline a strategy to avoid them, and review the surgical techniques to correct them.

METHODS AND MATERIALS

The deformities are categorized by the anatomic zones of the orbit, i.e., zygomatic, frontal, and nasoethmoidal, affected by low-, middle-, and high-energy impact. The common types of deformity and acute and late treatments are discussed for each category.

RESULTS AND/OR CONCLUSIONS

The optimal time to correct posttraumatic orbital deformities is during the acute phase. Extended open reduction and rigid fixation techniques have their own morbidity, which must not outweigh the deformity of an untreated or partially treated injury. The results of late reconstruction are always limited by scarring of the overlaying soft tissue envelope.

Predictors of outcome of floating knee injuries in adults: 89 patients followed for 2-12 years

Of the 98 floating knee injuries that were consecutively treated from 1987 to 1997, 89 patients were available for analysis. There were 80 males and 9 females, ranging from 15 to 70 years old. Average follow-up was 5 (2-12) years. Injury severity scores ranged from 18 to 45. 21 fractures were intra-articular. 55 fractures were open. Substantial comminuted and segmental fractures occurred in 57 cases and 35 cases, respectively. Multivariate analysis showed that increasing age was associated with delays in bony union and full weight bearing ability. An increase in the number of pack years smoked at the time of injury predicted the likelihood of knee stiffness, delays in bony union and full weight bearing ability. Higher injury severity scores were associated with delayed full weight bearing ability. The presence of open fractures predicted the likelihood of knee stiffness and delayed full weight bearing ability. Comminuted fractures were associated with malunion, and segmental fractures with delayed bony union. Using the outcome of floating knee injuries as fair or poor, according to Karlström and Olerud's criteria, we constructed a preoperative prognostic scoring scale which showed a sensitivity of 0.72 and a specificity of 0.90.

Percutaneous pin fixation of intercondylar fractures in young children

T-condylar fractures of the distal humerus are very rare in children. When they do occur they tend to affect those approaching skeletal maturity. Most agree that the undisplaced fracture can be managed conservatively. With increasing displacement and comminution the opinions tend to differ. As an alternative to open reduction and internal fixation we report the use of closed reduction and percutaneous pin fixation for displaced and comminuted T-condylar fractures in a series of three young children. In addition to the classical medial and lateral column fixation we report the use of a transcondylar wire to stabilise the distal fragments and discuss the use of intra-operative arthrography in low supracondylar fractures to exclude a missed intercondylar extension on plain xrays. Although small this series represents the largest series of children less than eight years of age.

Ender nail fixation of pediatric femur fractures: a biomechanical analysis

SUMMARY

Biomechanical testing was performed to determine the effects of flexible intramedullary nail fixation on simulated transverse and comminuted midshaft femur fractures using two Ender nails. A synthetic adolescent-size femur model was used. The axial and rotational stiffness values for the simulated comminuted fracture were equivalent to those of the transverse fracture under "touch-down weight-bearing" loads. These data suggest that length and rotational control of comminuted midshaft femur fractures with two divergent Ender nails may be sufficient for early mobilization.

Coronal split fracture of the proximal tibia epiphysis through a partially closed physis: a new fracture pattern

SUMMARY

A comminuted coronal split fracture of the proximal tibial epiphysis is an uncommon injury in children. The authors evaluated and treated two patients who sustained an epiphyseal fracture through a partially closed proximal tibial epiphysis. Plain radiography and computed tomography with three-dimensional reconstruction showed a comminuted coronal split fracture of the proximal tibial epiphysis. Each patient underwent definitive operative fixation of the fracture and was followed at least 1 year after clinical union. A mechanism consisting of three-point bending on the tibial plateau is proposed.

[Unstable fracture of the distal radius and its treatment: comparison of three techniques: external fixation, intramedullary pinning and AO plates]

This retrospective study compares 94 distal radius fractures. Sixty one women (median age 66) and 33 men (median age 42) were reviewed clinically and radiologically by a surgeon not involved in treatment. Fractures were classified into three AO groups. Standard X-rays were used for radiological evaluation. Fractures of the distal ulna were evaluated separately. Chi-square tests, Wilcoxon, Mann-Whitney and Fisher's tests were used for statistical evaluation. Women presented mainly "A" type fractures. They were treated by intramedullary pinning. Forty two fractures were grafted, using autogenous bone for young patients and bone substitute for the elderly. Twelve scapholunate dissociations were recorded, all but one were detected in women, 50 years of age or more. Four were painfree, two presented climatic pain and six claimed pain during effort; none had snapping. Radio-ulnar laxity was similar with or without styloid fractures. External fixator and autogenous grafts appeared the most efficient technique for maintaining radial length. Ulnar head fractures were related to a significant higher incidence of sympathetic dystrophy with reduced prono-supination, a correlation not previously noted to your knowledge. This suggests that radius and ulnar head fracture should be classified independently. The amount of pain was not related to classification, internal fixation or gender.

Classification of posterior fracture dislocation of the hip joint: a modification of the Thompsen Epstein classification

The purpose of this paper was to describe a classification of posterior fracture dislocations of the hip joint, which would highlight the important aspects of managing this injury and more closely correlate with the prognosis. During the period from July 1994 to September 1997, the senior author operated on 60 posterior fracture dislocations of the hip joint. The results of the surgery were scored according to our ability to accurately anatomically reconstruct the acetabulum. We found that the degree of comminution was a greater determent of whether we could achieve an anatomical reconstruction than the presence of an associated acetabular floor fracture. Epstein showed conclusively that type II and III injuries have significantly different outcomes, but then grouped them together as type IV injuries if there was an associated floor fracture. We felt it more appropriate to continue with Epstein's fundamental feature of ascribing a grade according to the comminution and subdivided his type IV injuries.

Early weight-bearing after statically locked reamed intramedullary nailing of comminuted femoral fractures: is it a safe procedure?

BACKGROUND

The purpose of this study was to determine the safety of early weight-bearing after statically locked reamed nailing of comminuted fractures of the femoral diaphysis, and to assess the rate of implant failure and fracture healing.

METHODS

Thirty consecutive patients with comminuted diaphyseal femur fractures (Winquist type II, III, and IV) were treated with statically locked reamed intramedullary nailing. Six patients were lost to follow-up, and the remaining 24 patients were followed at least 1 year. Early weight-bearing was allowed and encouraged in the first 2 weeks after the operation. The nail diameters were 13 mm in 16 patients, 12 mm in 6 patients, and 14 mm in 2 patients.

RESULTS

Most of the patients could start weight-bearing between the first 2 and 4 weeks postoperatively. None of the patients, except one, were using any walking aids at the second month postoperatively. All the fractures healed without any significant complications. Nail bending or breakage did not occur in any patients, but there was slight bending in one distal interlocking screw and one proximal interlocking screw. The fractures of the patients with bent screws healed uneventfully.

CONCLUSION

This study showed that early weight-bearing after reamed static interlocking nailing of Winquist type II, III, and IV femoral fractures is a safe and effective method, and the risk of implant failure does not preclude the procedure.

Clinician variability in characterizing mandible fractures

PURPOSE

This study evaluated variability in the clinical parameters commonly used to characterize mandible fractures.

PATIENTS AND METHODS

Inter-rater reliability of 18 oral and maxillofacial surgeons was assessed using radiographs of 22 cases of mandible fractures. Raters were asked to evaluate each case based on several parameters including number, location, and displacement of the individual fractures and severity of the composite injury. To evaluate intra-rater reliability, selected cases were reviewed at a second session by a subgroup of these surgeons. Tests of concordance used to quantify measurement reliability included the interclass correlation coefficient and multiple-rater kappa statistics.

RESULTS

Inter-rater agreement on the number of constituent fractures ranged from excellent for simpler fractures to poor for complex gunshot injuries. Even within raters, the range of interclass correlation for complex injuries was only 0.33 to 0.42 between the 2 assessments. Clinicians appeared to be better at delineating coronoid, condyle, ramus, and angle fractures; symphyseal and canine region fractures had lower inter- and intrarater agreement. Tests of concordance showed moderate to excellent reliability when fracture displacements were expressed in millimeters, but only fair reliability when displacements were expressed as categories. Even when the clinicians concurred on displacement measurements, a large overlap was observed in their categorization of these displacements. Despite the differences in the assessment of individual parameters, the high intrarater reliability coefficient (0.78) indicated that the individual clinicians had a high internal consistency in their assignment of summary severity scores. Multiple regression analysis revealed the number of constituent fractures, the type of fracture, and amount of fracture displacement (millimeters) to be significant predictors of clinician ratings of injury severity.

CONCLUSIONS

The clinician variability underscores the difficulties involved in trauma description and scoring. The study identifies some sources of clinician variability and emphasizes the need to standardize the characterization of mandible fractures by using explicit guidelines.

Computer-assisted quantitative measurements by three-dimensional images on zygomatic fracture deformities

OBJECTIVE

To investigate an available method for quantitative diagnosis of zygomatic fractures that allow quantitative classification and diagnosis.

METHODS

The radiographs and 2- and 3-dimensional CT images of 57 patients with zygomatic fractures were measured and analyzed by a computer-assisted measuring system before and after treatment. This was used to diagnose the displacement and deformity of the fractures.

RESULTS

(1) Using anthropology points and a computer-assisted measuring system, a new method was established to assess the displacement of the zygomatic fractures. (2) Displacement of the zygomatic fractures was approximately diagnosed by measuring different angles of the CT images. (3) A new classification was proposed based on the deformities of the zygomatic fractures: Type A, zygomatic body was intact and not displaced; Type B, zygomatic body was intact but displaced (including comminuted zygomatic arch fractures); Type C, zygomatic body was comminuted and displaced. (4) There were 4 subtypes with characteristics in the most common Type B fractures. (5) Different images had different advantages for diagnosing zygomatic fractures.

CONCLUSIONS

(1) Displacement of the zygomatic fractures can be quantitatively diagnosed by measuring 3-D CT images. (2) The computer-assisted 3-D CT measuring system is accurate, reliable, and clinically feasible for diagnosing zygomatic fractures. (3) The best image to diagnose the displacement of the fractures should be used.

Treatment of comminuted intraarticular distal femur fractures with limited internal and external tensioned wire fixation

OBJECTIVE

Evaluate the treatment of C3 distal femur fractures with limited internal fixation and tensioned wire circular external fixation.

DESIGN

Prospective cohort study, from June 1992 to July 1996.

SETTING

Urban Level I trauma center.

PATIENTS

Sixteen fractures in sixteen patients: nine male, seven female. Fractures: C3.1 one, C3.2 one, C3.3 fourteen. Twelve fractures were open: one GI, seven GII, two GIIIA, one GIIIB, and one GIIIC.

INTERVENTION

Fractures were treated with limited open fixation of the condylar joint surface and tensioned wire circular external fixation of the metaphysis and shaft for axial alignment. Three fractures had acute autologous bone grafts.

MAIN OUTCOME MEASUREMENTS

The patient's extremity function was evaluated by the authors by using the Sanders et al. Distal Femur Functional Evaluation.

RESULTS

Sixteen of sixteen fractures healed. Two patients had delayed bone grafting for delayed union. Average frame time was twenty-five weeks. Average range of motion was 0 to 92 degrees. Five patients had less than 90 degrees of flexion. Five patients required a quadricepsplasty. Average follow-up was thirty-five months. One patient developed a pintract infection. One patient developed septic arthritis, and another developed osteomyelitis. The average Sanders et al. Function knee score was twenty-eight, with a maximum possible score of forty.

CONCLUSIONS

C3 fractures of the distal femur are associated with severe soft tissue injuries and bone loss. Loss of function appears to be directly related to these factors. Treatment with limited internal fixation and tensioned wire external fixation has equivalent results to other methods but has a higher incidence of infection and complications. Joint motion is retarded by binding of the soft tissues with fixation wires and pins. The technique is recommended only for salvage of severely comminuted and open fractures of the distal femur with extensive soft tissue injury. Distal femur fractures with moderate comminution and soft tissue injury should be treated with alternate methods.

Function after early radial head resection for fracture: a retrospective evaluation of 15 patients followed for 3-18 years

We reviewed the results of early radial head resection in 15 patients after fracture of the radial head or neck: 4 Mason's type II fractures and 11 Mason's type III fractures. The average age at operation was 41 years and the patients were reexamined after mean 10 (3-18) years. Only 5 patients had no pain and all patients had reduced elbow power, in several of them a substantial loss.

The results of the surgical and conservative treatment of non-neurologic comminuted thoracolumbar fractures

A retrospective radiologic study of 40 non-neurologic thoracolumbar fractures allowed for the evaluation of the long-term results of surgical and conservative treatment in terms of correction of the post-traumatic deformity. The Magerl classification and the McCormack scale were used to select compressive type fractures (type A), and fractures characterized by comminution of the vertebral body without involvement of the posterior elements. Instability related to comminution and to considerable diastasis of the fragments is at the basis of failure of conservative (plaster brace) and surgical (short posterior fixation and posterolateral fusion) treatments. Severe type A fractures treated conservatively have, in fact, at follow-up shown significant residual deformity, while failure of the instrumentation or loss of correction in 40% of cases treated surgically has been revealed.

Comminuted pelvic ring disruption in toddlers: management of a rare injury

Pediatric pelvic fractures are rare injuries. The clinical management, classification, and operative treatment of this type of injury was presented in two toddlers ranging in age from 1 to 3 years. The CT examination proved to be the most reliable diagnostic tool for the assessment of the fracture morphology. The findings of the CT examination provide the possibility for an exact classification and operative planning. The surgical treatment was performed with the AO instrumentation for small fragments by using the approved standard approaches of adult surgery. The postoperative management has to be adapted to the physiology of the children. It is important to remove the osteosynthesis material in due time to avoid the risk of epiphysiodesis at the pelvis. To detect late sequelae of the trauma, follow-up should be performed regularly until growth is completed.

Internal fixation of distal radius fractures with dorsal dislocation: pi-plate or two 1/4 tube plates? A prospective randomized study

BACKGROUND

Severely comminuted distal radius fractures can be treated by different methods. Our routine procedure in dorsal dislocated fractures is the dorsal stabilization with two 1/4 tube plates. The new pi-plate is an other device that matches optimally the anatomy of the distal radius and allows a near half-circumferential dorsal buttress of comminuted intraarticular and extra-articular radial fractures.

METHODS

In a prospective randomized study, comminuted distal radius fractures with dorsal displacement were stabilized either with two 1/4 tube plates or with the pi-plate. All patients were reviewed at 1, 3, and 6 months after surgery by thorough clinical examination and standard radiographs of both wrists. Results were analyzed and compared in both groups.

RESULTS

Subjective and objective results in the pi-plate group are disappointing. Although optimal anatomic results were achieved, the complication-rate was high (14.3%) and the range of motion was limited. At final review, extension and flexion of the injured wrist had recovered to an average of 67% of the normal, contralateral side. Radial and ulnar deviation were limited to 64%, whereas pronation and supination reached 89% and 87%, respectively. Overall, results were good to excellent only in 56%. In a comparable group of patients with similar fractures and stabilization with two 1/4 tube plates, 82% of patients achieved excellent to good results, wrist motion was significantly better (p < 0.05), and no complications occurred.

CONCLUSION

With open reduction, cancellous bone grafting, and internal plate fixation in comminuted distal radial fractures, excellent results can be achieved. In our experience, we cannot recommend the 7pi-plate in its current shape and prefer to stabilize distal radius fractures and dorsal fragment dislocations with two 1/4 tube plates.

[Osteosynthesis under arthroscopic control of separated tibial plateau fractures. 26 case reports]

PURPOSE OF THE STUDY

Arthroscopic treatment of tibial plateau fractures may reduce morbidity compared to open articular surgery. But bony fixation is necessarily percutaneous and minimal. The purpose of our study was not only to assess immediate results but also long term functional and anatomic results after arthroscopic treatment of tibial plateau fractures, with special reference to radiographical results.

MATERIAL AND METHODS

Twenty-six patients (mean age 42 years, range 18 to 70 years, 17 men, 9 women) were arthroscopically treated for a fresh tibial plateau fracture. According to Schatzker classification, there was 2 type I, 17 type II, 6 type III and 1 type IV. No type V or VI were treated in this series. The fixation device was: percutaneous cannulated screw in 23 cases, Kirchner wire in 2 cases, and bone cement filing of the fracture site in 1 case. We did not use cancellous bone graft but we used a hydroxyapatite plug in one case. There were 8 meniscal injuries: 2 underwent arthroscopic suture, 1 had partial meniscectomy and 5 were left in place. Twenty-six cases were suitable for immediate post op follow up. 19 were reviewed at long term. A clinical (Knee Society scoring system) and radiographical examination were done with an average follow-up of 32.7 months.

RESULTS

There were no complications except one immediate postoperative septic osteoarthritis (case with hydroxyapatite plug) and one bony depression of the lateral tibial plateau at the fourth month. Passive motion of the knee started at 1.8 days postop with no pain. Mean flexion at 3 months was 130 degrees. At revision, the average score was: 94.1 for the knee, 94.7 for the function. In two cases we found early signs of osteoarthrosis. There were no secondary bony depression or significant valgus deformity on X-rays.

CONCLUSION

Arthroscopic management of tibial plateau fractures allows a complete articular screening. Rapid rehabilitation, short hospital stay, and low rate of complications reduce morbidity. The long term results are as good as those with open surgical technique for the types of fracture that we have treated (type III and IV). A minimal, percutaneous osteosynthesis which was the only possibility under arthroscopic control, did not modify the anatomical results.

[Instability of spinal fractures--therapeutic relevance of different classifications]

PURPOSE

To investigate if the assessment of spinal fracture stability according to the Magerl classification permits a better therapy decision than using the Denis 3-column model.

MATERIAL AND METHODS

The X-ray and CT images of 99 consecutive patients treated for thoracolumbar spine fractures were analysed and the fractures were classified according to the above mentioned classifications. Using the 3-column model, the involvement of two or more columns was considered as unstable, whereas the fracture types A3.2, A3.3, B and C of the Magerl classification were defined as unstable. The stability evaluation was compared with the therapy decision and outcome.

RESULTS

According to the 3-column model, 23 of 53 fractures which were classified as unstable were operated. Only five of the 30 conservatively treated unstable fractures showed a reduced healing process. The 46 stable fractures were treated conservatively with good results. Using the Magerl classification, 21 of the 28 unstable fractures were operated and 4 of the remaining 7 cases showed a reduced healing process. Of the 71 stable fractures only 2 were operated and in one patient minimal neurological symptoms occurred.

CONCLUSION

The Magerl classification enables a more exact definition of stable and unstable spinal fractures.

Assessment and management of three-and four-part proximal humeral fractures

Three-and four-part comminuted fractures of the proximal humerus are difficult and technically demanding to treat. The various treatment methods reported in the literature are reviewed. It is recommended that three-part fractures be treated with open reduction and internal fixation. Four-part fractures in the younger, active patient also can be treated successfully with open reduction and internal fixation. However, in the elderly and in the patient with osteoporosis, a hemiarthroplasty is the treatment of choice. There is a need for universal agreement on a scoring system for measuring outcome in these fractures to allow a meaningful comparison between reported treatment methods.

Management of comminuted fractures of the distal radius in the adult. Conservative or surgical?

Displaced fractures of the distal radius are difficult to treat successfully by traditional nonoperative methods. The goal in the management of these fractures is to achieve extraarticular alignment and an articular step off of less than 2 mm. Cast immobilization has been supplemented with pins and plaster technique and external fixators. Percutaneous are limited open reduction techniques, combined with wrist arthroscopy, have been shown to be useful in the management of intraarticular distal radius fractures. Despite these advances, there are still a significant number of fractures in which the articular surface cannot be reconstructed without open reduction and internal fixation. The main objective is to restore articular integrity as perfectly as possible. Attention to meticulous surgical technique will facilitate good results. When articular restoration cannot be accomplished, early arthrodesis or arthroplasty should be indicated. In the absence of osteoarthritis, intraarticular osteotomy can be used for intraarticular malunions with a step off greater than 2 mm. Radius malalignment usually requires a dorsal opening wedge osteotomy, insertion of a corticocancellous graft, and a dorsal buttress plate. Early recognition and treatment of distal radioulnar joint injuries associated with fractures of the distal radius are paramount to reduce the incidence of painful sequelae and functional deficits.

Fractures of the clavicle in the adult. Epidemiology and classification

From 1988 to 1994 a consecutive series of 1000 fractures of the adult clavicle was treated in the Orthopaedic Trauma Clinic of the Royal Infirmary of Edinburgh. In males, the annual incidence was highest under 20 years of age, decreasing in each subsequent cohort until the seventh decade. In females, the incidence was more constant, but relatively frequent in teenagers and the elderly. In young patients, fractures usually resulted from road-traffic accidents or sport and most were diaphyseal. Fractures in the outer fifth were produced by simple domestic falls and were more common in the elderly. A new classification was developed based on radiological review of the anatomical site and the extent of displacement, comminution and articular extension. There were satisfactory levels of inter- and intraobserver variation for reliability and reproducibility. Fractures of the medial fifth (type 1), undisplaced diaphyseal fractures (type 2A) and fractures of the outer fifth (type 3A) usually had a benign prognosis. The incidence of complications of union was higher in displaced diaphyseal (type 2B) and displaced outer-fifth (type 3B) fractures. In addition to displacement, the extent of comminution in type-2B fractures was a risk factor for delayed and nonunion.

[Indications and results of shoulder prosthetics in complex proximal humerus fractures]

Complex fractures of the proximal humerus are uncommon injuries and a therapeutic challenge to the orthopaedic surgeon. Successful treatment requires proper evaluation of the patient and analysis of standardized high-quality radiographs. The trauma series of radiographs (including true anteroposterior and lateral views in the scapular plane, and axillary view) is essential for accurate fracture assessment. Generally, joint-preserving reconstructive techniques are emphasized, aiming at restoration of the anatomy of the proximal humerus. In young individuals with excellent quality of the bone fragments, careful techniques of reduction and fixation, avoiding additional surgical devascularization, should be performed, even in case of possible impairment of the vascular supply to the humeral head. In elderly individuals with osteoporotic bone and limited compliance throughout aftercare, humeral head replacement may be indicated less restrictively. In the latter group hemiarthoplasty generally can be expected to result in painfree shoulders. However, recovery of function and range of motion are much less predictable.

Resection of the radial head after Mason type-III fractures of the elbow: follow-up at 16 to 30 years

We reviewed 21 patients with Mason type-III fractures of the radial head treated by resection, evaluating the results at 16 to 30 years by a standard questionnaire and clinical and radiological examination of the elbow and wrist. Seventeen patients had an excellent result, three were good and one fair. Resection of the radial head is a satisfactory method of treatment of such fractures. Prosthetic replacement seems to be indicated only when there is valgus instability of the elbow.

Open book (AP compression) pelvis fracture

A simple pelvic fracture classification is presented based on the metaphor of a pelvis as a book. Resuscitative fluid and blood requirements can be estimated by knowledge of the pelvic fracture pattern. Open book (AP compression) pelvis fractures generally have the largest amounts of blood loss.

Seinsheimer's classification of subtrochanteric fractures. Poor reproducibility of 4 observers' evaluation of 50 cases

We examined the reliability of the Seinsheimer classification of subtrochanteric fractures of the femur. 50 consecutive anteroposterior and lateral radiographs were assessed independently by 4 observers twice with a 6-week interval. The interobserver variation was large; only 13 of the 50 fractures were classified identically by all 4 observers. The intraobserver variation showed identical classification in 26-37 of 50 radiographs. When assessing only whether the fracture was subtype 3A or not, the 4 observers agreed in 31 of 50 radiographs. We conclude that the Seinsheimer classification has no value in clinical practice.

A simple means of demonstrating skull fractures using radiographic altered image geometry

Multiple comminuted fractures distributed around a skull and resulting from repeated weapon impacts were poorly demonstrated on conventional lateral and upper frontal radiographs. This was due to superimposition of contralateral fractures, normal anatomy and tangential projection angles. Simple modification of a standard dental x-ray generator and manipulation of projection geometry allowed isolation of individual fractures with improved image quality. The above technique lends itself to cases in which soft tissue remains to obscure the detail of multiple fractures during clinical observation.

[4-fragment fractures of the proximal humerus. Alternative strategies for surgical treatment]

The operative treatment of dislocated fractures of the proximal humerus has been evolving in recent years. Replacement using endoprostheses often results in only moderate functional outcome, and with the high risk of aseptic necrosis with ORIF, new methods of minimally invasive stabilisation have been developed. These methods reduce the opening of the fracture site to a minimum and thereby limit the risk of iatrogenic damage to local vascularity and the rotator cuff. This study reviewed 18 patients operated on with minimal osteosynthesis for dislocated four-part fractures of the proximal humerus from March 1991 to October 1994. Only tension band wiring with resorbable cords from woven polydioxanone was applied. After an average follow-up of 26 months (20-37 months), 72% (n = 13) of the four-part fractures were rated as good and very good results according to the Neer Score. In 16.7%, a complete head necrosis occurred, requiring a prosthetic replacement. Two patients with partial necrosis (11.1%) had a good functional outcome. With regard to these results, we recommend head-preserving tension band wiring with resorbable cords and preservation of the articular surface. At the present time the procedure seems comparable with prosthetic replacement in respect of shoulder function.

Fractures of the distal radius and ulna

Associated fractures of the distal ulnar metaphysis were present in 19 of 320 distal radial fractures requiring either closed manipulation or surgical treatment over a 2-year period. Four morphological patterns of ulnar fracture were encountered, the commonest being the type 1 simple extra-articular fracture of the distal end of ulna with minimal comminution (eight out of 19). 15 patients were treated conservatively and two each were treated by internal and external fixation. 15 patients were reviewed after a mean follow-up of 23.8 months and there were four excellent, five good, five fair clinical results and one poor result. Radiographically the distal radio-ulnar joint (DRUJ) was normal in eight wrists, but longitudinal or horizontal disruption of the DRUJ was present in seven wrists. Fracture callus encroached on the DRUJ in three patients, who also had limitation of forearm rotation. Two comminuted ulnar fractures (type 4) developed non-union, but both patients had full forearm rotation, in contrast to restriction of forearm rotation in four out of five patients with type 1 fractures.

Operative treatment of acute displaced intra-articular calcaneus fractures

A retrospective study of 18 operatively treated calcaneal fractures was conducted. The fractures were all type II and type III fractures according to the classification system of Crosby et al. The average follow-up was 32 months and consisted of subjective and objective criteria. The findings were compared with the results of nonoperative treatment reported by Crosby et al. The findings suggests that type II fractures have a similar outcome when either operative or nonoperative treatment is used. Type III fractures, however, fared considerably better with operative intervention when compared with those treated with nonoperative techniques.