The use of external fixation in fractures of the tibial pilon

The authors report the results of a review of 25 cases of fracture of the tibial pilon, treated by external fixation and minimal internal synthesis. Fractures were classified according to Rüedi and Allgower; they were: type 2: 11 (of which one exposed); type 3: 4 (of which 6 exposed). Complications observed during treatment were: pseudarthrosis: 1; osteomyelitis: 2; healing in valgus at 10 degrees: 2; osteolysis of the distal screws of the fixator: 4; these were all resolved with further surgery, except for an osteomyelitis that required amputation. Follow-up ranged from 3 to 10 years and clinical and functional evaluation, based on the Olerud and Molander score system revealed 80% good (56%) and excellent (24%) results.

Bone fracture fixation

This article reviews the anatomy, physiology and biomechanics of bone and describes various types of fractures. It discusses the comparative advantages of different imaging techniques for fracture diagnosis and the radiographic characteristics of some common fractures. The article concludes with a description of fixation techniques and the role of imaging after treatment.

In vitro biomechanical properties of 2 compression fixation methods for midbody proximal sesamoid bone fractures in horses

OBJECTIVE

To evaluate 2 methods of midbody proximal sesamoid bone repair--fixation by a screw placed in lag fashion and circumferential wire fixation--by comparing yield load and the adjacent soft-tissue strain during monotonic loading.

STUDY DESIGN

Experimental study.

SAMPLE POPULATION

10 paired equine cadaver forelimbs from race-trained horses.

METHODS

A transverse midbody osteotomy of the medial proximal sesamoid bone (PSB) was created. The osteotomy was repaired with a 4.5-mm cortex bone screw placed in lag fashion or a 1.25-mm circumferential wire. The limbs were instrumented with differential variable reluctance transducers placed in the suspensory apparatus and distal sesamoidean ligaments. The limbs were tested in axial compression in a single cycle until failure.

RESULTS

The cortex bone screw repairs had a mean yield load of 2,908.2 N; 1 limb did not fail when tested to 5,000 N. All circumferential wire repairs failed with a mean yield load of 3,406.3 N. There was no statistical difference in mean yield load between the 2 repair methods. The maximum strain generated in the soft tissues attached to the proximal sesamoid bones was not significantly different between repair groups.

CONCLUSIONS

All repaired limbs were able to withstand loads equal to those reportedly applied to the suspensory apparatus in vivo during walking.

CLINICAL RELEVANCE

Each repair technique should have adequate yield strength for repair of midbody fractures of the PSB immediately after surgery.

Complications after treatment of tibial pilon fractures: prevention and management strategies

Complications after treatment of tibial pilon fractures can occur intraoperatively or in the early or late postoperative period. Perioperative complications include malreduction, inadequate fixation, and intra-articular penetration of hardware, all of which may be minimized by preoperative planning and meticulous operative technique. Wound complications can lead to deep infection, with potentially catastrophic consequences. The incidence of wound complications may be lessened by delaying surgery 5 to 14 days, until the posttraumatic swelling has subsided. Temporary fixation with a medial spanning external fixator is recommended if definitive internal fixation is delayed. Fracture blisters should be left undisturbed until the time of surgery. Incisions through blood-filled blisters should be avoided whenever possible. Limited incisions to achieve reduction and fixation should be made directly over fracture sites, to minimize soft-tissue stripping. An indirect reduction technique involving the use of ligamentotaxis and low-profile small-fragment implants that minimize tension on the incision should be used. Late complications, such as stiffness and posttraumatic arthritis, correlate with the severity of the initial injury and the accuracy of reduction. Loss of ankle motion can be minimized by early range-of-motion exercise after stable fixation has been achieved. Posttraumatic ankle arthrosis should be initially treated with anti-inflammatory medication, activity modification, and walking aids. Symptomatic patients often require an ankle arthrodesis.

[Treatment of multiple ribs fractures]

Of 267 patients with multiple fractures of the ribs, 69 patients had mobile costal valves. As a rule, the presence of the floatable chest wall site, is a cause of increasing respiratory failure ending in lethal outcome in 40 to 80% of cases. Indications for combined conservative therapy and its scope are specified and efficiency of different methods of restoration the chest wall frame is evaluated. The technique of pericostal ligature fixation of the mobile costal valves to the thorax splint offered by the authors was improved. The performance of this manipulation may be essentially easier thanks to the use of the device for passing ligature around the ribs and breast bone, which was developed by the authors and patented in Russian Federation. Clinical application of the developed technique allows rather quickly to control respiratory failure. The lethality tell 6 times in comparison with patients who were treated with the use of the other methods of the floatable costal valves fixation.

FRACAS: a system for computer-aided image-guided long bone fracture surgery

This article describes FRACAS, a computer-integrated orthopedic system for assisting surgeons in performing closed medullary nailing of long bone fractures. FRACAS's goal is to reduce the surgeon's cumulative exposure to radiation and surgical complications associated with alignment and positioning errors of bone fragments, nail insertion, and distal screw locking. It replaces uncorrelated, static fluoroscopic images with a virtual reality display of three-dimensional bone models created from preoperative computed tomography and tracked intraoperatively in real time. Fluoroscopic images are used to register the bone models to the intraoperative situation and to verify that the registration is maintained. This article describes the system concept, software prototypes of preoperative modules (modeling, nail selection, and visualization), intraoperative modules (fluoroscopic image processing and tracking), and preliminary in vitro experimental results to date. Our experiments suggest that the modeling, nail selection, and visualization modules yield adequate results and that fluoroscopic image processing with submillimetric accuracy is practically feasible on clinical images.

[The functional treatment of transcondylar and epicondylar fractures of the humerus in children]

Functional treatment of 275 children with epicondylar and transcondylar fracture of shoulder bone with II-IV degree dislocation was done. The conventional method of functional treatment was applied using dissected in articulation ulnaris plaster bandage, the Blaunt bandage and the elaborated method using the external fixation apparatuses--hinge-rotational apparatus (HRA). The highest efficacy of functional treatment using HRA was noted.

Centralization of ulna for infected nonunion of radius with extensive bone loss. A modified Hey-Groves procedure

We describe a case of infected nonunion of the radius with extensive bone loss in an 11-year-old boy treated by centralization of the ulna. The technique used differs from the original Hey Groves procedure in that it preserves the distal end of the ulna with its important triangular fibrocartilage complex, thereby retaining stability and contour of the wrist joint. Our patient obtained a functionally and cosmetically satisfactory, stable forearm and wrist. We present the technique as a useful armament in the management of extensive bony defect of the radius arising from trauma or infection.

Percutaneous and limited open fixation of fractures of the distal radius

Percutaneous and limited open fixation of fractures of the distal radius is an important method of treatment for many unstable fractures such as unstable dorsal bending fractures, shearing fractures of the radial styloid and lunate facet, and simple articular fractures. The quality of the reduction is monitored with image intensification and the tactic of the reduction is based on manipulation of the fracture fragments by longitudinal traction, percutaneous manipulation, and in some instances by direct manipulation through small incisions. The role of arthroscopy remains uncertain and may represent an alternative to open exposure of the articular surface in some patients although bone grafting may be necessary in patients with fractures with significant metaphyseal defects.

Missile injuries of the knee joint

The results of the treatment of missile injuries of 170 knees in 162 patients are analyzed. The injuries were caused by infantry weapon missiles in 52(32.1%) and by fragments of mine or explosive devices in 110(67.9%) patients. The most frequent were penetrating injuries of the joint with multifragment fractures which in 15.8% cases were associated with injuries of the neurovascular bundle. Stabilization of bone fragments was required in 111(65.3%) knees. Stabilization was done by external fixation in 42(37.8%) and by plaster of Paris in 69(62.2%) knees. Additional mini osteosynthesis was required in 13(30.9%) knees stabilized by external fixation and in 3(4.3%) knees stabilized by plaster of Paris. Amputations were performed in 13(7. 6%) injured knees. During the postoperative period local and general complications occurred in 27(16.6%) patients. The most frequent local complications were suppurative articular infections requiring repeated surgery. Soft tissue defect covering was necessary in 53(33. 1%) patients. The poor late results were present in missile fractures of the knee. The most frequent were degenerative changes with bone defects. The possible surgical solutions in such cases are arthrodesis or total endoprosthesis implantation.

Percutaneous treatment of carpal, metacarpal, and phalangeal injuries

Percutaneous fixation of hand fractures is a common technique that takes advantage of the subcutaneous nature of hand bones, their small size, and their limited loading potential for stress placed on hardware. Percutaneous wire fixation supplements cast fixation when plaster cannot hold particular reductions, and allow surgical fixation with limited postoperative swelling. In the first part of the current study, the types of wires that are used for hand fixation, fluoroscopy, helpful instruments, and the basic techniques used for this type of surgery are discussed. In the second part of the study, specific fixation techniques for different fractures of the carpals, metacarpals, and phalanges are outlined.

Pilon fractures. Treatment protocol based on severity of soft tissue injury

One hundred seven pilon fractures in 107 patients were treated according to a staged prospective protocol. All pilon fractures were stabilized immediately by the application of calcaneal traction. Open fractures or fractures in patients with multiple injuries were stabilized with traveling traction that was applied in the operating room. A distraction computed tomography scan was obtained before definitive treatment. Treatment groups were based on the degree of soft tissue compromise. Forty-one patients with Tscherne Grade 0 or Grade I injuries underwent open reduction and internal fixation (open plating) using contemporary techniques and low-profile implants. Sixty-four patients with Tscherne Grade II and Grade III closed injuries and all patients with open fractures underwent definitive treatment with limited open reduction and stabilization using small wire circular external fixators. Clinical and radiographic evaluations were performed at an average 4.9 years after injury. For all fracture types (AO classification), 81% of the patients who were treated with external fixation and 75% of the patients who were treated with open plating had good or excellent results. For severe fracture patterns (Type C), patients in both groups had significantly poorer results than patients with Types A and B fractures. The patients in the open plating group had a significantly higher rate of nonunion, malunion, and severe wound complications compared with the patients who received external fixation for Type C fracture patterns. Because of the increased incidence of bony and soft tissue complications when treating open or closed Type C fractures, use of limited exposures and stabilization with small wire circular external fixators is recommended.

A review of 100 cases of supracondylar fractures in children seen in Ibadan

Supracondylar fracture of the humerus in children is one of the commonest fractures in children of school age all over the world. The experience of the mode of presentation, mechanism of injury and the different modalities of treatment in the University College Hospital, Ibadan is presented. The results suggest that severely displaced supracondylar fractures in this environment are better managed with open reduction and internal fixation.

Percutaneous fixation of proximal humeral fractures

The purpose of the current study is to evaluate the technique of closed reduction and percutaneous pinning of proximal humeral fractures and to determine whether this technique provides enough stability to permit early active range of motion and subsequent fracture healing. Fractures were classified according to Neer et al and were included if the surgical or anatomic neck were angulated greater than 45 degrees, separation between fragments was greater than 1 cm, or the greater tuberosity was displaced more than 0.5 cm. There were 21 Type II, 16 Type III, and four Type IV fractures. Fractures were pinned using distally threaded Dynamic Hip Screw guide pins, 2-mm Kirschner wires, or 2.5-mm distally threaded Schantz pins. Patients were evaluated for union rates and motion. Assessment was made using the Modified American Shoulder and Elbow Surgeons Form. Thirty-six patients with 37 fractures were available for review with followup averaging 40 months (range, 12-68 months). All patients with Neer Type IV fractures did not respond to fixation and three had avascular necrosis develop, irrespective of the type of pin used. In the remaining 33 patients with Neer Type II and Type III fractures, a union rate of 94% was observed at an average of 2.6 months. All patients had good functional results. In the current series, there were no failures using Schantz pins. There was a 20% failure rate with Dynamic Hip Screw pins (2% if the patients with Type IV fractures were excluded) and a 100% failure rate with Kirschner wires. Stable fixation with early motion and subsequently good results can be obtained using percutaneous fixation in patients with Type II and Type III fractures; however, terminally threaded pins must be used and smooth Kirschner wires must be avoided. Percutaneous fixation cannot be recommended in patients with Type IV fractures.

Evidence-based analysis of odontoid fracture management

Object

The management of odontoid fractures remains controversial. Evidence-based methodology was used to review the published data on odontoid fracture management to determine the state of the current practices reported in the literature.

Methods

The Medline literature (1966–1999) was searched using the keywords “odontoid,” “odontoid fracture,” and “cervical fracture” and graded using a four-tiered system. Those articles meeting selection criteria were divided in an attempt to formulate practice guidelines and standards or options for each fracture type. Evidentiary tables were constructed by treatment type.

Ninety-five articles were reviewed. Five articles for Type I, 16 for Type II, and 14 for Type III odontoid fractures met selection criteria. All studies reviewed contained Class III data (American Medical Association data classification).

Conclusions

There is insufficient evidence to establish a standard or guideline for odontoid fracture management. Given the extent of Class III evidence and outcomes reported on Type I and Type III fractures, a well-designed case-controlled study would appear to provide sufficient evidence to establish a practice guideline, suggesting that cervical immobilization for 6 to 8 weeks is appropriate management. In cases of Type II fracture, analysis of the Class III evidence suggests that both operative and nonoperative management remain treatment options. A randomized trial or serial case-controlled studies will be required to establish either a guideline or treatment standard for this fracture type.

Hip fracture outcomes: quality of life and functional status in older adults living in the community

BACKGROUND

People who return to living in the community after a hip fracture are considered to have the best outcome. However, their quality of life (QOL) and its relationship with function over the longer term have not been fully assessed.

AIMS

This case control study of community dwelling subjects six to 12 months post hip fracture aims to investigate their QOL and functional independence.

METHOD

The Short Form-36 (SF-36) was utilised to measure QOL. The Modified Barthel Index (MBI), the Frenchay Activities of Daily Living Index (FAI), the Timed 'Up & Go' (TUG), and the Berg Balance Scale (Berg) were used to measure functionality.

RESULTS

Ninety-two subjects and 92 controls were recruited. Despite being age and gender matched, the hip fracture subjects scored significantly (p<0.05) worse than the controls in all measures of function. The fracture group was slower on the TUG (19 vs 10.5 seconds), had more difficulties with balance (46 vs 54 out of 56), and was less active and more dependent than the control group (FAI 24 vs 31 out of 42). The SF-36 has eight domains: physical function, role physical, bodily pain, mental health, role emotional, social function, general health and vitality. The control group had a higher (p<0.05) perception of their QOL in all domains.

CONCLUSION

The effects of impaired balance and mobility along with reduced functional and social independence are reflected in the diminished QOL perceived by the fracture group. This indicates that many do not return to their pre-fracture lifestyle.