Dissociating advances in orthopaedic trauma management from the climbing patient expectations

Clinical Outcomes and Management Strategies for Capitellum and Trochlea Fractures: A Systematic Review

Purpose

Capitellum and trochlea fractures, also referred to as coronal shear fractures of the distal humerus, are infrequent yet challenging intra-articular fractures of the elbow. There are a variety of surgical approaches and fixation methods with often variable outcomes. This systematic review investigates interventions, outcomes and complications of capitellum and trochlea fractures.

Methods

A systematic review of studies published in MEDLINE, EMBASE, Web of Science and Cumulative Index to Nursing and Allied Health literature (CINAHL) was conducted to assess the clinical outcomes of capitellum and trochlea fractures managed surgically. Data on patient demographics, surgical approach, implant usage, postoperative outcomes and complications were compiled.

Results

Forty-one studies met the inclusion criteria with a total of 700 patients. Surgical interventions primarily utilized either the lateral (79%) or antero-lateral (15%) approaches with headless compression screws as the most common fixation method (68%). Clinical outcomes were measured using the Mayo Elbow Performance Index (MEPI) with a mean score of 89.9 (±2.6) and the DASH score with a mean of 16.9 (±7.3). Elbow range of motion showed a mean flexion of 126.3° (±19.4), extension of 5.71° (±11.8), pronation of 75.23° (±12.2), and supination of 76.6° (±9.8). The mean flexion-extension arc was 113.7° (±16.9), and the mean pronation-supination arc was 165.31° (±9.41). Complications occurred in 19.8% of cases, with re-interventions required in 8.3% of cases, mainly due to symptomatic implants and elbow stiffness requiring surgical release. Other complications included implant removal (10.4%), overall reported stiff elbows (6%), nerve palsies (2%), non-union (1.5%), and infection (1.2%).

Conclusion

The treatment of capitellum and trochlea fractures yields satisfactory outcomes but has a considerable rate of complications and reoperations primarily due to symptomatic implants and elbow stiffness. There is noteworthy variability in the achieved range of motion, suggesting unpredictable outcomes. Deficits in functionality and range of motion are common after surgery, especially with more complex injury patterns.

Interlocking intramedullary nail for forearm diaphyseal fractures in adults-A systematic review and meta-analysis of outcomes and complications

PURPOSE

The purpose of this systematic review is to examine the outcomes, complications, and potential advantages of using anatomical interlocking intramedullary nails (IMN) in the treatment of radius and ulnar shaft diaphyseal fractures in adults.

METHODS

Medline, Embase, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched between January 2000 and January 2023. Studies meeting criteria were observational or randomized controlled trials evaluating outcomes in IMN for adult diaphyseal forearm fractures. Standardized data extraction was performed and a quality assessment tool was used to evaluate individual study methodology. Descriptive statistics for interventions, functional outcomes, and complications were reported. Meta-analysis was performed for patient-reported outcome measures and operative time.

RESULTS

A total of 29 studies involving 1268 patients were included with 764 (60%) undergoing IMN, 21% open reduction and internal fixation (ORIF), and 9% hybrid fixation. There was no significant difference between groups in DASH and Grace-Eversmann scores. Operative time was significantly shorter in IMN compared with ORIF. The DASH scores were: 13.1 ± 6.04 for IMN, 10.17 ± 3.98 for ORIF, and 15.5 ± 0.63 in hybrids. Mean operative time was 65.3 ± 28.7 in ORIF and 50.8 ± 17.7 in IMN. Complication rates were 16.7% in the IMN group, 14.9% in ORIF, and 6.3% in hybrid constructs. There were 11 cases of extensor pollicis rupture in the IMN group. Average IMN pronation and supination were 78.3° ± 7.9° and 73° ± 5.0°, respectively. Average ORIF pronation and supination was 82.15° ± 1.9° and 79.7° ± 4.5°, respectively.

CONCLUSIONS

Similar functional outcomes and complication rates along with shorter operative times can be achieved with IMN compared with ORIF. The use of IMN is promising, however, higher quality evidence is required to assess appropriate indications, subtle differences in range of motion, implant-related complications, and cost-effectiveness. Trail Registration PROSPERO (International Prospective Register of Systematic Reviews) (ID: CRD42022362353).

LEVEL OF EVIDENCE III

The association between lower limb fractures and weight gain in adults: a prospective analysis of body mass index trends

PURPOSE

Despite understanding the connection between obesity and fracture risk, there is limited research on the implications of lower limb fractures on subsequent changes in body mass index (BMI). Our study aimed to assess the impact of lower limb fractures on BMI alterations over an 18-month period.

METHODS

A multi-center, prospective cohort study was conducted between January 2021 to June 2023, involving 494 adults with lower limb fractures. Participants were recruited within 2 weeks post-injury and were assessed for demographics, injury details, and weight at seven distinct time points. By 18 months, the primary outcome was the mean weight gain.

RESULTS

The average age of the participants was 39 (± 12.7) with a baseline weight and BMI of 80.4 kg and 27.6, respectively. At the 18-month follow-up, 75% of patients experienced an average weight increase in 4 kg (± 5.39 kg), equating to a BMI rise of 1.39 (± 1.88). Most patients attributed weight changes to their injury, with nearly half expressing distress from their weight change. Only 37% believed that they had resumed their previous activity levels by the final follow-up. Approximately 31% of the patients sought some form of external weight management care in the form of nutritionist advice, training programs, medication and weight management procedures.

CONCLUSIONS

Lower limb fractures significantly affect weight gain over an 18-month period, with substantial psychological and physical consequences. Healthcare providers should anticipate potential weight gain post-fracture and incorporate strategies addressing both physical and mental aspects of rehabilitation to enhance recovery outcomes. Early and even immediate weight bearing may play a pivotal role in mitigating weight changes and returning the patient to their previous level of activity. Further detailed studies focusing on different fractures and postoperative interventions are recommended.

Operative treatment of distal radius fractures involving the volar rim-A systematic review of outcomes and complications

PURPOSE

Distal radius fractures involving the volar rim are a subset of unstable and extremely distal fractures involving the volar lunate and/or scaphoid facets. Volar rim fractures (VRF) are challenging to manage and different treatment options have been described. This study aimed to compare outcomes and assess the rates of complications and implant removal for different treatment methods of wrist fractures involving VRF.

METHODS

A systematic review of studies published in MEDLINE, EMBASE, Web of Science and Cumulative Index to Nursing and Allied Health literature (CINAHL) was conducted to assess the operative outcomes of VRF. Data on patient demographics, implant usage, postoperative outcomes, complications, and implant removal were compiled.

RESULTS

Twenty-six studies met the inclusion criteria with a total of 617 wrists. The most commonly used implants were 2.4 mm variable-angle volar rim plate (DePuy Synthes) (17.5%), Acu-Loc II (Acumed) (14%) and standalone hook plates (13%). The average outcome measures were Q-DASH (10.9 ± 7), MWS (85.8 ± 7.5), PRWE (15.9 ± 12.1), and DASH (14 ± 8.5). The overall complication rate was 14% (n = 87), with 44% (n = 38) involving flexor tendon problems. The implant removal rate was 22%, with routine removal being performed in 54% and non-routine removal in 46% of cases.

CONCLUSION

The current treatment of VRF yields favorable functional outcomes across different treatment options. However, these fractures have a high rate of complications and re-interventions, particularly for symptomatic implants.

LEVEL OF EVIDENCE

Therapeutic IV.

Successful nonoperative treatment of a closed posteromedial ankle dislocation without associated fractures - a case report

Pure ankle dislocations occurring in the absence of malleolus fractures are extremely rare injuries. These injuries often present with high-energy trauma and ligamentous injury. Comprehensive research is not available due to the rarity of the injury. However, recent literature has supported treatment by nonoperative means. This case report aims to discuss a similar case and offer insight into the prognosis of such injuries.

Case presentation

A previously healthy 26-year-old male was diagnosed with a closed posteromedial ankle dislocation without associated fractures. Reduction was performed under procedural sedation and confirmed with postreduction radiographs. The patient was immobilized and scheduled for serial follow-up in the outpatient department. Weight bearing was gradually introduced at 6 weeks along with physiotherapy. The American Orthopedic Foot and Ankle Score was 90 and 100 at 6 months and 1 year follow-up, respectively. Return to sports was possible at 1 year postinjury. Range of motion was normal apart from a 5-8° ankle dorsiflexion deficit. Radiographs, computed tomography, and MRI were unremarkable with longer term follow-up.

Conclusion

Patients who sustain pure ankle dislocations with an intact distal tibiofibular syndesmosis can expect favorable outcomes with immobilization, splinting, and gradual rehabilitation, as evident by the high American Orthopedic Foot and Ankle Score and the time to return to sports. This case report serves to provide prognostic information and anticipate outcomes in patients with similar injuries.

Intraoperative arthrography favorably impacts the early outcome of operatively managed fractures of the lateral humeral condyle displaced 1-5 mm in children

BACKGROUND

Controversy exists surrounding the optimal approach to managing pediatric lateral humeral condyle fractures (LHCF). The difficulty in assessing the articular surface using radiography and the intra-articular element potentially involved make LHCF susceptible to complications and delayed diagnoses. Arthrography has been used to delineate the articular surface to aid in deciding whether closed or open reduction is necessary. However, there has been scarce evidence to determine the accuracy of using radiography versus arthrography to predict articular disruption in LHCF displaced 1-5 mm. This study assesses; (1) the utility of intraoperative arthrography in modifying the method of operative reduction, (2) the accuracy of plain radiography in identifying articular integrity, and (3) the clinical outcomes of early operative treatment.

METHODS

This was a single-center prospective study that involved operatively treated pediatric LHCF with a displacement of 1-5 mm. Patient demographics, radiographic displacement, predicted radiographic articular integrity, articular integrity on arthrograms, modification of management and follow-up clinical outcomes were obtained.

RESULTS

A total of 72 patients were included with a mean displacement of 2.6 mm and a mean follow-up of 16 months. The articular surface was disrupted in 21% of patients. The reduction method (open versus closed) was modified in 15 patients (21%) after an intraoperative arthrogram. Out of 25 patients with displacement < 2 mm, four of which (15%) had disrupted articular surface and were subsequently treated with open reduction internal fixation (ORIF). While eleven patients with > 4 mm displacement had an intact articular hinge that were managed with closed reduction and percutaneous pinning (CRPP). All patients achieved union with no documented major complications. The ability of radiography to discriminate between disrupted/ intact articular integrity decreases as displacement decreases.

CONCLUSIONS

Data from this study suggest using the degree of displacement measured on plain radiography is insufficient in predicting articular integrity for fractures displaced 1-5 mm. The use of arthrography guides reduction method and adequacy, avoiding scenarios of unnecessary open reduction and insufficient closed reduction. Further, a significant amount of outliers exist that have intact articular hinges above 4 mm and disrupted hinges below 2 mm of displacement. Finally we report favorable outcomes using a lower threshold for early operative treatment.