The external fixation in the treatment of humeral diaphyseal fractures: outcomes of 84 cases

The use of external fixation in the emergency department: applications, common errors, complications and their treatment

The use of an external fixator (EF) in the emergency department (ED) or the emergency theatre in the ED is reserved for critically ill patients in a life-saving attempt. Hence, usually only fixation/stabilization of the pelvis, tibia, femur and humerus are performed. All other external fixation methods are not indicated in an ED and thus should be performed in the operating room with a sterile environment.

Anterior EF is used in unstable pelvic lesions due to anterior-posterior compression, and in stable pelvic fractures in haemodynamically unstable patients.

Patients with multiple trauma should be stabilized quickly with EF.

The C-clamp has been designed to be used in the ED to stabilize fractures of the sacrum or alterations of the sacroiliac joint in patients with circulatory instability.

Choose a modular EF that allows for the free placement of the pins, is radiolucent and is compatible with magnetic resonance imaging (MRI).

Planning the type of framework to be used is crucial.

Avoid mistakes in the placement of EF.

Cite this article: EFORT Open Rev 2020;5:204-214. DOI: 10.1302/2058-5241.5.190029

Lateral External-fixation Adjacent to Radial Nerve

Introduction The aim of our study was to describe the injury pattern and outcomes of active-duty subjects that underwent humeral external fixation and to determine if the placement of external fixator pins outside of the radial nerve safe zones is correlated with injury to the radial nerve. Materials and methods We examined all US Service members treated with humeral external fixation at our facility from June 2005 through June 2015. The mechanism of injury, injury pattern, location of external fixation application, pre- and postoperative radial nerve function, presence or absence of radial nerve transection from injury or external fixation, anatomic location of pins in relation to the radial nerve safe zone, and final radial nerve outcomes were recorded. We defined the proximal safe zone as 5 cm distal to the acromion to 14.8 cm proximal to the lateral epicondyle, and we defined the distal safe zone as the proximal 70% of the transepicondylar width of the humerus when projected proximally from the lateral epicondyle. Results  For our study, 123 patients were identified over our date range, and 16 subjects were included with documentation regarding nerve function/injury characteristics, appropriate radiographs, and active duty status. Around 80% of injuries resulted from a blast mechanism, and 80% of injury patterns included either an intraarticular or open fracture. The radial nerve safe zone was violated in 15 of the 16 subjects (94%). The one subject with a safe construct did not sustain a nerve injury. Complete preoperative documentation on nerve function was only available for half of the subjects. Two of five subjects known to have intact function prior to external fixation had a postoperative neurologic deficit (40%). Of eight subjects with unknown radial nerve function prior to external fixation, seven subjects had full nerve function at the final follow up, and one subject had partial sensory function only. Of the three subjects with impaired preoperative radial nerve function, two made a full recovery, and the third recovered sensory function only. Around 50% of all subjects required medical retirement. Conclusion External fixation of upper extremity injuries in combat is rarely absolutely indicated, often results in the placement of pins outside of the radial nerve safe zone, and is associated with up to a 40% incidence of radial nerve injury.

External Fixation as a Definitive Treatment for Humeral Shaft Fractures: Radiographic and Functional Results With Analysis of Outcome Predictors

OBJECTIVES

To evaluate the results obtained using unilateral external fixation as a definitive treatment for humeral shaft fractures and to identify possible predictors of radiographic and functional outcomes.

DESIGN

Retrospective study.

SETTING

One large metropolitan hospital.

PATIENTS

A consecutive cohort of 107 patients who underwent external fixation for 109 humeral shaft fractures.

MAIN OUTCOME MEASURES

Union rate, time to fracture healing, and functional assessment with disabilities of the arm, shoulder, and hand questionnaire, Constant score, Mayo Elbow Performance Index, and return to prefracture sports activity at a minimum of 2 years after surgery. Comorbidities were evaluated using the Cumulative Illness Rating Scale. Multiple linear regression analysis was used to determine whether any explanatory variables were significantly associated with the outcomes.

RESULTS

The union rate in 109 humeral shaft fractures was 97.2% (106/109) at a mean of 99.2 days. Two patients (1.8%) had delayed union, and 1 patient (0.9%) did not achieve union. At the latest follow-up, the mean Constant score, Mayo Elbow Performance Index, and disabilities of the arm, shoulder and hand questionnaire score was 85.6, 97.4, and 7.4 points, respectively. All patients engaged in sports activities before fracture resumed a sport activity. At the multiple linear regression analysis, obesity was directly related to a delayed healing of fracture (P = 0.010) and comorbidity was the most important determinant of the functional outcomes at follow-up (P < 0.001).

CONCLUSIONS

These data support the use of unilateral external fixation as an effective therapeutic option in patients with humeral shaft fracture. Comorbidity as assessed by Cumulative Illness Rating Scale score is the most important determinant of functional outcomes.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Closed Humeral Fracture Complicated with Acute Hematogenous Osteomyelitis: A Case Report

Introduction:

Acute hematogenous osteomyelitis (AHO) has been noted mainly in open fractures injuring soft tissue immunological defenses and in immuneincompetent patients. Osteomyelitis complicating closed fractures in immunocompetent adult patients is, therefore, a rare clinical entity with scarce literature.

Case Report:

We report a case of primary Staphylococcus aureus bacterial infection of a closed, humeral shaft fracture occurring in a previously healthy 28-year-old male patient. The patient was involved in a motorcycle accident and was admitted to the surgical ward with a chest drain. While hospitalized, a peak of fever was noted, but no source was found. Diagnosis of the closed fracture infection was noted on primary open reduction and internal fixation (ORIF), and although the patient was treated with antibiotics, local osteomyelitis developed. Treatment including serial debridements utilizing gentamycin beads and an additional ORIF procedure until the full union was achieved. The patient regained full, painless, motion of the arm and shoulder.

Conclusion:

Although AHO complicating a closed fracture in immunocompetent adults is very rare, it should not be overlooked, and special attention should be sought in such cases. Meticulous debridement and rigid fixation are utmost for the eradication of infection and fracture union. Patients presenting with such infections should, therefore, be followed closely and treated promptly.

The treatment of distal third humeral diaphyseal fractures: Is there still a place for the external fixation?

INTRODUCTION

The treatment for humeral diaphyseal fractures is still controversial. The purpose of this study was to evaluate the clinical and radiographic outcomes of treating humeral distal third diaphyseal fractures by using external fixation technique.

MATERIALS AND METHODS

We retrospectively review 65 cases of diaphyseal humeral fractures (31 type A, 23 type B and 11 type C of the AO/OTA classification) treated with external fixation (Orthofix FAD small) between 2008 and 2013. The mean follow-up was 48 months (24-72 months). There were 12 open fractures; however, no cases of concomitant vascular injury were described. The transolecranic traction was always applied to promote partial reduction through ligamentotaxis. In case of interposition of soft tissues impeding reduction, a small incision was performed allowing mobilization of bone ends.

RESULTS

All fractures resulted healed at a mean of 11 weeks (range 9-13 weeks); the average time of removal of the external fixator was 88 days (range 65-95 days). At the last follow-up, the mean elbow flexion was 132.6° (Min 126°-Max 137°) and the mean elbow extension was 6.4° (Max 0°-Min 13°). The Cassebaum's index rated as excellent in 47.8 % (31 patients), good in 37 % (24 patients), fair in 9.2 % (6 patients) and poor in 6 % (4 patients). The mean DASH score at the final follow-up was 14.7 (range 0-33); 15 patients had a range score between 10 and 20, 43 had less than 10, and seven had more than 20. We observed three cases of superficial infections and two cases of acute radial nerve palsy recovered within 3 months.

CONCLUSION

According to the excellent clinical results and full rate of consolidation, we state external fixation as a valid option in the treatment of distal third humeral diaphyseal fractures.

Simultaneous bilateral "floating arm" of the humeri: an uncommon presentation of a rare complex injury and review of the literature

The timing of definitive fixation for simultaneous fractures of the humerus in polytrauma patient is controversial. We report on the management of a patient that sustained bilateral "floating arm" fractures of the humeri. When dealing with such injury patterns, it is important to always carry out stabilization of the humeral diaphysis first and afterwards to treat the sub-injury or over-injury fractures. Our patient healed after twelve weeks in both humeri. After seven years MEPS showed excellent and good results in the right and left arms, while UCLA scores proved excellent in both sides. We encountered no intraoperative and postoperative complications.

Complications and outcomes of minimally invasive percutaneous plating for proximal humeral fractures

BACKGROUND

The minimally invasive plate osteosynthesis (MIPO) technique using periarticular locking plates may be a good option for the repair of displaced proximal humeral fractures. However, axillary nerve complications related to this technique may be underestimated. The purpose of this study is to evaluate the outcomes of the minimally invasive plating, focusing on the complications.

METHODS

The records of 21 consecutive patients treated for proximal humerus fractures using the MIPO technique with locking plates were retrospectively reviewed. These patients were treated between March 2009 and March 2011 with a minimum one-year follow-up. The clinical function, complications, and radiological bony union were evaluated.

RESULTS

All of the patients, with one exception, showed at least 90 degrees of flexion and abduction at the shoulder joint six months postoperatively. The average Constant scores at three months, six months, and one year follow-ups were 74.0 (range, 62 to 90), 79.4 (range, 64 to 91), and 82.7 (range, 66 to 92), respectively. All of the patients achieved bony union within the average of 3.2 months (range, 2 to 6 months). There was one case of delayed union, one case of intra-articular screw penetration, and one case of axillary nerve paresis (incomplete injury), which did not completely recover during the one year of follow-up.

CONCLUSIONS

The MIPO technique using periarticular locking plates is a useful option for the treatment of selected cases of displaced proximal humeral fractures. However, nerve complications such as axillary nerve paresis should be considered along with implant-related complications when choosing patients for minimally invasive plating.

Enhanced wound healing associated with Sharpey's fiber-like tissue formation around FGF-2-apatite composite layers on percutaneous titanium screws in rabbits

BACKGROUND

Pin-tract infections are the most common complications of external fixation. To solve the problem, we developed a fibroblast growth factor-2 (FGF-2)-apatite composite layer for coating titanium screws. The purpose of this study was to elucidate the mechanism of the improvement in infection resistance associated with FGF-2-apatite composite layers.

METHOD

We analyzed FGF-2 release from the FGF-2-apatite composite layer and the mitogenic activity of the FGF-2-apatite composite layer. We evaluated time-dependent development of macroscopic pin-tract infection around uncoated titanium control screws (n = 10). Screws coated with the apatite layer (n = 16) and FGF-2-apatite composite layer (n = 16) were percutaneously implanted for 4 weeks in the medial proximal tibia in rabbits.

RESULTS

A FGF-2-apatite composite layer coated on the screws led to the retention of the mitogenic activity of FGF-2. FGF-2 was released from the FGF-2-apatite composite layer in vitro for at least 4 days, which corresponds to a period when 30% of pin-tract infections develop macroscopically in the percutaneous implantation of uncoated titanium control screws. The macroscopic infection rate increased with time, reaching a plateau of 80-90% within 12 days. This value remained unchanged until 4 weeks after implantation. The screws coated with an FGF-2-apatite composite layer showed a significantly higher wound healing rate than those coated with an apatite layer (31.25 vs. 6.25%, p < 0.05). The interfacial soft tissue that bonded to the FGF-2-apatite composite layer is a Sharpey's fiber-like tissue, where collagen fibers are inclined at angles from 30 to 40° to the screw surface. The Sharpey's Wber-like tissue is rich in blood vessels and directly bonds to the FGF-2-apatite composite layer via a thin cell monolayer (0.8-1.7 μm thick).

CONCLUSION

It is suggested that the enhanced wound healing associated with the formation of Sharpey's fiber-like tissue triggered by FGF-2 released from the FGF-2-apatite composite layer leads to the reduction in the pin-tract inflammation rate.

Novel 3D hexapod computer-assisted orthopaedic surgery system for closed diaphyseal fracture reduction

BACKGROUND

Long-bone fractures are very common in trauma centers. The conventional Arbeitsgemeindschaft fur Osteosynthesefragen (AO) technique contributes to most fracture healing problems, and external fixation technology also has several disadvantages, so new techniques are being explored.

METHOD

A novel hexapod computer-assisted fracture reduction system based on a 3D-CT image reconstruction process is presented for closed reduction of long-bone diaphyseal fractures. A new reduction technique and upgraded reduction device are described and the whole system has been validated.

RESULTS

Ten bovine femoral fracture models were used with random fracture patterns. Tests results were as follows: residual deviation 1.24 + 0.65 mm for the axial deflection, 1.19 + 0.37 mm for the translation, 2.34 + 1.79° for the angulation, and 2.83 + 0.9° for the rotation.

CONCLUSION

The reduction mechanism has the advantages of high positioning, reduction and computer accuracy, and intra-operative stability for both patients and surgical team. With further investigation, it could be applied in many kinds of long-bone diaphyseal fractures.