Best of Both Worlds? Fixation of Distal Femur Fractures with the Nail-Plate Construct

OBJECTIVES

Distal femoral fractures are a significant injury sustained by low- and high-energy trauma. Common treatment practices are lateral locking plate or intramedullary nail fixation, with disadvantages including risk of non and malunion and limited post-operative weightbearing status. Combining both techniques as a nail-plate construct (NPC) theoretically achieves enhanced fixation to allow immediate weightbearing. The aim of this study is to examine radiographic union, malunion and patient-reported outcomes in distal femur NPC fixation.

METHODS

Single-center retrospective study including all patients >18 years who sustained distal femur fractures treated with NPC. Primary outcomes were radiographic union, malunion and patient reported outcome measures at minimum 1-year follow-up. Secondary outcome measures included post-operative mobility, length of stay and complications. Relevant variables of normality are reported as mean with standard deviation. Subgroup analysis of patients aged <65 and ≥65 years are provided.

RESULTS

Sixteen patients were included in the study. Rate of radiographic union was 100%. There was no case of malunion. All patients were allowed to bear full weight immediately post-operatively. Mean length of stay was 9.50 days, with 37.5% of patients discharged directly home. The majority (85.7%) of patients returned to pre-injury mobility. Early post-operative complications occurred in three patients. Three patients returned to theater. The mean EQ-5D-5L index value was 0.713, with 71.4% describing no problems with self-care and 85.7% reporting no or slight problems with usual daily activities.

CONCLUSION

The NPC provided stable fixation permitting full weightbearing post-operatively with no cases of non or malunion. Return to pre-injury mobility and activity are encouraging. Based on these results we support the use of nail-plate construct fixation in the management of distal femur fractures.

Biomechanical Performance of Total Wrist Arthrodesis Plates With and Without Arthrodesis of the Carpometacarpal Joint

BACKGROUND

It is unknown whether total wrist arthrodesis (TWA) should be performed with or without arthrodesis of the carpometacarpal joint (CMCJ). The aim of this study is to compare CMCJ-spanning TWA plates using 3D printed wrist arthrodesis model with and without arthrodesis of the CMCJ.

METHODS

Total wrist arthrodesis plates mounted to 3D printed models were tested under a 4-N bending load at 4 Hz for 50 000 cycles, increased by 15% every 10 000 cycles until failure.

RESULTS

Plates with arthrodesis CMCJ were stiffer and failed at a significantly greater load and number of cycles than plates mounted to models without CMCJ arthrodesis. The Synthes stainless steel locking TWA plate performed better than the Trimed plate applied to the model without CMCJ arthrodesis and the Acumed plate applied to the model with CMCJ arthrodesis. Based on these findings, we recommend arthrodesis of the CMCJ in TWA.

CONCLUSIONS

Incorporation of the CMCJ in TWA may protect against plate failure. If arthrodesis of the CMCJ is not performed, plate removal should be considered before breakage occurs.

LEVEL OF EVIDENCE

IV.

Plating vs Closed Reduction for Fractures in the Distal Radius in Older Patients: A Secondary Analysis of a Randomized Clinical Trial

Importance

Distal radius fractures are common and are managed with or without surgery. Current evidence indicates surgical treatment is not superior to nonsurgical treatment at 12 months.

Objective

Does surgical treatment for displaced distal radius fractures in patients 60 years or older provide better patient-reported wrist pain and function outcomes than nonsurgical treatment at 24 months?

Design, Setting, and Participants

In this secondary analysis of a combined multicenter randomized clinical trial (RCT) and a parallel observational study, 300 patients were screened from 19 centers in Australia and New Zealand. Of these, 166 participants were randomized to surgical or nonsurgical treatment. Participants who declined randomization (n = 134) were included in the parallel observational group with the same treatment options and follow-up. Participants were followed up at 3, 12, and 24 months by a blinded assessor. The 24-month outcomes are reported herein. Data were collected from December 1, 2016, to December 31, 2020, and analyzed from February 4 to October 21, 2021.

Interventions

Surgical treatment consisting of open reduction and internal fixation using a volar-locking plate (VLP group) and nonsurgical treatment consisting of closed reduction and cast immobilization (CR group).

Main Outcomes and Measures

The primary outcome was patient-reported function using the Patient-Rated Wrist Evaluation (PRWE) questionnaire. Secondary outcomes included health-related quality of life, wrist pain, patient-reported treatment success, patient-rated bother with appearance, and posttreatment complications.

Results

Among the 166 randomized and 134 observational participants (300 participants; mean [SD] age, 71.2 [7.5] years; 269 women [89.7%]), 151 (91.0%) randomized and 118 (88.1%) observational participants were followed up at 24 months. In the RCT, no clinically important difference occurred in mean PRWE scores at 24 months (13.6 [95% CI, 9.1-18.1] points for VLP fixation vs 15.8 [95% CI, 11.3-20.2] points for CR; mean difference, 2.1 [95% CI, -4.2 to 8.5]; P = .50). There were no between-group differences in all other outcomes except for patient-reported treatment success, which favored VLP fixation (33 of 74 [44.6%] in the CR group vs 54 of 72 [75.0%] in the VLP fixation group reported very successful treatment; P = .002). Rates of posttreatment complications were generally low and similar between treatment groups, including deep infection (1 of 76 [1.3%] in the CR group vs 0 of 75 in the VLP fixation group) and complex regional pain syndrome (2 of 76 [2.6%] in the CR group vs 1 of 75 [1.3%] in the VLP fixation group). The 24-month trial outcomes were consistent with 12-month outcomes and with outcomes from the observational group.

Conclusions and Relevance

Consistent with previous reports, these findings suggest that VLP fixation may not be superior to CR for displaced distal radius fractures for patient-rated wrist function in persons 60 years or older during a 2-year period. Significantly higher patient-reported treatment success at 2 years in the VLP group may be attributable to other treatment outcomes not captured in this study.

Trial Registration

ANZCTR.org Identifier: ACTRN12616000969460.

Increased orthopaedic presentations as a result of COVID-19-related social restrictions in a regional setting, despite local and global trends

BACKGROUND

The coronavirus (COVID-19) pandemic has affected the utilisation of emergency department (ED) services worldwide. The aim of this study was to assess the impact of COVID-19-related public health measures on orthopaedic presentations to a regional Australian hospital.

METHODS

A case-control study was performed at a regional trauma hospital in New South Wales (NSW), Australia. Data was collected prospectively from patients that required orthopaedic review in the period corresponding to a declaration of a global pandemic to the end of the NSW lockdown, and compared with retrospective data from the corresponding period in 2019. The five-year average of orthopaedic presentations to ED during the study period were obtained for comparison. The primary outcomes were overall number of presentations, mechanism and anatomical location of injuries, operative versus non-operative management and disposition.

RESULTS

During the study period in 2020, presentations requiring orthopaedic review were significantly more frequent than 2019 (496 vs. 280, p < 0.0001), with more requiring admission in 2020 (p < 0.0001). The absolute number of patients managed operatively was higher (p = 0.0002) and significantly more patients were referred for community follow-up (p < 0.0001). There was a 20% increase of consults in 2020 compared to the average number of referrals during the same period in the previous five years.

CONCLUSIONS

Contrary to other published literature, lockdown conditions imposed during the COVID-19 pandemic resulted in a surprising 77% increase in orthopaedic presentations to this regional Australian hospital. These findings can be used to better direct resources, preparation and staff education in the current and for future pandemics.

Surgical Plating vs Closed Reduction for Fractures in the Distal Radius in Older Patients: A Randomized Clinical Trial

Importance

The burden of injury and costs of wrist fractures are substantial. Surgical treatment became popular without strong supporting evidence.

Objective

To assess whether current surgical treatment for displaced distal radius fractures provided better patient-reported wrist pain and function than nonsurgical treatment in patients 60 years and older.

Design, Setting, and Participants

In this multicenter randomized clinical trial and parallel observational study, 300 eligible patients were screened from 19 centers in Australia and New Zealand from December 1, 2016, until December 31, 2018. A total of 166 participants were randomized to surgical or nonsurgical treatment and followed up at 3 and 12 months by blinded assessors. Those 134 individuals who declined randomization were included in a parallel observational cohort with the same treatment options and follow-up. The primary analysis was intention to treat; sensitivity analyses included as-treated and per-protocol analyses.

Intervention

Surgical treatment was open reduction and internal fixation using a volar-locking plate (VLP). Nonsurgical treatment was closed reduction and cast immobilization (CR).

Main Outcomes and Measures

The primary outcome was the Patient-Rated Wrist Evaluation score at 12 months. Secondary outcomes were Disabilities of Arm, Shoulder, and Hand questionnaire score, health-related quality of life, pain, major complications, patient-reported treatment success, bother with appearance, and therapy use.

Results

In the 300 study participants (mean [SD] age, 71.2 [7.5] years; 269 [90%] female; 166 [81 VLP and 85 CR] in the randomized clinical trial sample and 134 [32 VLP and 102 CR] in the observational sample), no clinically important between-group difference in 12-month Patient-Rated Wrist Evaluation scores (mean [SD] score of 19.8 [21.1] for VLP and 21.5 [24.3] for CR; mean difference, 1.7 points; 95% CI -5.4 to 8.8) was observed. No clinically important differences were found in quality of life, wrist pain, or bother at 3 and 12 months. No significant difference was found in total complications between groups (12 of 84 [14%] for the CR group vs 6 of 80 [8%] for the VLP group; risk ratio [RR], 0.53; 95% CI, 0.21-1.33). Patient-reported treatment success favored the VLP group at 12 months (very successful or successful: 70 [89%] vs 57 [70%]; RR, 1.26; 95% CI, 1.07-1.48; P = .005). There was greater use of postoperative physical therapy in the VLP group (56 [72%] vs 44 [54%]; RR, 1.32; 95% CI, 1.04-1.69; P = 0.02).

Conclusions and Relevance

This randomized clinical trial found no between-group differences in improvement in wrist pain or function at 12 months from VLP fixation over CR for displaced distal radius fractures in older people.

Trial Registration

http://anzctr.org.au identifier: ACTRN12616000969460.

Radiation Exposure in Patients with Isolated Limb Trauma: Acceptable or Are We Imaging Too Much?

The aim of our study was to investigate the cumulative effective dose of radiation resulting from medical imaging in orthopaedic patients with isolated extremity trauma. Deidentified radiology records of consecutive patients without age restriction with isolated extremity trauma requiring operative treatment at a regional hospital were reviewed retrospectively over a 1-year period, and the effective dose per patient for each study type of plain film X-ray, computed tomography, and operative fluoroscopy was used to calculate cumulative effective dose. Values were summarised as mean, ± standard deviation, maximum, and proportion with overdose (>20 mSv). The study cohort included 428 patients (193 male and 235 female) with an average age of 44 years (±28). There were 447 procedures performed, i.e., all involved operative fluoroscopy, 116 involved computed tomography, and 397 involved X-ray. The mean cumulative effective dose per patient was 1.96 mSv (±4.98, 45.12). The mean cumulative effective dose for operative fluoroscopy was 0.32 mSv (±0.73, 5.91), for X-ray was 1.12 mSv (±3.6, 39.23) and for computed tomography was 2.22 mSv (±4.13, 20.14). The mean cumulative effective dose of 1.96 mSv falls below the recommended maximum annual exposure of 20 mSv. This study can serve as a guide for informing clinicians and patients of the acceptable radiation risk in the context of isolated extremity trauma.

A Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly (CROSSFIRE): a statistical analyses plan

Background

We are performing a combined randomised and observational study comparing internal fixation to non-surgical management for common wrist fractures in older patients. This paper describes the statistical analysis plan.

Methods/design

A Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly (CROSSFIRE) is a randomised controlled trial comparing two types of usual care for treating wrist fractures in older patients, surgical fixation using volar locking plates and non-surgical treatment using closed reduction and plaster immobilisation. The primary aim of this comparative-effectiveness study is to determine whether surgery is superior to non-surgical treatment with respect to patient-reported wrist function at 12 months post treatment. The secondary outcomes include radiographic outcomes, complication rates and patient-reported outcomes including quality of life, pain, treatment success and cosmesis. Primary analysis will use a two-sample t test and an intention-to-treat analysis using the randomised arm of the study. Statistical analyses will be two-tailed and significance will be determined by p < 0.05. Sensitivity analyses will be conducted to assess for differences in intention-to-treat, per-protocol and as-treated analyses. Sensitivity analyses will also be conducted to assess selection bias by evaluating differences in participants between the randomised and observational study arms, and for bias relating to any missing data. An economic analysis will be conducted separately if surgery is shown to provide superior outcomes to a level of clinical significance.

Discussion

This statistical analysis plan describes the analysis of the CROSSFIRE study which aims to provide evidence to aid clinical decision-making in the treatment of distal radius fractures in older patients.

Trial registration

CROSSFIRE was approved by The Hunter New England Human Research Ethics Committee (HNEHREC Reference No: 16/02/17/3.04). Registered on 22 July 2016 with The Australian and New Zealand Clinical Trials Registry (ANZCTR Number; ACTRN12616000969460).

This manuscript is based on v.11 of the statistical analysis plan. A copy of v.11, signed by the chief investigator and the senior statistician is kept at the administering institution.

Screw placement is everything: Risk factors for loss of reduction with volar locking distal radius plates

AIM

To determine factors correlated with postoperative radial shortening in patients with distal radius fractures treated with volar locking distal radius plates.

METHODS

A total of 250 patients with a distal radius fracture stabilised with volar locking plates between January 2010 and December 2014 were included in a multicentre retrospective cohort study. We measured the distance of the distal locking screws to the joint line immediately postoperatively and then measured radial shortening after six to eight weeks using the change in ulnar variance.

RESULTS

Multivariate linear regression analysis showed that there was a significant linear association between the distance of the screws from the joint line and radial shortening. No other patient, injury, or treatment-related characteristic significantly influenced radial shortening in multivariate analysis.

CONCLUSION

Distal locking screws should be placed as close as possible to the subchondral joint line to prevent postoperative loss of reduction.

A combined randomised and observational study of surgery for fractures in the distal radius in the elderly (CROSSFIRE)-a study protocol

Fractures of the distal radius are common and occur in all age groups. The incidence is high in older populations due to osteoporosis and increased falls risk. Considerable practice variation exists in the management of distal radius fractures in older patients ranging from closed reduction with cast immobilisation to open reduction with plate fixation. Plating is currently the most common surgical treatment. While there is evidence showing no significant advantage for some forms of surgical fixation over conservative treatment, and no difference between different surgical techniques, there is a lack of evidence comparing two of the most common treatments used: closed reduction and casting versus plating. Surgical management involves significant costs and risks compared with conservative management. High-level evidence is required to address practice variation, justify costs and to provide the best clinical outcomes for patients.

METHODS AND ANALYSIS

This pragmatic, multicentre randomised comparative effectiveness trial aims to determine whether plating leads to better pain and function and is more cost-effective than closed reduction and casting of displaced distal radius fractures in adults aged 60 years and older. The trial will compare the two techniques but will also follow consenting patients who are unwilling to be randomised in a separate, observational cohort. Inclusion of non-randomised patients addresses selection bias, provides practice and outcome insights about standard care, and improves the generalisability of the results from the randomised trial.

ETHICS AND DISSEMINATION

CROSSFIRE(Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly) was reviewed and approved by The Hunter New England HREC (HNEHREC Reference No: 16/02/17/3.04). The results of the trial will be published in a peer-reviewed journal and will be disseminated via various forms of media. Results will be incorporated in clinical recommendations and practice guidelines produced by professional bodies.

REGISTRATION

CROSSFIRE has been registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR: ACTRN12616000969460).

U-type bilateral sacral fracture with spino-pelvic dissociation caused by epileptic seizure

Sacral fracture with spino-pelvic  dissociation is a rare and unstable injury caused by high-energy trauma, often with serious haemodynamic and neurological implications. Diagnosis is easily delayed or missed as it is often masked by severe associated injuries. Here, we present an unusual case of spino-pelvic dissociation sustained during a seizure episode in a young epileptic patient on long-term anticonvulsant therapy with previous thoracolumbar spinal arthrodesis. This unique case brings to light the need for clinicians to consider sacral fractures in patients presenting with low back pain with no preceding trauma who otherwise may have risk factors for pathological fractures.

Volar locking distal radius plates show better short-term results than other treatment options: A prospective randomised controlled trial

AIM

To compare the outcomes of displaced distal radius fractures treated with volar locking plates and with immediate postoperative mobilisation with the outcomes of these fractures treated with modalities that necessitate 6 wk wrist immobilisation.

METHODS

A prospective, randomised controlled single-centre trial was conducted with 56 patients who had a displaced radius fracture were randomised to treatment either with a volar locking plate (n = 29), or another treatment modality (n = 27; cast immobilisation with or without wires or external fixator). Outcomes were measured at 12 wk. Functional outcome scores measured were the Patient-Rated Wrist Evaluation (PRWE) Score; Disabilities of the Arm, Shoulder and Hand and activities of daily living (ADLs). Clinical outcomes were wrist range of motion and grip strength. Radiographic parameters were volar inclination and ulnar variance.

RESULTS

Patients in the volar locking plate group had significantly better PRWE scores, ADL scores, grip strength and range of extension at three months compared with the control group. All radiological parameters were significantly better in the volar locking plate group at 3 mo.

CONCLUSION

The present study suggests that volar locking plates produced significantly better functional and clinical outcomes at 3 mo compared with other treatment modalities. Anatomical reduction was significantly more likely to be preserved in the plating group. Level of evidence: II.

Treatment of distal femur fractures in a regional Australian hospital

AIM: To review our outcomes and compare the results of the Less Invasive Stabilization System (LISS) to other implants for distal femur fracture management at a regional Australian hospital.

METHODS: The LISS is a novel implant for the management of distal femur fractures. It is, however, technically demanding and treatment results have not yet been assessed outside tertiary centres. Twenty-seven patients with 28 distal femur fractures who had been managed surgically at the Mackay Base Hospital from January 2004 to December 2010 were retrospectively enrolled and assessed clinically and radiologically. Outcomes were union, pain, Lysholm score, knee range of motion, and complication rates.

RESULTS: Twenty fractures were managed with the LISS and eight fractures were managed with alternative implants. Analysis of the surgical techniques revealed that 11 fractures managed with the LISS were performed according to the recommended principles (LISS-R) and 9 were not (LISS-N). Union occurred in 67.9% of fractures overall: 9/11 (82%) in the LISS-R group vs 5/9 (56%) in the LISS-N group and 5/8 (62.5%) in the alternative implant group. There was no statistically significant difference between pain, Lysholm score, and complication rates between the groups. However, there was a trend towards the LISS-R group having superior outcomes which were clinically significant. There was a statistically significant greater range of median knee flexion in the LISS-R group with compared to the LISS-N group (P = 0.0143) and compared with the alternative implant group (P = 0.0454).

CONCLUSION: The trends towards the benefits of the LISS procedure when correctly applied would suggest that not only should the LISS procedure be performed for distal femur fractures, but the correct principle of insertion is important in improving the patient’s outcome.

More is not necessarily better. A biomechanical study on distal screw numbers in volar locking distal radius plates

INTRODUCTION

Currently available volar locking plates for the treatment of distal radius fractures incorporate at least two distal screw rows for fixation of the metaphyseal fragment and have a variable-angle locking mechanism which allows placement of the screws in various directions There is, however no evidence that these plates translate into better outcomes or have superior biomechanical properties to first generation plates, which had a single distal screw row and fixed-angle locking. The aim of our biomechanical study was to compare fixed-angle single-row plates with variable-angle multi-row plates to clarify the optimal number of locking screws.

MATERIALS AND METHODS

Five different plate-screw combinations of three different manufacturers were tested, each group consisting of five synthetic fourth generation distal radius bones. An AO type C2 fracture was created and the fractures were plated according to each manufacturer's recommendations. The specimens then underwent cyclic and load-to-failure testing. An optical motion analysis system was used to detect displacement of fragments.

RESULTS

No significant differences were detected after cyclic loading as well as after load-to-failure testing, neither in regard to axial deformation, implant rigidity or maximum displacement. The fixed-angle single-row plate showed the highest pre-test rigidity, least increase in post-testing rigidity and highest load-to-failure rigidity and least radial shortening. The radial shortening of plates with two distal screw rows was 3.1 and 4.3 times higher, respectively, than that of the fixed-angle single-row plate.

CONCLUSION

The results of our study indicate that two distal screw rows do not add to construct rigidity and resistance against loss of reduction. Well conducted clinical studies based on the findings of biomechanical studies are necessary to determine the optimal number of screws necessary to achieve reproducibly good results in the treatment of distal radius fractures.

Adherence to Canadian C-Spine Rule in a regional hospital: a retrospective study of 406 cases

INTRODUCTION

Cervical spine radiography may be over-utilised in an emergency department setting. The Canadian C-Spine Rule has been developed to reduce unnecessary radiography. Our aim was to retrospectively determine the proportion of cervical spine radiographs requested through the emergency department for trauma patients that were clinically indicated, according to the Canadian C-Spine Rule.

METHODS

This was a cross-sectional survey conducted at a regional centre in Northern Queensland, Australia. All cervical spine radiographs for trauma, performed at the Mackay Base Hospital from 1 January 2009 to the 31 December 2009, were reviewed. The relevant patient charts were audited for evidence of indications for radiography.

RESULTS

Of 406 patients in the study, 155 patients (38%) (95% confidence interval 33.3%, 42.7%) had cervical spine imaging performed that was not indicated according to the Canadian C-Spine Rule. None of these patients had a significant cervical spine injury on radiography.

CONCLUSION

Applying the Canadian C-Spine Rule would have safely reduced the incidence of cervical spine radiography by 38%. This would also reduce costs, patient morbidity and radiation exposure.

Influence of screw diameter and number on reduction loss after plating of distal radius fractures

BACKGROUND

The current options for plate-screw combinations in volar locking distal radius plates used for the treatment of distal radius fractures are either plates with a single distal screw row or plates with multiple distal screw rows. Additionally, the screws themselves may have either fixed angle locking or polyaxial locking mechanisms. To date, there is no evidence or consensus regarding the optimal plate-screw combination. The aim of this study was to assess the biomechanical behaviour of different plate-screw combinations with respect to total distal screw number, number of distal screw rows and screw projection surface area of the most distal row.

METHODS

Biomechanical study to assess six different plating configurations in five different volar locking plate models in a Sawbone distal radius fracture model. The specimens were loaded with 800 Newton loads for 2.000 cycles at 1 Hz. After cyclic loading, load-to-failure testing was performed.

RESULTS

  With cyclical testing, there was a significant and positive correlation between rigidity and a greater projection area of the most distal screws. Dorsal tilting was significantly more pronounced in plate models with a lesser projection area of the most distal screws and a smaller number of distal screws. With load-to-failure testing, there was a significant increase in rigidity with increasing screw projection area of the most distal row and total number of distal screws.

CONCLUSIONS

Additional distal screw rows in volar locking distal radius plates might not add substantially to resistance against loss of reduction in the post-operative period.

Does single application of topical chloramphenicol to high risk sutured wounds reduce incidence of wound infection after minor surgery? Prospective randomised placebo controlled double blind trial

OBJECTIVE

To determine the effectiveness of a single application of topical chloramphenicol ointment in preventing wound infection after minor dermatological surgery.

DESIGN

Prospective randomised placebo controlled double blind multicentre trial.

SETTING

Primary care in a regional centre in Queensland, Australia.

PARTICIPANTS

972 minor surgery patients.

INTERVENTIONS

A single topical dose of chloramphenicol (n=488) or paraffin ointment (n=484; placebo).

MAIN OUTCOME MEASURE

Incidence of infection.

RESULTS

The incidence of infection in the chloramphenicol group (6.6%; 95% confidence interval 4.9 to 8.8) was significantly lower than that in the control group (11.0%; 7.9 to 15.1) (P=0.010). The absolute reduction in infection rate was 4.4%, the relative reduction was 40%, and the relative risk of wound infection in the control group was 1.7 (95% confidence interval 1.1 to 2.5) times higher than in the intervention group. The number needed to treat was 22.8.

CONCLUSION

Application of a single dose of topical chloramphenicol to high risk sutured wounds after minor surgery produces a moderate absolute reduction in infection rate that is statistically but not clinically significant. Trial registration Current Controlled Trials ISRCTN73223053.

Volar fixed-angle plating of distal radius extension fractures: influence of plate position on secondary loss of reduction--a biomechanic study in a cadaveric model

PURPOSE

Treatment of extension fractures of the distal radius with volar fixed-angle plates has become increasingly popular in the past 2 years. It has been observed clinically that placement of the distal screws as close as possible to the subchondral zone is crucial to maintain radial length after surgery. The purposes of this study were (1) to evaluate radial shortening after plating with regard to plate position and (2) to evaluate whether plate position has an influence on the strength and rigidity of the plate-screw construct.

METHODS

An extra-articular fracture (AO classification, A3) was created in 7 pairs of fresh-frozen human cadaver radiuses. The radiuses then were plated with a volar distal radius locking compression plate. Seven plates were applied subchondrally; 7 plates were applied 4.5 mm to 7.5 mm proximal to the subchondral zone. The specimens were loaded with 800-N loads for 2,000 cycles to evaluate radial shortening in the 2 groups. Each specimen then was loaded to failure.

RESULTS

Radial shortening was significantly greater when the distal screws were placed proximal to the subchondral zone. The amount of shortening after cyclic loading correlated significantly with the distance the distal screws were placed from the subchondral zone. Rigidity of the plate systems was significantly higher in radiuses in which the distal screws were placed close to the subchondral zone.

CONCLUSIONS

To maintain radial length after volar fixed-angle plating, placement of the distal screws as subchondral as possible is essential. The subchondral plate-screw-bone constructs showed significantly greater rigidity, indicating higher resistance to postoperative loads and displacement forces.

Osteosynthesis of distal radial fractures with a volar locking screw plate system

We developed a locking screw plate system for the stabilisation of distal radial fractures, which can be inserted through a standard volar approach and in which the locking mechanism allows early post-operative mobilisation. Forty-nine patients with 50 fractures underwent surgical treatment; 66% were type C fractures. The mean follow-up was 26 months. According to the scores of Gartland and Werley and Green and O'Brien, 92% and 68% respectively had an excellent or good outcome; 46% were radiologically identical to the uninjured side and in 42% the reduction remained unchanged after 2 years. The most frequent complication was rupture of the flexor pollicis longus tendon, which occurred in six cases (12%) at a mean of 10 months after operation.

[The treatment of severe head-brain injuries in Austria]

INTRODUCTION

We performed this study in order to assess epidemiology and current practice of treatment of severe traumatic brain injury in Austria. Our survey followed the methods of a study published by J. Ghajar et al in the USA in 1995 and we compared the results to the Brain Trauma Foundation's "Guidelines For The Management Of Severe Head Injury".

METHODS

The collected data represent answers to telephone interviews of 60 surgical intensive care units. We were able to evaluate data from all departments which treat severe brain traumas (Glasgow Coma Scale < or = 8) in Austria.

RESULTS

At the time the treatment modalities of severe head injuries are not homogeneous and there are also big interdisciplinary management differences (trauma surgeons versus neurosurgeons).

CONCLUSIONS

Results showed that there is a need for a brain trauma databank in Austria. We also recommend formation of an interdisciplinary brain trauma working group in order to control whether guidelines and standardized therapeutic modalities are being followed.