The importance of adequate diagnosis of pediatric forearm bowing fractures: A case report

Introduction

Correct diagnosis of pediatric bowing fractures has proven to be challenging. Consequently, these entities are often underdiagnosed both at the initial presentation and at further follow-up. We present a case of an ulnar fracture with subsequent non-union and initially missed associated plastic deformity of the radius to highlight the importance of adequate diagnosis of bowing fractures and obtaining appropriate imaging in pediatric forearm trauma to prevent sequelae.

Case presentation

A 13-year old male sustained a diaphyseal fracture of the left ulna after a fall on the outstretched hand which was treated conservatively. A non-impact incident (push up on outstretched arm) 4.5 months after the initial trauma caused an ulnar fracture at the same location and was initially considered a simple refracture. Operative treatment was decided on due to significant clinical forearm valgus alignment. Intraoperatively however, a mobile non-union of the ulna was found and anatomic reduction was not possible due to radial bowing. Exploration of the radius showed a clear malalignment with periosteal callus reaction, indicative of a mal-union of the radial bone as a result of the initial injury. To correctly restore alignment, a closing wedge osteotomy of the radius was necessitated followed by plate and screw fixation of both the radius and the ulna.

Conclusion

In this patient, failure of recognizing the associated plastic deformity of the radius during the initial presentation led to radial malunion and non-union of the ulna. As a result of this complication, an osteotomy was necessary which probably could have been prevented if an adequate initial diagnosis had been made.

Mal-union of sustentaculum tali fracture with talo-calcaneal coalition leading to tarsal tunnel syndrome: A case report

Displaced isolated fractures of sustentaculum tali are rare. Inadequate treatment of these injuries can rarely lead to non-union or mal-union and in most cases are treated non-surgically. We report a unique case of undiagnosed mal-union of sustentaculum tali in the setting of underlying tarsal coalition that resulted in symptoms of tarsal tunnel. Osteotomy and excision of the mal-united fragment and coalition along with decompression of the tarsal tunnel was performed. The patient had immediate improvement in pain and the paraesthesia recovered by the end of 6 weeks post-operatively. The Foot and Ankle disability score (FADI) score improved from 26.0 pre-operatively to 96.2 at 3 years' follow-up. This case highlights that isolated fractures of sustentaculum tali warrant advanced imaging and surgical reduction and fixation may be appropriate to avoid long-term disability where displacement compromises the tarsal tunnel or function of the subtalar joint.

Plate vs. nail for extra-articular distal tibia fractures: How should we personalize surgical treatment? A meta-analysis of 1332 patients

BACKGROUND

Treatment for distal diaphyseal or metaphyseal tibia fractures is challenging and the optimal surgical strategy remains a matter of debate. The purpose of this study was to compare plate fixation with nailing in terms of operation time, non-union, time-to-union, mal-union, infection, subsequent re-interventions and functional outcomes (quality of life scores, knee- and ankle scores).

METHODS

A search was performed in PubMed/Embase/CINAHL/CENTRAL for all study designs comparing plate fixation with intramedullary nailing (IMN). Data were pooled using RevMan and presented as odds ratios (OR), risk difference (RD), weighted mean difference (WMD) or weighted standardized mean difference (WSMD) with a 95% confidence interval (95%CI). All analyzes were stratified for study design.

RESULTS

A total of 15 studies with 1332 patients were analyzed, including ten RCTs (n = 873) and five observational studies (n = 459). IMN leads to a shorter time-to-union (WMD: 0.4 months, 95%CI 0.1 - 0.7), shorter time-to-full-weightbearing (WMD: 0.6 months, 95%CI 0.4 - 0.8) and shorter operation duration (WMD: 15.5 min, 95%CI 9.3 - 21.7). Plating leads to a lower risk for mal-union (RD: -10%, OR: 0.4, 95%CI 0.3 - 0.6), but higher risk for infection (RD: 8%, OR: 2.4, 95%CI 1.5 - 3.8). No differences were detected with regard to non-union (RD: 1%, OR: 0.7, 95%CI 0.3 - 1.7), subsequent re-interventions (RD: 4%, OR: 1.3, 95%CI 0.8 - 1.9) and functional outcomes (WSMD: -0.4, 95%CI -0.9 - 0.1). The effect estimates of RCTs and observational studies were equal for all outcomes except for time to union and mal-union.

CONCLUSION

Satisfactory results can be obtained with both plate fixation and nailing for distal extra-articular tibia fractures. However, nailing is associated with higher rates of mal-union and anterior knee pain while plate fixation results in an increased risk of infection. This study provides a guideline towards a personalized approach and facilitates shared decision-making in surgical treatment of distal extra-articular tibia fractures. The definitive treatment should be case-based and aligned to patient-specific needs in order to minimize the risk of complications.

Patient care modifications and hospital regulations during the COVID-19 crisis created inequality and functional hazard for patients with orthopaedic trauma

PURPOSE

The COVID pandemic has decreased orthopaedic fracture operative intervention and follow-up and increased the use of virtual telemedicine clinics. We assessed the implications of this management on future orthopaedic practice. We also surveyed patient satisfaction of our virtual fracture follow-up clinics.

METHOD

We prospectively analysed 154 patients during two weeks of 'lockdown' assessing their management. We surveyed 100 virtual fracture clinic follow-up patients for satisfaction, time off work and travel.

RESULTS

Forty-nine percent of patients had decisions affected by COVID. Twelve percent of patients were discharged at diagnosis having potentially unstable fractures. These were all upper limb fractures which may go onto mal-union. Twenty-nine percent of patients were discharged who would have normally had clinal or radiological follow-up. No patients had any long-term union follow-up. Virtual telemedicine clinics have been incredibly successful. The average satisfaction was 4.8/5. In only 6% of cases, the clinician felt a further face-to-face evaluation was required. Eighty-nine percent of patients would have chosen virtual follow-up under normal conditions.

CONCLUSION

Lessons for the future include potentially large numbers of upper limb mal-unions which may be symptomatic. The non-union rate is likely to be the same, but these patients are unknown due to lack of late imaging. Telemedicine certainly has a role in future orthopaedic management as it is well tolerated and efficient and provides economic and environmental benefits to both clinicians and patients.

A comparative study of fixation methods in adults with two-thirds distal isolated ulnar shaft fractures with a minimum of 2 year follow-up

BACKGROUND

Adult isolated ulnar shaft fractures (IUSF) are rare. There remains a need to establish the best methods to manage these fractures. The aim of this study was to compare two forms of treatment for IUSF: intramedullary stabilization by k-wire (IMF) versus Open Reduction Internal Fixation by plating (ORIF), in order to identify differences in clinical (1) and radiological outcomes (2), as well as comparative costs (3).

HYPOTHESIS

The hypothesis of this study was assessing whether intramedullary stabilization was as feasible as plating in the treatment of isolated ulnar shaft fractures in clinical practice.

PATIENTS AND METHODS

A retrospective analysis was undertaken on patients diagnosed IUSF between January 2015 and March 2017 with a minimum of 2 years follow-up. They were treated with IMF (group 1) or ORIF (group 2). Demographic information, clinical outcomes and complications were collected. Cost, including implant cost, operative time, sterilization and inpatient stay were compared. Radiographs were reviewed to evaluate axial angulation, shortening, displacement and residual deformity.

RESULTS

54 patients with a mean age of 41.2 years were treated by IMF (27/54) and ORIF (27/54). The mechanism of injury included high-energy (55%) and low-energy falls (45%). AO/OTA 2018 fracture classification was simple (39/54), wedge (14/54) and complex (1/54). The locations were 37/54 (70%) distal third and 17/54 (30%) mid-shaft fractures. There was no significant difference pre and post-operatively between the 2 groups regarding radiologic criteria. 3 cases of non-union, 4 delay-union and 1 regional complex syndrome occurred in group 2. No complication was reported in group 1. The function determined by range of motion (ROM) at wrist and elbow was excellent in 72% (group 1) and 80% (group2), 18% satisfactory in group 1 and 20% in group 2. There was no difference for QuickDASH and pain. Implant removal was necessary in 70% of patients without sequelae in nailing, 11% after plating. Average operation time was 29 ± 5 min for ORIF and 18 ± 6 min for IMF. Total estimated cost per patient was 3678.4€ for IMF and 7051.9€ for ORIF.

CONCLUSIONS

Compared with ORIF, IMF significantly reduced the operation time and cost with lower complications.

TYPE OF STUDY

Retrospective study.

TYPE OF PROOF

Level 4.

Non-union in lateral locked plating for distal femoral fractures: A systematic review

INTRODUCTION

This study aims to identify patient and intra-operative factors that contribute to non-union in locked lateral plating for distal femoral fractures.

METHODS

Systematic searches of English-language articles in Ovid Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews were undertaken in February 2018 according to the PRISMA guidelines. The search terms were (fracture or fracture*) AND (distal femur or distal femoral) AND (malunion or non-union). Eligible studies published at any time reported non-union rates and compared patient and intraoperative factors in patients who underwent locked lateral plating for traumatic distal femoral fractures. The quality of included papers was assessed using The Journal of Bone and Joint Surgery levels of evidence (Wright et al., 2003), and further appraised using the Downs and Black score (Downs and Black, 1998).

RESULTS

Eight studies investigating 1380 distal femoral fractures were found to satisfy the inclusion and exclusion criteria. These studies analysed a variety of patient and intra-operative factors that may contribute to non-union. These include high BMI, open fracture, comminution, fracture infection, stainless steel plate material, shorter working length, open reduction and internal fixation when compared with minimally invasive plate osteosynthesis, high construct rigidity scores and purely locking screw constructs.

CONCLUSION

This review has identified multiple factors which potentially contribute to non-union including stainless steel plate material, high construct rigidity scores and purely locking screw constructs. These findings may reflect that overly rigid plating constructs can contribute to non-union. However, they should be taken in the context of heterogeneity amongst included studies, with further research necessary to support these findings.

How well do we reduce ankle fractures intra-operatively: A retrospective 1 year review using Pettrone's criteria

INTRODUCTION

Ankle ORIF is a common orthopaedic procedure. Assessment of the reduction is often performed by 'eyeballing' the intra-operative images.

AIMS

This study aimed to assess the radiographic reduction of all ankle fracture ORIFs at COCH over a 1-year period using Pettrone's criteria METHOD: Using the trauma database at the COCH all patients admitted for ankle ORIF over a 1 year period (n = 284) were identified. Each patient was retrospectively reviewed, duplicates or non-ankle fractures excluded and data collected on: patient demographics, Lauge-Hansen classification, time from injury to theatre, level of primary surgeon, type of fixation, reduction of medial, lateral or posterior malleolar reduction, syndesmosis reduction, date and satisfaction at last clinic appointment and complications.

RESULTS

After exclusions 187 patients were included in the study. The average age of patients was 49 years old (14-93). The most common Lauge-Hansen fracture classifications were SER (51.6% (98)) and PER (29.9% (57)). Registrars were first surgeon in 49.7% (93) of cases. 80% (111 of 139) of medial malleoli were reduced, 90% of lateral malleoli were reduced 11% (21) had residual talar shift. The syndesmosis was reduced in 76.4% (143) of cases. 19% (36) had further operations. There were 35 major complications in 25 (13.4%) patients. Not all malposition of fracture fixation were in the same ankles, 34.2% (64) ankle ORIFs had residual deformity after being fixed.

CONCLUSION

The implications of this study are very important. The authors aim to raise awareness of Pettrone's radiographic criteria of a successful ORIF of the ankle and subsequently improve the mal-reduction rate of post-fixation ankle ORIF.

Functional Results of Unstable (Type 2) Distal Clavicle Fractures Treated with Superior Anterior Locking Plate

BACKGROUND

The treatment of distal clavicle fracture is always a challenge, as it is mostly unstable and has higher rate of delayed union, malunion, non-union and associated acromioclavicular arthritis. So the management of these fractures remains controversial. The purpose of this study is to evaluate the functional results of Type 2 distal end clavicle fractures treated with superior anterior locking plate.

METHODS

From June 2011 to August 2015 a retrospective study of12 male patients (mean age of 41.3 years) 11 with unilateral and 1 with bilateral distal clavicle fractures treated with superior anterior locking plate was done. They were evaluated at regular intervals with mean follow up of 14 months(12-18 months). Those with minimum one year follow up were included in our study. All were evaluated for the functioning of the shoulder joint by both Oxford shoulder score and Quick DASH scores, rate of bone union, complications and earliest time for return to work.

RESULTS

All fractures union seen within 6-8 weeks (mean time: 7.1 weeks). All had good shoulder range of motion. The average oxford shoulder and Quick DASH score were 46.2 and 6.5. There were no major complications in our study viz. non-union, plate failure, secondary fracture. But one patient had superficial wound infection. All patients returned to work within 3 months of postoperative period.

CONCLUSION

Displaced distal clavicle fractures treated with superior anterior locking plates achieved excellent results in terms of bony union with rarely any complications and demonstrate promising results with this novel technique.

An unfavourable outcome after periprosthetic fracture following metal-on-metal surface hip arthroplasty

We report a case of a varus malunited periprosthetic femoral neck fracture following metal-on-metal hip resurfacing operation. Failure to closely observe and poor compliance in the young and active group of patients may contribute to such an unfavourable outcome.