Functional and radiological results of percutaneous K-wire aided Métaizeau technique in the treatment of displaced radial neck fractures in children

OBJECTIVES

The aim of the present study was to determine the radiological and functional results and the efficiency of paediatric radial neck fracture fixation following reduction with the Métaizeau technique together with percutaneous K-wire applied under fluoroscopy to ensure minimum soft tissue damage.

METHODS

The study included 20 patients with Judet Type 3, Type 4a and Type 4b fractures operated on with the Métaizeau technique aided by percutaneous K-wire between 2007 and 2014. The mean age of the patients was 9.75 years (range, 4-13 years). Mean preoperative angulation was measured as 52.4° (range, 35°-85°). The average postoperative follow-up time was 34.65 months (range, 13-84) months. Postoperative radiological evaluations were made according to the Ursei classification and functional assessment with the Tibone - Stoltz classification system.

RESULTS

Radiologically, the difference between preoperative and postoperative radius head angulation was found statistically significant (p0.001). In the clinical assessment of injured and uninjured arms, there was no statistically significant difference between flexion-extension (p = 0.330) and supination-pronation range of motion (p = 0.330) and carrying angles (p = 0.094). According to the radiological Ursei evaluation, 17 (85%) patients were in perfect condition and 3 (15%) were good. In the classification of Tibone - Stoltz, 16 (80%) patients were evaluated as perfect, 3 (15%) as good and 1 (5%) as fair.

CONCLUSION

From the results of this study and related literature, the use of the Métaizeau technique in displaced radial neck fractures requiring surgical treatment in children can be recommended since it creates minimum damage to the soft tissue, is easy to apply and the results are satisfactory.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Analysis of the factors causing tight cast syndrome after closed reduction and casting of pediatric distal radius fractures

Objective

The aim of this study was to evaluate the most important factors which can cause “tight cast syndrome’’ (TCS) in pediatric patients with distal radius fractures.

Methods

Patients, who were at or under 15 years old and treated conservatively with an diagnosis of distal radius fracture between August 2015 and August 2017 were included in to the study. Fifty four patients, who had been found to experience TCS were accepted as group 1 and sixty-two patients without TCS as group 2. Cast index, pre-/post reduction translation, pre-/post reduction angulation, localization and displacement of the fracture, need for re-manipulation, and presence of associated distal ulna fracture were evaluated for both groups. Statistical analysis was performed to evaluate cut off value for cast index values for both TCS and loss of reduction and logistic regression analysis of the other possible factors.

Results

Pre-/post-reduction translation (over 50% and 10%, respectively) (odds ratios:0.167 and 0.524, respectively), a cast index value below than 0.775 (odds ratio:3.080), displaced type fracture (odds ratio:8.028), presence of re-manipulation (odds ratio:0.131) and associated distal ulna fracture (odds ratio:2.029) were found to be statistically significantly important for the occurrence of TCS. The most important factors were decreased cast index value and presence of initially displaced type fracture. Loss of reduction (LOR) risk was found to be increased in patients with a cast index value of greater than 0.875.

Conclusion

One should be very careful when following a pediatric patient who have a displaced distal radius fracture which has initial/post reduction translation in AP plane, which is associated with distal ulna fracture, which required re-manipulation and most importantly which cast index is under than 0.775 in terms of occurrence of TCS. We recommend obtaining a cast index value between 0.775 and 0.875 to prevent both TCS and LOR.

Level of evidence

Level III, Therapeutic study.

Corrective osteotomy for hyperextended elbow with limited flexion due to supracondylar fracture malunion

BACKGROUND

Extension deformity of the distal humerus after a malunited supracondylar fracture can restrict elbow flexion. Here we report a computer-assisted operative procedure and review the results of clinical cases in which corrective surgery was performed.

METHODS

The medical records of the patients who underwent corrective osteotomy for hyperextended elbow malunion of the distal humerus with limited elbow flexion (flexion angle ≤100°) were reviewed retrospectively. Osteotomy was performed using patient-specific instruments designed based on preoperative 3-dimensional computer simulation.

RESULTS

Three patients, a 55-year-old woman and two 12-year-old boys, met the inclusion criteria. The angles of hyperextension of the affected distal humerus were 29°, 29°, and 25°, respectively. The range of flexion/extension of the elbow motion in the first patient improved from 95°/25° preoperatively to 140°/-10° postoperatively, in the second patient from 100°/20° to 145°/5°, and in the third patient from 80°/25° to 140°/10°. Bone union was achieved in all patients. There were no major complications. The corrective operations not only improved elbow flexion but also increased the total range of motion in the elbow by rebuilding the anterior curve of the distal humerus.

CONCLUSIONS

Correction of the extension deformity of the distal humerus after a malunited supracondylar fracture is a reasonable option for patients older than 10 years with restricted elbow flexion. Preoperative computer simulation and the use of patient-specific instruments can be a useful alternative that enables accurate deformity correction and improves the total range of motion.

Malunited lateral condyle fracture of humerus with elbow dislocation: a diagnostic dilemma

Fracture of lateral condyle with dislocation of the elbow joint is rare in pediatric age. Diagnosis and management of these injuries could be a challenge. Delayed presentation of such injuries could be mistaken for a malunited supracondylar fracture of the humerus and treatment of these injuries remains controversial. We present 2 such cases, where the diagnosis of dislocation of elbow was missed at initial presentation and caused diagnostic confusion at late presentation. The problems faced in the diagnosis of these injuries and the management of late presenting cases are discussed.

[Talus fracture in a young woman with a dislocated ankle]

Talus fractures are rare but often associated with complications and significant post-traumatic patient morbidity. They frequently occur at high-energy traumas such as traffic accidents. This is a case report of a young woman who after a fall from a roof, presented in an emergency department with a dislocated ankle which was initially misdiagnosed as a bimalleolar fracture and attempted repositioned as such before X-ray. Dislocated talus fractures, however, need urgent anatomic reduction after diagnostic imaging and often subsequent and acute osteosynthesis.

[Osteotomy after Distal Radius Fractures - Five-Year Clinical and Radiological Outcomes]

PURPOSE OF THE STUDY The purpose of our retrospective study is to evaluate 5-year functional and radiological outcomes in patients following corrective osteotomy of the distal radius and ulnar osteotomy for malposition after a distal radius fracture, to identify differences in the outcomes of corrective osteotomies depending on the type of the original fracture according to the AO classification, the grade of arthritis of radiocarpal (RC) joint, surgical approach and the way of stabilisation of the osteotomy. MATERIAL AND METHODS The followed-up group of 22 patients (8 men and 14 women) underwent osteotomy for malposition of distal radius in the period 2007-2011. The age of patients in the followed-up group ranged from 21 to 72 years, with the mean age of 51 years at the time of surgery. The indications for corrective osteotomy due to distal radius deformity were the following: functional limitation, pain and radiological parameters confirming the deformity. The opening wedge osteotomy of distal radius performed through volar or dorsal approach, isolated shortening osteotomy of ulna and a combination of both the methods were used. The observations included: the original type of fracture according to AO/OTA classification, functional outcomes - Disabilities of the Arm Shoulder and Hand (DASH) score, Mayo Wrist Score (MWS), range of motion, grade of wrist arthritis and specific complications. The follow-up period was 5 years. RESULTS Average results were obtained in the group of patients before/after the osteotomy: DASH score- 35/14, MWS- 54/77, flexion- 44°/64°, dorsiflexion- 48°/61°, supination- 75°/79°, pronation- 72°/83°, ulnar duction- 20°/23°, radial duction- 9°/16°, grip strength in percentage- 59%/83%. After osteotomy, a statistically significant increase was observed in flexion, dorsiflexion, supination, pronation, radial duction, ulnar duction, grip strength in percentage, MWS, while in the DASH score a statistically significant decrease was reported. Based on the statistical evaluation of differences in functional outcomes after osteotomy, in patients with type A and C original distal radius fractures no difference in range of motion parameters was found after osteotomy. As to the mean values, the flexion and dorsiflexion range of motion was greater by 10° in patients after extra-articular osteotomy for malposition following the type A original fracture as compared to the type C fracture. By measuring the Joint Space High (JSH) ratio, no statistically significant changes were found regarding the progression of arthrosis of the radiolunate and radioscaphoid part of the RC joint as against the arthrosis in patients up to 5 years after corrective osteotomy of the distal radius. In patients with distal radius malposition and RC joint grade 1-2 arthritis according to the Knirk and Jupiter classification, better functional outcomes were achieved than in the limited and total wrist arthrodesis. In our patients, at 5 years after osteotomy no worsening was observed of the existing wrist arthritis and no arthritis was newly diagnosed. Specific complications were found in 4 cases (18.2 %). In 2 patients after radial osteotomy from dorsal approach (extensor tendon irritation, rupture of the long extensor tendon of the thumb), removal of osteosynthesis material was necessary in both the patients. In one patient after the isolated ulnar shortening osteotomy, an intraoperative fissure of distal ulnar fragment was detected, which healed without any further complications. In one patient an iatrogenic fracture of anterior superior iliac spine was observed after harvesting the corticospongious graft from the ala of the ilium. DISCUSSION Corrective osteotomy is a well-established method for treating distal radius deformities following a fracture. Even at present, there are various opinions regarding the indications, contraindications, timing of the surgery, osteotomy technique and the need to use a bone graft. Limited or total wrist arthrodeses in the area of wrist arthrosis and deformities bring good results with respect to the pain relief, but a limited range of motion occurs mainly in younger patients. Bearing this in mind, in grade 1-2 wrist arthritis in patients with distal radius deformities, a better functional outcome can be achieved by osteotomy. By using dorsal or volar approach, comparable outcomes can be obtained, but with the dorsal approach there is higher frequency of complications and the need to remove the osteosynthesis material. CONCLUSIONS Corrective osteotomies resulted in an improved functional outcome in the treatment of deformities after a distal radius fracture. Apart from deformity correction, the treatment has been affected also by the RC joint arthritis. The study confirmed neither statistically significant differences in the osteotomy outcomes in patients with the original type A or type C distal radius fracture according to the AO classification, nor the statistical significance of the RC joint arthritis. Our results have proven better functional outcomes of deformity correction achieved by osteotomy in case of grade 1 and 2 arthritis than by the limited wrist arthrodesis. In patients showing arthritic changes, no progression was reported within five years after the osteotomy. Key words: distal radius fracture, distal radius deformity, osteotomy, functional results.

Koebner phenomenon induced by failed revisional orthopedic surgery but remitted with bone union: A case report

RATIONALE

Trauma or surgical incision might cause Koebner phenomenon (KP) in patients with cutaneous diseases, but seldom studies reported KP induced by repeated orthopedic surgery.

PATIENT CONCERNS

The 22-year-old man did not have any prior histories of cutaneous diseases. Two months after the revision surgery for nonunion of the left femoral shaft fracture, KP was noted by psoriasis presented at the surgical scar, left thigh, scalp, and trunk. Phototherapy and topical treatments were prescribed but the effect was limited.

DIAGNOSIS

KP induced by failed revisional orthopedic surgery.

INTERVENTIONS

Because of implant failure, he underwent the second revision surgery, which was performed on the previous scar surrounded and covered by psoriatic plaques.

OUTCOMES

After the second revision surgery successfully corrected the orthopedic problem, the psoriatic lesion remitted along with the bone union.

LESSONS

In a patient having KP, to perform an operation on psoriatic lesion sites was safe and the surgical wound could heal well. The most important to treat KP induced by orthopedic surgery might be the underlying bone stability.

[Validation of the Osteomyelitis Diagnosis Score on the Basis of a Retrospective Analysis of 100 Patients with Non-Union of the Tibia]

Background: The accurate diagnosis of "osteomyelitis" is difficult and is often delayed. However, early and radical therapy of osteomyelitis is essential. The osteomyelitis diagnosis score (ODS) was developed to predict the probability of osteomyelitis. The aim of our study was to validate the ODS and to investigate its practicability in daily routine. Material and Methods: The ODS is based on five diagnostic procedures: 1. clinical history/risk factors, 2. clinical examination/laboratory results, 3. diagnostic imaging, 4. microbiology and 5. histopathology. Each diagnostic procedure includes numerous individual findings, which are rated with 1-6 points, depending on their relevance. If the sum of the five diagnostic criteria is ≥ 17 points, the diagnosis "osteomyelitis" can be viewed as safe, between 8-17 points as probable and between 2-7 points as possible. This retrospective study included 100 patients with non-union of the tibia (2002-2010). The patients were classified into two groups: septic non-union of the tibia (experimental intervention; gold standard: positive detection of bacteria and/or positive histology) and aseptic non-union of the tibia (control intervention; no detection of bacteria and/or histology). Epidemiological data, the score's total number of points and the number of points of the score's five diagnostic procedures were analysed. Results: 71 patients exhibited aseptic non-union of the tibia, 29 patients septic non-union. Patients with septic non-union obtained a mean of 20.8 points, and 24 at least 18 points; the diagnosis "osteomyelitis" is then presumed to be certain. Patients with aseptic non-union obtained a mean of 11.3 points, and only 3/71 patients received > 17 points. Both groups obtained the majority of points in the diagnostic procedure "clinical history". The difference between the two groups is highly significant (p < 0.001). The score's sensitivity is 82.8 %, with a specificity of 95.8 %. Conclusion: The ODS was proved to be a valid score. Patients with septic non-union were identified, even if bacteria were not detected. However, the use of the ODS is demanding, as there are 104 individual findings. Many of these individual findings were negative in all patients. It would be desirable to optimise ODS, by reducing the number of queried parameters, without reduction sensitivity.

Hamate hook nonunion initially mistaken for ulnar nerve compression: a case report with review of literature

BACKGROUND

Hamate hook (HH) stress fractures are rare, often presenting with misleading symptoms and easily overlooked/misdiagnosed. These fractures occur frequently in individuals participating in sports activities involving racquets, bats, or clubs. Symptoms are non-specific and often mimic other clinical conditions, such as ulnar nerve entrapment or ulnar vessel thrombosis.

CASE REPORT

A 17-year-old tennis player with no history of trauma presented with dominant hand weakness together with pain and paresthesia on the ulnar side, which exacerbated with tennis play. The patient was treated for ulnar nerve compression with activity cessation and rest for 2 months. After 6 months of persistent symptoms, the patient underwent open Guyon tunnel release, although preoperative electromyoneurography revealed no signs of nerve damage and bone scans showed a small area of increased uptake in the hypothenar region. Postoperatively, symptoms resumed and the patient reported to our department for a second opinion. Point tenderness over HH, hypothenar muscles hypotrophy, paresthesia, hand weakness and pain with ulnar deviation, and flexion of distal phalanges of the two ulnar fingers were observed. HH fracture was suspected. Computerized tomography scan revealed fractured HH and the patient underwent hook excision. One month postoperatively, the pain intensity reduced together with function and strength improvement; 2 months postoperatively, the patient was pain free and had returned to tennis.

CONCLUSIONS

In patients involved in racquet sports with hypothenar pain and paresthesia of the ulnar side of the hand, HH fracture should be suspected. Symptoms can mimic ulnar nerve entrapment and may lead to overlooking the correct diagnosis. Treatment of choice is fractured fragment excision.

Evaluation of three-dimensional scapular kinematics and shoulder function in patients with short malunion of clavicle fractures

BACKGROUND

The presence of short malunion of clavicle fractures could result in alterations in static scapular position and dynamic scapular motion. Nevertheless, no report has ever addressed the kinematic changes of the scapula in patients with short malunion of clavicular fractures. The goal of this study was to compare the changes of shoulder function, and the consequent scapular kinematic changes between the fractured side and the sound side of the shoulder in non-surgically treated patients.

METHODS

Fourteen patients with a short malunion (>10 mm) of midshaft clavicular fracture following conservative treatment were recruited. Outcome analysis included standard clinical follow-up, plain radiography, Shoulder Pain and Disability Index (SPADI) score, shoulder range of motion (ROM), shoulder muscle strength and scapular resting position. The 3-dimensional scapular motion during arm movement in the scapular plane was recorded using an electromagnetic tracking device. The kinematic changes between the fractured side and sound side were analyzed.

RESULTS

The mean shortening length of the clavicle was 12.9 ± 2.8 mm. The fractured sides showed a significantly higher SPADI score and limited ROM in both shoulder flexion and abduction. Significantly weaker shoulder external rotators (1.1 kg, p = 0.017) and lower trapezius (0.7 kg, p = 0.041) were found in the fractured sides when compared with the sound side. The fractured side exhibited significantly more forward shoulder (3.9 mm, p = 0.034) and slightly more anteriorly tilted scapula (5.8°, p = 0.094) in static scapular position. Scapular kinematics showed that the fractured side trended toward greater scapular internal rotation and smaller posterior tilt during arm elevation and lowering phases, especially after the arm rising above horizontal level.

CONCLUSIONS

This study showed that significant changes in scapular kinematics and shoulder function were found after short malunion of clavicle fractures. Recognition and evaluation of the changes could lead to a comprehensive framework regarding the treatment of shortened clavicle fractures.

Complications of Pediatric Elbow Fractures

Fractures about the elbow in children are common and varied. Both diagnosis and treatment can be challenging, and optimal treatment protocols continue to evolve with new research data. This article reviews common complications related to pediatric elbow fractures and presents recent literature to help guide treatment.

First mid-term results after cancellous allograft vitalized with autologous bone marrow for infected femoral non-union

BACKGROUND

Surgical treatment of infected femoral non-union is challenging. Only few reports exist including autologous bone grafting (ABG) from the iliac crest promoting union. Vitalized allogeneic bone grafting (VABG) is an alternative promoting osseous healing and reconstructing bone defects. VABG contains allogeneic cancellous bone, impregnated with autologous bone marrow puncture harvested from the iliac crest. Yet, no systematic trial exists summarizing the results of septic femoral non-union using VABG analyzing the infection eradication rate, rate of osseous integration with union, and osseous remodeling.

METHODS

In this prospective non-randomized cohort study, 18 patients treated by nailing or plating for femur fractures that subsequently developed a septic non-union were included. The surgical intervention included a standardized protocol by eradicating infection first, followed by implantation VABG to promote osseous union. Main outcome measurements were radiographic union and clinical parameters.

RESULTS

Mean follow-up was 5.9 years (range: 2-8 years). Infection eradication was achieved for all patients, while union was achieved in 15 out of 18 cases (83.3 %). Mean time for union took 16.9 weeks (range: 12-24). Radiographic analysis proved osseous remodeling and full integration of VABG within 12 months for 15 patients. No infection recurrence occurred at final follow-up.

CONCLUSIONS

VABG demonstrated a high union rate without donor site morbidity as the main advantage over ABG. Sufficient osseous integration within 3 months and remodeling within 12 months are promising aspects, as no late fatigue fractures occurred. However, further trials are necessary due to the limitations of this study.

[Joint-preserving osteotomy for calcanean malunions]

BACKGROUND

Calcaneal malunions lead to a considerable loss of global foot function through the loss of the physiological hindfoot lever arm, bony and soft tissue impingement, and involvement of the subtalar joint. In the majority of cases correction of the malunion has to be combined with subtalar fusion because of a rapid development of posttraumatic subtalar arthritis.

METHODS

Joint-preserving corrective osteotomy may be considered in carefully selected patients with intact joint cartilage, sufficient bone quality, and good patient compliance. This is the case in extra-articular malunion and intra-articular malunion with displacement of the complete posterior facet of the subtalar joint.

RESULTS

While respecting the criteria for indications, overall good functional results could be achieved in two clinical studies on this subject. Only 1 of the 26 reported patients required a secondary subtalar fusion. In case of development of subtalar arthritis a secondary in situ fusion of the subtalar joint can be performed on a corrected hindfoot with good prospects.

CONCLUSION

In carefully selected cases of malunited intra-articular calcaneal fractures, joint-preserving osteotomy is an alternative to corrective subtalar fusion.

[Surgical treatment of humerus condylar fracture]

55 patients with intra-articular condyles fractures of humerus were operated in terms 1998 to 2013 year in the Clinic of Traumatology and Orthopedics of the Presidential Administration. All patients were operated by using of perosseous osteosynthesis method with external fixing device design A.I. Gorodnichenko. Indications for osteosynthesis were open and closed fractures of C1,2,3 types accordingly to AO Classification. Closed, atraumatic and reliable fixation of bone fragments intensifies patients faster, improves their life quality, decreases time of hospitalization and minimizes complications rate. Fractures consolidation was achieved in all cases. It was observed such complications as soft tissue inflammatory around shafts in 4 (7.3%) observations. Long-term results were studied in 51 (92.7%) patients including 9 (17.6%) patients with excellent results, 24 (47.1%) patients with good results and 18 (35.3%) patients with satisfactory results. It was not detected unsatisfactory results. The method permits early reconstructive treatment of patients and improves functional results in case of condyles fractures. This preserves active moving function of damaged elbow from the first day after operation and during all period of treatment.

Corrective arthrodeses and osteotomies for post-traumatic hindfoot malalignment: indications, techniques, results

Hindfoot malunions after fractures of the talus and calcaneus lead to severe disability and pain. Corrective osteotomies and arthrodeses aim at functional rehabilitation and reduction of pain resulting from post-traumatic arthritis, eccentric loading and impingement due to hindfoot malunion. Preoperative analysis should include the three-dimensional outline of the malunion, the presence of post-traumatic arthritis, non-union, or infection, the extent of any avascular necrosis or comorbidities. In properly selected, compliant patients with intact cartilage cover little or no, AVN, and adequate bone quality, a corrective joint-preserving osteotomy with secondary internal fixation may be carried out. In the majority of cases, realignment is augmented by arthrodesis for post-traumatic arthritis. Fusion is restricted to the affected joint(s) to minimise loss of function. Correction of the malunion is achieved by asymmetric joint resection, distraction and structural bone grafting with corrective osteotomies for severe axial malalignment. Bone grafting is also needed after resection of a fibrous non-union, sclerotic or necrotic bone. Numerous clinical studies have shown substantial functional improvement and high subjective satisfaction rates from pain reduction after corrective osteotomies and fusions for post-traumatic hindfoot malalignment. This article reviews the indications, techniques and results of corrective surgery after talar and calcaneal malunions and nonunions based on an easy-to-use classification.

AO X-shaped midfoot locking plate to treat displaced isolated greater tuberosity fractures

Although various implants exist for 3- and 4-part fractures, few implants are appropriate for isolated greater tuberosity fractures. This retrospective study evaluated the efficacy of AO X-shaped midfoot locking plates for greater tuberosity fractures. Between May 2008 and September 2009, nineteen patients with displaced greater tuberosity fractures were treated with open reduction and internal fixation using AO X-shaped midfoot locking plates. Postoperatively, radiographs, functional results, and complications were evaluated. All patients were followed up for a mean 33.2 months (range, 24-42 months). Mean healing time was 9.4 weeks (range, 8-14 weeks). Mean Constant score was 90.6±4.0 points (range, 77-95 points). Excellent results were obtained in 16 cases, good in 2 cases, moderate in 1 case, and poor in 0 cases. The excellent-good rate was 94.7%. No recurrence of dislocation occurred in the 11 cases with shoulder dislocation. All fractures healed without the complications of wound infection, skin numbness, subacromial impingement syndrome, nonunion, secondary displacement, and implant loosening. The described technique is an effective, simple, and inexpensive method with a short learning curve.

Accuracy of ICD-9 codes to identify nonunion and malunion and developing algorithms to improve case-finding of nonunion and malunion

OBJECTIVE

To evaluate the accuracy of using ICD-9 codes to identify nonunions (NU) and malunions (MU) among adults with a prior fracture code and to explore case-finding algorithms.

STUDY DESIGN

Medical chart review of potential NU (N=300) and MU (N=288) cases. True NU cases had evidence of NU and no evidence of MU in the chart (and vice versa for MUs) or were confirmed by the study clinician. Positive predictive values (PPV) were calculated for ICD-9 codes. Case-finding algorithms were developed by a classification and regression tree analysis using additional automated data, and these algorithms were compared to true case status.

SETTING

Group Health Cooperative.

RESULTS

Compared to true cases as determined from chart review, the PPV of ICD-9 codes for NU and MU were 89% (95% CI, 85-92%) and 47% (95% CI, 41-53%), respectively. A higher proportion of true cases (NU: 95%; 95% CI, 90-98%; MU: 56%; 95% CI, 47-66%) were found among subjects with 1+ additional codes occurring in the 12months following the initial code. There was no case-finding algorithm for NU developed given the high PPV of ICD-9 codes. For MU, the best case-finding algorithm classified people as an MU case if they had a fracture in the forearm, hand, or skull and had no visit with an NU diagnosis code in the 12-month post MU diagnosis. PPV for this MU case-finding algorithm increased to 84%.

CONCLUSIONS

Identifying NUs with its ICD-9 code is reasonable. Identifying MUs with automated data can be improved by using a case-finding algorithm that uses additional information. Further validation of the MU algorithms in different populations is needed, as well as exploration of its performance in a larger sample.

Malunion of the distal radius

Fractures of the distal radius are extremely common injuries, which are steadily becoming a public health issue. One of the most common complications following distal radius fractures is still malunion of the distal radius. This review of the literature surrounding distal radius malunion covers the biomechanics of distal radial malunion, treatment options, indications for surgery, surgical techniques, and results.

[Correlation of disability degree and Tile type of pelvic fracture caused by traffic accidents]

OBJECTIVE

To analyze the relevance of Tile type of pelvic fracture and the degree of disability and explore how to understand the malunion and severe malunion of pelvic fracture for the injured in the traffic accidents.

METHODS

Eighty-six cases of pelvic fractures caused by traffic accidents from August 2008 to August 2011 in Forensic Judical Appraisal Institute of Suzhou Municipal Hospital were collected. At first, the grade of disability for every case was evaluated by 3 senior forensic experts independently. Then, the Tile type of pelvic fractures for every case was determined by 3 radiologists independently. At last, the correlation of the types of the fracture with the grades of disabilities was analyzed.

RESULTS

In all the cases there were 19 cases determined as A-type fracture and evaluated as non-grade disability. There were 43 cases determined as B-type fracture. And in these cases there were 41 cases determined as tenth grade of disability, one case as non-grade disability and one case as ninth grade disability. There were 24 cases determined as C-type fracture. And in these cases there were 14 cases evaluated as tenth grade disability and 10 cases evaluated as ninth grade disability. There was a correlation between the grade of disability and the type of the fracture (r = 0.760).

CONCLUSION

The disability degree caused by pelvic fracture correlates significantly with the type of the fracture. The finding is potentially useful to understand the malunion and severe malunion of pelvic fracture in forensic practice.

Clavicle and scapula fracture problems: functional assessment and current treatment strategies

Historically, nonsurgical treatment was recommended for both clavicle and scapula fractures. Good functional outcomes were reported with nonsurgical treatment, whereas surgical treatment had a high complication rate. Recent studies have shown that the functional outcomes of nonsurgically treated fractures may not be as acceptable as had been previously believed. These studies also support the surgical treatment of clavicle and scapula fractures in certain circumstances. Relative indications for surgical treatment of clavicle fractures include skin compromise, neurologic or vascular injury, open fractures, high-energy closed fractures with greater than 15 to 20 mm of shortening, fractures with 100% displacement, and fractures with comminution. Relative indications for the surgical treatment of scapula fractures include displaced acromion or coracoid process fractures (> 10 mm), displaced intra-articular glenoid fractures (> 5 mm), and those associated with humeral subluxation.

Magnetic stimulation for fracture consolidation--clinical study

This paper presents a randomized clinical design for evaluating magnetic fields in the consolidation of femoral shaft fractures. The study involved the design and construction of 20 devices (stimulators and placebos) and the development of 3D computer models of stimulated patient's thighs. A total of 64 patients were included in the study. Follow up time was 8 weeks with 1 hour of stimulation a day. The electrical signals estimated in the computer models were magnetic field, current density and voltage for different frequencies and currents. The results revealed 83% consolidated cases, and 7% with nonunion within the stimulation group, and 72% of consolidated cases and 14% with non-union for the control group. The consolidation results of patients who received stimulation were superior in time and number, but were not statistically significant. The values of electrical variables estimated by the computational model were found to be within a range not harmful to the patient (μA/m2, μT, nV).

New concepts in the treatment of distal radius fractures

Fracture of the distal radius is the type of fracture most commonly seen in emergency departments. The understanding of nonsurgical and surgical care of distal radius fractures is evolving with recently developed methods of fixation. It is worthwhile to review some new methods of treatment, the role of bone grafting and synthetic substitutes, the principles of complex fracture management, and the treatment of common complications of distal radius fractures.

Reconstruction of posttraumatic disorders of the forearm

Forearm rotation is crucial for full upper extremity mobility. The two-bone unit with its proximal and distal radioulnar joints should be considered as a single bicondylar articulation. After a traumatic bony forearm injury, surgical treatment for complications, such as deformity, bone loss, or failed fracture healing is challenging because complete return of forearm rotation can be difficult to achieve. It is important to be aware of methods for assessing and managing posttraumatic forearm bony complications, including preoperative assessment and osteotomy techniques for malunited fractures. The vascularized fibular transplant also has been proven as an effective treatment method. Although nonunion of forearm fractures is uncommon, it can prove problematic; therefore, it is beneficial to review options for surgical management.

Pisotriquetral arthrosis after triquetral malunion: a case report

We report a patient with chronic ulnar palmar wrist pain caused by malunion after isolated fracture of the triquetrum. Intra-articular malunion of the triquetrum body resulted in posttraumatic pisotriquetral arthrosis. The diagnosis was made by magnetic resonance imaging, computed tomography, bone scintigraphy, and wrist arthroscopy 5 months after the injury. The patient's symptoms were relieved by excision of the pisiform.

Stress fracture of the distal tibia secondary to severe knee osteoarthritis: a case report

Stress fracture of the tibia secondary to sports-related activities is relatively common, but rarely occurs secondary to osteoarthritis of the knee. Such fractures usually involve the proximal tibia. We report a 61-year-old woman with osteoarthritis and severe varus deformity of the knee who had a stress fracture of the distal tibial shaft. The patient had declined total knee replacement for severe osteoarthritis. She developed a stress fracture that subsequently malunited. The patient presented late and the diagnosis was not made for several months. The pathomechanics, diagnosis, and management options for this patient are discussed.

Post-calcaneus fracture reconstruction

This article outlines the pathoanatomy of malunited calcaneal fractures and reviews the literature on resulting painful sequelae, diagnostic work-up, as well as reconstructive treatment options and their outcome.

Pediatric fractures of the forearm

Forearm fractures are common injuries in childhood. There are a number of important principles that should be followed to achieve the ideal goal of fracture healing without deformity or dysfunction. I will review the general principles, classifications, diagnosis, treatment, and complications of pediatric forearm fractures, including some specific injuries such as Monteggia fractures, Galeazzi injuries, and open fractures. The basic principle is to accurately align the fracture fragments and to maintain this position until the fracture is united. Forearm fractures in children can be treated differently from adult fractures because of continuing growth in both bones (radius and ulna) after the fracture has healed. As long as the physes are open, remodeling can occur. However, generally it is thought that rotational deformity does not remodel. Undisplaced fractures may be treated in a cast until the fracture site is no longer painful. Most displaced fractures of the forearm are best maintained in a long arm cast. However, redisplacement occurs in 7 to 13% of cases, usually within 2 weeks of injury. Unstable metaphyseal fractures should be percutaneously pinned. Unstable diaphyseal fractures can be stabilized by intramedullary fixation of the radius and ulna. If none of these techniques is helpful, plate and screw fixation is the best choice.

Pediatric fractures and dislocations of the hip and pelvis

Recognition of an unstable pelvic fracture or a significant hip injury in children is important. Clinical assessment plays a valuable role as does the judicious use of imaging modalities in determining the most effective form of treatment, but the routine use of the standard AP pelvic radiograph is questioned. The concept of age and skeletal maturity has been re-evaluated, allowing the appropriate identification of cases that would benefit from an aggressive operative approach. A dual-tier approach to the treatment of pediatric pelvic trauma is suggested with an appreciation that there is no substantial evidence base for the surgical treatment of most injuries. Displaced femoral neck fractures and injuries to the hip joint that damage the articular or physeal cartilages require careful assessment and prompt and careful reduction and stabilization.

Long-term follow-up of a malunited, isolated fracture of the capitate in a 6-year-old boy

A 6-year-old boy with an isolated fracture of the capitate was presented. First radiograghs at our clinic revealed an oblique fracture with a displacement of 5 mm on the lateral view, which we successfully treated with immobilization. When complete union was recognized in the radiographs, the capitate had a deformity consisting of a large prominence on the palmar aspect. During follow-up, the capitate showed marked remodeling and at four and a half years after injury it had regained an almost normal shape. Eleven years after injury, there were no radiographic changes such as malalignment or arthrosis in the carpal bones.

[Coronal fractures of scaphoid]

Two cases of frontal fracture of the scaphoid proximal pole after a high energy trauma are reported. Diagnosis was delayed in both cases and was only possible with a CT-scan. One fracture was slightly displaced: the patient was treated conservatively and followed during 11 years with an excellent result. The other patient was operated on because of persistent pain and malunion. Only during surgery was the correct diagnosis made and due to scaphoid malunion, a proximal row carpectomy was performed. At a post operative assessment, in both cases, X-rays showed a double contour of the proximal pole of the scaphoid. We believe than an arthroCT-scan or MRI is necessary to assess the fracture displacement and search for an associated ligamentous injury.

Common complications of fracture repair

Complications are a reality of fracture repair. Many can be avoided or minimized by being aware of their pathophysiology and predisposing factors. Others are unavoidable but their resolution may be aided by early diagnosis and appropriate treatment. Major complications of fracture repair include osteomyelitis, delayed union, nonunion, malunion, premature physeal closure, and fracture associated sarcoma. Consideration of these complications should factor into presurgical patient evaluation as well as postoperative management. This discussion focuses on how to avoid, recognize, and treat these complications.

Treatment of malunited fractures of the anterior tibial spine

Avulsion fractures of the anterior tibial spine are uncommon injuries, and most often seen in childhood. They can be associated with other intraarticular lesions and have, if adequately treated, a good long-term prognosis. In adults these fractures can be complicated by loss of knee extension because of the displacement of the bony fragment. This is most often as a result of non- or malunion of the displaced fragment. We review two cases of malunited fractures of the anterior tibial spine. Both patients reported persistent knee pain and loss of knee extension, and had had an anterior knee laxity for a long time. They had been treated extensively by physiotherapy. In one patient, arthroscopy in another hospital revealed no reasons for the clinical symptoms. More than twenty years after the initial trauma, both patients visited our hospital. A radiograph and a magnetic resonance imaging were respectively carried out both of which revealed a malunited avulsion fracture. According to the examinations, the patients were treated by open reduction and internal fixation, and in the follow up exploration both no longer had discomfort. Clinical and radiological features of this less common and rarely reported injury are discussed and the surgical treatment is demonstrated.

Long-term outcome after tibial shaft fracture: is malunion important?

BACKGROUND

Fractures of the shaft of the tibia often heal with some angulation. Although there is biomechanical evidence that such angulation alters load transmission through the joints of the lower limb, it is not clear whether it can eventually lead to osteoarthritis.

METHODS

One hundred and sixty-four individuals who had sustained a tibial shaft fracture were assessed in a research clinic thirty to forty-three years after the injury. The subjects were evaluated with regard to self-reported lower limb joint pain, stiffness, and disability (assessed with the Western Ontario and McMaster Universities [WOMAC] osteoarthritis questionnaire); clinical signs of osteoarthritis; and radiographic evidence of osteophytes and joint-space narrowing in the knees, ankles, and subtalar joints.

RESULTS

Twenty-two (15%) of the 151 subjects who reported no other knee injury reported at least moderate knee pain, and eight (6%) of the 145 subjects who reported no other ankle injury reported at least moderate ankle pain. Seventeen (13%) of the 135 subjects who reported no other knee or ankle injury reported at least moderate disability. The ipsilateral side demonstrated a higher prevalence than the contralateral side in terms of pain with passive ankle movement (nineteen versus nine subjects, p = 0.02), pain with passive subtalar movement (fifteen versus four subjects, p = 0.01), and radiographic signs of ankle joint space narrowing (twelve subjects versus one subject, p = 0.0055). Knee osteoarthritis was frequently bilateral. Forty-seven fractures (29%) healed with coronal angulation of > or = 5 degrees. Apart from an association between shortening of > or = 10 mm and self-reported knee pain (p = 0.016), there were no significant univariate associations between these malunions and the development of osteoarthritis. Seventeen (15%) of 114 eligible subjects had overall malalignment of the lower limb, defined as a hip-knee-ankle angle outside the normal range of 6.25 degrees of varus to 4.75 degrees of valgus. This malalignment was due to the fracture malunion in nine subjects and predated the fracture in eight. In limbs with varus or valgus malalignment, there was an excess of subtalar stiffness (p = 0.04) and a nonsignificant trend toward more frequent knee pain. In limbs with varus malalignment, there was a nonsignificant trend toward more frequent radiographic evidence of osteoarthritis in the medial compartment of the knee joint. Most of the subjects in whom osteoarthritis was observed had normal overall alignment of the lower limb.

CONCLUSIONS

The thirty-year outcome after a tibial shaft fracture is usually good, although mild osteoarthritis is common. Fracture malunion is not the cause of the higher prevalence of symptomatic ankle and subtalar osteoarthritis on the side of the fracture. Although varus malalignment of the lower limb occurs occasionally and may cause osteoarthritis in the medial compartment of the knee, other factors are more important in causing osteoarthritis after a tibial shaft fracture.

Neurological complications in insufficiency fractures of the sacrum. Three case-reports

Three cases of nerve root compromise in elderly women with insufficiency fractures of the sacrum are reported. Neurological compromise is generally felt to be exceedingly rare in this setting. A review of 493 cases of sacral insufficiency fractures reported in the literature suggested an incidence of about 2%. The true incidence is probably higher since many case-reports provided only scant information on symptoms; furthermore, sphincter dysfunction and lower limb paresthesia were the most common symptoms and can readily be overlooked or misinterpreted in elderly patients with multiple health problems. The neurological manifestations were delayed in some cases. A full recovery was the rule. The characteristics of the sacral fracture were not consistently related with the risk of neurological compromise. In most cases there was no displacement and in many the foramina were not involved. The pathophysiology of the neurological manifestations remains unclear. We suggest that patients with sacral insufficiency fractures should be carefully monitored for neurological manifestations.

The role of arthroscopy in the investigation of wrist disorders

The findings at arthroscopy of the wrist in 48 consecutive cases carried out over a 4.5 year period have been retrospectively reviewed. In correlating the clinical and arthroscopic findings in the 36 patients with wrist instability and triangular fibrocartilage injuries we found concurrence in 28 of the cases. In the six patients in whom we were unable to make any provisional clinical diagnosis we did not find arthroscopy helpful. Arthroscopy usefully influenced the management in two of the six patients in whom the articular surface was assessed. We feel that a careful clinical examination of the wrist is the mainstay of diagnosis in wrist disorders. Arthroscopy remains useful in selected cases but has a limited specialized role which should continue to be provided from specialist centres.

The surgical dilemma of the malunited calcaneal joint depression fracture: the VAMC Miami experience

During the period of October 1985 through March 1995, 25 patients presented to the Veterans Affairs Medical Center, Miami with a chief complaint of chronic pain status post calcaneal joint depression fracture. Their acute injury was treated conservatively at this and various other institutions. Nine patients were managed conservatively with orthotics, University of California Biomechanics Laboratory braces (UCBLs), shoe modification, or prosthetics. Sixteen patients underwent hindfoot fusions. Good to excellent results were obtained in 15 of the 16 fusions. The remaining patient, having an isolated subtalar fusion, was later diagnosed with multiple sclerosis. Proper evaluation of the chronic pain patient is critical when mapping out an appropriate treatment plan. Hindfoot arthrodesis with soft tissue decompression is a successful tool in eliminating chronic pain due to malunited depression fractures.