Dynamic external fixation for distal radius fractures

Thirty adult patients with closed comminuted and mostly intraarticular fractures of the distal radius were treated by closed reduction and immobilization with a dynamic external wrist fixator during a 2-year period. In 13 patients with severely comminuted and unstable fractures, additional Kirschner wires were used. After 10 to 14 days of rigid fixation in neutral position, the motion element was unlocked to allow up to 30 degrees flexion. Six weeks later, the fixator was removed. The patients then were observed for an average of 24 weeks. An excellent functional outcome was seen in 6 patients (20%), a good outcome in 20 patients (67%), and a fair outcome in 4 patients (13%). Anatomically, 15 patients (50%) had an excellent result, 14 (47%) a good outcome, and 1 (3%) a fair outcome. Only minimal loss of reduction averaging 1 degree palmar tilt was seen during mobilization. There were 2 major complications: 1 deep Kirschner wire tract infection and 1 index metacarpal fracture. Minor complications such as sensory disturbances and pin tenderness were present but recovered completely after removal of the fixator. This study provides promising data and offers an alternative method in the treatment of distal radius fractures with severe comminution. In cases with postreductive unstable fragments, additional Kirschner wires should be used to allow early mobilization of the wrist.     

Long-term results of the external fixation of distal radius fractures

OBJECTIVES: Prostate cancer (PCa) has a familial predisposition imparting an increased risk of developing the disease in those with a family history. The pathologic characteristics are similar to sporadic cases; however, the disease-free survival rates of hereditary PCa have recently been disputed, with one major study suggesting that familial cases have higher recurrence rates. Our study seeks to support or refute this association and to evaluate the genetic biomarkers p53, bcl-2, Ki-67, and neovascularity between familial and sporadic disease. METHODS: We retrospectively reviewed data of 573 patients who underwent radical prostatectomy over an 11-year period. Of these, 474 patients had known family history data. Univariable statistical analysis using the Pearson chi-square test and Kaplan-Meier disease-free survival analysis was performed to identify any correlation between the tested variables and family history. Smaller subsets of this cohort that had available archival material for immunohistochemical staining and family history data were analyzed in a similar manner. RESULTS: The preoperative variables (prostate-specific antigen, prostatic acid phosphatase, clinical stage, highest biopsy Gleason sum, and glandular differentiation) and postoperative variables (stage, highest Gleason sum, and glandular differentiation) did not correlate with family history. Kaplan-Meier disease-free survival analysis revealed no differences between sporadic and familial cases. The analysis of p53, bcl-2, Ki-67, and angiogenesis revealed that only increasing p53 expression and positive family history of PCa approached significance (P = 0.057). CONCLUSIONS: Prognostic variables routinely used in PCa and selected genetic biomarker immunostaining abnormalities are not significantly different in men with and without a family history of PCa. Disease-free survival after radical prostatectomy is also unaffected by family history.     

Orthofix external fixation of distal radius fractures: complications associated with screw size

We did a retrospective analysis of 28 patients who were treated with the Orthofix external fixation system for complex fractures of the distal radius to study complications associated with screw size. The 14 patients in group 1 had a 4.5/3.5-mm tapered screw placed in the metacarpal bone; the 14 patients in group 2 had a 3.5/3.3-mm tapered screw placed in the metacarpal bone. Both groups had 4.5/3.5-mm tapered screws placed in the radius. Two patients in group 1 had metacarpal pin tract infections; no patients in group 2 had a distal pin tract infection. Two patients in group 1 had a fracture of the metacarpal; only one patient in group 2 had a fracture of the metacarpal. In both groups two patients had proximal pin tract infections at the radius screw fixation site. There was no screw breakage in either group. The unique design of the tapered Orthofix screw allows it to be removed almost painlessly in the clinic. At installation in the operating room, however, the surgeon must remember not to back the threaded pin out for fine adjustment of bony penetration. Any reverse excursion of the threaded shaft will loosen the tapered screw and cause early failure of the fixation. We no longer use the 4.5/3.5-mm screw when managing wrist fractures with the Orthofix external fixation system. It is now our policy to use the 3.5/3.3-mm screw for fixation of the Orthofix external frame to both the metacarpal bone and the radius.     

Arthroscopic-assisted reduction of distal radius fractures

The outcomes of seven patients with severe comminuted intraarticular fractures of the distal radius treated by arthroscopic reduction and percutaneous external fixation (ARPEF) were retrospectively reviewed. All of the fractures were classified as C3 types using the AO classification scheme. Outcomes were evaluated using the Gartland and Werley functional criteria, an objective wrist examination, a radiographic analysis, and a self-assessment outcome form at an average follow-up of 27 months (range, 12 to 45 months). All patients were free of pain and had returned to their prior occupations. No patient had articular incongruency of greater than 1 mm, and there was no evidence of radiocarpal degenerative change. Active range of motion and maximal grip strength averaged 92% and 98%, respectively, of the uninjured wrist. The technique of arthroscope-assisted reduction and percutaneous external fixation yielded excellent results in a small group of patients, with minimal complications.     

Over-distraction of the radio-carpal and mid-carpal joints following external fixation of comminuted distal radial fractures

Seven patients with Frykman type 7 and 8 distal radial fractures, who had been treated with external fixation, were noted to have significant over-distraction of 5-8 mm in the radio-carpal and mid-carpal joints. One patient, who also had abnormal negative ulnar variance of 2 mm, had a fair result using modified Gartland and Werly (1951) criteria. The remaining six patients had good results, indicating that over-distraction does not significantly alter the final outcome, so long as a normal distal radio-ulnar relationship is maintained.     

Biological fixation of subtrochanteric fractures by external fixation

Fifty-one subtrochanteric fractures have been stabilized by external fixation over the last 9 years. Union occurred in all types of fractures, usually within 6 months. Soft tissue interposition led to non-union in three patients. Refracture in one patient and significant limb-length discrepancy in two patients was seen. The technique is versatile, easily reproducible and 'biological'. Protected weight-bearing is not necessary after removal.     

Is the static external fixator a suitable method in the treatment of multi-fragmented fractures of the distal radius?

We present a retrospective study of 21 patients treated with an external fixator for comminuted fractures of the distal radius from May 1993 until May 1994. Mean follow-up was 14.5 months after operation. The 21 patients were on average 59 years old. The distal radius fractures were classified according to the AO: Type A2 (four times), Type A3 (two times), Type C1 (one time), C2 (nine times), C3 (five times). We mounted the external fixator generally in a static way. After two weeks it was dynamized. The fixator was removed after four to at least six weeks. An additional osteosynthesis with Kirschner wires was performed in twenty cases. Three times we added a primary cancellous bone graft, in one case an implantation of Endobone was used.     

Intra-articular fractures of the distal end of the radius treated with an adjustable fixator system

Twenty-five wrists with comminuted, displaced, intra-articular fractures of the distal radius were prospectively treated with an adjustable external fixator for an average of 51 days. Twenty fractures (80% [20 of 25] were available for follow-up) in 16 adults (mean age, 34 years) were treated with the Wrist Jack external fixator system (Hand Biomechanics Lab, Sacramento, CA) and evaluated at a mean follow-up period of 25 months. Ten patients (12 fractures) sustained high-energy trauma with multiple injuries, while 6 patients (8 fractures) sustained isolated distal radius fractures. Percutaneous pins supplemented the fixation in 6 fractures. All fractures were reduced to restore articular congruity to within 1 mm. At follow-up, 5% were excellent, 75% good, 20% fair, and none as poor using the demerit point system of Gartland and Werley as modified by Sarmiento. Grip strength averaged 80% of the unaffected limb. Seventeen of the 20 fractures showed some evidence of articular incongruity at follow-up evaluation. Restoration of palmar tilt, radial inclination, radial length, and range of motion were at acceptable values. Subjective analysis confirmed 85% of the patients to have only occasional pain or none at all and 15% to have some pain with weakness or limitation of motion. Two patients required additional surgery: 1 underwent a Darrach procedure and the other a tendon transfer for a rupture of the extensor pollicis longus tendon. Results suggest that an external fixator system provides an additional alternative to the surgical armamentarium for an otherwise difficult fracture fixation problem.     

Type-II external fixation, using new clamps and positive-profile threaded pins, for treatment of fractures of the radius and tibia in dogs

A new external fixation system for repair of fractures of the radius and tibia was developed that uses positive-profile threaded pins. This system allows for addition of a fixation clamp between 2 installed clamps, predrilling of pin holes through a drill sleeve, use of positive-profile threaded pins in all locations, and easier application of full pins. Type-II external fixators were applied, using this system, to fractures in 10 client-owned dogs, and outcome was evaluated. All fractures healed without complications. Duration of surgery, mean time until radiographic evidence of a bridging callus, and mean time until removal of the external fixator were shorter, and frequency of pin loosening were less than with other techniques. Pin loosening was uncommon. This system provides an important improvement in external skeletal fixation.     

Small wire external fixation of high energy tibial plateau fractures

Open plate osteosynthesis for high energy tibial plateau fractures with dissociation between the metaphysis and diaphysis has been plagued with frequent soft tissue complications. The Harbor-University of California at Los Angeles Medical Center's experience with small wire external fixation supplemented by limited internal fixation is examined. This alternative method of adequate stable fixation offers the advantage of minimal soft tissue compromise. Twenty-four patients with Schatzker Type VI tibial fractures were treated with small wire external fixation. Supplementary limited internal fixation was used with percutaneous screws in 10 patients and with open reduction in one patient. Sixteen patients had isolated fractures, and eight others suffered multiple injuries. Minimum followup was 12 months. All fractures healed. Complications included one septic knee, two infections at screw sites, and one 10 degrees knee flexion contracture. One knee had Grade 3 radiographic arthrosis, five had Grade 2, 10 had Grade 1, and eight showed no arthrosis. The outcomes (Knee Society clinical rating system) of this study compare favorably with outcomes described in reports published previously for this type of fracture, despite inclusion of eight multiply injured patients. This technique preserves the goals of early range of motion and stable fixation for these devastating injuries, while decreasing the observed major wound complications and nonunion rates. However, longer followup may reveal higher arthrosis rates, specifically in those fractures that were not anatomically reduced.     

Transcutaneous reduction and external fixation for the treatment of noncomminuted zygoma fractures

PURPOSE: This study evaluated the effectiveness of the treatment of noncomminuted monofragment zygoma fractures with closed reduction using transcutaneous threaded pins and an external fixation device instead of open reduction and internal rigid fixation. PATIENTS AND METHODS: In 46 patients, transcutaneous pin was inserted into the center of the fractured zygoma, and the segment was reduced by moving the pin to counteract the initial vector force of injury. After reduction, the fractured segment was immobilized by the external fixation device for 9 to 14 days. RESULTS: All patients except one showed accurate fracture reduction without malunion or any complications. CONCLUSION: This method has advantages over the conventional closed methods in the management of uncomplicated noncomminuted fractures of the zygoma.     

Use of rigid external fixation in fractures of the mandibular condyle

In this article the use of a rigid external fixation system is proposed for the early treatment of condylar fractures. This method offers the advantage of not damaging the articular structures during reduction and allows early mobilization for a rapid recovery. In our Centre 28 patients have been treated with the rigid external fixation system, with good functional results. Of these 15 men and 13 women, 22 had a monocondylar fracture and 6 had a bicondylar fracture. In all the cases there was complete recovery of the occlusal stituation and of the mouth opening; no patient surgically treated with this method has ever presented problems of a local or general nature. The purpose of this report was to evaluate the use of external fixation for the treatment of extracapsular condylar fractures with luxation of the fragment out of the glenoid cavity.     

Management of comminuted fractures of the distal radius in the adult. Conservative or surgical?

Displaced fractures of the distal radius are difficult to treat successfully by traditional nonoperative methods. The goal in the management of these fractures is to achieve extraarticular alignment and an articular step off of less than 2 mm. Cast immobilization has been supplemented with pins and plaster technique and external fixators. Percutaneous are limited open reduction techniques, combined with wrist arthroscopy, have been shown to be useful in the management of intraarticular distal radius fractures. Despite these advances, there are still a significant number of fractures in which the articular surface cannot be reconstructed without open reduction and internal fixation. The main objective is to restore articular integrity as perfectly as possible. Attention to meticulous surgical technique will facilitate good results. When articular restoration cannot be accomplished, early arthrodesis or arthroplasty should be indicated. In the absence of osteoarthritis, intraarticular osteotomy can be used for intraarticular malunions with a step off greater than 2 mm. Radius malalignment usually requires a dorsal opening wedge osteotomy, insertion of a corticocancellous graft, and a dorsal buttress plate. Early recognition and treatment of distal radioulnar joint injuries associated with fractures of the distal radius are paramount to reduce the incidence of painful sequelae and functional deficits.     

Open reduction without fixation of dislocated condylar process fractures: long-term clinical and radiologic analysis

PURPOSE: This study evaluates the long-term results of open reduction without fixation for displaced fractures of the condylar process. PATIENTS AND METHODS: Clinical and radiologic examinations were performed on 27 patients with 29 operated joints an average of 6.7 years postoperatively. The postoperative result was evaluated on the basis of occlusal and joint function, as well as radiographic assessment of condylar changes. RESULTS: Clinically, satisfactory results were achieved. Radiologically, despite correct intraoperative alignment of the fractured segments, a slight medial deviation of the condylar process was found on the posteroanterior radiograph. However, in only two cases was a 20-degree deviation observed. On final follow-up, 48% of the cases had a normal condylar configuration radiologically, and in the remaining cases, normal function was established even though there were condylar changes. Fully exposed and devascularized condylar processes generally showed more severe changes than those in which partial vascularization was maintained. CONCLUSION: The surgical management described enables a satisfactory outcome to be achieved with dislocated condylar process fractures.     

Use of an internal fixator device to treat comminuted fractures of the distal radius: report of a technique

An internal fixator technique for stabilizing comminuted Colles fractures has been developed in the anatomy laboratory and used in 35 clinical cases. The Colles Fracture Plate (Biomet, Inc, Warsaw, Indiana) can be used to treat any comminuted Colles fracture for which an external fixator is considered proper management. We have determined, based on our surgical experience with both the internal and external fixator techniques, that internal fixation using the Colles Fracture Plate is technically just as simple as external fixation. In addition to requiring a significantly less expensive device, internal fixation using this technique offers the advantages of better patient acceptance and fewer complications. This report will be followed by a more comprehensive analysis of the technical outcome of this procedure to further substantiate the initial results presented here. The process of compiling and analyzing these data is under way.