Treatment of isolated distal ulnar shaft fractures with below-elbow plaster cast. A prospective study

In a prospective study 52 patients with an isolated fracture of the distal ulna were treated with a below-elbow plaster cast. The histories of 46 patients were reviewed after a mean follow-up of 3.5 years (ranging from 10 months to 7 years). Forty-three fractures united. There were two non-unions. One fracture displaced while in the plaster, so that there was no longer any bone contact between the fragments. The fracture was consequently treated by open reduction and internal fixation. The type of fracture, the initial displacement (all fractures had bone contact) or the initial angulation (maximum 10 deg) was not found to influence the final clinical results. Below-elbow plaster cast appeared to produce satisfactory results in 89% of the patients.     

Long-term outcome of isolated lesser tuberosity fractures of the humerus

Ten cases of an isolated fracture of the lesser tuberosity and their long-term outcome are described. The patient ages at the time of injury ranged from 11 to 68 years, averaging 30 years. In six cases, the injury was acute; in four cases, it had occurred more than 6 months previously. Of the six acute cases: three were treated conservatively, and the result was satisfactory for all of them; surgery was carried out in the other three cases, of which, two outcomes were judged to be excellent, and one outcome was satisfactory. Regarding the four chronic cases, muscle-strengthening exercises were given in two cases, whereas an operation was performed after exercise failed in the remaining two cases. The results of all four cases were graded as excellent. The combination of open reduction and internal fixation is the method most often recommended for acute cases. In chronic cases, conservative treatment is usually the most appropriate. However, when conservative treatment proves to be ineffective, then open reduction and internal fixation should be considered.     

Therapeutic management in trochanteric fractures

The authors present the management of trochanteric fractures based on 343 fractures treated in Department of Orthopaedics and Trauma in Clinical Hospital of Emergencies of Ia?i for 5 years. The non-operative treatment was used in 17.2% of cases and the conservative methods were plaster immobilization, continuous traction and early mobilization. The surgical treatment was used in 82.8% of cases. The reduction of the fractures was usually possible using closed methods. For fixation, the authors used four types of implants: the 135 degrees blade-plate in 9.2% of cases, the condylar blade plate in 44.7%, Ender nails in 45.4% and DHS in 0.6% of cases. The choice of one of this methods depends on the type of fracture, age of the patient and on his biological status.     

Functional analysis of linker insertions and point mutations in the alpha-Amy2/54 GA-regulated promoter

First metatarsal fractures are rare because of their thick size and shape. They are to be treated aggressively because of the prolonged disability associated with such fractures. Any injury to the first ray may drastically alter the pattern of normal gait and weight-bearing. Most of the literature regarding such fractures is anecdotal, and there is little in the way of scientific articles that investigate their management. The general consensus for treatment of closed, nondisplaced first metatarsal fractures is to use some form of plaster immobilization. Nevertheless, there is much variation in the literature concerning the length of time patients should be casted. Rigid internal fixation using AO techniques is preferred if open reduction is to be instituted. Long-term complications with first metatarsal fractures are attributed mostly to malunion in the sagittal plane, resulting in a nonplantigrade foot.     

Fractures of the hip in children and adolescents

Long-term results of 52 fractures of the hip in 51 children and adolescents are discussed. A distinction was made between fractures in children (aged 1 to 11 years) and those in adolescents (aged 12 to 18 years). Irrespective of the type of fracture it was found that immediate operative treatment leads to the best results. In children as well as in adolescents the risk of avascular necrosis, premature closure of the epiphysis and non-union is less following immediate operative treatment than following delayed operative treatment or conservative treatment. The prognosis of these fractures depends on the amount of damage to the vascularization. Treatment of children consisted of open reduction and fixation with K-wires followed by postoperative immobilization in a hip-spica for 6 weeks. Adolescents were treated with three-flanged nails usually without postoperative plaster immobilization. In both children and adolescents internal fixation may also be carried out with screws, in which case these must not cross an open epiphyseal plate. In both groups a non-weight-bearing period of 6 to 12 months is advisable. The results in adolescents were definitely poorer than in children. Seemingly completely destroyed hips can reintegrate even to a nearly "restitutio ad integrum" state after a period of years.     

Proximal intra-articular tibial fracture in skiers

56 cases of proximal intraarticular tibia fractures over a 4-year period are reviewed. In every case the patients described a preceding valgus-compression trauma of their knee. Clinically we always found a hemarthrosis combined with a tenderness on pressure at the fractured condyle. Roentgenograms should be performed in 4 projections, eventually followed by conventional tomograms or computed tomography. Frequency of the several fracture types is demonstrated following the classification of the AO working group for osteosynthesis. The Eminentia intercondylaris was concerned in 13 cases as avulsion fracture of the anterior cruciate ligament (ACL) with a double peak distribution in the under 20-years- and over 40-years-age group. In the remaining cases we observed split- and/or compression fractures of the lateral tibial plateau of the 40 to 60 year old skier, in 20% communitive fractures. In 85% of the ACL-avulsion fractures we applied a cast brace as a conservative measure, whereas 75% of the tibia plateau fractures were treated operatively by mean of open reconstruction of the articular surface and internal fixation based on the AO-principles as well as bone graft buttressing in two third of the cases.     

Detection of circulating epithelial cells in prostate cancer]

The authors report 10 segmental fractures of the femoral head associated with a dislocation of the hip. Using PIPKIN's classification, they noted 1 type I, 7 type II and 2 type III fractures. The initial treatment of the hip dislocation was conservative in all cases. Failure of reduction was noted in 6 cases and was complicated by fracture of the femoral neck in 2 cases. The attitude regarding the head fragment was: conservative in 5 cases, the reduction was considered satisfactory in 4 cases and poor in 1 case; surgical in the other 5 cases: screw fixation in 1 case, excision of the fragment in 1 case and prosthetic replacement of the femoral head in 3 cases. After a mean follow-up of 5 years, functional results were satisfactory in the majority of cases. The radiological assessment showed malunion without osteoarthrosis in one case and avascular necrosis of the femoral head in three cases. The authors propose a treatment policy based upon their experience and a review of the literature.     

Operative treatment of fractures of the tibial plafond. A randomized, prospective study

We performed a randomized, prospective study to compare the results of two methods for the operative fixation of fractures of the tibial plafond. Surgeons were assigned to a group on the basis of the operation that they preferred (randomized-surgeon design). In the first group, which consisted of eighteen patients, open reduction and internal fixation of both the tibia and the fibula was performed through two separate incisions. An additional patient, who had an intact fibula, had fixation of the tibia only through an anteromedial incision. The second group consisted of twenty patients who were managed with external fixation with or without limited internal fixation (a fibular plate or tibial interfragmentary screws). Ten (26 per cent) of the thirty-nine fractures were open, and seventeen (44 per cent) were type III according to the classification of Rüedi and Allg?wer. There were fifteen operative complications in seven patients who had been managed with open reduction and internal fixation and four complications in four patients who had been managed with external fixation. All but four of the complications were infection or dehiscence of the wound that had developed within four months after the initial operation. The complications after open reduction and internal fixation tended to be more severe, and amputation was eventually done in three patients in this group. At a minimum of two years postoperatively (average, thirty-nine months; range, twenty-five to fifty-one months), the average clinical score was lower for the patients who had had a type-II or III fracture, regardless of the type of treatment. With the numbers available, no significant difference was found between the average clinical scores for the two groups. All of the patients, in both groups, who had had a type-II or III fracture had some degree of osteoarthrosis on plain radiographs at the time of the latest follow-up. With the numbers available, there was no significant difference between the two groups with regard to the osteoarthrotic changes. We concluded that external fixation is a satisfactory method of treatment for fractures of the tibial plafond and is associated with fewer complications than internal fixation.     

Failure of femoral nailing in the elderly

Failure of fixation of a fracture of the mid-shaft of the femur in a 73-year-old male occurred 4 weeks after insertion of a reamed Grosse-Kempf nail. The oblique locking screw had cut out, despite having been correctly sited at the primary operation. A satisfactory result was obtained following open nailing using an AO nail. Two transverse proximal locking screws provide more certain fixation in osteoporotic bone of elderly patients.     

Clinical and functional outcomes of internal fixation of displaced pilon fractures

The clinical and functional outcomes for patients treated with open reduction and plate fixation of displaced tibial pilon fractures were determined. A retrospective search of the authors' trauma database was conducted for AO and Orthopaedic Trauma Association Code 43 injuries (pilon fractures) in adults 18 years or older who were treated between December 1988 and December 1992. The group of 64 patients who required open reduction and internal fixation to treat their fractures make up the primary cohort for this analysis. Twenty of these cases required no fibular fixation; the remainder were mostly fixed with 1/3 tubular or 3.5-mm compression plates. Tibial fixation was done using most commonly 3.5-mm cloverleaf plates, 1/3 tubular plates, or both. Of the 64 patients treated with open reduction and internal replacement, four (5%) patients had deep infection develop. Two (7%) of 14 patients had open fractures, and two (4%) of 50 patients had closed fractures. Three of these four patients smoked tobacco products; one was also an intravenous drug abuser. Staphylococcus aureus was the organism in two cases; Enterobacter, in the other two. The infection was controlled with a free flap in two cases, with antibiotics and wound debridement in one and with an arthrodesis in one. Thirty of the 64 patients completed the Short Form-36; two of these patients had bilateral fractures. The study group had significant differences in general health perceptions, physical function, physical role function, emotional role function, social and mental function, and pain and energy levels when compared with age matched population data and patients with tibial plateau fractures. The effect of other injuries on these functional status results cannot be determined specifically.     

Results of an operative policy in the treatment of periprosthetic femoral fracture

OBJECTIVE: To determine the clinical outcome of patients with periprosthetic femoral fractures treated operatively. DESIGN: Retrospective analysis from 1986 to 1993. SETTING: Edinburgh Orthopaedic Trauma Unit, Edinburgh, Scotland. PATIENTS: Forty-five patients identified from a computer database as being admitted to the Edinburgh Orthopaedic Trauma Unit with periprosthetic femoral fractures. MAIN OUTCOME MEASURES: Clinical outcome grade (good, fair, poor) dependent on integrity of fixation, refracture rate, and ability to perform activities of daily living analyzed against age, type of fracture, prosthetic alignment, loosening, and method of fixation. RESULTS: Type I fractures were more common in uncemented or loosely cemented prostheses, whereas type II fractures occurred predominantly in securely cemented prostheses. Type I fractures treated by revision had the poorest results. Outcome in type II fractures was equally good whether treated by internal fixation or by revision. Age, loosening, and prosthetic alignment did not influence outcome. The mortality rate in this series was 20%. CONCLUSIONS: If a prosthesis is loose, it should be revised, or treatment varies with fracture and prosthetic type. In type I fractures, an uncemented stem may be revised to a cemented one; however, a securely cemented prosthesis probably is better when fixed internally. Type II fractures should be fixed internally because there is less operative insult. Type III fractures probably are not related to the prosthesis and should be fixed internally according to normal practice. The results of an operative policy compare well with the results of conservative management and avoid the problems of long-term immobilization.     

Acute abdomen. When to operate immediately and when to observe

BACKGROUND: Seat belt type injury of thoracolumbar spine is an uncommon injury characterized by disruption of the posterior elements of the spine. The fracture has long been treated conservatively, but progressive kyphotic deformity developed frequently. METHODS: From January, 1991 through December, 1992, 10 cases of seat belt type injury of the thoracolumbar spine were encountered at our hospital with an incidence of 8% in overall spinal fractures. Of these patients, eight patients were male and two were female, average age 30.7 years old. The causes included motor-vehicle accident in five patients, fall from height in four, and stricken by a falling electric pole in one. None of the victims of motor vehicle accidents wore seat belt. All of them received open reduction, posterior internal fixation and posterior fusion. RESULTS: After follow-up for an average of 42.2 months, the average kyphotic angulation was 5.7 degrees. Back pain and function of these patients were all rated good. None of them suffered from neurologic deficit. One patient with breakage of transpedicular screws was encountered during follow-up, but there was no complaint. CONCLUSIONS: In treating seat belt type injuries of spinal column, benefits of operation outweigh the risks. Besides, the clinical result is satisfactory and more aggressive surgical approach should be encouraged.     

Volar fracture dislocations of the second and third carpometacarpal joints associated with acute carpal tunnel syndrome

Volar fracture dislocation of the second and third metacarpal bases associated with acute carpal tunnel syndrome in a 17-year-old football player were treated with open reduction, via volar incision to decompress the carpal tunnel, and via a second dorsal incision for internal fixation of the fracture dislocations with Kirschner wire fixation and reinsertion of the avulsed extensor carpi radialis:longus tendon. Anatomic reduction by closed or open reduction is recommended to avoid leaving patients with a weak grip and pain over the site of the fracture.     

Supramalleolar fracture of the ankle (Malgaigne's fracture)

A retrospective study of 26 cases of supramalleolar fracture is presented. Types II and III were most common. All but the one had accompanying fibular fracture. The incidence of open fracture was 41.7% (10/24). The most common mechanism of injury was a high energy impacting force in the direction of axial compression. The supramalleolar fracture was subgrouped into four types. Twenty patients were treated by closed reduction and cast immobilization for an average of five months, six by open reduction and internal fixation, and two by skeletal traction in the early course of treatment. Of the 21 patients who were followed for an average of 33 months, only seven were found to have satisfactory results and were free from complications. Fourteen patients were found to have complications.     

Traditional methods vs rigid internal fixation of mandible fractures

OBJECTIVE: To compare traditional methods (ie, intermaxillary fixation with interosseous wiring or external fixation) with newer techniques (ie, plating, use of lag screws) of open reduction and fixation of mandible fractures. DESIGN: Retrospective analysis of data from medical records. SETTING: Academic urban medical center. PATIENTS: Nonrandomized sample of 356 patients admitted to the hospital for treatment of mandible fractures from 1987 through 1991; 155 patients treated with open reduction and fixation were studied. INTERVENTIONS: Sixty-nine patients were treated with interosseous wire fixation or external fixation, 86 patients with rigid internal fixation. MAIN OUTCOME MEASURES: Presence of infection, nerve impairment, nonunion, malunion, operative time, and follow-up. RESULTS: No significant difference was noted between the two groups for sex, treating service, delay in presentation, antibiotic coverage, mechanism of injury, or type of fracture. The incidence of infection, nerve injury, and unavailability for follow-up were greater in patients treated by the newer techniques. Overall expense and operative time were greater in the group treated with plates and lag screws. CONCLUSIONS: We advocate traditional techniques for patients with mandible fractures requiring open reduction and fixation.     

A fixator-pin-wire-plaster technique in war conditions]

Technique fixateur-pin-wire/plaster is an original method. It is connected very much with the primary treatment in the cases of the improvised war hospitals, where are no elements for internal fixation. In the act "open" fixation the free fragments are connected with Shantz pins. Around the pin is the wire (as inter-fragmentary compression with a screw). In this way, when the fixateur is not necessary it can be removed, but the place of fracture is fixed. During the coming treatment the plaster can be used, but it may not. In this way we can finish the treatment without use of surgery. This method we have used continually as a clinical treatment. In the paper we shall our first good experiences.     

Clinical results of primary intramedullary osteosynthesis with the unreamed AO/ASIF tibial intramedullary nail of open tibial shaft fractures

From 04/91 to 06/96 sixty-nine open fractures of the tibia were primarily treated on the day of the accident with unreamed nailing (UTN, Synthese). The distributions of fracture type according to the AO classification and of soft tissue injury according to Gustilo were as follows: fracture type: A: 28%, B: 52%, C: 20%; soft tissue injury: I: 30%, II: 28%, IIIA: 12%, IIIB: 12%, IIIC: 6%. Of the 65 fractures assessed 46 (71%) healed within 18 weeks without secondary intervention. There was delayed healing in three fractures requiring secondary conversion to reamed nailing. Eight fractures (12%) developed pseudarthrosis of which five (8%) healed uneventfully. Deep infections was manifest in four fractures (6%). Three of these infections developed after secondary intervention to treat pseudarthrosis. Seven of the eight pseudarthroses and three of the four infections healed eventually. Revision procedures were necessary in 11 patients (17%) to deal with disturbed fracture healing or infection (10 reamed nailing procedures, three cancellous bone grafts, and one of each of the following: sequestrectomy, fibular osteotomy, plate fixation, external fixator, monorail procedure). The results show that the same good infection rates were achieved for the UTN as for the external fixator. The advantages of the UTN are, however, a lesser need for secondary intervention and greater patient comfort. Therefore, we find the UTN to be a good alternative to the external fixator in the treatment of open fractures with severe soft tissue damage.     

Combined fractures of the femoral and tibial shafts in the same limb

This paper reports a study of ipsilateral fractures of the femoral and tibial shafts in 21 patients treated according to a detailed plan including shock treatment, prophylaxis against fat embolism, soft-tissue and fracture treatment. Death due to hypovalaemic shock was eliminated and the incidence of fat emboliism (9-5%) reduced in comparison with an earlier series. The tibial fracture was stabilized by plaster or internal fixation as soon as conditions allowed. In most cases the femoral fracture was treated by medullary mailing. Results have improved compared with earlier series. All fractures healed within 15 months, and functional end results have been excellent in the majority of the surviving patients (89%).     

Transpedicular fixation with Zielke instrumentation in the treatment of thoracolumbar and lumbar injuries

STUDY DESIGN: Sixty-five patients who underwent transpedicular fixation for thoracolumbar and lumbar injuries were studied for type of injury, the severity of paralysis, the degree of postoperative correction, and instrumentation failures. OBJECTIVES: To evaluate the surgical approaches and the selection of instrumentation to determine indications for using the transpedicular fixation procedure. SUMMARY OF BACKGROUND DATA: Various transpedicular fixation devices have been used for different type of injuries, and satisfactory postoperative results were not obtained in some studies. METHODS: Forty patients had burst fractures, 19 had fracture dislocations, and six had chance-type fractures. An anterior decompression procedure was used for most cases of burst fracture and some cases of fracture dislocation where anterior compression factors were present. The Zielke or modified Zielke system was used as an internal fixator for posterior segmental fixation. RESULTS: No patient had neurologic deterioration after surgery. Twenty of 28 patients with incomplete lesions improved postoperatively according to Frankel grades. The instrumentation failed in only one patient, in whom a nonunion developed. CONCLUSION: With transpedicular fixation, it is possible to provide solid internal fixation that is circumscribed to the injured vertebral segments. The elasticity of the Zielke rod makes it an excellent transpedicular fixation device because it is easily attached and reduction is easily performed. Anterior decompression with fusion needs to be used with transpedicular fixation in the treatment of injuries (especially burst fractures).     

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An avulsion fracture of the insertion of the extensor carpi radialis longus tendon is rare. There have been only five reports of this injury in the literature [1, 2, 4]. We describe an additional case in which open reduction with internal fixation gave a satisfactory result.