外固定架结合皮瓣技术治疗合并软组织缺损的胫骨和腓骨骨折

目的应用外固定架结合皮瓣技术治疗合并软组织缺损的胫、腓骨骨折。方法应用单臂或环型外固定架固定胫骨骨折，根据小腿皮肤软组织损伤情况选用背阔肌皮瓣、股前外侧皮瓣、腓肠肌皮瓣、足背岛状皮瓣等8种不同皮瓣修复。结果临床应用30例，其中合并软组织缺损的胫、腓骨骨折急诊治疗16例、骨或钢板外露12例、骨不愈合及软组织瘢痕2例。经2年以上随访全部骨折均愈合，无感染发生。2例皮瓣出现小面积组织坏死，经换药后治愈，其余皮瓣成活良好。结论应用外固定架结合皮瓣技术是治疗合并软组织缺损的胫、腓骨骨折的有效方法。     

Is there a place for external fixation in humeral shaft fractures?

There is a good indication for unilateral axial dynamic external fixation in fractures of the humeral shaft when the fracture appears in the distal third or in cases of bilateral fractures. A non-union or a posttraumatic paralysis of the radial nerve may be indications for external fixation as well as fractures associated with multiple injuries. Further indications include osteitis, infected non-union and comminuted fracture. There is maximum protection of the soft tissue with this method of treatment. External fixation combines the advantages of conservative and operative treatment by influencing callus formation by dynamizing, distraction or compression. Minimizing soft tissue damage facilitates the decision for early exploration of the radial nerve in cases of palsy. A safer positioning technique of the distal screws of the fixator is described.     

Tibial pilon fractures

Tibial pilon fractures are severe injuries to the distal articular surface of the tibia. Such injuries frequently result from high-energy axial impact and are often associated with extended soft tissue injury. Various treatment methods are available, depending not only on the fracture type but mostly on the extent of the soft tissue injury; one of the most frequent procedures is a two-stage surgery: the initial closed reduction of the fracture via primary placement of an ankle joint-spanning external fixator, if possible in conjunction with open reduction and internal fixation of the fractured fibula followed by a secondary procedure after soft tissue recovery by open reduction and internal fixation of the tibial plafond. By now, new types of low-profile and locking plates are available for internal fixation allowing the anatomical reconstruction of the fractured articular surface while sparing the soft tissue. Nonetheless, the treatment of tibial pilon fractures is technically demanding because of their potential for severe complications.     

Staged management of high-energy proximal tibia fractures

High-energy proximal tibia fractures are complicated by soft tissue compromise and this may result in sub-optimal outcomes. There is a high association of open injuries, compartment syndromes, and vascular injuries with these bony disruptions. Surgical treatment of these injuries has been associated with significant complications such as infection, knee stiffness, malunion, loss of fixation, soft tissue failure, and amputations. The loss of fixation is an issue especially in the elderly, with failure associated with age more than sixty years, premature weight bearing, preoperative displacement, fracture fragmentation, and severe osteoporosis. The use of two-stage reconstruction for the treatment of distal tibia fractures has been successful in decreasing the complication rates, including wound compromise. The two stages involve: 1. stabilization of the injured limb with a bridging external fixator to allow the soft tissues to improve and recover and 2. definitive fixation for reconstruction of the articular surface and meta-diaphyseal fractures. The use of such a protocol has been proposed for high-energy proximal tibia fractures to decrease the high rate of soft tissue compromise associated with traditional open methods of treatment. The choice of definitive fixation may include plates, nails, or non-bridging external fixation.     

One-stage treatment of open tibial fracture in a child using a distally based sural artery flap: a case report.

Open fractures in children have a high level of morbidity and require early treatment. This case describes the successful treatment of a child who sustained an open tibial fracture with soft tissue loss. The fracture was stabilized with a monolateral external fixator devised in our clinic, and the soft tissue loss was covered with a distally based sural artery flap. The flap is simple, can be done quickly, and a surgeon does not need microsurgical or specialty training to perform the operation. This combined use of external fixation and distally based sural artery flap is a straightforward technique in distal tibial open fractures of children with soft tissue loss.     

Pilon-tibiale-Frakturen

In the AO classification, the distal tibia is 43 and A type injuries are extra-articular, B type partial articular and C type involve the whole of the articular surface with complete separation of the joint from the diaphysis. The term pilon fracture should be confined to B(3) and C type fractures. The injury mechanism of pilon fractures will vary from a simple fall to a high energy road traffic accident, leading to increasing fracture comminution and greater soft tissue injury with more open fractures. Plain radiographs and CT-scans are diagnostic prerequisites. A spanning external fixator, with or without fixing the fibula, is the initial method of choice. The goal is to span the zone of injury with the fixator, to align the limb, to reduce the articular surface through very limited approaches, and to minimize complications related to treatment to maintain length and provisionally align the fracture. When soft tissue swelling has subsided definitive stabilization is performed. Bone grafting of defects is rarely necessary.     

Stabilizing the open fracture with the external fixator]

External fixation plays a major role in contemporary trauma care. Indications are not limited to the obviously open fracture but also to cases with severe "closed" soft tissue injuries (contusions, burns etc.). The technique is reviewed and importance of pin placement, fixator geometry, minimal internal fixation and staged fixator removal are stressed. The modern external fixation techniques may be used to obtain bony union or they may be used temporarily switching to definitive internal fixation upon obtention of soft tissue healing.     

Behandlungsergebnisse nach Versorgung von Unterschenkeletagenbrüchen

Between 1965 and 1982 68 patients with segmental-fracture of the tibia have been treated at the Department of Traumatology of the University of Mainz. These patients and their medical records have been investigated. The segmental-fracture of the tibia is characterized by a high percentage (56%) of open injuries and a large amount (11,5%) of bad results. The main problem is the open fracture with major soft tissue injuries. The results of our investigations show, that the degree of soft tissue involvement has a large influence on healing. Because of the critical blood-supply of the tibia and the major circulatory impairment in segmental fractures nailing with a thin nail is a good treatment. In open fractures with major soft tissue injuries the external fixator should be preferred, because it doesn't cause additional soft-tissue-injury.     

External fixator as primary and definitive treatment of tibial fracture with severe soft tissue damage

The initial treatment of choice of fractures with severe soft tissue damage of the leg is the stabilization with an external fixator. After successful healing the question arises whether to continue the initial treatment with the external fixator to bone union or to change the initial concept by an internal fixation. Our experience with 62 fractures of the tibia (follow-up of 59 fractures) from 1985 to 1989 shows that 72% of the fractures were healed by the external fixator alone. Delayed union or pseudoarthrosis occurred in 17% and were mostly treated by late internal fixation. An analysis of the fracture types (new AO classification) did not show certain fracture types, that did not respond to the external fixator treatment alone. We conclude that the reason for a delayed union or pseudoarthrosis is less a morphological than a biological one. We recommend the first and final external fixator as treatment for fractures with severe soft tissue damage of the leg.     

ARM: a modular hinged joint for the AO tubular external fixator

Certain complex traumatic elbow lesions challenge the orthopaedic and trauma surgeon. If they are not treated correctly, they cause a high rate of disability, arising from elbow instablility and stiffness, either by fibrosis or joint incongruity. Injuries such as complex fractures of the proximal third of the ulna, coronoid fractures associated with radial head fractures (the "terrible triad"), are even worse if they are accompanied by soft tissue lesions. Hinged external fixators, complemented by other surgical procedures, are, for many, a recommended alternative when dealing with irreparable lesions. The AO tubular external fixator, by virtue of its versatility, is a very important tool in orthopaedics and trauma, but there is not the possibility of using it as a hinged fixator. The authors describe a prototype of a hinged joint that can be applied easily to the AO tubular external fixator, converting it into a hinged one. This hinged joint, in conjunction with the AO tubular external fixator, has been applied in 5 patients; 2 "terrible triads", one posterior elbow fracture-dislocation with radial head fracture, one Monteggia fracture-dislocation and an anterior elbow dislocation that developed a forearm compartment syndrome. The patients' age range was between 20 and 72 years (median 45,6); 4 were male and 1 female. In 3 patients, either a type III coronoid fracture or a radial head fracture, could not be repaired. One radial head was totally removed and another one partially removed. The remaining indications were because of severe soft tissue lesions. Results were evaluated using the Mayo Elbow Score Scale and the Broberg and Morrey radiographic evaluation scale. The median follow up was 18 months(range 6 to 48 months). All 5 patients got a maximum score of 100 points in the Mayo's Elbow Score Scale, indicating excellent results. No patient suffered elbow pain, or any type of elbow instability. The median range of motion in flexion was of 127.5 degrees (max. 140 degrees and min. 120 degrees ) and the median extension loss was 20 degrees (max. 25 degrees and min. 15 degrees ). One patient had pronation limited to 70 degrees and one had supination limited to 70 degrees . Every patient was able to resume a normal daily life activity and returned to normal work. In 3 patients the radiographic evaluation was Grade 0 and in the other 2, Grade I. Two complications occurred, one was a distal ulnar Schanz screw loosening with osteolysis and the other was a superficial infection of one Schanz screw. It can be concluded that good results can be obtained in injuries with severe elbow instability and soft tissue lesions, using this hinged external fixator. With this new clamp, the AO tubular external fixator is transformed into a hinged one and a new use is added to this already very versatile system. This clamp is very easy to apply.     

克氏针外固定支架在治疗近指间关节骨折中的应用

目的 介绍一种克氏针外固定支架治疗近侧指间关节骨折方法.方法 自2006年7月-2009年7月,采用自行设计制作的克氏针外固定支架治疗近侧指间关节骨折9例.其中食指1例,中指3例,环指2例,小指3例;开放性骨折5例,闭合性骨折4例;单纯性骨折6例,粉碎性骨折3例.受伤至治疗时间为2h～8d,平均2d.随访5～36个月,平均13个月.手部功能恢复按TAM标准评价.结果 骨折全部愈合,按TAM标准评价：优5例,良2例,可2例,优良率77.8%.结论 克氏针外固定支架能够对近侧指间关节骨折起到良好的固定作用,而且其结构简单,方便实用,价格低廉.     

Schräg dorsaler Beckenfixateur Entwicklung und biomechanische Testung

In haemodynamically unstable patients with an unstable pelvic ring injury the primary stabilisation of the pelvis and thus reduction of pelvic volume is important for the success of the treatment. The pelvic C-clamp is an approved emergency device for these unstable pelvic ring injuries. A secondary procedure though is necessary in most of the cases with a hig rate of wound problems in already traumatized soft tissue areas. The ventrally placed external fixator is a simple and quick procedure with little soft tissue damage. Though primary stability is sufficient even for C-type injuries, biomechanic stability of the posterior pelvic ring is often insufficient for mobilization. Based on biomechanic considerations, a new dorsal oblique pelvic external fixator was developed for pelvic C-type injuries. With the advantages of the supraacetabular fixator and two additional Schanz screws the ventral fixator should stabilize the posterior pelvic ring with comparable stability to the pelvic C-clamp. A primary and already definitive minimal invasive stabilization of the posterior pelvic ring was the aim. In the first series several variations of this asymmetric fixator with two different Schanz screw applications were tested biomechanically. In a second series the favorite version was tested versus the supraacetabular fixator and the pelvic C-clamp. Both of the biomechanic test series were performed with artificial pelves in the one leg stance model in the material testing machine. SI disruption and sacral fracture were the posterior instability types in 6 pelves each. There was no statistically significant difference between the dorsal oblique fixator and the pelvic C-clamp. But the new fixator was significantly more stable than the supraacetabular fixator or the new fixator without pretension.     

Operative Therapie der distalen Radiusfraktur

Distal dislocated radius fractures are now mostly treated surgically. Closed reduction and internal fixation with Kirschner wires are increasingly giving way to internal fixation with screws or fixed-angle plates and to the use of the fixateur externe. For fractures with concomitant severe soft tissue injury treatment with a bridging external fixator and adequate soft tissue management are first necessary. External fixation is needed in addition, however, once soft tissue repair has been achieved by means of internal fixation with screws or K-wires, and the external fixator should remain in place until the fracture has started to heal. If possible preference should be given to the use of nonbridging fixators. Conservative treatment can now no longer be justified except for stable and nondislocated fractures. Arthroscopy/assisted reconstruction of the carpal articular surface is the subject of some controversy and is not yet accepted as a standard procedure.     

Chirurgisches Vorgehen bei offenen Kalkaneusfrakturen

Background

Open calcaneal fractures represent a group of rare injuries which should be treated by an interdisciplinary experienced team of surgeons. The degree of soft tissue damage determines the surgical therapy of the fracture.

Classification

Calcaneal fractures are classified according to the internationally recognized system proposed by Sanders, while the accompanying soft tissue damage is classified according to Gustilo and Anderson.

Therapy

Emergency treatment includes wound debridement and immobilization with an external fixator. Until the soft tissue situation is under control, further revision procedures might be necessary. Internal definitive osteosynthesis should be carried out up to 3 weeks after trauma, when wound closure can be accomplished simultaneously or carried out within a further 48 h of the operation. In some cases flap coverage might be required. Whenever internal fixation is not possible, external fixation should aim at a reduction according to the length, axis and rotation of the calcaneus. External fixation should be maintained as a hinged fixator to allow passive and active motion in the ankle and the subtalar joint.     

Alternative treatment methods in complex fractures and fracture-dislocations of the anterior tarsus

Obtaining and maintaining an anatomic reduction are the keystones in the treatment of severe midtarsal injuries to avoid long-term disability. The use of the small external fixator or the minidistractor allows an indirect reduction with careful management of the soft tissues. By leaving the external fixation for at least 8 weeks the important length of the medial and lateral longitudinal arch can be maintained. Further advantages are the postoperative observation of the soft tissues and circulation without cast immobilisation.     

微型外固定支架治疗掌指关节囊内粉碎性骨折

目的 评价应用微型外固定支架治疗掌指关节囊内粉碎性骨折的疗效.方法 8例掌指关节囊内粉碎性骨折,其中开放性损伤6例,闭合性损伤2例.采用Orthofix微型外固定支架固定,其中2例同时加用克氏针内固定,2例采用皮瓣覆盖创面.结果 术后平均8周骨折均愈合,未出现关节面不平整或关节间隙狭窄,受伤关节无不稳定.掌指关节活动范围达65°～85°,手握力达健侧80%～90%.结论 应用Orthofix微型外固定支架治疗掌指关节囊内粉碎性骨折,不仅能有效固定关节内的骨折,且大大缩短了骨折端的愈合时间,早期功能锻炼有效地减少了手指的致残率.     

Beckenverletzungen aktuell: Die Rolle des Fixateurs bei Ringinstabilitäten

The ventral external fixator is still the most versatile device for stabilization of pelvic ring instabilities. The fixator is minimally invasive and can be rapidly applied with high patient safety. The external fixator can also be mounted by experienced surgeons outside the operating room (e.g. intensive care unit, trauma bay or intermediate care unit). In the acute phase of severe bleeding in type B injuries the ventral external fixator can also be used alone as the best available procedure. In open book injuries it can internally rotate the displaced hemipelvis and in the case of lateral compression fractures with dislocated fragments, the fixator can externally rotate and distract the fractured hemipelvis. In type C injuries the ventral external fixator is predominantly applied as a complementary measure to dorsal stabilization (e.g. pelvic clamp). In cases of extensive soft tissue compression and/or contamination in complex pelvic injuries (e.g. Morel-Lavallée injuries) a ventral external fixator is often the only implant which can be used. In the secondary phase the ventral external fixator can remain in place after internal stabilization of the dorsal pelvic ring and leads to a higher patient safety during mobilization; however, the use as a secondary stand alone implant is rarely indicated for type B injuries, mainly because of the disadvantages and patient discomfort. Under these circumstances and particularly for multifragmentary fractures of the ventral pelvic ring, it is worthwhile considering the use of a subcutaneous supra-acetabular internal fixator if plate osteosynthesis is not possible.     

Einsatzmöglichkeiten des Fixateur externe bei Oberarm- und Ellbogenverletzungen

The treatment of diaphyseal fractures of the humerus is the subject of some controversy, as can be seen from the literature.For many decades, conservative treatment was the only option for these fractures.The range of indications for the application of external fixators in therapy of diaphyseal fractures of the humerus is now very narrow.We believe its use is indicated only as a primary treatment for polytraumatized patients and patients with severe soft tissue damage. Internal fixation should then follow as soon as possible because of the high rate of complications with external fixation of humeral fractures. Temporary fixation of the elbow joint is a very useful means of stabilization in cases of distal humeral fracture or elbow trauma with severe soft tissue damage or in polytraumatized patients. Elbow stability and a functional range of motion can be successfully reestablished by definitive treatment of the elbow joint with a hinged external fixator in the case of capsuloligamentous rupture and osseous instability after surgery.     

Therapie der distalen Radiusfraktur mittels Fixateur externe

The external fixator has a firmly established place in the treatment of distal radius fractures, including complex fractures (AO C2 and C3). Its use is also indicated for open fractures and compartment syndrome in the lower arm. In the context of “damage control orthopaedics” the external fixator is used in the distal radius as a fast, minimally invasive method of treatment in multiply injured and polytraumatised patients. Open reduction and internal fixation with plates (ORIF) can then be performed after consolidation of the soft tissue mantle and the patient’s general condition. Depending the fracture type and overall injury pattern complete healing can be achieved while the fixator is in place, with further supportive care as appropriate (K-wires, cancellous bone). The downside of treatment with the fixator is the long period of immobilization of the wrist with a protracted rehabilitation. Non-joint-bridging external fixators can have an advantage in individual cases. In the long term, there is no significant difference in the range of movement and strength developed after fracture treatment with internal rather than external fixators.     

Therapie von Femurschaftfrakturen

Femoral shaft fractures usually occur following high- impact trauma. Therefore, patients may suffer additional life- threatening injuries, which require adequate diagnostic work up and appropriate therapy. In addition to polytrauma injuries, diagnostic attention must be directed to detect vascular and nerval lesions. Often primary stabilization is performed using an external fixator as part of the concept of damage control surgery. For definitive stabilization, ante- or retrograde intramedullary nailing is predominately used and less frequently conventional or angular stable plate osteosynthesis or combination of these stabilization techniques. The concept of i.m. nailing preserves the soft tissue envelope by utilizing insertion points distant to the fracture site. Regularly, closed techniques can be employed for fracture reduction. Femur shaft fractures may be accompanied by ipsilateral fractures of the femur, and by injuries of the knee joint and lower leg. Although compartment syndrome is a rare complication of femoral shaft fractures, soft tissue condition require careful clinical evaluation prior to and after fracture stabilization.