Fractures of the shaft of humerus

Humeral shaft fractures account for 1–3% of all fractures. Non-surgical management with functional bracing is arguably the standard of care for most humeral shaft fractures.It results in high union rates and in general the outcome is excellent. Surgical management is indicated in some cases, such as open fractures, polytrauma, those with associated vascular injury, pathological fractures, floating elbow injuries and fractures that have failed non-surgical management. Options for surgical fixation include open reduction and internal fixation with plate osteosynthesis, antegrade or retrograde intramedullary nailing and external fixation. Both plate osteosynthesis and intramedullary nailing yield similar results, with a slightly higher rate of complications and re-operations with nailing. A high incidence of radial nerve injury has been associated with humeral shaft fractures and should be actively sought. The management of nerve injuries is still a matter of debate, however; initial expectant treatment with delayed exploration if needed seems to yield similar results to early exploration. Proper patient selection is key to achieving good outcomes with both surgical and non-surgical management of these injuries.     

Paediatric lateral condyle fractures of the distal humerus

Lateral humeral condyle fractures are the most common intra-articular fracture of the skeletally immature elbow and the second most common elbow fracture in children (approximately 16%). Inadequately treated fractures can lead to non-union and growth disturbance which results in deformity and loss of function. Controversy remains regarding the management of these fractures, as there are no randomized controlled trials of treatments and the literature consists mainly of retrospective case series. In this article, we will present the key points from the literature currently available. This includes recent articles that define the consistent fracture plane and studies that suggest the optimal imaging techniques to determine amount of displacement, which is an important factor for prognosis, unlike medial epicondyle fractures. We offer pragmatic management strategies for lateral humeral condyle fractures.     

Paediatric supracondylar fractures: an overview of current management and guide to open approaches

Supracondylar fractures of the humerus are common fractures in children. Closed reduction and percutaneous pinning is the primary method of management, though 2–12% of these fractures require open reduction. There is no conclusive evidence to dictate the best surgical approach to the fracture. This paper aims to review supracondylar fractures of the humerus and discusses the early and late associated complications. The treatment options are then examined, with a focus on the preferred surgical approach to open reduction. If an orthopaedic surgeon is going to learn only one approach for reduction of these challenging fractures, then we recommend becoming familiar with the anterior approach. This is the approach one would need to use in most open fractures and in those where exploration of the brachial artery is indicated. It gives access to the neurovascular structures, to the fracture site and also to the soft tissues that are likely to block reduction. The cosmetic and functional outcomes are reported to be good.     

Fractures of the tibial shaft in adults

Diaphyseal tibial fractures are the most common long bone fracture. There are a variety of treatment options, both operative and non-operative, and satisfactory outcomes are reliant on a thorough understanding of the strengths and weaknesses of the different treatment modalities, and their most useful applications. Certain fracture patterns present particular difficulties and these must be recognized pre-operatively so that an appropriate surgical strategy can be planned. Compartment syndrome can be a devastating complication, and must be kept in mind at all times.     

Complications of hand surgery

Hand surgery involves the surgical treatment of hand conditions and encompasses small bone fixation, arthroscopy, joint replacement and reconstruction of tendon and nerves. Complications following surgery to the hand may be due to patient factors, surgical decisions and the complex anatomy of the hand. Here we describe the complications associated with common surgical interventions for both elective and traumatic injuries to the hand. Following hand surgery, a balance between immobilisation and early range of motion is offset by the risk of wound complications, non-union of fractures and tendon re-rupture with stiffness and reduced range of motion of the digits. Superficial infection is relatively common following procedures to the hand, however long-term sequelae are rare. Implant failure, subsidence, instability and reduced range of motion are seen following arthroplasty procedures. Complex regional pain syndrome offers a significant challenge following injury to the hand and specifically after surgical procedures. Surgeons should consider the risk of particular surgical techniques, other perioperative factors and patient factors that may contribute to the development of complications following hand surgery. Patients should be adequately counselled in order to make an informed decision regarding the management of their condition.     

Fractures of the proximal humerus: overview and non-surgical management

Proximal humeral fractures account for 6% of all adult fractures, usually occurring in elderly patients following a low-energy fall. Fracture patterns occur because of the intricate bony anatomy of the proximal humerus and its rotator cuff attachments, which cause displacement of the tuberosities in a predictable nature. This can lead to long-term functional deficit, not only due to mechanical restrictions but also biological consequences such as impaired vascularity and avascular necrosis. The majority of fractures can be treated non-operatively to give satisfactory restoration of function for the vast majority of patients, with recent literature evidence supporting this method of management.     

Distal humeral fractures in the adult

The management of distal humeral fractures in adults presents a unique set of challenges. Almost always they necessitate operative management, which might include complex intra-articular fracture fixation of very comminuted free fragments in an already complex joint, or, increasingly, novel arthroplasty techniques. Clinicians managing these injuries must be confident that they possess the requisite skills set, and, in the UK at least, this in itself is under scrutiny. This summary aims to acquaint the reader with the basic knowledge sufficient to begin to understand the approaches to managing these injuries, and some of the decision-making difficulties that are encountered.     

Fractures of the mandibular condyle: evidence base and current concepts of management

Management of mandibular condylar fractures remains a source of ongoing controversy. While some condylar fractures can be managed non-surgically, recognition of fracture patterns that require surgical intervention and selection of an appropriate operative procedure are paramount to success in treating these injuries.The objective of this review is to appraise the current evidence regarding the effectiveness of interventions that are used in the management of fractures of the mandibular condyle.     

(iv) Hemiarthroplasty in proximal humeral fractures: surgical technique

Proximal humeral fractures are common and increasing in incidence. The majority of undisplaced injuries can be treated conservatively but the optimal management of displaced three and four part fractures remains debatable. Hemiarthroplasty is typically used for fractures that cannot be reliably reconstructed using locking plates or where there is evidence that the blood supply to the head has been significantly compromised.This article focuses on the surgical technique of hemiarthroplasty and highlights the key principles necessary to achieve an optimal outcome. Finally, the option of reverse shoulder arthroplasty for the treatment of proximal humeral fractures is briefly discussed.     

Surgical fixation of the adult distal radius fracture: when and why?

Distal radius fractures (DRF) are common. They have a bimodal distribution typically occurring as a high-energy injury in the young or a low-energy injury in the older patient with osteoporosis. With the number of DRF predicted to rise, it is important to know how to manage DRF appropriately. The options for the surgical management of adult DRF can appear varied and bewildering. This is further confused by the expanse of literature available regarding the different options, the different types of plate design, and the almost bipartisan belief that either minimalist techniques may be all that are required versus the compulsion to meticulously restore normal anatomy in an attempt to maximize function and reduce disability.     

The rationale behind surgical approaches to ankle fractures

Ankle fractures and fracture dislocations are one of the commonest injuries seen by orthopaedic surgeons. Decisions around the surgical fixation of ankle fractures require an understanding of the bony and ligamentous anatomy of the joint as well as an appreciation of the normal ankle joint biomechanics. The operative treatment of these injuries aims to hold the joint securely in an anatomically reduced position throughout the period of healing, and allow initiation of joint motion as soon as possible. If these treatment goals are met, a good outcome is a reasonable expectation, given the proviso that disruption of any articular surface can result in permanent damage. However the functional outcome of fractures involving a posterior malleolar fragment is often not satisfactory and recent debate has surrounded ankle fracture fixation, with the posterior malleolus in particular being subject to increased scrutiny for its contribution towards long-term ankle stability. With the advent of excellent results from the use of open reduction and rigid internal fixation, the gold standard of treatment for displaced ankle fractures has become surgical fixation. This article explores the evidence behind commonly used surgical approaches to ankle fracture fixation and the rationale behind their use.     

ȧ�Ǹ�������۵�����

提要：颧骨复合体骨折（zygomatic complex fractures,ZCF）是颌面部常见的骨折之一,近年来发病率呈上升趋势。目前,颧骨复合体骨折的治疗包括保守治疗和手术治疗两类。随着“功能与外形双项标准” 的提出,颧骨复合体骨折的开放治疗逐渐增多。本文介绍了颧骨复合体骨折治疗的现状以及存在的问题,并对颧骨复合体骨折的规范治疗做一简述。     

Paediatric humeral supracondylar fractures

The supracondylar humeral fracture is the most common elbow fracture in children accounting for just under one-fifth of all paediatric fractures and 60% of paediatric elbow fractures. Modifications of the Gartland classification have been made over the years. The mainstay treatment option is that of closed reduction and percutaneous wiring. However, there remains no gold standard in the management of this injury. Outcomes from other treatment options, including traction and external fixator application have been described and report good results. There remains controversy in the wiring configuration used, and there is no consensus on the approach to be used when faced with an irreducible fracture. This article aims to provide an up-to-date overview of the current practices in the management of this common injury, including the ‘pink pulseless’ hand, ‘poorly perfused white’ hand, surgical techniques, and the associated complications that can ensue.     

(ii) Thoracolumbar spinal fractures: review of anatomy,biomechanics, classification and treatment

The management of thoracolumbar spine fractures remains a controversial issue. There is disagreement both as to how to describe these injuries and how to manage them.No ideal classification system, accepted by the world of spinal surgery, exists and such systems are under on-going development. While the majority of these injuries can be managed conservatively, new surgical techniques have been developed alongside the evolution of diagnostic tools classification systems.This article aims to revise important concepts that may help surgeons in training to understand spinal injuries and the modern approach to the management of thoracolumbar trauma.We describe relevant thoracolumbar spine anatomy and biomechanics followed by a discussion of historical and modern classification systems, and the treatment methods available to surgeons.     

Extraoral approach to mandibular condylar fractures: Our experience with 100 cases

IntroductionMandibular condylar fractures are very common. The current literature contains many indications and methods of treatment. Extraoral approaches are complicated by the need to avoid injury to the facial nerve. On the other hand intraoral approaches can make fracture reduction and/or fixation difficult. The mini-retromandibular approach provides an excellent view of the surgical field, minimises the risk of injury to the facial nerve, and allows rapid and easy management of condylar fractures.We have collected and reviewed our first 100 condylar fractures treated by means of a mini-retromandibular approach.Patients and methodsBetween June 2006 and June 2012, Eighty-seven patients with extracapsular condylar fractures underwent open reduction and rigid fixation for 100 extracapsular condylar fractures via a mini-retromandibular approach.ResultsDental occlusion and anatomic reduction were restored in all 100 condylar fractures. Postoperative infection developed in three patients. There was one sialocele and one case of plate fracture. Four patients experienced transient palsy of the buccal branch of the facial nerve. No permanent deficit of any facial nerve branch was observed.No patient showed condylar head resorption.ConclusionsOur experience with the treatment of the first 100 condylar fractures using the mini-retromandibular approach has demonstrated that this technique has allowed the Authors to safely manage extracapsular condylar fractures at all levels.     

Indications and principles of surgical treatment in injuries affecting the thoracolumbar spine

Vertebral fractures are very common and primarily affect the thoracolumbar spine as the result of an isolated injury or in polytrauma patients. The majority of these fractures can be treated non-operatively. Surgical stabilization of thoracolumbar fractures may be indicated after high-energy trauma or in the multiply injured patient. Surgery aims to provide a stable spinal column to allow early mobilization and optimize neurological outcome. This article considers the principles of clinical assessment and decision-making in the surgical management of thoracolumbar fractures. The AO spine thoracolumbar classification system can be used to guide treatment because the choice of surgical strategy depends on the biomechanics of the injury. Most injuries can be stabilized through a posterior approach but anterior column reconstruction can be performed, either as a stand-alone procedure or in order to support a posterior stabilization. The use of minimally invasive techniques is discussed. Interventional spinal technologies for osteoporotic vertebral compression fractures are also considered.     

钛板内固定术治疗颌骨骨折并发症及其防治

目的：探讨颌骨骨折钛板内固定术并发症的防治对策,方法：总结1999年1月至2007年12月间颌骨骨折钛板内固定患者412例。其中上颌骨骨折113例,下颌骨骨折201例,上下颌骨联合骨折98例。结果：经过术后3～12个月随访,40例术后出现不同程度的并发症。其中咬合关系不良19例,感染7例,钛板外露6例,神经损伤4例,牙损伤2例,颌骨部分坏死2例。结论：严格规范的手术操作和正确的术后处理是防治颌骨骨折钛板内固定术并发症的关键。     

Radial head fractures – update on classification and management

Radial head fractures require careful assessment and appropriate treatment to prevent disability from stiffness, deformity, post-traumatic arthritis, or other serious complications. Most undisplaced fractures are treated non-surgically, the main emphasis being focussed on early mobilization in order to achieve good results. The treatment of more complex radial head fractures associated with, or without, elbow instability remains controversial with the surgical choices ranging between open reduction and internal fixation and radial head excision – either early or late, with the option of radial head replacement to be considered. Simple, early excision of the radial head has more recently been reported to result in an unfavourable outcome in a significant number of cases. The Mason classification is widely used and guides the treatment plan. Understanding the mechanisms of normal elbow function and practising good surgical technique are crucial in the management of these injuries. This article discusses the aetiology, mechanism of injury, classification and management of radial head fractures.     

Less common orbital fracture patterns: the role of computed tomography in the management of depression of the inferior oblique origin and lateral rectus involvement in blow-in fractures.

During the past decade, advances in radiographic imaging have made it possible for the surgeon managing orbital fractures to adopt a rational therapeutic strategy based on a knowledge of alterations in surgical anatomy secondary to traumatic injury. To illustrate the value of computed tomography in the surgeon's armamentarium for management of orbital fractures, cases are presented in which imaging proved decisive in planning a course of therapy. Two patients presented with two types of isolated lateral blow-in fracture, an uncommon fracture pattern. The other cases underscore the value of defining involvement of the inferior oblique origin and lateral rectus muscles in imaging complex orbital fractures, issues not emphasized in earlier literature. Although diplopia alone does not always warrant surgical intervention, diplopia in the context of computed tomography-defined muscle entrapment or muscle origin displacement justifies operative therapy. These cases demonstrate the value of computed tomography in directing surgical therapy with resolution of diplopia and prevention and correction of enophthalmos.     

Paediatric medial epicondyle fractures of the distal humerus

Medial humeral epicondyle fractures represent approximately 12% of elbow injuries in children. It is a controversial topic in paediatric fracture management, as there is a trend towards extending the indications for surgical management that is not supported by high-quality evidence. In fact, the current literature can be contradictory and consists of mainly retrospective studies including small numbers of patients. The only absolute indication for surgery is when the medial epicondyle fragment becomes incarcerated within the elbow joint. In this article, we will present the important anatomical, physiological and interventional factors to allow independent interpretation of the literature. The current literature will be reviewed and a pragmatic approach to treatment presented. Due to the porosity of the current evidence on medial epicondyle fractures high-quality research is urgently required in the form of a adequately power definitive randomized control trial.