Treatment of open fractures and dislocations of hand long bones

Efficiency of different fixation methods of open fractures and dislocations of hand tubular bones on the basis of treatment experience of 206 patients has been investigated in clinical conditions. Immobilization with a plaster bandage, osteosynthesis and transarticulation fixation by wires, osteosynthesis by external fixation apparatus were used. An analysis of long-term results of treatment of 128 patients demonstrated that fixation of damaged bones and joints by the external fixation apparatus is the most effective one.     

Management of distal tibial intra-articular fractures with circular external fixation

The treatment of tibial plafond fractures requires careful management of the soft tissue envelope, reconstruction of the articular surface and stable fixation with minimal additional damage. Thirty cases of AO type 43 C tibial fractures were treated by transosseous osteosynthesis (Ilizarov technique). The external fixator constructs used were Ilizarov (Transosseous osteosynthesis: theoretical and clinical aspects of the regeneration and growth of tissue, Springer, Berlin, 1992) and Sheffield (Classification AO des fractures, Springer, Berlin, 1987) circular fixator systems. All tibial plafond fractures healed. Using radiological criteria for assessment of reduction of the articular fragments and the clinical scoring system described by Teeny and Wiss, there were excellent and good restoration of articular structure in 27 cases and good clinical results in 14. This treatment method compares well with previous published series and is to be recommended for this group of difficult fractures.     

Arthrodese – Pseudarthrosen am Sprunggelenk Die fehlgeschlagene Arthrodese

Non-unions after fracture dislocation of the ankle joint are extremely rare with predominantly operative treatment. In contrast, after fractures of the tibial plafond (pilon fractures) infections are seen in the literature in 37 % and non-unions are seen in 27 % after open reduction and internal fixation, requiring secondary ankle arthrodesis in about one quarter of all cases. In contrast to aseptic non-union or arthrosis, which can be salvaged with screw arthrodesis, with prevailing infection and severe osteoporosis external fixation (either one- or two-sided) is the treatment of choice. In isolated non-unions of the malleoli, either plate osteosynthesis with 3.5 low-contact dynamic compression plate or tension banding with autologous bone graft interposition, or alternatively sliding graft technique, is performed with good results.     

Early history of operative treatment of fractures

Surgery in the first half of the nineteenth century was primarily dominated by pain and fear of lethal infections. Therefore, the absolute majority of fractures and dislocations were treated non-operatively. Development of operative treatment of fractures was influenced by three major inventions: anaesthesia (1846), antisepsis (1865) and X-rays (1895). The first to use external fixation is traditionally considered to be Malgaigne (1843). However, his devices cannot be considered as external fixation. Von der Höhe, in 1843, fixed a non-union of the femur by inserting into both fragments a couple of screws transversely connected outside the wound. Von Langenbeck in 1855 treated a non-union of the humerus with screws connected by a devise designed for this purpose. A predecessor of nailing of acute diaphyseal fractures may be considered to be fixation of diaphyseal non-unions of the femur, humerus and tibia with ivory intramedullary pegs, performed by Dieffenbach in 1846. Nevertheless, until 1885, osteosynthesis was still a Cinderella having at its disposal mainly wires, ivory pegs and very primitive types of external fixation. During the following 35 years (1886–1921), operative treatment of fractures witnessed an unprecedented revolution. Radiology became an integral part of bone and joint surgery. All types of osteosynthesis, i.e. plates (Hansmann 1886), external fixation (Parkhill 1897) and intramedullary nails (Schöne 1913) were introduced into clinical practice. Basic experiments were undertaken, surgical approaches described and the first textbooks on osteosynthesis published.     

Die operative Behandlung diaphysärer Tibiafrakturen

From 1988 to 1990 a total of 187 fractures of the tibia (92 compound, 95 closed fractures) were treated with a primary osteosynthesis. In 102 fractures an external fixation was performed, 85 internal fixations were divided into 58 intramedullary nails and 27 plates. In a follow-up study the fracture healing was analysed, 90% of the patients were examined about 18 months after the accident. The mean healing time was between 12 weeks (internal fixation) and 16 weeks (external fixateur). After primary Fixateur externe 54 were treated by secondary internal fixation, intramedullary nailing was the method of choice. Contamination rate of the tibia, taken by an intraoperative wound swab before nailing was 30%. Infection occurred in 3.2%, non union and refractures in 1.5% and 1%. Over all 80% excellent and good results were found after consolidation. 10% fair and 10% bad results including three amputations after III^o compound fractures and three death after polytrauma.     

External fixation as an alternative when treating 2nd and 3rd degree open lower leg fractures

Summary The infection rate of open lower leg fracture is extremely high. Surgical treatment guarantees a reduced risk of infection when compared with conservative treatments. But even osteosynthetic methods such as screw or compression plate fixation show unsatisfactory results because of the additional traumatization of the primarily injured soft tissue combined with a reduction of blood circulation. From July 1973 till September 1976 we treated 57 2nd and 3rd degree open shank fractures with osteosynthetic methods: 46 with compression plate osteosynthesis and 11 primarily or secondarily with external fixation. The osteitis-rate was 14%, in addition to that there was a soft-tissue infection rate of 5%. In order to change our therapeutical procedure we stabilized 2nd and 3rd degree open lower limb fractures and lower leg fractures complicated by soft-tissue damages consequently by external fixation.From October 1976 till May 1978 we treated 39 open shank fractures; 25 of them were 2nd and 3rd degree open fractures. They were treated by external fixation. This change in our surgical treatment resulted in an osteitis-rate of 2.6%, there was no case of soft-tissue inflammation.These results underline the superiority of treating 2nd and 3rd degree open lower leg fractures and fractures combined with soft-tissue injuries consequently and chiefly with AO external fixation.     

Surgical treatment of intra-articular calcaneal fractures

PURPOSE OF THE STUDY The calcaneus is one of the most complex bones in the human body. If fractured, restoration of its anatomy is demanding and displaced fractures may have permanent consequences affecting both daily living and work activities of the patient. In this prospective study, the authors present the results of surgical treatment of 48 dislocated intra-articular fractures of the heel bone. MATERIAL In the period from September 2006 to September 2009, 48 dislocated intra-articular fractures in 41 patients were surgically treated at the Department of Trauma Surgery in Bratislava-Kramare. Seven (17 %) patients, six men and one woman, had bilateral calcaneal fractures. In the group of 41 patients, 32 (78 %) were men and nine (22 %) were women. The average age of the group was 41 years (range, 16 - 64 years). METHODS Based on computed tomography scans, the fractures (n=48) were classified according to the Sanders system into Sanders II to IV subgroups. This included 26 Sanders II fractures (54 %), 15 Sanders III fractures (31 %) and seven Sanders IV fractures (15 %). Minimally invasive reduction and osteosynthesis (MIOS) was used to treat 16 Sanders II fractures (33.33 %) and two Sanders IV fractures (4.16 %). Open reduction and internal fixation (ORIF) was employed in 10 Sanders II fractures (20.83 %), all 15 Sanders III fractures (31 %) and one Sanders IV fracture (2.08 %). Four comminuted fractures (8.33 %) classified as Sanders IV fractures were stabilised with an external fixator. The surgical technique was selected in accordance with the bone morphology, soft tissue condition and patient's overall state. RESULTS The patients were followed up for 6 to 36 months and clinical assessment was based on the Creighton Nebraska Health Foundation scoring system (C-N score) and the AOFAS Ankle-Hindfoot Scale (A-H score). The functional outcomes were excellent in 25 fractures (52 %), good in nine (18.75 %), less satisfactory in eight (16.6 %) and poor in six fractures (12.5 %). Complications of wound healing were recorded in three fractures (6.25 %) treated by ORIF, and only involved superficial marginal wound necrosis. There was no deep wound infection. Algodystrophic syndrome developed in two cases (4.16 %). X-ray measurements were used to assess the final B?hler's angle, whose value after treatment ranged from 8° to 38°, with an average of 27°. DISCUSSION At present the selection of an operative technique is being discussed. The advocates of MIOS emphasise a lower com- plication rate associated with wound healing and the possibility of using this technique when the treated tissues are in a critical condition. The advantage of ORIF lies in exact open reduction and stable osteosynthesis. CONCLUSIONS The method of percutaneous reduction and osteosynthesis is the optimal treatment for Sanders II dislocated fractures. Severely dislocated fractures (Sanders II and III) require open reduction and plate osteosynthesis. Comminuted fractures should be treated first by external fixation and by arthrodesis at the second stage if problems arise.     

钢板与外固定架治疗桡骨远端不稳定骨折的疗效分析

目的 探讨钢板内固定与外固定架治疗桡骨远端不稳定骨折的临床疗效.方法 回顾性分析2004年10月～2008年10月期间应用钢板与外固定架固定治疗62例桡骨远端不稳定骨折的临床疗效.其中切开复位钢板内固定27例(钢板组),闭合性骨折23例,开放性骨折4例;骨折按AO分型:B型17例,C型10例.平均手术时间86 min(...     

Ist die Behandlung der instabilen distalen Radiusfraktur beim älteren Menschen mittels Fixateur externe nicht mehr indiziert?

BACKGROUND: In recent years there has been an increasingly marked shift in the operative treatment of unstable fractures of the distal radius. The introduction of locking compression plates has made it possible to extend the indications for palmar stabilisation according to the principles of internal fixation to extension fractures even in osteoporotic bone, and since then the new design has been used more and more widely. First clinical results show very good and good clinical and radiological outcomes in over 80% of cases after locking compression plate osteosynthesis. All this raises the question of whether external fixation is no longer indicated for distal radius fractures in the elderly, or is now no more than a second-line treatment. PATIENTS AND METHODS: Within a 5-year period, 67 patients over 65 years of age were identified among 220 who had had unstable fractures of the distal radius in our hospital with external fixation. The average follow-up period (clinical and radiological examinations) was 37 months. We devoted particular attention to the analysis of complications and problems during the treatment. RESULTS: Complete bone healing was observed in all patients treated with external fixation. In most cases, complications were minor pin-track infections (10%). The radiological follow-up examination revealed radial shortening by an average of 2 mm and an average radial shift of 0.2 mm. The joint angle was 2.5 degrees with lateral irradiation and 18 degrees with dorso-palmar irradiation. According to the Gartland and Werley score, the functional, radiological and subjective outcome was excellent or good in 87% of these patients. CONCLUSIONS: Overall, internal fixation with angular fixed plates has definite benefits. The medium- and long-term follow-up and functional outcome still show no benefits over external fixation, however. External fixation is a genuine option, even if as second-line treatment.     

Biology and Biomechanics in Osteosynthesis of Proximal Humerus Fractures

Abstract Surgical treatment of proximal humeral fractures still remains a challenge. This is primarily due to the fact that sufficient implant fixation in humeral head fractures is often not achieved due to substantial bone tissue loss with increasing age. In the last few years the locking plates and locking nails have been introduced into clinical practice with varying results. The biomechanical studies have focused on locking plate osteosynthesis as well. The following paper focuses on bone quality, biomechanical studies and biology of proper osteosynthesis and reviews the most recent literature.     

面中份骨折小钛板内固定和钢丝骨间结扎治疗的比较观察

目的 比较钢丝骨间结扎和小钛板内固定治疗面中份骨折的临床效果。方法 采用头皮冠状入路及辅助切口,对40例面中份骨折行钢丝骨间结扎和小钛板坚固内固定治疗。结果 钢丝骨间结扎不能获得良好的稳定性,而小钛板坚固内固定则可重建面中份骨骼的支柱结构,获得足够的三维稳定性和重建理想的面部外形。在眶下缘、颧上颌缝区,手术野显露较差,小钛板内固定较钢丝骨间结扎更为方便可靠。结论 小钛板坚固内固定是治疗面中份骨折的最佳方法。     

面中份骨折小钛板内固定和钢丝骨间结扎治疗的比较观察

目的比较钢丝骨间结扎和小钛板内固定治疗面中份骨折的临床效果。方法采用头皮冠状入路及辅助切口,对４０例面中份骨折行钢丝骨间结扎和小钛板坚固内固定治疗。结果钢丝骨间结扎不能获得良好的稳定性,而小钛板坚固内固定则可重建面中份骨骼的支柱结构,获得足够的三维稳定性和重建理想的面部外形。在眶下缘、颧上颌缝区,手术野显露较差,小钛板内固定较钢丝骨间结扎更为方便可靠。结论小钛板坚固内固定是治疗面中份骨折的最佳方法。     

Transosseous osteosynthesis with Gorodnichenko's devices in the treatment of polytrauma

From 1997 to 2003 eighty-three patients with poly- and multiple fractures underwent transosseous osteosynthesis with rod and pin-rod Gorodnichenko's devices, without drilling of bone marrow canal. Primary osteosynthesis was performed during 48 hours after trauma. The new pin apparatus of external fixation were the best method of osteosynthesis of poly- and multiple fractures in patients with polytrauma. This policy permitted to achieve good and satisfactory results in 94.3% patients with polytrauma.     

面中份骨折小钛板内固定和钢丝骨间结扎治疗的比较观察

目的比较钢丝骨间结扎和小钛板内固定治疗面中份骨折的临床效果。方法采用头皮冠状入路及辅助切口,对40例面中份骨折行钢丝骨间结扎和小钛板坚固内固定治疗。结果钢丝骨间结扎不能获得良好的稳定性,而小钛板坚固内固定则可重建面中份骨骼的支柱结构,获得足够的三维稳定性和重建理想的面部外形。在眶下缘、颧上颌缝区,手术野显露较差,小钛板内固定较钢丝骨间结扎更为方便可靠。结论小钛板坚固内固定是治疗面中份骨折的最佳方法。     

Konservative vs. operative Behandlung bei Oberarmschaftfrakturen

The treatment of diaphyseal fractures of the humerus is discussed in the literature as a controversial subject. For many decades, conservative treatment was regarded as the only option for these fractures, but in the last 10 years there has been a remarkable shift towards internal stabilization and fixation with plates or unreamed nails. Use of an external fixator is very seldom indicated for diaphyseal fractures of the humerus. It should be used exclusively for temporary primary fixation in polytraumatized patients and in cases with severe soft tissue damage. An internal osteosynthesis should follow as soon as possible, because of the high rate of complications – pin-track infections in up to 50%, deviation of axis in 64%, nonunion in up to 57% – with external fixation of humeral fractures.     

The role of plating in the operative treatment of severe open tibial fractures: a systematic review

Open fractures of the tibial diaphysis are the result of high-energy trauma. They are usually associated with extensive soft tissue loss and represent serious clinical problems. Surgical treatment of these injuries has been associated with substantial complications such as osteomyelitis, delayed bone healing, poor functional outcome, soft-tissue failure, or even amputations. More recently a staged treatment, with initial application of spanning external fixators followed by definitive fixation at secondary phase, has been advocated. Plating of these fractures in the acute setting remains a topic of heated discussion. A systematic review of the literature was carried out in order to investigate the existing evidence concerning the efficacy and safety of this method of osteosynthesis. Eleven papers met the inclusion criteria, accumulating 492 open tibial fractures treated with plating. The overall union rate ranged from 62-95% across all studies, with time to union ranging from 13-42 weeks. The reoperation rate ranged from 8-69% and a pooled estimate of deep infection rate was calculated at 11%. Plate fixation for the treatment of open tibial fractures can be considered under specific conditions which need to be elicited and clarified with future well-designed and conducted clinical trials.     

The use of external fixation apparatus in injuries to the hand bones]

An analysis of experimental studying the stability of osteosynthesis and clinical application of apparatuses of external fixation in 282 patients with fractures and sequellae of traumas of the bones and joints of the hand is presented. Main conditions influencing stability of fixation of the hand bones were determined. A universal complex of details is recommended which allows to make the optimum construction of the device as applied to the specific kind of trauma. It was proved that choice of the individual construction of the apparatus considerably widened the scope of using the method of external fixation and improved results of the treatment.     

肋骨环抱接骨板内固定治疗多发性肋骨骨折的临床分析

目的探讨肋骨环抱接骨板内固定治疗多发性肋骨骨折的疗效。方法回顾性分析我科2010年6月～2011年3月收治的56例多发性肋骨骨折患者的临床资料,比较肋骨环抱接骨板内固定组(A组)与加压包扎外固定组(B组)的疗效。结果患者均治愈出院,骨折断端骨性愈合。A组肺部感染、肺不张、胸廓畸形、骨折移位等并发症的发生率均较B组低(P<0.01);而且A组患者在胸腔引流管留置时间、术后卧床时间和住院时间上均短于B组(P<0.05)。结论肋骨环抱接骨板内固定治疗多发性肋骨骨折具有操作简便、创伤小、痛苦小、组织相容性好、并发症少、固定可靠、术后恢复快等特点,利于促进骨折愈合和改善呼吸功能,是治疗多发性肋骨骨折较理想的方法。     

Carbon external fixator--CARBOELASTOFIX in treatment of tibia diaphysis fractures]

The authors presents the results of healing status of tibia diaphysis fractures treated with carbon-plate fixator on a group of 12 patients (9 men and 3 women with age between 27 and 89 years). Long-term mechanical investigations and studies at animals, performed at our Department have shown advantages of bone fixation performed with a new device for osteosynthesis, called by authors CARBOELASTOFIX. General principle of the method is the use of external fixation device, made of carbon-epoxide resin composite plates with variable flexibility, enabling hastened fracture healing. The research allowed also to work out the guidelines of indications for surgery, surgical technique and method of modifying flexibility of fixation consistently with fracture healing course. The mean time of observation (from the operation to the healing) was 23 weeks, having 10 good and 2 bad results.     

Die Versorgung der distalen Radiusfraktur

Background

How effective is open reduction and internal fixation with palmar locking plates compared to closed reduction and internal fixation with K-wires in the treatment of fractures of the distal radius?

Method and materials

A systematic review of the literature was performed for the years 2002 to 2012 to find controlled studies comparing K-wires and locking palmar plates. Follow-up, complications, functional results, radiographic results and peculiarities of the studies were analyzed.

Results

A total of five controlled studies could be found and additionally the data of one unpublished controlled prospective study were added. In two studies a better function (DASH) could be achieved following palmar locking plate osteosynthesis, in one study better results were found following K-wire osteosynthesis and three studies found no significant differences. Ulna variation was found to be better restored following palmar locking plate osteosynthesis in two, palmar inclination in two and radioulnar inclination in one study. There were 7.3% complications following palmar locking plate osteosynthesis compared to 20% following K-wire fixation; however, the complications following plate osteosynthesis were more severe.

Conclusions

Palmar locking plates as well as K-wire fixation are suitable techniques for the treatment of fractures of the distal radius. The higher stability of locking plates seems to lead to an earlier functional recovery but this possible advantage disappears in the long-term follow-up.