Évaluation d’une modification de la technique d’arthrodèse totale du poignet rhumatoïde selon Mannerfelt. À propos de 19 cas

We studied a technical modification of Mannerfelt's total wrist fusion technique in a series of 19 wrists. A fully intramedullary technique without dorsal carpal fixation was used to protect the extensor tendons. Two intramedullary Rush pins without dorsal staples were used during the arthrodesis procedure. Nineteen rheumatoid arthritis wrists (2 bilateral cases) were reviewed with a mean follow-up of 4.9 years (range 2–10 years). Clinical outcomes were assessed using the VAS pain scale, DASH-score and wrist strength measurements. Wrist fusion was assessed on AP and lateral X-rays of the wrist. The position of the carpal Rush pin entry points and distal hook orientation were also assessed. Pain was 8.9 preoperatively and 1.1 at the last follow-up with 95% patients satisfied. Mean DASH-score was 46.9 points. The pinch strength was 79% and the grip strength was 68% of the contralateral wrist. Carpal height, carpal anterior subluxation and ulnar deviation were stable at the last follow-up. All of the wrists were in straight position and no extensor tendon ruptures were noted. Fusion was complete in all cases within 6 to 12 weeks, except in one case. The technical modification proposed in the current study — intraosseous fixation only — appears to be a good alternative to Mannerfelt's original technique. Every case treated with this modified technique had good functional results and none required pin removal.     

改良Uhl闭合穿针技术治疗Colles骨折回顾性研究

目的:回顾性分析中国接骨学(Chinese osteosynthesis,CO)理念指导下改良Uhl技术治疗Colles骨折的优势。方法:回顾性研究2016年1月至2021年6月采用改良Uhl闭合穿针技术治疗Colles骨折358例,符合条件的纳入120例,按照手术方法不同分为两组:闭合穿针组和切开复位组。闭合穿针组68例,采用CO接骨理念指导下改良Uhl闭合复位经皮穿针技术;切开复位组52例,采用切开复位钢板内固定技术。术后6个月比较两组腕关节改良的Sarmiento影像学评分、Gartland-Werley腕关节评分及手术时间、住院时间、治疗费用。结果:两组患者均获得6个月以上随访。两组在Sarmiento影像学评分、Gartland-Werley腕关节评分方面比较,差异无统计学意义(P>0.05)。闭合穿针组手术时间(35.88±14.11) min、住院时间(9.78±2.48) d、治疗费用(16 074.91±1 964.48)元,与切开复位组手术时间(65.48±14.26) min、住院时间(15.88±2.00) d、治疗费用(20 451.27±1 760.2...     

The management of forearm fractures in children: a plea for conservatism

A retrospective review was undertaken to evaluate the efficacy of primary nonoperative treatment (closed reduction and long-arm casting) along with pins and plaster as a salvage technique for those reduction failures. A total of 730 closed fractures (1987-1993) was compiled, of which 300 required closed reductions and casting. Excluded from the study were teenagers whose growth plates were closed. Of the 300 fractures requiring closed reductions, 22 went on to require remanipulations, and 12 required the use of pins-and-plaster technique to obtain or maintain satisfactory reduction. Complications in the group treated in this manner included two superficial pin infections treated with antibiotics and two forearms with moderate loss of pronation/supination not requiring treatment. We believe that closed reduction of pediatric forearm fractures remains the accepted standard and the technique of pins and plaster should be considered a reliable alternative for the unstable injuries.     

Evaluation of pediatric lower extremity fractures managed with external fixation: outcomes in a deployed environment

External fixation of pediatric lower extremity fractures is usually reserved for severe, open fractures in polytraumatized patients, but it is often the only available treatment option for deployed military surgeons. We analyzed the outcomes and complications of 17 consecutive pediatric long bone fractures treated with external fixation at a Forward Surgical Team facility in an austere environment during Operation Enduring Freedom in Afghanistan during a 12-month period. Treatment consisted of uniplanar external fixation for 12 femoral shaft fractures (11 closed), 4 tibial shaft fractures (all open), and 1 subtrochanteric fracture (closed) in 14 males and 3 females with an average age of 7.4 years. All 17 fractures went on to union with no incidences of refracture. Complications included 1 broken pin and 3 pin site infections treated with wound care and oral antibiotics. In a deployed environment, external fixation is the treatment method of choice for lower extremity fractures by virtue of patient, environment, equipment, and mission factors. This case series validates the usage of a simple, uniplanar external fixator for a variety of open and closed pediatric long bone fractures as evidenced by the successful union rate and low number of complications.     

Treatment of displaced supracondylar fractures of the humerus in children by a pin leverage technique

This study aimed to evaluate the use of pin leverage in the reduction of Gartland type III supracondylar fractures of the humerus in children. The study comprised 95 children, who were split into three groups according to the type of method of reduction used. Group 1, had an open reduction, group 2, had closed reduction and percutaneous pin fixation and group 3, the pin leverage technique. Each group was analysed according to the time to surgery, the duration of the procedure, the incidence of complications, and the clinical and radiological outcome. The mean duration of the operative procedure in groups 1, 2 and 3 was 119 minutes (80 to 235), 57 minutes (20 to 110) and 68 minutes (30 to 90), respectively. At a mean follow-up of 30 months (12 to 63) the clinical results were declared excellent or good in all children and the radiological results intermediate in five patients in group 2. The results of the closed reduction using the pin leverage technique was classified as failure in two children. Our findings lead us to believe that the pin leverage method of reduction gives good results in the treatment of Gartland type III fractures.     

A comparison of plate and pin fixation for arthrodesis of the rheumatoid wrist

This retrospective study compared plate fixation versus pin fixation in 57 patients with rheumatoid arthritis who underwent wrist arthrodesis. Fixation was achieved by using plates in 32 patients and longitudinal pins in 25 patients. Clinical follow-up averaged 29 months (range: 12-57 months) and radiographic follow-up averaged 16 months (range 12-39 months). Union occurred in 97% of the wrists fixed with plates and in 96% of the wrists fixed with pins. There were 6 (19%) complications in the plate group and 7 (28%) complications in the pin group. Three (12%) wrists fixed with pins moved from the immediate postoperative position to a position of relative volar flexion, while radiographs showed no changes in wrist position in the plate group. With both methods, successful arthrodesis stabilized the wrist in a high percentage of patients. Plate fixation offers an excellent alternative method for arthrodesis of the rheumatoid wrist.     

Arthrodesis of the wrist by internal fixation in rheumatoid arthritis: a follow-up study of forty-five consecutive cases

Between 1972 and 1981, 59 wrists of 44 patients destroyed by rheumatoid arthritis were arthrodesed by internal fixation with a Rush pin. This study comprises 45 wrists of 38 surviving patients--nine men and 29 women, aged 20 to 72 years. The follow-up time ranged from 1 to 11 years with a mean of 3.9 years. The surgical technique used in this study is simple and safe, and a good position of the wrist in both frontal and lateral projections can easily be achieved. The Rush pin is passed down the third metacarpal and into the radius. It stabilizes the wrist adequately. All the wrists operated on obtained a strong bony fusion of the radiocarpal joint. The complication rate was low. Five of 45 Rush pins were removed because the subcutaneously located distal tip between the metacarpals irritated tendons and skin. In one male patient a thin Rush pin broke and a pseudoarthrosis of the intercarpal joints developed; there was, however, no need to remove the pin.     

Cross pinning of supracondylar fractures from a lateral approach. Stabilization achieved with safety

Purpose Various pin configurations are possible to stabilize a supracondylar fracture. While cross pinning gives the best stabilty the disadvantage is the risk of iatrogenic ulnar nerve injury. We combine a cross pin fixation with a lateral approach. The aim of the study was to prove our method retrospectively to show the advantage of lateral cross-pinning achieving stabilty and avoiding ulnar nerve injury. Method Between 1 January 2001 and 31 December 2002, 84 supracondylar fractures were treated with invasive surgical procedure. The intention was a primary closed reduction. Following closed reduction under general anaesthesia, two K-wires were introduced from the lateral side, one ascending and the other descending. If it was not possible to perform a closed reduction, an open reduction was performed by medial–lateral crossed K-wire fixation. After either an open or closed reduction, the pins were buried under the skin. The results were evaluated using Flynn’s score. The mean time of follow-up was 18.9 months. Results Seventy-seven percent of the patients were treated with a closed reduction, while 23% needed an open reduction. A clinical follow-up examination was done at an average of 18.9 months following the trauma. Of those treated with a closed reduction alone, 93% had an excellent or good functional result. Of those requiring an open reduction, 88% had excellent or good result. None of our patients exhibited secondary dislocation or iatrogenic ulnar palsies. Conclusion Closed reduction and lateral crossed pin fixation with ascending and descending K-wires buried under the skin is an effective method to treat type II and III supracondylar fractures in children. The method gives stability and avoids iatrogenic ulnar nerve injuries.     

Management of tibial fractures with the orthofix dynamic external fixator

We report our experience with the use of the Orthofix external fixator for the management of closed and open tibial fractures. One hundred fractures were treated in 96 patients between May 1985 and December 1989. There were 47 closed and 53 open fractures. Of the open fractures, 11 were grade I, 16 were grade II and 26 were grade III. Forty-five closed fractures and 49 open fractures went on to solid bony union in an average of 15.2 and 20.5 weeks, respectively. Non-union requiring operative intervention occurred in two closed and four open fractures (6%). The other main complications were pin track infection (30% of cases) and malunion which occurred in 14% of closed fractures and 32% of open fractures. We concluded that dynamic axial fixation is a useful method of treatment for open and difficult closed tibial fractures. Our experience indicates that malunion and pin track infection remain common problems and have still to be overcome.     

Evaluation of the role of pin fixation versus collar and cuff immobilisation in supracondylar fractures of the humerus in children

Long term results of children with supracondylar humeral fractures treated with manipulation and strapping and manipulation followed by pin fixation were evaluated. Forty patients were regarded as Gartland type II injuries. 33 of these were treated with closed reduction and collar and cuff immobilisation and 7 with closed reduction and percutaneous pinning. Two cases of cubitus varus were reported one from each treatment modality. Forty-four patients were included as Gartland type III injuries. Of these 14 were treated with closed reduction and collar and cuff immobilisation, 25 with closed reduction and percutaneous pinning and five with open reduction and pinning. There were two cases of cubitus varus and one case of cubitus valgus following pin fixation. In addition one case of extension lag and one significant ulnar nerve neurapraxia was recorded following pin fixation. One case of cubitus varus was seen following manipulation and collar and cuff treatment. There was no statistical difference between either treatment modality in terms of predicting a better outcome (p0.05).We conclude that pin fixation has no advantages over simple immobilisation in certain Gartland II and III type injuries. Although pin fixation is beneficial in unstable injuries collar and cuff immobilisation continues to have an important role in the treatment of stable supracondylar fractures.     

External fixation of femoral shaft fractures in children: enhanced stability with the use of an auxiliary pin.

From 1989 through 1994, we used a monolateral external fixator (Orthofix) to treat 39 femur fractures in 37 patients. The average age of the patients was 9.5 years (range, 5+11 to 18+8 years); 38 fractures were closed, and one was a grade I (Gustillo-Anderson classification) open fracture. Twenty-two fractures were treated by using the standard Orthofix pin configuration with two or three pins held in the pin clamps both above and below the fracture. We treated the remaining 16 fractures identically, except for the addition of an auxiliary pin, which was secured to the body of the fixator by using wire and methylmethacrylate. All patients were followed up to union and fixator removal at a mean of 97 days after fixator placement (range, 50-175 days). Thirty-one (84%) patients were followed up for 1 year after injury. Six of 22 femurs without an auxiliary pin required remanipulation for loss of reduction. Only one of 16 femurs treated with an auxiliary pin required remanipulation. Four of 22 femurs without an auxiliary pin went on to malunion. No femur with an auxiliary pin went on to malunion.     

Percutaneous elastic fixation of proximal humeral fractures: operative indications, techniques, results and complications

We present a technique of osteosynthesis of proximal humeral fractures using Kirschner wires, assembled in an elastic manner. We report 29 patients (mean age, 68 years) with types II, III and V fractures, according to Neer's classification, treated with closed or open (seldom) reduction and percutaneous pinning. The pin placement was antegrade: the wires started on the epiphysis and aimed at the diaphysis, with the proximal ends fixed with an external clamp and the distal ends crossed and laying on the endosteal surface. Patients were evaluated with the Constant-Murley scale at the end of treatment. Radiological and clinical outcome was satisfactory in all but one patient, in whom the closed reduction was insufficient. Percutaneous elastic pinning is an effective treatment of proximal humeral fractures. If necessary, it should be associated with open reduction. Received: 20 August 2001/Accepted: 6 September 2001     

Results of the wafer procedure for ulnar impaction syndrome in the ulnar negative and neutral wrist

Thirteen wrists with ulnar neutral or negative variance were treated by open distal ulna excision (the wafer procedure). The mean follow-up was 25 months (range, 12-38). At final follow-up grip strength had increased a mean of 14 kgf and 12 of the 13 patients were very satisfied with the functional outcome and pain relief. In treatment of the ulnar impaction syndrome, the wafer procedure provides excellent pain relief and functional restoration particularly in patients with ulnar neutral or negative wrists in whom triangular fibrocartilage tears have not yet developed.     

Tibia nonunions treated by interlocked nailing: increased risk of infection after previous external fixation

Eighteen patients, mean age 36 years (range of 22-76 years), with tibia-shaft nonunions were treated with interlocked nailing. There were 12 nonunions originally treated with either cast, lag screws, plate, or Ender nails (nine closed, two open grade I and one grade II injury). The remaining six nonunions, all open fractures (five grade II and one grade III injury) initially received external fixation. After removal of the fixator, 72 days postinjury (range of 58-111 days), there was a delay of 218 days (range of 112-449 days) before the nailing procedure in those patients primarily treated with external fixation. All 12 nonunions not primarily treated with external fixation healed without complications after nailing within 17 weeks (range of 12-24 weeks). All six nonunions primarily treated with external fixation had temporary pin-tract infections, which healed after pin extraction. Two of the nonunions healed without any complication, whereas four developed intramedullary infection with the same bacteria as from the pin-tract site. Although the number of patients is small in this report, there is an apparently high incidence of intramedullary infection in the group originally treated with external fixation. The sequential procedure of external fixation followed by intramedullary nailing is, therefore, not recommended in the treatment of open tibia fractures.     

134 tibial shaft fractures managed with the Dynamic Axial Fixator

We have reviewed the results of 134 tibial shaft fractures treated with the Dynamic Axial Fixator. In 86 closed fractures, the average union time was 4 months. 76 fractures had united by 5 months; delayed union occurred in 7 cases. 3 closed fractures failed to unite.

In 48 open fractures, the union time was related to the severity of soft tissue trauma. The average union time was 5 months for grade II and 6 months for grade III open fractures. 33 open fractures had united by 5 months and delayed union occurred in 11 fractures. 4 open fractures failed to unite.

The commonest complication was minor pin site infection, which was seen in 34 percent. These responded rapidly to treatment and external fixation continued. Major pin site infections were uncommon (5 percent) and none led to any serious sequelae. We have found the Dynamic Axial Fixator a safe and reliable device for treating fractures of the tibial shaft.     

Results of treatment of 202 fresh tibial shaft fractures, managed with unilateral external fixation (monofixateur)

From 1982 to 1986, a total of 202 lower leg fractures (70 closed, 132 open fractures) were treated with a monoexternal fixation device, and 148 cases were included in the follow-up study. The mean healing time was 15.4 weeks for closed fractures and 18.4 weeks for open fractures. Infection was occurred in 3.4% of the patients followed up (5.1% open fractures, as 0% closed fractures), aseptic delayed in 8.8%, and pin tract infection in 2.5%. The group of patients with open fractures treated with additional lag screws (n = 74) showed a higher rate of refractures (10.9% vs 4.5%) and bone grafting (65.5% vs 29.5%) than the control group without lag screws (n = 58). The healing times (15.8% vs 15.5 weeks) and rates of non-union (10.9% vs 11.4%) were similar in both groups. Among 14 cases of secondary intramedullary nailing, osteitis occurred in 2. In the dynamized group (n = 53) healing time was reduced to 16.0 weeks, as against 18.0 weeks in the n-dynamized group (n = 95).     

Traumatic dislocations and instability of the trapeziometacarpal joint of the thumb

The surgeon treating traumatic injuries to the TMC joint should be aware of the fundamental misconceptions and pervasive axiomatic myths perpetuated in the medical literature: namely that the volar beak ligament is the prime stabilizer, that the dorsal ligament complex plays no significant role in TMC joint function, and that the APL is a deforming force in Bennett fractures. On the contrary, stability of the TMC joint in power pinch and power grasp depends on the TMC joint's two prime stabilizers, the volar beak of the thumb metacarpal and the dorsal radial ligament complex; and the APL is not a deforming force in a Bennett fracture. Screw-home-torque occurs in the final phase of opposition; the acute Bennett fracture can be treated closed and percutaneously fixed if the screw-home-torque technique is used to anatomically reduce the fracture. After soft tissue interposition, if a semi-acute Bennett fracture is diagnosed late, it should be treated open with a volar approach, the screw-home-torque reduction technique, and screw or pin fixation. Rolando multipart fractures of the thumb metacarpal into the TMC joint are best treated closed, with traction in opposition with pin fixation; pure dislocations of the TMC joint that tear the dorsal ligament complex and Bennett fractures with an associated dorsal ligament complex tear (as diagnosed by the screw-home-torque technique) require open reduction and dorsal ligament complex repair. The current literature is so replete with myths and folklore regarding the anatomy that a conscientious surgeon treating a traumatic dislocation or in-stability of the TMC joint should return to the cadaver room and carefully review and understand TMC joint anatomy.     

The small pin circular fixator for distal tibial pilon fractures with soft tissue compromise

A Monticelli-Spinelli small pin circular external fixator was used in combination with closed reduction or a limited open reduction internal fixation in five cases in an attempt to salvage a satisfactory result in distal tibia pilon fractures when associated soft tissue compromise prevented standard fixation with plates and screws. The small pin fixator enhances the ability to perform a closed reduction through a technique that uses distraction with pins in the tibia and calcaneus, combined with correction of angulation by tensioning wires with a stop nut. Small pin stabilization of these comminuted fractures allows early patient mobilization. The small diameter pins support the soft cancellous bone fragments. This technique attempts to combine the benefits of traction, external fixation, and limited internal fixation. We recommend this technique as a salvage procedure when plates and screws are contraindicated because of poor bone and soft tissue conditions.     

Treatment of external fixation pins about the wrist: a prospective, randomized trial

BACKGROUND: Pin-track infection remains one of the most troublesome complications of external fixation, in some cases compromising otherwise successful fracture treatment. METHODS: One hundred and eighteen patients (120 wrists) who had been managed with the placement of an external fixation device for the treatment of a displaced, unstable, distal radial fracture were randomized into one of three treatment groups: (1) weekly dry dressing changes without pin-site care; (2) daily pin-site care with a solution of one-half normal saline solution and one-half hydrogen peroxide; and (3) treatment with the placement of chlorhexidine-impregnated discs (Biopatch) around the pins, with weekly changes of the discs by the treating surgeon. The patients were followed at weekly intervals until the external fixator was removed. Radiographs were made biweekly. The patients were evaluated with regard to (1) erythema, (2) cellulitis, (3) drainage, (4) clinical or radiographic evidence of pin-loosening, (5) the need for antibiotics, and (6) the need for pin removal before fracture-healing due to infection. Differences in complication rates among the three groups, with adjustment for patient age, gender, and the performance of an associated open procedure, were evaluated. RESULTS: The average age of the patients was fifty-four years. Forty-seven wrists had an open procedure (either bone-grafting or open reduction and internal fixation) in addition to treatment with the external fixator. The fixators remained in place for an average of 5.9 weeks. Twenty-three patients (19%) had a complication related to the pin track, with twelve of these patients requiring oral antibiotics for the treatment of a pin-track infection. There were no significant differences among the three groups with regard to the prevalence of pin-site complications. The age of the patient was found to be significantly associated with an increased risk of postoperative pin-track complications (p = 0.04). CONCLUSIONS: We found a high rate of local wound complications around external fixation pin sites; however, most complications were minor and could be observed or treated with oral antibiotics. The prevalence of these complications was not decreased in association with the use of hydrogen peroxide wound care or chlorhexidine-impregnated dressings. On the basis of these results, we do not recommend additional wound care beyond the use of dry, sterile dressings for pin-track care after external fixation for the treatment of distal radial fractures.