Phalangeal neck fractures in adults

The author investigated the pattern of injury and outcome of management in 11 adults with phalangeal neck fractures. The mean age was 40 years. The fracture occurred at the neck of the proximal phalanx of the thumb in seven cases and at the neck of the middle phalanx of the fingers in the remaining four cases. One patient had an undisplaced (Type I) fracture and was treated with splinting; the final result was graded as excellent. Nine patients had Type II fractures (the displaced distal fragment maintaining bone-to-bone contact with the proximal fragment) and all patients were treated with closed reduction and single K-wire fixation. The final outcome of Type II fractures was considered good in eight patients and fair in one patient. One patient had a Type III fracture (the displaced distal fragment was rotated 180 degrees with no bone-to-bone contact with the proximal fragment). The fracture required open reduction and K-wire fixation and the final result was poor.     

闭合穿针治疗掌指关节周围部位骨折

目的 探讨闭合穿针治疗掌指关节周围部位骨折的临床疗效.方法 2005年以来,对17例掌骨颈或近节指骨基底部骨折患者,采用C型臂X线机透视下闭合复位克氏针内固定治疗.单部位骨折11例,其中掌骨头或颈部骨折7例,近节指骨基底部骨折4例;多部位骨折6例,其中2处以上掌骨颈骨折3例,2～5指近节指骨基底部均骨折1例,2～4指近节指骨基底部均骨折1例,第五掌骨颈骨折伴环指近节指骨基底部骨折1例.均为闭合性骨折.急诊手术4例,伤后5 d内手术12例,伤后11 d手术1例.术后2-3周拆除石膏,4周拔克氏针.结果 术后X线片显示骨折均达到良好复位.随访6～9个月,骨折愈合良好.手功能按TAM系统评定法评定:优13例,良4例.结论 闭合穿针治疗掌指关节部位骨折创伤小、方法简单、疗效佳,是治疗掌指关节部位骨折理想的方法.     

An irreducible variant of femoral neck fracture: A minimally traumatic reduction technique

We present 25 cases of irreducible variant femoral neck fractures that require surgical management after routine manipulative manoeuvre attempts have failed. In our study, an irreducible variant of femoral neck fractures is defined as a reduction that cannot be achieved after multiple attempts at closed reduction. This was evident radiographically, as seen in displaced-impacted femoral neck fractures when the proximal femur compacts and rotates along with the distal part, and anatomical reduction cannot be achieved with manipulative manoeuvres. Another rare situation also included is when the proximal fragment disconnects from the femur and dislocates as a ‘floating’ component, consequently resulting in failure of alignment of the distal fragment to the proximal femur.Here, we describe a technique, applied as a minimally traumatic procedure to achieve anatomic reduction in such cases. With the patient placed in supine position on the fracture table under general anaesthesia, the injury site is exposed and the procedure performed under intra-operative radiographic control. Location of the femoral artery is done first by palpation. The insertion site of the K-wires or Steinman pins on the proximal thigh is 1.5-3 cm lateral to the femoral artery. The K-wires or Steinman pins are inserted vertically into the middle 1/2-2/3 of the femoral head and more than 1 cm inferior to the sub-chondral bone of the femoral head to a depth of approximately, 1/2 diameter of the femoral head. The pins are then used as a joystick to control the movement of the proximal femur. With the help of the K-wires, surgeons can manually control the movement of the proximal femur and ensure anatomic reduction with the distal fragment using routine-closed reduction. Three cannulated screws are used to stabilise the fracture after anatomic reduction is achieved and maintained in a stable position. All cases were treated with this minimally invasive procedure and internal fixation, 25 fractures united, uneventfully, whilst two of them developed femoral head necrosis at 10 months and 4.5 years postoperatively, respectively.     

腹部带蒂皮瓣修复多指中末节掌侧皮肤缺损

目的 报告采用腹部带蒂皮瓣修复多手指中末节掌侧皮肤缺损的临床疗效.方法 对5例同手多指中、末节掌侧皮肤缺损患者,选用腹部带蒂皮瓣进行修复.结果 术后皮瓣全部存活,皮瓣经分期断蒂、并指分指及整形,术后随访3～12个月,皮瓣色泽、质地、弹性良好,皮瓣无明显臃肿或挛缩现象,手功能恢复优良.结论 利用合理的创面设计,选用血液供应良好、手术方法简单、安全、供区损伤小的传统皮瓣修复多指皮肤缺损,可获得较为满意的疗效.     

L’embrochage centro-medullaire dans les fractures du col du radius de l’adulte

Fractures of the neck of the radius (Mason’s type IV) are rarely seen in the adult although they are the most frequent in the child. There is no satisfactory treatment at the present time and the authors present 2 cases treated by intramedullary nailing with good results. This technique was described by Metaizeau and al for the child. The first case was a woman 46 years old presenting a dislocation of the left elbow with a radial neck fracture Mason’s type IV. The angulation between the radial head and the diaphysis was 55°. The dislocation was spontaneously reduced and an intramedullary nailing was performed on the radial neck fracture. Six months later the mobility of the elbow was normal except 10° loss of extension. The X-rays showed a radial head with no evidence of necrosis, and no residual angulation. The second case is a 25-year-old man with a Mason’s type IV radial neck fracture. The angulation was 50°. At 6 months of follow up the elbow still had 15° loss of extension. The X-rays appearances were the same that for the first case. The procedure is detailed. The entry point is at the distal metaphysis. A kirschner wire is curved at its extremity and pushed into the medullary canal. The radial head is pinned by the sharp curved extremity of the wire. A rotating motion of the wire allows reduction and fixation of the fracture. The authors experience and the 6 cases presented by Keller shows that intramedullary nailing seems a good solution for fixation of the radial neck fractures.     

Changes in radiological parameters during reduction of femoral neck fractures: A radiographic evaluation of cadavers

ObjectiveTo investigate changes in the Garden index and other radiological parameters during reduction of femoral neck fractures.MethodsTen healthy, human femoral specimens were obtained. A 2.0 mm diameter Kirschner wire was implanted in the centre of the femoral head. A perpendicular osteotomy was made in the middle of the femoral neck. The distal osteotomy surface was used as the angle of rotation (pronation and supination up to 90° at 10° intervals). Anterior-posterior and lateral view radiographs were taken at different angles. The Garden index and other relevant data were analysed using the picture archiving and communication system. Changes in the area of the femoral head fovea at different rotation angles were measured.ResultsThere were no significant differences in the Garden index between 0–30° of pronation and supination (p > .05). For angles of 40–90°, there were statistically significant differences in the Garden index (p < .05). The area of femoral head fovea decreased with increasing pronation angle, and increased with increasing supination angle.ConclusionsThe Garden index does not change significantly if the angle of fracture rotation is 0–30° (in either pronation or supination) during femoral neck fracture reduction. Therefore, it is impossible to judge the rotation of fracture in this range of angles. The Garden index can detect the rotation of fracture for rotation angles of 40–90° (in either pronation or supination). Changes in the area of the femoral head fovea can help determine the rotation of femoral neck fractures.Level of EvidenceLevel V.     

末节指骨基底背侧撕脱骨折的手术治疗

目的介绍应用克氏针和抽出钢丝固定末节指骨背侧撕脱骨折的手术方法。方法对21例末节指骨背侧撕脱骨折，采用切开复位，末节指骨过伸位，顺行或逆行穿入克氏针，再加抽出钢丝加强撕脱骨块固定的方法。术后撕脱骨折全部解剖复位。4周拔除克氏针，6周拔出钢丝。结果术后随访3个月，按TAM法评定疗效：优16例，良5例，优良率达100％。骨折全部愈合。结论采用克氏针和抽出钢丝固定末节指骨背侧撕脱骨折，能有效治疗锤状指畸形，手术方法简便，疗效满意。     

Use of a relative motion flexion orthosis with dorsal hood to protect a middle phalanx finger fracture and zone III extensor tendon repair,while correcting a secondary fixed flexion proximal interphalangeal joint flexion contracture: A case report

BackgroundProximal interphalangeal joint (PIPJ) contractures, zone III extensor tendon injuries and phalanx fractures are challenging to treat in isolation. In this case the patient presented with all 3 of these issues in a single digit, presenting a unique problem for the hand therapist.PurposeA case report to examine the effectiveness of using single orthosis to treat an index finger following a combined zone III extension tendon repair, surgically stabilized second phalanx fracture and PIPJ flexion contracture.MethodsA patient presented to therapy with a 40° PIPJ flexion contracture and minus 70° of active PIPJ extension (ICD10 M25.64) after left index surgical fixation of a middle phalanx fracture (ICD10 S62.621B) and zone III extensor tendon repair (ICD10 S66.321A). To correct the contracture, a distal elastic strap was added to a relative motion flexion orthosis with dorsal hood. This applied a gentle extension force to the PIPJ. Once the contracture resolved a short arc motion program (SAM) was initiated using the same orthosis.ResultsAt 20 weeks post initial therapy evaluation, active range of motion (extension/flexion) of the PIPJ was 5°/100° and distal interphalangeal joint (DIPJ) 0°/60°. The Quick DASH score improved 50 points from an initial 59 points to 9 points. The patient reported good satisfaction and full function of the hand.ConclusionOur case report demonstrated the effective use of a single relative motion flexion orthosis with a dorsal hood when treating a complex hand injury involving an open zone III injury, second phalanx fracture and 40-degree PIPJ contracture.     

A Case of Coronal Intra-articular and Epiphyseal Fractures of the Metacarpal Head in Early Adolescence

Intra-articular metacarpal head fracture is relatively rare. We report a case of coronal intra-articular and epiphyseal fractures of Salter–Harris type IV injury in the metacarpal head of the index finger. Surgery was performed by a dorsal approach. The volar fragment that was displaced proximally was gently reduced while bending the metacarpophalangeal (MP) joint, and it was fixed with cortical screws inserted proximal to the articular cartilage facilitating early rehabilitation. We consider the mechanism of injury to be a force applied from the distal phalanx that was transmitted unevenly to the volar side when the MP joint was slightly flexed. A three-dimensional computed tomography scan was useful in making the precise diagnosis, confirming the fracture pattern and planning fixation of the fracture.     

经甲下克氏针压迫复位技术治疗Mallet骨折

目的 介绍一种治疗Mallet骨折的新方法. 方法 自2003年3月至2007年7月,采用远侧指间(DIP)关节背侧切口,将1枚克氏针从甲床与指骨间顺行自指尖穿出,骨块复位后,过伸DIP关节将克氏针逆行打入中节指骨,然后屈曲DIP关节,弯曲的克氏针压迫骨折块,使之维持复位状态.共治疗Mallet骨折17例. 结果 17例骨折均于术后4周临床愈合,9例得到随访,随访时间4～54个月(平均16个月),采用Crawford法进行疗效评定:优2例,良4例,可3例,差0例.结论 该方法 不损伤关节软骨,避免了骨块碎裂,简单易行、疗效可靠,是治疗Mallet骨折的较好方法.     

Direct reduction may need to be considered to avoid postoperative subtype P in patients with an unstable trochanteric fracture: a retrospective study using a multivariate analysis

Introduction

It has recently been reported that the cases with an anterior femoral neck cortex posterior to the distal fragment (subtype P) in the lateral view of a postoperative radiograph have a risk of excessive sliding of lag screws compared to those located anterior to the distal fragment (subtype A) or perfectly continuous to the distal fragment (subtype N) following osteosynthesis for the treatment of a trochanteric fracture. The purpose of this study was to investigate factors that influence the postoperative subtype in the lateral view of radiographs.

Patients and methods

This study reviewed 136 patients who underwent osteosynthesis using an intramedullary hip nail for the treatment of a trochanteric fracture. A closed reduction was performed in 130 patients (95.6 %), while a direct reduction via a small elevator with a small skin incision was performed in the other six patients (4.4 %). The 136 patients were divided into two groups (subtype P and subtype A or N) based on postoperative radiographs taken of the lateral view. Both clinical and radiological factors were analyzed using the univariate and multivariable analyses.

Results

Thirty-nine patients (29 %) were categorized as subtype P and 97 patients (71 %) were categorized as subtype A or N. A multivariate analysis demonstrated that unstable fractures were associated with a significant risk of postoperative subtype P (Odds ratio: 24.45, P = 0.0024).

Conclusions

The results of this study suggest that direct reduction via a small elevator with a small skin incision or percutaneous intrafocal pinning may be needed in these cases.     

Subcondylar fossa reconstruction for malunion of fractures of the proximal phalanx in children

Subcondylar fractures of the proximal or middle phalanx occur at the neck of the phalanx, usually as a result of a crush injury, and almost exclusively in the pediatric age group. The distal fragment rotates dorsally and the degree of displacement may be misjudged if a true lateral radiograph is not obtained. If malunion occurs, there is a block to flexion. Subcondylar fossa reconstruction by removal of bone through a palmar approach removes this bony block. Three patients are presented in whom this procedure allowed an average increase in flexion of 41.7 degrees.     

近节指背逆行岛状皮瓣修复手指皮肤缺损

目的 探讨应用多源供血的指背逆行岛状皮瓣修复手指皮肤缺损的方法及疗效.方法 2005年1月至2008年12月,应用包含指动脉背侧皮支、指固有神经背侧支营养血管和深筋膜血管网三重血供来源的多源供血近节指背逆行岛状皮瓣,修复2-5指中、末节皮肤缺损59例71指,皮瓣切取面积为2.0 cm × 1.5 cm～4.0 cm × 2.8 cm.结果 术后皮瓣全部存活,随访6个月至2年,手指外形满意,皮瓣两点分辨觉达4.5～10.0 mm,平均6.6 mm,患指近指间关节活动正常,供区无明显并发症.结论 多源供血的近节指背逆行岛状皮瓣具有血供可靠、不牺牲主要血管、皮瓣感觉恢复良好的优点,是修复手指中、末节皮肤缺损的理想术式.     

Flexor digitorum profundus avulsion with associated fracture of the distal phalanx

Two unusual cases of flexor digitorum profundus avulsion with an associated fracture of the distal phalanx are reported. In one case the injury consisted of avulsion of a large bone fragment from the distal phalanx and an associated profundus avulsion from the fragment. The other case showed simultaneous shaft fracture of the distal phalanx with avulsion of the profundus tendon, which could not be included in the existing classification of profundus injuries. The latter injury was misdiagnosed initially.     

Bony mallet finger without epiphyseal plate injury in childhood

IntroductionIt is commonly thought that Salter–Harris type I or II appears in mallet fingers in childhood, with S–H type III appearing in adolescence.Presentation of caseWe present a case of bony mallet finger in childhood. Radiographs showed a small fragment above the distal interphalangeal joint, and this fragment was separated from the dorsal epiphysis without injury to the epiphyseal plate. Open reduction and fixation were performed and bone union was achieved without complications.DiscussionBony mallet finger in childhood manifests as S–H types I, II, and III in typical cases. However, it depends on narrowing of the epiphysis and the strength of the axial forces on the tip of the distal phalanx. In the case of epiphysis narrowing and only small forces affecting the region, an avulsion fracture without injury to the epiphyseal plate will occur in rare cases.ConclusionWe presented here a rare case of a bony mallet finger in childhood without epiphyseal plate injury.     

Fracture–luxation complexe de l’articulation interphalangienne proximale. À propos d’un cas et mise au point sur les fractures–luxations palmaires interphalangiennes proximales

The palmar fracture-dislocation of the proximal interphalangeal (PIP) joint of fingers is an uncommon injury. We report a complex form in a 16-year old teenager, associating a palmar fracture-dislocation and a fracture of the base of the middle phalanx with the dorsal fragment dislocated between the neck of the proximal phalange and the palmar plate. The management was surgical with open reduction and fixation of the fragments by K-wires and temporary PIP arthrorisis. The result at 6 months of follow- up after removal of the wires and physiotherapy was satisfactory. The patient was painless with a range of motion of 115°. Clinically, the sagittal and frontal stability of the joint both in flexion and extension was maintained. Osseous healing was obtained on X-ray control. The patient went back to his usual activities. A focus on palmar fracture-dislocations of PIP joint is presented through incidence, mechanism and treatment.     

Outcome Following Acute Primary Distal Ulna Resection for Comminuted Distal Ulna Fractures at the Time of Operative Fixation of Unstable Fractures of the Distal Radius

Optimal acute management of the highly comminuted distal ulna head/neck fracture sustained in conjunction with an unstable distal radius fracture requiring operative fixation is not well established. The purpose of the present study was to determine the clinical, radiographic, and functional outcomes following acute primary distal ulna resection for comminuted distal ulna fractures performed in conjunction with the operative fixation of unstable distal radius fractures. Between 2000 and 2007, 11 consecutive patients, mean age 62 years (range, 30–75) were treated for concomitant closed, comminuted, unstable fractures of the distal radius and ulna metaphysis. All 11 patients underwent distal ulna resection through a separate dorsal ulnar incision with ECU tenodesis following surgical fixation of the distal radius fracture. According to the Q modifier of the Comprehensive Classification of Fractures, there were six comminuted fractures of the ulnar neck (Q3) and five fractures of the head/neck (Q5). Operative fixation of the distal radius fracture included volar plate fixation in four patients and spanning external fixation with supplemental percutaneous Kirschner wires in seven patients. At a mean of 42 months (range, 18–61 months) postoperatively, clinical, radiographic, and wrist-specific functional outcome with the modified Gartland and Werley wrist score were evaluated. At latest follow-up, mean wrist range of motion measured 53° flexion (range, 35–60°), 52° extension (range, 30–60°), 81° pronation (range, 75–85°), and 77° supination (range, 70–85°). Mean grip strength measured 90% of the contralateral, uninjured extremity (range, 50–133%). No patient had distal ulna instability. Final radiographic assessment demonstrated restoration of distal radius articular alignment. According to the system of Gartland and Werley as modified by Sarmiento, there were seven excellent and four good results. No patient has required a secondary surgical procedure. Acute primary distal ulna resection yields satisfactory clinical, radiographic, and functional results in appropriately selected patients and represents a reliable alternative to open reduction and internal fixation when anatomic restoration of the distal ulna/sigmoid notch cannot be achieved. Primary distal ulna resection with distal radius fracture fixation may help avoid secondary procedures related to distal ulna fixation or symptomatic post-traumatic distal radioulnar joint arthrosis.     

Fractures of the anatomical neck of the scapula: two cases and review of the literature

Anatomical neck fractures of the scapula are rare. The authors have found in the literature only four radiologically documented fractures of the anatomical neck of the scapula. Two of them were published by Hardegger et al., the third case was published by Arts and Louette. The last case, in fact only a radiograph and a rather poor 3D CT reconstruction of a fracture of the anatomical neck of scapula, was published by Jeong and Zuckerman. Together with author’s two patients, the group of radiologically verified anatomical neck fractures of the scapula comprises six cases in total (four men, one woman, one gender unspecified). Analysis of the radiographs showed that in all these cases, the fracture line separated only the glenoid fossa from the scapular body, with a short spike of the lateral border of the scapula. The proximal part of the vertical fracture line ran into the coracoglenoid notch, between the upper border of the glenoid and the base of the coracoid process. The distal part of the fracture line crossed the lateral border of the scapular body 2–4 cm distal to the inferior pole of the glenoid fossa. The gleniod fragment was always formed by the glenoid fossa and a short spike of the lateral border of the scapular body. In five cases, the glenoid fragment, together with the humeral head, was displaced distally and the humeral head came to lie below the level of the coracoid process. At the same time, the glenoid fragment rotated into a valgus position. Only in one case, did the radiographs fail to show valgus displacement and the fracture was angulated in the transverse plane. In all six cases, the subacromial space between the acromion and the humeral head was widened. All fractures were operated on via a Judet posterior approach. In five cases, the outcome of the operation was assessed at 3, 5, 12, 21 and 120 months after surgery, three-being rated as excellent or very good, one as good and one as poor.     

Chronic post-traumatic radial head dislocation associated with dissociation of distal radio-ulnar joint: a case report

We present an unusual case of an isolated interosseous membrane disruption of the forearm without any fracture pattern. Dislocation of both radial head and distal radio-ulnar joint was presented. Open reduction of the radial head with radial neck shortening osteotomy was performed.     

PIP Fracture/Dislocation Treatment Technique: Use of a Hemi-Hamate Resurfacing Arthroplasty

The nature of injury following a PIP fracture dislocation is determined by the direction of force transmission and the position of the joint at the time of impact. Dorsal dislocations with palmar lip fractures are the most frequently encountered and can be classified based on stability. The degree of stability is directly determined by the amount of middle phalangeal palmar lip involvement; the larger the palmar lip fracture, the more unstable the joint becomes. When there is persistent instability or greater than 30 degrees of flexion is required to maintain reduction, treatment must be aimed at reconstituting the cup shaped geometry and buttressing effect of the volar lip of the middle phalanx if stability is to be restored. The use of a hemi-hamate autograft to reconstruct the base of the middle phalanx is a new technique that restores joint congruity and stability while allowing for early motion. This operative technique replaces the damaged palmar lip of the middle phalanx with a size-matched portion of the hamate obtained from its distal dorsal articular surface between the 4th and 5th metacarpals. By restoring both articular congruity and osseous stability the advantage of this procedure is that it allows more immediate rehabilitation with a potential for earlier motion, less stiffness and possibly less post-traumatic arthritis.