Noncontiguous fractures of the femoral neck,femoral shaft,and distal femur

BACKGROUND: Multifocal fractures of the femur are uncommon injuries and present unique management challenges. Combined ipsilateral fractures of the femoral shaft and femoral neck or the femoral shaft and distal femur have been described. The combination of noncontiguous ipsilateral femoral neck, femoral shaft, and distal femoral articular injuries, however, has not been described. The purposes of this report are to document the incidence and characteristics of this injury and to present a treatment rationale. METHODS: This was a retrospective study conducted at a Level I trauma center. RESULTS: Over a 5-year period, 1639 adult patients with femur fractures were definitively managed at the authors' institution. Five male and two female patients (average age, 43.3 years) sustained ipsilateral, noncontiguous fractures of the femoral neck, femoral shaft, and distal femoral articular surface (0.43%). All femoral neck fractures were vertically oriented. All distal femoral injuries were unicondylar. A variety of fixation methods were used, dependent on individual fracture characteristics. The femoral neck fractures were prioritized in all cases. Stabilization of the distal femoral articular surface was then performed before diaphyseal fixation in patients with sagittally oriented condylar fractures. Patients were followed for an average of 19.3 months. All fractures healed without the need for secondary procedures. CONCLUSION: This injury constellation is rare. Open reduction and internal fixation of the displaced femoral neck fracture should be the primary focus of orthopedic management, followed by stable reduction and fixation of displaced distal femoral articular injuries. The diaphyseal fracture should be treated with a technique that does not jeopardize either the proximal or the distal fractures. Patients who are critically ill can be managed in a similar sequence over the course of several days, depending on their overall condition.     

An irreducible Salter-Harris type IV distal ulna fracture

Epiphyseal fractures of the distal radius are common in children but those involving the distal ulna are rare. Distal ulna epiphyseal injuries are usually Salter-Harris type II and are usually reduced closed and held in plaster to produce good results. In this paper we describe a Salter-Harris type IV injury of the distal ulna epiphysis which required open reduction and internal fixation due to soft tissue interposition.     

Epiphyseal separations in spastic cerebral palsy

Metaphyseal and diaphyseal fractures have been reported in children with severe spastic cerebral palsy, but there is no reference to epiphyseal separations in these patients. We report nine epiphyseal separations involving the distal femur and proximal humerus in four severely affected children with spastic quadriplegic cerebral palsy. The clinico-radiological features confirmed the cause to be scurvy. These epiphyseal separations have a good prognosis unlike the physeal injuries reported in children with myelodysplasia. Treatment with vitamin C and splintage resulted in rapid healing with excellent remodeling. Scurvy should be considered a potential cause for an epiphyseal slip in a child with severe spastic cerebral palsy. Routine dietary supplementation of vitamin C is recommended for these malnourished and nonambulant children.     

Remodeling of forearm fractures in children

A prospective study of 42 children with forearm fractures, treated by closed reduction and plaster, was conducted to assess the remodeling capacity of the radial epiphyseal plate after union of fracture with angulation. The children's ages ranged from 3 to 15 years. The effect of residual angulation of the healed fracture on the distal radial epiphyseal plate was examined radiographically over a median follow-up time of 3 years and 2 months, to observe the behavior of the distal radial epiphyseal plate during remodeling and to identify the factors that influenced this process. On the basis of these findings, guidelines are proposed for the treatment of forearm fractures that have healed with residual angulation. The inclinations of the distal radial epiphyseal plate on the fractured and normal forearms were compared on anteroposterior and lateral radiographs, at union and at final follow-up, in both the radioulnar and the dorsovolar planes. An alteration of inclination was seen in all patients with dorsovolar angulation of the radial growth plate, which always tended toward a correction of the abnormal inclination. In diaphyseal fractures, the distal radial epiphyseal plate realigned well only in children aged < or = 10 years, whereas with distal radial fractures, realignment of the epiphyseal plate and restoration of function was uniformly good up to age 15. Diaphyseal fractures, with radioulnar angulation in the growth plate, did not seem to remodel completely and were associated with loss of motion, whereas in distal fractures, irrespective of the final inclination of the epiphyseal plate, the range of motion returned completely at the end of follow-up. Abnormal angulation in the radioulnar plane was poorly corrected in all patients. These results could be helpful in the treatment of forearm fractures that are positioned or have healed in residual angulation.     

Segmental radius and ulna fractures with scaphocapitate fractures and bilateral multiple epiphyseal fractures

Segmental forearm fractures are rare in children, and management is controversial. Epiphyseal injuries further complicate matters. We report the case of a 15-year-old boy who had segmental radius and ulna fractures with a coronal split of a metaphyseal fragment, along with bilateral epiphyseal fractures of the distal radius and ulna as well as ipsilateral scaphocapitate fractures with perilunate dislocation. There was also a contralateral fracture through the radial neck. The patient underwent immediate internal fixation of the forearm fractures and delayed fixation of the scaphocapitate fractures. Results at 12 months showed excellent functional outcome.     

Intraosseous Vascularity of the Distal Radius: Anatomy and Clinical Implications in Distal Radius Fractures

This study aimed to describe the intraosseous blood supply of the distal radius and its clinical implications in distal radius fractures. Twelve adult wrists from fresh cadavers (six males, six females, 50–90 years of age, mean 68 years) were injected through the brachial artery with latex. Dissections were performed using magnifying loupes and hands were processed using the Spalteholz technique. The distal radius was supplied by three main vascular systems: epiphyseal, metaphyseal, and diaphyseal. The palmar epiphyseal vessels branched from the radial artery, palmar carpal arch, and anterior branch of the anterior interosseous artery. These vessels entered the bone through the radial styloid process at level of the Lister's tubercle but palmar and sigmoid notch. The dorsal contribution to Lister's tubercle is to the dorsal epiphyseal vessels. The intraosseous point of entry to the dorsal epiphyseal vessels was from the fourth and fifth extensor compartment arteries. In the metaphyseal area, we found numerous periosteal and cortical branches originating deep in the pronator quadratus and the anterior interosseous artery. These branches provided the main supply to the distal radius. Vessels perforated the bone and formed an anastomotic network. In the diaphyseal area, only the nutrient vessel provided intraosseous vascularity in the distal radius. Numerous metaphyseal–epiphyseal branches arise within the pronator quadratus and the anterior interosseous artery and course towards the distal radius. These branches may be fundamental to the healing of the distal radius fractures and make nonunion a rare complication.     

The minimally invasive <Emphasis Type="Italic">flexor carpi radialis</Emphasis> approach: a new perspective for distal radius fractures

The minimally invasive flexor carpi radialis approach can be used for volar locking plate fixation of distal radius fractures. After 15-mm incision on the lateral aspect of the FCR tendon and all structures but the radial artery are reclined ulnarly, a plate is inserted under the pronator quadratus just proximal to the “watershed line.” The distal epiphyseal screws are put in place, and the proximal part of the plate is exposed by flexion of the wrist to put in place the proximal screws. No drainage or postoperative immobilization is used. It offers the advantage of preserving ligamentotaxis which facilitates the reduction, and the small size of the scar improves the esthetic result of the procedure. It is indicated for extra-articular fractures of the distal radius. In the case of an intraarticular fracture, an arthroscopy may be associated. In the case of a proximal diaphyseal extension of the fracture, a second proximal approach can be added in order to use a longer plate. Relative contraindications are comminuted articular fractures in elderly osteoporotic patients. Functional and radiological results are comparable to those obtained with the extented flexor carpi radialis approach. A conversion of the procedure for a larger incision is always possible in the case of a difficult reduction.     

Fracture patterns in Nottingham children

The incidence and pattern of fractures in children less than or equal to 12 years of age living in Nottingham, England, have been reviewed. The annual incidence rate is 16/1,000 children. Fractures are rare in those less than 18 months of age, and incidence increases with age. The most common cause of fracture was a fall in or around the home; the incidence rate of fractures after road traffic accidents was similar in all age groups. Fractures of the distal radius and ulna accounted for 35.8% of all fractures seen, with hand fractures the second largest group (14.7%). The most common fracture type was a green-stick fracture (51.6%), and 18.5% of fractures were epiphyseal injuries. Epiphyseal injuries in children less than 5 years of age, were uncommon whereas spiral/oblique fractures were more common. Rotational trauma is more likely to cause a spiral or oblique shaft fracture in a younger child and an epiphyseal fracture in an older child.     

Isolated Salter-Harris Type IV Fracture of the Distal Ulna in a 12-Year-Old Boy

Abstract Epiphyseal injuries to the distal radius are common in children, but those involving the distal ulna are rare. The most common type of epiphyseal fracture is Salter-Harris type II. The authors report on an isolated epiphyseal injury to the distal ulna Salter-Harris type IV, without an associated distal radius injury. To their knowledge, isolated injury Salter-Harris type IV to the distal ulnar epiphysis has not been reported in the literature.     

Radioulnargelenkverletzungen

The proximal and distal radioulnar joints are both responsible for free rotation of the forearm and thus functionally interconnected. The Monteggia injury (ulna fracture + radial head luxation) and the Galeazzi injury (diaphyseal radial fracture + dislocation of the radioulnar joint) have a better prognosis than radioulnar joint injuries in conjunction with distal radius fractures. The latter lead to injury of the ulnocarpal complex and more frequently to malalignment of the distal radioulnar joint, which in turn leads to arthrosis. This is characterized by early occurrence of pain, loss of strength in the hand, and limited rotation of the forearm. Thus, surgical management should be especially directed at restoration of the articular surface, correct length adjustment, and reconstruction of the anatomic angle. The choice of surgical procedure depends on the extent of destruction of the distal radial articular surface, the degree of dislocation, and the presence of soft tissue damage.     

Evolution of minimally invasive plate osteosynthesis (MIPO) in the femur

Problems with conventional open reduction and internal plate fixation of distal femoral fractures are well established. These problems have been associated with extensile exposures of the fracture site. "Biological plating", like intramedullary nail fixation, of distal femoral fractures preserves the soft tissues about the fracture, and is associated with early fracture consolidation and low rates of infection. Anatomical restoration of the articular surface continues to be the main goal in the treatment of these fractures regardless of the stabilization technique. Submuscular plating techniques, which provide for closed reduction of the diaphyseal/metaphyseal component of the fracture, have improved significantly.     

Methods for Testing the Mechanical Properties of the Rat Femur

A modular apparatus to measure the bending and torsional properties of the rat femur is presented. Both intact femur diaphyses and diaphyseal fractures in different phases of healing can be tested. It is also possible to measure the bending-strength of the distal femur metaphysis and the epiphyseal plate.

The apparatus can be used to investigate the effect of drugs and hormones on the remodelling of the rat femur.     

Methods for Testing the Mechanical Properties of the Rat Femur

A modular apparatus to measure the bending and torsional properties of the rat femur is presented. Both intact femur diaphyses and diaphyseal fractures in different phases of healing can be tested. It is also possible to measure the bending-strength of the distal femur metaphysis and the epiphyseal plate.

The apparatus can be used to investigate the effect of drugs and hormones on the remodelling of the rat femur.     

Submuscular plating of the distalfemur

A variety of implants are available for the treatment of distal femur fractures. However, continued problems includeinfection, nonunion, need for bone grafting, malunions, joint stiffness, and loss of fixation. “Biological plating” emphasizes maintenance of the soft tissue environment around the fracture. The concept of “biological plating” in supracondylar femur fractures has been very advantageous. The Less Invasive Stabilization System (LISS) for fractures of the distal femur combines these biological advantages of submuscular fixation with the biomechanical advantage of fixed angled, locked screws for fixation of the distal femoral block. The LISS may be particular helpful in the setting of complex articular pathology, a short distal segment, and osteoporotic bone. LISS methodology relies on traditional internal fixation of the articular surface, closed reduction of metaphyseal/diaphyseal component of the fracture, and placement of a submuscular LISS fixator. Percutaneous locking screws are then placed for proximal fixation. In this review, the evolution of submuscular fixation of supracondylar femur fractures and the technique are described.     

Fractures and epiphyseal injuries in children with myelomeningocele

Between February 1971 and February 1988, 947 children with myelomeningocele were treated at the Model Center of Heidelberg University Orthopedic Clinic. In 82 of these children, a total of 224 osseous lesions were seen. Metaphyseal and diaphyseal fractures were far more common than epiphyseal lesions, among which epiphysiolysis dominated. Diagnostically important symptoms included swelling, local hyperthermia, and high temperature. Owing to the paralysis, pain is of no value in diagnosing fractures. Protruding periosteal detachments are a common feature of lesions, and if this special form of healing of such fractures is unknown they may cause problems in differential diagnosis. Fractures in children with spina bifida should be treated conservatively, except for fractures of the femoral neck and epiphyseal lesions, which are treated with transcutaneous Kirschner wiring. Immobilization in plaster, postoperatively and during treatment of the injury, is the most common cause of osseous lesions in spina bifida children. Immobilization in plaster should therefore be minimized.     

Ipsilateral proximal and distal forearm fracture/fracture dislocation in children

Fifteen children with segmental forearm fractures were classified into two groups based on their proximal injury pattern. Proximal injury in group A was either Monteggia fractures or its variant and in group B it was diaphyseal fractures. The distal lesions in both these groups were either a metaphyseal fracture or an epiphyseal separation, or a combination of these two. Eleven children of group A were managed conservatively, whereas three of four children in group B required open reduction. After 2.67 years of follow-up in 13 children, clinical outcome based on modified Boyd and Boal's criteria was good in eight and fair in two children of group A, and good in two children and fair in one child of group B. The clinical outcome of pediatric segmental forearm fractures is good (P=0.05) and it may frequently need surgical intervention when the proximal fracture is diaphyseal.     

Telegraph antegrade nailing in the treatment of humeral fractures with rotator interval split technique

Twenty-four proximal humeral fractures were treated by surgical internal fixation with a locked antegrade intramedullary nail. The purpose of this paper was to assess the clinical outcomes of proximal epiphyseal and diaphyseal humeral fractures treated with an antegrade humeral nail implanted after an interval rotator split. We treated six proximal epiphyseal fractures and seven bifocal fractures of the epiphysis and shaft and eleven diaphyseal fractures. The mean follow-up was 23 months (range 12 to 34 months). Twenty patients were available for follow-up. All but two fractures progressed to healing. The Mean Constant score was 80%, Relative Constant score was 95.5%. We divided the clinical outcomes by fracture pattern to define the best surgical indication. There were good clinical outcomes in all three groups, but the clinical score was highest in the shaft fracture group. An intramedullary antegrade nail inserted through the interval rotator without penetrating the rotator cuff had a good clinical outcome and with certain fracture types can be an effective and satisfactory device.     

Telegraph antegrade nailing in the treatment of humeral fractures with rotator interval split technique

Twenty-four proximal humeral fractures were treated by surgical internal fixation with a locked antegrade intramedullary nail. The purpose of this paper was to assess the clinical outcomes of proximal epiphyseal and diaphyseal humeral fractures treated with an antegrade humeral nail implanted after an interval rotator split. We treated six proximal epiphyseal fractures and seven bifocal fractures of the epiphysis and shaft and eleven diaphyseal fractures. The mean follow-up was 23 months (range 12 to 34 months). Twenty patients were available for follow-up. All but two fractures progressed to healing. The Mean Constant score was 80%, Relative Constant score was 95.5%. We divided the clinical outcomes by fracture pattern to define the best surgical indication. There were good clinical outcomes in all three groups, but the clinical score was highest in the shaft fracture group. An intramedullary antegrade nail inserted through the interval rotator without penetrating the rotator cuff had a good clinical outcome and with certain fracture types can be an effective and satisfactory device.     

The acute effects of periosteal stripping and medullary reaming on regional bone blood flow

The immediate effects of surgical dissection on regional bone blood flow were studied using the hydrogen washout technique and the results were compared in mature and immature rabbits. Epiphyseal circulation in young animals was eliminated by stripping the epiphyseal periosteum, and even in mature rabbits epiphyseal blood flow was markedly reduced by periosteal stripping. This suggests that after skeletal maturity blood supply crossing from the metaphysis into the epiphysis is limited. The blood flow rate was not altered by wide reaming of the epiphyseal center in either young or old animals. The rates of bone blood flow in the metaphysis and diaphysis were not altered by separate periosteal stripping or medullary reaming in either age group. Combined reaming and stripping eliminated blood flow in the diaphyseal cortical bone, but in the metaphysis fairly rapid blood flow remained even after reaming and periosteal stripping were done. These findings suggest that arterial supply and venous drainage traverse both endosteal and periosteal surfaces, and either system is capable of sustaining adequate bone tissue circulation.     

Dorsal nail plate fixation of distal radius fractures

Intramedullary fixation of distal radius fractures is an emerging concept. The Dorsal Nail Plate is a new device that links a specifically designed stem to a small distal plate; bone fixation is supported by fixed-angle screws. The device is inserted dorsally using a minimally invasive technique ; its indications are unstable dorsally displaced extra-articular or simple articular distal radius fractures. To evaluate the results obtained with this implant, we retrospectively studied 47 extra-articular (36 cases) or simple articular (11 cases) dorsally displaced distal radius fractures in 46 patients treated with this technique. Patients had a mean follow-up of 11 months and were evaluated radiographically and clinically using the Mayo Wrist Score and the DASH score systems. The minimally invasive operative technique is described. Complications occurred in three cases. Two were observed intra-operatively--partial rupture of extensor pollicis longus tendon--and one postoperatively--loosening of one epiphyseal screw. Excellent reduction was obtained at operation in all but two patients; loss of initial reduction was observed in 2 fractures. All fractures were considered healed radiologically at 40 days. Average final DASH score was 6 (0-20). According to the Mayo Wrist score, 29 patients had excellent, 12 good and 5 satisfactory results. The Dorsal Nail Plate (DNP) has shown to effectively stabilize distal radius fractures with dorsal displacement, leading to an early satisfactory functional recovery. Accurate surgical technique minimizes soft tissue dissection and reduces the risk of complications.