Stress fractures of the tibia in elderly women]

Five women with stress fractures of the tibia with concomitant osteoarthritis of the knee were treated at the Department of Orthopaedics and Traumatology of the Lublin University of Medical Sciences between 1996 and 2001. The patients' age ranged from 57 to 78 years. Three fractures were located in the proximal part of the tibial shaft and 2 in the distal part of the tibial shaft. Two patients were unable to ambulate and 3 walked with crutches. In 2 cases the fracture healed after immobilisation in a walking cast for a period of 5 and 6 months respectively. Two cases with a concomitant varus or valgus deformity were treated surgically. In a 72-year-old woman the fracture healed 10 months after stabilisation with a locked intramedullary nail. In a 78-year-old woman the fracture healed 7 months after surgical correction of the tibial axis without internal fixation and a simultaneously performed Charnley knee arthrodesis. Immobilisation was achieved by a long plaster cast. A knee endoprosthesis was implanted in this patient a year after the first procedure because of advanced osteoarthrosis. A 72-years-old patient could not be treated because of poor general condition and advanced degenerative changes in both knee joints. All treated patients were pain free and ambulation parameters improved.     

Rates of neurovascular injury,compartment syndrome,and early infection in operatively treated civilian ballistic forearm fractures

PurposeThe purpose of this study is to evaluate the incidence of neurovascular injuries, compartment syndrome, early postoperative infection as well as the injury factors predictive of neurovascular injury following ballistic fractures of the radius and ulna.MethodsA retrospective review was performed to identify all ballistic fractures of the radius and ulna in skeletally mature patients over a 5-year period at a single level-1 trauma center. Chart and radiographic review was performed to identify patient and injury demographics, associated neurologic or vascular injuries, and fracture characteristics. Fracture location was measured on computerized imaging software and fractures were grouped into bone(s) segments involved. Proximal, mid-diaphyseal, and distal locations were used for statistical analysis.ResultsFifty-six extremities in fifty-five patients were identified (mean age 32 years; male to female ratio 9:1). Overall incidence of neurologic injury was 50%, arterial injury 32%, and compartment syndrome 7.1%. Presence of a proximal third forearm fracture was associated with an increased risk for neurologic injury (p < 0.01), with an odds ratio of 5.7 (95% confidence interval, 1.7–18.4). Furthermore, all high velocity/energy ballistic injuries had associated neurologic injuries (p = 0.02).ConclusionBallistic forearm fractures result in high rates of neurovascular injury. Fractures caused by high velocity/energy firearms have extremely high rates of neurologic injury when compared with low velocity ballistic injuries. Ballistic fractures involving the proximal third of the radius or ulna are five times more likely to be associated with neurologic injury after a ballistic injury and should be assessed carefully on initial evaluation.     

A new approach in the miniminvasive treatment of fractures

The use of biological cement with provisory closed percutaneous Kirschner wire (K-wire) fixation enabled the treatment of 12 patients with fractures. Within the period November 2010—February 2011, we have treated at Saint Pantelimon Emergency Orthopaedics Clinic 12 patients using this specific method, namely: 8 humeral fractures, 1 distal radial fracture, 1 distal radial fracture associated with carpal scaphoid fracture, 1 ankle fracture, and a delayed union of distal tibial fracture. In the specialized literature, the use of bone substitutes or of biological bone cement has never been described in the treatment of fractures without the opening of the fracture site. Some bone fillers for bone defects have been injected before, together with osteosynthesis means, plates and screws, respectively. The assessment of the results has to take into account the consolidation range of each type of fracture, and the cast fixation must be extended accordingly. The recovery shall depend upon the fracture’s callus biology, the fracture’s type and location as well as the age of the patient. We evaluate the results after clinical and radiological criteria. Consolidation was achieved in all cases. We will present also the complications related to first use of this new method. The use of Kryptonite-X injected under fluoroscopic control in the conservative treatment of the fractures is a novelty. Thus, it is introduced the perspective of an innovative way of treating the fractures. Consolidation was achieved in all cases.     

The epidemiology of fractures of the proximal ulna

IntroductionThe aim of our study was to report the epidemiological characteristics of fractures of the proximal ulna.MethodsFrom our prospective trauma database of 6872 fractures, we identified all acute fractures of the proximal ulna from a 1-year period between July 2007 and June 2008. Age, gender, mode of injury, fracture classifications, associated injuries and treatment were the factors documented and analysed.ResultsThere were 78 fractures of the proximal ulna with a mean age of 57 years (15–97). Males (n = 35) sustained their fracture at a significantly younger age than females (p = 0.041), with no gender predominance seen (p = 0.365). The overall fracture distribution was a unimodal older male and unimodal older female type-F curve. The most common mode of injury was a simple fall from standing height (n = 52, 67%), with younger patients more likely to sustain their injuries following a high-energy mechanism such as sports or a motor vehicle collision (p < 0.001). Seventeen (22%) patients sustained associated injuries to the ipsilateral limb, with an associated proximal radial fracture most frequent (n = 13, 17%). Open fractures were seen in five (6.4%) patients. A total of 64 patients had a fracture of the olecranon, with the Mayo 2A most frequently seen (n = 47, 60%).ConclusionsFractures of the proximal ulna are fragility fractures that predominantly occur in elderly patients. Given the number of elderly patients sustaining these injuries, research is needed to determine the role of non-operative treatment for these fractures, particularly in patients with multiple co-morbidities and low functional demands.     

An Early-Life Femoral Shaft Fracture and Bone Mineral Density at Adulthood

High peak bone mass and density in early adulthood is an important protective factor against osteoporotic fractures in later life, but it is not known whether injuries to growing bones adversely affect the attainment of peak bone mass and density. The purpose of this study was therefore to examine with dual-energy X-ray absorptiometry the areal bone mineral density (BMD) of the injured and uninjured extremity (the femoral neck, trochanter area of the femur, distal femur, patella, proximal tibia and distal tibia), lumbar spine and distal radius of young adults with a history of an early-life femoral shaft fracture and to find out whether the fracture had affected the attainment of peak bone density of these patients. Thus, the BMD and clinical status of 41 patients (28 men, 13 women) who had sustained a femoral shaft fracture in childhood or adolescence (between 7 and 15 years of age, average 13 years before the study) were examined. The fracture had led to a statistically significant difference in BMD between the injured and uninjured side distal to the fracture site (men/women: distal femur, −3.7%/−3.9%; patella, −3.1%/−5.9%; proximal tibia, −2.0%/−4.6%; distal tibia, −3.4%/−5.2%), whereas the proximal femur did not show such differences. The male patients’ spinal BMD was significantly lower (−7.9%) than that in their age-, height- and weight-matched healthy controls. The female patients’ spinal BMD tended to be fairly comparable (−1.6%) to that of the controls (NS). In summary, this study indicates that early-life femoral shaft fracture results in a moderate (−2% to −6%) long-term side-to-side BMD difference distal to the fracture site. Patients’ spinal BMD values also tend to be lower than that of controls. Thus, a femoral shaft fracture sustained in childhood or adolescence seems to disturb somewhat the attainment of peak bone density, the important predictor of osteoporotic fractures in later life. Received: 23 December 1998 / Accepted: 1 April 1999     

Clinical signs and methods of treatment of enchondromas located outside the hand]

160 patients (72 men and 88 women) in the age from 12 to 71 were admitted to Orthopaedic and Traumatology Department Skubiszewski Medical University in Lublin because of enchondromas. In 126 patients chondromas were located in hand, and in 34 remaining patients (21,3%) in: humerus, forearm, femur, tibia, fibula and foot. The typical signs of enchondroma were: pain, little limitation of movement, thickening of tissues or pathological fracture. 31 patients were operated on. Enchondroma was resected with cutterage, the walls of osseus cavity cleaned with reamer and bone loss filled up with bone grafts or bone cement. 1 case of recurrence of chondroma of toe was noted. In one patent malignant change of chondroma of proximal metaphysis of tibia to chondrosarcoma was observed. Lesion resection and filling up the bone defect is the best method of treatment of enchondroma.     

Long-term results comparison of simultaneous open reduction and subtalar arthrodesis with the efficacy of closed reduction in the treatment of fresh fractures of calcaneus]

AIM: The aim of the study was the retrospective comparison of results of treatment of fresh fractures of calcaneus with open reduction and simultaneous subtalar arthrodesis performed at Orthopaedic and Traumatology Department in Lublin with closed reduction according to Westhues in Traumatology and Orthopaedic Department in Krosno. MATERIAL AND METHODS: In the years 1994-2001 in Orthopaedics and Traumatology Department in Lublin 33 patients were treated because of 35 fractures of calcaneus (2 bilateral fractures). The comparative material consists of 31 patients treated because of 38 fractures of calcaneus (7 bilateral fractures) in Traumatology and Orthopaedic Department in Krosno in the years 1994-2004. In retrospective study preoperative and postoperative B?hler's angle was measured, as wellas type of fracture was defined according to Essex-Lopresti classification. The clinical results of treatmentwas evaluated with Rowe's classification. RESULTS: Long-term evaluation was made to all of the patients treated at Orthopaedic and Traumatology Department in Lublin. The follow up is from 5 to 12 years (average 8 years). Clinical results according to Rowe's classification is from 15 to 100 points (average 84.4 pts.). 17 patients treated in Traumatology and Orthopaedic Department in Krosno with closed reduction according to Westhues were evaluated. The follow up is from 2 to 12 years (average 7 years) with the average 52.35 pts in Rowe's classification. The lack of healing of subtalar arthrodesis was observed in one patient, meanwhile osteoarthritis of subtalar joint was observed at 14 patients after closed reduction according to Westhues. CONCLUSIONS: Closed reduction according to Westhues gives possibility for B?hler's angle restoration, but it does not create the chance for anatomical reduction of articular surface. The considerable percentage of patients suffering pain after Westhues's method testifies about incomplete reduction of articular surface. Open reduction of fracture of calcaneus, combined with simultaneous subtalar arthrodesis restores the correct B?hler's angle and prevents from pain during walking.     

Tibial plateau fractures in elderly patients

Tibial plateau fractures are complex injuries which, if not adequately treated, can lead to invalidating sequelae. They constitute on average about 1% of all fractures, and up to 8% in patients over 65 years, and can be caused by both high- and low-energy trauma. Unlike in younger subjects, treatment of tibial plateau fractures in the elderly is not univocal and depends on the patient’s functional needs, bone quality and systemic comorbidities. In this retrospective study, 49 patients with a mean age of 72 years, who underwent surgical treatment of a tibial plateau fracture, were assessed by the Rasmussen’s clinical and radiological grading systems. Clinical and radiographic outcomes were satisfactory in 75.5 and 59.1% of cases, respectively. Data were also analyzed, in terms of fracture type, age and gender, to detect any statistically significant correlation between these parameters and clinical and radiographic outcomes.     

Proximal Tibial Sleeve Fracture: Case Report of a Rare Injury and Review of the Literature

A sleeve fracture occurs when a ‘‘sleeve’’ of cartilage or periosteum is avulsed with or without an osseous fragment, an injury most commonly reported in the patella. Proximal tibial sleeve fractures are extremely rare and we present a case in an adolescent male who had concomitant osteochondral as well as chondral fractures of his patella. Sleeve fractures present in the skeletally immature, and may look relatively benign on radiographs, but misdiagnosis may lead to adverse consequences. Clinicians should have a high index of suspicion if a child or adolescent presents with a knee injury with clinical concerns regarding the extensor mechanism. Given that the ‘‘sleeve’’ of the injury contains tissue with osteogenic potential, we recommend that displaced proximal tibial sleeve fractures should be managed operatively to avoid dysfunction of the extensor mechanism. These patients should also have perioperative assessment for occult osteochondral and chondral injuries that are potentially repairable and thus may have implications for prognosis.     

Classification of proximal tibial fractures in children

Purpose  To develop a classification system for all proximal tibial fractures in children that accounts for force of injury and fracture patterns. Methods  At our institution, 135 pediatric proximal tibia fractures were treated from 1997 to 2005. Fractures were classified into four groups according to the direction of force of injury: valgus, varus, extension, and flexion–avulsion. Each group was subdivided into metaphyseal and physeal type by fracture location and Salter–Harris classification. Also included were tibial tuberosity and tibial spine fractures. Results  Of the 135 fractures, 30 (22.2%) were classified as flexion group, 60 (44.4%) extension group, 28 (20.8%) valgus group, and 17 (12.6%) varus group. The most common type was extension-epiphyseal-intra-articular-tibial spine in 52 fractures (38.5%). This study shows that proximal tibial fractures are age-dependent in relation to: mechanism, location, and Salter–Harris type. In prepubescent children (ages 4–9 years), varus and valgus forces were the predominate mechanism of fracture creation. During the years nearing adolescence (around ages 10–12 years), a fracture mechanism involving extension forces predominated. With pubescence (after age 13 years), the flexion–avulsion pattern is most commonly seen. Furthermore, metaphyseal fractures predominated in the youngest population (ages 3–6 years), with tibial spine fractures occurring at age 10, Salter–Harris type I and II fractures at age 12, and Salter–Harris type III and IV physeal injuries occurring around age 14 years. Conclusion  We propose a new classification scheme that reflects both the direction of force and fracture pattern that appears to be age-dependent. A better understanding of injury patterns based on the age of the child, in conjunction with appropriate pre-operative imaging studies, such as computer-aided tomography, will facilitate the operative treatment of these often complex fractures.     

Protective effect of female gender against bone loss in the forearm following clean-cut tendon injuries, repair, and passive mobilization

The aim of this study was to investigate whether there is any significant difference in bone loss between female and male patients as a result of early passive mobilization after surgery for acute tendon–artery–nerve clean-cut injuries at the wrist level. A total of 51 patients who underwent such operations were enrolled in this study. Group I consisted of 40 male patients (mean age 30.2 ± 9.1 years, age range 15–44 years) and group II consisted of 11 female patients (mean age 24.1 ± 9.9 years, age range 14–43 years); postmenopausal women were not included in this group. Twenty-one patients in group I and six patients in group II were operated on for clean-cut tendon injury combined with nerve injury, artery injuries, or both. Bone mineral density (BMD) measurements of injuired forearms were obtained at 1 week, 6 weeks, 3 months, and 12 months after operation. The BMD of the radius and ulna did not change significantly throughout the follow-up period in group II (P > 0.05). In group I, BMD values were reduced significantly in the distal regions of the ulna and in the ultradistal region of the radius at the follow-up measurements when compared to the values at week 1 and the reduction was higher in month 3 than at other times. On the other hand, after 12 months, the BMD values of the ultra-distal region of the ulna and radius were higher than those after 3 months. In conclusion, our results showed that there is considerable bone loss of the radius and ulna in patients operated on for acute clean-cut tendon injuries on the volar side of the wrist at postoperative month 3 in male patients. These bone losses were recovered after 12 months. Additionally, female patients are less likely to experience immobilization-induced bone loss than male patients.     

Outcome of lateral humeral condylar mass fractures in children associated with elbow dislocation or olecranon fracture

Of 2,502 elbow/humeral injuries treated at our department between 1990 and 2005, we identified a cohort of 20 lateral condylar mass (LCM) fractures of the humerus in children associated with elbow dislocation (n = 12; mean age 8.2 years) or with olecranon fracture (n = 8; mean age 4.1 years). Eight patients with undisplaced fracture pattern were treated conservatively yielding a satisfactory outcome. Good to excellent results were obtained in the majority (85%). Overall, the result was poor in three patients (15%; 25% of the operated cohort) due to terminal 20–30° loss of extension. There was no obvious difference in the outcome between the isolated displaced LCM fractures described in the literature and this cohort. Testing of elbow stability by examination under anaesthesia is stressed. Undisplaced fracture patterns need to be closely observed. Parents should be warned about the likelihood of some degree of unfavourable outcome in the displaced LCM fractures with associated elbow injuries.

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Resume  Sur les 2502 cas de traumatismes du coude traités dans notre département entre 1990 et 2005, nous avons identifié une cohorte de 20 fractures du condyle externe (LCM) associées à une luxation du coude (n = 12, moyenne d’age: 8,2 ans) ou avec une fracture de l’olécrane (n = 8, moyenne d’age 4,1 ans). 8 patients présentant une fracture non déplacée ont été traités orthopédiquement avec un très bon résultat obtenu dans la majorité des cas (85%). Cependant, les résultats ont été médiocres chez 3 patients (15%; 25%) du fait d’une perte d’extension. Il n’y a pas de différence évolutive entre ces patients présentant une fracture isolée du condyle externe comparés aux patients relevant d’une étude de la littérature. Le groupe de patients avec fractures déplacées doit être averti de la possibilité de résultats moins favorables, notamment s’il existe des lésions associées du coude.

     

Sister’s fracture history may be associated with perimenopausal bone fragility and modifies the predictability of fracture risk

Summary  The present study investigated the effects of first degree relatives’ fractures on fracture incidence after the menopause. Sister’s, but not other relatives’, wrist or hip fracture history was associated with increased risk of fragility fractures after the menopause. This suggests genetic predisposition to bone fragility among postmenopausal women. Objective  The aim of the present study was to investigate the association between first degree relatives’ fractures and perimenopausal bone fragility. Materials and methods  The study sample of 971 perimenopausal women was extracted from randomly selected Kuopio Osteoporosis Risk Factor and Prevention cohort and measured with dual X-ray absorptiometry in femoral neck (FN) in baseline (1989–1991), in 5 years (1994–97), and in 10 years (1999–2001). All low-trauma energy fractures during the 10-year follow-up were recorded based on self-reports and validated from medical records. First degree relatives’ history of life-time hip and wrist fractures (exact classification or trauma energy not specified) was questioned by postal inquiries. Results  There was a significant correlation between fathers’ vs. brothers’ and mothers’ vs. sisters’ fractures (p < 0.01 in Pearson bivariate correlations). Sister’s, but not mother’s, father’s, or brother’s wrist and hip fractures were associated with significantly lowered 10-year fragility fracture-free survival rate (HR = 0.56, p = 0.006). Sisters’ or other relatives’ fractures were not associated with FN bone loss rate or bone mineral density (BMD) in the follow-up measurements (p = NS in ANCOVA). The predictive power of BMD for fragility fractures differed according to sisters’ fracture history: Baseline FN T score predicted fracture-free survival only among women without sisters’ fracture history (HR 0.62, p < 0.001 vs. women with sisters’ fracture in Cox regression). Conclusions  In conclusion, sisters’ fracture history is associated with 10-year fracture-free survival in perimenopausal women but not with BMD or its changes. Predictability of fragility fracture risk with BMD may depend on sister’s fracture history. This may indirectly suggest genetic predisposition to bone fragility independently of BMD.     

Fractures in the proximal humerus: functional outcome and evaluation of 70 patients treated in hospital

Introduction Patients with proximal humeral fractures are mostly elderly. In addition to the proximal humeral fracture, they often have other injuries related to poor bone quality. The surgical treatment of proximal humeral fractures in elderly patients with comminuted fractures is associated with several problems and a high frequency of complications. The aims of this study were to evaluate patients with a proximal humeral fracture treated in a hospital, assess the outcome of the fracture treatment, and decide whether surgical treatment of displaced proximal humeral fractures is superior to conservative treatment or not.Materials and methods Patients with fractures of the proximal part of the humerus treated in our hospital were followed during two different periods (14 and 10 months). The study in the first time period was retrospective in design, while in the second period the patients were followed prospectively. Seventy patients, (71% women) with a mean age of 71 years, were included in the study. A functional test was performed within 12–14 months after the injury using a modified Rowe shoulder score. Surgical treatment was performed in 15 patients (21%). Neither the surgical approach nor the implants used for osteosynthesis were standardized. Fifty-five patients (79%) were treated conservatively with a modified Velpeau bandage or a sling.Results The fractures were classified according to AO into type A (27%), type B (58%) and type C (14%). Osteoporotic risk factors were present in many of the patients, mainly characterized by other skeletal injuries than the proximal humeral fracture (43%). In the group of complex, displaced, non-impacted fractures B2, B3, C2, C3 included (20 fractures), the group treated conservatively had a mean Rowe score of 48/75 (64% of maximum score) and SD 16.8, while in the surgically treated group the mean score was 28/75 (38% of maximum score) and SD 8.1. The difference between the two treatments was significant, with a p-value of 0.01 in favour of the conservatively treated group.Conclusion The number of patients in each of the fracture groups was low, but surgery did not benefit the patients with complex, displaced fractures in this study.     

Traditional bone setter’s gangrene

 Traditional bone setter’s gangrene (TBSG) is the term we use to describe the sequelae sometimes seen after treatment with native fracture splints. Twenty five consecutive complications were recorded in 25 patients aged between 5–50 years with a median age of 10 years. The major complication of the native fracture splint treatment was distal limb gangrene necessitating proximal amputations in 15 cases.

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Résumé  La gangrène causée par la fixation traditionelle des fractures est le mot que nous utilisons pour décrire la sequelle due a l’utilisation de l’attelle fabriquée de facon traditionelle par des bambous. Cependant, l’implication de cette pratique commune n’a pas étéétudié objectivement. Vingt cinq complications consécutives ont été reportées sur 25 patients agés entre 5–50 ans avec la moyenne d’age de 10 ans. Le rapport entre male et femélle était 4:1. La complication majeure de l’utilisation de l’attelle pour fracture était la gangréne de la partie distale du membre nécessitant d’amputer dans 15 (60%) des cas étudiés.

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Accepted: 4 January 1999     

The long-term predictive value of bone mineral density measurements for fracture risk is independent of the site of measurement and the age at diagnosis: results from the Prospective Epidemiological Risk Factors study

Although the utility of bone mass measurements has been the subjects of extensive investigations, the number of studies comparing the predictive value of bone mass measurement at different skeletal sites in the same cohort with a large number of clinically verified endpoints is limited. Furthermore, scant information is available on how age at the time of diagnosis influence the risk of future fractures posed by low bone mineral density (BMD). We have followed 5,564 Danish postmenopausal women for a mean period of 7.3 years. Bone mineral content (BMC) at the forearm and BMD at the spine and hip were assessed at baseline. Vertebral fractures were assessed on digitalized images of lateral X-rays of the thoracic and lumbar spine, whereas non-vertebral fractures were self-reported. At follow-up, 17.6% of the women revealed an incidental vertebral fracture and 14.2% reported a new non-vertebral fracture. The absolute risk per 1,000 person-years of osteoporotic fracture increased significantly with decreasing bone mass at all three skeletal sites (P<0.001). Osteoporotic BMD (T-score ≤−2.5) had similar predictive values of fractures regardless of the skeletal site of measurement. Furthermore, the absolute risk of osteoporotic fractures increased significantly with increasing age at the same level of bone mass. Interestingly, the relative risk (RR) of vertebral fracture accompanying 1 SD decrease in spine BMD was similar across different age groups: <55 years (RR:2.1, 95% CI 1.3–3.3), 55–64 years (RR:2.3, 95%CI 1.7–3.2), 65–74 years (RR:2.0; 95%CI 1.5–2.6). Furthermore, women with any prior osteoporotic fracture had a 2.4-fold (95% CI 2.01–2.75, P<0.001) increased risk of a new vertebral fracture. Both age and prior fracture are strong predictors of future fractures. The long-term predictive value of bone mass measurement is independent of the site of measurement and the age at diagnosis.     

缝线辅助锁定钢板治疗老年肱骨近端骨折的病例对照研究

目的：探讨应用缝线辅助锁定钢板治疗老年肱骨近端骨折的临床疗效.方法：自2005年1月至2013年1月,收治老年肱骨近端3、4部分骨折55例,分为治疗组和对照组.治疗组31例,采用缝线辅助锁定钢板治疗,其中男12例,女19例;年龄65～85岁,平均（74.00±5.42）岁;NeerⅢ型19例,Ⅳ型12例;低能量损伤23例,高能量损伤8例.对照组24例,采用锁定钢板治疗,其中男7例,女17例;年龄65～85岁,平均（72.79±5.34）岁;NeerⅢ型16例,Ⅳ型8例;低能量损伤17例,高能量损伤7例.记录并比较两组患者的手术时间、术中出血量、骨折愈合时间,术后采用Neer评分评价肩关节功能恢复情况.结果：55例均获随访,时间6～24个月,平均16.1个月.治疗组平均出血量（495.806±143.150） ml;Neer评分中的功能（22.645±2.443）分,活动范围（18.194±2.613）分,解剖（7.935±1.504）分,总分77.161±8.335.而对照组平均出血量（641.667±169.851） ml;Neer评分中功能（13.955±1.989）分,活动范围（13.083±2.165）分,解剖（5.500±1.978）分,总分58.792±7.313.以上指标比较,治疗组结果均优于对照组.结论：采用缝线辅助锁定钢板治疗老年肱骨近端骨折,具有术中出血少、复位简单有效、术后肩关节功能恢复效果更好的优点,是治疗老年肱骨近端骨折的有效方法.     

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.