Percutaneous flexible double pinning (Py–Desmanet’s procedure) for pediatric distal radius fractures

Purpose

The purpose of this study is to report the results of percutaneous flexible double pinning for pediatric distal radius fractures.

Methods

Thirteen unstable fractures (three physeal and ten metaphyseal) of the distal radius in which the physeal plate could be still identified were treated with percutaneous flexible double pinning between 2008 and 2011. The average age of these cases was 9.8 years (range, 2–16 years). According as Py–Demanet’s original technique, the fracture was fixed with two percutaneous transepiphyseal intramedullary wires. Kirschner wires or c-wires of 1.4–1.6 mm in diameter were used in each case depending on age. Operative and short follow-up outcomes were assessed.

Results

The average operative duration was 23 min (range, 5–45 min). Comorbid distal ulnar fractures were further stabilized by intramedullary pinning. Additional external splintage was administered in all cases for 6 weeks postoperatively. Wires were removed after an average of 7.2 weeks (range, 4–10 weeks). Bone union was achieved in all cases. Neither malunion nor early epiphyseal closure of the distal radius was identified at mean follow-up of 12 months (range, 3–51 months).

Discussion

Flexible double pinning has been successfully used for distal radius fractures in adults. Since this technique is minimally invasive, quick, and technically easy, it is also a good treatment option for unstable distal radius fractures in children. Level of clinical evidence: Therapeutic Level IV     

Distal radius fractures and the volar lunate facet fragment: Kirschner wire fixation in addition to volar-locked plating

Background

The volar lunate facet fragment of a distal radius fracture may not be stabilized with volar-locked plating alone due to the small size and distal location of the fragment. Identification and stabilization of this small fragment is critical as unstable fixation may result in radiocarpal and radioulnar joint subluxation. The addition of spring wire fixation with volar plating can provide stable internal fixation of this critical fracture fragment.

Methods

A retrospective review (2006–2011) identified nine patients with distal radius fractures with an associated volar lunate facet fragment that were treated with volar-locked plating and spring wire fixation of the volar lunate facet fragment. Radiographic indices, range of motion, grip strength, and postoperative Patient-related wrist evaluation (PRWE) scores were obtained to assess pain and function.

Results

All distal radius fractures healed, and the volar lunate facet fragment reduction was maintained. The mean follow-up was 54 weeks. Mean active range of motion was 46° wrist flexion, 51° wrist extension, 80° pronation, and 68° supination. The mean grip strength was 21 Kg, achieving 66 % of the uninjured limb. The average PRWE score was 17. No patient required removal of hardware or had evidence of tendon irritation.

Conclusions

The addition of spring wire fixation to volar-locked plating provided stable fixation of the volar lunate facet fragment of distal radius fractures without complication. This technique addresses a limitation of volar-locked plating to control the small volar lunate facet fragment in distal radius fractures otherwise amenable to volar plating.

Level of Evidence

A retrospective case series, Level IV.     

Use of bone graft substitute in the treatment for distal radius fractures in elderly

Introduction

Fractures of the distal radius in elderly patients are often associated with metaphyseal defects that can lead to collapse, malunion and therefore decreased function. An alternative approach to simple reduction is to fill the defects with materials that can provide structural support.

Methods

We used synthetic hydroxyapatite (HA) in unstable fractures of the distal radius in thirty-one elderly patients, of which four patients lost to follow-up, leaving twenty-seven patients for this study. All subjects underwent closed reduction with K-wire fixation and HA augmentation. They were followed up at 8- and 16-week intervals post-operatively to assess the functional outcome using patient-related wrist evaluation [PRWE], clinical outcome and radiological outcome.

Results

At mean 16 weeks, our results show that patients treated with this method showed no metaphyseal defect, no collapse and had satisfactory clinical outcome as assessed by PRWE.

Conclusion

We believe that fixation with hydroxyapatite augmentation for fractures of the distal radius in elderly patients is an attractive therapeutic option. This experience has changed our clinical practice.     

Treatment of isolated diaphyseal fractures of the radius with an intramedullary nail in adults

Background

The goal of the radius diaphysis fractures in surgical treatment is restoration of bone length, rotation correction and to secure fixation that allows early mobilization. The purpose of this study is evaluating the results of intramedullary (IM) radius nail for the treatment of isolated adult diaphyseal fractures of the radius.

Materials and methods

We retrospectively reviewed adults with isolated fractures of the radius, who were treated with closed or mini open reduction with a IM radius nail between May 2008 and November 2011 and who were followed for a least 1 year. Patients with a Galeazzi fracture, a pathological fracture, or patients with nonunion after previous surgeries were excluded. All patients were allowed full range of motion without any external support. Primary outcomes were Grace and Eversmann rating, Disabilities of the Arm, Shoulder and Hand (DASH) scores.

Results

Twenty-three enrolled patients (mean age 34 years; 17 men) had 23 isolated radius fractures. Mean time to fracture union was 12 weeks (range 10–13 weeks) for radius fractures. No patient had nonunion, deep infections, or radioulnar synostosis. Follow-up ranged from 12 to 42 months. Grace and Eversmann ratings of 21 patients were excellent or good, and 2 patients were medium. Mean DASH score was 4.2 points (range 0–13.3).

Conclusions

Our experience indicates that this new IM radius nail may be considered as an alternative to plate osteosynthesis for fractures of the radius diaphysis in adults. IM nailing of radius fractures provides reliable bony union and excellent postoperative clinical results in adults.     

A novel closed reduction with extension block and flexion block using Kirschner wires and microscrew fixation for mallet fractures

Background

Some patients with mallet fractures who undergo extension block pinning complain of exposed wires, which delay their return to sports and causes inconvenience while performing tasks that require the use of hands during the early postoperative period. The purpose of this retrospective study was to present and evaluate a novel surgical procedure for mallet fractures.

Methods

We treated 20 patients (14 males and six females; mean age, 38.4 years; range 17–68 years) with displaced mallet fractures involving >30 % of the articular surface using the closed reduction and microscrew fixation between January 2009 and January 2012. The distal interphalangeal joint (DIP) joint was immobilized with a splint for 1–3 weeks on an individual case basis. According to Wehbe and Schneider’s classification, there were 12 type IB, six type IIB, and two type IA fractures. The mean follow-up duration was 12.6 months (range 6–31 months).

Results

Bone union was achieved in all patients within a mean period of 6.8 weeks, with no incidence of infection, skin necrosis, permanent nail deformity, or secondary osteoarthritis. Only two complications—temporary nail ridging in one patient and a dorsal bump caused by the screw in one patient—were observed. Minimum postoperative displacement was observed in one patient, for whom immobilization with a splint was continued for 4 weeks. Articular incongruity was <1.0 mm in four patients and 1.0–2.0 mm in two patients. Mean DIP joint extension loss was 6.5° and mean flexion was 67.8°. The surgical outcomes were excellent in seven patients, good in nine, and fair in four according to Crawford’s evaluation criteria.

Conclusion

Our novel surgical procedure combining closed reduction with extension block and flexion block using Kirschner wires and microscrew fixation produces good clinical results with relatively few complications.     

The use of T-LCP (locking compression plate) for the treatment of the lateral malleolar fractures

Background

The authors evaluated results and hardware-related complications after the fixation of Danis-Weber (D-W) types A and B lateral malleolus fractures using a 3.5-mm T-shaped locking compression plate (T-LCP) for distal radius.

Methods

Twenty-six patients with Danis-Weber type A or B lateral malleolar fractures treated between January 2001 and February 2008 were included in this study. Mean age of the patients was 52.6 (28–77) years. All patients were treated using a 3.5-mm T-shaped locking plate for distal radius fractures. The distal fragment was fixed with at least 2 locking screws more. Ankle motion was allowed early after surgery. The authors evaluated serial radiographs, range of motion, skin irritation, and AOFAS scores at final follow-ups.

Results

All fractures united during follow-up. Eight cases were of D-W type A, and 18 were of D-W type B. A mean number of three screws were placed at the distal fragment (2–4). There were 6 cases (23.1%) of implant irritation over the operative site, but no other complications were encountered. At final follow-ups, the AOFAS score of affected ankles was 97.1 ± 4.4.

Conclusion

T-LCP use for type A or B lateral malleolar fractures resulted in low hardware-related complications and produced good results at follow-up.     

Nicht gelenküberbrückender Fixateur externe vs. palmare winkelstabile Plattenosteosynthese in der Behandlung der distalen extraartikulären Radiusfraktur

Aim/Purpose

The aim of operative treatment of distal radius fractures is to achieve anatomic restoration and stable fixation allowing early wrist movement. The extraarticular radio-radial fixator may provide both. In a prospective randomized trial, the nonbridging external fixator was compared with open reduction and internal fixation by volar fixed angle plating.

Methods

A total of 62 patients with extraarticular fractures of the distal radius were included in a prospective randomized trial: 33 patients were treated by external fixation and 29 patients by internal plate fixation. Follow-up examinations were carried out 8 weeks, 6 months, and 1 year after surgery.

Results

The time for surgery using the nonbridging external fixator was significantly less (41 minutes) than using volar plating (56 minutes), whereas intraoperative fluoroscopy time turned out to be twice as long (2 minutes). The functional outcome was good or excellent in both treatment groups. Eight weeks after surgery, patients with nonbridging external fixation presented with significantly less grip strength (26% of the contralateral hand) compared to patients with volar plating (48% of the contralateral hand). The restoration of the physiological volar tilt was achieved more precisely by external fixation. The results of the SF-36 health survey did not show any significant differences between both groups.

Conclusion

Nonbridging external fixation is a good alternative treatment option to open reduction and volar plating. The minimally invasive technique allows for anatomical restoration and safe reduction permitting early range of motion. The clinical and radiological results are good to excellent accompanied by a low rate of complications.     

Effect of untreated triangular fibrocartilage complex (TFCC) tears on the clinical outcome of conservatively treated distal radius fractures

Objective

The purpose of this study was to investigate the effect of untreated triangular fibrocartilage complex (TFCC) tear on the clinical outcome of conservatively treated distal radius fractures.

Materials and methods

This prospective study comprised 47 consecutive patients who presented at our clinic between January 2009 and January 2010 with displaced radius distal fracture and were treated with closed reduction and casting. During the first 15 days of treatment, all patients underwent wrist MR imaging to detect traumatic TFCC tears. At the final follow-up, all patients were evaluated with Mayo wrist function score and wrist radiographs. Patients were divided into two groups according to presence of TFCC tear, and two groups were analyzed statistically.

Results

The mean follow-up period was 38.9 ± 3.5 months (range 36–48). TFCC tear was detected in 24 cases, and remaining 23 cases had no TFCC tear. Both groups were statistically similar regarding age (p = 0.574), gender (p = 0.108), dominant side involvement (p = 0.339), fracture type (p = 0.709) and immobilization period (p = 0.514). According to Mayo wrist score, excellent results were obtained in 21 (44.7 %) cases, good in 16 (34.0 %) and satisfactory in 10 (21.3 %). No significant difference was observed between groups in wrist function scores (p = 0.451). Radiographic measurements were similar between groups (radial length p = 0.835, volar til p = 0.464, radial inclination p = 0.795).

Conclusions

Traumatic TFCC tears which are frequently seen together with distal radius fractures do not affect the long-term functional results. Therefore, further diagnostic tests and treatment of TFCC tears in patients with stable distal radius fractures may be unnecessary. However, it should be borne in mind as a reason for continuing wrist pain and instability after distal radius fractures despite proper radiologic recovery.     

Scapholunate dissociation associated with distal radius fractures

Objective

The exact prevalence of scapholunate dissociation (SLD) associated with distal radius fracture (DRF) and the effect of persistent SLD on the function of the wrist are not known. So, we examined the association between SLD and DRF and the effects of treatment on clinical outcomes.

Methods

Eight hundred and twenty-nine patients with 839 DRF were included in the study. The radiographs of the patients were examined with special reference to SLD both in pre- and post-reduction period. Persistent SLD cases were evaluated by the scoring system of Green and O’Brien at least 2 years after the fracture.

Results

Of the 839 fractures, 215 had SLD after the injury. When post-reduction radiographs were examined, SLD persisted in 98, but in 14 SLD was detected in the post-reduction period while not apparent in initial radiographs. So, a total of 112 patients (13.4 %) had persistent SLD. Nineteen patients were lost to follow-up and remaining 93 wrists examined clinically. Seventy-nine had pain on the scapholunate joint and 14 had not. When these patients were evaluated by Green and O’Brien system, symptomatic patients had fair or poor results but asymptomatic had good. The association between DRF and SLD is 13.4 %.

Conclusions

Severity of the distal radius fractures is not associated with SLD. Intra-articular fractures were associated with significant increase in the prevalence of SLD. In some cases, SLD may appear after reduction in distal radius. Most cases with SLD are symptomatic, and this may be the reason of poor cases following distal radius fracture.     

Outcomes and complications of fractures of distal radius (AO type B and C): volar plating versus nonoperative treatment

Objectives

Management of AO type B and C fractures of the distal radius is controversial. This study compares outcomes and complications of AO type B and C fractures of the distal radius treated with volar locked plating and nonoperative methods.

Materials and methods

Sixty-four patients with fractures of the distal radius (AO type B and C) were included in this study, according to inclusion criteria, and were allocated to the volar plating group or nonoperative group by alternate randomization: 32 patients with odd numbers went into the nonoperative group and the other 32 with even numbers went into the volar plating group. Patients in the nonoperative group were managed with closed reduction of the fracture and plaster cast application under an image intensifier. Those in the volar plating group were managed by open reduction and fixation with a volar locked plate. Preoperative and postoperative serial clinico-radiological follow-up was done. The range of movement, grip strength, functional outcome scores and radiological parameters were compared. Student’s t-test was used for statistical analysis with significance at p < 0.05.

Results

Range of movement and functional scores were significantly (p < 0.001) better in the volar plating group, but the difference in ulnar variance and radial and ulnar deviation was insignificant as compared to the nonoperative group. At 24 months follow-up, the nonoperative group had significantly more cases with malunion, articular incongruity and osteoarthritis.

Conclusion

In cases of AO type B or C fractures of the distal radius, volar locked plating provides anatomical stable fixation and early mobilization with better clinico-radiological outcome as compared to conservative treatment.     

Volar locking plate fixation of distal radius fractures: use of an intra-operative ‘carpal shoot through’ view to identify dorsal compartment and distal radioulnar joint screw penetration

Introduction

We report our experience using a ‘carpal shoot through’ view of the distal radius to identify dorsal compartment screw penetration intra-operatively when performing volar plating of the distal radius.

Methods

A prospective study of 42 patients (mean age 56 years) with acute distal radius fractures treated with open reduction internal fixation was undertaken. Surgical fixation was performed using a volar locking plate in all patients. After plate application, inclined posteroanterior and lateral radiographs were taken followed by the carpal shoot through view.

Results

In six cases (14 %), the carpal shoot through view revealed dorsal screw protrusion, which was not detectable on standard PA and lateral views. In one case, a screw had penetrated the distal radioulnar joint (DRUJ), which was only apparent on the shoot through view. The overall screw exchange rate was 17 %.

Conclusions

Using the hand and carpus to minimise the contrast in X-ray penetration, the dorsal cortex of the distal radius may be imaged intra-operatively and dorsal compartment screw penetration detected in cases with significant multifragmentation when screw measurement is difficult. This view potentially reduces the risk of post-operative pain and extensor tendon injury and also provides excellent visualisation of the DRUJ.     

Erste Ergebnisse der multidirektional-winkelstabilen palmaren Osteosynthese der distalen Radiusfraktur

Background

The management of fractures of the distal radius continues to evolve. New operative strategies have recently been developed including the use of fixed-angle plates. This study reviews the results of 20 patients with fractures of the distal radius treated with a new multidirectional fixed angle plate.

Method and materials

A total of 20 patients with closed Colles type fractures of the distal radius were treated with Medartis (Aptus 2.5) palmar fixed-angle plates. Surgery was performed under plexus anesthesia using the standard or extended flexor carpi radialis (FCR) approach. Patients were evaluated prospectively with a mean follow-up of 26 weeks (range 23–28 weeks). Pain, range of motion, grip strength, DASH score, modified Mayo wrist score and radiographs were obtained. The level of significance was set at 95% and the χ² and ANOVA tests in combination with a post hoc Tukey test were used for statistical analysis.

Results

The average range of motion (ROM) in extension-flexion was 87° (76% of the contralateral side) and in ulnar-radial deviation 42° (88% of the contralateral side). Pain values (visual analogue scale 0–100) at follow-up were 3 (without stress) and 24 (with stress). Grip strength improved to 84% of the contralateral side, the mean DASH score was 13 points and the modified Mayo wrist score confirmed the excellent results with a mean value of 83±27 points. Radiological examination showed a satisfactory result with an ulna variance of 0.9±0.4 mm, radio-ulnar inclination of 21±5° and palmar inclination of 4±6°.

Conclusions

Our data show that treating unstable distal radius fractures with multidirectional palmar fixed-angle plates is reliable and effective and produces good early functional and radiological results. However, long-term results with a larger number of patients and randomized prospective studies comparing this technique with other established procedures are required.     

Alternative treatment of forearm double fractures: new design intramedullary nail

Objective

This study aims to evaluate the results of intramedullary nail treatment in surgical treatment of adult displaced radius and ulna diaphyseal fractures.

Patients and methods

Eighteen patients (36 forearm fractures) who underwent intramedullary nail treatment due to radius and ulna fractures were retrospectively analyzed. Adult patients with displaced forearm double fractures were included in this study. Patients with open physeal lines, pathological fractures, Monteggia and Galeazzi fractures, distal radioulnar joint instability, bilateral fractures and bone loss were excluded.

Results

Thirteen patients were male (72.2 %) and five were female (27.8 %). Average age of the patients was 35.16 (18–63). Twelve patients (66.7 %) suffered right and six patients (33.3 %) left forearm fractures. Average follow-up period was 77.7 (55–162) weeks, average bleeding amount was 51.11 (15–100) ml, average time to bone union was 11.3 (8–20) weeks, average surgery time was 61.94 (45–80) min and average fluoroscopy time was approximately 2 (1–5) min. According to Grace-Eversman criteria, results were excellent in 14 (77.8 %) patients, good in 3 (16.8 %) and acceptable in 1 (5.6 %). Average DASH questionnaire score was 15.15 (4–38.8). There was no iatrogenic vascular, neural and bone injury during surgery. There was late rupture of extensor pollicis longus tendon in one patient, 4 months after surgery.

Conclusion

Intramedullary fixation method has advantages, such as closed application, short surgery period, good cosmetic results and early return to movement. We think intramedullary fixation method may be used as an alternative treatment method to plate osteosynthesis in surgical treatment of radius and ulna diaphyseal fractures.     

Osteosynthesis of distal radius fractures with the Micronail®

Introduction

The Micronail^® is a minimally invasive intramedullar titanium locking screw fixation for two-part dislocated extra-articular fractures and average displaced intra-articular fractures.

Patients and methods

In a retrospective study we analyzed the outcome of 20 distal radius fractures in 18 patients (17 female, mean age 78 years), which were treated by Micronail^®. Average follow-up time was 4 months. We describe the operative technique. All fractures were classified according to AO guidelines. We studied the radiologic and clinical outcome.

Results

According to the AO classification there were 12 A2, 3 A3, 1 B1, and 1 B3 fracture. Three patients had an antebrachii fracture. Mean American Society of Anesthesiologists (ASA) score was 2.4. Eight patients had associated lesions. Average operative time was 58 min. All fractures healed without major loss of alignment. There were two major complications: one patient developed a carpal tunnel syndrome and one device secondary dislocated. With the use of the Micronail^®, we found no infections or complications due to the insertion of the osteosynthesis materials. Patients experienced good to excellent results, on an analogue scale, in function of their wrist from the procedure. All patients had a good range of motion of the operated wrist; the difference between their two wrists was maximal 10° in all directions.

Conclusion

This intramedullary implant intends to minimize some of the disadvantages of other surgical options in the treatment of distal radius fracture; the Micronail^® causes less tissue damage and has early load-carrying capacity. This minimally invasive technique seems suitable in selected, two-part dislocated extra-articular and average displaced intra-articular, distal radius fractures.     

Operative vs. konservative Therapie nichtdislozierter Skaphoidfrakturen

Purpose

Within a prospective, multicenter cohort study we investigated whether operative treatment of scaphoid bone fractures leads to earlier return to previous activity levels.

Methods

Only isolated, acute, complete, stable and non-displaced fractures of the mid-third of the scaphoid bone were included. A total of 94 patients with the same number of fractures were recruited. In the operative group, fractures were fixed with a cannulated screw and had postoperative splint immobilization for a maximum of 1 week. In the conservative group a short arm cast was applied until fracture union was achieved. Both groups were followed for 6 months.

Results

By 15 weeks patients receiving surgical treatment had returned significantly earlier to their full time work and home activities and achieved significantly better results for functional status, pain, and overall satisfaction. However, after screw fixation, complication rates concerning union and secondary operative management were higher.

Conclusion

Operative treatment primarily facilitates earlier return to previous activity levels, as well as better functional status, less pain and higher patient satisfaction, but conservative treatment seems to be safer and associated with a lower complication rate.     

The olecranon osteotomy provides better outcome than the triceps-lifting approach for the treatment of distal humerus fractures

Introduction

Intra-articular distal humeral fractures can be approached in a variety of ways. The purpose of this study is to evaluate and compare the functional outcomes of two approaches: approach with olecranon osteotomy and triceps-lifting approach for the treatment of intra-articular distal humeral fractures.

Methods

This study shows a consecutive series of 54 intra-articular distal humeral fractures of 54 patients who were treated with open reduction and internal fixation with anatomic plating. Lateral plating was performed in 10 (45.5 %) patients, and medial and lateral parallel plating was performed in 12 (54.5 %) patients in olecranon osteotomy group, while lateral plating was performed in 8 (25 %) patients, and medial and lateral parallel plating was performed in 24 (75 %) patients in triceps-lifting group.

Results

Mean follow-up was 38.3 months for olecranon osteotomy group and 41.4 months for triceps-lifting group. Functional outcomes according to MAYO elbow score and extension-flexion motion arc values were significantly better in olecranon osteotomy group (p < 0.05).

Conclusion

Approach with olecranon osteotomy provided better functional outcomes than triceps-lifting approach. Additionally, intra-articular distal humerus fractures can be safely treated with olecranon osteotomy which provides more control over the elbow joint and better visualisation and allows early postoperative rehabilitation.

Level of evidence

IV.     

Intraoperative evaluation of dorsal screw prominence after polyaxial volar plate fixation of distal radius fractures utilizing the Hoya view: a cadaveric study

Background

The irregular nature of the dorsal surface of the distal radius makes it difficult to detect prominent screws with volar plate fixation for distal radius fractures using standard fluoroscopic images. This study evaluates the accuracy of a new radiographic method, the Hoya view, for the assessment of dorsal cortical screw penetration with volar plate fixation.

Methods

Eight cadaveric upper extremities underwent application of a volar distal radius plate with polyaxial locking screws placed distally. Utilizing a mini C-arm, lateral and Hoya views were obtained with notation of any dorsal cortical screw prominence. Dissection of the cadavers was then performed for direct visualization of screw prominence. The screws were then exchanged sequentially for screws 2-mm longer than their initial measurements with repeated imaging and direct visualization.

Results

The Hoya view revealed that 9.4 % of the screws penetrated the dorsal cortex with an average screw prominence of 1.08 mm (range 0.5–2 mm). None of the six prominent screws were detected with lateral views. With the Hoya view, six of six prominent screws were identified. With locking screws exchanged for screws 2-mm longer, 76.6 % of the screws had violated the dorsal cortex; of these, 24.5 % were detected with lateral imaging versus 100 % with the Hoya view.

Conclusions

This study supports the intraoperative use of the Hoya view to evaluate screw length and dorsal cortical screw penetration in volar plate fixation of distal radius fractures. However, this view may be difficult to obtain in patients with limitations in elbow or shoulder range of motion.     

Distal radius fracture fixation with volar locking plates and additional bone augmentation in osteoporotic bone: a biomechanical study in a cadaveric model

Background

Fractures of the distal radius represent the most common fractures in adults. Volar locked plating has become a popular method for treating these fractures, but has been subject to several shortcomings in osteoporotic bone, such as loss of reduction and screw purchase. In order to overcome these shortcomings, cement augmentation has been proposed.

Methods

AO-type 23-A3.3 fractures were made in 8 pairs of fresh frozen osteoporotic cadaveric radial bones. All specimens were treated with volar plating, and divided into cement augmentation or non-augmentation groups (n = 8/group). Constructs were tested dynamically and load to failure, construct-stiffness, fracture gap movement and screw cutting distance were measured.

Results

Cement augmentation resulted in a significant increase in cycles and load to failure, as well as construct stiffness at loads higher than 325 N. When compared to the non-augmented group, fracture gap movement decreased significantly at this load and higher, as did screw cutting distance at the holes of the ulnar column. The cycles to failure depend on the BMD in the distal region of the radius.

Conclusion

Cement augmentation improves biomechanical properties in volar plating of the distal radius.     

Fractures of the sustentaculum tali

Objective

Anatomical reconstruction of displaced sustentaculum tali fractures via a direct medial approach.

Indications

Displaced fractures of the sustentaculum tali with incongruity or depression of the medial facet of the subtalar joint, entrapment of the flexor hallucis longus or flexor digitorum longus tendons, fracture line extending into the posterior facet of the subtalar joint.

Contraindications

Infected or grossly contaminated soft tissue, severely restricted vascular supply to the foot, high perioperative risk.

Surgical technique

Direct medial approach over the sustentaculum tali, retraction of the tendons, joint exploration, fracture reduction using the medial facet and cortical outline as guidelines, fracture fixation with two small fragment screws from medial to lateral directed slightly plantarly and posteriorly. Fractures with depression of the medial facet as a whole can alternatively be reduced and fixed percutaneously.

Postoperative management

Lower leg splint for 5–7 days, partial weight-bearing with 20 kg for 6–8 weeks (until radiographic signs of consolidation) in the patient’s own shoewear, early range of motion exercises of the ankle, subtalar and mid-tarsal joints.

Results

Over a course of 15 years, 31 patients were treated operatively for sustentacular fractures. In all, 27 patients (87?%) had additional fractures to the same foot and ankle. Eighteen patients with a mean age of 41 years treated at our institution with screw fixation for a unilateral fracture of the sustentaculum tali could be followed for a mean of 80 months (range 15–151 months). No wound healing problems or infections were seen with the medial approach. At the time of follow-up, 15 sustentaculum tali fractures had an average Foot Function Index of 21.6 and an average AOFAS Ankle–Hindfoot Score of 83.6. Patients with isolated fractures of the sustentaculum tali had significantly better scores than those with additional injuries. In 1 patient, an additional lateral process fracture of the talus required subtalar fusion due to persistent pain. Care must be taken not to overlook these atypical calcaneal fractures and accompanying injuries to the mid-tarsal joint and the lateral talar process as seen in 45% and 23%, respectively, in the present series.