Treatment of displaced radial head fractures by internal fixation with absorbable pins

Objective: To study the effect of internal fixation with absorbable pins on treatment of displaced radial head fractures. Methods: From May 1999 to May 2004, 16 patients with displaced radial head fractures (Mason typesⅡandⅢ) were treated with internal fixation by absorbable pins. The duration of follow-up averaged 22.6 months (12-58 months). The outcome was assessed on the basis of elbow motion, radiographic findings and the functional rating score delineated by Broberg and Morrey. Results:All fractures healed within 10 months without avascular necrosis of radial head. The mean elbow flexion loss was 15°(0°-35°), and pronation and supination decreased by 10°(0°-30°) on average compared with those of the contralateral elbow. Five patients had an excellent result, 6 a good result, and 3 a fair result according to the criteria of Borberg and Morrey. Conclusions: Internal fixation with absorbable pins is an effective method in treating displaced radial head fractures. It can maintain the biomechanical stability of forearm, improve the elbow function and avoid second operation.     

Open reduction and internal fixation of fractures of the radial head

BACKGROUND: The purpose of this retrospective study was to analyze the functional results following open reduction and internal fixation of fractures of the radial head and to determine which fracture patterns are most amenable to this treatment. METHODS: Fifty-six patients in whom an intra-articular fracture of the radial head had been treated with open reduction and internal fixation were evaluated at an average of forty-eight months after injury. Thirty patients had a Mason Type-2 (partial articular) fracture, and twenty-six had a Mason Type-3 (complete articular) fracture. Twenty-seven of the fifty-six fractures were associated with a fracture-dislocation of the forearm or elbow or an injury of the medial collateral ligament. Fifteen of the thirty Type-2 fractures were comminuted. Fourteen of the twenty-six Type-3 fractures consisted of more than three fragments, and twelve consisted of two or three fragments. The result at the final evaluation was judged to be unsatisfactory when there was early failure of fixation or nonunion requiring a second operation to excise the radial head, <100 degrees of forearm rotation, or a fair or poor rating according to the system of Broberg and Morrey. RESULTS: The result was unsatisfactory for four of the fifteen patients with a comminuted Mason Type-2 fracture of the radial head; all four fractures had been associated with a fracture-dislocation of the forearm or elbow, and all four patients recovered <100 degrees of forearm rotation. Thirteen of the fourteen patients with a Mason Type-3 comminuted fracture with more than three articular fragments had an unsatisfactory result. In contrast, all fifteen patients with an isolated, noncomminuted Type-2 fracture had a satisfactory result. Of the twelve patients with a Type-3 fracture that split the radial head into two or three simple fragments, none had early failure, one had nonunion, and all had an arc of forearm rotation of > or =100 degrees. CONCLUSIONS: Although current implants and techniques for internal fixation of small articular fractures have made it possible to repair most fractures of the radial head, our data suggest that open reduction and internal fixation is best reserved for minimally comminuted fractures with three or fewer articular fragments. Associated fracture-dislocation of the elbow or forearm may also compromise the long-term result of radial head repair, especially with regard to restoration of forearm rotation.     

Absorbable pins of self-reinforced poly-L-lactic acid for fixation of fractures and osteotomies.

We reviewed 27 patients with small-fragment fractures or osteotomies treated by internal fixation with absorbable self-reinforced poly-L-lactide pins. The follow-up time ranged from eight to 37 months. The two most common indications were chevron osteotomy of the first metatarsal bone for hallux valgus and displaced fracture of the radial head. No redisplacements occurred, and there were no signs of inflammatory foreign-body reaction. Biopsy in two patients 20 and 37 months after implantation showed that no polymeric material remained.     

可吸收自身增强软骨钉治疗桡骨小头骨折

 目的 评估可吸收自身增强软骨钉治疗桡骨小头骨折的临床疗效。方法 回顾性分析2008年1月至2011年12月采用切开复位、可吸收自身增强软骨钉固定治疗22例桡骨小头骨折患者资料,其中18例资料完整,男10例,女8例;年龄13~55岁,平均36.8岁;左侧10例,右侧8例。按Mason分型：Ⅱ型14例,Ⅲ型3例,Ⅳ型1例;其中2例合并桡骨颈骨折,9例合并肱骨小头软骨骨折,1例合并肘关节后脱位伴尺骨鹰嘴撕脱性骨折。术中对桡骨小头骨折复位后先以克氏针临时固定,再用直径为1.5 mm、长度为16~24 mm可吸收自身增强软骨钉固定,螺钉不穿过对侧骨皮质,螺钉头埋入软骨下;对同时存在的颈部骨折,先复位桡骨小头,以软骨钉固定,再复位颈部,用微型“T”形钢板或解剖型钢板固定。对合并肱骨小头骨软骨骨折,其中4例给予软骨片复位、可吸收缝线经肱骨外上髁固定,5例因骨软骨片较小无法固定而去除。结果 18例患者均获得随访,随访时间6~54个月,平均31.3个月;骨折均顺利愈合,愈合时间5~12周,平均8.7周。随访时无一例出现内固定失败、血肿、积液、窦道形成、桡骨小头溶骨性变化等并发症。Broberg-Morrey评分为68~100分,其中优13例,良4例,可1例,优良率为94.44％(17/18)。术后肘关节屈伸活动度为90°~150°,平均123.8°;前臂旋转活动度为130°～180°,平均152.5°。结论 可吸收自身增强软骨钉可治疗各种类型桡骨小头骨折,术后疗效满意。     

Dorsal plating for comminuted intra-articular fractures of the distal end of the radius.

Forty-one dorsally displaced intra-articular fractures of the distal radius were treated by open reduction and internal fixation with the dorsal Symmetry plates. The average age at the time of the injury was 49 years. An average follow-up period was 15 months. The final radial length averaged 11 mm, radial inclination 23 degrees, volar tilt 7 degrees, ulnar variance 1.5 mm, and articular incongruity 0.3 mm. According to the Gartland and Werly scales, 36 fractures were excellent and five were good. However, ulnar variance increased more than 3 mm during follow-up in eight patients, and volar tilt increased more than 5 degrees during follow-up in ten patients. Use of dorsal Symmetry plate is effective for unstable comminuted intra-articular distal radius fractures, but severely comminuted fractures may possibly undergo re-displacement post-operatively.     

Newly defined fracture pattern specific to Mason III radial head fractures: fracture description, management and outcomes using screw fixation

Background: Radial head fractures are the most common type of elbow fracture and are universally classified under the Mason classification system. Mason type III fractures are comminuted and are the most difficult to treat, generally requiring plating if possible, or more commonly arthroplasty or excision, which gives a variable outcome. We hypothesized that a new and specific fracture pattern of the radial head (Mason III) can be treated successfully with screw fixation. Methods: Six patients presented to the senior surgeon's clinic with this unusual Mason III fracture pattern. In these patients, the fracture was acute, requiring an open reduction and internal fixation with the use of three headless compression screws. Average follow‐up time was 21 months. Using serial X‐rays and the Broberg–Morrey elbow score, the six acute fractures were evaluated radiologically and functionally. Results: All six patients had good to excellent results using the Broberg–Morrey scoring system. All patients showed radiological and clinical union within 3 months of injury. No patient required revision surgery or excision at a later date. Discussion: We have recognized a specific type of comminuted and displaced Mason III radial head fracture that has not previously been described in the literature. This type of fracture is amenable to open reduction internal fixation with buried compression screws giving a good to excellent outcome, while avoiding the common consequences seen with a radial head excision, arthroplasty or plate fixation.     

Internal fixation of proximal radial head fractures

The treatment of choice for proximal radial head fractures remains controversial. The goal of any treatment for an intra-articular fracture must be the complete restoration of the joint and its function. Nonoperative treatment leads to full motion in cases of less than 1-2 mm of fracture displacement. Resection of the radial head can be recommended only for very comminuted fractures. All other fracture types should be treated by open reduction and internal fixation. Our own personal follow-up observation of 19 patients who had surgical intervention demonstrated restoration of elbow function after an average follow-up time of 11.7 months. Five patients had a slightly restricted range of motion of less than 10 degrees extension and flexion as well as less than 8 degrees pronation and supination, without signs of arthritis. Because complications were minimal, we recommend internal fixation of displaced proximal radial head fractures to restore the anatomic function of the elbow. This is especially true in cases with accompanying proximal ulna fractures and/or ruptured collateral ligaments of the elbow joint and/or disruption of the distal radio-ulnar joint.     

Arthroscopic reduction and suture fixation of displaced tibial intercondylar eminence fractures in adults

Introduction Tibial intercondylar eminence fractures are uncommon. In a review of the literature, most authors agreed that conservative treatment was suggested for non-displaced fractures. Displaced fractures were considered an indication for surgery.Materials and methods Between April 2000 and November 2001, five adult displaced tibial eminence fractures were treated by arthroscopic reduction and non-absorbable suture fixation. Postoperatively, the knee was immobilized in a hinged knee brace locked in full extension with non-weight bearing for 4 weeks. Range of motion and quadriceps-strengthening exercises were started 4 weeks later. Partial weight-bearing was allowed in the following 4 weeks.Results The average follow-up was 24.6 months (range 18–36 months). Subjectively, there was no instability or residual pain in the knee. The patients were able to resume their normal activities. Objectively, the average Lysholm Score was 95.6 (range 93–98). The average knee range of motion was 2° to 135° (range 0°–140°). All patients had a negative Lachmans test and no pivot shift phenomenon. All fractures showed good union according to radiological evaluation.Conclusion Arthroscopy-assisted screw fixation is more stable, and it allows early exercise. However, the fragment must be large enough to be fixed with a screw. Comminuted or small fragments present limitations for screw fixation techniques. We used the non-absorbable intraligmentous suture to pull down the fragment regardless of small size or comminuted status. The technique is simple and provided secure fixation without damage to the ACL insertion. A second operation is not required to remove the hardware.     

Experience with the AO Pi-plate for displaced intra-articular fractures of the distal radius.

We have used open reduction and internal fixation (ORIF) with the AO pi-plate in 32 displaced, intra-articular fractures of the distal radius. The indication was a displaced intra-articular fracture with a step-off of more than 1 mm and a gap between fragments of more than 3 mm, judged from the primary computed tomograms (CT). All fractures were classified as AO type C3. Twenty-nine patients were followed-up after a mean of 23 (9-46) months. The dorsal tilt, the radial length, the radial inclination, the articular step-off, and the intra-articular gap between fragments were substantially improved postoperatively. All the patients had excellent or good extra-articular and intra-articular alignment. Two patients had reduced extension power of the first finger. Seventeen patients had Disability of the arm, shoulder, and hand (DASH) scores of less than 10 points, five had scores between 11 and 20, three between 21 and 30, three between 31 and 40, and one patient had a score of 65 points. Complications occurred in two patients: one had a painful amputation neuroma of the superficial radial nerve, and one developed adhesions of the flexor tendons of the second and third fingers because the screws were too long and had penetrated the tendon sheaths. We conclude that the AO pi-plate is an excellent option for the most comminuted fractures of the distal radius.     

Severely comminuted distal radial fracture as an unsolved problem: complications associated with external fixation and pins and plaster techniques

Seventy-six patients with severely comminuted distal radial fractures were treated at two institutions, of which the overwhelming majority were Frykman class VIII. Fifteen fractures were open. Thirty patients were seen at the University Hospital; 17 had pins and plaster and 13 had external fixation. Forty-six patients were seen at Kaiser Hospital; all had pins and plaster treatment. The complication rate for those with pins and plaster at the University Hospital was 53%; the complication for external fixation rate was 62%. The affiliated-hospital complication rate was 52%. All patients with ipsilateral forearm shaft and carpal fractures developed a nonunion of the carpal fracture. Few patients maintained anatomic reduction, and many had significant intra-articular malalignment. External fixation with threaded half pins did not obviate pin problems in our series. These methods may help manage severely comminuted distal radial fractures, but complications should be anticipated and alternative treatment considered, especially when ipsilateral carpal or forearm shaft fractures are present.     

On-table reconstruction of comminuted fractures of the radial head

The most widely accepted treatment for comminuted fractures of the radial head is either the excision or open reduction and internal fixation. The purpose of the present study is to evaluate the value of an ‘on-table’ reconstruction technique in severely comminuted fractures of the radial head. In this study, two patients with a Mason type-III and four patients with a Mason type-IV radial-head fracture were treated with ‘on-table’ reconstruction and fixation using low-profile mini-plates. After a mean follow-up of 112 months (47-154 months), the mean elbow motion was 0-6-141° extension flexion with 79° of pronation and 70° of supination. The mean Broberg and Morrey functional rating score was 97.0 points, the Mayo Elbow Performance Index was 99.2 points and the mean Disabilities of the Arm, Shoulder, and Hand (DASH) Outcome Measure score was 1.94 points. One patient had symptoms of degenerative changes, with a slight joint-space narrowing. There were no radiographic signs of devitalisation at final examination. Comminuted fractures of the radial head, which would otherwise require excision, can be successfully treated with an ‘on-table’ reconstruction technique.     

Dislocated fractures of the talus treated with biodegradable internal fixation

Six patients with a displaced fracture of the neck or body of the talus were treated using biodegradable screws and rods. During an average follow-up time of 24 (range, 18–31) months, there were no redisplacements nor collapses due to avascular necrosis. All the fractures united. The functional result was mainly dependent on the presence or absence of other injuries, being excellent in 4, good in 1 and poor in 1 patient who also had bilateral highly comminuted calcaneal fractures. Thus, biodegradable implants seem to be suitable for the fixation of displaced fractures of the talus.     

Management of comminuted radial head fractures with replacement arthroplasty

Radial head arthroplasty is indicated for displaced comminuted radial head fractures that cannot be managed reliably with open reduction and internal fixation and that have an associated elbow dislocation. Replacement also is indicated in patients with comminuted radial head fractures that have or are likely to have a disruption of the medial col-lateral, lateral collateral, or interosseous ligaments. Biomechanical studies have demonstrated that metallic implants restore elbow stability similar to the native radial head. The early and midterm clinical experience with metallic radial head arthroplasty has been encouraging relative to earlier reports with silicone devices. Newer modular designs incorporate improved sizing to better reproduce the anatomy of the proximal radius and are easier to insert intraoperatively.     

Totally absorbable fixation in the treatment of fractures of the distal femoral epiphyses

Nine adolescent patients with a femoral fracture involving the physeal plate were treated by using self-reinforced absorbable polyglycolide (SR-PGA) and poly-L-lactide (SR-PLLA) screws with a follow-up for an average of 2 years and 2 months. During the follow-up all but one of the femurs became skeletally mature. In two of nine patients a clinically significant growth disturbance occurred. The average length difference of the femurs was –5 mm (ranging from +8 mm ––41 mm). One valgus deformity was noted. In four patients a lengthening and in four patients a shortening of the operated femur were registered at the end of follow-up. Open reduction and fixation with absorbable screws seem to be suitable for the fixation of distal femoral fractures in adolescents.     

Displaced intra-articular calcaneal fracture treated surgically with limited posterior incision

The incidence of calcaneal fracture has been slowly increasing; however, the ideal treatment for displaced intra-articular fracture is not available yet, even though the fracture brings frequent complication and disability. Between April 1991 and March 1998, we treated 103 displaced intra-articular calcaneal fractures of 92 patients surgically with limited posterior incision, modified Gallie approach. There were thirty-seven tongue-type fractures, fifteen tongue-type fractures with moderate comminution, nineteen joint-depression fractures, twenty-nine joint-depression fractures with moderate comminution, and three extensively comminuted fractures. The fracture fragments were fixed mainly with partly threaded small cancellous screws or Steinmann pins without any bone graft. Ankle and subtalar motion was permitted immediately if fixation were stable enough. Otherwise, a short period of cast immobilization was utilized. With a mean follow-up of 28 months (range, 12 to 66 months), eighty six percent of feet had no pain or only occasional pain not requiring medication. Using American Orthopedic Foot and Ankle Society hindfoot score system for assessment, ninety percent of feet rated as good to excellent. We used "Circle draw test" for evaluation of subtalar motion during follow-up visitation and found eight-seven percent of feet showed good to excellent correlation with the functional recovery. We recommend a limited posterior incision for reduction and internal fixation of displaced intra-articular calcaneal fractures. For displaced intra-articular fractures with three or four large fragments without further comminution and without a displaced fracture of the calcaneal cuboid joint, this method is particularly useful. We also recommend a Circle draw test for evaluation of subtalar joint motion as well as an indicator of functional recovery after displaced calcaneal fractures.     

Risk factors for nonunion in 337 displaced midshaft clavicular fractures treated with Knowles pin fixation

Background

Clavicular fractures account for nearly 10 % of all fractures, and the majority of those fractures involve the midshaft. Historically, these fractures were treated nonoperatively; however, recent data suggest an increased risk of nonunion and symptomatic malunion for displaced, comminuted midshaft clavicular fractures treated conservatively. Surgical intervention via plate osteosynthesis or intramedullary fixation with pins, nails, or screws has been shown to reduce, but not eliminate, this risk. Identification of risk factors predictive of nonunion would improve the overall management of displaced, comminuted midshaft clavicular fractures.

Methods

The medical records of 337 consecutive patients who underwent Knowles pin fixation and supplemental cerclage for the treatment of displaced, comminuted midshaft clavicular fractures between April 2007 and March 2009 were retrospectively reviewed. The records of the mechanism of injury, side of injury, Robinson fracture classification, presence of associated injuries, cerclage material, and patient-related variables, including diabetes mellitus, hypertension and smoking, were analyzed. Variables were assessed by univariate and multivariate analysis to identify those factors significantly associated with the development of fracture nonunion.

Results

A total of 19 nonunions occurred. Increasing age and use of wire for supplemental cerclage fixation were significantly associated with an increased risk for fracture nonunion (p < 0.001). Although suggested as predictors of nonunion in other studies, female gender and fracture severity were not significantly associated with nonunion.

Conclusions

Nonunion remains a significant complication in the treatment of displaced, comminuted midshaft clavicular fractures even with intramedullary fixation. Use of absorbable suture in place of wire for cerclage fixation and careful selection of treatment strategy in the elderly may reduce the risk for nonunion.     

Biodegradable implants versus standard metal fixation for displaced radial head fractures. A prospective, randomized, multicenter study

This multicenter, prospective, randomized study compares the use of biodegradable polylactide pins with standard metal mini-fragment implants for the treatment of displaced radial head fractures. It compares complication rates and clinical outcomes of both treatment methods. At 2 years, 135 (82%) of 164 patients were available for evaluation. Equivalence of treatment method was defined as a difference of 10% or less in the number of complication-free patients. Functional status was assessed by using the Broberg and Morrey Elbow Score and compared by an unpaired t test. Good or excellent clinical results were achieved by 92% (56/61) of the control patients and 96% (71/74) of the polylactide patients. The incidence of complication-free patients was 3.7% less in the polylactide group than in the control group. The 1-sided 95% confidence interval for the treatment difference between the 2 groups was more than -6.1%. Biodegradable polylactide pins have at least comparable outcomes as standard metal implants for the internal fixation of reconstructable displaced radial head fractures.     

Treatment of proximal humeral fractures with a new intramedullary nail

We have developed a new intramedullary nail (All-in-One Nail) that is specifically designed for elastic fixation of a surgical neck fracture of the humerus. This nail has three pins and a plate, and the pins become divergent as the nail is inserted into the marrow cavity through the deltoid tuberosity and then advanced to the humeral head. We reviewed 31 patients with an age range of 58–91 years (mean 75 years) who underwent surgery with this nail for A3.2 (two-part), B2.2 (three-part), or C2.1 (valgus-impacted) fractures of the proximal humerus. Bony union was obtained in 29 patients, and these patients had a Japanese Orthopaedic Association shoulder score of 60–92 (mean 78) in a follow-up examination performed 6–32 months (mean 13 months) postoperatively. The All-in-One Nail system is easy to use, provides an acceptable clinical outcome, and is a treatment option for unimpacted surgical neck fractures and valgus-impacted fractures of the humerus.     

External fixation of intra-articular fracture of the distal radius in young and old adults

Forty patients (18–89 years old, mean 58 years) with comminuted intra-articular fractures of the distal radial end (AO-type C 2 or C 3) treated with external fixation could be followed for an average of 2.3 years. After 3 weeks, the distraction was released, and after another 3 weeks, the device was removed. Complications seen were one malunion, one radial shaft fracture caused by excentric drilling of a Schanz screw, one Sudeck atrophy, and one subcutaneous pin-track infection. Radial and ulnar deviations were reduced to 52% and 71% of the untreated wrist, whereas the range of motion in the other planes reached about 80% or more of the healthy side. In all, 82.5% of the patients showed good or excellent radiological and functional results. This study demonstrates that external fixation of distal radial C 2 and 3 fractures for 6 weeks results in good recovery for young patients and elderly patients with osteoporosis.Preliminary results of this study were presented at the German Congress of Surgeons, Munich, April 13–17, 1993, and at Eurosurgery, London, September 15–17, 1993.     

Radial head fractures with acute distal radioulnar dislocation. Essex-Lopresti revisited

Seven adults with displaced radial head fractures had concurrent dislocation of the distal radioulnar joint. Because support of the radius was lost at both the elbow and wrist, proximal migration of the radius from 5 to 10 mm occurred. Different types of fractures were classified to designate the best method of restoring radial length to prevent chronic wrist pain and stiffness. Type I fractures had large displaced radial head fragments with minimal or no comminution and amenable to interfragmentary fixation. Type II fractures had severe comminution requiring radial head excision and prosthetic replacement. Type III were old injuries with irreducible proximal migration of the radius managed by ulnar shortening and radial head prosthetic replacement. There were three Type I, two Type II, and two Type III fractures. Results of treatment were graded as 3, excellent; 2, good; 1, fair; and 1, poor. The three excellent results were in patients in which restoration of radial length was achieved within one week of injury. Suboptimal results occurred in the remaining four patients when definitive surgery was delayed four to ten weeks. The poor result was in a patient treated only by radial head excision and who refused further surgery. Recommendations include meticulous clinical and roentgenographic examination of the distal radioulnar joint in all patients with displaced radial head fractures. Preservation of the radial head with anatomic reduction and rigid internal fixation is preferred, but radial head replacement may be necessary in cases with extensive comminution. Radial head excision alone, though contraindicated, may be restructured by ulnar shortening and radial head prosthetic replacement.