Closed Zickel nailing

A closed technique for Zickel nail insertion decreases morbidity, blood loss, and operative time. The Zickel intramedullary nail was originally developed as an open fixation device for fractures of the proximal third of the femur and subtrochanteric area. The open technique requires a lengthy incision, moderate blood loss, and time for insertion. For pathologic or impending pathologic fractures in sick patients, such a major operation is undesirable. The closed technique has been used successfully in five impending pathologic, three pathologic, and two traumatic subtrochanteric fractures. For these ten patients, the average operating time was one hour and 28 minutes with an average blood loss of 400 ml, a reduction of 40 minutes and 460 ml, respectively, over other available data. Time to ambulation and length of hospital stay are comparable to fractures treated openly. The closed technique is ideal for impending pathologic fractures, but may also be applicable to any pathologic or traumatic fractures that do not require an open procedure for alignment or supplementary fixation.     

Orthopaedic treatment of paediatric multiple trauma patients. A new technique

In multiple trauma, skeletal injuries are generally responsible for long hospital stays, with concomitant nursing inconveniences and for most of the sequelae. A new operating technique has been perfected, especially adapted to paediatric traumatology: stable elastic rodding, precise and less aggressive technique. It avoids plastering and traction systems, and rapidly restores sufficient independence for a return to school. It is especially useful in multiple trauma patients, where nursing facilities and easy transport may be very helpful. The hospital regularly uses this technique for patients over six years old with femur fractures, tibia fractures associated with a contralateral lower limb injury, and forearm fractures where conservative treatment has failed.     

Management of the fractured scaphoid using a new bone screw

A new and simple operative technique has been developed to provide rigid internal fixation for all types of fractures of the scaphoid. This involves the use of a double-threaded bone screw which provides such good fixation that, after operation, a plaster cast is rarely required and most patients are able to return to work within a few weeks. A classification of scaphoid fractures is proposed. The indications for operation included not only acute unstable fractures, but also fractures with delayed healing and those with established non-union; screw fixation was combined with bone grafting to treat non-union. In a prospective trial, 158 operations using this technique were carried out between 1977 and 1981. The rate of union was 100 per cent for acute fractures and 83 per cent overall. This method of treatment appears to offer significant advantages over conventional techniques in the management of the fractured scaphoid.     

Evaluation and operative technique to repair isolated sternal fractures

A series of 12 patients with traumatic sternal fractures without internal organ injury are reported to have had their fractures repaired with a standard operative technique that has proved to be effective up to 17 years of follow-up. Although sternal fractures are often seen in emergency departments of trauma centers, rarely are they recommended for correction. Often patients experience physical deformity, chronic pain, and abnormal physical habits. A standard operative technique is proposed with highly satisfactory results. Thoracic surgeons should be familiar with this problem and with available standard methods to correct it.     

Netzwerkpartner Arbeitstherapeut im Rehabilitationsmanagement

Due to the functional importance of the patella, accurate reduction and rigid fixation of patellar fractures are required. Tension band wiring has long been the standard treatment of these fractures, but there are several problems associated with this technique, e.g. loosening of the wires, fracture dislocation and poor outcome. Another possibility in the treatment of transverse patellar fractures is screw fixation. Although this technique ensures stable osteosynthesis, anatomical reduction is often problematic, especially in comminuted fractures. A good option in the treatment of (comminuted) patellar fractures is the newly designed locking patella plate, which combines anatomical reduction and stable osteosynthesis. In biomechanical tests the plate provided a more stable fixation of the patellar fracture and showed higher mechanical strength compared to classic tension band wiring. The first clinical applications achieved optimal fracture reduction. No complications have occurred to date following the use of the plate. Thus the patella plate represents a good option in the treatment of patellar fractures.     

The spectrum of intramedullary nailing of the tibia

Intramedullary nailing of the tibia has been used mainly in selected cases of fresh diaphyseal fractures and nonunions. However, with modern variations of the technique, the indications can be expanded considerably. Interlocking nailing has increased the number of fractures suitable for intramedullary fixation. With this technique or with other additional measures, intramedullary fixation can be used after correction osteotomies and for stabilization of metastases and pathologic fractures. When used on correct indications and in the absence of complications, intramedullary nailing is the method of choice for stabilization of the tibia. The advantages are short stay in hospital, short morbidity, early range of motion exercises, and weight-bearing without immobilization in plaster. A prerequisite, however, is that the surgeon be very familiar with the technique, and its indications and complications.     

Boot top fractures.

Low transverse fractures of the tibiofibular complex due to ski injuries were formerly virtually unknown but are now met in ever increasing numbers. A series of 126 such fractures occurring in patients 13 years or older was analyzed. The sex and age distributions of these patients were found to differ significantly from those in skiers with other tibial shaft fractures. Among boot top fractures cases, boys younger than 20 years predominated much more than among patients with other fractures of the tibial shaft. In the boot top fracture there is characteristically a backward angulation, which may be combined with a forward displacement of the distal fragment. A simple technique for reduction of this typical deformity is described. According to this technique the surgeon should take a steady grip on the foot held in extreme plantar flexion. By applying strong traction, disimpaction is achieved after which the distal fragment is forced back into position and the fracture is immobilized with the foot in full equinus. This technique was successfully applied in the majority of our cases (112 of 126). Patients with boot top fractures were hospitalized for shorter periods than were skiers with other tibial fractures, and they were able to resume their normal activities much sooner. This held true even when allowance was made for differences in age. During the last few years a new type of boot top fracture has been observed. In this type there is a forward instead of a backward angulation. Its occurrence is most probably related to the new "scoot foot" or "sitting back" technique in downhill skiing. The appearance of this new type of boot top fracture implies that successful prevention can be achieved only with safety bindings that release not only at rotation but also when the skier falls backward.     

Maintenance of reduction of pediatric distal radius fractures with a sugar-tong splint

Distal radius fractures are common injuries in children. Displaced fractures have traditionally been treated with closed reduction followed by immobilization in a long arm cast. Because of variable success rates with this technique, a trend in the literature is toward operative fixation of these fractures. A popular alternative practice involves temporary immobilization in a sugar-tong splint, though we are unaware of any studies demonstrating the efficacy of this technique in children. We present our experience in treating these injuries initially with a sugar-tong splint and then with a short arm cast. We retrospectively reviewed the cases of 53 patients (age range, 2-12 years) treated with closed reduction and a sugar-tong splint followed by conversion to a short arm cast after 2 to 3 weeks. In 51 (96%) of 53 fractures, reduction was maintained without more aggressive intervention. The sugar-tong splint is effective in maintaining reductions in pediatric distal radius fractures and has none of the added risks associated with current alternative methods.     

Extra-articular technique for semiextended tibial nailing

Intramedullary nailing is a widely accepted technique for the stabilization of unstable diaphyseal tibia fractures. When this method of stabilization is applied to proximal and distal metadiaphyseal fractures, achieving and maintaining fracture reduction is more difficult. The intramedullary nailing of proximal metadiaphyseal fractures in semiextension has been advocated to make stabilization less difficult. The intra-articular nature of this technique makes it less appealing. We present a nailing technique that facilitates extra-articular semiextended tibial nailing. The technique simplifies intraoperative imaging, fracture reduction, and maintenance of reduction during nail insertion and locking.     

A fluted intramedullary rod for subtrochanteric fractures.

A new intramedullary rod has been developed for the treatment of subtrochanteric fractures. The stepped fluted rod is designed as a single unit and has exceptional bending strength and rigidity as well as excellent torsional load-carrying capacity. It has been used successfully in eighteen patients with a variety of subtrochanteric fractures. Union was achieved in all instances and no failure of the implant occurred. The simplified technique of insertion, the strength of the device, and the results of this study indicate that the fluted subtrochanteric rod has several advantages over other available devices.     

The "rubber band technique": a simple method for closing large skin defects

Traditional methods of obtaining definitive soft-tissue cover in open wounds after high-energy trauma necessitate repeated surgical procedures and sophisticated soft-tissue reconstructions. A simple one-stage technique to treat skin loss in severe open fractures is described. The "rubber band technique" enables postoperative exposure and drainage of the fracture site. The wound closes gradually by facilitated mobilization of skin in response to continuous tension from the rubber band. This technique may prevent the need for additional procedures. Continuous drainage is achieved. When deep infection is suspected, removal of the elastic rubber band permits sufficient exposure of the deep tissues. The "rubber band technique" has proved to be a safe, simple, and efficient method for treating extensive soft-tissue loss in open fractures and after incisions for open reduction or fasciotomy.     

Flexible intramedullary nail removal using a broken screw removal set

The use of flexible titanium intramedullary nails for management of pediatric long bone fractures and some adult fractures has become common. Nail removal after union can be challenging and often requires a larger exposure than nail placement to allow the insertion of grasping devices, such as pliers. A percutaneous technique for the removal of flexible intramedullary nails using extraction bolts from a broken screw removal set is presented. The technique is especially useful when the end of the nail is not prominent and where a hollow reamer from the same set can expose the nail end for the extraction bolt to be used.     

Distal femoral fractures and LISS stabilization

In recent years, the technique of surgical stabilization in the distal femur has changed. This change decreased the number of non unions and the need for bone grafting. Minimally invasive surgical techniques with a submuscular plate placement have replaced the emphasis on anatomical reduction in the shaft area. Reconstruction of complex articular injuries has been simplified by more direct visualization of the articular surface with the lateral peripatellar approach. Problems remaining are surgical technique and implant considerations. The Less Invasive Stabilization System (LISS) simplifies the surgical technique for percutaneous plate osteosynthesis. An insertion guide is used to insert monocortical, self-tapping screws through a stab incision. A thread in the plate provides the angular stability for the anchoring of these screws. In extra-articular fractures and simple intra-articular fractures, the distal femoral nail permits intramedullary stabilization. A spiral blade improves fixation of the distal femoral condylar block. Despite the enhanced surgical technique and implant possibilities, a great number of patients show a functional deficiency. These are particularly patients with complex intra-articular fractures. The 'fatigue failure' of the osteoporotic implant-bone construct is a problem in elderly patients. The LISS represents a good option to avoid the addition of bone cement to an osteosynthesis.     

The conservative management of fractures of the shafts of the phalanges of the fingers by combined traction-splintage

Recent publications discussing fractures of the shafts of the phalanges of the fingers discount their management by traction because of possible complications and difficulties of application. A technique using splintage combined with isometric skin traction, used for many years in Southampton, has proved effective and free of complications. The results of the treatment of eighteen consecutive appropriate fractures using this technique are discussed.     

Arthroscopically assisted placement of a supracondylar intramedullary nail: Operative technique

The use of retrograde interlocking intramedullary nails has been described for the treatment of selected supracondylar fractures. A medial parapatellar incision and arthrotomy with its attendant morbidity is generally used for nail placement. Although a closed technique of nail placement has been described, the risks of damaging intra-articular structures with a blind approach have precluded the widespread use of this method. In this article, we present a simple, arthroscopically assisted method for the retrograde intramedullary nailing of supracondylar femoral fractures. This technique affords the potential benefits of intramedullary fixation of these fractures while avoiding the morbidity and complications associated with an arthrotomy. Potential benefits over the standard placement using an arthrotomy include earlier ambulation and soft tissue healing, decreased risk of damage to the knee joint, earlier convalescence with decreased hospitalization time, and better cosmesis.     

Protective intramedullary fixation after harvest of an osteocutaneous radial free flap.

The osteocutaneous radial free flap, even after 30 years, is still considered to be the "workhorse" for head and neck reconstruction. A high incidence of donor site fractures has remained a major problem, however. The technique described here is a method developed for the prophylaxis of fractures of the donor site of the harvested radial bone and is based on a modification of the intramedullary Rush nail fixation. The data were collected from 18 patients in whom the radial forearm free flap had been used during reconstruction. None of the prophylactically-nailed radii fractured. The complications experienced with this technique are general complications, such as scarring of the forearm and dehiscence of the wound. This technique is simple, and has given excellent results. Aesthetic and functional results were comparable to those of other flaps used for reconstruction. We recommend this technique because of its simplicity, vascular safety, and cost effectiveness.     

Ultrasound in the diagnosis of scaphoid fractures

A prospective study of the possibility of confirming clinically suspected scaphoid fractures was carried out over one year. Analysis of the results suggest that ultrasound scanning of suspect scaphoid fractures is a reliable method of assessing this condition. It has one weakness in that the diagnosis is based on subjective sensation and this may at times be faulty. Our results, however, suggest that once practice in the technique has been achieved, then mistakes are rarely made.     

Management of humeral shaft fractures

Humeral shaft fractures account for approximately 3% of all fractures. Nonsurgical management of humeral shaft fractures with functional bracing gained popularity in the 1970s, and this method is arguably the standard of care for these fractures. Still, surgical management is indicated in certain situations, including polytraumatic injuries, open fractures, vascular injury, ipsilateral articular fractures, floating elbow injuries, and fractures that fail nonsurgical management. Surgical options include external fixation, open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and antegrade or retrograde intramedullary nailing. Each of these techniques has advantages and disadvantages, and the rate of fracture union may vary based on the technique used. A relatively high incidence of radial nerve injury has been associated with surgical management of humeral shaft fractures. However, good surgical outcomes can be achieved with proper patient selection.     

Konservatives Vorgehen bei körperfernem Speichenbruch

Fractures of the distal radius represent one of the most common fractures, with an incidence of 2–3/1,000/year, and have a high social-economic relevance. There are about 200,000 cases a year with costs reaching the 100s of millions. For treatment, such fractures need a practical classification and therapeutic standards. For stable A2-fractures, we prefer closed reduction, and only in special cases K-wire fixation. Such fractures are reduced using the technique of Charnley. A plaster cast based on the principle of three-point fixation is applied to immobilize the fractured part. Instable and displaced intra-articular fractures according to the AO-scheme type A 3 and C 1–3 are indications for percutaneous pinning, transfixation or plate osteosynthesis. Differential management has led to a change from purely conservative treatment to a more varied treatment of such fractures.     

Temporizing Management of Pediatric Femur Fractures Using J-splints

This article describes a novel splinting technique for the temporizing management of pediatric femur fractures. The J-splint is a reliable, simple, and rapidly applied splint that prevents many of the complications and pitfalls of other described temporizing measures, such as skeletal traction, skin traction, traction splinting, and posterior splinting. This technique of J-splinting femur fractures has low morbidity and provides many advantages in the temporizing management of pediatric femur fractures.