Comparison of closed reduction and percutaneous pinning versus open reduction and percutaneous pinning in displaced supracondylar fractures of the humerus in children.

A retrospective review of 29 children with displaced supracondylar humerus fractures was performed. Fifteen patients treated with closed reduction and percutaneous pinning and 14 patients treated with open reduction and percutaneous pinning were evaluated at a minimum of 18 months (range 18-80 months). Results were graded according to the criteria of Flynn et al. (Flynn JC, Matthews JG, Benoit RL: Blind pinning of displaced supracondylar fractures of the humerus in children. J Bone Joint Surg [Am] 56:263-272, 1974) using both cosmetic and functional evaluations. Excellent or good results were obtained in 14 of the 15 fractures treated with closed reduction and percutaneous pinning and in 12 of the 14 fractures treated with open reduction and percutaneous pinning. The three fair cosmetic results were associated with inadequate reduction and residual medial angulation. Ten to 15 degrees of motion loss occurred in three older patients. One patient in each group had a minor pintract infection. There were no cases of iatrogenic nerve injury or myositis ossificans. The treatment goal in displaced supracondylar humerus fractures in children is anatomic reduction. If an anatomic reduction cannot be achieved with closed reduction, open reduction is indicated. This can be done without an increased risk of complications.     

Results of treatment of displaced long bones fractures in children--comparison of different methods]

Authors compared functional results of treatment of 48 patients; 25 children with displaced supracondylar humeral fractures, 16 treated with skeletal traction (group I, mean age 7.9 year), 9 treated with closed reduction and percutaneous K-wire fixation (group II mean age 7.7 year), and 23 patients with displaced femoral shaft fractures, 10 treated with traction (group III, mean age 7.5 year), 13 treated with closed reduction and elastic intramedullary nailing. Good results after supracondylar humeral fractures were obtained in 37.5% of patients treated with traction and in 66.7% treated with percutaneous K-wire fixation, and after femoral fractures in 70% treated with traction and 84.6% treated with intramedullary nailing. The use of instrumental methods of treatment allowed to reduce significantly the duration of hospitalization (respectively: 19.8 vs. 6.4, and 28.5 vs. 9.5 days). In authors' opinion, a closed reduction secured by percutaneous K-wire fixation as well as a closed reduction with elastic intramedullary nailing are the methods of choice in treatment of discussed fractures in children.     

Open reduction and internal fixation of acute displaced scaphoid waist fractures

Fourteen consecutive patients with acute displaced scaphoid waist fractures were treated with open reduction and internal fixation. The operative technique consisted of anatomic reduction of the displaced scaphoid waist fracture, correction of carpal instability, radial bone grafting for comminution, and internal fixation with K-wires or Herbert screw. The patients were evaluated an average of 26 months (range, 4-48 months) after surgery. Thirteen of the 14 (93%) fractures united. The average time to union was 11.5 weeks (range, 8-20 weeks). Fracture union was confirmed with trispiral tomography. Final radiographic assessment consistently revealed a healed scaphoid fracture, restored intrascaphoid alignment, and no evidence of carpal instability. All patients regained functional wrist range of motion (wrist extension, 57 degrees; wrist flexion, 52 degrees ) and grip strength. Open reduction and internal fixation of acute displaced scaphoid waist fractures restores scaphoid alignment and leads to predictable union. Early operative intervention avoids malunion and carpal instability that often occurs with closed management of these complex fractures.     

The operative management of supracondylar fractures

Supracondylar fractures of the humerus occur in either an extension or flexion pattern. Both patterns have three types distinguished by the degree of displacement. Extension fractures, type III patterns in which there is complete displacement, usually require operative intervention in the form of a closed reduction with percutaneous pin fixation. In those in which an adequate reduction is not achieved, an open reduction is the preferred alternative treatment. Recognition of the role of the anterior periosteum in interfering with an adequate reduction is important. In addition, determination of the posteromedial or posterolateral displacement of the distal fragment is important in recognizing which neurovascular structures are more likely to be injured, which pin to place first, and which surgical approach is proper for an open reduction. Flexion fractures, type II displaced fractures, often require pin fixation, and type III displaced fractures usually require an open reduction.     

Displaced supracondylar humeral fractures in children: open reduction vs. closed reduction and pinning

Introduction In the literature the best results for pediatric supracondylar humerus fractures have been achieved by closed reduction and wire fixation. However, in these reports the patient group of open reduction and pinning contained the patients who had had previous ineffective closed reduction trials. This retrospective study compared open and closed reduction with pinning, in which the first group of patients was all consecutively treated with open reduction.Materials and methods The study included 99 children with displaced extension-type supracondylar fractures of humerus who had complete follow-up. Open reduction patients had not had a previous attempted closed reduction. Open reduction and pinning were performed through a posteromedial incision in the first 44 patients and closed reduction and pinning in the subsequent 55 patients. Mean duration surgery was 15 h with open reduction and 17 h with closed reduction. Mean follow up was 35 months with the open reduction and 21 months with closed reduction. Humeral-ulnar angle was compared to the contralateral elbow, clinical flexion deficiency and extension lag, and complications were evaluated.Results At the latest follow-up the open group had an average of 5.1° valgus change and the closed group 3.6° valgus change in humeral-ulnar angle compared to their uninvolved elbow. Average flexion deficiency was 8.61° in the open and 5.25° in the closed group. Average extension lag was 6.23° in the open and 0.6° in the closed group. Functional results were satisfactory in 71% of patients in the open and 93% of those in the closed reduction group. Cosmetic results were satisfactory in 95% of both groups.Conclusions Closed reduction and pinning is superior to open reduction and pinning for the treatment of pediatric supracondylar humerus fractures. In the case of technical insufficiencies open reduction and pinning through a posteromedial incision is an alternative treatment for decreasing the surgical time and complications. Complications was not caused in either group by the delayed surgical timing compared to reports in the literature.     

Surgical treatment of avulsion fracture of the posterior cruciate ligament and postoperative management

BACKGROUND: Avulsion fractures of the posterior cruciate ligament have long been regarded as rare injuries. In the past, it was common practice to use cast immobilization as an external adjunct after open reduction and internal fixation of fractures. METHODS: Sixteen patients with displaced avulsion fractures of the posterior cruciate ligament were treated with open reduction and internal fixation between August 1989 and July 1993. Malleolar screws were chosen as fixation devices in 14 patients. In the other two, pull-through sutures were used because the size of the fractured fragments was too small to obtain purchase of screws. The postoperative management protocol evolved from an initial regimen of 6 weeks' immobilization in a cast with the knee flexed to 40 degrees for the first five patients (group I), to 4 weeks' immobilization in a cast for the next six patients (group II), to the present protocol of immediate postoperative range of motion (40-70 degrees) with muscle-strengthening exercises in a functional brace for the last five patients (group III). The average follow-up period was 36 months (range, 24-58 months). Hughston's criteria were used to assess the clinical results. RESULTS: Overall, there were 12 (75%) good and 4 fair (25%) results. There was no poor result. CONCLUSION: Avulsion fractures of the posterior cruciate ligament should be treated with open reduction and stable internal fixation if any displacement is seen on initial radiographs at presentation. With the use of functional brace and aggressive postoperative rehabilitation program (i.e., immediate range of motion of 40-70 degrees with muscle-strengthening exercises), satisfactory results can be expected and achieved.     

Flexible 3D laparoscopic assisted reduction and percutaneous fixation of acetabular fractures: Introduction to a new surgical option

The gold standard for fractures of the acetabulum is to perform an open reduction and internal fixation in order to achieve anatomical reduction. In a well-defined subset of patients, percutaneous techniques may be employed but achieving reduction by closed means can be challenging especially for fractures with large degrees of displacement. Such patient may include elderly patients who may not have the physiologic reserve to withstand open approaches. In our paper, we present a new option using laparoscopic assisted reduction of the acetabular fracture and percutaneous fixation. The young obese patient refused all forms of blood products transfusion and presented with a displaced transverse posterior wall fracture. While we do not recommend routine use of such technique and recognize its numerous limitations, we present it as an alternative strategy in a small subset of patients.     

骶髂螺钉固定治疗垂直不稳定骨盆后环骨折的疗效分析

目的评价骶髂螺钉治疗不稳定型骨盆骨折的临床疗效。方法采用骶髂螺钉治疗42例不稳定型骨盆骨折。应用Tornetta复位情况评价表评估复位情况,应用Majeed骨盆骨折评分系统评价疗效。结果 42例均获随访,随访时间为4~34个月,平均15个月。闭合复位骶骨钉内固定骨盆骨折后环不稳术后分疗效满意。结论掌握骶骨置钉技巧,应用骶骨钉固定骨盆骨折后环不稳,手术操作简单、疗效好、适于基层医院广泛开展。     

Surgical treatment of displaced fractures of posterior column and posterior wall of the acetabulum

We evaluated the results of open reduction and internal fixation of displaced posterior wall and posterior column fractures of the acetabulum. This was a prospective clinical evaluation of such cases where the main surgical strategy was open reduction and internal fixation with interfragmentary screws and reconstruction plates. Data on 11 patients treated by open reduction (all via Kocher-Langenbech approach)/internal fixation with interfragmentary screws and reconstruction plates were collected. The follow-up period was 61 (18-102) months. Reduction with a fracture gap of less than 2mm without articular stepping was achieved in all 11 cases. Postoperative complications developed in five patients, including subcutaneous haematoma in one, avascular necrosis of the femoral head (AVNFH) in one and heterotopic ossification (HO) in three. All but the patient with AVNFH, had anatomic radiological reduction, and good to excellent functional results. Open reduction and internal fixation with interfragmentary screws and reconstruction plates is the treatment of choice in displaced posterior wall and posterior column fractures of the acetabulum.     

Technique of Kirschner wire reduction and fixation of displaced two-part valgus angulated proximal humerus fractures at the surgical neck

This article describes the technique of closed reduction with percutaneous fixation using Kirschner wires in helping the reduction of two-part valgus angulated and displaced proximal humerus fractures at the surgical neck. Traditional open reduction may lead to more accurate anatomic reduction; however, extensive tissue dissection increases the risk of avascular necrosis. Thus, closed reduction of unstable fracture mostly required forceful reduction maneuvers, which can harm the vascular supply and increase hematoma formation. Reduction of the fractured sides can easily be performed by engaging Kirschner -wires with a joystick method and fixation can be secured by using threaded pins. Thirty-six consecutive patients with displaced, two-part, valgus-angulated proximal humerus fractures at the surgical neck were treated by this method. The patients were followed for an average of 38 months. All fractures healed. According to the Constant scoring system, 21 patients (58%) had excellent, 9 patients (25%) had good, and 6 patients (17%) had fair results. The technique of closed reduction with a joystick method and percutaneous fixation is regarded as a reasonable treatment alternative in displaced two-part valgus angulated proximal humerus fracture.     

经皮椎弓根螺钉内固定治疗胸腰段骨折的围手术期临床研究

目的评价闭合复位经皮椎弓根螺钉固定治疗胸腰段骨折的临床应用价值。方法研究对象为本院2011年1月-2013年1月收治的连续43例AO分类为A1、A2型胸腰段骨折患者,分别行腰椎后路开放复位椎弓根螺钉固定手术和腰椎闭合复位经皮椎弓根螺钉固定手术。2组患者年龄、骨折分布无差异。回顾性分析比较2组患者手术时间、出血量、切口长度、住院天数、疼痛视觉模拟量表（visual analogue scale,VAS）评分。术前、术后摄腰椎正侧位X线片,比较2组患者伤椎高度、伤椎Cobb角。结果 2组患者手术时间差异无统计学意义（P〉0.05）;经皮手术组患者术中出血量、术后引流量、平均住院天数、切口长度明显小于开放手术组（P〈0.05）,术后VAS评分明显少于开放手术组（P〈0.05）。2组手术在矫正伤椎高度及伤椎Cobb角能力方面相比差异无统计学意义（P〉0.05）。结论腰椎闭合复位经皮椎弓根螺钉内固定手术治疗AO分类为A1、A2型胸腰段骨折具有手术创伤小、术后恢复快的优点,其矫形能力与开放复位椎弓根螺钉内固定术相当。     

Outcome of Gartland type II and type III supracondylar fractures treated by Blount's technique

Background:

According to some orthopedic surgeons, almost all supracondylar humerus fractures should be treated operatively by reduction and pinning. While according to others, closed reduction and immobolization should be used for Gartland type II and some type III fractures. However, the limit of this technique remains unclear. We present 74 patients with displaced extension-type supracondylar fractures treated by closed reduction and immobilization with a collar sling fixed to a cast around the wrist. The purpose of the study is to give a more precise limitation of this technique.

Materials and Methods:

Retrospective data acquisition of 74 patients with a Gartland type II or type III fractures treated by closed reduction and immobilization (Blount''s technique) between January 2004 and December 2007 was done. The mean age was 6.3 years (range, 2–11). The mean time of follow-up was 6.5 months (range, 3–25). All open injuries and complex elbow fracture dislocations or T-condylar fractures were excluded from the study. All patients were evaluated with standardized anteroposterior and true lateral x-rays of the elbow, and Flynn criteria were used for functional assessment.

Results:

Gartland type II fractures had 94% good or excellent final results. Gartland type III fractures had 73% good or excellent final result. The Gartland type III outcome depended on the displacement. The fractures remained stable in 88% for the posterior displacement, and 58% for the posteromedial displacement. These displacements were mild. However, for the posterolaterally displaced fractures, only 36% were stable; 36% had a mild displacement and 27% had a major displacement.

Conclusion:

Pure posterior displacement is more stable than posteromedial displacement which is more stable than posterolaterally displaced fractures. This study suggests that Gartland type II and pure posterior or posteromedial displaced Gartland type III fractures can be treated by closed reduction and immobilization with success.     

Open reduction and internal fixation of the posterior malleolus fragment via the posterolateral approach is radiologically superior to ‘A to P’ screw fixation

PurposeFunctional outcome in trimalleolar fractures is largely correlated to the reduction of the posterior fragment. Until recently, fixation was mainly performed for large fragments, by percutaneous anterior to posterior (‘A to P’) screw placement after closed reduction. Nowadays, ORIF via a posterolateral approach seems to gain in popularity. The aim of this study was to compare the postoperative photographs of operated trimalleolar fractures after either fracture treatment method, for fracture diastasis and step-off.Material and methodsAll consecutive patients with trimalleolar fractures, including posterior fragments of >5% of the articular surface and operated between 2007–2013 were analysed on size of posterior fragment, post-operative gap and step-off by three observers. The patients were divided into three groups; A to P screw fixation, ORIF via the posterolateral approach and no posterior fragment fixation at all.Results180 patients with trimalleolar ankle fractures were included for analyses. Twenty five posterior fragments were fixated percutaneously from anterior to posterior (group 1) and 51 underwent open reduction and internal fixation through a posterolateral approach (group 2). 104 patients underwent no posterior malleolus fixation (group 3). The average size of posterior fragment was 34% in group 1, 27% in group 2 and 16% in group 3. A postoperative step-off >1 mm was found in 40% (group 1), 9% (group 2) or 34% respectively (group 3).ConclusionsFixation of the posterior malleolus through an open posterolateral approach leads to better radiological results as compared to percutaneous ‘A to P’ screw fixation or no fixation at all.     

2种内固定方法治疗98例踝关节骨折的疗效比较

目的比较闭合复位经皮空心螺钉内固定与传统切开复位内固定治疗踝关节骨折的疗效。方法 2004年3月～2009年8月收治的98例非粉碎型内外踝双骨折根据内固定方法不同分为闭合复位经皮空心螺钉内固定(闭合复位组)和传统切开复位内固定(切开复位组),比较2组患者的手术时间、术中出血量、骨折愈合时间、骨折愈合后外踝有无疼痛及术后1年AOFAS足踝评分。结果闭合复位组术中出血量、术后切口感染发生率及骨折愈合后外踝出现疼痛发生率明显优于切开复位组(P<0.05)。闭合复位组51例术后随访16～81个月,平均29.7月,骨折全部愈合;切开复位组42例随访17～80个月,平均28.3月,4例出现切口红肿、皮缘坏死,经换药后切口愈合,无深部感染发生,1例出现骨折不愈合。结论与传统切开复位内固定比较,闭合复位经皮空心螺钉内固定治疗踝关节骨折具有出血少、术后切口并发症发生率低、骨折愈合后外踝疼痛发生率低的优点,并能获得与切开复位内固定等同的踝关节功能。     

Open Reduction and Internal Fixation Better than Percutaneous Plate Osteosynthesis in Distal Tibial Fractures

ABSTRACT

Minimally invasive percutaneous plate osteosynthesis (MIPPO) was compared with traditional open reduction and internal fixation (ORIF) in treating distal tibial fractures. Patients diagnosed with displaced extraarticular distal tibial fractures during October 2005–June 2007 were randomly assigned to a closed (treated using MIPPO) and an open (treated using ORIF) group. Ninety-four patients with fractures were treated and followed up, of which 42 and 52 patients were enrolled in the open and closed groups, respectively. The 94 fracture cases were classified into three types: Type A, 52 (55.3%); Type B, 24 (25.5%); and Type C, 18 (19.1%). The average follow-up time was 15.6 and 16.2 months for the open and closed groups, respectively. In the open group, 35 fractures healed within six months. Delayed union was observed in three fractures and nonunion in four fractures. Two cases had superficial wound infection after operation. No malunion was observed. In the closed group, 47 fractures healed within six months. Delayed union was observed in four fractures. Locking plate was broken nine months after operation in one case. Malunion was observed in five cases: two rotational and three posterior angular deformities. No statistically significant differences were observed in the healing time of Types A and B between the open and closed groups (p > .05). The healing time of Type C in the open group was longer than that in the closed group (p < .05). The first choice for Type C fractures is MIPPO, whereas that for Type A is open reduction.     

撬拨复位与切开复位固定治疗跟骨关节内骨折

目的 前瞻性比较经皮撬拨复位内固定与切开复位内固定治疗移位型跟骨关节内骨折的临床疗效.方法 随机方法将2008年3月7日至2010年1月22日收治的40例移位型跟骨关节内骨折患者分为经皮撬拔复位内固定组和切开复位内固定组.结果 术后第2天及术后1年,两组患者在B(o)hler角、侧位片上跟骨长度、轴位片上跟骨宽...     

后方入路治疗胫骨平台后方骨折

目的:探讨后方入路治疗胫骨平台后方骨折的骨折类型、手术方法和临床疗效。方法:回顾性分析自2008年6月至2011年2月采用后方入路治疗且随访完整的8例胫骨平台后方骨折,男5例,女3例;年龄23～55岁,平均41.1岁。致伤原因:车祸伤5例,高处坠落伤3例。2例胫骨平台后方冠状面骨折伴后交叉韧带撕脱和1例后外侧平台劈裂伴塌陷骨折采用正后方"S"形入路,2例后内侧平台骨折采用后内侧倒"L"型入路,3例同时累及胫骨平台前后侧及胫骨干骺端骨折者采用后内侧倒"L"形入路联合前外侧入路行钢板螺钉内固定。关节面塌陷者采用同种异体骨或自体髂骨植骨术。结果:所有患者获得随访,时间8～39个月,平均20个月。全部病例获得影像学上的骨性愈合,愈合时间11～21周,平均14.5周。术中未出现血管、神经损伤,术后无一例出现切口感染、内固定松动及断裂。所有患者术后即刻与术后6个月胫骨平台内翻角(TPA)、内外侧平台后倾角(PA)度数均无统计学差异。术后末次随访Rasmussen膝关节功能评分为19～29分,平均25.60分,其中优4例,良3例,可1例。术后末次随访Rasmussen放射学评分14～18分,平均17.25分,其中优6例,良2例。结论:胫骨平台骨折以后侧为主时,后方入路能得到很好的骨折端暴露,有利于直视下复位固定,术后近期疗效满意。     

肩胛骨骨折的手术治疗

目的探讨肩胛骨骨折的临床特征及手术疗效。方法对于2002年3月至2007年3月本院手术治疗不稳定肩胛骨骨折共20例的临床资料进行回顾性分析。按照Miller分型方法Ⅰ—A2例，Ⅰ—B1例，Ⅱ—C1例；Ⅱ-A2例，Ⅱ一B2例，Ⅱ—C5例。Ⅲ2例，Ⅳ5例。根据骨折类型选择手术入路（后入路17例，前入路3例），内固定物分别或结合应用“K”钢板，重建钢板，拉力螺钉固定骨折。结果全部病例均获随访，随访6月～28月，平均14月。根据Hercovici疗效标准，术后肩关节的功能评分为4～16分，平均14．5分，优良率为92．8％。结论手术治疗不稳定肩胛骨骨折能使患者早期功能锻炼，改善肩关节功能。     

切开复位克氏针张力带与闭合复位经皮空心钉内固定治疗髌骨骨折的疗效比较

目的比较切开复位克氏针张力带与闭合复位经皮双头加压空心钉内固定治疗髌骨骨折的疗效。方法回顾性分析自2013-01—2016-01诊治的65例横形髌骨骨折,采用闭合复位经皮双头加压空心钉内固定治疗30例(空心钉组),采用切开复位克氏针张力带内固定治疗35例(张力带组)。比较2组术后0.5、3、6个月的VAS评分及膝关节功能Lysholm评分。结果 65例均获得随访6~12个月,平均8个月。张力带组2例出现克氏针松动退出刺激皮肤,取出内固定后缓解。空心钉组无内固定松动断裂及皮肤刺激等并发症。空心钉组术后0.5、3、6个月VAS评分均低于张力带组,空心钉组术后0.5、3、6个月膝关节功能Lysholm评分高于张力带组,差异有统计学意义(P0.05)。结论闭合复位经皮空心钉内固定治疗髌骨骨折可取得满意的临床效果,术后患者可以获得良好的膝关节功能,且疼痛轻,并发症少。     

Calcaneus fractures. Open reduction and internal fixation

AIM OF THIS STUDY: Critical analysis of the medium-term results of open reduction and internal fixation (ORIF) of displaced intra-articular calcaneus fractures with a standardized protocol in a greater patient cohort. METHODS: From October 1993 to December 1999 314 patients (mean age 42.3 years) with 348 calcaneus fractures were seen at the Dresden University Hospital. 41 fractures were open, 4 with 1st degree, 28 with 2nd and 9 with 3rd degree soft tissue damage. 275 displaced intra-articular fractures were treated with ORIF, 262 (95.3 %) with plate osteosynthesis via an extended lateral approach. 169 patients could be evaluated at a mean of 18 months (range 10-47 months) postoperatively with an extended protocol of questionnaire, physical and radiographic examination. RESULTS: The Maryland Foot Score after 18 months follow-up averaged 80.8/100, the mean Zwipp score averaged 146.4/200. The functional result with the Merle d'Aubigné score was judged good to excellent in 86% of cases. Rates of deep infection and superficial wound edge necrosis increased significantly with open fractures and delay in surgery of more than 2 weeks after injury in closed fractures. Clinical results were adversely affected by even minor residual steps in the posterior facet (1-2 mm) as judged by CT or Brodén views (p < 0.001). B?hler's tuberosity-joint-angle had an impact on the final result when falling short compared to the unaffected contralateral side by more than 30% (p < 0.001). CONCLUSIONS: Management of intra-articular calcaneus fractures with a standardized protocol of ORIF and early mobilization leads to reproducible good or excellent clinical results in a majority of patients. New approaches like an interlocking calcaneus plate, the use of subtalar arthroscopy, early soft tissue coverage for complex open injuries and percutaneous screw fixation for selected fractures should further improve prognosis.