Complications of K-wire fixation of fractures and dislocations in the hand and wrist

Kirschner wire (K-wire) fixation of fractures and dislocations of the hand and wrist is a common procedure. Of the 590 K-wire fixations performed on 236 patients, 36 (15.2%) experienced complications which included osteomyelitis, tendon rupture, nerve lesion, pin tract infection, pin loosening or migration. There were no deep soft-tissue pin infections or pyarthrosis. Technical failure, mainly when the procedure was performed by residents, and poor patient compliance were the major causes of complications. K-wire fixation is a simple but demanding procedure that cannot be left to an inexperienced resident. Elimination of technical failure, supervision in the operating room, close monitoring, prompt treatment upon discovery of a complication, and improvement of patient compliance can reduce the rate of complications. Received: 30 October 2000     

Difficult wrist fractures. Perilunate fracture-dislocations of the wrist

Perilunate dislocations of the wrist have a common pathway of disruption that occurs from extensive dorsiflexion injuries. Open reduction and internal fixation of these injuries is required to provide accurate alignment and the option for ligament repair. Both dorsal and palmar surgical incisions may be indicated. Associated injuries to the median nerve must be recognized. Treatment includes scaphoid and radial styloid stabilization with multiple K-wires or internal compression screw (Herbert or Association for the Study of Internal Fixation [ASIF] screws). In these injuries, the lunate must be reduced first and stabilized. The scaphoid proximal segment follows the lunate unless the scapholunate (SL) ligament is torn. The distal scaphoid fragment, capitate, and triquetrum are reduced and aligned with the lunate and need to be held with K-wires. Ligament repair and augmentation may be necessary at both scapholunate and lunotriquetal areas if there has been serious ligament injury. Palmar ligament repair is often required, and we recommend a palmar exploration in most patients along with release of the median nerve. Surgical treatment results of perilunate fracture-dislocations of the wrist appear better than conservative treatment methods, but complications following both indicate the need for improved internal fixation and fracture-dislocation realignment. These fractures are a real challenge to the treating surgeon who must use patience, precise surgical techniques, and careful roentgenographic study (including tomograms and traction views) to assure the best result.     

Results of crossed versus lateral entry K-wire fixation of displaced pediatric supracondylar humeral fractures: A systematic review and meta-analysis

PurposeSupracondylar humeral fractures (SCHF) are among the most common injuries in children. The aim of this systematic review was to investigate functional and radiographic outcome after crossed and lateral K-wire fixation for displaced extension-type SCHF, and complications related to the type of K-wire construction used.MethodsRCTs and prospective comparative cohorts on the functional outcome and complications after fracture reduction and K-wire fixation were identified in MEDLINE, Embase, Web of Science and the Cochrane Library.ResultsThirteen studies were identified, including 1158 patients in seven RCTs and six prospective comparative cohorts. According to the Flynn criteria, there was no difference in outcome between the K-wire configurations (Relative Risk 1.07). Loss of reduction occurred in 27 (11.6%) of 232 patients treated with crossed K-wires, and in 35 (12.4%) of 282 patients treated with lateral entry K-wires. Twenty (4.1%) of 493 patients in the crossed group were diagnosed with iatrogenic ulnar nerve injury, compared with 2 (0.3%) of 666 patients in the lateral entry group. The overall incidence of persistent ulnar nerve related complaints was 3.5/1000.ConclusionsCrossed and lateral entry pin fixation of SCHF result in similar construct stability and functional outcome. Although ulnar nerve injury was three times more likely in the crossed K-wire group, the overall incidence of this complication was very low. The available evidence does not support the use of either approach for daily practice. If the surgeon wishes to avoid all potential risk of iatrogenic ulnar nerve injury, the lateral K-wire approach is safest.     

External wire-frame fixation of digital skin grafts: A non-invasive alternative to the K-wire insertion method

Background and Aim

The current skin graft fixation methods for digits, including the Kirschner wire insertion technique, can be limited by inadequate or excessive fixation and complications such as infection or secondary injuries. Therefore, the external wire-frame fixation method was invented and used for skin grafting of digits. This study aimed to investigate external wire-frame fixation of digital skin grafts as a non-invasive alternative to the K-wire insertion method.

Methods

In 2005–2012, 15 patients with burn scar contractures on the hand digits received a skin graft that was then fixed with an external wire frame. The intra-operative time needed to make the wire frame, the postoperative time to frame and suture removal, the graft survival rate, the effect of contracture release and the complications were recorded.

Results

In all cases, the contracture release was 100%. The complete graft survival rate was 98.6%. Four patients had epithelial necrosis in <5% of the total area. There were no other complications such as pressure ulcer or hypoxia of fingers.

Conclusions

External wire-frame fixation is simple, minimally invasive and a custom-made technique for skin grafting of the fingers. It was designed for its potential benefits and the decreased risk it poses to patients with scar contractures on their fingers. It can be implemented in three phases of grafting, does not affect the epiphyseal line or subsequent finger growth and is suitable for children with multi-digit involvement.     

Cemented K-wire fixation for the treatment of shaft fractures of middle phalanges

BackgroundThe objective of this report is to introduce an external-fixation technique using the combination of K-wires and cement.MethodsFrom February 2009 to January 2015, 51 patients with shaft fractures of middle phalanges were treated with cemented K-wire fixation. The mean age of patients at surgery was 41 years. The mean time interval from injury to operation was 6 ± 5.78 days. Injured digits included index (n = 18), long (n = 15), ring (n = 7), and little (n = 11) fingers. Types of fractures were transversal (n = 32), short oblique or spiral (n = 5), and comminuted (n = 14) fractures. Active range of motion of the fingers was measured. Total active motion was scored based on the American Society for Surgery of the Hand. All measurements were compared with those on the opposite fingers. Patients also reported on their satisfaction using the 100-mm visual analogue scale.ResultsAt the final follow-ups of 2 years, range of motion of metacarpophalangeal joint, proximal phalangeal joint, and distal interphalangeal joint reached 97% ± 2.88, 93% ± 6.65, and 96% ± 3.22 of the opposite fingers, respectively. Based on Total active motion scoring system, we obtained 36 excellent and 15 good results. Based on VAS, patient satisfaction was 96 ± 3.44.ConclusionsThe cemented K-wire fixation is a reliable technique for the treatment of shaft fractures of middle phalanges. The technique is a minimally invasive procedure with minimal complications.Level of evidenceTherapeutic study, Level IVa.     

Determining the optimal radiologic wrist and forearm position to visualize screw protrusion in scaphoid fixation

Background

Surgical fixation of scaphoid fractures may result in unrecognized screw protrusion and subsequent cartilage damage to the adjacent joints. The purpose of this study was to use a three-dimensional (3D) scaphoid model to determine the wrist and forearm positioning that will allow intra-operative fluoroscopic visualization of screw protrusions.

Methods

Two 3D scaphoid models, with the wrist in neutral and 20° ulnar deviated, were reconstructed from a cadaveric wrist using the Mimics software. The scaphoid models were divided into three segments and further divided into four quadrants in each of the three segments along the scaphoid axes. Two virtual screws, with a 2 and 1 mm groove from the distal border, were placed so that the screws protrude from each quadrant. The wrist models were rotated along the long axis of the forearm and the angles at which the screw protrusions were visualized were recorded.

Results

One-millimetre screw protrusions were visualized at a narrower range of forearm rotation angles compared to 2 mm screw protrusions. One-millimetre screw protrusions in the middle dorsal ulnar quadrant could not be detected. Visualization of the screw protrusion in each quadrant varied with forearm and wrist positioning.

Conclusion

In this model, all screw protrusions, except 1 mm protrusions in the middle dorsal ulnar quadrant, were visualized with the forearm in pronation, supination or in the mid-pronation position and with the wrist in neutral or 20° ulnar deviated.     

克氏针张力带内固定配合U型石膏治疗Pilon骨折

目的 探讨克氏针张力带内固定配合U型石膏治疗Pilon骨折的临床疗效。方法 采用克氏针张力带内固定配合U型石膏治疗Pilon骨折27例。根据AO分型,C1型4例,C2型19例,C3型4例。按Helfet评价标准进行疗效评价。结果 全部病例获得随访,时间5～36个月,平均13个月。骨折愈合时间9～13周,踝关节功能评分：优20例,良6例,差1例。结论 克氏针张力带内固定配合U型石膏治疗Pilon骨折优良率高,并发症少,手术简单。     

经皮克氏针撬拨与空心钉固定治疗跟骨骨折的疗效比较

跟骨骨折是临床常见的足部骨折之一,尤其是波及距下关节的跟骨骨折,若不能得到良好而稳定的骨折复位固定,易出现长期肿胀、疼痛、行走困难,甚至遗留严重的后遗症。自1999年3月-2005年4月共收治跟骨骨折63例,2003年以前38例采用经皮克氏针撬拨固定治疗,2003年以后25例采用经皮空心钉固定治疗,进行回顾性分析比较,现报告如下。1资料与方法1.1一般资料本组63例,均为闭合性骨折,足跟局部均有不同程度的肿痛、畸形,足弓变浅,足跟加宽,X线片示Bohler角变小、消失或变负,载距突及关节面塌陷不平。其中克氏针撬拨组38例,男30例,女8例;年龄16~62岁,…     

Pressing fixation of mallet finger fractures with the end of a K-wire (a new fixation technique for mallet fractures)

AimThe aim of this study was to describe and evaluate a surgical technique for the treatment of mallet finger fractures using a K-wire stabilization of the distal interphalangeal (DIP) joint and another K-wire pressing the bone fragment.MethodsBetween June 2007 and March 2014, 41 patients (28 men, 13 women) with isolated closed mallet finger fracture were treated using two K-wires. In the cohort, the mean joint surface involvement was 44.3% (range: 28–62%). With a mean period of 23.6 months, patient follow-up lasted 13–34 months. The fingers were evaluated for loss of extension and flexion of the (DIP) joints. The results were graded using Crawford's criteria.ResultsUnion of all fractures took place at an average of 5.5 weeks after the surgical procedure. Average extension lag was 4°, and active flexion 71°. According to the Crawford rating scale, 35 fingers were excellent, four were good, one was fair, and one was poor.ConclusionsPressing fixation of the bone fragment with the end of a K-wire was a useful technique in the treatment of mallet finger fractures.Type of study/level of evidenceTherapeutic IV.     

经皮与经肌间隙入路椎弓根螺钉内固定术治疗单节段胸腰椎骨折疗效的Meta分析

【摘要】 目的：系统评价经皮椎弓根螺钉内固定术（percutaneous pedicle screw fixation,PPSF）与经肌间隙入路椎弓根螺钉内固定术（mini-open Wiltse approach with pedicle screw fixation,MWPSF）治疗单节段胸腰椎骨折的疗效,为临床决策提供参考依据。方法：计算机检索Pubmed、Web of Science、Cochrane Library、万方数据库（Wangfang Database）、中国期刊全文数据库（CNKI）中关于PPSF与MWPSF治疗单节段胸腰椎骨折的临床对照研究,检索时限为自建库起至2020年3月。纳入文献包含下列参考指标中的两项以上：手术时间、术中出血量、术中透视次数、术后腰痛视觉模拟评分（visual analogue scale,VAS）、椎体后凸角（Cobb角）、伤椎椎体前缘高度比值（VBH）、Oswestry功能障碍指数（ODI）、手术并发症例数。Meta分析采用Cochrane Library提供的Rev-Man 5.3 软件进行。结果：共纳入17篇文献[3篇随机对照研究（randomized controlled trial,RCT）、14篇队列研究]、1057例患者,其中PPSF组519例,MWPSF组538例。MWPSF组手术时间较短[SMD=17.87,95%CI（11.60,24.15）,P＜0.05],术中透视次数较少[SMD=4.96,95%CI（4.29,5.63）,P＜0.05];末次随访时,MWPSF组Cobb角矫正较多[SMD=-7.56,95%CI（-10.61,-4.52）,P＜0.01],矫正丢失较少[SMD=1.76,95%CI（0.41,3.11）,P=0.01],VBH矫正丢失较少[SMD=0.90,95%CI（0.30,1.51）,P＜0.05]; PPSF组术中出血较少[SMD=-62.01,95%CI（-78.84,-45.18）,P＜0.05],术后1周VAS评分较低[SMD=-0.49,95%CI（-0.87,-0.11）,P=0.01]。在末次随访时两组的VAS评分、Cobb角、VBH、ODI、手术并发症无显著性差异（P＞0.05）。结论： PPSF和MWPSF治疗单节段胸腰椎骨折安全可靠,疗效一致。相较于MWPSF,PPSF具有创伤小、出血少及术后恢复快的优点,但增加手术时间和医源性辐射,且后凸矫形能力不足。     

后路椎弓根钉棒短节段固定治疗AO-B1型胸腰椎骨折脱位

目的探讨后路椎弓根钉棒短节段固定治疗AO-B1型胸腰椎骨折脱位的疗效。方法对12例AO-B1型胸腰椎骨折脱位伴脊髓损伤患者行一期后路经骨折脱位间隙相邻上下椎弓根置钉、复位、植骨融合并椎弓根钉棒系统两节段内固定。X线检查了解手术前后及末次随访时胸腰椎骨折脱位椎间隙、骨折椎体高度恢复及脱位畸形矫治情况;Frankel分级方法比较手术前后脊髓损伤恢复情况。结果 12例均获随访,时间12~36(23±5)个月。术后Frankel分级:A级9例中1例恢复至C级,1例恢复至D级,余7例双下肢瘫痪均未恢复;C级2例和D级1例末次随访时均恢复至E级。术后及末次随访时影像学检查提示:内固定物在位,12例矢状面脱位均完全纠正,复位率达100%。椎间隙及椎体高度恢复,末次随访时高度无明显丢失,均无钉棒断裂现象。3例出现明显邻近节段退变。结论 AO-B1型胸腰椎骨折脱位可选择4钉2棒短节段固定;术前CT检查对诊断与治疗非常必要。     

单、双侧椎弓根螺钉固定在微创TLIF中的疗效比较

目的比较单侧和双侧椎弓根螺钉固定TLIF治疗单节段腰椎间盘突出症的疗效。方法回顾性研究应用单侧或双侧椎弓根螺钉固定进行单节段经椎间孔腰椎椎间融合治疗的患者36例,对比分析其手术时间、失血量、并发症等。结果两组术后VAS、ODI评分均有改善,但两组之间无统计学差异;双侧椎弓根螺钉固定组失血量多,单侧椎弓根螺钉内固定组手术时间短,两组融合率无显著差异(P0.05)。两组无椎弓根螺钉内固定并发症的发生。结论单侧椎弓根螺钉固定经椎间孔椎间融合在术后1年的临床疗效方面,与双侧椎弓根螺钉固定相似。     

Intra-operative screw trimming in direct screw fixation of the odontoid process fracture — Technical note

Summary For a satisfactory direct screw fixation of fractures of the odontoid process it is necessary to use a screw of the proper total length and thread length, but such an optimal ready-made screw is not always available. The authors describe a technique of intra-operative screw trimming using a high-speed diamond drill. This adjustment is easily and quickly performed. It enables the screw to act as a compression screw, which facilitates fusion of the fractured surfaces.     

微创经皮与Wiltse入路椎弓根钉内固定治疗胸腰椎骨折的疗效比较

目的比较微创经皮与Wiltse入路椎弓根钉内固定治疗胸腰椎骨折的临床疗效。方法回顾性分析自2013-12—2015-06诊治的32例无神经系统损伤的胸腰椎骨折,采用微创经皮椎弓根钉内固定治疗14例(微创组),采用Wiltse入路椎弓根钉内固定治疗18例(Wiltse入路组)。比较2组术中X线透视次数、切口长度、手术时间、术中出血量、VAS评分、ODI指数、伤椎前缘高度及Cobb角。结果 32例均获得平均14(12~18)个月随访。与Wiltse入路组比较,微创组手术切口较小、术中出血量较少,术后1 d、1周VAS评分较低,但手术时间较长,术中X线透视次数较多,差异均有统计学意义(P0.05)。2组术后3、12个月的VAS评分、ODI指数比较差异无统计学意义(P0.05)。微创组与Wiltse入路组术后3 d、3个月、12个月的Cobb角和伤椎前缘高度比较,差异无统计学意义(P0.05)。结论微创经皮与Wiltse入路椎弓根钉内固定治疗胸腰椎骨折均安全、有效,在伤椎前缘高度恢复、矢状位后凸畸形矫正及术后腰部功能恢复方面具有相同的效果,但是微创手术切口较小,术中出血量较少,术后疼痛缓解明显。     

Odontoid screw fixation for type IIodontoid fractures

The optimal management of type II odontoid fractures continues to generate controversy in the literature. There is ahigh rate of nonunion and malunion reported with displaced type II odontoid fractures treated nonoperatively. Posterior atlantoaxial arthrodesis is the most frequent procedure performed in this country to treat this condition. Loss of cervical mobility necessarily results and may lead to functional disability in young, active patients. Direct anterior screw osteosynthesis of the odontoid was initially described 15 years ago to treat displaced odontoid fractures without arthrodesis. This technique involves an indirect reduction of the fracture followed by interfragmentary compression with screw fixation. The purpose of this article is to review the technical aspects of this procedure. We will also examine the indications, surgical results, and complications associated with anterior screw osteosynthesis. Screw fixation of displaced type 11 odontoid fractures remains a valuable tool in the armamentarium of the spinal surgeon.     

可吸收螺钉临床应用87例体会

[目的] 探讨可吸收螺钉在骨折内固定的治疗。[方法] 从2002年8月～2004年4月，本院共87例骨折患者应用可吸收螺钉复位内固定治疗。[结果] 骨折87例最长随访16个月，平均随访14个月，其中髋臼骨折6例，根据Chamley髋关节功能分数分级，优良率为97．3％。胫骨髁间嵴骨折15例，采用Lysholm评分法评估患者手术后的功能，平均88．5分，优良率86．2％。[结论] 可吸收螺钉治疔内固定可靠，免除了2次手术再损伤，并发症少，对关节周围组织及关节本身损伤小，最大限度的恢复了关节功能，在髋关节较应用于四肢骨折更有意义。     

Perilunate dislocations and fracture-dislocations of the wrist, a review of 14 cases

OBJECTIVES: We report a retrospective series of 14 dislocations or perilunate fracture-dislocations. The results of our series are compared with the data of the literature and we discuss epidemiology, types of lesions, surgical treatment, complications and prognosis of this pathology. METHODS: The series included seven pure dislocations and seven fracture-dislocations including three trans-scapho-lunate forms (including one Fenton's syndrome). The displacement of all these lesions was posterior. The mean age was 35 years. Sixty-four percent were manual workers. All 14 patients had undergone surgical treatment through a dorsal approach in the first seven days following the injury. They were reviewed clinically and radiologically with a mean follow-up of 25 months. RESULTS: The average Cooney functional score was 72/100 with two excellent, six good, four fair and two poor results. Average flexion-extension motion arc was 74%, the grip strength was 77% compared to the other wrist. Persistent wrist pain was almost constant. One carpal instability was observed and one patient required a four-corner arthrodesis for SLAC wrist. Eighty-five percent of all patients were employed at least. CONCLUSIONS: Early diagnosis and anatomical reduction can provide satisfactory functional results. Emergency surgical treatment is required. We prefer a dorsal approach and we do not perform primary closed reductions.