Treatment of distal tibial fractures: plate versus nail

A study of 24 patients who sustained an extra-articular fracture of the distal third of the tibial shaft was performed to determine the effect of the type of treatment, open reduction and internal fixation (ORIF) or closed reduction and intramedullary (IM) nailing, on the occurrence of malalignment. All patients were treated in our clinic between 1993 and 2001 for a fracture in the distal third of the tibia. Twelve patients treated with ORIF were matched to 12 patients treated with IM nailing, with regard to gender, age decade, and the AO classification of the fracture. The group treated with IM nailing was assessed after a mean 6.0 years versus ORIF after a mean of 4.5 years. Two patients treated with ORIF versus six patients treated with IM nailing had a malalignment of the tibia. Furthermore, we found no difference with regard to time to union, non-union, hardware failure or deep infections between ORIF and IM nailing. Our results suggest that control of alignment is difficult with IM nailing of distal tibial fractures. For optimal alignment we advise considering the use of ORIF for closed and type I open extra-articular fractures in the distal third of the tibia.     

Treatment of distal metaphyseal tibia fractures with involvement of the ankle by combination of locked intramedullary nailing and covered screw osteosynthesis

Fractures of the distal metaphysis of the tibia often include an extension into the ankle. Intramedullary nailing combined with covered screw osteosynthesis should reduce the high incidence of soft tissue and ankle problems and should be an alternative to open plate fixation, with good ultimate functional outcome. Between January 1993 and December 1995, a prospective study on 49 patients with distal metaphyseal tibia fracture and involvement of the ankle was performed. All the fractures were treated with intramedullary nailing combined with covered screw osteosynthesis, and plate fixation in cases of fibula fractures. There were 27 men and 22 women with an average age of 46.4 +/- 12.7 years (range 21-90). In most studies of the use of intramedullary nailing in distal tibial fractures the classification has been inadequate. Therefore a new classification according to Robinson et al. (1995) was used: 10 fractures were type II B (20.4%), 13 were type II C (26.5%), and 26 patients suffered a combination of type II B and type II C (53.1%). This fracture type was defined as type II D for use in this study. The severity of soft tissue injury was recorded using the Gustilo system in case of open (n = 19) and the Tscheme system in case of closed fractures (n = 30). In 31 patients distal tibia fracture was accompanied by a fracture of the fibula, which was first stabilized using a plate. For reconstruction of the distal articular surface, covered screw osteosynthesis was done. At the next step intramedullary nails were inserted and were statically locked proximally and distally. From January 1993 to February 1994, the reamed AO standard nail was used. After introduction of the unreamed tibial nail (UTN) all fractures were treated by this implant. Full load on the operated leg was allowed after 8 weeks. Union of the fracture was assessed by standard radiological and clinical criteria. Misalignment was defined as more than 5 degrees of angular rotation. Further surgery due to a valgus deformity in the ankle joint had to be done in three cases. There were no deep infections. Three patients had a superficial infection in the ankle area, but surgical debridement was not necessary. A leg shortening was found in 4 cases, but it was less than 1 cm in every case. Therefore, surgical correction was not done. Patients were reviewed at intervals of 2, 6, and 12 weeks, and after 6, and at least 12 months. All 49 patients were finally reviewed after an average time of 15.7 months (range 12-38). Bone fusion was reached 12.8 weeks (range 9-21) after the operative treatment. A specific assessment of the ankle symptoms was made using the score of Olerud and Molander (1984). In 29 patients excellent results were recorded. A satisfactory result was attained with 17 patients and just 3 patients were found to be unsatisfactory. Although proximity of distal tibia fracture to the ankle makes the treatment more complicated than for fractures of the tibial diaphysis, closed intramedullary nailing combined with covered screw fixation is a good alternative to open reduction and plate fixation. The major advantages are closed procedure and simplified interlocking techniques. Therefore, closed intramedullary nailing combined with covered screw fixation is a safe and effective method of managing this type of fracture.     

磁力导航髓内钉小切口微创治疗胫骨干骨折

目的探讨磁力导航髓内钉小切口微创治疗胫骨干骨折的临床效果。方法 2008年8月至2010年2月我院对收治的32例胫骨干骨折患者,实施了骨折闭合复位或小切口切开复位磁力导航带锁髓内钉内固定手术。结果闭合复位成功12例,小切口开放复位20例,锁定钉远端一次性锁定30例,成功率93.8%。髌韧带内侧切口平均长度3.1 cm,骨折端切口平均长度2.6 cm。无感染及切开皮肤坏死病例。随访28例,平均随访6.3个月,骨折平均愈合时间为2.8个月,无骨折不愈合及髓内钉松动断裂。功能按Johner-Wruhs评定标准进行评价,优20例,良7例,中1例,优良率96.4%。结论磁力导航髓内钉小切口微创治疗胫骨干骨折锁钉定位准确,损伤小,疗效好,优于传统髓内钉内固定技术。     

Minimally invasive plate osteosynthesis (MIPO) in the treatment of the femoral shaft fracture where intramedullary nailing is not indicated

The aim of this study was to examine the results of minimally invasive plate osteosynthesis (MIPO) of the femoral shaft fracture in patients where intramedullary nailing is contraindicated and evaluate the proper number of the screws for stable fixation. This was a retrospective study of 36 closed femoral shaft fractures which underwent MIPO using a conventional 4.5 broad dynamic compression plate (DCP) with 14-18 holes fixed with three or four screws in the proximal and distal fragments. Thirty-three fractures had bony union in 21.0 weeks (range, 12-28 weeks), two had delayed union that required bone graft and union at 28 and 32 weeks. Malalignment occurred in five cases. Sixty-two fragments were fixed with three screws--40 in cluster and 22 in separated positions. Ten fragments were fixed with four screws--eight in cluster and two separated. Broken screws were found in three cases; all were in the group with three screws fixed in cluster group. MIPO of the femoral shaft fracture is an alternative treatment in the patient where intramedullary nailing is contraindicated. Malalignment is the common complication that must be carefully evaluated intraoperatively. We recommend using at least three separated screws in each fragment to reduce the risk of screw breakage.     

Traction and spica casting for closed femoral shaft fractures in children

PURPOSE: To evaluate the treatment outcome of skin traction followed by spica casting for closed femoral shaft fractures in children. METHODS: Between September 1997 and December 2001 inclusive, outcomes of 63 children aged one month to 15 (mean, 5.3) years with closed femoral shaft fractures managed with skin traction and spica casting were reviewed. Depending on age, patients were kept in traction from 2 to 15 (median, 9) days, then in spica casts for 2 to 8 (median, 5) weeks. RESULTS: Bony union took 3 to 12 (median, 6) weeks. There were no malunion, nonunion, or rotational deformities. Nor were there any significant limb length discrepancies, pressure sores, or nerve palsies. On no occasion was a spica cast removed and reapplied for loss of fracture reduction. At final follow-up, limb length discrepancy was noted in 14 (22%) of the patients, but none had a discrepancy of greater than 1.5 cm or a short-legged gait. CONCLUSION: Skin traction followed by spica casting for closed femoral shaft fractures in children is safe, cost-effective and associated with a low complication rate. It is effective in children below 5 years of age and no less effective in older children, except in instances of open fracture, multiple fractures, or older children with large statures, which conditions render them intolerant to spica casts.     

股骨干骨折接骨板或髓内针固定的局部并发症

目的 探讨股骨干骨折局部并发症发生的影响因素,并比较接骨板和髓内针固定方法在并发症方面的差异。方法 对我院１９８５－１９９４年间３２５例经内固定治疗的股骨干骨折进行分析。结果 ７２例发生局部并发症,发生率为２２％,其中髓内针组４６例;接骨板组２６例。结论髓内针固定股骨干骨折较接骨板有明显的优势,但在股骨下段,粗隆下肌折应用接骨板是较好的选择。     

Pediatric femoral fractures: a systematic review of 2422 cases

BACKGROUND: The incidence of femoral fractures in children comprise 20 per 100,000 yearly in the United States and Europe. The treatment of femoral shaft fractures in the pediatric population remains controversial. The child's age often directs the management. Nonoperative treatment options include functional treatment for the very young, Pavlic harness, skin or skeletal traction, and spica casting. Operative treatment options include closed reduction and external fixation, open reduction and internal plate fixation, closed reduction and minimally invasive plate osteosynthesis (MIPO), and closed reduction and intramedullary nailing with either flexible or rigid nails. The effect of operative versus nonoperative treatment has been the focus of several comparative studies. OBJECTIVE: To determine the effect of different treatment options on the rate of union, malunion, leg-length discrepancy (LLD), complications, and outcome after femoral shaft fractures in children.     

带锁髓内钉治疗股骨干骨折失败原因分析及其对策

目的探讨带锁髓内钉治疗股骨干骨折失败的原因及其预防措施。方法1999年4月至2002年9月采用带锁髓内钉治疗股骨干骨折患者213例,其中失败18例。回顾性分析这18例患者的临床资料,并对其进行分类。结果18例患者中,按失败原因可分为断钉3例,其中主钉断裂2例,主钉合并远端锁钉断裂1例;远端锁钉退出7例;近端锁钉退出3例;膝关节纤维性强直3例;迟发感染2例。手术技术、手术适应证选择、康复锻炼的规范性、髓内钉的强度及合适与否是导致失败的相关原因。结论应用带锁髓内钉治疗股骨干骨折应掌握好适应证,强调术前准备充分,术中操作规范,术后锻炼应循序渐进,避免过早负重,是减少或防止内固定失效的重要措施。     

Locked intramedullary femoral nailing without fracture table or image intensifier

The present retrospective study aims to evaluate the outcome in 41 patients of femoral shaft fractures, who had closed intramedullary nailing in lateral decubitus position without fracture table or image intensifier. Mean age was 33.2 (range, 18–70) years. The cannulated reamer in proximal fragment (as intramedullary joystick) and Schanz screw in the distal fragment (as percutaneous joystick) were simultaneously used to assist closed reduction of the fracture without the use of image intensifier. Closed reduction was successful in 38 patients. Open reduction was required in 3 patients. Schanz screw was used for closed reduction in 12 patients. Average number of intra-operative radiographic exposures was 4.4. Two patients had exchange nailing using large diameter nails. One patient had nonunion. Angular and rotatory malalignments were observed in seven patients. We are of the opinion that the present technique is a safe and reliable alternative to achieve closed locked intramedullary nailing and is best suited to stable, less comminuted (Winquist–Hansen types I and II) diaphyseal fractures of the femur.     

钢板及交锁髓内钉治疗肱骨干骨折疗效对比

目的：比较两种手术方法的优缺点。方法：两组患者,一组行开放复位钢板内固定,另一组行闭合复位交锁髓内钉固定。结果：闭合复位交锁髓内钉固定组骨愈合率高于钢板固定组,桡神经损伤、感染等低于钢板固定组,但肩关节功能差有一定比较。结论：闭合复位交锁髓内钉固定治疗肱骨干骨折是一种行之有效的方法。     

The influence of body injuries on bone union of femoral shaft fractures treated by different operative methods]

Femoral shaft fracture is very often main musculo-skeletal injury in polytrauma patient. We analysed bone union of femoral shaft fractures treated by different operative open methods--AO plate osteosynthesis, Zespol method and open intramedullary nailing and by closed intramedullary nailing, in patients with concomitant body injuries. We compared patients operated by open methods without complications with the group demanding fracture reoperation. We found out no statistical correlation between the frequency of local complications demanding reoperation and the presence of associated injuries p = 0.209 or their severity expressed in ISS p = 0.202. The highest ISS 29.5 points occurred in the group operated on by closed intramedullary nailing. Lack of complications in this group gives evidence of efficiency of this method of treatment.     

Operative treatment of humeral shaft fractures. The Leuven experience

For many years, plating has proved to be a reliable method for the fixation of fractures of the humeral shaft. In the early nineties however, intramedullary devices became increasingly popular for fractures of the humeral shaft. This was based on a global tendency towards minimally invasive surgery, and the attractiveness of the relatively simple procedure and potentially lower complication rate of intramedullary nailing, which had proved to be successful in osteosynthesis of the lower limb, However, until now there is no consensus in the literature as to which device is preferable for different indications. We reviewed 161 patients, operatively treated for a fracture of the humeral shaft in our department between 1986 and 1999. Our experience shows in most indications a higher union rate, better functional results and a lower reoperation rate after plate and screw fixation. In addition, even though plating requires a more technically demanding procedure, in experienced hands, it gave rise to fewer iatrogenic fractures, and fewer persisting pain problems. We recommend the use of plate and screws as primary treatment in all operative indications, except for pathological fractures, very obese patients, and open fractures.     

非扩髓闭合交锁髓内钉治疗股骨干骨折

目的　观察与分析闭合非扩髓交锁髓内钉技术治疗股骨干骨折的临床疗效与优点。方法　应用闭合非扩髓交锁髓内钉技术治疗新鲜股骨干骨折 2 83例。 2 83例患者均进行了 1次以上随访 ,随访时间为 3个月～ 4年 (平均随访时间 30个月 )。结果　骨折愈合时间 9～ 15周 ,平均 12周。术后3个月时 ,膝关节伸屈活动已与伤前相仿 ,无一例发生感染 ,无患肢疼痛、肿胀或关节僵硬等并发症。2 4例C型骨折中有 3例患肢短缩 1cm ,2例患肢轻度内翻 ,但成角 <7° ,1例交锁髓内钉在远端交锁螺钉孔处发生断裂。结论　闭合非扩髓交锁髓内钉内固定手术创伤小、保留了骨折处的血肿、不剥离骨折周围软组织、较少破坏骨内膜血供 ,为骨折愈合提供了良好的条件。同时 ,可进行早期功能锻炼 ,从而可防止关节肿胀、僵硬等骨折并发症发生 ,是目前治疗股骨干骨折较为理想的方法     

闭合复位带锁髓内钉治疗股骨干骨折

目的：探讨闭合复位带锁髓内钉治疗股骨干骨折的临床疗效.方法：自2006年3月至2011年12月采用闭合复位带锁髓内钉治疗103例股骨干骨折患者,其中男76例,女27例;年龄19～55岁,平均36岁.按照AO分型：A型64例,B型27例,C型12例;开放性骨折13例（Gustilo Ⅰ型5例,Ⅱ型8例）.观察术后患者骨折愈合时间,并采用膝关节HSS评分标准对术后1年膝关节功能恢复情况进行评价.结果：术中发生股骨颈骨折1例,股骨近端骨折1例,均于术中更换重建钉固定,术后骨折愈合.术中发生腓总神经损伤1例,营养神经治疗4个月后恢复.103例患者全部获得随访,时间12～28个月,平均22个月.全部患者获得骨性愈合,愈合时间3～9个月,平均5个月.髋关节功能全部恢复正常,术后1年膝关节行HSS评分平均90.89±5.06.结论：注重手术操作,力求闭合复位,减少并发症,带锁髓内钉是治疗股骨干骨折的首选方法.     

4种内固定方法治疗锁骨中段骨折疗效比较

目的比较不同内固定方法治疗锁骨中段骨折的疗效。方法应用重建锁定钢板、锁定解剖钢板、Herbert中空螺钉和交锁髓内钉4种内固定方法治疗111例锁骨中段骨折患者。比较4种手术方法的手术时间、切口长度、术中出血量、骨折愈合时间及肩关节功能。结果患者均获得随访,时间12~18个月。手术时间:重建锁定钢板组长于锁定解剖钢板组、Herbert中空螺钉组和交锁髓内钉组,差异有统计学意义(P0.05)。术中出血量:重建锁定钢板组和锁定解剖钢板组多于Herbert中空螺钉组和交锁髓内钉组,差异有统计学意义(P0.05)。切口长度:重建锁定钢板组和锁定解剖钢板组长于Herbert中空螺钉组和交锁髓内钉组,差异有统计学意义(P0.05)。骨折愈合时间:重建锁定钢板长于锁定解剖钢板组、Herbert中空螺钉组和交锁髓内钉组,差异有统计学意义(P0.05)。4种手术方法肩关节功能JOA评分比较差异无统计学意义(P0.05)。并发症:重建锁定钢板组、锁定解剖钢板组各有2例钢板断裂,Herbert中空螺钉组2例退钉,交锁髓内钉组无并发症发生。结论 4种固定方法治疗锁骨中段骨折均取得满意疗效,Herbert中空螺钉和交锁髓内钉固定治疗锁骨中段骨折较重建锁定钢板和锁定解剖钢板固定更符合生物力学特性,更具合理性。     

闭合复位带锁髓内钉适宜治疗合并桡神经损伤的肱骨干骨折吗?

目的探讨肱骨干骨折合并的桡神经损伤是否会因为带锁髓内钉置入时的闭合复位操作而导致神经损伤的加重。方法2002年1月～2005年1月手术治疗的353例肱骨干骨折患者中,63例术前合并桡神经损伤。对此63例患者的体检、手术记录、X线片及治疗结果进行回顾性分析。11例行闭合复位带锁髓内钉固定；52例行切开复位内固定术及桡神经探查术,应用PEMS 3．1版本的卡方检验对11例行闭合复位带锁髓内钉固定术的患者与19例可以采用带锁髓内钉固定但行切开复位内固定术及桡神经探查术的患者桡神经恢复情况进行统计学分析。结果52例行切开复位内固定术及桡神经探查术的患者中,9例(17．3%)桡神经被骨折端嵌压,其余43例均为桡神经挫伤。63例患者中,除2例外,桡神经损伤均于术后2～12周(平均8周)自行恢复。所有患者术后3～4个月获骨性愈合。闭合复位带锁髓内钉术与切开复位内固定及神经探查术对肱骨干骨折合并桡神经损伤患者的影响差异无显著性意义(P=0．3931)。结论闭合复位带锁髓内钉固定治疗合并桡神经损伤的肱骨干骨折患者是适宜的。     

Non-accidental injury,femoral shaft and neck fractures in children

Fractures of the femur present some unique challenges to the treating orthopaedic surgeon. Non-accidental injury must always be considered. There are various modalities that can be used in the management of shaft fractures and these should be treated with careful consideration of not just the fracture pattern but also the patient’s age, weight, bone maturity and social circumstances. Treatment options include: Pavlik harness, traction, spica casting, elastic nailing, sub-muscular plating, external fixation and intramedullary nailing. Selection of one treatment option over another should be done with full involvement of the patient and family. Femoral neck fractures, while rare, are associated with high-energy trauma and generally need to be treated as emergencies. Accurate anatomical reduction and fixation is crucial; despite this they have high rates of complications and these patients should be followed up for an extended period of time.     

Intramedullary nailing for the treatment of aseptic femoral shaft non-unions after plating failure: Effectiveness and timing

This retrospective, multicentre study aimed to evaluate reamed intramedullary nailing (IMN) for the treatment of 30 cases of aseptic femoral shaft non-union after plating failure. Following nailing, 29 non-unions had healed by a mean 7.93 months. In one case a hypertrophic non-union required renailing after 8 months, using a nail of greater diameter, and united within five further months. Healing times were not related to whether the fracture was open or closed, the type non-union or the type of fracture. The delay from the initial plating to intramedullary nailing had a statistically significant effect on healing time and final outcome. This treatment is cost effective and should be implemented as soon as the non-union is diagnosed.     

逆行置入交锁髓内钉治疗肱骨干骨折

目的　总结临床采用逆行置入交锁髓内钉治疗肱骨干骨折的经验。方法　采用 AO的专用钻头在鹰嘴窝上约 2 cm处钻孔 ,确定和准备进针入点 ,由肘向肩逆行置入 AO的非扩髓交锁髓内钉的方法治疗闭合性肱骨干骨折 15例。结果　 15例骨折在 3个月内全部骨性愈合 (8～ 12周 ) ,15例肩关节活动度于术后 3个月时已达正常对侧的 95 % ,肘关节活动度达正常的 85 %。有 2例病人肘关节活动度伸直较健侧相差 2 0°,拔钉后功能锻炼 1个月后恢复良好。结论　逆行置入交锁髓内钉治疗肱骨干骨折 ,避免了对肩袖的干扰 ,固定牢靠 ,肩肘关节功能恢复快 ,二期拆除内固定简便 ,是治疗肱骨干骨折的有效方法     

Fresh femoral shaft fractures treated with un-reamed intramedullary nail: 203 cases

OBJECTIVE: To discuss the experience treating fresh femoral shaft fractures with un-reamed intramedullary nail. METHODS: 203 cases of fresh femoral shaft fractures who had been treated with un-reamed intramedullary nail from November. 1995 to January. 1999 were analyzed retrospectively. 18 cases were open, classified as Gustilo I, and. 185 cases were closed. Traction table and image intensifier were used during operation. Closed reduction, un-reamed and free hand distal locking technique were used. Active movements of nearby joints were encouraged and partial weight bearing of 10 - 15 kg were allowed right after operation. RESULTS: All 203 cases of fresh femoral shaft fractures got bone union within 4 - 6 months. No case of delayed union and infection happened. 1 distal locking screw was broken. All patients gained normal extremity functions. CONCLUSION: Un-reamed intramedullary nailing of fresh femoral shaft fracture has less damage to the local soft tissue and blood supply. It has a relative stable fracture fixation, and less interruption to the healing procedure. It is one of the best methods for treating femoral fracture.