Surgical treatment of comminuted intra-articular fractures of the distal humerus with double tension band osteosynthesis

Intra-articular fractures of the distal humerus are usually treated with cancellous screws for the condylar metaphysis itself and two Y-shaped plates for fixation of the metaphysis to the shaft. Twenty-four patients with comminuted intra-articular fractures (class C on AO/ASIF classification) were treated with crossed K-wires for the condylar metaphysis and double tension band osteosynthesis for fixation of the metaphysis block to the shaft. Excellent or good results were achieved in 83% of patients. This technique is easier to perform and more cost effective than most other fixation methods. Additionally, it offers good stability and allows for earlier functioning of the elbow. Complication rates are comparable to other methods of internal fixation.     

Olecranon osteotomy for exposure of fractures and nonunions of the distal humerus

Although olecranon osteotomy provides excellent exposure of the distal humerus, enthusiasm for this approach has been limited by reports suggesting numerous complications. It has been suggested that specific techniques for creating and repairing an olecranon osteotomy may help limit complications. This paper describes a technique for olecranon osteotomy using an apex, distal, chevron-shaped osteotomy, Kirschner wires directed out the anterior ulnar cortex distal to the coronoid process and bent 180degrees and impacted into the olecranon proximally, and two 22- gauge, figure-of-eight, stainless steel tension wires. A single surgeon used this technique for exposure of a fracture (16 patients) or nonunion (29 patients) of the distal humerus in 45 consecutive patients. One patient returned to activity too soon, had loosening of the wire fixation, and required a second operation for plate fixation of the ulna. The remaining 44 osteotomies (98%) healed with good alignment within 6 months. There were no broken or migrated wires prior to healing. Twelve patients (27%) had removal of the wires used to repair the olecranon: in 6 patients, this was for symptoms related to the wires (13%); 1 for septic olecranon bursitis, and 5 at the time of another procedure (elbow capsular release in 4 patients and submuscular ulnar nerve transposition in 1). Olecranon osteotomy can be used for exposure of the distal humerus with a low rate of complications when specific techniques are used.     

Pediatric supracondylar humerus fractures

Pediatric supracondylar humerus fracture can occur in children and young teenagers; however, it is an injury seen most commonly between ages 5 and 8 years. Injuries tot he left arm are more common than to the right. Girls are affected as frequently as boys. Concurrent fractures in the same limb are possible, particularly fractures of the forearm and distal radius.     

Treatment of high-energy supracondylar/intercondylar fractures of the distal humerus

Operative treatment of high-energy intra-articular fractures of the distal humerus is challenging and controversial. We conducted a retrospective study at a Level I trauma center to evaluate the results of a specific treatment protocol. Seventy-one patients were treated through a posterior olecranon osteotomy. Capsulectomy was performed in patients who perceived their functional range of motion to be limited after an average of 10~months. Clinical followup consisted of physical examination, radiography, and completion of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Average followup duration was 22 (range, 6 to 70) months. Sixty-five percent of the patients achieved excellent or good results, 28% fair, and 7% poor. Thirty-one percent underwent capsulectomy, with 59% of those patients achieving excellent or good results. This is the largest series reported to date. Our patients experienced mild functional impairment and a low rate of nonunion. We advocate capsulectomy for patients with limited range of motion postoperatively.     

Fracture stability after pinning of displaced supracondylar distal humerus fractures in children

Between January 1, 1994 and December 31, 1997, we evaluated 138 children with displaced supracondylar distal humerus fractures treated by closed reduction and percutaneous pinning. There were 49 type II fractures and 89 type III fractures. Three principal pin configurations were used at the surgeon's discretion: 2 lateral pins (42 fractures), 1 medial and 1 lateral pin (37 fractures), and 1 medial and 2 lateral pins (57 fractures). There was no statistically significant difference in clinical stability between these groups. One type III fracture pinned using two lateral pins showed marked rotational instability. We recommend using two lateral pins when treating type II fractures. Type III fractures should be treated using two lateral pins initially and, if the elbow demonstrates significant intraoperative rotational instability, a medial pin should be added. If a medial pin is necessary, and the ulnar nerve cannot be identified by palpation, a small incision should be made and the pin placed under direct vision.     

Transarticular joint reconstruction and indirect plate osteosynthesis for complex distal supracondylar femoral fractures

In a prospective study conducted between 1992 and 1995, displaced Müller type C2-C3 intraarticular fractures of the distal femur were treated using an indirect plate fixation technique and a lateral parapatellar arthrotomy for the direct reduction of the condylar block. There were 6 closed, and 2 open fractures (1 grade II and 1 grade IIIB). Following reconstruction of the articular block, the block was indirectly reduced and fixed to the shaft by a plate inserted by the retrograde method beneath the vastus lateralis. Transcutaneous/transmuscular screws were used to fix the plate to the shaft. Time to bone healing was 12 weeks (median range 8-17 weeks) after surgery without needing primary or secondary bone grafts. There were no infections or refractures. Except for one case which required a corrective osteotomy for 10 degrees of varus malalignment, there were no revisions. According to the Neer score, there were 6 excellent or satisfactory results, 2 unsatisfactory results, and no failures. At follow-up, there were 2 varus-valgus deformities greater than 5 degrees, 2 leg length discrepancies greater than 10 mm, and 2 rotational deformities of 15 degrees. The treatment results for complex supracondylar/intracondylar fractures of the distal femur obtained with this technique compare favourably with other reported series using different techniques without the added morbidity associated with autogenous bone grafting. However, the surgical technique is demanding and special care must be taken to ensure correct axial alignment.     

Tension band osteosynthesis with absorbable cords in proximal comminuted fractures of the humerus

We reviewed 25 cases of comminuted fractures of the proximal humerus that were operatively treated from December 1984 to December 1988. Ten patients were treated by a Magerl operation modified by Marti using a metallic wire as a tension band. Twelve patients were operated on using a resorbable PDS (Polydioxanon) thread in the same manner. In this paper the PDS thread technique is described. The two groups are clinically and radiologically comparable. Using a PDS thread as a tension band has evident advantages: the relatively simple technique and the absence of implant removal.     

Managing supracondylar fractures of the distal humerus in children in a district general hospital

Introduction

Controversy exists regarding the timing of surgery in children with displaced supracondylar fractures of the humerus.

Methods

We reviewed retrospectively the postoperative outcomes and complications in these children managed in a district general hospital.

Results

There were 81 children with displaced supracondylar fractures (64 Gartland type III and 17 type IIA). Of these, 46 children were treated within 6 hours of presentation and 35 were treated later. The rate of open reduction was higher in children treated early (23%) than in late cases (11%). There was no significant difference in the postoperative outcomes and complications between the groups.

Conclusions

In children with a supracondylar fracture, the timing of surgical treatment (before or after six hours from presentation to hospital) had no effect on postoperative complications and outcomes.     

Surgical treatment of fractures of the distal clavicle with polydioxanone suture tension band wiring: an alternative osteosynthesis

 Fracture of the distal clavicle type II (Neer) is an indication for surgical intervention. We report our experience in 12 patients with acute clavicular fractures and operative treatment with polydioxanone suture (PDS) tension band wiring. The patients were assessed 6 and 12 weeks postoperatively by radiological and clinical evaluation and with the Constant Murley score. All 12 patients had an excellent functional result 12 weeks postoperatively. The Constant Murley score was excellent in all patients. The PDS band can be considered as an alternative osteosynthesis. In the context of the current literature, the advantages and disadvantages of this new procedure are discussed. Received: October 26, 2001 / Accepted: April 1, 2002     

改良张力带钢丝治疗肱骨髁上骨折的生物力学研究及其临床应用

目的 应用自行设计改良张力带钢丝内固定技术治疗小儿肱骨髁上骨折。方法 对11侧人工肱骨髁上骨折标本应用改良张力带钠丝与交叉克氏针固定后，进行相关的生物力学测试。临床治疗肱骨髁上骨折患儿46例，随访6－78个月，平均38个月。结果 生物力学试验测试结果显示改良张力带钢丝的桡侧绑结可使骨折端产生压应力，固定强度明显优于交叉克氏针。临床随访显示骨折愈合佳，功能活动好，术后并发症发生率低。结论 改良张力带钢丝内固定治疗肱骨髁上骨折的效果明显优于克氏针交叉内固定，其稳定性允许废弃外固定，并能早期活动肘关节，是一种更符合生物力学原理的技术，值得临床推广应用。     

Patterns of pediatric supracondylar humerus fractures

PURPOSE: The Wilkins-modified Gartland classification of pediatric supracondylar humerus fractures does not consider coronal or sagittal obliquity. The purposes of our study were (1) to identify and describe fracture characteristics with unique properties and (2) to propose a fracture classification system that can be reproduced reliably. METHODS: We retrospectively studied 203 consecutive displaced pediatric extension-type supracondylar humerus fractures treated operatively from January 1998 to January 2003. Fracture characteristics (eg, coronal and sagittal obliquity, postoperative alignment), type of surgical treatment, outcome, and complications were assessed and analyzed statistically with Student t test and a receiver operating characteristic curve. Significance was defined as P < 0.05. We incorporated significant cutoff values for fracture obliquity into our classification scheme and tested the classification's interobserver and intraobserver reliability. RESULTS: We identified 4 coronal (typical transverse, medial oblique, lateral oblique, and high fractures) and 2 sagittal (low sagittal and high sagittal) subtypes with significantly different characteristics and outcome. Compared with fractures with coronal obliquity of less than 10 degrees, fractures with coronal obliquity of 10 degrees or greater were associated with significantly more comminution and rotational malunion. Compared with fractures with sagittal obliquity of less than 20 degrees, fractures with sagittal obliquity of 20 degrees or greater were associated with a significantly higher incidence of additional injuries and were more likely to result in extension malunion. Analysis of the interobserver and intraobserver reliability for our system identified correlation coefficients ranging from 0.772 to 0.907 and 0.860 to 0.899, respectively. CONCLUSIONS: Because pediatric extension-type supracondylar humerus fractures vary significantly in terms of characteristics, identification of sagittal oblique and coronal oblique angles may have an important role in surgical decision making and may impact outcomes.     

双钢板治疗肱骨远端C型骨折

2007年2月～2011年9月,我院手术治疗25例肱骨远端C型骨折患者,疗效满意,报道如下。1材料与方法1.1病例资料本组25例,男19例,女6例,年龄22～58岁。左侧10例,右侧15例。开放损伤1例(为GustiloⅠ型),闭合损伤24例。骨折按照AO/     

Supra- and intercondylar fractures of the distal humerus in adults. Apropos of 28 osteosynthesis

The authors report their experience of the surgical fixation of supra- and intercondylar fractures over a 13 year period. Twenty eight cases were reviewed with a mean follow-up of 3 years and 85% good and very good results. Postoperative complications were related to defective fixation and inappropriate material. The 4 poor or tolerable results involved compound and comminutive fractures in the context of polytrauma or complicated by sepsis. Amongst the various plates used, A0 3.5 plates (strong and mouldable) provided satisfactory fixation with the possibility of early physical rehabilitation (between 3 and 21 days).     

The treatment of pediatric supracondylar humerus fractures

Based on the best current evidence and a systematic review of published studies, 14 recommendations have been created to guide clinical practice and management of supracondylar fractures of the humerus in children. Two each of these recommendations are graded Weak and Consensus; eight are graded Inconclusive. The two Moderate recommendations include nonsurgical immobilization for acute or nondisplaced fractures of the humerus or posterior fat pad sign, and closed reduction with pin fixation for displaced type II and III and displaced flexion fractures.