Mason type II radial head fractures: operative versus nonoperative treatment.

The most appropriate treatment of Mason type II radial head fractures remains controversial. Recommended treatment has included closed reduction and immobilization, resection, or open reduction and internal fixation. The cases of 29 Mason type II radial head fractures treated at Naval Hospital Oakland from 1983 to 1989 were identified. Twenty-six or 90% were available for detailed follow-up. All cases underwent standardized elbow evaluations and results were compared using an elbow score based on a 100-point scale. The parameters evaluated were pain, motion, elbow and grip strength, and function in activities of daily living. In addition, injury and follow-up radiographs were analyzed. Mean follow-up was 18 months. There were 10 cases treated by open reduction and internal fixation and 16 cases treated by closed means. At final follow-up, the operatively treated group had a mean elbow score of 92 and 90% good/excellent results. The nonoperatively treated group had a mean elbow score of 77 and 44% good/excellent results. This difference was statistically significant (p less than 0.01). Radiographic analysis revealed a higher incidence of articular depression, displacement, and joint narrowing in the nonoperatively treated group. We conclude that displaced radial head fractures treated nonoperatively have a higher incidence of pain, functional limitations, loss of strength, and radiographic evidence of arthritis when compared to those treated by open reduction and internal fixation.     

Displaced intraarticular calcaneal fractures: long-term outcome in women

BACKGROUND: This study compared the outcomes of displaced intraarticular calcaneal fractures in women treated operatively or nonoperatively. This was part of a prospective, randomized, controlled, multi-center, clinical trial performed at four level I trauma hospitals. In addition, we compared the long-term outcomes in women with those reported in men in an earlier study. METHODS: Forty-one women (43 fractures) required treatment for displaced intraarticular calcaneal fractures. Patients' ages ranged from 17 to 65 years at the time of injury. All fractures were closed injuries and had posterior facet displacement of more than 2 mm. Patients were randomly assigned to either the nonoperatively or operatively treated groups. Nonoperative treatment included ice and elevation, while operative treatment consisted of open reduction and internal fixation using a standard lateral approach. Outcomes were measured using the validated Short Form-36 Health Survey (SF-36) and the Visual Analogue Scale (VAS). RESULTS: Women were 3.18 times (RR 3.18, 95% CI 1.03- 9.79) more likely to report high SF-36 scores after operative treatment than those who received nonoperative treatment. Operative outcomes in women were better than those reported in an earlier study in men (SF-36: 77.47 in women compared to 67.56 in men, p = .07; VAS: 81.47 in women compared to 67.04 in men, p = .01). In women the fractures generally were caused by low-energy trauma that produced less severe injuries (higher Bohler angles). Most patients were not receiving Workman's Compensation benefits and did light to moderate work. CONCLUSION: Operative treatment of the fractures showed statistically significant better results when compared to nonoperative treatment (SF-36: p = .04; VAS: p = .10) in women. Displaced intraarticular calcaneal fractures in women should be treated by open reduction and internal fixation through a lateral approach.     

Fractures of the hip in children and adolescents

Hip fractures account for fewer than 1% of all fractures in children, and many can be successfully treated nonoperatively. Transepiphyseal, transcervical, and displaced cervicotrochanteric fractures, however, generally require closed reduction or open reduction and internal fixation to avoid complications of coxa vara deformity and nonunion. Avascular necrosis appears to be related to the severity of the initial injury and unaffected by treatment.     

Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective,randomized, controlled multicenter trial

BACKGROUND: Open reduction and internal fixation is the treatment of choice for displaced intra-articular calcaneal fractures at many orthopaedic trauma centers. The purpose of this study was to determine whether open reduction and internal fixation of displaced intra-articular calcaneal fractures results in better general and disease-specific health outcomes at two years after the injury compared with those after nonoperative management. METHODS: Patients at four trauma centers were randomized to operative or nonoperative care. A standard protocol, involving a lateral approach and rigid internal fixation, was used for operative care. Nonoperative treatment involved no attempt at closed reduction, and the patients were treated only with ice, elevation, and rest. All fractures were classified, and the quality of the reduction was measured. Validated outcome measures included the Short Form-36 (SF-36, a general health survey) and a visual analog scale (a disease-specific scale). RESULTS: Between April 1991 and December 1997, 512 patients with a calcaneal fracture were treated. Of those patients, 424 with 471 displaced intra-articular calcaneal fractures were enrolled in the study. Three hundred and nine patients (73%) were followed and assessed for a minimum of two years and a maximum of eight years of follow-up. The outcomes after nonoperative treatment were not found to be different from those after operative treatment; the score on the SF-36 was 64.7 and 68.7, respectively (p = 0.13), and the score on the visual analog scale was 64.3 and 68.6, respectively (p = 0.12). However, the patients who were not receiving Workers' Compensation and were managed operatively had significantly higher satisfaction scores (p = 0.001). Women who were managed operatively scored significantly higher on the SF-36 than did women who were managed nonoperatively (p = 0.015). Patients who were not receiving Workers' Compensation and were younger (less than twenty-nine years old), had a moderately lower B?hler angle (0 degrees to 14 degrees ), a comminuted fracture, a light workload, or an anatomic reduction or a step-off of < or =2 mm after surgical reduction (p = 0.04) scored significantly higher on the scoring scales after surgery compared with those who were treated nonoperatively. CONCLUSIONS: Without stratification of the groups, the functional results after nonoperative care of displaced intra-articular calcaneal fractures were equivalent to those after operative care. However, after unmasking the data by removal of the patients who were receiving Workers' Compensation, the outcomes were significantly better in some groups of surgically treated patients.     

Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures: on behalf of the Evidence-Based Orthopaedic Trauma Working Group

BACKGROUND: Fractures of the clavicle were reported to represent 2.6% of all fractures with an overall incidence of 64 per 100,000 per year (1987, Malm?, Sweden). Midshaft fractures account for approximately 69% to 81% of all clavicle fractures. Treatment options for acute midshaft clavicle fractures include nonoperative treatment (mostly sling or figure-of-eight bandage), open reduction and internal fixation with plates, and closed or open reduction and internal fixation with intramedullary pins, wires, or a nail. Most surgeons prefer nonoperative treatment of nondisplaced midshaft clavicle fractures. However, the optimal treatment option for isolated acute displaced midshaft clavicle fractures remains controversial. OBJECTIVES: This study was designed to systematically summarize and compare results of different treatment options (nonoperative, operative extramedullary fixation, and operative intramedullary fixation) in the management of midshaft clavicle fractures, specifically for displaced fractures.     

Metatarsal fractures

Metatarsal fractures are relatively common and if malunited, a frequent source of pain and disability. Nondisplaced fractures and fractures of the second to fourth metatarsal with displacement in the horizontal plane can be treated conservatively with protected weight bearing in a cast shoe for 4-6 weeks. In most displaced fractures, closed reduction can be achieved but maintenance of the reduction needs internal fixation. Percutaneous pinning is suitable for most fractures of the lesser metatarsals. Fractures with joint involvement and multiple fragments frequently require open reduction and plate fixation. Transverse fractures at the metaphyseal-diaphyseal junction of the fifth metatarsal ("Jones fractures") require an individualized approach tailored to the level of activity and time to union. Avulsion fractures of the fifth metatarsal bone are treated by open reduction and tension-band wiring or screw fixation if displaced more than 2 mm or with more that 30% of the joint involved. The metatarsals are the most common site of stress fractures, most of which are treated nonoperatively. Symptomatic posttraumatic deformities need adequate correction, in most cases by osteotomy across the former fracture site.     

跟骨钢板治疗严重移位肩胛骨骨折

目的探讨跟骨钢板治疗严重移位肩胛骨骨折的手术适应证及疗效。方法10例严重移位肩胛骨骨折患者采用跟骨钢板内固定治疗。结果随访6个月-4年，根据Hardegger功能评定标准：优7例，良2例，可1例。结论切开复位跟骨钢板内固定是治疗移位肩胛骨骨折较理想的方法之一。     

Management of displaced ankle fractures

BACKGROUND: Ankle fractures excluding pilon fractures, account for approximately 9% of all fractures with the majority being OTA type B injuries. Although surgeons generally treat undisplaced or minimally displaced injuries nonoperatively and displaced fractures operatively, opinions diverge regarding the management of those displaced fractures with acceptable closed reduction. There is also debate about the use of biodegradable implants in operatively managed ankle fractures, the type and technique of fixation for operatively treated syndesmotic injuries as well as the approach to postoperative rehabilitation. OBJECTIVE: We aimed to review the highest level of available evidence on the operative management of ankle fractures. We focused specifically on studies comparing (1) nonoperative versus operative management of displaced ankle fractures, (2) biodegradable versus metal implants, (3) syndesmotic fixation, and (4) postoperative rehabilitation protocols.     

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.     

Operative management of children's fractures of the shoulder region

Fractures about the shoulder in children rarely require operative treatment. Exceptions include open fractures and those associated with neurovascular compromise. Fractures of the proximal humerus in older children that cannot be adequately reduced and maintained should be treated with open reduction and internal fixation. Interposition of periosteum and biceps tendon can lead to difficulty in fracture reduction. Irreducible displaced fractures of the clavicular shaft, fractures that develop nonunion, and congenital pseudarthrosis of the clavicle can be treated by an intramedullary pin technique with bone grafting. Posterior displacement of fractures of the medical clavicle sometimes become an orthopedic emergency. Reduction by closed or open means should be accomplished to relieve compression of mediastinal structures. This injury does not require internal fixation. Types IV, V, and VI distal clavicle injuries require open reduction and reefing of the periosteal tube with occasional need for temporary lag-screw fixation. There is some debate about the type III injury. Large glenoid fractures involving the anterior rim that are associated with instability of the glenohumeral joint are best treated by open reduction and internal fixation.     

Arthroscopically assisted percutaneous fixation of triplane fracture of the distal tibia

Triplane ankle fractures typically occur in the adolescent age group. Although many are minimally displaced and can be managed nonoperatively, some are displaced and difficult to reduce by closed methods and need open reduction and internal fixation. Traditionally satisfactory articular reduction is achieved through an open approach, which can be extensive. We describe our experience of treating displaced triplane fractures in four patients, assisted by ankle arthroscopy to ensure anatomical reduction and minimal soft tissue disruption. We achieved excellent reduction and stable fixation in all four cases. All patients regained full range of movement within 6 weeks.     

Treatment of femoral shaft fractures associated with acute spinal cord injuries

Twenty-seven femoral shaft fractures in 23 patients with acute spinal cord injuries were reviewed for evaluation of the outcome of operative versus nonoperative treatment. Three groups were identified: 11 nonoperative, eight early operative, and eight delayed operative. Patients treated initially by nonoperative methods developed five impending nonunions (31%), which subsequently were treated by open reduction and internal fixation. One femur in each of the operative groups developed a refracture after early removal of metal fixation devices. In the delayed operative group, four patients (50%) required manipulation under general anesthesia for treatment of poor knee motion. Patients with complete neurologic lesions whose femurs were treated nonoperatively incurred more complications, i.e., decubitus ulcers, than those treated operatively. Operative stabilization of the femur within six weeks of injury rendered the most favorable outcome with the least number of orthopedic or medical complications in patients with both complete and incomplete cord lesions. All of the eight fractures united.     

Open reduction and stable fixation of isolated, displaced talar neck and body fractures

BACKGROUND: The purpose of this retrospective review was to evaluate the long-term results of surgical treatment of isolated, displaced talar neck and/or body fractures with stable internal fixation. METHODS: The study included twenty-five patients with a total of twenty-six displaced fractures isolated to the talus that had been treated with open reduction and stable internal fixation and followed for a minimum of forty-eight months after the injury. The final follow-up examination included standard radiographs, computed tomography, and a clinical evaluation. Variables that were analyzed included wound type, fracture type, Hawkins type, comminution, timing of the surgical intervention, surgical approach, quality of fracture reduction, Hawkins sign, osteonecrosis, union, time to union, posttraumatic arthritis, and the AOFAS scores including subscores (pain, function, and alignment). RESULTS: The average duration of follow-up was seventy-four months. Surgical intervention resulted in sixteen fractures with an anatomic reduction, five with a nearly anatomic reduction, and five with a poor reduction. All eight noncomminuted fractures were anatomically reduced. The overall union rate was 88%. All closed, displaced talar neck fractures healed, regardless of the time delay until surgical intervention. Posttraumatic arthritis of the subtalar joint was the most common finding and was seen in all patients, sixteen of whom had involvement of more than one joint. Osteonecrosis was a common finding, seen after thirteen of the twenty-six fractures overall and after six of the seven open fractures. CONCLUSIONS: Open reduction and internal fixation is recommended for the treatment of displaced talar neck and/or body fractures. A delay in surgical fixation does not appear to affect the outcome, union, or prevalence of osteonecrosis. Posttraumatic arthritis is a more common complication than osteonecrosis following operative treatment. Patients with a displaced fracture of the talus should be counseled that posttraumatic arthritis and chronic pain are expected outcomes even after anatomic reduction and stable fixation. This is especially true following open fractures.     

Displaced acetabular fractures

Displaced acetabular fractures occur primarily in young adults involved in high energy trauma and can lead to disabling posttraumatic arthritis. An initial roentgenographic evaluation with accurate delineation of all fracture lines provides the key to decisions about whether to give closed or open treatment. When open treatment is indicated, a surgical approach can be chosen that will almost always lead to reduction without the necessity of a second approach. The authors have found that the Kocher-Langenbeck, ilioinguinal, and extended iliofemoral approaches are the most useful. A fracture table and specialized reduction instruments aid fracture reduction and fixation. Satisfactory operative reduction of the fracture is the factor that correlates best with a satisfactory clinical result. The rate of satisfactory operative reductions improved gradually over the first 50 operations of a prospective study of 121 displaced acetabular fractures. Overall, there were 80% satisfactory clinical results in this series. Complications included a 3% infection rate and a 5% incidence of nerve palsy. Open reduction and internal fixation are indicated for the majority of displaced fractures. However, closed treatment can produce satisfactory results in selected patients.     

B、C型桡骨远端骨折的治疗

目的 探讨AO分类B、C型桡骨远端骨折的治疗方法。方法 对93例B、C型桡骨远端骨折采用手法复位石膏固定、闭合性复位经皮克氏针内固定及切开复位钢板螺钉内固定。结果 全部病例均随访2年以上。优良率：手法复位石膏固定组为82．05％，经皮克氏针内固定组为81．82％，切开复位钢板螺钉内固定组为80．95％。结论 手法复位能达到解剖或近似解剖复位并经石膏固定可达到良好固定者应采用非手术治疗；Bl、B3、C1型中的Colles骨折应采用闭合性复位经皮克氏针内固定；B2、Cl、C2型中的Simth骨折应采用切开复位钢板螺钉内固定；C3型骨折因干骺端粉碎应采用松质骨移植恢复桡骨的长度；伴有严重的骨质疏松的患者避免用内固定治疗。     

Displaced malleolar fractures associated with spiral fractures of the tibial shaft

A displaced fracture of the lateral malleolus, of the posterior tibial margin (posterior malleolus), or of both requiring open reduction and internal fixation was observed in association with ipsilateral spiral tibial shaft fracture in five patients. The malleolus fracture components all were managed using AO (ASIF) instrumentation. The tibial shaft fracture was treated nonoperatively in three patients and with interfragmentary screw fixation in two with more severe initial displacement. The bony healing of all fractures was uneventful. These combined injuries amounted to 0.9% of all admitted tibial shaft fractures and 3.9% of those with spiral configuration. An associated displaced malleolar fracture in tibial shaft fractures, sometimes even indiscernible in the anteroposterior view, may be overlooked unless roentgenograms are focused on the ankle joint. Examination of the joints above and below the fracture is of particular importance in clinics advocating functional treatment of tibial shaft fractures.     

Nonoperative treatment of closed displaced midshaft clavicle fractures

Background  

Closed displaced midshaft clavicle fractures used to be treated nonoperatively, and many studies have reported that nonoperative treatment gave good results. However, more recent studies have reported poorer results following nonoperative treatment, whereas the results of operative treatment have improved considerably. The aim of this paper was to report the results of treating closed displaced midshaft clavicle fractures nonoperatively.     

Triplane fractures of the distal tibial epiphysis

Triplane distal tibial fractures can occur as two-, three-, or four-part fractures with or without a fibular fracture. Diagnosis of the particular anatomy of each fracture is ascertained by plain radiographs; if the fracture is displaced 2 mm or more on any view, anteroposterior and lateral tomograms and, if possible, a limited computerized tomography (CT) scan should be done. A plaster cast in situ for non-displaced fractures or closed reduction for displaced fractures should be attempted first by internal rotation and anterior movement of the fibular metaphyseal piece. Failure to obtain and/or maintain an adequate closed reduction (less than 2 mm displacement), determined by plain radiographs, is an indication for operative treatment. Operative treatment consists of screw fixation for the metaphyseal fragment alone in two-part fractures and both metaphyseal and epiphyseal screw fixation in three-part fractures. Associated fibular fractures may also require internal fixation. The prognosis is generally good if adequate reduction has been achieved by closed or open means.     

Fractures of the shaft of the tibia treated with AO-compression osteosynthesis

Ninety-six displaced fractures of the shaft of the tibia in a series of 162 consecutive fractures were treated by AO internal fixation. Forty per cent were open fractures, of which 93 per cent received prophylactic treatment with antibiotics at the time of admission. The average time between the accident and the operation was 10 hours in closed fractures and 5 hours in open fractures. All cases were operated on by senior surgeons.The infection rate was 5.3 per cent in closed fractures, and 0 in open fractures. The average stay in hospital was 13 days. More than 90 per cent returned to work within 6 months after the accident. No case of pseudarthrosis or re-fracture was seen. The median time to final review was 36 months.Rigid internal fixation is advocated for all displaced fractures of the shaft of the tibia and is advocated as an urgent procedure especially in open fractures, and should be performed by experienced surgeons only. Rigid internal fixation appears to provide effective prophylaxis against secondary soft-tissue damage and limits the consequences of the initial soft-tissue damage.     

The floating knee in the pediatric patient. Nonoperative versus operative stabilization

The results of nonoperative and operative or rigid stabilization of ipsilateral femur and tibia fractures in children and adolescents were evaluated. Twenty-nine consecutive patients with open physes (30 affected extremities) were reviewed. Their mean followup was 8.6 years (range, 1.1-18.6 years). The nonoperative group consisted of 16 patients and 16 extremities treated by skeletal traction of the femoral fracture, closed reduction and splinting or casting of the tibia fractures, and eventual immobilization in a hip spica cast. The operative group, was comprised of 13 patients and 14 extremities in which one or both fractures were treated by open reduction and internal fixation, intramedullary fixation, or external fixation. Despite higher modified injury severity scores and skeletal injury scores, the patients who were treated operatively had a significantly reduced hospital stay, 20.1 days versus 34.9 days, respectively; decreased time to unsupported weightbearing, 16.8 weeks compared with 22.3 weeks, respectively; and fewer complications. Operative stabilization of the femur had a significant effect on decreasing the length of hospital stay and the time to unassisted weightbearing. The patients also were analyzed according to their age at the time of injury: 9 years of age or younger and 10 years of age and older. The younger children who were treated nonoperatively had an increased rate of lower extremity length discrepancy, angular malunion, and need for a secondary surgical procedure as compared with younger children who were treated operatively with rigid fixation. Based on the results of the current study, operative stabilization of at least the femur fracture and, preferably, both fractures in the treatment of a child with a floating knee is recommended, even for younger children.