Les traumatismes de l’articulation radio-ulnaire distale

Distal radio-ulnar joint injuries are common. Most of the time, these injuries are secondary to distal radius or ulna fractures. Diagnosis is generally made with standard X-rays. Surgery is required in cases of distal radioulnar joint or displaced fractures. In such cases, fracture reduction and osteosynthesis, with pins or plate, are performed. However, malunion may occur in cases of imperfect reduction or postoperative displacement, leading to pain, limited pronosupination and distal radio-ulnar joint osteoarthritis. In such cases, conservative or palliative surgical treatment is often necessary.     

Arthroskopie des Handgelenks

Background

The increasing use of arthroscopy in the diagnosis and treatment of acute and chronic injuries of the wrist has also led to an increase in new knowledge. In fresh fractures of the wrist, accompanying soft tissue injuries are often only first discovered and treated by arthroscopy and repositioning of articular fragments by optical control is more accurate than by radiological imaging. However, due to the large number of distal radius fractures and the various types of extra-articular and intra-articular fractures there is currently a broad and very controversial discussion about the indications for arthroscopy.

Objectives

This study was carried out investigate whether criteria for distal radius fractures with the varied injury situations can be found which are appropriate to establish the indications for arthroscopy of the wrist based on an algorithm.

Methods

Following a selective literature review and taking our own results from a collective of 50 patients with distal radius fractures and arthroscopically assisted fracture treatment into account, possible criteria for the indications for arthroscopy of the wrist in distal radius fractures were established and are demonstrated using case examples.

Results

Based on this study an algorithm has been created for the treatment of distal radius fractures with the integration of arthroscopy as an essential diagnostic and therapeutic procedure.

Conclusions

Numerous well-known radiological findings can be used to justify the indications for arthroscopy in distal radius fractures and an improvement of the therapeutic results is expected due to increased use of arthroscopy.     

Pelvic fractures: an analysis of factors affecting prehospital triage and patient outcome

Using an established prehospital regional triage protocol, 175 patients sustaining fractures of the pelvis were managed in a level one trauma center during a 38-month interval. The majority of injuries (51.7%) were caused by motor vehicle accidents and involved an average trauma score (TS) of 13 and an average injury severity score (ISS) of 24. The overall mortality was 16%; 43.5% had open fractures, 13.2% had closed fractures, and 30.6% had been in pedestrian accidents. Significant risk factors for mortality were age, blood pressure on admission, associated injuries, and the presence of an open pelvic fracture. It appears that TS alone is not reliable in prehospital triage of patients with pelvic fractures. Age and mechanism of injury may better identify the patient at risk for morbidity and mortality.     

Non-operative treatment of common finger injuries

Finger fractures are common injuries with a wide spectrum of presentation. Although a vast majority of these injuries may be treated non-operatively with gentle reduction, appropriate splinting, and careful follow-up, health care providers must recognize injury patterns that require more specialized care. Injuries involving unstable fracture patterns, intra-articular extension, or tendon function tend to have suboptimal outcomes with non-operative treatment. Other injuries including terminal extensor tendon injuries (mallet finger), stable non-articular fractures, and distal phalanx tuft fractures are readily treated by conservative means, and in general do quite well. Appropriate understanding of finger fracture patterns, treatment modalities, and injuries requiring referral is critical for optimal patient outcomes.     

Management of osteoporosis in an orthopaedic department: audit improves practice

Patients presenting with an osteoporosis-related fracture are at increased risk of further fractures. We performed a retrospective survey to determine if elderly patients presenting to the orthopaedic unit at Manchester Royal Infirmary with low energy hip or distal radius fractures were being managed appropriately with regards to assessment, investigation and treatment for possible osteoporosis. The initial survey demonstrated that only 16% of elderly female patients with low energy hip fractures and none of those (0%) with distal radius fractures were started on treatment or referred for further investigations for possible osteoporosis. After changes in our practice, 76% (p < 0.00001) of patients with hip fractures and 81% (p < 0.00001) of those with distal radius fractures were investigated, started on treatment or referred to a consultant physician for the management of osteoporosis.     

Distal Forearm Fracture Open Reduction–Internal Fixation: Sonographic Detection of Hardware Malalignment and Associated Tendon Injuries Missed by Radiography

Tendon injury is a known complication of distal radius fracture plate and screw fixation. Targeted musculoskeletal sonography is uniquely capable of assessing both tendon integrity and hardware abnormalities not recognized on radiographs. Each of the 3 patients described presented with pain after an open reduction–internal fixation following a distal forearm fracture. In each patient, radiographic findings, specifically the hardware position, were interpreted as normal. Important radiographically occult observations were subsequently made with sonography, including 3 proud screws and tendon injuries, all of which required surgical treatment. This case series demonstrates the clinical utility of musculoskeletal sonography in symptomatic patients after distal radius open reduction–internal fixation with negative radiographic findings. In our practice, sonography has been the most useful modality for precluding missing or delaying the diagnosis and treatment of these hardware complications. We advocate its use as an adjunct in any department performing musculoskeletal imaging.     

Pediatric hand and wrist injuries

In the last 40 years, childhood hand and wrist injuries have become progressively more common as children have become heavier and more active in high impact sports. The majority of children with such injuries do well, but treatment is not always straightforward. Distal radius fractures, scaphoid fractures, metacarpal and phalangeal fractures, nailbed injuries, and amputations are among the pediatric hand and wrist injuries most often seen by orthopedists. These are all discussed, with a focus on the most recent literature and areas of evolving controversy.     

An unusual complication of radial head fractures

Radial head fractures are a fairly common injury secondary to falls on the outstretched forearm. Specific combinations of injuries involving radial head fractures and triceps tendon avulsion have been reported. Compartment syndromes secondary to distal forearm fractures are common; however fracture of the radial head rarely results in an acute compartment syndrome. A patient is reported with the combination of radial head fracture and triceps tendon avulsion complicated by the acute development of a compartment syndrome.     

Distal forearm fractures: the analytical approach for treatment

Although distal radius fractures are in the centre of orthopedic surgeons' attention, the rate of unsatisfactory treatment results remains very high. This study evaluates the analytical approach to distal radius fracture treatment. We observed 59 patients divided into 4 groups according to a modified Fernandez classification, regarding the patomechanism of injury: 1. bending extraarticular fractures; 2. shearing fractures; 3. comminuted fractures, and 4. malunions. We also took account of patients' compliance and demands. 1st and 2nd group patients underwent ORIF, the 3rd group was subjected to external fixation, and the 4th group underwent radial corrective osteotomy with plating. We obtained 53% good, 40% satisfactory and 7% poor results according to the Mattis score. We consider such analytical approach to distal forearm fracture treatment very promising and well-founded.     

Recent progress in orthopaedic managements of osteoporosis-related fractures

Recent progress in orthopaedic treatment of osteoporosis-related fractures was reviewed. In the treatment of femoral neck fractures, impacted or nondisplaced type is treated by three cannulated cancellous pins. Displaced type of femoral neck fracture is treated by bipolar prosthesis. Results of femoral neck fractures are influenced by the complications of each patients. Osteoporotic spine fractures are commonly healed within 2 or 3 months. Spinal compression with paraparesis or paraplegia is unusual complication in burst type of spine fractures. Surgical decompression, bone grafting and stabilization with instrumentation can result in some correction of deformity and neurogenic recovery. Distal radius fractures are common fractures in the eldery. Recently advances includes external fixation and plate fixation for the comminuted fractures in the distal radius. Treatments of osteoporosis-related fractures are still difficult problems to be resolved.     

Factors affecting functional prognosis of patients with hip fracture

Having a hip fracture is considered one of the most fatal fractures for elderly people, resulting in impaired function, and increased morbidity and mortality. This challenges clinicians in identifying patients at risk of worse outcome, in order to optimise and intensify treatment in these patients. A variety of factors such as age, prefracture function and health status, fracture type, pain, anaemia, muscle strength, and the early mobility level have been shown to influence patient outcome. Thus, the outcome of patients with hip fracture is considered multi-factorial, and can therefore not be related to just one or two single factors. The current article reviews important factors affecting the functional prognosis, and clinicians are encouraged to include all factors potentially influencing the outcome of patients with hip fracture in their individualised treatment and rehabilitation plan. Especially, older age and having a low prefracture functional level are considered strong factors.     

Neuropathic ankle fractures

AbstractA 65-year-old diabetic female presented with a 3-week history of a left swollen foot after a minor inversion injury and was found to have a minimally displaced fibular fracture. Despite casting and strict instructions to remain non-weight bearing, the patient continued to bear weight and later developed a significantly more displaced fracture with a draining ulcer. This injury eventually required a tibiotalocalcaneal arthrodesis using a retrograde hindfoot nail. Neuropathy and neuropathic fractures can be devastating complications of diabetes and thus require early diagnosis and intervention because they may result in significant morbidity for the patient. Thorough assessment involving imaging, a complete history and physical examination, and tools such as a 129 Hz tuning fork and the 10 g Semmes-Weinstein monofilament are paramount to establishing an accurate initial diagnosis. These tactics aid in future follow-up of the patient's injury and can be employed in both the clinic and the emergency department. Although management remains controversial for neuropathic ankle fractures because both conservative and surgical treatment regimens have high complication rates, open reduction and internal fixation continues to be the treatment of choice once closed reduction has been attempted and fails. Education is essential because diabetic patients have compromised pain and pressure sensation, which can lead to injuries and subsequent complications of which they are simply unaware. Physicians must be diligent when evaluating the diabetic foot and be explicit when providing instructions to these patients because preventing these injuries and their complications is the best patient care available.     

Clinical pathway after hip fracture

Purpose: Hip fracture occurs frequently, resulting in considerable morbidity, mortality and utilization of healthcare resources. Technical advances in fracture fixation and surgical treatment have improved outcomes following hip fracture in the elderly. However, further improvement in outcomes of hip fracture patients may be possible with utilization of a clinical pathway designed to enhance outcomes in a standardized, cost-effective manner. This paper presents a clinical pathway for the treatment of hip fractures in the elderly with the above aims.

Method: The clinical pathway presented is based on personal experience and literature pertaining to the treatment of the elderly hip fracture patient. It outlines a suggested algorithmic approach to the patient that begins with the initial evaluation, progresses on through pre-operative and operative management, and ends with post-operative rehabilitation and treatment.

Results: The clinical pathway for the hip fracture patient in this paper is a working treatment algorithm that has been successful in personal experience.

Conclusion: This treatment algorithm has been utilized successfully in personal experience. Further input from healthcare professionals may prove to enhance outcomes in a cost-effective, standardized manner.     

Neuropathic ankle fractures

A 65-year-old diabetic female presented with a 3-week history of a left swollen foot after a minor inversion injury and was found to have a minimally displaced fibular fracture. Despite casting and strict instructions to remain non-weight bearing, the patient continued to bear weight and later developed a significantly more displaced fracture with a draining ulcer. This injury eventually required a tibiotalocalcaneal arthrodesis using a retrograde hindfoot nail. Neuropathy and neuropathic fractures can be devastating complications of diabetes and thus require early diagnosis and intervention because they may result in significant morbidity for the patient. Thorough assessment involving imaging, a complete history and physical examination, and tools such as a 129 Hz tuning fork and the 10 g Semmes-Weinstein monofilament are paramount to establishing an accurate initial diagnosis. These tactics aid in future follow-up of the patient's injury and can be employed in both the clinic and the emergency department. Although management remains controversial for neuropathic ankle fractures because both conservative and surgical treatment regimens have high complication rates, open reduction and internal fixation continues to be the treatment of choice once closed reduction has been attempted and fails. Education is essential because diabetic patients have compromised pain and pressure sensation, which can lead to injuries and subsequent complications of which they are simply unaware. Physicians must be diligent when evaluating the diabetic foot and be explicit when providing instructions to these patients because preventing these injuries and their complications is the best patient care available.     

微创克氏针置入并外固定架修复桡骨远端不稳定骨骺骨折

背景:单纯使用克氏针或外固定架治疗桡骨远端骨骺骨折的临床实践中,仍存在桡骨短缩、骨折移位等固定后并发症,尤其在不稳定骨骺骨折情况下.克氏针主要治疗桡骨远端骨折,对其骨骺骨折使用相对较少.目的:观察外固定支架结合经皮克氏针复位固定微创治疗桡骨远端不稳定性骨骺骨折的临床效果.方法:对90例桡骨远端骨骺骨折患儿行固定治疗,在不切开情况下微创闭合复位骨折骨骺,随机分成2组,对照组采用单纯跨腕关节外固定支架固定方案;观察组采用跨腕关节外固定支架结合经皮克氏针闭合帮助复位固定骨骺骨折方案.固定后行腕关节功能锻炼,分别于固定后9周及24个月随访观察.对比两组患者固定后中远期的临床疗效、腕关节功能恢复及X射线检查情况.结果与结论:固定后24个月随访按Cooney标准评定腕关节功能,对照组优良率77%,X射线评定优良率63%;观察组腕关节功能优良率93%,X射线评定优良率为90%,两组差异具有显著性意义(P < 0.01).两组骨骺骨折患者均获临床骨愈合,腕关节均功能恢复.提示外固定支架结合克氏针闭合复位微创治疗桡骨远端不稳定骨骺骨折,可应用克氏针辅助复位掌倾角及尺偏角,治疗简单,固定可靠,腕关节功能恢复良好,骨骺畸形愈合并发症少,固定后基本生活学习功能恢复正常,疗效稳定满意,其临床疗效明显优于单纯跨外固定支架固定.     

Arthroskopisch assistierte Frakturversorgung am distalen Radiusende

After establishment of wrist arthroscopy the positive experiences gained for arthroscopically assisted treatment of fractures especially around the knee joint were transferred to the stabilization of distal intra-articular radius fractures. Simultaneous osteosynthesis by the use of external fixators and K-wires (ARPEF) was pushed into the background due to the rapid development of osteosynthesis techniques, especially of stable angle plating systems. Arthroscopic experience in acute wrist trauma helps to focus on early diagnosis of concomitant carpal injuries, because lesions of intercarpal ligaments and the triangular fibrocartilage complex (TFCC) highly influence the final functional outcome even in cases of exact anatomic reduction of the radius fracture. Most of the concomitant injuries can be treated very early by minimally invasive techniques, so it is advisable to carefully look for corresponding signs. Therefore, wrist arthroscopy represents an important tool for early diagnosis in acute trauma and possibly minimally invasive treatment of carpal injuries and markedly contributes to an improvement of final functional results of distal intra-articular radius fractures.     

Distal radius fractures in the athlete

Purpose of Review

Distal radius fractures are one of the most common upper extremity fractures. Athletes with distal radius fractures are treated according to the same principles as non-athletes but present several unique considerations. At all levels of sport, injured athletes desire to return to play as rapidly as possible.

Recent Findings

Earlier operative fixation may allow an athlete to return to play more quickly. Volar locking plates are most commonly used for operative treatment of distal radius fractures due to their stability and low incidence of complications.

Summary

Although the majority of distal radius fractures in athletes are treated non-operatively, operative intervention is offered when required to restore and maintain acceptable skeletal alignment. Return to sport is individualized guided by fracture stability, athlete age, and wrist-specific demands for competition.

     

Clinical pathway after hip fracture

Purpose: Hip fracture occurs frequently, resulting in considerable morbidity, mortality and utilization of healthcare resources. Technical advances in fracture fixation and surgical treatment have improved outcomes following hip fracture in the elderly. However, further improvement in outcomes of hip fracture patients may be possible with utilization of a clinical pathway designed to enhance outcomes in a standardized, cost-effective manner. This paper presents a clinical pathway for the treatment of hip fractures in the elderly with the above aims.

Method: The clinical pathway presented is based on personal experience and literature pertaining to the treatment of the elderly hip fracture patient. It outlines a suggested algorithmic approach to the patient that begins with the initial evaluation, progresses on through pre-operative and operative management, and ends with post-operative rehabilitation and treatment.

Results: The clinical pathway for the hip fracture patient in this paper is a working treatment algorithm that has been successful in personal experience.

Conclusion: This treatment algorithm has been utilized successfully in personal experience. Further input from healthcare professionals may prove to enhance outcomes in a cost-effective, standardized manner.     

Point-of-Care Ultrasound Fracture–Physis Distance Association with Salter–Harris II Fractures of the Distal Radius in Children: The “POCUS 1-cm Rule”

Salter–Harris II fractures of the distal radius can result in serious complications. The aim of this study was to measure the fracture–physis distance using point-of-care ultrasound (POCUS) to determine whether a certain distance is associated with Salter–Harris II fractures, compared with other fracture types, in a cohort of children with X-ray–identified distal radius fractures. Participants were from a parent diagnostic study conducted in an Australian tertiary pediatric emergency department, which prospectively evaluated the diagnosis of pediatric distal forearm fractures using POCUS compared against X-ray. Nurse practitioners, who underwent 2 h of training, administered a six-view POCUS protocol in clinically non-angulated pediatric forearm injuries prior to X-ray. This was a secondary analysis of data from the parent study. The 122 participants with X-ray–identified distal radius fractures from the parent study had their POCUS images interpreted by two emergency physician sonologists, who measured the fracture–physis distance. The median and maximum fracture–physis distances for Salter–Harris II fractures (n = 19) were 8.00 and 9.85 mm, whereas minimum and median distances for incomplete fractures (n = 22) were 10.20 and 15.98 mm, and those for complete fractures (n = 9) were 10.85 and 12.85 mm. Buckle fracture (n = 72) distances ranged from 4.35 to 26.55 mm, with a median of 13.65 mm. In children diagnosed with a distal radius fracture on X-ray, a fracture–physis distance cutoff of 1 cm differentiated Salter–Harris II fractures from other cortical breach fracture types, but not buckle fractures. Although this exploratory study suggests the “POCUS 1-cm rule” could be used as a secondary sign to augment the diagnosis of Salter–Harris II distal radius fractures using POCUS, further research is required to validate this measurement prospectively.     

Common pediatric elbow fractures

Fractures of the elbow are a very common injury in children. The most common mechanism of injury is a fall on an outstretched upper extremity during play. Ranging in complexity from low-energy nondisplaced occult fractures to high-energy fractures with associated severe soft-tissue and neurovascular injuries, elbow fractures are a challenging problem for all pediatric healthcare providers. Because of the wide spectrum of fracture severity and associated bony and ligamentous injury, a very diverse spectrum of treatment modalities is necessary for optimal results. Management is based on fracture pattern, patient age and bone quality, extent of soft tissue damage, functional needs of the patient, and the presence of associated injuries. This article will give a brief overview of 4 common pediatric fractures, current treatment algorithms, and frequent complications associated with these injuries.