Recovery of knee function in the isolated MCL and combined ACL–MCL deficient knee

Background

The MCL is the prime medial stabiliser of the knee and is a commonly injured structure which leads to valgus instability of the knee.

Objectives

We aim to analyse differences in recovery of knee motion and muscle function over one year follow up in the isolated MCL and combined ACL–MCL injured knee. We hypothesized that combined ACL–MCL injuries lead to greater knee motion and muscle function deficits at 1 year.

Methods

Isolated MCL (Group I) or combined ACL–MCL injuries (Group II) from 2006–2010 were included. Those with a previous MCL injury, injury to contralateral limb or presenting 2 weeks post-injury were excluded. At certain outpatient follow up intervals, we recorded pre-determined parameters of knee function. Follow-up was at weeks 2, 6, 12, 26, 52.

Results

The cohort included 82 patients (54 males:28 females) with a mean age of 32 (range 16–56). Group II showed a deficit in Total Range of Movement (TROM) and flexion at 6 month follow up (p < 0.05). Group II showed an extension deficit at week 2 (p < 0.05). The Peak Torque Deficit (PTD) and Average Power Deficit (APD) improved for quadriceps and hamstrings across all follow up intervals (p > 0.05).

Conclusion

There is a TROM and flexion deficit at 6 months in group II, resolving by 1 year. There was no difference in PTD or APD in either group.     

How is Forearm Compliance Affected by Various Circumferential Dressings?

Background

The forearm is the second most common location for extremity compartment syndrome. Compliance is a physical property that describes a material’s ability to expand with an increasing internal volume. The effect of circumferential dressings on extremity pressures has been investigated in various animal models and in some nonphysiologic mechanical models, but the importance of this effect has not been fully investigated in the human upper extremity. In addition, the physical property of compliance has not been reported in the analysis of compartment volume-pressure relationships.

Questions/purposes

We created a physiologic cadaver model for acute compartment syndrome in the human forearm to determine (1) how much volume is required to reach the pressure threshold of 50 mm Hg in forearms, undressed and dressed with various circumferential dressings, (2) differences in forearm compliances that result from dressings, and (3) whether univalving or bivalving of those dressings adequately reduces compartment pressures.

Methods

A sealed inflatable bladder was placed deep in the volar compartment of seven fresh-frozen cadaveric forearms and overlying fascia and skin were closed. Compartment pressures were measured as saline was infused in the bladder, and compliance was calculated from pressure versus volume curves. This was repeated for each specimen using five external wraps, splints, and casts. At a baseline of 50 mm Hg, each dressing then was univalved (and bivalved, when appropriate for the material) and the decrease in compartment pressure was measured. For each of the seven cadaver forearms, one test was performed without dressings and then for each of five dressing conditions.

Results

Forearms in fiberglass casts accommodated only a mean of 19 mL (SD, 11 mL; 95% CI, 9–28 mL) before reaching the 50 mm Hg pressure threshold, which was much less than in undressed forearms (mean, 77 mL; SD, 25 mL; 95% CI, 55–98 mL; p < 0.001). Mean compliances were as follows: ACE™ wrap (1.75 mL/mm Hg; SD, 0.41 mL/mm Hg), Webril™ (1.54 mL/mm Hg; SD, 0.56 mL/mm Hg), Kling^® (1.23 mL/mm Hg; SD, 0.52 mL/mm Hg), sugar tong splint (1.05 mL/mm Hg; SD, 0.52 mL/mm Hg), and fiberglass cast (0.38 mL/mm Hg; SD, 0.27 mL/mm Hg). Univalving of all circumferential wraps dropped the mean compartment pressure from the 50 mm Hg starting point: ACE™ (46%; SD, 14%), Webril™ (52%; SD, 20%), Kling^® (70%; SD, 18%), sugar tong splint (52%; SD, 19%), and fiberglass cast (58%; SD, 7%), with p less than 0.001 for all dressings.

Conclusions

We observed the compressive effect of various commonly used upper-extremity splints and wraps, finding the least amount of accommodation afforded by fiberglass casts. Univalve release resulted in reduction in forearm compartment pressures, even in fiberglass casts.

Clinical Relevance

A rigid circumferential dressing can have a dramatic effect on extremity compartment compliance. Contrary to common clinical teaching, univalving of forearm circumferential dressings effectively reduced compartment pressures, as shown in this physiologic model.     

Capitellum Fracture Fragment Excision: a Case Series

Background

Fractures of the capitellum are rare injuries, and few studies have reported the results of fragment excision.

Questions/Purposes

The purpose of this study was to determine range of motion and short-term clinical outcomes for patients treated with capitellum excision.

Methods

A retrospective review was performed to identify all patients with an isolated capitellum fracture who underwent excision as definitive treatment at our institutions. Mechanism of injury, associated elbow injuries, type of capitellum fracture, complications, and postoperative outcomes including final elbow range of motion (ROM), elbow instability, and Disabilities of the Arm, Shoulder and Hand (DASH) score were recorded.

Results

Four patients met the inclusion and exclusion criteria of this study. All patients were female with an average age of 69 years (range 42–85). Based on the Bryan and Morrey classification system, three (75%) fractures were classified as type I and one (25%) fracture as type III. The average clinical follow-up was 11 months. Final examination demonstrated a mean elbow range of motion from 14° (range 0–30) of extension to 143° (range 130–160) of flexion. All patients had full forearm rotation, and there was no clinical evidence of elbow instability. The average DASH score was 18.3 (12.5–24.2) at final follow-up.

Conclusion

Excision of the capitellum, much like excision of the radial head, results in acceptable short-term outcome scores and elbow range of motion in patients with fractures that are not amenable to open reduction and internal fixation.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-015-9452-x) contains supplementary material, which is available to authorized users.     

Biomechanical comparison of semi-rigid pediatric locking nail versus titanium elastic nails in a femur fracture model

Background

The treatment for length-unstable diaphyseal femur fractures among school-age children is commonly intramedullary elastic nails, with or without end caps. Another possible treatment is the semi-rigid pediatric locking nail (PLN). The purpose of this biomechanical study was to assess the stability of a length-unstable oblique midshaft fracture in a synthetic femur model stabilized with different combinations of intramedullary elastic nails and with a PLN.

Methods

Twenty-four femur models with an intramedullary canal diameter of 10.0 mm were used. Three groups with various combinations of titanium elastic nails (TEN) with end caps and one group with a PLN were tested. An oblique midshaft fracture was created, and the models underwent compression, rotation, flexion/extension, and a varus/valgus test, with 50 and 100 % of the forces generated during walking in corresponding planes.

Results

We present the results [median (range)] from 100 % loading during walking. In axial compression, the PLN was less shortened than the combination with two 4.0-mm TEN [by 4.4 (3.4–5.4) mm vs. 5.2 (4.8–6.6) mm, respectively; p = 0.030]. No difference was found in shortening between the PLN and the four 3.0-mm TEN [by 7.0 (3.3–8.4) mm; p = 0.065]. The two 3.0-mm TEN did not withstand the maximum shortening of 10.0 mm. In external rotation, the PLN rotated 12.0° (7.0–16.4°) while the TEN models displaced more than the maximum of 20.0°. No model withstood a maximal rotation of 20.0° internal rotation. In the four-point bending test, in the coronal and the sagittal plane, all combinations except the two 3.0-mm TEN in extension withstood the maximum angulation of 20.0°.

Conclusions

PLN provides the greatest stability in all planes compared to TEN models with end caps, even though the difference from the two 4.0-mm or four 3.0-mm TEN models was small.     

Acute compartment syndrome secondary to disruption of the perforating branch of the peroneal artery following an acute inversion injury to the ankle

INTRODUCTION

Although ankle sprain by inversion is common in daily practice, acute compartment syndrome following ankle inversion injury is unusual. Only a few cases of this uncommon entity have been reported.

PRESENTATION OF CASE

This report describes a case of acute compartment syndrome following severe inversion of an ankle injury secondary to disruption of the perforating branch of the peroneal artery 3 h after the trauma. Although emergent fasciotomy was performed, residual weakness of ankle dorsiflexion still presented six months after surgery.

DISCUSSION

To the best of our knowledge, this case is the third in literature on an acute compartment syndrome following severe inversion ankle injury secondary to disruption of the perforating branch of the peroneal artery.

CONCLUSION

This report underscores the importance of considering compartment syndrome when individual has an inversion ankle injury, even when no fracture exists.     

Ulnar variance as a predictor of persistent instability following Galeazzi fracture-dislocations

Background

We investigated the radiographic parameters that may predict distal radial ulnar joint (DRUJ) instability in surgically treated radial shaft fractures. In our clinical experience, there are no previously reported radiographic parameters that are universally predictive of DRUJ instability following radial shaft fracture.

Materials and methods

Fifty consecutive patients, ages 20–79 years, with unilateral radial shaft fractures and possible associated DRUJ injury were retrospectively identified over a 5-year period. Distance from radial carpal joint (RCJ) to fracture proportional to radial shaft length, ulnar variance, and ulnar styloid fractures were correlated with DRUJ instability after surgical treatment.

Results

Twenty patients had persistent DRUJ incongruence/instability following fracture fixation. As a proportion of radial length, the distance from the RCJ to the fracture line did not significantly differ between those with persistent DRUJ instability and those without (p = 0.34). The average initial ulnar variance was 5.5 mm (range 2–12 mm, SD = 3.2) in patients with DRUJ instability and 3.8 mm (range 0–11 mm, SD = 3.5) in patients without. Only 4/20 patients (20 %) with DRUJ instability had normal ulnar variance (−2 to +2 mm) versus 15/30 (50 %) patients without (p = 0.041).

Conclusion

In the setting of a radial shaft fracture, ulnar variance greater or less than 2 mm was associated with a greater likelihood of DRUJ incongruence/instability following fracture fixation.     

Segmental neck of femur fractures: A unique case report of an ipsilateral subcapital,greater trochanteric and intertrochanteric fracture and proposed management algorithm

INTRODUCTION

Neck of femur fractures are now increasingly common in an ageing population. The management is well known and has been described in great detail. Concomitant ipsilateral segmental fractures of the neck of femur (SFNOF) however are rare and their investigation and management is poorly described.

PRESENTATION OF CASE

We present the surgical management of a unique and complex case of an ipsilateral subcapital, greater trochanteric and intertrochanteric fracture sustained in an 87-year-old female following a low trauma injury. This fracture configuration has not been described in the literature to date, neither has our method of reconstruction for this fracture, namely hemiarthorplasty, trochanteric stabilising plate and cerclage wires.

DISCUSSION

15 cases from 1989 to 2011 managed by 8 different fixation devices and followed up for an average of 17 months (2–58 months). There was an initial mortality rate of 13% (n = 2). All associated with low energy trauma occurred in female (n = 8), and most with high energy trauma occurred in males (83%; n = 5). The diagnosis was delayed or missed in 20% of cases, and the most common pattern was a concomitant undisplaced subcapital and intertrochanteric fracture (37.5%, n = 6). The overall risk of avascular necrosis was 20%, with a greater risk in patients greater than 65 years of age (33%).

CONCLUSION

Ipsilateral SFNOF are rare injuries with a bimodal distribution, and carry a greater risk of AVN. We advise that all SFNOF should have pre-operative CT planning and propose an algorithm to treat these patients with a standardised surgical approach.     

Is there an association between body temperature and serum lactate levels in hip fracture patients?

Introduction

Hyperlactataemia is associated with adverse outcomes in trauma cases. It is thought to be the result of anaerobic respiration during hypoperfusion. This produces much less energy than complete aerobic glycolysis. Low body temperature in the injured patient carries an equally poor prognosis. Significant amounts of energy are expended in maintaining euthermia. Consequently, there may be a link between lactate levels and dysthermia. Hyperlactataemia may be indicative of inefficient energy production and therefore insufficient energy to maintain euthermia. Alternatively, significant amounts of available oxygen may be sequestered in thermoregulation, resulting in anaerobic respiration and lactate production.Our study investigated whether there is an association between lactate levels and admission body temperature in hip fracture patients. Furthermore, it looked at whether there is a difference in the mean lactate levels between hip fracture patients with low (<36.5°C), normal (36.5–37.5°C) and high (>37.5°C) body temperature on admission, and for patients who have low body temperature, whether there is a progressive rise in serum lactate levels as body temperature falls.

Methods

The admission temperature and serum lactate of 1,162 patients presenting with hip fracture were recorded. Patients were divided into the euthermic (body temperature 36.5–37.5°C), the pyrexial (>37.5°C) and those with low body temperature (<36.5°C). Admission lactate and body temperature were compared.

Results

There was a significant difference in age between the three body temperature groups (p=0.007). The pyrexial cohort was younger than the low body temperature group (mean: 78 vs 82 years). Those with low body temperature had a higher mean lactate level than the euthermic (2.2mmol/l vs 2.0mmol/l, p=0.03). However, there was no progressive rise in serum lactate level as admission temperature fell.

Conclusions

The findings suggest that in hip fracture patients, the body attempts initially to maintain euthermia, incurring an oxygen debt. This would explain the difference in lactate level between the low body temperature and euthermic cohorts. The fact that there is no correlation with the degree of temperature depression and lactate levels indicates that the body does not fuel thermohomeostasis indefinitely with oxygen. Instead, in part, it abandons thermoregulatory mechanisms. Consequently, in this population, active rewarming may be indicated rather than depending on patients’ own thermogenic ability.     

Comparative study of fresh femoral neck fractures managed by multiple cancellous screws with and without fibular graft in young adults

Objectives

Aim of our study was to assess the role of addition of fibular strut graft to multiple cancellous screws in functional outcome, union and complications associated with those managed by only multiple cancellous screws in fresh femoral neck fractures.

Methods

A randomized control trial study was conducted on the patients of femoral neck fractures managed with multiple cancellous screws (group A) and multiple cancellous screws with fibular graft (group B). Patients aged between 20 and 50 years, having Gardens type III or IV fracture with duration of injury less than two weeks were included in the study.

Results

Eighty seven cases were analysed n = 45 were in group A and n = 42 in group B. Functional outcome (Harris hip score) was excellent in 30 patients in group A as compared to 12 in Group B which was statistically significant favouring group A. The time of full weight bearing, union and non union rates showed no statistical significance (p > 0.05). On statistical grounds none of the procedures proved to be better than other.

Conclusions

Fresh femoral neck fracture in young adults managed with multiple cancellous screws fixation with fibular graft has no added advantage over multiple cancellous screws fixation alone.     

Posterior Glenoid Wear in Total Shoulder Arthroplasty: Eccentric Anterior Reaming Is Superior to Posterior Augment

Background

Uncorrected glenoid retroversion during total shoulder arthroplasty may lead to an increased likelihood of glenoid prosthetic loosening. Augmented glenoid components seek to correct retroversion to address posterior glenoid bone loss, but few biomechanical studies have evaluated their performance.

Questions/purposes

We compared the use of augmented glenoid components with eccentric reaming with standard glenoid components in a posterior glenoid wear model. The primary outcome for biomechanical stability in this model was assessed by (1) implant edge displacement in superior and inferior edge loading at intervals up to 100,000 cycles, with secondary outcomes including (2) implant edge load during superior and inferior translation at intervals up to 100,000 cycles, and (3) incidence of glenoid fracture during implant preparation and after cyclic loading.

Methods

A 12°-posterior glenoid defect was created in 12 composite scapulae, and the specimens were divided in two equal groups. In the posterior augment group, glenoid version was corrected to 8° and an 8°-augmented polyethylene glenoid component was placed. In the eccentric reaming group, anterior glenoid reaming was performed to neutral version and a standard polyethylene glenoid component was placed. Specimens were cyclically loaded in the superoinferior direction to 100,000 cycles. Superior and inferior glenoid edge displacements were recorded.

Results

Surviving specimens in the posterior augment group showed greater displacement than the eccentric reaming group of superior (1.01 ± 0.02 [95% CI, 0.89–1.13] versus 0.83 ± 0.10 [95% CI, 0.72–0.94 mm]; mean difference, 0.18 mm; p = 0.025) and inferior markers (1.36 ± 0.05 [95% CI, 1.24–1.48] versus 1.20 ± 0.09 [95% CI, 1.09–1.32 mm]; mean difference, 0.16 mm; p = 0.038) during superior edge loading and greater displacement of the superior marker during inferior edge loading (1.44 ± 0.06 [95% CI, 1.28–1.59] versus 1.16 ± 0.11 [95% CI, 1.02–1.30 mm]; mean difference, 0.28 mm; p = 0.009) at 100,000 cycles. No difference was seen with the inferior marker during inferior edge loading (0.93 ± 0.15 [95% CI, 0.56–1.29] versus 0.78 ± 0.06 [95% CI, 0.70–0.85 mm]; mean difference, 0.15 mm; p = 0.079). No differences in implant edge load were seen during superior and inferior loading. There were no instances of glenoid vault fracture in either group during implant preparation; however, a greater number of specimens in the eccentric reaming group were able to achieve the final 100,000 time without catastrophic fracture than those in the posterior augment group.

Conclusions

When addressing posterior glenoid wear in surrogate scapula models, use of angle-backed augmented glenoid components results in accelerated implant loosening compared with neutral-version glenoid after eccentric reaming, as shown by increased implant edge displacement at analogous times.

Clinical Relevance

Angle-backed components may introduce shear stress and potentially compromise stability. Additional in vitro and comparative long-term clinical followup studies are needed to further evaluate this component design.     

Failure in the application of fragility fracture prevention guidelines

Introduction

The cost of fragility fractures to the UK economy is predicted to reach £2.2 billion by 2025. We studied our hip fracture population to establish whether national guidelines on fragility fracture prevention were being followed, and whether high risk patients were identified and treated by local care services.

Methods

Data on a consecutive series of trauma hip fracture admissions were collected prospectively over 14 months. National Institute for Health and Care Excellence (NICE) and National Osteoporosis Guideline Group (NOGG) recommendations and FRAX^® risk calculations were applied to patients prior to their admission with a new hip fracture.

Results

Overall, 94 patients were assessed against national guidelines. The mean population age was 77 years. Almost a quarter (22%) of patients had suffered a previous fragility fracture. The mean FRAX^® ten-year probability of hip fracture was 7%. According to guidelines, 45% of the study population required treatment, 35% fulfilled criteria for investigation and reassessment, and 20% needed no further management. In practice, 27% received treatment, 4% had undergone dual energy x-ray absorptiometry and were untreated, and 69% had not been investigated and were untreated. In patients meeting intervention thresholds, only 33% of those who required treatment were receiving treatment in practice.

Conclusions

In conjunction with NICE and NOGG recommendations, FRAX^® was able to identify 80% of our fracture population as intermediate or high risk on the day of fracture. Correct management was evident in a third of cases with a pattern of inferior guideline compliance seen in a London population. There remains a lack of clarity over the duty of care in fragility fracture prevention.     

Dorsal fracture-dislocations of the proximal interphalangeal joint: evaluation of closed reduction and percutaneous Kirschner wire pinning

Background

The purpose of this study is to evaluate the outcome of closed reduction and percutaneous Kirschner wire pinning in acute dorsal fracture-dislocations of the proximal interphalangeal (PIP) joint.

Methods

Eight men and one woman were treated with closed reduction and percutaneous Kirschner wire pinning by one orthopaedic surgeon. The ring finger was injured in six patients, the small finger in two patients and the middle finger in one patient. The mean joint surface involvement was 36 % (range, 26–49 %). The Kirschner wires were removed after an average of 28 days (range, 24–37 days).

Results

All patients demonstrated a painless, but fusiform, swollen PIP joint after a mean follow-up of 6.5 months. The average flexion of the PIP joint was 106° (range, 80–110), and the average extension of the PIP joint was 4° short of full extension (range, 10 hyperextension–15 flexion contracture). All patients had a concentrically reduced PIP joint with a healed fracture on radiographs. Two patients had radiographic evidence of degenerative changes, but were asymptomatic. One patient developed a superficial pin track infection, which quickly resolved with a short course of antibiotics, and avascular necrosis affecting one of the condyles of the proximal phalanx.

Conclusions

In agreement with previous studies, closed reduction and percutaneous Kirschner wire pinning in dorsal fracture-dislocations of the PIP joint is a minimally invasive and simple technique which appears to give satisfactory outcomes in the short to intermediate term.     

Effect of callus development on the deformation of external fixation frames

Purpose

We designed a sensor that measures the bending moments at the articulations and the torque of the rod of a Hoffmann II® external fixation. We considered the effect of the callus formation in the stabilisation of a “fracture-fixation system.”

Methods

Four Hoffmann II® frame configurations were mechanically tested. Two carbon fibre tubes represent the bone fragments (length 180 mm, outer diameter 25 mm, inner diameter 19 mm). The callus is represented by the interposition of springs of different rigidity (10–405 N/mm) in the fracture gap between the tubes.

Results

The deformation of the frame is in inverse proportion to the stiffness of the callus; the slope of the curve drops rapidly during early development of the callus, to reach a plateau after some 50 % of recovery of the normal mechanical characteristics of the bone. This simulation supports the theoretical approach, i.e. the external frame resists larger stresses at the start of the fracture healing. Over a callus stiffness of some 200 N/mm the pattern of the curves remains similar, regardless of the frame configuration.

Conclusion

An optimisation of the frame is possible, adapted to the actual mechanical situation of the callus. A monitoring system is deemed reliable after making sure that the elementary components behave the same way in the clinical condition as in the laboratory. In an experimental set up we confirmed its reliability in a clinical-like situation.     

Routine use of locking shaft screws is not necessary in volar plate fixation of distal radius fractures

Hypothesis

Volar locking plate fixation is a common treatment method for distal radius fractures. Recently, implants have been designed with an option to use locking screws in the shaft portion of the plate. While there is a high incidence of low bone mineral density in patients who sustain fragility fractures of the distal radius, the need for locking shaft screws is not well defined. Our hypothesis is that the routine use of locking screws in the shaft portion of volar plates is not required to maintain reduction or to prevent hardware failure.

Methods

A retrospective review was performed in all patients over age 50 years who underwent volar plate fixation using an implant with non-locking shaft screws for a distal radius fracture during a 2-year period. Patients were permitted to perform early range of motion exercises. Radiographs were examined and measurements were obtained to assess maintenance of reduction and incidence of hardware failure. Patients were followed at least until fracture healing. Patients were excluded from analysis if locking shaft screws were utilized or if follow-up was inadequate.

Results

Forty-one patients met the inclusion criteria. The average age was 62 years (range 50–79). There were 12 men and 29 women. The implant used incorporated 3.5-mm shaft screws in 26 patients and 2.4-mm shaft screws in 15 patients. All patients healed within acceptable radiographic parameters (mean volar tilt = 4.9°, mean radial inclination = 21.7°, mean radial height = 11.6 mm). There were not any instances of hardware failure.

Discussion

Distal radius fractures frequently occur in patients with low bone mineral density. Non-locking, bicortically placed shaft screws provide adequate stability to allow for early range of motion without loss of reduction or hardware failure. The routine use of locking screws in the shaft portion of volar plates does not appear justified.     

Reliability of the sit-up test in individuals with spinal cord injury

Objective

To determine the day-to-day reliability of blood pressure responses during a sit-up test in individuals with a traumatic spinal cord injury (SCI).

Design

Within-subject, repeated measures design.

Setting

Community outpatient assessments at a research laboratory at the University of British Columbia.

Participants

Five men and three women with traumatic SCI (age: 31 ± 6 years; C4-T11; American Spinal Injury Association Impairment Scale A-B; 1–17 years post-injury).

Outcome measure

Maximum change in systolic (ΔSBP) and diastolic (ΔDBP) blood pressure upon passively moving from a supine to seated position.

Results

The average values for ΔSBP were –11 ± 13 mmHg (range –38 to 3 mmHg) for visit 1, and −12 ± 8 mmHg (range −26 to −1 mmHg) for visit 2. The average values for ΔDBP were −9 ± 8 mmHg (range -21 to 0 mmHg) for visit 1, and –13 ± 8 mmHg (range –29 to –3 mmHg) for visit 2. The ΔSBP demonstrated substantial reliability with an intraclass correlation coefficient of 0.79 (P = 0.006; 95% CI 0.250–0.953), while the ΔDBP demonstrated almost perfect reliability with an intraclass correlation coefficient of 0.92 (P < 0.001; 95% CI 0.645–0.983). The smallest detectable differences in ΔSBP and ΔDBP were 7 mmHg and 6 mmHg, respectively.

Conclusion

Blood pressure responses to the sit-up test are reliable in individuals with SCI, which supports its implementation as a practical bedside assessment for orthostatic hypotension in this at risk population.     

Is nonoperative treatment of pediatric type I open fractures safe and effective?

Purpose

There is limited literature on nonoperative treatment of open type I pediatric fractures. Our purpose was to evaluate the rate of infection in pediatric patients with type I open fractures treated nonoperatively at our institution without admission from the emergency department (ED).

Methods

We performed a retrospective chart review of all patients who sustained a type I open fracture of the forearm or tibia from 2000 through 2013. Forty patients fit the inclusion criteria: <18 years old with type I open fracture treated nonoperatively with irrigation and debridement, followed by closed reduction and casting of the fracture under conscious sedation in the ED. All patients were discharged home. The primary outcome was presence of infection. Secondary outcomes included occurrence of a delayed union, time to union, complications, and residual angulation.

Results

There were no reported or documented infections. There was one case of a retained foreign body (<1 cm) in a mid-diaphyseal forearm fracture, which was removed in clinic at 4 weeks after the patient developed a granuloma with no infectious sequela. There was one case of a delayed union; all patients eventually had complete bony union. There was minimal residual angulation in both upper and lower extremities at last follow-up.

Conclusions

Nonoperative treatment of type I open fractures in pediatric patients can be performed safely with little risk of infection. This preliminary evidence may serve as a foundation for future prospective studies.     

Morphological characteristics of Schatzker type IV tibial plateau fractures: a computer tomography based study

Purpose

The objective of this study was to evaluate the morphological characteristics of Schatzker type IV tibial plateau fractures.

Methods

A retrospective analysis of radiographic and computed tomographic data of tibial plateau Schatzker type IV fractures from January 2010 to December 2011 was conducted in a level 1 trauma centre. The medial fracture angle (MFA), surface area percentage (SAP), and medial fracture height (MFH) were measured on CT images using the Picture Archiving and Communication System.

Results

Based on the location of fracture and the MFA, 75 cases of Schatzker type IV fracture were divided into three subtypes: anteromedial fracture (seven cases, 9.3 %), total medial plateau fracture (36 cases, 48 %), and posteromedial fracture (32 cases, 42.7 %). The anteromedial fracture was located on the anterior part of the medial plateau, the average MFA was positive 47.5°, the SAP was 38.3 % and the MFH was 41.6 mm. The total medial plateau fracture usually involved the entire medial plateau, the mean value of MFA was 81.2°, the SAP was 53.9 % and the MFH was 64.0 mm. The posteromedial fracture was located on the posterior part of the medial plateau, the MFA was negative 42.5°, the SAP was 32.4 % and the MFH was 44.8 mm.

Conclusion

The direction and location of Schatzker type IV fractures are highly variable. Proper operative approach and fixation method should be selected based on the morphological characteristics of individual medial plateau fractures.     

Evaluation of functional outcome and complications of locking calcaneum plate for fracture calcaneum

Background

Open reduction and internal fixation (ORIF) is the treatment of choice for displaced intra-articular calcaneal fracture at many orthopaedic trauma centres. In this prospective study, we evaluated the functional outcome and complications of locking compressive calcaneum plate for displaced intra-articular fracture calcaneum.

Methods

Between October 2011 and March 2012, 30 patients with displaced intra-articular fracture calcaneum attending the outdoor and emergency of our institute were included in the study. All the included patients were operated using standard lateral approach and followed up to 1 year.

Results

Of 30 patients, 14 (48%) patients were Sander''s type II, 10 (33%) were type III, and 6 (20%) were type IV. All the patients were evaluated post-operatively. Articular surface of posterior facet of calcaneum and crucial angle of Gissane was maintained in all patients. Four patients had post-operative Boehler''s angle <20° and 26 patients had between 21° and 40°. All the patients having post-operative Boehler''s angle <20° were type IV as compared to types II and III (statistically significant). Ninety-six percentage of patients having post-operative Boehler''s angle 21–40° were more satisfied at 1 year as compared to 25% of patients having post-operative Boehler''s angle <20° (statistically significant). Complications were present in 6 (20%) patients.

Conclusion

ORIF with locking compressive plate in displaced intra-articular fracture calcaneum gives good outcome. Results are more favourable in less comminuted as compared to more comminuted. Maintenance of Boehler''s angle is also necessary for satisfactory results along with maintenance of articular congruence of posterior facet of calcaneum and crucial angle of Gissane.     

Tibial fractures in children: A retrospective 27-year follow-up study

Background

Tibial fracture is the third most common long-bone fracture in children. Traditionally, most tibial fractures in children have been treated non-operatively, but there are no long-term results.

Methods

94 children (64 boys) were treated for a tibial fracture in Aurora City Hospital during the period 1980–89 but 20 could not be included in the study. 58 of the remaining 74 patients returned a written questionnaire and 45 attended a follow-up examination at mean 27 (23–32) years after the fracture.

Results

89 children had been treated by manipulation under anesthesia and cast-immobilization, 4 by skeletal traction, and 1 with pin fixation. 41 fractures had been re-manipulated. The mean length of hospital stay was 5 (1–26) days. Primary complications were recorded in 5 children. The childrens’ memories of treatment were positive in two-thirds of cases. The mean subjective VAS score (range 0–10) for function appearance was 9. Leg-length discrepancy (5–10 mm) was found clinically in 10 of 45 subjects and rotational deformities exceeding 20° in 4. None of the subjects walked with a limp. None had axial malalignment exceeding 10°. Osteoarthritis of the hip and/or knee was seen in radiographs from 2 subjects.

Interpretation

The long-term outcome of tibial fractures in children treated non-operatively is generally good.Tibial fractures are among the most common long-bone fractures in children (Shannak 1988, Landin 1997, Mäyränpää et al. 2010). Primary complications such as vascular or nerve injuries or compartment syndrome are rare. Secondary complications include malunion and premature physeal closure in fractures extending to physis.Operative treatment has recently gained popularity, although most uncomplicated tibial fractures can be safely treated with closed reduction and cast-immobilization (Setter and Palomino 2006, Heinrich and Mooney 2010). There have been very few reports on the long-term results of tibial fracture treatment in children.Here we present long-term outcomes in children (< 15 years of age) who were treated for a tibial fracture in Aurora City Hospital, Helsinki during the period 1980–89. Aurora City Hospital was the primary treatment center for fractures in children in Helsinki during the study period.     

The utility of radiographs prior to pin removal after operative treatment of supracondylar humerus fractures in children

Purpose

To determine the safety, utility, and efficacy of pin removal prior to radiographs during the postoperative care of surgically treated displaced pediatric supracondylar humerus fractures.

Methods

Retrospective review of 532 children with supracondylar humerus fractures treated with closed reduction and pinning from 2007 to 2012. Group 1: children who had their splint/cast removed and radiographs prior to pin removal. Group 2: children with radiographs taken after removal. Data recorded and analyzed included: demographic and radiographic data at the time of surgery and at final follow-up, including the number of radiographs taken prior to pin removal and if pins were ever retained after radiographs were performed on the date of intended removal.

Results

There was no difference between the groups’ demographics. The number of postoperative radiographs taken prior to pin removal ranged from zero to two. No statistically significant change in Baumann’s (p = 0.79) or lateral humeral capitellar angles (p = 0.19) was noted between the groups. No children in group 1 (0/438) had their pins retained after radiographs were taken on the date of intended removal.

Conclusion

Obtaining postoperative radiographs prior to pin removal, although commonplace, is not necessary. If fracture stability is noted intraoperatively, and there is an uneventful postoperative course, it is safe and effective to discontinue immobilization and remove pins prior to X-ray. This is safely done without change in alignment or clinical sequelae. Doing so can aid in clinic flow, may decrease child anxiety, and limit multiple cast room visits.

Level of evidence

Level III therapeutic study.