Pylon fractures of the distal tibia

Forty-two patients with pylon fractures were categorized into Rüedi and Allg?wer Type I (26%), Type II (29%), and Type III (45%) subgroups and assessed. The mean follow-up period was 4.4 years (range, two to eight years). Type I fractures were usually torsion injuries, whereas Types II and III fractures were associated with violence (i.e., motor vehicle accident or fall from a height). Types I and II pylon fractures proved to be amenable to open reduction and restoration of anatomic position, stable internal fixation, early joint motion, and delayed weight bearing. Over 80% of these patients had satisfactory function. Nonanatomic reduction, unstable fixation, infection, nonunion, malunion, and secondary arthrosis were associated with disability from Type III pylon fracture treatment. Only 32% of Type III pylon fracture patients had satisfactory joint function.     

Odontoid fractures, with special reference to the elderly patient

A retrospective review of 262 consecutive cervical spine fractures revealed that 41 (16%) were odontoid fractures. Twenty patients were younger than 40 years of age (19 fractures were the result of a motor vehicle accident), whereas 19 fractures occurred in subjects older than 60 (13 were the result of a fall). Fractures were of the Anderson-D'Alonzo Types I (one patient), II (19 patients), and III (21 patients). Significant displacement was present in 31 patients. Anterior and posterior displacement occurred equally, but most of the anterior fractures were seen in patients younger than 40, and the majority of the posterior fractures occurred in those older than 60. Primary fusion was performed in 12 cases. Conservative management was used in 26. Three patients died (one from a spinal cord transection and two from other injuries). In the conservatively treated group, the average time to healing was 12 weeks, but the overall nonunion rate was nine out of 26 (7/13 Type II, 2/13 Type III fractures). The halothoracic jacket was poorly tolerated in patients older than 75 years of age. If daily supervision is not possible, early C1-2 fusion or treatment in an appropriate brace seems superior in the elderly patient.     

Reduction and operative fixation ofproximal tibial physeal fractures

Types I and II growth mechanism fractures of the proximal tibia generally may be reduced closed and maintained by nonoperative methods. However, operative stabilization of even these patterns may be necessary in more complex injuries such as a floating knee or multiple trauma.Types III and IV injuries of the proximal physis and injuries at the periphery of the epiphysis, particularly the tibial spines and tibial tuberosity, usually require open reduction and internal fixation. Techniques of closed and operative management of these various injury patterns are described.     

Intraoperative femoral fractures associated with cementless total hip arthroplasty

Between 1982 and 1986, 56 femoral fractures associated with cementless total hip arthroplasty (THA) were evaluated and compared to a randomly selected cementless THA control group without fractures. Depending upon the femoral shaft location, these fractures were classified as Types I, II or III. There were 45 (80%) Type I, 9 (16%) Type II, and 2 (4%) Type III fractures. Patient evaluations were quantified using a modified d'Aubigne-Harris scoring system. Nonparametric statistical methodology was used for fracture and control group comparisons. Treatment protocols were divided into various modalities, depending upon fracture classification. Type I and Type II fractures have no long-term prognostic hazards associated with them (P greater than 0.1), while Type III fractures appear to have analogous clinical results (sample size was too small for statistical analysis).     

Tibial intercondylar fractures in children: a review of the classification and the treatment of mal-union

Forced flexion with internal rotation of the knee in a child can result in an avulsion fracture of the tibial intercondylar area by the anterior cruciate ligament. Accurate radiological assessment of the size of the fragment is difficult. Conservative treatment with plaster immobilization in 30–50 ° of flexion is recommended for Type I fractures. Operative reduction is suggested for all Type III and some Type II fractures. Correction of mal-union can be achieved by excision of a wedge of tibial bone and reattachment of the origin of the anterior cruciate ligament.     

Analysis of six hundred and twenty-two intertrochanteric hip fractures.

Of 622 intertrochanteric fractures, 57% were stable (Types I and II). Twenty-eight per cent were Type III, and 15% were Type IV (the unstable types). The 150-degree telescoping Massie nail proved superior to the fixed 135-degree Jewett nail (particularly for unstable fractures) because it allowed a controlled impaction of the fracture fragments to a stable position. In about one-third of the fractures, some medial displacement occurred. With anatomical reduction and the use of the Massie or ASIF nails, we achieved a decrease in the morbidity and mortality and 96% satisfactory results. Our prospective study was compared with a retrospective study in which other devices were used. Early ambulation and weight-bearing also was a major contributing factor to the improved results in the prospective study. Intertrochanteric hip fractures that are unstable can be fixed with a collapsible nail, and that treatment appears to give as good or better results than the displacement method of Dimon and Hughston or Sarmiento.     

Arthroscopic fixation of avulsion fractures of the tibial eminence: technique and outcome

PurposeThe purpose of this study was to review an arthroscopic technique using screw or suture fixation for repair of types II and III fractures of the tibial eminence and review patient outcomes.Type of studyRetrospective review.MethodsWe conducted a review of 17 patients with Meyers and McKeever type II or III fractures of the tibial eminence treated with arthroscopic suture or screw fixation. We reviewed records and administered a questionnaire that included the International Knee Documentation Committee (IKDC) form, Tegner Activity scale, and Lysholm Knee Score.ResultsFive men and 12 women comprised the study group. Average age was 26.6 years (range, 7.5 to 60.1 years). Mean follow-up time was 32.6 months (range, 14 to 51 months). The study included 8 type II and 9 type III fractures. At follow-up evaluation, the mean Tegner score was 6.35 and mean Lysholm score was 94.2. In general, the best outcomes were seen in younger patients. For continuous age, significant differences were found for the IKDC functional scores, symptom scores, and IKDC final scores. For categorical age, younger patients had significantly better scores for the IKDC function and final scores. No significant differences were seen in outcomes with regard to fixation type. In 10 cases the intermeniscal ligament was interposed between the avulsed fracture and the tibia and was retracted or resected to allow fracture reduction. No significant differences were seen in the outcomes of these patients.ConclusionsWe found that displaced tibial eminence fractures could be successfully treated in both younger and older patients using arthroscopic suture or screw fixation, with most patients returning to their previous activity levels. The interposed intermeniscal ligament must be retracted or resected to allow for anatomic fracture reduction.Level of evidenceLevel III, Case Series.     

Posterior malleolar fracture morphology determines outcome in rotational type ankle fractures

IntroductionRotational type ankle fractures with a concomitant fracture of the posterior malleolus are associated with a poorer clinical outcome as compared to ankle fractures without. However, clinical implications of posterior malleolar (PM) fracture morphology and pattern have yet to be established. Many studies on this subject report on fragment size, rather than fracture morphology based on computed tomography (CT). The overall purpose of the current study was to elucidate the correlation of PM fracture morphology and functional outcome, assessed with CT imaging and not with –unreliable- plain radiographs.MethodsBetween January 2010 and May 2014, 194 patients with an operatively (ORIF) treated ankle fracture, were prospectively included in the randomized clinical EF3X-trial at our Level-I trauma center. The current study retrospectively included 73 patients with rotational type ankle fractures and concomitant fractures of the posterior malleolus. According to the CT-based Haraguchi fracture morphology, all patients were divided into three groups: 20 Type I (large posterolateral-oblique), 21 Type II (transverse medial-extension) and 32 Type III (small-shell fragment). At 12 weeks, 1 year and 2 years postoperatively the Foot and Ankle Outcome Scores (FAOS) and SF-36 scores were obtained, with the FAOS domain scores at two years postoperative as primary study outcome. Statistical analysis included a multivariate regression and secondary a mixed model analysis.ResultsHaraguchi Type II PM ankle fractures demonstrated significantly poorer outcome scores at two years follow-up compared to Haraguchi Types I and III. Mean FAOS domain scores at two years follow-up showed to be significantly worse in Haraguchi Type II as compared to Type III, respectively: Symptoms 48.2 versus 61.7 (p = 0.03), Pain 58.5 versus 84.4 (p < 0.01), Activities of Daily Living (ADL) 64.1 versus 90.5 (p < 0.01).ConclusionPosterior malleolar ankle fractures with medial extension of the fracture line (i.e. Haraguchi Type II) are associated with significantly poorer functional outcomes. The current dogma to fix PM fractures that involve at least 25–33% of the tibial plafond may be challenged, as posterior malleolar fracture pattern and morphology - rather than fragment size - seem to determine outcome.     

Phalangeal neck fractures in adults

The author investigated the pattern of injury and outcome of management in 11 adults with phalangeal neck fractures. The mean age was 40 years. The fracture occurred at the neck of the proximal phalanx of the thumb in seven cases and at the neck of the middle phalanx of the fingers in the remaining four cases. One patient had an undisplaced (Type I) fracture and was treated with splinting; the final result was graded as excellent. Nine patients had Type II fractures (the displaced distal fragment maintaining bone-to-bone contact with the proximal fragment) and all patients were treated with closed reduction and single K-wire fixation. The final outcome of Type II fractures was considered good in eight patients and fair in one patient. One patient had a Type III fracture (the displaced distal fragment was rotated 180 degrees with no bone-to-bone contact with the proximal fragment). The fracture required open reduction and K-wire fixation and the final result was poor.     

Unreamed locked tight-fitting nailing for acute tibial fractures

OBJECTIVES: Treatment of tibial fractures by unreamed locked nailing with loose-fitting nails has previously been shown to be associated with a low union rate and high implant failure rate. This report describes the authors' experience in using tight-fitting nails that were relatively larger than loose-fitting nails. DESIGN: Prospective cohort study. SETTING: University medical center. PATIENTS: Forty-eight consecutive patients with fifty-two tibial fractures (excluding open IIIC fractures and those with bone loss) were studied: thirty-four men and fourteen women, with a mean age of 38 years. There were twenty-five closed fractures, nine Type I, eight Type II, four Type IIIA, and six Type IIIB open fractures. INTERVENTION: Unreamed nailing with tight-fitting nails using the Russell-Taylor system. OUTCOME MEASURES: Union rate, time to union, complication rate, and functional recovery, as well as nailing time, hospital time, and crutch-walking time were recorded. RESULTS: Union occurred in forty-eight of fifty-two fractures (92%) with a mean time to union of 18.2 weeks. Compartment syndrome occurred in three patients. Deep infection occurred in one Type II and one Type IIIB open fracture. Four fractures required additional exchange nailing or bone grafting to achieve union: one Type II, one Type IIIA, and two Type IIIB open fractures. Three malalignments resulted from operative technical error. The rate of both intraoperative bony split and screw breakage was 3.8% (2 of 52), but neither complication interfered with fracture healing. Recovery of joint motion was essentially normal in those patients without knee or ankle injury. CONCLUSIONS: Unreamed locked nailing with tight-fitting nails can produce satisfactory clinical results for acute tibial fractures. It has the advantages of technical simplicity and an acceptable risk of implant failure.     

Open fractures of the tibia in children

Forty-one children who had forty-two open fractures of the tibial metaphysis or diaphysis were studied retrospectively. Twelve fractures were Type I; eighteen, Type II; six, Type IIIA; four, Type IIIB; and two, Type IIIC, according to the classification of Gustilo et al. All fractures were irrigated and debrided, and antibiotics were given for a minimum of forty-eight hours after the injury. Twenty fractures were initially treated with external fixation and twenty-two, with immobilization in a plaster cast. Three patients had an early infection of the wound, one of which was associated with osteomyelitis; all were successfully treated. The average time to healing of the fracture was five months (range, two to twenty-one months). The time to union was related to the severity of the soft-tissue injury, the pattern of the fracture, the amount of segmental bone loss, the occurrence of infection, and the use of external fixation. There were six delayed unions. Four patients had an angular malunion of more than 10 degrees, which spontaneously corrected in three. One patient who had a proximal metaphyseal-diaphyseal segmental fracture had a progressive valgus deformity. Four patients who had a severe fracture that was treated with external fixation had more than one centimeter of tibial over-growth. There were no amputations. The incidences of compartment syndrome, vascular injury, infection, and delayed union were similar to those reported for open tibial fractures in adults.     

Complications of fractures of the femoral neck

The results of a series of 82 medial femoral neck fractures are presented. Complications arose in 34% of 24 non-operated impacted fractures (17% redisplacement, 17% necrosis of the femoral head). 58 patients were treated with a sliding screw plate device (Zimmer). The Garden stage I and II fractures united uneventfully. Out of a total of 52 Garden stage III and IV fractures, 14 (27%) had to be reoperated with total hip arthroplasty, due to redisplacement or necrosis of the femoral head. All redisplacements occurred in cases of unsuccessful reduction, indicating that quality of reduction is the prime determinant with regard to redisplacement. As all Garden stage I and II fractures, and 73% of the Garden stage III and IV fractures united, the material points at the gliding screw plate device as a most recommendable treatment in femoral neck fractures.     

Radial head fractures with acute distal radioulnar dislocation. Essex-Lopresti revisited

Seven adults with displaced radial head fractures had concurrent dislocation of the distal radioulnar joint. Because support of the radius was lost at both the elbow and wrist, proximal migration of the radius from 5 to 10 mm occurred. Different types of fractures were classified to designate the best method of restoring radial length to prevent chronic wrist pain and stiffness. Type I fractures had large displaced radial head fragments with minimal or no comminution and amenable to interfragmentary fixation. Type II fractures had severe comminution requiring radial head excision and prosthetic replacement. Type III were old injuries with irreducible proximal migration of the radius managed by ulnar shortening and radial head prosthetic replacement. There were three Type I, two Type II, and two Type III fractures. Results of treatment were graded as 3, excellent; 2, good; 1, fair; and 1, poor. The three excellent results were in patients in which restoration of radial length was achieved within one week of injury. Suboptimal results occurred in the remaining four patients when definitive surgery was delayed four to ten weeks. The poor result was in a patient treated only by radial head excision and who refused further surgery. Recommendations include meticulous clinical and roentgenographic examination of the distal radioulnar joint in all patients with displaced radial head fractures. Preservation of the radial head with anatomic reduction and rigid internal fixation is preferred, but radial head replacement may be necessary in cases with extensive comminution. Radial head excision alone, though contraindicated, may be restructured by ulnar shortening and radial head prosthetic replacement.     

Treatment of unstable tibial shaft fractures by closed intramedullary nailing with flexible (Ender-type) pins.

Eighty patients with unstable tibial diaphyseal fractures were treated by closed intramedullary nailing with Ender-type flexible pins. The majority of injuries occurred from falling while snow skiing. Sixty-six fractures were closed and 14 were open. Fifty-eight fractures involved the distal, 21 fractures the middle, and one fracture the proximal one third of the tibial shaft. The average time to roentgenographic union was 15.5 weeks (range, ten to 34 weeks) for closed and open Grade I and II fractures. The time to union in Grade III fractures was 50 weeks (range, 36-64 weeks). There were two nonunions and two delayed unions. Both nonunions occurred in Grade IIIA open shaft fractures. Intramedullary stabilization with flexible, Ender-type pins provides good control of unstable tibial shaft fractures. The use of pins with a smaller diameter (3.5 or 4 mm) allows the surgeon to place more pins across the fracture site. The use of multiple pins and packing the intramedullary canal may provide better rotational stability. The use of Ender-type pins for fixation of Type IIIA open tibial shaft fractures is contraindicated.     

Treatment in fractures of the odontoid process

Fifty-eight cases of odontoid fractures treated at Keio University Hospital and affiliate hospitals from 1965 through 1985 were reviewed. Six patients under age 7 years (group A), were characterized as having epiphysiolysis. Among 52 patients over 8 years of age (group B), there were two Type I, 31 Type II and 19 Type III fractures. All cases in group A were treated conservatively by a plaster cast or a neck brace, and achieved bony union in 6 to 27 weeks. Five of 24 fractures in group B, treated conservatively, failed to unite. Nineteen cases of Type II and six cases of Type III were treated surgically. Transoral fusion was performed in six cases, internal fixation using a compression screw in ten, bone peg fixation in one, posterior fusion in eight, and posterior decompression in one. Two cases treated with transoral fusion and two with screw fixation failed to unite. We recommend conservative treatment of group A patients, Type I, and acute cases of Type III with minimal displacement in group B. Surgery should be performed in acute cases of Type II, Type III with significant displacement, and nonunion cases in Type II and Type III.     

Collagens synthesized by healing fractures

Several extracellular matrices are formed by healing fractures, and the collagens within these matrices have been identified in rabbit and rat fracture models. Type III collagen is the major collagen of the fibrous matrix that forms along the periosteal surface. Type I collagen is secreted in large amounts as trabeculae of bone develop within the fibrous tissue. Type V collagen is found in both the fibrous tissue and bone; it is particularly associated with blood vessels. Type II collagen is the last of the major collagens to be synthesized; its synthesis is dependent on the mechanical conditions under which the fractures are healing. A large area of cartilage, and hence of Type II collagen, is formed only if the fracture is mechanically unstable. Of the minor collagens, only Types IX and X have been identified to date. Type IX collagen is present throughout the large areas of cartilage, and Type X is present only in calcified regions. The matrices are compared with those produced during embryonic limb development. Although cartilage in the embryo provides a rapidly growing model of the future bone, in healing fractures cartilage is produced only where the cellular environment precludes the differentiation of osteoblasts. The effects of mechanical stability on the matrices support and illustrate this conclusion.     

钢板结合髓内钉治疗胫骨单髁伴同侧胫骨干中、远段骨折

 目的 探讨钢板结合髓内钉治疗同侧胫骨平台单髁伴胫骨干中、远段骨折的可行性和临床疗效。方法 2003年 5月至 2008年11月,钢板结合髓内钉固定治疗胫骨平台单髁伴同侧胫骨干骨折21例,男15 例,女6 例;年龄20～55岁,平均34岁。按Schatzer分类,Ⅰ型4例、Ⅱ型11例、Ⅲ型6例。胫骨干骨折按部位分型,胫骨干中段骨折13例、中下1∕3骨折8例。复位后,先钢板固定胫骨平台再髓内钉固定胫骨干19例,先髓内钉固定胫骨干再钢板固定胫骨平台2例。结果 所有病均例获得随访,随访时间0.9～4年,平均2.2年。所有患者均获骨性愈合,胫骨平台平均愈合时间为12周;胫骨干骨折平均愈合时间为29周,3例患者胫骨干骨折延迟愈合,拆除交锁钉使之动力化后愈合。1例胫骨平台未能解剖复位导致骨折畸形愈合。根据HSS膝关节评分标准[2],优17例(80.95%)、良3例(14.29%)、中1例(4.76%)。结论 注意一些技术要点,应用两种熟悉的手术技巧,钢板结合髓内钉能够成功治疗胫骨平台单髁伴同侧胫骨干骨折。     

Management of supracondylar humerus fractures in children: current concepts

Supracondylar humerus fractures are the most common elbow fractures in the pediatric population. Type I fractures are managed nonsurgically, but most displaced injuries (types II, III, and IV) require surgical intervention. Closed reduction and percutaneous pinning remains the mainstay of surgical management. Numerous studies have reported recent alterations in important aspects of managing these fractures. Currently, many surgeons wait until 12 to 18 hours after injury to perform surgery provided the child's neurovascular and soft-tissue statuses permit. Increasingly, type II fractures are managed surgically; cast management is reserved for fractures with extension displacement only. Two to three lateral pins are adequate for stabilizing most fractures. Evolving management concepts include those regarding pin placement, the problems of a pulseless hand, compartment syndrome, and posterolateral rotatory instability.     

Pilon fractures of the tibia: a study based on 19 cases

Twenty-seven pilon fractures of the tibia were identified from 733 adult tibial and ankle fractures admitted to the Coventry and Warwickshire Hospital in 5 years. Nineteen of the 27 were reviewed. The fractures were classified into types I, II and III according to the AO/ASIF system. Treatment was by splintage in plaster-of-Paris or open reduction and internal fixation, and an external fixator for one type III. Non-operative treatment produced good functional results in all type I fractures, poor results in type II and was not applicable to type III. Eight of 11 types II and III fractures, treated by internal fixation achieved good functional results. Hindfoot disability was assessed from subtalar movements. It is concluded that open reduction and internal fixation is indicated in types II and III pilon fractures. Subtalar motion is negligibly restricted in type I fractures, while in types II and III internal fixation is followed by recovery of hindfoot function.     

Infra-isthmal fractures of the femur: a review of 82 cases

Eighty-two infra-isthmal fractures of the femur were reviewed in order to develop a fracture classification, to determine the results of treatment, and to define the best treatment methods for certain specific fracture patterns. Type I (transverse or short oblique) fractures were seen in 36 patients (mean age, 33 years). They had a 25% complication rate when treated by open reduction, and a high malunion rate when treated by closed means. Type II (spiral or long oblique) fractures were generally caused by falls, and were seen in 36 patients (mean age, 56 years). Most patients treated by operation had an unsatisfactory result. Malunion was seen in 29% of the patients treated by closed means. The remaining ten patients had either severely comminuted (Type III), or pathological (Type IV) fractures. Intramedullary nail fixation should be used wherever possible in these fractures since many of the complications in the operative group were related to rigid plate fixation. Closed treatment resulted in an unacceptably high incidence of malunion in this study, particularly in Type I fractures. Conventional methods of internal fixation were not successful in dealing with Type II fracture, and alternative methods are proposed.