Open reduction and internal fixation of un-united fractures of the distal radius: does the size of the distal fragment affect the result?

Two cohort populations consisting of 13 patients with an un-united fracture of the distal radius in whom the distal fragment had more than 5 mm of subchondral bone supporting the articular surface distal to the site of the nonunion and ten patients with an un-united fracture of the distal radius with a smaller distal fragment were compared. There were no preoperative differences with respect to age, gender, interval between injury and index procedure, preoperative amount of radius tilt, ulnar inclination and ulnar variance, or the preoperative function. Independent of the size of the distal fragment in all patients the distal radius was restored to gain bony union and realignment with preservation of some wrist motion. The length of the follow-up period averaged 30 months for the small fragment group compared with 22 months for the large fragment group. Bony union was achieved in 22 patients. One patient out of the large fragment group failed to heal the fracture and had wrist fusion. At the follow-up examination there were no significant differences in the radiological and clinical outcome between the two groups. No differences were seen on total range of motion of forearm supination and pronation with an average of 135 degrees in the large fragment group and 145 degrees in the small fragment group. Wrist motion revealed no significant differences in the flexion-extension arc, averaging 90 degrees in the large fragment group and 83 degrees in the small fragment group. Total range of motion of radial and ulnar deviation of the wrist was similar, averaging 39 degrees in the large fragment group and 43 degrees in the small fragment group. Grip strength averaged 59% compared with the opposite limb for the large fragment group and 67% for the small fragment group. We believe that the results of reconstruction of un-united fractures of the distal end of the radius for patients in whom the distal fragment had less than 5 mm of subchondral bone supporting the articular surface distal to the site of the nonunion are comparable to the results for patients with a larger distal fragment. Therefore, we believe that surgeons should try to preserve even a small amount of wrist motion and reserve wrist fusion as a final resort.     

New classification of the distal attachment of the fibularis brevis — Anatomical variations and potential clinical implications

BackgroundAlthough the lateral compartment of the leg is characterized by a high degree of morphological variation, very little information exists on the morphological variability of the fibularis brevis muscle (FBM) and fibularis digiti quinti (FDQ). The main aim of the study was to characterize the morphology of the FBM tendon and its accessory bands, to classify them and to determine the incidence of FDQ. The work attempts to determine the relationship between the types of the insertion of the FBM tendon and the occurrence of FDQ.MethodsClassical anatomical dissection was performed on 102 lower limbs fixed in 10% formalin solution. The morphology of the insertion of the FBM and of the FDQ was evaluated.ResultsThe FBM was present in all specimens. Two types of insertion were observed, the most common being Type I (70.6%): a single distal attachment in which the tendon inserts into the tuberosity at the base of the fifth metatarsal bone. The second most common was Type II (29.4%); this group was divided into three subtypes (A–C). The FDQ was present in 17.7% of specimens and always with Type I FBM.ConclusionBoth the FBM tendon and FDQ present significant morphological variation. Two main types of the FBM tendon determine the presence of the FDQ.Level of evidenceII Basic Science Research.     

Computed tomography’s influence on the classifications and treatment of the distal radius fractures

Introduction

Distal radius fractures are common in emergency centers. The radiographic routine includes at least two radiographic projections used for diagnosing most of these fractures. Computed tomography (CT) is indicated for evaluating complex fractures that affect the articular surface, as well as the fragments’ size and position. There are not enough comparative studies on choosing classification and treatment by means of the four radiographic projections and computed tomography (CT) and the association of these with the levels of expertise.

Methods

We conducted a randomized cross-sectional study by observing images from 61 patients with distal radius fractures organized in two phases: the first phase comprising radiographic images alone and the second one with those same images associated with tomograms. Seventeen evaluators with different levels of training and expertise classified the fractures according to the AO and Universal classification systems and proposed treatment guidelines.

Results

The agreement between the AO and Universal classification ratings was poor (worse for the former), with smaller Fleiss’ kappa resulting from data obtained by orthopedics residents and non-specialist orthopedists. CT influenced the classification choice, with a higher change frequency for more complex patterns in the AO classification system and intra-articular and irreducible fractures in the Universal classification system, especially in the group comprised of orthopedic residents and orthopedic physicians. CT did not influence the treatment choice made by the group comprised of hand surgery residents and hand surgeons.

Conclusion

The less experienced in hand surgery the observer was, the more important computed tomography was for determining the fracture pattern.     

A revolution in the management of fractures of the distal radius?

The recent development of locking-plate technology has led to a potential revolution in the management of fractures of the distal radius. This review examines the evidence for pursuing anatomical restoration of the distal radius and the possible advantages and pitfalls of using volar locking plates to achieve this goal. The available evidence for adopting volar locking plates is presented and a number of important and, as yet unanswered, questions are highlighted.     

Post-traumatic osteolysis of the distal clavicle, pubis and ischium in 7 patients

Post-traumatic osteolysis (PTOL) is a very rare disease occurring after acute trauma or repetitive micro-trauma, which is characterized by persistent pain in the injured site. In this study, we reported 7 patients, in whom osteolysis developed in the distal clavicle, pubis and ischium.     

Comparison of complications after laparoscopy-assisted distal gastrectomy and open distal gastrectomy for gastric cancer using the Clavien–Dindo classification

Background  

The complication rate after surgery for gastric cancer varies according to the particular definition of morbidity. Complications after gastrectomy should be reported using a standardized method. The present study retrospectively analyzed patient outcomes after open distal gastrectomy (ODG) and laparoscopy-assisted distal gastrectomy (LADG) for gastric cancer using a standardized classification system of the severity of complications (the Clavien–Dindo system).     

Where is the distal fracture line location of dorsally displaced distal radius fractures?

No consensus currently exists on the facture location of dorsally displaced distal radius fractures (DRFs). We present a systematic evaluation of the distal fracture line (DFL) location of DRFs and possible influencing factors. Determining the average location of DRFs provides a basis for developing more sensitive tests to determine bone strength using a variety of imaging techniques and for developing improved biomechanical models to test fracture characteristics and surgical implants. Initial radiographs of 157 DRFs dorsally displaced DRFs in patients aged 40–74 years were identified, patient and trauma specific data were collected, and standard radiographic measurements and (AO) fracture classification were performed. The dorsal and palmar DFL locations relative to the corresponding apex of the lunate facet were measured. The DFL was located dorsally 7.9 ± 2.7 mm and palmarly 11.7 ± 3.9 mm proximal to the corresponding lunate fossa apex. The dorsal DFL was significantly distal to the palmar one (p < 0.001), but the two did not correlate (r² = 0.018, p = 0.095). DFL location was independent of age, energy of the fall, and fracture complexity. © 2010 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 29:489–494, 2011     

Osteosynthesis of distal radius fractures with the Micronail®

Introduction

The Micronail^® is a minimally invasive intramedullar titanium locking screw fixation for two-part dislocated extra-articular fractures and average displaced intra-articular fractures.

Patients and methods

In a retrospective study we analyzed the outcome of 20 distal radius fractures in 18 patients (17 female, mean age 78 years), which were treated by Micronail^®. Average follow-up time was 4 months. We describe the operative technique. All fractures were classified according to AO guidelines. We studied the radiologic and clinical outcome.

Results

According to the AO classification there were 12 A2, 3 A3, 1 B1, and 1 B3 fracture. Three patients had an antebrachii fracture. Mean American Society of Anesthesiologists (ASA) score was 2.4. Eight patients had associated lesions. Average operative time was 58 min. All fractures healed without major loss of alignment. There were two major complications: one patient developed a carpal tunnel syndrome and one device secondary dislocated. With the use of the Micronail^®, we found no infections or complications due to the insertion of the osteosynthesis materials. Patients experienced good to excellent results, on an analogue scale, in function of their wrist from the procedure. All patients had a good range of motion of the operated wrist; the difference between their two wrists was maximal 10° in all directions.

Conclusion

This intramedullary implant intends to minimize some of the disadvantages of other surgical options in the treatment of distal radius fracture; the Micronail^® causes less tissue damage and has early load-carrying capacity. This minimally invasive technique seems suitable in selected, two-part dislocated extra-articular and average displaced intra-articular, distal radius fractures.     

Low-energy distal radius fractures in middle-aged and elderly men and women—the burden of osteoporosis and fracture risk

Summary  

One third of 218 men and half of 1,576 women with low-energy distal radius fractures met the bone mineral density (BMD) criteria for osteoporosis treatment. A large proportion of patients with increased fracture risk did not have osteoporosis. Thus, all distal radius fracture patients ≥50 years should be referred to bone densitometry.     

SeSAME/EAST syndrome—phenotypic variability and delayed activity of the distal convoluted tubule

Background

Mutations in the K⁺ channel KCNJ10 (Kir4.1) cause an autosomal recessive syndrome featuring seizures, sensorineural deafness, ataxia, mental retardation, and electrolyte imbalance (SeSAME). Kir4.1 localizes to the basolateral membrane of the renal distal convoluted tubule, and its loss of function mimics renal features of Gitelman syndrome, with hypokalemic alkalosis, hypomagnesemia, and hypocalciuria. Presentation early in life due to seizures provides an opportunity to investigate the development of the electrolyte defect with age.

Methods

We used DNA sequencing, electrophysiology, confocal imaging, and biochemistry to identify a new KCNJ10 mutation in a previously unreported family and determine its impact on channel function. We examined medical records to follow the development of electrolyte disorders with age.

Results

The four affected members were all homozygous for a novel T57I mutation that confers biochemical loss-of-function. Electrolytes in affected children were normal in the first years of life but showed significant worsening with age, resulting in clinically significant defects at age 5–8 years. Similar findings were seen in other SeSAME patients.

Conclusions

These findings provide evidence for a delayed activity of salt reabsorption by the distal convoluted tubule and suggest an explanation for the delayed clinical presentation of subjects with Gitelman syndrome.     

Does socioeconomic status influence the epidemiology and outcome of distal radial fractures in adults?

Purpose

The aim of this study in adult patients with a distal radial fracture was to determine whether socioeconomic status influenced the epidemiology, mechanism of injury, fracture severity, or the outcome according to function, radiographic assessment, and rate of associated complications.

Methods

We identified 3983 distal radial fractures over a 7-year period. Socioeconomic status was assigned using the Carstairs score, and the population was divided into quintiles depending on deprivation. Patient demographics, mechanism of injury, fracture severity, and radiographic assessment at time of injury were assessed for epidemiological differences according to social quintile. Functional outcome was assessed using grip strength, Moberg pickup test, return to normal use of the hand, and range of movement. Radiographs were assessed at 1 week, 6 weeks, and 1 year. Complications were defined as malunion, carpal tunnel syndrome, complex regional pain syndrome (CRPS), persistent pain, and subjective cosmetic deformity of the wrist.

Results

Socioeconomically deprived patients were significantly younger (p < 0.001) and more likely to be male (p = 0.017); after adjusting for confounding factors, deprived patients were 3.1 (95% CI 1.4–4.7) years younger than the most affluent patients (p < 0.001). Deprived patients were more likely to sustain their fracture by a high-energy mechanism (p = 0.004). There were no significant differences between quintiles in outcome. There was a significantly greater prevalence of CRPS in more affluent patients (p = 0.004).

Conclusions

Socioeconomically deprived patients sustaining a distal radial fracture are more likely to be younger and male. Outcome is not influenced by socioeconomic status, but the prevalence of CRPS is greater in more affluent patients.

     

Clinical and radiological outcomes after stabilisation of complex intra-articular fractures of the distal radius with the volar 2.4 mm LCP

Aim  

The purpose of the present study is to evaluate the results of the treatment of intra-articular fractures with the volar 2.4 mm LCP with regard to loss of reduction, clinical outcome and complications.     

Treatment of the rupture of the distal tibiofibular syndesmosis with “Engelbrechts syndesmosis hook”

Summary After completing the osteosynthesis of the lateral malleolus, the hook is positioned 3–5 cm cranial of the syndesmosis and fixed to the tibia with a screw. It is expected to allow undisturbed ligament healing of the syndesmosis with early formation or fibres under limited motion. No immobilisation is necessary and no early removing of the implant. Results: Of 62 patients questioned, 53 were examined, after an average of 50 months (2–6 years p. o.). Using the Weber score, 51 had excellent or good results. Twelve patients reported discomfort while jumping, in five cases the ROM concerned dorsal extension, and in three cases plantar flection was reduced. Four patients showed distinct radiologic signs of osteoarthrosis, and two patients slight signs.      

Fractures of the distal humerus in the elderly: is internal fixation the treatment of choice?

The incidence of osteoporotic fractures of the distal humerus is increasing, and the treatment of these injuries merits closer review. We assessed the results of 28 elderly patients (29 fractures) with a mean age of 85 years (range, 75-100 years). Open reduction and internal fixation was done on 21 elbows, and eight elbows were treated nonoperatively. Orthopaedic Trauma Association grading showed that the group treated with internal fixation had favorable results (three excellent, nine good, seven fair, and two poor) compared with the nonoperatively treated group (zero excellent, two good, three fair, and three poor). Mean loss of extension and mean flexion were better in the surgically treated patients (23.5 degrees and 99 degrees ) than in the nonoperatively treated patients (33.5 degrees and 71 degrees ). Substantial pain relief (mild or no pain) was achieved in a higher proportion (52%) in the surgically treated group than in the nonoperatively treated group (25%). Anatomic restoration of distal humeral tilt and articular congruity also were better in the surgically treated patients. Rates of complications were observed to be comparable to those described in the literature for younger patients. These findings reflect the relevance of surgical fixation of such fractures in this age group highlighting the need for additional clinical studies.     

What are the radiological predictors of functional outcome following fractures of the distal radius?

The fracture most commonly treated by orthopaedic surgeons is that of the distal radius. However, as yet there is no consensus on what constitutes an 'acceptable' radiological position before or after treatment. This should be defined as the position that will predict good function in the majority of cases. In this paper we review the radiological indices that can be measured in fractures of the distal radius and try to identify potential predictors of functional outcome. In patients likely to have high functional demands, we recommend that the articular reconstruction be achieved with less than 2 mm of gap or step-off, the radius be restored to within 2 mm of its normal length, and that carpal alignment be restored. The ultimate aim of treatment is a pain-free, mobile wrist joint without functional limitation.     

Bridging and non‐bridging external fixation in the treatment of unstable fractures of the distal radius: A retrospective study of 588 patients

Background and purpose?Bridging external fixation is used more frequently than non‐bridging fixation in the management of unstable distal radius fractures, despite evidence from randomized controlled trials of better outcome with the latter technique. This study was designed to investigate the generalizability of the technique of non‐bridging external fixation, and to define the indications for the use of each technique and their complications.

Methods?641 patients with unstable displaced fractures of the distal radius were treated with bridging or non‐bridging external fixation. Non‐bridging external fixation was used where there was space for pins in the distal fragment. 52 patients were lost to follow‐up, leaving 588 patients available for study. Complete data from radiographic measurements after fracture healing were available for 546 patients. 59 % of fractures were treated with the non‐bridging technique.

Results?Fractures treated with bridging external fixation had a 6 times increased risk of dorsal malunion (p < 0.001) and a 2.5 times increased risk of radial shortening (p < 0.001) after adjusting for confounding factors (95% CI for odds ratio: 3–13 and 1.5–4, respectively) compared to non‐bridging techniques. Minor pin tract infections were more common in the non‐bridging group.

Interpretation?Non‐bridging external fixation of the distal radius is a generalizable technique, and reduces the risk of dorsal malunion compared with bridging external fixation. Major complication rates are low and the technique is applicable to most unstable fractures of the distal radius. We recommend that non‐bridging external fixation be used where there is space for the pins in the distal fragment.