Computed tomographic scanning of cervical spine fractures: does it influence treatment?

OBJECTIVE: To determine whether the superior sensitivity of computed tomography (CT) results in changes in treatment plans for cervical spine fractures that have been diagnosed on plain films alone. DESIGN: Retrospective review of radiographic studies for cervical spine trauma. SETTING/PARTICIPANTS: An orthopaedic spine surgeon (SS), an orthopaedic traumatologist (OT), an orthopaedic spine fellow (SF), and an orthopaedic chief resident (CR) were independently presented thirty-nine cases of cervical spine trauma imaged with adequate plain radiographs and with CT. MAIN OUTCOME MEASURES: Agreement was measured by calculation of kappa coefficients. RESULTS: The detection rate of total fractures on plain radiographs alone ranged from 47 percent to 71 percent, and the diagnosis changed an average 53 percent of cases. Change in treatment plans ranged from 10 percent (SS) to 46 percent (CR) of cases. Of these changes, undertreatment occurred as follows: SS =3 percent, OT =8 percent, SF =36 percent, and CR = 46 percent. The mean kappa coefficient for intraobserver agreement of treatment plans was 0.69. The experienced observers demonstrated "excellent" agreement with an average kappa coefficient of 0.85, whereas the mean coefficient for inexperienced observers was 0.54 or "moderate" agreement. Complete diagnostic agreement occurred between the experienced observers after review of both the plain films and CT scans. The interobserver agreement of treatment plans for the experienced observers increased from 0.79 to 0.88. CONCLUSIONS: CT scanning afforded additional information for all observers. Experienced observers can reliably determine treatment plans for cervical spine trauma diagnosed on plain films alone, whereas inexperienced observers are less reliable. For the experienced observers, interobserver agreement on treatment plans increased after the addition of CT.     

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.     

Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction?

In a randomised prospective study, 20 patients with intra-articular fractures of the distal radius underwent arthroscopically- and fluoroscopically-assisted reduction and external fixation plus percutaneous pinning. Another group of 20 patients with the same fracture characteristics underwent fluoroscopically-assisted reduction alone and external fixation plus percutaneous pinning. The patients were evaluated clinically and radiologically at follow-up of 24 months. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and modified Mayo wrist score were used at 3, 9, 12 and 24 months postoperatively. In the arthroscopically- and fluoroscopically-assisted group, triangular fibrocartilage complex tears were found in 12 patients (60%), complete or incomplete scapholunate ligament tears in nine (45%), and lunotriquetral ligament tears in four (20%). They were treated either arthroscopically or by open operation. Patients who underwent arthroscopically- and fluoroscopically-assisted treatment had significantly better supination, extension and flexion at all time points than those who had fluoroscopically-assisted surgery. The mean DASH scores were similar for both groups at 24 months, whereas the difference in the mean modified Mayo wrist scores remained statistically significant. Although the groups are small, it is clear that the addition of arthroscopy to the fluoroscopically-assisted treatment of intra-articular distal radius fractures improves the outcome. Better treatment of associated intra-articular injuries might also have been a reason for the improved outcome.     

External fixation in comminuted,displaced intra-articular fractures of the distal radius: is it sufficient?

Introduction: External fixation has been extensively used to treat the intra-articular fractures of the distal radius and it has several distinct advantages over conventional POP cast and plate fixation. However, the limitation of external fixation to achieve articular congruity in the comminuted intra-articular fractures of the distal radius has been documented in the literature. This could be because external fixation alone does not expand crushed cancellous bone and cannot work without soft tissue hinges. This prospective study was conducted to look at the results of comminuted, displaced intra-articular fractures of the distal radius treated exclusively by external fixation. Materials and methods: A 2-year follow-up of 27 patients with comminuted, displaced intra-articular fractures of distal radius that were treated exclusively by external fixation is presented. The radiological results, functional results and complications were analyzed according to the scoring system given by Jakim et al. Results: Anatomical reduction could not be achieved in 12 patients (44%) and reduction was lost in two patients (7%). Excellent and good results were seen in 59.3%, fair results were seen in 22.2% and poor results were seen in 18.5% of the cases. Outcome scores of patients without articular step were significantly better as compared to the patients with articular step at healing. There was a positive correlation between the restoration of normal anatomy (radiological results) and the functional outcome (r=0.775). Overall nine patients (33%) had complications. Conclusion: We conclude that although the external fixation is reliable in maintaining the reduction in displaced comminuted intra-articular fractures, it is inadequate in restoring articular congruity in many cases. The complications of external fixation are frequent and may be potentially serious in nature.     

Closed reduction of distal radius fractures: does instability mean irreducibility?

Introduction

The belief that not all distal radius fractures can be initially anatomically reduced with conservative means is rising. The aim of this study was to examine whether adequate reduction with a closed reduction technique is possible and to assess the importance of each step.

Materials and methods

We prospectively enrolled 63 distal radius fractures (62 patients). A standardized reduction technique was implemented. Reduction was radiologically evaluated in hanging traction, after reduction, and in plaster. Subgroup analysis was performed for fracture-dependent and fracture-independent factors on their influence on reduction.

Results

The mean radiological values (radial inclination, dorsal tilt, ulnar variance) showed near anatomic reduction of all fractures in plaster. Fracture severity according to AO classification, initial displacement, number of instability criteria and patient age did not affect the reduction outcome.

Conclusions

All types of enrolled fractures were nearly anatomically reduced. This contradicts the opinion that some “severe” fractures are too unstable to be initially reduced by closed means.     

Redisplacement of paediatric distal radius fractures: what is the problem?

PurposeDistal radius fractures represent one of the most common fractures in children. Our purpose is to analyze risk factors for redisplacement in children with distal radius fractures treated by means of closed reduction and plaster cast immobilization.MethodsRetrospective study, including children under the age of 17 years, who underwent closed manipulation and cast immobilization for a distal third radius fracture, between 2012 and 2015. Preoperative radiographs were reviewed for initial translation, angulation and shortening, distance of the fracture from the physis, degree of fracture obliquity and the presence of an ulna fracture. Postoperative radiographs were analyzed for translation, angulation and shortening, as well as the quality of closed reduction. Cast index, gap index and three-point index, were measured on the postoperative radiographs. Redisplacement and re-intervention during follow-up were registered.ResultsA total of 26 patients were included in this study. Comparison between post-reduction and immediate post-cast removal radiographs did not show any statistically significant difference between translation or shortening. Coronal (p = 0.002) and sagittal (p = 0.002) angulation showed a statistically significant difference, but both median values remained below cut-off values for redisplacement. Redisplacement was observed in four patients. Only one patient underwent remanipulation. All four had full remodelling and proper radiological alignment at final follow-up. Quality of reduction was found to be a statistically significant risk factor for redisplacement (p = 0.013).ConclusionClosed reduction and cast immobilization under general anaesthesia yields good results in the treatment of distal forearm fractures in paediatric patients. Quality of reduction was the only risk factor that we found to be predictive of redisplacement.Level of Evidence:Level III – Retrospective comparative study     

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.     

Is primary total elbow arthroplasty safe for the treatment of open intra-articular distal humerus fractures?

ObjectivesTotal elbow arthroplasty (TEA) is a viable treatment for elderly patients with distal humerus fracture who frequently present with low-grade open fractures. This purpose of this study was to evaluate the results of a protocol of serial irrigations and debridements (I&Ds) followed by primary TEA for the treatment of open intra-articular distal humerus fractures.MethodsSeven patients (mean 74 years; range 56–86 years) with open (two Grade I and five Grade 2) distal humerus fractures (OTA 13C) who were treated between 2001 and 2007 with a standard staged protocol that included TEA were studied. Baseline Disabilities of the Arm, Shoulder and Hand (DASH) scores were obtained during the initial hospitalization, and the 6- and 12-month follow-up visits. Elbow range of motion (ROM) measurements were obtained at each follow-up visit.ResultsFollow-up averaged 43 (range 4–138) months. There were no wound complications and no deep infections. Complications included one case of heterotopic ossification with joint contracture, one olecranon fracture unrelated to the TEA, and two loose humeral stems. The average final ROM was from 21° (range 5–30°) to 113° flexion (range 90–130°). DASH scores averaged 25 at pre-injury baseline and 48 at the most recent follow-up visits.ConclusionsTEA has become a mainstream option for the treatment of distal humerus fractures which are on occasion open. There is hesitation in using arthroplasty in an open fracture setting due to a potential increased infection risk. The absence of any infectious complications and satisfactory functional outcomes observed in the current series indicates that TEA is a viable treatment modality for complex open fractures of the distal humerus.     

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.     

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.     

Surgical treatment of displaced intra-articular calcaneal fractures: is bone grafting necessary?

Background

The aim of this retrospective study was to determine the need for bone grafting in the surgical treatment of displaced intra-articular calcaneal fractures. We reviewed 390 cases of displaced intra-articular calcaneal fractures treated with plate osteosynthesis with or without autologous iliac bone grafting, and compared outcomes and complications related to fracture stabilization.

Materials and methods

Three hundred ninety patients with displaced intra-articular calcaneal fractures that were treated with plate osteosynthesis from December 2002 to December 2010 were reviewed. Two hundred two patients (group A) were treated by osteosynthesis with autologous bone grafting, and 188 patients (group B) were treated by osteosynthesis without bone grafting. One hundred eighty-one patients with an AO type 73-C1 fracture (Sanders type II), 182 patients with an AO type 73-C2 fracture (Sanders type III), and 27 patients with an AO type 73-C3 fracture (Sanders type IV) were included in this study. Bohler’s angle, the crucial angle of Gissane, and calcaneal height in the immediate postoperative period and at the 2-year follow-up were compared. Any change in the subtalar joint status was documented and analyzed. The final outcomes of all patients were evaluated by the AOFAS Ankle–Hindfoot Scale and compared in both groups.

Results

The mean full weight-bearing time in group A (with bone grafting) was significantly lower (median 6.2 months, range 2.8–9.2 months) than that in group B (without bone grafting; median 9.8 months, range 6.8–12.2 months). The immediate-postoperative Bohler’s angle and that at the 2-year follow-up were significantly higher in group A. The loss of Bohler’s angle after 2 years was significantly lower in group A (mean 3.5°; 95 % CI 0.8°–6.2°) than in group B (mean 6.2°; 95 % CI 1.0°–11.2°). The average change in the crucial angle and the average change in calcaneal height were not statistically significant for either group. The infection rate in the bone grafting group was higher, though statistically insignificantly so, than in the nongrafting group (8.3 vs. 6.3 %). No significant difference was found between the groups in terms of the rates of good reduction, postoperative osteoarthritis, and subtalar fusion. Regarding the efficacy outcomes, the mean AOFAS score was lower (mean 76.4 points; 95 % CI 65.8–82.9 points) in group A than in group B (mean, 81.6 points; 95 % CI, 72.3–88.8 points), but this difference was not significant (p > 0.05).

Conclusions

Bohler’s angle showed improved restoration and the patients returned to full weight-bearing earlier when bone grafting was used in the treatment of intra-articular calcaneal fracture. However, the functional outcomes and complication rates of both groups were similar.     

Continuous compartment pressure monitoring for tibia fractures: does it influence outcome?

BACKGROUND: Compartment syndrome is common in acute fractures of the tibia. Early diagnosis is important, as delayed treatment leads to significant complications. Continuous compartment pressure monitoring has been recommended to prevent late diagnosis of compartment syndrome associated with tibia fractures. In this study, we aim to examine the effect of continuous compartment pressure monitoring on outcome in acute tibia fractures. METHODS: We randomized 200 consecutive acute extra-articular tibia fractures into monitored and nonmonitored groups. The monitored group received continuous compartment pressure for 36 hours and the nonmonitored group received usual postoperative observations. In alert patients, the diagnosis of compartment syndrome was made clinically. In unconscious patients, a difference between compartment pressure and diastolic blood pressure (DeltaP) of less than 30 mm Hg was the criteria for fasciotomy. Patients were assessed for late sequelae of compartment syndrome (sensory loss, muscle weakness, contracture, and toe clawing) at 6 months. RESULTS: Eighty-nine percent of patients were followed up for a minimum of 6 months or to fracture union. There were five cases of compartment syndrome in the nonmonitored group and none in the monitored group. At 6 months, the complication rates and late sequelae in both groups were not significantly different. In the monitored group, there were 18 patients with DeltaP less than 30 mm Hg, none of whom developed compartment syndrome or late sequelae. In both groups, patients with high energy or open fractures had significantly more late sequelae. CONCLUSIONS: Continuous compartment pressure monitoring is not indicated in alert patients who are adequately observed.     

Why do we use arthroscopy for distal radius fractures?

The management of distal radius fractures needs to be adapted to the increasingly complex traumas in patients with greater functional requirements. The goal remains to restore normal anatomy in order to preserve function. A pre-operative assessment using x-rays and thin-slice CT scans with three-dimensional reconstructions enables the best possible understanding of the fracture prior to surgery and planning of the pre-operative strategy. Arthroscopy is a technique that allows visualisation of the bone fragments and their displacement, as well as their reduction. It is the only tool that allows diagnostic and prognostic assessment of the associated injuries. Arthroscopy is the gold standard for identifying and grading scapholunate injuries. It allows treatment of the lesions where necessary and a dynamic appreciation of the stability of the osteosynthesis. Recognition of articular fragmentation patterns and instability features can therefore aid treatment choice to prevent poor outcomes due to malunion and degenerative arthritis. We recommend arthroscopic-assisted internal fixation for articular fractures for any active patient, not only for young adults, displaced or a gap by more than 2 mm, potential scapholunate ligament injuries, and fractures of the ulnar styloid. A strong initial learning and a minimal experience are recommended to avoid the complications of this invaluable procedure.     

Can external fixation maintain reduction after distal radius fractures?

BACKGROUND: The purpose of this study was to assess the effectiveness of external fixation and percutaneous pinning in maintaining distal radius fracture reduction over a 6-month period and to identify factors that might predict loss of fracture reduction. METHODS: Seventy cases had complete radiographic evaluation before surgery; at surgery; and at 6-week, 3-month, and 6-month follow-up. Radiographic parameters measured included volar tilt, dorsal displacement, radial inclination, radial height, radial shift, and ulnar variance. RESULTS: Dorsal tilt averaged 17.5 degrees from neutral before surgery; this value was corrected to 0.9 degree at surgery, but then progressed to 4.2 degrees by the 6-month follow-up. At 6-month follow-up, 49% of cases had lost more than 5 degrees of initially reduced volar tilt. However, none of these patients went from an acceptable initial reduction to an unacceptable reduction at 6 months. Initial deformity, patient age, use of bone graft, and duration of external fixation were not predictors of loss of reduction. CONCLUSION: Loss of reduction of volar tilt was seen for a period of up to 6 months after fixation, despite the use of pinning to hold the reduction. No specific predictor of loss of reduction was noted, although there was a trend toward loss of reduction in younger patients.