Distal metadiaphyseal tibial fractures

Extra-articular fractures of the distal tibial metaphysis, metadiaphyseal junction and adjacent diaphysis are distinct in their management from impaction derived “pilon”-type fractures and mid-diaphyseal fractures. The optimum management of these metadiaphyseal fractures is controversial, with advocates for intramedullary nail, plate and external fixation. The evolution of treatment options for these fractures has been closely linked to developments in implant technology and surgical technique. Further developments in this area, particularly with respect to minimally invasive plating techniques and nail design are ongoing. The literature suggests that both intramedullary nail fixation and minimally invasive plating are appropriate management options for these fractures, but further studies are required to determine the superiority of one technique over the other.     

Treatment of distal tibial metaphyseal fractures: Plating versus shortened intramedullary nailing

BACKGROUND: Fractures in the distal tibial metaphysis are more complicated to treat than diaphyseal fractures. We compared treatment with plating to treatment with shorted intramedullary (IM) nailing. METHODS: Patients with AO type 43A fractures were treated with plate fixation (group A, n=14) or shortened IM nailing (group B, n = 13). We compared postoperative radiographic deformities, functional results (Iowa ankle scores), and symptoms (Olerud and Molander ankle scores). RESULTS: All fractures had healed at final follow-up (mean, 33 month). Mean union times were 27.8 week (range, 18-36 week) in group A and 22.6 week (range, 18-30 week) in group B (P<0.05). Mean postoperative valgus angulations were larger in group B (3.7 degrees ) than in group A (0.5 degrees ) (P<0.05). However, malunions did not differ between groups (P<0.05). Functional results and postoperative symptoms were similar. CONCLUSIONS: Both plate fixation and shortened IM nailing were effective for treating distal tibial metaphyseal fractures.     

Management of distal tibial intra-articular fractures with circular external fixation

The treatment of tibial plafond fractures requires careful management of the soft tissue envelope, reconstruction of the articular surface and stable fixation with minimal additional damage. Thirty cases of AO type 43 C tibial fractures were treated by transosseous osteosynthesis (Ilizarov technique). The external fixator constructs used were Ilizarov (Transosseous osteosynthesis: theoretical and clinical aspects of the regeneration and growth of tissue, Springer, Berlin, 1992) and Sheffield (Classification AO des fractures, Springer, Berlin, 1987) circular fixator systems. All tibial plafond fractures healed. Using radiological criteria for assessment of reduction of the articular fragments and the clinical scoring system described by Teeny and Wiss, there were excellent and good restoration of articular structure in 27 cases and good clinical results in 14. This treatment method compares well with previous published series and is to be recommended for this group of difficult fractures.     

髓内钉与钢板内固定治疗胫骨远端关节外骨折的比较研究

目的通过对已发表文献进行汇总分析,根据现有数据资料总结髓内钉与钢板内固定治疗胫骨远端关节外骨折预后的比较。方法通过系统检索1975年1月～2011年5月发表的关于钢板或髓内钉治疗胫骨远端关节外骨折的英文文献。2位作者全文阅读并决定是否符合纳入标准或排除标准,收集相关结果和数据,通过循证医学分析方法,加权汇总分析两种治疗方案的功能预后和并发症。结果有22篇文献纳入研究,包括880例手术患者。髓内钉组的平均手术时间长于钢板组,但差异无统计学意义。髓内钉组的平均愈合时间显著短于钢板组。髓内钉组的感染率低于钢板组,但差异无统计学意义。髓内钉组的畸形愈合率显著高于钢板组。髓内钉组骨折的延迟愈合率和不愈合率与钢板组无统计学差异。髓内钉组的二次处理率(13.6%)高于钢板组(8.9%),但差异无统计学意义。结论根据此项研究结果,髓内钉内固定治疗胫骨远端关节外骨折可以更快愈合,使患者更早进行功能锻炼,但畸形愈合的概率高于钢板组,因此,具体的术式选择还应该根据患者的具体情况和医生的习惯决定。     

Functional outcome 5 years after non-operative treatment of type A spinal fractures

This study was conducted to study the functional outcome after non-operative treatment of type A thoracolumbar spinal fractures without neurological deficit. Functional outcome was determined following the International Classification of Functioning, Disability and Health, measuring restrictions in body function and structure, restrictions in activities, and restrictions in participation/quality of life. All patients were treated non-operatively for a type A thoracolumbar (Th11-L4) spinal fracture at the University Hospital Groningen, The Netherlands. Thirty-three of the eighty-one selected patients agreed to participate in the study (response-rate 41%). Respondents were older than non-respondents (mean 50.5 years vs. 39.2 years), but did not differ from each other concerning injury-related variables. Patients with a neurological deficit were excluded. Treatment consisted either of mobilisation without brace, or of bedrest followed by wearing a brace. Restrictions in body function and structure were measured by physical tests (dynamic lifting test and bicycle ergometry test); restrictions in activities were measured by means of questionnaires, the Roland Morris Disability Questionnaire (RMDQ) and Visual Analogue Scale Spine Score (VAS). Restrictions in participation/quality of life were assessed with the Short Form 36 (SF-36) and by means of return to work status. Thirty-seven per cent of the patients were not able to perform the dynamic lifting test within normal range. In the ergometry test, 40.9% of the patients performed below the lowest normal value, 36.4% of the patients achieved a high VO₂-max. Mean RMDQ-score was 5.2, the mean VAS-score was 79. No significant differences between patients and healthy subjects were found in SF-36 scores, neither were differences found between braced and unbraced patients in any of the outcome measures. Concerning the return to work status, 10% of the subjects had stopped working and received social security benefits, 24% had arranged changes in their work and 14% had changed their job. We conclude that patients do reasonably well 5 years after non-operative treatment of a thoracolumbar fracture, although outcome is diverse in the different categories and physical functioning seems restricted in a considerable number of patients.     

阻挡钉结合交锁髓内钉治疗胫骨远端骨折的生物力学研究

目的比较交锁髓内钉在治疗胫骨远端骨折时不使用阻挡钉、使用1枚阻挡钉、使用2枚阻挡钉3种条件下的生物力学稳定性。方法将8具国人新鲜尸体的双侧胫骨制成胫骨远端骨折模型,每具尸体的左右侧胫骨随机分成A、B2组。其中A组截骨平面位于踝关节平面上方7cm,用以模拟低位胫骨远端骨折,能使用2枚冠状面锁钉的骨折类型;B组截骨平面位于踝关节平面上方5cm,用以模拟极低位胫骨远端骨折,仅能使用1枚冠状面锁钉的骨折类型。A、B2组均在不使用阻挡钉、使用1枚阻挡钉、使用2枚阻挡钉3种条件下进行生物力学稳定性测试。结果在A组实验中,不使用阻挡钉、使用1枚阻挡钉、使用2枚阻挡钉之间位移明显,差异有统计学意义（P〈0．05）;在B组测试中,不使用阻挡钉与使用1枚阻挡钉时位移差异无统计学意义（P〉0．05）,但使用1枚和2枚阻挡钉时位移差异有统计学意义（P〈0．05）。结论在A组类型骨折中使用交锁髓内钉,可以结合阻挡钉以显著提高内固定的稳定性;在B组类型骨折中使用交锁髓内钉,必须使用2枚阻挡钉方可在一定程度上改善内固定的稳定性,但与A组相比,总体稳定性明显变差,如在临床中确需使用,需加用恰当的外固定或采用改良型交锁髓内钉。     

Functional outcome of arthroscopic assisted fixation of distal radius fractures

Background:

Many studies in literature have supported the role of wrist arthroscopy as an adjunct to the stable fixation of unstable intraarticular distal radial fractures. This article focuses on the surgical technique, indications, advantages, and results using wrist arthroscopy to assess articular reduction and evaluates the treatment of carpal ligament injuries and triangular fibrocartilage complex (TFCC) injuries in conjunction with the stable fixation of distal radial fractures.

Materials and Methods:

We retrospectively evaluated 27 patients (16 males and 11 females), who underwent stable fixation of intraarticular distal radial fractures with arthroscopic evaluation of the articular reduction and repair of associated carpal injuries. As per the AO classification, they were 9 C 1, 12 C2, 2 C3, 3 B 1, and 1 B2 fractures. The final results were evaluated by modified Mayo wrist scoring system. The average age was 41 years (range: 18-68 years). The average followup was of 26 months (range 24-52 months).

Results:

Five patients needed modification of the reduction and fixation after arthroscopic joint evaluation. Associated ligament lesions found during the wrist arthroscopy were TFCC tears (n=17), scapholunate ligament injury (n=8), and luno-triquetral ligament injury (n=1). Five patients had combined injuries i.e. included TFCC tear, scapholunate and/or lunotriquetral ligament tear. There were 20 excellent, 3 good, and 4 fair results using this score.

Conclusion:

The radiocarpal and mid carpal arthroscopy is a useful adjunct to stable fixation of distal radial fractures.     

Functional outcome of AO type C distal humeral fractures

PURPOSE: To review the functional outcome of AO type C distal humeral fractures (bicondylar fractures) managed with dual orthogonal plate fixation. METHOD: Twenty-three patients were reviewed retrospectively at a mean of 45.1 months. Patient-rated outcomes (Disabilities of the Arm Shoulder and Hand [DASH], Patient Rated Ulnar Nerve Evaluation [PRUNE], American Shoulder and Elbow Surgeons Elbow form [ASES-e], and Short Form-36 [SF-36]), clinical, radiographic, and objective evaluations were used to assess outcomes. RESULTS: Almost 40% of patients required a third plate for adequate fixation. Patients identified minimal subjective deficits (10%) with a mean satisfaction of 93%. The arc of motion was decreased in the flexion-extension plane (122 degrees relative to 138 degrees, p <.01), whereas strength was lower for both elbow flexion-extension and forearm rotation (p <.05). The overall complication rate was 48%, however, most were minor and resolved without further surgery. No ulnar neuropathies were identified at follow-up after routine ulnar nerve transposition. CONCLUSIONS: Outcomes of AO type C distal humeral fractures were good with dual orthogonal plating, ulnar nerve transposition, and early motion. Additional plating may be required with distal fracture patterns or osteopenic bone.     

胫骨远端内侧型锁定加压钢板微创治疗胫骨远端骨折

2007年11月-2010年1月,我科采用微创技术结合胫骨远端内侧型锁定加压钢板（LCP）内固定治疗胫骨远端骨折34例,效果良好,报道如下。     

Clinical and Patient reported outcomes following open reduction and internal fixation for distal tibial intra-articular fractures

IntroductionIntra-articular distal tibial plafond fractures are rare injuries, provide a challenge for the surgeon and can often have poor outcomes. The aim of this paper was to report long term patient reported functional outcomes, health related quality of life (QoL) scores and rates of complications in order to fully counsel the patient on likely outcomes and set realistic post-operative expectations for the patient.MethodsWe conducted a retrospective review of 20 patients with distal tibial intra-articular fractures that presented to our institution between September 2014 and September 2020. All patients underwent open reduction and internal fixation (ORIF). Clinical, radiological and patient reported outcome measures (PROMS), quality of life (QoL) scores and complications were collected.ResultsThe mean age of the patients at the time of surgery was 50.6 years (24−71). There were 7 males and 13 females. There were 4 open and 16 closed fractures. There were 7 Rüedi and Allgöwer (RA) Type 1, 9 Type 2 and 4 Type 3 fractures. The mean follow-up was 3.8 years [1–7]. The mean OMAS score was 54.3, reaching a peak at 2 years from injury. The mean QoL score (EQ5D5L) was 0.602, representing only 70 % of aged matched, UK population based norms.ConclusionsWhilst clinical outcomes are comparable with other studies, this report highlights this is a devastating injury, with most people taking 2 years to reach peak recovery. QoL outcome scores only reach 70 % normal and only 35 % of patients return to within 10 % of age matched population based norms.     

Distal medial tibial locking plate for fixation of extraarticular distal humeral fractures; an alternative choice for fixation

Objective

The aim of this study was to describe an alternative fixation method for distal humeral extra-articular fractures through posterior approach using distal tibia anatomic locking plate; and to evaluate the patient's functional outcome and union condition.

急诊解剖型钢板治疗胫骨远端骨折

目的探讨急诊解剖型钢板治疗胫骨远端骨折的临床效果。方法82例胫骨远端骨折患者急诊采用解剖型钢板手术治疗,按AO/ASIF分型:A1型25例,A2型27例,A3型21例,B1型9例。结果82例获得6~20个月的随访,骨折全部愈合,无钢板螺钉断裂、退出等,表浅感染3例。踝关节功能评价参照Mazur标准,优良率93·9%。结论解剖型钢板手术简单,固定牢固,是急诊治疗胫骨下段骨折的一种较好内固定方法。     

微创经皮钢板内固定治疗胫骨远端骨折

胫腓骨远端骨折在胫腓骨骨折中最为常见，由于其创伤解剖的特殊性，治疗方法的选择有一定的难度，特别是远端粉碎性骨折，术后易发生骨不连、切口皮肤坏死、感染及关节功能障碍等并发症。自2001年3月-2004年7月我院应用微创经皮钢板内固定（MIPPO）治疗胫骨远端骨折32例，疗效满意，报告如下。     

外固定架与DVR解剖锁定板治疗C型桡骨远端骨折的疗效对比

目的:比较DVR解剖锁定钢板与外固定架治疗C型桡骨远端骨折的临床效果。方法:对2009年1月至2013年12月收治的52例C型桡骨远端骨折患者的临床资料进行回顾性分析,其中31例采用掌侧入路切开复位、DVR解剖锁定钢板内固定(钢板内固定组),男11例,女20例;年龄24~65岁,平均(47.3±10.9)岁;左侧13例,右侧18例;按桡骨远端骨折AO分型,C1型12例,C2型15例,C3型4例。21例采用闭合复位、外固定架固定(外固定架组),男8例,女13例;年龄26~69岁,平均(48.1±12.1)岁;左侧10例,右侧11例;按桡骨远端骨折AO分型,C1型7例,C2型11例,C3型3例。对两组患者的术后影像学、腕关节活动度及Gartland-Werley功能评分进行比较。结果:术后52例患者均获得随访,钢板内固定组随访时间13~36个月,平均20.4个月;外固定架组随访时间11~33个月,平均17.1个月。钢板内固定组患者掌倾角和尺偏角均优于外固定架组(P0.05),两组患者桡骨高度和Gartland-Werley评分比较差异无统计学意义(P0.05)。钢板内固定组1例出现腕关节僵硬、握力下降;外固定架组发生钉道感染2例,固定松动1例,腕关节僵硬、握力下降2例。结论:采用DVR解剖锁定钢板治疗C型桡骨远端骨折,操作简单,固定可靠,疗效优于外固定架,但DVR解剖锁定钢板内固定手术费用高,需二次手术取出内固定,临床上可根据患者具体情况选择治疗方式。     

Functional outcome of retrograde intramedullary nailing for femoral fractures

We evaluated the functional outcome of 12 femoral fractures treated using retrograde intramedullary nailing via an intercondylar approach. Patients were 9 men and 3 women with an average age of 39.4 years (range, 16–69 years). The follow-up period was 13–185 months, with an average follow-up of 95 months. Functional outcome was assessed by the knee-rating system of the Hospital for Special Surgery (HSS) and Neer's criteria. The average score was 76 points (44 –100 points) by HSS, and 77 points (36–100 points) by Neer's criteria. The outcomes over good results were seen in 67% (8/12) and 58% (7/12), according to respective rating system. Although retrograde nailing for the femoral fractures is useful method, it is still problematic about its efficacy on the basis of our acceptable rate.     

解剖钢板固定治疗胫骨远端骨折

2002～2006年,我科应用胫骨远端解剖钢板治疗胫骨远端骨折患者31例,取得满意疗效。     

桡骨远端骨折影像学测量指标与近期疗效的关系

目的 通过对桡骨远端骨折患者的影像学测量,分析各影像学参数和近期疗效之间的关系.方法 对62例桡骨远端骨折闭合复位石膏外固定的患者,利用StarPACS影像系统进行测量,并记录所有患者X线片的桡骨高、掌倾角及尺偏角的情况,并分析影像学测量指标与自测腕关节功能之间的关系.结果 62例桡骨远端骨折中,有50例(占80.6%)经保守治疗后效果优良.当桡骨高大于6.0 mm,掌倾角大于5°,尺偏角大于18°时,自测腕关节功能优良率较高.影像学指标和自测腕关节功能的相关性桡骨高＞掌倾角＞尺偏角.结论 桡骨高、掌倾角及尺偏角等可以作为桡骨远端骨折治疗效果评估的影像学指标,手法复位后影像学不达标者应当重新复位或采用手术治疗,桡骨远端骨折时应当首先考虑桡骨高的恢复.     

Trajectory of functional outcome and health status after moderate-to-major trauma in Hong Kong: A prospective 5 year cohort study

BackgroundTrauma care systems in Asia have been developing in recent years, but there has been little long-term outcome data from injured survivors. This study aims to evaluate the trajectory of functional outcome and health status up to five years after moderate to major trauma in Hong Kong.MethodsWe report the five year follow up results of a multicentre, prospective cohort from the trauma registries of three regional trauma centres in Hong Kong. The original cohort recruited 400 adult trauma patients with ISS ≥ 9. Telephone follow up was conducted longitudinally at seven time points, and the extended Glasgow Outcome Scale (GOSE) and Short-Form 36 (SF36) were tracked.Results119 out of 309 surviving patients (39%) completed follow up after 5 years. The trajectory of GOSE, PCS and MCS showed gradual improvements over the seven time points. 56/119 (47.1%) patients reported a GOSE = 8 (upper good recovery), and the mean PCS and MCS was 47.8 (95% CI 45.8, 49.9) and 55.8 (95% CI 54.1, 57.5) respectively at five years. Univariate logistic regression showed change in PCS - baseline to 1 year and 1 year to 2 years, and change in MCS - baseline to 1 year were associated with GOSE = 8 at 5 years. Linear mixed effects model showed differences in PCS and MCS were greatest between 1-month and 6-month follow up.ConclusionsAfter injury, the most rapid improvement in PCS and MCS occurred in the first six to 12 months, but further recovery was still evident for MCS in patients aged under 65 years for up to five years.     

胫骨远端骨折两种治疗方法的疗效比较

目的：评价两种不同方法治疗胫骨远端骨折的临床适应证、并发症及其疗效。方法：45例闭合性胫骨远端骨折采用不同手术方法：A组25例,男18例,女7例;按AO／ASIF分类：A型4例,B型14例,C型7例;采用切开复位解剖型钢板内固定。B组20例,男12例,女8例;A型5例,B型9例,C型6例;采用微创经皮锁定钢板内固定。术后观察患者疼痛程度、切口皮肤坏死、深部感染发生率等并发症以及骨折愈合时间、踝关节运动功能进行对比研究。结果：患者术后随访10-15个月,平均12个月。按视觉模拟量袁（VAS）评分：A组中度-重度,B纽轻度-中度;骨性愈合时间：A组平均（16．0±4．2）周,B组平均（13．0±3．2）周,差异有统计学意义（火0．01）。A组术后并发症发生率高于B组（P〈0．05）。踝关节功能评定按照Kofoed评分标准,术后踝关节功能恢复B组总体优良率明显高于A组（P〈0．05）。结论：微创经皮锁定钢板内固定较切开复位解剖型钢板内固定治疗胫骨远端骨折具有手术创伤小,对骨骼血供影响小,骨折愈合快,并发症少,踝关节功能恢复好的优点,符合生物力学内固定。     

Functional outcome of tibial plateau fractures treated with the fine-wire fixator

OBJECTIVE: To review the functional outcome of patients with complex tibial plateau fractures treated with fine-wire fixation. DESIGN: Retrospective review with follow-up of patients in outpatient clinic. SETTING: Tertiary trauma center. PATIENTS: All patients who had fine-wire fixation for tibial plateau fractures between 1996 and January 2001 were reviewed. INTERVENTIONS: Fine-wire fixation with/without limited internal fixation for complex tibial plateau fractures. MAIN OUTCOME MEASURES: Knee range of motion, adequacy of articular surface reduction, mechanical axis, Knee Society Clinical Rating Scale and Short-Form 36 Health Questionnaire. RESULTS: Eighteen of twenty-one eligible patients were available for follow-up. There were 14 Shatzker VI and 4 V fractures. Seven fractures were open. Average follow-up was 28.2 months. All fractures united. There were three cases of delayed union, all progressed to union following additional procedures and bone grafting. There were no cases of osteomyelitis, septic arthritis or deep vein thrombosis. Seven patients had Knee Society Clinical Rating Scores of good/excellent (38.9%), and 11 had fair/poor scores (61.1%). Abnormal mechanical axes and multiple co-morbid injuries were associated with poorer outcomes. Although SF-36 scores were lower in the study group compared to matched population norms, 15 of 18 patients had full or partial return to pre-injury levels of functioning. CONCLUSION: Fine-wire fixation with limited internal fixation is a satisfactory method of managing complex high-energy fractures of the tibial plateau where soft tissue injury and bony comminution make traditional techniques of open reduction and internal fixation unsuitable.