Percutaneous Intramedullary Screw Fixation of Distal Fibula Fractures: A Case Series and Systematic Review

The current reference standard for unstable ankle fractures is open reduction and internal fixation using a plate and lag screws. This approach requires extensive dissection and wound complications are not uncommon. The use of intramedullary screw fixation might overcome these issues. The aim of our study was to provide an overview of the published data regarding intramedullary screw fixation of fibula fractures combined with a small consecutive case series. We performed a search of published studies to identify the studies in which fibula fractures were treated with percutaneous intramedullary screw fixation. Additionally, all consecutive patients treated for an unstable ankle fracture in a level 1 trauma center using an intramedullary screw were retrospectively included. The literature search identified 6 studies with a total of 180 patients. Wound infection was seen in 1 patient (0.6%), anatomic reduction was achieved in 168 patients (93.3%), and a loss of reduction was seen in 2 patients (1.1%). Implant removal was deemed necessary in 3 patients (1.7%) and nonunion was seen is 2 patients (1.1%). A total of 11 patients, in whom no wound complications occurred, were included in our study. The follow-up duration was a minimum of 12 months. A secondary dislocation was seen in 1 patient, and delayed union was observed after 7.5 months in 1 other patient. In conclusion, intramedullary screw fixation is a safe and adequate method to use for fibula fractures, with a low risk of wound complications. Additional research regarding functional outcome is warranted.     

A Completely Displaced Salter-Harris I Fracture of the Distal Radial Epiphysis with Intact Ulna: a Case Report and Review of the Literature

We present a 12-year-old boy with a displaced fracture of the distal radial epiphysis type I according to the Salter-Harris classification. The distal radial epiphysis was completely dorsally displaced, while the distal ulna remained intact. The injury was result of a fall on the patient’s outstretched hand. Closed reduction was applied and the forearm was immobilized with a long arm cast.

In the radiological re-examination a week later, a complete re-displacement of the fracture was detected. Open reduction followed and interposed flexor tendons (flexor pollicis longus and flexor carpi radialis) were found in the anatomical position of the distal radial epiphysis. The displaced epiphysis was reduced and fixed with two Kirschner wires and a long arm cast for a period of 6 weeks.

The follow-up examination 2 years later showed that the movement range of the wrist joint was not limited and skeletal growth of the radius was not disturbed.

The failure of closed reduction in these fractures is due to anatomical obstacles such as periosteum, flexor tendons and pronator quadratus interposition. Repeated forceful manipulations to achieve closed reduction must be avoided because of the potential for a number of complications, such as growth arrest, compartment syndrome, and avascular necrosis of the epiphysis.     

胫腓下联合分离伴踝部骨折的治疗

目的探讨踝关节损伤时胫腓下联合分离的机制及胫腓下联合固定的利弊.方法伴胫腓下联合分离的踝关节损伤共31 例,其中19 例未行胫腓下联合分离固定,10 例用螺针固定胫腓下联合,2 例用下胫腓钩固定.内踝骨折以螺钉或张力带钢丝固定.外踝以螺钉或钢板固定,后踝用松质骨螺钉加压固定.结果胫腓下联合固定患者中2 例松动,2 例术后1～2 a取出固定螺钉,其余10 例均6～12周取出胫腓下联合固定螺钉.未发生胫腓下联合螺钉断裂.内外踝及后踝骨折内固定于6～29个月取出.未行胫腓下联合分离固定的病例均未出现胫腓下联合分离.结论胫腓下联合的稳定性不仅仅取决于胫腓下联合本身,胫腓下联合韧带损伤时,只有同时伴有踝关节内侧骨韧带复合体损伤,才会出现临床上的胫腓下联合分离,因此踝关节骨折脱位时,只要内外踝或后踝解剖复位,固定牢固,胫腓下联合分离即可自动复位,一般不必做胫腓下联合的固定.     

Clinical Comparison of Minifragment Plates Versus Conventional Semitubular Plates for Fixation of Distal Fibula Fractures

BackgroundAlthough operative stabilization of unstable distal fibula fractures is frequently performed and discussed, the ideal implant and technique for these injuries is still debated.Questions/PurposesThe purpose of this study was to determine if minifragment plating of distal fibula fractures would clinically provide equivalent fixation and cost and minimize hardware prominence when compared with standard one-third tubular plating.ResultsThe minifragment group demonstrated equivalency in maintenance of fracture reduction relative to standard tubular plating. Both groups were able to maintain the talocrural angle with less than 1° of change from initial postoperative to final postoperative radiographs. No significant differences were seen in postoperative hardware irritation between groups.ConclusionsUse of a minifragment plating system for displaced fibula fractures appears to be safe but comes with the significant potential added cost of the technology. Interestingly, no significant differences were seen in implant-related irritation or implant removal, but further investigation with a larger study population would help better determine these outcomes.     

Bicortical Screw Fixation of Distal Fibula Fractures With a Lateral Plate: An Anatomic and Biomechanical Study of a New Technique

One of the potential drawbacks of lateral plating of distal fibula fractures is less than satisfactory fixation of unicortical screws commonly placed in the distal fragment to avoid implant penetration of the ankle joint. This study examines the anatomy of the distal fibula, proposes new techniques for bicortical screw fixation and radiographic evaluation of screw placement, and compares pullout strength of unicortical versus bicortical screws in this area. Sixteen pairs of human cadaver feet were used in this study. It was found that a large percentage of the surface area of the distal fibula is nonarticular and that the distal fibula could be divided into 3 zones with distinct anatomic features. Zone I is defined as the distal most 1.5 cm of the fibula, zone II is the next 1 cm of fibula proximal to zone I, and zone III is defined as the fibula above the ankle joint, starting at just over 2.5 cm proximal to the tip of the fibula. We determined a safe corridor for bicortical screw placement by means of a lateral plate in each zone. An improved radiographic view is described for confirmation of extraarticular screw placement. Screw pullout testing was performed on 8 pairs of fresh-frozen human cadaver fibulas. In both zone I and zone II, the bicortical screw fixation was significantly stronger than the unicortical screw fixation. In zone I, the average pullout strength for the bicortical screw fixation was 2.3 times higher than the unicortical screw fixation. In zone II, the average pullout strength for the bicortical screw fixation was 3.3 times higher than the unicortical screw fixation. This study shows that not only is bicortical screw placement in the distal fibula technically feasible, but it is also biomechanically stronger than unicortical placement in this area.     

Comparison of Locking Versus Nonlocking Plates for Distal Fibula Fractures

Locking plates might offer a biomechanical fixation advantage for distal fibula fractures with comminution or osteoporotic bone. In January 2011, our unit introduced a bone-specific locking plate for the distal fibula. The aim of the present study was to compare it against more conventional plating system implants for lateral malleolar fixation in terms of outcomes, crude costs, and complications. We retrospectively reviewed a consecutive cohort of patients with closed ankle fractures who presented within a 24-month period. The clinical and radiographic outcomes were compared among conventional plating using a one-third semitubular plate, a 3.5-mm limited-contact dynamic compression plate, and a 2.7-mm/3.5-mm locking compression distal fibula plate. A total of 145 patients with ankle fractures underwent surgical fixation: 87 (60.0%) with the semitubular plate, 22 (15.2%) with the limited-contact dynamic compression plate, and 36 (24.8%) with the locking compression distal fibula plate. A greater proportion of patients with established osteoporosis or osteoporosis risk factors were in the locking compression distal fibula plate group (27.8% versus 2.3% and 0%). Four patients (2.8%) required washout for infection. No significant differences were found between the sex distribution within the 3 groups (p?=?.432). No significant difference was found in the complication rate (p?=?.914) or the reoperation rate (p?=?.291) among the 3 groups. Although costing >6 times more than a standard fibula fixation construct (implant cost), bone-specific locking compression distal fibula plates add to the portfolio of implants available, especially for unstable fractures with poor bone quality.     

移位髋臼骨折的手术治疗

目的探讨移位髋臼骨折的手术方法。方法对22例髋臼骨折按不同类型、不同手术入路分别用加压螺钉、重建钢板等予以内固定治疗。结果平均随访14个月(5~30个月)。术后发生1例伤口感染和1例坐骨神经牵拉伤,未发生血管损伤及深静脉栓塞。复位情况按Judet方法评估,达到解剖复位者18例,复位满意者4例。按美国矫形外科研究院标准评估疗效,优14例,良5例,可2例,差1例。结论重建钢板内固定治疗移位髋臼骨折是有效的方法,正确的骨折分型、手术切口的选择是复位成功的关键。     

Report of the Case of a Rare Pattern of Maisonneuve Fracture

The classic Maisonneuve fracture is localized to the proximal portion of the fibula, in association with disruption of the ankle that involves tibiofibular diastasis. This report, however, describes a case involving a Maisonneuve fracture in the presence of intact deltoid and tibiofibular syndesmotic ligaments. When this injury is suspected, further diagnostic imaging and intraoperative assessment may be useful, and operative repair does not require the use of trans-syndesmotic fixation. Level of Clinical Evidence: 4.     

解剖型锁定钢板内固定治疗肱骨远端C型骨折

目的探讨应用解剖型锁定钢板内固定治疗C型肱骨远端骨折的疗效。方法肱骨远端C型骨折28例,按AO/ASIF分类:C1型10例,C2型15例,C3型3例;均采用采用尺骨鹰嘴截骨入路,解剖型锁定钢板内固定。受伤至手术时间平均5.8 d(2 h~10 d)。结果术后28例均获随访,平均20(2~30)月。骨折愈合时间平均3.5(2~10)个月。根据Cassebaum评分系统评定肘关节功能:优10例,良12例,可5例,差1例,优良率为78.6%,结论采用尺骨鹰嘴截骨入路,早期切开解剖复位、解剖型钢板内固定及早期有计划地康复训练治疗肱骨远端骨折,复位良好,固定可靠,能最大限度地恢复肘关节功能。     

Atypical Chronic Ankle Instability in a Pediatric Population Secondary to Distal Fibula Avulsion Fracture Nonunion

Chronic ankle instability is a disabling condition, often occurring as a result of traumatic ankle injury. A paucity of published data is available documenting chronic ankle instability in the pediatric population. Much of the data has been confined to the adult population. We present 2 cases of chronic ankle instability, 1 in a 12-year-old and 1 in a 9-year-old patient. Unlike the typical adult etiology, the cause of instability was a dysfunctional lateral ligamentous complex as a consequence of bony avulsion of the tip of the fibula. Both patients had sustained a twisting injury to the ankle. The fractures failed to unite. The nonunion resulted in dysfunction of the anterior talofibular ligament with consequent chronic ankle instability. At the initial clinical assessment, magnetic resonance imaging was requested for both patients. In patient 1 (12 years old), the fracture was fixed with 2 headless screws and was immobilized in a plaster cast for 6 weeks. In patient 2 (9 years old), because of the small size of the avulsed fragment, fixation was not possible. A modified Gould-Broström procedure was undertaken, facilitating repair of the avulsed fragment using anchor sutures.     

Maisonneuve Equivalent Injury With Proximal Tibiofibular Joint Dislocation: Case Report and Literature Review

We report the case of a 31-year-old male who presented with traumatic dislocation of both proximal and distal tibiofibular joints without fibular fracture. The patient underwent closed reduction of the proximal tibiofibular joint and surgical stabilization of the distal tibiofibular joint. An 18-month postoperative evaluation confirmed a very good clinical outcome after anatomic reduction. This type of trauma is very rare and, to our knowledge, has only been described 3 times previously. Furthermore, our surgical management was different from that used for the previous cases and proved to be satisfactory.     

复杂闭合性踝关节骨折的治疗

目的　探讨复杂闭合性踝关节骨折的治疗方法。　方法　将 82例 85侧AO Danis Weber分型中的B、C型踝关节骨折的患者 ,随机分为两组。A组 3 0例 3 3侧采用闭合复位石膏外固定 ,B组 5 2例 5 2侧采用开放复位内固定治疗。比较两组患者踝关节疼痛、肿胀、功能恢复情况。　结果　参照Teenny和Wiss评分系统 ,A组的优良率为 3 6% ,B组的优良率为 70 % ,B组疗效优于A组 (P <0 .0 5 )。　结论　开放复位内固定是治疗复杂踝关节骨折的有效方法。     

内外侧联合入路治疗内倾型后踝骨折

目的探讨内外侧联合入路治疗内倾型后踝骨折的临床疗效。方法回顾分析2009年3月至2013年3月治疗的117例资料完整的后踝骨折患者,根据术前影像学资料筛选出21例内倾型后踝骨折。男14例,女7例;年龄19~72岁,平均45.2岁;平地扭伤9例,坠落伤7例,车祸伤5例;均为闭合性骨折;均伴腓骨远端骨折及关节软骨面损伤;患者术前均表现为足踝部肿胀、畸形及活动受限。根据Haraguchi CT分型:Ⅰ型13例,Ⅱ型5例,Ⅲ型3例;从外伤到手术时间1~12 d,平均5.1 d;采用内外侧联合入路切开复位内固定;术后定期随访切开及骨折愈合情况,并采用Baird Jackson评定标准和SF-36分别评价术后踝关节功能和术后患者生活质量。结果 21例患者均获完整随访,时间13~46个月,平均22.3个月。手术时间55~90min,平均(65.7±29.6)min;住院时间5~17d,平均(8.2±1.8)d;术后2 d X线片显示,解剖复位(胫骨远端关节面无台阶)17例,复位良(有1 mm台阶)4例,解剖复位率81.0%;切口均一期愈合;骨折愈合时间11~19周,平均14.6周,无骨不连及畸形愈合。末次随访时Baird Jackson评分为91~100分,平均95.5分,其中优14例,良7例,优良率100%。SF-36生理评分33.2~66.5分,平均(47.6±5.7)分,SF-36心理评分28.9~66.5分,平均(48.4±4.9)分。结论内倾型后踝骨折采用内外侧联合入路可以获得良好的手术视野,并可直视下复位固定所有骨折块,使之达到解剖复位,从而获得满意临床疗效,是值得推荐的手术入路。     

Nontraumatic Osteonecrosis of the Distal Tibia: A Case Presentation and Review of the Literature

Osteonecrosis, although commonly occurring in the hip, can also affect the leg and foot. In the foot, it most commonly occurs in the talus. The incidence of osteonecrosis occurring in the tibia is relatively rare. We report a case of a woman who presented to our clinic with ankle pain that was idiopathic in nature. Subsequent magnetic resonance imaging showed findings consistent with osteonecrosis of the bilateral distal tibias and several other lesions located in the shoulder, hip, and calcaneus. The present report also serves as a review of both etiology and treatment of osteonecrosis as it relates to the lower extremity.     

股骨远端骨折的外科治疗

目的:探讨股骨远端骨折手术治疗的方法和临床疗效。方法选择股骨远端骨折手术治疗37例,根据AO/A S IF分型,A型8例,B型9例,C型20例,分别采用股骨髁支持钢板、L-梯形钢板、逆行带锁髓内钉、拉力螺钉进行固定,术后随访6个月~8年。结果6例骨折不愈合、3例出现化脓性骨和膝关节感染、3例出现钢板断裂。根据K olm enrt股骨远端功能评定标准,优17例,良14例,一般2例,差4例,优良率83.7%。结论手术治疗股骨远端骨折能最大限度获得骨折复位和膝关节功能的恢复,临床疗效满意,是治疗股骨远端骨折较理想的方法。     

逆行交锁髓内钉治疗股骨远端骨折

目的 探讨逆行交锁髓内钉在治疗股骨远端骨折中的应用价值。方法 采用逆行交锁髓内钉对22例AO分型为A、C型新鲜股骨远端骨折病例行内固定。结果 所有病例均获随访，21例获牢固骨性愈合，未见畸形愈合、感染。1例发生主钉尾端处骨折，1例发生近端锁钉断裂。术后根据KSS评分体系，评价优14例，良6例，一般2例，优良率90．9％。结论 逆行交锁髓内钉适用于股骨远端骨折，具有高度的稳定性，操作简单，出血少，并发症少，功能恢复快。     

Distal Tibiofibular Syndesmosis Dysfunction: A Systematic Literature Review of Dynamic Versus Static Fixation Over the Last 10 Years

The goal of the present work was to perform a systematic review of the literature of the past 10 years regarding dynamic and static fixation of the distal tibiofibular syndesmosis to determine any clinical differences between the 2 procedures. A literature search of the PubMed MEDLINE database was conducted to identify relevant studies related to distal tibiofibular syndesmosis. Studies before January 1, 2007, were excluded to limit the project to the recent literature. Clinical outcomes, device removal rates, time to weightbearing after the initial procedure, and the cost effectiveness of each device were explored. In these 26 studies, 350 patients were treated using a dynamic technique and 845 were treated using a static technique. The weighted American Orthopedic Foot and Ankle Score was 91.70 (standard error [SE] 1.87) for dynamic fixation patients and the weighted average was 86.48 (SE 2.17) for static fixation patients (p?=?.068). A secondary procedure to remove the fixation device was performed in 7.7% of dynamic fixation patients and in 39.4% of static fixation patients when studies with 100% device removal were excluded (p < .0001). The mean time to weightbearing was 5.96 (SE 0.72) weeks for patients who underwent dynamic fixation and 10.45 (SE 0.99) weeks for those who had static fixation (p?=?.0002). The cost for dynamic fixation was found to be less than that for static fixation when secondary procedures for device removal were considered. Based on similar clinical functional scores, lower secondary procedure rates, faster time to full weightbearing, and lower costs to patients, dynamic fixation of the distal tibiofibular syndesmosis may be a superior option compared with static fixation.