Grade III open fracture of the femoral diaphysis in a polytraumatized child

Authors describe the case of a 7.5 years old girl run over and with polytrauma, whose bilateral fracture of the femoral diaphysis was treated with osteosynthesis. The operative indication was the III. degree open fracture on one side. Anatomical reduction was performed on both sides, with DC plate on the closed side and with fixateur externe after insertion of adaptation screws on the open one. The missing soft tissues were substituted with delayed split thickness mashgraft flaps. The injuries healed with good function. If the operative treatment of the femoral diaphysis is founded the lamellar osteosynthesis or the fixateur externe method is suggested.     

Stable fixation of fragments of the femur in unstable fractures

The authors make an analysis of treatment of 87 patients with closed unstable fractures of diaphysis of the femoral bone with the application of their two devices for immersional and extrafocal osteosynthesis. In all 87 patients consolidation of the fracture was achieved. Results of the treatment were recognized as good in 84 patients (96.6%) and as satisfactory in 3 patients (3.4%).     

Surgical treatment of unstable femoral neck fractures

Results of the treatment of 378 patients with unstable fracture of the femur neck were analyzed. The authors recommend to use osteosynthesis with a three-blade rod with an additional fixation by a lateral plank and screws to the femur diaphysis combined with osseous allotransplant introduced parallel to the metallic fixator. The follow-up studies for 6 years have shown the false joint to be formed in 5% of the patients operated by the proposed method while osteosynthesis by a three-blade rod only gave it in 23,8% of cases.     

Intra-articular fracture of the calcaneus. Classification, assessment and surgical procedures

Our experience with open reduction of calcaneus fractures and internal stabilization without joint transfixation (n = 83) has shown us that the following features are mandatory in order to obtain normal postoperative foot statics and dynamics, normal joint mobility, and normal foot function: (1) restoration of the normal height, length and width of the calcaneus; (2) reduction of all joint surfaces and (3) stable screw- or H-plate osteosynthesis, allowing functional treatment later. Our own fracture classification (X-fragment/Y-joint fracture) allowed us to determine the type of fracture, its severity, and the prognosis, as well as the choice of operative treatment. A detailed +/- 200-point follow-up scoring system assured operative quality control and comparability of results. The complications were: 9 cases of superficial wound-edge necrosis (8%), 2 hematomas requiring revision, and 1 deep bone infection (1.2%). During our first operative period (1983-1985, mostly unilateral medial approach and trans-articular K-wire fixation), we had only 50% good-to-excellent results. During the second period (1986-1988, bilateral, extended lateral approach and stable screw/H-plate osteosynthesis), 76.5% (29 of 51 patients) had good-to-excellent results. Our experience thus indicates that our operative treatment principles can be recommended for patients who are either professionally active or active in sports.     

Multifragment fracture of the patellar apex: basket plate osteosynthesis compared with partial patellectomy

Introduction The purpose of the present study was to evaluate and compare the long-term results of operative treatment of a multifragment fracture of the inferior patellar pole by basket plate osteosynthesis and partial patellectomy. Materials and methods We retrospectively studied two groups of patients who had operative treatment of a multifragment fracture of the inferior patellar pole between 1988 and 2004. Seventy-one patients who had osteosynthesis by basket plate (Group 1) and 49 patients who had partial patellectomy (Group 2) were followed for an average of 5.3 years. The final evaluation was based on the modified Cincinnati Knee rating system test. Results The results were excellent or good in 90.1% patients of Group 1, and 73.5% patients of Group 2. Significant differences between the groups were noted with regard to knee pain, swallowing, level activity, compression pain, range of motion, muscular atrophy, muscular strength, and final patellofemoral score which confirms statistical analysis. Conclusion The stability of the osteosynthesis by basket plate allows osseous consolidation of the fracture and permits immediate mobilization and early weight bearing. Osteosynthesis by basket plate can provide better clinical results.     

Severely comminuted femoral shaft fractures: treatment by bridging-plate osteosynthesis

We report on 71 severely comminuted femoral shaft fractures that were operated on between 1980 and 1984 at the Berufsgenossenschaftliche Unfallklinik Duisburg-Buchholz. The method of operative stabilization was plate osteosynthesis in two variations: In one group 39 fractures (ten open) were stabilized by plate osteosynthesis after anatomical reduction of the fractured area. The other group comprised 32 fractures (six open) fixed with a bridging-plate osteosynthesis, without preparation of the fracture zone. The rate of postoperative complications was strikingly diminished after bridging-plate osteosynthesis. Fracture healing occurred within 23 (16-32) weeks after bridging-plate osteosynthesis and within 36 (32-40) weeks after anatomical reduction. No special instrumentation or equipment is necessary to perform a bridging-plate osteosynthesis. The patient rests in a supine position. There is no need for intraoperative image-intensifier control. For operative treatment of severely comminuted femoral fractures we consider the technique of bridging-plate osteosynthesis advantageous, especially in multiply injured patients.     

Osteosynthesis in fractures of proximal epiphyseal metaphysis of the femur

The results of operative treatment of the proximal epimetaphysis femoris fracture in elderly patients were analyzed. The unified table of optimal methods of their operative treatment was elaborated.     

Treatment of distal metaphyseal tibia fractures with involvement of the ankle by combination of locked intramedullary nailing and covered screw osteosynthesis

Fractures of the distal metaphysis of the tibia often include an extension into the ankle. Intramedullary nailing combined with covered screw osteosynthesis should reduce the high incidence of soft tissue and ankle problems and should be an alternative to open plate fixation, with good ultimate functional outcome. Between January 1993 and December 1995, a prospective study on 49 patients with distal metaphyseal tibia fracture and involvement of the ankle was performed. All the fractures were treated with intramedullary nailing combined with covered screw osteosynthesis, and plate fixation in cases of fibula fractures. There were 27 men and 22 women with an average age of 46.4 +/- 12.7 years (range 21-90). In most studies of the use of intramedullary nailing in distal tibial fractures the classification has been inadequate. Therefore a new classification according to Robinson et al. (1995) was used: 10 fractures were type II B (20.4%), 13 were type II C (26.5%), and 26 patients suffered a combination of type II B and type II C (53.1%). This fracture type was defined as type II D for use in this study. The severity of soft tissue injury was recorded using the Gustilo system in case of open (n = 19) and the Tscheme system in case of closed fractures (n = 30). In 31 patients distal tibia fracture was accompanied by a fracture of the fibula, which was first stabilized using a plate. For reconstruction of the distal articular surface, covered screw osteosynthesis was done. At the next step intramedullary nails were inserted and were statically locked proximally and distally. From January 1993 to February 1994, the reamed AO standard nail was used. After introduction of the unreamed tibial nail (UTN) all fractures were treated by this implant. Full load on the operated leg was allowed after 8 weeks. Union of the fracture was assessed by standard radiological and clinical criteria. Misalignment was defined as more than 5 degrees of angular rotation. Further surgery due to a valgus deformity in the ankle joint had to be done in three cases. There were no deep infections. Three patients had a superficial infection in the ankle area, but surgical debridement was not necessary. A leg shortening was found in 4 cases, but it was less than 1 cm in every case. Therefore, surgical correction was not done. Patients were reviewed at intervals of 2, 6, and 12 weeks, and after 6, and at least 12 months. All 49 patients were finally reviewed after an average time of 15.7 months (range 12-38). Bone fusion was reached 12.8 weeks (range 9-21) after the operative treatment. A specific assessment of the ankle symptoms was made using the score of Olerud and Molander (1984). In 29 patients excellent results were recorded. A satisfactory result was attained with 17 patients and just 3 patients were found to be unsatisfactory. Although proximity of distal tibia fracture to the ankle makes the treatment more complicated than for fractures of the tibial diaphysis, closed intramedullary nailing combined with covered screw fixation is a good alternative to open reduction and plate fixation. The major advantages are closed procedure and simplified interlocking techniques. Therefore, closed intramedullary nailing combined with covered screw fixation is a safe and effective method of managing this type of fracture.     

Surgical treatment of ununited fractures and pseudarthroses of the femoral diaphysis

The article analyses experience in the treatment of 125 patients with ununited fractures and pseudarthrosis of the humeral diaphysis by osteosynthesis with massive compressing metal plates. The possibility of creating the necessary reserve of mechanical stability at the expense of the massive plates and strained fixation allows immobilization in a plaster cast to be avoided in most cases and early motor rehabilitation of the patients to be undertaken. The results were positive in 96.8% of cases, which makes it possible to consider the method to be sufficiently effective in the management of fractures of the humeral diaphysis and their sequelae.     

Functional bracing for the treatment of fractures of the humeral diaphysis

BACKGROUND: Nonoperatively treated fractures of the humeral diaphysis have a high rate of union with good functional results. However, there are clinical situations in which operative treatment is more appropriate, and, though interest in plate osteosynthesis has decreased, intramedullary nailing has gained popularity in recent years. We report the results of treating fractures of the humeral diaphysis with a prefabricated brace that permits full motion of all joints and progressive use of the injured extremity. METHODS: Between 1978 and 1990, 922 patients who had a fracture of the humeral diaphysis were treated with a prefabricated brace that permitted motion of adjacent joints. The injured extremities were initially stabilized in an above-the-elbow cast or a coaptation splint for an average of nine days (range, zero to thirty-five days) prior to the application of the prefabricated brace. Orthopaedic residents, supervised by teaching staff, provided follow-up care in a special outpatient clinic. Radiographs were made at each follow-up visit until the fracture healed. RESULTS: We were able to follow 620 (67 percent) of the 922 patients. Four hundred and sixty-five (75 percent) of the fractures were closed, and 155 (25 percent) were open. Nine patients (6 percent) who had an open fracture and seven (less than 2 percent) who had a closed fracture had a nonunion after bracing. In 87 percent of the 565 patients for whom anteroposterior radiographs were available, the fracture healed in less than 16 degrees of varus angulation, and in 81 percent of the 546 for whom lateral radiographs were available, it healed in less than 16 degrees of anterior angulation. At the time of brace removal, 98 percent of the patients had limitation of shoulder motion of 25 degrees or less. We were unable to follow most of the patients long-term, as they did not return to the clinic once the fracture had united and use of the brace had been discontinued. CONCLUSIONS: Functional bracing for the treatment of fractures of the humeral diaphysis is associated with a high rate of union, particularly when used for closed fractures. The residual angular deformities are usually functionally and aesthetically acceptable. The present study illustrates the difficulties encountered in carrying out long-term follow-up of indigent patients treated in charity hospitals that are affiliated with teaching institutions. These difficulties are also becoming common with patients insured under managed-care organizations and are frequent in our peripatetic population.     

From unstable internal fixation to biological osteosynthesis. A historical overview of operative fracture treatment

The first techniques of operative fracture treatment were developed in the 19th century. In fact, these methods only consisted of an open reduction of the fracture followed by a usually very unstable fixation. This method gave rise to the combination of the disadvantages of the conservative and the operative fracture treatment: the fracture had to be opened with a real risk for (sometimes lethal) infection, the bone healing was disturbed, there was muscular atrophy and joint stiffness. The successes were very rare and catastrophes were often seen. Küntscher's endomedullary rods can be considered as the first useful implants in the treatment of diaphyseal fractures. Reaming of the medullary canal and the development of interlocking nails have enlarged the indications for intramedullary nailing. The classic Dynamic Compression Plates from the seventies were the key to a very rigid fixation, leading to primary bone healing. Nevertheless, the use of strong plates and reamed nails disturbed the vascularisation of the bone fragments, leading to a high infection rate (particularly in open fractures) and delayed union (particularly after plate and screw fixation). These insights lead to the development of the "biological osteosynthesis" : a terminology introduced to indicate a new type of osteosynthesis leading to a sufficiently stable fixation of the bone fragments allowing early mobilisation, but without major disturbance of the vascularisation. The unreamed nail can also be considered as a biological osteosynthesis and in a lot of cases it is the implant of choice for tibial and femoral shaft fractures, especially in polytrauma patients. Finally, some new devices contributing to the principles of biological osteosynthesis like locking plates and the LIS-System are gaining popularity.     

Oberschenkelschaftsfrakturen im Kindes- und Wachstumsalter

Excellent results in the treatment of childhood femoral fractures can be achieved by Weber’s extension method. Easy reposition and reliable retention of the fracture, exact control and correction of the fragment rotation as well as comfortable positioning and easy nursing are the main advantages of this method. Absolute indication for operative treatment is given in second and third degree compound fractures, in fractures combined with nerve and/or vascular lesions and in unstable subtrochanteric and supracondylar fractures. Relative indication for osteosynthesis exists in multiply injured children with severe cerebral contusion and convulsion, in bilateral shaft fractures and serial fractures of one extremity as well as in older children or adolescents shortly before cessation of growth with unsatisfying reposition. Through the years 1971 to 1977 67 femoral fractures in 64 children were treated, 3 of these were symmetric and 9 were at the proximal and distal end of the femur each. 21 children were multiply injured. 52 patients were treated conservatively; in 12 children the fracture was stabilized by osteosynthesis. 45 children were controlled 6 to 30 months later, 30 of these after treatment according to Weber’s extension method. Length difference of the femur was 0.5 to 1 cm in 20 children, no length difference was observed in 10. Differences of the angel of antetorsion were found only in 2 children, 8 had a varus deformity of up to 15 degrees. In 9 cases, 3 months after operative treatment, no deformities of the femoral shaft or differences in length were observed. Weber’s extension method and strongly indicated stable plate osteosynthesis are suitable in more than 90 percent of the cases to manage a restitutio ad integrum. Unstable osteosynthesis or medullary nailing, however, cause more often posttraumatic deformities and length differences, which require correction osteotomies after cessation of growth.     

Indications, dangers and results of surgical treatment of humeral shaft fractures

A series of 78 fractures of the humeral shaft is presented that were treated operatively between 1978 and 1987. Open fractures, fractures with primary palsy of the radial nerve, distal fractures with an intraarticular component, fractures in polytraumatized patients and non-unions were absolute indications for operative stabilization in this series. In 71 fractures, internal stabilization was performed and in 7 fractures external fixation. In 16 fractures (20.6%), primary palsy of the radial nerve was present. In 10 patients (12.8%), radial nerve palsy appeared postoperatively. Nonunions and deep infections did not occur. In two cases, a second osteosynthesis was necessary after loosening of the implants. The humeral shaft fracture shows normal bony consolidation after conservative treatment as well as appropriate plate osteosynthesis. Nine of the 16 patients with primary radial nerve palsy (56.2%) and 6 of the 10 patients with secondary radial nerve palsy (60%) had total functional recovery. In our series, intraoperative palsy of the radial nerve was the most frequent complication after dissection of spiroid fractures in the middle or lower third of the humeral shaft. In this fracture form, a more unstable osteosynthesis, such as intramedullary pinning in accordance to Hackethal, should be chosen.     

Operationsindikation und Verfahrenswahl beim distalen Radiusbruch—Draht,Platten, Fixateur externe

The treatment of the typical fracture of the radius is predominantly conservative. Unstable frctures, bending fractures and open fractures will receive operative treatment. Hereby Kirschner wires, blade plates and screws are applived for osteosynthesis. Heavy comminuted fractures were stabilized, besides by minimal osteosynthesis, by a mini-external fixation unit. The results of operative treatment in the Unfallchirurgische Klinik Gießen were in 50% excellent and good, in 38% satisfactory and in 12% bad. The main complications were disturbances of sensibility in the area of the superficial branch of the radial nerve.     

Severely comminuted femoral shaft fractures: Treatment by bridging-plate osteosynthesis

Summary We report on 71 severely comminuted femoral shaft fractures that were operated on between 1980 and 1984 at the Berufsgenossenschaftliche Unfallklinik Duisburg-Buchholz. The method of operative stabilization was plate osteosynthesis in two variations: In one group 39 fractures (ten open) were stabilized by plate osteosynthesis after anatomical reduction of the fractured area. The other group comprised 32 fractures (six open) fixed with a bridging-plate osteosynthesis, without preparation of the fracture zone. The rate of postoperative complications was strikingly diminished after bridging-plate osteosynthesis. Fracture healing occurred within 23 (16–32) weeks after bridging-plate osteosynthesis and within 36 (32–40) weeks after anatomical reduction. No special instrumentation or equipment is necessary to perform a bridging-plate osteosynthesis. The patient rests in a supine position. There is no need for intraoperative image-intensifier control. For operative treatment of severely comminuted femoral fractures we consider the technique of bridging-plate osteosynthesis advantageous, especially in multiply injured patients.     

Implementation of locking compression plate together with intramedullary fibular graft in atrophic type humeral nonunions

Objective

This study aims to report the results of locking compression plate along with intramedullary fibular graft that was implemented in patients with the diagnosis of nonunion of humerus diaphysis.

Materials and methods

Five patients, operated between 2000 and 2009 for atrophic type nonunion of humeral diaphysis, were included in this study. Two patients were women (40%) and three were men (60%). The mean age was 49.2?years. Nonunion was found to be on the right humerus of 3 patients and on the left side of 2 patients. Causes of fractures were traffic accident in 2 cases, simple fall in 2 cases, and fall from height in 1 case. Mean duration after the elementary fracture was 70?months. Nonunion was diagnosed at 1/3 proximal humeral diaphysis in 2 patients, 1/3 distal humeral diaphysis in 2 patients, and 1/3 middle humeral diaphysis in one patient. Initially, conservative treatment was chosen for 3 cases and plate-screw osteosynthesis for 2 cases.

Results

Complete union was obtained in all cases radiologically. Mean union time was 20.1?weeks. With a mean of 1.78?cm, shortening was detected in comparative radiographies of both humeri. Mean range of motion at the elbow was 118° in flexion–extension arch of patients. The mean Constant-Murley score was 88 points. There was no complication regarding the operation and graft donor sites.

Conclusion

The management of atrophic type humeral nonunions is difficult. The method that we practice in such patients is a reliable treatment option with its stabile fixation and high union rates.     

Behandlungsergebnisse operativ versorgter Frakturen und Pseudarthrosen der Humerusdiaphyse

Between 1969 and 1975 94 patients with fractures and pseudarthrosis of the diaphysis of the humerus were seen. During the summer of 1977 in 56 of these patients a follow-up study was done. The operations were performed only with strict indications. The best results were achieved with the osteosynthesis using compression plates, according to the recommendations of the AO (working group for problems of osteosynthesis). If the radial nerve was damaged, the fracture was revised and a neurolysis was done as early as possible; if necessary, the radial nerve was displaced to the flexor side of the bone. In short transverse and oblique fractures of the humerus the osteosynthesis with compression plates can be recommended; alternating these fractures can be treated with nails.     

False aneurysm of perforating branch of the profunda femoris artery following intertrochanteric fracture, a rare vascular complication: clinical, radiological features and management: case report and review of the literature

Rare cases of pseudoaneurysm of the profunda femoris artery following hip fractures have been described in the literature. Awareness of this complication and a high level of suspicion allow early diagnosis and treatment, and thereby reduce the morbidity of this condition. We present a case of a false aneurysm of a perforating branch of the profunda femoris artery following osteosynthesis of an intertrochanteric fracture, which was treated successfully by coil embolisation.     

Differentiated therapy of distal radius fracture

The fracture of the distal radius loco typico is one of the most frequently occurring fractures. This article presents types of fractures, in particular Colles', Smith's, Barton's and multiple-fragment's fractures. Conservative and operative treatment is described, as well as problems related to the different procedures. Besides fracture retention by plaster splint or cast, Besides fracture retention by plaster splint or cast, transcutaneous osteosynthesis by Kirschner wire, lag screws, osteosynthesis by buttress plate and the use of the external fixator are described as examples of operative therapeutics.     

Bone and muscle mass after femoral neck fracture

The cortical bone mineral density (BMD), bone volume, bone mass and muscle volume of the thigh, and the BMD of the distal femur and proximal tibia were measured quantified by quantitative computed tomography (QCT) after an operation for a displaced femoral neck fracture. Twenty patients were randomized to osteosynthesis or total hip arthroplasty (THA). Both legs were scanned after 18 months, and the operated side was compared with the healthy side. Clinical assessment was performed with a Harris hip score. A reference group of 9 patients, who had undergone THA because of arthrosis, was chosen. In the fracture patients, we found a 9% decrease in bone mass and muscle volume of the middle femur. The BMD of the distal femur and proximal tibia showed a more marked osteopenia. There was no difference in these parameters between the two groups. In the reference group of operated arthrosis patients, we did not find any differences between sides postoperatively. After the operation, the fracture patients had a lower Harris score than the arthrosis patients, and this was most pronounced among those who had undergone osteosynthesis. The finding of a marked osteopenia after a femoral neck fracture, irrespective of treatment, but no bone loss after THA because of arthrosis, implies that patients with a femoral neck fracture are more sensitive to osteopenia, and that the bone loss is not proportional to the operative trauma. caused by the disuse and the posttraumatic effect on the bone caused by the operation. Also, the magnitude of the operative trauma may play a role in the development of the osteopenia. Thus, a displaced femoral neck fracture, treated with osteosynthesis or total hip arthroplasty (THA), offers a possibility to distinguish between the osteopenia caused by the fracture and the role of the operation, since the degree of the operative trauma is different. The aim of this study was to investigate whether or not the bone loss after a displaced femoral neck fracture depends on the mode of treatment.