Physical therapy within the scope of fracture treatment in children. Recommendations of the Traumatology in Childhood Study Group

Physiotherapeutic follow-up treatment is required only in exceptional cases of fractures in childhood. Physiotherapeutic indications are justified for fractures with months of immobilisation, multiple fractures, fractures accompanied by soft-tissue defects and nerve injuries, vertebral fractures, fractures and craniocerebral trauma, and fractures entailing the risk of bone necrosis. Passive exercises are not at all indicated.     

Fracture interaction in the extremities, The possible relevance of posttraumatic osteopenia

Regional osteopenia may persist after certain types of fractures. To investigate the practical importance of this observation, the authors studied 2744 past fractures in 1659 patients with present fractures. Radial fractures rarely occurred ipsilateral to previous radial fractures, whereas fractures of the hand were more often ipsilateral to previous hand fractures. Hip fractures rarely recurred in the same hips. Patients with previous cervical hip fractures, unlike those with previous trochanteric fractures, had a predominance of subsequent fractures distal to the hip ipsilaterally. Those with previous femoral shaft fractures were more likely to have subsequent fractures ipsilaterally. Both femoral shaft and patellar fractures were more often seen on the side of previous lower extremity fractures. Patients with previous tibial fractures had more subsequent fractures of the femur and tibia ipsilaterally, and their present tibial fractures were more frequently ipsilateral when these fracture types had occurred in the past. Some of these shifts from the equal distribution of fractures between the two sides may be due to posttraumatic osteopenia.     

Spontaneous fractures of the hip in the elderly

The authors found 41 patients with 42 fractures of the hip who had no distinct history of trauma in the total of 1,449 hip fractures treated. They were all women ranging in age from 64 to 91 years. Most of the fractures were of intracapsular type. Three extracapsular fractures, however, were found. Fractures were randomly selected with clear history of trauma, which were matched to the patients with no trauma for age, sex, and type of fracture as a control group. The grades of osteoporosis of the femoral neck, estimated with the Singh index, and of the spine, estimated with the spinal score, were noted statistically significantly higher in the patients than those in the control group. Most of spontaneous fractures of the hip in the elderly are considered similar phenomena to the compression fractures of the dorsolumbar spine.     

Clavicle fractures in the newborn

A retrospective review of 21,632 live births from January 1982 to July 1987 was performed to determine the incidence and risk factors associated with fractures of the clavicle in the newborn. Fifty-eight fractures (57 patients) were identified, for an incidence of 2.7 clavicle fractures per 1000 live births. Fractures of the clavicle were associated with heavy neonates and shoulder dystocia. Three patients had concurrent clavicular fractures and Erb's palsy. These findings suggest that the incidence of clavicle fractures in the newborn may be reduced by identifying the macrosomic fetus and by minimizing shoulder dystocia. When clavicle fractures occur, a brachial plexus injury should be ruled out.     

Diagnostic strategy for suspected scaphoid fractures in the presence of other fractures in the carpal region

Bone scintigraphy will identify up to 25% of occult scaphoid bone fractures after negative scaphoid X-rays. Consequently, it deserves a place in the diagnostic process of suspected scaphoid fractures. However, the role of bone scintigraphy is less clear if scaphoid X-rays show other fractures in the carpal region. We analysed 111 consecutive patients with a suspected scaphoid fracture on physical examination. Scaphoid X-rays revealed 61 fractures. Fifty-five patients had scaphoid fractures only and six patients had other fractures in the carpal region but no scaphoid fracture. In 50 cases, no bone injury was seen on these X-rays. In three out of the six patients with other fractures in the carpal region, bone scintigraphy revealed four occult concomitant fractures: one scaphoid, one scaphoid and trapezial and one capitate fracture. In conclusion, bone scintigraphy is required when scaphoid X-rays do not confirm a suspected scaphoid fracture, even in the presence of other fractures in the carpal region.     

Fractures of the dens in adult patients

The series involves 42 consecutive acute fractures of the dens, of which 41 were treated nonoperatively. There were 26 Type II and 16 Type III fractures, as classified by Anderson and D'Alonzo. All Type III fractures and undisplaced or anteriorly displaced Type II fractures united. Posteriorly displaced Type II fractures had an overall nonunion rate of 50%, which increased to 75% if displacement was more than 5 mm. Eight patients died within 40 days after sustaining their fracture; seven had Type II fractures with an average of 10-mm posterior displacement. Seven patients with a Type II fracture had an associated atlas fracture; five of these patients died early. In Type II fractures, posterior displacement is an important prognostic factor for union and possibly for early mortality of elderly patients. In Type II fractures with an associated atlas fracture, the mortality rate is high. Nonoperative management, preferably halo-thoracic immobilization, is successful in all acute fractures of dens, except posteriorly displaced Type II fractures.     

Tosic external fixator in the management of proximal tibial fractures in adults.

This retrospective clinical study assessed proximal tibial fractures managed with the Tosic external fixator. Nineteen patients with 21 proximal tibial fractures treated with the Tosic external fixator between July 1997 and October 1998 comprised the study population. Eleven fractures were graded as 41A2, 3 fractures as 41 A3, 4 fractures as 41C1, and 3 fractures as 41 C2. Fourteen fractures were closed, and 7 fractures were open. Average time to healing was 1 7 weeks. No revision of fixation was needed. There were five cases of pin tract infection. Average range of knee motion was 2 degrees-135 degrees. These results indicate the Tosic external fixator is an efficient and simple way to treat proximal tibial metaphyseal fractures.     

Fractures of the lateral humeral condyle: role of the cartilage hinge in fracture stability.

This study investigates the hypothesis that the integrity of the cartilage hinge at the distal humeral epiphysis determines the stability of fractures of the lateral humeral condyle. Sixteen patients with lateral humeral condyle fractures were studied with radiographs and magnetic resonance imaging (MRI). The clinical course of each patient was compared using these imaging studies to determine whether initial fracture displacement and the integrity of the cartilage hinge correlated with fracture stability. Radiographically, 4 fractures were considered unstable (with initial fracture displacement >3 mm) and 12 were stable (initial displacement < or =3 mm). On MRI, 6 fractures were complete (with disruption of the lateral cartilage hinge) and 10 were incomplete. All unstable fractures had complete fractures on MRI. Ten of the 12 patients with radiographically stable injuries had incomplete fractures on MRI. None of these displaced during treatment. Two patients had radiographically stable fractures and complete fractures on MRI. One of these fractures displaced, confirming the hypothesis that the stability of lateral humeral condyle fractures is related to the integrity of the cartilage hinge.     

The use of the Lottes nail in the treatment of closed and open tibial shaft fractures.

During the years 1979 through 1987, 98 patients with 101 acute tibial fractures were initially treated with Lottes' nails at the authors' institution. Ninety-one percent of the fractures healed uneventfully. The average healing times were 15.7 weeks for the 40 closed fractures and 20.5 weeks for the 61 open fractures. Infection occurred in one of the 40 closed fractures (2.5%) and in eight of the 61 open fractures (13.1%). By Gustilo grade, infection occurred in none of the 22 Grade I fractures (0%); one of the 22 Grade II fractures (4.5%); and seven of the 17 Grade III open fractures (41.2%). Seven of the eight malunions resulted from preventable technical errors. Five of the six nonunions healed after a secondary procedure. Lottes nailing is recommended in closed fractures and Grade I and II open fractures when internal fixation is required. Grade III open fractures, treated with the Lottes nail, had a high rate of infection.     

Fracture of the proximal metaphysis of the tibia in children

Forty children seen consecutively with fractures of the proximal tibial metaphysis were reviewed to assess the frequency of the types of fracture and likelihood of developing progressive valgus deformity. The incidence of this fracture was 5.6 per 100,000 children per year. There were 17 fissure and buckle fractures, 15 greenstick fractures and 8 complete fractures. Valgus deformity was not seen after fissure or buckle fractures. Only 15 per cent of the greenstick and complete fractures progressed to valgus deformity. Predisposing factors were a young age and persistent valgus at the fracture site at union.     

Changes in bone mass and fracture type in patients with hip fractures. A comparison between the 1950s and the 1980s in Malm?, Sweden

A consecutive series of 970 hip fractures from 1950 to 1958 were reevaluated and compared with roentgenograms of 1359 hip fractures from 1983 to 1985. The femoral neck index (FNI) was measured and the Singh index (SI) determined. The number of trochanteric fractures has increased more than the number of cervical fractures during the past 30 years. There has been a shift during the last 30 years toward more dislocated cervical fractures. There has been no change in the distribution between stable and unstable trochanteric fractures. The FNI was significantly lower in the 1980s compared with the 1950s, both in men and women. In the 1980s, men and women with cervical fractures had a lower FNI compared with men and women with trochanteric fractures, even after age correction. The SI was significantly lower in the 1980s than in the 1950s, both in men and women, but the difference was significant in trochanteric fractures only. In the 1980s, trochanteric fractures had a lower SI compared with cervical fractures; this relationship was significant both in men and women. Our findings indicate that the bone mass, both cortical and trabecular, measured on roentgenograms of the hip, has diminished in the urban population during the past three decades. This could be one of many reasons for the increased incidence of hip fractures.     

Fractures of the proximal phalanx and metacarpals in the hand: preferred methods of stabilization

Treatment of fractures of the proximal phalanx and metacarpals is based on the presentation of the fracture, degree of displacement, and difficulty in maintaining fracture reduction. A wide array of treatment options exists for the variation in fracture patterns observed. Inherently stable fractures do not require surgical treatment; all other fractures should be considered for additional stabilization. In general, of the many combinations of internal fixation possible, Kirschner wires and screw-and-plate fixation predominate. Early closed reduction typically is successful for unicondylar fractures of the head of the proximal phalanx. Bicondylar proximal phalanx fractures usually are treated with plate fixation. Transverse and short oblique proximal phalanx fractures generally are treated with Kirschner wires, although a stable short oblique transverse shaft fracture can be managed with an intrinsic plus splint. Plate fixation is used in comminuted proximal phalanx as well as comminuted metacarpal fractures, and lag screws in spiral long oblique phalanx shaft fractures and metacarpal head fractures. Kirschner wire fixation is successful in metacarpal neck fractures as well as both short and long transverse oblique shaft fractures.     

Ultrasound in the diagnosis of fractures in children

We compared the results of primary ultrasonographic examination of 163 children with 224 suspected fractures with the subsequent radiological findings. The aim was to assess the value of ultrasound in the diagnosis of fractures in children. We found a good correlation for fractures of the long bones of the upper and lower limbs. Ultrasound was most reliable for the detection of simple femoral and humeral diaphyseal fractures and fractures of the forearm. It was less dependable for compound injuries and fractures adjacent to joints, lesions of the small bones of the hand and foot, non-displaced epiphyseal fractures (Salter-Harris type 1) or those with a fracture line of less than 1mm. We were able to distinguish several types of fracture in which the use of ultrasound alone gave reliable information and further radiography was unnecessary. We discuss the advantages and disadvantages of skeletal ultrasonographic studies in children.     

Fractures of the proximal humerus in adults

Fractures of the proximal humerus are a common upper-extremity injury, particularly in the elderly. The literature suggests that the results of treatment of displaced fractures are generally unsatisfactory. Since Neer's articles in 1970 we found little reported in the literature on these fractures. We conclude from our review of 90 fractures that the results of treatment of displaced fractures continue to be unsatisfactory, and we believe that displaced proximal humeral fractures, along with femoral neck fractures, should be classified as unsolved fractures.     

The significance of segmental fibular fractures in the management of associated tibial fractures

One hundred seventy-six patients with 179 tibial shaft fractures (between March 2003 and August 2007) with a minimum of 4 months follow up were retrospectively reviewed by the author. Twenty-nine of these fractures were found to have segmental fibular fractures. These 29 fractures were analysed and compared with the total of 179 tibial fractures. Segmental tibial fractures with and without segmental tibial comminution were also analysed and compared.The segmental fibular fracture group had a greater incidence of associated injuries, associated fractures, open tibial fractures, Gustilo III B type fractures, major flap procedures, bony infection and bone grafting procedures which was statistically significant. The coincidence of segmental fibular fractures and segmental tibial fracture with segmental comminution indicated a bad prognosis. Segmental fibular fracture (associated with tibial fracture) appear more severe injury than segmental tibial fracture.     

Current concepts in the treatment of fractures of the clavicle

Clavicle fracture is a common injury in all age groups. Injuries can be classified into groups. Group I includes fractures of the middle one third, the most frequent site. Group II fractures account for 10% of fractures of the clavicle and involve the clavicle lateral to the coracoclavicular ligament and are caused by direct violence. These injuries are divided into two subsets. Group II Type I fractures occur lateral to the coracoclavicular ligaments and are stable. Group II Type II fractures occur just medial to the coracoclavicular ligaments and are unstable. These latter injuries require stabilization. Group III fractures are uncommon and involve the medial end of the clavicle and are rarely caused by direct violence. Most fractures of the clavicle can be treated closed with excellent results. Open treatment is only occasionally indicated and then only under certain stringent conditions. Most complications occur with open treatment and include nonunion and infection. Neurovascular complications are uncommon but not unusual. Although reasonable shoulder function is compatible with surgical resection of the clavicle, it cannot be done with impunity.     

Treatment of intracapsular fractures of the femoral neck in Denmark: trends in indications over the past decade

A questionnaire survey was set up in Denmark in 1996 including 40 orthopedic departments and 20 departments of general surgery, all dealing with the treatment of intracapsular fractures of the femoral neck. The aim of the survey was to investigate whether the treatment of these complex fractures in Denmark followed the international standard, the "gold standard", recommended in the recent international literature. A shift in the treatment was noted, as compared with an earlier questionnaire survey in 1988, with more orthopedic departments performing a graduated treatment with respect to the age of the patients and fracture grade (Garden class). That is: a) nondisplaced fractures, b) displaced fractures (b.1 below 75 years and b.2 above 75 years). Cannulated screws/pins were more commonly used in Garden I and II fractures (non displaced fractures) and in Garden III and IV fractures (displaced fractures) in patients below 75 years. Hemiarthroplasty/arthroplasty were more commonly used in the older age group, above 75 years, in displaced fractures (Garden III-IV). It is concluded that a shift in the treatment of these fractures has occurred, especially in orthopedic departments. One reason for this may be an increasing number of orthopedic specialists with experience in arthroplastic surgery, making it possible to perform and/or supervise younger surgeons in this procedure. Another reason must be an increasing awareness among orthopedic specialists in Denmark that complication rates in osteosynthesis of the displaced fractures (Garden III-IV) have been too high.     

三维CT重建在累及关节面的复杂骨折治疗中的指导意义

目的　探讨三维CT重建在累及关节面的复杂骨折治疗中的指导意义。方法　自 1997年至今 ,我科共收治累及关节面的复杂骨折 35例 (包括髋臼骨折 4例、胫骨平台骨折 2 0例、距下关节骨折 11例 ) ,术前均行X线摄片并行CT扫描和三维CT重建 ,对关节面损伤程度进行评估并制定最佳治疗方案。结果　 4例髋臼骨折中 3例行手术治疗 ,2 0例胫骨平台骨折中 15例行手术治疗 (12例行植骨 ) ,11例距下关节骨折 7例行手术治疗。结论　三维CT重建能清楚地显示传统X线摄片所不能直接显示的关节面骨折 ,对手术前的骨折分类、治疗方案制订以及手术入路选择有一定的指导意义     

Stress fracture of the fifth metatarsal in athletes

Between 1975 and 1984 11 athletes with stress fractures of the fifth metatarsal were treated. There were 6 diaphyseal fractures, all of them in runners, and 5 transverse fractures of the base (Jones' fractures). The diaphyseal fractures healed with rest in 3-4 weeks. One patient with Jones' fracture was treated conservatively with a non-weight-bearing toe-to-knee plaster with good results. Four patients with delayed unions were treated operatively, three with a tension band and two Kirschnerwires, one with drilling and a single, thick Kirschner-wire. The fractures treated operatively progressed to bony union in about 3 months. The tendency of the Jones' fracture to delayed union and non-union in active athletes makes special requirements to the initial therapy of stress fractures. Best results have been obtained with a toe-to-knee cast with non-weight-bearing for 6-7 weeks. In delayed unions we recommend a tension band fixation with two Kirschner-wires. Non-unions should be treated with curettage and bone-grafting.     

Fractures of the fifth metatarsal in children and adolescents

OBJECTIVE: Fractures of the fifth metatarsal are the most common metatarsal fractures in children. Their treatment is based on the adult literature. The purpose of our study was to identify the different types of fifth metatarsal fractures, to determine the mean time to healing, and to examine whether current adult recommendations can be extrapolated to children and adolescents. METHODS: A total of 103 patients met the inclusion criteria. The fractures were classified according to location. Type I represented an apophyseal injury. Type II represented tubercle fractures with intra-articular extension. Type III injuries represented Jones fracture. Metatarsal neck and shaft fractures were included separately. RESULTS: Apophyseal fractures did well with a short-leg walking cast for 3 to 6 weeks. Displaced intraarticular fractures had a significant delay in healing versus nondisplaced ones. Jones fractures had delays in healing if not treated surgically. Neck and shaft fractures did well with casting. CONCLUSIONS: Most fractures of the fifth metatarsal in the pediatric population do well clinically after a course of walking cast, unless the fracture is an intra-articular displaced fracture type or the fracture occurs in the proximal diaphyseal area. Fixation of Jones fractures in active adolescents should be considered to allow faster return to regular activities and prevent refracture. We recommend non-weight bearing casts for all angulated or displaced intra-articular injuries to avoid delays in healing and angulation. From our series, it is evident that most pediatric fifth metatarsal fractures behave as those found in adults and can be treated similarly.