Displaced subcapital fractures of the femur: a prospective randomized comparison of internal fixation, hemiarthroplasty and total hip replacement

In a prospective trial of 278 patients aged over 65 years, treatment of displaced subcapital fractures was randomly allocated to closed reduction and internal fixation with a sliding compression screwplate, Moore hemiarthroplasty, or total hip treatment with a Howse semicaptive prosthesis. One year after operation there was little difference between the three groups in mortality (25 per cent) or general complications. The revision rate within the first year was highest for internal fixation (25 per cent), but many of the replacements also required a further anaesthetic for reduction of a dislocation (Moore, 11 per cent; Howse 12.5 per cent). Total hip replacement resulted in the least pain and most mobility at 1 year, while hemiarthroplasty was worst in these respects. We conclude that internal fixation and particularly primary total hip replacement should be given serious consideration in the management of the elderly patient with a displaced subcapital fracture.     

Displaced fractures of the hip in children. Management by early operation and immobilisation in a hip spica cast

Fractures of the hip in children have been associated with a very high rate of serious complications including avascular necrosis (up to 47%) and coxa vara (up to 32%). Over a period of 20 years, we have treated displaced fractures by early anatomical reduction, internal fixation and immobilisation in a spica cast to try to reduce these complications. We have reviewed 18 patients who had a displaced non-pathological fracture of the hip when under 16 years of age. Their mean age at the time of the injury was eight years (2 to 13). They returned for examination and radiography at a mean follow-up of eight years (2 to 17). Each patient had been treated by early (" 24 hours) closed or open reduction with internal fixation and 16 had immobilisation in a spica cast. By Delbet's classification, there was one type-I, eight type-II, eight type-III, and one type-IV fractures. There were no complications in 15 patients. Avascular necrosis occurred in one patient (type-III), nonunion in one (type-II, one of the two patients who did not have a cast) and premature physeal closure in one (type-I). There were no cases of infection or complications as a result of the cast. Our treatment of displaced hip fractures in children by early reduction, internal fixation, and immobilisation in a spica cast gave reduced rates of complications compared with that of large published series in the literature.     

Juxta-epiphyseal fractures of the base of the proximal phalanx of the fingers in children and adolescents

A series of 34 juxta-epiphyseal fractures of the base of the proximal phalanx of the fingers of children and adolescents are presented. The pattern of injury appeared identical in all these fractures, with a lateral angulation force separating a small triangular metaphyseal fragment from the base of the phalanx on the side of angulation and the fracture line then continuing through the metaphysis, 1-2 mm distal to the growth plate. Fractures were classified into two types according to the degree of displacement. Type 1 fractures (n=18) were mildly displaced and were all successfully treated with closed reduction and splinting. Type 2 fractures (n=16) were severely displaced and problems with obtaining an adequate reduction and long-term residual deformities were encountered. One patient with a severely displaced fracture required open reduction and Kirschner-wire fixation because of flexor tendon entrapment at the fracture site. Another five cases required Kirschner-wire fixation after closed manipulation in order to maintain the reduction. The remaining 10 patients with Type 2 fractures were treated by closed reduction and splinting, and two patients healed with malunion causing a "pseudo-claw" deformity.     

Intra-articular fractures of the distal end of the radius in young adults

Intra-articular fractures of the distal part of the radius in young adults comprise a distinct subgroup of fractures that are difficult to manage and are associated with a high frequency of post-traumatic arthritis. The effect of residual radiocarpal incongruity after this fracture has not been investigated previously. A retrospective study of forty-three fractures in forty young adults (mean age, 27.6 years) was done to determine the components that are critical to the outcome. Treatment included application of a cast alone in twenty-one fractures, insertion of pins and application of a plaster cast in seventeen, external fixation in two fractures, and open reduction and internal fixation in three fractures. At a mean follow-up of 6.7 years, 26 per cent were rated as excellent; 35 per cent, as good; 33 per cent, as fair; and 6 per cent, as poor. There was radiographic evidence of post-traumatic arthritis in twenty-eight (65 per cent) of the fractures. Accurate articular restoration was the most critical factor in achieving a successful result. Of the twenty-four fractures that healed with residual incongruity of the radiocarpal joint, arthritis was noted in 91 per cent, whereas of the nineteen fractures that healed with a congruous joint, arthritis developed in only 11 per cent. A depressed articular surface (a so-called die-punch fragment) was reduced anatomically by closed means in only 49 per cent and was responsible for residual incongruity in 75 per cent of the incongruous joints at late follow-up. Non-union of the ulnar styloid process adversely affected the results. Restoration and maintenance (extra-articular reduction) of the dorsal tilt and radial length did not prove critical except when severe radial shortening occurred.     

Displaced intra-articular fractures of the tarsal navicular

Between 1980 and 1987, twenty-one patients who had a displaced fracture of the body of the tarsal navicular were treated with open reduction and internal fixation. A classification system was devised on the basis of the direction of the fracture line, the pattern of disruption of the surrounding joints, and the direction of displacement of the foot. In a Type-1 injury, the fracture line is in the coronal plane and there is no angulation of the fore part of the foot. In a Type-2 fracture, the primary fracture line is dorsal-lateral to plantar-medial, and the major fragment and the fore part of the foot are displaced medially. In a Type-3 injury, there is a comminuted fracture in the sagittal plane of the body of the tarsal navicular, and the fore part of the foot is laterally displaced. Satisfactory reduction, which was defined as restoration of more than 60 per cent of the joint surface in the anteroposterior and lateral planes, was achieved in all Type-1 injuries, 67 per cent of the Type-2 fractures, and 50 per cent of the Type-3 fractures. Radiographic evidence of healing was seen at an average of 8.5 weeks after injury. At an average follow-up of forty-four months (range, twelve to 106 months), a good result was noted in fourteen patients (67 per cent); a fair result, in four (19 per cent); and a poor result, in three (14 per cent). Both the type of fracture and the accuracy of the operative reduction directly correlated with the final clinical outcome.     

Treatment of displaced supracondylar fractures of the humerus in children at the orthopaedic ward of the Children's Hospital in Kielce]

Ninety five children in age from 4 to 12 years (61 boys and 34 girls) with displaced supracondylar distal humerus fractures were treated at the orthopaedic ward of The Children's Hospital in Kielce between I 2000-XII 2001. The method of choice was closed reduction and percutaneous fixation with Kirschner wires (74 children). We also used closed reduction and application of an above elbow cast (12 children), skeletal traction with fixation after swelling resignation (5 children), and open reduction and internal fixation (4 children). In 90 cases we did not observe any neurovascular disorders, and early functional results were good or satisfactory. 2 cases were associated with transient, postreduction radial nerve palsy. In 2 children surgical intervention was necessary due to external compression of the brachial artery in one case, and contusion with brachial artery spasm in another. In one girl we observed development of Volkmann's contracture (treated surgically with good functional result). The authors conclude that the closed reduction and percutaneous K-wire fixation can be used as a treatment of choice for displaced supracondylar fractures of the humerus in children.     

Fractures of the tibial plateau. Treatment by closed reduction and spica cast.

A retrospective study of sixty-one displaced fractures of the tibial plateau treated by closed manipulative reduction and immobilization for six weeks in a molded single hip-spica cast revealed that there was bone union in all cases. Weight-bearing was carefully avoided for twelve to sixteen weeks while motion of the knee was regained. Fifty-three patients were followed for six months to twenty-two years, an average of 3.8 years. Objectively, 85 per cent of the patients' results were rated good or excellent while subjectively 94 per cent of the patients were satisfied with their results.     

Treatment of acute midshaft clavicle fractures: systematic review of 2144 fractures: on behalf of the Evidence-Based Orthopaedic Trauma Working Group

BACKGROUND: Fractures of the clavicle were reported to represent 2.6% of all fractures with an overall incidence of 64 per 100,000 per year (1987, Malm?, Sweden). Midshaft fractures account for approximately 69% to 81% of all clavicle fractures. Treatment options for acute midshaft clavicle fractures include nonoperative treatment (mostly sling or figure-of-eight bandage), open reduction and internal fixation with plates, and closed or open reduction and internal fixation with intramedullary pins, wires, or a nail. Most surgeons prefer nonoperative treatment of nondisplaced midshaft clavicle fractures. However, the optimal treatment option for isolated acute displaced midshaft clavicle fractures remains controversial. OBJECTIVES: This study was designed to systematically summarize and compare results of different treatment options (nonoperative, operative extramedullary fixation, and operative intramedullary fixation) in the management of midshaft clavicle fractures, specifically for displaced fractures.     

Fracture of the neck of the talus. A clinical study

A clinical evaluation of 46 patients treated for fractures of the neck of the talus has been made after a mean follow-up period of 6 years. The cause of injury was most frequently motor vehicle accidents (26) and falls from heights (11). In non-displaced fractures plaster with immobilization was used and displaced fractures were treated by closed or open reduction. At follow-up most of the patients complained of symptoms hampering daily activities. Objectively, excellent to good results were obtained in 75 per cent of the non-displaced fractures and in 42 per cent of the displaced. Delayed union occurred in 15 per cent. Avascular necrosis was found in 15 per cent and degenerative changes in 97 per cent. A decreased density of bone under the articular cartilage, called subchondral atrophy, was seen in 50 per cent.     

Displaced forearm fractures in children treated with AO plates

Internal fixation with AO compression plates was carried out in 8 per cent of all children with displaced diaphyseal fractures of the forearm. Primary treatment for 23 of these 43 fractures consisted of primary fixation. All fractures healed in anatomical alignment. Deep infection was observed in 1 child. All fractures united but 1 refractured. Of 29 children, 27 were reexamined after a mean observation time of 5 years; 22 had obtained normal function of the arm, and nobody had restriction of rotation of the forearm exceeding 20 °. The mean overgrowth of the bones was 2.4 mm. Fifty-six per cent of the children had discrepancies in the linear growth between the radius and the ulna in the fractured arms. These disturbances had no influence on the functional results. We conclude that internal fixation with AO plates is preferable when closed reduction fails or when secondary displacement cannot be corrected by repeated gentle manipulation.     

Fractures of the neck of the talus. Long-term evaluation of seventy-one cases.

Seventy-one fractures through the neck of the talus were clinically evaluated and classified on the basis of roentgenographic appearance. The follow-up interval averaged 12.7 years. Good or excellent results were achieved in 59 per cent of the fractures. Accurate anatomical reduction of displaced fractures, if necessary by open reduction and internal fixation, is recommended. Avascular necrosis of the talar body occurred in 52 per cent of the fractures (in two of thirteen non-displaced fractures, in half of the fractures with subluxation or dislocation of the subtalar joint, and in sixteen of nineteen fractures with complete dislocation of the body of the talus). Many patients with avascular necrosis treated conservatively had satisfactory results. The complications of avascular necrosis, malunion, subtalar arthritis, and infection required twenty-five secondary procedures. Triple arthrodesis, tibiocalcaneal fusion, and dorsal beak resection of the talar neck all resulted in a high percentage of satisfactory results, but talectomy did not.     

Subtalar dislocations: long-term follow-up of 39 cases.

A total of 39 cases of subtalar dislocations, treated during a 10-year period, have been reviewed retrospectively. The average age in this series was 35 years and the average follow-up period was 5.5 years (range 2-10 years); medial dislocations predominated (74 per cent) and a large percentage were open (41 per cent). Associated fractures were frequent (64 per cent). Treatment included closed manipulative reduction but if this was not successful, open reduction was performed followed by Kirschner (K)-wire fixation. Wound cleansing and excision were carried out on the open cases. Results were assessed according to Hardcastle's scoring system and 11 good, 7 fair and 21 poor results were obtained. Associated fractures and open injuries were strongly related to the poor results. Good results were associated with an accurate reduction. Open reduction with K-wire fixation is advocated if minor displacement persists.     

Hook-pin fixation of subcapital fractures of the femur: an atraumatic procedure?

Eighty-seven patients with subcapital fractures of the femur treated by hook-pin fixation were reviewed clinically and radiologically with an average follow-up time of 29 months. There were 58 undisplaced and 29 displaced fractures. Seven per cent of the undisplaced and 31 per cent of the displaced fractures developed avascular necrosis (AVN) and failure of fixation was seen in 3.5 per cent and 10 per cent respectively. Overall, 23 per cent of patients developed healing complications of which just over one-half had revision arthroplasty.

The AVN rate in the undisplaced group was relatively low, though there was no clear advantage over simple screw fixation. In contrast, the incidence of AVN in displaced fractures was higher than with other methods. Fixation failure was related to surgical error in most instances.     

Osteosynthesis of Displaced Fractures of the Femoral Neck: A Comparison Between Smith-Petersen Osteosynthesis and Sliding-Nail-Plate Osteosynthesis - A Radiological Study

Smith-Petersen osteosynthesis has been compared with sliding-nail-plate osteosynthesis in a prospectively planned, randomized, follow-up study of 197 cases of displaced medial fractures of the femoral neck. A total of 131 patients were followed for more than 2 years. After Smith-Petersen osteosynthesis 66 per cent of the fractures united and after sliding-nail-plate osteosynthesis 77 per cent united. The results showed that the choice of fixation devices is of minor importance compared with exact reduction of the fracture and optimal positioning of the nail.     

Treatment of open tibial-shaft fractures. External fixation and secondary intramedullary nailing

Between 1979 and 1986, sixteen of 369 open fractures of the tibial shaft were treated by external fixation followed by intramedullary nailing. These fractures comprised one Type-I, two Type-II, and thirteen Type-III injuries. This method of treatment was the original treatment plan in nine patients (56 per cent), for delayed union while the external fixator was still in place in four patients (25 per cent), for loss of reduction in a plaster cast in two patients (13 per cent), and for osteomyelitis and a segmental defect in one patient (6 per cent). The average duration of external fixation was 8.5 weeks; the average time between removal of the external fixator and intramedullary nailing, three weeks; and the average time between injury and nailing, twelve weeks. All sixteen patients were followed until either the fracture had united (eleven patients) or there was an established non-union (five patients). At that time, seventeen additional procedures were performed, including bone-grafting, fibulectomy, and re-nailing. Only five of the sixteen fractures healed without additional surgical procedures or major complications. The five fractures that progressed to a non-union were all Type III, and all were complicated by a deep infection. Over-all, the complications included seven deep infections (an intramedullary infection in four patients, osteomyelitis in two, and a chronic draining sinus associated with a ring sequestrum in one); five minor infections during external fixation, which developed into five of the seven deep infections that occurred after the secondary intramedullary nailing; and eight non-unions, three of which progressed to union after multiple procedures. The over-all incidence of non-union was 50 per cent and that of deep infection, 44 per cent. On the basis of the high incidence of complications in both the present series and the few reports in the literature, we concluded that alternative treatment options should be carefully considered before electing this sequential method of fixation.     

Fractures of the shaft of the tibia treated with AO-compression osteosynthesis

Ninety-six displaced fractures of the shaft of the tibia in a series of 162 consecutive fractures were treated by AO internal fixation. Forty per cent were open fractures, of which 93 per cent received prophylactic treatment with antibiotics at the time of admission. The average time between the accident and the operation was 10 hours in closed fractures and 5 hours in open fractures. All cases were operated on by senior surgeons.The infection rate was 5.3 per cent in closed fractures, and 0 in open fractures. The average stay in hospital was 13 days. More than 90 per cent returned to work within 6 months after the accident. No case of pseudarthrosis or re-fracture was seen. The median time to final review was 36 months.Rigid internal fixation is advocated for all displaced fractures of the shaft of the tibia and is advocated as an urgent procedure especially in open fractures, and should be performed by experienced surgeons only. Rigid internal fixation appears to provide effective prophylaxis against secondary soft-tissue damage and limits the consequences of the initial soft-tissue damage.     

Osteosynthesis of Displaced Fractures of the Femoral Neck: A Comparison Between Smith-Petersen Osteosynthesis and Sliding-Nail-Plate Osteosynthesis - A Radiological Study

Smith-Petersen osteosynthesis has been compared with sliding-nail-plate osteosynthesis in a prospectively planned, randomized, follow-up study of 197 cases of displaced medial fractures of the femoral neck. A total of 131 patients were followed for more than 2 years. After Smith-Petersen osteosynthesis 66 per cent of the fractures united and after sliding-nail-plate osteosynthesis 77 per cent united. The results showed that the choice of fixation devices is of minor importance compared with exact reduction of the fracture and optimal positioning of the nail.     

Osteosynthesis of displaced fractures of the femoral neck. A comparison between Smith-Petersen Osteosynthesis and sliding-nail-plate osteosynthesis -- a radiological study.

Smith-Petersen osteosynthesis has been compared with sliding-nail-plate osteosynthesis in a prospectively planned, randomized, follow-up study of 197 cases of displaced medial fractures of the femoral neck. A total of 131 patients were followed for more than 2 years. After Smith-Petersen osteosynthesis 66 per cent of the fractures united and after sliding-nail-plate osteosynthesis 77 per cent united. The results showed that the choice of fixation devices is of minor importance compared with exact reduction of the fracture and optimal positioning of the nail.     

Treatment of open fractures of the tibial shaft with the use of interlocking nailing without reaming.

Fifty open fractures of the tibial shaft that were treated with débridement and interlocking nailing without reaming were followed for an average of twelve months. Most of the fractures were the result of high-energy trauma, and 68 per cent of the fracture wounds were grade III. Forty-eight (96 per cent) of the fifty fractures united at an average of seven months; there were no malunions. There were four infections (8 per cent), all at the sites of grade-III fractures. Locking screws broke in five tibiae (10 per cent), but the breakage did not result in a loss of reduction. Three nails broke, two at the sites of ununited fractures and one at the site of a healed fracture. These results are comparable with, or better than, those obtained with other forms of fixation, including immobilization with a cast, unlocked intramedullary nailing, and external fixation.     

Fractures of the distal radius. Current concepts for treatment

The authors review the treatment of fractures of the distal radius, based on their experience and from data in the literature. The choice of a treatment for any given fracture must take into account first of all the stability of the fracture. The best results are achieved in stable fractures. Only minimally displaced distal radius fractures can be treated functionally. However, a plaster cast for one week is indicated for the comfort of the patient. In displaced but stable fractures both closed reduction and percutaneous fixation are indicated. In case of closed reduction, the plaster cast should be applied for 5 to 6 weeks with an above-elbow cast for 3 weeks. Percutaneous fixation gives the best results in extraarticular fractures in younger patients. Because of its simplicity however, it should not be ignored in the elderly osteoporotic patients. In the authors' experience, both techniques were only used for extraarticular fractures. Good and excellent results were found in the closed reduction and plaster cast group in 74% of the patients; the Kapandji technique gave 75% good and excellent results. These results are in line with other findings which show that, for simple fracture types, the Kapandji technique and closed reduction seem to give similar results. External fixation is widely used for intra-articular comminuted fractures. Dynamic external fixation does not show any advantage over static devices. Additional K-wires or bone grafting may be necessary. External fixation gives superior results to plate and screw fixation. Internal fixation should be reserved for fractures with ventral comminution or severe displacement with unacceptable reduction by closed or minimally invasive techniques.