The importance of isotope investigations in skeletal fractures

A useful technique for the investigation of skeletal fractures is the application of 99mTc phosphon isotope. This method may complete the X-rays and physical examinations, and it is especially useful in cases, when the date of vertebral compression is unknown.     

Magnetic resonance imaging of foot and ankle trauma

MRI is a useful diagnostic tool in the assessment of traumatic lesions of the foot and ankle. It is especially useful in demonstrating acute and chronic tendon and ligament injuries. Subtle fractures, including osteochondral, nondisplaced, and stress fractures, are well shown with MRI but may be difficult to detect on radiographs. A bone scan may also be used to detect these fractures; however, with MRI the fracture extent may be determined. MRI is also useful in diagnosing complication of trauma, such as ischemic necrosis and bone and soft-tissue infections.     

Die Behandlung von Humerusschaftfrakturen und subkapitalen Humerusfrakturen im Kindesalter

The orthopedic treatment is the first choice in shaft fractures of the humerus in children. Angulations of more than 10 degrees need reduction, in that case anesthesia should be used for surgical stabilization.The preferred method is the elastic-stable intramedullary nailing (ESIN). In adolescents, even unreamed interlocking medullary nails are used. The primary paresis of the radial nerve is not an indication for nerve exploration in principle, but may be useful in special fracture situations. In subcapital fractures, more distinct angulations can be left untouched because of the highly potent epiphyseal plate. In severe displaced fractures, reduction and stabilization by ESIN is recommended in patients over the age of 10 years.The method is even applicable to pathological fractures in juvenile bone cysts. In adolescents after the start of epiphyseal plate closure, angle-stable implants are an alternative.     

Die Behandlung von Humerusschaftfrakturen und subkapitalen Humerusfrakturen im Kindesalter

The orthopedic treatment is the first choice in shaft fractures of the humerus in children. Angulations of more than 10 degrees need reduction, in that case anesthesia should be used for surgical stabilization. The preferred method is the elastic-stable intramedullary nailing (ESIN). In adolescents, even unreamed interlocking medullary nails are used. The primary paresis of the radial nerve is not an indication for nerve exploration in principle, but may be useful in special fracture situations. In subcapital fractures, more distinct angulations can be left untouched because of the highly potent epiphyseal plate. In severe displaced fractures, reduction and stabilization by ESIN is recommended in patients over the age of 10 years. The method is even applicable to pathological fractures in juvenile bone cysts. In adolescents after the start of epiphyseal plate closure, angle-stable implants are an alternative.     

The use of bioabsorbable plate fixation for nasal fractures under local anaesthesia through open lacerations.

Nasal fractures are the most common facial fractures. The majority of nasal fractures have been discussed as minor injuries and managed by closed reduction and intranasal packing. However, in cases of a nasal fracture with open laceration on fracture site, the plates fixation may be accomplished with definite reduction through the open laceration. But, metallic reconstruction plates can sometimes produce palpable irregularity at the site of fixation in nasal bone fractures. We performed rigid fixation through open laceration wound with bioabsorbable plate and screws under local anesthesia. Satisfactory result was obtained in both functional and aesthetic aspect. Open reduction through external laceration and bioabsorbable fixation under local anesthesia is a reliable and useful method for the treatment of extensive and comminuted nasal fractures.     

Intravenous regional anaesthesia

Intravenous regional anaesthesia, or Bier's block, is a useful and safe technique for anaesthetizing distal limbs for short surgical procedures. It is most commonly used for reduction of forearm fractures within the emergency department and can be a useful method of providing anaesthesia in patients who may be unsuitable for a general anaesthetic, or when skills or equipment for other forms of regional anaesthesia are unavailable. When performed as recommended it has a proven safety record.     

Two cases of odontoid fracture in preschool children

Halo application is a standard method for cervical immobilization. However, complications may occur in children because of their thin skull and immature bone. The authors report two cases of odontoid fracture in preschool children treated with a Minerva cast. Two 4-year-old children sustained displaced odontoid fractures in motor vehicle accidents. The fractures were immediately reduced and immobilized using a Minerva cast, followed by the application of a soft collar. By the 1-year follow-up, uneventful bone union had occurred, and the children were able to attend preschool with minimal or no neurologic deficits. The Minerva cast is a classic, inexpensive method of cervical immobilization and is still useful for this kind of fracture. Immediate reduction and immobilization with a Minerva cast is a viable option for displaced odontoid fractures in preschool children.     

Intravenous regional anaesthesia

Intravenous regional anaesthesia, or Bier's block, is a useful and safe technique for anaesthetizing distal limbs for short surgical procedures. It is most commonly used for reduction of forearm fractures within the emergency department and can be a useful method of providing anaesthesia in patients who may be unsuitable for a general anaesthetic, or when skills or equipment for other forms of regional anaesthesia are unavailable. When performed as recommended it has a proven safety record.     

Epiphyseal injuries of the foot and ankle

A thorough knowledge of functional growth plate anatomy and physiology is essential to proper management of epiphyseal foot and ankle injuries. The ability to classify foot and ankle fractures according to the Salter-Harris anatomic and radiographic classification provides useful prognostic information that may affect treatment. The Dias-Tachdjian mechanistic classification system for pediatric ankle fractures provides useful information about the extent of osseous and soft tissue injury and the best method of closed reduction and correlates well with the Lauge-Hansen system, which is widely used for adult ankle fractures. Most epiphyseal foot fractures involve the metatarsals or phalanges and can usually be managed with closed reduction. Considerable spontaneous correction of deformity can be expected in the younger child (under age 10 years), but one should be aware that sagittal plane and rotational malalignment of the metatarsal heads may cause significant problems. Salter-Harris type I and II fractures of the ankle can usually be managed with closed reduction. Salter-Harris type III and IV ankle fractures with greater than 2 mm of displacement require open reduction and internal fixation. One must also have a high index of suspicion for juvenile Tillaux and triplane transitional fractures that may not be obvious on plain radiographs. Although these fractures usually do not produce significant limb-length discrepancies, they are intra-articular fractures and ankle joint arthritis can result. Finally, younger children (under age 10 years) have a better prognosis for spontaneous correction of nongrowth arrest-induced deformities but a much poorer prognosis with growth arrest injuries than do older children, in whom growth arrest does not usually cause a significant problem. All children with growth plate injuries should be followed at regular intervals for at least 2 years or to skeletal maturity in the case of physeal disturbance. Treatment of epiphyseal fractures of the foot and ankle must be individualized but should always be based upon a thorough knowledge of anatomy, bone growth physiology, classification, potential pitfalls, and prognosis.     

Comparison of antibiotic beads and intravenous antibiotics in open fractures

This study compared the efficacy of antibiotic impregnated beads with conventional intravenous antibiotics in the treatment of open fractures. A randomized prospective study was designed and conducted during a 29-month period. Sixty-seven patients with 75 open fractures were treated similarly, with the exception of the method of antibiotic administration, and were followed up for at least 1 year after injury. Infection occurred in two of 24 (8.3%) fractures treated with antibiotic beads alone and in two of 38 (5.3%) fractures treated with conventional intravenous antibiotics. In an unanticipated nonrandomized third cohort group, patients received antibiotic beads and intravenous antibiotics administered for nonorthopaedic reasons or limb threatening injury, or both. Two of 13 (15.4%) fractures in this high risk group became infected. Infection ultimately resolved in all fractures treated with antibiotic beads alone or antibiotic beads in conjunction with conventional intravenous antibiotics. This study was unable to achieve statistical significance; however, the data suggest antibiotic beads may be useful in preventing infection in open fractures. Thus, a larger multicenter randomized prospective study of isolated open fractures, eliminating other variables, is justified.     

Fixation choices for closed simple unstable oblique phalangeal and metacarpal fractures

Percutaneous K-wire fixation is still a useful technique for closed oblique phalangeal and meta-carpal fractures when an adequate closed reduction can be achieved. Lag screw fixation may be the best choice for open fixation of long oblique phalangeal and metacarpal fractures. For short oblique fractures, plating or tension band wiring is recommended. Plating provide rigid fixation to allow early mobilization; however, one may encounter frequent complications such as extensor lag, stiffness, or joint contracture when plating technique is used in phalangeal fractures. Tension band wiring technique at the phalangeal location may reduce such complications. Overall, successful outcomes of treating phalangeal and metacarpal fractures require a clear appreciation of fracture anatomy and pattern. It is mandatory for the treating surgeon to be familiar with all the treatment techniques discussed in order to tailor a specific technique for a particular injury and patient type.     

The use of Goetze cerclage in the treatment of tibial fractures]

On the basis of the authors' experiences and the data of the available literature Goetze's cerclage in the treatment of tibia fractures is discussed--as far as the authors know, this is the first report of this method in the Hungarian literature. On the basis of the authors' material, the method is very useful for the treatment of the long, spiral and oblique fractures of the leg.     

Concept of treatment in supracondylar humeral fractures

This opinion of treatment for children's supracondylar humeral fractures discusses techniques of fracture reduction and stabilization. A useful method of external visualization of the fracture is reviewed. The article discusses the treatment of 95 fractures in children using crossed and two lateral pin techniques.     

Treatment of femur shaft fractures in children with Ender nails

Ender-nailing is a proved method in the treatment of sub- and pertrochanteric fractures in old people. In special cases Ender-nailing can be useful in the treatment of other types of fractures. 3 cases of Ender-nailing of femoral shaft fractures in childhood are reported.     

Acute fractures of the scaphoid

Nondisplaced fractures of the scaphoid heal with cast immobilization in most cases, but operative treatment is being offered with greater frequency to active patients as an approach to reduce the period of cast immobilization. Computed tomography is more useful for evaluating displacement than standard radiography. Displaced fractures are at greater risk for nonunion and malunion-both of which have been associated with the development of radiocarpal arthritis in long-term studies--and should therefore be treated operatively. Surgical treatment is also recommended for complex fractures (open fractures, perilunate fracture-dislocations, and scaphoid fractures associated with fracture of the distal radius), very proximal fractures, and fractures for which the diagnosis and treatment have been delayed. Operative treatment of fractures of the scaphoid has been simplified by the development of cannulated screws. Internal fixation of fractures of the scaphoid may offer some advantages, including earlier return to athletics or manual labor.     

Tension band fixation of medial malleolus fractures.

A prospective study on tension band fixation of medial malleolus fractures was performed on 30 consecutive patients with 31 fractures from October 1987 until December 1990. All patients had at least a displaced medial malleolus fracture unreduced by closed methods. The fractures were classified into small, medium and large using a modified Lauge-Hansen classification. There were no nonunions or movements of wires postoperatively and only two patients had subjective complaints with reference to the wires that required hardware removal. There was one 2-mm malreduction and one patient with a wound slough and subsequent osteomyelitis. One fragment had 2 mm of displacement after fixation but went on to union. A biomechanical study was undertaken to compare fixation of the medial malleolus with K wires alone, K wires plus a tension band, and two cancellous screws. The tension band fixation provided the greatest resistance to pronation forces: for times stiffer than the two screws and 62% of the intact specimen. Tension band fixation of the medial malleolus is a biomechanically strong and clinically acceptable method of treatment for displaced medial malleolus fractures. This method of fixation may be especially useful for small fragments and in osteoporotic bone.     

股骨粗隆下骨折手术治疗进展

股骨粗隆下区骨折是髋关节周围骨折中最难处理的一种骨折类型,多由高能量创伤所致的粉碎性骨折。非手术治疗有较高的畸形愈合、不愈合以及其他并发症发生率,因而,粗隆下骨折多主张手术治疗。Russell-Taylor分类方法临床较常用,有利于指导内固定方法的选择。对于小粗隆以下平面的骨折,采用标准的交锁髓内钉较理想。骨折波及到小粗隆但梨状窝未累及时,选用头髓钉或95°角钢板可取得满意效果。对于大粗隆骨折并累及梨状窝时,采用滑行钉器械固定较好。DHS器械不适宜用于粗隆下骨折的治疗。     

Closed cast treatment of scaphoid fractures.

Cast immobilization of the wrist remains the treatment of choice for stable fractures of the waist and distal pole of the scaphoid. Criteria for diagnosis of stability should be stringent; plain radiographs may be misleading. CT may provide more accurate information on displacement. Immobilization of the thumb confers no advantage and restricts function unnecessarily. Evidence to support immobilization of the elbow is weak, but it may be useful for selected fractures. A cast does not protect the carpus from the effects of axial loading, which can produce large angulatory forces at the fracture. A gap or fracture offset of 1 mm or more are indicators of instability with potential for nonunion or malunion; internal fixation should be considered for these fractures. Internal fixation may also be considered routinely for proximal pole fractures, regardless of the degree of displacement, in view of their long healing time and high risk of nonunion after cast treatment.     

Radiographic methods for evaluating osteoporotic vertebral fractures

Reproducible methods for the radiological assessment of osteoporotic vertebral fractures, defined based on accurate criteria, are needed in everyday practice and in therapeutic trials and epidemiological studies.ObjectivesTo describe and to evaluate methods for osteoporotic vertebral fracture assessment based on standard radiographs or dual-energy X-ray absorptiometry (DXA) and to determine the role for each method in clinical practice, therapeutic trials, and epidemiological studies.MethodsA review written by a rheumatologist based on his clinical experience and on a literature review was submitted to four experts. Studies in English or French published between 1975 and February 2008 were retrieved from Medline using the keywords vertebral fracture, osteoporosis, vertebral deformity, and vertebral fracture assessment.ResultsOne hundred forty-nine articles were selected and read in their full-text version. There was no consensus regarding the definition of osteoporotic vertebral fractures. The following methods were evaluated: visual assessment, Genant's semi-quantitative assessment, Jiang's algorithm-based qualitative method, morphometric radiography, and DXA of the spine. In everyday practice, Genant's semi-quantitative assessment on standard radiographs may provide useful information on the severity and prognosis of osteoporosis. DXA done for bone mineral density measurement may detect vertebral fractures in asymptomatic patients. Assessment of standard radiographs remains the reference standard for diagnosing vertebral fractures in patients with suggestive symptoms (e.g., pain in the thoracic or lumbar spine, height loss, or thoracic kyphosis). For therapeutic trials and epidemiological studies, Genant's semi-quantitative assessment used by a trained and experienced observer is the preferred method, based on its good reproducibility and ability to differentiate fractures from other deformities. However, thousands of radiographs may be needed, making routine interpretation by an expert impractical. A visual semi-quantitative method may be used to separate normal radiographs from radiographs showing possible or obvious fractures, which can then be read by an expert. Alternatively, radiomorphometric indices can be determined on digitized radiographs in combination with a semi-quantitative assessment, with discordant cases being reviewed by an expert. We do not recommend Jiang's method at present, as it is still undergoing validation.     

Floating knee fracture (ipsilateral fracture of the femur and tibia)--treatment by closed Ender nailing

Fourteen cases of ipsilateral fractures of the femur and tibia (floating knee fracture) were reviewed and patients were graded according to the type of fracture and the method of treatment. Using the criteria for assessment described by Karlstr?m and Olerud, patients were graded as excellent, good, fair and poor. Excellent results were achieved in five patients, good in three and fair in six. When the fracture extended into the knee, it caused knee problem in three out of five. In ten cases the femoral shaft fractures were nailed and in five both bones were nailed. Nailing of both femur and tibia gave good or excellent result in all five cases. As the comminution is often severe in the cases of floating knee fracture, intramedullary nailing by Küntscher may be difficult. We have introduced a closed Ender nailing for femoral and tibial shaft fractures and we have found that this method is also useful for the floating knee fracture. It is advantageous for this type of fracture, because it is technically simple, it has wide indications and it results in rapid bone union without knee disturbance.