Treatment of unstable tibial shaft fractures by closed intramedullary nailing with flexible (Ender-type) pins.

Eighty patients with unstable tibial diaphyseal fractures were treated by closed intramedullary nailing with Ender-type flexible pins. The majority of injuries occurred from falling while snow skiing. Sixty-six fractures were closed and 14 were open. Fifty-eight fractures involved the distal, 21 fractures the middle, and one fracture the proximal one third of the tibial shaft. The average time to roentgenographic union was 15.5 weeks (range, ten to 34 weeks) for closed and open Grade I and II fractures. The time to union in Grade III fractures was 50 weeks (range, 36-64 weeks). There were two nonunions and two delayed unions. Both nonunions occurred in Grade IIIA open shaft fractures. Intramedullary stabilization with flexible, Ender-type pins provides good control of unstable tibial shaft fractures. The use of pins with a smaller diameter (3.5 or 4 mm) allows the surgeon to place more pins across the fracture site. The use of multiple pins and packing the intramedullary canal may provide better rotational stability. The use of Ender-type pins for fixation of Type IIIA open tibial shaft fractures is contraindicated.     

External fixation of paediatric subtrochanteric fractures using calcar rather than neck pins

Subtrochanteric femoral fractures in children are uncommon and have received limited attention in the literature. Its treatment is controversial, and different options are available: traction, spica casting, internal fixation and external fixation. The aim of this study is to present our results with external fixation of subtrochanteric femoral fractures in children using Ilizarov frame. Between January 2012 and January 2014, 14 patients with closed subtrochanteric femoral fractures were treated in Cairo University School of Medicine Teaching Hospital. The average age at the time of injury was 6.4 years (range 3.8–11.5 years). Pathological fractures and fractures associated with neuromuscular diseases were excluded from this study. Two patients were multiply injured with abdominal injuries (as ruptured spleen). In all cases, a low profile Ilizarov frame was inserted using two half pins inserted proximally from greater to lesser trochanters parallel to the hip joint orientation line (line between tip of greater trochanter and femoral head centre) and secured to an arch, and another three half pins were inserted distally perpendicular to the femoral shaft and secured to an arch that was connected by three rods to the proximal arch. No post-operative spica was used. Average follow-up was 18 months (range 12–36 months). All fractures united with anatomical alignment within an average of 8 weeks (range 6–12 weeks). There were no deep infections and no significant limb length discrepancies. At the latest follow-up, no patient had any restriction of activities. External fixation with a low profile Ilizarov frame appears as a good treatment option for subtrochanteric femoral fractures in children.Level of evidence: Level IV.     

Simultaneous ipsilateral diaphyseal fractures of the femur and tibia: treatment and complications

We present our experience of intramedullary nailing (IM) and external fixation in the treatment of 54 patients with ipsilateral diaphyseal fractures of the femur and tibia. Eight femoral and 24 tibial fractures were open. They were classified into three groups: IM nailing of both fractures (group A, 19 patients); IM nailing of the femoral and external fixation of the tibial fracture (group B, eight patients); and external fixation of both fractures (group C, 27 patients). In group C (which included all but one grade III open fracture), two patients died and four underwent amputation. Femoral fractures treated with external fixation had significantly more complications and reoperations than those treated with IM nailing. In tibial fractures this difference was also present but not statistically significant. We believe that IM nailing is the method of choice for femoral fractures and is preferable for tibial fractures, with the exception probably of grade III B and C open injuries.     

Vascular trauma to the lower extremity: the Lebanese war experience

The authors' experience with 386 patients who were operated on for vascular injuries to the lower extremities is reviewed. Of these, 118 had popliteal injuries, 252 had femoral injuries and 16 had tibial injuries. The overall mortality rate was 2.33% with no mortality in the popliteal and tibial injuries group whereas there were nine deaths in the femoral injuries group. The overall amputation rate was 5.95%, with 3.17% amputation rate for the femoral injuries group versus 11.86% for the popliteal injuries group and 6.25% for the tibial injuries group. Delay in repair (more than 6h from injury), associated femoral fractures and shocked condition on admission led to increased amputation rate. Prompt surgical repair, arterial as well as venous repair for popliteal and femoral injuries especially if femoral fracture is present, external skeletal fixation and/or traction, and fasciotomy when necessary led to improved limb salvage.     

High energy tibial plateau fractures treated with hybrid fixation: is knee bridging necessary?

This article assesses the necessity of knee bridging in high-energy tibial plateau fractures treated with ring or hybrid frames. One hundred twelve tibial plateau fractures were treated with hybrid fixation. Thirty fractures underwent simple tibial fixation and 82 fractures required provisional extension of the femoral fixation. Mean follow-up was 5 years (range: 28 months to 13 years). Seventy-three percent of the injuries had at least one indication for fixation and 57% had more than one indication for tibiofemoral fixation. The most common indications include comminution, soft-tissue compromise, and ligamentous injuries. The majority of high-energy tibial plateau fractures are associated with such injuries that require knee bridging. Fixed tibiofemoral fixation offers better subjective, clinical, functional, and radiologic results.     

Complex femur fractures in children: treatment with external fixation

External fixation was used to treat complex femur fractures in 10 children. These injuries were associated with head trauma, cerebral palsy, epidermolysis bullosa, open wounds, and failed casting. The duration of external fixation averaged 8 weeks, and the mean follow-up was 5 years 8 months. At follow-up, one patient had 2.6 cm of residual shortening, and two had overgrowth. Complications included one refracture. Three children developed superficial pin site drainage. Although most femur fractures can be treated with traction or casting, external fixation may simplify overall care in children with multiple injuries and is effective in controlling unacceptable femoral shortening and angulation.     

Outcomes of external fixation of pediatric femoral shaft fractures

Thirty-seven femoral shaft fractures, in 33 patients, were treated with unilateral external fixation after reduction from 1992 through 1998. Ten girls and 23 boys ranged in age from 4 to 14 years. Thirteen children had multiple injuries, whereas 20 children had isolated fractures. Average follow-up was 3 years, 9 months, with only five children lost to follow-up. The average duration in fixator was 107 days. Thirty-six of 37 fractures healed, and there was one delayed union. There was minimal angulation, and limb-length inequality was generally <1 cm; 72.7% had pin-tract infections. Eight (21.6%) patients refractured; four occurred in the four patients with bilateral femur fractures. We agree with previous reports that external fixation remains a viable option for treatment of pediatric femoral shaft fractures. However, in our series, rate of refracture (21.6%) after removal of the external fixator is significantly higher than previously reported in literature. Children with bilateral femur fractures were at greatest risk.     

Fracture of the tibia complicated by acute compartment syndrome

A consecutive series of 32 patients with tibia fractures complicated by compartment syndrome was treated with fasciotomy. One group was also treated with closed reduction of the fracture and cast immobilization and compared with a comparable group treated with internal fixation without case immobilization after fasciotomy. All other patients were treated with fasciotomy and reduction followed with either external skeletal fixation, pins and plaster, or skeletal traction. Care of the open fasciotomy incisions, observation of the neurovascular status of the limb, and rehabilitation of the extremity were facilitated by internal fixation operations without subsequent external cast immobilization. The anatomic and functional results in this group were better than those treated with fasciotomy and cast immobilization. All fractures were united by 20 weeks. Complications in both groups were similar, although one deep infection, which was resolved with appropriate treatment, occurred in the group treated with internal fixation. Six open tibia fractures were treated with external skeletal fixation after fasciotomy; the results were less satisfactory, but the initial injuries were also more severe in this group. Patients with closed tibial fractures complicated by compartment syndromes should be treated expeditiously with fasciotomy, followed by stable internal fixation.     

Reconstruction plate fixation of subtrochanteric femoral fractures in children

Pediatric subtrochanteric femoral fractures are rare and have received limited attention in the literature Treatment is controversial. Different treatment options are used: skin traction, 90/90 skeletal traction, spica casting, cast bracing, internal fixation and external fixation. The aim of this study is to present our results with internal fixation of subtrochanteric femoral fractures in children using a reconstruction plate. Between 2000 and 2004, eighteen patients with closed subtrochanteric femoral fractures were treated in the Mansoura Emergency Hospital. The average age at the time of injury was 8.2 years (range 5.3 years to 11.5 years). Pathological fractures and fractures associated with neuromuscular diseases were excluded from this study. Eight patients had head injuries and/or multiple injuries. In all cases a single 4.5 mm contoured reconstruction plate was used and a 6.5 mm cancellous screw was inserted through the plate into the femoral neck. Average follow-up was 38 months (range, 12 to 47 months). All fractures united with anatomical alignment within an average of 8 weeks (range 6 to 12 weeks). There were no deep infections and no significant limb length discrepancies. At the latest follow-up, no patient had any restriction of activities. Internal fixation with a reconstruction plate appears as a good treatment option for children with subtrochanteric femoral fractures.     

Flexible intramedullary nails for ipsilateral femoral and tibial fractures

Between June 1981 and August 1983, six patients were treated with flexible intramedullary nails for both femoral and tibial fractures in six floating knees. All six patients were males averaging 26 years of age and all six were involved in motor vehicle accidents. Concomitant associated injuries were common. Two femoral and five tibial fractures were open. All fractures were stabilized within 24 hours of injury by closed intramedullary nailing with Ender nails. At final followup, there was one femoral and one tibial nonunion in the same patient. For the remaining patients, femoral union averaged 10.3 weeks and tibial union averaged 18 weeks. Five patients regained full motion at the hip, and four regained full motion at the knee and ankle. Four patients returned to their preinjury level of function; two were less active, one ambulating without the use of external assistive devices, and one using a cane.     

Operative treatment of tibial fractures in children: are elastic stable intramedullary nails an improvement over external fixation?

BACKGROUND: Operative treatment of tibial fractures in children requires implants that do not violate open physes while maintaining tibial length and alignment. Both elastic stable intramedullary nails and external fixation can be utilized. We retrospectively reviewed our experience with these two techniques to determine if one is superior to the other. METHODS: We retrospectively reviewed the operative records and trauma registries of three institutions within our hospital system and identified thirty-five consecutive patients with open physes who had undergone operative treatment of a tibial fracture between April 1997 and June 2004. Four patients were excluded because they had been managed with locked intramedullary nails or with pins and plaster. Of the thirty-one remaining patients, sixteen had been managed with elastic stable intramedullary nails and fifteen had been managed with unilateral external fixation. The clinical and radiographic outcomes were compared. The functional outcomes were compared with use of the Pediatric Outcomes Data Collection Instrument. Complications related to treatment, such as malunion, delayed union, nonunion, infection, and the need for subsequent surgical treatment also were compared. RESULTS: Thirty-one patients with thirty-one operatively treated tibial fractures were available for evaluation. Fifteen patients had been managed with external fixation. Seven of these patients had a closed fracture, and eight had an open fracture. There were seven healing complications in this group, including two delayed unions, three nonunions, and two malunions. Sixteen patients had been managed with elastic stable intramedullary nailing. Eleven patients had a closed fracture, and five had an open fracture. The mean time to union for the intramedullary nailing group (seven weeks) was significantly shorter than that for the external fixation group (eighteen weeks) (p < 0.01). The functional outcomes for the intramedullary nailing group were significantly better than those for the external fixation group in the categories of pain, happiness, sports, and global function (the mean of the mean scores of the first four categories) (p < 0.01 for these comparisons). CONCLUSIONS: When surgical stabilization of tibial fractures in children is indicated, we believe that the preferred method of fixation is with elastic stable intramedullary nailing.     

Tibial shaft fractures in children and adolescents

Tibial shaft fractures are among the most common pediatric injuries managed by orthopaedic surgeons. Treatment is individualized based on patient age, concomitant injuries, fracture pattern, associated soft-tissue and neurovascular injury, and surgeon experience. Closed reduction and casting is the mainstay of treatment for diaphyseal tibial fractures. Careful clinical and radiographic follow-up with remanipulation as necessary is effective for most patients. Surgical management options include external fixation, locked intramedullary nail fixation in the older adolescent with closed physis, Kirschner wire fixation, and flexible intramedullary nailing. Union of pediatric diaphyseal tibial fractures occurs in approximately 10 weeks; nonunion occurs in <2% of cases. Some clinicians consider sagittal deformity angulation >10 degrees to be malunion and indicate that 10 degrees of valgus and 5 degrees of varus may not reliably remodel. Compartment syndromes associated with tibial shaft fractures occur less frequently in children and adolescents than in adults. Diagnosis may be difficult in a young child or one with altered mental status. Although the toddler fracture of the tibia is one of the most common in children younger than age 2 years, child abuse must be considered in the young child with an inconsistent history or with suspicious concomitant injuries.     

Femoral shaft fractures in children

Femoral shaft fractures are the commonest diaphyseal fractures of childhood after those of the radial and ulnar shaft and the tibial shaft. Common mechanisms include falls, particularly from playground equipment, motor vehicle accidents and sporting injuries. Unlike in adults, femoral shaft fractures are commonly isolated injuries in children. In infants, they may be due to non-accidental injury. Treatment of femoral shaft fractures varies with the age and size of children, associated injuries and local practice. Current modalities used for the treatment of femoral shaft fractures include various forms of traction, immediate and late spica casting, elastic nailing, external fixation, plate fixation, and conventional intramedullary nailing for older children and adolescents. All these forms of treatment have been reported as being successful in cohort studies. Very few comparative studies exist. The main current controversies are the age at which elastic nailing becomes appropriate instead of conservative management, and secondly, the treatment of the older, heavier child for whom elastic nails may not be appropriate. Familiarity with several methods of femoral shaft stabilisation is appropriate. The major determinant in the choice of treatment is cultural.     

手术治疗浮膝损伤52例

目的 探讨手术治疗浮膝损伤的意义。方法 根据不同骨折部位采用不同内固定器械及外固定治疗浮膝损伤５２例,其中３４例胫骨,３８例股骨切开复位内固定,１８例胫骨,１４例股骨用外固定支架固定。     

Closed tibial pilon fractures treated with external fixation

Fractures of tibial pilon are due to a high energy trauma. Associated skin complications are frequent as those of surgery of this pattern. Thus we performed external fixation as treatment for these fractures. Authors report a retrospective study of 17 closed fracture of tibial pilon, type C of Ruedi and Heim classification, treated by osteotaxis using external fixation of Hoffman with osteosynthesis of fibula by screwed plate. Our patients are of a mean age of 34 years with 11 men and 6 women. The right side was most frequently involved (12 patients). Skin injuries as phlyctena were seen in 6 patients. Delay of treatment did not exceed 72 h. We performed a closed reduction of the fracture of tibial pilon after internal fixation of fibula by screwed plate. Results were assessed after 24 months of study. Track pins infection was noted in three cases. Reduction was usually good, despite one case of recurvatum, one case of valgus, one case of Sudeck’s atrophy, three cases of arthritis have been noticed. Mobility decreased at about 30%. External fixation is a real alternative solution for treatment of these fractures for which osteosynthesis is not suitable. It allows us to avoid skin complications despite mobility decreasing.      

带锁髓内钉治疗股骨、股骨干骨折的临床应用

目的 带锁髓内钉治疗股骨、胫骨干骨折临床应用研究。方法 应用带锁髓内钉治疗股骨、胫骨干骨折104例。结果 闭合复位穿钉内固定术后6－10周愈合,切开复位内固定8－12周愈合,48周后拔出内固定物。无断钉、骨折延迟愈合或不愈合、感染、脂肪栓塞、关节僵硬等并发症发生。104例均获随访,平均随访20个月,无1例再次骨折。结论 带锁髓内钉内固定治疗股骨、胫骨干骨折与传统钢板螺丝钉内固定相比,具有固定牢固,防止骨折端扭转、分离,术后不需要外固定支持,能早期负重行走,骨折愈合率高,治疗效果可靠的优点。     

External fixation of complex femoral shaft fractures

Conversion of temporary external fixation to an intramedullary nail within the first 2 weeks after a femoral shaft fracture is standard practice. However, due to financial constraints, in large parts of the world external fixation of femoral shaft fractures is often the definitive treatment. Out of 60 fractures, 47 were followed-up for a minimum period of 39 weeks. The average follow-up time was 75 weeks. Fourteen fractures were closed, and 33 open. Forty-four fractures united at an average of 31 weeks. There were four non-unions, three of them infected. Secondary surgical procedures were performed for four non-unions and in eight cases of delayed union. One re-fracture occurred, which was successfully treated with repeat external fixation. Only six patients regained full range of motion. The average flexion was 72 degrees . Pin tract infections occurred in 26 patients, leading to loosening of four pins. Satisfactory results can be obtained with definitive external fixation of femoral shaft fractures. Pin tract infections, although a common occurrence, are not a major problem and can be treated by local wound care and antibiotic therapy. The most common problem is significant decrease in the range of motion of the knee.     

Plates versus external fixation in severe open tibial shaft fractures. A randomized trial

A prospective study of 59 patients with Grade II or III open tibial shaft fractures compared internal and external fixation. Bony stabilization was with plating by AO principles or with external fixation with the one-half pin technique, prospectively randomized. In 12 cases, minimal internal fixation of the tibia and external fixation were combined. Definitive wound closure was delayed in all cases. Three free-flap transfers and two gastrocnemius myoplasties were done; vascular injury necessitated three early limb amputations. Fifty-six patients were followed for at least one year. Five plate fixations (19%) were complicated by severe osteomyelitis, and three plate fixations failed. Severe osteomyelitis occurred in one case (3%) treated with external fixation. Three pin-tract infections occurred. In two patients, a 10 degrees anteroposterior angulation occurred after external fixation removal. One patient healed with a 25 degrees external rotation deformity. At final follow-up evaluation, all tibial shaft fractures had healed. Knee and ankle ranges of motion were affected by ipsilateral femoral shaft fracture, knee injury, or ankle and foot trauma but not by the type of fixation. Both methods yielded excellent results, but the rate and extent of complications were lower with external fixation. Therefore, external fixation using the one-half pin technique should be regarded as a primary method of stabilization for Grades II and III open tibial shaft fractures.     

Popliteal artery injuries associated with fractures and dislocations about the knee

The authors present the results of a retrospective review of popliteal artery injuries associated with fractures and dislocations about the knee. They treated 41 patients with popliteal artery injuries associated with either fractures about the knee or knee dislocations. Thirty-five of the patients were males, 6 females; the mean age was 23 years. The delay before accessing the hospital was 17 hours (range: 3 hours to 10 days). Thirty-two fractures were open. Together with the vascular injury, 12 femoral fractures, 20 tibial and fibular fractures, 5 knee dislocations, 4 femoral + tibial fractures were identified. Twenty-three patients underwent external fixation, 8 internal fixation, 6 plaster cast immobilization, 4 minimal osteosynthesis and plaster cast immobilization. The arterial injury was treated by end-to-end anastomosis in 5 cases, saphenous vein anastomosis in 29 cases and thrombectomy in 7 cases. Nine patients were amputated. Delay in surgery, blunt trauma, extensive soft tissue defect and bone fracture or dislocation, are associated with high amputation rate following popliteal artery injury. The influence of each of these factors alone on the amputation rate could not be evaluated in this study, as no statistically significant correlation could be demonstrated.     

Fractures of the tibia treated by flexible external fixation

Thirty-four patients with fractures of the tibial diaphyseal shaft were treated by flexible anterior half-frame external fixation. The average time to union in the frame was 12 weeks for a simple closed tibial fracture and 26 weeks for a complex open tibial fracture. Complications included malalignment and loss of initial reduction. Most of the complications could have been avoided if special attention had been paid to technical details of reduction of the fracture and insertion of the pins.