Treatment of Bennett, Rolando, and vertical intraarticular trapezial fractures

Intraarticular fractures at the first trapeziometacarpal joint include Bennett, Rolando, and vertical intraarticular fractures of the trapezium. If these fractures heal in a displaced position, a traumatic arthritis quickly develops at the thumb base. Open reduction and lag screw rigid internal fixation of a Bennett fracture is advisable if a satisfactory closed reduction cannot be obtained. If the palmar and dorsal displaced fragments of a Rolando fracture are of adequate size, an open reduction internal fixation may be performed with small lag screws incorporated through a T- or L-shaped buttress plate. A displaced vertical intraarticular fracture of the trapezium may be easily misdiagnosed as a trivial chip fracture, unless specific radiographic views are obtained. Open reduction internal fixation is the only treatment method that will provide a satisfactory outcome for this fracture.     

Ankle fractures resulting from rotational injuries

Ankle fractures are among the most common skeletal injuries; selection of an optimal management method depends on ankle stability. Stable fractures (eg, isolated lateral malleolar) generally are managed nonsurgically; unstable fractures (eg, bimalleolar, bimalleolar equivalent) usually are managed with open reduction and internal fixation. Stress radiographs may aid in the management of incomplete deltoid injury in which there is medial swelling and tenderness without radiographic talar shift. A posterior malleolar fracture should be reduced and stabilized if it comprises >30% of the articular surface and remains displaced after fibular stabilization. Ankle fractures with syndesmotic injury have additional tibiofibular instability that can be controlled by screw fixation. However, the choice between metal and bioabsorbable screws, screw size, number of cortices fixed, and indications for screw removal remain controversial. Conditions such as diabetes or advanced age are no longer contraindications to usual management recommendations.     

Metatarsal fractures

Metatarsal fractures are relatively common and if malunited, a frequent source of pain and disability. Nondisplaced fractures and fractures of the second to fourth metatarsal with displacement in the horizontal plane can be treated conservatively with protected weight bearing in a cast shoe for 4-6 weeks. In most displaced fractures, closed reduction can be achieved but maintenance of the reduction needs internal fixation. Percutaneous pinning is suitable for most fractures of the lesser metatarsals. Fractures with joint involvement and multiple fragments frequently require open reduction and plate fixation. Transverse fractures at the metaphyseal-diaphyseal junction of the fifth metatarsal ("Jones fractures") require an individualized approach tailored to the level of activity and time to union. Avulsion fractures of the fifth metatarsal bone are treated by open reduction and tension-band wiring or screw fixation if displaced more than 2 mm or with more that 30% of the joint involved. The metatarsals are the most common site of stress fractures, most of which are treated nonoperatively. Symptomatic posttraumatic deformities need adequate correction, in most cases by osteotomy across the former fracture site.     

Displaced Salter-Harris Type I Distal Fibula Fractures: Two Case Reports and a Review of the Literature

Salter-Harris type I (SH-I) fractures of the distal fibula are commonly encountered in pediatric orthopedics. We describe 2 unique cases of adolescents with completely displaced SH-I distal fibula fractures that were treated operatively. In the first case, a closed reduction attempt failed and the patient required open reduction and internal fixation of the distal fibula and syndesmosis. The syndesmotic ligaments were avulsed from the distal fibular metaphysis. In the second case, closed reduction of the distal fibula fracture was partially successful, but anatomic reduction could not be achieved without open reduction. The distal fibula fracture was fixed with an intramedullary screw. We believe this pattern of injury represents a variant of the adolescent transitional ankle fracture. Because the distal tibial physes were nearing complete closure in these patients, the energy propagated through the distal fibular physis. To the best of our knowledge, this combination of injuries has not been previously reported. This type of physeal fracture raises concern for premature physeal closure, fibular growth disturbance, syndesmotic instability, and medial (deltoid ligament) injury. Both patients had excellent outcomes after anatomic reduction and fixation of the displaced SH-I distal fibula fractures at 1 and 6 years of follow up, respectively.     

Bioabsorbable versus stainless steel screw fixation of the syndesmosis in pronation-lateral rotation ankle fractures: a prospective randomized trial

Thirty-two patients who had pronation-lateral rotation (PLR) fractures occurring four centimeters or more proximal to the ankle joint or lower if the talus was displaced greater than one centimeter laterally were enrolled in this study. Seventeen patients were randomized to fibular plate fixation with a 4.5 ml polylactic acid (PLA) bioabsorbable syndesmotic screw, and fifteen patients randomized to fibular plate fixation with a 4.5 mm stainless steel syndesmotic screw. All thirty-two patients had uncomplicated healing of their fibular fracture without loss of reduction. There was neither evidence of osteolysis nor sterile effusion in the patients who were treated with the PLA screw. There were no wound complications in either group. No difference in range of motion or subjective complaints was noted in either group. Use of the PLA syndesmotic screw at short-term follow-up was well tolerated and avoided the need for subsequent screw removal.     

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.     

Correlation of interosseous membrane tears to the level of the fibular fracture

OBJECTIVES: To correlate interosseous membrane (IOM) tears of the ankle to the height of fibular fractures in operative ankle fractures. DESIGN: Prospective clinical trial. SETTING: University Level 1 trauma center. PATIENTS: All patients admitted with a closed operative ankle fracture were included. Of 93 patients originally evaluated, 73 patients had adequate MRI for evaluation. INTERVENTION: Open reduction and internal fixation of each ankle fracture was performed after preoperative MRI evaluation of the IOM. Transsyndesmotic screw fixation was performed when evidence of syndesmotic instability was shown by intraoperative stress testing. MAIN OUTCOME MEASUREMENTS: Radiographs were analyzed for fracture classification and prediction of ligamentous injuries about the ankle. MRI evaluated the IOM integrity, correlating it to the height of the fibular fracture. RESULTS: Of the 73 ankle fractures with adequate MRI evaluation, 30 had identifiable complete IOM tears on MRI. Ten of the 30 IOM tears did not correlate with the level of the fractured fibula. Seven cases had IOM tears proximal to the fibular fracture as detected by MRI. Five of these cases were Weber B type fractures, and two were Weber C type fracture patterns. Conversely, three cases of Weber C type fractures had IOM tears that remained distal to the level of the fibular fracture. CONCLUSIONS: The level of the fibular fracture does not correlate reliably with the integrity or extent of the interosseous membrane tears identified on MRI in operative ankle fractures. One cannot consistently estimate the integrity of the IOM and subsequent need for transsyndesmotic fixation based solely on the level of the fibular fracture. An intraoperative syndesmotic stress test is recommended to establish the presence or absence of syndesmotic instability.     

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.     

Screw osteosynthesis of displaced fractures of the radial condyle of the humerus in childhood. A long-term prospective study

Summary Pseudoarthrosis and cubitus valgus as main complications following displaced fractures of the radial condyle in children can be prevented by open reduction and fixation by K wires. However, delayed union and stimulation of the radial physis with condylar overgrowth and varisation of the elbow as well as fishtail deformities of the distal end of the humerus are reported nevertheless. To prevent those growth disturbances all primary and secondary (4-day X-ray control) displaced fractures of the radial condyle, i. e. those with a central gap of more than 2 mm, were prospectively treated by open reduction and osteosynthesis with a metaphyseal lag screw beginning 1974. Sixty-six patients (41 boys, 25 girls) with an average follow-up of 10 years (2–22 years) sustained 28 primary and 6 secondary displaced fractures. In 5 cases a K wire fixation was performed in view of the smallness of the fragment. Two children with conservative treatment following overlooked displaced fractures showed condylar overgrowth and varisation of the elbow. Screw osteosynthesis led to symmetric elbow angles and function in all cases, whereas fishtail deformities could be observed in 8 of 27 children, probably as a consequence of the remaining central fracture instability. Conclusion: Open reduction and osteosynthesis with a metaphyseal lag screw prevents condylar overgrowth in displaced fractures of the radial condyle by guaranteeing fracture healing in anatomic position within 3–4 weeks. However, fishtail deformity can not be prevented by metaphyseal compression only.      

Observer assessment of femoral neck radiographs after reduction and dynamic hip screw fixation

Introduction It is not known how the described methods of reduction and dynamic hip screw (DHS) fixation of displaced intracapsular femoral neck fractures translate into proper assessment of the postoperative radiographs. At teaching or evaluation sessions in daily practice, frequent discussion arises about postoperative technical assessment. The assessment of correct reduction and DHS fixation using the described methods in the literature may be subject to differences between observers. The aim of this study was to assess the extent of inter- and intraobserver agreement on technique, based on the methods in the literature, in a simulated daily practice setting. Materials and methods The postoperative anteroposterior (AP) and lateral radiographs of 35 randomly selected patients aged 60–90 years were rated twice, 2 months apart, by six surgical observers from three institutions with similar views on reduction and DHS fixation for this fracture type. The radiographs were of sufficient quality for proper assessment. Criteria for reduction and fixation could be rated as either adequate or inadequate. An adequate rating was assigned if in the observers opinion, regardless of likely outcome, technical perfection according to the described methods had been achieved. The kappa statistic was calculated as a measure of agreement.Results Fracture reduction on the AP view approached a good kappa value (0.54). Poor to moderate interobserver agreement was found for fracture reduction on the lateral view and aspects of DHS fixation (kappa 0.10–0.36). Intraobserver agreement was good for five out of six observers for reduction and DHS fixation aspects (kappa 0.51–0.81).Conclusion During routine practice six surgical observers can nearly agree on adequate fracture reduction on the AP view, but do not agree on adequate reduction on the lateral view and adequate DHS fixation on the postoperative radiographs of displaced intracapsular femoral neck fractures.     

Percutaneous fixation of scaphoid fractures

Recent advances in techniques and implants have led to renewed interest in percutaneous screw fixation of acute scaphoid fractures. The closed (cast) treatment of acute scaphoid fractures generally has good outcome, with bony union resulting; however, closed treatment can result in delayed union, nonunion, malunion, cast- induced joint stiffness, and lost time from employment and avocations. Acute percutaneous fixation of scaphoid fracture has been proposed as a means to minimize some of the complications of closed (cast) treatment. Percutaneous treatment of both nondisplaced and displaced scaphoid fractures reportedly can achieve a nearly 100% union rate with minimal complications. Fixation of scaphoid fractures with headless compression screws can be done using both volar and dorsal approaches. The fracture reduction and alignment are assessed by fluoroscopy and arthroscopy. Appropriately performed acute percutaneous internal fixation is now a standard treatment option for a selected group of patients with acute scaphoid fracture.     

Is Fibular Fracture Displacement Consistent with Tibiotalar Displacement?

We believed open reduction with internal fixation is required for supination-external rotation ankle fractures located at the level of the distal tibiofibular syndesmosis (Lauge-Hanssen SER II and Weber B) with 2 mm or more fibular fracture displacement. The rationale for surgery for these ankle fractures is based on the notion of elevated intraarticular contact pressures with lateral displacement. To diagnose these injuries, we presumed that in patients with a fibular fracture with at least 2 mm fracture displacement, the lateral malleolus and talus have moved at least 2 mm in a lateral direction without medial displacement of the proximal fibula. We reviewed 55 adult patients treated operatively for a supination-external rotation II ankle fracture (2 mm or more fibular fracture displacement) between 1990 and 1998. On standard radiographs, distance from the tibia to the proximal fibula, distance from the tibia to the distal fibula, and displacement at the level of the fibular fracture were measured. These distances were compared preoperatively and postoperatively. We concluded tibiotalar displacement cannot be reliably assessed at the level of the fracture. Based on this and other studies, we believe there is little evidence to perform open reduction and internal fixation of supination-external rotation II ankle fractures.     

手法复位空心螺钉固定治疗儿童胫骨远端三平面骨折

目的 评估采用手法复位、经皮空心螺钉固定方法治疗儿童胫骨远端三平面骨折的疗效.方法 2004年9月至2009年3月,采用手法复位、空心螺钉固定方法治疗胫骨远端三平面骨折15例.男9例,女6例.术前经X线片或CT检查确诊.全部病例均为闭合性骨折,经手法复位治疗失败(X线片上骺板及关节面骨折间隙＞2mm)后行手术治疗.手术在"C"型臂X线机监视下进行,行踝关节轴向牵引,根据骨折类型内旋或外旋足,达到解剖复位后行经皮空心螺钉固定.术后行CT检查,确定骨折解剖复位,骺板及关节面骨折间隙＜2mm.术后石膏托固定8周.以改良Weber评估标准评价踝关节功能及愈合情况.结果 全部病例随访15-68个月,平均26个月.末次随访时按改良Weber评分,优13例,良2例.X线片检查所有病例均骨性愈合,未发现骨桥形成及关节面不平整现象,无肢体旋转和短缩畸形.所有患儿均能参加正常的体育活动.2例结果为良的患儿均与负重过早有关,主要表现为充分用力时患侧踝关节有轻度疼痛感.结论 对于闭合性胫骨远端三平面骨折手法复位失败者,采用手法复位、经皮空心螺钉固定方法手术操作简单,疗效满意.     

Cast immobilization in bayonet position versus reduction and pin fixation of overriding distal metaphyseal radius fractures in children under ten years of age: a case control study

PurposeCompletely displaced distal radius fractures in children have been traditionally reduced and immobilized with a cast or pin fixed. Cast immobilization leaving the fracture displaced in the bayonet position has been recently suggested as a non-invasive and effective treatment alternative. This is a pilot comparative study between reduction and no reduction.MethodsWe assessed subjective, functional and radiographic outcome after a minimum 2.5-year follow-up in 12 children under ten years of age who had sustained a completely displaced metaphyseal radius fracture, which had been immobilized leaving the fracture in an overriding position (shortening 3 mm to 9 mm). A total of 12 age-matched patients, whose similar fractures were reduced and pin fixed, were chosen for controls. ResultsAt follow-up none of the 24 patients had visible forearm deformity and the maximal angulation in radiographs was 5° Forearm and wrist movement was restored (< 10° of discrepancy) in all 24 patients. Grip strength ratio was normal in all but three surgically treated patients. All patients had returned to their previous activities. One operatively treated boy who was re-operated on reported of pain (visual analogue scale 2).ConclusionThe results of this study do not demonstrate the superiority of reduction and pin fixation over cast immobilization in the bayonet position of closed overriding distal metaphyseal radius fractures in children under ten years with normal neurovascular findings.Level of evidenceIII     

Recent scaphoid fractures (within the first three weeks)

Scaphoid fractures are the most common carpal fracture, accounting for 70 a 80% of all fractures of the wrist. The diagnosis of acute fracture of the scaphoid still continues to be missed despite an increasing improvement of imaging techniques. In fact, these fractures are mainly neglected because of minimal early symptoms or quick resolution of initial symptoms. X-ray analysis of acute fractures is rather difficult because of the irregular shape of the scaphoid and its overlapping with other structures. In case of doubtfull or negative initial radiographic views, a technetium 99 bone scan or MR imaging should be consisidered. These fractures occuring in the young and most active members of our society represents a population that doesn't have the patience for traditionnal immobilisation in cast. Thus patients with undisplaced fractures for whom early return to work or sport is a primary concern, percutaneous repair with cannulated screw fixation using fluoroscopy and even aided with arthroscopy represents an increasing option. Nevertheless, in thoses cases, cast immobilisation should always be first considered. If percutaneous internal fixation is the first choice in proximal pole fractures or fractures seen with a delay, in the other cases, it can only be advocated if internal fixation will provide a stable reduction. There is little controversy for the treatment of displaced unstable scaphoid fractures. Open repair and internal fixation with a screw represents the golden standard. Complex displaced or dislocated fractures are often comminuted and associated with bony defect. Accurate reduction may need to perform a bone graft. The ligamentous injuries should also be carefully repaired . Evidence of associated cartilagenous lesions must be asessed with precision, as they always jeopardize the end result.     

Closed reduction and internal fixation for acute midshaft clavicular fractures using cannulated screws

BACKGROUND: Although most acute midshaft clavicular fractures can be successfully treated nonsurgically, surgery is more appropriate for cases with severe displaced fractures, skin tenting, initial shortening of fracture ends, and associated with multiple injuries. However, methods of surgical treatment for such fractures remain controversial. This study discusses a closed reduction and internal fixation technique for midshaft clavicular fracture. METHODS: Between 2000 through 2003, 34 acute midshaft clavicular fractures were operatively treated with cannulated screws using closed reduction technique by one surgeon. The follow-up and clinical evaluation was performed by another surgeon. RESULTS: Thirty-one patients were followed for an average of 27.4 months (range, 24-37 months). Thirty (96.8%) fractures healed within 12 weeks, and one fracture healed at 18 weeks. No major surgical complications occurred, although superficial wound infection occurred in one patient. No implants needed to be removed. The final union rate was 100%. CONCLUSIONS: Closed reduction and internal fixation with cannulated screw is an alternative choice for treating acute midshaft clavicular fracture in selected cases where surgery is indicated and should be done cautiously.     

Cannulated variable pitch compression screw fixation of scaphoid fractures using a limited dorsal approach

Scaphoid fractures are common in the young, active patient. Treatment is challenging because of the complex three-dimensional anatomy of the scaphoid and the tenuous blood supply. Traditionally, cast immobilization has been used for the management of non-displaced fractures with satisfactory outcomes reported in the literature. However, non-surgical treatment may result in a delayed union or nonunion particularly if the fracture is unstable, displaced, or involves the proximal pole. Recently there has been increased interest in the fixation of non-displaced scaphoid fractures. The proposed advantages for operative treatment include avoiding the morbidity and inconvenience of prolonged cast immobilization and a lower incidence of delayed union or nonunion. A variety of surgical approaches for fixation of an acute scaphoid fracture have been described. The most common techniques include percutaneous fixation, arthroscopically assisted reduction and fixation, or open reduction and internal fixation via a volar approach. The senior author favors a limited dorsal approach with compression screw fixation of all proximal pole fractures as well as displaced and non-displaced fractures of the waist region. The technique is simple permitting accurate screw placement in the central axis of the scaphoid, which is biomechanically advantageous and important for achieving union.     

Syndesmotic disruption in low fibular fractures associated with deltoid ligament injury

Low fibular fractures that were associated with deltoid ligament disruption and inferior tibiofibular syndesmotic disruption were studied. All of the patients had a Type B Weber fibular fracture associated with a deltoid ligament injury. It was difficult to detect the syndesmosis disruption on the initial assessment of the anteroposterior and mortise radiographs obtained preoperatively because there was no obvious talar shift on the plain radiograph. Careful evaluation of the plain radiograph and determination of all the recommended measurements were necessary to diagnose the syndesmotic disruption. However, the syndesmotic disruption was easily recognizable on axial computed tomography scans when comparing the injured and the noninjured sides. Axial computed tomography scans also showed a shallow incisura fibularis in all patients and in three cases it revealed anterior fibular subluxation that was not appreciated on the plain radiographs obtained preoperatively. On the basis of the current study using the level of the fibular fracture as a guideline for application of the syndesmotic screw as suggested by some authors may not be accurate. There are several factors that should be considered including the depth of the incisura fibularis, posterior malleolus fractures, deltoid ligament injury, and subluxation of the fibula. The surgeon's impression in the operating room of syndesmosis stability should be considered as the best guideline in the application of syndesmosis fixation rather than depending on the level of the fibular fracture.     

Assessment of articular displacement of distal radius fractures

Intraarticular step and gap displacements represent the most common indication for surgical treatment of distal radius fractures. Most often, treatment decision making relies only on good-quality plain radiographs taken before and after reduction with measurement accuracy maximized by using the longitudinal axis method. When plain radiographs alone prove insufficient, CT scans or tomograms will significantly improve interobserver and intraobserver reliability of measurements, especially when evaluated using the arc method. Tomography is an effective method for postoperative evaluation of fractures immobilized in splints or casts. The role of MRI in assessing intraarticular distal radius fractures is limited to confirming injuries to carpal ligaments or the triangular fibrocartilage complex. Intraoperatively, we use fluoroscopy to obtain 30 degrees cephalad posteroanterior views and as 22 degrees lateral views to best observe articular surface reduction. Our current operative indications include fractures with radiocarpal or distal radioulnar joint step or gap deformities greater than 1-2 mm, gross distal radioulnar joint instability, or those with extensive metaphyseal comminution rendering them particularly unstable after closed reduction. In general, we tend to lean toward operative fixation in younger, more active patients.     

The influence of the timing of surgery on soft tissue complications and hospital stay. A review of 84 closed ankle fractures

BACKGROUND AND AIMS: Open reduction and internal fixation of an extensively swollen ankle may lead to wound closure problems, blistering, wound edge necrosis and infection. Accordingly, internal fixation should be accomplished either before or after the period of critical soft tissue swelling. The object of the study was to investigate if the timing of surgery had any influence upon soft tissue complications and hospital stay. PATIENTS AND METHODS: The clinical course of the first 6 postoperative weeks of 84 closed ankle fractures treated by open reduction and internal fixation were reviewed. Seventeen patients were not operated on early due to lack of operative capacity and were thus operated on after 5 days or more. These patients were compared to the patients operated on within 8 hours (n = 67). The groups were comparable with respect to age, gender and fracture types. RESULTS: Despite a higher incidence of primary soft tissue injuries in the early group, the patients operated on delayed had a higher incidence of wound infections (17.6% vs. 3.0%) and hospital stay was prolonged with 12.4 days compared to early surgery. All wound infections were found in grossly displaced fractures despite adequate closed reduction immediately after arrival in the hospital. CONCLUSIONS: Delayed surgery of closed ankle fractures increases the risk of soft tissue complications and prolongs hospital stay. Immediate surgery is particularly indicated in the severely displaced ankle fracture, and if not achievable, temporary reduction and immobilization is recommended.