弹性髓内钉固定与外固定支架治疗儿童股骨干骨折疗效比较

目的：比较弹性髓内针与外固定支架治疗儿童股骨干骨折的疗效。方法：2002年9月至2008年8月治疗儿童股骨干骨折共67例,使用弹性髓内针治疗儿童股骨干骨折36例,男23例,女13例,年龄5～11岁,平均（7.1±1.6）岁;外固定支架治疗31例,男19例,女12例,年龄3～12岁,平均（6.5±2.3）岁。所有病例均为闭合复位,对两种不同内固定术后骨折愈合时间、术后并发症进行比较分析。结果：全部病例均获随访,时间9～24个月,平均（12±3）个月。弹性随内针组治疗小儿股骨骨折在骨折临床愈合时间和骨性愈合时间均短于外固定支架组（P〈0.05）。外固定支架组,继发钉道感染5例,骨折延迟愈合3例,再骨折2例,螺钉断裂1例;弹性髓内针组钉尾激惹3例。结论：弹性髓内针治疗儿童股骨干骨折有很大优势,而对高能量骨折及多发伤的病例外固定支架则不失为一种良好的选择,股骨近端和远端骨折尽量避免使用弹性髓内针固定。     

TriGen肱骨钉治疗肱骨干骨折的临床应用

目的探讨TriGen肱骨钉治疗肱骨干骨折的疗效。方法采用顺行TriGen肱骨钉治疗新鲜闭合肱骨干骨折患者24例。结果患者均获随访,时间4～18个月,骨折均愈合。肩关节功能按Neer评分标准进行评价:优20例,良3例,可1例。优良率为95.8%(23/24)。无桡神经损伤、切口感染及骨不连发生。结论TriGen肱骨钉治疗肱骨干骨折,能提供足够的稳定性,可早期功能锻炼,近期临床疗效满意,尤其适合粉碎性或骨质较差的肱骨干骨折。     

Treatment of acute closed humeral shaft fractures with Ender nails

The effect of semirigid Ender nails (EN) in the treatment of closed humeral shaft fractures was reviewed and analyzed. Clinical study was set retrospectively with detailed parameters. One hundred and eighteen closed humeral shaft fractures, treated with closed reduction and internal fixation with ENs, were collected. The follow-up period was 78 (24-175) months. The average operation blood loss was 105 cc, operation time was 57 min, hospital stay was 6.5 days, and union time was 10.5 weeks. The postoperative complications included three superficial infections, one iatrogenic radial nerve palsy, eight nail backouts, and eight nonunions. In our experience, for closed humeral shaft fractures fixed surgically, EN is a good choice for its simplicity and efficacy, but the fracture gap should be minimized after fixation and postoperative care should be closely observed.     

交锁髓内钉治疗肱骨干骨折14例

目的 评价交锁髓内钉治疗肱骨干骨折的临床效果。方法 对14例肱骨干骨折病人行交锁髓内钉内固定术,其中肱骨上1/3骨折2例,中1/3骨折11例,下1/3骨折1例。9倒闭合复位,5例开放复位。结果 14例患者随访4～16个月,骨折均愈合,无合并桡神经损伤和骨不连等并发症。结论 交锁髓内钉适合肱骨干骨折的治疗。     

HUCKSTEP INTRAMEDULLARY NAILING FOR NON-UNION OF HUMERAL SHAFT FRACTURES

Background : Various techniques of internal fixation for non-union of humeral shaft fractures have been attempted, leading to union rates of between 50 and 90% with persisting non-union causing pain and disability. Some of these techniques have led to shoulder and elbow dysfunction. Methods : Eight patients treated with Huckstep nail fixation for humeral shaft non-union were reviewed and the rate of union was determined. Elbow and shoulder function were assessed as well as the presence of pain or disability. Results : Union was achieved in seven of the eight patients (87.5%). Four patients had occasional mild pain after union. All patients achieved good arm function. Average shoulder abduction was 157° and flexion 151° excluding one patient with antecedent advanced osteoarthrosis of the gleno-humeral joint. No patient experienced any permanent neurological deficit. Conclusions : Huckstep nail fixation achieved union rates comparable to or higher than the other techniques of internal fixation for non-union of humeral shaft fractures. Unlike the various methods of closed nailing, Huckstep nail fixation is not associated with shoulder and elbow dysfunction. It should be considered as a therapeutic option in humeral shaft fracture and non-union, especially where the fracture site needs to be opened.     

Unilateral external fixator in the treatment of lower third humeral shaft fractures

Lowerthirdhumeralshaftfracturesareoftenmanifestedbyoblique,spiralorcomminutedfractureswithahighincidenceofcomplicatingradialnerveinjury.Thispartofhumerusisirregularanatomicallyandneartheelbowjoint.Soitisdifficult toselectproperinternalfixationinstrumentswhile exploringradialnervethroughanterolateralapproach,whichaddsdifficultyinthetreatmentofthiskindof fractures.Inrecent6yearsweusedunilateralexternal fixatorstotreatsuchkindoffracturesinourdepartment andsatisfactoryresultswereachieved.METHOD…     

Humeral shaft fractures: national trends in management

Background

The incidence of humeral shaft fractures has been increasing over time. This represents a growing public health concern in a climate of cost containment. The purpose of this study is to analyze national trends in surgical management of humeral shaft fractures and determine factors predictive of surgical intervention.

Materials and methods

Humeral shaft fractures were identified by the International Classification of Diseases, Ninth Revision, Clinical Modification codes 812.21 and 812.31 in the United States Nationwide Inpatient Sample from 2002 to 2011. Open reduction and internal fixation (ORIF) was identified by code 79.31 (ORIF, humerus). Other case codes analyzed were 79.01 (closed reduction without internal fixation), 79.11 (closed reduction with internal fixation), and 79.21 (open reduction without internal fixation). Multivariate regression analysis was utilized to determine predictive factors for utilization of ORIF.

Results

27,908 humeral shaft fractures were identified. Utilization of ORIF increased from 47.2% of humeral shaft fractures in 2002 to 60.3% in 2011. Demographically, patients who underwent ORIF were younger (51.5 versus 59.7 years, p < 0.001; odds ratio 0.87 per decade of age). There were modest increases in ORIF usage with private insurance, open fracture, and hospital size, which persisted with multivariate regression analysis. Surprisingly, there was a tendency to shift from a slight increase in ORIF for males with the bivariate case to a slight preference for females in the multivariate case.

Conclusion

Utilization of ORIF for humeral shaft fractures has been steadily increasing with time. Surgical intervention was more common with younger patients, female gender, private insurance, and larger hospital size. The increasing incidence of surgical management for humeral shaft fractures may represent a public health burden given the historical success of non-operative management.

Level of evidence

IV.

     

Isolated posterior cruciate ligament injuries associated with closed tibial shaft fractures: a report of two cases

Introduction  Knee ligament injuries associated with tibia shaft fractures are usually neglected and treatment is delayed. To our knowledge, no case presentation discusses the clinical result of closed tibial shaft fracture with concomitant ipsilateral isolated PCL injury. In this literature, we report the clinical result of two cases that sustained closed tibial shaft fracture with concomitant PCL injury and discuss the treatment options. Materials and methods  We report the clinical result of two cases that sustained closed tibial shaft fracture with concomitant posterior cruciate ligament (PCL) injury. Case 1 received open reduction with plate fixation for the tibial shaft fracture, and he also received arthroscopic reconstruction of PCL with bone-patellar tendon-bone graft due to neglecting PCL injury 5 months later after fracture fixation. Case 2 sustained left tibial-fibular shaft fracture with isolated PCL injury confirmed by magnetic resonance image on the first day of injury. She received tibia fixation with intramedullary nail and conservative treatment with bracing and rehabilitation for PCL injury. Results  In case 1, the male patient only focused on fracture healing without any knee rehabilitation. His knee flexed deeply for protected weight bearing in the injured leg which may have exacerbated the posterior instability and reduced the possibility of PCL healing. The end result of knee function was poor even though PCL reconstruction was done later. In case 2, the female patient with diagnosed posterior cruciate ligament injury on the day of injury, her knee was immobilized in brace with full extension, which improved PCL healing. In addition, she received rehabilitation of quadriceps strengthening, and hamstring muscle contraction was avoided in her daily activity. After rehabilitation, the female patient did not complain of severe subjective instability even with an obvious posterior translation on posterior drawer test. Conclusions  We need to perform a careful physical examination of ipsilateral knee in cases of leg fractures, and MRI of knee before surgery if any doubt exists. However, a further research is needed to conclude on the best operation and rehabilitation program in patients with combined tibial shaft fracture and PCL injury. No support from any institution was gained for this study.     

带锁髓内钉治疗新鲜四肢长骨干骨折1224例疗效分析

目的总结带锁髓内钉治疗肱骨干、股骨干、股骨髁上、胫骨干和转子间骨折的疗效。方法自1996年10月至2004年6月间使用带锁髓内钉治疗的有完整资料的新鲜四肢骨折1224例,男778例,女446例;平均年龄39岁(16￣92岁)。骨折位于肱骨干92例,股骨转子间210例,股骨干488例,股骨髁上92例,胫骨342例。闭合骨折按AO分型:A型642例;B型364例;C型218例。开放骨折15例(GustiloⅠ型8例,GustiloⅡ型7例)。受伤至手术时间平均为8d(3h￣33d)。闭合复位1203例,切开复位23例;扩髓409例,非扩髓815例。结果平均随访时间为24个月(6￣70个月)。1204例骨折愈合,愈合率为98.2%,平均愈合时间为5个月(3￣12个月)。骨折不愈合22例,其中肱骨4例,股骨8例,股骨髁上4例,胫骨6例,总不愈合率为1.8%。术后无急性感染发生,3例发生晚期深部感染,总感染率为0.2%。术中16例发生严重骨折劈裂,4例为肱骨逆行髓内钉固定,4例Gamma钉固定,9例为股骨逆行髓内钉固定,占1.3%。6例发生医原性神经损伤,占0.4%。股骨髓内钉主钉断裂1例,锁钉断裂9例(0.6%)。晚期髓内钉末端骨折3例,占0.2%。53例主诉髓内钉尾端部位不适,占4.3%。结论闭合复位带锁髓内钉治疗骨干骨折在骨折愈合率、感染率、出血量、功能恢复情况和早期活动方面均较满意,是治疗骨干骨折较好的方法,但     

Antegrade locked nailing for humeral shaft fractures

Treatment results of antegrade locked nailing of acute humeral shaft fractures, including union rate and recovery of shoulder function, have been inconsistent. This led the current authors to hypothesize that implant design and surgical techniques might account for this inconsistency. In the current study, 47 fractures (38 acute; nine pathologic) in 47 patients achieved union with the techniques of closed nailing, short to long segment nailing, and fracture compression. Satisfactory recovery of shoulder function occurred because of minimal surgical trauma, prevention of impingement by the nail or locking screws, and prevention of axillary nerve injury or comminution of the humeral head. Forty-seven patients with 38 acute fractures and nine pathologic fractures were treated with humeral locked nails. Mean followup time was 21.4 months. With a single operation, all 38 acute fractures proceeded to eventual union; the average time to union was 7.8 weeks. Thirty-five patients had excellent or satisfactory recovery of shoulder function. Complications included slipout of the proximal screw, nail breakage, fragment displacement, and transient postoperative radial nerve palsy. All nine patients with pathologic fractures had substantial pain relief and increased arm function after surgery. The current study shows the reliability of antegrade locked nailing for proximal and middle third fractures of the humeral shaft.     

Early results of low-velocity ballistic femoral shaft fractures

IntroductionBallistic femur fractures are a common injury treated at United States civilian trauma centers. This study investigates the outcomes of these injuries by comparing the rates of infection, nonunion, secondary operations, and associated injuries from low-velocity gunshot (GSW) injuries with fractures sustained by blunt trauma.MethodsA retrospective cohort comparative study was performed at a Level 1 trauma center. 345 patients with closed blunt or GSW femoral shaft fractures over 10 years were included. All were treated with intramedullary nail fixation. Superficial and deep infection, vascular injury, compartment syndrome, nonunion, and secondary operations were identified.Results148 patients in the GSW group and 197 patients in the blunt trauma group had overall mean age 33.5 years and 80% were male. Deep infection rates were similar There were no nonunions in the GSW group, contrasted with 8 (4.4%) nonunions in the blunt trauma group (p = 0.02). The rate of compartment syndrome was higher in the GSW group (6.1% vs 0, p < 0.001). Arterial injury occurred in 9% following GSW (vs 0, p < 0.001). Overall, secondary unplanned procedure rates were the same: 8.1% for both groups.DiscussionBallistic femoral shaft fractures are often equated with open injuries; however, rates of infection and secondary operations closely mirror that of closed injuries resulting from blunt force trauma. Nonunions may be more common after blunt injury, and compartment syndrome and arterial injury are substantially more common following GSW, warranting careful clinical assessment.Level of evidencePrognostic, level III.     

Modern treatment of tibial shaft fractures: Is there a role today for closed treatment?

PurposeThe decision to attempt closed treatment on tibial shaft fractures can be challenging. At our institution, we attempt treatment of nearly all closed, isolated tibial shaft fractures. The purpose of this study was to report the results of 10 years of experience to develop a tool to identify patients for whom non-operative treatment of tibial shaft fractures may be a viable optionMethodThis was a retrospective review of patients with tibial shaft fracture seen at a level 1 trauma center over 10 years. Patients with closed, isolated injuries underwent sedation, closed reduction, long-leg casting, and outpatient follow-up. Patients were converted to surgery for inability to obtain or maintain acceptable alignment or patient intolerance. Radiographic characteristics and patient demographics were extracted. Logistic regression analysis was used to develop a model to predict which patient and injury characteristics determined success of nonoperative treatment.Results334 patients were identified with isolated, closed tibial shaft fractures, who were reduced and treated in a long leg cast. 234 patients (70%) converted to surgical treatment due to inability to maintain alignment, patient intolerance, and nonunion. In a regression model, coronal/sagittal translation, sagittal angulation, fracture morphology, and smoking status were shown to be significant predictors of success of nonoperative treatment (p < 0.05). We developed a Tibial Operative Outcome Likelihood (TOOL) score designed to help predict success or failure of closed treatment. The TOOL score can be used to identify a subsegment of patients with injuries amenable to closed treatment (38% of injuries) with a nonoperative success rate over 60%.ConclusionNon-operative treatment of tibial shaft fractures is feasible, although there is a relatively high conversion rate to operative treatment. However, it is possible to use injury characteristics to identify a cohort of patients with a higher chance of success with closed treatment, which is potentially useful in a resource-constrained setting or for patients who wish to avoid surgery.Level of EvidencePrognostic Level 3     

闭合复位带锁髓内钉适宜治疗合并桡神经损伤的肱骨干骨折吗?

目的探讨肱骨干骨折合并的桡神经损伤是否会因为带锁髓内钉置入时的闭合复位操作而导致神经损伤的加重。方法2002年1月～2005年1月手术治疗的353例肱骨干骨折患者中,63例术前合并桡神经损伤。对此63例患者的体检、手术记录、X线片及治疗结果进行回顾性分析。11例行闭合复位带锁髓内钉固定；52例行切开复位内固定术及桡神经探查术,应用PEMS 3．1版本的卡方检验对11例行闭合复位带锁髓内钉固定术的患者与19例可以采用带锁髓内钉固定但行切开复位内固定术及桡神经探查术的患者桡神经恢复情况进行统计学分析。结果52例行切开复位内固定术及桡神经探查术的患者中,9例(17．3%)桡神经被骨折端嵌压,其余43例均为桡神经挫伤。63例患者中,除2例外,桡神经损伤均于术后2～12周(平均8周)自行恢复。所有患者术后3～4个月获骨性愈合。闭合复位带锁髓内钉术与切开复位内固定及神经探查术对肱骨干骨折合并桡神经损伤患者的影响差异无显著性意义(P=0．3931)。结论闭合复位带锁髓内钉固定治疗合并桡神经损伤的肱骨干骨折患者是适宜的。     

The management of humeral shaft fractures with associated radial nerve palsy: a review of 117 cases

Patients and methods  

This single center retrospective study reviews the management and outcomes of 117 consecutive patients with humeral shaft fractures and associated radial nerve palsy (RNP) treated over a 20-year period (1986–2006). A total of 101 fractures were managed conservatively and 16 fractures underwent external fixation for poor bony alignment. Sixteen grade 1 and 2 open fractures underwent wound toileting alone. No patients underwent initial radial nerve exploration or opening of the fracture sites.     

Titanium elastic nails for pediatric tibial shaft fractures

Purpose  The purpose of our study was to investigate the safety and efficacy of elastic stable intramedullary nailing for unstable pediatric tibial shaft fractures using titanium elastic nails (TENs). To our knowledge, this is the largest series reported in the literature of this specific fixation technique. Methods  We reviewed all children with tibial shaft fractures treated operatively at our tertiary care children's hospital to find those patients who underwent fixation with TENs. Between 1998 and 2005, we identified 19 consecutive patients who satisfied inclusion criteria. The average age of the patients in our series was 12.2 years (range 7.2–16 years), and mean follow-up was 15.7 months (range 6–28 months). Patient charts and radiographs were retrospectively reviewed to gather the clinical data. Outcomes were classified as excellent, satisfactory, or poor according to the Flynn classification for flexible nail fixation. Results  All patients achieved complete healing at a mean of 11.0 weeks (range 6–18 weeks). At final follow-up, mean angulation was 2° (range 0°–6°) in the sagittal plane and 3° in the coronal plane (range 0°–9°). Five patients (26%) complained of irritation at the nail entry site; there were no leg length discrepancies or physeal arrests as a result of treatment. Two patients required remanipulation after the index procedure to maintain adequate alignment. According to the Flynn classification, we had 12 excellent, six satisfactory, and one poor result. Conclusion  Although the indications for operative fixation of pediatric tibial shaft fractures are rare, occasionally surgical treatment is warranted. Based on our results, elastic stable intramedullary nailing with titanium elastic nails is an effective surgical technique which allows rapid healing of tibial shaft fractures with an acceptable rate of complications. No authors received any financial support or compensation for this study.     

The Efficacy of Ultrasound for Visualizing Radial Nerve Lesions with Coexistent Plate Fixation of Humeral Shaft Fractures

IntroductionUltrasound has been commonly employed for depicting the morphology of the lesions in patients with radial nerve neuropathy, including entrapment, tumor, trauma, and iatrogenic injury. However, few studies have evaluated the efficacy of ultrasound for visualizing radial nerve lesions with coexistent plate fixation of humeral shaft fractures. This study aimed to address this special clinical issue.MethodsWe retrospectively examined the efficacy of ultrasound for visualizing radial nerve lesions with coexistent plate fixation of humeral shaft fractures based on intraoperative findings in patients who were treated in our hospital from January 2007 to June 2019.ResultsForty-six patients were included, and there was a 100% concordance between the ultrasound and intraoperative findings on radial nerve lesions. Ultrasonography revealed four types of lesions: radial nerve in continuity in thirty-one patients, neuroma in continuity in four patients, radial nerve stuck under the plate in three patients, and radial nerve transection in eight patients. The lesion radial nerve in continuity comprised two situations according to intraoperative electrodiagnostic test results, which could not be differentiated by ultrasonography, radial nerve in continuity treated with neurolysis in twenty-five patients and radial nerve in continuity treated with nerve graft in six patients.ConclusionUltrasonography can accurately depict radial nerve lesions with coexistent plate fixation of humeral shaft fractures. It provides a basis for determining the extent of nerve damage in all patients except those with the lesion radial nerve in continuity, which is conducive to making treatment decisions as early as possible.     

Radial nerve transposition with humeral fracture fixation: preliminary results

Humeral shaft fractures traditionally have been managed with closed treatment. In patients with polytrauma, open fractures, and patients at risk for nonunion, open reduction and internal fixation and intramedullary nailing have been advocated. The current study describes a technique used in humeral shaft fractures that reduces the risk of iatrogenic radial nerve injury during plate osteosynthesis in fracture patterns at high risk of nonunion (highly comminuted, transverse fractures). Ten patients who had radial nerve transposition were reviewed retrospectively using the electronic records database at the authors' institution. The average age of the patients was 27 years and average followup was 25 months. All had humeral shaft fractures, AO class A3.2 in four patients, B3.2 in five patients, and C2.2 in one patient. All fractures were deemed to be at high risk for nonunion. There were no iatrogenic nerve palsies as a result of the transposition, and no infections. Two patients had delayed or nonunion, who achieved healing after a second intervention. Transposition of the radial nerve is a useful adjunct to plating of humeral shaft fractures in patients at high risk for nonunion. The technique is safe, does not cause iatrogenic injury, and protects the radial nerve during all subsequent approaches to the fracture site.     

Russell-Taylor交锁髓内钉治疗肱骨干骨折

目的 总结Ｒｕｓｓｅｌｌ－Ｔａｙｌｏｒ交锁髓内钉（ＲＴ钉）治疗肱骨干骨折的效果。方法 用非扩髓的ＲＴ钉治疗１６例肱骨干骨折,其中新鲜骨折１２例,病理骨折３例,骨折不愈合１例。２例新鲜骨折伴有桡神经挫伤。结果 平均随访１４．５个月,１５例骨折愈合,平均愈合时间为１６．５周,２例肩部疼痛。结论 ＲＴ钉可有效治疗肱骨干骨折,尤其适用于病理性骨折、骨折不愈合、多段骨折及粉碎性骨折。     

微创旋入钉内固定技术治疗伴桡神经麻痹的肱骨干中下段骨折

目的：总结微创旋入钉内固定技术在治疗伴桡神经麻痹的肱骨干中、下段骨折的应用效果。方法：自2004年1月至2008年1月,收治36倒伴桡神经麻痹的肱骨干中、下段骨折患者。其中男28例,女8例;年龄20～58岁,平均36．5岁。致伤原因：机械伤18例,交通伤8例,意外伤10例,均为闭合性骨折。根据AO分型：A1型5例,A2型7例,B1型8例,B2型7例,B3型5例,C3型4例。于骨折部位外侧做小切口,探查桡神经后,复位骨折。经肩峰外侧做小切口,分开三角肌,于大结节后侧开槽,顺行用髓腔钻扩髓,挑选合适旋入钉旋入髓腔远端,沿槽口打入锁片完成固定。记录术后并发症、骨折愈合时间、桡神经功能恢复时间、肩关节和肘关节屈伸范围。采用ASES肩关节和HSS肘关节评分标准评价疗效.结果：36例患者切口均Ⅰ期愈合。获随访9-36周,平均18．5周。骨折愈合时间12～16周,平均为15．6周。桡神经功能术后12～36周完全恢复,平均17．8周。肩关节外展150°～170°,平均160°;肘关节活动范围130°～140°,平均135°。肩关节功能根据ASES评分标准,由术前的（43．85±8．90）分上升至术后的（91．27±7．66）分,差异有统计学意义（t=24．238,P=0．000）,其中优20例,良12例,可4例;肘关节根据HSS评分标准,由术前的（39．97±16．06）分上升至术后的（96．22±3．59）分,差异有统计学意义（t=20．512,P=0．000）,36例均为优。结论：采用微创旋入钉内固定技术治疗伴桡神经麻痹的肱骨干中、下段骨折可获得良好效果。     

Treatment of middle third humeral shaft fractures: minimal invasive plate osteosynthesis versus expandable nailing

The purpose of this study is to compare the results of middle third humeral shaft fractures treated with minimally invasive plate osteosynthesis (MIPO) with those treated with an expandable nail technique. Thirty-four patients with middle third humeral shaft fractures were retrospectively analyzed and divided into two groups: group A included 15 patients treated by MIPO and group B included 19 patients treated with an expandable intramedullary nail. The operation time, postoperative complications, time to fracture union, the UCLA End-Result score of the shoulder, and Mayo elbow performance index (MEPI) were recorded and compared. The mean operation time in group A was 108.3 ± 28.7 min and 85.0 ± 35.7 min in group B, a difference of 23.3 (27.4%) minutes (P < 0.05). There were no cases of iatrogenic radial nerve palsy or superficial infection in either group. All fractures united. The mean time to fracture union in group A was 16.1 ± 6.0 (8–32)weeks, versus 15.0 ± 2.5 (10–21) weeks in group B (P > 0.05). One case of delayed union was identified in group A. The mean UCLA End-Result score in group A was 34.2 ± 1.1 points (31–35 points)and 31.8 ± 2.6 points (26–35) in group B (t = 3.318 P = 0.002, P < 0.05). All the patients had excellent elbow functions. In surgical treatment of middle third humeral shaft fractures, MIPO appeared to offer advantages in terms of better shoulder and no iatrogenic radial nerve injuries, although technically more difficult and time consuming.