Pilon fractures of the wrist. Displaced intra-articular fractures of the distal radius.

22 patients who sustained high energy wrist injuries are reported. These complex injuries resulted in articular disruption of the distal radius. Associated injuries included scapho-lunate dissociation (18%), central die-punch injuries (14%), ulnar fractures (41%) and diastasis at the distal radioulnar joint (23%). Nine fractures (41%) were open and almost a third of patients had other skeletal injuries. All patients were treated by external fixation and reviewed after a mean follow-up of 2 1/2 years. There were no excellent results and only ten good ones (45%). The mean functional impairment was 32%. The external fixator was effective in maintaining extra-articular alignment, but not in ensuring accurate reduction of the articular surface. Residual incongruity of the joint surface was an adverse prognostic feature. All five patients (22%) with an articular step of more than 2 mm. developed symptomatic arthritis. Failure to restore the joint line did not account for all the unsatisfactory results; persistent scapho-lunate dissociation and problems at the distal radioulnar joint were also important.     

Percutaneous and limited open reduction of the articular surface of the distal radius

Between 1979 and 1986, 40 patients with intraarticular fractures of the distal radius, in which anatomic reduction could not be obtained by closed manipulation or external fixation, underwent a combination of percutaneous and/or limited open reduction techniques to restore articular congruity. All 40 patients' radiographs that were retrospectively reviewed with an average follow-up of 4 years showed satisfactory extraarticular alignment in 85% of cases, and 37 patients (92.5%) demonstrated an articular step-off of less than or equal to 1 mm. Thirty-one patients retrieved for follow-up had a good functional result. The treatment goals of intraarticular fractures of the distal radius are anatomic restoration of the joint surface and optimal fixation to maintain reduction in an effort to prevent posttraumatic arthrosis of the wrist.     

Fractures of the distal radius treated with a nonbridging external fixation technique using multiplanar k-wires

PURPOSE: Joint-bridging external fixation is a minimally invasive treatment option for distal radius fractures. Although radial length can be restored easily the anatomic reduction of articular fragments and restoration of the normal volar tilt proves to be more difficult. A method of nonbridging hybrid fixation of distal radius fractures facilitates fracture reduction and allows for free wrist movement. METHODS: Twenty-five consecutive patients with fractures of the distal radius were treated with nonbridging external fixation for 6 weeks. The stepwise surgical technique comprised a preliminary joint-bridging construction for reduction purposes, the subsequent insertion of 3 to 4 K-wires in the distal fragment, the assembling of wires to a bar nearly parallel to the fracture line, and lastly the removal of the joint-bridging part. Clinical and radiologic evaluation was performed on the first and seventh days and at 6 weeks and 2 years after surgery. RESULTS: All fractures united. Palmar tilt (> or =0 degrees ) and articular surface (articular step-off < 2 mm) were restored in all patients whereas loss of radial length occurred in 4 patients having the distal fracture fragment secured with 3 K-wires. No radial shortening was seen in fractures with 4 K-wires inserted in the distal fragment. Functional results at 2 years after surgery showed an average extension of 55 degrees and flexion of 64 degrees without significant differences between extra-articular and intra-articular fractures. There was no extensor tendinitis or pin loosening in the distal fragment; however, 3 pin track infections of proximal pins occurred. CONCLUSIONS: This surgical technique of nonbridging external fixation is a good treatment option for distal radius fractures: it permits wrist movement. We recommend the insertion of 4 K-wires in the distal fracture fragment.     

External fixation in comminuted,displaced intra-articular fractures of the distal radius: is it sufficient?

Introduction: External fixation has been extensively used to treat the intra-articular fractures of the distal radius and it has several distinct advantages over conventional POP cast and plate fixation. However, the limitation of external fixation to achieve articular congruity in the comminuted intra-articular fractures of the distal radius has been documented in the literature. This could be because external fixation alone does not expand crushed cancellous bone and cannot work without soft tissue hinges. This prospective study was conducted to look at the results of comminuted, displaced intra-articular fractures of the distal radius treated exclusively by external fixation. Materials and methods: A 2-year follow-up of 27 patients with comminuted, displaced intra-articular fractures of distal radius that were treated exclusively by external fixation is presented. The radiological results, functional results and complications were analyzed according to the scoring system given by Jakim et al. Results: Anatomical reduction could not be achieved in 12 patients (44%) and reduction was lost in two patients (7%). Excellent and good results were seen in 59.3%, fair results were seen in 22.2% and poor results were seen in 18.5% of the cases. Outcome scores of patients without articular step were significantly better as compared to the patients with articular step at healing. There was a positive correlation between the restoration of normal anatomy (radiological results) and the functional outcome (r=0.775). Overall nine patients (33%) had complications. Conclusion: We conclude that although the external fixation is reliable in maintaining the reduction in displaced comminuted intra-articular fractures, it is inadequate in restoring articular congruity in many cases. The complications of external fixation are frequent and may be potentially serious in nature.     

关节镜诊治关节内桡骨远端粉碎性骨折的软组织损伤

Objective To diagnose and evaluate soft tissue injuries in intra-articular fractures of the distal radius using arthroseopy. Methods Twenty young patients with displaced intra-articular fractures of distal radius were recruited in this prospective study. Three AO C2 and 17 C3 fractures were included. After arthroseopie examination fractures of distal radius were treated by external fixation with limited internal fixation or open plate fixation. Results Triangular fibrocartilage complex （TFCC） injury was found in 18 patients （90%） . Most were isolated Palmer type 1D injuries （67 % ）. Seapho-lunate ligament injury was found in two patients： one partial tear （grade H） and one complete tear （grade HI ）. Follow-ups ranged from 6 to 18 months. At the last follow-up, wrist function was excellent in one patient （6%）, good in eight（44% ） and fair in 11 （50%）. Conclusion TFCC injuries are common in intra-artieular fractures of the distal radius while injuries to seapho-lunate ligament are uncommon.     

Articular fractures of the distal part of the humerus

BACKGROUND: The purpose of this retrospective study was to identify the patterns of distal humeral articular fractures and to analyze the results of open reduction and internal fixation of these injuries. METHODS: The cases of twenty-one patients with an articular fracture of the distal part of the humerus were reviewed at an average of forty months after the injury. Five components of the injury were identified: (1) the capitellum and the lateral aspect of the trochlea, (2) the lateral epicondyle, (3) the posterior aspect of the lateral column, (4) the posterior aspect of the trochlea, and (5) the medial epicondyle. All fractures were reduced and were stabilized with implants buried beneath the articular surface. RESULTS: All fractures healed, and no patient had residual ulnohumeral instability or weakness. Ten patients required a second operation: six, for release of an elbow contracture; two, for treatment of ulnar neuropathy; one, for removal of hardware causing symptoms; and one, because of early loss of fixation. The average arc of ulnohumeral motion was 96 degrees (range, 55 degrees to 140 degrees ). The results according to the Mayo Elbow Performance Index were excellent in four patients, good in twelve, and fair in five. CONCLUSIONS: Apparent fractures of the capitellum are often more complex fractures of the articular surface of the distal part of the humerus. Treatment of these injuries with operative reduction and fixation with buried implants can result in satisfactory restoration of elbow function.     

Open treatment for displaced articular fractures of the distal radius

Fifteen patients with severely displaced Type 4 articular fractures of the distal radius required open treatment for the reduction and fixation of disrupted articular surfaces and for the repair of associated nerve, tendon, or arterial injuries. These patients were predominantly young men whose wrists had been exposed to violent compression forces. Five cases were rated excellent, nine good, and one fair according to the McBride and Lidstr?m systems of evaluation. In this study, distal radial fractures with wide displacement or rotation of the articular surfaces were treated by prompt and precise repair of skeletal and soft tissue damage.     

Transradioulnar single Kirschner-wire fixation versus conventional Kirschner-wire fixation for unstable fractures of both of the distal forearm bones in children

The purpose of this study was to introduce transradioulnar single Kirschner-wire (K-wire) fixation technique for unstable fractures of both of the distal forearm bones in children and to evaluate the differences in clinical and radiographic results of osteosynthesis between this method and conventional K-wire fixation. Forty-one patients (20 conventional K-wire fixation, 21 transradioulnar single K-wire fixation) were reviewed who underwent a closed or mini-open reduction with K-wire fixation for fractures of both of the distal forearm bones. Their mean age at operation was 10.7 years (range, 8-16 years). Surgical intervention was indicated (1) when in addition to a complete ulnar fracture, the radius showed a 50% of displacement or greater, or 20-degree angulation or greater, (2) when in addition to an incomplete ulnar fracture, the radius was completely displaced, and (3) when reangulation was 15 degrees or greater in any direction at follow-up. The minimum follow-up period was 2 years. Bony union was achieved in both groups at approximately 7 weeks after surgery, and there were no significant differences in the operative time, duration of hospitalization, and duration of external support between the 2 groups. There were no major complications such as nonunion, radioulnar synostosis, premature physeal closure, or redisplacement or reangulation. Transradioulnar single K-wire fixation technique was a relatively simple procedure with comparable outcomes compared with conventional K-wire fixation technique. In addition, physeal injuries could be avoided, and there was no need for passing across the fracture line. Thus, it is suggested that transradioulnar single K-wire fixation technique can be a good alternative method for high-risk fractures of both of the distal forearm bones in children.     

Closed reduction and percutaneous fixation of supracondylar fracture of the humerus and ipsilateral fracture of the forearm in children

We treated 22 children with a supracondylar fracture of the humerus and an ipsilateral fracture of the forearm by closed reduction and percutaneous fixation. There were four Gartland type-II and 18 Gartland type-III supracondylar fractures of the humerus. There were fractures of both bones of the forearm in 16 and of the radius in six. Both the supracondylar and the distal forearm fractures were treated by closed reduction and percutaneous fixation. The mean follow-up time was 38.6 months. At the latest follow-up there were 21 excellent or good results and one fair result. There were no cases of delayed union, nonunion or malunion. Five nerve injuries were diagnosed on admission and all recovered spontaneously within eight weeks. No patient developed a compartment syndrome.     

动力跨关节型外固定架在不稳定性桡骨远端骨折中的应用

目的 探讨手法复位或辅以有限内固定结合动力跨关节型外固定架跨腕关节固定治疗不稳定性桡骨远端骨折的效果.方法 应用手法复位或辅以内固定结合动力跨关节型外固定架跨腕关节固定治疗35例不稳定性桡骨远端骨折,骨折愈合后拆除外固定架.结果 随访6～16个月,骨折愈合时间7～9周.最后一次随访时,按Cooney腕关节评分系统(包括疼痛、功能状况、腕关节活动度、握力):优18例,良14例,可1例,优良率为91.4%.结论 手法复位或辅以有限内固定结合动力跨关节型外固定架跨腕关节固定治疗桡骨远端骨折既能使骨折复位、固定满意,又有利于术后早期手和腕部的功能康复锻炼,是治疗不稳定性桡骨远端骨折的有效方法.     

Augmented external fixation versus percutaneous pinning and casting for unstable fractures of the distal radius--a prospective randomized trial

PURPOSE: Many outcome studies of various surgical techniques for unstable fractures of the distal radius have been published but applicability of the results remains limited because the majority of these trials were not done in a prospective and/or randomized manner. In this study we evaluated 2 common surgical techniques used in the treatment of unstable distal radius fractures in a randomized prospective fashion with a 1-year radiographic and clinical follow-up period. Our hypothesis was that external fixation with augmentation would provide superior results compared with percutaneous pinning and casting. METHODS: Fifty patients younger than 65 years of age with unstable fractures of the distal radius were randomized into 1 of 2 surgical treatment groups: percutaneous pins with casting or augmented external fixation. All surgery was performed by 1 of 3 surgeons within 10 days of injury. Over 80% of the fractures were classified as AO-ASIF C2 or C3 and there was a similar distribution of fracture types in each group. RESULTS: The use of augmented external fixation did not improve the mean radiographic parameters of radial length, radial angulation, or volar tilt. Restoration of volar tilt of highly comminuted fractures was difficult to achieve regardless of the technique. Improved articular surface reduction was realized with the use of an external fixator but overall only 3 patients were noted to have steps or gaps greater than 2 mm. No significant differences in mean Disabilities of the Arm, Shoulder, and Hand scores, total range of motion, grip strength, or health-related quality of life were observed between the groups. All 3 patients diagnosed with sympathetic dystrophy had had external fixation. CONCLUSIONS: Although augmented external fixation represents a popular first line treatment for unstable fractures of the distal radius this study suggests that for fractures with minimal articular displacement similar clinical results can be obtained with percutaneous pinning and casting.     

动力性外固定支架和闭合复位治疗桡骨远端关节内移位骨折的疗效比较

目的 回顾性分析和比较动力性外固定支架(dynamic external fixation，DEF)与闭合复位石膏外固定两者治疗桡骨远端关节内移位骨折的疗效评价。方法 对96例急性桡骨远端关节内移位骨折患者，49例应用动力性外固定支架、47例采用闭合复位石膏外固定治疗。结果 治疗后均随访1年。96例桡骨远端关节内骨折，按AO分型属B型或C型骨折复位评分及Lidstrom功能评分标准评定：(1)石膏固定组：复位评分：优良率为44．7％，一般为36．2％，差者19．1％。功能评分：优良率为46．8％，一般为31．9％，差者21．3％。(2)动力性外固定支架组：复位评分：优良率达95．9％，一般及差仅占4．1％。功能评分：优良率为91．8％，一般及差为8．2％。结论 动力性外固定支架组的复位和功能评分明显优于石膏组，是治疗桡骨远端关节内严重移位、粉碎性骨折的好方法。     

Minimally invasive reduction and osteosynthesis of articular fractures of the distal radius

Treatment of displaced fractures of the distal radius has changed over the course of time. For many years, closed reduction with plaster immobilization was considered the treatment of choice. Subsequent use of pins and plaster, percutaneous pin fixation, and the development of external fixation devices all contributed to improving fracture stability. More recently a new generation of external fixation devices has been developed to permit distraction and palmar translation. In addition, over the past twenty years, we have seen the development of more sophisticated internal fixation devices for the treatment of displaced fractures of the distal radius. The indications for open reduction and internal fixation have been defined largely on the basis of numerous studies which support the concept that articular malreduction is predictive of traumatic arthritis and poor functional result. Knirk and Jupiter have reported poor results for intra-articular fractures of the distal radius having an articular step-off greater than 2 mm. More recently, wrist arthroscopy has been used to improve visualization of articular surfaces and aid fracture reduction. In addition, bone grafting techniques have been employed more frequently to accelerate fracture healing. With improvement in techniques, we are able to provide our patients with better functional results and return them to their activities of daily living and vocation more rapidly.     

Plating of the distal radius

Distal radius fractures are common injuries that can be treated by a variety of methods. Restoration of the distal radius anatomy within established guidelines yields the best short- and long-term results. Guidelines for acceptable reduction are (1) radial shortening < 5 mm, (2) radial inclination > 15 degrees , (3) sagittal tilt on lateral projection between 15 degrees dorsal tilt and 20 degrees volar tilt, (4) intra-articular step-off < 2 mm of the radiocarpal joint, and (5) articular incongruity < 2 mm of the sigmoid notch of the distal radius. Treatment options range from closed reduction and immobilization to open reduction with plates and screws; options are differentiated based on their ability to reinforce and stabilize the three columns of the distal radius and ulna. Plating allows direct restoration of the anatomy, stable internal fixation, a decreased period of immobilization, and early return of wrist function. Buttress plates reduce and stabilize vertical shear intra-articular fractures through an antiglide effect, where-as conventional and locking plates address metaphyseal comminution and/or preserve articular congruity/reduction. With conventional and locking plates, intra-articular fractures are directly reduced; with buttress plates, the plate itself helps reduce the intra-articular fracture. Complications associated with plating include tendon irritation or rupture and the need for plate removal.     

T型钢板在桡骨远端不稳定骨折治疗中的应用

目的 总结桡骨远端不稳定骨折T型钢板内固定治疗的效果,以提高桡骨远端不稳定骨折的治疗效果。方法 本组45例采用T型钢板固定,其中15例因骨缺损较严重同时植骨。结果 平均随访25．36个月。远期疗效优良者41例（1例双侧）,优良率91．11％。结论 桡骨远端不稳定骨折手法复位较困难,并因外固定难以维持复位而常发生再移位。这类骨折应尽早切开复位内固定,术后配合合理有效的功能锻炼,可以获得较好的效果。对远期功能影响最大的因素是桡骨短缩程度和关节解剖复位的满意程度。     

Open reduction and internal fixation of the posterior malleolus fragment via the posterolateral approach is radiologically superior to ‘A to P’ screw fixation

PurposeFunctional outcome in trimalleolar fractures is largely correlated to the reduction of the posterior fragment. Until recently, fixation was mainly performed for large fragments, by percutaneous anterior to posterior (‘A to P’) screw placement after closed reduction. Nowadays, ORIF via a posterolateral approach seems to gain in popularity. The aim of this study was to compare the postoperative photographs of operated trimalleolar fractures after either fracture treatment method, for fracture diastasis and step-off.Material and methodsAll consecutive patients with trimalleolar fractures, including posterior fragments of >5% of the articular surface and operated between 2007–2013 were analysed on size of posterior fragment, post-operative gap and step-off by three observers. The patients were divided into three groups; A to P screw fixation, ORIF via the posterolateral approach and no posterior fragment fixation at all.Results180 patients with trimalleolar ankle fractures were included for analyses. Twenty five posterior fragments were fixated percutaneously from anterior to posterior (group 1) and 51 underwent open reduction and internal fixation through a posterolateral approach (group 2). 104 patients underwent no posterior malleolus fixation (group 3). The average size of posterior fragment was 34% in group 1, 27% in group 2 and 16% in group 3. A postoperative step-off >1 mm was found in 40% (group 1), 9% (group 2) or 34% respectively (group 3).ConclusionsFixation of the posterior malleolus through an open posterolateral approach leads to better radiological results as compared to percutaneous ‘A to P’ screw fixation or no fixation at all.     

Classification and management of intra-articular fractures of the distal radius

A classification of distal radial articular fractures is described, based on observations of consistent patterns of fracture fragmentation and displacement. The classification categorizes articular fractures into four types, with the medial complex assuming a pivotal position as the cornerstone of both the radiocarpal and distal radioulnar joints. The purpose of this classification is four-fold: (1) to afford identification and an understanding of the displacement characteristics of the major fracture components, (2) to provide practical and rational guidelines for the management of these injuries based on specific fracture patterns, (3) to emphasize the frequency of concurrent soft tissue and other skeletal injuries associated with the more severe types of articular disruption, and (4) to serve as a prognostic gauge for the varied spectrum of distal radius articular injury. Optimal management of distal radius fractures necessitates the differentiation of articular from extra-articular fractures as well as prompt detection of unstable injuries. While the majority of unstable fractures can be successfully managed by closed methods, a substantial and increasing number require open treatment for restoration of articular congruity as well as repair of concomitant soft tissue and skeletal injuries. In all cases, precise reduction of the key medial fragments is essential to maximum recovery.     

The use of tricorticocancellous bone graft in severely comminuted intra-articular fractures of the distal radius

PURPOSE: We report the results of a retrospective study of the use of tricorticocancellous iliac crest bone graft in 12 patients with acute AO type C3.2 or type C3.3 fractures of the distal radius who were followed up for at least 1 year. METHODS: Twelve of 17 patients treated with the protocol were available for follow-up evaluation. All fractures were treated with open reduction and combined internal and external fixation. Five fractures were plated dorsally, 1 volarly, and 5 volarly and dorsally. RESULTS: Five patients had AO type C3.2 fractures and 7 had AO type C3.3 fractures. Nine of 10 radiographic parameters that were restored to near-normal values during the surgery were maintained at near-normal levels at the final follow-up evaluation at a mean of 28 months after surgery. Nine fractures had less than 2 mm of articular step-off of the distal radius and 8 had less than 3 mm of total articular incongruity (gap plus step-off). In 10 patients the radial length was restored to at least 10 mm. The mean arc of flexion-extension was 67% and the mean grip strength was 57% of that of the uninjured side. According to the Gartland and Werley demerit-point system 5 of the patients had good or excellent results. According to the modified Green and O'Brien clinical rating system 2 patients had good or excellent results. Poor results for 2 patients according to the demerit-point system and for 6 patients according to the Green and O'Brien clinical rating system were associated with severe ipsilateral soft-tissue and osseous injuries of the wrist, forearm, and arm. The total articular incongruity had a moderately strong correlation with the outcome as assessed by the demerit-point system. CONCLUSIONS: Tricorticocancellous bone grafting in conjunction with combined internal and external fixation is a satisfactory treatment that can lead to a high rate of return to work and sports, a high level of patient satisfaction, and a low rate of complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Noncontiguous fractures of the femoral neck,femoral shaft,and distal femur

BACKGROUND: Multifocal fractures of the femur are uncommon injuries and present unique management challenges. Combined ipsilateral fractures of the femoral shaft and femoral neck or the femoral shaft and distal femur have been described. The combination of noncontiguous ipsilateral femoral neck, femoral shaft, and distal femoral articular injuries, however, has not been described. The purposes of this report are to document the incidence and characteristics of this injury and to present a treatment rationale. METHODS: This was a retrospective study conducted at a Level I trauma center. RESULTS: Over a 5-year period, 1639 adult patients with femur fractures were definitively managed at the authors' institution. Five male and two female patients (average age, 43.3 years) sustained ipsilateral, noncontiguous fractures of the femoral neck, femoral shaft, and distal femoral articular surface (0.43%). All femoral neck fractures were vertically oriented. All distal femoral injuries were unicondylar. A variety of fixation methods were used, dependent on individual fracture characteristics. The femoral neck fractures were prioritized in all cases. Stabilization of the distal femoral articular surface was then performed before diaphyseal fixation in patients with sagittally oriented condylar fractures. Patients were followed for an average of 19.3 months. All fractures healed without the need for secondary procedures. CONCLUSION: This injury constellation is rare. Open reduction and internal fixation of the displaced femoral neck fracture should be the primary focus of orthopedic management, followed by stable reduction and fixation of displaced distal femoral articular injuries. The diaphyseal fracture should be treated with a technique that does not jeopardize either the proximal or the distal fractures. Patients who are critically ill can be managed in a similar sequence over the course of several days, depending on their overall condition.