Traumatic damage to the cartilage influences outcome of anatomically reduced acetabular fractures: a medium-term retrospective analysis

We reviewed 77 patients with an acetabular fracture, treated operatively through a non-extensile approach after an average time of 45 months. The ilioinguinal approach was chosen in 41, the Kocher–Langenbeck approach in 36 patients. Following the Letournel classification, the most frequent lesions were posterior wall (26%), two-column (22.1%) and anterior column (14.3%) fractures. Subchondral impaction, intra-articular fracture fragments and fracture comminution, called modifiers, could be identified in the preoperative CT-data of 38 patients (49.4%). Patients were operated after an average of 4 days. Average hospital stay was 19 days. Sciatic nerve and peroneal nerve palsy were registered in 5.6%. Deep venous thrombosis was seen in 10.4%, peri-articular ossifications in 7.8%. During the 45-months follow-up, 10.4% patients needed secondary total hip arthroplasty.Using the Merle d’Aubigné score, 15 patients had an excellent, 39 a good, 15 a moderate, and 8 a bad result. In accordance with the Harris Hip Score, 29 patients achieved an excellent, 26 a good, 9 a moderate and 13 a bad result. Twenty of twenty-three (Merle d’Aubigné score) and twenty of twenty-two (Harris Hop Score) patients with moderate or bad results had one or more modifiers. Patients with operatively treated acetabular fractures, who had CT-findings such as subchondral impaction, fracture comminution or intra-articular fracture fragments in their preoperative examination, score significantly lower at middle term in the Harris Hip and Merle d’Aubigné scoring systems.     

Marknagelung distaler Unterschenkelfrakturen am Beispiel des ExpertTM Tibianagels

Objective

Restoration of axis, length, and rotation of the lower leg. Sufficient primary stability of the osteosynthesis for functional aftercare and to maintain joint mobility. Good bony healing in closed and open fractures.

Indications

Closed and open fractures of the tibia and complete lower leg fractures distal to the isthmus (AO 42), extraarticular fractures of the distal tibia (AO 43 A1/A2/A3), segmental fractures of the tibia with a fracture in the distal tibia, and certain intraarticular fractures of the distal tibia without impression of the joint line with the use of additional implants (AO 43 C1)

Contraindications

Patient in reduced general condition (e.g., bed ridden), flexion of the knee of less than 90°, patients with knee arthroplasty of the affected leg, infection in the area of the nail??s insertion, infection of the tibial cavity, complex articular fractures of the proximal or distal tibia with joint depression.

Surgical technique

Closed reduction of the fracture preferably on a fracture table or using a distractor or an external fixation frame. If necessary, use pointed reduction clamps or sterile drapery. In some cases, additional implants like percutaneous small fragment screws, poller screws or k-wires are helpful. Open reduction is rarely necessary and must be avoided. Opening of the proximal tibia in line with the medullary canal. Canulated insertion of the Expert^TM tibia nail (ETN; Synthes GmbH, Oberdorf, Switzerland) with reaming of the medullary canal. Control of axis, length, and rotation. Distal interlocking with the radiolucent drill and proximal interlocking with the targeting device.

Postoperative management

Immediate mobilization of ankle and knee joint. Mobilization with 20?kg weight-bearing with crutches. X-ray control 6 weeks postoperatively and increased weight-bearing depending on the fracture status. In cases with simple fractures, good bony contact, or transverse fracture pattern, full weight-bearing at the end of week 6 is targeted.

Results

Between July 2004 and May 2005, 180 patients were included in a multicenter study. The follow-up rate was 81% after 1?year. Of these, 91 fractures (50.6%) were located in the distal third of the tibia. In this segment, the rate of delayed union was 10.6%. Malalignment of >?5° was observed in 5.4%. A secondary malalignment after initial good reduction was detected in only 1.1% of all cases. The implant-specific risk for screw breakage was 3.2%. One patient sustained a deep infection. If additional fibula plating was performed an 8-fold higher risk for delayed bone healing was observed (95%CI: 2.9?C21.2, p<?0.001). If the fracture of the fibula was at the same height as on the tibia, the risk for delayed healing was even 14-fold (95%CI: 3.4?C62.5, p<?0.001). Biomechanically plating of the fibula does not increase stability in suprasyndesmal distal tibia-fibular fractures treated with an intramedullary nail. Using the ETN with its optimized locking options, fibula plating is not recommended, thus, avoiding soft tissue problems and potentially delayed bone healing.     

Isolated fractures of the greater tuberosity of the proximal humerus: a long-term retrospective study of 30 patients

Background and purpose

The diagnosis and treatment of isolated greater tuberosity fractures of the proximal humerus is not clear-cut. We retrospectively assessed the clinical and radiographic outcome of isolated greater tuberosity fractures.

Patients and methods

30 patients (mean age 58 (26–85) years, 19 women) with 30 closed isolated greater tuberosity fractures were reassessed after an average follow-up time of 3 years with DASH score and Constant score. Radiographic outcome was assessed on standard plain radiographs.

Results

14 of 17 patients with undisplaced or slightly displaced fractures (≤ 5 mm) were treated nonoperatively and had good clinical outcome (mean DASH score of 13, mean Constant score of 71). 8 patients with moderately displaced fractures (6–10 mm) were either treated nonoperatively (n = 4) or operatively (n = 4), with good functional results (mean DASH score of 10, mean Constant score of 72). 5 patients with major displaced fractures (> 10 mm) were all operated with good clinical results (mean DASH score of 14, mean Constant score of 69). The most common discomfort at the follow-up was an impingement syndrome of the shoulder, which occurred in both nonoperatively treated patients (n = 3) and operatively treated patients (n = 4). Only 1 nonoperatively treated patient developed a non-union. By radiography, all other fractures healed.

Interpretation

We found that minor to moderately displaced greater tuberosity fractures may be treated successfully without surgery.Isolated fractures of the greater tuberosity account for approximately 20% of all proximal humeral fractures (Chun et al. 1994, Kim et al. 2005, Gruson et al. 2008). They are often associated with anterior glenohumeral dislocation or can result from an impaction injury, also called a shear injury, against the lower surface of the acromion or superior glenoid (Court-Brown et al. 2001, George 2007).The diagnosis and classification of isolated greater tuberosity fractures are mainly based on standard plain radiographs. However, these fractures may be challenging to identify because of osseous overlap; Ogawa et al. (2003) reported that two-thirds of these fractures were missed on initial evaluation. It is generally accepted that undisplaced and slightly displaced (≤ 5 mm) fractures of the greater tuberosity should be treated non-surgically, but the magnitude of displacement that warrants surgical intervention is debatable (Park et al. 1997, Gaebler et al. 2003, Platzer et al. 2005).Although isolated greater tuberosity fractures are well recognized and frequently described to be a special group of proximal humeral fractures, only a few studies have specifically evaluated the clinical outcome of these injuries. We retrospectively assessed the clinical outcome of isolated greater tuberosity fractures.     

Fractures of the distal humerus in the elderly. Pros and cons of endoprosthetic replacement

The intraarticular fracture of the distal humerus in an elderly patient remains a challenge for trauma surgeons. In case of severe co-morbidities and/or osteoporosis stable fixation with screws and plates is difficult and in some cases can be impossible. Even if osteosynthesis is feasible the clinical outcome is still incalculable due to delayed or non-union of the fracture fragments. Endoprosthetic replacement of the elbow joint for comminuted distal humerus fractures has been used for almost 20 years. The clinical results are predominantly excellent or good and better predictable than those of osteosynthesis. There still is no guideline when a prosthesis for the elbow joint should be used. We reviewed the literature and outline the current recommendations for diagnostics and surgical therapy for distal humerus fractures in the elderly.     

Die Problematik der Tuberkularefixation in der Frakturprothetik des Humeruskopfes

Since Neer described the replacement of the humeral head in non-reconstructable proximal humerus fractures, this procedure has become standard. Even though Neer published good results, no other authors have been able to reproduce these results yet. All further studies described a good reduction of the pain level, while the function of the shoulder was moderate or poor. The development of special fracture prostheses did not change these findings. Several clinical studies revealed that the bony union of the tuberosities is one of the key factors to achieve good results. The different fixation techniques and clinical and biomechanical results are reviewed in the present article.     

Extending the indications of intramedullary nailing with the Expert Tibial Nail

Numerous modifications in nail and screw design have led to the development of the Expert Tibial Nail. It enables the surgeon to further extend the spectrum of fractures eligible for intramedullary nailing. In the proximal metaphysis spongious bone screws achieve an optimized purchase in the cancellous bone. Multidirectional interlocking screws ensure that alignment can be well maintained and stability preserved in short proximal or distal tibial segments. The end cap achieves angular stability between the proximal oblique screw and the nail. These changes in implant design enhance the stability of the bone-nail construct and reduce the risk for secondary malalignment. The results of our prospective case series demonstrate favorable results and extended indications, compared to standard tibial nails.     

Intramedullary nailing vs. palmar locked plating for unstable dorsally comminuted distal radius fractures: A biomechanical study

BackgroundThe purpose of this study was to compare the stability of a 2.4 mm palmar locking compression plate and a new intramedullary nail-plate-hybrid Targon DR for dorsally comminuted distal radius fractures.MethodsAn extraarticular 10 mm dorsally open wedge osteotomy was created in 8 pairs of fresh frozen human radii to simulate an AO–A3-fracture. The fractures were stabilized using one of the fixation methods. The specimens were loaded axially with 200 N and dorsal-excentrically with 80 N. 2000 cycles of dynamic loading and axial loading-to-failure were performed.FindingsAxial loading revealed that intramedullary osteosynthesis (Targon DR: 369 N/mm) was significantly (p = 0.017) stiffer than plate osteosynthesis (Locking compression plate: 131 N/mm). With 214 N/mm the intramedullary nail also showed higher stability during dorsal excentric loading than the Locking compression plate with 51 N/mm (p = 0.012). After 2000 cycles of axial loading with 80 N the Targon DR-group was significantly stiffer than the Locking compression plate-group under both loading patterns. Neither group showed significant changes in stiffness after 2000 cycles. Under dorsal excentric loading the Targon DR-group was still significantly stiffer with 212 N/mm than the Locking compression plate-group with 45 N/mm (p = 0.012). The load to failure tests demonstrated higher stability of intramedullary nailing (625 N) when compared to plate osteosynthesis (403 N) (p < 0.025).InterpretationThe study shows that intramedullary fixation of a distal AO–A3 radial fracture is biomechanically more stable than volar fixed-angle plating under axial and dorsal-excentric loading in an experimental setup.     

Acute Compartment Syndrome of the Upper Extremity

Abstract Compartment syndrome of the upper extremity is rare, but happens frequently. It most often affects the forearm, compartment syndromes of the upper arm and hand are seen much more seldom. Early diagnosis and efficient fasciotomy is of highest importance to achieve good outcome and prevent development of Volkmann's ischemic contracture.