Distal Fracture Line Research Articles

Dorsal Plating for Specific Fracture Pattern of the Distal Radius.

Background: Volar locking plates have provided the capability to repair both simple and complex fractures. However, complications related to the inability to fix or to maintain the fixation of some fracture patterns have been reported with volar locking plates. The purpose of this study was to evaluate the results of dorsal plating treatment for specific pattern of fractures. Methods: Patients with distal radius fractures were retrospectively evaluated. Inclusion criteria for this study were those related to the patient and treatment (adult patients, internal fixation with dorsal plating, a minimum follow-up of 12 months), and those related to the fracture pattern (displaced central articular fragment, volar distal fracture line not enough to allow volar fixation, displaced dorsal-ulnar fragment, dorsal partial fractures, combination of these patterns). Clinical outcome information including active range of motion, radiographs, PRWE and DASH questionnaires were collected. Complications were recorded. Results: During a 6-year period, 679 distal radius fractures were treated with open reduction and internal fixation. Of these, 27 patients fulfilled the inclusion criteria. Patients were examined at a median of 34 months' follow-up. All but pronation, supination, and radial deviation had a statistically significant difference compared to the opposite side. The median score on the DASH was 4.5 and 3.2 on the PRWE. No patient suffered loss of reduction during the follow-up nor were tendon ruptures recorded. Conclusions: Although most of the distal radius fractures can be treated with volar locking plates, almost 5% of them present specific patterns that are amenable to treatment with dorsal fixation, without postoperative loss of reduction. These specific patterns are: (1) displaced central articular fragment, (2) volar distal fracture with less of 1cm distance from the distal volar edge of the radius, (3) displaced dorso-ulnar fragment, (4) Barton's fracture, (5) combination of these patterns.

Precontoured buttress plate vs reconstruction plate for acetabulum posterior wall fractures: A biomechanical study.

BACKGROUNDThe purpose of open reduction and internal fixation of acetabulum posterior wall fractures is to restore anatomical structure and stability of the hip joint, in order to start weight bearing as soon as possible and prevent hip arthrosis; restoration of the anatomy should preserve function of the joint as well. Although “special shaped precontoured plates” have been developed in recent years for surgical treatment of this region, studies comparing the traditional plates with the newly designed precontoured plates are lacking.AIMTo evaluate the biomechanical properties of precontoured anatomic buttress and conventional curved reconstruction plates (CCRPs) for posterior wall acetabulum fracture treatment.METHODSTwelve pelvis models were created for testing plate treatment of fracture in the posterior wall of the acetabulum. These 12 pelvis models were used to create 24 hemipelvis models (experimental) by cutting from the sagittal plane and passing over the center of gravity, after which the posterior wall acetabular fractures (of similar type and size) were created. In these experimental models, the right acetabulum was fixed with a 5-hole CCRP, while the left was fixed with a precontoured anatomic buttress plate (PABP). Samples were placed through the test device and were subjected to static load testing, with a constant testing velocity of 2 mm/min until the load reached 2.3 kN or the acetabular fixation failed. Dynamic tests were also performed with sinusoidal wave load, with a maximal load of 2.3 kN and a load ratio of 0.1.RESULTSThe average stiffness values were 460.83 ± 95.47 N/mm for the PABP and 291.99 ± 118.58 N/mm for the 5-hole CCRP. The precontoured anatomic acetabulum buttress plates had significantly higher rigidity than the CCRPs (P = 0.022). There was a statistically significant difference between the unloaded and 2.3 kN-loaded values of AL (posterosuperior fracture line vertical to the ground surface) and CL (posteroinferior fracture line vertical to the ground surface) parameters for both the PABPs and the 5-hole CCRPs (P = 0.036 and P = 0.045, respectively). According to the static tests, the amount of total displacement was significantly less in the PABPs than in the CCRPs. Comparative analysis of the displacement in the BL (posterior wall fracture line horizontal to the ground) parameter yielded no statistically significant differences between the PABP and the 5-hole CCRPs (P = 0.261).CONCLUSIONPABP provides more stable fixation in acetabulum posterior wall fractures than 5-hole CCRP, allowing for proximal or distal fracture line screw application without reshaping.

Can Jones fracture be treated conservatively?

Category: Midfoot/Forefoot Introduction/Purpose: Operative management is the treatment of choice for Jones fracture. Situations are fought where operative management may not be possible or may not be accepted. Such situations being more common in developing countries, clinicians are forced to undertake conservative management. Pertain to this, many questions are still unanswered. Can conservative management succeed? If so, what should be the protocol? What all could be the possible complications? And how to overcome them? To answer all these questions, we undertook a study to evaluate results of conservative management of Jones fracture. The purpose of this study was also to suggest conservative management guidelines. Methods: Retrospective analysis of 32 conservatively treated Jones fracture cases over period of two years was done with average follow up of nine months. Only cases included were those between the ages of 20 to 50 years, not willing for operative management. Cases in the same age group, willing for surgery and cases lost to follow up were excluded. Conservative management comprised of full length below knee non weight bearing plaster cast in eversion and dorsiflexion for four weeks followed by short length below knee weight bearing plaster cast in neutral position of ankle and subtalar joint. Radiological evaluations were done at the end of 4, 8, 14, 20 and 26 weeks. Results of serial clinical and radiological assessments were analysed. Results: Thirty out of 32 cases went on to sound clinical as well as radiological union. With respect to average time to union, two major group of cases could be segregated. First group (20 cases) had a proximal fracture line nearer to zone 1 and took 11 weeks to unite. Second group (12 cases) had a distal fracture line nearer to zone 3 and took 18 weeks to unite. Both the nonunion cases were from this group. Clinical union preceded radiological union by average of 2 to 3 weeks. Conclusion: Jones fracture could be successfully treated conservatively even in young and active population provided specific protocol is followed. Initial full length below knee plaster in dorsiflexion and eversion neutralized deforming forces of peronei and plantar fascia while next short below knee walking plaster cast helped to regain muscle tone, increased perfusion and simulated walking leading to union. Fractures nearer the tuberosity had a faster union in comparison to distal fractures nearer the shaft. In view of short follow up with small numbers of present study, a multicentric prospective study comparing results of surgical versus conservative treatment is deemed.

Similar function and complications for patients with short versus long hip nailing for unstable pertrochanteric fractures.

Purpose: To compare short with long intramedullary hip nailing for elderly patients with unstable pertrochanteric fractures.Methods: We prospectively studied 50 patients (33 women, 17 men; mean age, 80 years; range, 74–93 years) with unstable pertrochanteric fractures admitted and treated with a short (group A) or a long (group B) intramedullary hip nail from January 2013 to 2017. The patients were randomly allocated into each group according to their order of admission. The mean follow-up was 2 years (range, 1–5 years). We evaluated operative time, function, fracture healing, varus/valgus loss of reduction, and distance between the distal line of the fracture and the distal locking screw of the nail.Results: Operative time was significantly shorter in group A. Function, fracture healing and varus/valgus loss of reduction was similar between the two groups. The mean distance between the distal fracture line and distal locking screw was 7.2 cm (range, 3–10 cm) in patients of group A; in all patients of group B, an appropriate nail length was chosen so that the distal locking screw was inserted at least 3 times the diameter of the bone at the distal fracture line. Complications included periprosthetic fracture (one patient of group A), and z-effect phenomenon (one patient of group B); complications rate was similar between the two groups.Conclusion: Short intramedullary hip nailing is associated with similar function and complications, but shorter operative time compared to long intramedullary hip nails for patients with unstable pertrochanteric fractures.

Primary Wrist Hemiarthroplasty for Irreparable Distal Radius Fractures in the Independent Elderly

Objective: Despite the improvement of open reduction and internal fixation (ORIF) of distal radius fractures (DRFs) provided by locked volar plating in elderly patients, there are still complex distal DRF not amenable to any satisfactory fixation. The purpose of this article is to define irreparable acute DRF in autonomous elderly patients and to review the preliminary results of a prospective series using wrist hemiarthroplasty at the acute stage. Methods: A total of 12 wrists in 10 women were prospectively included. The average age was 74 years (range, 65-87). All patients were autonomous at home. All were intra-articular Arbeitsgemeinschaft für Osteosynthe-sefragen (AO) “C” type fractures. Circumferential comminution was present in all cases. Impaction and cartilage defect were present in all cases. All patients sustained wrist hemiarthroplasty through a single dorsal approach. The proximal part of a total wrist arthroplasty was used in 10 cases and a modified implant with a longer stem was used in 2 cases. An ulnar head resection was associated in 10/12 cases whereas the ulnar head could be kept intact in 2 wrists. Postoperative immobilization was 3 weeks followed by a splint for 3 weeks. Follow-up consisted of clinical and radiographic evaluation at 6 weeks and 2, 6, and 12 months. The average clinical and radiological follow-up was 27 months (minimum 12, maximum 41). Results: There were no dislocation, loosening, or implant removal. One wrist was reoperated on for stiffness followed by a significant improvement. Complex pain regional syndrome (CPRS) was present in 3 patients. At follow-up, Visual Analog Scale (VAS) pain was 10/100. Average Quick Disability of the Arm, Shoulder and Hand (QuickDASH) was 32 points and Patient-Rated Wrist Evaluation (PRWE) was 24.7. Mean active motion values were as follows: pronation 74°, supination 77°, extension 34°, and flexion 26°. The average grip strength was 14 kg, 67% of the contralateral side. The average wrist score was 69%. Radiologically, periprosthetic bone healing was observed in all cases. We observed 1 radial and 3 ulnar inclination of the implant. This was not observed with the longer stem implant. Discussion: Implant surgery at the acute stage for complex fractures in the elderly is an old validated concept for hip, shoulder, and elbow. Indeed some DRFs in the autonomous elderly are beyond any ORIF possibilities due to the combination of comminution and a very distal fracture line. Our results suggest that primary wrist hemiarthroplasty is a viable method to treat these difficult wrist injuries in this specific population. Further controlled prospective studies are necessary to validate this concept.

Location of civilian ballistic femoral fracture indicates likelihood of arterial injury

BackgroundWe evaluated whether the location of a ballistic femoral fracture helps predict the presence of arterial injury. We hypothesized that fractures located in the distal third of the femur are associated with a higher rate of arterial injury. MethodsWe conducted a retrospective review of electronic medical records at our level I trauma centre and found 133 consecutive patients with femoral fractures from civilian gunshots from 2002 to 2007, 14 of whom sustained arterial injury. Fracture extent was measured with computerized viewing software and recorded with a standard technique, calculating proximal, distal, and central locations of the fracture as a function of overall length of the bone. Analyses were conducted with Student's t, Chi-squared, and Fisher's exact tests. ResultsThe location of any fracture line in the distal third of the femur was associated with increased risk of arterial injury (P<0.05). The odds ratio for the presence of arterial injury when the proximal fracture line was in the distal third of the femur was 5.63 (95% confidence interval, 1.7–18.6; P<0.05) and when the distal fracture line was in the distal third of the femur was 6.72 (95% confidence interval, 1.78–25.44; P<0.05). ConclusionsA fracture line in the distal third of the femur after ballistic injury is six times more likely to be associated with arterial injury and warrants careful evaluation. Our data show that fracture location can help alert clinicians to possible arterial injury after ballistic femoral fracture.

A Review of 202 Periprosthetic Fractures - Stem Revision and Allograft Improves Outcome for Type B Fractures

We report a retrospective review of the outcome of treatment of 202 periprosthetic fractures around total hip arthroplasty (THA) from two specialised arthroplasty centres. Fractures were classified according to the Vancouver classification. The aim was to evaluate treatment methods with respect to stem revision and grafting. Transverse B1 fractures treated with stem revision compared to those treated with open reduction and internal fixation (ORIF) with a plate showed a trend towards improved overall union rate (OR=2, p=0.6, 95% CI:0.14-28.4) and shorter times to union (p=0.038, mean 12 months SD 6.573 for ORIF versus 4.48 months SD 0.757 for stem revision). B2 fractures undergoing stem revision and grafting were significantly more likely to unite compared to ORIF alone (OR=17.3, p=0.018 95%CI:1.63-184.4). B3 fractures presented with significant variation in fracture configuration and bone loss and therefore their treatment was individualised. When treated with stem revision and grafting healing was achieved in a mean time of 7 months (n=81). Periprosthetic fractures of the femur are highly complex and challenging. Stem revision for transverse B1 fractures is now considered as a viable treatment modality as this fracture configuration is difficult to control with single plating, and fixation with a long stem bypassing the distal fracture line is necessary to achieve axial stability and healing. Bone allografting, whether used as a cortical onlay or in morselised impacted form for B2 and B3 fractures enhances fracture healing.

Where is the distal fracture line location of dorsally displaced distal radius fractures?

No consensus currently exists on the facture location of dorsally displaced distal radius fractures (DRFs). We present a systematic evaluation of the distal fracture line (DFL) location of DRFs and possible influencing factors. Determining the average location of DRFs provides a basis for developing more sensitive tests to determine bone strength using a variety of imaging techniques and for developing improved biomechanical models to test fracture characteristics and surgical implants. Initial radiographs of 157 DRFs dorsally displaced DRFs in patients aged 40-74 years were identified, patient and trauma specific data were collected, and standard radiographic measurements and (AO) fracture classification were performed. The dorsal and palmar DFL locations relative to the corresponding apex of the lunate facet were measured. The DFL was located dorsally 7.9 ± 2.7 mm and palmarly 11.7 ± 3.9 mm proximal to the corresponding lunate fossa apex. The dorsal DFL was significantly distal to the palmar one (p < 0.001), but the two did not correlate (r² = 0.018, p = 0.095). DFL location was independent of age, energy of the fall, and fracture complexity.

Impaction femoral allografting and cemented revision for periprosthetic femoral fractures

We reviewed retrospectively the outcome of the treatment by impaction grafting of periprosthetic femoral fractures around loose stems in 106 patients with Vancouver type-B2 and type-B3 fractures. Eighty-nine patients had a cemented revision with impaction grafting and a long or short stem. The remaining 17 had cemented revision without impaction grafting. Fractures treated by impaction grafting and a long stem were more than five times likely to unite than those treated by impaction grafting and a short stem (odds ratio = 5.5, 95% confidence interval (CI) 1.54 to 19.6; p = 0.009). Furthermore, those with impaction grafting and a long stem were significantly more likely to unite than those with a long stem without impaction grafting (odds ratio = 4.07, 95% CI 1.10 to 15.0; p = 0.035). There was also a trend towards a higher rate of union in those treated by impaction grafting than in those without (odds ratio = 2.69, 95% CI 0.86 to 8.45; p = 0.090). Impaction grafting is being increasingly widely used for the restoration of femoral bone stock. It can be successfully applied to periprosthetic femoral fractures but a long stem should be used to bypass the distal fracture line.

Dall-Miles plates for periprosthetic femoral fractures: A critical review of 16 cases

Fourteen patients with 16 periprosthetic femoral fractures around hip replacement were treated with Dall-Miles plates between June 1996 and February 2000. There were 10 Vancouver B3, three B1 and three type C fractures. In addition to a Dall-Miles plate, two of the fractures (one B3 and one C type) were also stabilised with one strut graft and nine B3 fractures were revised with impaction grafting. Of the three B1 fractures treated with plates, two failed through fracture of the plate. A further two patients with B3 fractures treated with plates also failed with fracture of the plate. Failure of these plates occurred within 6 months of surgery. All non-unions and fixation failures in this series were in cases where the femoral component did not bypass the most distal fracture line by at least two cortical diameters. The Dall-Miles plates and cable system alone is insufficient for the treatment for periprosthetic femoral fractures. It must be supplemented with additional intramedullary or extramedullary fixation.

3-dimensional movement analysis after internal fixation of pelvic ring fractures. A computer simulation

Several studies exist describing the biomechanical behavior of several external or internal fixation techniques of the posterior and anterior pelvic ring. Recently, the traditional models using isolated anatomical sections or fixed pelvic ring specimens for evaluation of linear or two-dimensional data have been replaced by three-dimensional measurement systems and simulations of muscle forces. These studies have contributed important information to the understanding of the biomechanics of the intact and injured pelvic ring, however, a consequent movement analysis is still missing. In the present study, 3-D data acquired during several series of testing implants for stabilization of the posterior pelvic ring (sacrum: sacral bars, sacral plates, transiliosacral lag screws; Sl joint: anterior plates, transiliosacral lag screws), using a complete pelvic ring model with single leg stance and static abductor muscle simulation, were converted into a commercially available 3-D animation package. By use of simple graphical representation of anatomical elements of the posterior pelvic ring, reproducible and reliable movement patterns for different types of stabilization could be identified, which demonstrated potential "weakness" of the fixation before failure occurred. These movements were analyzed by "replay functions" and were comparable to observations during the original experiment. The following movements were observed. Sacral fracture, transforaminal: (1) rotation of the transiliosacral lag screws around its axis, even with a second screw into S1; (2) Sacral bars: shearing with compression of the cranial-posterior fracture zone; (3) Sacral plates: minimal translation in the proximal fracture zone and distraction in the distal fracture line, effectively compensated by an additional plate at the S3 level. Sl joint disruption: (1) anterior plating (two plates), minimal translation in the plane of the Sl joint; (2) transiliosacral lag screws, rotational movement around the axis of the screws with only minimal movement at the S1 level. The provided information confirmed the observations and allowed a more detailed and comfortable examination of movement patterns. A better understanding of potential "failure zones" might be useful to optimize the dimensions, design, and the positioning of implants for the pelvic girdle. For further studies, more complex computer models including finite element technology might be useful to add accessory information and could result in a decreased need of living specimen testing.