Distal Fragment Research Articles

Metacarpal Shortening with Intramedullary Screw Fixation: A Cadaveric Study.

Background Intramedullary screw fixation is a commonly used technique for the management of metacarpal fractures. However, compression across the fracture site can lead to unintentional shortening of the metacarpal. Questions/Purposes Our aim was to evaluate the risk of overshortening with differing intramedullary device designs for fixation of metacarpals. Methods The small finger metacarpal of nine fresh-frozen cadavers were included. A metacarpal neck fracture was simulated with a 5-mm osteotomy. Three different intramedullary screw designs were compared. Each screw was placed in a retrograde fashion into the intramedullary canal and the amount of shortening measured. Screws were reversed and the number of reverse turns with the screwdriver needed to release overshortening were measured. Results The average shortening at the osteotomy site was 2.5 mm. The mean shortening was 80%, 58%, and 12% for the partially threaded screw, fully threaded screw, and threaded nail, respectively. The mean differences of the distance shortened were statistically significant for the threaded nail compared with the partially and fully threaded screws. The partially threaded screw had the most shortening, while the threaded nail provided the least amount of shortening. When the screws were reversed, the screws did not disengage until the screw was fully removed from the osteotomy site. Conclusion The fully threaded nail demonstrates less shortening and possibly minimizes overshortening of fractures compared with partially threaded and fully threaded screw designs. Overshortening cannot be corrected by unscrewing the screw unless completely removed from the distal fragment. Clinical Relevance Orthopaedic surgeons may select intermedullary screws based on the design that is suited for the particular metacarpal fracture pattern.

Reverse distal similarity of hapten structure enhancing antibody’s group-specificity: Development of an immunochromatographic strip for tylosin and tilmicosin in milk and water

The most common macrolide veterinary drugs used in animal husbandry are tylosin and tilmicosin. To protect human health, tylosin and tilmicosin residues in animal products and environmental water samples must be monitored on-site. A monoclonal antibody and gold nanoparticle-based lateral flow immunochromatographic strip (LFIS) were used in this study to detect tylosin and tilmicosin simultaneously, allowing for quantitative detection with a portable reader. The four-parameter equation fit produced a standard sigmoid curve under optimized conditions, with IC50 of 17.69 ng/mL and LOD(IC10) of 1.72 ng/mL for tylosin and IC50 of 18.95 ng/mL and LOD(IC10) of 7.07 ng/mL for tilmicosin. Additionally, good linearity results were obtained in the actual concentration range of 3.25–50 ng/mL, with R squares of 0.9946 for tilmicosin and 0.9953 for tylosin. The degree of cross-reactivity with other analogs was less than 0.1%. The average recoveries for tylosin and tilmicosin ranged from 77.5% to 119.7% and from 80% to 126.1% in milk, from 81.1% to 108.0% and from 98.3% to 106.8% in environmental water, respectively. The results could be obtained in 5–8 min. Therefore, the developed lateral flow immunochromatographic strip was met for the rapid detection of tylosin and tilmicosin residues in milk and environmental water samples using group screening. Furthermore, we discovered that the high matching of three dimensional structure at the distal structural fragments of the hapten arm site, as well as the consistency of the frontier orbital distribution, are very critical factors for the analytical performance of antibody against target molecules and should be considered as a universal theoretical guide for hapten design.

Multi-split intra-articular fractures of the distal humeral metaepiphysis in children

Background: The need to minimize the immobilization of the elbow joint in multifragmental fractures of the distal metaepiphysis of the humerus is confirmed by a number of factors, including the complexity of its anatomical structure, the uniqueness of biomechanics, as well as the limited ability of hyaline cartilage to regenerate. The restoration of the motor potential of the limb in multifragmentary fractures of the distal metaepiphysis of the humerus determines the priority of the treatment technique, which allows the patient to return to his usual lifestyle in the near future.Objective: Demonstration of the effectiveness of percutaneous spinal osteosynthesis with wires in fractures of distal metaepiphysis of the humerus in adolescent children.Clinical cases: This paper describes two clinical cases in adolescent children with multifragmentary fractures (open and closed) of the distal part of humerus (12В and 13С according to the AO classification). In both cases, the treatment consisted of sequential application of skeletal traction, for fragments traction and their mobility increase, then closed reposition of fragments under the control of electron-optical converter with metal osteosynthesis with wires. Moreover, taking into consideration the U- and T-shape nature of the fractures, the first stage of reposition included stabilization and fixation of the distal fragments to each other and then to the proximal fragment.Conclusion: In our opinion, it is the combination of traditional methods of treatment (application of skeletal traction system), modern technologies (EOC control), alternative (atypical) options for using metal structures that allow achieving good functional treatment results in this category of patients.

Offset nail fixation for intertrochanteric fractures improves reduction and lag screw position.

Surgery for intertrochanteric fractures using intramedullary hip nails (IHNs) is among the most common surgical procedures in the orthopedic field. Although IHNs provide good overall outcomes, they sometimes cause complications, such as loss of reduction and cut-out. Here, we investigated the usefulness of IHNs with an anterior offset (Best Fit Nail® [BFN]) in maintaining fragment reduction and ensuring proper lag screw position compared with conventional non-offset nails (Proximal Femoral Nail Antirotation® [PFNA]), using postoperative computed tomography (CT). Fifty consecutive patients with intertrochanteric fractures who underwent surgery with BFNs (BFN group) and 50 patients who underwent surgery with PFNAs (PFNA group) were retrospectively analyzed. Indices evaluated by postoperative CT were displacement distance of proximal fragment relative to distal fragment, reduction status (intramedullary, anatomical, and extramedullary types), lag screw direction, and angle between lag screw and femoral neck axis (deviation angle). Median [interquartile range] displacement distance was significantly smaller in the BFN group (0 [0, 0] mm) compared with the PFNA group (5.2 [3.6, 7.1] mm) (p<0.001). Reduction status was significantly better in the BFN group (anatomical type, 40 cases; intramedullary type, in 9 cases, and extramedullary type in 1 case) than in the PFNA group (anatomical type, 6 cases; intramedullary type, 43 cases; extramedullary type, 1 case) (p<0.001). Deviation of lag screw direction was observed in significantly fewer cases in the BFN group (20 cases; 40%) compared with the PFNA group (36 cases; 72%). Lag screw deviation angle was significantly smaller in the BFN group (-0.71°±4.0°) compared with the PFNA group (6.9°±7.1°). No adverse events related to surgery were observed in either group. Intertrochanteric fracture surgery using offset BFNs exhibited significantly smaller displacement distance, better reduction status, and higher frequency of no deviation with central lag screw position, compared with surgery using non-offset PFNAs.

Abstract 12175: A Migrated External Iliac Stent - To Retrieve or Not to Retrieve

Endovascular venous stenting has become a more favorable intervention for occlusive, symptomatic deep vein thromboses (DVTs), especially given its decreased complication rate and shorter recovery time than its predecessor, open venous bypass. Risks, however, still exist and can include stent fragmentation and dislodgement causing cardiopulmonary complications. A 57-year-old man with bilateral lower extremity DVTs status post left external ilio-femoral stent and inferior vena cava (IVC) filter placement presented with one month of atypical chest discomfort. CT chest showed migration of his 40cm iliac stent to the IVC and right atrium. Interventional radiology visualized both a patent stent and IVC, however, attempted endovascular removal from the distal margin failed with initial retrieval of fragments only. Other fragments subsequently embolized to the pulmonary and lower lobe arteries and right ventricles. Extraction of more distal fragments was deferred due to risks of structural damage, arrhythmias, and pulmonary vasculature perforation. Fragment analysis by pathology demonstrated evidence of clot, yet cardiothoracic surgical intervention was deferred.The patient continued to experience chest pain and underwent a repeat CT chest three months later that demonstrated the stent extending from the right atrial junction to the infrahepatic IVC. Fragmented portions of the filter in the right ventricle and multiple stent fragments retained in the right upper and bilateral lower pulmonary lobes remained as prior with no evidence of pulmonary embolism (PE), pericardial effusion, or tamponade. Although rare, stent removal complications can occur with increased risk of long-term sequelae. Stent fracturing and dislodgement can result in foreign bodies showering the pulmonary vasculature and cardiac chambers, ultimately placing patients at risk for arterial perforation or dissection, pulmonary hemorrhage, intracardiac damage, tamponade, PE, and chronic thromboembolic pulmonary hypertension (CTEPH). The consideration of such risks, in addition to early involvement of interdisciplinary teams and thorough risk-benefit discussions between patients and providers are essential when undergoing stent removal and related interventions.

An innovative technique - Axial Loading and Compression Fixation (ALCF Technique) of scaphoid fracture by percutaneous K-wire

Backgrounds Surgical fixation techniques used for the treatment of scaphoid fracture is still a topic of discussion among hand surgeons especially in terms of approach, implants and surgical techniques. We present an innovative technique of scaphoid fracture fixation by K-wire, which we accidentally encountered when the guide wire broke while doing a cannulated screw for the scaphoid. This technique of axial aligning, compression loading over a bent tip of K-wire across the fracture fragments of scaphoid is innovative. Materials The study included 16 patients operated for Scaphoid fracture between January-2017 to January-2020 by ALCF Technique. the patient age ranged from 18 to 69 years,M:F12:4, 13 fractures on dominant hand,10 fracture presented within 2 weeks, 7 were trans-scaphoid displaced fractures sustained in RTA, 3 proximal pole fractures sustained after a fall, 6 were delayed presentation more than 3 months. Method The technique used to pass a K wire from dorsally in ante grade fashion to align the fracture fragments along the anatomical axis of the scaphoid then bend the K wire at the proximal end so as to hook the proximal fragment. The distal end of the K wire is then applied manual traction load with gentle rotation to achieve compression at the fracture ends with rotational alignment on the distal fragment. The distal fragment is anvil on the proximal fragment by a K-wire binder before distally binding to achieve compression &amp; relative stable fixation. Conclusion It is a simple, easy to reproduce, economic method to achieve reduction, compression using axial traction and union in all types of scaphoid fractures.

Correction of Pediatric Cubitus Varus by Centralization of the Distal Humeral Fragment: A Surgical Technique to Avoid Lateral Condylar Prominence.

Cubitus varus is a well-recognized late complication of supracondylar humerus fractures in children. Various osteotomies have been described to correct this deformity, but each has disadvantages. The purpose of this study was to investigate the outcomes of a surgical technique, lateral closing wedge osteotomy combined with centralization of the distal humeral fragment, in cubitus varus. Meanwhile, the occurrence of postoperative lateral condylar prominence was observed. From January 2015 to December 2019, 36 pediatric cubitus varus deformity patients who were treated with lateral closing wedge osteotomy combined with centralization of the distal fragment in our institution were included. The corrective osteotomies were performed through a standard lateral approach and fixed with crossed Kirschner wires. The preoperative and postoperative full-length anteroposterior and lateral radiographs of bilateral upper limbs were assessed. At the same time, clinical and radiologic parameters were reviewed. Lateral condylar prominence index (LCPI) and any other complications were evaluated. The mean preoperative humerus-elbow-wrist angle (HEWA) on the affected side was 20.9 degrees of varus, which was significantly improved to 9.2 degrees of valgus postoperatively. The mean postoperative value of LCPI was -0.047. Postoperative LCPI and HEWA was compared with the normal side, and there was no significant difference. All of the patients had excellent clinical and radiographic alignment. No surgical complications and limitation of range of motion were noted. No patient complained of lateral bony prominence. Lateral closing wedge osteotomy by centralization of distal fragment is a safe and highly effective method and prevents lateral prominence with a minimal complication rate. We recommend this technique for the treatment of cubitus varus in children. Level IV Case series.

A Cadaveric Study Verifying the Potential of a Rotational Biplanar Chevron Osteotomy to Correct the 3-Dimensional Hallux Valgus Deformity.

Metatarsal pronation is present in 87% of patients with hallux valgus (HV) deformity. The chevron osteotomy is commonly used worldwide to correct mild to moderate HV deformities. Many modifications have been described, but few address the rotational deformity of the first metatarsal. The rotational biplanar chevron osteotomy (RBCO), described by M. Prado et al, presents a variation of a biplanar chevron osteotomy that can be used to address first metatarsal rotation. The objective of this study is to investigate and verify the technique of the RBCO. We conducted our study performing an RBCO on 9 cadaveric limbs. The technique uses a medial-based wedge parallel to the plantar limb of the osteotomy to make the distal fragment free to correct rotation. A goniometer was used by 2 individual surgeons to control the rotational correction achieved. The osteotomy was considered simple to perform and we experienced no complications, such as fractures or instability. The result was satisfactory alignment and adequate stability. On average, a 2 mm wedge resulted in 11° of rotational correction. We predict that RBCO can safely be used for correcting the metatarsal rotation when necessary in mild to moderate HV deformity foot. Level IV.

Supracondylar Dome Osteotomy With a Posterior Triceps-splitting Approach for Acute Correction of Posttraumatic Cubital Axis Deformities in Adolescent Patients.

Fractures around the elbow are common in children. Their management remains challenging. Inadequate treatment often leads to malunion, causing growth disturbance or avascular necrosis. This can develop into cubital axis deformities. This study evaluated our modified supracondylar dome osteotomy technique for acute correction of posttraumatic cubital axis deformities in adolescent patients. Eighteen cases of posttraumatic cubital axis deformity that underwent acute correction through supracondylar dome osteotomy in our department between 2012 and 2019 were retrospectively evaluated. The radiologic results were measured through the carrying angle. The clinical functional outcomes were assessed using the Mayo Elbow Performance Index. No neurovascular injuries occurred and there was no notable loss of muscular strength or functional deficiencies in any of the patients. Symmetrical cubital axes were achieved in all cases. All cases were consolidated in a timely matter and no malunion was observed upon consolidation. Besides 1 case of hardware damage caused by a severe fall due to heavy alcohol intoxication, there was no correction loss, no secondary displacement, and no implant-related discomfort. None of the patients were left with a limited range of motion or reduced weight-bearing capacity. An excellent level of elbow functionality was achieved in all cases, with an average Mayo Elbow Performance Index of 97.8. The supracondylar dome osteotomy technique showed promising results in both radiologic outcomes and clinical performance, with a low complication rate. The dome-shaped osteotomy allows simultaneous multiplanar correction of not only varus or valgus deformities but also additional extension or flexion deformities. This technique also enables translation of the distal fragment in the frontal plane, which contributes to a more balanced anatomic geometry of the distal humerus. We consider the posterior triceps-splitting approach to be a safe technique that preserves muscle strength and improves the cosmetic appearance of the surgical scar. We recommend a cast-free plate fixation to allow early movement after surgery. We believe any residual deformities that present 18 months after the initial trauma should be addressed through surgical correction before clinical symptoms become apparent to avoid the chronic manifestation of functional deficiencies. Level IV, therapeutic study, case series.

Effect of Fibular Malrotation on Tibiotalar Joint Contact Mechanics in a Weber B Ankle Fracture Model.

In minimally displaced Weber B ankle fractures, the distal fibular fracture fragment can be externally rotated. This malrotation is difficult to detect on radiographs and, when left malreduced through nonoperative treatment, may contribute to altered joint mechanics, predisposing to posttraumatic osteoarthritis. This study evaluates the effects of fibular malrotation on tibiotalar joint contact mechanics. Six cadaveric ankles were tested using a materials testing system (MTS) machine. A tibiotalar joint sensor recorded contact area and pressure. Samples were tested in the intact, neutrally rotated, and malrotated state. Each trial applied a 686N axial load and a 147N Achilles tendon load in neutral position, 15° dorsiflexion, and 15° plantarflexion. In the comparison of malrotated to intact ankles, peak contact pressure was found to be significantly greater at neutral flexion (intact 5.56 MPa ± 1.39, malrotated 7.21 MPa ± 1.07, P = .03), not significantly different in dorsiflexion, and significantly decreased in plantarflexion (intact 11.2 MPa ± 3.04, malrotated 9.01 MPa ± 1.84, P = .01). Significant differences in contact area were not found between conditions. The findings suggest that fibular malrotation contributes to significant alterations in tibiotalar joint contact pressures, which may contribute to the development of posttraumatic osteoarthritis. When malrotation of the fibula is suspected on plain radiographs, a computer tomography (CT) scan should be obtained to evaluate its extent and further consideration should be given to surgical treatment. Level V: Bench testing.

Optimizing fixation methods for stable and unstable intertrochanteric hip fractures treated with sliding hip screw or cephalomedullary nailing: A comparative biomechanical and finite element analysis study

BackgroundDespite recent advances in implants and surgical techniques, catastrophic and clinical failures in the treatment of intertrochanteric fractures continue to occur, with dire consequences in an overall frail population subset. The aim of the current study is to evaluate the effect of the factors under the surgeons’ control, namely fracture reduction and implant selection, on the biomechanical behavior of fracture fixation constructs. Material-MethodsAn experimental protocol was conducted with the use of instrumented sawbones, in order to validate the finite element models. The implants used were the Gamma3®and DHS systems. Subsequently, a series of scenaria were considered, including various reduction and implant angle combinations. Data were retrieved concerning the peak cancellous bone stresses around the hip screw and the volume of cancellous bone in the femoral head stressed at critical levels, as well as implant stresses and stresses on the cortical bone of the distal fragment. ResultsAll stable fracture models displayed significantly decreased cancellous bone stresses and implant stresses compared to their unstable counterparts, regardless of implant used. The effect of increasing implant angle led to a decrease in implant stresses in all models studied, but had a beneficial effect on the stresses in the cancellous bone of the proximal fragment only in the subgroups of stable fractures with both implants and unstable fractures treated with a cephalomedullary nail (CMN). In unstable fractures anatomically reduced, the use of CMN led to significantly lower peak stresses in the cancellous bone and a smaller volume of bone stressed at critical levels. Increasing the reduction angle by 5 ° led to a significant decrease in both peak stresses and volume of bone stressed at critical levels, more prominent in the sliding hip screw (SHS) models. Decreasing the reduction angle into varus by 5 or 10 ° led to a significant increase in bone and implant stresses regardless of implant used. ConclusionsIn stable two-part (AO31.A2) fractures the use of the SHS appears to be biomechanically equivalent to CMN. In unstable, anatomically reduced fractures, the use of CMN leads to significantly reduced cancellous bone stresses and decreased rotation of the proximal fragment during loading.A reduction in varus should be avoided at all costs. In unstable fractures treated with SHS a reduction in slight valgus appears to be biomechanically beneficial. The highest implant angle that allows for proper screw position and trajectory in the femoral head should be used for stable fractures with both implants and unstable fractures treated with Gamma3®.

Rotation of both X- and Y-axes is a predictive confounder of ulnar nerve injury and open reduction in pediatric lateral flexion supracondylar humeral fractures: A retrospective cohort study.

BackgroundRotation of the distal fragment often occurs in flexion-type supracondylar humerus fractures (SCHFs), potentially leading to ulnar nerve injury (UNI) and open reduction. We analyzed the correlation between the rotations and UNI or open reduction and then assessed the risk factors associated with these rotations.MethodsData of Wilkins type III lateral flexion SCHFs were collected over a 10-year time period (1 January 2012 to 31 December 2021) in Children's Hospital of Fudan University Anhui Hospital. We defined the rotation of the distal fragment on the coordinate axis as two types, IIIA (X-axis rotation) and IIIB (the rotation of both X- and Y-axes) on X-ray radiography. Demographic data, the incidence of the two-type rotation, odds ratios (ORs) of UNI and open reduction, and risk factors of the rotation of both X- and Y-axes were analyzed.ResultsTotally, 152 patients were found (50 with IIIA vs. 102 IIIB). The UNI rate was 13%, and the open reduction rate was 22%. The UNI rate of the IIIB was five-fold higher than that of the IIIA [OR, 5.143; 95% confidence interval (CI), 1.414–23.125; p = 0.019], and the open reduction rate of the IIIB was nearly five-fold higher than that of the IIIA (OR, 4.729, 95%CI, 1.584–14.495; p = 0.003). In these two types, patients with UNI had a higher risk of open reduction than those without UNI (OR, 9.816; 95%CI, 3.503–27.508; p = 0.001). In the multiple regression analysis, a high level of fracture was identified as a risk factor for the rotation of both X- and Y-axes.ConclusionType IIIB lateral flexion-type SCHFs have higher rates of UNI and open reduction, and a high level of fracture is a risk factor associated with this type.

Incidence of Flexor Tendon Injuries in Complex Intra-Articular Distal Radius Fractures Fixed With Volar Rim Plate Osteosynthesis

The volar rim plate is anatomically contoured to provide buttressing of distal radius fragments including the lunate fossa. The low-profile design of the plate minimizes flexor tendon irritation. This study aims to determine the Disabilities of the Arm, Shoulder, and Hand (DASH) score and the presence of flexor tendon irritation at around one-year post operation. Between June 2020 and May 2021, all patients with AO-23B3 and AO-23C (1-3) distal radius fractures who were treated with a volar rim plate fixation were included in this study. At 12 months after surgery, the patients were evaluated utilizing DASH score as a routine as well as evidence of flexor tendon rupture or irritation. Twenty-five patients were finally included in this study. Of these, three required additional dorsal plating for dorsal subluxation, four required fixationof ulna styloid with tension band wiring, and the rest (18) had volar rim plate fixation in isolation. The mean DASH score was 16.3. Two of the patients had flexor tendon irritations; one in the middle finger and another in the ring and little finger. None had flexor tendon rupture. The volar rim plate is designed to tackle complex intra-articular distal fractures which are near the watershed line. There was no evidence of flexor tendon irritation on routine follow-up. The outcome was satisfactory in this small series despite the complexity of the fractures. Evidence of flexor tendon irritation requires prompt attention to enable early implant removal.

Preventing Iatrogenic Fibula Fractures using the Push-Pull Technique: A Biomechanical Comparison of Unicortical vs Bicortical Post Screws

Category: Ankle; Basic Sciences/Biologics; Sports; Trauma Introduction/Purpose: In displaced diaphyseal fractures fixed with a plate, reduction is often achieved using the direct reduction method known as the Push-Pull Technique. In this method, the plate is attached to the distal fragment of the fracture while a post screw is placed on the proximal fragment. A bone spreader is then placed between the plate and the post screw to achieve length by distracting the fracture for reduction. After fixation, the post screw is removed. This screw is placed either bicortically or unicortically based upon surgeon preference. Anecdotally, the force imparted onto the unicortical screw may cause iatrogenic fracture of the bone. This study evaluates the relative risk of causing iatrogenic fibula fracture with either a unicortical or bicortical post screw during the push-pull technique. Methods: Four matched pairs of fresh-frozen human cadaveric lower limbs were used. A 2 cm oblique osteotomy was performed on the distal diaphysis of the fibula to simulate a displaced, oblique fracture. A 6-hole tubular locking plate was attached distally. For the post screw, a 12 mm unicortical screw or 20 mm bicortical screw was placed 1 cm proximal to the proximal end of the plate. For all constructs, the only difference was the type of post screw used. Each leg was secured to a wooden jig in the neutral position, and the jig was mounted to the platform of an MTS 858 Mini-Bionix testing system which provided compressive load as well as data measurements. The tip of the spreader was wedged between the plate and post screw to simulate the 'push' phase of the 'push-pull' distraction technique. Force applied, displacement, and number of ratchet clicks were recorded for each specimen. Results: All unicortical screws failed at under 15 clicks of the lamina spreader. There was no significant difference between applied load, energy absorbed, or stiffness at the greatest common displacement prior to any failure (22.64 mm, or 10 'clicks') between unicortical and bicortical post screw placement. At maximum applied spreader load, there were statistically significant differences in displacement (p=0.002) and energy absorbed (p=0.023). Post-hoc power analysis shows 99% power achieved for displacement and 90% power achieved for energy. The failure mode for all unicortical screws was through screw toggle and bone cut-out, while all bicortical screws failed through bending of the screws with no visible damage to the bone at the screw site. Conclusion: Clinically speaking, if a distal fibula fracture requires minimal distraction to achieve proper reduction (less than approximately 10 spreader 'clicks'), then it may be appropriate to use a unicortical post screw in order to minimize residual cortical bone damage post-surgery at the post screw location. When performing extensive reductions that require longer distractions, a bicortical post screw should be used to prevent screw toggle and potential bone chipping or fracture at the expense of residual diaphyseal bicortical screw holes.

Treatment of fractures of the main phalanx of the fingers in children

BACKGROUND: Fractures of the bones of the hand and wrist account for 25% of all fractures in children, whereas the phalanges are the most common localization of these injuries and account for 15%30% of all fractures of the upper limb. To fix fractures of the neck of the middle and main phalanx of the fingers, traumatologists resort to retrograde osteosynthesis with a spoke, which in all cases passes through the articular surface of the distal fragment, thereby blocking the joint adjacent to the fracture. This significantly complicated postoperative rehabilitation to restore movements.&#x0D; AIM: This study aimed to comparatively analyze the results of extra-articular osteosynthesis of fractures of the distal metaphysis of the main phalanx of childrens fingers.&#x0D; MATERIALS AND METHODS: A prospective cohort study included 52 children with fractures of the main phalanx of the fingers. The study cohort of children was divided into two groups. The main group included 29 children who underwent osteosynthesis of the distal fragment of the phalanx with spokes according to the authors method without passing them through the distal or proximal interphalangeal joint. The comparison group included 23 children who, during osteosynthesis, had spokes carried out retrogradely, through the articular surface of the distal phalanx fragment. The total volume of the restored active movements in the proximal interphalangeal joint was compared after 3, 6, and 12 weeks from the moment of surgery, including local signs of inflammation in the needle insertion site after 3 and 7 days from the moment of surgery.&#x0D; RESULTS: In the main group, signs of inflammation were found only in 10% of the cases, whereas in the comparison group, more serious signs were observed, such as the release of exudate along the spokes in two cases on day 3. The average values of the amplitude of movements at week 3 in the main group are more than two times higher than the average values of the comparison group, 12.06 and 5.56, respectively. The volume of movements in the main group was restored more than two times more efficiently, and in several patients, by week 12, it was restored to 100 of the total volume of active movements in the joint (p 0.05).&#x0D; CONCLUSIONS: The authors method of extra-articular and antegrade osteosynthesis of the fractures of the neck of the main phalanges in children made it possible to achieve better functional results in comparison with the standard method.

Acute on Chronic Distal Radius Fracture: A Case Series and Technique Description

Distal radius fractures are the most common fractures in adults. Because of the prevalence of these injuries, patients may present with a repeat distal radius fracture on the same wrist through the site of a malunion. We clinically refer to this as an acute on chronic distal radius fracture. In this setting, the restoration of acceptable alignment can be challenging. There is little guidance in the literature for the management of these fractures. We report our experience with acute on chronic distal radius fractures. The secondary fracture plane was used to correct the prior deformity, and the construct was fixated with a fixed angle volar locking plate. Records of patients with malunion of the distal radius who experienced an acute fracture of the ipsilateral distal radius were reviewed. Inclusion required treatment with open reduction internal fixation using a distal fragment first technique and a volar locking plate through the extended flexor carpi radialis approach. Clinical outcomes and complications were collected. Across 13 patients, the mean follow-up term was 13 months (range, 6-40 months). Radiographic union was noted in all patients. The mean visual analog scale score for pain was 1.8, and the mean Quick Disabilities of the Arm, Shoulder, and Hand score was 21.9. There were no recorded complications. Our results and described technique provide reproducible guidance for the management of acute on chronic distal radius fractures. These cases can be managed using the secondary fracture plane, a distal fragment first technique, and a volar locking plate to correct the preexisting deformity. Therapeutic IV.

Predictive factors for open reduction of flexion-type supracondylar fracture of humerus in children

ObjectiveThe incidence of open reduction and internal fixation (ORIF) in flexion-type supracondylar humerus fractures (SCHF) in children is significantly higher than that of extension-type fractures. This study aimed to identify risk factors for ORIF in flexion-type SCHF.MethodsOne hundred seventy-one patients with Wilkins type III flexion-type SCHF from January 2012 to December 2021 were retrospectively enrolled in a tertiary paediatric hospital. Patients were divided into ORIF group versus closed reduction and internal fixation (CRIF) group. Then, patients data of age, sex, injury side, obesity, deviation of displacement, fracture level, rotation, nerve injury, and delay from injury to surgery were reviewed. Univariate analysis and multivariate logistic regression were used to identify independent risk factors and odds ratios (OR) of ORIF.ResultsOverall, 171 children with type III flexion-type SCHF were analyzed (average aged 7.9 ± 2.8 years). Displacement was lateral in 151 cases, medial in 20. 20 cases had combined ulnar nerve injury. The failed closed reduction rate was 20%. Univariate analysis indicated age, distal fracture fragment rotation, and ulnar nerve injury were significantly associated with ORIF. (P = 0.047, P = 0.009, and P = 0.001, respectively). Multivariate logistic regression analysis showed that distal fracture fragment rotation (OR, 3.3; 95%CI:1.1–9.5; P = 0.028) and ulnar nerve injury (OR, 6.4; 95%CI:2.3–18.3; P = 0.001) were independent risk factors; however, the age was not an independent one (OR, 1.5; 95%CI:0.6–3.5; P = 0.397) for ORIF in the Wilkins type III flexion-type SCHF.ConclusionDistal fracture fragment malrotation on initial x-rays and ulnar nerve injury were significant risk factors for ORIF in Wilkins type III flexion-type SCHF. Surgeons should prepare tourniquets or other open reduction instruments when treating these types of fractures.Level of evidenceLevel IV

Extrinsic Compression of the Gastric Wall by a Ventriculoperitoneal Shunt Catheter: Case Report and Literature Review

Abstract Introduction Ventriculoperitoneal (VP) shunt is commonly used in the treatment of hydrocephalus and may present complications in up to 30% of patients. The present report addresses an uncommon complication in the abdominal cavity, in which the catheter caused extrinsic compression of the gastric wall. Case report A 30-year-old man presented a decreased level of consciousness, associated with severe headache and vomiting. He had a history of congenital neurotoxoplasmosis and VP shunt insertion at 7 years of age. Imaging exams demonstrated the formation of an encapsulated retrogastric pseudocyst and extrinsic compression of the gastric wall by a VP shunt catheter. Through videolaparoscopy, decompression of the gastric wall and removal of the pseudocyst were performed, with the reestablishment of the drainage of cerebrospinal fluid. An analysis of the distal fragment of the removed catheter revealed obstruction by fibrotic material. The patient was discharged with a reestablished baseline after four days of hospitalization. Comments The literature shows that ∼ 47% of the complications presented by patients are related to the distal end of the catheter, and 8.2% of these come from migration to the abdominal cavity. However, there is an extreme paucity of studies that demonstrate extrinsic compression of the gastric wall by a VP shunt catheter. Therefore, we suggest that further studies on complications involving the VP shunt be performed to improve diagnostic and therapeutic results, in addition to complementing the literature on this complication.

Outcomes of Primary Ilizarov Ring Fixator for Segmental Tibial Fracture with Compromised Skin: A Prospective Study

Background: Tibial diaphyseal fracture is the most commonly encountered fracture in orthopedic practice. There are various methods to treat the same, ranging from conservative to operative treatment. The operative methods include internal fixation using nailing and plating and external fixation using fixator/ring fixator. This study aims to evaluate the results of primary treatment of segmental tibial fracture in patients with a compromised skin condition using the Ilizarov fixator and look for complications.&#x0D; Methods: This prospective study was conducted at a tertiary level health care center. It included a series of 40 patients with segmental tibial fractures. Classification of the segmental tibial fractures was done according to Melis et al. The fixator was designed with three fixation blocks and two working length sections. The patients were evaluated for the progression clinically and radiographically at 2-week intervals for the first 2 months and were then followed by 4-week intervals. Results were evaluated according to the Association for the Study and Application of the Methods of Ilizarov (ASAMI) classification.&#x0D; Results: We treated 40 patients with a segmental tibial fracture with compromised skin using the Ilizarov ring fixator. Patients were followed up after surgery with an average follow-up of 13.8 months. The average union time came out to be 27.6 weeks for the proximal segment and 33.31 weeks for the distal segment. Out of the total patients, 15 (37.5%) patients had pin tract infection, and one (2.7%) patient had nonunion, which later required bone grafting. Bone results of patients at final follow-up as evaluated by ASAMI score were 91.7% excellent, 5.6% good, and 2.7% poor. Functional results of patients at final follow-up as evaluated by ASAMI score were 80.5% excellent, 1.7% good, and 2.8% poor.&#x0D; Conclusion: In the existing literature, segmental tibial fractures have always been difficult to treat. They are associated with high complication rates due to the lack of surrounding soft tissues. The proximal and distal fragments may be more difficult to treat because of the serious direct injury to the soft tissues overlying the segment and the difficulty stabilizing this bone segment with implants. With the use of Ilizarov technique, there is a good mean time to union, a low rate of reoperations, and good functional and general health-status outcome.

Distal Metatarsal Metaphyseal Osteotomy (DMMO) for lesser toe metatarsalgia: a case series of 195 osteotomies

Objective: The aim of the study was to radiographically evaluate the result of this minimally invasive technique for the surgical treatment of metatarsalgia. Methods: Radiographic images of 195 osteotomies in 48 patients (65 feet) who were exclusively submitted to the Distal Metatalsal Metaphyseal Osteotomy (DMMO) technique in the central rays (second, third, and fourth metatarsals) with a minimum follow-up of six months were analyzed. Bone healing, metatarsal shortening, and bone healing positioning (central, lateral, or medial) were evaluated. All statistical analysis was performed using the R software, and Wilcoxon statistical tests and Student’s t-test paired for continuous variables were used. Results: The mean length of the second metatarsal reduced 7.0mm (p&lt;0.001), the third 6.8mm (p&lt;0.001), and the fourth 6.6mm (p&lt;0.001). In only one case, there was no bone consolidation (second metatarsal). Most osteotomies were consolidated in a central position of the distal fragment. Conclusion: DMMO showed a high rate of bone healing (99.5%), metatarsal shortening, and consolidation in the central position of the distal fragment when performed in the surgical treatment of metatarsalgia. Level of Evidence IV; Case Series.