Early Functional Aftercare Research Articles

Clavicle fractures: practical approach in clinical routine

Fractures of the clavicle are among the most common fractures. They typically result from afall onto the lateral shoulder or the extended arm and are often related to sports and bicycle accidents. Obtaining the exact trauma mechanism, proper clinical findings and adequate X‑rays usually lead to the correct diagnosis. Non-displacement fractures can be treated conservatively with good results. Unstable and displaced fractures should be treated operatively. Open fractures or looming penetration are emergencies und should be treated immediately. In addition to fracture classification and morphology, other factors such as additional injuries and patient-related factors need to be considered in order to make an individualized therapy decision. In operative treatment, angular stable plating is the therapy of choice, and in most cases early functional aftercare is possible.

Conservative treatment of fractures involving the coronoid process

Abstract Background Fractures of the coronoid process require adequate treatment, as otherwise they often lead to chronic instability and the development of rapidly progressive cubital osteoarthritis. Commonly, such patients are treated surgically; however, a defined fraction of patients might benefit from conservative treatment. Methods We systematically reviewed the available literature searching Medline using the PubMed interface. The primary objective was to determine indications, treatment protocols, and associated functional outcomes and complications of entirely conservatively treated fractures of the coronoid. The PRISMA guidelines were applied. Results We included five studies, all retrospective in design, with a total of 62 patients. For the indication of conservative treatment, joint congruency on imaging was a prerequisite in all studies. This was supplemented on most occasions by dynamic clinical examinations, with a focus on pain, range of motion, and adequate joint stability. Treatment protocols included close-meshed imaging, early functional mobilization, and some form of resting immobilization. Treatment success, defined as excellent or good results according to the Mayo Elbow Performance Score, was 95.1% at an average follow-up of 36 months. Six patients (9.7%) underwent surgical treatment during follow-up; 19 patients (30.6%) suffered complications that did not result in surgery. Conclusion The data of this work indicate that most patients achieve satisfactory results following conservative treatment of coronoid fractures caused by rotational moments. Concentric reduction of the joint, clinical exclusion of even mild subluxations, systematic early functional aftercare, and close radiographic monitoring appear to be mandatory requirements. The evidence remains scarce, and conclusions drawn from this review should be viewed with caution, as prospective randomized controlled trials are not available to date. Level of evidence IV, therapeutic

Radial head fractures : Epidemiology, diagnosis, treatment and outcome

Radial head fractures account for the majority of bony injuries to the elbow. The usual clinical signs include hemarthrosis, pain and limitations in movement. The standard diagnostic tool is radiological imaging using X‑rays and for more complex fractures, computed tomography (CT). Concomitant ligamentous injuries occur more frequently than expected and must be reliably excluded. The classification is based on the modified Mason classification. Mason typeI fractures are usually treated conservatively with immobilization and early functional aftercare. Mason typeII fractures can be well-addressed by screw osteosynthesis but higher grade fractures (Mason typesIII-IV) can necessitate a prosthetic radial head replacement. In this case, prosthesis implantation is to be preferred to aradial head resection. The outcome after treatment of radial head fractures can be described as good to very good if all accompanying injuries are adequately addressed.

Study on functional outcome of the proximal humeral internal locking system (PHILOS) for displaced proximal humeral fractures in adults

Background: The Incidence of trauma related skeletal injuries have been on the rise in recent years and proximal humerus fractures are one of the most common fractures occurring in the human body. Hence the present study was conducted to evaluate the clinical and functional outcome of the proximal humeral internal locking system (PHILOS) technology.The present study was undertaken to assess the functional and radiological outcome of the proximal humeral internal locking system (PHILOS) for displaced proximal humeral fractures in adults. Method:The present prospective observational study was conducted in adults with proximal humerus fractures admitted to department of orthopedics, GSL Medical College and General hospital Rajahmundry during study period from 1st October 2015 to 31st March 2017. The study was approved by the institute’s ethical committee. Patients were undergo Open reduction internal fixation with philos locking plating for the sustained fracture under general anaesthesia. Post-operative physiotherapy followed according to protocol, to evaluate the functional outcome. Result: The average age of patients was 44 years. Males were 16 and females were 09. Most common mechanism of injury observed was Road traffic accident in 72%. The Constant- Murley score was significantly improved (p=.000) over the successive follow-up period. 01 (04%) patient had excellent Constant-Murley scores, 11 (44%) patients had good scores, as like 11 (44%) had moderate scores and only 2 (08%) patients had a poor functional outcome. Conclusion:In conclusion, the proximal humeral locking plate seems to be an adequate device for the fixation of displaced two-part, three-part and four-part proximal humerus fractures. Due to stable fixation, early functional aftercare is possible and allows the patient to regain good shoulder function and resume normal activities much earlier.

Treatment of traumatic lesions of the bursa olecrani and chronic bursitis olecrani

Complete olecranon bursectomy with debridement, protection of veins and nerves. Risk-adapted antibiotic therapy and early functional aftercare. Acute, traumatic laceration of the bursa olecrani, chronic therapy-resistant bursitis olecrani. For traumatic bursa injuries: general contraindications for anesthesia and surgery; chronic bursitis: initially not closable skin defect (plastic surgery required), hemodynamically instable patient (e.g. systemic inflammatory response syndrome [SIRS] or sepsis), pre-existing skin infection. Local anesthesia beyond the lesion, careful debridement, identification and removal of the entire bursa, excision of contaminated skin, lavage, drain insertion (Redon, Easy-flow, Penrose). Wound closure, elastic bandage, and splint. Elastic bandage for 2 days, followed by drain removal. Wound assessment, early functional aftercare without splint, antibiotic therapy in septic bursitis for 2weeks, PRICE scheme. Removal of stitches after 10-12days. Over 5years, 138 cases of traumatic bursa lesion or chronic bursitis olecrani were treated in our clinic, 82patients underwent surgery. Ten patients were treated with vacuum-assisted closure therapy and consecutive wound healing; fistulae occurred in two patients and in another two dehiscence developed. All of the defects could be closed without flaps.

Injuries of the acromioclavicular joint: Hook plate versus arthroscopy

Acute acromioclavicular (AC) joint injuries are common in clinical practice. The hook plate is a well-established conventional operative treatment option for high grade instability; however, arthroscopically-assisted flexible double button techniques are increasingly being used. Both procedures lead to good or excellent results. The advantages of the hook plate are the simple surgical technique and the possibility of an early functional aftercare. The minimally invasive one-step procedure with the possibility of identification and treatment of frequently concomitant glenohumeral pathologies is advantageous for the arthroscopic technique but mobilization is more restrictive. Available comparative studies have shown no significant clinical differences but a tendency towards better results with a higher degree of acceptance among patients for the arthroscopic and minimally invasive non-rigid double button procedures.

High bone consolidation rates after humeral head-preserving revision surgery in non-unions of the proximal humerus

Fractures of the subcapital and proximal humerus shaft region are common fractures of the human skeleton. Their treatment should provide an early functional after-care of the shoulder joint, that is prone to arthrofibrosis. Although the upper extremity is not weight-bearing the occurrence of proximal humerus non-unions leads to severe impairment with inability to work and restrictions of activity of daily life. The aim of this study was to investigate whether an operative revision of proximal humerus non-unions with reosteosynthesis and application of distant autologous bone grafts can lead to sufficient bone healing. The second aim was to find out whether patients achieved an acceptable functional outcome, as alternatively patients could be treated by reconstruction with a shoulder prosthesis. 27 patients (female = 15, male = 12) with reosteosynthesis of the proximal humerus and proximal humeral shaft due to non-union after initially operative fracture treatment were included between 2008 and 2014. Average age of patients was 56 years (23-87), 48% had no comorbidities, while 52% of the patients had at least 1 comorbidity such as diabetes, hypertension or nicotine abusus. The mean number of prior surgical intervention was 1.2 (1-3). The mean time between initial surgery and re-osteosynthesis was 12.3 months. Patients with signs of infection pseudarthrosis were excluded. The initial type of osteosynthesis was with plates (n = 16; thereof PHILOS Plate n = 14), and intramedullary nails (T2, Targon Nail, PHN, Seidel Nail; n = 11). Revision surgery was done with plate osteosynthesis (n = 26; thereof PHILOS Plate n = 4; LC Plate n = 10; angle plate n = 12). In 23 patients (89%) a distant bone transplantation was done from the iliac crest, and 1 patient received allogenous bone. Three patients (11%) received bone morphogenetic protein 7 (BMP 7) in combination with distant bone graft. Intraoperative swabs from the pseudarthrosis area showed no bacterial pathogen after 14 days of incubation. DASH score and Constant score were used to evaluate the functional outcome after revision surgery. Bone healing was determined by standard X-rays and evaluated by a modified radiological score. 89% of the patients could be followed for an average of 28 months and the radiological follow-up was at 9 months. The radiological score showed very good (50%), or good results, and a sufficient bone healing was shown in 25 of 27 patients (93%). The pseudarthrosis revision surgery failed in two cases (n = 1 persisting non-union; n = 1 humeral head necrosis after re-operation with angle plate). DASH scores provided a mean of 40 ± 28.8 with a range from 0-97 points, and the results from the Constant score provided 45 ± 25.4. The analysis with variation of age showed a trend for better results in female patients < 60 years of age. As complications after bone graft 3 patients had persistent local dysesthesia (11%), in one case fracture of the iliac bone occurred that healed with conservative treatment. The pseudarthrosis revision surgery with humeral head preserving re-osteosynthesis with bone transplantation is an effective treatment for non-unions of the proximal humerus and the proximal humeral shaft and the current results showed high bone consolidation rates. As the functional results remained limited after revision an individual treatment decision should be made concerning the most appropriate therapy. While a shoulder prosthesis may be considered in the aged patient, a revision strategy with reosteosynthesis should be considered particularly in younger patients.

Intramedulläre Nagelung von proximalen Tibiafrakturen

Restoration of axis, length, and rotation of the lower leg. Sufficient primary stability of the osteosynthesis for early functional aftercare. Maintaining mobility of knee joint. Bone healing in closed and open fractures. Closed and open isolated proximal tibia and lower leg fractures (AO 42). Extraarticular fractures of the proximal tibia (AO 41 A2/A3). Intraarticular fractures of the proximal tibia (AO 41 C1/C2) in combination with other implants. Segmental tibia fractures (AO 42 C1/C2) with short proximal fragment. Comminuted tibia shaft fractures (AO 42 C3) with short proximal fragment. Very poor general condition (e.g., bedridden). Flexion of knee less than 90°. Infection in the nail's and bolt's insertion area. Infection of the tibia intramedullary canal. Complex fractures of the tibia plateau (AO 41 C3). Open physis. Closed reduction of the fracture. If necessary, use of reduction clamps through additional stab incisions or open surgical procedures. In some cases, additional osteosynthesis procedures are necessary (e.g., compression screws). Positioning of the patient on a radiolucent table or a traction table. Opening of the proximal tibia in line with the medullary canal. Cannulated or noncannulated insertion of the nail with or without reaming of the medullary canal. Control of axis, length, and rotation of the lower leg. Triple proximal interlocking in three different planes with the targeting device. Double distal interlocking. Immediate mobilization of the knee joint. Depending on the type of fracture, mobilization with 20kg partial weight bearing or pain-dependent full weight bearing with crutches. X-ray controls after 3, 6, and 12 weeks and increase of weight bearing depending on the fracture status. In a prospective multicenter study on the stabilization of tibia fractures with the Expert Tibial Nail, 22 patients with proximal third tibia fractures were documented. Seventeen patients could be reviewed clinically and radiologically after 1year. A non-union was registered in 1patient (5.9%), a malalignment in any plane above 5° in 3fractures (17.6%).

Tibiamarknagelung mit dem Expert Tibia Nagel®

Restoration of axis, length, and rotation of the lower leg. Sufficient primary stability of the osteosynthesis for functional aftercare. Early functional aftercare to maintain joint mobility. Good bony healing in closed and open fractures. All closed and open fractures of the tibia and complete lower leg fractures (AO 42). Certain extraarticular fractures of the proximal and distal tibia (AO 41 A2/A3; AO 43 A1/A2/A3). Segmental fractures of the tibia. Certain intraarticular fractures of the tibia with use of additional implants (AO 41 C1/C2; AO 43 C1/C2). Stabilization during and after segmental bone transport or callus distraction of the tibia. Patients in poor general condition (e.g., bedridden). Flexion of the knee of less than 90 degrees . Infection in the nail's insertion area. Infection of the tibial cavity. Complex articular fractures of the proximal or distal tibia with joint depression. Closed reduction of the fracture. If necessary, use of reduction clamps through additional stab incisions or open surgical procedures. In some cases, additional osteosynthesis procedures are necessary (e.g., screws). Positioning of the patient may be performed on a radiolucent table or a traction table. Opening of the proximal tibia in line with the medullary canal. Cannulated or noncannulated insertion of the Expert Tibia Nail((R)) with or without reaming of the medullary canal depending on the fracture type and soft-tissue condition. Control of axis, length, and rotation. Distal interlocking with the radiolucent drill and proximal interlocking with the targeting device. Immediate mobilization of ankle joint and knee joint. Depending on the type of fracture, mobilization with 20 kg partial weight bearing or pain-dependent full weight bearing with crutches. X-ray control 6 weeks postoperatively and increased weight bearing depending on the fracture status. In a prospective, international multicentric study, 181 patients with 186 fractures were included between July 2004 and May 2005. 57 of these fractures (30.7%) initially were graded open, 15 of them grade I, 32 grade II, and ten grade III. Most of the fractures (36%) were shaft fractures. After 1 year, 146 patients (81%) could be evaluated clinically and radiologically. The overall pseudarthrosis rate was 12.2% (18.2% for open and 9.7% for closed fractures). The risk for secondary operations or revisions (including dynamization of the nail) was 18.8%. Without consideration of dynamization procedures, revisions were necessary in only 5.4% of all patients. The risk for varus, valgus or antecurvation malalignment of more than 5 degrees in any plane on radiologic long leg views was 4.3% for shaft fractures, 1.5% for distal fractures, and 13.6% for proximal fractures. The implant-specific risk for bolt breakage was 3.2%.

Ergebnisse der antegraden, intramedullären Kirschner-Draht-Schienung der subkapitalen MHK‐V-Fraktur nach Foucher

One of the most common hand injuries is the subcapital fracture of the fifth metacarpal bone. We propose a surgical procedure when the fracture is angulated for at least 40 degrees in a palmar direction or when we find a rotatory deformity. Our standard operation procedure is a closed reposition with an intramedullar Kirschner-wire pinning with 2 curved wires according to Foucher's technique. During the period from 8/2003 to 6/2006 we repaired 126 distal metacarpal fractures in the mentioned technique with the use of 1.2 mm Kirschner wires. We suggest an early functional aftercare with a middle hand brace for four weeks. In a retrospective study we were able to examine 41 patients. Our research included objective parameters like the grip power and the range of motion as well as subjective parameters with the use of the DASH score and a self-created questionnaire to check the individual satisfaction with the operative procedure. 41 patients (94 %) were satisfied or very satisfied with the result of the operation and 35 (79 %) were satisfied or very satisfied with the local anaesthesia.

Patellotibial external fixation for ruptures of the distal extensor apparatus of the knee

Objectives The Marburg external patellotibial (Mpt) fixator is designed to temporarily protect a reconstructed distal extensor apparatus of the knee. It allows an early functional aftercare.

Traumatic sternoclavicular instability. A therapeutic alternative

Traumatic instability of the sternoclavicular joint is a rare diagnosis. It is usually treated by different bandaging techniques without the possibility of early functional aftercare. In the period between 1 January 1996 and 31 December 1998, a total of eight patients with unstable sternoclavicular joints requiring surgical treatment were treated with Balser plates. The population comprised seven anterior and one posterior dislocations. The results achieved with this alternative treatment option, which offers the advantage of enabling early functional aftercare, are presented. Seven of eight patients were available for follow-up. The eighth patient moved from the area. The Constant Score ranged between 84 and 100 points (average 89 +/- 6.6).

Combined Percutaneous and ???Minimal??? Internal Fixation for Displaced Articular Fractures of the Calcaneus

Forty-one displaced intraarticular fractures of the calcaneus in 38 patients were treated with open reduction and screw fixation of the posterior facet, bone grafting, and percutaneous pinning of the body. A single extensile posterolateral approach was used in all but two cases in which an additional medial incision was needed. Using early functional aftercare, all fractures healed without secondary displacement in an average of eight weeks. Follow-up periods averaged 4.2 years. Results were graded as excellent in 14 patients, good in 16, fair in three, and poor in five. There was a strict correlation between the clinical results and the severity of the articular comminution. A satisfactory outcome depended on the restoration of articular congruency and extraarticular alignment of the os calcis.