Mid-shaft Fractures Research Articles

Accordion maneuver with Ilizarov placed plate in situ, in a case of femoral shaft non-union and refracture with quiescent infection, discussion on treatment strategies: a case report

Introduction: Aim of this study to evaluate the clinical efficacy and highlight their relevance in present orthopedics practice where multiple newer choices have been become famous. Accordion maneuver design with modified Ilizarov apparatus, a single stage procedure in femoral shaft non-union and re-fracture with quiescent infection place dynamic compression plate (DCP) in situ. Femoral shaft fractures (FSFs) are frequently occurring injury due to RTA. Infection (0.4%) and non-union (1.1 - 14%) are the morbid complications of femur fractures. The healing rate for femora shaft non-unions is too high (90%).1 Accordion Maneuver (AM) is the “Bloodless Stimulation” of bone healing described by Professor G. A. Ilizarov. It comprises of alternate compression and distraction which produce stress in living tissue and also convert biologically inactive scar tissue at non-union site into tissue capable of neo-osteogenesis.2 The suggested treatment for quiescent type of infected non-union is a single stage procedure with minimal or no debridement and if implant is provide sufficient stability it placed in situ.3 Case Report: In the case, a 26 years man treated by DCP with MIPO for his Gustilo type – Ⅰ open, comminuted fracture of mid femoral shaft (Left) following RTA. Post-operative infection occurred within 2 weeks of operation. Infection controlled by exploration and surgical toileting with antibiotic. After four (4) months later he was sustained re-fractured with bending plate due to fall again. Finally he was diagnosed as H. Rosen`s type 3 Quiescent infected non-union (Oligotrophic) and Romano stage -1 post-implant infection with re-fracture mid shaft of left femur. Then he was treated following accordion principles with modified Ilizarov frame. AM was applied according to protocol of Baruah and Patowary of non-union treatment. Result: After complete union and consolidation, substantiated by radiological evidence Ilizarov apparatus was dispelled six (6) months later of installation without removal of plate and four (4) months of that finally plate was removed. After one (1) year and four (4) months of mounted Ilizarov frame, the patient was in full free movement of knee and hip. He had no problem during walking even running. Conclusion: We pursue for the treatment, accordion maneuver with Ilizarov apparatus, a single stage procedure in femoral shaft non-union and re-fracture with quiescent infection kept plate in situ. Few authors reported, Accordion Maneuver (AM) techniques with Ilizarov apply over intramedullary nail (IMN) in situ for aseptic non-union of femur. In this study, we discussed the role of this tool (AM) for the treatment of femoral shaft non-union and re-fracture with quiescent infection place plate (DCP) in situ.

Effects of fixation of clavicle fracture using wide-awake local anesthesia no tourniquet (WALANT) technique on intra-operative bleeding volume, surgical duration, and post-operatively visual analog scale (VAS); A case series study

Clavicle fractures are common fractures with a rate of 2–5 percent among fractures. Mid-shaft fractures of the clavicle are more common than the other sites of the clavicle. Traditionally, surgical fixation of clavicle fractures has been performed under General Anesthesia (GA). The purpose of this study was to assess the effects of WALANT on intraoperative bleeding, pain control during and after surgery, postoperative complications and patients’ function. In the current study, 30 patients with clavicle fractures were surgically fixed using the WALANT technique. The obtained results showed that it could be an effective technique for pain control during the operation and also early postoperative period. Moreover, the WALANT technique could be considered safe in patients who are at risk for GA because of medical comorbidities, cervical spine injuries, or other factors that make intubation difficult.

Revision surgery after failed surgical treatment of midshaft clavicle fractures is often associated with positive detection of bacteria.

Midshaft clavicle fractures are common, and the proportion of patients treated surgically has increased in recent years. With this increase in surgical treatments, the complication rate, for instance of infection, non-union, or implant failure, has also risen. This study evaluates the frequency of pathogen detection during revision surgeries occurring after a prior failed osteosynthesis of midshaft clavicle fractures. All patients treated in our hospital with a prior failed surgical therapy of a clavicle midshaft fracture between January 2013 and March 2022 were screened. Epidemiological data, intraoperative tissue samples, sonication, and the type of revision surgery were assessed. A postoperative follow-up at a minimum of 6month was defined and osseous consolidation was verified. Twenty-one patients (twelve male and eight female) were included with a mean age of 40.4 ± 14.1years. Eleven of the patients showed pathogen detection (Group I), and seven remained without (Group II). A significant difference in age existed between Groups I and II (36.1 ± 12.8 and 51.6 ± 11.5, p ≤ 0.05). The three most common pathogens were Cutibacterium acnes (n = 7), Staphylococcus epidermidis (n = 4), and Staphylococcus sacchorlyticus (n = 3), respectively. Thirteen patients presented for a follow-up. In nine patients (69%), bone healing was detectable. Four patients received a second revision surgery. Revision surgery frequently shows pathogen detection without signs of infection. Cutibacterium acnes is the most common pathogen. Despite pathogen detection, bone healing can be achieved with revision surgery, although the rate of repeat revision surgeries is high.

Canceling Notch Improves the Mechanical Safety of Clavicle Locking Plate: A 3D Finite Element Study.

Implant failure is a disastrous complication of the operative treatment of midshaft clavicle fractures, and improving the osteosynthesis plate is a strategy for preventing this. We aimed to investigate whether canceling the notch and adding screw-hole inserts enhanced the mechanical properties of the plate. A clavicle model was generated based on the CT images of six adult volunteers (age range, 20-40 years; three males and three females; height range 160-175) using dedicated software, and a midshaft fracture model was created. The domestically made seven-hole locking plate commonly used for midshaft clavicle fractures was simulated (Model I); modifications were made to the plate (Model II). Using 3D finite element analysis, we simulated the fracture construct under three different load conditions-downward cantilever bending, axial compression, and axial torsion-and compared the stress distribution. We found that under axial compression, Model II experienced its maximum stress on the plate at 551.9MPa, which was less than that in Model I (790.4 MPa). Moreover, a greater stress concentration at the fracture site was observed under axial torsion, despite the maximum stress of both the models being similar. Canceling the notch and filling the screw holes near the fracture can ameliorate stress concentration on the internal fixation construct and enhance its reliability under axial compression. This improvement has substantial effects on the mechanical properties of implants and potentially prevents implant failure. Modern osteosynthesis anatomical implants need to be improved.

Radial Nerve Injury In Patients With Closed Fracture Of Humerus Shaft In High Energy Trauma Cases.

Fracture of the humerus usually result in radial nerve injury. This study was done with the aim to determine the incidence of Radial Nerve Injury in patients with closed fracture of the humerus shaft in high-energy trauma cases. This descriptive study was conducted in the Department of Orthopaedics and Emergency room, Ghurki Teaching Hospital, Lahore from January to December 2021 recruiting consecutive such patients. Standard ward protocol was followed to manage the patients initially including fracture stabilization and analgesia requirement. All the patients were carefully assessed to detect radial nerve injury. Data analysis was done through SPSS 26.0. A total of 80 patients were included with the confirmed diagnosis of fracture of the humerus. There were 55(68.5%) males and 25(31.25%) females. The age range was 20 to 60 years and the mean age of males and females was 31.62±8.35 and 38.43±5.06 respectively with overall mean age±SD was 38.93±6.19. There were 32 (40%) cases of spiral fracture, 17 (21.25%) cases of transverse fracture, 16 (20%) cases of communized fracture, and 15 (18.75%) cases of segmental fracture. Radial nerve injury was present in 7 (8.75%) patients. Out of these 7 cases of radial nerve injury; 4 (57.1%) cases were recorded in patients with spiral closed fracture of midshaft of humerus, 1 (14.3%) cases were recorded in transverse closed fracture of humerus shaft, 1(14.3%) cases in comminuted closed fracture of midshaft of the humerus while 1 (14.3%) were segmental fractures. Our study highlighted the frequency of radial nerve palsy in humeral shaft cases with most common in spiral closed fracture of the midshaft of the humerus.

Data on inter-locking nail in humeral shaft fractures among Indian patients.

Humeral shaft fractures are commonly seen orthopaedics injuries. Open reduction with internal fixation (ORIF) with plating is a gold standard procedure despite various issues such as infection, radial nerve palsy and no-nunion. Close reduction with interlocking nails (ILN) is not a very popular procedure. Therefore, it is of interest to collect data on the significance of interlocking nail in different pattern of humerus shaft fracture. 30 patients with closed humeral shaft fracture participated in this study. The fractures were classified according to their descriptive location as proximal, middle and distal. All surgeries were performed by a single surgeon familiar with the ILN procedure. All patients had appropriate clinical, radiological and pre and postoperative assessment. Data on patients were collected at 2, 6weeks, 12weeks, 18 weeks and 6 months. 19 cases with middle third and distal third fractures were united within 10-14 weeks. 6 cases of proximal shaft fracture were united in 14-18 weeks. According to Rodrı ´guez-Merchant criteria - Middle shaft fracture has shown good results (n=9, 75%) followed by distal third shaft fracture (n=6, 60%) and proximal third fracture (n=1, 12.5%). Though there is decrease in mean ASES score in all three groups of fractures but the Mid shaft fracture has shown significant decline in ASES score suggesting improvement in pain and ROM after 6 months. Thus, ILN of humerus is a simple and a safe procedure for treating fractures of middle and distal third shaft humerus. However, this study does not support ILN for the management of proximal third humerus fracture.

Management of Unstable Per-trochanteric Fracture in Old Patient by Primary Prosthetic Replacement

Background: Peritrochanteric fractures are frequent of the proximal femur and represents about half of all proximal femur fractures. They are associated with disability, mainly in elder patients. Its management aiming to achieve immediate ambulation and to regain the pre-operative ambulation.
 Aim and objectives; to evaluate and assess the functional and radiological outcomes of primary prosthetic replacement in old age cases of unstable per-trochanteric femur fractures,
 Subjects and methods: The current work was an interrupted time series clinical trial (quasi experimental), included 15 patients suffering from unstable per-trochanteric fracture presented to us within a week of sustaining injury. They were clinically assessed and checked for fitness for surgery. Then and after surgery, they were followed by for functional outcome by Harris Hip Scale and any complications were recorded.
 Results: Patients age ranged between 61 and 94 years. Females were more affected than males (80.0% vs 20.0%). Associated comorbidities were hypertension, diabetes and both conditions among 33.3%, 6.7% and 33.3%, successively. Falling was the commonest mode of injury (60.0%), and the left side was more affected than the right (60.0% vs 40.0%). Associated injuries were 1(6.7%) fracture surgical neck hummers, 1(6.7%) contralateral both bone leg fracture, 1(6.7%) had fracture mid shaft ulna. Regarding outcome, all cases were free from postoperative complications. However, blood loss was reported among 11(73.3%). Twelve (80%) patients had an excellent, 2 (13.3%) had good and 1(6.7%) had fair functional outcome. There was significant association between functional outcome and patients, gender, associated comorbid medical conditions, mode of trauma, side of trauma, or blood loss.
 Conclusion: Primary prosthetic replacement is a valid surgical option in management of unstable trochanteric fractures in elderly. The main advantages are the safety, effectiveness and early full weight bearing.

Causes and Treatment of Birth Trauma-Related Femoral Fracture: A Longitudinal Study

Aim: To determine the causes and treatment of birth trauma related femoral fractures. Study design: A longitudinal study Place and Duration: This study was conducted at DIMC, Dow University of Health Sciences, Karachi from January2021 to January 2022. Methodology:The study included cases of femoral fractures in neonates caused by birth trauma. The cases of birth histories were investigated in terms of gestational age, birth weight,and mode of delivery. The category of femoral fracturesand the treatment performed were both noted. Cases were followed until they were recovered.A comprehensive clinical examination was performed. Other birth traumas, fractures, nerve palsies, and/or symptoms of other musculoskeletal, genetic diseases, such as blue sclera and hypermobile joints (osteogenesis imperfecta), were noted. Results:A total of 15 newborns with femoral fractures were included in this study.The average gestational age was 38.2 weeks, with an average diagnosis time of 3 days. In the majority of cases, the infant was born breech and delivered via Caesarean section. Eleven instances had mid-shaft fractures, while four had subtrochanteric fractures. After an average of 3.1 weeks, all patients had a complete union. Conclusion:A femoral fracture in a neonate due to birth related trauma is quite uncommon. It occurs more frequently in Caesarean sections performed for breech presentation. Preterm and/or low birth weight newborns are at a higher risk. The femur shaft is commonly fractured. The prognosis for these fractures is excellent, and they heal completely after immobilization. Keywords: Birth Trauma, Femoral Fracture, Management, Risk Factors

Experimental and numerical investigation on ZnP coated Mg-Mn based composite materials for internal fixation of tibia midshaft fracture: A comprehensive study

The study is aimed to assess the role of Ca10(PO4)6(OH)2 (HAp) and Zn3(PO4)2 (ZnP) bioceramics respectively as powder reinforcement and coating agent for magnesium alloys. The nano-sized HAp powder was synthesised and Mg-2Mn-1.5Zn (MZ21) and Mg-2Mn-1.5Zn/1HAp (MZ21/HAp) metal matrix nanocomposites were developed using vacuum-assisted stir casting process in Ar-SF6 protected environment. The chemical conversion coatings of ZnP were prepared on fabricated composites using Teflon lined stainless steel with zinc phosphate-based reaction solution. X-ray diffraction was used to assess the interaction of Mn and Zn on Mg crystal lattice. Microstructural observations were made using optical and scanning electron microscopy with energy dispersive X-ray spectroscopy. Mechanical properties were determined using tensile, hardness and dynamic mechanical analysis. Tensile yield and ultimate strengths of the MZ21 (60.31 ± 0.24 MPa, 142.83 ± 18.40 MPa) and MZ21/HAp (73.41 ± 2.24 MPa, 139.65 ± 16.16 MPa) showed a two-fold increase compared to pure Mg (30.36 ± 2.66 MPa, 73 ± 5.74 MPa). In-vitro studies indicated 10 % and 59 % improvement in cell viability, and 60 % and 33 % reduction in hemolysis rate respectively for MZ21 and MZ21/HAp by employing ZnP, and its bioactivity resulted in increased cell attachment. The effectiveness of the material was biomechanically evaluated and analysed using finite element approach. The results indicated that the developed composites reduced the mechanically shielded region and could provide enhanced healing in transverse tibial shaft fracture.

Risk Factors for Failure of Closed Forearm Fracture Reduction in the Pediatric Emergency Department.

This study aimed to explore risk factors for failure of forearm fracture closed reduction in the pediatric emergency department (ED) and to suggest indications for initial surgery. This retrospective cohort study included all patients aged 0 to 18 years who presented to our pediatric ED with an extraarticular forearm fracture treated with closed reduction between May 2017 and April 2021. We explored risk factors for procedural failure, defined as a need for surgical intervention within 6 weeks of the closed reduction attempt. Of 375 patients (median age 8.1 years, 294 [78.2%] boys), 44 (11.7%) patients sustained a reduction failure, of whom 42 (95.5%) had both radius and ulna fractures. Of the 259 patients with fractures of both bones, the following parameters were independent predictors for reduction failure: refracture (adjusted odds ratio [aOR] 17.6, P < 0.001), open fracture (aOR 10.1, P = 0.007), midshaft fracture (aOR 2.6, P = 0.004), radial translation rate 37% and higher in either plane (aOR 5.1, P = 0.004), and age of 10 years and older (aOR 2.9, P = 0.01). Most pediatric forearm fractures can be successfully managed by closed reduction in the ED. Two-bone fractures had the strongest association with reduction failure. Refracture, open fracture, midshaft location, initial radius bone translation of 37% and higher (and not initial angulation), and patient age of 10 years and older are independent risk factors for reduction failure in two-bone fractures. We propose a risk score for reduction failure that can serve as a decision-making tool.

Clinical and radiographic evaluations of healing femoral fractures managed with conventional and novel allo-cadaveric bone plates in dogs

Femoral diaphyseal fractures are usually amenable to reduction with the use of orthodox fixation implants, which in most cases are expensive and cause intense stress to the patient, hence the need for safer, new biomaterials. This study assessed the use of allo-cadaveric bone plates (CBP-A) and conventional bone plates in managing femoral fractures in dogs. A total of four 8-12 kg Nigerian indigenous dogs were randomly divided into two groups, with each consisting of a male and female dog. Sterilized osteotome wire was employed to surgically create transverse mid-shaft femoral fractures in all the dogs. The fractures in Group I dogs were managed using Vitallium-alloy bone plates and served as control, while Group II fractures were reduced and fixed using CBP-A. Clinical and radiographic assessments for three months were carried out to compare the fracture healing between the groups. Results showed an early stabilization of vital parameters with a premature attempt to use the operated limb on days 4 and 5 post-reduction in groups I and II, respectively. The radiographs revealed good fracture reduction and fixation in all the dogs with the gradual disappearance of the fracture line, as well as progressive bone remodelling as the fracture healing advanced through the sixth week. At 12 weeks, there was distinct medullary and cortical continuity in all the dogs. Therefore, the novel CBP-A used in this study has effectively provided the needed fixation stability with minimal external immobilization for the repair of dog femoral fractures; hence, it should be recommended for use.

Intraoperative fluoroscopic protocol to avoid rotational malalignment after nailing of tibia shaft fractures: introduction of the ‘C-Arm Rotational View (CARV)’

PurposeRotational malalignment (≥ 10°) is a frequent pitfall of intramedullary-nailing of tibial shaft fractures. This study aimed to develop an intraoperative fluoroscopy protocol, coined ‘C-Arm Rotational View (CARV)’, to significantly reduce the risk for rotational malalignment and to test its clinical feasibility.MethodsA cadaver and clinical feasibility study was conducted to develop the CARV-technique, that included a standardized intraoperative fluoroscopy sequence of predefined landmarks on the uninjured and injured leg in which the rotation of the C-arm was used to verify for rotational alignment. A mid-shaft tibia fracture was simulated in a cadaver and an unlocked intramedullary-nail was inserted. Random degrees of rotational malalignment were applied using a hand-held goniometer via reference wires at the fracture site. Ten surgeons, blinded for the applied rotation, performed rotational corrections according to (1) current clinical practice after single-leg and dual-leg draping, and (2) according to the CARV-protocol. The primary outcome measure was the accuracy of the corrections relative to neutral tibial alignment. The CARV-protocol was tested in a small clinical cohort.ResultsIn total, 180 rotational corrections were performed by 10 surgeons. Correction according to clinical practice using single-leg and dual-leg draping resulted in a median difference of, respectively, 10.0° (IQR 5.0°) and 10.0° (IQR 5.0°) relative to neutral alignment. Single-leg and dual-leg draping resulted in malalignment (≥10°) in, respectively, 67% and 58% of the corrections. Standardized correction using the CARV resulted in a median difference of 5.0° (IQR 5.0°) relative to neutral alignment, with only 12% categorized as malalignment (≥10°). The incidence of rotational malalignment after application of the CARV decreased from 67% and 58% to 12% (p = <0.001). Both consultants and residents successfully applied the CARV-protocol. Finally, three clinical patients with a tibial shaft fracture were treated according to the CARV-protocol, resulting all in acceptable alignment (<10°) based on postoperative CT-measurements.ConclusionThis study introduces an easy-to-use and clinically feasible standardized intraoperative fluoroscopy protocol coined ‘C-arm rotational view (CARV)’ to minimize the risk for rotational malalignment following intramedullary-nailing of tibial shaft fractures.

Numerical simulation and biomechanical analysis of locking screw caps on clavicle locking plates.

Background:The risk of displaced and comminuted midshaft clavicle fractures is increased in high-energy traumas such as sport injuries and traffic accidents. Open reduction and plate fixation have been widely used for midshaft clavicle fractures. Among various plates for clavicle shaft fractures, superior locking compression plates (LCPs) have been mostly used. In plate fixation, nonunion caused by implant failure is the most difficult complication. The most common reasons for metal plate failure are excessive stress and stress concentration caused by cantilever bending. These causes were easily addressed using a locking screw cap (LSC).Methods:The clavicle 3-dimensional image was made from a computed tomography scan, and the clavicle midshaft fracture model was generated with a 10-mm interval. The fracture model was fixed with a superior LCP, and finite element analysis was conducted between the presence (with LSC model) and absence (without LSC model) of an LSC on the site of the fracture. The stresses of screw holes in models with and without LSCs were measured under 3 forces: 100 N cantilever bending force, 100 N axial compression force, and 1 N·m axial torsion force. After the finite element analysis, a validation test was conducted on the cantilever bending force known as the greatest force applied to superior locking plates.Results:The mean greatest stress under the cantilever bending force was significantly greater than other loading forces. The highest stress site was the screw hole edge on the fracture site in both models under the cantilever bending and axial compression forces. Under the axial torsional force, the maximum stress point was the lateral first screw hole edge. The ultimate plate stress of the with LSC model is completely lower than that of the without LSC model. According to the validation test, the stiffness, ultimate load, and yield load of the with LSC model were higher than those of the without LSC model.Conclusions:Therefore, inserting an LSC into an empty screw hole in the fracture area reduces the maximum stress on an LCP and improves biomechanical stability.

Titanium Elastic Nailing System of Diaphyseal Femur Fracture in a 7 Years Old Child: A Case Report

Objective: Midshaft femur fracture commonly treated conservatively in paediatric patients. However, complications are seen in conservative treatments and lately surgical interventions are being practised tremendously to minimise the complications. Case Report: A 7 years old boy, sustained a closed fracture midshaft left femur after a motor vehicle accident. Operative management was decided for this patient using Titanium Elastic Nailing System, which revealed a good outcome within 3 months of duration. Conclusion: Titanium Elastic Nailing System is fixed with minimally invasive techniques in children 6-16 years of age with diaphyseal femoral fractures, which gives a good outcome and minimizes the complications and allows earlier rehabilitation and return to school life by speeding up the fracture healing. However, an experienced surgeon and good surgical technique is desired to minimize the complications that may occur.

Risk Factors for Upper Extremity Refractures in Children.

Multiple descriptive studies have been published on refracture patterns, particularly for forearm fractures. However, few large cohorts have been analyzed quantitatively including the odds of refracture, and with a comprehensive assessment of the possible predictive factors associated with refracture. This study aimed to assess the frequency and timing of upper extremity refracture in a large pediatric orthopaedics practice, and to evaluate the strength of association of various patient-level and fracture-related factors with refracture. Medical records were reviewed retrospectively for patients 1 to 18 years of age with at least 1 upper extremity fracture (ICD-9 codes 810 to 819) between June 1, 2010 and May 31, 2011. Characteristics of patients and fractures were assessed for the association with refracture using bivariate analysis and multivariable logistic regression. Among 2793 patients with a total of 2902 upper extremity fractures, 2% were treated for refracture within 2 years, at a median of 6 months (188d) after the initial injury. Midshaft location, and characterization of the fracture as angulated or buckle, were associated with being more likely to refracture. Eighty percent of refractures were the result of a fall, with almost 25% involving a high-energy mechanism and about 15% from monkey bars or other playground equipment. The adjusted odds of refracture were 4 times higher if noncompliance with treatment recommendations was documented, when controlling for insurance type and number of days before orthopaedic evaluation. Forearm fractures were almost 4 times more likely to refracture compared with other bones, controlling for midshaft location, days immobilized, and buckle or torus characterization of the fracture. Our practice saw a refracture occurrence in 2% of patients, with median time to refracture of ~6 months. The factors most strongly associated with refracture were midshaft fracture location, forearm fracture as opposed to clavicle or humerus, and noncompliance as defined in the study. Falls and high energy activities, such as use of wheeled devices, skis, or trampolines, were important mechanisms of refracture. This study is a Level II prognostic study. It is a retrospective study that evaluates the effect of patient and fracture characteristics on the outcome of upper extremity refracture.

A Biomechanical Comparison of Fixation Techniques in Metacarpal Shaft Fractures.

Background Typically, metacarpal shaft fractures are treated with closed reduction percutaneous pinning, intramedullary nails, or plate fixation. Recently some surgeons have begun using intramedullary headless compression screws. Questions/Purposes The purpose of this study was to compare intramedullary screw fixation to K-wire fixation, which is the standard of care in a transverse metacarpal midshaft fracture, using a cadaveric model. Our hypothesis was that intramedullary screw fixation would have a biomechanical advantage (higher stiffness and peak load to failure) when compared with dual Kirschner wire fixation of transverse metacarpal shaft fractures. Methods Four-point bend testing was performed to compare stiffness and failure load values of seven paired 2nd and 3rd metacarpals instrumented with headless intramedullary compression screw fixation or Kirschner wire fixation. Similar testing was performed on 14 unpaired 4th metacarpals. Results There was no significant difference in peak load ( p = 0.60) or stiffness ( p = 0.85) between fixation groups for the 2nd and 3rd instrumented metacarpals. For the instrumented 4th metacarpals, there was no significant difference in peak load ( p = 0.14), but the stiffness was significantly greater ( p = 0.01) for the compression screw group compared with the Kirschner wire fixation. Conclusions/Clinical Relevance In this study, the load to failure was not different between the two fixation methods and likely both techniques can sustain physiologic loads needed for rehabilitation. The greater stiffness in the 4th metacarpal compression screw group may be related to the smaller canal morphology than in the 2nd and 3rd metacarpals. Larger diameter screws may be needed to obtain a better fit particularly in the 2nd and 3rd metacarpals.

Fracture Fixation Strength in Metacarpal Plating Versus Intramedullary Nailing Using a 3-Point Bending Model: A Cadaveric, Biomechanical Study

The purpose of our study was to evaluate the ultimate load to failure for 2 metacarpal fracture fixation strategies, plating versus intramedullary nailing, and then compare them to the native metacarpal. Our hypothesis was that the intramedullary nail after fracture fixation would more closely restore the native strength of the metacarpal when compared to plate fixation. Matched pairs of cadaveric hands (age range, 19-49; 5 men and 6 women) were dissected to produce 88 intact and equally distributed metacarpals (little, ring, middle, and index fingers). The metacarpals were then randomly selected to undergo either plate fixation or intramedullary nail fixation. A 3-point bending model was used to test the native metacarpal strength to the point of fracture and, subsequently, the fracture fixation construct. The data were then compared against the native metacarpal for normalized load to failure, normalized displacement, and stiffness. The normalized maximum force (ratio of fixation:native) for the intramedullary nail specimens was significantly closer to normal than for the plated specimens for the little, middle, and index fingers, as well as for all metacarpals combined. We did not detect a difference in maximum force for the ring finger. When compared to plate fixation, metacarpal intramedullary nailing more closely restores the ultimate load to failure of the native metacarpal after midshaft fracture. For metacarpal fracture patterns amenable to intramedullary screw fixation, an intramedullary nail has biomechanical properties that are superior to a plate and screws in a 3-point bending model.

Results of using intramedullary autogenous fibular strut graft as an adjunct to dynamic plating in atrophic non-union of humeral mid-shaft fracture

Introduction: Atrophic nonunion of the humerus is rare and complex condition to treat. Several surgical techniques have been used for the treatment of non-union, which include compression plating, intramedullary nailing and use of external fixators, with or without bone grafts. Use of autogenous fibular as a strut graft is proposed to achieve good union and functional recovery. The aim of this study was to assess the clinical result of the intramedullary fibular graft adjunct to dynamic plate fixation in diaphyseal atrophic non-union of the humerus.Methods: The present prospective study was carried out within the period of January 2019 to December 2021 in the Department of Orthopedic Surgery of Bangabandhu Sheikh Mujib Medical University. Fifteen patient (09 male and 06 female) with atrophic non-union of the humerus midshaft fracture within the age range of 41-60 years were selected. All the case had non-union of the fracture of the middle third of humerus with a delay in commencement of specific treatment. The clinical and radiological outcome of Surgery has been assessed using definite recommendation. Statistical results were obtained by using the SPSS program.Result: The mean union time was 5.65 months. Post-operative complications were noticed in 3 patients, infection in 01 patient and 02 patients had persistent pain due to failure of union. Regarding the final outcome, satisfactory results were found in 86.66% case and unsatisfactory result in 13.33% case.Conclusion: The intramedullary fibular auto graft with dynamic plating results in satisfactory clinical outcome in atrophic osteoporotic diaphyseal non-unions of the humerus.

Study of prevalence and operative results of fracture shaft femur in adults

Background: Being the principal weight bearing of the lower limb, fractures related to the femur pose a threat to humans and affect the overall quality of life. Conservative management is no longer preferred, and stable internal fixation is the modality of treatment these days. Aims and Objectives: The aim of this article is to study the operative outcomes of fixation of fracture shaft femur in terms of union, stability, functional outcomes, and complications. Materials and Methods: This study is a retrospective study of 35 patients with proximal, mid-shaft, and extra-articular distal shaft femur fractures admitted to Smt. SCL Municipal Hospital for 3 years from May 2019 to May 2022. Results: The results showed improvement in all the functional and radiological outcomes. More than 70% of the patients achieved greater than 125° of knee flexion. The radiological union of fractures was 4.4 months in our study. According to Neer’s score, 33 patients scored excellent to satisfactory. Conclusion: Internal fixation of fractures in the femoral shaft is an absolute must and has gained widespread acceptance as implants and technology have improved. The rationale for internal fixation is that it restores anatomical alignment and allows early mobilization of the patient and limb.

Paper 63: Remodeling of Adolescent Displaced Clavicle Fractures: A FACTS Study

Objectives:The phenomenon of bony remodeling of healed displaced clavicle midshaft fractures in adolescents remains poorly understood. The purpose of the current study was to evaluate and quantify clavicle remodeling in a large population of adolescents with completely displaced fractures treated non-operatively to understand the factors that may influence this process.Methods:Patients were identified from the database(s) of a multi-center study group investigating the functional outcomes of adolescent clavicle fractures. Patients between the ages of 10 and 19 years with completely displaced mid-diaphyseal clavicle fractures that were treated non-operatively who had further imaging of the affected clavicle at a minimum of 9 months from initial injury were included. Radiographic measurements were performed on the injury and final follow-up films. Fracture remodeling was subjectively classified as ‘complete/near-complete’, ‘moderate’, or ‘minimal’ (Figure 1) and subsequently analyzed quantitively and qualitatively to determine factors associated with deformity correction.Results:Ninety-eight patients (mean age of 14.4±2.2 years) were analyzed at a mean radiographic follow-up of 3.4± 2.3 years. Fracture shortening, superior displacement, and angulation significantly improved during the follow-up period by 59%, 61%, and 30% respectively (p<0.001). Fracture remodeling was found to be associated with follow-up time; those with longer follow-up time demonstrate more remodeling (p<0.001). Ninety-two percent of patients <14 years and 79% of patients ³14 years-old at time of injury with a minimum follow-up of four years underwent complete/near-complete remodeling.Conclusions:Significant clavicle remodeling occurs in adolescent patients with displaced fractures, including older adolescents and particularly when followed for longer time intervals. This finding may help explain why symptomatic malunions are so infrequently observed in adolescent patients, even in severely displaced fractures.