Malunited Fractures Research Articles

Delayed open reduction and internal fixation of a neglected fracture dislocation of the ankle

Neglected fracture dislocations of ankle are rare in western countries. Failure to achieve anatomic reduction is associated with a poor prognosis. We present a case of a patient with a neglected Weber B fracture of the fibula with postero-lateral subluxation of the ankle. In theatre, the subluxation could not be reduced, and a posterior and lateral soft tissue release was performed. Granulation tissue was removed from the medial gutter. The fibular fracture was reduced and fixed with a six-hole dynamic compression plate. Post-operative radiographs was satisfactory and the patient was followed up for 12 months with full range of movement and function of the joint. In our case, correction was not obtained by osteotomy of the lateral malleolus alone, and medial and posterior soft tissue release was required. This was due to disruption of the deltoid ligament and posterior tibiofibular ligament and the associated scar tissue. Previous studies have shown that, if anatomic reduction is achieved, results with delayed surgery can be as good as those obtained with immediate surgery. Surgically correcting an old fracture dislocation is a difficult undertaking due to soft-tissue contractures and malunited fractures. It is important to preserve as much soft tissue attachments and periosteum to prevent avascular necrosis.

Outcome after corrective osteotomy for malunited fractures of the forearm sustained in childhood

We analysed the operative technique, morbidity and functional outcome of osteotomy and plate fixation for malunited fractures of the forearm sustained in childhood. A total of 20 consecutive patients underwent corrective osteotomy of 21 malunited fractures at a mean age of 12 years (4 to 25). The mean time between the injury and the osteotomy was 30 months (2 to 140). After removal of the plate, one patient suffered transient dysaesthesia of the superficial radial nerve. The mean gain in the range of movement was 85 degrees (20 degrees to 140 degrees ). The interval between injury and osteotomy, and the age at osteotomy significantly influenced the functional outcome (p=0.011 and p=0.004, respectively). Malunited fractures of the forearm sustained in childhood can be adequately treated by osteotomy and plate fixation with excellent functional results and minimal complications. In the case of established malunion it is advisable to perform corrective osteotomy without delay.

Ist die Korrekturosteotomie der fehlverheilten distalen Radiusfraktur auch beim älteren Menschen indiziert?

Corrective osteotomy of the distal radius is a well accepted procedure in younger, manual working and active patients with a malunited distal radius fracture. These functional improving procedures are often abandoned in elderly patients on accout of an uncertain benefit. To investigate the radiological and clinical outcome after corrective osteotomy for malunited fractures of the distal radius in the elderly and to answer the question, whether there is a benefit or not. In a prospective study the results of corrective osteotomy for malunion of distal radius fractures in 17 patients aged 65 years and more were investigated and compared with the results of 31 patients below an age of 65 years. Radiological parameters were radius tilt, ulnar inclination and ulnar variance. Clinically wrist motion, forearm rotation, pain at activity and grip strength were measured. Both groups were comparable according to their preoperative data. The statistical analyses were performed with use of the Mann-Whitney-U-test and the Wilcoxon test for paired differences, accepting p < 0.05 as significant. All osteotomies achieved bony union. Loss of correction or other complications did not occur. Postoperatively both groups demonstrated improvement of all clinical and radiological parameters. Improvement was significant in eleven of twelve parameters in the group below 65 years and for eight of twelve parameters in the elderly. A comparison among the two groups revealed significant better results for five of the twelve parameters in the younger patients. Radial corrective osteotomy leads to an improvement of the clinical situation not only in the younger but also in the elderly patient. Therefore, radial corrective osteotomy can be recommended for elderly patients. However, elderly patients may not experience the same amount of benefit from a corrective osteotomy of the distal radius as the younger patients. An age-related higher complication rate or unsatisfying long term results were not detected.

Effects of distal radius malunion on distal radioulnar joint mechanics—an in vivo study

Patients with a malunited distal radius often have painful and limited forearm rotation, and may progress to arthritis of the distal radioulnar joint (DRUJ). The purpose of this study was to determine if DRUJ congruency and mechanics were altered in patients with malunited distal radius fractures. In nine subjects with unilateral malunions, interbone distances and dorsal and palmar radioulnar ligament lengths were computed from tomographic images of both forearms in multiple forearm positions using markerless bone registration (MBR) techniques. The significance of the changes were assessed using a generalized linear model, which controlled for forearm rotation angle (-60 degrees to 60 degrees ). In the malunited forearm, compared to the contralateral uninjured arm, we found that ulnar joint space area significantly decreased by approximately 25%, the centroid of this area moved an average of 1.3 mm proximally, and the dorsal radioulnar ligament elongated. Despite our previous findings of insignificant changes in the pattern of radioulnar kinematics in patients with malunited fractures, we found significant changes in DRUJ joint area and ligament lengthening. These findings suggest that alterations in joint mechanics and soft tissues may play an important role in the dysfunction associated with these injuries.

Corrective osteotomy after malunited fractures of the distal end of the radius. Comparative study between volar locking plate fixation and non-bridge external fixation

Corrective osteotomy after malunited fractures of the distal end of the radius. Comparative study between volar locking plate fixation and non-bridge external fixation

Malunion of the clavicle causes significant glenoid malposition: a quantitative anatomic investigation

An experimental cadaver model was used to assess the effects of a malunited fracture of the middle third of the clavicle on the functional anatomy of the shoulder joint. Anatomic samples were prepared with simulated shortening and axial malposition of the clavicle. From these, alterations in glenoid fossa position were measured and depicted graphically. Healing of clavicle fractures with bony shortening leads to a ventromedialcaudal shift in glenoid fossa position. The following malpositions of the clavicle lead to the respective glenoid fossa positional changes: caudal deviation leads to a mediocaudal shift, cranial deviation leads to a dorsolateral shift of the glenoid fossa, ventral deviation causes a ventrolateral shift, dorsal deviation leads to mediocaudal shift of the fossa, cranial rotation leads to ventrolateral shift in fossa position, and caudal rotation leads to a dorsomedial shift in glenoid fossa position. Clinical implication of these data is that bony shortening in combination with caudal displacement leads to distinct functional deficits in abduction, particularly overhead motion. Using the above data, a vector model was created to calculate position of the glenoid fossa dependent on clavicle position/malposition. The model is a valuable tool to be used for planning open reduction and fixation of clavicular fractures or malunions.

2.5 Correction of malunited intra-articular distal radius fractures with an inside-out osteotomy technique

2.5 Correction of malunited intra-articular distal radius fractures with an inside-out osteotomy technique

Absorbable Implants in Surgical Correction of a Capitellar Malunion in an 11-year-old

We present the case of an 11-year-old girl who had a corrective osteotomy reconstruction using absorbable implants for a malunited capitellar fracture 3-1/2 months after a dislocation of her elbow joint. This operative stabilization enabled early joint mobilization and, finally, excellent results in terms of anatomy and function at a 2-year follow-up. We were not able to find any similar report in the English literature dealing with corrective osteotomy reconstruction using absorbable implant fixation for a malunited capitellum in a child.

Corrective osteotomy of malunited fracture of upper extremity using 3D computer simulation and custom made template

Corrective osteotomy of malunited fracture of upper extremity using 3D computer simulation and custom made template

Subclavian and axillary vein compression of musculoskeletal origin.

Twenty instances of subclavian-axillary vein compression of musculoskeletal origin in 14 patients are reported. In 9 thrombosis had occurred and in the remainder the compression was intermittent. The cause appeared to be extraluminar factors such as the subclavius muscle, the scalenus anterior, the pectoralis minor and a malunited fracture of the clavicle. Ten cases were treated surgically with satisfactory results.

Results of Osteotomy, Open Reduction, and Internal Fixation for Late-Presenting Malunited Intra-articular Fractures of the Base of the Middle Phalanx

To present our results in the treatment of late-presenting impaction fractures of the base of the middle phalanx treated by osteotomy with full exposure of the articular surface to restore the normal anatomy. Eleven patients with a malunited (impacted) fracture of the base of the middle phalanx were treated by osteotomy more than 5 weeks after the injury. All fractures had varying degrees of impaction, comminution, and dorsal subluxation. The malunited joint surface was visualized by dislocating the joint by hyperextension (shotgun approach). The restoration of the cup-shape contour of the middle phalangeal base was accomplished by osteotomy and mobilization of small osteochondral fragments. Rigid fixation was performed by cerclage wire, screws, or a combination of these. A distal radius bone graft was placed beneath disimpacted fragments in 9 of the 11 procedures. Ten of 11 patients were followed-up for more than than 1 year. One patient with a volar lateral impaction fracture was lost to follow-up study 4 weeks after the surgery and was excluded from the results. All patients except 1 achieved a functional range of motion of the proximal interphalangeal joint. Moderate limitations of the distal interphalangeal joint motion were common. Grip and thumb-affected finger tip pinch strengths were 95% and 90%, respectively, of the healthy side. The average pain level (as rated on a visual analog scale of 0-10) improved from a preoperative score of 9.1 to a postoperative score of 0.8. One patient was somewhat dissatisfied; all other patients were satisfied or very satisfied. All returned to their previous work at an average of 13 weeks after surgery. Favorable results have been achieved in this challenging scenario in the short- and middle-term in 9 of 10 patients. Previous surgery and moderate to severe wearing of the cartilage of the proximal phalanx head negatively affected the results.

Surgical Management of Remote, Isolated Type II Odontoid Fractures with Atlantoaxial Dislocation Causing Cervical Compressive Myelopathy

The remote (more than 6 mo after injury) and isolated (not associated with any other cervical spinal fractures) Type II fractures of the odontoid (RI IIO) are unique in being inherently unstable and prone to malunion or nonunion, leading to cervical compressive myelopathy. The present study discusses their surgical management. Nineteen patients with RI IIO with atlantoaxial dislocation (AAD) causing compressive myelopathy were treated. Their preoperative disability was graded as Grade I: neurologically intact (presented with hyperreflexia and mild spasticity; n = 3); Grade II: independent with minor disability (n = 7); Grade III: partially dependent for daily needs (n = 6); and Grade IV: totally dependent (n = 3). They were classified as irreducible AAD caused by 1) malunited fracture of the odontoid (n = 2), 2) fixed anterolisthesis of the anterior arch of a C1-fractured odontoid complex (n = 3), and 3) fixed retrolisthesis of the anterior arch of a C1-fractured odontoid complex (n = 1); and reducible AAD caused by 1) mobile AAD (n = 11) and 2) hypermobile AAD (n = 2). The patients with irreducible AAD underwent a transoral decompression and posterior fusion; those with a malunited fracture underwent surgery immediately, whereas those with fixed anterolisthesis or retrolisthesis were initially placed in cervical traction. The patients with reducible AAD underwent a direct posterior fusion. In the patient with "hypermobile" AAD, a proper alignment of the fractured segment of the odontoid relative to the body of the axis in a neutral position of the neck was ensured before the posterior fusion was performed. At follow-up (mean, 15.37 +/- 9.67 mo), three patients in Grade I maintained their neurological status. Of the seven patients in Grade II and six in Grade III, five had improved to Grade I, and eight were in Grade II. The three patients in Grade IV improved to Grade I, II, and III, respectively. The patients with RI IIO may be divided into five groups on the basis of their differing management protocols. There is a considerable risk of delayed myelopathy unless surgical reduction and stabilization are performed. Posterior stabilization is the preferred option in dealing with these fractures. Despite the presence of severe neurological deficits and the prolonged duration of symptoms, a significant neurological improvement usually occurs after surgery.

Advanced virtual corrective osteotomy

This paper presents a new software system for preoperative planning and intraoperative support for corrective osteotomy. Patients with a malunited fracture of the distal radius undergo a surgical intervention in which the radius is cut into two segments and the distal segment is repositioned. The osteotomy is first carried out virtually. The products of this process are templates which, using a navigation system and intraoperative radiological imaging, guide the physical osteotomy.

Staged Reconstruction for Malunited Fractures of the Distal Radius

This prospective study assessed the outcomes of 26 symptomatic malunited distal radial fractures which were treated with an opening wedge corrective osteotomy and bone grafting with rigid fixation. An ulnar shortening osteotomy was subsequently required as a second-stage operation in five cases to restore normal ulnar variance. A wrist arthroscopy was indicated as a third stage procedure with persistent ulnar sided wrist pain in order to address central tears of the triangular fibrocartilage. Satisfactory functional scores were achieved by 20 of the 26 patients after distal radial osteotomy alone and, 24 of the 26 after subsequent ulnar shortening osteotomies and arthroscopy when necessary. The one, two or three stage concept of reconstructing the malunited distal end radius could optimise the outcome rather than using a single-stage strategy.

The Northern Ireland Troubles and limb loss

The Troubles in Northern Ireland have now lasted 34 years. Divisions and strife between the opposing loyalist and republican communities, and between the communities and the security forces, have led to thousands of deaths and injuries. The violence has often been indiscriminate injuring and killing totally innocent people. Staff at the Regional Disablement Services at Musgrave Park Hospital, Belfast have had the responsibility for helping to rehabilitate those who have suffered limb loss, both civilians and security forces personnel. In this study the authors present patient demographics for those survivors, referred for prosthetic fitting, who have sustained limb amputations as a result of the Troubles from 1969 to 2003, with the cause of injury, resulting levels of amputation, associated injuries, time to first prosthetic fitting and reason for any delay in fitting identified. One hundred and twenty-nine (129) patients sustained amputations, 110 male and 19 female with an age range at the time of injury from 7 to 60 years. Seventy-two (72) were civilian. Ninety-three (93) underwent immediate amputation, the most frequent level of amputation being trans-femoral. Delayed healing of deep wounds was the most common reason for delayed amputation; other causes were chronic osteomyelitis, malunited fractures and failed arthrodesis, often associated with chronic pain. Ninety-two (92) patients required amputation of one limb or part thereof, 35 required amputation of 2 limbs and 2 underwent triple amputation. Three (3) patients lost both hands. Sixty seven percent (67%) had other associated physical injuries. Thirty-two (32) patients had a delay of 6 months or more in fitting a prosthesis. The most common cause of injury was the car bomb.

Complications of intra-articular fractures of the calcaneus.

Most complications of calcaneal fractures are due to the combination of the dynamic nature and the mechanism of the injury itself. Complications are usually secondary to three integral parts of this complex fracture pattern: 1) fracture and depression of the subtalar joint, 2) loss of the height of the calcaneal body with varus rotation, and 3) expansion of the lateral wall of the calcaneus. Other complications occur with less frequency. This article describes the complications and sequelae of old, malunited intra-articular calcaneal fractures in relation to the nature and the components of these unique fractures.

Lengthening of Finger Stump and Elimination of Phalanges and Metacarpal Bone Shortening

The experience in treatment of 369 patients with stumps, shortenings and defects of finger phalanges and metacarpal bones is presented. Distraction method alone and distraction with combination of bone autoplasty were used. Thirty patients (8,1%) with amputated stumps, 77 patients (20,9%) with ununited and 93 patients (25,2%) with malunited fractures were treated using distraction only. In 42 patients (11,4%) with amputation stumps, 29 patients (7,9%) with pseudoarthroses, 31 patients (8,4%) with ununited, 28 patients (7,6%) with malunited fractures and in 39 patients (10,6%) with the defects of articular ends and metacarpal bones the distraction in combination with bone autoplasty was performed. Long term results were evaluated in 281 patients (76,1%). Good results were achieved in 163 patients (58%), satisfactory - in 111 (39,5%) and unsatisfactory - in 7 patients (2,5%).

Rotational deformity in malunited fractures of the distal radius

Purpose To evaluate rotational deformity in malunited fractures of the distal radius and its efffect on forearm rotation. Methods Thirty-seven patients with a symptomatic malunion of the distal radius (25 with dorsal angulation and 12 with volar angulation) were assessed for rotational deformity of the distal fragment. Spiral computed tomographic scans were taken of both wrists. Rotational deformity was evaluated by comparing the radial torsion angle of the injured and uninjured sides according to Frahm. Multivariable regression analyses were used to identify the radiologic parameter that had the most important influence on forearm rotation. Results Of the 37 patients, 23 showed a rotational deformity of the distal radius. In both dorsally and volarly angulated malunions, pronation and supination deformities were identified. There was a tendency toward more pronation deformities with volar malunion. Volar angulated malunion with a rotational deformity of less than 10° showed the smallest amount of forearm supination. Losses of pronation-supination did not correlate with the amount of rotational deformity. Conclusions This study showed that rotational deformity is common with angulated malunions of the distal radius. The effect on forearm rotation should not be overestimated. Pretreatment computed tomographic scanning of both wrists to identify and measure malrotation of the distal radius may be helpful to improve the outcome after corrective osteotomy.

Dysfunction of flexor pollicis longus tendon after malunited fracture of the distal radius. A case report

Dysfunction of flexor pollicis longus tendon after malunited fracture of the distal radius. A case report

Surgical correction of deformities of the distal radius due to fractures in pediatric patients.

The indication and treatment of malunited fractures of the distal radius in the growing skeleton differ from those for adults. The literature results are scarce. In this study we examined the results of surgical correction following fractures of the distal radius in infants. Seven infant patients with malaligned fractures of the distal radius that demonstrated significant functional deficit and poor prognosis for spontaneous recovery were treated with surgical correction. Two of them were treated because of growth disturbance from post-traumatic closure of the distal radial physis. All seven osteotomies healed with acceptable radiologic alignment. After an average follow-up period of 3 years and 1 month (range 10 months to 8 years and 4 months), patients had an average range of wrist motion (ROM) of 131 deg in extension and flexion (93% of the contralateral side, 130% of presurgical situation); 65 deg in ulnar and radial deviation (94% of the contralateral side, 122% of presurgical situation); and 177 deg in pronation and supination of the forearm (97% of the contralateral side, 115% of presurgical situation). The average grip strength of 71.4 kPa was nearly equal to the other side with 72.8 kPa. The average postoperative angulation of the distal radius was 12 (range 10-17) deg, the radial inclination 20 (range 12-30) deg, and the ulnar variance was -0.6 (range -3 to +2) mm. According to the Fernandez point score system as well as the scale of Fernandez, there were five excellent results and two good results. The patients described low disability on the DASH scores, with a median of 4 (range 0-41) points. Surgical correction for malunited fractures of the distal radius provides good and excellent radiological and functional results in the growing skeleton. It should be considered immediately if there is poor remodeling capacity and disabling loss of function.