Metaphyseal Comminution Research Articles

Fractures of the radial head

Most fractures of the radial head are stable undisplaced or minimally displaced partial fractures without an associated fracture of the elbow or forearm or ligament injury, where stiffness following non-operative management is the primary concern. Displaced unstable fractures of the radial head are usually associated with other fractures or ligament injuries, and restoration of radiocapitellar contact by reconstruction or prosthetic replacement of the fractured head is necessary to prevent subluxation or dislocation of the elbow and forearm. In fractures with three or fewer fragments (two articular fragments and the neck) and little or no metaphyseal comminution, open reduction and internal fixation may give good results. However, fragmented unstable fractures of the radial head are prone to early failure of fixation and nonunion when fixed. Excision of the radial head is associated with good long-term results, but in patients with instability of the elbow or forearm, prosthetic replacement is preferred. This review considers the characteristics of stable and unstable fractures of the radial head, as well as discussing the debatable aspects of management, in light of the current best evidence.

Closed Reduction and Cast Immobilization for the Treatment of Distal Radius Fracture: Does Dorsal Metaphyseal Comminution Predict Radiographic and Functional Outcomes?

Purpose: The purpose of this study was to determine the relationship between dorsal metaphyseal comminution and the radiographic and functional outcomes of patients with distal radius fractures treated by closed reduction and cast immobilization. Methods: Twenty-six patients with acute distal radius fractures were retrospectively reviewed. The mean age of this patient group was 62.8 years (range, 45-87 years). Eighteeen cases were AO type-A3 and 8 were AO type-A2. Radiographic and functional parameters were analyzed and compared between the patients who presented with or without dorsal metaphyseal comminution on their initial radiographs in order to assess the clinical outcomes. The radiographic parameters included radial inclination, radial length, volar/dorsal tilt, and ulnar variance. In order to measure the functional outcomes, each patient’s range of motion, grip strength, Quick disabilities of the arm, shoulder, and hand (DSAH), visual analog scale (VAS), and Mayo score were determined. Results: Seventeen patients (65%) presented with dorsal metaphyseal comminution on the initial radiographs. Radial inclination, radial length, and volar/dorsal tilt were decreased and ulnar variance was increased on the final radiographs in comparison with the postreduction. However, there were no statistically significant differences between the two groups that presented with or without dorsal metaphyseal comminution (p>0.05). None of the functional parameters (i.e., range of motion, grip strength, DASH, Mayo, and VAS score) were significantly different between the two groups (p>0.05). Conclusion: Dorsal metaphyseal comminution seems to have no significant impact on radiographic and functional outcomes when closed reduction and cast immobilization was planned for the treatment of distal radius fracture.

Treatment of Proximal Humerus Fractures with the Stryker T2 Proximal Humeral Nail: A Study of 61 Cases

Background Surgical treatment of displaced proximal humerus fractures remains controversial. There is little guidance on which patients are likely to do well with humeral nailing. Therefore we present our study evaluating the Stryker T2 proximal humeral nail (T2-PHN). Methods Sixty-one consecutive patients with acute unilateral displaced proximal humerus fractures were treated with the T2-PHN and followed up for a mean of 19 months. There were 46 females and 15 males with mean age 68 (range 36–97). By Neer's classification there were 25 two-part, 28 three-part and 8 four-part fractures. Results Union occurred at a mean of 3 months. Fifty-five patients had Constant-Murley scores with a mean score of 64.9. Mean Constant-Murley was 59.9 for over 70s, 69.7 in under 70s, 68.0 in 2-part fractures, 67.5 in 3-part fractures, 36.6 in 4-part fractures, 50.6 in post-operative varus, 73.5 in post-operative neutral, 72.7 in post-operative valgus, 55.5 in medial metaphyseal comminution and 69.5 without comminution. Fifty-four patients had Oxford Shoulder scores with a mean score of 21.7. Conclusions The T2-PHN has a learning curve. Important points include adequate recessing of the nail tip and suturing of tuberosities. The best results can be expected in under 70s, 2 and 3-part fractures, patients without medial metaphyseal comminution and patients with neutral post-operative neck-shaft alignment.

Relationship between the Length of Distal Locking Screws and Diaphyseal Screws in Volar Plate Fixation of Distal Radius Fractures

Wall LB, Brodt MD, Silva MJ, Boyer MI, Calfee RP. The effects of screw length on stability of simulated osteoporotic distal radius fractures fixed with volar locking plates. J Hand Surg Am. 2012;37:446-453. Length of the distal locking screws can be estimated with length of a diaphyseal screw. This information may help surgeons to select adequate length of distal locking screws during volar plating of distal radius fractures. During volar plate fixation of distal radius fractures, determining the adequate screw length may be difficult due to the metaphyseal comminution. We hypothesized that the length of distal locking screws would correlate with the length of diaphyseal screws which can be measured more easily with depth gauge. The purpose of this study was to determine the relationship between the length of distal locking screws and diaphyseal screws in volar plate fixation of distal radius fractures.

Proximal Humerus Fractures: Pin, Plate, or Replace?

No definitive treatment algorithm exists regarding the optimal treatment for displaced proximal humerus fractures. Factors affecting decision making include facture type, bone quality, metaphyseal comminution, risk of head osteonecrosis, joint congruity, and patient functional demands. With good bone quality, percutaneous fixation is appropriate for 2-part fractures without metaphyseal comminution and select 3-part and 4-part valgus-impacted fractures with preserved medial hinge. Open reduction internal fixation is appropriate for displaced fractures with joint congruity. Hemiarthroplasty is preferred in head-splitting large impaction fractures or a devascularized head. Many displaced 4-part fractures are treated with open reduction and internal fixation, despite the risk of avascular necrosis in younger patients in whom implantation of a prosthesis is undesirable. This article reviews indications and surgical techniques to maximize successful outcomes of proximal humerus fracture treatment.

Minimally invasive plate osteosynthesis in the treatment of multifragmentary fractures of the proximal tibia

Background Proximal tibia fractures with metaphyseal comminution present a difficult treatment challenge. Minimally invasive plate fixation (osteosynthesis) (MIPO) has theoretical advantages for the treatment of these injuries. This report presents the clinical results of the MIPO system for the treatment of a series of patients with complex proximal tibia fractures. Patients and methods Between March 2003 and February 2007, 28 consecutive patients with comminuted proximal tibia metaphyseal fractures with intra-articular extension were treated with MIPO in Benha Faculty of Medicine. The mean age of the patients was 37 years (range between 21 and 60 years). There were 22 closed fractures and six grade I open fractures (Gustilo Anderson classification). Results The average follow-up was 23 months (range 12–48). In 26 (92.8%) out of 28 patients, the fracture heeled after the index procedure and had satisfactory results. One patient had a fair result because of valgus malalignment and replating was performed. One patient had a poor result because of deep infection and loosening. Postoperative fracture alignment was satisfactory in 26 out of the 28 cases and was maintained in all patients at union. There was no deep venus thrombosis or compartment syndrome. Conclusion The MIPO can be used safely to treat complex proximal tibia fractures without the need for additional medial stabilization. Surgeons attempting to use MIPO should familiarize themselves with the significant technical differences between these and traditional plating systems to ensure satisfactory results.

Are conventional reconstruction plates equivalent to precontoured locking plates for distal humerus fracture fixation? A biomechanics cadaver study

BackgroundThe optimal plate type and configuration for distal humerus fracture fixation has yet to be defined. Available biomechanical studies show conflicting results. No existing studies compare conventional reconstruction plates to newer precontoured distal humerus locking plates in both parallel and perpendicular configurations. MethodsThree groups of humerus specimens were compared via biomechanical testing in a cadaver model simulating metaphyseal comminution. Group 1 consisted of conventional reconstruction plates in a perpendicular configuration. Group 2 used precontoured locking plates in a perpendicular configuration. Group 3 used precontoured locking plates in a parallel configuration. Each group was tested for stiffness in anterior bending, posterior bending, axial compression, and torsion. The specimens then underwent cyclic loading followed by single load to failure in posterior bending. FindingsThere was no significant difference between the three groups for anterior bending, posterior bending, axial compression, or torsional stiffness. There was no significant difference in load to failure for any of the three groups. Screw loosening was significantly higher in Group 1 when compared to Groups 2 and 3 after cyclic loading. InterpretationIn the early postoperative period, less expensive perpendicular conventional reconstruction plate constructs provide similar stiffness and load to failure properties to newer precontoured locking plate systems regardless of plate configuration.

Predictors of the postoperative range of finger motion for comminuted periarticular metacarpal and phalangeal fractures treated with a titanium plate

BackgroundPlate and screw fixation was introduced for complex fractures of the hand. Several risk factors for a poor functional outcome have been identified, but there is a paucity of evidence regarding predictors of finger stiffness in difficult hand fractures. The purpose of this prospective cohort study was to identify independent prognostic factors of the postoperative total active motion (%TAM) in the treatment of metacarpal and phalangeal fractures. MethodsSeventy-two patients (62 males, 10 females; 37±15years) with periarticular fractures involving metaphyseal comminution and displacement were evaluated at a minimum of 1 year following surgery. There were 49 phalangeal bone fractures, 30 intra-articular fractures and 20 associated soft-tissue injuries. The locations of plate placement were lateral in 42 patients and dorsal in 30. The mean duration from injury to surgery was 7.6 days (range, 0–40 days). There were eight examined variables related to patient characteristics (age, gender and hand dominance), fracture characteristics (fracture location, joint involvement and associated soft-tissue injury) and surgical variables (location of plate placement and duration from injury to surgery). Univariate and multivariate linear regression analysis were used to identify the degree to which variables affect %TAM at the final follow-up. ResultsUnivariate analysis indicated moderate correlations of %TAM with fracture location, associated soft-tissue injury and age. Multiple linear regression modelling including fracture location, age and associated soft-tissue injury resulted in formulae that could account for 46.3% of the variability in %TAM: fracture location (β=−0.388, p<0.001), age (β=−0.339, p<0.001) and associated soft-tissue injury (β=–0.296, p=0.002). ConclusionPhalangeal fracture, increasing age and associated soft-tissue injury were important risk factors to identify the postoperative %TAM in the treatment of comminuted periarticular metacarpal or phalangeal fracture with a titanium plate.

The biomechanical effects of a deepened articular cavity during dynamic motion of the wrist joint

BackgroundA deepened articular cavity of the distal radius due to a metaphyseal comminution zone is associated with early osteoarthritis and reduced joint motion. As this deformity has not been investigated biomechanically, the purpose of this study was to evaluate the effects of a deepened articular cavity on contact biomechanics and motion range in a dynamic biomechanical setting. MethodsSix fresh frozen cadaver forearms were tested in a force controlled test bench during dynamic flexion and extension and intact mean contact pressure and contact area as well as range of motion were evaluated. Malunion was then simulated and intraarticular as well as motion data were obtained. Intact and malunion data were compared for the scaphoid and lunate facet and the total radial joint surface. FindingsDue to malunion simulation, cavity depth increased significantly. Motion decreased significantly to 54–69% when compared to the intact state. Malunion simulation led to a significant decrease of contact area in maximum extension for all locations (by ~50%). In maximum flexion and neutral position, contact area decrease was significant for the scaphoid fossa (by 51–54%) and the total radial joint surface (by 47–50%). Contact pressure showed a significant increase in maximum extension in the scaphoid fossa (by 129%). InterpretationAlready a small cavity increase led to significant alterations in contact biomechanics of the radiocarpal joint and to a significant range of motion decrease. This could be the biomechanical cause for degenerative changes after the investigated type of malunion. We think that restoration of the normal distal radius shape can minimize osteoarthritis risk post trauma and improve radiocarpal motion.

Distractive bridge plating in metaphyseal comminuted fractures of the distal radius through a pronator sparing approach

For distal radial fractures with metaphyseal comminution and radial shortening, the key treatment goal, aside from anatomic reduction of the articular surface, is maintenance of radial length, in order to maintain the normal biomechanics of the wrist. Our distractive bridge plating technique, applied via a pronator sparing approach, was expected to be effective in maintaining the radial length of distal radial fractures with metaphyseal comminution treated with volar plating. However, there were some disadvantages to this approach, namely exposure of the surgeon to additional radiation as compared with conventional plating, satisfactory reduction except radial length by manual manipulation, and provisional fixation is a prerequisite to plating. Our technique has important benefits, in particular, the ability to preserve vascular supply and restore radial length.

Locking plate fixation of humeral head fractures with a telescoping screw. A comparative biomechanical study versus a standard plate

ObjectivesLocking plate fixation of humeral head fractures bares the risk of glenohumeral screw penetration. In order to circumvent this problem it is recommended to insert shorter locking screws having at least a 6mm distance to the humeral head cortex. This in turn may reduce fixation stability and may lead to early varus displacement. One second frequent failure mechanism is cranial displacement of the greater tubercle. The study evaluates the biomechanical properties of a locking plate employing an additional telescoping screw that may enhance resistance to varus displacement. Screw in screw fixation of the greater tubercle may reduce the rate of cranial displacement. MethodsIn four paired fresh-frozen human cadaver humeri (age>70 years) a Neer IV/3 fracture was created with a 5mm osteotomy gap simulating metaphyseal comminution. Limbs were randomly assigned to receive plate fixation with an additional telescoping screw (Humerus Tele Screw: HTS) and on the contralateral limb Philos plate fixation before biomechanical evaluation (MTS-Bionix 858.2). Standard locking screws were placed in both groups 6mm below the radiological head circumference; the telescoping screw was placed in the subchondral layer. The greater tubercle was fixed with an additional screw in both techniques, in the HTS group the screw was anchored in the sleeve of the telescrew (screw in screw fixation). FindingsFixation stability with a mean stiffness of 300.9±28.8N/mm in the HTS plate group proved to be significantly higher than in the Philos plate group (184.2±23.4N/mm; p=0.006). The HTS plate also resisted higher loads in terms of fixation failure with loss of reduction at 290±58.6N in comparison to 205±8.6N for the Philos plate (p=0.2). Displacement of the greater tubercle occurred in no case of the HTS plate group and in two out of four cases in the Philos plate group. InterpretationThe HTS plate provides high fixation stability in an in vitro humeral head fracture model and securely prevents displacement of the greater tubercle.

Minimally Invasive Plate Osteosynthesis Using a Locking Compression Plate for Distal Femoral Fractures

To evaluate treatment outcomes of minimally invasive plate osteosynthesis (MIPO) for distal femoral fractures in 31 patients. 22 male and 9 female consecutive patients aged 21 to 65 (mean, 42) years underwent minimally invasive plate osteosynthesis using a locking compression plate (LCP) for distal femoral fractures. The causes of injury were vehicular accidents (n=24), falls (n=6), and assault (n=1). According to the AO classification, the fractures were classified as types A1 (n=10), A2 (n=7), and A3 (n=14). Most fractures were closed; 3 were Gustilo type-II fractures. Clinical and functional outcomes were assessed using the Knee Society Scores. The mean operating time was 70 (range, 60-100) minutes. The mean length of hospital stay was 9 (6-14) days. The mean time to union was 3.7 (range, 2.8-4.6) months. The mean follow-up period was 18 (14-26) months. At the one-year follow-up, 29 of the patients had good or excellent outcomes. No patient had angular or rotational deformity of >10º. One osteoporotic woman with a type-A1 fracture had implant failure at 10 weeks and underwent revision surgery. Another patient with a type-A1 fracture had persistent pain on the lateral aspect of the distal thigh and underwent implant removal at 22 months. No patient developed deep infection, malunion or nonunion. MIPO using a LCP achieves favourable biological fixation for distal femoral fractures with few complications. Bone grafting is not needed even in cases of metaphyseal comminution. Proper patient selection and preoperative planning are essential to prevent complications.

Bone graft substitutes for articular support and metaphyseal comminution: What are the options?

Subchondral and metaphyseal bone defects pose a great challenge for the Orthopaedic surgeon not only because the support for the articular surface has been lost but also because the mechanism for the nourishment of articular cartilage through the subchondral plate is distorted. A number of options are available to the surgeons, none of them perfect. Autografting has an appreciable high rate of harvest site morbidity, allograft is associated with infection transmission and host immunologic response. These realities have stimulated interest in supplying bone replacement materials (demineralised bone matrix, synthetic bone substitutes, bone morphogenic proteins). This paper presents the indications and applications of bone substitutes for metaphyseal defects and subchondral support in orthopaedic trauma.

Tibial plateau fractures: A review

Tibial plateau fractures are uncommon injuries of the proximal tibia which vary in severity from minimally displaced stable injuries to high energy complex fractures with significant articular and metaphyseal comminution and severe associated soft tissue injuries. Following initial assessment and appropriate investigation a number of management options are available to the treating surgeon. We discuss the presentation, initial management and investigation as well as outlining the various treatment options with an emphasis on operative treatment. We further discuss the common complications and outcomes following tibial plateau fracture.

Predicting failure after surgical fixation of proximal humerus fractures

Background Several studies reported high failures rates after internal fixation of proximal humerus fractures. Loss of reduction and screw cut-out are the most common reasons for revision surgery. Several risk factors for failure have been described in the literature. The aim of the present study was to assess risk factors for failure after surgical fixation of unstable proximal humerus fractures in a multivariate setup. Methods Two different surgical techniques (PHILOS locking plate and Humerusblock) were used. In the PHILOS group, every kind of postoperative relative movement between the implant and the humeral head or shaft was defined as failure. In the Humerusblock group, postoperative movement between the humeral head and the shaft in terms of angulation or translational displacement was defined as failure. The following parameters were assessed: age, gender, cancellous bone mineral density (BMD) of the humeral head, fracture type, medial metaphyseal comminution, medial metaphyseal head extension, initial angulation of the humeral head in the frontal plane, initial anteversion of the humeral head, medial hinge displacement, maximum displacement of the tuberosities with respect to the head, surgical technique, anatomic reconstruction and restoration of the medial cortical support. Results The following parameters were found to have a significant influence on the failure rate: age, local BMD, anatomic reduction, and restoration of the medial cortical support. The failure rate significantly increased with the number of risk factors. Conclusion Preoperative assessment of the local BMD and the patients’ biological age as well as intraoperative anatomic reduction and restoration of the medial cortical support are the essentials for successful surgical fixation of proximal humerus fractures. Multifragmentary fracture patterns in old patients with low local BMD are prone for fixation failure. If the surgeon is not able to achieve anatomic reduction and restoration of the medial cortical support intraoperatively in this situation, adjustments such as augmentation or primary arthroplasty should be considered.

A triangular support screw improves stability for lateral locking plates in proximal tibial fractures with metaphyseal comminution: a biomechanical analysis

This study evaluates a proximally angulated cortical screw forming a triangular construct in lateral locking plates of comminuted intraarticular tibial plateau fractures. Sixteen composite tibiae were used for the fracture model and a complete articular fracture of the proximal tibia (AO 41.C2) was performed. A compression force was applied to the medial tibial plateau with an alternating, stepwise loading: 250 N-10 N-300 N-10 N-350 N-10 N-400 N. The relative motion between the different fragments of each sample was measured using a contactless, 3-dimensional digital image correlation system. Between the medial and lateral condyle, elastic as well as plastic shear was significantly lower using the triangular support screw (p < 0.05). In the metaphyseal region, elastic deformation remained identical, independent of the screw positioning. However, plastic deformation (varus collapse) was significantly reduced by 30-40% using a triangular support screw at higher compression forces (>300 N; p < 0.05). Based on the results of this study, the use of a triangular support screw in metaphyseal comminuted tibial plateau fractures might enhance fracture stability. However, further studies are necessary to prove these biomechanical results in composite bone.

USE OF THE VOLAR FIXED ANGLE PLATE FOR COMMINUTED DISTAL RADIUS FRACTURES AND AUGMENTATION WITH A HYDROXYAPATITE BONE GRAFT SUBSTITUTE

Treatment of distal radius fractures with a volar fixed angle plate achieves sufficient stabilisation and permits early physical exercise. However, secondary displacement after surgery sometimes occurs in elderly patients with a metaphyseal comminution and/or cases in which the subchondral support pegs were not placed immediately below the subchondral zone. We treated elderly patients suffering from distal radius fractures with metaphyseal comminution, using both volar fixed angle plate with or without augmentation with a hydroxyapatite bone graft substitute to investigate the benefit of augmentation for maintaining a fracture reduction. We evaluated the differences among radiographic parameters including palmar tilt, radial inclination, and ulnar variance on immediate postoperative and final follow-up radiographs to analyse the maintenance of the initial reduction. There were no significant differences between the two groups in terms of palmar tilt (P = 0.80) and radial inclination (P = 0.17); however, ulnar variance increased significantly in the group treated with a volar fixed angle plate without augmentation (P < 0.05). It might be useful to use a combination technique of a locking plate system and the hydroxyapatite bone graft substitute as augmentation to treat distal radius comminuted fractures in elderly patients.

Axial Malalignment after Minimally Invasive Plate Osteosynthesis in Distal Femur Fractures with Metaphyseal Comminution

Axial Malalignment after Minimally Invasive Plate Osteosynthesis in Distal Femur Fractures with Metaphyseal Comminution

Management of distal radius fractures: Treatment protocol and functional results

Distal radius fractures are the most frequent lesions encountered during clinical practice. The treatment is controversial and still debated in the literature. For a correct management of these lesions many authors recently emphasised the importance of anatomical reduction, a stable fixation and early joint mobilisation. We report our experience in the daily management of these lesions. The fractures are evaluated considering fracture type, fracture reduction criteria, adequacy of reduction criteria and overall fracture stability. The best treatment option must be decided in accordance to the type of fracture, the extent of metaphyseal comminution, the quality of the bone and the medical condition of the patient.

Comminution of the dorsal metaphysis and its effects on the radiographic outcomes of distal radius fractures

Comminution of the dorsal metaphysis is a relatively common feature of distal radius fractures. However, its effects on the radiographic outcomes of these fractures are not entirely understood. One hundred and twenty-four conservatively managed distal radius fractures were analysed retrospectively to assess the effect of dorsal metaphyseal comminution on fracture stability, especially with respect to initial displacement (minimally displaced versus displaced) and age group. Seventy-seven fractures (62%) had radiographic evidence of dorsal comminution. The secondary displacement rate of these fractures was 75%, compared to 45% in non-comminuted counterparts (P<0.001). In minimally displaced fractures, the secondary displacement rate was higher in those with dorsal comminution as compared to those without (57% vs. 31%, P=0.086). Dorsal metaphyseal comminution was found in 75% of fractures in patients 65+years old (P=0.05). Among those with dorsal comminution, the secondary displacement rates were similar for both men and women (63% vs. 79%; P=0.20). In conclusion, distal radius fractures with dorsal metaphyseal comminution had significantly higher rates of secondary displacement compared to non-comminuted counterparts, and there exists a correlation with this displacement and increasing patient age but not gender.