Distal Metaphyseal Fractures Research Articles

The influence of distal locking on the need for fibular plating in intramedullary nailing of distal metaphyseal tibiofibular fractures

Using human cadaver specimens, we investigated the role of supplementary fibular plating in the treatment of distal tibial fractures using an intramedullary nail. Fibular plating is thought to improve stability in these situations, but has been reported to have increased soft-tissue complications and to impair union of the fracture. We proposed that multidirectional locking screws provide adequate stability, making additional fibular plating unnecessary. A distal tibiofibular osteotomy model performed on matched fresh-frozen lower limb specimens was stabilised with reamed nails using conventional biplanar distal locking (CDL) or multidirectional distal locking (MDL) options with and without fibular plating. Rotational stiffness was assessed under a constant axial force of 150 N and a superimposed torque of ± 5 Nm. Total movement, and neutral zone and fracture gap movement were analysed. In the CDL group, fibular plating improved stiffness at the tibial fracture site, albeit to a small degree (p = 0.013). In the MDL group additional fibular plating did not increase the stiffness. The MDL nail without fibular plating was significantly more stable than the CDL nail with an additional fibular plate (p = 0.008). These findings suggest that additional fibular plating does not improve stability if a multidirectional distal locking intramedullary nail is used, and is therefore unnecessary if not needed to aid reduction.

Management of Tibial Metaphyseal Fractures by Hybrid External Fixator

Introduction: The Hybrid External Fixator combines the advantages of the monolateral pin fixators and the circular Ilizarov wire fixators. Principle of early motion has been touted as the functional savior of major intra articular injuries in application of hybrid external fixation. Materials & Methodology: 48 patients were considered for the study with tibial fractures admitted in Mamata General Hospital from May 2011 to May 2013. Results: The union and functional outcome of hybrid external fixator in simple and complex proximal and distal metaphyseal fractures of tibia in adults was evaluated at our centre. The fractures of the proximal tibia united with an average of 13.3 weeks (12 - 16 weeks). The fractures of the distal tibia united with an average of 14.42 weeks (13 - 22 weeks) with minimal complications. Conclusion: Our study shows high satisfaction rate after fixation, provides adequate stability and allows early motion of the joint. It is also effective in extra articular fractures occurring within 5 cm of the joint as the IM nails often do not provide enough stability and plating requires extensive soft tissue dissection.

Does timing of surgery affect the outcome of open articular distal humerus fractures

Open intraarticular distal humerus fractures classified as Orthopaedic Trauma Association (OTA) 13 C may have devastating consequences for patient's quality of life, especially if leading arm in younger active patient is involved. We conducted a study to determine whether the timing of open reduction and internal fixation of open intraarticular distal humerus fractures affects the outcomes. Multicentric prospective study: In the first group, there were 15 patients, 10 men and 5 women, mean age 38.7 years, operated in <6 h of injury. In the second group 17 patients, 11 men and 6 women, mean age 42.3 years operatively treated in delayed settings, mean delay to operation 4.6 days of injury. In both groups, patients had open distal humerus articular metaphyseal multifragmentary fractures classified as OTA 13.C2 or 13.C3. Functional outcome was assessed with Mayo elbow performance score and Disabilities of Arm and Shoulder and Hand (DASH). Mean Mayo elbow performance (MEP) score in the first group was 71 (range 30-100); in the second, mean MEP was 64.3 (range 25-100). The mean DASH in the first group was 27.89 (range from 1.7 to 75.8), and in the second, mean DASH score was 32.6 (range 5.8-77.5). There were no statistically significant differences between two groups, MEP t(28)=0.935, p<0.358; DASH t(28)=-0.636, p<0.530. Our study shows that early open reduction and internal fixation of open distal articular humerus fractures reduces the hospital stay, but does not significantly affect the overall outcomes and complications.

The Retrograde Tibial Nail: Presentation and biomechanical evaluation of a new concept in the treatment of distal tibia fractures

Displaced distal tibia fractures require stable fixation while minimizing secondary damage to the soft tissues by the surgical approach and implants. Antegrade intramedullary nailing has become an alternative to plate osteosynthesis for the treatment of distal metaphyseal fractures over the past two decades. While retrograde intramedullary nailing is a standard procedure in other long bone fractures, only few attempts have been made on retrograde nailing of tibial fractures. The main reasons are difficulties of finding an ideal entry portal and the lack of an ideal implant for retrograde insertion.The Retrograde Tibial Nail (RTN) is a prototype intramedullary implant developed by our group. The implant offers double proximal and triple distal interlocking with an end cap leading to an angle-stable screw-nail construct of the most distal interlocking screw. Its design meets the requirements of a minimally invasive surgical approach, with a stable fracture fixation by multiple locking options. The 8mm diameter curved nail, with a length of 120mm, is introduced through an entry portal at the medial malleolus. We see possible indications for the RTN in far distal tibial shaft fractures, distal extraarticular metaphyseal tibial fractures and in distal tibia fractures with simple extension into the ankle joint when the nail is combined lag screw fixation.A biomechanical comparison of the current RTN prototype against antegrade nailing (Expert Tibial Nail, Synthes®, ETN) was performed. Both implants were fixed with double proximal and triple distal interlocking. Seven biomechanical composite tibiae were treated with either osteosynthesis techniques. A 10mm defect osteotomy 40mm proximal to the joint line served as an AO 43-A3 type distal tibial fracture model. The stiffness of the implant-bone constructs was measured under low and high extra-axial compression (350 and 600N) and under torsional load (8Nm). Results show a comparable stability during axial loading for the two implant types with slightly higher stability in the RTN group. Rotational stability was superior for the RTN. Statistical analysis proved a significant difference (p<0.05) between the ETN and RTN for rotational stability. This study suggests that retrograde tibia nailing with the RTN is a promising new concept for the treatment of distal tibia fractures.

Intrafocal Pinning for Distal Radius Metaphyseal Fractures in Children

The purpose of this retrospective case control study was to evaluate the results of intrafocal pinning for distal radius metaphyseal fractures in children and to compare these results with conventional pinning. Data were collected from medical records and radiographs from patients who underwent closed reduction and percutaneous pinning for distal radius fracture in a Level I trauma center at the authors' institution between 2008 and 2010. Inclusion criteria included a dorsally angulated metaphyseal fracture without physeal involvement, an open distal radius physis, and a follow-up to radiographic union. A total of 10 patients with intrafocal pinning were compared to 26 patients with conventional pinning. Preoperatively, angulation was greater in patients who received intrafocal pinning than conventional pinning based on anteroposterior radiographs. Postoperatively, the 2 groups did not differ in angulation on either anteroposterior or lateral radiographs. One malunion and 2 pin-related complications occurred in the conventional pinning group, and 1 pin-related complication occurred in the intrafocal pinning group. The 2 groups did not differ by age, sex, side of injury, days to surgery, or initial shortening. This study affirms that the intrafocal pinning technique is an alternative to the conventional pinning technique for the stabilization of displaced metaphyseal distal radius fractures in children. Intrafocal pinning can also be used as a reduction tool for fractures that cannot be reduced by closed manipulation. The complications are comparable between the 2 techniques.

Treatment of distal tibia metaphyseal fractures; plating versus intramedullary nailing: A systematic review of recent evidence

Treatment of distal tibia metaphyseal fractures is challenging. The purpose of this study was to systematically review the recent literature regarding management of extra-articular distal tibia fractures with a view to compare the outcome of intramedullary nailing with plate fixation. Advanced literature search was performed using Medline (Ovid), Embase (Ovid) and Cochrane databases. Data were extracted regarding number of participants, fracture fixation devices, percentage of open fractures, malunions, nonunions, wound infections and metal removal etc. After inclusion, exclusion criteria, two RCTs and four retrospective comparative studies were deemed suitable for this review. The overall results showed relatively higher rate of infection in plating group as compared to intramedullary nailing. However malalignment was more common with intramedullary nailing. Both techniques can provide adequate treatments in appropriately selected patients. None of the studies had sufficient power to show clinically significant difference. Further studies are required to compare new locking plates with intramedullary nails.

Management of Pediatric Displaced Distal Metaphyseal Forearm Fracture: Comparison between Cast Immobilization and Percutaneous Kirschner Wire Fixation

Background: Distal metaphyseal forearm fracture is one of the common injuries in children. Closed reduction and above elbow cast is the standard method of treatment but reported to be associated with redisplacement rate of 7-25%. Closed reduction and fixation with percutaneous Kirschner wire is an alternative treatment option to prevent redisplacement. Methods: Thirty five children (group I) of age between 6 to 13 yrs with displaced ( more than 50% of cortical diameter) or angulated (more than 20°) distal metaphyseal forearm fracture managed with closed reduction and above elbow cast were compared with 21 children (group II) managed with closed reduction and percutaneous crossed Kirschner fixation. Clinical outcomes and complications were compared in both groups after 12 weeks of follow up. Results: Preoperative variables in both the groups were comparable. Mean loss of elbow flexion and extension (12° vs. 4°, p =0.08), wrist dorsflexion and palmerflexion (27° vs. 14°, p=0.12) and forearm supination and pronation (27° vs. 15°, p= 0.143) were more in group I but were statistically not significant. Complications rate (28.4% vs. 19.04%, p= 0.04) was higher in group I (such as fracture redisplacement and swelling) than in group II (pin tract infection). Conclusions: Grossly displaced or angulated distal metaphyseal forearm both bone fracture in children treated with either closed reduction and above elbow cast or closed reduction with crossed Kirschner wire fixation have no statistically significant clinical outcomes in terms of loss of movement of elbow, wrist and forearm but complication rate is higher in cast group. Percutaneous Kirschner wire fixation prevents redisplacement. DOI: http://dx.doi.org/10.3126/noaj.v2i1.8133 Nepal Orthopaedic Association Journal Vol.2(1) 2011: 1-6

A Minimally Invasive Technique of Reducing Difficult Distal Radius Fractures

Severely displaced distal metaphyseal fractures of radius can some times be difficult to reduce by manipulation. In such cases, the operating surgeon normally proceeds with an open reduction of the fracture through a standard incision. In cases where manipulation has failed to achieve proper reduction of fracture, and open reduction is being considered, a technique is presented by the author, which he has used for a number of years, to achieve satisfactory reduction through a very small incision instead.

Atrophic femoral nonunion successfully treated with teriparatide

Teriparatide is a synthetic polypeptide hormone that contains the 1-34 aminoacid fragment of the recombinant human parathyroid hormone. It has been approved for the treatment of postmenopausal women with osteoporosis who are at high risk for sustaining a fragility fracture. It has been shown that teriparatide also accelerates fracture healing by improving the biomechanical properties of the fracture callus, increasing endochondral ossification and bone remodeling in animal models. This effect has been observed in several case reports. Fracture healing disorders negatively affect the patient's quality of life and result in high healthcare costs, as a second surgery is required to stabilize the fracture and stimulate bone biology. Future biotechnologies that accelerate fracture healing may be useful tools. We present a case report of delayed union of a femoral fracture treated with teriparatide. She was diagnosed with right distal metaphyseal femoral fracture on total knee arthroplasty. She underwent surgery at our center consisting of ORIF with lateral femoral locking plate in October 2011. Radiologic controls at 5 and 7 months did not show any signs of healing. After 2 months of treatment with teriparatide, the X-ray showed the presence of bone bridges and a decreased gap between fragments and a different aspect of neoformed bone. After 3 months of treatment, healing was complete. Our case report seems to confirm the possible effect of TPTD as bone induction through a more rapid healing of fractures. The TPTD could have a potentially important role in treating some forms of nonunion and delay in consolidation. Thus, one could hypothesize the possibility of a medical treatment with TPTD both as a preventive way and also as a support to the synthesis in high risk of nonunion fractures and complexed fractures in osteoporotic bone.

Titanium elastic nailing radius and ulna fractures in adolescents

Over the last 40 years, anatomic reduction with plate stabilization has become the standard in adult patients with diaphyseal fractures of the radius and ulna. When operative fixation has been indicated in skeletally immature patients with these fractures, a variety of techniques have been reported, with intramedullary fixation becoming increasingly accepted. There is currently significant variability in the treatment of adolescents with forearm fractures. The purpose of this study was to investigate the clinical and radiographic outcomes in the adolescent population after intramedullary fixation of both bone forearm fractures. A retrospective review identified 32 patients 12-18 years of age who had undergone intramedullary fixation of both forearm bones in the past 20 years at our institution. Galeazzi, Monteggia, radial head, and distal metaphyseal fractures were excluded. Radiographic evaluation was performed to determine union and postoperative radial bow. Clinical follow-up was carried out for postoperative complications and range of motion of the wrist, forearm, and elbow. The mean age of the patients was 14.1 years. A total of 19 fractures were closed injuries, nine were grade 1, three were grade 2, and one fracture was a grade 3b. Of the patients, 15.6% had limited postoperative range of motion. All patients in the older age group, 15-18 years of age, had a normal range of motion. A decrease in radial bow was not associated with limitation in motion. There was a 98% union rate, and all unions occurred by 7.5 months. Only three major complications occurred, two refractures and one ulnar hardware migration, and subsequent radius nonunion occurred in the one grade 3b injury. Flexible intramedullary nailing of both bone forearm fractures provides reliable bony union and excellent postoperative clinical results in adolescents. Level of evidence, IV.

Weichteilschonende minimal-invasive Osteosynthesen bei Mittelhandfrakturen II–V

Soft tissue protection, closed reduction or short open reconstruction of length, rotation and articulation of metacarpals. Aftercare: early active exercises protected by additive orthesis. Closed or grade1 open fractures with significant dislocation, deviation of rotation or loss of length. Fractures of the metacarpal, metaphyseal and extensive oblique or spiral fractures. Intra-articular fractures of the distal metacarpal that can be reduced without a step in articular surface. Proximal partial articular fractures that can be reduced without a step in articular surface in the mini-open technique. Grade2 and 3 open fractures, extensive bending fractures in the middle third and absence of the palmar bony restraint. Multifragmentary proximal and distal metaphyseal fractures that cannot be reduced by closed methods. Intra-articular fractures that cannot be reduced without a step in articular surface. Intramedullary antegrade or percutaneous K-wires or mini-open repair screw/K-wire osteosynthesis. Two or three finger forearm cast for about 3-4 days, subsequent metacarpal orthesis, an integrated hard cast Longuette (Combicast) SoftCast™ is preferred beginning with active and passive exercises of the fingers. In this retrospective study we analyzed metacarpal (MC) fractures that were treated with minimally invasive osteosynthesis during the period 2009-2010 and 65 patients (mean age 34.8 years, female/male 13/52) with 75 metacarpal fractures were enrolled. Fractures affected MC-2 (n=9), MC-3 (n=5), MC-4 (n=15) and MC-5 (n=46). Removal of implant was performed after 6-12 weeks in 44 patients. All fractures except one showed bony healing in x-ray. At 2-months follow-up 61 patients could be evaluated and at 27-months (15-37) follow-up 34 patients could be evaluated according to the DASH score. Median DASH score results were 16 points (SD 49, n = 61) after 2 months and median DASH score results were 5 points (SD 23, n = 34) after 27 months (15-37). Range of motion was limited in 6 patients after 8 weeks (range 6-12 weeks) with a deficit in flexion of finger to distal palmar crease of 1.0cm (range 0.5-1.5cm), 2 patients showed a deficit in finger extension of 10° in the metacarpophalangeal joint. One patient showed restricted finger extension of 15° in the proximal phalangeal joint after tendon rupture and tendon reconstruction. Complications were observed, such as circumscribed redness in two patients at the entry point of k-wires which was managed by early removal of the implant. Perforation of the k-wire occurred in one patient with subcapital and diaphyseal fracture and was managed by plate osteosynthesis. One diaphyseal transverse refracture healed after plate osteosynthesis, three circumscribed cases of paresthesia occurred, one at the entry point of the K-wires and two at the level of fracture.

Intramedullary osteosynthesis for metaphyseal and diaphyseal humeral fractures in developmental age

Diaphyseal and metaphyseal fractures of the humerus are relatively frequent in children. The treatment is often conservative, even in the case of displaced fractures for the high rate of spontaneous recovery of these fractures. The limits of nonsurgical treatment and its applications as well as the type of surgical treatment are controversial issues in the literature. The aim of this study is to review a series of metaphyseal and diaphyseal fractures of the humerus treated with intramedullary osteosynthesis, to discuss the results obtained and the problems found, and to propose some parameters that should be taken into account to choose the most appropriate osteosynthesis. The retrospective study was performed on a group of 105 proximal and distal metaphyseal fractures and of displaced diaphyseal fractures of the humerus (excluding epiphyseal trauma, supracondylar fractures, and pathologic fractures) treated from 2001 to 2005. Out of a total of 105 patients, only 22 had fracture reduction under anesthesia, followed by intramedullary osteosynthesis; in 11 cases, intramedullary osteosynthesis was performed using Kirschner wires and in the remaining 11 elastic nails were used. In all treated patients, fracture healing was achieved. In the patients treated with Kirschner wires, no complications were observed, whereas in the patients treated with intramedullary nails, there were three cases with involvement of the skin and subcutaneous layers at the nail insertion site and one case of temporary paralysis of the radial nerve disappearing spontaneously after 2 months. Considering the results obtained and the low number of technique-related complications (low anesthesiologic and infectious risk), we can conclude that intramedullary osteosynthesis is a simple, safe, and rapid method suitable at any age in childhood. level IV.

Early correction of paediatric malunited distal metaphyseal radius fractures using percutaneous callus osteoclasis (“Calloclasis”)

Closed reduction of secondary displacements of distal metaphyseal radius fractures is an easy procedure only when performed within the first ten to fifteen days post-trauma, prior to the occurrence of malunion. When a hard bony callus prevents proper reduction, an open osteotomy is generally advocated. We suggest the use of a less invasive technique which aims at correcting early malunion when closed reduction is made impossible: the percutaneous callus osteoclasis. Callus osteoclasis consists in a series of multiple bone-drilling in a postage stamp pattern performed under image intensifier using a large diameter pin, at a distance from the growth plate. Once the bone has been weakened, reduction is obtained by using the pin as an intrafocal lever. The pin is then pushed through the opposite cortex to ensure postero-lateral stabilization. Twenty-one patients were managed using this technique and reported good results with no complications. This technique offers a low aggressive management of malunions and may be performed within two to six weeks after trauma. Level IV. Multicenter retrospective study.

Pediatric Distal Femur Fixation by Proximal Humeral Plate

Distal femoral metaphyseal fractures are common injuries in children. Multiple treatment options have been described for this type of injury. For older children with distal metaphyseal fracture, there is still no optimal method of fixation. We propose that the commonly used proximal humeral plate can provide good method of fixation for this fracture in adolescents. Two children (12 and 14 years old) with distal metaphyseal femoral fracture were treated with proximal humeral plate. We describe the surgical technique and postoperative management. The two children healed with good alignment and full range of motion of the knee. No external immobilization (other than knee immobilizer for the first 2 weeks) was used. We concluded that proximal humeral plate can provide adequate fixation for teenagers with distal femoral metaphyseal fracture. It is readily available; provide multiple options for screw fixation in the distal part of the fracture and fits easily on the distal part of the femur proximal to the physis.

Distal metaphyseal radius fractures in children following closed reduction and casting: can loss of reduction be predicted?

The aim of this study was to identify factors which contribute to loss of reduction (LOR). Outpatient records and initial, post-reduction (PR) and follow-up radiographs of patients with a distal radial metaphyseal fracture were reviewed to determine demographic factors; fracture characteristics (obliquity, comminution, intact ulna); three-point cast index (3PI); and initial, PR, and follow-up displacement (angulation and translation in the sagittal and coronal planes). Univariate and multivariate regression were used to identify significant risk factors for LOR. A total of 161 patients were included in our series (119 boys and 42 girls). Fifty-seven (35%) patients met the criteria for LOR. Multivariate logistic regression revealed that patients over 14 years old were 4.8 times more likely (p=0.01) to lose reduction, and those with more than 10% PR translation in the sagittal plane were four times more likely (p=0.03) to lose reduction. In younger patients, initial coronal translation and PR sagittal translation were independent risk factors. Patients with over 10% initial translation in the coronal plane were 2.4 times more likely (p=0.01) to lose reduction, and those with over 10% PR translation in the sagittal plane were 2.7 times more likely (p=0.03) to lose reduction. Three point cast index was not found to be a significant risk factor (1.64 vs. 1.57, p=0.43). Our study, the largest dedicated series of distal radial metaphyseal fractures, indicates that loss of reduction is common. Our analysis suggests that an anatomical reduction, which minimises residual translation, is the most important variable in preventing a loss of reduction.

Late-onset fracture-associated osteosarcoma in a cat

An 18-year-old male, castrated Domestic Shorthaired cat was presented with the complaint of acute severe lameness of the left pelvic limb. There was no history of trauma, apart from a distal physeal left femoral fracture that had been repaired 17 years previously. Radiology revealed a displaced distal metaphyseal femoral fracture with marked areas of bone lysis and periosteal proliferations. A pathological fracture due to a bone neoplasia was suspected. An amputation with coxofemoral disarticulation was performed. Histopathology confirmed the tentative diagnosis of appendicular osteo-sarcoma. No postoperative complications were encountered and the cat made a full recovery. This case shows an unusual presentation of a late-onset fracture-associated feline osteosarcoma.

Distal locking in femoral intramedullary nailing system: Is one cross screw sufficient?

Introduction: The indications for intramedullary nail fixation of fractures of the femoral shaft have been greatly expanded by techniques of interlocking nailing. However, distal locking screw fixation remains the most technically demanding and problematic portion of the procedure and maybe responsible for as much as one-half of the exposure of the surgeon’s hands to radiation during the procedure. Objective: This biomechanical study was undertaken to compare the stability of using one distal locking cross screw versus two cross screws in femoral fractures fixed with intramedullary nailing (IMN) system. Materials: A composite model made from a stainless steel IMN (12 mm × 1 mm) was connected to a load cell (Instron machine). Axial forces upto 2 kN (3 times body weight) was applied or until a maximum displacement of 1 mm was reached. The distal locking end of the intramedullary nail was secured with stainless steel cylinders of different dimensions 50 mm × 5 mm, 75 mm × 5 mm and 100 mm × 3 mm to represent the proximal femoral diaphysis, diaphyseo-metaphyseal junction and distal femoral metaphyseal respectively. The distal locking end of the intramedullary nail was attached to the cylinder with a dedicated single or two rods (5 mm diameter), made from stainless steel, to represent the distal locking cross screw. Results: In the 50 mm cylinder, the mean stiffness (±standard deviation) of the system using either single or two screws were similar i.e. 3298 ± 144 N/mm. But in the 75 mm and 100 mm cylinders, the mean stiffness of the fracture model with two distal locking cross screws fixation was 2.059 ± 96 N/mm and 0.816 ± 122 N/mm and with single distal locking cross screw fixation were 0.643 ± 142 N/mm and 0.289 ± 88 N/mm respectively. Conclusion: Single distal locking cross screw fixation provide poorer fracture stability compared to two distal locking cross screws when used to fix distal femoral metaphyseal fractures.

Isolated distal radial metaphyseal fractures with an intact ulna: Risk factors for loss of reduction

The purpose of this study was to determine the risk factors for loss of reduction in patients with an isolated distal radius fracture and intact ulna. Outpatient records and initial, post-reduction, and follow-up radiographs of children with displaced distal radial metaphyseal fractures and intact ulnas that required closed reduction and casting at our institution were reviewed for demographic factors, body mass index (BMI), initial fracture displacement, residual displacement after reduction, and 3-point cast index. Loss of reduction was defined as angulation ≥15° in the coronal plane for all ages and/or angulation ≥20° in the sagittal plane for patients ≥11years of age and ≥30° for children <11 years of age. Additionally, all patients who were remanipulated and/or pinned were considered to have lost reduction. Thirty-five of the 76 patients in our series met the criteria for loss of reduction (46%). Multivariate logistic regression revealed that initial angulation in the coronal plane and post-reduction translation in the coronal plane were independent predictors for loss of reduction. Patients with >11° of initial angulation in the coronal plane were 6.3times as likely to lose reduction (confidence interval [CI]: 1.43-28.3, P=0.015) and those with any amount of residual translation in the coronal plane after closed reduction were 7.8times as likely to lose reduction (CI: 2.5-24.0, P<0.001). Our study, the largest dedicated series of distal radial metaphyseal fractures with intact ulnas, indicates that loss of reduction is common, and that risk factors include initial angulation in the coronal plane and post-reduction translation in the coronal plane.

Stabilization of Juxta‐Physeal Distal Tibial and Fibular Fractures in a Juvenile Tiger Using a Hybrid Circular–Linear External Fixator

To report stabilization of closed, comminuted distal metaphyseal transverse fractures of the left tibia and fibula in a tiger using a hybrid circular-linear external skeletal fixator. Clinical report. Juvenile tiger (15 months, 90 kg). From imaging studies, the tiger had comminuted distal metaphyseal transverse fractures of the left tibia and fibula, with mild caudolateral displacement and moderate compression. Multiple fissures extended from the fractures through the distal metaphyses, extending toward, but not involving the distal tibial and fibular physes. A hybrid circular-linear external skeletal fixator was applied by closed reduction, to stabilize the fractures. The fractures healed and the fixator was removed 5 weeks after stabilization. Limb length and alignment were similar to the normal contralateral limb at hospital discharge, 8 weeks after surgery. Two weeks later, the tiger had fractures of the right tibia and fibula and was euthanatized. Necropsy confirmed pathologic fractures ascribed to copper deficiency. Closed application of the hybrid construct provided sufficient stability to allow this 90 kg tiger's juxta-articular fractures to heal with minimal complications and without disrupting growth from the adjacent physes.

Mechanical performance of poller and blocking screws in distal metaphyseal fractures of the tibia

Mechanical performance of poller and blocking screws in distal metaphyseal fractures of the tibia