Open Anatomic Reduction Research Articles

Expanding indications of the horizontal belt plate: A technical note

BackgroundAlthough the standard treatment for articular fractures usually involves open anatomic reduction and internal fixation with the concept of absolute stability, achieving adequate fracture stabilisation in multifragmentary patterns is always challenging. Several anatomical implants were developed to increase stabilisation and improve clinical outcomes in articular fractures. However modern implants, especially in developing countries, are expensive and not always available for routine use. Horizontal rafting plate has recently emerged as an alternative technique to treat complex tibial plateau fractures using simple implants that function as a large washer. ObjectiveThis technical note aims to describe horizontal belt plate use for treatment of periarticular fractures including the tibial plateau, thereby expanding its initial indication. ConclusionHorizontal belt plate is an effective, safe, and inexpensive treatment alternative for complex articular fractures. However, the surgeon must carefully analyse the fracture pattern to verify if the horizontal belt plate can be used alone or with traditional techniques.

English

Fractures of the forearm present a unique management problem for years. A forearm fracture involving both bones requires open anatomical reduction with stable fixation.[1] The forearm represents the critical anatomic unit of upper limb, permitting the effect of organ of the upper limb, the hand, to perform multi axial daily activities of living. Historically, the closed management of forearm fractures has been met with frustration in adults and resulted in poor functional outcome, hence perfect fracture reduction and rigid fixation is mandatory and achieved by plating. [2] The number of forearm fractures is increasing faster than the predicted rate due to increasing number of road traffic accidents, increased incidence of violence, rapid industrialization, and various sports activities. Conservative treatment has resulted in malunion, non-union, synostosis and ultimately poor functional outcome. [3] The present study is undertaken to know the functional outcome, advantages and complications of the LC-DCP. Thirty cases of fracture both bones of forearm were selected along the inclusion criteria’s and treated with LC-DCP in Department of Orthopedics, Kempegowda Institute of Medical Sciences, Bangalore. BACKGROUND: Fractures of forearm are difficult to treat because of rupture of interosseous membrane, interposition of soft tissue and malunion and nonunion.

Modified Extracorporeal Reduction of the Mandibular Condylar Neck Fracture

There are many treatment options in management of mandibular condylar neck fractures. Closed reduction is the most conservative treatment; however, achievement of anatomic reduction is difficult, and there are some risks of mandibular functional impairment. Open anatomic reduction and internal fixation have some advantages; therefore, many oral and maxillofacial surgeons have attempted to achieve anatomic reduction through the open approach and extracorporeal reduction and fixation. However, when using this method, there is some risk of resorption of the fractured mandibular condylar head. Therefore, we designed a modified extracorporeal reduction technique, without detaching the lateral pterygoid muscle in order to maintain the blood supply to the fractured mandibular condylar head. We believe that this minor modification may minimize the risk of resorption of the fractured mandibular condylar head. In this article, we introduce this technique in detail, and report on two cases.

Primary stability of an intramedullary calcaneal nail and an angular stable calcaneal plate in a biomechanical testing model of intraarticular calcaneal fracture

BackgroundNowadays, open anatomic reduction and internal fixation can be considered as a valuable treatment for displaced intra-articular fractures of the calcaneus. However, the application of a calcaneal plate via an extensile lateral approach is at risk for a substantial rate of complications including delayed healing, skin necrosis, or infection. There is some evidence that a limited exposure might contribute to a decreased soft tissue complication rate bearing in mind that most minimally invasive techniques have to accept a reduced primary stability compared with the open application of an angular stable plate. Recently, an intrafocal minimal invasive reduction technique has been established employing an intramedullary nail for fracture stabilisation and support of the subtalar joint. The aim of this study was to compare the primary biomechanical performance of the new device versus lateral angular stable plating. Material and methodsBiomechanical testings were performed on 14 human cadaveric feet (7 pairs). Dry calcaneal bones were fractured resulting in a Sanders type IIB fracture pattern and fixed by either a calcaneal locking plate or an intramedullary calcaneal nail. Compressive testing via the corresponding talus was employed at a constant loading velocity until failure with an universal testing machine and a specific mounting device to avoid any shear forces. Apart from the data of the load deformation diagram the relative motion of the fracture elements during loading was recorded by 8 extensometric transducers. After failure the specimens were carefully examined to check the failure patterns. ResultsThe displacement of the subtalar joint fragment was substantially lower in specimens fixed with the nail. Stiffness and load to failure were significantly higher after fixation with the intramedullary nail than after application of the angular stable plate. Failure with both fixation modes generally occurred at the anterior calcaneal process fragment. ConclusionsThe primary stability of an intramedullary nail appeared to be superior to an angular stable plate representing the present standard technique in open reconstruction of the fractured calcaneus. The results from the experimental model speak in favour of the clinical use of the intramedullary calcaneal nail.

Treatment of the Acetabular Fracture

Acetabular fractures resulting from a high-energy injury show variable forms according to each fracture mechanism, and are composed of complex anatomical structures. Plain radiographs accompanying threedimensional computer tomography is inevitable, because it is necessary to perform a multidirectional imaging analysis as a diagnosis. Conservative treatment, open reduction with internal fixation, percutaneous screw fixation, and primary artificial hip replacement can be performed. Despite the various treatment methods to the associated injuries, such as comminuted fracture, articular surface injury, poor bone quality and etc, are huge burden for the treatment. Further, there are varying complications, such as thromboembolism, post-traumatic osteoarthritis, avascular necrosis, infection, nerve palsy, heterotopic bone formation and etc. Therefore, physicians need to an accurate classification of fracture and be able to provide rehabilitation, as soon as possible, after rigid internal fixation via open anatomical articular reduction. also In addition, physicians must also pay great attention to prevent complications.

Primary open reduction and internal fixation with headless compression screws in the treatment of Chinese patients with acute Lisfranc joint injuries

Although primary open anatomic reduction and stable internal fixation has become a standard treatment principle of Lisfranc joint injuries, there are still some debates existed among surgeons as to the most appropriate treatment of this injury. The aim of this cohort study was to analyze the early (mean, 3.2 years) clinical and radiographic outcomes of one surgeon's experience associated with a standardized protocol of open reduction and internal fixation using headless compression screws (HCS) in a consecutive series of Chinese patients with Lisfranc joint injuries. This study is to retrospectively evaluate the clinical and radiographic outcomes of a series of Chinese patients with Lisfranc joint injuries that underwent open reduction and internal fixation with HCS. There were 29 patients (30 feet) included in our study. The average score of American Orthopaedic Foot and Ankle Society Midfoot score and the Visual Analog Pain Scale were 80.6 and 2.4 points at the final follow-up point, respectively. Anatomic initial reduction was obtained in 26 patients (27 feet, 90%). At the last follow-up point, only one case had the loss of reduction. Posttraumatic osteoarthritis was observed in 10 patients (10 feet, 33%), and 2 of them (2 feet, 7%) were scheduled for arthrodesis because of persistent pain. Our results have shown that fixation of an unstable tarsometatarsal joint with AO 3.0 mm HCS can provide the firm stability, the precise reduction of the joint, and satisfactory short-term clinical and radiographic outcomes without any screw breakage, although posttraumatic osteoarthritis in the midfoot is still a significant challenge for orthopedic surgeons.

Fracture ipsilatérale du talus et du calcanéus

The concomitant fracture of the talus and the calcaneus is a very rare combination, and it is a serious injury; it is caused by axial compression. Only surgical treatment with open anatomic reduction and internal fixation can lead to favorable clinical results.We report a case of ipsilateral fracture of talus and calcaneus in a 30-year-old man treated surgically by the fixation of a plate in the calcaneus and a screw in the talus, with a satisfactory clinical outcome.

Surgical treatment of displaced acetabular fractures

Acetabular fractures are severe injuries, generally caused by high-energy trauma, most frequently from traffic accidents or falls from heights. Fractures of the extremities, head injuries, chest, abdomen and pelvic ring injuries are most commonly associated injuries. The purpose of this study was to evaluate the results of open reduction and internal fixation of acetabular fractures. The open anatomical reduction of the articular surface combined with a rigid internal fixation and early mobilisation have become the standard treatment of these injuries. We conducted a retrospective analysis of 22 patients of average age 43.13 years. The patients were treated by open reduction and internal fixation at the Orthopaedic Clinic of Nis from 2005-2009. The follow-up was 12 to 60 months, with the average of 21.18 months after surgery. All injured patients were operated on between 4 and 11 days (5.7 days on the average). According to the classification by Judet and Letournel, 15 (68.18%) patients had an elementary acetabular fracture, whereas 7 (31.82%) patients had associated fracture. A satisfactory postoperative reduction implying less than 2 mm of displacement was achieved in 19 (86.36%) patients. The radiological status of the hip joint, determined according to Matta score, was excellent in 15 (68.18%) patients, good in 4 (18.18%) patients and moderate in 3 (13.63%) patients. According to Merle d'Aubigné Scale, the final functional results of the treatment of all operated patients were excellent in 12 (54.54%) patients, good in 7 (31.81%) patients and moderate in 3 (13.63%) patients. Surgical treatment of dislocated acetabular fractures requires an open reduction and a stable internal fixation. Excellent and good results can be expected only if anatomical reduction and stable internal fixation are achieved.

Closed Reduction and Minimally Invasive Percutaneous Fixation of Proximal Humerus Fractures Using the Humerusblock

To evaluate the results after closed reduction and percutaneous fixation of displaced fractures of the proximal humerus with the Humerusblock system. Prospective case series. Level 1 trauma center. Fifty-eight consecutive patients with displaced proximal humerus fractures were followed over a mean period of 15.2 (12-28) months. All patients were treated by closed reduction and percutaneous fixation using the Humerusblock. Intra- and postoperative complications, secondary fracture displacement, rate of avascular necrosis, range of motion, pain according to a visual analogue scale, and the Constant-Murley shoulder score. No intra-operative complications occurred. Implant removal was performed 6 to 8 weeks after the initial surgery. In 13 (22%) cases, secondary impaction of the humerus lead to perforation of k-wires through the articular surface requiring premature removal of the entire implant after an average time of 4.9 weeks. Five patients required revision surgery, including open reduction and fixation because of secondary fracture displacement. In five patients, k-wires loosened and backed out laterally, requiring revision surgery and retightening of the clamping screws in three cases and premature implant removal in two. Two patients showed radiologic signs of partial avascular necrosis at the final follow-up. The average range of motion of the operated shoulder was flexion 119.2 degrees, extension 33.5 degrees, internal rotation 64.2 degrees, external rotation 41.4 degrees. and abduction 107 degrees. The mean visual analogue scale pain score was 1.1 points, and the mean Constant-Murley score was 73.6 points, representing 88% of the mean Constant-Murley score of the unaffected shoulder. The Humerusblock system allows reliable minimally invasive fixation of selected displaced proximal humerus fractures, even in elderly patients with potentially reduced bone mass. In this study, postoperative rates of avascular necrosis were lower than that which has been reported after conservative treatment and open anatomic reduction and internal fixation. The overall unplanned re-operation rate of 40% was high, comparable with what has been reported for conventional percutaneous pinning. However, clinical outcome was good in 77% of the patients, and reduction could be held in 91% successfully, including elderly patients with potentially reduced bone mass.

Bilateral plate fixation for type C distal humerus fractures: experience at a single institution

Type C fractures of the distal humerus are difficult to treat and typically require open anatomical reduction and internal fixation. Here we describe our experience treating patients with type C distal humerus fractures using a trans-olecranon approach with bilateral plate fixation. Fifty-six patients (30 males, 26 females; mean age 49.8 years) were treated over a period of six years. Thirteen fractures were open and 43 closed; all were caused by falls or traffic accidents. All operations were performed successfully with no intraoperative complications. Mean duration of follow-up was 30 months (range 6-70). Mean duration of fracture healing was 2.8 months (range 2-4). Forty-seven out of 56 patients (84%) suffered no postoperative complications. One patient exhibited symptoms of ulnar nerve injury following surgery (nine exhibited symptoms before and after surgery). Two patients had mild cubitus varus deformities, four delayed olecranon osteotomy site healing, and two heterotopic ossifications. In summary, complications were minimal and outcomes satisfactory in patients with type C distal humerus fractures who underwent bilateral plate fixation via a trans-olecranon approach.

Developments and controversies in maxillofacial trauma: Repair of facial injuries

Craniofacial trauma remains a common health problem throughout many areas of the UK. Although the ‘combination of alcohol and testosterone’ is often regarded as a major aetiological factor, a significant number of injuries are not related to either. Motor vehicle collisions and equine-related sports injuries in particular can result in devastating injuries to the skull and face and are frequently seen.Over the last few decades, management has moved away from closed methods to open exposure, anatomical reduction and internal ‘rigid’ fixation of facial fractures, with significant improvements in outcomes. Nevertheless, current management of ‘high energy’ or complex fractures can still result in residual functional disability and cosmetic deformity.Today’s challenge is to restore patients back to their pre-injury form and function, consistently, but this is not always possible. Greater understanding and a number of developments have significantly improved outcomes, although controversy still exists in some areas. Some of these will be discussed.

Osteosynthese von Zwei-Pfeiler-Frakturen des Azetabulums über den ilioinguinalen Zugang

Open anatomic reduction and stable internal fixation of both-column acetabular fractures by screw and plate osteosynthesis via the ilioinguinal approach. Displaced both-column fractures of the acetabulum with incongruence of the hip joint, central femoral head displacement, unstable hip joint, and/or loss of hip joint congruence without the potential of a secondary congruence (near anatomic fragment orientation due to ligamentotaxis). General contraindications. Displaced fracture of the posterior wall. Extension of the posterior column fracture to the apex of the greater sciatic notch. Indirect open reduction of a both-column fracture of the acetabulum that is typically characterized by a multifragmentary anterior column fracture and a simple posterior column fragment using an ilioinguinal approach. Stepwise reduction and reconstruction of the anterior column according to the "proximal-to-distal" rule. Reduction and fixation of the posterior column fragment against the reconstructed anterior column. Partial weight bearing for 8-12 weeks with 15 kg body weight, beginning on the 2nd postoperative day. Thereafter, pain-dependent weight bearing. Thrombosis prophylaxis. Analysis of 27 patients treated between 1991 and 2005. A high-velocity trauma was the cause of injury in 74.1% of cases. Most patients showed an isolated injury of the acetabulum. In 55.5%, an additional central hip joint displacement was observed. A primary injury to the sciatic nerve was present in 14.8% of cases. Mean fracture gap/step was 14.3 mm. 81.5% of these fractures were anatomically reduced and stabilized; all joints were congruent. At 2-year follow-up, 14 out of 17 patients had no signs of posttraumatic osteoarthritis. Excellent and good functional results according to the Merle d'Aubigné Score were observed in eleven and five cases, respectively. One patient had a moderate functional outcome.

Osteosynthese von Frakturen der hinteren Wand des Azetabulums

Open anatomic reduction and stable internal fixation of a posterior wall fracture of the acetabulum by screw and plate osteosynthesis via the Kocher-Langenbeck appoach. Displaced fractures or fracture-dislocations of the posterior wall of the acetabulum in combination with an unstable hip joint, presence of an additional femoral head fracture or intraarticular fragments, reduction inability in fracture-dislocations or deterioration of an additional sciatic nerve injury. Poor general condition (due to additional injuries or medical disease). Local soft-tissue damage. Presence of only small bony avulsion fragments of the posterior capsule with hip joint stability. Open reduction of the posterior wall fracture with stable internal fixation by screw and plate osteosynthesis. Depending on their presence: reduction and fixation of marginal impaction zones. Partial weight bearing of the injured side with 15 kg body weight for 6 weeks. Thereafter, pain-dependent weight bearing. In cases of marginal impaction partial weight bearing is extended to 12 weeks. Between January 1, 1972 and December 31, 2005, 137 patients with fractures of the posterior wall of the acetabulum were treated operatively. A high-velocity trauma was the cause of injury in 91.1% of cases. 94.1% of these patients had an additional hip dislocation, which was reduced within 6 h post injury in 83.7%. A primary sciatic nerve injury was present in 22.2%. Additional injuries to the acetabular cartilage were found in 43%, additional femoral head lesions in 27.4%, and Pipkin fractures in 14.1%. Anatomic joint reconstruction (0-1 mm) was observed in 96.3%, the other five patients had near anatomic reconstructions (2-5 mm). All hip joints were congruent on conventional radiography. The overall complication rate was 11.8%. Osteosynthesis-related complications were seen in 6.7%. 86 patients had follow-up results after a mean of 52 months. A perfect or good functional result (Merle d'Aubigné Score) was observed in 73.3% of cases, a posttraumatic arthrosis of the hip joint was present in 31.4%.

Posteromedial Dislocation of the Elbow with Lateral Condyle Fracture in Children

Posteromedial dislocation of the elbow with lateral condyle fracture is a rare injury, and only a few cases have been reported in the literature. We report 3 children who had posteromedial dislocation of the elbow with Milch type II lateral condylar fracture of the distal humerus. Major complications included malunion, nonunion of the fracture, heterotophic calcification and elbow subluxation. From our experience and a review of the literature, open anatomical reduction and internal fixation of the lateral condyle fracture is the mainstay of treatment for these children. Poor reduction of the lateral condyle fracture results in incongruity of the joint surface and leads to poor results.

A Representative Case of Osteoporotic Distal Radius Fracture

We present a case with nonsimultaneous bilateral dorsally displaced unstable osteoporotic distal radius fractures treated by open reduction and internal fixation using a volar and dorsal locking-plate system in a 69-year-old man. On the left side the patient had a loss of reduction as a result of plate bending 1 week after palmar plating. Correction of the dorsopalmar tilt was achieved through additional dorsal plating. Three months later the same patient sustained a distal radius fracture on his right forearm. Open anatomic reduction could only be achieved using palmar and dorsal locking plates, and the large metaphyseal defect was filled with resorbable bone substitute. Six weeks after surgery the patient reported persisting wrist pain. The x-rays showed loss of reduction. Because of flexor tendon irritation, the plate had to be removed after healing malunited. At the final follow-up at 18 months, the patient showed good subjective results according to the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire results. Active wrist motion was 60 degrees extension on the left and 55 degrees extension on the right. The active range of flexion was 50 degrees for left and right wrist, and active pronation and supination were unrestricted for both forearms. Grip strength was 50 kg on either side. Although recently good and excellent results have been reported treating distal radius fractures using volar locking plates in elderly individuals, we believe these implants still have their limits depending on local bone quality and fracture pattern. Decisionmaking for surgery versus conservative treatment should balance the risks and advantages for each patient accurately.

Bilateral Hahn–Steinthal fracture: a case report and review of literature

Capitellar fractures are rare. If anatomy is not reconstructed accurately, elbow function is sub-optimal. Various studies have shown good outcome in Type I Hahn–Steinthal fractures. There is only one report of a bilateral capitellar fracture in the English literature so far. We report another case of the same. A 26-year-old mother slipped and fell on level ground. She sustained closed injury to both her elbows. Radiographs revealed bilateral, displaced Hahn–Steinthal fracture of the capitellum. She underwent open anatomic reduction and stabilisation with two partially threaded 4 mm cancellous screws, inserted from posterior to anterior. At 2 months, both fractures united. At final follow-up, 19 months post-operatively, she had full range of movement of both elbows. Anatomic reduction, stable internal fixation and early mobilisation of Type I Hahn–Steinthal capitellar fracture achieves excellent results.

Fractures of the distal humerus

Fractures of the distal humerus are challenging injuries to treat. They are rare injuries and frequently involve the joint. The advent of modern operative fixation techniques has led to an increasing trend towards open anatomical reduction and internal fixation of these fractures. This review examines the basic anatomy of the distal humerus and the applied anatomy with regards to fracture classification and surgical approach. This is followed by a discussion of the methods and results of treatment.

The Hyperplantarflexion Ankle Fracture Variant

Various patterns of ankle fractures that are not accounted for by common classification systems have been the subject of case reports. The first difficulty with these variant patterns is recognizing all associated pathology, followed by the successful application of stable fixation. The purpose of this study was to describe the common morphologic features and ligamentous injuries of a unique variant fracture pattern, as well as the surgical treatment technique and the short-term functional and radiographic outcomes. Of 121 consecutive unstable ankle fractures over a 2-year period, 7 patients were found to have a similar constellation of injuries around the ankle. A vertical shear fracture of the posteromedial tibial rim was the main feature. Six of the 7 also had a fracture of the posterior malleolus. On magnetic resonance imaging, the deltoid and posterior tibiofibular ligaments were intact in all cases. Fractures were treated with open anatomic reduction of the posteromedial and posterior fragments with antiglide plate fixation. All fractures healed at 2 months without loss of reduction, fixation failure, or surgical complications. The average American Academy of Orthopaedic Surgeons lower extremity score was 79 at an average of 8 months' follow-up. The common radiographic and morphologic features associated with this posteromedial fracture indicate that it likely occurs through a common mechanism that involves hyperplantarflexion. The characteristics of this fracture pattern have not been fully described previously, but this ankle fracture variant may occur in up to 6% of cases. Unstable ankle fractures should be evaluated carefully for evidence of posteromedial involvement so appropriate treatment may proceed.

Simultaneous bilateral tibial tubercle avulsion fracture in an adolescent: a case report and review of the literature

Avulsion fractures of the tibial tubercle are uncommon. Bilateral tibial tubercle avulsion fractures are extremely rare. In this article, we describe Watson-Jones type III simultaneous bilateral tibial tubercle avulsion fractures in a 17-year-old boy who fell on the ground while taking off in high jump in sport. An open anatomic reduction and internal fixation was performed. We report here on the successful surgical treatment of a simultaneous bilateral fracture of the tibial tuberosity in an adolescent. These types of fractures involve a growth plate, extend through the articular surface and appear to do well with open reduction and secure internal fixation despite their bilateral nature, with recovery and functional outcome comparable to results from unilateral tibial tubercle avulsion fractures.

Kalkaneusfraktur

Although screw or plate fixation of the fractured calcaneus was first described in the 1920s, surgical treatment using open anatomical reduction and stable internal fixation only commenced at the start of the 1980s. This treatment was made possible by the introduction of new imaging methods such as CT which allowed better detection of the fracture pathology and provided the basis for new surgical strategies. New procedures, including modified surgical approaches related to vascular anatomy, arthroscopic control of the subtalar joint during open or closed reduction, early free flap coverage in severe open or closed fractures with full-thickness skin necrosis, increasingly available (3)D intraoperative radiographic monitoring, and the use of interlocking calcaneus plates, have significantly improved the functional outcome in the treatment of fractures of the calcaneus.