Significant Comminution Research Articles

Calcaneocuboid joint involvement in calcaneal fractures.

The charts and radiographs of 48 surgically treated patients who underwent surgery for calcaneal fractures (right in 25 patients, left in 22, and bilateral in 1) between 1987 and 1994 were retrospectively reviewed. Coronal computed tomographic scans alone were obtained in 33 patients, and both coronal and axial computed tomographic scans were obtained in 9 patients. Three fractures exiting close to the calcaneocuboid joint (CCJ), but not involving the joint, were excluded. Nineteen patients (38.7%) had involvement of the CCJ. The extension of the fracture to the CCJ was apparent in anteroposterior or oblique radiographs or both in 18 patients. There was intra-articular fracture displacement of < or = 1 mm in 6 patients, and 13 patients had a step or a gap of > or = 2 mm with or without angulation. Eleven patients had joint depression type fractures, 6 had tongue type fractures, and 2 had comminuted fractures. Extension of the calcaneal fracture into the CCJ was significantly more common with the joint depression type calcaneal fractures (chi-square test; P = 0.008). The coronal computed tomographic images showed significant lateral subluxation of posterior facet fragments in 8 patients and considerable comminution of the lateral calcaneal wall with or without lateral subluxation of posterior facet fragment in 10 patients. These patients also had CCJ involvement, thus establishing a strong correlation between lateral subluxation of the posterior facet fragment or comminution of the lateral calcaneal wall and CCJ involvement. CCJ involvement is more common with joint depression type fractures. Extension of the fracture line into the CCJ should be suspected in presence of significant lateral column comminution or lateral talar subluxation.

Meniscal Detachment to Approach Lateral Tibial Plateau Fractures

This retrospective study evaluated 18 patients in whom an extensile approach to the lateral tibial plateau involving anterior detachment and retraction of the lateral meniscus was used to improve visualization of the tibial articular surface. All patients in this study had a significantly comminuted tibial plateau fracture with a minimum articular depression of 10 mm. Four of the 18 patients had peripheral meniscal tears that were repaired at the time of tibial fixation. All patients had a minimum followup of 13 months. The average range of motion was 0 degrees to 117 degrees. None of the patients had evidence of meniscal symptoms. Functional evaluation revealed that 13 of the patients had an excellent result, 5 had a good result, and 1 a poor result. Five patients evaluated with arthroscopy showed complete healing of the anteromedial detachment site of the meniscus. Two of the 5 patients also had a meniscal repair that healed. For patients in whom there is significant comminution and depression of the lateral tibial plateau, this is a safe and effective method of treatment that provides excellent exposure of the articular surface to allow an accurate reduction.

Closed Unstable Fractures of the Tibia

Unstable closed tibial fractures are those with major soft tissue damage, complete displacement, significant comminution, direct force mechanism, or articular surface involvement. Although the "average" tibial fracture is effectively managed without surgery, patients with such injuries frequently have prolonged convalescence and unsatisfactory anatomic and functional results. This review of recent literature reveals that in appropriately chosen patients, surgical fixation of unstable closed tibial fractures produces faster recovery and less residual disability or deformity. This is especially true when intramedullary nailing is indicated, as in transverse, short oblique, or segmental fractures. Plate and screw fixation is preferable for metaphyseal fractures. External fixation may be safest when soft tissue crushing is extensive, especially if fasciotomy is required.

Ipsilateral Femoral Neck and Shaft Fractures

A technique for ipsilateral femoral neck and shaft fracture using the sliding compression hip screw with plate combined with trochanteric antegrade Ender nailing of the femur was applied in two cases. Ender nails can be passed without difficulty past a compression hip screw and the bicortical plating screws. The hip and femur can be fixed internally through a single approach in a single position. Sliding compression hip screw devices can provide excellent preliminary stable femoral neck fixation. Blood supply to the femoral head is not disturbed while the femoral intramedullary fixation is performed. Antegrade Ender nailing avoids the common knee complications associated with other retrograde techniques. Decreased operative time, less blood loss, less technical difficulty, and early mobilization are important factors in the multiple-injured patient. Femoral intramedullary fixation may require open reduction, circlerage to ensure stability, and maintenance of alignment in case of significant comminution to allow early crutch ambulation. This mode of fixation may be advantageous for selected cases.

The results of plating humeral shaft fractures in patients with multiple injuries. The Sunnybrook experience.

Excellent results can be achieved by plating fractures of the shaft of the humerus in patients with multiple injuries. This helps in nursing care and in the management of other injuries. In 38 patients admitted to a regional trauma centre, 39 humeral shaft fractures were plated. There were 27 men and 11 women, with an average age of 31.5 years. Fourteen of the humeral fractures were compound and 20 had significant comminution; 23 were fixed by a plate on the day of admission and all 39 by the twentieth day. Follow-up of 34 fractures showed that all had united, 33 primarily. All patients but one had a fully functional shoulder and no patient with a fractured humerus alone had lost any elbow movement. Complications were rare--one case each of non-union, fixation failure and infection. No permanent nerve injuries were produced at operation. The plating of fractures of the humerus in these circumstances has been shown to produce excellent results and has a place in the management of the patient with multiple injuries.