Significant Loss Of Reduction Research Articles

RADIOLOGIC FEATURES AS A PROGNOSTIC INDICATOR OF FOREARM FRACTURES

This study was conducted to investigate the characteristics, complications, radiologic features and clinical course of patients undergoing reduction of forearm fractures in order to better inform patient prognosis and postoperative management.We conducted a retrospective cohort study of 1079 pediatric patients treated for forearm fractures between January 2014 and September 2021 in a 327 bed regional medical center. A preoperative radiological assessment and chart review was performed. Percent fracture displacement, location, orientation, comonution, fracture line visibility and angle of angulation were determined by AP and lateral radiographs. Percent fracture displacement was derived by: (Displacement of Bone Shafts / Diameter) x 100% = %Fracture Displacement. Angle of angulation and percent fracture displacement were calculated by averaging AP and lateral radiograph measurements.80 cases, averaging 13.5±8.3 years, were identified as having a complete fracture of the radius and/or ulna with 69 receiving closed reduction and 11 receiving fixation via an intramedullary device or percutaneous pinning. Eight patients (10%) experienced complications with four resulting in a refracture and four resulting in significant loss of reduction (LOR) without refracture. Fractures in the proximal ⅔s of the radius were associated with a significant increase in complications compared to fractures in the distal ⅓ of the radius (31.6% vs 3.4%) (P=.000428). Likewise, a higher percent fracture displacement was associated with a decreased risk of complications (28.7% vs 5.9% displacement)(P=0.0403). No elevated risk of complications was found based on fracture orientation, angulation, fracture line visibility, forearm bone(s) fractured, sex, age or arm affected.Our result highlights radius fracture location and percent fracture displacement as markers with prognostic value following forearm fracture. These measurements are simply calculated via pre-reduction radiographs, providing an efficient method of informing risk of complications following forearm fracture.

Pediatric Forearm Fracture Characteristics as Prognostic Indicators of Healing.

Background This study was conducted to investigate the characteristics, complications, radiologic features, and clinical course of patients undergoing reduction of forearm fractures to better inform patient prognosis and postoperative management. Methodology We conducted a retrospective chart review of 75 pediatric patients treated for forearm fractures between January 2014 and September 2021 in a 327-bed regional medical center. A preoperative radiological assessment and chart review was performed. Percent fracture displacement, location, orientation, comminution, fracture line visibility, and angle of angulation were determined by anteroposterior (AP) and lateral radiographs. Percent fracture displacement was calculated as 𝐵𝑜𝑛𝑒 𝑆ℎ𝑎𝑓𝑡 𝐷𝑖𝑠𝑝𝑙𝑎𝑐𝑒𝑚𝑒𝑛𝑡 / 𝐷𝑖𝑎𝑚𝑒𝑡𝑒𝑟 × 100% = % 𝐷𝑖𝑠𝑝𝑙𝑎𝑐𝑒𝑚𝑒𝑛𝑡. The angle of angulation and percent fracture displacement were calculated by averaging AP and lateral radiograph measurements. Results A total of 75 cases, averaging 11.6 ± 4.1 years, were identified as having a complete fracture of the radius and/or ulna, with 66 receiving closed reduction and nine receiving fixation via an intramedullary device or percutaneous pinning. Eight (10.7%) patients experienced complications, with four resulting in a refracture and four resulting in significant loss of reductionwithout refracture. Fractures in the proximal two-thirds of the radius were associated with a significant increase in complications compared to fractures in the distal one-third of the radius (33.3% vs 3.6%) (p = 0.0005). Likewise, a greater fracture displacement percentage was associated with a lower risk of refracture post-reduction as those experiencing complications had over 30% greater total displacement pre-reduction compared to patients who did not experience complications such asrefracture or loss of reduction (p < 0.0001). No elevated risk of complications was found based on fracture orientation, angulation, fracture line visibility, forearm bone(s) fractured, sex, age, or arm affected. Conclusions Our results highlight radius fracture location and percent fracture displacement as markers with prognostic value following forearm fracture. These measurements are simply calculated via pre-reduction radiographs, providing an efficient method of informing the risk of complications following forearm fracture reduction.

Efficacy of percutaneous short segment fixation in the treatment of Magerl A3 thoracolumbar fractures with low bone mineral density:a retrospective study

To explore the clinical efficacy of percutaneous pedicle screw short segment internal fixation with or without the intermediate screw in the treatment of Magerl A3 thoracolumbar fractures with low bone mineral density. Patients with Magerl A3 thoracolumbar fracture underwent percutaneous pedicle screw short segment internal fixation from January 2017 to July 2020 were retrospectively analyzed, 93 cases met the diagnosis and inclusion criteria, 9 cases were excluded according to the exclusion criteria, and the remaining 84 cases obtained complete imaging follow-up data. There were 38 males and 46 females, the age ranged from 56 to 73 years old with an average of (64.78±7.12) years old, bone mineral density (BMD) ranged from 0.61 to 0.89 g/cm3 with an average of (0.73±0.14) g/cm3, the follow-up time was 11 to 25 months with an average of (17.58±6.12) months. There were 45 cases in group A with intermediate screw and 39 cases in group B without intermediate screw. The operation time and intraoperative blood loss were recorded, Oswestry Disability Index (ODI) and visual analogue scale (VAS) were used for clinical evaluation. The Cobb angle, vertebral wedge angle (VWA) and anterior vertebral body height (AVBH) were measured by X-ray after the operation. The corrected loss of the above parameters was calculated. There were 5 cases of screw loosening in 84 patients (2 cases in group A and 3 cases in group B, P>0.05). There were significant differences in operation time and intraoperative blood loss between two groups(P<0.01). Clinical effects of two groups were good, postoperative VAS and ODI after operation obviously improved, there was no significant difference between two groups during all follow-up periods (3 days, 1 month after operation and the final follow-up) (P>0.05). Three days after the operation, the image evaluations (Cobb angle, VWA and AVBH) were significantly improved (P<0.05), but significant reduction loss was observed in both groups at 1 month after the operation and at the final follow-up (P<0.05). At the final follow-up, the loss of Cobb angle, VWA and AVBH in group A were (5.26±4.18) °, (4.63±3.80) ° and (9.54±8.71)%, respectively;group B was (6.01±4.34) °, (6.55±6.21) ° and (11.67± 9.95)%, respectively;however, there was no significant difference in reduction loss between the two groups(P>0.05). Although the curative effect of the patients is satisfactory, the stability of the patients can not be improved by increasing the middle injured vertebra screw placement, the two groups of percutaneous short segment internal fixation can not resist the reduction loss of Magerl-A3 thoracolumbar fracture with low bone mineral density. Because the injured vertebra screw increases the operation time and intraoperative blood loss, it is not significant to use the intermediate screw for the elderly Magerl A3 thoracolumbar fractures with low bone mineral density.

Reduction and fixation of proximal humeral fracture with severe medial instability using a small locking plate

BackgroundCurrently, the reduction and support of comminuted medial cortex of humeral fracture remains a challenge, Therefore, a novel reduction and fixation technique that employs an anteromedial small locking plate was explored in this study, and its viability and the associated complications were assessed.MethodsFifteen cases of proximal humeral fractures with medial instability (five cases were classified as three-part and ten as four-part by Neer classification) were treated by the proposed reduction technique using an anteromedial small locking plate. Subsequently, the radiological and clinical outcomes were evaluated over an average follow-up period of 18.53 months.ResultsThe average operation time was 108 min (range, 70–130 min), and the mean fracture union time in all patients was 12.13 weeks (range, 8–16 weeks). Complications such as infection and neurovascular injury were not observed. Postoperative X-ray showed avascular necrosis and screw penetration in one patient, while screw penetration, varus malunion, or significant reduction loss was not found in the other cases. The mean Constant score was 79.8 (range, 68–92) during the final visit.ConclusionsThe use of an anteromedial small locking plate improved the reduction efficiency, reconstructed the medial support, and alleviated the occurrence of complications in proximal humeral fractures with medial instability.

Does Dynamic Anterior Plate Fixation Provide Adequate Stability for Traumatic Subaxial Cervical Spine Fractures at Mid-Term Follow-Up?

Background: It remains questionable if the treatment of cervical fractures with dynamic plates in trauma surgery provides adequate stability for unstable fractures with disco-ligamentous injuries. The primary goal of this study was to assess the radiological and mid-term patient-reported outcome of traumatic subaxial cervical fractures treated with different plate systems. Patients and Methods: Patients, treated with anterior cervical discectomy and fusion (ACDF) between 2001 and 2015, using either a dynamic plate (DP: Mambo™, Ulrich, Germany) or a rigid locking plate (RP: CSLP™, Depuy Synthes, USA), were identified. For radiological evaluation, the sagittal alignment, the sagittal anterior translation and the bony consolidation were evaluated. After at least two years, the patient-reported outcome measures (PROM) were evaluated using the German Short-Form 36 (SF-36), Neck Disability Index (NDI) and the EuroQol in 5 Dimensions (EQ-5D) scores. Results: 33 patients met the inclusion criteria (DP: 13; RP:20). Twenty-six patients suffered from AO Type B or C fractures. Both the sagittal alignment and the sagittal translation could be sufficiently improved in both groups (p ≥ 0.05). No significant loss of reduction could be observed at the follow-up in both groups (p ≥ 0.05). Bony consolidation could be observed in 30 patients (DP: 12/13 (92%); RP: 18/20 (90%); (p ≥ 0.05)). In 20 patients, PROMs could be evaluated (follow-up: 71.2 ± 25.5 months). The whole cohort showed satisfactory PROM results (EQ-5D: 72.0 ± 4.9; SF-36 PCS: 41.9 ± 16.2, MCS: 45.4 ± 14.9; NDI: 11.0 ± 9.1). without significant differences between the DP and RP group (p ≥ 0.05) Conclusion: The dynamic plate concept provides enough stability without a difference in fusion rates in comparison to rigid locking plates in a population that mostly suffered fragile fractures.

Radiographic alterations in clavicular bone tunnel width following anatomic coracoclavicular ligament reconstruction (ACCR) for chronic acromioclavicular joint injuries.

To evaluate tunnel widening and its relationship in loss of reduction and clinical outcomes in patients undergoing anatomic coracoclavicular ligament reconstruction (ACCR) using free tendon grafts for chronic acromioclavicular (AC) joint injuries. A retrospective chart review was performed on patients undergoing ACCR for type III-VI AC joint injuries between January 2003 and December 2017. For radiographic analysis, pre- and post-operative coracoclavicular distance (CCD) and tunnel width of the medial and lateral clavicular bone tunnel were measured at the earliest (EPO) and latest postoperative follow-up (LPO). To determine the clinical relevance of improvement in clinical outcome score (American Shoulder and Elbow Surgeons score) substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) thresholds were used. Twenty-four patients with a mean clinical follow-up of 37 ± 35 months (mean age 44.7 ± 13.4) were included in the study. Both the medial (5.6 ± 0.2mmEPO-6.6 ± 0.7mmLPO; p < 0.001) and lateral (5.6 ± 0.5mmEPO-6.8 ± 1mmLPO; p < 0.001) clavicular bone tunnel showed significant widening from EPO to LPO. There was a significant loss of reduction at LPO (CCDLPO 10.1 ± 4mm) compared to EPO (CCDEPO: 6.2 ± 3.8mm) (p < 0.001). No significant correlation between loss of reduction and medial (p = 0.45; r = - 0.06) or lateral (p = 0.69; r = - 0.06) tunnel widening was found. Alterations in tunnel width were shown having no influence on clinical outcomes. Patients who underwent ACCR using a free tendon graft for the treatment of chronic type III-VI ACJ injuries showed significant clavicular bone tunnel widening during the postoperative course. No correlation between tunnel widening and loss of reduction was shown with radiographic findings having no influence on clinical benefit and satisfaction. Case Series; Level of evidence, IV.

Medial Buttress Plating for Humerus Fractures With Unstable Medial Column.

The purpose of this study was to report surgical tips and techniques on the use of additional medial buttress plate fixation in proximal humeral fractures with unstable medial column restoration after lateral locking compression plate fixation. Between April 2011 and January 2017, 17 patients with medial cortical deficiency were treated using this technique. The average follow-up period was 30 (range, 12-81) months. Successful fracture healing was achieved in all 17 cases. The mean neck-shaft angle change was 1.33 degree (range, 0-7.4 degree). Anterior glenoid rim erosion occurred in 1 patient. No avascular necrosis of the humeral head or significant loss of reduction, and no implant failure or screw perforation occurred. In the first part of this study, we described in detail the indications and surgical technique applied to these fractures. In the second part, we reviewed the clinical and radiographic outcomes of these patients. Supplemental medial buttress plate fixation after lateral locking compression plate fixation was effective in preventing varus collapse and implant failure for proximal humeral fractures with an unstable medial column.

Comparison of cross pinning versus lateral three pins in type three supracondylar fracture of distal humerus in children.

Background:&#x0D; Supracondylar fracture of distal humerus is the most common paediatric fracture. Type III supracondylar fractures should be treated with anatomical reduction and stable Kirschner wire (K- wire, pin) fixation to prevent the cosmetic deformity. The configuration of wires is debatable. Although two crossed K-wires are bio-mechanically stable, there is a risk of iatrogenic ulnar nerve injury. Lateral 3 K-wires is a good alternative. This study was done to compare the outcome of cross K- wire and lateral 3 K-wires in terms of stability.&#x0D; Materials and Methods:&#x0D; This is a prospective study done in Manipal Teaching Hospital. All the Gartland type 3 supracondylar fractures of the distal humerus were treated with closed reduction and stabilized with K wires. In Group I, fractures were stabilized with cross K wire fixation and in group II they were stabilized with 3 lateral K-wires. The patients were followed up at 4-5 weeks for wire removal and at 3 months and 6 months after surgery. Baumann's angle, a functional outcome as per Flynn's criteria, and range of motion were recorded in each visit. Outcomes were compared in term of displacement of fracture.&#x0D; Result:&#x0D; Seventeen children in each group were taken up for the study. There were no significant differences in term of patients and fracture character. No patients had significant loss of reduction at final follow up. There is no statistically significant difference seen in mean changes of Bauman's angle. According to Flynn's criteria good result was seen in more than 95% of cases in both groups.&#x0D; Conclusion:&#x0D; Both cross K-wires and Lateral 3 K-wires provide good stability. Fixation of supracondylar fracture from lateral side had an advantage of no risk of iatrogenic Ulnar nerve injury. Addition of third K-wire from lateral side provides good stability as that of cross K- wire fixation.

Dorsal transosseous reduction and locking plate fixation for articular depressed middle phalangeal base fracture.

An articular depressed fragment at the base of the middle phalanx can be an obstacle to congruent reduction and stable fixation. This study assessed the outcomes of a transosseous reduction technique combined with locking plate fixation for the treatment of articular depressed middle phalangeal base fracture. Between 2015 and 2017, seven patients (eight fingers) with intraarticular comminuted middle phalangeal base fracture were included in this study. Mean follow-up was 19 months (range 12-30 months). All patients showed depression of the articular fragment on sagittal computed tomography (CT) scan and were treated with a transosseous reduction technique and dorsal locking plate fixation. Radiographic evaluation was performed to ensure restoration of a concentric articular surface postoperatively. Total active range of motion (TAM) of the finger, grip strength, and the quick Disabilities of the Arm, Shoulder and Hand (quick DASH) score were evaluated at the last follow-up. Complications were also assessed. All fractures obtained bony union with a concentric joint. There was no significant loss of reduction during the follow-up period. The mean active proximal interphalangeal (PIP) joint and distal interphalangeal joint motion arcs at follow-up were 89° and 61°, respectively. Mean TAM of the affected finger and mean grip strength were 94% (range 80-100%) and 94% (range 86-100%) of the contralateral side, respectively. Mean quick DASH score was 2.3 (range 0-9.1). All patients returned to work. No surgery-related complications occurred. This technique provides satisfactory restoration of articular congruence and enables the early joint mobilization of articular depression-type fractures of the base of the middle phalanx. Therapeutic, level IV.

Tibial plateau posterior column fractures treated via the posteromedial approach dissecting the gastrocnemius medial head

Objective To discuss the treatment of tibial plateau posterior column fractures via the posteromedial approach which dissects the medial head of the gastrocnemius muscle. Methods From July 2013 to September 2016, 7 patients were treated at Department of Orthopaedics and Trauma, The First Affiliated Hospital to Dalian Medical University by surgery via the posteromedial approach dissecting the medial head of the gastrocnemius muscle for tibial plateau posterior column fractures. They were 6 men and one woman, aged from 38 to 61 years (49.3 years on average). According to AO/OTA classification, 4 cases belonged to type 41-B3.3, one to type 41-B3.1, one to type 41-C3.3 and one to type 41-C3.1. According to the three-column classification, 3 cases were categorized into three-column fracture, 2 cases into fracture of both medial and posterior columns, and 2 cases into simple posterior column fracture. Of the posterior column fractures, 5 had the medial posterior column split and the lateral column collapsed, and 2 had the medial posterior column split. According to Schatzker classification, 5 cases were categorized into type Ⅳ, one into type Ⅴ and one into type Ⅵ. Fracture reduction was assessed according to the Rasmussen criteria postoperation. The knee function was assessed at final follow-ups using The Hospital for Special Surgery (HSS) scoring system. The postoperative complications were documented. Results Insertion rupture of the posterior cruciate ligament was found in one case, lateral meniscus injury in 2 cases, and tibial external dislocation combined with bone fragment incarceration into the lateral femoral condyle in one case. All the lesions were repaired. All the incisions were healed at the first stage. No major neurovascular injuries were found. The 7 patients were followed up for 8 to 12 months (mean, 11.4 months). Bony union was achieved in all after 12 to 16 weeks (mean, 14.3 weeks). The postoperative Rasmussen reduction scores averaged 17.7 points. The average tibial plateau tilt angle was 9.5° postoperatively and 10.8° at final follow-ups; the average tibial plateau varus angle was 86.7° postoperatively and 87.3° at final follow-ups. The HSS knee scores at final follow-ups averaged 91.4 points. No significant reduction loss, implants loosening, infection or malunion was observed at final follow-ups. Conclusion The posterior medial approach which dissects the medial head of the gastrocnemius muscle is a safe and practical one for treatment of tibial plateau posterior column fractures, because it can well expose the posterior column of the entire tibial plateau so that is beneficial to the anatomical reduction of the fracture and placement of implants, leading to fine short-term curative effect. Key words: Tibial; Fractures, bone; Fracture fixation, internal; Posteromedial approach; Medial head of the gastrocnemius muscle

Prospective study of comminuted articular distal radius fractures stabilized by volar plating inthe elderly.

The objective was to assess the ability of the volar locking plate to maintain the radiographic parameters over the time in elderly patients with complex intra-articular distal radius fractures. Prospective cohort of 66 consecutive patients with mean age of 68 (range 60-81) years and AO type C fractures treated with volar locking plate. Radiographic measurements were performed pre and post-operatively at each follow-up. Clinical assessment was made by Patient-Rated Wrist Evaluation scores, Disabilities of the Arm, Shoulder and Hand score, range of motion, and grip strength. The mean post-operative follow-up was 31 (range, 24-47) months. The most difficult parameters to restore intra-operatively were volar tilt and radial height, while radial inclination and ulnar variance were restored in a high rate of patients. There was significant loss of reduction within four post-operative months in volar tilt (p = 0.001) and radial height (p = 0.029). Mean radiographic parameters had no changes from fourmonths to final evaluation. At final follow-up, 50.1% of the patients had all radiographic parameters restored in comparison with the noninvolved wrist, but 83.3% had all radiographic parameters within a functional range (p = 0.001). No significant relationship between radiographic and functional outcomes was found (p = 0.474). This study found that volar locking plate fixation for displaced intra-articular distal radius fractures in elderly patients was an effective procedure to obtain success functional outcomes. Although reduction loss in volar tilt and radial height occurred within four first months, volar plate was able to maintain fracture stabilization with radiographic parameters within functional range over the time in most patients of these elderly patients.

The Kapandji Technique of Closed Reduction Using Sommer - Pins in the Treatment of Completely Dislocated Fractures of the Distal Radius in Children.

BACKGROUND:The fractures of the distal radius are one of the most frequent cases in the pediatric population. The primary way of treating these fractures is conservative, with manual reduction and cast immobilisation. In patients where reduction and retention of the fracture cannot be achieved, a surgical approach is the treatment of choice.AIM:To evaluate the benefits of using the minimally invasive surgical treatment of closed reduction using Sommer - pins in the treatment of the fractures of the distal radius in the pediatric population with the method of the Kapandji technique.MATERIAL AND METHODS:In this study, we used cases treated from 2012 to 2017, of 48 completely dislocated fractures of the distal radius in patients ages 6 -14 yrs., where the use of non-surgical treatment proved ineffective. In the surgical treatment, we used one or two Sommer - pins to achieve a correct reduction and fixation.RESULTS:The post-op immobilisation lasted 4 - 7 weeks with an underarm cast. The patients were closely followed in the period of 6 months following the intervention. The anatomic reduction was easily achieved with this type of technique in every case. In the post-op period, there was no significant loss of reduction and another surgical procedure was not needed in any of the cases.CONCLUSION:With the use of the closed reduction Kapandji technique, an easy and good anatomical reduction is achieved with good post-op results in the treatment of completely dislocated fractures in the distal radius in children.

Sequential management of tibial fractures using a temporary unicortical external fixator.

Introduction: The development of damage control orthopedics (DCO) procedures has led to the development of temporary unicortical external fixators (TUEFs) intended to limit deep infectious complications and facilitate early conversion to internal fixation.Methods: A retrospective study was conducted in two French military trauma centers, including on patients being treated for tibial fractures with a TUEF (UNYCO® − Orthofix®) followed by an early conversion to intramedullary nailing.Results: Eleven patients with an average age of 41 were included between September 2015 and June 2017. A total of 12 TUEFs were implanted for one closed fracture and 11 open fractures, including one type I, eight types II, and two Gustilo types IIIB. The indication of DCO was related to hemodynamic instability in three cases, to the severity of soft tissue lesions in eight cases, and to the context of treatment in one case. The conversion to IM nailing was made after an average of 7.6 days. No significant loss of reduction was observed until internal osteosynthesis, which was performed with “fixator in place” in ten cases. The coverage of Gustilo type III injuries was performed by free flap transfers at the same time as IM nailing. All the patients were reviewed with an average follow-up of 16.5 months. Bone union was achieved in all cases. Two IM nailing dynamizations were carried out, but no bone grafting was required. Two cases of pandiaphysitis were observed and treated without functional complications.Discussion: Despite a limited number of patients, this study demonstrates the reliability of the TUEF to maintain the reduction of tibial fractures and facilitate early conversion to IM nailing. Unicortical fixation does not prevent septic complications related to the severity of soft tissue injuries.

Role of percutaneous pinning and cast application in extra-articular and simple intra-articular management of distal radius fractures: A clinical study

Background: Distal end radius fracture is a common fracture seen in the routine orthopedic practice. Although most of these fractures are managed by cast application, the loss of reduction and malunion rates are high. Closed reduction, percutaneous pinning, and cast application offers a simple method of managing these fractures. This study was done to evaluate the functional and radiological of extra-articular and simple intra-articular distal radius fractures using closed pinning and cast immobilization. Materials and Methods: A prospective study of 73 skeletally mature patients with displaced extra- and intra-articular fractures without significant comminution was done. Closed reduction was done under anesthesia and fixation done with 2 or 3 Kirschner-wires followed by cast for 6 weeks. Final follow-up was done after 6 months using Sarmiento's modification of Lindstrom criteria and demerit point system of Gartland and Werley. Results: The fracture united in all the 73 patients. The average preoperative radial height changed from 2.7 to 13.2 mm postoperatively and a final value of 10.9 mm. The average volar tilt changed from −11.25° preoperatively, 12.1° postoperatively, and 9.7° at the final follow-up. Only two patients had a significant loss of reduction. Pin tract infection, joint stiffness, pin migration, and complex regional pain syndrome were the major complications. Conclusion: Closed reduction, percutaneous pinning, and cast immobilization is a technically simple and an effective method for managing displaced extra-articular and simple intra-articular distal radius fractures.

Results of Surgical Treatment of Distal Humerus (AO/OTA Type C) Fractures Using Double Anatomical Plates

Objective: Distal humerus fractures are complex injuries that are particularly challenging to treat. For predictable outcomes and early joint mobilization, they should be surgically treated using double anatomical locking plates. However, several complications have been reported, such as stiffness, decreased range of motion, nerve dysfunction, posttraumatic degenerative changes, and wound and skin infections. The purpose of this study was to report the outcomes and complications after open reduction and internal fixation of intra-articular distal humerus fractures using double anatomical locking plates. Materials and Methods: Between April 2010 and May 2013, we treated 11 patients with intra-articular distal humerus fracture (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association [AO/OTA] type C). Four patients were male and 7 were female. The average age was 47.0 (range, 22-80). The pretreatment AO/OTA type was C1 in 2 patients, C2 in 6, and C3 in 3. All fractures were treated with open reduction and internal fixation using double anatomical locking plates. Intraoperative ulnar nerve anterior transposition was performed for 10 patients. Postoperative immobilization was 1 week followed by active range of motion. Results: All patients obtained bone union. Regarding range of motion, mean elbow flexion arc was 106.5° (mean extension was −11.5° and mean flexion was 118°). The Mayo Elbow Performance Score was excellent in 4 patients, good in 6, and fair in 1. Radiographic evaluation was performed immediately and 6 months after surgery. There was no significant reduction loss between these time periods. Postoperative complications in the 10 cases included 7 with ulnar nerve neuropathy (3 with motor weakness and 4 with sensory disturbance), 2 with refixation of the olecranon, and 1 with infection. All patients with motor weakness improved and 5 patients had persistent numbness. Conclusions: No significant reduction loss was seen between the postoperative radiological evaluation performed immediately after surgery and that performed 6 months after surgery. For treating distal humeral intra-articular fractures, double anatomical locking plates can provide good stability for early active mobilization. However, this surgical method includes some complications, especially ulnar nerve dysfunction. Because gentle management of the ulnar nerve is necessary, hand surgeons should perform this surgery.

The amount of impaction and loss of reduction in osteoporotic proximal humeral fractures after surgical fixation.

After surgical fixation, osteoporotic proximal humeral fractures often show high impaction and loss of reduction. This study aims at assessing the amount of impaction and loss of reduction at a short and medium follow-up. We found an alarming percentage of cases showing these complications in the first postoperative months. This study seeks to quantify the amount of humeral head impaction and loss of reduction in a consecutive series of osteoporotic proximal humerus fractures treated with a locking plate. A series of displaced proximal humerus fractures were prospectively treated with minimally invasive reduction and ostheosynthesis using a locking plate. Diagnosis and classification of fractures were based on X-ray examination and CT scan. Proximal humerus cortical bone thickness (CBTAVG) was studied to assess osteoporosis. Amount of loss of reduction and head fragment impaction were noted at 3 and 18months of follow-up. Constant score was calculated at 6 and 18months of follow-up. Thirty-one osteoporotic fractures were studied. Most of the fractures (21, 67.7%) had a CBTAVG of less than 4mm. At 3months of follow-up, 7 cases (22.5%) had significant loss of reduction and the mean amount of impaction was 2.8mm. At 18months of follow-up, only 1 additional fracture showed loss of reduction and mean impaction was 3mm (p < 0.05). At 6months follow-up, the mean Constant score was 58%; while at 18months, it was 70% (p = 0.02). Amount of impaction was significantly correlated to age of patients (p = 0.031), female sex (p = 0.011), CBTAVG (p = 0.019), and metaphyseal comminution (p = 0.013). Osteoporotic proximal humerus fractures may present an important impaction and loss of reduction in the first 3months after surgery even if treated with a rigid device and multiple head screws. Surgeons treating these osteoporotic fractures should be aware of these complications even when using a rigid device.

Intraoperative assessment of closed reduction for developmental dislocation of the hip using 3-dimensional fluoroscopy.

Postoperative imaging for operatively treated developmental dislocation of the hip typically uses computed tomography or a magnetic resonance imaging (MRI). Neither imaging modality offers the ability to intervene intraoperatively. The 3-dimensional (3D) C-arm provides an attractive alternative providing immediate intraoperative feedback on the quality of a hip reduction. Our primary research question was to determine whether 3D fluoroscopy could assess hip position after closed reduction and spica casting. Secondary questions included whether reduction was maintained postoperatively when compared with postoperative MRI, and to determine the radiation dose received by the infant. We retrospectively identified 16 patients from 2010 to 2013 who underwent closed reduction and spica casting for a developmentally dislocated hip who underwent both intraoperative 3D fluoroscopy and postoperative MRI imaging. Scans were retrieved and assessed by a blinded pediatric orthopaedic fellow. Assessment of hip reduction was graded based on the modified Shenton line of the pelvis in axial plane images. Effective radiation doses between imaging modalities were compared using an anthropomorphic phantom. All hips were reduced on 3D fluoroscopic images. Comparing the intraoperative 3D scans with the postoperative MRI images all 16 hips were in the same position. At 12 weeks all hips were reduced and no signs of subluxation were identified on the plain anteroposterior radiograph. 3D fluoroscopy achieved the lowest effective dose of radiation per study measuring 0.3 mSv compared with 0.5 mSv for low-dose CT and 0.48 mSv for 60 seconds of live fluoroscopy. Accurate assessment of the quality of hip reduction is possible in the axial plane using 3D fluoroscopy with no significant loss of reduction in the early postoperative period. When comparing the effective radiation exposure to limited-cut computed tomography protocols, 3D fluoroscopy offers a low-dose alternative that may facilitate cost savings and early discharge. Diagnostic studies-investigating a diagnostic test; study of nonconsecutive patients with consistently applied gold standard; level III.

Distal radius fractures: Should we use supplemental bone grafts or substitutes in cases of severe osteoporotic or comminution?

ObjectivesThe purpose of this study was to assess the need of bone graft or bone substitutes in unstable distal radius fractures (DRF) treated with locking compression plates (LCP). Patients and methodsAn observational and prospective study was conducted on 60 patients with DRF AO-type A3 and AO-type C3, treated surgically by LCP plates without bone grafts or substitutes. Ranges of motion in flexion (F), extension (E), pronation (P), and supination (S) were measured in the injured wrist and compared with the healthy contralateral wrist. X-ray parameters: palmar tilt (PT), radial inclination (RI), ulnar variance (UV), and radial height (RH) were calculated in the injured wrist one year after surgery and then compared, with those parameters in the healthy contralateral wrist and in the follow-up postoperative X-ray of the injured wrist. PRWE and DASH scores were used to evaluate patient satisfaction. ResultsThe range of motion loss was F 12°±16.1°, E 9°±13.1°, P 2.5°±7.5°, and S 5°±10°, but they remained within functional parameters. Good results were also obtained in the PRWE and DASH scores (DASH 12.6±14.16 and PRWE 9.5±9.5). All the fractures were healed without significant collapse (IP 0.55±1.7°, IR 0.31±1.5°, VC 0.25±0.8mm, and AR 0.1±0.9mm). ConclusionsAll fractures healed without problems or with significant loss of reduction. Bone graft and bone substitutes are not mandatory for treatment of unstable DRF with LCP plates. Their use increases the cost and is not exempt of morbidities. This study also reinforces the role of LCP plates in surgical treatment of unstable DRF.

Allogenic bone grafting for augmentation in two-part proximal humeral fracture fixation in a high-risk patient population.

The surgical fixation of unstable, varus displaced two-part fractures of the proximal humerus remains challenging. In a case series of 10 non-compliant, high-risk patients (median age 63 years; range 52-78), a cancellous allograft was used to augment plate fixation of the fractures. After a median follow-up of 28.5 months, all but one fracture were healed, with the bony allografts incorporated without any systemic or local complications. No significant loss of reduction or evidence of avascular necrosis of the humeral head was seen. The median Constant-Murley Score was 72.0 (range 45-86). Median pain on a visual analog scale was 1 (range 0-7). Median values for the range of motion were flexion: 155° (range 90-170), abduction: 168° (range 95-180) and external rotation: 43° (range: 30-50). Compared to the uninjured contralateral side, flexion was impaired by 13 %, abduction by 14 %, and external rotation by 15 %. Median abduction power was 64 % of the uninjured side. The median varus displacement was 51° (range 45-59) preoperatively, 4° (range -5 to 19) intraoperatively, and 13° (range 1-18) at the time of the final follow-up, relating to an improvement of 38° compared to the preoperative status. The augmentation of proximal humeral fracture fixation using a cancellous allograft might be a viable and reliable alternative to prevent early varus failure and to, moreover, lead to bony union in a non-compliant or high-risk patient population.

Fracturas de radio distal: ¿es necesario el aporte de injerto o sustitutivo óseo en los casos con osteoporosis o conminución severa?

ObjectivesThe purpose of this study was to assess the need of bone graft or bone substitutes in unstable distal radius fractures (DRF) treated with locking compression plates (LCP) Patients and MethodsAn observational and prospective study was conducted on 60 patients with DRF AO-type A3 and AO-type C3, treated surgically by LCP plates without bone grafts or substitutes. Ranges of motion in flexion (F), extension (E), pronation (P), and supination (S) were measured in the injured wrist and compared with the healthy contralateral wrist. X-ray parameters: palmar tilt (PT), radial inclination (RI), ulnar variance (UV), and radial height (RH) were calculated in the injured wrist one year after surgery and then compared, with those parameters in the healthy contralateral wrist and in the follow-up postoperative x-ray of the injured wrist. PRWE and DASH scores were used to evaluate patient satisfaction. ResultsThe range of motion loss was F 12°±16.1°, E 9°±13.1°, P 2.5°±7.5°, and S 5°±10°, but they remained within functional parameters. Good results were also obtained in the PRWE and DASH scores (DASH 12.6±14.16 and PRWE 9.5±9.5). All the fractures were healed without significant collapse (IP 0.55±1.7°, IR 0.31±1.5°, VC 0.25±0.8mm, and AR 0.1±0.9mm). ConclusionsAll fractures healed without problems or with significant loss of reduction. Bone graft and bone substitutes are not mandatory for treatment of unstable DRF with LCP plates. Their use increases the cost and is not exempt of morbidities. This study also reinforces the role of LCP plates in surgical treatment of unstable DRF.