Surgical Management Of Fractures Research Articles

Treatment Options After Failed Distal Radial Fracture Treatment (Salvage Procedures)

The vast majority of distal radius fractures respond well to either nonsurgical or surgical treatment methods. Several fracture patterns, however, are known to be problematic. Failure to recognize their particular intricacies may result in the formation of fracture nonunions , malunions, wrist arthritis, and/or carpal instability. The aforementioned consequences of failed treatment often require salvage techniques to improve upper extremity function. Techniques for limiting complications associated with surgical fracture management are presented in an algorithmic format to assist the treating physician. Indications and contra-indications of each technique are reviewed, and our preferred methods and surgical pearls are presented.

Management of a femoral diaphyseal fracture in a patient with Klippel-Trenaunay-Weber syndrome: a case report

IntroductionKlippel-Trenaunay-Weber syndrome is a rare congenital disorder of the peripheral vascular system that is characterized by haemangiomas, soft tissue and/or osseous hypertrophy, venous and lymphatic anomalies as well as arterio-venous malformations. To our knowledge there are no documented cases of surgical fracture management in such patients.Case presentationWe present the case of a 42-year-old female patient previously diagnosed with Klippel-Trenaunay-Weber syndrome, who had sustained a left femoral shaft fracture. She was treated with a closed, locked intramedullary nailing procedure. The nail was peripherally locked free-hand with a single screw due to the increased vascularity and intraoperative haemorrhage of the area. The patient was transfused with 7 units of blood intra-operatively and was subsequently transferred to the Intensive Care Unit where 3 more units of blood were transfused. Her post-operative course was uneventful. One year following the operation the fracture had united and the patient remained well.ConclusionThe surgical management of long bone fractures in patients with such pathology is associated with increased intra and post-operative risk, mainly due to vascular complications. It is therefore mandatory that high dependency facilities and sufficient quantities of blood products are available prior to the procedure. A less invasive fixation method should be used when possible.

Internal fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: A prospective study

Background:The indications for surgical management of fractures of the shaft of the humerus are clear, but selecting the right implant for internal fixation of humeral fractures has been a dilemma.Materials and Methods:Thirty-six patients (mean age 40.53 years) with fractures of the shaft of the humerus were followed for 12 to 24 months in a prospective study. Eighteen patients each underwent open reduction and internal fixation with compression plating and ante grade interlock nailing. Clinical and radiographic outcome measures included fracture healing, shoulder and elbow functions, need for additional procedures and any complication such as infection and recovery of radial nerve palsy. The results were analyzed statistically using the SPSS 11.5 software, with parametric and nonparametric tests.Results:Nine of the fractures treated with compression plating and seven of those treated with interlock nailing achieved union within six months. Though there was no significant difference in union time between the treatment groups, patients operated with interlock nailing underwent more number of secondary bone grafting procedures to obtain union (six against two). There were 12 patients (66.6%) with excellent and good results in the plating group compared to four patients (25%) in the nailing group. Interlock nailing was associated with significant reduction in shoulder function (P=0.03) and in overall results (P=0.02).Conclusion:Though there was no significant difference between plating or nailing in terms of time to union, compression plating is the preferred method in the majority of fractures of the shaft of the humerus with better preservation of joint function and lesser need for secondary bone grafting for union.

A study of antimicrobial prophylaxis in surgical management of fracture

A study of antimicrobial prophylaxis in surgical management of fracture

Treatment of thoracolumbar burst fractures with variable screw placement or Isola instrumentation and arthrodesis: case series and literature review.

The controversy of burst fracture surgical management is addressed in this retrospective case study and literature review. The series consisted of 40 consecutive patients, index included, with 41 fractures treated with stiff, limited segment transpedicular bone-anchored instrumentation and arthrodesis from 1987 through 1994. No major acute complications such as death, paralysis, or infection occurred. For the 30 fractures with pre- and postoperative computed tomography studies, spinal canal compromise was 61% and 32%, respectively. Neurologic function improved in 7 of 14 patients (50%) and did not worsen in any. The principal problem encountered was screw breakage, which occurred in 16 of the 41 (39%) instrumented fractures. As we have previously reported, transpedicular anterior bone graft augmentation significantly decreased variable screw placement (VSP) implant breakage. However, it did not prevent Isola implant breakage in two-motion segment constructs. Compared with VSP, Isola provided better sagittal plane realignment and constructs that have been found to be significantly stiffer. Unplanned reoperation was necessary in 9 of the 40 patients (23%). At 1- and 2-year follow-up, 95% and 79% of patients were available for study, and a satisfactory outcome was achieved in 84% and 79%, respectively. These satisfaction and reoperation rates are consistent with the literature of the time. Based on these observations and the loads to which implant constructs are exposed following posterior realignment and stabilization of burst fractures, we recommend that three- or four-motion segment constructs, rather than two motion, be used. To save valuable motion segments, planned construct shortening can be used. An alternative is sequential or staged anterior corpectomy and structural grafting.

Five sides of trauma

The television programmes ER (American) and Casualty (British) have proved so successful that there is now a technical subspecialty devoted to the simulation of the more gruesome side of injury, on which producers tend to dwell. Issues such as accident prevention, the basic science of trauma, and how injury services should be delivered, understandably, get neglected by television. Nor can a five-part Lancet series on trauma be comprehensive-eg, the role of imaging, the surgical management of fractures, and the special features of head injury are underplayed. However, the journal has been very fortunate to have as its series adviser Ronald V Maier, from Seattle, Washington, a state that takes service provision for trauma very seriously indeed. 1 Washington State's Office of Emergency Medical Services and Trauma Prevention. http://www.doh.wa.gov/hsqa/emtp/oemsts.htm Google Scholar Maier wonders if the way trauma is handled could be a model for all medical services. 2 Maier RV Trauma: the paradigm for medical care in the 21st century. J Trauma. 2003; 54: 803-813 Crossref PubMed Scopus (24) Google Scholar The series' focus on injury prevention, the organisation of trauma teams and centres, and on the basic sciences accords with that view. Maier sees problems ahead, notably on funding and recruitment, but is proud of what has been achieved in the USA: “Trauma is not only the first specialty to self-assess how care can best be delivered, but importantly, also self-imposed a tiered triage system and regionalized care.” 2 Maier RV Trauma: the paradigm for medical care in the 21st century. J Trauma. 2003; 54: 803-813 Crossref PubMed Scopus (24) Google Scholar Starting this week and for the next four issues, The Lancet's trauma series will review recent progress and current controversy in: Development of trauma systems and effect on outcomes after injuryThe ideal system for management of trauma remains controversial, especially in respect of prehospital care and regionalisation of trauma-care delivery. To explore these issues, we compare two differing trauma systems—in the USA the focus is on the trauma centre, with a lesser emphasis on prehospital care, whereas in France there is more emphasis on prehospital care coordinated by the Service d'Aide Médicale Urgente. We describe the historical developments, current structure, and major controversies with regard to trauma-care delivery in the two countries. Full-Text PDF

Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology.

The advent of 'biological internal fixation' is an important development in the surgical management of fractures. Locked nailing has demonstrated that flexible fixation without precise reduction results in reliable healing. While external fixators are mainly used today to provide temporary fixation in fractures after severe injury, the internal fixator offers flexible fixation, maintaining the advantages of the external fixator but allowing long-term treatment. The internal fixator resembles a plate but functions differently. It is based on pure splinting rather than compression. The resulting flexible stabilisation induces the formation of callus. With the use of locked threaded bolts, the application of the internal fixator foregoes the need of adaptation of the shape of the splint to that of the bone during surgery. Thus, it is possible to apply the internal fixator as a minimally invasive percutaneous osteosynthesis (MIPO). Minimal surgical trauma and flexible fixation allow prompt healing when the blood supply to bone is maintained or can be restored early. The scientific basis of the fixation and function of these new implants has been reviewed. The biomechanical aspects principally address the degree of instability which may be tolerated by fracture healing under different biological conditions. Fractures may heal spontaneously in spite of gross instability while minimal, even non-visible, instability may be deleterious for rigidly fixed small fracture gaps. The theory of strain offers an explanation for the maximum instability which will be tolerated and the minimal degree required for induction of callus formation. The biological aspects of damage to the blood supply, necrosis and temporary porosity explain the importance of avoiding extensive contact of the implant with bone. The phenomenon of bone loss and stress protection has a biological rather than a mechanical explanation. The same mechanism of necrosis-induced internal remodelling may explain the basic process of direct healing.

Growth factor regulation of fracture repair.

Growth factor regulation of fracture repair.

Transpedicular screw fixation of the lumbar spine: review and technique

Transpedicular fixation of the lumbar spine is an integral element in the surgical management of fractures, spondylolysthesis, neoplasms, scoliosis, and various other spine conditions. Experience over the past 15 years has better defined the indications, limitations, and potential risks of this surgical technique. Although segmental fixation using pedicle screws has many advantages, meticulous attention to detail and advanced training is required to avoid serious complications. This article outlines the pertinent clinical anatomy, preoperative evaluation, and surgical technique for transpedicular fixation of the lumbar spine.

Surgical management of fractures of the acetabulum: the Sheffield experience 1976–1994

Of 56 acetabular fractures treated in Sheffield between 1976 and 1994, 43 fractures in 40 patients underwent open reduction and internal fixation. This paper reviews the surgically managed fractures with emphasis on the quality of operative reduction and outcome, in particular the development of degenerative osteoarthritis leading to total hip replacement. A good clinical result following operative management was seen to correlate closely with a near perfect reduction; in contrast, all cases with a poor reduction underwent joint replacement in the follow-up period. The relatively few cases managed at a major referral centre in this series suggest that either the incidence of acetabular fracture is low in the area or that only a proportion of cases are referred from the surrounding district general hospitals.

Surgical management of intra- and postoperative fractures of the femur about the tip of the stem in total hip arthroplasty

Six techniques for the surgical management of fractures of the femur about the tip of the stem of a total hip arthroplasty were evaluated. Seven embalmed human femurs were prepared to receive the correct-size femoral component of a total hip system. A transverse osteotomy was performed at the level of the tip of the stem. Stability and strength of each reconstruction were tested on each femur under semidynamic loading conditions. This study showed that cementless revision to a long-stem prosthesis does not provide adequate stability. The highest strength and stability were achieved by supplementing the long-stem conversion with allograft struts and cable cerclage. Good results were obtained by lateral compression plating with unicortical screws proximally. Failure was due to pull-out of the proximal screws.

Analysis of failed surgical management of fractures of the base of the fifth metatarsal distal to the tuberosity: the Jones fracture.

Failure of surgical management of fractures of the base of the fifth metatarsal distal to the tuberosity is uncommon. Only one such failure has been reported in the literature to date. The purpose of this article is to present the clinical course of 11 patients with failure of surgically managed jones fractures reviewed by the senior author (J.S.T.). Surgical management was complicated by delayed union in three patients, refracture in seven patients, and nonunion in one patient. The 11 procedures were divided between two established techniques: (1) intramedullary screw fixation (N = 6) and (2) inlaid corticocancellous bone graft (N = 5). In the six intramedullary fixation procedures, using other than a 4.5-mm ASIF malleolar screw for internal fixation correlated with failure. In the five inlaid bone graft procedures, undersized corticocancellous grafts and incomplete reaming of the medullary canal correlated with failure. Also, after both procedures, early return to vigorous physical activity is believed to have played a role in delayed union and refracture.

Reconstructive Procedures for Malunion and Traumatic Arthritis

Despite the fact that surgical management of fractures of the distal radius has become more aggressive, leading to substantial improvement of anatomic results, malunion and post-traumatic arthritis remain the two most common complications following conservative treatment. Techniques, operations, and salvage procedures are discussed in this article.

Surgical management of fractures of the thoraco-lumbar spine by anterior approach. Indications according to a personnal classification

Surgical management of fractures of the thoraco-lumbar spine by anterior approach. Indications according to a personnal classification

Diagnosis and surgical management of fractures of the orbit and optic canal

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The prevalence and significance of missed scapular fractures in blunt chest trauma.

Recent concepts regarding surgical management of fractures of the glenoid and scapular neck provide a new imperative to their early recognition. The initial routine supine chest radiograph obtained in patients with major blunt chest trauma provides the earliest opportunity to identify scapular fractures. A retrospective analysis of 100 patients with major blunt chest trauma who were discharged with the diagnosis of scapular fracture was performed to determine (1) the frequency with which the diagnosis of scapular fracture was made on the initial chest radiograph and (2) the prevalence and type of regional injuries that could serve to identify which of these patients are most likely to have sustained scapular fracture(s). The scapular fracture was diagnosed on the initial chest radiograph in only 57 (57%) of 100 patients and, although present, was not recognized in 43 (43%) of 100. In the group in which the fractures were not recognized, the fracture was visible and frankly overlooked in 31 (72%) of 43. The fracture was not included on the examination in eight (19%) of 43; and it was obscured by superimposed structures or artifacts in four (9%) of 43. Ipsilateral regional injuries were present in 88 (88%) of 100. These included multiple upper rib fractures in 40 (40%), clavicular fractures in 17 (17%), acromioclavicular separation in six (6%), and "other" in 26 (26%). "Other" included subcutaneous emphysema, pneumothorax, pleural effusion, and pulmonary contusion. The presence of ipsilateral regional skeletal injuries and soft-tissue injuries after major blunt chest trauma should prompt a diligent search for concomitant scapular fractures.

Surgical management of fracture of the captulum humeri.

A follow-up study of 20 patients operated upon for fracture of the capitulum humeri is reported. In 8 cases the fracture fragment was removed while in 12 others open reduction was performed. Open reduction gave the best results and is therefore recommended as the treatment of choice.