The Influence of Medial Comminution in the Treatment Choice of Radial Head Fracture

@#Introduction: The aim of our retrospective study was to investigate the role of the medial side involvement in the treatment choice of radial head fractures. Materials and Methods: We searched the databases of our institutions for the surgical procedures diagnosed as "fracture of the radial head" and for the procedures related to "prosthesis of the radial head" and "osteosynthesis of the radial head" in the period from May 2014 to October 2017. The fractures were first classified according to the Mason classification . We then allocated the patients into three study groups according to the site of the fracture, either the medial or lateral side of the radial head : Group A, with an isolated lateral fracture of the radius head; Group B1, with a medial fracture of the radius head with two medial fragments; and Group B2, with a medial fracture of the radius head with multiple medial fragments. We performed a multivariate analysis to identify statistically significant correlation between the pre-operative classifications of Mason and our study, the type of surgical procedure, and the clinical outcome. Results: Mayo Elbow Performance (MEP) scores determined at the final follow-up of the study (mean 16.6 months, range 12-26 months) was excellent in 17 patients (4 in Group A, 6 in Group B1 and 7 in Group B2), and good in 12 patients (3 in Group A, 7 in Group B1, and 2 in Group B2). One patient showed a poor result in MEP score probably because of an infection and implant removal. Conclusion: Regarding medial fractures of the radial head, our study showed satisfactory results with a radial head prosthesis for comminuted or multifragmentary radial head fractures. For surgeons with advanced elbow fracture expertise, osteosynthesis could be attempted in a fracture pattern that involved only two medial fragments.

Management Of Comminuted Tibial Diaphyseal Fractures By Means Of Interlocking Nails

Introduction:This study assesses the outcome of interlocking tibia nail in comminuted fractures of tibial diaphysis. Objectives: To study the functional outcomes of interlocking tibia nail in comminuted tibial diaphyseal fractures, with respect to time to bony union, mobility achieved, complications of the procedure and secondary procedures. Material and Methods: The present prospective study included 25 patients of comminuted fracture shaft of tibia admitted to the Department of Orthopaedics at MMIMSR, Mullana and at Civil Hospital, Rajpura who were managed with interlocking tibia nail. Results:All 25 cases united with interlocking nailing. 1 case needed additional exchange nailing and bone grafting. 3 cases had a malunion but had an acceptable functional outcome. Conclusions: Due to the simple surgical technique, good healing rate and minimum complications, it is recommended that interlocking tibia nail should be used in comminuted fractures of tibial diaphysis

Use of Miniplate for Severe Comminuted Metadiaphyseal Fractures of the Distal Radius

PURPOSE: This study investigated the clinical and radiological outcomes of patients undergoing provisional fixation in conjunction with locking plate fixation. Miniplates were used as the reduction plates for the surgical treatment of severe comminuted metadiaphyseal fractures with an intra-articular fracture of the distal radius. MATERIALS AND METHODS: The radial length, radial inclination, volar tilt, and radial intra-articular step-off were measured preoperatively, postoperatively, and at one year after surgery in 12 patients (eight males, four females, mean age 55.4 years old). The patients underwent volar locking plate fixation with miniplate as a reduction plate for severe comminuted metadiaphyseal fractures with an intra-articular fracture of the distal radius. Clinical evaluations were conducted using the modified Mayo wrist score (MMWS). RESULTS: Bone union was achieved in all cases. The mean MMWS was 81.8 points, including two excellent, three good, and seven fair cases. Radiological improvements were observed in the average radial length (preoperative, 6.4 mm; postoperative, 11.8 mm), average radial inclination (10.2° to 22.4°), average volar tilt (−4.5° to 10.6°), and average radial intra-articular step-off (4.8–0.8 mm) (all, p0.05). CONCLUSION: Miniplate fixation can be an effective treatment option as a reduction plate for the treatment of distal radial fractures, which is challenging to reduce and maintain due to severely comminuted metadiaphysis fractures with the intra-articular fracture.

Comparison of the Treatment Results between Reduction with Percutaneous Wiring and Reduction without Percutaneous Wiring in Reverse Oblique Trochanteric Fractures (AO Classification 31-A3.3)

PURPOSE: The aim of this study was to investigate the utility of percutaneous wiring in the reduction of reverse oblique trochanteric fractures (AO classification 31-A3.3) by analyzing the treatment results with or without the use of percutaneous wiring. MATERIALS AND METHODS: Thirty-five cases from January 2008 to August 2014 that could be followed-up for at least one year were selected among patients with unstable trochanteric fractures who underwent either internal fixation or open reduction. Seventeen patients underwent surgery with percutaneous wire fixation but another 18 patients underwent surgery without it. All patients received a closed reduction and internal fixation with an intramedullary nail. The factors evaluated were as follows: the length of operation, loss of blood, length of in-hospital stay, lower limb function scale, return to preinjury daily life, change in femur neck shaft angle, postoperative gap of the fracture site, time taken for bone attachment, quality of post-operative reduction, and complications. RESULTS: No significant difference in the mean operative time, loss of blood, length of in hospital stay, lower limb function scale, return to pre-injury daily life, change in femur neck shaft angle, postoperative gap of the fracture site, and quality of postoperative reduction was observed between the two groups. A significant difference was noted in the time taken for bone attachment (p=0.032). Bone attachment took 13.3 weeks (9–17 weeks) on average when fixed with percutaneous wiring and no patient was found to have any complications. When treated without percutaneous wiring, however, bone attachment took 17.8 weeks (12.5–28.0 weeks) on average and three cases resulted in delayed union. CONCLUSION: Percutaneous wiring is a recommended treatment option for patients with an unstable trochanteric fracture.

Effect of dynamic articulars panning external fixation combined with finite internal fixation for comminuted fractures of distalradius / 中国基层医药

Objective To observe the effect of dynamic articulars panning external fixation combined with limited internal fixation for distal radius comminuted fracture.Methods 100 comminuted distal radius fractures patients during September 2014 and September 2014 in our hospital were selected and randomly divided into control group and research group,50 cases in each group.Patients of the control group accepted conventional manual reduc-tion combined with plaster external fixation,patients of the research group accepted dynamic articulars panning exter-nal fixation combined with limited internal fixation treatment.Curative effect,the palm inclination angle and feet were compared between the two groups.Results (1)After surgical treatment and rehabilitation therapy,15 patients in the control group achieved optimal degree,28 cases in the research group achieved optimal degree(P =0.086);9 cases in the control group were the poor degree;only 2 patients in the research group were poor degree(P =0.025).Statistical analysis showed that two differences were statistically significant,(P <0.05).(2)After 3 months,the palmar tilt of patients in the control group was (6.5 ±2.2)°,while that of the research group was (8.5 ±2.5)°(t =4.25,P <0.000 1 );The average ulnar deviation of control group was (12.3 ±4.3)°,and that of the research group was (15.6 ±6.6)°(t =2.96,P =0.003 8).In a word,the average palmar tilt and ulnar deviation of the research group were greater than those in the control group,the difference showed statistically significant.6 months later,the average palmar tilt of the control group patients was (6.2 ±2.3)°,that of the research group was (8.8 ±2.5)°(t =5.41, P <0.000 1 );the ulnar deviation of the control group was (12.1 ±4.1 )°,and that of the research group was (16.3 ±4.4)°(t =4.93,P <0.000 1),the difference was statistically significant.Conclusion Dynamic articulars panning external fixation combined with limited internal fixation for the treatment of distal radius comminuted fracture effect is significant,which is worthy of clinical promotion.

Features of Lateral Malleolar Fractures in Elderly Patients and Clinical Outcome of Locking Compression Plate Fixation / 대한정형외과학회잡지

PURPOSE: Several studies have reported on the biomechanical advantages of a locking compression plate (LCP) for treatment of lateral malleolar fracture. However, few studies have reported clinical outcome after treatment of lateral malleolar fracture using a LCP in elderly patients. Thus, this study investigated the trends of lateral malleolar fractures in elderly patients and evaluated the clinical and radiological outcome of treating them using a 'locking compression distal fibula plate'. MATERIALS AND METHODS: Twenty-one patients (male: 3, female: 18) over 65 years old, who were followed-up for at least one year were enrolled in this study. They were treated surgically with open reduction and internal fixation using a LCP for lateral malleolar fracture from 2011 to 2014. Lauge-Hansen and Danis-Weber classification were used for preoperative classification of fractures. Visual analog scale (VAS) pain scores, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores, 4-graded subjective satisfaction and post-operative range of motion were used for the clinical evaluation. Time to bone union, non-union, mal-union, metal failure and implant loosening were assessed for radiographic outcomes. RESULTS: The mean age of patients was 71.2 years old, pain VAS and AOFAS score was 1.6 points and 94.2 points, respectively and 18 cases (85.7%) showed more than satisfaction in subjective satisfaction. Comminuted fracture was observed in 8 cases (38.1%) and lag screw insertion was performed in 7 ankles (33.3%). The mean bony union period was 3.6 months. There were 5 cases of mal-union, no case of non-union and metal failure. CONCLUSION: Satisfaction level of elderly patients with lateral malleolar fracture was significantly associated with only pain at the final follow-up. Fixation with a LCP distal fibula plate can sometimes lead to metal irritation but largely resulted in good clinical outcome without serious complication.

Results of Tension Band Wiring and Additional Circumferential Wiring in Treatment of Comminuted Patella Fracture

PURPOSE: The purpose of this study is to evaluate the results of tension band wiring and additional circumferential wiring in treatment of comminuted patella fractures. MATERIALS AND METHODS: A retrospective study of 67 patients with follow-up period longer than six months who underwent tension band wiring and additional circumferential wiring for comminuted patellar fracture from January 2004 to December 2012 was conducted. Analysis was based on radiological evaluation of bony union and articular surface displacement, and clinically by evaluating the postoperative function of the knee joint using the Levack scoring system. RESULTS: Only one case out of 67 (1.5%) showed nonunion without metal breakage while good bone union was achieved in all other cases. Excluding the nonunion case, range of motion was 90 degrees minimum, 135 maximum, 129 on average. Average displacement was less than 2 mm, and 64 out of 67 cases showed satisfactory outcome with excellent functional score according to the Levack scoring system. CONCLUSION: Tension band wiring and additional circumferential wiring technique for treatment of comminuted patella fractures can be considered as an effective treatment for achievement of good bone union and restoration of normal knee function.

Medial Minimally Invasive Percutaneous Plate Osteosynthesis in Proximal Tibial Comminuted Fractures / 대한정형외과학회잡지

PURPOSE: This goal of this study is to evaluate the clinical and radiological outcomes of proximal tibial comminuted fractures treated with medial minimally invasive percutaneous plate osteosynthesis (MIPPO). MATERIALS AND METHODS: We evaluated 43 patients who underwent medial MIPPO from February 2008 to February 2012 and were followed up for more than one year. According to the AO/OTA classification, there were 30 patients of 41-A3 and 13 patients of 41-C2. Thirty-six patients had closed fractures and seven patients had open fractures. We assessed clinical outcomes, radiologic results and postoperative complications. RESULTS: All fractures were united at an average of 18.3+/-8.1 weeks except three patients with nonunion. According to Schatzker and Lambert assessment, excellent results were achieved for 22 patients and good results were achieved for 21 patients. The average tibial plateau angle was 89.1degrees+/-2.7degrees and the average posterior tibial slope angle was 10.5degrees+/-4.6degrees. In assessment of lower limb alignment, the average femorotibial angle was 175.1degrees+/-2.9degrees and the mean deviation of mechanical axis was 46.5%+/-12.7%. In terms of complications, three patients had nonunion, but complete bony union was achieved by autogenous cancellous bone grafting. Seven patients complained of skin irritation around the plate. However, there was no skin necrosis, infection, or limited range of motion in seven patients with skin irritation. CONCLUSION: Medial MIPPO for proximal tibial comminuted fractures provides favorable clinical outcomes and good radiological alignments.

Modified Tension Band Wiring Combined with Anti-Gliding Loop Augmentation Technique for the Treatment of Comminuted Patellar Fracture: Technical Note and Report of Early Results: Technical Note

In order to investigate the feasibility of a modified tension band combined with anti-gliding loop augmentation technique for the treatment of comminuted patellar fracture, 21 patients with comminuted patellar fracture were enrolled in this study. After the modified tension band wiring of patellar fracture, a cerclage wire was passed around the patella. Anti-gliding loops were made on the bending sites of Kirshner-wires. A knot was tied using both ends of the anti-gliding loops, and the cerclage wire was tightened using proximal knots. Bone union was achieved at 4.5+/-1.5 months postoperatively without nonunion. The Lysholm score was 87.1+/-2.8, and the range of motion of the knee was 2.1degrees+/-3.4degrees to 132.2degrees+/-6.5degrees at the last follow-up. The modified tension band combined with anti-gliding loop augmentation technique might be considered an alternative modification of modified tension band wiring for the treatment of comminuted patellar fracture.

Gunshot injuries in the maxillofacial region: a retrospective analysis and management

Aim: To analyze gunshot wounds to the face, assessing the characteristics, immediate treatment,late treatment, complications and after effects. Methods: A retrospective observational study wascarried out involving 75 cases of victims of gunshot wounds to the face treated at the Oral andMaxillofacial Traumatology Unit of the Dr. Arthur Ribeiro de Saboya Hospital in the city of SãoPaulo (Brazil).Data analysis used the chi-square test with the level of significance set at 5% (p dd0.05). Results: There was a predominance of the 21-to-30-year-old age group (38.7%), malegender (92%) and wounds occurring due to assaults (37.3%). There was a predominance ofentry wounds on the left side of the face (58.5%). The most affected sites were the mandible(50.7%), maxilla (18.3%), zygomatic region (7.0%), eye socket (4.2%) and nose (1.4%).Comminuted fractures (88.2%) and simple fractures (10.3%) were recorded. No fracture occurredin 1.5% of the cases. The predominant treatment was rigid internal fixation (RIF) (57.2%),followed by exploratory surgery (23.2%) and conservative treatment (19.6%). Among thecases in which the RIF system was used, there was predominance in the mandible (64.0%). Thechi-square test revealed a significant correlation between the 2.4-mm RIF system and the mandiblein 48.0 % of cases. Conclusions: In conclusion, gunshot wounds tended to pierce the face,mainly affecting the mandible and caused comminuted fractures treated with rigid internal fixation.Immediate complications occurred in 25% of cases and after effects occurred in 11.7%.

Internal Fixation Using Double Plates for Comminuted Olecranon Fractures in Adults

PURPOSE: To evaluate the clinical usefulness of internal fixation with double plates for comminuted olecranon fractures. MATERIALS AND METHODS: Nine patients with olecranon fractures which are classified into Mayo type IIB (7 cases) and type IIIB (2 cases) underwent internal fixation using double plates from June 2002 to September 2005. They were followed-up for more than 12 months and average period of follow-up was 14 (12~18) months. Six cases were males and three were females. Mean age was 40.7 (21~63) years. We used open reduction and internal fixation using double plates. Clinical assessment index was pain, range of motion (ROM), stability and function of joint at last follow-up. The sum of four indices were compared. Also, we evaluated starting time of full ROM exercise, bony union time and complications. RESULTS: All cases started postoperative ROM within 7 days and clinical results were evaluated using Mayo elbow performance index. 'Excellent', 'good' were 2, 6 cases, respectively and 1 case was 'fair'. Elbow ROM was more than 110o in all cases except one. Mean radiological bony union time was 3.9 (2.5~5) months postoperatively. There were heterotrophic ossifications in 3 cases as complication. CONCLUSION: Internal fixation using double plates for comminuted olecranon fractures in adults can be good treatment option which obtains good clinical results and enables early ROM.

Treatment of comminuted patella fractures with medical titanium cable cerclage / 中国矫形外科杂志

[Objective]To study the effects of titanium cable system used as a treatment alternative for comminuted patella fractures.[Method]Fifty-seven cases of comminuted patella fractures were treated from November 2004 to August 2007.The patients were divided into three groups:the group of titanium cables,AO modified tension band and nickel titanium-patella catcher respectively,according to the choice of internal fixation.The operation time,the amount of blood loss,the first knee exercise time after operation,length of hospitalisation,medical expenses,time off for employees,complication and long-term knee function were studied.All the data were analyzed and compared by statistical ways.[Result]The 57 patients were followed up for 11 to 48months(means,22.4 m).Patients who were fixed with titanium cables could start most early extending and flexing the knee(5.6 d after operation),but most expense in medical usages(9500 RMB).The good or excellence rate was 95.1% in patients treated with titanium cables cerclage,which was better than that of the other two groups.[Conclusion]Titanium cables cerclage can cure comminuted patella fractures.The method had advantage of better long-term curative effect and less complication,and so on.It's worthy to be recommended for the therapy of comminuted patella fracture.

Treatment of intercondylar humeral comminuted fractures / 中国矫形外科杂志

[Objective]To evaluate surgical treatment and curative effect of intercondylar humeral comminuted fractures.[Method]Twenty-one cases of intercondylar humeral comminuted fractures were collected from February 2001 to December 2005. The fractures were classified to 5 cases of C1,9 cases of C2 and 7 cases of C3 according to the AO classification.Seventeen fractures were internal fixed by open-reduction, and 4 fractures were treated by total elbow replacement. After olecranon osteotomy, capitate eminence and trochlea humerus were reducted and fixed with bone screw,while shaft of humerus and the distal end of humerus were fixed with AO double plate or Y-shaped plate in internal fixed group. Early physiotherapy were started as soon as possible. The elbow replacement group were replaced by semi-restriction elbow prosthesis and fixed with cemente following physiotherapy after 4 to 7 days.[Result]forteen of 17 cases were postoperatively followed-up in internal fixed group from 12 to 44 months, and all cases had been visited for 14 to 36 months in elbow replacement group. According to modified Cassebaum scoring system, 71.4% were good in internal fixed group and 100% in elbow replacement group.[Conclusion]It has good curative effect in intercondylar humeral comminuted fractures with olecranon osteotomy, the AO double plate or Y-shaped plate internal fixation and early physiotherapy. With severe injury of the distal end of humerus, obviously osteoporosis and older than 50 years, the total elbow arthroplasty and replacement are preferred.

Primary Subtalar Arthrodesis for the Treatment of Intra-articular Calcaneal Comminuted Fractures

PURPOSE: To evaluate the functional outcomes of the severely comminuted intra-articular calcaneal fractures that were selectively treated with primary subtalar arthrodesis. MATERIALS AND METHODS: This study is based on the 9 patients, 10 feet of intra-articular severely comminuted calcaneal fractures that were treated with open reduction and internal fixation with primary subtalar arthrodesis due to inability to reconstruct the subtalar articular surface with follow-up of more than 1 year. Postoperative clinical evaluation was performed with AOFAS Hindfoot functional scores. The patient satisfaction, returning to previous occupation and complications were also investigated. RESULTS: Follow-up period was average 20.3 months. Overall AOFAS functional score at final follow-up was average 71.8 points and VAS pain score was 3.9. Fifty percent of the patients were satisfied with the surgery and 80% of the patients were able to return to their previous occupations at average 8.4 months after trauma. Post-operative complications were 2 cases of sural nerve injuries and 1 hindfoot valgus malunion. CONCLUSION: We concluded that the primary subtalar arthrodesis is a viable surgical option for severely comminuted calcaneal fractures with favorable functional result and early returning of most patients to their previous occupations.

A case of traumatic eyeball extrusion with complex, comminuted fractures

PURPOSE: Traumatic extrusion of the eyeball is rare. We experienced and successfully reconstructed a case of the eyeball extrusion with complete avulsion of the optic nerve, and complex, comminuted fractures of medial and inferior orbital walls. METHODS: A 27-year-old man presented with the ocular pain and eyeball extrusion of the right eye after the trauma. There were multiple lacerations of the eyelid and the conjunctiva of the right eye, the complete avulsion of the optic nerve and the avulsion of extraocular muscles except the lateral rectus muscle, and the eyeball extrusion of the right eye. We performed the enucleation with Medpor(R) sphere implantation and the reconstruction of the inferior and medial walls with Medpor(R) one channel and sheet implant. RESULTS: At one-year follow-up, there were no implant exposure and infection, and good cosmetic result was seen without enophthalmos. CONCLUSIONS: In a case of eyeball extrusion with complex, comminuted fractures after trauma, we could reconstruct these successfully with enucleation with Medpor(R) sphere implantation, and repair of fractures with Medpor(R) channel and sheet implant.