Fractura triplanar de tibia distal: Reporte de un caso y revisión de la literatura / Triplanar fracture of proximal tibia: A case report and literature review

Las fracturas triplanares de tibia distal, son fracturas complejas caracterizadas por afectación multiplanar, clasificándose como Salter Harris tipo IV, en el periodo de cierre fisiario. Son poco frecuentes, representando el 5-15% de las fracturas pediátricas. El mecanismo de lesión que ocurre con mayor frecuencia, consiste en supinación y rotación externa. La tomografía computarizada es actualmente el Gold Standard para el diagnóstico de este tipo de fractura, nos permite evaluar todos los planos, siendo la radiografía simple insuficiente para el diagnóstico ya que puede pasar desapercibida. Paciente de 14 años de edad con fractura triplanar en 2 partes de tibia distal, con resolución quirúrgica. Nuestro caso es un ejemplo de una fractura triplanar de tibia distal, la cual es de baja frecuencia, difícil diagnostico e interpretación. Presentamos imágenes preoperatorias, intraoperatorias y postoperatorias del manejo de esta lesión, obteniendo resultados satisfactorios clínicos, funcionales y en estudios de imágenes. Es indispensable lograr una reducción anatómica de la superficie articular para lograr una evolución satisfactoria. Se recomienda una tomografía computarizada para diagnosticar y manejar esta lesión de manera adecuada. El seguimiento postoperatorio es crucial para el manejo de este paciente, ya que se espera una discrepancia en la longitud de las extremidades y/o deformidad(AU)

Triplane fractures of the distal tibia are complex fractures characterized by multiplane effects. They are classified in the Salter-Harris system as type IV in the period of physeal closure. These fractures are rare and represent 5-15% of pediatric fractures. The most common mechanism of injury is supination and external rotation. Computed tomography is currently the Gold Standard for the diagnosis of this type of fracture since it allows us to evaluate all planes, while plain radiography is insufficient because the fracture can go unnoticed. The objective is to report the clinical case of a 14-year-old patient with triplanar fracture in 2 parts of the distal tibia with surgical resolution. This case is an example of a triplanar fracture of the distal tibia, which is of low frequency, and difficult to diagnose and interpret. Preoperative, intraoperative and postoperative images of the management of this lesion are presented, obtaining satisfactory clinical, functional and imaging study results. It is essential to achieve an anatomical reduction of the joint surface to achieve a satisfactory evolution. A CT scan is recommended to properly diagnose and manage this injury. Postoperative follow-up is crucial for the management of this patient, as a limb length discrepancy and/or deformity is expected(AU)

Stabilization of dorsal intra-articular fragment in distal radius fracture after volar locking plate fixation / 中华创伤骨科杂志

Objective:To explore the risk factors that may affect the stabilization of dorsal intra-articular fragment in distal radius fracture after volar internal fixation.Methods:A retrospective analysis was performed of the patients with distal radius fracture who had been treated by volar internal fixation at Department of Traumatic Orthopedics, Tongji Hospital Affiliated to Tongji University from July 2016 to July 2020. After 3D reconstruction of their preoperative CT scans by software Mimics 20.0, 66 patients with a dorsal intra-articular fragment were screened out. They were 31 males and 35 females, aged from 23 to 78 years (average, 53.4 years). By the AO classification, there were 17 case of type C1, 22 cases of type C2, and 27 cases of type C3. The displacement of dorsal intra-articular fragment was judged by X-ray observation on postoperative day 2 and X-ray follow-up at the outpatient department. The 13 patients with displacement of dorsal intra-articular fragment>2 mm were assigned into a displacement group while the other 53 ones into a displacement-free group. The 2 groups were compared in terms of preoperative general data and anatomical data of the dorsal intra-articular fragment (total preoperative displacement, radius-ulnar length, dorsal-volar length, aspect ratio, proximal-distal length and volume) to analyze the correlations between them and displacement.Results:There was no significant difference in preoperative general data (age, gender, affected side, cause of injury or AO classification) between the 2 groups, showing comparability between groups ( P>0.05). All patients were followed up for 6 to 24 months (mean, 14 months) after surgery. There were no postoperative complications like neurovascular lesion or infection. None of the patients in the displacement group underwent revision surgery, and the fractures healed successfully during the postoperative follow-up. The total preoperative displacement in the displacement group was(10.0±1.3) mm, significantly larger than that in the displacement-free group [(7.8±1.5) mm]; the radius-ulnar length in the displacement group was (8.2±1.3) mm, significantly shorter than that in the displacement-free group [(10.8±2.3) mm]; the aspect ratio of the fragment in the displacement group was 1.2±0.2, significantly lower than that in the displacement-free group (1.4±0.2); the fragment volume in the displacement group was (690.5± 201.4) mm 3, significantly smaller than that in the displacement-free group [(995.8±295.0) mm 3]. There were significant differences in the above items between the 2 groups ( P<0.05). Conclusion:The total preoperative displacement, radius-ulnar length, aspect ratio and volume of a dorsal intra-articular fragment are important factors which may affect the displacement of the dorsal fragment after volar internal fixation.

Chronic isolated fracture of a metatarsal head in lesser toes treated with open reduction and internal fixation / 中华创伤骨科杂志

Objective:To report our clinical outcomes of open reduction and internal fixation (ORIF) of chronic isolated fractures of a metatarsal head in the lesser toes.Methods:A retrospective consecutive case-series study was performed in 5 patients with symptomatic chronic isolated shear fracture of a metatarsal head in the lesser toes who had been treated from January 2018 to April 2021 at Department of Foot and Ankle Surgery, Beijing Jishuitan Hospital. There were 4 males and one female, with an average age of 26.2 years (from 19 to 36 years) at the time of injury. The fracture had been missed at the initial diagnosis in 2 of the patients. Their main symptom was limited dorsiflexion of the metatarsophalangeal joint (MTPJ). Preoperative X-rays and CT scans revealed dorsal displacement of the distal fragment without dislocation of the MTPJ. All patients were treated by ORIF. Their American Orthopaedic Foot & Ankle Society-lesser metatarsophalangeal-interphalangeal (AOFAS-LMI) score, visual analog scale (VAS), and range of passive dorsiflexion of the MTPJ were compared between preoperation and the final follow-up. Postoperative complications were also recorded.Results:The 5 patients were followed up for an average of 27.8 months (from 6 to 45 months). All the chronic fractures achieved bony union. At the final follow-up, the average AOFAS-LMI score was 90.6 (from 82 to 100), the average VAS score 0 (from 0 to 2), and the average range of passive dorsiflexion of the MTPJ 40.0° (from 35° to 45°), all improved compared with the preoperative values [70.6 (from 59 to 79), 4 (from 2 to 5) and 10.0° (from 5.0° to 10.0°), respectively]. All the patients recovered their activity levels before injury. Three patients developed arthritis of the MTPJ.Conclusion:ORIF may achieve good short- and mid-term clinical outcomes in patients with chronic isolated shear fracture of a metatarsal head in the lesser toes.

Isolated capitellar fracture fixation with headless screws in different configurations / Fixação de fratura isolada do capítulo do úmero com parafusos sem cabeça em diferentes configurações

ABSTRACT Introduction We evaluated the clinical and radiological outcomes of capitellar fractures treated with modified screw insertion (inserting the first fixation screw anteroposteriorly and the second screw posteroanteriorly), a technique that can be applied with a minimally invasive lateral elbow approach. Materials and Methods Twenty-one isolated capitellum fractures that were surgically treated were included in the study. Fixation was achieved with two headless cannulated compression screws placed in anteroposterior and posteroanterior order using the modified lateral elbow approach. The Broberg-Morrey rating system was used to assess the post-operative functional status of the patients. Results According to the Broberg-Morrey criteria, the mean score was 92.7 (77-100) and 13 cases had excellent, 7 had good, and 1 had fair results. None of the patients developed avascular necrosis or heterotopic ossification. According to the Broberg-Morrey arthrosis score, two cases had Grade 1 and one had Grade 2 arthrosis. One patient had a superficial wound site infection that was treated with antibiotics, and in one case a 60° extension loss was observed in the elbow. Conclusion Treatment of isolated capitellar fractures with 2 headless screws placed anteroposteriorly and posteroanteriorly can provide stable fixation and is less traumatic for the elbow joint. Level of Evidence IV; Therapeutic Studies - Investigating the results of treatment.

RESUMO Introdução Avaliamos os resultados clínicos e radiológicos das fraturas do capítulo do úmero tratadas com a técnica de inserção de parafuso modificada (inserção do primeiro parafuso de fixação anteroposterior e do segundo parafuso posteroanterior), que pode ser aplicada com acesso lateral minimamente invasivo do cotovelo. Material e Método Foram incluídas no estudo 21 fraturas isoladas do capítulo que foram tratadas cirurgicamente. A fixação foi obtida com dois parafusos de compressão canulados sem cabeça colocados em ordem anteroposterior e posteroanterior, usando acesso lateral modificado do cotovelo. O sistema de classificação Broberg-Morrey foi usado para avaliar o estado funcional pós-operatório dos pacientes. Resultados De acordo com os critérios de Broberg-Morrey, o escore médio foi de 92,7 (77-100) e 13 casos foram excelentes, 7 bons e 1 regular. Nenhum paciente desenvolveu necrose avascular ou ossificação heterotópica. De acordo com o escore de artrose de Broberg-Morrey, dois casos tinham Grau 1 e um tinha artrose de Grau 2. Um paciente tinha infecção superficial da ferida, que foi tratada com antibióticos, e em um caso observou-se perda de 60° da extensão do cotovelo. Conclusão O tratamento de fraturas isoladas do capítulo do úmero com 2 parafusos sem cabeça colocados anteroposterior e posteroanteriormente pode proporcionar fixação estável e é menos traumático para a articulação do cotovelo. Nível de evidência IV; Estudos terapêuticos - Investigação dos resultados do tratamento.

Arthroscopy-assisted reduction and internal fixation via traditional anterolateral approach for posterolateral tibial plateau fractures / 中华创伤骨科杂志

Objective:To evaluate the arthroscopy-assisted reduction and internal fixation (ARIF) via the traditional anterolateral approach for the treatment of posterolateral tibial plateau fractures (PTPF).Methods:A retrospective study was conducted of the 79 patients with PTPF who had been treated from March 2014 to February 2020 at Department of Articular Surgery, Linyi Central Hospital. They were 37 males and 42 females, aged from 17 to 71 years (average, 46.0 years). According to treatment methods, they were assigned into an ARIF group (37 cases) and a control group (42 cases). The ARIF group was treated by ARIF via the traditional anterolateral approach and the ARIF varied according to the extents of articular collapse and split and displacement of fracture fragments. The control group was treated by traditional reduction and internal plate fixation of the proximal tibia. The 2 groups were compared in terms of operation time, blood loss, iliac bone grafting, hospitalization time, follow-up time, Hospital for Special Surgery (HSS) score, maximum flexion and extension, fracture healing time, Rassmussen functional and anatomical scores, visual analogue scale (VAS) pain score and complications.Results:There was no statistically significant difference in the general data between the 2 groups, showing comparability ( P>0.05). All patients were followed up for 6 to 18 months (average, 11.4 months). The operation time [(48.9±8.2) min], blood loss [(73.1±20.8) mL], hospitalization time [(9.3±2.5) d], and fracture healing time [(12.5±1.8) weeks] in the ARIF group were all significantly less than those in the control group [(55.2±9.9) min, (100.8±30.3) mL, (11.8±2.8) d and (15.1±2.1) weeks] while the HSS score [(93.5±4.6) points], maximum flexion angle (107.8°±10.4°) and Rassmussen functional score [(27.1±1.8) points] in the ARIF group were significantly higher than those in the control group [(88.4±7.4) points, 100.4°±10.0° and (26.1±2.4) points] (all P<0.05). There was no significant difference between the 2 groups in iliac bone grafting, follow-up time, maximum extension angle, Rassmussen anatomical score, VAS score, or rate of complications (all P>0.05). Conclusions:Compared with traditional surgery, ARIF which varies with the extents of articular collapse and split and displacement of fracture fragments may lead to shorter operation time, reduced surgical trauma and more accurate reduction of the articular surface. Therefore, it can be an additional choice in the treatment of PTPF.

Study the Fixation and Role of Surgical Treatment and Functional Outcome of the Posterior Tibial Condylar Fractures with its Complications

Tibial plateau fractures are intra-articular fractures caused by high-velocity trauma. They are usually associated with neurovascular injury, compartment syndrome, compounding of fractures, and crushing of soft tissues. The aim of our study is to investigate the benefits of using posterior approach and the surgical technique is beneficial for the union of fractures and prevention of postoperative complications in posterior fractures of the tibial plateau. Methods: This is a comparative prospective study on 50 adult patients was carried out in a tertiary level trauma center, after getting ethical committee clearance by the Institutional Review Board. All skeletally mature patients with closed tibial plateau fractures involving the posterior condyles confirmed on CT scan were included in the study. Open fractures, polytrauma, old or maluniting fractures, pathological fractures, and floating knee injuries or those associated with patella fractures were excluded from the study. Preoperative planning consisted of anteroposterior and lateral views in all cases and amount of displacement, depression and angulation were recorded. Computed tomography (CT) scan was kept as an option in cases where fracture pattern or amount of depression was unclear. Results: There were 22 male and 3 female in group A and in group B 21 Male and 4 female patients were mostly affected by traffic accidents. Most common mode of injury was road traffi c accidents; the second most common mode of injury was fall from height. Complications were not found to be significant in between the two groups. Perioperative parameters showed significant differences in both the groups; time for undertaking surgery posttrauma was significantly different. Conclusion: The fixation does not expedite the fracture healing, but rehabilitation and patient‑related scores are significantly better in our study. Surgical treatment with adequate physiotherapy can give good results in tibial plateau fractures.

A Comparative Study between Double Tension Band Wiring and Reconstruction Plate and Screws for the Treatment of Displaced Bicondylar Intra-Articular Fractures of the Distal Humerus

Objective: In this study our main goal is to evaluatetheoutcome of double tension band wiring and reconstructionplate and screws for the treatment of displaced bicondylar intraarticular fractures of the distal humerus.Methodology: This perspective and randomized study wasconducted at the National Institute of Traumatology andOrthopaedic Rehabilitation (NITOR), Dhaka from July 2003 to2005. Where out of 24 patients 12 were selected for operativetreatment by reconstruction plate and screws (Group –I), and12 were selected for operative treatment by double tensionband wiring (Group-II) as on random basis.Results: During the study, in group-1 and group-2 most of thepatients belongs to 18-30 age group., 75% patients’ injury inleft limb whereas, 35% had injury in left limb in group-2.33.33% patients with reconstruction Plate and Screw, hadexcellent recovery after treatment where as 25% had excellentrecovery when they had double Tension Band Wiring.Conclusion: From our study we can conclude that, operativetreatment of displaced bicondylar intra-articular fractures of thedistal humerus by reconstruction plate and screws gives amore rigid fixation with better functional outcome than bydouble tension band wiring.

Böhler's Angle-Comparison Between the pre- and Postoperative in Displaced Intra-Articular Calcaneal Fractures / Ângulo de Böhler-comparação entre o pré e pós-operatório nas fraturas intra-articulares desviadas do calcanhar

Abstract Objective To compare pre- and postoperative variation of radiographicmeasurements of the Böhler angle (BA) in fractures with two types of deviations: severe and moderate. Methods Pre- and postoperative BAs in 31 calcaneal fracture radiographs were retrospectively analyzed. A total of 4 patients were female (6.5%) and 26 were male (83.9%), with age ranging from 23 to 72 years old, and a mean age of 44.5 years old. Results The results show that the postoperative BA was significantly larger than the preoperative BA (p = 0.000). At the intraevaluator and overall assessments, the postoperative BA was, on average, 10.6° higher than the preoperative measure. The postoperative angle was, on average, 108% higher than the preoperative angle. In the global assessment, the agreement between evaluatorswas excellent, bothregarding the estimated point value (0.98) and the intraclass correlation (ICC) confidence interval (CI). Conclusion In the global analysis, the postoperative BAs were, on average, significantly higher than the preoperativemeasurements. The farther from the normal range (20° to 40°) the preoperative angle is, the greater the difference after the surgery. When the preoperative angle was normal, the postoperative angle was, on average, 1.28 times the preoperative measurement. If the preoperative BA was abnormal, the postoperative angle was, on average, 17.3 times the preoperativemeasurement. It was demonstrated that more severe fractures present better anatomic results when compared with moderate fractures. The present study also confirms a good interobserver correlation for the BA.

Resumo Objetivo Comparar a variação dos resultados dasmedidas radiográficas do ângulo de Böhler, no pré e pós-operatório, em fraturas com dois tipos de desvio: graves e moderadas. Métodos: O ângulo de Böhler foi analisado retrospectivamente em 31 radiografias pré e pós-operatórias de fraturas do calcâneo. Quatro pacientes eram do sexo feminino (6,5%) e 26 do masculino (83,9%), entre 23 e 72 anos, média de 44,5. Resultados As medidas pré e pós-operatória demonstraram que o ângulo de Böhler após a cirurgia foi significativamente maior do que o ângulo de Böhler pré-operatório (p-valor = 0,000). Nas análises intraobservador e global, o ângulo de Böhler pósoperatório foi, em média, 10,6 graus maior do que no pré-operatório. O ângulo pósoperatório foi, em média, 108% maior do que o ângulo pré-operatório. No global, a concordância entre os avaliadores é excelente, tanto em relação ao valor pontual estimado (0,98) quanto em relação ao intervalo de confiança do ICC. Conclusão Na análise global, verificou-se que asmedidas do ângulo de Böhler no pósoperatório são, em média, significativamente maiores do que as do ângulo préoperatório. Quanto mais distante da faixa de normalidade (20 a 40 graus) estiver o ângulo pré-operatório, maior a diferença no ângulo após a cirurgia. Quando o ângulo pré-operatório está na faixa de normalidade, o ângulo pós-operatório será, em média, 1,28 vez o ângulo pré-operatório; se o ângulo de Böhler pré-operatório estiver fora da

Irreducible Acute Patellar Dislocation due to a New Anatomical Variant - the Notched Patella / Dislocação patelar aguda irredutível devido a uma nova variante anatômica - a patela entalhada

Abstract Irreducible patella dislocations are rare and are usually associated with complex mechanisms. Theauthors report the clinical case of an irreducible lateral patellardislocationdueto an anatomical variant. The authors assisted a 16-year-old patient who presented with a lateral patella dislocation that was impossible to reduceby closedmanipulation, even under general anesthesia. During the imaging study, the computed tomography (CT) exam showed a notch in the medial facet of the patella, impacted in the lateral condyle, which prevented the reduction. This anatomical variant was later confirmed during surgery. In a bilateral follow-up CT, this variant was also present in the contralateral, normal knee, excluding traumatic reshaping as the reason for this patellar notch. The authors used a medial parapatellar approach for open reduction of the dislocation and to repair themedial retinaculum. According to Wiberg, there are three different patella types. The authors describe a variation of type III patellawith a notch inthemedial border that is not included in the previous classification. They emphasize the importance of a CTstudy in the presence of an irreducible dislocation and the recognition of this anatomical variant of the patella, as further aggressive maneuvers have proven to be unsuccessful. Open reduction appears to be the best option in this scenario.

Resumo As luxações irredutíveis da patela são raras e são geralmente associadas a mecanismos complexos. Os autores relatam o caso clínico de uma luxação patelar lateral irredutível devido a uma variante anatômica. Os autores atenderam um paciente de 16 anos que apresentou uma luxação lateral da patela de redução impossível por manipulação fechada, mesmo sob anestesia geral. Durante o estudo de imagem, a tomografia computadorizada (TC) mostrou um entalhe na faceta medial da patela, impactada no côndilo lateral, o que impediu a redução. Esta variante anatômica foi posteriormente confirmada durante a cirurgia. Em uma TC bilateral de acompanhamento, esta variante anatômica também estava presente no joelho contralateral, normal, excluindo o remodelamento traumático como o motivo deste entalhe patelar. Os autores utilizaramuma abordagem parapatelar medial para a redução aberta do deslocamento e para o reparo do retináculo medial. De acordo comWiberg, existem três tipos diferentes de patela. Os autores descrevem uma variação da patela de tipo III com um entalhe na margem medial que não está incluída na classificação anterior. Ressalta-se a importância de um estudo de TC na presença de luxação irredutível e o reconhecimento desta variante anatômica da patela, já quemanobras agressivas foram testadas sem sucesso. A redução aberta parece ser a melhor opção neste cenário. Abstract Irreducible patella dislocations are rare and are usually associated with complex mechanisms. The authors report the clinical case of an irreducible lateral patellar dislocation due to an anatomical variant. The authors assisted a 16-year-old patient

Surgical Treatment Strategy for Distal Humerus Intra-articular Fractures

Treating distal humerus fractures, especially those involving intra-articular lesions, is complex and often technically demanding. Although there still exist many controversial issues, the goal of treatment is to establish anatomical stable fixation by restoring the two columns and the articular surface. Universally, a posterior midline incision is applied, and the approach varies according to the further management of the triceps or olecranon. Evidence supports dual plate fixation as the optimal fixation method, and debates regarding appropriate plating configuration are still ongoing. As multiple clinical studies comparing results of parallel and perpendicular plate fixation have shown no actual difference, it is important to place the plates according to the fracture configuration.

Reoperation strategy of malunited tibial plateau fracture / 中华骨科杂志

Objective@#To explore the revision strategy of the malunited tibial plateau fracture and to analysis the main points of four common revision operations and the clinical effect.@*Methods@#From January 2012 to December 2016, 18 patients (5 males and 13 females) aged 35-60 years (average 49.7 years) underwent tibial plateau revision surgery in our hospital were collected. The time from the second revision operation to the first operation was 2-24 months (average 10.4 months). Our revision strategies were as follows: Firstly, to determine whether there is an infection or not. If there was infection, we changed the original internal fixation to external fixator to control infection. Secondly, todetermine whether the patient could suffer re-reduction and internal fixation. If the patient was older (>65 years old) or with severe local bone defect, total knee arthroplasty should be performed. Thirdly, patients were divided into four operation modes according to the tibial plateau fracture malunion type: 1. the original fracture line osteotomy; 2. the tibial tubercle + original fracture line osteotomy; 3. tibial metaphyseal window-rod reduction; 4. the osteotomy of fibula head and original fracture line osteotomy.@*Results@#All patients were followed up for 12-30 months (average 16.8 months), and the operation time was 120-300 min (average 185 min). 2 cases were infected before operation and the original internal fixation were removed to instead of external fixator;1 patient underwent total knee arthroplasty; 3 cases were treated with metaphyseal open window-rod reduction and internal fixation; 6 cases were operated with the original fracture line osteotomy and internal fixation; 4 cases were treated with tibial tubercle osteotomy+original fracture line osteotomy and internal fixation; 2 patients underwent fibular head osteotomy+ original fracture line osteotomy and internal fixation. All patients achieved bony union at the last follow-up. The healing time was 3-6 months (mean 3.6 months). The postoperative knee Rasmussen score was 19-29 (average 22.9), compared with average 14.4 points before operation (t=-10.169, P=0.001). The postoperative range of motion of knee joint was 60-110 degrees (mean 94.5 degrees), compared with average 55 degrees before operation (t=-5.773, P=0.001). The post-operative VAS pain score was average 1.1 points, compared with average 4.2 points before operation (t=8.960, P=0.001). Fracture reduction was excellent in 12 cases and good in 5 cases, with the excellent and good rate of 100%. 3 patients still had 2mm collapse on the articular surface, while 3 patients still had mild valgus (less than 5 degrees). There were 2 cases of superficial infection of the wound surface after operation.@*Conclusion@#It was difficult to revise the malunion of tibial plateau fracture and it was necessary to make a detailed operation plan before the operation. Satisfactory clinical effects could be obtained for the patients by correct revision strategy. The key to success was the proper revision strategy which was adopted according to the different characteristics of the tibial plateau fracture malunion of the patients.

Diagnostic value of radiography for intra-articular fracture of distal radius with wrist instability / 中国基层医药

Objective@#To study the clinical value of radiographic diagnosis of intra-articular fractures of distal radius with instability of wrist joint.@*Methods@#From July 2017 to June 2018, 72 patients with intra-articular fracture of distal radius with wrist instability in Yiwu Central Hospital were divided into two groups according to random digital table, with 36 patients in each group.The control group was examined by X-ray.The observation group was diagnosed by X-ray and CT.The results of diagnosis and treatment of intra-articular fracture of distal radius with wrist instability were compared between the two groups.@*Results@#In the observation group, the detection rates of the radius shortened(58.33%), the ulnar angle changed(86.11%), the dorsal articular surface compressed and collapsed(83.33%), the articular surface separated(77.78%), the bone mass of the articular surface more than 3 (63.89%), fracture with ulnar subluxation (69.44%) were higher than those of the control group(33.33%, 58.33%, 61.11%, 52.78%, 41.67%, 44.44%), the differences were statistically significant(χ2=4.532, 6.923, 4.431, 4.963, 4.531, 4.589, all P<0.05). The 1-month recovery rate(88.89%) and 2-month recovery rate(94.44%) in the observation group were higher than those in the control group(69.44%, 77.78%), the differences were statistically significant(χ2 =4.126, 4.181, all P<0.05).@*Conclusion@#The combined use of X-ray and CT in the diagnosis of intraarticular fracture of distal radius with instability of wrist joint has a higher diagnostic accuracy and can provide valuable reference for clinical treatment.

Paratricipital two window approach for complex intraarticular distal humerus fractures: A prospective analysis of 27 patients / 中华创伤杂志(英文版)

Background:@#To investigate the utility and complications of paratricipital 2 window approach for complex intra articular distal humerus fractures (AO/OTA type C).@*Methods:@#Between December 2012 and September 2016, 27 patients (male-14, female-13) having mean age of 39 years (range, 22-62 years) with closed intra articular fracture (AO/OTA 13 type C) were surgically managed using paratricipital 2 window approach. Fractures were fixed as per AO principles. All patients were followed up for 21 months (range, 12-28 months) prospectively. Functional outcome was measured using Mayo Elbow Performance Score (MEPS) and complications were observed. Student ttest, Pearson co-relation coefficient and Kruskal Wallis test used for statistical evaluation.@*Result:@#All cases unite by the end of 3 months. Mean flexion achieved was 120° and extension lag was 10°. Mean arc of motion was 111°. Mean pronation and supination was 70° and 77° respectively. MEPS and motion arc were weak negatively co-related with surgical delay and advancement in age. Postoperative transient ulnar nerve palsy and heterotrophic ossification (HO) was noted in 3.7% cases and infection occurred in 7.4% cases. Hardware prominence noted in 11.1% cases. Mean MEPS was 82. MEPS was excellent in 18.5%, good in 62.9%, fair in 11.1% and poor in 7.4% cases.@*Conclusion:@#Paratricipital 2 window approach for these fractures had good functional outcome with fewer complications. We advocate paratricipital 2 window approach when dealing with these complex fractures particularly, in type C1 and type C2.

A 3D CT-based fracture map study of intra-articular distal radial fractures / 中华骨科杂志

Objective@#To map OTA/AO type B and type C distal radial fractures according to three-dimensional (3D) CT scan data, and to describe the morphological distribution of fracture lines.@*Methods@#A total of 468 cases of distal radius fractures admitted to the Affiliated Hospital of Chengdu University from January 2016 to March 2019 were analyzed and AO classification were performed. AO type B and type C fractures meet the inclusion criteria and then CT data were 3D reconstructed, and morphological description were performed on the fracture lines of each joint surface, including fracture shape angle, fracture area and fracture ratio. At the same time, the articular surface fracture model was superimposed on the standard model, then fracture line and fracture area distribution map were drawn to create the fracture map of intra-articular distal radial fractures.@*Result@#Intra-articular fractures of the distal radius were 209 cases, accounting for 44.7% (209/468) of the distal radius fractures, among which 67 cases of AO type B fracture. In type B fractures, average fracture height were 20.30±11.26 mm, average fracture width were 12.24±6.83 mm, average fracture area were 189.61±101.84 mm2, average angle were 57.23°±14.95°, and average area ratio of fracture (fracture zone area/joint surface area ratio) were 32.42%±10.24%. 142 cases were OA type C fracture, the average fracture height were 24.43±11.37 mm, average fracture width were 20.38±7.59 mm, average fracture area were 425.26±314.31 mm2, average angle were 51.26°±13.17°, and average area ratio of fracture were 73.81%±26.29%. According to fracture map formed by main fracture lines, five different fracture areas were identified: ① 63 cases in central area; ② 25 cases in Lister's nodule area; ③ 59 cases in scaphoid area; ④ 36 cases in lumbar fossa area; ⑤ 26 cases in lower iliac area. Main fracture lines were concentrated in the area on the dorsal side of the central area and the scaphoid area. The fracture lines of type B fracture mainly concentrated in scaphoid region, which accounted for 29.85% (20/67), and dorsal side and central area accounted for 26.87% (18/67). The fracture lines of type C fracture accounted for 27.46% (39/142) in scaphoid area and 31.69% (45/142) in central area. The fracture line of type C fracture increased in the lumbar fossa region (17.61%, 25/142) and the lower ulnar region (12.68%, 18/142) compared with type B fracture (28.69%). Compared with the type B fracture, the overall distribution of the fracture line of the type C fracture is more central.@*Conclusion@#The map of intra-articular fracture of distal radius was drawn and morphological distribution of fracture lines were quantified. Fracture-prone site and shape of fracture line were visually recognized. At the same time, description of articular surface fracture line and fracture area of type B and type C fractures of OA classification were improved, which may help with new classification and diagnosis.

Comparison of the effect of operation and manipulation reduction on ankle fracture / 中国基层医药

Objective@#To compare the clinical effect of operation and manual reduction in the treatment of ankle fracture and provide guidance for clinical practice.@*Methods@#From March 2015 to March 2018, 88 cases of ankle fracture who admitted and treated in the People's Hospital of Xianju County were selected as the observation objects.Forty-eight patients in the operation group were treated with surgery.Forty cases in the manipulation group were treated by manipulation reduction.The two groups were followed up for half a year, and the rate of excellent and good reduction, hospitalization time, hospitalization cost, fracture healing time, excellent and good recovery rate of ankle joint function, ankle joint function score and incidence of complications were compared between the two groups.@*Results@#The positive and negative rate of reduction in the operation group was 93.75%(45/48), which was higher than 75.00%(30/40) in the manipulation group(χ2=6.092, P<0.05). The length and cost of hospitalization in the operation group were (17.56±3.12)d, (14 265.56±1 543.78)CNY, respectively, which in the manipulation group were (6.42±2.25)d, (2 565.56±487.69)CNY, respectively.There were statistically significant differences between the two groups(t=18.856, 46.019, all P<0.05). The healing time of fracture in the operation group was (9.12±1.25)weeks, which was shorter than that in the manipulation group[(11.56±2.36)weeks](t=6.200, P<0.05). There was no statistically significant difference in ankle function score between the two groups(P>0.05). The excellent and good rate of ankle function recovery in the operation group was 95.83%(46/48), which in the manipulation group was 92.50%(37/40), there was no statistically significant difference(P>0.05). The incidence rate of complications in the operation group was 14.58%(7/48), which was higher than that in the manipulation group [2.50%(1/40)](χ2=3.855, P<0.05).@*Conclusion@#The treatment of ankle fracture by operation and manual reduction has good results, both of which have advantages and disadvantages.The treatment cost of manual reduction is less than surgery, and the length of hospitalization is shorter than surgery.However, the fracture healing time is long, and a reasonable treatment plan can be developed in combination with the patients' condition and family economy.

Reoperation strategy of malunited tibial plateau fracture / 中华骨科杂志

Objective To explore the revision strategy of the malunited tibial plateau fracture and to analysis the main points of four common revision operations and the clinical effect. Methods From January 2012 to December 2016, 18 patients (5 males and 13 females) aged 35-60 years (average 49.7 years) underwent tibial plateau revision surgery in our hospital were col?lected. The time from the second revision operation to the first operation was 2-24 months (average 10.4 months). Our revision strategies were as follows: Firstly, to determine whether there is an infection or not. If there was infection, we changed the original internal fixation to external fixator to control infection. Secondly, todetermine whether the patient could suffer re-reduction and in?ternal fixation. If the patient was older (＞65 years old) or with severe local bone defect, total knee arthroplasty should be per?formed. Thirdly, patients were divided into four operation modes according to the tibial plateau fracture malunion type: 1. the origi?nal fracture line osteotomy; 2. the tibial tubercle+original fracture line osteotomy; 3. tibial metaphyseal window-rod reduction; 4. the osteotomy of fibula head and original fracture line osteotomy. Results All patients were followed up for 12-30 months (aver?age 16.8 months), and the operation time was 120-300 min (average 185 min). 2 cases were infected before operation and the origi?nal internal fixation were removed to instead of external fixator;1 patient underwent total knee arthroplasty; 3 cases were treated with metaphyseal open window-rod reduction and internal fixation; 6 cases were operated with the original fracture line osteotomy and internal fixation; 4 cases were treated with tibial tubercle osteotomy+original fracture line osteotomy and internal fixation; 2 pa?tients underwent fibular head osteotomy+original fracture line osteotomy and internal fixation. All patients achieved bony union at the last follow?up. The healing time was 3-6 months (mean 3.6 months). The postoperative knee Rasmussen score was 19-29 (aver?age 22.9), compared with average 14.4 points before operation (t=-10.169, P=0.001). The postoperative range of motion of knee joint was 60-110 degrees (mean 94.5 degrees), compared with average 55 degrees before operation (t=-5.773, P=0.001). The post?operative VAS pain score was average 1.1 points, compared with average 4.2 points before operation (t=8.960, P=0.001). Fracture reduction was excellent in 12 cases and good in 5 cases, with the excellent and good rate of 100%. 3 patients still had 2mm col?lapse on the articular surface, while 3 patients still had mild valgus (less than 5 degrees). There were 2 cases of superficial infec?tion of the wound surface after operation. Conclusion It was difficult to revise the malunion of tibial plateau fracture and it was necessary to make a detailed operation plan before the operation. Satisfactory clinical effects could be obtained for the patients by correct revision strategy. The key to success was the proper revision strategy which was adopted according to the different charac?teristics of the tibial plateau fracture malunion of the patients.

Efficacy comparison between plate fixation with in situ reinforcing ulnar nerve and anterior transposition for humeral intercondylar fracture / 中华创伤杂志

Objective To investigate the clinical efficacy of plate fixation with in situ reinforcing ulnar nerve and anterior transposition by olecranon osteotomy approach in the treatment of type C2 and C3 humeral intercondylar fractures.Methods A retrospective case control study was conducted to analyze the clinical data of 23 patients with humeral intercondylar fractures admitted to the Affiliated Hospital of Hangzhou Normal University from June 2014 to January 2017.There were 17 males and six females,aged 19-56 years,with an average of 41.2 years.According to AO classification,there were 15 patients with type C2 and eight with type C3.All patients were treated with plate internal fixation by olecranon osteotomy approach.The patients were divided into anterior group (11 patients) which was treated with ulnar nerve release anterior transposition and in situ reinforcing group (12 patients) which was treated with ulnar nerve release in situ.The operation time,intraoperative blood loss,fracture healing time,elbow flexion and extension range,elbow joint Mayo score,and excellent and good rate were compared between the two groups.Postoperative complications were recorded.Results All patients were followed up for 15-43 months,with an average of 26.7 months.All patients had no need of blood transfusion.There were no significant differences between anterior group and in situ reinforcing group in operation time [(219.1 15.1) minutes vs.(211.2 ± 17.1) minutes],intraoperative blood loss [(263.6 ± 35.3) ml vs.(237.5 ±25.6)ml] and fracture healing time [(18.2±2.4)weeksvs.(18.9±1.7)weeks] (P＞0.05).Nosignificant differences were found between the two groups in elbow flexion [(120.3 ±7.1) ° vs.(120.3 ±4.1)°],straightness [(3.7±2.7)° vs.(4.1 2.4)°],Mayo score [(89.09 ±9.17)points vs.(86.67 ±10.29)points] and excellent and good rate [91％ (10/12) vs.83％ (10/12)] (P ＞0.05).After operation,no complications such as infection,heterotopic ossification,ulnar neuritis,elbow valgus deformity,or internal fixation failure occurred.Conclusions For humeral intercondylar fracture,the plate fixation with in situ reinforcing ulnar nerve and anterior transposition by olecranon osteotomy approach both have advantages such as small surgical trauma,strong fixation,fewer complications,satisfactory recovery of elbow function.Ulnar nerve anterior transposition or not does not affect the occurrence of ulnar neuritis,and both can obtain satisfactory clinical efficacy.

Comparison of the effect of operation and manipulation reduction on ankle fracture / 中国基层医药

To compare the clinical effect of operation and manual reduction in the treatment of ankle fracture and provide guidance for clinical practice.Methods From March 2015 to March 2018,88 cases of ankle fracture who admitted and treated in the People＇s Hospital of Xianju County were selected as the observation objects.Forty-eight patients in the operation group were treated with surgery.Forty cases in the manipulation group were treated by manipulation reduction.The two groups were followed up for half a year ,and the rate of excellent and good reduction,hospitalization time, hospitalization cost , fracture healing time, excellent and good recovery rate of ankle joint function,ankle joint function score and incidence of complications were compared between the two groups . Results The positive and negative rate of reduction in the operation group was 93.75%(45／48),which was higher than 75.00%(30／40) in the manipulation group(χ2 ＝6.092,P＜0.05).The length and cost of hospitalization in the operation group were (17.56 ±3.12)d,(14 265.56 ±1 543.78)CNY,respectively,which in the manipulation group were (6.42 ±2.25) d, ( 2 565.56 ±487.69) CNY, respectively.There were statistically significant differences between the two groups(t＝18.856,46.019,all P＜0.05).The healing time of fracture in the operation group was (9.12 ±1.25)weeks,which was shorter than that in the manipulation group [(11.56 ±2.36)weeks](t＝6.200,P＜0.05).There was no statistically significant difference in ankle function score between the two groups (P＞0.05).The excellent and good rate of ankle function recovery in the operation group was 95.83%(46／48),which in the manipu-lation group was 92.50%(37／40),there was no statistically significant difference (P＞0.05).The incidence rate of complications in the operation group was 14.58%(7／48), which was higher than that in the manipulation group [2.50%(1／40)] (χ2 ＝3.855,P＜0.05).Conclusion The treatment of ankle fracture by operation and manual reduction has good results,both of which have advantages and disadvantages.The treatment cost of manual reduction is less than surgery,and the length of hospitalization is shorter than surgery.However,the fracture healing time is long, and a reasonable treatment plan can be developed in combination with the patients ＇condition and family economy.

Diagnostic value of radiography for intra-articular fracture of distal radius with wrist instability / 中国基层医药

Objective To study the clinical value of radiographic diagnosis of intra-articular fractures of distal radius with instability of wrist joint.Methods From July 2017 to June 2018,72 patients with intra-articular fracture of distal radius with wrist instability in Yiwu Central Hospital were divided into two groups according to random digital table,with 36 patients in each group.The control group was examined by X-ray.The observation group was diagnosed by X-ray and CT.The results of diagnosis and treatment of intra-articular fracture of distal radius with wrist instability were compared between the two groups.Results In the observation group,the detection rates of the radius shortened (58.33 ％),the ulnar angle changed (86.11％),the dorsal articular surface compressed and collapsed(83.33％),the articular surface separated(77.78％),the bone mass of the articular surface more than 3 (63.89％),fracture with ulnar subluxation (69.44％) were higher than those of the control group (33.33％,58.33％,61.11％,52.78％,41.67％,44.44％),the differences were statistically significant(x2 =4.532,6.923,4.431,4.963,4.531,4.589,all P ＜ 0.05).The 1-month recovery rate (88.89％) and 2-month recovery rate (94.44％) in the observation group were higher than those in the control group(69.44％,77.78％),the differences were statistically significant (x2 =4.126,4.181,all P ＜ 0.05).Conclusion The combined use of X-ray and CT in the diagnosis of intraarticular fracture of distal radius with instability of wrist joint has a higher diagnostic accuracy and can provide valuable reference for clinical treatment.

Juxta-articular Plate Fixation in Distal Radius Intra-articular Fractures with Accompanying Volar Free Fragments beyond the Watershed Line

BACKGROUND: Although distal radius fractures (DRF) are common fractures, intra-articular comminuted DRF with volar free fragments are uncommon. There is considerable difficulty in the fixation of free fragments beyond the watershed line using the existing volar locking plate. We aimed to examine the efficacy and potential complications associated with the use of juxta-articular volar plates in intra-articular DRF accompanied by free fragments beyond the watershed line. METHODS: The patients were enrolled in a consecutive manner between 2007 and 2016. In cases of DRF with free fragments beyond the watershed line, we employed a 2.4-mm small fragment juxta-articular volar locking compression plate using a volar Henry approach. A total of 32 patients were included in this study. There were 15 males and 17 females with a mean age of 52.3 years (range, 33 to 69 years). The mean follow-up period was 14.5 months (range, 10 to 24 months). Preoperative radiographs and three-dimensional computed tomography images were used to analyze fracture patterns and assess the free fragments beyond the watershed line. The mean number of free fracture fragments beyond the watershed line was 2.33. Plain radiographs of immediate postoperative and last follow-up were used to confirm fracture union, incongruence, radial height, volar tilt, radial inclination, and arthritic changes. For functional assessment, we measured grip strength, range of motion (ROM), modified Mayo wrist score (MMWS) and determined Disabilities of Arm, Shoulder and Hand (DASH) scores at the last follow-up. Postoperative complications were monitored during the follow-up period. RESULTS: All patients obtained sound union without significant complications. At the last follow-up, 16 cases presented with an articular step-off of more than 1 mm (mean, 1.10 mm). The mean MMWS was 76.3 (range, 55 to 90), mean DASH score was 15.38 (range, 9 to 22), mean visual analogue scale score for pain was 1.2 and mean grip strength was 75.5% of the opposite side. The mean ROM was 74.3° for volar flexion and 71.5° for dorsiflexion. CONCLUSIONS: In cases of intra-articular DRF with free fragments beyond the watershed line, a volar approach with use of a juxtaarticular plate provided favorable outcomes without significant complications.