Fracturas de húmero distal en pacientes mayores de 65 años: ¿cuál es la mejor opción terapéutica? / Distal humerus fractures in patients over 65 years: what is the best therapeutic option? / Fraturas do úmero distal em pacientes maiores de 65 anos: qual é a melhor opção terapêutica?

Introducción: Las fracturas del húmero distal corresponden al 2% de todas las fracturas. Son los pacientes más añosos, los que presentan mayor desafío terapéutico. Suelen presentarse con huesos osteoporóticos, lo que conlleva a producir fracturas con mayor conminución articular y metafisaria; así como también dificultar una fijación estable y rígida de las mismas, que permita una movilidad precoz. Estas características generan controversia a la hora de elegir el tratamiento adecuado. El objetivo de este estudio es revisar la bibliografía de la última década, acerca de cuál es la mejor opción terapéutica para las fracturas de húmero distal en pacientes añosos. Materiales y métodos: Se realizó una búsqueda sistematizada a través de los buscadores electrónicos PubMed y Timbó en agosto 2019. La búsqueda llego a un total de 475 artículos, de los cuales se seleccionaron 24 según criterios de inclusión y exclusión. Discusión: La mayoría de los estudios analizados son estudios de serie de casos retrospectivos. En los trabajos revisados, existen fracturas tanto extra como intra-articulares. Se analizaron los resultados de los distintos tratamientos realizados según parámetros clínicos, scores funcionales y complicaciones. Conclusiones: El tratamiento conservador es una opción válida para aquellos pacientes en los que el terreno no permita una intervención quirúrgica. Para las fracturas tipo extra-articulares y parcialmente articulares, la reducción abierta y fijación interna es el tratamiento de elección. Para las fracturas articulares completas, no hay diferencias significativas en cuanto a scores utilizados entre la reducción abierta y fijación interna con la artroplastia de codo. Faltan estudios prospectivos que comparen ambos tratamientos.

Introduction: Distal humerus fractures account for 2% of all fractures. It is the elderly patients who present the greatest therapeutic challenge. Osteoporotic bones, more common in this population, lead to the production of fractures with greater joint and metaphyseal comminution. As a result, stable and rigid fixation becomes more difficult, hindering early mobility. These characteristics generate controversy when choosing the appropriate treatment. The aim of this study is to review the literature of the last decade regarding the best therapeutic option for distal humerus fractures in elderly patients. Methods: A systematized search was performed through the electronic search engines PubMed and Timbó in august 2019. The search reached a total of 475 articles, of which 24 were selected according to inclusion and exclusion criteria. Discussion: Most of the studies analyzed are retrospective case series studies. In the articles reviewed, there are both extra and intra-articular fractures. The results of the different treatments performed were analyzed according to clinical parameters, functional scores and complications. Conclusions: Conservative treatment is a valid option for those patients where the terrain does not allow surgical intervention. For extra-articular and partial-articular fractures, open reduction and internal fixation is the treatment of choice. For complete articular fractures, there are no significant differences in scores used between open reduction and internal fixation and elbow replacement. There is a lack of prospective studies comparing both treatments.

Introdução: Fraturas do úmero distal correspondem a 2% de todas as fraturas. São os pacientes mais idosos os que apresentam maior desafio terapêutico. Geralmente apresentam-se com ossos osteoporóticos, o que implica produzir fraturas com maior cominuição articular e metafisária; assim como também dificultar uma fixação estável e rígida das mesmas, que permita uma mobilidade precoce. Estas características geram controvérsia na escolha do tratamento adequado. O objetivo deste estudo é rever a bibliografia da última década, sobre qual é a melhor opção terapêutica para fraturas de úmero distal em pacientes idosos. Materiais e métodos: Foi realizada uma pesquisa sistematizada através dos buscadores eletrônicos Pubmed e Timbó em agosto 2019. A pesquisa chegou a um total de 475 artigos, dos quais 24 foram selecionados segundo critérios de inclusão e exclusão. Discussão: A maioria dos estudos analisados são estudos de série de casos retrospectivos. Nos trabalhos revisados, existem fraturas tanto extra como intra-articulares. Foram analisados os resultados dos diferentes tratamentos realizados segundo parâmetros clínicos, scores funcionais e complicações. Conclusões: O tratamento conservador é uma opção válida para os pacientes em que o terreno não permita uma intervenção cirúrgica. Para fraturas tipo extra-articulares e parcialmente articulares, a redução aberta e fixação interna é o tratamento de escolha. Para fracturas articulares completas, não há diferenças significativas em termos de scores utilizados entre a redução aberta e a fixação interna com artroplastia do cotovelo. Faltam estudos prospectivos que comparem os dois tratamentos.

Complicaciones en fracturas de platillos tibiales de alta energía / Complications in high energy tibial plateau fractures

El enfrentamiento y el manejo de las fracturas de platillos tibiales de alta energía representan un desafío para todo cirujano. El compromiso de partes blandas y la conminución articular secundaria a la energía involucrada determinan una mayor tasa de complicaciones y morbilidad. OBJETIVOS: Evaluar la tasa de complicaciones en fracturas de platillos tibiales de alta energía. MATERIALES Y MÉTODO: Estudio clínico imagenológico retrospectivo de fracturas de platillo tibial Schatzker V y VI con mecanismo de alta energía, tratadas con fijador externo y osteosíntesis diferida, entre 2007-2013. Análisis estadístico usando STATA 12.0. RESULTADOS: Cincuenta y dos fracturas se presentaron durante el periodo de estudio, 39 de ellas fueron seleccionadas considerando los criterios de inclusión. Promedio edad 42,4 años, seguimiento 41,8 meses. Complicaciones: neuropraxia 5%, infección Schatzker V (20%) 16,2%, VI (80%) 12,1% (p=0,759). Sin asociación entre infección y edad (p=0,6056), mecanismo involucrado (p=0,131), tiempo de prefijador externo (p=0,0556), ni tiempo en el uso de fijador externo (p=0,53). DISCUSIÓN: Las fracturas de platillos tibiales secundarias a traumatismos de alta energía se asocian a un importante compromiso de partes blandas. La reducción y osteosíntesis inmediata determina altas tasas de complicaciones; utilizar fijador externo transitorio las disminuiría. El abordaje anterior en línea media ha mostrado elevadas complicaciones, mientras que el uso de doble abordaje regularía esta situación. CONCLUSIÓN: Al afrontar el tratamiento de las fracturas de platillos tibiales de alta energía debemos considerar el uso de fijador externo transitorio para un adecuado control de la fractura y de las partes blandas para la cirugía definitiva.

The approach and management of high energy tibial plateau fractures is a challenge for every surgeon. Soft tissue injuries and joint comminution due to the energy involved are associated with a higher rate of complications and morbidity. OBJECTIVES: To evaluate the rate of complications in high energy tibial plateau fractures. MATERIALS AND METHODS: A retrospective imaging-clinical study of Schatzker type V and IV high-energy tibial plateau fractures, treated with an external fixation and delayed osteosynthesis, was conducted between 2007 and 2013. Statistical analysis was performed using STATA 12.0. RESULTS: A total of 52 fractures were treated during the study period, of which 39 met the criteria for selection. The mean age of the patients was 42.4 years, with a follow-up time of 41.8 months. The complications include, neuropraxia, 5%, Schatzker V infection (20%), 16.2%, and Vl (80%), 12.1% (P=.759). There was no relationship between infection and age (P=.6056), mechanism involved (P=.131), time between accidents and the installation of an external fixator (P=.0556), or the time used for external fixation (P=.53). DISCUSSION: High-energy tibial plateau fractures are associated with significant soft tissue injuries. Immediate reduction and osteosynthesis are determining factors for high rates of complications, while using transient external fixation should decrease them. A midline anterior approach has shown increased complications, while a double approach could improve this situation. CONCLUSION: The approach to high energy tibial plateau fractures must consider the use of a temporary external fixation for an adequate control of the fracture and the soft tissue for a definitive surgical treatment.

Buddy Taping: Is It a Safe Method for Treatment of Finger and Toe Injuries?

BACKGROUND: Buddy taping is a well known and useful method for treating sprains, dislocations, and other injuries of the fingers or toes. However, the authors have often seen complications associated with buddy taping such as necrosis of the skin, infections, loss of fixation, and limited joint motion. To our knowledge, there are no studies regarding the complications of buddy taping. The purpose of this study was to report the current consensus on treating finger and toe injuries and complications of buddy taping by using a specifically designed questionnaire. METHODS: A questionnaire was designed for this study, which was regarding whether the subjects were prescribed buddy taping to treat finger and toe injuries, reasons for not using it, in what step of injury treatment it was use, indications, complications, kinds of tape for fixation, and special methods for preventing skin injury. Fifty-five surgeons agreed to participate in the study and the survey was performed in a direct interview manner at the annual meetings of the Korean Pediatric Orthopedic Association and Korean Society for Surgery of the Hand, in 2012. RESULTS: Forty-eight surgeons (87%) used buddy taping to treat finger and toe injuries, especially proximal interphalangeal (PIP) injuries of the hand, finger fractures, toe fractures, metacarpophalangeal injuries of the hand, and PIP injuries of the foot. Sixty-five percent of the surgeons experienced low compliance. Forty-five percent of the surgeons observed skin injuries on the adhesive area of the tape, and skin injuries between the injured finger and healthy finger were observed by 45% of the surgeons. CONCLUSIONS: This study sheds light on the current consensus and complications of buddy taping among physicians. Low compliance and skin injury should be considered when the clinician treats finger and toe injuries by using buddy taping.

Comparison of Clinical and Physiological Efficacies of Different Intermittent Sequential Pneumatic Compression Devices in Preventing Deep Vein Thrombosis: A Prospective Randomized Study

BACKGROUND: There are few comparative studies about the optimal method of pneumatic compression to prevent deep vein thrombosis (DVT). The aim of this prospective randomized study was to compare venous hemodynamic changes and their clinical influences between two graded sequential compression groups (an alternate sequential compression device [ASCD] vs. a simultaneous sequential compression device [SSCD]). METHODS: In total, 34 patients (68 limbs) undergoing knee and spine operations were prospectively randomized into two device groups (ASCD vs. SSCD groups). Duplex ultrasonography examinations were performed on the 4th and 7th postoperative days for the detection of DVT and the evaluation of venous hemodynamics. Continuous data for the two groups were analyzed using a two-tailed, unpaired t-test. Relative frequencies of unpaired samples were compared using Fisher exact test. Mixed effects models that might be viewed as ANCOVA models were also considered. RESULTS: DVT developed in 7 patients (20.6%), all of whom were asymptomatic for isolated calf DVTs. Two of these patients were from the ASCD group (11.8%) and the other five were from the SSCD group (29.4%), but there was no significant difference (p = 0.331). Baseline peak velocity, mean velocity, peak volume flow, and total volume flow were enhanced significantly in both device groups (p < 0.001). However, the degrees of flow and velocity enhancement did not differ significantly between the groups. The accumulated expelled volumes for an hour were in favor of the ASCD group. CONCLUSIONS: Both graded sequential compression devices showed similar results both in clinical and physiological efficacies. Further studies are required to investigate the optimal intermittent pneumatic compression method for enhanced hemodynamic efficacy and better thromboprophylaxis.

Stability after close reduction and stabilization by two percutanious pinning technique in type-Ill supracondylar fracture of humerus

The objectives of this study were to compare the stability of fixation in Supracondylar fracture humerus in children between two techniques of pin fixation [cross K wires and two parallel wires] at four weeks and to compare Ulnar Nerve injury. Study design was Quasi experimental and done at Orthopaedic Complex, Bahawal Victoria Hospital Bahawalpur. The study period was one and half year. Two groups A and B of thirty patients each formed after convenience non-probability sampling technique. Group A was treated by medial lateral cross K wire fixation after close reduction. Group B was treated by lateral two pins placed parallel to each other. In-group A there was 23 male and 7 female children. In-group B there was 24 male and 6 female children. All treated patients were evaluated clinically on next day for distal neurovascular status especially for ulnar nerve in group A. Reduction checked on plane AP and Lat elbow X-rays. On AP Bauman's angle and on lateral X-ray shaft condyl angle measure and compare with normal side X -rays. After four weeks X-ray again done and compared with the first post-op X-rays. A difference of 5 degree noted as mild stability loss and change of 5-10 degree taken as major stability loss. Three patients treated by lateral k wires and one in patients treated with cross k wires had a mild loss of reduction. No patient in either group had a major loss of reduction. No ulnar nerve injury noted in both groups. Cross k wire fixation method is more stable than lateral paralle wires. Cross K- wire fixation method is also safe with no iatrogenic ulnar ner injury when medial wire pass after lateral wire and extending the elbc beyond the 90 degree with medial incision on epicondyle

TMJ total joint prosthesis for condylar fracture malunion / Prótesis articular total de ATM para malunión de fractura condilar

In the international literatura exist some information related to temporomandibular joint (TMJ) involvement in condylar fracture malunion; the treatment is variated being executed with a bone reconstruction, ramus vertical osteotomy or condilar plate. This case demonstrates that TMJ replacement with prosthetic joint is technically possible and appropriate in the case of malunion of condylar fracture.

La literatura internacional presenta información asociada a la mal unión de fracturas condilares de laarticulación temporo mandibular; el tratamiento es variado siendo ejecutado con reconstrucciones óseas, osteotomía vertical de rama mandibular o instalación de placas con forma condilar. Este caso demuestra que el reemplazo de ATM con prótesis articular es técnicamente posible y apropiado en casos de malunion de fracturas condilares.

Complication Rate and Pitfalls of Temporary Bridging External Fixator in Periarticular Communited Fractures

BACKGROUND: A second staged operation using temporary bridging external fixation (TBEF) has been widely used in patients with periarticular complex fracture, yet few papers have been published on the related complications. The purpose of this study was to report the complication rate and pitfalls directly related to TBEF through a retrospective study and to suggest some solutions. METHODS: Fifty-nine cases that were treated by using TBEF were studied among 195 periarticular complex fractures. We retrospectively collected the clinical and radiological data and then the study data was evaluated for 1) cases with unsatisfactory restoration of length, 2) cases with deep infection caused by half pins invading the zone of definitive fixation, and 3) neurovascular injuries related to half pins. RESULTS: Complications were observed in 7/59 cases (11%). Problems related to the achievement of length were observed in one case of distal tibia fracture and 2 cases of distal femur fracture. Half pin related infection was observed in 2 cases of distal femur fracture. Neurovascular injury (medial calcaneal nerve injury in a distal tibia fracture) was observed in 2 cases. Among 7 complications, four were related to using TBEF in distal femur fracture. This is because the abundant leg muscles have strong deforming force and infection might be increased due to frequent irritation by the half pins. CONCLUSIONS: TBEF is a simple procedure with several advantages. However, complications might be observed if certain principles are not followed. It is thought that many complications due to TBEF can be reduced if the half pins are not inserted in the zone of injury, restoration of length is fully achieved and the neurovascular characteristics are carefully considered. In particular, much more caution is needed in the distal femur, which has abundant muscles surrounding it.

Comparison of shoulder function, radial nerve palsy and infection after nailing versus plating in humeral shaft fractures

To compare shoulder function, radial nerve palsy and infection after interlocking nailing with plating of fractures of shaft of humerus during 30 weeks of follow-up. Experimental study. Orthopaedic Wards of Combined Military Hospital, Rawalpindi, from November 2006 to November 2008. Two groups of 30 patients each were inducted. Group A [n=30] was treated with intramedullary interlocking nailing while Group B [n=30] underwent plating with dynamic compression plate [DCP]. Shoulder function using ASES score, radial nerve palsy and infection were observed for 30 weeks. In group A, 11 patients had severe or moderate shoulder dysfunction [ASES score below 39], out of whom 8 [72%] were above 50 years. This age related disability was significant [p=0.003]. Transient palsy was observed in 3 patients [10%] and mild wound infection in 2 [6%], which was not associated with age or open fracture. In group B, only 1 patient had severe shoulder dysfunction, the difference was statistically significant between the two groups [p=0.001], especially in patients above 50 years of age. There was no statistical difference in infection and palsy rates between the two groups. Although nailing and plating are effective treatments for fractures of shaft of humerus, ante-grade nailing may not be suitable in elderly patients, as it can cause significant shoulder dysfunction

Management of iatrogenic rupture of profunda femoris artery after femoral fracture fixation with stent graft implantation

Vascular injuries with acute or chronic arterial hemorrhage after femoral shaft fractures are a rare but a life -threatening complication. We observed a case of iatrogenic rupture of the profunda femoris artery after the internal fixation of a femoral shaft fracture. The pseudoaneurysm, presenting with painful expansile swelling and hemodynamic instability, together with the rupture was evident on femoral angiography. Endovascular stent graft placement was performed successfully, and there was no sign or symptom at 9 months' follow-up

Avaliação pós-operatória da fixação esquelética externa em 29 cães: estudo retrospectivo / Post surgical evaluation of external skeletal fixation in 29 dogs: a retrospective study

In this retrospective study 29 dogs of both sexes of several breeds, were evaluated. Complications of external skeletal fixation were common. The most frequent post-surgical complications were chronic pin track drainage or pin loosing (11; 37.9 percent), followed by dry crust at the skin-to-pin interface (5; 17.1 percent). In five cases (17.1 percent) occurred the healing of the fracture without complications. In three dogs (10.4 percent) occurred nonunion and it was used another fixation method. It was observed individual cases of poor limb use (3.5 percent) or breakage of the pin (3.5 percent) or of the acrylic column (3.5 percent). Pin track drainage or loosing was related to the owners care. The most did not come back to the hospital as was demanded or did not follow the instructions to inspect the apparatus daily. This behaviour contributed to increase the rate of post-surgical complications. The external fixation has the advantage to be less invasive and can be used to treat closed and open fractures, limb deformities, nonunion and infected fractures.

Anterior cervical plating.

Although anterior cervical instrumentation was initially used in cervical trauma, because of obvious benefits, indications for its use have been expanded over time to degenerative cases as well as tumor and infection of the cervical spine. Along with a threefold increase in incidence of cervical fusion surgery, implant designs have evolved over the last three decades. Observation of graft subsidence and phenomenon of stress shielding led to the development of the new generation dynamic anterior cervical plating systems. Anterior cervical plating does not conclusively improve clinical outcome of the patients, but certainly enhances the efficacy of autograft and allograft fusion and lessens the rate of pseudoarthrosis and kyphosis after multilevel discectomy and fusions. A review of biomechanics, surgical technique, indications, complications and results of various anterior cervical plating systems is presented here to enable clinicians to select the appropriate construct design.

External fixator in the management of trochanteric fractures in high risk geriatric patients--a friend to the elderly.

The best treatment option for trochanteric fracture in a geriatric high risk patient with all associated medical and surgical problems remains debatable. Conservative methods of treatment are associated with dangerous complications of prolonged recumbency while open reduction and internal fixation under anaesthesia significantly increases the mortality and morbidity rates. We treated 110 elderly patients who were unfit or high risk cases for anaesthesia and major surgery for internal fixation due to associated medical and surgical conditions, by external fixation under local anaesthesia. The average age was 65 years and mean follow up was 18 months. 83.3% were ambulatory with support and 97.2% were able to manage activities of daily living at the time of discharge. At 18 months post surgery, 74% were ambulatory with a stick or better. The fracture united in an average of 16.4 weeks. Overall satisfaction rate was 80% at end follow up. The mortality rates were comparable to series of open reduction and internal fixation. Pin tract infection and knee stiffness were the major complications. External fixation done under local anaesthesia offers advantages in the form of a quick, simple relatively inexpensive procedure with negligible blood loss, preserves fracture haematoma, can be easily removed as an out patient procedure, besides it provides earliest possible ambulation and day care to the elderly high risk patient.

Fijación externa ósea: resultados y evaluación crítica de las complicaciones / External bone fixation: results and critical evaluation of complications

Se realiza un estudio retrospectivo de 120 pacientes que sufrieron lesiones óseas, tratados con fijación externa en el Servicio de Ortopedia y Traumatología del Hospital General Docente Comandante Pinares, de San Cristóbal, Pinar del Río. En la casuística se incluyen pacientes con fracturas (abiertas y cerradas), seudoartrosis (sépticas y asépticas) y lesiones articulares. Estos pacientes presentaron lesiones traumáticas o sus complicaciones, en ambos casos con un grado alto de complejidad en general. En muchos de ellos se consiguió resolver lo que por otros medios habría sido difícil o imposible de solucionar. Se destaca la alta frecuencia de los tratamientos de la tibia. Se hace un estudio de las complicaciones aparecidas en la transcurso del tratamiento. La evaluación se realizó de acuerdo con un patrón establecido. Se obtuvo el 65 por ciento de buenos resultados, el 10,8 por ciento de resultados regulares y el 23, 4 por ciento de resultados no favorables. Se analiza críticamente aquellos que no fueron óptimos y se comprobó que estuvieron influidos por múltiples factores que no atentan necesariamente contra el uso del método en sí. Finalmente se recomienda la fijación externa como método ideal de tratamiento en las lesiones del aparato locomotor para las cuales está indicado(AU)

Falha da fixaçäo com placa nas fraturas diafisárias do fêmur: avaliaçäo das causas / Failure of plate fixation in the diaphyseal fractures of the femur. Evaluation of the failure causes

Os autores analisaram, no período de junho de 1984 a junho de 1993, 177 pacientes com fratura diafisária do fêmur, tratados por reduçäo aberta e fixaçäo com placa, conforme os princípios da AO, dos quais 17 (10 por cento) apresentaram fratura do material de síntese ou soltura dos parafusos. Em oito casos (47 por cento), houve falha técnica envolvida, em três casos (17,6 por cento), carga precoce, em três (17,6 por cento), queda acidental, um caso (5,8 por cento) de infecçäo e dois casos (11,7 por cento) foram considerados falha do método. Observou-se ainda que na maioria dos casos a quebra ocorreu entre o 3§ e o 5§ mês. A partir dos dados, salienta-se a importância de uma técnica cirúrgica acurada, orientaçäo pós-operatória rigorosa e maior atençäo durante o 3§ e o 5§ mês, como forma de minorar a incidência desta complicaçäo.

Complicacoes vasculares no metodo de Ilizarov / Vascular complications in the Ilizarov method

Os autores apresentam as observacoes de cinco casos com complicacoes vasculares na evolucao de tratamento ortopedico pelo metodo de Ilizarov (metodo para fixacao externa usado no tratamento de casos dificeis). No periodo de junho de 1987 a maio de 1991, 209 pacientes foram submetidos ao metodo de Ilizarov no Departamento de Ortopedia e Traumatologia do Hospital das Clinicas da F.M.U.S.P para o tratamento de pseudoartroses e fraturas de ossos longos, para alongamento osseo e correcao de deformidades, segundo as diferentes indicacoes do metodo. Complicacoes por lesoes vasculares ocorreram em cinco pacientes. A manifestacao clinica foi a hemorragia no ponto de emergencia cutanea dos fios de transfixacao ossea do fixador externo circular de Ilizarov. A lesao ocorreu na arteria femoral superficial, na arteria poplitea e na arteria tibial posterior, uma em cada paciente. Em dois nao foi possivel determinar o local de origem do sangramento; nesses pacientes foi realizada apenas a retirada do fio por onde corria a hemorragia, com boa evolucao do ponto de vista vascular ou seja, com o desaparecimento do sangramento (um paciente no membro superior, com o fixador externo aplicado no numero e, o outro, no membro inferior, com o fixador do femur).