Comparison of the efficacy of three types of Kirschner wire tension bands for ulnar olecranal fracture / 中国骨伤

OBJECTIVE@#To compare the clinical effect of three types of Kirschner wire tension band for olecranon fracture.@*METHODS@#The clinical data of 64 patients with olecranon fracture treated by Kirschner wire tension band fixation from March 2016 to May 2020 were retrospectively analyzed. Among them, 19 patients were treated with intramedullary K-wires fixation(group A) including 8 males and 11 females with an average of (48.2±18.3) years old, 3 patients were typeⅠ, and 16 patients were typeⅡ according to Mayo classification;20 patients were treated with transcortical K-wires fixation (group B) including 13 males and 7 females with an average of (43.5±20.4) years old, 3 patients were typeⅠand 17 patients were typeⅡ according to Mayo classification;25 patients were treated with perforated Kirschner wire(group C) including 15 males and 10 females with an average of (55.2±17.5) years old, 4 patients were typeⅠand 21 patients were typeⅡ according to Mayo classification. The operative time, intraoperative blood loss, times of Intraoperative fluoroscopy, fracture healing time and complications of 3 groups were compared. At the final follow-up, elbow function was assessed using the Mayo Elbow Function Scale.@*RESULTS@#There were differences in operative time, intraoperative fluoroscopy times, postoperative VAS and soft tissue irritation among the three groups(P<0.05). The operative time, intraoperative fluoroscopy times in group A and C was better than that in group B. The postoperative VAS score, skin irritability in group C was better than that of group B. The difference was statistically significant on Mayo elbow function score at the final follow-up among three groups(P<0.05), the scores of group A and C were higher than that of group B.@*CONCLUSION@#Compared with transcortical K-wires screw fixation, both intramedullary K-wires screw fixation and perforated Kirschner wire fixation, which can significantly reduce the occurrence of soft tissue irritation, reduce surgical complications and shorten the operation time.

Pseudoartrosis diafisaria de cúbito y radio con minifijador externo modelo RALCA® e injerto óseo homólogo / Diaphyseal Pseudoarthrosis of the Ulna and Radius Treated with the RALCA® Model External Minifixator and Homologous Bone Graft

RESUMEN Introducción: Las pseudoartrosis diafisarias de cúbito y radio constituyen un desafío terapéutico para el cirujano ortopédico, a causa de la dificultad para lograr y mantener la reducción de dos huesos paralelos en presencia de músculos pronadores y supinadores que ejercen influencias angulares y rotacionales. Objetivo: Evaluar la eficacia de la aplicación del minifijador externo combinado con el injerto óseo homólogo en esta afección. Métodos: Se realizó un estudio longitudinal, retrospectivo de corte transversal en 74 pacientes operados de pseudoartrosis diafisaria de cúbito y radio desde enero de 2000 hasta diciembre de 2014, en el Complejo Científico Ortopédico Internacional Frank País, en los que se utilizó el modelo de minifijación externa RALCA® e injerto óseo homólogo del Banco de Tejidos ORTOP. Resultados: La pseudoartrosis fue más frecuente en hombres (73 por ciento) y en las edades comprendidas entre 30 y 39 años. La localización más frecuente fue en el cúbito, en su tercio superior (52 por ciento). La mayoría de los pacientes presentaron una pseudoartrosis no viable (56 por ciento). Se consolidó en 66 por ciento de los pacientes antes de las 18 semanas y en solo uno no se obtuvo la consolidación. El hueso que menos tiempo requirió para consolidar fue el radio. En la evaluación de la eficacia de la técnica quirúrgica se obtuvo 62 por ciento de resultados buenos, 33 por ciento regulares y 5 por ciento malos. Conclusiones: La asociación de la minifijación externa modelo RALCA® e injerto óseo homólogo de banco mostró buenos resultados en el tratamiento de la pseudoartrosis de cúbito y radio(AU)

ABSTRACT Introduction: Diaphyseal pseudoarthroses of the ulna and radius constitute a therapeutic challenge for the orthopedic surgeon, due to the difficulty to achieve and maintain the reduction of two parallel bones in the presence of pronator and supinator muscles that exert angular and rotational influences. Objective: To evaluate the effectiveness of using external minifixator combined with homologous bone graft in the treatment of this condition. Method: A longitudinal, retrospective and cross-sectional study was carried out with 74 patients operated on, from January 2000 to December 2014, for diaphyseal pseudoarthrosis of the ulna or radius at Frank País International Orthopedic Scientific Complex, cases in which RALCA® external minifixation and homologous bone graft from the ORTOP Tissue Bank were used. Results: Pseudoarthrosis was more frequent in men (73 percent) and at ages 30-39 years. The most frequent location was the ulna, in its upper third (52 percent). Most of the patients had nonviable pseudoarthrosis (56 percent). The condition was consolidated in 66 percent of the patients within 18 weeks, and only one did not achieve consolidation. The bone that took the least time to heal was the radius. In the evaluation of the effectiveness of the surgical technique, 62% obtained good outcomes; 33 percent fair outcomes; and 5 percent, poor outcomes. Conclusions: The association of the RALCA® model miniexternal fixation and homologous bone graft from the Bank showed good outcomes in the treatment of ulna and radius pseudoarthrosis(AU)

Tratamiento conservador versus tratamiento quirúrgico de fracturas de estiloides cubital en el contexto de fracturas del radio distal / Conservative vs. surgical management of ulnar styloid fractures associated with distal radius fractures

Objetivo: Determinar si los resultados clínicos y radiográficos difieren después del tratamiento conservador y el tratamiento quirúrgico para las fracturas de la estiloides cubital asociadas a fracturas inestables del radio distal tratadas mediante placa volar bloqueada. Materiales y Métodos: Estudio multicéntrico, retrospectivo y descriptivo que incluye pacientes operados en cuatro instituciones, entre 2009 y 2012. Todos tenían fracturas de la estiloides cubital en el contexto de una fractura del radio distal. Las fracturas de la estiloides cubital fueron tratadas de forma conservadora (grupo I) o con cirugía (grupo II). Resultados: El seguimiento promedio fue de 56 meses. Se evaluó a 57 pacientes; grupo I (29 casos) y grupo II (28 casos). Los pacientes del grupo II tuvieron 2,76 veces (IC95% 1,086; 8,80) más posibilidades de lograr una consolidación que aquellos del grupo I. El puntaje DASH y el dolor, tanto en reposo como en actividad, no presentaron diferencias significativas (p = 0,276 y p = 0,877). La desviación cubital y la fuerza obtuvieron mejores resultados en el grupo I (p = 0,0194 y p = 0,024). Conclusiones: Aunque los pacientes con estabilización quirúrgica de la estiloides cubital tuvieron 2,76 más posibilidades de lograr la consolidación que aquellos del grupo I, no hubo diferencias significativas en la evaluación subjetiva (DASH y dolor) entre ambos grupos. Tampoco hubo diferencias significativas cuando se consideró el grado de compromiso de la estiloides cubital, pero la fuerza y la desviación cubital presentaron mejores resultados en el grupo sin fijación de la estiloides cubital. Nivel de Evidencia: III

Objectives: To evaluate potential differences in clinical and radiological outcomes after surgical versus conservative management of ulnar styloid fractures associated with unstable distal radius fractures treated by locked volar plating. Materials and Methods: This was a multicenter, retrospective and descriptive study including surgical patients treated at four different institutions between 2009 and 2012 for ulnar styloid fractures associated with unstable distal radius fractures. Ulnar styloid fractures were treated conservatively in group I and surgically in group II. Results: The average follow-up was 56 months. The study included 57 patients divided into two groups (group I [29 cases] and group II [28 cases]). Patients in group II had 2.76 times (95% CI: 1.086; 8.80) more chances of achieving bone union than those in group I. DASH and pain scores, both at rest and during activity, did not show significant differences between the two groups (p = 0.276 and p = 0.877). Group I presented milder ulnar deviation and better strength (p = 0.0194 and p = 0.024). Conclusions: Although patients who underwent surgery for ulnar styloid fractures had 2.76 more chances of achieving bone union than those who received conservative management, there were no significant differences between both groups in subjective evaluations (DASH and pain scores) or when considering the degree of ulnar styloid involvement. However, the parameters of strength and ulnar deviation were better in the conservative management group. Level of Evidence: III

Fracturas diafisarias radiocubitales en pacientes pediátricos. Revisión de resultados de tratamiento / Forearm diaphyseal fractures in pediatric patients. Review of treatment results

Resumen: Objetivo: Describir los tipos de fracturas más comunes en pacientes menores de 16 años de edad a nivel de antebrazo y evaluar, dependiendo del nivel de la fractura, el tratamiento con mejores resultados. Material y métodos: Realizamos un análisis retrospectivo para determinar frecuencia de las fracturas de antebrazo en menores de 16 años, en el período de Enero 2013-Julio 2017. Se ingresó en sistema los siguientes diagnósticos: fractura de antebrazo, fractura de radio, fractura de cúbito y fractura radiocubital. Resultados: Se incluyeron 573 pacientes: 413 hombres, 160 mujeres; lado afectado derecho: 230, izquierdo 338, bilateral 5; nivel afectado: 438 distales, 102 medias y 33 proximales. La edad pico de presentación fue a los ocho años. El tratamiento inicial fue conservador en 92%, seguido de reducción cerrada y fijación percutánea con 4.71% y se tuvo 2.4% para reducción abierta y fijación interna con placas. Se tuvo un tratamiento inicial fallido en 3.83% al encontrarse una reducción inadecuada. Discusión: Encontramos que el tratamiento de las fracturas en nuestra institución es conservador en 92%, se usa la reducción cerrada y fijación percutánea sólo en 4.71% y sólo se realiza de primera intención la reducción abierta y fijación interna en 2.4% siendo la mayor prevalencia en pacientes mayores de 12 años con fracturas diafisarias medias radiocubitales.

Abstract: Objective: To describe the most common types of fractures in patients under 16 years of age at the forearm level, and to evaluate depending on the level of the fracture, the treatment with better results. Material and methods: We perform a retrospective analysis to determine the frequency of forearm fractures in patients under 16 years, in the period from January 2013-July 2017. The following diagnoses were entered into the system: forearm fracture, radius fracture, ulnar fracture and bilateral fracture. Results: We included 573 patients: 413 male, 160 females; right affected side: 230, left: 338, bilateral 5. Affected level: 438 distal, 102 mid-shaft and 33 proximal. The peak age of presentation was eight years. The initial treatment was conservative in 92%, followed by closed reduction and percutaneous fixation with 4.71 and 2.4% for open reduction and internal fixation with plates. There was a failed initial treatment at 3.83% when an inadequate reduction was found. Discussion: We found that the treatment of this fractures in our institution is conservative in 92%, closed reduction and percutaneous fixation in 4.71% and open reduction and internal fixation in a 2.4% being The highest prevalence in patients older than 12 years with bilateral mid-shaft fractures.

Fragmento dorso-ulnar en fracturas de radio distal: clasificación y manejo / Dorso-ulnar fragment in distal radius fractures: classification and treatment

INTRODUCCIÓN: El fragmento dorso-ulnar (FDU) en la fractura intraarticular de radio distal es de especial importancia puesto que implica una alteración en la articulación radio-carpiana así como también en la articulación radio-ulnar distal (RUD), donde la incongruencia articular permanente puede generar secuelas a largo plazo. OBJETIVO: Proponer una clasificación del FDU, definiendo cuándo realizar el procedimiento quirúrgico con asistencia artroscópica, basado en una serie consecutiva de casos operados de fractura del radio distal estudiados con tomografía computada (TC). MÉTODO: Estudio descriptivo de una serie de casos de pacientes operados por fractura del radio distal entre enero del 2015 y diciembre del 2016. En base a eso, se elabora una clasificación del FDU y se sugiere un esquema de manejo específico. Se describe el FDU como aquel fragmento específico ubicado en la esquina dorso-ulnar de la carilla articular del radio distal, con compromiso de más del 30% de la superficie articular RUD y más de 5mm desde el borde ulnar hacia radial de la cortical dorsal del radio observado en el corte axial de la TC preoperatoria. Se considera un fragmento mayor (FM) cuando el rasgo de fractura compromete hacia radial hasta el tubérculo de Lister y se considera fragmento menor (Fm) cuando el rasgo no alcanza a comprometer el tubérculo de Lister. Nuestra propuesta de clasificación reconoce 4 tipos: tipo I (FM sin desplazamiento, en fracturas tipo C de la AO); tipo II (FM con desplazamiento, en fracturas tipo C de la AO); tipo III (Fm independiente del desplazamiento, en fracturas tipo C de la AO) y tipo IV (FM/Fm con desplazamiento, en fracturas tipo B2 de la AO). Esquema de manejo: Tipo I síntesis con placa bloqueada por abordaje palmar, sin obligación de asistencia artroscópica. Tipo II síntesis con placa bloqueada por abordaje palmar, con asistencia artroscópica requerida. Tipo III síntesis percutánea dorsal contornillo canulado, bajo asistencia artroscópica. Tipo IV síntesis dorsal con placa o tornillo mediante abordaje dorsal bajo visión directa o con asistencia artroscópica, usando portales artroscópicos volares. RESULTADOS: Se operaron 488 fracturas de radio distal durante el período mencionado; 375 fracturas clasificadas como tipo C de la AO. Del total operadas, solo 392 fracturas contaban con TC peroperatoria, que permitía evaluar la presencia del FDU, el cual estuvo presente en 127/392 de los casos (32,4%). Analizados por grupo, 38 casos presentaban fragmentos tipo I, 22 tipo II, 69 tipo III y 7 tipo IV. DISCUSIÓN: El FDU se presentó en un 32,4% de los casos evaluables por TC en nuestra serie. El manejo dirigido de este fragmento con asistencia artroscópica permitió una reducción anatómica con fijación estable específica de éste. CONCLUSIÓN: Proponemos una nueva clasificación del FDU basada en la TC preoperatoria que permite realizar un adecuado plan prequirurgico y abordar este fragmento de manera específica sugiriendo cuando utilizar asistencia artroscópica.

INTRODUCTION: The dorsal-ulnar fragment (DUF) in the distal radius fracture is of special importance since it implies an alteration in the radio-carpal joint as well as in the distal radio-ulnar joint (DRUJ), where permanent joint incongruence can generate long-term sequelae. OBJECTIVE: To propose a classification of the DUF, advising when to perform arthroscopic assistance, based on a consecutive series of operated cases of distal radius fracture studied with computed tomography (CT). METHODS: Descriptive study of a series of cases of patients operated of distal radius fracture between January 2015 and December 2016. We describe a classification of the DUF and suggest a specific treatment scheme. The DUF is described as that specific fragment located in the dorso-ulnar corner of the articular surface of the distal radius, which involves more than 30% of the articular surface of the DRUJ and more than 5mm of the ulnar edge of the dorsal cortex of the radius observed in the axial section of the preoperative CT. It is considered a major fragment (FM) when the fracture compromises the Lister tubercle and is considered a minor fragment (Fm) when it does not. Our classification recognizes 4 types of DUF: type I (FM without displacement, in type C fractures of the AO); Type II (FM with displacement, in type C fractures of the AO); Type III (Fm independent of displacement, in fractures type C of the AO) and type IV (FM/Fm with displacement, in fractures type B2 of the AO). Treatment scheme: Type I: synthesis with a palmar locked plate without arthroscopic assistance required. Type II: synthesis with palmar locked plate with arthroscopic assistance. Type III dorsal percutaneous synthesis with cannulated screw with arthroscopic assistance. Type IV dorsal synthesis with plate or screw by dorsal approach under direct vision or with arthroscopic assistance using volar portals. RESULTS: A total of 488 distal radius fractures were operated during this period. Only 392 fractures had preoperative CT, which allowed to evaluate the presence of the DUF. It was present in 127/392 of the cases (32.4%). Analyzed by group, 38 cases presented fragments type I, 22 cases type II, 69 cases type III and 7 cases type IV. DISCUSSION: The DUF was presented in 32.4% of the cases in our series. The management of this fragment with arthroscopic assistance allowed an anatomical reduction with specific stable fixation of this fragment. CONCLUSION: We propose a novel classification of the DUF based on preoperative CT that allows a specific management of this fragment and suggest when to use arthroscopic assistance.

Injerto óseo vascularizado pediculado del radio distal para tratar la seudoartrosis recalcitrante del cúbito / Vascularized bone graft of the distal radius for recalcitrant ulnar pseudoarthrosis

Introducción: El objetivo de este trabajo es presentar los resultados clínicos y radiológicos de una serie de pacientes tratados con injerto óseo vascularizado pediculado del radio distal para seudoartrosis recalcitrantes de cúbito diafisario o proximal. Materiales y Métodos: Se realizó un estudio retrospectivo que incluyó a pacientes con seudoartrosis del cúbito diafisario o proximal con defectos <6 cm y, al menos, tres cirugías previas y un seguimiento mínimo de dos años tratados con injerto óseo vascularizado pediculado del radio distal. Se registró la cantidad de cirugías previas. Se evaluaron el rango de movilidad del codo y la muñeca, la fuerza de puño comparativa, el dolor mediante la escala analógica visual, el cuestionario QuickDASH y el puntaje de la Clínica Mayo para codo. Resultados: Se incluyó a siete pacientes. La edad media fue de 42 años (rango 26-64). El número promedio de cirugías previas fue 4 (rango 3-7). El seguimiento medio fue de 31 meses (rango 24-43). Todas las seudoartrosis consolidaron. El puntaje de la Clínica Mayo fue bueno en 4 pacientes, excelente en 2 pacientes y moderado en uno. El puntaje QuickDASH posoperatorio promedio fue de 13 (rango 0-29). El arco de flexo-extensión de la muñeca fue del 81% del contralateral. El rango de movilidad del codo fue >100° en 5 pacientes y de 50°-100° en 2 pacientes. Conclusión: El injerto óseo vascularizado pediculado del radio distal es una alternativa eficaz para el tratamiento de la seudoartrosis del cúbito. Nivel de Evidencia: IV

Introduction: The purpose of this study was to analyze the clinical and radiological outcomes of a series of patients treated with pedicled distal radius vascularized bone graft for recalcitrant ulnar nonunions. Methods: A retrospective study was performed. The inclusion criteria were patients with diaphyseal or proximal ulnar nonunions with bone defects <6 cm, at least three previous surgeries and a minimum follow-up of 2 years, treated with pedicled vascularized bone graft of distal radius. The number of previous surgeries was recorded. Elbow and wrist range of motion, comparative grip strength, and pain using the Visual Analogue Scale, QuickDASH questionnaire and Mayo Clinic score for elbow were evaluated. Results: Seven patients were included. The mean age was 42 years (range 26-64). The average number of previous surgeries was 4 (range 3-7). The mean follow-up was 31 months (range 24-43). All pseudoarthrosis consolidated. The Mayo Clinic score was good in 4 patients, excellent in 2 patients and moderate in one patient. The mean postoperative Quick- DASH score was 13 (range 0-29). Flexion-extension arch of the wrist was 81% of the contralateral. The elbow range of motion was >100° in 5 patients and 50°- 100° in 2 patients. Conclusion: The pedicled vascularized bone graft of the distal radius is an effective alternative for the treatment of recalcitrant ulnar nonunions. Level of Evidence: IV

Osteossíntese de rádio e ulna em Gavião Caboclo (Buteogallus meridionalis) / Radius and ulna osteosynthesis in a Savanna Hawk (Buteogallus meridionalis)

Foi atendido um Gavião Caboclo (Buteogallus meridionalis), de vida livre e histórico desconhecido. O paciente apresentava impotência funcional da asa direita e solução de continuidade de aspecto recente envolvendo a região de rádio e ulna direitos caracterizando fratura aberta grau II. Os achados radiológicos foram fratura completa cominutiva de diáfise média de ulna e fratura completa tranversa de diáfise média de rádio. A estabilização da fratura de rádio foi realizada com miniplaca de 1,5mm de 6 orifícios, com 2 parafusos proximais e 2 parafusos distais e, osteossíntese de ulna com placa bloqueada de 2,0mm de 12 orifícios, com 3 parafusos proximais e 2 parafusos distais. Aos 180 dias de pós-operatório, os implantes ortopédicos foram removidos e o paciente recebeu alta. Conclui-se que o emprego de placa bloqueada para tratamento de fraturas abertas em ulna de Gavião Caboclo, pode propiciar adequada consolidação e retorno à função do membro sendo capaz de voar.(AU)

A wild Savanna Hawk (Buteogallus meridionalis) of unknown history, was seen at the veterinary hospital. The patient presented with a dropped right wing and soft tissue damage that appeared to be a recent wound involving the right radius and ulna region, characterizing an open fracture grade II. The radiological findings were a comminuted complete fracture of the ulnar diaphysis and complete transverse fracture of the radial diaphysis. Stabilization of the radius fracture was performed with a 1.5mm miniplate with 6 holes, with 2 proximal screws and 2 distal screws, and ulna osteosynthesis with a 2.0mm locking plate with 12 holes, with 3 proximal screws and 2 distal screws. At 180 postoperative days, the implants were removed and the patient was discharged. The use of locking plate for the treatment of open fractures in ulna of Savanna Hawks may provide adequate healing and return to limb function being able to fly.(AU)

Defectos óseos diafisarios postraumáticos en la extremidad superior de niños / Post-traumatic diaphyseal bone defects in the upper extremity of children

Introducción: El objetivo de este estudio fue evaluar si la combinación de osteosíntesis asociadas a autoinjerto óseo representa un método terapéutico eficaz y confiable en niños con defectos óseos segmentarios diafisarios crónicos en el húmero o los huesos del antebrazo. Materiales y Métodos: Se evaluó retrospectivamente a nueve niños, tratados entre 2005 y 2015, con fracturas en huesos largos de la extremidad superior que se infectaron y resultaron en defectos óseos segmentarios; todas con ≥6 meses de evolución desde el trauma inicial. Se incluyó a 7 niños y 2 niñas, con una edad promedio de 9.9 años. Cuatro defectos óseos se localizaban en el húmero; tres, en el cúbito y dos, en el radio. Todos habían sido sometidos a intervenciones quirúrgicas (promedio 3,7) que originaron defectos óseos de 4,5 cm en promedio. El tiempo entre el trauma inicial y la cirugía definitiva promedió los 21.8 meses. Resultados: El seguimiento promedio fue de 2.2 años. Se obtuvo la consolidación en todos los casos. En un paciente, se utilizó espaciador de cemento y, en otro, injerto libre de peroné. Dos pacientes con lesión en el húmero presentaron un acortamiento significativo. Todos los niños retomaron sus actividades deportivas y recreativas sin limitaciones. Conclusiones: Mediante la combinación de diferentes tipos de autoinjerto óseo, diversas placas colocadas puenteando la lesión y la técnica de la membrana inducida, se logró la consolidación y los nueve niños con defectos óseos diafisarios segmentarios en húmero, cúbito o radio retornaron a sus actividades normales. Nivel de Evidencia: IV

Introduction: The aim of this study was to evaluate the results achieved in children with chronic segmental bone defects at the humerus or forearm. Methods: Nine children, treated between 2005 and 2015, presenting long bone upper extremity fractures that got infected resulting in segmentary bone defects were retrospectively evaluated; all lesions had 6 or more months from trauma. Seven patients were male and two female, with an average age of 9.9 years. Four defects were located at the humerus, three at the ulna, and two at the radius. All patients had had previous surgical interventions (average 3.7), originating bony defects that averaged 4.5 cm. Time from initial trauma to definitive surgery averaged 21.8 months. Results: Follow-up averaged 2.2 years. Union was achieved in all patients. A cement spacer was used in one case, in another case a free fibular bone graft was used. Two patients with humeral defects had significant shortening. All patients returned to their recreational and sports activities without limitations. Conclusions: The combination of different types of bone autograft, various plaques placed bypassing the lesion and the induced membrane technique allowed us to obtain consolidation and return to normal activity in the nine children with segmental bone defects in humerus, ulna or radius. Level of Evidence: IV

Formación de un solo hueso en antebrazo, en pseudoartrosis infectada de cúbito proximal / Formation of a single bone in the forearm in infected pseudoarthrosis of the proximal ulna

Propósito: Presentar el resultado exitoso de la técnica de formación de un solo hueso en antebrazo en un paciente con fractura inicial de cúbito con múltiples osteosíntesis e injertos fallidos. Caso: Paciente masculino dedicado a labores del campo que, a los 39 años de edad, sufre fractura de cúbito izquierdo, después de una evolución de 13 años y 5 intervenciones quirúrgicas con diversos tipos de osteosíntesis e injertos fallidos, que finalizaron en seudoartrosis infectada de cúbito izquierdo, decidiendo efectuarle la formación de un solo hueso en antebrazo evolucionando satisfactoriamente en función. Actualmente: supinación de 20º de antebrazo, flexoextensión de codo y muñeca completas, fuerza muscular adecuada, actualmente integrado en su trabajo de campo sin limitaciones funcionales. Conclusión: La técnica de formación de un solo hueso en antebrazo es, en casos adecuadamente seleccionados, una excelente alternativa de cirugía de reconstrucción o de salvamento en extremidad torácica.

Purpose: To present the successful results of the single-bone reconstruction technique in the forearm in a patient who sustained an ulnar fracture and underwent multiple osteosyntheses and failed grafts. Case: Male patient, agricultural worker, who at age 39 sustained a left ulnar fracture. After 13 years and 5 surgeries involving different types of osteosyntheses and failed grafts, which resulted in infection of the left ulnar pseudoarthrosis, we decided to do a single-bone reconstruction of the forearm. He did well and achieved good function. His current status is: 20º of forearm supination, full elbow and wrist flexion and extension, appropriate muscle strength, and he returned to his job without functional limitations. Conclusion: The single-bone forearm reconstruction technique is, in properly selected cases, an excellent surgical alternative when reconstruction or salvage of the thoracic limb is required.

Fractura múltiple en miembro superior: Caso clínico / Multiple fracture of the upper limb: Case report

Las fracturas multifocales de la extremidad superior son poco frecuentes. Presentamos un caso de fractura de húmero proximal ipsilateral, fracturas de antebrazo proximal y distal y su manejo quirúrgico.

Multifocal fractures of the upper limb are infrequent. We report a case of ipsilateral proximal humerus fracture, proximal and distal forearm fractures, and their surgical management.

Flexor Carpi Radialis Brevis: An Unusual Anomalous Muscle of the Wrist

During imaging studies or surgical procedures, anomalous forearm and wrist muscles are occasionally encountered. Among them, the flexor carpi radialis brevis is very rare. Because the trend is growing toward treating distal radius fractures with volar plating, the flexor carpi radialis brevis is worth knowing. Here, we report two cases with a review of the literature.

Olecranon fracture

The objective of the study is to assess the clinical and radiological outcome after tension band wiring of olecranon fractures. Descriptive study. Department of Orthopedics and Spine Surgery, Hayatabad Medical Complex Peshawar. July 2007 to June 2010. 29 consecutive patients of either sex with age above 20 years, having olecranon fracture. Fracture osteosynthesis was achieved with the insertion of two parallel 1.8 mm Kirschner wires from the tip of the olecranon and an 18 gauge wire in a figure of eight fashion. Then functional outcome is evaluated with Mayo Elbow Performance scores [MEPS] while radiological outcomes is evaluated with standard radiographs. Out of 20 patients, male were 19[65.5%] while female were 10[34.5%]. Minimum age was 20, maximum 80 and average age was 47.5 years. There were 7[24.1%] patients with type A, 6[20.7%] type B, 9[31%] type C, 6[20.7%] type E and 1[3.4%] with Schatzker type F fracture. Mayo Elbow Performance Score was Excellent in 13 [44.8%], Good in 10[34.5%], Fair in 4[13.6%] and Poor in 2[6.9%] patients. There were 10[34.5%] complications including prominent wire in 3[10.3%], osteoarthritis in 1[3.4%], broken skin in 3[10.3%], irritation of skin in 1[3.4%], erythema in 1[3.4%] and serous discharge in 1[3.4%] patient. There was no non union recorded in this study. Olecranon fractures heal well in most instances achieving recovery of normal function in more than 95% of patients. Functional outcome is dependent on fracture severity, length of immobilization, and patient factors

Outcome of intramedullary kirschner wire fixation in children

To know the functional outcome of Intramedullary Kirschner Wire fixation of unstable Radius-Ulna fractures in children. Descriptive study. 27/03/2009 to 26/03/2010. Department of Orthopedic and Trauma, Khyber Teaching Hospital, Peshawar. All patients were admitted from OPD. Children less than 16 years with Unstable Radius-Ulna fractures were included in the study. Patients with open fractures and adults with polytrauma were excluded from the study. Unstable Radius-Ulna fractures were treated by Intramedullary Kirschner Wire fixation under general anesthesia and tourniquet control. Follow up till radiological and clinical union was done. K-wires were removed after healing of fractures. Patients were assessed functionally and radiologically and results were graded according to Price et al Criteria. A total of 64 children with unstable radius and ulna fractures were included in the study. The age range was 6 to 15 years with average age of 10.41 years. 47 were male and 17 were female. The average time of radiological union was 7 weeks and K-wires were removed at 8 weeks time. At final assessment there were 47 Excellent, 10 Good and 7 Fair results. Excellent results can be achieved by Intramedullary K-Wires fixation. In children with unstable Radius-Ulna fractures. It should be the method of choice for treating these fractures

Tratamiento de las lesiones secuelares del extremo distal de la articulacion radiocubital distal / Treatment of sequelae of the distal radioulnar injuries

Introducción: Las fracturas del extremo distal del radio asociadas con lesiones ligamentarias o epifisarias distales del cúbito se presentan de manera poco frecuente en pacientes esqueléticamente inmaduros. La subestimación de los mecanismos lesionales lleva a tratar este tipo de fracturas con tratamientos incruentos, lo que da como resultado reducciones insatisfactorias y pérdidas de la amplitud de movimiento. Materiales y métodos: Se estudiaron 10 casos cuyo tratamiento fue la reconstrucción articular de las fracturas mencionadas entre enero de 2000 y marzo de 2008. Las edades promedio fueron de 11,9 años. Se analizaron tanto los mecanismos fracturarios como la demora de diagnóstico, el tratamiento de reducción definitivo y el número de intervenciones quirúrgicas efectuadas antes. Resultados: El seguimiento promedio hasta la maduración esquelética de los pacientes fue de 3,4 años. El promedio de cirugías antes del tratamiento definitivo fue de 2,1, variando desde intentos de reducciones cerradas bajo anestesia hasta enclavijados percutáneos en la mayoría de los casos. En el 87 por ciento de los pacientes mejoró la amplitud de movimiento luego de la cirugía definitiva en el último control. Conclusiones: El patrón fracturario presentado generalmente es subvalorado a la hora de evaluar el tratamiento para instituir en niños; la reducción en este tipo de lesiones debe ser quirúrgica para lograr una adecuada alineación. Los padres deben estar al tanto de esta modalidad, su evolución y las posibles cirugías posteriores para restablecer los ejes articulares y la longitud adecuada de los huesos de la muñeca.

Anatomic safe zone for proximal ulnar fixation: a cadaver study.

OBJECTIVE: To study the location and characterization of the safe zone with respect to bony landmarks on volar surface of proximal ulna for the protrusion of various ulnar fixations. MATERIAL AND METHOD: The present study was done on 39 upper extremities from 20 embalmed human, adult cadavers. The average ages of the cadavers were 67.28 +/- 10.96 years (range from 40 to 82 years), 10 females, and 29 males. The safe zone dimensions, both in coronal and sagittal planes, were measured. RESULTS: The distance between median nerve and volar surface of proximal ulna in sagittal plane at 2 cm and 4 cm distal to tip of coronoid process were 0.99 +/- 0.15 cm (range from 0.76-1.32 cm) and 0.85 +/- 0.17 cm (range from 0.64-1.75 cm), respectively. The distances between the lateral border of the proximal ulna and medial border of the median nerve in coronal plane at 2 cm and 4 cm distal to the tip of the coronoid process were 0.95 +/- 0.19 cm (range from 0.66-1.36 cm) and 0.82 +/- 0.14 cm (range from 0.52-1.14 cm), respectively. CONCLUSION: Based on the present results, if intra-medullary screws or K-wire fixations were used, it should theoretically be long enough to reach their proximal ulna in order to bite into the cortical bone, but should not be so long as to cut out into its lateral part and, in the sagittal plane, the protrusion should not be longer than 0.92 cm. Orthopedic surgeons must remain vigilant with regard to any types of fixation in the upper extremity because the risk of neurovascular injury is high.

Estudo comparativo entre as osteossínteses com placas e osteossínteses com placas associadas a enxertos de proteína morfogenética óssea (Gen-Tech®) em fraturas distais de rádio-ulna em cães com menos de 6 quilos / A comparative study of osteosynthesis with plates and plates associated with grafts of bone morphogenic proteins (Gen-Tech®) in distal radio-ulna fractures in dogs with less than 6 quilograms

Sabe-se que Bone morphogenic proteins (BMP) são promotores de osteogênese, mas pesquisas ainda estão sendo feitas no intuito de descobrir sua atuação clínica na reparação de fraturas. As dificuldades inerentes da reparação de fraturas de rádio-ulna de cães abaixo de 6 quilos são conhecidas, principalmente, com a ocorrência freqüente de não-união óssea devido a pouca vascularização da porção distal do radio. Tendo em vista esta realidade objetivou-se a comparação da velocidade de formação de calo ósseo entre o tratamento com placas e parafusos e tratamento com placas e parafusos associados a BMP. Foram realizadas 33 osteossinteses de regiões distais de rádio-ulna de cães, sendo 17 animais do grupo controle (tratamento com placas e parafusos) e 16 animais do grupo BMP (tratamento com placas e parafusos com adição de proteína morfogenética óssea BMP). Avaliou-se, comparativa-mente, o tempo de formação de calo ósseo, por exames radiográficos, aos 30, 60, 90,120, 180 e 210 dias de pós-operatório. Foi encontrada a média de tempo de cicatrização de 127,5 +/- 34,15 dias no grupo controle e, no grupo tratado com a proteína morfogenética óssea, a média foi de 32 +/- 15 dias. Com isto pode-se concluir que as fraturas distais de rádio e ulna, em cães menos de 6 kg, tratadas com proteína morfogenética óssea sofreram redução significativa do tempo de formação de calo ósseo.

It is well known that bone morphogenic proteins (BMP) cause osteogenesis, yet clinical research must be performed in order to really show their benefits. Animals weighing less than 6 kg show well known difficulties regarding radius and ulna fracture repair mainly with bone non-union, due to poor vascularization of the distal portion of the radius. Therefore this study aimed to compare the velocity of bone callus formation in the treatment of fracture repair with plates and screws alone or with plates and screws plus BMP. Thirty three dogs with radius and ulna fractures were distributed into two groups, where animals of the control group received the conservative treatment performed with screws and plates alone, whilst the other group received the conservative treatment and BMP. The time of bone callus formation was evaluated comparatively through radiographic exams 30, 60, 90, 120, 180 and 210 days after the surgical procedure. Animals treated with BMP showed a healing time of 32±15 days, which was significantly different (p <0.001) from the control group which required 127±34 days. With the results obtained, it can be concluded that the distal radio-ulna fractures of dogs weighing less than 6 kg suffered a significant reduction of the bone callus formation time, which was around 90 days.

Intramedullary Kirchner wire fixation of unstable radius-ulna fractures in children

To evaluate the results and outcome of paediatric unstable fractures of radius and ulna treated by Kirchner wire fixation. Prospective quasi experimental study from July 2004 to May 2007. Department of Orthopaedics and Trauma, Khyber Teaching Hospital, Peshawar. Children with displaced fractures of both forearm bones, in whom closed manipulation had failed. The children were treated with open reduction and internal fixation of both forearm bones with Kirchner wires [K wires]. Under general anesthesia and tourniquet control the fractures were fixed by retrograde method. Patients were followed every month for clinical and radiological union of fracture and for any complications. The K wires were removed after healing of fractures. The patients were assessed for symptoms such as pain, ability to participate in physical activities or sports, and physical examination was done to see range of motion of wrist, elbow and forearm, Grading of the results was done according to modified Price criteria. The total number of patients was 22. Sixteen were males and six were females. The age range was 6-12 years with an average age of 9.5 years. In most cases the middle third was involved. The average time of surgery was 65 minutes [range 50-95 minutes]. The average time for clinical and radiological union was 9.2 weeks. The mean interval between the initial surgery and removal of the K wires was 3.2 months. At final assessment there were 18 excellent, two good and two fair results. In unstable fractures involving both forearm bones, open reduction and internal fixation [ORIF] with Kirchner wires have excellent results amongst children

Elastic intramedullary titanium rod fixation of paediatric forearm fractures

Fourteen patients with unstable fractures of both bones of the forearm were treated with flexible titanium intramedullary nails during the period from January 2000 through July 2001. The mean age of the studied group was 8.4 years. Ten patients were treated by closed reduction under image intensifier, while four needed open reduction to allow insertion of the nails. Full union was achieved at a mean time of 12.5 weeks ranging from 10 to 16 weeks. There were no recorded cases of re-displacement or nonunion. All cases healed with good alignment less than 5 degrees of angulation. Pull range of motion at wrist, elbow and radioulnar joints were achieved in all patients except one [7.2%] who had ten degrees limitation of supination

Median nerve palsy after operative treatment of olecranon fracture.

Olecranon fracture is not an uncommon fracture in clinical practice. Simple olecranon fracture usually heals quite well without any types of iatrogenic complications. Despite close proximity of the fracture to the nerve, median nerve palsy after operative treatment of olecranon fracture is a rare complication. To the authors' knowledge, this complication has not been previously reported in the Thai or English literature. The authors present a patient who had median nerve palsy after tension-band wiring for olecranon fixation. Intraoperative finding revealed that the median nerve was injured by the tip of K-wire. While this complication is uncommon on a per-person basis, it may results in serious complication, such as nerve palsy or limb ischemia. Orthopedic surgeons must remain vigilant with regard to any type of internal fixation in the upper extremity because the risk of neurovascular injury is high.