Outcomes following operative treatment of open fractures of the distal radius: a case control study.

PURPOSE: To report radiographic, clinical, and patient-based functional outcomes following contemporary operative treatment of patients who sustained an open distal radius fracture and compare them to a similar group of patients treated operatively for closed distal radius fractures. METHODS: Over five years, 601 patients with a distal radius fracture presented to our academic medical center, including one Level 1 trauma hospital, and were prospectively enrolled in an upper extremity trauma database. Patients with open distal radius fractures underwent irrigation, debridement, and operative fixation within 24 hours of presentation. Closed distal radius fractures requiring operative fixation were treated electively. Retrospective review of the database identified eighteen open fractures of the distal radius (11 type I, 6 type II, 1 type IIIa). The open fracture patients were individually matched with eighteen closed distal radius fracture patients who underwent surgical fixation based on age, sex, injury to dominant extremity, fracture pattern, and method of fracture fixation. Clinical, radiographic, patient- based functional outcomes, and complications were recorded at routine postoperative intervals. RESULTS: Follow-up was greater than 77% in both groups at all time points. The open and closed groups were similar in regards to age, gender, BMI, race, tobacco use, income, employment status, hand dominance, injury to dominant extremity, mechanism of injury, fracture classification, method of fracture fixation, and presence of concomitant injury. Postoperative complications and reoperation rates were similar between the open and closed groups. Union rates and radiographic alignment one year postoperatively were similar between the open and closed fracture groups. At final follow-up, range of motion parameters, grip strengths, DASH indices, and subjective pain scores were similar between both groups. DISCUSSION: Open distal radius fractures treated with early debridement and fixation achieved similar outcomes to surgically treated closed fractures of the distal radius when followed for a year or more postoperatively.

Outcomes after knee joint extensor mechanism disruptions: is it better to fracture the patella or rupture the tendon?

OBJECTIVES: The purpose of this study was to compare the outcome after the operative treatment of patella fractures (PFs) as compared with those of quadriceps tendon and patella tendon (PT) ruptures. DESIGN: This pertains to a retrospective case control. SETTING: The setting was in academic teaching hospitals. PATIENTS: Ninety-four patients with 99 extensor mechanism disruptions were treated operatively. Of these, 50 (50%) were PFs; 36 (37%) were quadriceps ruptures; and 13 (13%) were PT ruptures. MAIN OUTCOME MEASURES: The patients were evaluated at 6 and 12 months and were tested for range of motion, quadriceps circumference and strength, SF36, Lysholm, and Tegner outcome scores by independent observers. Radiographs of the knee were obtained to assess bony healing, posttraumatic arthritis, and heterotopic ossification. RESULTS: A minimum of 12-month follow-up (range 12-81 months) was available for 76 patients (77%). PFs were seen more commonly in women (P < 0.001) and PT ruptures tended to occur in younger males (P < 0.001), with no difference in the body mass index. Thigh circumference was significantly smaller than normal in PFs at 1 year as compared with tendon injuries. At latest follow-up, there were no significant differences noted with respect to knee range of motion, radiographic arthritis, Tegner, Lysholm, or SF36 scores. CONCLUSIONS: There were no significant differences with regard to outcome in patients sustaining these injuries. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment of lower-extremity long-bone fractures in active, nonambulatory, wheelchair-bound patients.

A retrospective review of surgically treated lower-extremity long-bone fractures in wheelchair-bound patients was conducted. Between October 2000 and July 2009, eleven lower-extremity fractures in 9 wheelchair-bound patients underwent surgical fixation. The Short Musculoskeletal Function Assessment, Short Form, and Spinal Cord Injury Quality of Life questionnaires were used to assess functional outcome. Mechanism of injury for all patients was a low-energy fall that occurred while transferring. Four patients who sustained a distal femur fracture, 1 patient who sustained a distal femur fracture and a subsequent proximal tibia fracture, and 1 patient who sustained a proximal third tibia shaft fracture underwent open reduction and internal fixation with plates and screws. Three patients with 4 midshaft tibia fractures underwent intramedullary nailing. At last follow-up, all 9 patients had returned to their baseline preoperative function. Quality of life was significantly higher (P<.01) than the Spinal Cord Injury Quality of Life questionnaire's reference score. Self-reported visual analog scale pain scores improved significantly from time of fracture to last follow-up (P=.02). All fractures achieved complete union, and no complications were reported. This study's findings demonstrate that operative treatment in active, wheelchair-bound patients can provide an improved quality of life postinjury and a rapid return to activities.

Efficacy of popliteal block in postoperative pain control after ankle fracture fixation: a prospective randomized study.

OBJECTIVES: To compare postoperative pain control in patients treated surgically for ankle fractures who receive popliteal blocks with those who received general anesthesia alone. DESIGN: Institutional Review Board approved prospective randomized study. SETTING: Metropolitan tertiary-care referral center. PATIENTS: All patients being treated with open reduction internal fixation for ankle fractures who met inclusion criteria and consented to participate were enrolled. INTERVENTIONS: Patients were randomized to receive either general anesthesia (GETA) or intravenous sedation and popliteal block. MAIN OUTCOME MEASURES: Patients were assessed for duration of procedure, total time in the operating room, and postoperative pain at 2, 4, 8, 12, 24, and 48 hours after surgery using a visual analog scale. RESULTS: Fifty-one patients agreed to participate in the study. Twenty-five patients received popliteal block, while 26 patients received GETA. There were no anesthesia-related complications. At 2, 4, and 8 hours postoperatively, patients who underwent GETA demonstrated significantly higher pain. At 12 hours, there was no significant difference between the 2 groups with regard to pain control. However, by 24 hours, those who had received popliteal blocks had significantly higher pain with no difference by 48 hours. CONCLUSIONS: Popliteal block provides equivalent postoperative pain control to general anesthesia alone in patients undergoing operative fixation of ankle fractures. However, patients who receive popliteal blocks do experience a significant increase in pain between 12 and 24 hours. Recognition of this "rebound pain" with early narcotic administration may allow patients to have more effective postoperative pain control.

Fracture site augmentation with calcium phosphate cement reduces screw penetration after open reduction-internal fixation of proximal humeral fractures.

BACKGROUND: We sought to examine fracture settling and screw penetration after open reduction-internal fixation of 2-, 3-, and 4-part proximal humeral fractures and determine whether the use of calcium phosphate cement reduced these unwanted complications. METHODS: We performed a retrospective study of prospective data. Inclusion criteria included patient age of 18 years or older and an acute traumatic fracture of the proximal humerus that was treated with open reduction-internal fixation with a locked plate. Metaphyseal defects were treated with 1 of 3 strategies: no augmentation, augmentation with cancellous chips, or augmentation with calcium phosphate cement. Various radiographic measurements were made at each follow-up visit to assess for humeral head settling or collapse. Overall, 92 patients (81%) met the inclusion criteria and form the basis of this study. Augmentation type included 29 patients (32%) with cancellous chips, 27 (29%) with calcium phosphate cement, and 36 (39%) with no augmentation. RESULTS: There were no statistical differences among the groups with respect to patient age, sex, and fracture type. At the 3, 6, and 12-month follow-up visits, there was less humeral head settling with calcium phosphate cement compared with repair with no augmentation or with cancellous chips. Findings of joint penetration were significant among patients treated with plates and screws alone versus those augmented with calcium phosphate (P = .02) and for those augmented with cancellous chips versus those augmented with calcium phosphate (P = .009). CONCLUSION: Augmentation with calcium phosphate cement in the treatment of proximal humeral fractures with locked plates decreased fracture settling and significantly decreased intra-articular screw penetration.

Treatment of two-part proximal humerus fractures: intramedullary nail compared to locked plating.

BACKGROUND: Two-part proximal humerus fractures are common orthopedic injuries for which surgical intervention is often indicated. Choosing a fixation device remains a topic of debate. PURPOSE: The purpose of this study is to compare two methods of fixation for two-part proximal humerus fractures, locking plate (LP) with screws versus intramedullary nailing (IMN), with respect to alignment, healing, patient outcomes, and complications. To our knowledge, a direct comparison of these two devices in treating two-part proximal humerus fractures has never before been studied. We hope that our results will help surgeons assess the utility of LP versus IMN. METHODS: A retrospective chart review was performed on 24 cases of displaced two-part surgical neck fractures of the humerus. Twelve shoulders were treated using IMN fixation and 12 others were fixated with LP. Data collected included sociodemographic, operative details, and postoperative care and function. RESULTS: Radiographic comparison of fixation demonstrated an average neck-shaft angle of 124° and 120° in the IMN group and LP group, respectively. Adjusted postoperative 6-month follow-up range of motion was 134° of forward elevation in the IMN group and 141 in the LP group. The differences in range of motion and in complication rates were not found to be significant. CONCLUSIONS: Our results suggest that either LP fixation or IMN fixation for a two-part proximal humerus fracture provides acceptable fixation and results in a similar range of shoulder motion. Although complication rates were low and insignificant between the two groups, a trend toward increased complications in the IMN group is noted.