[Pilon fractures-considerations for treatment strategies and surgical approaches]. / Pilonfrakturen ­ Überlegungen zur Versorgung und Zugänge.

The majority of pilon or tibial plafond fractures are complex articular fractures and the treatment strategy, including the choice of the ideal surgical approach, is essential for a good functional outcome. In this paper, we discuss the considerations for dealing with such fractures as well as the pro and cons of the different approaches. The standard protocol consists of a two-staged procedure following the slogan span-scan-plan. After applying an ankle-spanning external fixator (span), the diagnostic work-up is completed by a CT scan with axial views, two-dimensional and three-dimensional reconstruction (scan) to fully understand the fracture pattern. Using this information, in coordination with the soft tissue situation, the ideal approaches, type and position of implants are planned in detail. This article, supported by clinical cases, describes different surgical approaches and the areas of interest which can be seen through these approaches as well as the implant position.

Radial nerve palsy in humeral shaft fractures with internal fixation: analysis of management and outcome.

INTRODUCTION: The incidence of radial nerve injury after humeral shaft fractures is on average 11.8% (Shao et al., J Bone Jt Surg Br 87(12):1647-1652, 2005) representing the most common peripheral nerve injury associated with long bone fractures (Korompilias et al., Injury, 2013). The purpose of this study was to analyze our current policy and long-term outcome, regarding surgically treated humeral shaft fractures in combination with radial nerve palsy. MATERIALS AND METHODS: We retrospectively analyzed the data of patients with surgically treated humeral shaft fractures from 01/01/2003 to 28/02/2013. The analysis included fracture type, soft tissue injury regarding closed and open fractures, type of fixation, management, and outcome of radial nerve palsy. RESULTS: A total of 151 humeral shaft fractures were fixed in our hospital. In 20 (13%) cases, primary radial palsy was observed. Primary nerve exploration was performed in nine cases. Out of the 13 patients with follow-up, 10 showed a complete, 2 a partial, and 1 a minimal nerve recovery. Two of them underwent a revision procedure. Secondary radial nerve palsy occurred in 9 (6%) patients postoperatively. In five patients, the radial nerve was not exposed during the initial surgery and, therefore, underwent revision with nerve exploration. In all 5, a potential cause for the palsy was found and corrected as far as possible with full recovery in 3 and minimal recovery in one patient. In four patients with exposure of the nerve during the initial surgery, no revision was performed. All of these 4 showed a full recovery. CONCLUSION: Our study showed an overall rate of 19% radial nerve palsy in surgically treated humeral shaft fractures. Most of the primary palsies (13%) recovered spontaneously, and therefore, nerve exploration was only exceptionally needed. The incidence of secondary palsy after surgery (6%) was high and mainly seen after plate fixation. In these cases, we recommend early nerve exploration, to detect and treat potential curable neural lesions.