Functional bracing for the treatment of fractures of the humeral diaphysis.

BACKGROUND: Nonoperatively treated fractures of the humeral diaphysis have a high rate of union with good functional results. However, there are clinical situations in which operative treatment is more appropriate, and, though interest in plate osteosynthesis has decreased, intramedullary nailing has gained popularity in recent years. We report the results of treating fractures of the humeral diaphysis with a prefabricated brace that permits full motion of all joints and progressive use of the injured extremity. METHODS: Between 1978 and 1990, 922 patients who had a fracture of the humeral diaphysis were treated with a prefabricated brace that permitted motion of adjacent joints. The injured extremities were initially stabilized in an above-the-elbow cast or a coaptation splint for an average of nine days (range, zero to thirty-five days) prior to the application of the prefabricated brace. Orthopaedic residents, supervised by teaching staff, provided follow-up care in a special outpatient clinic. Radiographs were made at each follow-up visit until the fracture healed. RESULTS: We were able to follow 620 (67 percent) of the 922 patients. Four hundred and sixty-five (75 percent) of the fractures were closed, and 155 (25 percent) were open. Nine patients (6 percent) who had an open fracture and seven (less than 2 percent) who had a closed fracture had a nonunion after bracing. In 87 percent of the 565 patients for whom anteroposterior radiographs were available, the fracture healed in less than 16 degrees of varus angulation, and in 81 percent of the 546 for whom lateral radiographs were available, it healed in less than 16 degrees of anterior angulation. At the time of brace removal, 98 percent of the patients had limitation of shoulder motion of 25 degrees or less. We were unable to follow most of the patients long-term, as they did not return to the clinic once the fracture had united and use of the brace had been discontinued. CONCLUSIONS: Functional bracing for the treatment of fractures of the humeral diaphysis is associated with a high rate of union, particularly when used for closed fractures. The residual angular deformities are usually functionally and aesthetically acceptable. The present study illustrates the difficulties encountered in carrying out long-term follow-up of indigent patients treated in charity hospitals that are affiliated with teaching institutions. These difficulties are also becoming common with patients insured under managed-care organizations and are frequent in our peripatetic population.

Tibial fracture stability. Analysis of external fracture immobilization in anatomic specimens in casts and braces.

Plaster casts, custom-fabricated fracture braces, and prefabricated fracture braces were compared in the laboratory for the stability they provided to closed, experimental, diaphyseal fractures of the tibia and fibula on anatomic specimens. The stability was comparable for each type of device tested for the loading conditions of isolated compression, bending, and torsion. Length stability (overriding at the fracture site) was poor, rotation was marginal (by clinical standards), and angulation was very good. Selective removal of portions of each cast and brace demonstrated that the classic patellar-tendon-bearing (PTB) extension proximally and below ankle extensions distally had insignificant effects on stability of these middle-third diaphyseal fractures for the conditions tested. The soft-tissue compression provided by a snug, tapered "cylindrical" sleeve, which encompassed the soft tissues from the tibial tubercle to the flare of the distal tibia and fibula, provided the stabilizing effect for all of the devices tested.

Diaphyseal fractures of the humerus. Treatment with prefabricated braces.

Using a prefabricated brace, we treated 233 patients who had a fracture of the humeral shaft. One hundred and seventy patients were available for follow-up, which ranged from five weeks to forty-eight months. In these patients (forty-three open and 127 closed fractures), the average time to union was 10.6 weeks; the average varus-valgus angulation, 5 degrees; the average anterior-posterior angulation, 3 degrees; and the average shortening, as measured radiographically, four millimeters. All but three of the patients had an excellent or a good functional result with a nearly full range of motion of the extremity. There were a minimum of complications, including three non-unions. Because of the low morbidity and high rate of success, we concluded that the treatment of choice for diaphyseal fractures of the humerus is the prefabricated brace.

Treatment of isolated ulnar shaft fractures with prefabricated functional fracture braces.

In a prospective study, from September 1980 to December 1984, 146 isolated ulnar shaft fractures were treated with prefabricated fracture braces. Clinical and roentgenographic follow-up data were available for 73 fractures. Functional results were rated excellent in 64 fractures (88%), good in seven (9%), and poor in two (3%). All fractures healed in an average time of 57 days. The mean angulation measured 6 degrees in the mediolateral plane and 4 degrees in the anteroposterior plane. The complication rate was 18%, relating mostly to residual angulation. Most isolated fractures of the distal one-half of the ulnar shaft can be treated successfully with prefabricated fracture braces.

Comminuted intraarticular fractures of the distal humeral condyles. Surgical vs. nonsurgical treatment.

Forty-two comminuted intraarticular fractures of the humeral condyles treated between 1975 and 1981 were analyzed in order to compare the results of operative versus nonoperative management. Twenty-nine patients were treated by open reduction and internal fixation; the remainder were treated by nonoperative techniques. Functional results were evaluated by the method of Bickel and Perry. Of the patients treated by open reduction and internal fixation, 76% had an excellent or good result. Of the nonsurgically-treated patients, only eight percent had a satisfactory result. Anatomic restoration by open reduction and rigid internal fixation in conjunction with early motion was associated with satisfactory results. The preferred surgical exposure was a posterior "U" incision with extraarticular olecranon osteotomy. This provided good visualization and facilitated anatomic restoration in these complex fractures.

Functional bracing of Colles' fractures: a prospective study of immobilization in supination vs. pronation.

In a prospective study, 156 Colles' fractures were treated with a functional Orthoplast brace. Approximately one-half were braced in pronation and one-half in supination. One hundred and four were available for follow-up. Results were analyzed by type of fracture and position of immobilization (pronation versus supination). In evaluating the results, we found that: (1) displaced Colles' fractures without articular involvement (Type II) braced in supination yielded superior anatomic results when compared with those treated in pronation; (2) Type IV (displaced intra-articular) fractures braced in supination obtained a significantly higher percentage of excellent functional and anatomic results than those braced in pronation. In general, treatment with functional bracing yielded 90% excellent or good functional results.