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PubMed2000

Reconstruction of posttraumatic elbow instability.

Successful reconstruction of posttraumatic elbow instability depends on restoration of the anatomic contributors to stability. The osseous and articular structures are paramount. The radial head and coronoid should be repaired or reconstructed and the olecranon (proximal ulna) should be repaired in anatomic alignment so that the contour and dimensions of the trochlear notch are restored and the radiocapitellar joint is aligned appropriately. The lateral collateral ligament complex is commonly disrupted and usually can be reattached to its origin from the lateral epicondyle. Patients with longstanding subluxation or dislocation may require temporary hinged external fixation or reconstruction of the collateral ligaments with tendon grafts.

Adult↗
PubMed2000

Percutaneous and limited open fixation of fractures of the distal radius.

Percutaneous and limited open fixation of fractures of the distal radius is an important method of treatment for many unstable fractures such as unstable dorsal bending fractures, shearing fractures of the radial styloid and lunate facet, and simple articular fractures. The quality of the reduction is monitored with image intensification and the tactic of the reduction is based on manipulation of the fracture fragments by longitudinal traction, percutaneous manipulation, and in some instances by direct manipulation through small incisions. The role of arthroscopy remains uncertain and may represent an alternative to open exposure of the articular surface in some patients although bone grafting may be necessary in patients with fractures with significant metaphyseal defects.

Arthroscopy↗
PubMed2002

Nonunion of nonoperatively treated fractures of the radial head.

Although fractures of the radial head traditionally are not associated with healing problems, delayed union and nonunion are being seen more frequently after operative and nonoperative treatment. Given the tenuous blood supply to the head of the radius, problems with healing are not surprising. As the current review of five patients with nonunion of nonoperatively treated radial head fractures treated during a 6-year period shows, healing problems rarely are symptomatic and often may go unrecognized. Even when the fracture still is apparent on radiographs obtained more than 1 year after the injury, healing still may occur. Operative treatment, although rarely necessary, achieved union in one of the current patients.

Adult↗
PubMed2003

Salvage of distal tibia metaphyseal nonunions with the 90 degrees cannulated blade plate.

Nonunion of distal tibia metaphyseal fractures after trauma is a major problem. Treating these nonunions is made more challenging by the presence of symptomatic ipsilateral tibiotalar arthrosis. The current study examined the use of the 90 degrees cannulated blade plate as an alternative method of stable internal fixation for 13 distal tibia metaphyseal nonunions and simultaneous fusion of three arthritic tibiotalar joints in 13 patients (seven males and six females) with an average age of 42.4 years (range, 21-73 years). Each patient had an average of three prior procedures (range, 2-6). Patients were followed up for an average of 34.2 months (range, 24-55 months). All 13 patients achieved radiographic and clinical union an average of 15.6 weeks (range, 12-20 weeks) from the date of the definitive procedure. There were two broken screws, but no secondary procedures were required to obtain fusion. All patients were ambulatory without support at the last followup. The implant proved effective for stable internal fixation of distal tibia metaphyseal nonunions alone or with simultaneous fusion of the tibiotalar joint.

Adult↗
PubMedDate not supplied

Salter-Harris type III and IV epiphyseal fractures in the hand treated with tension-band wiring.

We present tension-band wiring in the treatment of Salter-Harris types III and IV avulsion fractures in the hand. By placing a small-gauge wire through the insertion of the ligament into the fracture fragment, accurate reduction and stability, allowing early mobilization, are achieved, avoiding many of the pitfalls and complications of other methods of internal fixation. The technique is simple and adheres to important physiological and biomechanical principles.

Adolescent↗
PubMed1988

The role of external fixation in the treatment of posttraumatic osteomyelitis.

External skeletal fixation played a central role in the reconstruction of 30 limbs involved in posttraumatic osteomyelitis. The tibia was involved in 15, the femur in six, the ankle in five, and the foot and radius in two each. Of the thirty limbs, 27 were ununited. Positive bacteriology and/or histology was found in each case. A total of 36 frames were used with 20 unilateral half-frame constructs and 16 bilateral transfixion frames. The average duration of external fixation was 60 days. Specific procedures for soft tissue coverage were required in 21 cases and autogenous bone grafting in 26. Loosening and local infection occurred in three of 168 external fixation pins. There were no cases of pin-track osteomyelitis, fractures through pintracks, or neurovascular damage from pin insertion. Infection was controlled in 29 of 30 limbs, with one requiring a below-knee amputation. Skeletal union was achieved in all cases. At an average follow-up of 35 months, 20 of 28 lower limbs in 27 patients tolerated full weight bearing without ambulatory aides. Four used a patellar tendon-bearing polypropylene orthosis, two used a cane, and one a walker. In the 23 patients ambulating without upper-extremity aides, the average time from the start of treatment to reach this functional status was 14 months.

Adult↗
PubMed1988

Unicondylar fractures of the distal humerus: an operative approach.

This paper retrospectively reviews a series of 22 unicondylar fractures of the distal end of the humerus that were treated by open reduction and internal fixation over a 10 year period. The fracture patterns were classified according to the system of Müller et al. A strict rating scale was developed that incorporated subjective data, objective elbow motion, and the functional status of the involved elbow. At an average follow-up of 5.9 years (range 2.3 to 12.3 years), 12 elbows were rated as excellent, 6 as good, and 4 as fair. Complications included extensive posttraumatic arthritis in four patients, a nonunion in one, and a transient radial nerve palsy in one.

Adolescent↗
PubMed1991

The posterior Monteggia lesion.

Thirteen posterior Monteggia fracture-dislocations in adults were treated surgically at the Massachusetts General Hospital from 1980 to 1988. A characteristic lesion was observed, consisting of a proximal ulna fracture with a triangular or quandrangular fracture at or near the level of the coronoid, a posterior or posterolateral radiocapitellar dislocation, and, in 10 cases, a radial head fracture. Nine patients were women and four were men, with an average age of 56 years. Following reduction of the radiocapitellar dislocation, the ulnar fractures were treated with plates in each case. Seven fractured radial heads were excised, one replaced with a silicone prosthesis, and three treated by open reduction and internal fixation. The 11 surviving patients were observed using the performance index of Broberg and Morrey at an average follow-up time of 38.4 months. The conditions of three were rated excellent, three good, four fair, and one poor. Incomplete reduction of the ulnar fracture with residual posterior radiocapitellar subluxation was observed in four cases, all leading to loss of forearm supination. We believe this lesion to be more common than previously reported. Recognition of its specific anatomic features is essential to achieve a functional outcome.

Adult↗
PubMed1993

Ipsilateral tibia and ankle fractures.

This study reports on 18 cases of diaphyseal fractures of the tibia associated with ipsilateral but not contiguous ankle fractures. Thirteen of these complex fractures resulted from low-energy torsional forces, while five were caused by high-energy impact. Definitive treatment consisted solely of cast immobilization in four; 14 had operative stabilization of each fracture component. Of these 14, four patients were treated initially in long leg casts and one in a plaster splint, but each required surgical intervention to control fracture alignment. The average follow-up time was 21.2 months. In the nonoperative group of four patients, clinically significant shortening and/or rotational deformity were noted in three limbs, with ankle mobility decreased by > 50% and advanced posttraumatic arthritis evident in two ankles. Of the cases managed operatively, 10 (71%) had full structural and functional recovery, three patients regained only 75% of ankle mobility, and two patients developed slight valgus deformities, one with a concomitant rotational deformity of less than 10 degrees. These findings demonstrate the unstable nature of this complex fracture pattern and the advantages of operative management.

Adult↗
PubMed1993

Multiplane fracture of the distal humerus.

A unique but complex intraarticular fracture of the distal humerus is described. The term multiplane fracture has been applied to highlight a fracture pattern that features not only the well recognized T fracture lines in the sagittal and horizontal planes but also a coronal fracture of the trochlea. The Herbert screw was used in five cases to achieve stable fixation of the purely articular coronal fracture. At a follow-up of 20 months, on average, all fractures healed with an acceptable functional result. No radiographic evidence of avascular necrosis was seen in the follow-up radiographs.

Adult↗
PubMed1994

The floating radius in bipolar fracture-dislocation of the forearm.

Ten cases of bipolar forearm fracture-dislocation are presented. Recognition of the full extent of the skeletal, articular, and soft-tissue injuries is essential. Treatment consists of an anatomical reduction and proximal and distal stabilization of the skeleton to achieve control as well as maintain the position of the floating radius segment. The forearm bones can then be maintained in an optimal position to avoid interosseous soft-tissue contracture that will compromise the supination-pronation function of the forearm.

Adult↗
PubMed1995

The complications and difficulties of management of nonunion in the severely obese.

Operative fixation of 22 nonunited fractures was undertaken in 21 obese patients. Eleven patients were women and 10 were men, with an average age of 46.3 years (range 25-74). The average body mass index in this group of patients was 37.9 kg/m2 (range 33.2-57.1). Two patients were classified as morbidly obese and 19 as severely obese. The management of these patients proved to be fraught with difficulties related to their obesity. There were a number of occurrences believed to be related to poorly protective positioning and prolonged ischemic pressure under the patient's body weight during the administration of anesthetic, including a peroneal compartment syndrome, a gluteal compartment syndrome with sciatic nerve palsy, bilateral brachial plexus stretch injuries, an anterior interosseous nerve palsy, and the postoperative development of a patch of scalp alopecia. There were two wound separations and no episodes of thromboembolic disease. Sixteen nonunited fractures healed after the index procedure at an average time to healing of 5.6 months (range 2-14). Five nonunited fractures required a second procedure to gain union [average total time to healing 17 months (range 10-31)]. A single fracture remains ununited. Awareness of the unique technical demands and operative and anesthetic risks encountered when undertaking an operative procedure in a severely obese patient is imperative for the safe and successful treatment of orthopaedic surgical problems in these patients.

Adult↗
PubMed1995

Delayed onset of forearm compartment syndrome: a complication of distal radius fracture in young adults.

The signs and symptoms of elevated intracompartmental pressure in the volar forearm compartment developed on a delayed basis (range 18-54 h) in the absence of constricting casts or dressings in eight limbs after high-energy intraarticular fractures of the distal end of the radius. Intracompartment pressures averaged 80 mm Hg in the six limbs tested. Despite urgent decompression and fracture fixation with delayed wound closure, final functional outcomes were compromised in seven cases, reflecting the severity of the articular injuries, and poor in one case, in which a wrist fusion was later required. If potentially serious complications are to be prevented, careful observation of these patients, often for periods of 48 h, is important. Selective recording of forearm intracompartmental pressures may be advised in at-risk patients.

Adult↗
PubMed1996

Management of humeral nonunion after the failure of locking intramedullary nails.

We reviewed 21 cases of humeral nonunion following the failure of "locking" humeral nails. The nails had been inserted as the primary operative procedure following humeral fracture in fifteen cases or after the failure of closed treatment in six cases. Reconstruction after the failure of these implants was complicated by poor bone stock and difficulty in achieving union. Although technically difficult, open reduction and internal fixation with plating and bone grafting (successful in nine of nine cases) was more consistent than exchange nailing (successful in four of 10 cases) in achieving union (p = 0.01). Two patients refused further surgical intervention. The degree of bone loss associated with a loose nail, the lack of success of exchange nailing, and the insertion site morbidity associated with humeral nail removal differentiate these nonunions from similar lower extremity problems. The degree of bone loss following failed locking nailing of the humerus is a major concern, and exchange nailing alone may not be an acceptable option to deal with this problem.

Adolescent↗
PubMedDate not supplied

Repair of five distal radius fractures with an investigational cancellous bone cement: a preliminary report.

OBJECTIVE: The purpose of the study was to evaluate the feasibility of Norian SRS bone cement injected percutaneously into a distal radius following reduction in both preventing loss of reduction as well as safety. DESIGN: The study was a prospective clinical study with an established protocol. SETTING: The study was conducted at the Massachusetts General Hospital following approval of the institutions Investigational Review Board. All patients were required to read and approve an informed consent document. PATIENTS: While twenty patients' radiographs fulfilled the requirement of a dorsally displaced extraarticular fracture to have occurred within 72 hours of presentation, only five consented to participate fully and one voluntarily withdrew after a six-month follow-up. INTERVENTION: All fractures were reduced under regional or general anesthesia, and the Norian SRS was introduced via a catheter system into the metaphyseal defect of the fracture. A short arm cast was applied and remained in place for six weeks. MAIN OUTCOME MEASUREMENTS: Radiographic parameters of fracture reduction were measured prospectively by an independent radiologist throughout the 12 months of the study. Clinical parameters of hand and wrist function were measured prospectively by an independent occupational therapist. RESULTS: At 12-month follow-up, radial length was a mean 9.9 mm with an average loss of < 1 mm; radial angle maintained at a mean 25.4 degrees; volar angle was within normal range (0-21 degrees) in 4; and 1 patient had a dorsal angle of 7 degrees. Wrist motion improved 50 percent between 6 weeks and 3 months and improved further by 12 months when grip strength reached a mean of 88 percent of the contralateral side. Dorsal and volar extrusion of injected Norian SRS in 4 patients resorbed over time. There were no clinically significant adverse effects or complications. CONCLUSIONS: Norian SRS proved to be clinically safe and effective as a cancellous bone cement to maintain fracture reduction of unstable extraarticular distal radius fractures.

Bone Cements↗
PubMed1997

The management of femoral diaphyseal nonunions.

OBJECTIVE: To assess the efficacy of treatment and develop an algorithm for management of nonunions of the femoral diaphysis. STUDY DESIGN: Retrospective. SETTING: University hospital. METHODS: Forty-four patients treated at one institution for nonunion of the femoral diaphysis were studied. Thirteen of these patients had a history of infection. After debridement (where appropriate) and repair of the femoral nonunion, follow-up averaged twenty-eight months (range, 24 to 108 months). All patients were examined at final follow-up. RESULTS: Thirty-three patients achieved union after one procedure, and eight patients achieved union after additional procedures. One patient underwent above-knee amputation, and two patients remained ununited at the time of their final follow-up. Time to union averaged 11.8 months. Seventeen patients healed with more than two centimeters of shortening, and ten patients lost more than 30 degrees of knee flexion. CONCLUSION: Established femoral diaphyseal nonunions can be treated effectively, even in the presence of chronic sepsis. Selective use of a vascularized fibula transfer has proven beneficial in addressing intercalary defects. Plate fixation, with or without a vascularized fibula transfer, has been the predominant mode of skeletal stabilization in more complex reconstructions.

Adolescent↗
PubMed1997

Transolecranon fracture-dislocation of the elbow.

OBJECTIVE: To characterize the prevalence, morphology, and prognosis of anterior (transolecranon) fracture-dislocations of the elbow. DESIGN: Retrospective case series. SETTING: A consecutive series of thirteen patients from a single level-one trauma center, plus four patients from the practices of two of the senior authors. PATIENTS: Three of seventeen patients had simple, oblique fractures of the olecranon, and fourteen had complex, comminuted fractures of the proximal ulna, including fragmentation of the olecranon in seven patients, large coronoid fragments in eight patients, and segmental fractures of the ulna in six patients. Fourteen patients were male and three were female, with an average age of thirty-eight years (range, 18 to 78 years). INTERVENTION: All fractures were treated by open reduction and internal fixation. Two one-third tubular plates had to be revised to 3.5-millimeter dynamic compression plates within six weeks of the initial operation. MAIN OUTCOME MEASURE: Elbow performance rating of Broberg and Morrey. RESULTS: At an average follow-up of twenty-five months, overall outcome was rated as excellent in seven patients, good in eight, and fair in two. Mild posttraumatic arthritis was noted in only two patients. Large coronoid fragments and extensive comminution of the trochlear notch did not preclude a good result provided that stable, anatomic fixation was achieved. CONCLUSIONS: Anterior elbow dislocations occur most often as a fracture-dislocation in which the distal humerus is driven through the olecranon, thereby causing a complex, comminuted fracture of the proximal ulna. This injury is frequently confused with anterior Monteggia lesions by virtue of the readily apparent radiocapitellar dislocation. Stable restoration of the appropriate contour and dimensions of the trochlear notch of the ulna will lead to a good result in most cases.

Adolescent↗