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Cut-out of the lag screw after fixation of trochanteric fractures with intramedullary devices like the Gamma Locking Nail is a well documented cause of late mechanical failure. Avascular necrosis of the femoral head after trochanteric fractures is an uncommon complication and several causes have been described. As far as we know, the relation of the mechanical failure of fracture fixation and avascular necrosis of the femoral head in trochanteric fractures has never been described. We present a study of six consecutive patients who underwent arthroplasty after cut-out of the lag screw fixation of a trochanteric fracture with Gamma Locking Nail. All six femoral heads were studied histologically and a clinical retrospective study was also performed. In all cases, we found homogeneous avascular necrosis of the femoral head; in all but one, revascularisation was present in every area examined. We suggest that after fixation of these trochanteric fractures with the Gamma Locking Nail, there is a transitory ischaemia, if the revascularisation is not enough to provide a strong support for the lag screw, it may result in late mechanical failure in these fractures.
Minimal information exists regarding early complications after operatively treated proximal humeral fractures. Of the 82 shoulders that had osteosynthesis, 42 had a (nonmedical) complication, with 21 requiring further surgery. Of 42 shoulders with complications, 12 were related to incomplete reduction, 16 had loss of anatomic fracture fixation, 9 had delayed healing, 3 had an infection, 1 had rotator cuff failure, and 1 had loose bodies. Fixed-angle plates had lower rates of initial malpositioning and resultant malunion. Of the 22 shoulders requiring hemiarthroplasty, 14 had an early complication. Of these, 7 had complications relating to implant insertion or tuberosity malreduction at the index operation and 7 had problems with tuberosity healing. The rate of complications after operative treatment of proximal humeral fractures is high. All efforts at fracture fragment fixation with osteosynthesis and hemiarthroplasty should be directed at obtaining anatomic fracture fixation that resists displacement.
Between 1992 and 1995, 50 patients with 51 acetabular fractures underwent internal fixation using 3.5 mm cortical screws. There were 21 simple and 30 associated fracture types, as described by Letournel. Most of the patients had sustained multiple injuries with an average injury severity score (ISS) of 20 points. The modified extended iliofemoral approach was used in 32 cases, the Kocher Langenbeck approach in 9 cases, the ilioinguinal approach in 7 cases, the extended iliofemoral in 2 cases and the Kocher-Langenbeck approach combined with an ilioinguinal approach in a second stage procedure in 1. Anatomical reduction could be achieved with persistent displacement of no more than 1 mm in 40 fractures. Implant failure with loss of reduction occurred in 3 patients who underwent a revision procedure. At 2 year follow-up, 38 out of 44 of the patients had excellent or good clinical and radiological results. In acetabular fractures with sufficiently large fragments, screw fixation with 3.5 mm cortical screws proved satisfactory. In very comminuted fractures or where there is poor patient compliance an additional buttress plate should be used.
Acetabular fractures with medial displacement patterns, particularly medial displacement of the quadrilateral surface, may be technically challenging to treat. Minimal bone stock, limited anatomic access, and difficulty in obtaining stable internal fixation in the true pelvis contribute to the surgical challenge of open reduction and internal fixation. Applying a medial buttress plate across the quadrilateral plate below the iliopectineal line in the true pelvis can be a helpful adjunct to internal fixation in these fractures. The quadrilateral plate is approached from the opposite side of the injury through a standard ilioinguinal approach or a modified Stoppa approach. An undercontoured plate is secured posteriorly along the sciatic buttress posterior to the joint and the quadrilateral plate and anteriorly on the posterior surface of the pubic ramus. By resisting medial secondary redisplacement, this technique adds to stable fixation for acetabular fractures involving medial displacement, particularly of the quadrilateral plate.
Undisplaced fractures of the proximal radius can generally be treated conservatively with good results. In children, spontaneous correction of some angular deformities can be expected during growth. Nevertheless, more severely displaced fracture types may require reduction in children, too. Open reduction and internal fracture fixation have shown to lead to a loss in range of motion frequently. A technique of percutaneous fracture reduction is demonstrated that can provide good results in cases when closed techniques have failed. A Kirschner wire is used to manipulate the fracture fragments percutaneously, which can often prevent open techniques. An additionally performed elastic-stable intramedullary nailing can add to an effective stabilisation and encourage to early physiotherapy.
Resuscitation of the child with multiple injuries is similar to that for adults, except that instrumentation and therapy must be tailored in accordance with variable patient size, emotional maturity, and injury response. Because this response is rapid and often compensatory, there is greater reliance on noninvasive means to diagnose and manage the injured child. Children who suffer multisystem trauma typically present with head injury, followed in decreasing frequency by limb fracture and trauma to the torso. The timing of fracture fixation in a patient with multiple injuries remains controversial. In general, clinical judgment will determine the optimal timing for fracture reduction or operative fracture fixation. Management of an associated vascular injury must take into consideration the mechanism of injury, tissue viability, vessel size, and technical limitations. With appropriate initial resuscitation, careful monitoring, and sound clinical judgement, most injured children can be expected to have a good clinical outcome.
The method of external fixation of phalangeal fractures provides a solution for extensive hand injuries where internal fixation may be prohibited due to compromised skin coverage or bone loss. Early mobilization of adjacent joints is possible with these devices and is fundamental for the preservation of hand function. This paper describes the proper selection of cases and the versatility of its application. Representative clinical uses are summarized.
A basic understanding of biomechanics, the material and structural properties of bone, and the effects that forces have on long bones enables the veterinary orthopedic surgeon to make rational decisions in selecting the most appropriate method of fracture fixation. This knowledge should enhance a surgeon's clinical ability to create a biomechanically stable environment at the fracture site that is conducive to rapid bone healing and early return to function of the patient. Furthermore, the ability to comprehend biomechanics as it pertains to fracture management enables the surgeon to scientifically critique new implant systems as they are developed with regard to their inherent ability to effectively neutralize the potential disruptive forces acting on a fracture after stabilization.
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BACKGROUND: The most effective type of plate fixation for diaphyseal forearm fractures has not been defined. We performed a prospective, randomized trial in which the limited contact dynamic compression plate (LC-DCP) was compared with the Point Contact Fixator (PC-Fix) for the treatment of forearm fractures at one center. METHODS: Ninety-two patients with 125 forearm fractures were recruited for the study and were randomly assigned to fracture fixation with one of the two devices. The average age of the patients was thirty-six years. The average duration of follow-up was twenty-two months. Patients were assessed periodically with use of radiographs and were assessed with regard to pain and function at time of the latest follow-up. RESULTS: Three patients (four fractures) in the PC-Fix group and five patients (five fractures) in the LC-DCP group had a delayed union, but no patient in either group had a nonunion. With the numbers available, there was no significant difference between the two groups with regard to operative time, time to union, callus formation, pain, or functional outcome. Deep infection occurred in one patient with a closed fracture in the PC-Fix group and in one patient with an open fracture in the LC-DCP group. In addition, one refracture occurred in each group. Both refractures occurred at the site of a screw track. CONCLUSION: Despite the differences in the concept of fracture fixation, these two implants appear to be equally effective for the treatment of diaphyseal forearm fractures.
The arthroscope can assist in effectively treating traumatic injuries about the elbow, including some intra-articular fractures. Proper selection of patients is important to ensure effective treatment, but when used judiciously, arthroscopic-assisted debridement and fracture fixation is effective. The arthroscope is a valuable tool in the diagnosis and management of acute intra-articular fractures and in dealing with the sequelae that sometimes cause problems after healing has occurred. It allows for effective fracture treatment without the extensive soft tissue disruption that would be otherwise necessary for exposure. The authors certainly cannot advocate arthroscopic treatment of all intra-articular elbow fractures, but in specific circumstances, the arthroscope cannot only assist but also improve treatment of these sometimes difficult and often challenging injuries. The arthroscope is also useful in the identification of varus, valgus, and posterolateral rotatory instability, particularly when these instabilities are less obvious on clinical examination.
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BACKGROUND: During routine follow-up of patients treated with a three-piece stainless-steel modular femoral nail, osteolysis and periosteal reaction around the modular junctions of some of the nails were noted on radiographs. The purpose of this study was to evaluate the prevalence, etiology, and clinical relevance of these radiographic findings. METHODS: Forty-four femoral fractures or nonunions in forty-two patients were treated with a modular stainless-steel femoral intramedullary nail. Seventeen nails were excluded, leaving twenty-seven intramedullary nails in twenty-seven patients for this study. All patients had had a femoral diaphyseal fracture; nineteen had had an acute fracture and eight, a nonunion. These twenty-seven patients returned for radiographs, a physical examination, assessment of functional outcomes, assessment of thigh pain with a visual analog scale, determination of serum chromium levels, and nail removal if desired. A control group of sixteen patients treated with a one-piece stainless-steel femoral intramedullary nail was evaluated with use of the same outcome measures and was compared with the group treated with the modular femoral nail with regard to prevalence of thigh pain and serum chromium levels. Twelve modular femoral nails were removed according to the study protocol. The modular nail junctions were analyzed for corrosion products, and histopathologic analysis of tissue specimens from the femoral canal was performed. RESULTS: The twenty-seven patients were seen at a mean of twenty-one months after fracture fixation; twenty-six of the twenty-seven fractures healed. Twenty-three femora had at least one of three types of abnormalities-osteolysis, periosteal reaction, or cortical thickening--localized to one or both modular junctions. Eighteen patients had severe reactions, defined as osteolysis of > or =2 mm, cortical thickening of > or =5 mm, and/or a periosteal reaction (group 1). Nine patients had mild or no reactions (group 2). Serum chromium levels in group 1 (mean, 1.27 ng/ mL; range, 0.34 to 3.12 ng/mL) were twice as high as those in group 2 (mean, 0.53 ng/mL; range, 0.12 to 1.26 ng/mL). However, this difference did not reach significance with the numbers available. The differences in serum chromium levels between group 1 and the control group with a one-piece nail (mean, 0.26 ng/mL; range, 0.015 to 1.25 ng/mL) (p<0.01) and a control group without an implant (mean, 0.05 ng/mL; range, 0.015 to 0.25 ng/ mL) (p<0.01) were significant. The level of thigh pain recorded on the visual analog scale was also significantly different between group 1 and the control group with a one-piece implant (p = 0.03). Retrieved modular nails had signs of fretting corrosion as well as stainless-steel corrosion products adherent to the junction where the osteolysis occurred. Histologic and spectrographic analysis revealed two types of corrosion products that were consistent with stainless-steel within the peri-implant tissue and were associated with a foreign-body granulomatous response. CONCLUSIONS: The presence of corrosion products at the taper junctions suggests that particulate debris was a major factor in the etiology of the radiographic findings of osteolysis, periosteal reaction, and cortical thickening. Serum chromium levels were substantially elevated in the patients with a modular femoral nail, and such levels may serve as a marker of fretting corrosion of these devices.
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