James F Kellam

Open reduction and internal fixation of radial head fractures.

Open reduction and internal fixation of displaced fractures of the radial head were reviewed in 14 elbows. Follow-up averaged 32 months. The average elbow score for Mason type II fractures was 96.8 points, corresponding to 100% good or excellent results. Average flexion was 142.5Å, and the mean fixed flexion deformity was 3.9Å. There was no loss in grip strength. An almost normal elbow was the expected result. Good or excellent results were achieved in only 33% of Mason type III fractures treated with open reduction and internal fixation. The average elbow score was 72.9 points, and this was statistically significantly different than the Mason type II fractures (p < 0.05). An associated elbow dislocation did not affect the results significantly, but was associated with a slightly increased fixed flexion deformity. Fractures may be more comminuted than suggested by plain radiographs, and intraoperative decision making is required in deciding between reconstruction or excision of the radial head. Excellent results were obtained provided an anatomical reduction with stable fixation and early range of motion were achieved. If a stable anatomic reduction cannot be obtained, then alternative treatment methods should be considered.

Anterior approach and stabilization of the disrupted sacroiliac joint

Pelvic fractures with disruption of the important weight-bearing sacroiliac area can lead to impaired gait due to malunion or pelvic obliquity, back or buttock pain arising from the sacroiliac joint, and permanent neurologic damage. In eight patients with sacroiliac joint dislocation, an anterior retrofascial approach and stapling of the sacroiliac joint was performed. Six of these patients maintained an anatomic reduction of the sacroiliac joint and their results were rated as excellent. Two of the eight patients had a slight loss of reduction and because of intermittent mild pain were rated as having fair results. In another eight patients, plate fixation of the anterior sacroiliac joint was done. New stabilization methods utilizing dynamic compression plates, reconstruction plates, and a new four-hole plate have been developed to provide more secure fixation of these unstable injuries.

Comparison of torsional strength of humeral intramedullary nailing: a cadaveric study

Summary: Control of rotation after intramedullary fixation of the humeral shaft has been observed to vary clinically. Two of the newer intramedullary nails specifically designed for the humerus were tested. Transverse and spiral fractures were created in 35 fresh-frozen cadaveric humeri. The constructs were tested in a materials testing system to evaluate in vitro the torsional strength of the nailed humeral fractures. Intact bones showed a mean peak torque of 53 ± 17 Nm. The humeri fixed with the Russell-Taylor nail (n=18) using one interlocking screw proximally and one distally showed a mean torsional strength of 10.4 ± 3.6 Nm. The specimens fixed with the Seidel nail (n=17), interlocked proximally with two screws and distally by the friction of three expanded flanges against the inner cortex, had a significantly lower mean torsional strength of 1.5 ± 0.6 Nm (p<0.0005). When compared with intact bones, constructs using the Russell-Taylor nail achieved 20% of mean peak torque. This improved rotational strength should permit an earlier return to full functional use of the extremity.

Dynamic Condylar Screw: A New Device

Summary The dynamic condylar screw (DCS) is a new implant engineered by the AO/ASIF Group for use in management of proximal and distal femoral fractures. This device has some technical advantages over the AO condylar blade plate. In a prospective study we reviewed the use of the DCS in the treatment of supracondylar fractures, intertrochanteric fractures, subtrochanteric fractures, nonunions, and malunions in 18 patients (19 femora). The results are based on an average follow-up of 9 months. Seventeen femurs went on to clinical and radiological union with good functional results. There were two failures because of delayed unions.

Open versus closed intramedullary nailing of femoral shaft fractures.

A retrospective study was performed including only fractures involving the middle three fifths of the femoral shaft with a minimum of 2 years followup. There were 65 fractures in Group I treated with the closed technique utilizing the image intensifier. These were compared with 65 fractures treated with open reduction and nailing. Followup averaged 4 years (Group II). Group 1 had 92% satisfactory results; Group II achieved 97% satisfactory, not statistically significantly different. Our recommendations are delaying the procedure did not appear to be advantageous; excluding the fractures with segmental bicortical loss, there are limited indications for locked nails in these fractures; the decision to use a specific type of internal fixation should be based on the fracture pattern, the surgeons experience, and the equipment available; if a closed technique is chosen, be prepared to open the fracture if a satisfactory closed reduction cannot be attained. This, in our study, did not increase the risk of reducing the functional result.

Early Results of the Sunnybrook Experience with Locked Intramedullary Nailing

In the past two years the closed locked intramedullary nailing system has been used at the Sunnybrook Trauma Unit. This system has equalled the results reported by Hansen in the use of closed intramedullary nailing with conventional indications, and has provided an excellent means of handling complex and difficult shaft fractures of both the tibia and the femur. It appears to provide excellent rates of union with very rapid and early rehabilitation of the patient. It is particularly useful in the multiply injured patient with very difficult high energy femoral and tibial shaft fractures. It has a minimal blood loss and can be done with practice in a reasonable period of time. This technique will add greatly to the armamentarium of the trauma surgeon.

The management of injuries of the midfoot and forefoot in the patient with multiple injuries

Injuries to the midfoot and forefoot in patients with multiple injuries can be a major source of long-term functional disability. Careful clinical and radiologic assessment is necessary to define the precise injury pattern, which is frequently complex. Treatment of the soft tissues is the immediate priority to preserve a viable foot with normally innervated plantar skin. Dislocations and subluxations in the midtarsal area must be reduced congruously. Reduction must be maintained by external fixation or percutaneous Kirschner wires until ligaments have healed. Fractures should be treated using accepted principles of management. Displaced intraarticular fractures should be treated by open reduction and internal fixation, if technically possible, to allow functional rehabilitation. The length and alignment of metatarsal shaft fractures must be restored and maintained, by internal fixation if necessary. In severe injuries, an early decision should be made regarding useful viability of the foot. If necessary, amputation should be performed early at a definitive level.