Jesse B. Jupiter

Intra-articular fractures of the distal end of the radius in young adults.

Intra-articular fractures of the distal part of the radius in young adults comprise a distinct subgroup of fractures that are difficult to manage and are associated with a high frequency of post-traumatic arthritis. The effect of residual radiocarpal incongruity after this fracture has not been investigated previously. A retrospective study of forty-three fractures in forty young adults (mean age, 27.6 years) was done to determine the components that are critical to the outcome. Treatment included application of a cast alone in twenty-one fractures, insertion of pins and application of a plaster cast in seventeen, external fixation in two fractures, and open reduction and internal fixation in three fractures. At a mean follow-up of 6.7 years, 26 per cent were rated as excellent; 35 per cent, as good; 33 per cent, as fair; and 6 per cent, as poor. There was radiographic evidence of post-traumatic arthritis in twenty-eight (65 per cent) of the fractures. Accurate articular restoration was the most critical factor in achieving a successful result. Of the twenty-four fractures that healed with residual incongruity of the radiocarpal joint, arthritis was noted in 91 per cent, whereas of the nineteen fractures that healed with a congruous joint, arthritis developed in only 11 per cent. A depressed articular surface (a so-called die-punch fragment) was reduced anatomically by closed means in only 49 per cent and was responsible for residual incongruity in 75 per cent of the incongruous joints at late follow-up. Non-union of the ulnar styloid process adversely affected the results. Restoration and maintenance (extra-articular reduction) of the dorsal tilt and radial length did not prove critical except when severe radial shortening occurred.

Fractures of the distal radius

Fractures of the distal radius , Fractures of the distal radius , کتابخانه دیجیتال جندی شاپور اهواز

Open Reduction and Internal Fixation of Fractures of the Radial Head

BACKGROUND The purpose of this retrospective study was to analyze the functional results following open reduction and internal fixation of fractures of the radial head and to determine which fracture patterns are most amenable to this treatment. METHODS Fifty-six patients in whom an intra-articular fracture of the radial head had been treated with open reduction and internal fixation were evaluated at an average of forty-eight months after injury. Thirty patients had a Mason Type-2 (partial articular) fracture, and twenty-six had a Mason Type-3 (complete articular) fracture. Twenty-seven of the fifty-six fractures were associated with a fracture-dislocation of the forearm or elbow or an injury of the medial collateral ligament. Fifteen of the thirty Type-2 fractures were comminuted. Fourteen of the twenty-six Type-3 fractures consisted of more than three fragments, and twelve consisted of two or three fragments. The result at the final evaluation was judged to be unsatisfactory when there was early failure of fixation or nonunion requiring a second operation to excise the radial head, <100 degrees of forearm rotation, or a fair or poor rating according to the system of Broberg and Morrey. RESULTS The result was unsatisfactory for four of the fifteen patients with a comminuted Mason Type-2 fracture of the radial head; all four fractures had been associated with a fracture-dislocation of the forearm or elbow, and all four patients recovered <100 degrees of forearm rotation. Thirteen of the fourteen patients with a Mason Type-3 comminuted fracture with more than three articular fragments had an unsatisfactory result. In contrast, all fifteen patients with an isolated, noncomminuted Type-2 fracture had a satisfactory result. Of the twelve patients with a Type-3 fracture that split the radial head into two or three simple fragments, none had early failure, one had nonunion, and all had an arc of forearm rotation of > or =100 degrees. CONCLUSIONS Although current implants and techniques for internal fixation of small articular fractures have made it possible to repair most fractures of the radial head, our data suggest that open reduction and internal fixation is best reserved for minimally comminuted fractures with three or fewer articular fragments. Associated fracture-dislocation of the elbow or forearm may also compromise the long-term result of radial head repair, especially with regard to restoration of forearm rotation.

The Unstable Elbow

### Pathoanatomy The pathoanatomy of an elbow dislocation can be thought of as a disruption of the circle of soft tissue or bone, or both, that begins on the lateral side of the elbow and progresses to the medial side in three stages (Fig. 1-A). In stage 1, the lateral collateral ligament is partially or completely disrupted (the ulnar part is disrupted). This disruption results in posterolateral rotatory subluxation of the elbow, which can reduce spontaneously (Fig. 1-B). Stage 2 involves additional disruption anteriorly and posteriorly. There is an incomplete posterolateral dislocation of the elbow in which the concave medial edge of the ulna rests on the trochlea. On a lateral radiograph of the elbow, the coronoid process appears to be perched on the trochlea. This dislocation can be reduced with use of minimal force or by the patient manipulating his or her own elbow. Stage 3 is subdivided into three parts. In stage 3A, all of the soft tissues around and including the posterior part of the medial collateral ligament are disrupted, leaving only the important anterior band (the anterior medial collateral ligament) intact. This permits posterior dislocation by a posterolateral rotatory mechanism. The elbow pivots on the intact anterior band of the medial collateral ligament. Reduction is accomplished by gentle manipulation of the elbow beginning with supination and valgus stress, temporarily recreating the deformity, followed by application of traction, varus stress, and pronation simultaneously. The intact anterior medial collateral ligament provides stability if the forearm is kept in pronation to prevent posterolateral rotatory subluxation during valgus stress-testing. Stage-3A instability is most commonly seen in the presence of fractures of the radial head and coronoid process. In stage 3B, the entire medial collateral complex is disrupted. Varus, valgus, and rotatory instability are all present following reduction. In stage 3C, the instability …

Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures

A new plate designed specifically to address complex wrist pathology was used for the internal fixation of 22 complex fractures of the distal radius in 22 patients in a prospective multicenter trial. The majority of fractures were group C2- and C3-type fractures according to the Comprehensive Classification of Fractures. No plate failures, loss of reduction, nonunions, or infections occurred. Within the average follow-up time of 14 months, the functional results (including an average motion of 76% and an average grip strength of 56% of the contralateral side) were comparable to those reported for similar fractures in previous investigations. Five patients had irritation of the tendons in the second dorsal compartment. This trial serves both as a verification of the safety and efficacy of this distal radius plate as well as a demonstration of its utility in the treatment of complex fractures of the distal radius.

Intercondylar fractures of the humerus. An operative approach.

In this paper we review a series of thirty-four intercondylar fractures of the distal end of the humerus that were treated by open reduction over a ten-year period. The fracture patterns were classified according to the system of Müller et al. and a strict rating scale incorporating subjective data, objective motion, and the functional status of the involved elbow was used for the results. At a mean follow-up of 5.8 years, thirteen results were rated as excellent; fourteen, as good; four, as fair; and three, as poor. Complications included postoperative neuritis in five patients; three non-unions; and refracture, heterotopic bone, and deep sepsis in one patient each.

Fractures of the distal humerus.

We present a rational approach to the classification and surgical management of intraarticular fractures of the distal humerus. The fractures are classified on the basis of the surgical anatomy of the distal humerus, which is divided into two skeletal columns held together by the trochlea. The basic surgical aim is to restore all three elements with sufficient stability to permit functional movement. The surgical tactics are presented in detail.

Coronal Shear Fractures of the Distal End of the Humerus

We identified a shear fracture of the distal articular surface of the humerus, with anterior and proximal displacement of the capitellum and a portion of the trochlea, in six patients (five female and one male). The average age of the patients was thirty-eight years (range, ten to sixty-three years). Each fracture was the result of a fall from a standing height. A characteristic radiographic abnormality, which we have termed the double-arc sign, was seen on the lateral radiograph of each patient and represented the subchondral bone of the displaced capitellum and the lateral trochlear ridge. All patients were managed with open reduction, internal fixation, and early motion of the elbow. The average duration of follow-up was twenty-two months (range, eighteen to twenty-six months). The fracture united in all patients at an average of six weeks (range, four to nine weeks), without radiographic evidence of osteonecrosis of the fracture fragment. Flexion of the elbow averaged 141 degrees (range, 130 to 150 degrees), with an average flexion contracture of 15 degrees (range, 0 to 40 degrees). Pronation of the forearm averaged 83 degrees, and supination averaged 84 degrees. All patients had a good or excellent functional result, according to the elbow-rating scale of Broberg and Morrey.

Non-union of the clavicle. Associated complications and surgical management.

Twenty-three patients who had a clavicular non-union were treated operatively at the Massachusetts General Hospital from 1974 to 1985. Twenty-one non-unions were the result of fracture and two, secondary to osteotomy. Twenty non-unions were located in the middle third of the clavicle, while three were in the lateral third. Radiographically, eighteen non-unions were atrophic and three, hypertrophic. Two non-unions resembled pseudarthrosis. Of the etiological factors that were reviewed the extent of displacement of the original fracture was the most significant. Associated complications of the non-union included limited mobility of the shoulder in fourteen, neurological symptoms in eight, thoracic outlet syndrome in four, and arterial ischemia in one. Of the nineteen patients who were treated to obtain union, seventeen had a successful result at an average length of follow-up of 23.8 months. In sixteen (93.7 per cent) of the seventeen patients union was achieved by fixation with a plate; one patient required two procedures. Ancillary bone graft was used in eighteen patients, with three requiring a sculptured bicortical graft from the iliac crest to span a defect. Of the four other patients three were treated with a partial clavicular resection and one, with complete clavicectomy.

Management of Distal Radial Fractures

Interest in one of the most common injuries to the musculoskeletal system—the distal radial fracture—has been renewed. Literature over the past two centuries had even led some to believe that the distal radial fracture was a solved problem. In contrast, we are now confronted with a marked swing toward stable internal fixation being touted by some authors as the treatment of choice for all but the most stable, aligned fractures. Instructional courses, symposia, and skills courses worldwide are now oversubscribed, bearing witness to these changing perspectives. It is surprising that, despite this aggressive push toward internal fixation, there is no convincing evidence that supports this approach in the contemporary literature. To what can we attribute this dramatic shift in the management of the distal radial fracture? In this review, we will attempt to answer this question by looking in depth at a number of contributing factors—changing epidemiologic patterns; a growing understanding of the injury mechanism; the development of enhanced imaging techniques; novel plate designs, especially those featuring …