Loren L. Latta

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.

Effect of nonsteroidal antiinflammatory drugs on fracture healing: a laboratory study in rats.

Summary: We studied the effects of two nonsteroidal antiinflammatory drugs (NSAIDs) on fracture healing in rats: ibuprofen (30 mg/kg/day) and indometh-acin (1 mg/kg/day). Femoral fractures were induced via a three-point bending technique. NSAIDs were administered orally for 4 or 12 weeks. Control animals received no medication. In each group a minimum of six animals were killed at the following intervals: 2, 4, 6, 8, 10, and 12 weeks postfracture. Fracture healing was determined by mechanical testing and histologic evaluation. The bending strength of each fractured femur was expressed as a percentage of the strength of the intact, contralateral femur. Histologic evaluation was performed on serial longitudinal sections stained with hematoxylin and eosin using a qualitative score of maturity of the callus. Ibuprofen and indo-methacin both retarded fracture healing, with significant differences in “mechanical healing” found between the control and experimental groups after 10 weeks of drug administration. Both drugs also induced qualitative histologic changes manifested by delayed maturation of callus, which was noticeable earlier than the difference found by mechanical testing of bone. Our data suggest that NSAIDs have an inhibitory effect on fracture repair that is reversible after cessation of indomethacin but not ibuprofen.

Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures.

Results: One thousand two hundred and twenty-six participants (93%) completed one year of follow-up. Of these, 622 patients were randomized to reamed nailing and 604 patients were randomized to unreamed nailing. Among all patients, fifty-seven(4.6%)requiredimplantexchangeorbone-graftingbecauseofnonunion.Amongallpatients,105inthereamed nailing group and 114 in the unreamed nailing group experienced a primary outcome event (relative risk, 0.90; 95% confidenceinterval,0.71to1.15).Inpatientswithclosedfractures,forty-five(11%)of416inthereamednailinggroupand sixty-eight (17%) of 410 in the unreamed nailing group experienced a primary event (relative risk, 0.67; 95% confidence interval, 0.47 to 0.96; p = 0.03). This difference was largely due to differences in dynamization. In patients with open fractures,sixtyof206inthereamednailinggroupandforty-sixof194intheunreamednailinggroupexperiencedaprimary event (relative risk, 1.27; 95% confidence interval, 0.91 to 1.78; p = 0.16). Conclusions: The present study demonstrates a possible benefit for reamed intramedullary nailing in patients with closed fractures. We found no difference between approaches in patients with open fractures. Delaying reoperation for nonunion for at least six months may substantially decrease the need for reoperation. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.BACKGROUND There remains a compelling biological rationale for both reamed and unreamed intramedullary nailing for the treatment of tibial shaft fractures. Previous small trials have left the evidence for either approach inconclusive. We compared reamed and unreamed intramedullary nailing with regard to the rates of reoperations and complications in patients with tibial shaft fractures. METHODS We conducted a multicenter, blinded randomized trial of 1319 adults in whom a tibial shaft fracture was treated with either reamed or unreamed intramedullary nailing. Perioperative care was standardized, and reoperations for nonunion before six months were disallowed. The primary composite outcome measured at twelve months postoperatively included bone-grafting, implant exchange, and dynamization in patients with a fracture gap of <1 cm. Infection and fasciotomy were considered as part of the composite outcome, irrespective of the postoperative gap. RESULTS One thousand two hundred and twenty-six participants (93%) completed one year of follow-up. Of these, 622 patients were randomized to reamed nailing and 604 patients were randomized to unreamed nailing. Among all patients, fifty-seven (4.6%) required implant exchange or bone-grafting because of nonunion. Among all patients, 105 in the reamed nailing group and 114 in the unreamed nailing group experienced a primary outcome event (relative risk, 0.90; 95% confidence interval, 0.71 to 1.15). In patients with closed fractures, forty-five (11%) of 416 in the reamed nailing group and sixty-eight (17%) of 410 in the unreamed nailing group experienced a primary event (relative risk, 0.67; 95% confidence interval, 0.47 to 0.96; p = 0.03). This difference was largely due to differences in dynamization. In patients with open fractures, sixty of 206 in the reamed nailing group and forty-six of 194 in the unreamed nailing group experienced a primary event (relative risk, 1.27; 95% confidence interval, 0.91 to 1.78; p = 0.16). CONCLUSIONS The present study demonstrates a possible benefit for reamed intramedullary nailing in patients with closed fractures. We found no difference between approaches in patients with open fractures. Delaying reoperation for nonunion for at least six months may substantially decrease the need for reoperation.

Fracture healing in rat femora as affected by functional weight-bearing

Femoral fractures were created in rats to determine whether there were differences in healing under conditions of immobilization and under conditions of immediate weight-bearing. Histological and roentgenographic differences were present by the second week after fracture and differences in mechanical properties were also present. These differences became progressively greater during the next three weeks. Functional weight-bearing was found to accelerate the rate of fracture healing and to improve significantly the strength of the healing bone.

Comparison of patellar resurfacing versus nonresurfacing in bilateral total knee arthroplasty.

Twenty-five patients who received bilateral total knee prostheses were studied to evaluate the advantages and disadvantages of patellar resurfacing. Only patients with advanced patellofemoral disease were included in the study. In all patients, patellar resurfacing had been done in the right knee but not in the left knee. The DePuy porous-coated implant was used in all cases. Subjective criteria were compared with objective criteria, which included range of motion, knee flexion and extension, and roentgenographic evaluation. The findings in this study suggest that patellar resurfacing can offer the patient a superior knee with regard to pain relief and strength.

Precision oblique osteotomy for shortening of the ulna

The obstacles of prolonged healing time and technically demanding osteotomy and plate fixation in the performance of ulnar shortening osteotomies have been overcome by a precision system that includes a 45 degrees osteotomy and 2.7 mm interfragmentary lag screw. In 23 transverse osteotomies healing time averaged 21 weeks with one nonunion. In 17 precision oblique osteotomies healing time averaged a substantially shorter 11 weeks. Biomechanical data obtained from cadaveric testing comparing these two constructs demonstrated a structural stiffness that was clearly greater in torsion testing for the oblique osteotomy. No biomechanical difference was identified in the anteroposterior and lateral bending tests. The system permits the reliable performance of two parallel osteotomy cuts, allowing the removal of a precise amount of bone. The compression device and specialized plate permit easy coaptation of the osteotomy surfaces, which are locked into position by a precise 22 degrees interfragmentary lag screw. The surgical procedure is more quickly completed, and the frustration of this previously challenging procedure is now completely removed.

Closed functional treatment of fractures

1 The Rationale of Closed Functional Treatment of Fractures.- 1.1 Immobilization is Unnatural.- 1.2 Function is Natural.- 1.3 Function with Rigid Fixation.- 1.4 Minimizing Interference with the Natural Process.- 1.5 Clinical Management.- 1.6 Indications and Contraindications.- 1.6.1 Shortening and Angulation.- 1.6.2 Bracing as an Adjunct to Internal Fixation.- 1.6.3 Open Fractures.- 1.6.4 Fracture Reduction and Vascular Complications.- Summary.- 2 The Scientific Basis of Closed Functional Management of Fractures.- 2.1 The Role of Vascularity in Fracture Healing.- 2.2 Biochemical Changes Related to Endochondral Ossification.- 2.3 Fracture Callus Architecture.- 2.4 The Effects of Immobilization on Fracture Healing.- 2.5 Stability of Fractures.- 2.6 Anatomic Considerations.- 2.7 Material Considerations.- 3 Fractures of the Tibia.- 3.1 Anatomy and Function.- 3.2 Shortening and Angulation.- 3.3 The Tibial Fracture with an Intact Fibula.- 3.3.1 Angulatory Deformities.- 3.4 The Tibial Fracture with an Associated Fibular Fracture.- 3.5 Management Protocol.- 3.5.1 Stage One.- 3.5.2 Stage Two.- 3.5.3 Stage Three.- 3.6 Application of Casts and Braces.- 3.6.1 The Above-the-Knee Cast.- 3.6.2 The Functional Below-the-Knee Cast.- 3.6.3 The Plaster-of-Paris Below-the-Knee Functional Brace.- 3.6.4 The Plastic Below-the-Knee Functional Brace.- 3.6.5 Prefabricated Braces.- 3.7 Mechanical Function of the Brace.- 3.8 Brace-Soft Tissue Design.- 3.9 Materials and Mechanics.- 3.10 Clinical Experience.- 3.10.1 Fractures of the Proximal Tibia.- 3.10.2 Mid-diaphyseal Tibial Fractures with an Intact Fibula.- 3.10.3 Fractures of the Distal Third of the Tibia with an Intact Fibula.- 3.10.4 Fractures of the Proximal Tibia with Associated Fibular Fracture.- 3.10.5 Diaphyseal Tibial Fractures with Associated Fibular Fractures.- 3.10.6 Short Oblique Fractures of the Tibia.- 3.10.7 Distal Metaphyseal Fractures of the Tibia.- 3.10.8 Segmental Fractures of the Tibia.- 3.10.9 Bilateral Tibial Fractures.- 3.10.10 Open Tibial Fractures.- Clinical Data.- 4 Tibial Condylar Fractures.- 4.1 The Mechanical Role of the Fibula.- 4.2 Clinical Considerations.- 4.3 Clinical Management.- 4.3.1 Application of the Brace.- 4.4 Clinical Experiences.- 4.5 Bicondylar Fractures with Associated Fibular Fracture.- 4.6 Medical Condylar Fractures.- 4.7 Bicondylar Fractures with an Intact Fibula.- 4.8 Lateral Condylar Fractures with an Intact Fibula.- 5 Fractures of the Femur.- 5.1 Femoral Fracture Bracing.- 5.2 Application of the Functional Brace.- 5.3 Clinical Experience.- Clinical Data.- 6 Fractures of the Distal Radius.- 6.1 Management.- 6.2 Application of the Brace.- 6.3 Clinical Experience.- Clinical Data.- 7 Fractures of the Forearm.- 7.1 Fractures of Both Bones of the Forearm.- 7.1.1 Management.- 7.1.2 Application of the Brace.- 7.2 Clinical Experience with Fractures of Both Bones of the Forearm.- Clinical Data.- 7.3 Isolated Radial Fractures.- 7.3.1 Application of the Brace.- 7.4 Isolated Fractures of the Radius: Clinical Material.- Clinical Data.- 7.5 Isolated Ulnar Fractures.- 7.5.1 Management.- 7.6 Application of the Ulnar Sleeve.- 7.6.1 Clinical Material.- 7.7 Bilateral Ulnar Fractures.- 7.8 Segmental Isolated Fractures of the Ulna.- Clinical Data.- 8 Fractures of the Humeral Shaft.- 8.1 Humeral Shaft Fractures.- 8.2 Management.- 8.3 Clinical Experience.- 8.4 Bilateral Humeral Fractures.- Clinical Data.- 9 Delayed Unions and Nonunions of the Tibia.- 9.1 Delayed Unions and Nonunions of the Tibia.- 9.2 Clinical Experience.- 9.3 Infected Nonunions.- Clinical Data.- 10 Fractures in Children.- 10.1 Fractures in Children.- 10.2 Management.- 10.3 Clinical Experience.- 10.3.1 Tibial Fractures.- 10.3.2 Femoral Fractures.- 10.3.3 Forearm Fractures.- Clinical Data.

Minimal versus maximal plate fixation techniques of the ulna: the biomechanical effect of number of screws and plate length.

Objective To test the hypothesis that longer plates with the minimum number of screws provide equivalent or superior strength of fixation to standard compression plating using the maximum number of screws. Design Prospective analysis of biomechanical data was performed. Setting In vitro experimentation. Interventions A reproducible osteotomy was made in formalin-fixed ulnae. The osteotomies were stabilized employing six-, eight-, or ten-hole plates with two screws in the outermost holes and two screws in the innermost holes, and compared to stabilization with a six-hole plate with six screws. Main Outcome Measure Four-point mechanical testing to failure was performed in both apex–dorsal (tension-band) or medial–lateral bending modes. Load–displacement curves were obtained. Results All of the longer plates with the minimum number of screws were stronger than the six-hole plate with six screws when tested in the medial–lateral and the tension–band mode. The eight-hole plate with four screws, however, was statistically inseparable from the fully loaded six-hole plate. There was no statistical difference between any of the configurations in regard to the stiffness of the fixation. Conclusions In a cadaveric ulnar osteotomy model stripped of soft tissue, the number of screws is less important than the length of the plate in providing bending strength to the construct.

Computed tomography evaluation of stability in posterior fracture dislocation of the hip.

Measurements of the percentage of remaining posterior acetabulum on computed tomography (CT) scan (the Acetabular Fracture Index) in posterior fracture dislocations of the hip were evaluated to determine the stability of the joint. All hips with less than 34% of the remaining posterior acetabulum were unstable. Hips with greater than 55% were stable. Between these values, hips were either stable or unstable. A statistical analysis demonstrated highly significant differences in the average remaining posterior acetabulum between the stable and unstable group. These findings were based on a review of 26 patients with posterior fracture dislocations of the hip (Epstein Type I-IV injuries) combined with CT scan analysis. The clinical status of hip stability was correlated with the Acetabular Fracture Index, and this provided the basis for the study. A simple linear measurement of the remaining posterior acetabulum on CT (the Approximate Acetabular Fracture Index) can be done easily by a physician, and this closely approximates the true remaining acetabular arc. Seven of ten unstable hips in 31 Epstein Type I-V patients showed femoral head subluxation of 0.5 mm or more on CT scan, whereas none of the 21 stable hips had demonstrable subluxation. Risk analysis provided a means of predicting hip stability for individual patients.

Diaphyseal Humeral Fractures: Treatment Options

All of the current modalities have a place in the treatment of diaphyseal humeral fractures. Functional bracing renders a high rate of union and seems to be a safe method of treatment for most closed fractures. Type II and III open fractures seem to respond best to plate fixation or external fixation, particularly when there are associated neural or vascular pathologic findings. Patients with polytrauma who are unable to walk are also best treated with plate fixation. Plate fixation is also the best method of treatment when adequate alignment cannot be obtained with nonsurgical methods. Intramedullary nailing remains controversial because its complication rate is higher than that associated with either plate fixation or functional bracing. None of the treatments described is a panacea, and complications may occur with each one of them. An appropriate appreciation of the biologic response to the three modalities; an understanding of the indications, contraindications, and possible complications of the treatments; and a mastery of the techniques of application are essential for the attainment of satisfactory clinical results.