P Rommens

Retrograde locked nailing of humeral shaft fractures. A review of 39 patients

We treated 39 patients with fractures of the humeral shaft by closed retrograde locked intramedullary nailing, using Russell-Taylor humeral nails. The mean healing time of all fractures was 13.7 weeks. After consolidation, shoulder function was excellent in 92.3% and elbow function excellent in 87.2%. Functional end-results were excellent in 84.6% of patients, moderate in 10.3% and bad in 5.1%. One patient had a postoperative radial nerve palsy, which recovered within three months. There was additional comminution at the fracture site in three patients (7.7%) which did not affect healing, and slight nail migration in two older patients (5.1%). Two patients (5.1%) needed a second procedure because of disturbed fracture healing. One screw breakage was seen in a patient with delayed union. Retrograde locked humeral nailing appears to be a better solution for the stabilisation of fractures of the humeral shaft than anterograde nailing or plate and screw fixation. We found the complication rate to be acceptable and shoulder and elbow function to recover rapidly in most cases.

Radiation exposure to the hands and the thyroid of the surgeon during intramedullary nailing

During 41 procedures of intramedullary nailing of femoral and tibial fractures, the primary surgeon and the first assistant wore ring dosimeters on their dominant index fingers. While the average fluoroscopy time per procedure was 4.6 min, the average dose of radiation to the dominant hand of the primary surgeon was 1.27 mSv and 1.19 mSv to the first assistant. The dose limit for the extremities is 500 mSv per year, as recommended by the International Commission on Radiological Protection. Extrapolation of the mean dose of the primary surgeon and first assistant per procedure of 1.23 mSv leads to the result that the recommended dose limit of 500 mSv would only be exceeded if more than 407 intramedullary nailing procedures are carried out per year. The duration of fluoroscopy time correlated with the radiation dose to the hands of the surgeons, though it was determined by phantom measurements that the majority of radiation exposure occurred during brief exposures of the hands in the direct X-ray beam on the X-ray tube near side of the patient. In order to assess the surface doses of the thyroid gland to the primary surgeon with and without a lead shield, we performed in vitro measurements during operative procedures of the lower leg simulating different intraoperative situations under fluoroscopic control. The average registered ionizing dosage without a thyroid shield was approximately 70 times higher than with thyroid lead protection. In a previous study we found average fluoroscopy times during intramedullary nailing of the tibia and femur of 4.6 min per procedure. Extrapolation of this value leads to the result, that even when 1000 intramedullary nailings were carried out without wearing lead protection, only 13 per cent of the dose limit recommended by the International Commission on Radiological Protection for the thyroid of 300 mSv per year would be reached; by wearing the lead protection only 0.2 per cent of the recommended dose would be reached.

Humeral nailing revisited

Unreamed interlocked humeral nailing for stabilisation of acute humeral fractures was introduced a decade ago. Antegrade and retrograde nail insertion are equally popular. The role of nailing as opposed to plating of humeral fractures is the subject of continuous debate. Between 1997 and 2005, 99 acute fractures of the humeral shaft were treated operatively with the unreamed humeral nail (UHN, Synthes) in our Level I Trauma Centre. The mean age of the patients was 63 years. Only eight patients (8.1%) were polytraumatised, nine patients had an open fracture (9.1%), five had a primary radial nerve palsy (5.1%). There were 54 antegrade and 45 retrograde nailings. The procedures were performed by 19 different surgeons, who carefully followed a detailed operation protocol. There were 6 adverse events: 3 secondary radial nerve palsies (3%), 2 fissures at the insertion point (2%) and one false placement of a locking screw (1%). Three patients developed pseudarthrosis (3%). Eight further operation were necessary (8.1%): 3 exploration of the radial nerve, 3 for treatment of pseudarthrosis, one replacement of a locking screw and one wound revision for superficial wound infection. Ninety patients (92 fractures) were evaluated after bone healing. Shoulder function was assessed using the Constant Score, elbow function with the Mayo Elbow Score. 91.3% and 5.4% of patients had an excellent or good shoulder function, 81.5% and 14.1% had an excellent or good elbow function. All patients with a functional deficit of the shoulder joint had antegrade, all patients with a deficit at the elbow joint retrograde nailing. Motor function recovered in all radial nerve palsies. 93.5% of patients had an excellent or good functional end result. Unreamed humeral nailing is a valid therapeutic option for stabilisation of acute humeral shaft fractures. Antegrade and retrograde nailing are associated with specific but different complications. By strictly adhering to the operation technique, the number and severity of complications can be reduced. When good fracture alignment and stability are obtained, uneventful bone healing with good functional outcome is the rule.

Surgical management of osteoporotic pelvic fractures: a new challenge

The number and variety of osteoporotic fractures of the pelvis are rapidly growing around the world. Such fractures are the result of low-impact trauma. The patients have no signs of hemodynamic instability and do not require urgent stabilization. The clinical picture is dominated by immobilizing pain in the pelvic region. Fractures may be located in both the ventral and the dorsal pelvic ring. The current well-established classification of pelvic ring lesions in younger adults does not fully reflect the criteria for osteoporotic and insufficiency fractures of the pelvic ring. Most osteoporotic fractures are minimally displaced and do not require surgical therapy. However, in some patients, an insidious progress of bone damage leads to complex displacement and instability. Therefore, vertical sacral ala fractures, fracture dislocations of the sacroiliac joint, and spinopelvic dissociations are best treated with operative stabilization. Angular stable bridge plating, the insertion of a transsacral positioning bar, and iliolumbar fixation are operative techniques that have been adapted to the low bone mineral density of the pelvic ring and the high forces acting on it.

Retrograde nailing of humeral shaft fractures with the UHN. An international multicenter survey

SummaryCombined with the new unreamed humeral nail (UHN) (Synthes®), the retrograde approach to the endomedullary canal of the humeral shaft promises careful reduction and fixation of humeral shaft fractures. This prospective multicenter study reports and analyses 102 retrograde nailings with the UHN and their operative procedures. Seven patients with pathological fractures have died meanwhile, but 75 patients could be followed up until bone healing. Seventy-three fresh humeral shaft fractures, 12 pseudarthrosis, 3 refractures and 14 pathological fractures have been treated with the UHN. In 98 cases (96.1 %) the surgeon estimated fracture stability well enough to initiate immediate postoperative elbow and shoulder mobilization. The difficulties involved with free-hand interlocking proximally at the nail tip in 5.9 %, fissure or avulsion at the insertion point in 3.9 % and radial nerve palsy also in 3.9 % of the cases were the most important intraoperative complications. In all 75 patients followed up, bone healing occurred, but five fractures (6.7 %) needed more than 8 months connected with a second operative procedure. In one case spongious bone transplantion and new locking bolts had been performed. In three cases a special compression device has been used, whereas in one case also a new nail and in the second spongious bone transplantion had been added. In the fifth case plate osteosynthesis had been performed. At the end of treatment 89.4 % of the patients had excellent shoulder function and 88.0 % excellent elbow function. Once the indication for surgery is established, the UHN can be considered a reliable and safe implant for stabilizing humeral shaft fractures.ZusammenfassungDer retrograde Zugang zur Markhöhle des Humerusschaftes verspricht eine für Gelenke, Nerven und Weichteile schonende Repositon und Fixation von Humerusschaftfrakturen bei Verwendung des neuen speziell hierfür konzipierten unaufgebohrten Humerusverriegelungsnagels (UHN) (Synthes). Im Rahmen einer prospektiven multizentrischen Studie wurden 102 retrograde Nagelungen mit diesem Implantat aufgezeichnet und ausgewertet; 7 Patienten mit pathologischen Frakturen verstarben, 75 Patienten konnten bis zur Knochenheilung verfolgt und nachuntersucht werden. Insgesamt wurden in dieser Studie 73 frische Humerusschaftfrakturen, 12 Pseudarthrosen, 3 Refrakturen und 14 pathologische Frakturen berücksichtigt. In 98 Fällen (96,1 %) bewerteten die Operateure die Frakturversorgung mit dem UHN als ausreichend stabil, um postoperativ sofort mit Schulter- und Ellenbogenmobilisation zu beginnen. Bedeutsamste intraoperative Komplikationen waren Schwierigkeiten bei der proximalen Freihandverriegelung (5,9 %), Fissuren oder Aussprengungen an der Nageleintrittsstelle (3,9 %) und Paresen des N. radialis (3,9 %). Bei sämtlichen 75 Patienten, die prospektiv weiter verfolgt werden konnten, kam es zur Frakturheilung. Allerdings benötigten 5 Frakturen mehr als 8 Monate. Bei diesen 5 Patienten (6,7 %) wurde in 1 Fall eine Spongiosatransplantation und eine neue distale Verriegelung durchgeführt. In 3 Fällen wurde ein Kompressionsgerät benutzt, wobei in 1 Fall ein neuer Nagel und in 1 Fall zusätzliche Spongiosatransplantation notwendig wurden. Im 5. Fall wurde eine Plattenosteosynthese ausgeführt. Bei Behandlungsabschluß lag in 89,4 % der Fälle eine exzellente Schulterfunktion und in 88,0 % eine exzellente Ellenbogenfunktion vor. Eine Indikation zur operativen Versorgung vorausgesetzt, kann der UHN als sicheres und ausgereiftes Implantat zum Einsatz bei Humerusschaftfrakturen empfohlen werden.

Intrinsic problems with the external fixation device of Hoffmann-Vidal-Adrey: a critical evaluation of 117 patients with complex tibial shaft fractures

In the 1978-1986 period, 117 patients with 119 fresh and complex fractures of the lower leg were secured primarily with a Hoffmann-Vidal-Adrey external fixation device. Ninety-five fractures could be followed until bony consolidation. In 12 fractures (12.7%) a pseudarthrosis developed, and a deep infection in four (4.2%). The external fixation device was attached for an average time of 25.0 weeks. Pin loosening was seen in seven patients (7.3%), minor pin-tract infection in nine (9.4%), and major pin-tract infection in three patients (3.1%). Fourteen fractures needed a secondary internal fixation; in 17 other fractures a secondary transplantation of cancellous bone autografts without internal fixation was carried out. After healing of the soft tissues, the tibial fracture can be regarded as a closed one and other therapeutic procedures to accelerate bony consolidation should be taken into account. The advantages and disadvantages of a second internal stabilization should be evaluated for every fracture with bone healing problems. The alteration from external to internal fixation makes an early removal of the external fixator possible and prevents in this way the intrinsic problems combined with this fixation type such as delayed union, nonunion, pin loosening, or pin-tract infection.

Die proximale extraartikuläre Tibiafraktur

ZusammenfassungDie Stabilisierung proximaler extraartikulärer Tibiafrakturen stellt unter Verwendung der gebräuchlichen Osteosyntheseverfahren unverändert ein Problem dar. Die Wahl des Operationsverfahrens hängt unter anderem von der Situation der oftmals erheblich kompromittierten frakturumgebenden Weichteile ab. An der proximalen Tibia besteht zusätzlich das Problem von Fehlstellungen der Fraktur. Neben der Gefahr einer intraoperativen Frakturdislokation durch Muskelzug und den operativen Zugang kommt es gehäuft zu sekundären Fehlstellungen durch relative Implantatinstabilität.Es wurden verschiedene Verfahren zur Versorgung dieser Frakturen entwickelt; sie zeichnen sich durch differierende biomechanische Eigenschaften aus, erfordern unterschiedliche Operationstechniken und werfen ihrerseits spezifische Probleme auf.Insbesondere die neueren winkelstabilen Implantate (z. B. LISS = “less invasive stabilization system”) bieten entscheidende Vorteile gegenüber den instabileren konventionellen Plattenosteosynthesen und externen Fixationssystemen. Die Verbesserung der bisher üblichen Geometrie intramedullärer Kraftträger sowie die Einführung von Winkelstabilität im Bereich der proximalen Verriegelungsschrauben (PTN = “proximaler Tibianagel”) lassen dieses Verfahren theoretisch als biomechanisch optimale Lösung erscheinen. Vor dem Hintergrund eigener klinischer Erfahrungen und biomechanischer Untersuchungen werden Lösungsmöglichkeiten für diese spezielle Problematik aufgezeigt und bewertet.AbstractOperative stabilization of proximal tibial fractures by use of conventional osteosynthesis is still problematic. The choice of the osteosynthetic treatment is strongly influenced by the situation of the surrounding soft tissue. Additional problems in this particular location may occur with malalignment in the fracture site after operation. Primary intraoperative malalignment may occur due to dislocating muscle forces or to the operative approach itself. Secondary dislocation is mainly due to the unstable fixation of the proximal fragment by the implant.Today many different implants with specific biomechanical properties are available. Each system requires a particular operative technique and can lead to individual implant-related problems.The new angle stable implant systems (e. g. LISS = “less invasive stabilization system”), offer significant advantages over conventional plate osteosyntheses and external fixation systems.Improvement of the geometry of standard intramedullary osteosyntheses and introduction of angle stability in the proximal interlocking screws (PTN = “proximal tibial nail”) seemingly make this system the optimal solution, concerning biomechanics.On the background of our own clinical experiences and biomechanical investigations, the article discusses solutions for this particular problem.

The benefit of multislice CT in the emergency room management of polytraumatized patients.

Abstract The early treatment of polytraumatized patients needs an effective and standardized approach. Reducing time requirements for the primary diagnostic evaluation is a major concern in the early phase of polytrauma management. Multislice-CT (MSCT) is a quick and reliable method for the initial diagnostic evaluation. Computed tomography provides more detailed and more consistent information than conventional radiography. It has the great advantage of allowing rapid examination of the head, vertebral column, chest, abdomen and pelvis during one single examination. The CT-suite needs to be adequately equipped for resuscitation and reanimation, which is done parallel to the radiological investigations. Since polytrauma management is based on a multidisciplinary approach characterized by a coordinated interaction between trauma surgeons, anaesthesiologists and radiologists, members of all involved disciplines need adequate teaching. Guidelines and algorithms contribute to optimize the early management.

Fragility fractures of the sacrum: how to identify and when to treat surgically?

The increasing prevalence of fragility fractures of the sacrum (FFS) occurring predominantly in osteoporotic individuals poses a diagnostic and therapeutic challenge. The clinical presentation varies from longstanding low back pain without the patient remembering a traumatic event to immobilized patients after suffering a low-energy trauma. FFS are often combined with a fracture of the anterior pelvic ring; hence they are classified as a part of fragility fractures of the pelvis (FFP). If not displaced, the patients are treated with weight bearing as tolerated and analgesics; however, we advocate to treat displaced fractures surgically according to the fracture personality and the patient’s comorbidities. Surgical options include minimal invasive sacro-iliac screws, trans-sacral bar osteosynthesis, open reduction and internal fixation, or spinopelvic stabilization. In the light of the high complication rate associated with immobilized patients, an operative approach often is indicated to accelerate the patient’s mobility.

Pigmented villonodular synovitis of the shoulder: review and case report.

Abstract Pigmented villonodular synovitis (PVNS) as reviewed in detail elsewhere most frequently involves the knee and finger synovial structures; shoulder involvement is rare: A search through the English literature yielded 18 publications describing 25 cases of PVNS affecting the shoulder joint. Analyzing these reports we found the clinical and radiological findings generally to be nonspecific, often mimicking a malignancy, as in the case presented here of a 16-year-old boy with painful swelling in the area of the left proximal humerus. Magnetic resonance imaging showed a suspected malignant soft tissue mass involving the shoulder capsule and measuring 7.5 × 6 × 4 cm. Preoperatively the patient could recall no trauma; however, postoperatively he did report a distorsion trauma of the affected shoulder following a bicycle accident. Intraoperatively, two tumors were found infiltrating the axillary vessels and nerve and tendon structures originating in the capsule of the shoulder joint. Rapid sections of the tissue revealed no signs of malignancy; further pathohistological examination revealed localized PVNS. Preoperatively, the shoulder joint was not suspected as the primary site of origin of the tumor because the patient had no complaints or functional deficits of the shoulder. The clinical presentation of such a PVNS lesion over the proximal humerus is unusual and to date has only twice been described in the literature.