Toni M. McLaurin

Bridging external fixation and supplementary Kirschner-wire fixation versus volar locked plating for unstable fractures of the distal radius: A RANDOMISED, PROSPECTIVE TRIAL

We performed a prospective, randomised trial to evaluate the outcome after surgery of displaced, unstable fractures of the distal radius. A total of 280 consecutive patients were enrolled in a prospective database and 88 identified who met the inclusion criteria for surgery. They were randomised to receive either bridging external fixation with supplementary Kirschner-wire fixation or volar-locked plating with screws. Both groups were similar in terms of age, gender, hand dominance, fracture pattern, socio-economic status and medical co-morbidities. Although the patients treated by volar plating had a statistically significant early improvement in the range of movement of the wrist, this advantage diminished with time and in absolute terms the difference in range of movement was clinically unimportant. Radiologically, there were no clinically significant differences in the reductions, although more patients with AO/OTA (Orthopaedic Trauma Association) type C fractures were allocated to the external fixation group. The function at one year was similar in the two groups. No clear advantage could be demonstrated with either treatment but fewer re-operations were required in the external fixation group.

Are Outcomes of Bimalleolar Fractures Poorer Than Those of Lateral Malleolar Fractures with Medial Ligamentous Injury

BACKGROUND Recommendations for surgical treatment and expected outcomes differ for two unstable patterns of supination-external rotation ankle injuries. We compared the demographic characteristics and functional outcome following surgical stabilization between the two types of supination-external rotation type-4 fractures: distal fibular fracture with a deltoid ligament rupture and bimalleolar fracture. METHODS Demographic data on 456 patients in whom an unstable fracture of the ankle was treated surgically were entered into a database and the patients were prospectively followed. Two hundred and sixty-six of these patients sustained either a bimalleolar fracture or a lateral malleolar fracture with insufficiency of the deltoid ligament and widening of the medial clear space. No medial fixation was used in the patients with a deltoid ligament injury. All patients followed a similar postoperative protocol. The patients were followed clinically and radiographically at three, six, and twelve months after the surgery. Function was assessed with the Short Musculoskeletal Function Assessment and the American Orthopaedic Foot and Ankle Society score. RESULTS Bimalleolar fractures were more commonly seen in female patients, in those older than sixty years of age, and in patients with more comorbidities. There was no significant association between the fracture pattern and either diabetes or the length of the hospital stay. At a minimum of one year postoperatively, the patients with a bimalleolar fracture had significantly worse function, even after we controlled for all other variables. The overall complication rate, including elective hardware removal, was also higher in the group with a bimalleolar fracture (seventeen compared with nine patients). CONCLUSIONS At one year after surgical stabilization of an unstable ankle fracture, most patients experience little or mild pain and have few restrictions in functional activities. However, the functional outcome for those with a bimalleolar fracture is worse than that for those with a lateral malleolar fracture and disruption of the deltoid ligament, possibly because of the injury pattern and the energy expended.

Fixation of extra-articular distal humerus fractures using one locking plate versus two reconstruction plates: a laboratory study.

OBJECTIVE To compare the strength and stiffness of standard double-plate fixation with that of a single-locking plate for comminuted extra-articular distal humeral fractures. MATERIALS Eight matched pairs of humeri were used. One of each pair was fixed with two 3.5-mm standard reconstruction plates applied dorsally; the other was fixed with one precontoured locking plate applied to the posterior aspect of the lateral column. A 1-cm gap was created to simulate a distal fracture model with 100% metaphyseal comminution with no bony apposition. Stiffness testing of these constructs was performed in axial compression, anterior, posterior and lateral bending, and torsion. They were then cyclically loaded for 4000 cycles with 60 N in posterior bending and the stiffnesses retested. Finally, each construct was posteriorly loaded to failure to determine its ultimate strength. RESULTS The double-plate construct was significantly stiffer than the one locking plate construct in anterior bending (39%; p = 0.02), posterior bending (23%; p = 0.04), and lateral bending (60%; p = 0.01). No significant stiffness differences were seen in axial compression and torsion (p = 0.64 and 0.25, respectively). After cyclic loading, all construct stiffnesses were relatively unchanged. Both construct types had similar failure strengths (p = 0.76) of approximately 400 N. CONCLUSIONS Double-plating provides a more rigid fixation than a single-locked plate for fixation of extra-articular comminuted distal humeral fractures. This could be clinically relevant in situations with 100% comminution as seen in gun shot injuries.

The effect of knee-spanning external fixation on compartment pressures in the leg.

Objectives: External fixation is frequently used for provisional and/or definitive stabilization of open and closed fractures and dislocations involving the lower extremity. There is some concern, however, that application of an external fixator with subsequent reduction of the fractures with distraction may precipitate the development of compartment syndrome. The hypothesis of this study was that application of external fixation and restoration of limb length would have no effect on the compartment pressures. Design: Prospective cohort study. Setting: Academic medical center, 2 level 1 trauma centers. Patients: Between October 2003 and May 2006, 25 patients who met inclusion criteria and underwent immediate knee-spanning external fixation. Intervention: All 4 compartments of the injured leg were measured with a Solid-State Transducer Intra Compartment device or an arterial line set-up during the temporizing procedure at 4 different time points. In addition, at the time each pressure reading was taken, the patients diastolic pressure was recorded from the anesthesia monitor. Main Outcome Measurement: Elevation of compartment pressure at any of 4 distinct time points during the procedure. Each of the compartments was measured and recorded 4 times: (1) after the patient had been draped but before any fixation or reduction of the fracture, (2) immediately after the insertion of the fixator pins, (3) immediately after reduction of the fracture, and (4) 5 minutes after the reduction. A threshold of less than 30 mm Hg differential from diastolic pressure in conjunction with clinical examination was set as an indication for 4-compartment fasciotomy. Results: Twenty-five patients with a mean age of 52 years (range, 21-69 years) were enrolled in the study. Injuries included proximal tibial fractures (Orthopaedic Trauma Association types, 41) in 21 patients; knee fracture-dislocation (Moore type II) in 2 patients, and knee (femoro-tibial) dislocations in 2 patients. Two fractures were open, and all other injuries were closed. Fasciotomy was required in 3 cases at initial compartment measurement. In the remaining 22, there were no significant trends toward increased compartment pressures as a result of external fixation placement and knee reduction. There were 9 patients (41%) who had a transient ΔP < 30 mm Hg at some point during surgery. No patient had a ΔP < 30 mm Hg sustained through the conclusion of the procedure, and no compartments were released in any of these patients. None of the patients in the study developed compartment syndrome after surgery, and no sequelae of compartment syndrome were noted at minimum 6-month follow-up. Conclusions: Application of knee-spanning external fixation as a temporary measure for stabilization of high-energy proximal tibial fractures and dislocations may result in transient elevation of intracompartmental pressure of the leg. Although ΔP may fall below the threshold of 30 mm Hg, this does not appear to lead to compartment syndrome.

Superstorm Sandy's forgotten patient: A lesson in emergency preparedness in severe obesity

Superstorm Sandy gained national attention in late 2012 after its impact on the Northeastern US. In New York City, thousands of residents lost power, and multiple hospitals were forced to evacuate. Bellevue Hospital Center (BHC), the nations oldest public hospital, was forced to close for the first time in over 275 years. Two patients remained in BHC three days after the primary evacuation without water service and minimal power. Herein, we describe the challenges associated with evacuating a severely obese patient. Obesity management is challenging and at an institutional level must be addressed in emergency preparedness plans.

Incarceration of the radial head associated with a radial head fracture, radiocapitellar dislocation, and proximal radioulnar translocation.

We present a case report of an individual who sustained a locked proximal radioulnar joint fracture-translocation after a mechanical fall. After a failed attempt at closed reduction, intraoperative exploration revealed that the dislocated and fractured radial head was incarcerated along the medial aspect of the coronoid. After open reduction and internal fixation, the patient went on to uneventful healing and return of adequate function. To our knowledge, this is the first case report documenting an incarcerated fracture-translocation along the radiocapitellar and proximal radioulnar joints that required operative treatment.

Intra- and periarticular heterotopic ossification in the knee after a low-velocity gunshot wound treated with retrograde intramedullary nailing of the femur.

This is a case of a 32-year-old man who developed intra- and periarticular heterotopic ossification (HO) after sustaining a low-velocity gunshot wound to the femur treated with intramedullary nailing of the fracture using a retrograde technique. The association between HO after a high-velocity gunshot wounds is well established. In addition, there have been two case reports of intra-articular HO after retrograde intramedullary femoral nailing. However, HO in and around the knee after a low-velocity gunshot wound has not been reported and may be more common than initially thought.

Overlapping Dislocation of the Pubic Symphysis with an Open Reduction and Anterior and Posterior Pelvic Ring Fixation

Case:We present a case of a patient who sustained overlapping dislocation of the pubic symphysis (ODPS), which required an open reduction as well as anterior and posterior pelvic ring fixation. Conclusion:This case report is a valuable addition to the current literature on ODPS because we believe it to be the first report describing a patient who required both anterior and posterior fixation because of pelvic instability.

Unimalleolar Ankle Fracture: Lateral Malleolus Only/Supination External Rotation (SER) 4

A 64-year-old female with well-controlled type II diabetes sustained an injury to her right ankle when she slipped and fell on ice. She noted immediate right ankle pain and deformity, was unable to bear weight, and had diffuse swelling and ecchymosis throughout her ankle and tenderness to palpation over the lateral malleolus with no tenderness medially. Radiographs showed a long oblique lateral malleolus fracture at the level of the syndesmosis with a comminuted posterior malleolus fracture involving less than 10% of the articular surface and an incongruent tibiotalar joint with lateral subluxation of the talus seen on the mortise view. She was diagnosed with a Lauge-Hansen supination external rotation IV ankle fracture (SER IV) and underwent open reduction and internal fixation of this injury using lag-screw fixation and neutralization plating of the fibula with placement of a syndesmotic screw.

Treatment of Tibia Malunion with Circular External Fixation

A 33-year-old man presents with the complaint of a long-standing right ankle deformity due to a missed physeal injury sustained around age 11 or 12 that had resulted in a distal tibial deformity. He tolerated this deformity for over 15 years until he recently began noticing increasing problems with his gait and balance as well as an occasional sensation of his ankle giving way. He presented with the question of whether or not anything could be done for this chronic but worsening problem. Multiple options were discussed and he elected to proceed with correction of his tibial malunion using computer-assisted circular ring external fixation.