Faculty Bibliography

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

BACKGROUND: This study investigated which variables influence patients' return to sports after operative fixation of an unstable ankle fracture. MATERIALS AND METHODS: Over a 5-year period, 488 patients underwent surgical repair of an unstable ankle fracture. 243 patients preoperatively identified themselves as participating in vigorous activity. Clinical evaluation, functional outcome scores, and radiographic findings were reviewed retrospectively. RESULTS: At 3 months postoperatively, only 3% of all patients had returned to full sports. At 6 months, 14% of patients had returned, while at one year, only 24% of patients had returned. Younger age was predictive of return to sports by 3 months (p = 0.02), 6 months (p = 0.02) and 12 months (p = 0.0001). Males were more likely to return to sports at 6 (p = 0.001) and 12 months (p = 0.040). At 1 year, 88% of recreational athletes had returned to sports, while only 11.6% of competitive athletes had returned to sports (p = 0.043). At 12 months, bimalleolar injuries were more likely to return to sports than unimalleolar ankle fractures (p = 0.042). Furthermore, patients without an associated syndesmotic injury were more likely to return to athletic activities at 12 months (p = 0.011). A patient with an ASA of one or two was ten times more likely to return to sports versus a patient with an ASA of three or four (odds ratio > 10, p = 0.010). CONCLUSION: Predictors of return to sporting activities at one year include younger age, male gender, no or mild systemic disease, and a less severe ankle fracture. Negative predictors include older age, female gender, and the presence of severe medical comorbidities

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

Ankle syndesmosis injuries frequently occur with ankle fractures, but their treatment remains controversial. Although specific clinical and radiographic diagnostic measures are generally well-accepted, there remains a lack of consensus with respect to the treatment of these injuries. Controversy arises at almost every phase of treatment including: type of fixation (screw size, type of implant), number of cortices required for fixation, and need for hardware removal. Regardless of fixation technique chosen, the most important goal should be anatomic reduction and restoration of the syndesmosis and ankle mortise as this is the only significant predictor of functional outcome

Complex pertrochanteric fractures, such as those with reverse obliquity and subtrochanteric extension, represent a subset of hip fractures that sometimes is difficult to treat. Critical assessment of the available literature and a review of treatment indications, implant recommendations, and technical pitfalls will provide insight to physicians to enable better care of patients with these complex injuries

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 patient's 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 DeltaP < 30 mm Hg at some point during surgery. No patient had a DeltaP < 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 DeltaP may fall below the threshold of 30 mm Hg, this does not appear to lead to compartment syndrome

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

Objectives: High-energy tibial plateau fractures are complex injuries that have varying outcomes. Our purpose was to evaluate outcomes of operatively treated Schatzker type V and VI tibial plateau fractures and compare them to the radiographic results. Patients and methods: Eighty consecutive patients underwent operative treatment for Schatzker type V (21 fractures) or type VI (62 fractures) tibial plateau fractures. There were 64 closed (77.1%) and 19 open fractures (22.9%), with 11 extremities (13.3%) having compartment syndrome. Fifteen patients (18.8%) with 18 fractures were lost to follow-up. Finally, 65 patients with 65 extremities were available for clinical and radiographic examinations after a mean follow-up of 17 months (range 10 to 40 months). Functional assessments were made using the WOMAC (Western Ontario and McMaster Universities Arthritis Index) questionnaire. Results: The mean range of knee motion at the latest follow-up was 1 degrees (0 degrees to 20 degrees) - 115 degrees (60 degrees to 140 degrees) and the mean WOMAC score was 76.6+/-55. Radiographically, 15 knees (23.1%) had evidence for collapse and I I patients (16.9%) had evidence for post-traumatic arthritis. Both loss of fracture reduction (p=0.001) and arthritic changes (p=0.04) were associated with a poorer functional score on the WOMAC. Complications included five deep wound infections (7.7%), two nonunions (3.1%), and 10 patients required additional unplanned surgery (15.4%). Conclusion: Early loss of surgical reduction and development of radiographic evidence for arthritic changes are predictors of functional scores in Schatzker type V and VI tibial plateau fractures

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