不稳定型锁骨骨折的内固定术治疗

目的:探讨不稳定型锁骨骨折不同治疗方法的临床疗效。方法:15例锁骨骨折病人,应用钢板及重建钢板8例,钢针加钢丝6例,非手术治疗1例。据骨折愈合时间、质量,肩关节功能情况综合评价疗效。结果:15例随访6月～3年,骨折愈合2～4个月。3例出现畸形,无骨不愈合,12例肩关节功能优,3例良。结论:不稳定锁骨骨折,手术治疗能使病人尽快恢复正常功能且并不明显增加并发症。

锁骨钩钢板治疗锁骨远端骨折疗效观察

目的 探讨锁骨钩钢板在治疗锁骨远端骨折治疗中的疗效。方法 回顾总结采用锁骨钩钢板治疗锁骨远端骨折(NeerII型)26例。结果 26例锁骨远端骨折(NeerII型)术后随访,随访3--48个月,平均24个月。根据karlsson疗效标准,优:24例,良:2例,差:0例。结论 锁骨钩钢板治疗锁骨远端骨折操作简单,固定可靠,术后能早期功能锻炼,且肩锁关节保持了微动,是一种有效的手术方法,能使患者取得较好的效果。

Acute traumatic subclavian artery thrombosis and its successful repair via resection and end-to-end anastomosis

Subclavian artery thrombosis is a rare complication of clavicle fractures. We reported a 20-yearold man who was admitted to the emergency room after a road traffic accident. He was a pedestrian who was initially hit by a bus and after he fell down on the road, he was run over by a car. On evaluation, he was found to have multiple facial and rib fractures, distal fight humerus and right clavicle fracture. Significantly, right radial pulse was absent. After further evaluation including Doppler studies and an angiography which revealed complete obstruction of right subclavian artery just distal to its 1 st portion, the patient was urgently taken to the operation room. A midclavicular fracture was adjacent to the injured vessel. We established proximal and distal control, removed damaged part. After mobilizing the subclavian artery, an end-to-end anastomosis was made. Then open reduction and internal fixation of right distal humerus was performed. The rest of the postoperative course was unremarkable. To prevent complications of subclavian artery thrombosis, different treatment modalities can be used, including anticoagulation therapy, angioplasty, stenting and bypass procedures.

Sanders II-III calcaneal fractures fixed with locking plate in elderly patients

Purpose： To evaluate the clinical outcomes of locking calcaneal plate in treating calcaneal fracture （Sanders II-IIl） in elderly patients. Methods： From October 2012 to December 2013, 23 elderly patients suffering from calcaneal fracture （Sanders Ⅱ-Ⅲ） were treated and followed up. There were 15 males and 8 females with the mean age of 68.5 years （range： 65-79 years）. According to Sander＇s classification, 16 cases （16 feet） were type II fractures and 7 cases （7 feet） were type llI fractures. Anteroposterior, lateral and axial views of X-ray were taken to detect the calcaneum. CT scan was done to assess the amount of comminution and articular depression. Radiological assessment was performed using Bohler＇s angle and Gissane＇s angle. Functional outcome was assessed using the Maryland foot score. Results： All the patients were followed up for 13.7 months on average （10-20 months）. The mean time of bone union was 3.2 months （3-4 months）. The mean time of complete weight bearing was 3.2 months （3.1-4.0 months）. The soft tissue necrosis was found in 1 case. The mean Bohler＇s angle and Gissane＇s angle were 25.31° and 117.5° respectively. The overall excellent to good rate was 82.6%. Conclusion： Open reduction and internal fixation with locking calcaneal plate can obtain good functional outcome for Sanders II-III calcaneal fractures in elderly patients.

Dsteosynthesis with long volar locking plates for meta- physeal-diaphyseal fractures of the distal radius

Objective：Metaphyseal-diaphyseal fractures of the distal radius are a major treatment dilemma and orthopaedic surgeons have to pay due consideration to restoration of anatomy of distal radius together with rotation of the radial shaft and maintenance of radial bow and interosseous space.We performed this study to evaluate the clinic-radiological outcome of metaphyseal-diaphyseal fractures of the distal radius treated with long volar locking plates.Methods：This prospective study involved 27 patients （22 males and 5 females） with metaphyseal-diaphyseal fracture of the distal radius.Their mean age was （30.12±11.48） years （range 19-52 years） and the follow-up was 26.8 months （range 22-34 months）.All patients underwent open reduction and internal fixation with a long volar locking plate.According to AO/OTA classification,there were 7 type A3,13 type C2 and 7 type C3 fractures.Subjective assessment was done based on the disabilities of the arm,shoulder and hand （DASH） questionnaire.Functional evaluation was done by measuring grip strength and range of motion around the wrist and the radiological determinants included radial angle,radial length,volar angle and ulnar variance.The final assessment was done according to Gartland and Werley scoring system.Results：Postoperative radiological parameters were well maintained throughout the trial,and there was significant improvement in the functional parameters from 6 weeks to final follow-up.The average DASH scores improved from 37.5 at 6 weeks to 4.2 at final follow-up.Final assessment using Gartland and Werley scoring system revealed 66.67%（n=l8） excellent and 33.33% （n=9） good results.There was one case of superficial infection which responded to antibiotics and another carpel tunnel syndrome which was managed conservatively.Conclusion：Volar locking plate fixation for metaphyseal-diaphyseal fractures of distal radius is associated with excellent to good functional outcome,early rehabilitation and minimal complications.

Comparative prospective study between medial and lateral distal tibial locking compression plates for distal third tibial fractures

Purpose： Tibial fracture is the most common long bone fracture. Distal third tibial fractures are chal- lenging though open reduction and plating can result in anatomical reduction and rigid fixation. This paper aimed to evaluate and compare the results of medial and lateral locking compression plates for distal third tibial fractures. Methods： This prospective clinical study involved 36 patients with distal tibial fractures admitted in Department of Orthopaedics, Sawai Mansingh Medical College ＆ Affiliated Hospital, Jaipur, India, from June 2011 to May 2012, including 29 closed fractures and 7 open fractures at the mean age of 38.9 years. Thirty-six patients were divided equally into two groups based on treatment method, including medial plating group （18 patients） and lateral plating group （18 patients）. They were followed up for at least 5 months after discharge. The functional outcomes were evaluated using Tenny and Wiss clinical assess- ment criteria. Results： Malunion was found in 3 cases of medial plating group and in 1 case of lateral plating group. In the medial plating group, there were 5 cases of superficial infections, 1 deep infection, 1 nonunion and 3 wound dehiscence. In the lateral plating group, there was 1 case of superficial infections, 1 deep infection and 1 nonunion, in the lateral plating group, 4 patients reported feeling the plates and screws but none of them asked to remove the hardware. In the medial plating group, 9 patients reported symptomatic hardware problems and 7 asked to remove the hardware. The number of cases graded as excellent/good/ fair was 1/8/7 in the medial plating group and 3/7/7 in the lateral plating group respectively. In the medial plating group, the final range of motion was 17.2° in ankle dorsiflexion and 30.7° in ankle plantar flexion. In the lateral plating group, the final range of motion was 19° in ankle dorsiflexion and 34.2° in ankle plantar flexion. Conclusion： Lateral plating of distal tibia is safe and feasible, which can provide biological fixation and prevent the soft tissue complications associated with medial plating.

Treatment of distal femoral nonunion and delayed union by using a retrograde intramedullary interlocking nail

Objective: To analyze the causes of distal femoral nonunion and delayed union and assess the outcome of the corresponding treatment, retrograde intramedullary interlocking nail (RIIN). Methods: From June 1995 to December 1998, 15 patients (9 males and 6 females) with distal femoral nonunion and delayed union were treated with RIIN. The average age of the patients was 34.5 years (23 46 years). Bone grafting was performed in 10 patients, closed reaming was done in the other 5 patients. Correction osteotomy was performed in 2 patients, and intra articular release of knee adhesion in 11 patients. X ray examination and knee society clinical rating system (KSS) were used to evaluate the results. Results: All fractures were followed up for at least 9 months with average follow up duration of 14.5 months (9 33 months). Solid union was documented in all patients at 6.4 months on average. There were no infections or malunions in this series. Based on the final follow up data, acceptable functional range of motion (ROM) of over 90° was achieved in most patients. The average ROM was 93.5° with significant improvement of 28° ( 42.7 %, P< 0.05 ) compared with the preoperative ROM. The average knee score was 96. Excellent ROM emerged in 13 patients. The knee function score was 90.5 on average. Conclusions: The main causes of distal femoral nonunion and delayed union are improper indications and improper use of the implants. RIIN is an effective alternative for treatment of distal femoral nonunion and delayed union because it can provide a stable and reliable fixation which is beneficial for early functional exercise of knee. Bone grafting, closed reaming and intra articular release of knee adhesion should be considered in order to enhance the bone healing and improve ROM and the knee function.

Retrograde interlocking intramedullary nailing under arthroscopy for supracondylar femoral fracture

Objective: To evaluate the therapeutic effects of retrograde interlocking intramedullary nailing under arthroscopy on supracondylar femoral fractures. Methods: From June 1999 to December 2000, 17 patients with supracondylar femoral fracture were treated with arthroscopically assisted implantation of retrograde interlocking intramedullary nail and close reduction. Results: More than 6 month follow up study after operation in 11 patients revealed that the average healing time was 3 months. Average range of the knee motion for all the patients was more than 90 degrees. There was no implant breakage and infection. Conclusions: This new method, combining the advantage of arthroscope and retrograde interlocking intramedullary nail, can provide a stable and reliable fixation, and meanwhile is less invasive to the soft tissue and knee, less operative time and blood loss, minimal disruption of the blood supply in fracture site. It is conducive to the fracture healing and the functional recovery of the knee joint and worthwhile to be recommended.

Bilateral traumatic proximal humerus fractures managed by open reduction and internal fixation with locked plates

Fractures of the proximal humerus are uncommon in young patients.Although bilateral fracture of proximal humerus itself is rare,association with epilepsy and electrocution is frequent.Only one case of traumatic bilateral proximal humerus fracture has been reported in the literature.We report a rare case of bilateral traumatic displaced proximal humerus fractures in a 40 years old male patient,which was treated by means of open reduction and internal fixation with proximal humerus locked pates on both sides and obtained a good functional outcome.

Treatment of ipsilateral hip and femoral shaft fractures with reconstructive intramedullary interlocking nail

Objective: To evaluate the results of reconstructive intramedullary interlocking nail in the treatment of ipsilateral hip and femoral shaft fractures. Methods: From August 1997 to November 2001, 13 patients were treated with the reconstructive intramedullary interlocking nail. Nine patients were associated with ipsilateral femoral neck fractures, three with ipsilateral intertrochanteric fractures, and one with subtrochanteric fracture. Results: The follow up time was from 6 to 38 months with an average of 14 months. All the femoral shaft and hip fractures healed up well. There was no nonunion of the femoral neck, and only one varus malunion. No patient had avascular necrosis of the femoral head. The average healing time for femoral neck fracture was 4.6 months and for shaft fracture 5.8 months. The joint movement and other functions were fairly resumed. Conclusions: The reconstructive intramedullary interlocking nail, with less trauma, reliable fixation, and high rate of fracture healing, is an ideal method of choice in the treatment of ipsilateral hip and femoral shaft fractures.

Distal tibial fracture： An ideal indication for external fixation using locking plate

Objective： To evaluate the feasibility and efficiency of one-stage external fixation by using locking plate in distal tibial fractures. Methods： In this non-control prospective study, 28 patients with distal tibial fractures were included and underwent one-stage external fixation by using locking plate. There were 21 males and 7 females, with a mean age of 43 years （19-63）. According to AO/OTA fracture classification, there were 9 cases of Type A1, 9 of Type A2, 10 of Type A3 fractures. There were 21 close and 7 open fractures. The locking plate was placed on the anteromedial aspect of the tibia with 4-5 bicortical screws inserted in both distal metaphysis and diaphysis. The radiographic and clinic results were evaluated. Results： All patients were followed up for the average of 16 months （ranging from 12 to 21 months）. The average surgery duration was 38 （25-60） minutes. The mean time to fracture healing were 14.6 ± 2.67, 17.5 ± 3.66, and 18.4±3.37 （p 〈 0.05） weeks in type A1, A2, and A3 fractures respectively. By the end of the follow-ups, the mean AOFAS score were 96.11 ± 2.32, 92.67 ± 1.80 and 92.00± 2.06 （p 〉 0.05） in type A1, A2, and A3 fractures respectively. None of nonunion, deep infection, or breakage of screw or plate were observed. Conclusions： Distal tibial fracture was the ideal indication for external fixation using locking plate. The external plating is characterized by ease of performance, less invasive, fewer soft tissue impingement, improved cosmesis, and convenient for removal.

Intramedullary nailing of clavicular midshaft fractures in adults using titanium elastic nail

Objective： Studies showed elastic stable intramedullary nailing （ESIN） of displaced midclavicular fractures has excellent outcomes, as well as high complication rates and specific problems. The aim was to discuss ESIN of midshaft clavicular fractures.Methods： Totally 60 eligible patients （aged 18-63 years） were randomized to either ESIN group or non-operative group between January 2007 and May 2008. Clavicular shortening was measured after trauma and osseous consolidation.Radiographic union and complications were assessed. Function analysis including Constant shoulder scores and disabilities of the arm, shoulder and hand （DASH） scores were performed after a 15-month follow-up.Results： ESIN led to a signifcantly shorter time to union, especially for simple fractures. In ESIN group, all patients got fracture union, of which 5 cases had medial skin irritation and 1 patient needed revision surgery because of implant failure. In the nonoperative group, there were 3 nonunion cases and 2 symptomatic malunions developed requiring corrective osteotomy. At 15 months after intramedullary stabilization, patients in the ESIN group were more satisfied with the appearance of the shoulder and overall outcome, and they benefited a lot from the great improvement of post-traumatic clavicular shortening. Furthermore,DASH scores were lower and Constant scores were significantly higher in contrast to the non-operative group.Conclusion： ESIN is a safe minimally invasive surgical technique with lower complication rate, faster return to daily activities, excellent cosmetic and better functional results,restoration of clavicular length for treating mid-shaft clavicular fractures, resulting in high overall satisfaction, which can be regard as an alternative to plate fixation or nonoperative treatment of mid-shaft clavicular fractures.

Role of locking plates in treatment of difficult ununited fractures： a clinical study

Objective： To present our experience in treatment of difficult ununited long bone fractures with locking plate. Methods： Retrospective evaluation of locking plate fixation in 10 difficult nonunions of long bone fractures was done. Fixation was done with locking plate for femoral shaft fracture （3 patients）, supracondylar fracture of femur （gap nonunion）, fracture of clavicle, fracture of both forearm bones （radius and ulna） fracture of ulna, fracture of shaft of humerus, fracture of tibial diaphysis and supracondylar frac- ture of humerus （one patient each）. Five fractures had more than one previous failed internal fixation. One patient had infected nonunion which was managed by debridement with cast immobilization followed by fixation with locking plate at six weeks. Seven fractures were atrophic, two were oligotrophic, and one was hypertrophic. Fibular autograft was used in 2 cases and iliac crest cancellous bone graft used in all the patients. Results： Minimum follow-up was 6 months （range, 6 months to 2.5 years）. Average time for union was 3.4 months （range 2.5 to 6 months）. None of the patients had plate- related complications or postoperative wound infections. Conclusion： Along with achieving stability with locking compression plate, meticulous soft tissue dissection, acceptable reduction, good fixation technique and bone grafting can help achieve union in difficult nonunion cases. Though locking plate does not by itself ensure bony union, we have found it to be another useful addition to our armamentarium for treating difficult fracture nonunions.

Ipsilateral simultaneous fracture of the trochlea involving the lateral end clavicle and distal end radius：a rare combination and a unique mechanism of injury

Isolated trochlea fracture in adults is a rare surgical entity as compared to its capitellar counterpart.It has been only mentioned sporadically in the literature as case reports.Fracture of the trochlea is accompanied by other elbow injuries like elbow dislocation,capitellum fracture,ulnar fracture and extraarticular condylar fracture.Here we report a unique case of isolated displaced trochlea fracture associated with fractures of the lateral end clavicle and the distal end radius.We propose a unique mechanism for this rare combination of injuries：typical triad of injury,i.e.fracture of the distal end radius with trochlea and fracture of the lateral end of the clavicle.Nonoperative treatment is recommended for undisplaced humeral trochlea fractures;but for displaced ones,anatomical reduction and internal fixation are essential to maintain the congruous trochleacoronoid articulation and hence to maintain the intrinsic stability of the elbow.