Peri-articular and osteoporotic fractures of long bones are becoming more common and are very challenging injuries to treat even for a veteran orthopaedician. Peri-articularfractures occur in two different age groups -due to different types of injuries. In young patients peri-articularfractures occur due to high velocity injury such as road traffic accidents, fire arm injuries and sport’s injuries while in elderly patients with osteoporosis it occurs usually due to low velocity injury like fall during walking. Also these conditions do result from fractures in the young treated by conservative methods and which in the long term end up in non-unions and further more these conditions are compounded by disuse osteoporosis.
This is to certify that this dissertation titled “COMPARATIVE STUDY ON THE ANALYSIS OF FUNCTIONAL OUTCOME IN DISTAL RADIUS ARTICULARFRACTURES TREATED BY CLOSED REDUCTION THROUGH BRIDGING EXTERNAL FIXATOR AUGMENTED WITH K-WIRES AND VOLAR-LOCKING PLATING” is a bonafide record of work done by DR. KEERTHY CHANDRA BASSETTY, during the period of his postgraduate study from July 2012 to September 2014 under guidance and supervision in the INSTITUTE OF ORTHOPAEDICS AND TRAUMATOLOGY, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai- 600003, in partial fulfillment of the requirement for M.S.ORTHOPAEDIC SURGERY degree Examination of The Tamilnadu Dr. M.G.R. Medical University to be held in April 2015.
Materials and Methods: From May 2016 to Dec 2017, consecutive patients with intra articularfractures of the distal radius were included in our study. All subjects were recruited, operated, and assessed at Department of Orthopaedic Surgery, RMMCH, Annamalai University, Chidambaram, Tamilnadu. The patients were followed for a minimum period of 6 months. The results were evaluated using DASH scoring system Sarmiento’s modification of Lindstorm’s crtiria for radiological outcome for wrist.
In our study, routine evaluation of the DRUJ and transfixing wire was per- formed for the cases that required attention in both groups. Reduction of the joints with transfixing wires improved the outcome, as it reduces the complica- tions. DRUJ reduction is considered the cornerstone for the reduction of com- minuted distal radial fracture. Injury of the DRUJ has been classified into high energy or low energy trauma according to Fernandez and Jupiter  classifica- tion Fernandez and Jupiter based their classification on two main parameters; they considered soft tissue injury and DRUJ injury as the main factors which af- fect the outcomes of treatment for intra-articularfractures of distal radius.
As with many studies, this computed simulation study has its limitations. Firstly, it may overestimate the mag- nitude of stiffness, because the fixation could be weak- ened due to factors such as soft tissue insertion and bone destruction, which were not included in the study. Considering that the factors are inevitable, the relation of stiffness among different testing conditions should stay the same, so it is sufficient to compare the inter-configuration rigidity. Secondly, severely commi- nuted intra-articularfractures (AO/OTC C3 fracture) were not simulated in the study for extra fixations such as lag screws, headless screws, and K-wires would always be used in these cases , making the analysis even more complicated and results unreliable. Thirdly, a lar- ger sample size was not adopted, as we chose a humerus with standard morphology. Besides, large samples size is not that common in finite element analysis.
fragments in fractures with major joint involvement. Excessive distraction of the hardware, to obtain satisfactory reduction, can result in delayed union, nonunion, complex regional pain syndrome (CRPS) or digital stiffness [3, 4]. Despite the fact that randomized trials do not provide strong evidence regarding the type of surgical intervention that is the most appropriate treatment for fractures of the distal radius in adults, superior functional and radiological results of ORIF with respect to external fixation have been reported recently . Standard straight plates result in optimal diaphyseal stabilization but may be inadequate for fixing metaphyseal and epiphyseal fractures. When posi- tioned on the volar aspect of the radius, straight plates are too bulky and may create attritional damage to flexor tendons; they need to be bent to follow the radial volar inclination, and are not sufficiently wide to adequately fix the epiphysis and capture small articular pieces for such fractures. A new technique described by Ginn et al.  involves ‘‘bridging’’ the fracture using a standard 3.5 mm plate applied dorsally and fixed in distraction from the radius to the third metacarpal shaft distally. The distraction plate technique also uses the concept of ligamentotaxis and, like external fixation, is especially indicated for intra- articularfractures with small, comminuted fragments which may be difficult to manage with plates or other nonbridging methods; when distraction fails to obtain adequate reduction, the use of bone grafts, K-wires and supplementary screws are included in the procedure. The hardware is removed after radiographic evidence of con- solidation (mean time: 124 days) and wrist motion has been initiated. Excellent clinical and radiographical results are reported with this technique . Disadvantages of this method include the long period of immobilization of the wrist, the need for a second operation to remove the Fig. 3 Radioulnar synostosis at 9 months after osteosynthesis (Syn-
1. Patients with isolated shaft fractures (Group IS) of the upper extremity had the best outcome in full recovery in comparison with combined and isolated articularfractures. This applied with respect to ROM, pain, neurological impairment and the ability to use the extremity for work and sports-related activities. Similar results had also been described in a study by Ekholm et al. . In their stuy, 25 – 30% of patients with isolated articularfractures and combined fractures did not show full recovery when the short musculoskeletal functional assessment test was used. Therefore, our subanalysis provides more subtle information regarding the outcome when special focus was laid on the differentiation of shaft versus articularfractures. We feel that this information is helpful in the overall assessment of the patient with multiple injuries and provides additional information to that reported previously in a different patient subset (4). These results included arm/hand function, daily activities, emotional status and mobility, at follow up. Table 4 Subgroup analysis of patients with heterotopic ossifications
Extra articularfractures can be approached through a limited incision using a variety of techniques. An infrapatellar incision 4 to 5 cm long is made either directly over the patellar tendon or at its medial edge. The patellar tendon is correspondingly then either split longitudinally or retracted laterally (as for tibial nailing, hence the ability to fix a floating knee with minimal dissection) .The entry point is 5mm anterior to the attachment of posterior cruciate ligament and it lies slightly medial to the center of the distal femoral condyles. Direct visualization of the entry site in the intercondylar notch can be accomplished by excision of the fat pad. C -arm guidance confirms that the entry site is along the axis of the distal fragment in both the AP and lateral planes. Either of the two intrapatellar incisions can easily be extended to a formal medial para patellar arthrotomy if necessary. A ¼ - inch twist drill or Steinman pain is used to perforate the subchondral cortex. The subsequent path created in the distal fragment by passage of hand-held reamers is the most crucial reduction maneuver of the entire procedure. C-arm must confirm that the reduction is in perfect alignment along the longitudinal axis of the distal fragment, because the varus/valgus and sagittal alignment of the fracture will be determined by this.
Here, we report HA concentrations in the SF of healthy donors of between 1.8 and 3.33 mg/mL [11–14]. This compares with the slightly higher previously reported SF HA concentrations between 3.2 and 4.1 mg/mL . There is as yet no consensus regarding the change in HA levels of SF under pathologic conditions, such as in osteoarth- ritis (OA) and intra-articularfractures, although some authors have reported normal levels of HA in arthritic joints [13, 15]. Ludwig et al. measured the SF HA concen- trations of normal and osteoarthritic knees as 0.11 to 0.96 and 0.23 to 2.69 mg/mL, respectively . The SF HA concentration in OA patients was reported as between 1.2 and 2.2 mg/mL . According to one study, intra-articularfractures cause a decrease in HA levels in SF [11, 16]. Ballard et al. reported the mean HA levels of injured knees as 0.27 mg/mL . Here, we detected the HA concentra- tion of SF HA in healthy and injured knees as 0.841 and 0.901 mg/mL, respectively (p = 0.225), which are compar- able with those reported in the literature. Although some parameters (e.g., age, sex, trauma severity, and assay sensi- tivity) may affect these analyses , the concentration of HA in these samples did not differ between healthy and injured knees.
Calcaneal fractures account for approximately 1 – 2% of all fractures of the human body, with an annual incidence of 11.5 per 100,000 people. Displaced intra-articularfractures comprise 60 – 75% of calca- neal fractures [1, 2]. Conservative management of these injuries is often sub-optimal, resulting in arth- ritis of the subtalar joint, malunion and poor func- tional outcomes . In appropriately selected patients, operative fixation is therefore favoured in managing displaced intra-articularfractures of the calcaneus [4, 5]. The traditional approach to fixation has been open reduction and internal fixation (ORIF) through an extensile L-shaped lateral approach
There was a significant difference in the final outcome in both the study groups, assessed using The Modified Green O‟Brien System. However, we preferred using the external fixator application in the treatment of intra-articularfractures of the distal radius (Frykman Type VII and VIII). Although open reduction and internal fixation has advantages such as direct visualization and manipulation of the fracture segments, stable fixation and the possibility of immediate postoperative motion but we preferred the use of external fixator since it provides continuity of reduction under fluoroscopic control, improved reduction by ligamentotaxis, 15 and the ability to protect the reduction until
a better understanding of fracture pathology and provided the basis for newer classifications. 19,5 Intra-articularfractures of the calcaneum are amongst the most challenging fractures for orthopaedic surgeon because of complicated anatomy and difficulty in evaluating the fractures properly. Those who sustain them face a slow recovery, with possible permanent deformity and disability. When the fracture is joint depressed type of fracture, formal open reduction of fracture through a lateral approach, elevation of depressed posterior facet and fixation with a plate is required. This is a case series using a lateral approach for intra-articularfractures of calcaneum as previously described.
1. Rekli DA, Regazzoni P, Fractures of the distal end of radius treated by internal fixation and early function. A prelimainary report of 20 cases.JBoneand Joint Surgery(Br).1996;78(4):588-92. 2. Sripakarn Y, Niempong S, Boontanapibul K. The comparative study of reliability and reproducibility of distal radius fracture classification among AO Frykman and Fernandez classification systems. J Med Association, THAILAND2013; 96(1):52-7. 3. Medlone CP. Open treatment for displaced articularfractures of th distal radius .Clin Orthop.1986;202:103-11
A prospective quantitative descriptive cohort study was carried out over 2 years, from January 2016 to January 2018, in all consecutive cases of closed displaced intra-articularfractures of calcaneum in skeletally mature patients that presented to the Department of Orthopaedics at Dr. R.N. Cooper muncipal general hospital, Juhu, Mumbai.. Out of total 30 cases of calcaneal fractures that were managed during the study period, 25 cases were eligible for the study and 20 cases were available for final follow up. Open calcaneal fractures, patients unwilling for the operative management, skeletally immature patients, cases managed conservatively were excluded from the study. Written informed consent was obtained from all patients to be managed with ORIF with LBCP. The data were recorded in proforma including: epidemiological information, fracture details from X-rays and CT scans, preoperative, perioperative, and postoperative details including wound condition.Fractures classified using sanders classification. Routine investigations carried out to get fitness for surgery. Patients underwent Open reduction and internal fixation with locking branched calcaneal plate through extensile lateral approach under spinal anaesthesia. Post- operative physiotherapy followed according to protocol. Patients will be followed up at 6 weekly interval until fracture union. Clinical evaluation done by using Maryland foot scoring system. Radiological evaluation done by using Boehlers angle and Critical angle of Gissane on Lateral radiographs of calcaneum. Functional outcome was recorded at every followup after 12 wks of surgery.
From our study we can conclude that, Operative treatment of displaced bicondylar intra-articularfractures of the distal humerus by reconstruction plate and screws gives a more rigid fixation with better functional outcome than by double tension band wiring.
The majority of the patients underwent surgery on the day of admission or within two days. In three patients, the operation was delayed for another 2–3 days because of a high load at the operation department. In the majority of cases four rings, connected with steel rods, were used. In four patients with more comminuted fractures, a foot fixation with trans-calcaneal and trans-metatarsal wire fix- ation without hinges (foot extension), was added to the construction. Six minor re-operations were performed under general anaesthesia because of the re-insertion of wires after breakage or to improve fracture alignment. The median duration of surgery, which includes assem- bling the frame and dressings, was shorter for the extra- articularfractures, 152 min (range 50–224), compared with intra-articularfractures, 165 min (range 72–314). Patients with a foot extension had this fixation removed Table 2 Timing of the treatment
In our study we want to compare our early permissive weight bearing protocol to the currently existing AO treatment guidelines in a prospective comparative cohort study. In addition to the follow up, featuring clinical documentation and registration of weight bearing milestones, new techniques for ambulatory measurements of loading (i.e. gait analysis by means of insoles) and non-invasive quantification of muscle mass will be used. This study will be performed in patients with (peri)- or intra-articularfractures of the pelvis/ acetabulum and lower extremity after surgical treat- ment for which existing guidelines do not allow early full weight bearing in the first 6–12 weeks.
the plate does not depend on the friction created at the bone-plate interface to provide stability, the plate does not have to contact the bone directly which helps in preserving the periosteal blood supply [6,7]. Locked implants are typically indicated in patients with osteoporosis, fractures with metaphyseal comminution where the medial cortex cannot be restored, or with a short articular segment . Comminuted articularfractures can also be addressed more conveniently with the use of additional screws such as partially- threaded cancellous screws, herbert screws and other varieties of smaller screws. By making use of the technique of counter- sinking, the screw heads can be adjusted to seat the distal femur locking plate in a proper fashion. It also provides another useful choice for extra-articularfractures of distal femur . Thus, the flexibility of locking condylar plate with its fixed angle properties appears to offer an effective alternative to implants like DCS, condylar buttress plate and a supra- condylar or a distal femur retrograde nail. This study was done to study the functional and radiological outcome of distal femoral fractures in skeletally mature patients treated by open reduction and internal fixation with distal femur locking plate.
There were 25 intra articular calcaneal fracture operated for the duration of 6 years. Clinical evaluation for the swelling, and possible compartment syndrome was done in all cases. Radiological evaluation of the patients done either by x-ray or computer tomogram. Cases included were sanders 2 and 3 or both joint depression and tongue type intra-articularfractures. Surgical fixation was planned once swelling was subsided. Average duration between injury and surgery was 10 days (5-21 days). Surgical Technique
Distal femoral fractures are difficult to treat because they are often unstable and comminuted and have a potential for long term disability. Varus collapse, malunion and nonunion were the problems before fixed angle plates and indirect reduction techniques were introduced. In principle, therefore, all intra – articular distal femoral fractures should be treated surgically. Successful treatments of distal femoral fractures require surgery and maintenance of the congruence of the articular surfaces. The prognostic factor for supracondylar fracture includes age, intra articular involvement, method of treatment, timing of joint mobilization etc. Comparison of results with other studies is often difficult because of difference in the classifications schemes and the use of different methods of treatment [5-7] . Some articles have been published documenting superior functional results using internal fixation [8, 9] . Rigid fixation has also enabled earlier knee motion and weight bearing, which help prevent some of the serious complication attributed to prolonged bed rest and traction [5, 6] . In our study an attempt was made to assess the factors affecting functional outcome of distal femoral fractures with intra articular extension, treated by various surgical methods. The present study was conducted on 25 patients with supracondylar fracture with intra articular extension admitted in department of Orthopedics, in MGM Warangal, Hospital.