Proximal Hip Fracture
OpenReduction/InternalFixation and Rehabilitation
Surgical indications and Considerations
Anatomical Considerations: The hip is a ball and socket joint with the femoral head aligned towards the pelvic acetabulum. Stability of this joint is achieved by the surrounding ligaments and musculature that attach the pelvis to the femur. The medial and lateral femoral circumflex arteries supply the femoral neck and head with a majority of its blood supply. Fractures of the femoral head pose a threat to the vascular supply of this structure. However, displaced fracture of the femoral neck can occur with no disruption to the blood supply.
sions. In high-energy traumas, pelvic frac- tures should always be suspected and con- ducted together with other lesions. Pelvic fractures are challenging injuries to manage. Stabilisation of vital parameters takes pref- erence and significantly reduces mortality. Associated injuries are common and often have a substantial effect on the patient’s psychological status. Rehabilitation period is prolonged; however proper management yields a satisfactory outcome. Further analy- sis and studies including a larger number of patients are required to identify the prognos- tic factors for the late sequelae. This study should be a valid statistical analysis of out- comes in patients who treated surgically, by internalfixation. Early rigid stabilisation of both anterior and posterior pelvic ring injury with openreduction, internalfixation, which performed in our patients, has been sug- gested as a potential reason for favourable prognosis of these injuries.
This is an Open Access article that uses a fund-ing model which does not charge readers or their institutions for access and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0) and the Budapest Open Access Initiative (http://www.budapestopenaccessinitiative.org/read), which permit unrestricted use, distribution, and reproduction in any medium, provided original work is properly credited.
Distal radius fractures are the most frequent fractures in the upper extrem- ity. In adults they show a wide range of variation and are responsible for 10–20% of all skeletal fractures 1 . Volar displaced fractures of the distal end of radius include both intra-articular and extra-articular fractures i.e. Volar- Barton’s and Smith’s fractures. The main objective of the treatment is the re-establishment of anatomic integrity and functioning. There are several options for the same which include closed reduction and Kirschner (K) wires fixation with a plaster cast, external fixation (bridging or non-bridging, with or without K wires), and openreduction and internalfixation with plate and screws (non-locking or locking, pre-contoured plates). Y-locked plates are in the process of replacing conventional plates as they provide angular and axial stability and minimize the possibility of screw loosening and implant failure 4 . Volar plating has gained widespread use over the past decade 5 . The purpose of this study was to investigate the efficacy volar locking plate in the management of the intra-articular and extra articular volar fractures of distal end of radius of as well as to report the radiological and functional outcomes.
KEY WORDS: Comminuted mandible fracture, Gunshot injuries, Maxillomandibular fixation, Plating, Air way management, Openreductioninternalfixation.
Since last decade the incidence of violent crimes are on rise in our society. Gunshot injuries in particular have become increasingly more frequent in the civilian population 1-3 . Due to instability & increase in violence in our region, the number of deaths has also in- creased mainly due to firearm weapons. 4, 5 Main causes of the gunshot injuries in this part of the world are violent crimes, domestic violence, accidental dis- charge of bullet, suicidal attempts and air shooting 4, 5 . Surgical management of facial gunshot wounds is generally divided into 3 stages include debridement, fracture stabilization, and primary closure; reconstruc- tion of hard tissues, provided soft tissue coverage is adequate; and rehabilitation of the oral vestibule, al- veolar ridge, and secondary correction of residual de- formities 6,7 . Comminuted fractures of the mandible as a result Gunshot injuries have been treated by a num- ber of methods, including closed reduction, external pin fixation, internal wire fixation and more recently, openreduction and internal stable fixation using plates and/or screws 7 . Before the development of reli- able implants and instrumentation for rigid fixation, most comminuted mandibular fractures as a result of
of miniplates and microplates, it is possible to perform openreduction &
internalfixation without damaging the tooth buds.
As in the adult population inadequate reduction & fixation in pediatric, displaced facial fractures will result in malunion and contour deformities and secondary surgery may be needed to correct residual deformities. Although some remodeling potential remains in the pediatric cranio-facial skeleton, it is unpredictable and provides a poor rationale for inadequate anatomic reduction and fixation. Instead the bony fragments should be reduced in the pre injury pattern with the teeth in occlusion, until union has occurred. The increased osteogenic potential of the pediatric facial skeleton should make early definitive treatment the rule.
-based Q statistic. Egger
A meta-analysis was performed to assess the association between healing rate, avascular necrosis (AVN) of femoral head and two reductions-openreductioninternalfixation (ORIF) and closed reductioninternal
A literature-based search was conducted to identify all relevant studies published before September 10, 2013. The odd ratio (OR) and 95% confidence interval (CI) were used for estimating the effects of the two reduction
Methods: Seven patients (5 men) with perilunate dislocations were treated with openreduction and internal fixa- tion. The injuries included 2 dorsal trans-radial perilunate dislocations, 4 trans-radial styloid perilunate disloca- tions, and one combined dorsal and styloid trans-radial dislocations. Openreduction, internalfixation with K wires or cannulated screws, ligament repair, and external fixation using plaster were employed. The average follow-up period was 18 months (range, 10-26). The patients were evaluated according to a Mayo wrist score. Results: We obtained 2 excellent results, 3 good, and 2 fair, according to the Mayo wrist score. The mean active range of flexion- extension was 109.4°. The mean grip strength of the injured wrist was 84.2%, compared with the contralateral side.
This study performed openreduction through the combined dorsal and volar approach in 11 patients and only 1 patient with PLD injury received the dorsal approach. The surgeon first approached the wrist through a straight dorsal incision centered on Lister’s tubercle and opened the extensor retinaculum between the third and fourth compartments. Neurectomy of the posterior interosseous nerve was performed in all cases. Wrist arthrotomy was performed by incision in the dorsal wrist capsule and ex- posed the entire carpus. The researchers usually made no attempt to reduce the dislocation until performing the volar release of the adhesion through the extended carpal tunnel approach. The researchers retracted the flexor ten- dons and the median nerve radially to expose the volar cap- sule and the volar displaced lunate. An incision was made in the volar capsule (the surgeon did their best to save the short radiolunate ligament in order to preserve the lunate blood supply). After adhesion release, the surgeon tried to perform the reduction. The lunate was reduced under di- rect vision by manually pushing it back in between the cap- itates and radius, while applying longitudinal traction. If the reduction is difficult, it may be facilitated by passing a small retractor or Freer in the joint from dorsal to volar to support the lunate and elevate the capitate, with great care to avoid injury to the articular cartilage . In PLFD cases with scaphoid fracture, the surgeon reduced associated scaphoid fractures and internally fixed them using Her- bert screws in 2 patients and K-wires in 5. The carpal joint was then inspected from the dorsum and lunate aligned and pinned first to the distal radius to neutralize the radiol- unate alignment. When the researchers achieved restora- tion of carpal alignment, they pinned the joints with a 1- mm K-wire, which was passed from the scaphoid to both the capitate and lunate and from triquetrum to lunate.
Since many biomechanical studies have proven that preservation of radial head has a positive influence on elbow and wrist function, ORIF is now the preferred mode of treatment for radial head fractures and associated lesions. Zwingmann et al. performed a systematic review and meta-analysis of 58 studies in order to compare the clinical outcomes after various operative treatment methods for radial head fractures. 6 ORIF showed better results in type II and type III fractures with a success rate of 98% and 92% respectively. Ring et al. evaluated 56 cases of radial head fractures and suggested that ORIF is best suited for fractures with three of less articular fractures and associated fracture-dislocations can compromise the long-term results. 14 On the contrary, Nalbantoglu et al. found that elbow dislocation had no significant effect on the functional outcomes. 4 They proposed that the rate of chondral damage is less in cases of dislocation as the energy of trauma is redirected to the bones and ligaments causing less cartilage injury. Our results also provide evidence that ORIF should be considered as the choice of treatment in Mason type II, III and even type IV fractures (95% good to excellent results) . Anatomic reduction, appropriate implant selection, soft tissue repair or reconstruction along with early rehabilitation can provide good to excellent outcomes even in cases with dislocation
and anatomical fixation of the fracture and can enable primary or secondary fracture healing depending on the type of osteosynthesis and fracture pattern. Although there were no significant differences between our two groups according to the primary and secondary outcome measures, an anterior approach offers advantages. It allows supine positioning of the patient and offers safe exposure of the humerus as the radial nerve is not dir- ectly explored . To the best of our knowledge, there have been no prospective randomized studies comparing anterior and posterior plate fixation in terms of the heal- ing rate and clinical outcomes. Nevertheless, the cur- rently available literature confirms our finding that an anterior surgical approach with plating is a safe and effi- cacious treatment option for humeral shaft fractures. Re- liable results have been reported in one biomechanical study  and one retrospective clinical study  for anteromedial plating for shaft fractures in the upper ex- tremities with regard to bone union and iatrogenic neu- rovascular injury. One retrospective study of 96 humeral fractures treated with anteromedial plating presented a union rate of 97%, although 20% of the fractures in- cluded were open fractures . According to the neurological status, 18 patients with primary radialis palsy and one patient with brachial plexopathy were in- cluded in this study. Of these 19 patients, twelve achieved remission after ORIF. Two patients (2.1%) were noted to have secondary palsy (hypoesthesia in the lat- eral antebrachial cutaneous nerve distribution) after sur- gery. Another retrospective study was published by Boschi et al.  investigating the outcomes of the treat- ment of 280 humeral shaft fractures with ORIF in terms of the approach and plate location. The overall healing rate was 98.2%, without a significant difference in the approach or plate location. In accordance with the find- ings reported by Boschi et al. , no significant differ- ence in the operative duration was found between the two groups in our study; however, we found a wide vari- ation in the operative duration within the groups. As a level one trauma center and a university hospital, all op- erative procedures in both groups were performed by ei- ther trainee registrars or junior consultants, which might be one reason for the wide variation in the operative duration within the groups. The fact that the number of
The primary goals of the surgical management of tibial plateau fractures are the anatomical reduction and fix- ation of the articular fracture and the proper treatment of associated intra-articular lesions to achieve early mobilization and reduce the risk of stiffness, instability, and post-traumatic osteoarthritis of the knee . These objectives were traditionally pursued through open re- duction and internalfixation with plate and screws, but the last decades’ literature has shown the effectiveness of the arthroscopically assisted treatment [12–18]. Our study aimed to compare the clinical and radiological re- sults of ARIF and ORIF techniques used for Schatzker type I–III fractures in two different groups of patients.
This is to certify that this dissertation titled “Functional Outcome Analysis of Openreduction and internalfixation of complex Acetabular fractures” is a bonafide record of work done by DR.D.KAMALASEKARAN , during the period of his Post graduate study from June 2010 to May 2013 under guidance and supervision in the INSTITUTE OF ORTHOPAEDICS AND TRAUMATOLOGY, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai-600003, in partial fulfilment of the requirement for M.S.ORTHOPAEDIC SURGERY degree Examination of The Tamilnadu Dr.
MATERIALS AND METHODOLOGY
A Prospective clinical and radiological study was conducted on five patients reporting at the Department Of Oral And Maxillofacial Surgery, The Tamil Nadu Government Dental College and Hospital, Chennai. Patients with subcondylar fractures and who consented for surgery were included in the study. In all patients ORIF was done under general anaesthesia. In all patients Retromandibular transmassetric approach was used to expose the fracture site and the fracture was stabilized using 3 dimensional titanium trapezoidal plates. The following parameters such as mouth opening, mandibular deviation, occlusion, surgical accessibility, reduction of fracture, adaptability of plate, nerve weakness, wound infection, postoperative haematoma and scar were assessed.
Department of Orthopedics, the Fifth People’s Hospital of Shanghai, Fudan University, Shanghai, China. * Co-first authors.
Received July 15, 2016; Accepted November 29, 2016; Epub May 15, 2017; Published May 30, 2017
Abstract: Our study was to verify whether the approach of protecting supraclavicular nerve could effectively reduce the discomfort caused by iatrogenic injury to the supraclavicular nerve. A total of 37 patients with unilateral midcla- vicular fractures were enrolled and randomly assigned into the experimental group (patients received meticulous dissection by specially preservation of supraclavicular nerves with diameter > 0.5 mm during openreduction and internalfixation (ORIF)) and control group (patients received conventional ORIF). One year follow-up was performed after operation. Clinical outcomes including intraoperative and postoperative parameters were compared between groups. For the intraoperative parameters, no significant difference was found between groups in operative time (P = 0.074). However, the blood loss (P = 0.004) was significantly decreased and incision length (P = 0.008) was significantly longerin experimental group compared with control group. For postoperative parameters, the time of bone healing was similar between groups (P = 0.856). However, the degree and range of skin numbness were sig- nificantly decreased by specially preservation of supraclavicular nerves during ORIF compared with conventional ORIF at two weeks and one year after operation (P < 0.05). In addition, although no statistical significance (P = 0.090), the results also indicated a trend that experimental group had fewer patients with complications related to the supraclavicular nerve injury than control group, including hyperesthesia, Tinel’s sign, tenderness, afraid of cold or feel discomfort beneath the incision. The results of this study supported the application of preservation of supraclavicular nerves during ORIF in treatment of midclavicular fractures.
Background: Lateral condyle fractures of the distal humerus are the second most common fractures at the elbow in the paediatric population usually between the ages of 6-10 years old making up 5-20% of fractures in children. The aim of the present study was to assess the early results of patients with a displaced lateral humeral condyle fracture treated with openreduction and internalfixation. Methods: Our clinical trial was conducted involving 12 patients treated with openreduction and internalfixation (ORIF). Preoperative stage included clinical evaluation, routine investigations and radiological evaluation. Fractures were classified using the Milch. Patients were followed up weekly until radiological union of the fracture was evident. Results: 83.3% of our patients were males, while 16.7% were females. According to mechanism of injury, falling down continues to play a major role in causing disability. At (3-5) weeks all cases were with soft callus remove K wire; at 8 weeks, all cases were with union fracture; but at 12 weeks, one case (8.3%) was with mild stiffness and the rest was with full range of motion. As regards the carrying angle in our study, only 16.7% were with abnormal carrying angle. 33.3% were complicated; one case with mild limitation of motion and valgus; one case with varus and two cases with superficial infection. Conclusions: The openreduction and internalfixation of lateral humeral condyle fracture is the ideal treatment and it has a rate of complications.
The aim of the treatment is to provide the patient a painless, mobile joint and it needs a very strong technical knowledge and surgical expertise. Good surgical techniques and implants are essential for accurate articular reduction.
The initial disrepute of bicolumn fixation of complex tibial plateau fractures owes itself to poor surgical technique practiced earlier on. The use of a single midline incision and extreme soft tissue handling led onto a high incidence of wound breakdown and infection and put the orthopaedic fraternity on guard regarding bicolumn fixation 5,6,7 . The advent of locking plates shifted the spectrum towards isolated lateral plating using locking compression plates and stabilizing medial fragment through screws passed via the locking plate 13,18.
Orthopedic and Trauma Surgery, Al-Azhar University, Cairo, Egypt
Objectives: This study compared the clinical and radiological outcomes of two different methods for the treatment of distal radial intra-articular frac- tures. Patients and Methods: Forty-six patients with distal radius intra-arti- cular fractures were divided into two groups. Group I included 24 patients with type C fracture treated by external fixator augmented by percutaneous K-wires. Group II included 22 patients with type C fracture treated by volar locked distal radial plate augmented by K-wires. Two patients had complex injuries necessitating double plating (sandwich). All patients were evaluated clinically by Mayo Wrist Score and radiologically by Sarmiento’s radiological score. Results: Both groups reported good personal satisfaction according to Mayo Wrist Score, and the results were not statistically different between the two groups. In Group I, 19 patients (79.2%) had excellent radiological out- come and five patients (20.9%) had good radiological outcome according to Sarmiento’s radiological score. In Group II, 20 patients (90.9%) had excellent outcome, and two (9.1%) had good radiological outcome; there was no or in- significant deformity. Conclusions: Complex distal radial fractures can be treated either by external fixation (ligamentotaxis) or by locked pre-contoured plating. The clinical outcome of plating and external fixator in our study did not show any statistically significant difference. The radiological outcome had no correlation with the clinical outcome.
MIRPF veRsus ORIF FOR DIsPLACeD INTRA-ARTICuLAR CALCANeAL FRACTuRes
removing patients who were receiving workers’ compen- sation, the outcomes were significantly better in some groups of surgically treated patients. 9 The results of another RCT from the UK comparing the operative and non-operative treatments for these fractures reported that the outcomes after ORIF were no better than after non- operative treatment at two years, with higher complica- tions in the operative groups. 10 However, the UK heel trial was heavily criticized by Pearce et al in view of high selec- tion bias, recruiting only 30% of the total eligible patients (as the others did not wish to be included) and only two years of follow-up. 11 Another recently published multi- centre RCT from Sweden showed that patient-reported clinical, functional and quality-of-life outcomes were bet- ter after operative treatment at 8 to 12 years of follow- up. 12 Despite the advancements in surgical techniques, surgical fixation is still technically challenging and carries the risks of complications, such as wound infection, sural nerve injury and failure of the implants. 3,13-15
It also seriously affects the long-term efficacy and prognosis. The clinical efficacy of poking reductionfixation for Sanders type II fractures was studied for the first time in this trial, and it was comprehensively analyzed and compared with the traditional ORIF method. X-ray was used to make sure that after the Kirschner wire had reached the bottom of posterior articular calcaneal, upward poking could be conducted to reset the posterior articular surface and cal- caneal at the same time, and 2 Kirschner wires can be drilled in when necessary. The incision was sutured after satisfactory with the reduc- tion results in imaging examination, ensuring the complete reduction of the articular surface, long-term efficacy and prognosis [19, 20]. This type of research has not been widely reported both at home and abroad.