Results: After proper analysis and doing statistical comparison, we got p- value of 0.568 for functionaloutcome and 0.468 for anatomical outcome which is considered insignificant. (significance of p value determined as <0.05). But with regard to individual parameters in the scores, we got significantly better results in the values of volar tilt, radial inclination and intraarticular step off in volar lockingcompressionplate than dynamicexternalfixator. Regarding complications, among Ex fix group, 3 patients had superficial pin tract infection, one patient had deep infection, one had malunion and one had pin bending complications and among LCP group one had screw penetration into joint space and one had secondary collapse of the fracture.
The palmar ulnar cortex is richly embedded bone with the greatest trabecular density. The success of internal fixation techniques thrives on the fact that this superior quality thick bone, found in even the osteoporotic cadaver specimens. Distally, the radius attains a roughly trapezoidal shape. The radial styloid rotates palmarly 15 degrees off the axis of the radius. This makes it difficult to keep in reduced position from a dorsal approach. The lunate facet of the radius harbours the strongest bone. The line of force passes down the long finger axis, traversing through the capitolunate
of the GSH nail is its intraarticular starting point, which allows it to be used for very distalfractures. Closed placement with indirect reduction of the fracture minimizes soft tissue and periosteal damage, thus preserving vascularity. Less surgical dissection is required resulting in less blood loss, less muscle damage and less postoperative discomfort. Distal femoral fractures with hip implants or with total knee replacement with an open notch design also can be effectively treated with retrograde nails. It can also be used in cases of floating knees, for simultaneous fixation of tibial and femoral fractures, through the same incision. The design of the retrograde supracondylar nail is associated with potential disadvantages as well. The intraarticular portion will lead to knee stiffness, patello-femoral degeneration and synovial metallosis. The proximal tip of the nail generally lies in the mid or distal femoral shaft, creating a stress raiser 21 .
necessary preoperatively evaluation of the cardiac status with ECG, Chest x-ray, and 2D ECHO if necessary 2D ECHO was done. For the posted case of distal femoral fracture for surgery, internal fixation was done through the lateral incision just anterior to the intermuscular septum, for condylar buttress plate and lockingplate. All cases were done under spinal anesthesia in the operation theatre of NIMS. Image intensifier was used where ever necessary. The implants used are Condylar Buttress Plate [CBP], LockingCompressionPlate [LCP], Cancellous Screw Fixation [CSF] and externalfixator and Ilizarov fixator. Both cortical and cancellous bone grafting was done from iliac crest and fibula for severely comminuted metaphyseal and Intraarticular fractures and all Bone grafting were done along with primary operation.
In our study, 25 cases of distal femur fracture were operated with Open Reduction with internal fixation with Dynamic Condylar screw and Lockingcompressionplate. 10 patients of distal femur fractures operated with DCS and 15 patients were operated with lockingcompressionplate. Patients were followed up every 3 weeks till fracture united and thereafter at 3 months, 5 months and 1 year. The minimum follow up period in our study was 3 months and maximum follow up period was 12 months. Clinically, tenderness at fracture site, knee pain, limb length discrepancy, range of movements, any varus or valgus deformity were assessed at each follow up. The results were analyzed with standard anteroposterior and lateral radiographs. Clinical and radiological signs of union were analyzed at each follow up. The fracture was said to be radiologically united if callus was seen in at least 3 cortices in anteroposterior and lateral views. The functional outcomes were analyzed using scoring system of HOSPITAL FOR SPECIAL SURGERY.
the impacted lunate facet fragments and ke- eping adequate stabilization is the key issue that deserves surgeons’ greatest attention. In this study, we applied the traditional Henry or extended approach so as to obtain maximum exposure of the articular surface to capture and fix the lunate facet fragments. For frac- tures with bone loss after fracture reduction in fractures with intra-articular multifragments and metaphyseal comminution, we recommend autologous iliac bone to fill the gap or buttress the small impacted luante facet fragments. In addition, for lunate facet fragments of dorsal displacement that were unable to capture and fix by single VLP, we applied auxiliary kirschner wires or externalfixator to stabilize the frag- ments. Despite this, the mean values of articu- lar step-off was 0.6 mm (sd, 0.9 mm) and there were 5 cases (23.8%) of significant articular step-off (>2 mm) found at the last follow-up, both of which were higher that of previous stud- ies [13, 21, 22]. Primarily, we attributed this deviation to the greater severity of fractures, with C3 accounting for 76.2% in the DP group in this study. In contrast, the sample in their stud- ies was type B3 or type B and C . There- fore, multifragmentary fractures with impacted lunate facet significantly increased the difficul- ty in reduction and fixation during surgery. In addition, the specific anatomy of volar-ulnar corner of lunate facet made it impossible for VLP to provide similarly adequate stability for scaphoid and lunate facet [23-25]. Therefore, improvement of technical skills for fixation of small lunate facet fragments and innovative design of implants might be the future research subjects.
was checked in the C-arm in antero-posterior and lateral views (Fig. 1). Reduction was achieved via manual traction and closed reduction method in all cases. Sterile betadine dressing of the pin tract site was performed. A below- elbow plaster of Paris slab was applied in all patients for 1 week. The externalfixator was removed in all patients after 8 weeks. No extra wire was used in any patient since we were able to achieve reduction in fracture by use of pins only.
There are many treatment options for distalradius fractures.Undisplaced stable fractures can be treated conservatively with casting.Unstable fractures can be treated with percutaneous K wire fixation.Communited fractures can be treated with external fixation.But there is a period of immobilisation for the wrist joint when treated with external fixation which can lead to wrist stiffness (18) .There are dynamicexternal fixators available to treat communited distalradiusfractures but the reduction achieved with this method is frequently not satisfactory.Furthermore reduction of intraarticular fragments could not be achieved to a satisfactory degree with an externalfixator.
confirm the observation by others that anatomic restoration of the articular surface is a critical part of the operative treatment of intra-articularfractures of distalradius and has a direct influence on the final outcome. Bradway et al.19 and Knirk and Jupiter showed that >2 mm of articular incongruity (step-off) was associated with a high prevalence of post-traumatic arthritis and poorer functional results. The treatment of distalradiusfractures has undergone changes owing to the advances in technology. Improved imaging methods providing better understanding of fractures and elucidation of the effects of injury type on fracture formation and factors leading to instability have given way to new fixing methods and materials appropriate for the fracture. Distalradius is important in the kinematics of radiocarpal and radioulnar joints. Hence, anatomical reduction of the articular surface, stable fixation, restoration of the radial length, volar angulation and radial inclination are the prerequisite for good clinical outcome. All this reduces the incidence of post-traumatic osteoarthritis and allow early functional rehabilitation. The degree of disability after distal end radius fracture has been seen to correlate with the amount of residual deformity. Treatment options include closed reduction and pinning, bridging and non-bridging external fixation and open reduction with dynamiccompressionplate (DCP), precontoured locking and non locking plates and screw fixation through a variety of approaches 20 . Failure to reduce intra-articularfractures of the distalradius predisposes to pain, restricted movement and degenerative arthritis. Malposition is related to the radial height, radial angle, volar tilt and the accuracy of intra-articular reduction. In the treatment of comminuted distalradiusintraarticularfractures, surgeons may encounter serious complications such as difficult reduction and stabilization, loss of reduction, limitation of range of movement, post traumatic arthritis of the wrist. A brief classification should be made before treating the distal radial fractures.
The fractures of the distalradius are very common injuries accounting for about 8 to 17% of fractures seen the emergency room. The purpose of this study was to evaluate functional and radiological outcome of patients with intraarticulardistalradiusfracturestreated with a volar lockingcompressionplate. As with an increase in life expectancy there is an increase in the incidence of these fractures as well. There appears to be a bimodal distribution among these fractures where the younger group falling prey due to high velocity injuries like road traffic accidents and the older group due to a trivial fall mainly due to senile osteoporosis. In terms of management
Materials and methods: 20 patients with distal femur fractures were evaluated in between July 2011 to November 2013. Radiographs of knee were taken in AP & Lateral views. AO/Muller type B and C3 were excluded from the study. All the patients were operated under spinal/epidural anaesthesia and the patient position was supine with knee in 60-70 degrees flexion. Distal femur was exposed using modified lateral approach (minimally invasive) and the fracture was reduced by indirect reduction techniques. We used lockingcompressionplate to fix the fracture. Post operative radiographs were taken to assess the reduction and implant position.post operative rehabilitation was started from the 1 st post operative day. Patients were followed up at every 4-6 weeks interval to assess fracture union, limb length, alignment, knee range of movements and functionaloutcome. Hammer et al grading was used to assess union and the knee society scoring system was used to assess the functionaloutcome.
The linear externalfixator to be used will be a radiotransparent bar with two pin fastening platforms, with one platform being proximal on the radius and the other platform distal on the second metacarpal, offered by Synthes (code – 03.304.220S). Four threaded self-drilling pins will be used with the proximal platforms that are 4.0 mm in diameter and the distal platforms that are 2.5 mm in diameter. Osteosynthesis with an externalfixator will be achieved by the following surgical technique: closed reduction of the fracture by the reduction technique employing traction and contraction manipulation; confirmation of reduction with the image intensifier; a longitudinal incision of 1.5 mm in the dorsal aspect of the forearm and 8 cm proximal from the wrist joint on the longitudinal axis of the radius; exposure of the dorsal cortex of the radius by blunt dissection, introduction of the soft tissue protector positioned at a right angle to the coronal plane of the forearm; introduction of two 4.0 mm self-drilling Schanz pins with a T-handle; double 0.01 cm incisions over the dorsal aspect of the diaphysis of the second metacarpal with a 1 cm spacing between them; dissection and exposure of the dorsal cortex of the metacarpal; placement of the soft tissue protector at a right angle to the coronal plane of the hand; introduction of two 2.5 mm self-drilling Schanz pins, with a technique similar to that for the proximal pins, in the diaphyseal region of the second metacarpal. Should the fracture be intra-articular, this surgical technique may be combined with percutaneous fixation with 1.5 or 2 mm K-wires. Where dorsal comminution is present, a bone graft may be performed with bone removed from the iliac. Open reduction with volar approach and volar locked plate.
a cleft palate and was made out of molded gold. The late 1880's brought the next major change in bone plating; surgeons began burying the bone screws below the skin. There were many designs and ideas that developed over the next 70 years. Unfortunately, malunions, nonunions and bone infections were issues due to lack of sterile techniques, and bone plates that were biomechanically unable to provide rigid fixation. Robert Danis (1880-1962) developed the ideas of compression plating and experimented with many different designs during his lifetime. Modern bone plating started in the 1950's when a group of 15 surgeons lead by Maurice Muller formed AO/ASIF (Albeitgemeinshaft fur osteosynthenfragen/ Association for the study of internal fixation) to improve the principles of bone plating. AO remains purely a medical organization to advance the study of fracture treatment while Synthes is the commercial arm of the AO.
The use of an LCP as a definitive externalfixator did not seem to adversely affect bone healing. We note that an LCP is usually only applied as a temporary external fixation [9, 15]; after resolution of the infection or heal- ing of the wound, definitive internal fixation is generally performed, probably due to concerns regarding the po- tentially insufficient strength of an externallockingplate. Kanchanomai et al.  designed a biomechanical test of tibial fracture externally fixed with an LCP, and re- ported that an increased distance between the bone and the implant significantly decreased the construct stabil- ity; however, all models were cyclically loaded beyond 500,000 cycles without any failure of the LCP , and so failure of the LCP is unlikely to be a critical issue in clinical cases. This is supported by previous research; one study reported that eight open tibial fractures healed after only first-stage treatment due to patients’ refusal of second-stage treatment , a series of 12 tibial injuries treated using an LCP as a definitive fixator resulted in union with no loosening or failure of implant in all cases , and 31 patients with infected nonunion or open fracture mainly of the upper extremity treated using an AO-plate as an definitive externalfixator (via the same principle as an LCP) resulted in healing of both the in- fection and the nonunion . Similarly, in the present study, the outcome was satisfactory in all seven cases of infected nonunion of the humeral diaphysis treated with an LCP applied as definitive external fixation.
This was a retrospective study, approved by the ethics committee of The Third Hospital of Hebei Medical University. Between January 2013 and September 2018, patients with distalradiusfractures who underwent volar plate fixation in our hospital were included in this study. Electronic medical record (EMR) and picture archiving and communication system (PACS) were inquired to ex- tract perioperative data. Inclusion criteria were (1) age of 16 years and older, (2) definite diagnosis of distalradius fracture by radiograph or computed tomography (CT) scanning, and (3) treatment by VLP fixation. Exclusion criteria were (1) old fractures (> 3 weeks since fracture occurrence) or pathological (tumor metastasis) fracture, (2) treatments other than VLP, (4) patients who referred to another hospital for treatment of complications, and (5) patients who were lost to follow-up due to contact information change or due to personal affairs.
Fractures of the distal femur are complex injuries. They can produce significant long term disability. They account for 7% of all femoral fractures. If hip Fractures are excluded, 31% of femoral fractures involve distal portion. Although open reduction and internal fixation with plate and screws has Become a standard method of treatment for many types of fractures, the Management of comminuted, intraarticulardistal femoral fractures still remains Complex and challenging to the orthopaedic surgeon. Many of these fractures are the result of high energy trauma which generates severe soft tissue damage and articular and metaphyseal communition.
be a biocortical screw. Biomechanical studies reveals that monocortical locking head screw (LHS) has 70% holding force where as there is 100% in case of conventional bicortical 4.5 mm screwSo we can see that two monocortical screws for each main fragment is sufficient, ideally at least 30 .,self drillingscrews should exclusively be used as monocortical screws becausethe stick out length for anchoring in the opposite cortexis too long which increases possible harm to the soft tissues onthe opposite cortex andSelf tapping screws can be used as bicortical screws but in very osteoporotic bones, which typicallypresent a thin cortex or a bone segment under high torsionalloading, the use of bicortical screws is mandatory to enhancethe working length of the screws and to avoid torsional displacement of the fractured fragments
range 9%-98%) of the surface area of medial condyle of proximal tibia. Higgins et al., confirmed the fact and showed that the fragment occupied 25% of the total tibial articular surface. Usually it is a split fracture with more than 5mm displacement rather than a depression even in osteoporotic bones. As a result there have poor outcome after conservative treatment. It is often associated with injury to anterior cruciate ligament. Open reduction and internal fixation with buttress plating is the recent recommendation for these fractures. Since the fragment is postero-medial, the direct posterior approach placed the neurovascular structures at risk. Approaching the fragment anteriorly also posed risks in the form of extensive dissection of the medial capsular structures and needed tibial tubercle osteotomy for better exposure. In a study by Hsieh et al., they used anteromedial approach and advocated it since there is no risk of neurovascular injury or flexion contracture of the knee 30 . This approach involved erasure of semi-membranosus and semi-tendinosus tendons. The medial collateral ligament was also easily injury. Since the major blood supply of knee is from the medial side there is increased risk of soft tissue devitalisation in already compromised soft tissue from high velocity injury. In 1960s, posterior approach to knee involving dissection of the neurovascular bundle was introduced by Trickey 31 . Since it was a highly demanding procedure, many had complications.
diagnosed to have intraarticularfractures of distal tibia, were treated surgically using external fixators, uniaxially during the period JUNE 2015 to JUNE 2016. The clinical and radiological outcome was assessed and recorded. The ethical committee clearance was obtained from the institution.
Fractures of the distalradius though common and appear simple, affect the function of the wrist considerably. It is the commonest fracture seen in the outpatient department and most are treated with plaster immobilization. Most of these fractures are unstable resulting in loss of reduction and hence malunion, altered wrist kinematics, poor range of motion and early arthritis.