[Definitions and explanations on the topic of fracture reduction]. / Definitionen und Erklärungen zum Thema Frakturreposition.

The process of reduction is a key step for successful fracture treatment. The goal of fracture reduction is the realignment of the displaced fractured fragments caused by muscle tension or impaction back into the original anatomic relationship. The reduction process includes not only the application of force at or remote from the fracture site to reverse the deforming forces but also the preoperative planning where to apply these forces and by what means. Furthermore, consideration should be preoperatively given on how to position the patient and the C­arm and how to temporarily maintain reduction for intraoperative x­ray control of the axis, rotation and lengths before definitive fixation.

Minimally invasive plate osteosynthesis (MIPO) for scapular fractures.

OBJECTIVE: Presentation of a minimally invasive surgical approach for the treatment of scapular fractures and the clinical outcome using this technique. INDICATIONS: Displaced extra-articular fractures of the scapula body and glenoid neck (AO 14B and 14F) and simple intra-articular fractures of the glenoid. CONTRAINDICATIONS: Complex intra-articular fractures and isolated fractures of the coracoid base. SURGICAL TECHNIQUE: Make a straight or slightly curved incision along the lateral margin of the scapula leaving the deltoid fascia intact. Identify the interval between the teres minor muscle and infraspinatus to visualize the lateral column, whilst retracting the deltoid to visualize the glenoid neck. Reduce and align the fracture using direct and indirect reduction tools. A second window on the medial border of the scapula can be made to aid reduction and/or to augment stability. Small (2.0-2.7 mm) plates in a 90° configuration on the lateral border and, if required, on the medial border are used. Intra-operative imaging confirms adequate reduction and extra-articular screw placement. POSTOPERATIVE MANAGEMENT: Direct postoperative free functional nonweight-bearing rehabilitation limited to 90° abduction for the first 6 weeks. Sling for comfort. Free range of motion and permissive weight-bearing after 6 weeks. RESULTS: We collected data from 35 patients treated with minimally invasive plate osteosynthesis (MIPO) between 2011 and 2021. Average age was 53 ± 15.1 years (range 21-71 years); 17 had a type B and 18 a type F fracture according the AO classification. All patients suffered concomitant injuries of which thoracic (n = 33) and upper extremity (n = 25) injuries were most common. Double plating of the lateral border (n = 30) was most commonly performed as described in the surgical technique section. One patient underwent an additional osteosynthesis 3 months after initial surgery due to pain and lack of radiological signs of healing of a fracture extension into the spine of the scapula. In the same patient, the plate on the spine of scapula was later removed due to plate irritation. In 2 patients postoperative images showed a screw protruding into the glenohumeral joint requiring revision surgery. After standardisation of intra-operative imaging following these two cases, intra-articular screw placement did not occur anymore. No patient suffered from iatrogenic nerve injury and none developed a wound infection.

Plate vs. nail for extra-articular distal tibia fractures: How should we personalize surgical treatment? A meta-analysis of 1332 patients.

BACKGROUND: Treatment for distal diaphyseal or metaphyseal tibia fractures is challenging and the optimal surgical strategy remains a matter of debate. The purpose of this study was to compare plate fixation with nailing in terms of operation time, non-union, time-to-union, mal-union, infection, subsequent re-interventions and functional outcomes (quality of life scores, knee- and ankle scores). METHODS: A search was performed in PubMed/Embase/CINAHL/CENTRAL for all study designs comparing plate fixation with intramedullary nailing (IMN). Data were pooled using RevMan and presented as odds ratios (OR), risk difference (RD), weighted mean difference (WMD) or weighted standardized mean difference (WSMD) with a 95% confidence interval (95%CI). All analyzes were stratified for study design. RESULTS: A total of 15 studies with 1332 patients were analyzed, including ten RCTs (n = 873) and five observational studies (n = 459). IMN leads to a shorter time-to-union (WMD: 0.4 months, 95%CI 0.1 - 0.7), shorter time-to-full-weightbearing (WMD: 0.6 months, 95%CI 0.4 - 0.8) and shorter operation duration (WMD: 15.5 min, 95%CI 9.3 - 21.7). Plating leads to a lower risk for mal-union (RD: -10%, OR: 0.4, 95%CI 0.3 - 0.6), but higher risk for infection (RD: 8%, OR: 2.4, 95%CI 1.5 - 3.8). No differences were detected with regard to non-union (RD: 1%, OR: 0.7, 95%CI 0.3 - 1.7), subsequent re-interventions (RD: 4%, OR: 1.3, 95%CI 0.8 - 1.9) and functional outcomes (WSMD: -0.4, 95%CI -0.9 - 0.1). The effect estimates of RCTs and observational studies were equal for all outcomes except for time to union and mal-union. CONCLUSION: Satisfactory results can be obtained with both plate fixation and nailing for distal extra-articular tibia fractures. However, nailing is associated with higher rates of mal-union and anterior knee pain while plate fixation results in an increased risk of infection. This study provides a guideline towards a personalized approach and facilitates shared decision-making in surgical treatment of distal extra-articular tibia fractures. The definitive treatment should be case-based and aligned to patient-specific needs in order to minimize the risk of complications.

[Reduction techniques for minimally invasive stabilization of proximal humeral fractures]. / Repositionstechniken bei minimal-invasiver Stabilisierung proximaler Humerusfrakturen.

OBJECTIVE: The aim of surgical stabilization of proximal humerus fractures is to restore the anatomical relations between the greater and lesser tubercle, to reconstruct the joint and preserve the vascular supply of the fragments. INDICATIONS: Approximately 80% of proximal humeral fractures can be treated conservatively. Surgical treatment is indicated based on the fracture pattern, patient-related factors and the risk of avascular head necrosis. Two-part fractures with a metaphyseal comminution zone and 3/4-part fractures can benefit from near to anatomic reconstruction depending on the patient's demands and bone quality. Minimally invasive stabilization procedures allow for an anatomical reconstruction in the majority of fresh proximal humeral fractures with or without a proximal shaft fracture, provided that intraoperative traction allows the fracture to be aligned axially in the image intensifier by ligamentotaxis. Indirect, combined with direct reduction maneuvers, allow for an almost anatomical reconstruction, despite minimal invasive approaches. SURGICAL TECHNIQUE: Beach chair position. The arm is held in a pneumatic articulating traction device. Evaluation of the indirect reduction potential by ligamentotaxis with visualization of the alignment of the head fragments in relation to the shaft by traction, abduction/adduction, flexion/extension and rotation. The traction device and a foam roll in the axilla to neutralize the tension of the pectoralis major and teres major muscles while simultaneously adducting the elbow hold the reduction. Insufficient reduction of the fragments requires additional direct reduction maneuvers. Opening of the bursa and fixation of the rotator cuff with sutures to adjust reposition. A 2.5 mm-threaded K­wire is inserted into the head fragment as a joystick. Under protection of the axillary nerve, the plate is inserted under protection of the axillary nerve. Temporary fixation of the plate with Kirschner wires for positioning the plate 5-8 mm below the greater tubercle and 2-3 mm laterally of the sulcus of the long biceps tendon and subsequent radiographic control. Reduction of the shaft against the plate with a cortex screw. The threaded K­wire in the head can be used to adjust the varus and valgus alignment and to achieve adequate support of the calcar. Finally, complete the osteosynthesis with angular stable screws. POSTOPERATIVE MANAGEMENT: Immediate active assisted exercise in the shoulder under physiotherapeutic supervision. Temporary immobilization for patient comfort. Standard active and resistive mobilization after the first clinical and radiological checkup 6 weeks after surgery. Further radiological checks after 3 and 6 months and 1 year. No routine plate removal.

[Scaphoid fractures: diagnosis and therapy]. / Scafoïdfracturen: diagnostiek en therapie.

An adequate management of scaphoid fractures requires fast and reliable diagnosis. In this, proper history taking and physical examination are essential. Routine scaphoid x-rays miss over 20% of all scaphoid fractures. Therefore, in patients with a clinically suspected scaphoid fracture that cannot be proven by scaphoid x-rays, further diagnostic investigation is indicated. Which supplemental diagnostic tool (bone scintigraphy, MRI, CT) is preferred remains unclear. A below-the-elbow cast without immobilisation of the thumb is an adequate treatment for stable fractures. Unstable fractures and all proximal pole fractures are candidates for open or percutaneous treatment. In addition to the type of fracture, patient-specific requirements are important in deciding which type of management is the most suitable.