Non-Union in Upper Limb Fractures - Clinical Evaluation and Treatment Options.

Although non-unions in the upper limb are rare different treatment options of this challenging situation are still affected with up to 20% of failure rate due to current literature. Risk factors for delayed and non-union of fractures are mainly the size of the fracture gap and bone loss of open fractures or in primary surgery followed by other relevant internal and external factors. In the upper limb non-unions of long bones are described with up to 30% after operative intervention. Especially in the upper limb range of motion is limited in non-union cases and disables adjacent joints like the shoulder, elbow and wrist hence reducing the total activity level of affected patients. Beside careful investigation of the causes leading to the non-union a comprehensive treatment plan should be defined to achieve successful results. Treatment can be non-operative in several, selected cases, but in the majority of cases revision surgery is necessary to achieve osseous healing. Our own experience showed that non-union in the upper limb are rare and account for only 1.7% of all surgical managed upper limb fractures. Non-union of upper limb fractures occur most frequently in clavicle fractures followed by humeral fractures. Atrophic non-union is the most frequent reason for osseous non-union (57%) and osseous healing after revision surgery in non-unions is completed after a mean of 6.45 months. This article will give a brief overview of the genesis, clinical evaluation, treatment options and recommendations in upper limb non-unions according to the current literature. Key words: fracture, upper-limb, non-union, osteosynthesis, cancellous bone-graft.

Comminuted Fracture of Elbow - Ostheosynthesis vs. Total Joint Replacement.

Comminuted fractures of the elbow are very rare and in most cases very complex and the successful treatment can be a challenge for the treating surgeon. Due to the elbow joint's complex functional anatomy, the multi-fragmentary nature of many fractures and concomitant destabilizing associated injuries, comminuted fractures of the elbow still present a serious challenge for the orthopedic surgeon. Especially in more severe communicated injuries an osteosynthesis or endoprosthesis must be discussed with the patient. There is a lack of clear treatment recommendations based on solid evidence. An overview of the literature including a treatment algorithm to guide decision making for the distal humeral fracture in the adults is presented and own results are analyzed. Key words: comminuted fracture of elbow, total joint replacement of the elbow, elbow prosthesis, elbow arthroplasty, distal humeral fracture.

Reconstructive surgery for patellofemoral joint incongruency.

PURPOSE: A retrospective analysis of a heterogeneous patient cohort was performed to determine the outcome and eligibility of a combined trochleaplasty and soft tissue-balancing technique for repair of patellofemoral joint disorders. METHODS: A strict surgical treatment algorithm including trochleaplasty and reconstruction of the medial patellofemoral ligament and vastus medialis oblique muscle was implemented to restore the patellofemoral joint. A heterogeneous patient cohort including 46 consecutively treated symptomatic knees was reviewed. The median follow-up period was 4.7 years (range 24-109 months). RESULTS: No patellar redislocation occurred post-operatively, and the median Kujala score improved from 62 (9-96) to 88 (47-100) points (p < 0.001) at follow-up. Radiological signs of trochlear dysplasia were corrected, and both patellar height and trochlear depth were significantly restored after surgery. In total, 16% of affected patients with pre-existing patellofemoral degenerative changes showed progression of osteoarthrosis according to the Kellgren and Lawrence classification. CONCLUSION: The surgical combination of trochleaplasty and reconstruction of the medial patellofemoral ligament and vastus medialis oblique muscle offers excellent clinical and radiological results. The overall results of the present study showed significant improvement of the Kujala score in patients with Dejour grades C and D dysplasia. These results outline the clinical relevance of trochleaplasty with additional soft tissue balancing as an effective joint-preserving method with satisfying results in patients with pre-existing degenerative changes. LEVEL OF EVIDENCE: IV.

Management of femoral shaft fractures.

Femoral shaft fractures are severe injuries and are often associated with a high impact trauma mechanism, frequently seen in multiple injured patients. In contrast an indirect trauma mechanism can lead to a complex femoral shaft fracture especially in elderly patients with minor bone stock quality. Hence management of femoral shaft fractures is often directed by co-morbidities, additional injuries and the medical condition of the patient. Timing of fracture stabilization is depended on the overall medical condition of the patient, but definite fracture fixation can often be implemented in the early total care concept in management of multiple injured patients. The treatment of choice is intramedullary fracture fixation. Further development of existing intramedullary nailing systems now offer comfortable handling and different locking options. Ipsilateral fractures of the neck and shaft are therefore facilitated in management. Then again increasing numbers of obese patient are representing a new patient group with challenging co-factors in fracture management. Sufficient preoperative planning is helpful to choose the most adequate fixation device. Correct reduction of the fracture and perioperative control of the axis and rotation is mandatory to avoid postoperative malrotation, which still represents the most frequent complication.

Patellar fractures--a review of classification, genesis and evaluation of treatment.

The patellar bone is involved in repetitive, load bearing motion sequences every day and functions as a vectorial force translator. A fracture rate of 1% of all skeletal fractures is reported and surgical treatment often required. beside a direct trauma mechanism, indirect mechanism but as well as fatigue fractures after reconstructive knee surgery are published. The fracture management is dependent on the soft tissue condition and a variety of surgical options are known. new generation of low profile plates show promising results but the conventional cerclage wiring technique with K-wires is widely preferred. best functional results with sustainable stability are biomechanically seen after a combined fixation technique using anterior cerclage wiring with cannulated screw fixation. A definite algorithm of treatment of patellar bone fractures is yet not defied but a review of classification and surgical techniques should give assistance in decision making.