Outcomes of Local Bone Graft and Fixation of Proximal Pole Scaphoid Nascent Nonunions and Nonunions.

Background Fractures of the proximal pole of the scaphoid have an increased risk of nonunion due to its tenuous blood supply. The optimal treatment of proximal pole scaphoid nonunions remains controversial. Objectives To review a single surgeon's experience with proximal pole scaphoid nascent nonunions (delayed unions) and nonunions that underwent surgical fixation with a cannulated headless compression screw and local autologous bone graft from the distal radius. Patients and Methods After obtaining Institutional Review Board approval, the electronic medical record of one tertiary care center was queried for patients with the diagnosis of "proximal pole scaphoid fractures" who underwent surgical fixation by a single surgeon over an 11-year period (2006-2017). Fifteen patients met initial query criteria; upon review of records, four patients were excluded due to the acute nature of the fracture, and one was excluded as surgical fixation included a vascularized bone graft. Results The final study cohort consisted of 10 patients with a total of 10 proximal pole scaphoid nonunions. Almost all of the patients in this study were male (9/10 [90%]), and sporting activities were the most common mechanism of injury (8/10 [80%]). Volumetric measurements of the scaphoid fractures on computed tomography (CT) revealed that the mean total volume of the scaphoid was 2.4 ± 0.48 cm 3 and the mean volume of the proximal pole fragment was 0.38 ± 0.15 cm 3 . Postoperative CT scans were performed at a mean of 12.4 weeks (range: 8-16 weeks), with seven (7/10 [70%]) showing signs of complete union and three (3/10 [30%]) demonstrating partial union. None of the patients required additional procedures and there were no complications. Conclusions Our results suggest that proximal pole scaphoid fractures with delayed union and nonunion treated with surgical fixation and autologous local bone graft heal without the need for more complex vascularized procedures. The volume of the proximal pole fragment did not correlate with increased risk of ongoing nonunion after the index procedure. Level of Evidence This is a Level IV, case series study.

The Effect of Bisphosphonates on the Clinical and Radiographic Outcomes of Distal Radius Fractures in Women.

PURPOSE: To compare clinical and radiographic outcomes of distal radius fractures (DRF) treated with nonsurgical management in female postmenopausal patients receiving bisphosphonate (BP) therapy at the time of injury with those not receiving BP therapy. METHODS: We prospectively enrolled 33 female postmenopausal patients with 35 DRF between December 2010 and January 2014 at 2 Level I tertiary care centers. Eleven patients with 12 DRF were currently receiving BP at the time of injury (BP group) and were compared with 22 controls with 23 DRF (CONT group) who were not receiving BP at the time of injury. All were postmenopausal women with fragility fractures managed nonsurgically. Primary outcomes were radiographic healing measured by the Radius Union Scoring System (RUSS) score and clinical and functional outcomes. Radiographs, range of motion, pinch and grip strength, Patient-Rated Wrist Evaluation scores, and Disability of the Arm, Shoulder, and Hand scores were determined at 6, 9, and 12 weeks and 1 year from time of injury and compared between groups. RESULTS: The BP and CONT groups were similar in terms of age, comorbidities, and fracture severity. Both groups had progressively improving RUSS scores from the time of injury throughout subsequent evaluation, and all patients achieved radiographic union. Fracture healing was similar in both groups at 6, 9, and 12 weeks after injury. The RUSS scores were slightly better in the CONT group at 1 year. There were no differences in wrist range of motion, pinch, grip, Patient-Rated Wrist Evaluation, or Disability of the Arm, Shoulder, and Hand scores at any time point after injury. CONCLUSIONS: Patients receiving BP at the time of DRF had clinical outcomes similar to those not receiving antiresorptive treatment. Although there was a small difference in RUSS scores at 1 year after injury, this was not clinically relevant and all fractures united in a similar time frame with no healing complications. These results suggest that BP may be continued throughout nonsurgical management of DRF without detrimental effects on healing or function. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Time From Injury to Surgical Fixation of Diaphyseal Humerus Fractures Is Not Associated With an Increased Risk of Iatrogenic Radial Nerve Palsy.

OBJECTIVES: To determine whether time from injury to fixation of diaphyseal humeral fractures and nonunions is associated with the risk of iatrogenic radial nerve palsy. DESIGN: Retrospective review. SETTING: Two Level 1 trauma centers. PATIENTS/PARTICIPANTS: Between 2001 and 2015, 325 patients who had documented intact radial nerve function preoperatively were treated with fixation of a humerus fracture or humerus nonunion. INTERVENTION: Open reduction and internal fixation. MAIN OUTCOME MEASUREMENTS: Development of an iatrogenic radial nerve injury. Those with an injury were followed to either resolution of the nerve palsy or definitive treatment. RESULTS: The risk of iatrogenic radial nerve palsy was 7.7% (25/325). Time to surgery was not significantly associated with iatrogenic radial nerve palsy. In a multiple variable analysis, when comparing patients treated within 4 weeks to those treated 4-8 weeks (P = 0.41), 8-12 weeks (P = 0.94), and over 12 weeks (0.20), there were no significant associations. Independent risk factors for iatrogenic radial nerve palsy included distal location of fracture (P = 0.04, odds ratio 3.71) and previous fixation (P = 0.03, odds ratio 3.80). Of the 25 iatrogenic nerve injuries, 22 recovered fully with expectant management, 1 was lost to follow-up, and 2 required either nerve graft or tendon transfers. CONCLUSIONS: Time from injury to surgery does not seem to be a risk factor for developing an iatrogenic radial nerve palsy when treating diaphyseal humerus fractures. Patients with distal fractures, and those with previous fracture implants, are at increased risk of iatrogenic radial nerve palsy. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment Options for Distal Femur Fractures.

Despite advances in implant design, the management of distal femur fractures remains challenging. Fracture comminution and intra-articular extension can make it difficult to obtain an adequate reduction while preserving the soft tissue attachments to bone fragments to allow for bone healing. Many implant manufacturers have developed optimal anatomically contoured, distal femoral locking plates with percutaneous guides. This environment allows for the application of lateral locked plates in a biologically friendly manner. Although initial reports had high success rates, more recently a high rate of nonunion has been found, particularly in elderly patients. Limited literature is available for the treatment of patients with osteoporotic bone and associated ipsilateral total knee replacement and hip replacement. We present a patient with a distal femur fracture with significant comminution in the setting of an ipsilateral total hip replacement.