Comminuted long bone fractures in children. Could combined fixation improve the results?

Comminuted diaphyseal fractures in the pediatric age group represent a major orthopedic problem. It is associated with a high incidence of complications and poor outcomes because of the instability and difficulty in treatment. The aim of this study was to evaluate the efficacy of combined external skeletal fixation and flexible intramedullary nails in reconstruction of comminuted diaphyseal fracture in skeletally immature patients. Combined external fixator and elastic stable intramedullary nails were used in the management of 27 pediatric patients (15 males and 12 females) with unstable comminuted diaphyseal fractures of the tibia and femur. There were 19 fractures of the femur and eight fractures of the tibia. The average age of the patients was 8.7 years (range 7-14 years) for the femur and 10.8 years (range 6-15 years) for the tibia. Fractures were classified according to the system of Winquist and Hansen as grade II (five cases), grade III (nine cases), and grade IV (13 cases). All cases were operated within 6 days (range 0-6 days) after injury. The mean follow-up period was 2.8 years (range 2-3.5 years). The average duration of the external fixation was 1.6 months for fractures of the tibia, whereas it was 1.4 months for fractures of the femur. The average time for tibia fracture union was 2.8 months for fractures of the tibia, whereas it was 1.9 months for fractures of the femur. Malalignment in varus less than 5° was noted in one patient. One patient had a limb-length discrepancy of 1.5 cms. There were five cases (18.5%) with pin-tract infection. According to the Association for the Study and Application of the Methods of Ilizarov evaluation system, bone results were excellent in 23 cases (85.2%), good in three cases (11.1%), and poor in one case (3.7%). Functional results were excellent in 22 (81.5%) cases and good in five (18.5%) cases. Combined use of external fixators and elastic intramedullary nails is a good method for the treatment of comminuted long bone fractures in children.

Clinical, electrodiagnostic and pedobarographic assessments of leprotic patients with trans-tibial amputation.

The aim of present study was to investigate clinical, electrodiagnostic and pedobarographic findings of non-amputee limb in chronic leprotic patients with unilateral trans-tibial amputation to determine neuropathy and plantar foot pressure in non-amputee limb. During the present prospective cross-sectional study, 10 chronic leprotic patients with unilateral trans-tibial amputation were evaluated. The study was conducted in Tabriz Bababaghi and Imam Reza Hospitals at summer of 2008. Sensory nerve conduction (SNAP) and Compound Motor Action Potentials (CMAP) studies were performed in association with pedobarographic assessment. No reliable response was detected from tested sensory and motor nerves, except a very low amplitude finding in deep preoneal nerve of one patient. In comparing with healthy group, static total plantar area, dynamic total plantar area, static rarefoot peak pressure and dynamic rarefoot peak pressure were lower in leprotic patients (p = 0.047, p = 0.004, p = 0.029 and p < 0.001), while static forefoot peak pressure and dynamic forefoot peak pressure were higher in these patients (p = 0.011 and p = 0.031). All of leprotic patients with unilateral trans-tibial amputation suffered from severe neuropathy. Also, these patients have high plantar pressure under the forefoot. Collectively, severe neuropathy and abnormal plantar foot pressure expose in non-amputee foot expose leprotic patients to the higher risk of secondary amputation.

[Surgical techniques of open reduction and internal fixation for ankle fracture].

OBJECTIVE: To evaluate the surgical techniques of open reduction and internal fixation performed for ankle fracture retrospectively and the corresponding clinical outcomes. METHODS: From March 2001 to January 2006, 242 patients with ankle fracture were treated. A total of 85 patients with complete clinical data were analyzed. According to the Lauge-Hansen classification system, the fractures were classified into pronation-external rotation (grade II) in 12 cases and grade IV in 9 cases, supination-external rotation (grade II) in 34 cases and grade IV in 16 cases, supination-adduction (grade II) in 8 cases, and pronation-abduction in 6 cases. The reduction and internal fixation started with lateral malleolus, then medial malleolus and posterior malleolus, and distal tibiofibular syndesmosis in sequence. Among 10 cases, 5 of the distal tibiofibular syndesmosis were fixed with one screw through 3 layers of bone cortexes. All cases were auxiliarily fixed with plaster pad for 4 to 6 weeks after operation. RESULTS: The follow-up period varied from 6 to 36 months, with an average of 10 months. There were no local complications such as malunion or nonunion of the fractures and deformity of the ankle. The inserted screw to distal tibiofibular syndesmosis was not broken. The patients were evaluated with Baird-Jackson scoring system. The numbers of the patients who had excellent, good, fair and poor results were 53, 23, 6, 3, respectively. The excellent and good rate was 89.4%. CONCLUSION: Operative treatment may provide satisfactory clinnical outcomes for ankle fracture. Proper internal fixation and correct fracture pattern estimation are of importance to achieve and gain better long-term results.

Correction of severe foot deformities.

An arthrodesis between tibia and calcaneus was performed after extirpation of the lateral malleolus and the talus in 65 patients with severe stiff paretic feet in equinovarus position, 44 nonleprosy and 21 with leprosy. Early mobilization with weightbearing was allowed after 1 week. Bony fusion was achieved in 95% in the nonleprosy group and 76% in the leprosy group. The final appearance and function was very satisfying with a good range of motion in the Chopart joint.