Manejo de fractura de platillo tibial medial utilizando placas rim anteromedial y posteromedial / Management of Medial Tibial Plateau Fracture using Antero- and Posteromedial Rim Plates

INTRODUCCION En los últimos años, se ha descrito el uso de placas horizontales para la fijación de fracturas que comprometen el reborde articular de los platillos tibiales, lo que se conoce como placa rim. La mayoría de las publicaciones al respecto describen su uso en columnas posteriores y posterolaterales de los platillos tibiales, y a la fecha hay escasos reportes del uso de este tipo de placa en la columna anteromedial y ninguno para la posteromedial. El objetivo de este artículo es presentar dos casos clínicos de fracturas conminutas del platillo tibial medial mostrando su tratamiento con el uso de placas rim. CASOS CLINICOS El primer caso presentaba compromiso anteromedial y posteromedial, y el segundo, compromiso posteromedial. En ambos casos, se logró la reducción mediante un abordaje posteromedial y su fijación con placa bloqueada de 2,7 mm como placa rim. En cada caso, se detalló la estrategia de reducción y el manejo postoperatorio. RESULTADOS Ambos pacientes consiguieron la consolidación ósea entre las semanas 14 y 18 tras la osteosíntesis definitiva, sin presentar pérdidas de reducción. Ambos lograron rango de movilidad articular completo (0°­125°), y retornaron a sus trabajos a los 4 y 6 meses respectivamente. CONCLUSIONES Estas placas ofrecen una buena opción de tratamiento para fracturas articulares conminutas del borde del platillo tibial, tanto en la columna anteromedial como en la posteromedial. A pesar de la ausencia de grandes series de pacientes con uso de placas rim mediales, el resultado de los casos presentados aquí nos permite plantear su utilidad al momento de enfrentarnos a fracturas del reborde articular

INTRODUCTION In recent years, the use of horizontal plates has been described to achieve fixation of fractures that compromise the articular ridge of the tibial plateau; these plates are known as "rim plates." Most publications report their use in the posterior and posterolateral columns of the tibial plateau, and to date there are few reports of its use for the fixation of the anteromedial column and none for the posteromedial column. The objective of the present article is to report two clinical cases of comminuted fractures of the medial tibial plateau, showing their treatment with the use of medial rim plates. CLINICAL CASES The first case presented with an anteromedial and posteromedial tibial plateau fracture, and the second, a posteromedial fracture. In both cases, reduction was achieved through a posteromedial approach, and the fixation was performed with a 2.7-mm locked rim plate. The reduction strategy and postoperative management were detailed in each case. RESULTS Both patients achieved bone consolidation during the 14th and 18th weeks after the definitive osteosynthesis, without presenting loss of reduction. Both patients achieved full range of joint motion (0°­125°) and returned to work after four and six months respectively. CONCLUSION These plates offer a good treatment option for comminuted fractures of the rim of the tibial plateau, for both the anteromedial and posteromedial columns. Despite the absence of large series of patients with the use of medial rim plates, the results of the two cases herein presented enables us to propose it as a useful tool when dealing with fractures of the medial rim of the tibial plateau

INTRODUCTION In recent years, the use of horizontal plates has been described to achieve fixation of fractures that compromise the articular ridge of the tibial plateau; these plates are known as "rim plates." Most publications report their use in the posterior and posterolateral columns of the tibial plateau, and to date there are few reports of its use for the fixation of the anteromedial column and none for the posteromedial column. The objective of the present article is to report two clinical cases of comminuted fractures of the medial tibial plateau, showing their treatment with the use of medial rim plates. CLINICAL CASES The first case presented with an anteromedial and posteromedial tibial plateau fracture, and the second, a posteromedial fracture. In both cases, reduction was achieved through a posteromedial approach, and the fixation was performed with a 2.7-mm locked rim plate. The reduction strategy and postoperative management were detailed in each case. RESULTS Both patients achieved bone consolidation during the 14th and 18th weeks after the definitive osteosynthesis, without presenting loss of reduction. Both patients achieved full range of joint motion (0°­125°) and returned to work after four and six months respectively. CONCLUSION These plates offer a good treatment option for comminuted fractures of the rim of the tibial plateau, for both the anteromedial and posteromedial columns. Despite the absence of large series of patients with the use of medial rim plates, the results of the two cases herein presented enables us to propose it as a useful tool when dealing with fractures of the medial rim of the tibial plateau

Uso de placa malla en el manejo de fracturas conminutas de patela: reporte de caso / Use of mesh plate for the treatment of comminuted patellar fractures: case report

OBJETIVOS Describir la técnica quirúrgica para el uso de placa malla en un caso de fractura conminuta de patela y sus resultados en el seguimiento a mediano plazo. MATERIALES Y MÉTODOS Presentamos un caso de fractura conminuta de patela manejada con el uso de una placa malla y un tornillo canulado asociado, evitando de esta forma la patelectomía parcial y sus posibles complicaciones. RESULTADOS El paciente presentó una evolución satisfactoria, con rango de movimiento de rodilla completo y en condiciones de alta laboral a los cuatro meses desde la cirugía, sin complicaciones ni reintervenciones. DISCUSIÓN El uso de placas malla permite el manejo de fracturas conminutas de patela preservando stock óseo y restaurando la indemnidad del aparato extensor, con una osteosíntesis estable y poco prominente. Casos en que antiguamente la única alternativa era la patelectomía parcial y reinserción del tendón patelar ahora tienen etas placas como opción de manejo. CONCLUSIÓN El uso de placas malla en fracturas conminutas de patela es una alternativa atractiva por la estabilidad que brindan, la capacidad de reservar stock óseo, y la baja tasa de reintervenciones

OBJETIVE To describe the surgical technique for the use of a mesh plate in a case of comminuted patellar fracture and the mid-term follow up outcomes. MATERIALS AND METHODS We present a case of comminuted patella fracture managed with the use of a mesh plate and an associated cannulated screw, thus avoiding partial patellectomy and its possible complications. RESULTS Four months postoperatively, the patient presented full knee range of motion and could be discharged to return to work, with no complications or reinterventions. DISCUSSION The use of mesh plates enables the management of comminuted patellar fractures preserving bone stock and restoring the extensor mechanism with a stable and little prominent osteosynthesis. Cases which previously would only have been treated by partial patellectomy and patellar tendon reinsertion can be treated with these plates. CONCLUSION The use of mesh plates for comminuted patellar fractures is an attractive option due to their stability, their ability to preserve bone stock, and the low rates of reintervention.

Manejo no quirúrgico de la artrosis de rodilla: ¿Son efectivos los medicamentos orales complementarios? / Non-surgical management of knee osteoarthritis: are complementary oral medications effective?

La artrosis es una enfermedad progresiva de las articulaciones sinoviales que causa dolor, impotencia funcional, discapacidad, y degeneración progresiva de la articulación. En sus tratamientos, sobre todo en etapas tempranas, existen distintas intervenciones para evitar tanto su desarrollo y progresión como también para lograr un adecuado manejo de los síntomas, y hay tratamientos médicos orales no convencionales con evidencia controvertida. El objetivo de este trabajo es proporcionar una actualización, dirigida a especialistas en Ortopedia y Traumatología, respecto a la evidencia actual sobre las terapias complementarias orales en el tratamiento de la artrosis de rodilla. Se hace referencia a los métodos fármacológicos complementarios más usados y estudiados, mencionando el método de acción y las consecuencias estudiadas sobre la artrosis de rodilla. Se finaliza con una tabla de recomendaciones basada en evidencia actual.

Osteoarthritis (OA) is a progressive disease of the synovial joints that causes pain, functional impairment, disability, and progressive degeneration of the joint. Regarding its treatments, especially in early stages, there are different interventions to avoid its development and progression and also to achieve an adequate management of symptoms, and there are unconventional oral medical treatments with controversial evidence. The objective of the present paper is to provide an update, to specialists in Orthopedics and Traumatology, regarding the current evidence on complementary oral therapies in the treatment of knee osteoarthritis. References are made to the most widely used and studied complementary pharmacological methods, mentioning the method of action and the consequences studied on knee osteoarthritis. The article ends with a table of recommendations based on current evidence.

Tratamiento de la fractura conminuta de patela: ¿existen diferencias entre realizar o no una eversión? / Treatment of comminuted patellar fracture: are there differences between performing or not performing an eversion?

OBJETIVO Comparar los resultados clínicos, funcionales e imagenológicos de dos técnicas quirúrgicas para el manejo de fracturas conminutas de patela: con y sin eversión patelar. MÉTODOS En una serie de casos retrospectivos de fracturas conminutas de patela tratadas en el mismo centro entre 2014 y 2017, con un seguimiento ≥ 3 meses, se hizo una comparación entre el grupo con eversión y el grupo sin eversión. Los criterios de exclusión fueron patelectomía parcial o total, reinserción tendínea, o rehabilitación incompleta. Las variables analizadas fueron edad, sexo, tabaquismo, diabetes mellitus, energía del accidente, tipo de fractura, variables quirúrgicas (banda de tensión, tornillos, alambres, nudos, cerclaje circular), rango de movimiento (RDM) articular postoperatorio, presencia de osteosíntesis sintomática, puntaje de escalas funcionales (de Tegner-Lysholm y de Kujala) al alta definitiva, complicaciones (rigidez articular, infección, trombosis venosa profunda), y variables imagenológicos con tomografías computarizadas pre- y postoperatorias (brecha, desnivel articular > 2 mm, elementos de fijación intraarticular). RESULTADOS En total, 20 de 22 pacientes, 13 con eversión y 7 sin eversión, cumplieron con los criterios de selección. El seguimiento fue de 3 a 12 meses, y no hubo diferencias estadísticamente significativas respecto a las variables demográficas entre ambos grupos, lo cual los hace comparables. Destacaron el tiempo desde el ingreso al alta, con 7 meses para los pacientes con eversión y 5 meses para los sin eversión (p = 0.032), la proporción de pacientes con desnivel articular > 2 mm, con 7.7% para los con eversión y 14.3% para los sin eversión (p = 0.016), y una tendencia a resultados superiores en escalas funcionales para el grupo con eversión. CONCLUSIÓN El tratamiento de fracturas conminutas de patela con eversión parece ser una alternativa viable dados sus resultados imagenológicos y funcionales superiores a los de la técnica habitual.

PURPOSE To compare the clinical, functional and imaging outcomes of two surgical techniques for the treatment of comminuted patellar fractures: with and without eversion. METHODS In a retrospective series of cases of comminuted patellar fractures treated at a single center between 2014 and 2017, with a follow-up 3 months , we performed a comparison between the eversion group and the non-eversion group. The exclusion criteria were partial or total patellectomy, tendon reinsertion, or incomplete rehabilitation. The variables analyzed were age, gender, smoking, diabetes mellitus, the energy of the accident, the fracture type, surgical variables (tension band, screws, wires, knots, circular cerclage), postoperative joint range of motion (ROM), presence of symptomatic osteosynthesis, the scores on the functional scales (of Tegner-Lysholm and of Kujala) at the final discharge, complications (joint stiffness, infection, deep vein thrombosis), and pre- and postoperative computed tomography imaging variables (gap, step-off > 2mm, intra-articular fixation elements). RESULTS In total, 20 out of 22 patients, 13 undegoing eversion and 7 not undergoing eversion, met the selection criteria.. The follow-up ranged from 3 to 12 months, and there were no statistically significant differences regarding the demographic variables between both groups, which makes them comparable. The most remarkable results were the time from admission to final discharge, of 7 months for the patients in the eversion group, and of 5 months for those in the non-eversion group (p » 0.032), the proportion of patients with a step-off > 2 mm, with 7.7% for the eversion group and 14.3% for the non-eversion group (p » 0.016), and a tendency towards higher scores in the functional scales for the eversion group. CONCLUSION The treatment of comminuted patellar fractures with eversion seems to be a viable alternative, given its superior imaging and functional results compared to those of the usual technique.

Fracturas Mandibulares Conminutadas por Impacto de Proyectil Balístico: resultados Clínicos de Tratamiento Con Método de Fijación Alternativo / Mandibular Fractures Comminuted by Ballistic Projectile Impact: clinical Results of Treatment with Alternative Fixation Method

Las fracturas mandibulares conminutadas por impacto de proyectil balístico son un desafío terapéutico debido a la presencia de múltiples fragmentos óseos y el compromiso a nivel de periostio, plano muscular y mucoso. Su tratamiento inicial requiere de una estabilización de las urgencias médico - quirúrgicas y posteriormente tratar los segmentos óseos fracturados. La fijación externa con tutores mandibulares permite estabilizar los segmentos mandibulares de forma cerrada manteniendo así la viabilidad de los fragmentos sin interrumpir su suministro de sangre. El objetivo de este trabajo es presentar los resultados post operatorios obtenidos en tres casos clínicos de pacientes con diagnóstico de fractura mandibular conminutada por trauma por impacto de proyectil balístico, tratados por un método alternativo a los tutores de fijación externa convencional.

Comminuted mandibular fractures from ballistic missile impact are a therapeutic challenge due to the presence of multiple bone fragments and the involvement of periosteum, muscle and mucous membrane. Their initial treatment requires emergency medical and surgical stabilization and later treatment of the fractured bone segments. External fixation with mandibular stakes makes it possible to stabilize the mandibular segments in a closed manner, thus maintaining the viability of the fragments without interrupting their blood supply. The aim of this work is to present the post-surgical results obtained in three clinical cases of patients with diagnosis of comminuted mandibularfracture by ballistic missile impact, treated by an alternative method to the conventional external fixation tutors.

Interventions for treating fractures of the patella in adults.

BACKGROUND: Fractures of the patella (kneecap) account for around 1% of all human fractures. The treatment of these fractures can be surgical or conservative (such as immobilisation with a cast or brace). There are many different surgical and conservative interventions for treating fractures of the patella in adults. This is an update of a Cochrane Review first published in 2015. OBJECTIVES: To assess the effects (benefits and harms) of interventions (surgical and conservative) for treating fractures of the patella in adults. SEARCH METHODS: We searched CENTRAL (2020, Issue 1), MEDLINE, Embase, LILACS, trial registers and references lists of articles to January 2020. SELECTION CRITERIA: We included randomised controlled trials (RCTs) or quasi-RCTs that evaluated any surgical or conservative intervention for treating adults with fractures of the patella. The primary outcomes were patient-rated knee function, knee pain and major adverse outcomes. DATA COLLECTION AND ANALYSIS: At least two review authors independently selected eligible trials, assessed risk of bias and cross-checked data extraction. Where appropriate, we pooled results of comparable trials. MAIN RESULTS: We included 11 small trials involving 564 adults (aged 16 to 76 years) with patella fractures. There were 340 men and 212 women; the gender of 12 participants was not reported. Seven trials were conducted in China and one each in Finland, Mexico, Pakistan and Turkey. All 11 trials compared different surgical interventions for patella fractures. All trials had design flaws, such as lack of assessor blinding, which put them at high risk of bias, potentially limiting the reliability of their findings. No trial reported on health-related quality of life, return to previous activity or cosmetic appearance. The trials tested one of seven comparisons. In the following, we report those of the main outcomes for which evidence was available for the three most important comparisons. Four trials (174 participants) compared percutaneous osteosynthesis versus open surgery. Very low-quality evidence means that we are uncertain of the findings of no clinically important difference between the two interventions in patient-rated knee function at 12 months (1 study, 50 participants) or in knee pain at intermediate-term follow-up at eight weeks to three months. Furthermore, very low-quality evidence means we are uncertain whether, compared with open surgery, percutaneous fixation surgery reduces the incidence of major adverse outcomes, such as loss of reduction and hardware complications, or results in better observer-rated knee function scores. Two trials (112 participants) compared cable pin system (open or percutaneous surgery) versus tension band technique. The very low-quality evidence means we are uncertain of the findings at one year in favour of the cable pin system of slightly better patient-rated knee function, fewer adverse events and slightly better observer-rated measures of knee function. There was very low-quality evidence of little clinically important between-group difference in knee pain at three months. Very low-quality evidence from two small trials (47 participants) means that we are uncertain of the findings of little difference between biodegradable versus metallic implants at two-year follow-up in the numbers of participants with occasional knee pain, incurring adverse events or with reduced knee motion. There was very low-quality and incomplete evidence from single trials for four other comparisons. This means we are uncertain of the results of one trial (28 participants) that compared patellectomy with advancement of vastus medialis obliquus surgery with simple patellectomy; of one quasi-RCT (56 participants) that compared a new intraoperative reduction technique compared with a standard technique; of one quasi-RCT (65 participants) that compared a modified tension band technique versus the conventional AO tension band wiring (TBW) technique; and of one trial (57 participants) that compared adjustable patella claws and absorbable suture versus Kirschner wire tension band. AUTHORS' CONCLUSIONS: There is very limited evidence from nine RCTs and two quasi-RCTs on the relative effects of different surgical interventions for treating fractures of the patella in adults. There is no evidence from trials evaluating the relative effects of surgical versus conservative treatment or different types of conservative interventions. Given the very low-quality evidence, we are uncertain whether methods of percutaneous osteosynthesis give better results than conventional open surgery; whether cable pin system (open or percutaneous surgery) gives better results than the tension band technique; and whether biodegradable implants are better than metallic implants for displaced patellar fractures. Further randomised trials are needed, but, to optimise research effort, these should be preceded by research that aims to identify priority questions.

Informe de caso: Resultado clínico de TOE conservado después de un evento traumático de pie / Case report: Clinical outcome of TOE preserved after Traumatic event of foot

Introduction: Decision making in determining management of post-trauma patient is very important, especially for traumatic in the small bones, fingers and toes. The global predictor to determine the management of retaining or amputating the limb is using the Mangled Extrimity Severity Score (MESS) scoring system, values above 7 are the indication for amputation. The decision maker have to pay attention for the end result of the actions which were performed in the initial management. Material and Methods: One case is reported from Orthopaedic emergency department Hospital in Makassar, South Sulawesi, Indonesia. A 39-year old male with motor vehicle accident trauma at left foot region since 6 hours before admitted to hospital, later was diagnosed with open comminutive fracture shaft proximal phalang of left 5th toe, the Mangled Extrimity Severity Score (MESS) was 8. Patient underwent emergency debridement and retained the toe by performed Open Reduction Internal Fixation (ORIF) K-Wire. Results: This patient has a good clinical outcome by following up 2 weeks and 8 months after surgery by retain the affected side with debridement and Open Reduction Internal Fixation (ORIF) K-Wire. Patient can ambulate normally with full weight bearing, and there is no difficulty to wearing shoe or sandal. Conclusions: Determination of action by retaining the traumatized limb needs to be considered for the good of the patient, but it is necessary to provide informed consent to the patient and family that there will be a possibility of tissue death with the worst possibility of limb amputation

Evaluación de resultados calificada por el paciente en el análisis la diferencia de resultado funcional entre Fijación distal del segundo y tercer metacarpiano de placa de distracción dorsal en conminutivo distal fractura de radio / Patient-rated outcomes evaluation in analyzing the difference of functional outcome between second and third metacarpal distal fixation of dorsal distraction plating in comminutive distal radius fracture

Introduction: Comminuted distal radius fracture is one of the fractures that difficult to reduce. This study aimed to compare Patient-Rated Wrist Evaluation (PRWE) score between plating on second and third metacarpal groups. Methods: This study used a retrospective analytic research design with a sample of twenty seven cases of distal radius comminutive fractures that have been treated using dorsal distraction plating. Fifthteen cases with distal fixation in second metacarpal and twelve cases in third metacarpal. Data were then analyzed using the Mann-Whitney test. Results: The mean Pain scores in the second metacarpal and third metacarpal groups, respectively were 5.73 compared to 6.17. While the mean score of Function in the second metacarpal group and the third metacarpal group, respectively 12.67 compared to 13.83. The total PRWE score in the second metacarpal group was 18.40 compared to the third metacarpal group which was 20.0 (p>0.05). Conclusions: Patients with distal radius comminuted fracture treated using dorsal distraction plating with distal fixation in second metacarpal showed higher mean Pain, Function and total PRWE compared to third metacarpal, but there were no significant differences

Metatarsal Transfer Associated with Microsurgical Flap in Exposed Foot Fracture: A Case Report and 10-Year Follow-up.

CASE: A 35-year-old female patient presented with an exposed forefoot fracture with bone and dermal loss after a vehicular accident. There was a bone defect at the level of the second toe and the third metatarsal. She was treated by second toe resection and second metatarsal transfer to augment the third metatarsal diaphysis ray (nonvascularized, without any soft-tissue envelope) and a microsurgical forearm flap. CONCLUSION: As one option among the reconstruction techniques available for a metatarsal segmental defect, metatarsal transfer associated with a fasciocutaneous radial forearm flap proved to be effective in this patient.

Fratura de mandíbula causada por projétil de arma de fogo: relato de caso / Mandible Fracture Caused by Firearm Projectile: Case Report

Introdução: A face é uma região exposta a diversos traumas que são causados por várias etiologias, dentre eles por projétil de arma de fogo que são a segunda maior causa de fraturas perdendo somente para os acidentes automobilísticos. As fraturas acometem com frequência a região mandibular, por ser um osso de destaque na face devido sua proeminência. O objetivo deste trabalho é elucidar uma fratura cominutiva na região de côndilo e colo mandibular causada por ferimento de arma de fogo e seu respectivo tratamento. Relato de Caso: Paciente de 25 anos, compareceu a um serviço de atendimento de cirurgia bucomaxilofacial vítima de um ferimento por arma de fogo. Após a realização dos exames de imagem constatou-se que o projétil estava alojado no pescoço da vítima, causando a fratura cominutiva o ramo e o côndilo mandibular do lado esquerdo. A paciente foi submetida a anestesia geral para realização da osteossíntese da fratura. Considerações finais: O diagnóstico e o tratamento são realizados por uma equipe multidisciplinar para que o tratamento seja o mais correto e efetivo, com finalidade de minimizar morbidades e mortalidades, já que os pacientes sobrevivem com sequelas permanentes quando o diagnóstico e o tratamento não são realizados de forma correta... (AU)

Introduction: The face is a region exposed to several traumas that are caused by several etiologies, among them a firearm projectile that is the second major cause of fractures losing only to automobile accidents. The fractures frequently affect the mandibular region, as it is a prominent bone in the face due to its prominence. The purpose of this study is to elucidate a comminuted fracture in the condyle and mandibular neck region caused by a firearm injury and its respective treatment. Case Report: A 25-year-old patient who attended a buccomaxillofacial surgery service as a victim of a gunshot wound. After imaging examinations it was found that the projectile was lodged in the victim's neck, causing the comminuted fracture of the branch and mandibular condyle on the left side. The patient underwent general anesthesia to perform the fracture osteosynthesis. Final considerations: Diagnosis and treatment are performed by a multidisciplinary team so that treatment is the most correct and effective, in order to minimize morbidities and mortalities, since patients survive with permanent sequelae when diagnosis and treatment are not performed correctly... (AU)

Intra-articular Transcalcaneal Fracture-Dislocation Associated With Ipsilateral Transtalar Fracture: A Report of a Rare Combination.

The association of ipsilateral talar and calcaneal fractures is an uncommon combination and is typically the result of a high-energy trauma. It is often associated with comminution, marked fracture displacement, and soft-tissue compromise. Obtaining satisfactory clinical and radiographic results is very challenging. Residual deformities, multiple procedures, and limitations are usually the norm. Therefore, studies have suggested that primary arthrodesis may represent the best option of surgical treatment. In this study, we report a case of a 30-year-old male patient with a rare combination of a highly comminuted transcalcaneal fracture-dislocation associated with a talar neck fracture successfully treated with open reduction and internal fixation (ORIF) with an 18-month follow-up. This case demonstrates that even when there are associated fractures of the talus and calcaneus with severe bone loss, ORIF may provide satisfactory outcomes in the short-term postoperative period.Levels of Evidence: Level V: Case report.

Intranasal Bolsters: A Novel Technique for Nasal Bone Stabilization.

Nasal bone stabilization, in the setting of comminuted nasal fracture or surgical osteotomy, represents a challenging surgical experience. Postoperative shifting of osseous fragments may result in compromised outcomes in an otherwise well-performed procedure. Although prior studies have reported nasal bone fixation with implementation of wires, plates, or halos, these techniques are often difficult to employ routinely. Herein, the authors describe a novel and facile technique for the maintenance of unstable nasal bones using customized intranasal bolsters.

Fracturas Mandibulares Conminutadas por Impacto de Proyectil Balístico: Propuesta de Tratamiento Inicial Mediante Método de Fijación Alternativo / Mandibular Fractures Comminuted by Ballistic Projectile Impact: Initial Treatment Proposal Using Alternative Fixation Method

RESUMEN: El trauma maxilofacial por arma de fuego representa un desafío terapéutico principalmente debido a la gran conminución de tejidos que genera. Específicamente, en casos de fracturas mandibulares conminutadas, las modalidades de tratamientos incluye la reducción cerrada, fijación con tutor externo, fijación interna con alambres y reducción abierta y fijación interna utilizando placas y tornillos. El objetivo del presente trabajo es describir un tratamiento inicial con un método de fijación para fracturas mandibulares conminutadas como dispositivo alternativo al tutor externo clásicamente utilizado. Se desarrolla una revisión de la literatura actual acerca del tratamiento inicial o de urgencia de fracturas mandibulares conminutadas por impacto de proyectil balístico, haciendo énfasis en las indicaciones de cada modalidad de tratamiento y sus respectivas ventajas y desventajas. Luego se describe detalladamente el proceso de confección de un método de fijación alternativo junto con la exposición de casos clínicos donde fue utilizado como alternativa de tratamiento. La reducción y fijación obtenida por el dispositivo presentado logra resultados satisfactorios, sin encontrarse diferencias significativas a los elementos de fijación clásicos. Tanto el uso de placas de reconstrucción como el de tutor externo constituyen alternativas válidas para el tratamiento de fracturas mandibulares conminutadas. El dispositivo descrito y utilizado en los pacientes es una alternativa eficiente, de fácil confección y bajo costo económico demostrando buenos resultados en relación a la consolidación de fracturas conminutadas. Se debe conocer las indicaciones para la aplicación de cada modalidad de tratamiento.

ABSTRACT: Ballistic maxillofacial trauma represents a challenge for surgeons because of the important comminution process it presents. Specifically, in cases of mandibular comminuted fractures, the different treatment modalities include closed reduction, external fixation and internal fixation. The purpose of this case series is to describe an initial treatment modality, with a fixation method for comminuted mandibular fractures as an alternative for the classic external fixator. We conducted a literature review about the initial treatment for ballistic comminuted mandibular fractures, emphasizing indications of each treatment modality and their respective advantages and disadvantages. Next, we described the preparation process of an alternative fixation method along with a case series, where it was used as a therapeutical alternative. The reduction as well the fixation achieved by the external fixator, showed satisfactory results without significant differences noted with traditional fixation methods. Both, reconstruction plates and external fixators, are valid alternatives for treating comminuted mandibular fractures. The method described and used in these patients is and efficient alternative, easy to make and at a low cost, with good results in relation to fracture consolidation. We propose that every treatment modality and its indications should be evaluated in order to treat each case adequately.

Principios quirúrgicos en fracturas de platillos tibiales con compromiso de columna posterior / Surgical principles in posterior column tibial plateau fractures

Las fracturas de platillos tibiales son lesiones complejas que incluyen una variedad de patrones morfológicos cada vez mejor caracterizados en la literatura. Históricamente, los esquemas de clasificación se han basado en evaluar los rasgos de fractura en el plano frontal y las técnicas quirúrgicas en lograr la fijación de esos fragmentos, sin tomar en consideración el compromiso óseo que ocurre en la región posterior de los platillos tibiales. Con el advenimiento de la clasificación columnar basada en tomografía computada, se han logrado desarrollar estrategias de fijación optimizada, dando cada vez más relevancia a la columna posterior. Este artículo realiza una revisión extensa de la literatura, otorgando los fundamentos quirúrgicos que explican la importancia del tratamiento específico de la columna posterolateral y posteromedial, con el fin de restablecer la biomecánica normal de la rodilla y el razonamiento quirúrgico de las diversas vías de abordaje específicas para una reducción y osteosíntesis satisfactoria de esos fragmentos.

Tibial plateau fractures are complex injuries which include a variety of morphological patterns that have been increasingly better characterized in the literature. Historically, classifications have focused on description of fracture patterns in the frontal plane, while surgical techniques have focused on reduction of these fragments not considering the osseous defects that occur on the posterior region of the tibial plateau. With new CT scan column based classifications, strategies to optimize fixation have been developed, giving relevance to the posterior column. This article is an exhaustive review of the literature, providing the surgical foundations that explain the importance of specific treatment of the posterolateral and posteromedial column, aiming to restore normal knee biomechanics. Furthermore, this article provides the diverse specific surgical approaches rationale for a satisfactory open reduction and internal fixation of these fragments.

Suitability of Wrist External Fixator for Treatment of Mandibular Fracture.

The mandibular fracture is one of the most commonly fractures of the facial bones. In high-energy traumas, a comminuted mandible fracture may occur. The closed reduction with external fixator is an interesting alternative for these types of fractures. The aim of this article is to report the case of a patient with comminuted fracture in the right mandibular body, whose surgical treatment was the noninvasive reduction of fracture and stabilization using a Colles' wrist external fixator. After 1 year of follow-up, the patient is without complaints, with satisfactory dental occlusion, adequate contour, and mandibular alignment. External fixation with wrist orthopedic fixators adapted to the mandible provides many advantages owing to its versatility and simplicity of use. Therefore, this method should be remembered as a valid and affordable option for the treatment of complex lesions when indicated correctly.

Traumatic Complex Hawkins Type IV Talar Fracture: A Case Report.

Fracture-dislocations of the talus are one of the most complex injuries involving the foot and ankle. These injuries are often accompanied by additional traumatic orthopedic injuries, avascular necrosis, and infection. When approaching limb reconstruction and salvage, the overall prognosis and functionality of the limb are key factors to consider. In the present report, we draw attention to the importance of a multidisciplinary team approach for formulating a treatment plan that incorporates the talar injury and associated injuries or pathologic features. We also reviewed the published data related to avascular necrosis of the talus, open talar fracture management, and treatment outcomes.

Facial fractures caused by less-lethal rubber bullet weapons: case series report and literature review.

PURPOSE: The present study aims to describe three cases of patients inflicted by rubber bullets with severe facial fractures. METHODS: In addition, a review of English-language literature involving facial fractures by rubber bullets from 1975 to 2016 was performed. RESULTS: This current study demonstrated that the use of the LLRBW is unsafety even when applied by police enforcements exclusively. CONCLUSIONS: Management of facial fractures caused by LLRBW is done in a usual manner with closed or open reduction associated with bone mini-plates or reconstruction plates when indicated. Special initial wound care should be done to avoid secondary infection and additional procedures.

Intraobserver and interobserver agreement in the classification and treatment of proximal humeral fractures.

BACKGROUND: There is controversy surrounding the reliability of radiographic measurements and existing classifications for proximal humeral fractures. METHODS: Ten orthopedists, divided into 2 groups by length of experience, evaluated radiographs in 3 views from 40 proximal humeral fractures. We evaluated 11 radiographic criteria (including the Neer and pathomorphologic classifications, head-shaft angle, displacement of the humeral shaft, and lesser and greater tuberosities) and treatment indication. We also analyzed the criteria that most influenced the choice of treatment. RESULTS: Interobserver reliability was substantial for the presence of fracture of the greater tuberosity (κ = 0.749) and medial metaphyseal comminution (κ = 0.627) and moderate for the pathomorphologic classification (κ = 0.504), displacement of the greater tuberosity (κ = 0.422), and treatment decision (κ = 0.565). Intraobserver reliability was substantial for treatment indication (κ = 0.620) and presence of displacement of the fracture of the greater tuberosity (κ = 0.627 and 0.611) and moderate for the Neer (κ = 0.490) and pathomorphologic (κ = 0.607) classifications. The results were influenced by the observer's experience. The surgical indication was influenced by the pathomorphologic classification in 50% of the evaluators (odds ratio, 4.85; range, 3.30-8.65). CONCLUSION: The pathomorphologic classification has higher reliability than the Neer classification and was the factor that most influenced the surgical decision. The determination of the presence of fracture and displacement of the greater tuberosity and medial metaphyseal comminution is reliable with the use of simple radiographs, and the results were influenced by the observer's experience.

Extraperiosteal Dual Plate Fixation of Acute Mid-Shaft Clavicle Fractures: A Technical Trick.

Historically, surgical treatment of acute mid-shaft clavicle fractures has excellent outcomes with low rates of nonunion. More complex fracture patterns with significant comminution may limit the fixation that can be obtained with a single plate. The authors describe the surgical technique and case series of patients treated with extraperiosteal dual plating for acute mid-shaft clavicle fractures.

Effectiveness of external fixator combined with T-plate internal fixation for the treatment of comminuted distal radius fractures.

This study compared the efficacy between external fixator combined with palmar T-plate internal fixation and simple plate internal fixation for the treatment of comminuted distal radius fractures. A total of 61 patients classified as type C according to the AO/ASIF classification underwent surgery for comminuted distal radius fractures. There were 54 and 7 cases of closed and open fractures, respectively. Moreover, 19 patients received an external fixator combined with T-plate internal fixation, and 42 received simple plate internal fixation. All patients were treated successfully during 12-month postoperative follow-up. The follow-up results show that the palmar flexion and dorsiflexion of the wrist, radial height, and palmar angle were significantly better in those treated with the external fixator combined with T-plate compared to those treated with the simple plate only (P < 0.05); however, there were no significant differences in radial-ulnar deviation, wrist range of motion, or wrist function score between groups (P > 0.05). Hence, the effectiveness of external fixator combined with T-plate internal fixation for the treatment of comminuted distal radius fractures was satisfactory. Patients sufficiently recovered wrist, forearm, and hand function. In conclusion, compared to the simple T-plate, the external fixator combined with T-plate internal fixation can reduce the possibility of the postoperative re-shifting of broken bones and keep the distraction of fractures to maintain radial height and prevent radial shortening.