Human placenta-derived matrix with cancellous autograft and demineralized bone matrix for large segmental long-bone defects in two dogs with septic nonunion.

OBJECTIVE: To report the successful treatment of septic nonunion in two dogs with large segmental defects secondary to long-bone fractures by using a novel human placenta-derived matrix (hPM) as adjunct to fixation. ANIMALS: One 3-kg 9-year-old neutered male Yorkshire terrier with a distal antebrachial fracture and one 6-kg 4-year-old spayed female miniature pinscher with a distal humeral fracture. STUDY DESIGN: Short case series. METHODS: Both dogs presented for septic nonunion after internal fixation of Gustilo type II open diaphyseal fractures from dog bite injuries. During revision, debridement of nonviable bone resulted in segmental defects of 32% and 20% of the bone length for the antebrachial and humeral fractures, respectively. The antebrachial fracture was stabilized with a circular external fixator, and the humeral fracture was stabilized with biaxial bone plating. The fracture sites were not collapsed, and full length was maintained with the fixation. Autogenous cancellous bone graft and canine demineralized bone allograft were packed into the defects, and hPM was injected into the graft sites after closure. RESULTS: Radiographic union was documented at 8 weeks and 6 weeks for the antebrachial and humeral fractures, respectively. Both dogs became fully weight bearing on the affected limbs and returned to full activity. CONCLUSION: Augmenting fixation with grafts and hPM led to a relatively rapid union in both dogs reported here.

The Use of Bone Marrow-Derived Stem Cells in the Treatment of a Comminuted Tibiotarsal Fracture in a Juvenile Red-legged Seriema (Cariama cristata).

An adult red-legged seriema (Cariama cristata) presented with a comminuted fracture of the tibiotarsus and fibula. Surgery was performed, and a type II external fixator, with 2 distal and 2 proximal pins, was used to stabilize the fracture. After a 10-day stabilization period, the bird developed a second fracture on the same bone, proximal to the first fracture site. Another surgery was performed on the seriema similar to the first one. However, in this second surgical procedure a single pin, instead of 2 perpendicular pins, was placed proximally to the fracture site. After the second surgical procedure, bone marrow stem cells (BMSCs) from the seriema's left ulna were collected. Twenty-seven days after the second surgery, the BMSCs were transplanted, into the fracture sites. Twenty-four days after the stem cells were injected into the fractures (51 days after the second surgical procedure), radiographic images revealed healing bone calluses at the fracture sites. The fracture healing was relatively long for this case (a total of 75 days). The addition of bone marrow stem cell therapy to the use of external fixation may have contributed to the healing observed radiographically 24 days after administration; therefore, bone marrow stem cell therapy, in addition to traditional surgical fracture reduction and stabilization, may be a promising therapeutic approach for avian cases with similar injuries and bone anatomy. However, as this is a single case, this therapeutic modality deserves further application and study. Moreover, we suggest modifications in the bone marrow stem cell collection and therapy, which may be useful for future studies and application involving birds.

Humeral shaft fractures: union outcomes in a large cohort.

BACKGROUND: Humeral shaft fractures can be managed conservatively or operatively. Fracture characteristics were analyzed to identify patients who would benefit from early operative fixation. METHODS: We performed a retrospective cohort study of 126 consecutive humeral shaft fractures (2008-2015). Fractures were classified according to fracture type, location, separation, and comminution. RESULTS: Of 126 patients, 96 were managed conservatively. In 54%, union occurred before 26 weeks, and 13% had delayed union after 26 weeks, whereas 33% did not achieve union. Of 30 patients managed surgically, 63% had union before 26 weeks, 33% had delayed union, and 4% did not achieve union. A statistically significant difference favored operative management. This difference was maintained in specific fracture patterns (simple and spiral fractures) and locations (proximal- or distal-third humeral fractures). Early surgery had a significantly higher union rate than delayed surgery. No difference was present between plate and nail fixation regarding union or neurologic injury. Separation of fragments, open injury, and comminution were not associated with nonunion. A psychiatric history (including psychotic disorders, bipolar disorder, multiple involuntary psychiatric admissions, or dementia) was significantly associated with nonunion after conservative management (P = .016). Two patients with dementia died after their conservatively managed fractures progressed to open injuries. CONCLUSION: This study found high rates of delayed union and nonunion with conservative management. Patients with a significant psychiatric history may benefit from consideration of operative intervention.

Fractures of the Nasal Bones: Is External Splinting Really Warranted?

BACKGROUND: It has been advocated that reduction of nasal bone fractures should be followed by internal packing and/or external splinting. Despite the ample literature concerning the advantages and limitations of various splint types, the necessity and effectiveness of external splinting has not been well documented. OBJECTIVE: To present the authors' experience and review the literature on treatment of nasal bone fractures, focusing on the indications and effectiveness of external splinting following closed reduction. STUDY DESIGN: Retrospective analysis and literature review. PATIENTS AND METHODS: Medical records of all patients, treated at the Department of Oral and Maxillofacial Surgery of the "KAT" General Hospital of Attica between January 2010 and December 2016 for facial trauma including nasal bone fractures, were retrospectively reviewed. Patient demographic data, fracture type, applied treatment, complications, and final outcome were registered. RESULTS: A total of 77 patients (58 males; 19 females) were included in the study. The age range was 18 to 65 years (mean, 37.8). Closed reduction without external splinting was performed in 63 patients and open reduction with internal fixation in 6; 8 severely comminuted fractures were treated with closed reduction and external splinting. The mean follow-up was 4.8 months. All severely comminuted fractures presented complications. CONCLUSIONS: External splinting following closed reduction of nasal bone fractures should not be used routinely but only in selected patients with severe comminution. Since the pertinent literature is inconclusive on the indications and effectiveness of external splinting, randomized controlled studies are warranted to fully elucidate the issue.

An Alternative Method of Intermaxillary Fixation for Simple Pediatric Mandible Fractures.

PURPOSE: Mandibular fractures represent a substantial portion of facial fractures in the pediatric population. Pediatric mandibles differ from their adult counterparts in the presence of mixed dentition. Avoidance of injury to developing tooth follicles is critical. Simple mandibular fractures can be treated with intermaxillary fixation (IMF) using arch bars or bone screws. This report describes an alternative to these methods using silk sutures and an algorithm to assist in treating simple mandibular fractures in the pediatric population. PATIENTS AND METHODS: A retrospective chart review was performed and the records of 1 surgeon were examined. Pediatric patients who underwent treatment for a mandibular fracture in the operating room from 2011 to 2015 were identified using Common Procedural Terminology codes. Data collected included age, gender, type of fracture, type of treatment used, duration of fixation, and presence of complications. RESULTS: Five patients with a mean age of 6.8 years at presentation were identified. Fracture types were unilateral fractures of the condylar neck (n = 3), bilateral fractures of the condylar head (n = 1), and a unilateral fracture of the condylar head with an associated parasymphyseal fracture (n = 1). IMF was performed in 4 patients using silk sutures, and bone screw fixation was performed in the other patient. No post-treatment complications or malocclusion were reported. Average duration of IMF was 18.5 days. CONCLUSIONS: An algorithm is presented to assist in the treatment of pediatric mandibular fractures. Silk suture fixation is a viable and safe alternative to arch bars or bone screws for routine mandibular fractures.

Nonoperative treatment of humeral shaft fractures revisited.

PURPOSE: The purpose of this study was to examine the union rate of humeral shaft fractures treated nonoperatively and to establish whether a particular fracture type is more likely to go on to nonunion. METHODS: Radiographs and patient records of 207 humeral shaft fractures occurring during 5 years were retrospectively reviewed. All patients were initially managed nonoperatively and placed in a U-slab on diagnosis in the emergency department; this was converted to a functional humeral brace at 7 to 10 days after injury. Fracture location, morphology and comminution were assessed radiologically. Union was defined as the absence of pain and movement at the fracture site in the presence of radiographic callus formation. Nonunion was defined as no evidence of bone union by 1 year after injury or fractures requiring delayed fixation, defined as operative fixation undertaken more than 6 weeks after injury. RESULTS: The study included 138 humeral shaft fracture patients; 18 patients (11%) were lost to follow-up, and 24 went on to nonunion, giving an overall union rate of 83%. Of the 24 nonunions, 15 underwent delayed operative fixation at an average of 8.3 months after injury. The union rate for proximal-third fractures was 76% compared with 88% for middle-third fractures and 85% for distal-third fractures. Comminuted fractures (defined as 3+ parts) had a 89% union rate regardless of position. CONCLUSION: A lower threshold for surgical intervention may be considered in proximal-third, two-part spiral-oblique humeral shaft fractures. Brace therapy can be the optimal treatment regimen, but it is not the only option.

Treatment of mandibular symphyseal fracture combined with dislocated intracapsular condylar fractures.

OBJECTIVES: To evaluate the treatment methods of mandibular symphyseal fracture combined with dislocated intracapsular condylar fractures (MSF&DICF) and to compare the effect of different treatment methods of condylar fractures. METHODS: Twenty-eight patients with MSF&DICF were included in this study. Twenty-two sites were treated by open reduction, and all the medial condylar fragments were fixed with titanium screws; whereas the other 22 sites underwent close treatment. The surgical effect between these 2 groups was compared based on clinical examination and radiographic examination results. RESULTS: Seventeen of 22 condyle fractures were repositioned in the surgery group, whereas 4 of 22 condyle fractures were repositioned in the close treatment group. Statistical difference was observed between these 2 groups (P < 0.01). Functional outcomes of the patients treated in the surgical treatment group also were better than those in the close treatment group. CONCLUSIONS: The dislocated intracapsular condyle fractures should be treated by surgical reduction with the maintenance of the attachment of lateral pterygoid muscle, which is beneficial to repositioning the dislocated condyle to its original physiological position, to closure of the mandibular lingual gap, to restore the mandibular width.

Use of a bivalve finger fracture orthosis for a new treatment protocol of a PIP comminuted fracture and dorsal dislocation.

As therapists and physicians, we often need to work with our patients to cater treatment accordingly. These authors describe how they modified a treatment protocol for a patient that sustained a proximal interphalangeal joint comminuted fracture and dorsal dislocation, but refused surgery. Their modification allowed the patient to return to full activities. - Victoria Priganc, PhD, OTR, CHT, CLT, Practice Forum Editor.

Progressive kyphotic deformity in comminuted burst fractures treated non-operatively: the Achilles tendon of the Thoracolumbar Injury Classification and Severity Score (TLICS).

INTRODUCTION: The Thoracolumbar Injury Classification and Severity (TLICS) scale has been considered one of the best available grading systems for evaluating thoracolumbar fractures, especially due to the fact that, differently from previous classifications, it can be used as a practical algorithm to orient the clinical decision-making between conservative and surgical management. CASE REPORT: The authors describe a case of a 54-year-old patient presenting with low-back pain after having struck her back on the handrail. The neurological exam was unremarkable. The CT-scan of the lumbar spine demonstrated a L1 comminuted burst fracture. The MRI demonstrated no evidence of posterior ligamentous complex injury. According to the TLICS classification (total score of 2) the patient was managed conservatively with a thoracolumbar brace. Although at the 1-month follow-up the X-rays demonstrated no major changes and the pain had clinically improved, the patient was lost to follow-up. After 12 months the patient presented back to the emergency department with complaints of increased back pain. The repeat CT-scan demonstrated a remarkable worsening of the vertebral body fracture, with a major kyphotic deformity. The patient was submitted to a staged anterior-posterior procedure consisting in posterior decompression of the T12-L2 levels, a T10-L4 pedicle screw fixation and, finally, a lateral transpsoas approach for L1 corpectomy and reconstruction with an expandable interbody cage and plate fixation. At the 6-months follow-up, the patient presented another episode of back pain and a new L4 endplate fracture was identified. After 2 months of failed conservative treatment, the patient was treated with percutaneous kyphoplasty. At the 12-months follow-up after the initial surgical procedure, the patient was pain free and with stable radiographs. CONCLUSIONS: In this Grand Rounds presentation, the authors perform a comprehensive discussion about the historical developments in the classification systems for thoracolumbar fractures with special emphasis in the new TLICS system. Although such score presents several advantages in relation to other grading systems, patients with comminuted burst fractures deserve special attention, even if initially classified as non-operative according to the TLICS algorithm. In such cases, if a decision of conservative management is taken, a close follow-up is recommended due to the high likelihood of long-term kyphotic deformity.

Pins and rubber band traction for treatment of comminuted intra-articular fractures in the hand.

PURPOSE: To determine the efficacy of pins and rubber band traction for treatment of comminuted intra-articular fractures in the hand. METHODS: We performed a retrospective study from 1994 to 2013 to evaluate 33 patients in whom pins and rubber band traction was employed. We clinically evaluated the active range of motion of the affected fingers after surgery. Eleven of the 33 fractures were at the proximal interphalangeal joint, 10 at the distal interphalangeal joint, 5 at the thumb interphalangeal joint, and 2 at the metacarpophalangeal joint of the thumb. The remaining 5 patients had complex fracture-dislocation of the proximal interphalangeal joints. RESULTS: The mean follow-up period was 24 months. The average active motion of the metacarpophalangeal joints of the fingers was 91° (range, extension 0°-10°/flexion 85°-90°), proximal interphalangeal joints was 92° (range, extension/flexion 0°-10°/85°-100°), and distal interphalangeal joints was 73° (range, extension/flexion 0°-10°/60°-80°). The overall average of all active motion of the injured fingers except thumbs was 255° (range, 240°-270°). The average active motion of the of the thumb metacarpophalangeal joint was 56° (range, extension 5°-10°/flexion 50°-55°), and interphalangeal joint was 74° (range, extension 0°-10°/flexion 75°-80°). The average of active motion of the injured thumb metacarpal and interphalangeal joints combined was 130° (range, 125°-135°). CONCLUSIONS: Pins and rubber band traction is a treatment option for comminuted displaced intra-articular fractures of the digits that offers satisfactory clinical results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Open biological reduction and a locking compression plate for distal femoral fractures: a review of 40 cases.

OBJECTIVE: To determine the clinical results of patients with comminuted fractures of the distal femur treated by open biological reduction using an indirect reduction technique and locking compression plate (LCP) without primary bone grafting. MATERIAL AND METHOD: Prospective observation was conducted with 40 patients (24 males and 16 females), average age 48.7 years (range 20-81), with distal femoral fractures AO/OTA types A2 (5), A3 (17), C2 (8) and C3 (10) who were treated using an open indirect reduction technique and fixation with LCP between May 2010 and December 2013. Among the 40 patients, 28 were closed fractures and 12 were open fractures. Clinical results were evaluated using the Neer score six months after surgery. Follow-up periods ranged from 12 to 36 months (average 18.35). RESULTS: Thirty eight (95%) of the fractures healed completely without a secondary procedure. The average time to union was 14.45 weeks (range 12-24). The average knee range of motion was 2° (0-5) to 110° (20-140). Two patients had an implant failure which required revision and secondary iliac bone grafting. There were no varus or valgus deformities, no limb shortening and no deep infections. Neer scores were excellent in 18 cases (45%), good in 14 (35%), fair in 6 (15%) and poor in 2 (5%). The mean Neer score was 83.60 (range 50-100). CONCLUSION: The indirect reduction technique for the treatment of comminuted distal femoral fractures provides satisfactory results when combined with LCP fixation.

Pins and Rubbers Traction System for Treatment of Intraarticular Fractures of Distal Interphalangeal Joint.

Background: The pins and rubber traction system (PRTS) has proven effective in managing intra-articular fractures of the proximal interphalangeal joint. However, there is scant evidence in the literature regarding its efficacy in treating distal interphalangeal joint (DIPJ). This study aims to investigate the outcomes of PRTS in the treatment of comminuted intra-articular fractures of the DIPJ. Methods: We conducted a retrospective review of patients with comminuted intra-articular fractures of the DIPJ treated with PRTS between 2017 and 2021. At the final follow-up, we measured and compared the active range of motion (ROM) in both affected and non-injured contralateral fingers. The subjective evaluation utilised the Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) questionnaire and the Visual Analogue Scale (VAS). Results: Ten patients with a mean follow-up of 13.2 months (range: 12-17) were included in the study. Fracture locations included the base of the distal phalanx in two patients, the condyle of the middle phalanx in seven and both in one patient. At the final follow-up, the average VAS score was 0.5 (range: 0-2). The average active motion of the DIPJ was 61° (range: 50°-70°) for the injured side and 76° (range: 75°-80°) for the opposite side. The mean range of DIPJ movement was 80% (range: 68%-87%) of the non-injured side. Extension deficits were observed in five patients, with a median deficit value of 10° (range: 5°-10°). The average Quick-DASH score was 2.9 (range: 0-11.3). Conclusions: The PRTS can be considered as an effective surgical technique in managing comminuted intra-articular fractures of the DIPJ. Level of Evidence: Level IV (Therapeutic).

Sequelae of underdiagnosed foot compartment syndrome after calcaneal fractures.

The calcaneus is the most frequently fractured tarsal bone. Compartment syndrome (CS) complicates fractures and other injuries and is most commonly described in association with the lower leg. The long-term sequelae of CS of the foot can include toe clawing, permanent loss of function, persistent pain, muscle atrophy, contracture, painful warts, weakness, and sensory disturbances. The incidence and clinical significance of untreated CS after calcaneal fractures were questioned. All compliant patients treated by us for a calcaneus fracture underwent a physical examination and medical interview: 47 (49 fractures) were included in the final cohort (36 males, 11 females, mean age 49 ± 14.5 years, mean follow-up 23 ± 16 months). Missed CS sequelae were diagnosed by the presence of claw toes and plantar sensory deficits. The functional outcome and pain at rest and during activity were scored. Five patients (10%) had missed CS, and their functional score was significantly lower than for those without CS (52 ± 21.5 versus 77.4 ± 22 for no CS, p < .05). All missed CS cases were diagnosed in patients with a Sanders type 3 or 4 fracture. Intra-articular fracture was a significant factor associated with developing CS sequelae (p = .045). Untreated CS can cause muscle and nerve injury and contribute to a poor functional outcome. Because CS is more likely to develop after highly comminuted intra-articular fractures, these patients warrant close monitoring for CS development. Early detection and treatment might result in fewer late disabling sequelae of this injury.

Bedside ultrasound detection of long bone fractures.

INTRODUCTION: Rapid identification of fractures of long bones is prudent, since associated bleeding and neurovascular compromise can cause significant morbidity and mortality. We describe two patients who presented to the Emergency Department with orthopedic trauma and underwent bedside ultrasound of the affected extremity. Ultrasound rapidly revealed fractures in both patients, and led to early treatment and disposition. MATERIALS AND METHODS: Rapid bedside ultrasound of long bones was performed on affected extremities and compared to X-rays. CONCLUSION: Bedside ultrasonography of long bones is a rapid, reliable, and non-invasive method of evaluating patients with suspected orthopedic trauma.

Reconstruction of comminuted long-bone fracture using CF/CPC scaffolds manufactured by rapid prototyping.

BACKGROUND: Stabilization and bone healing of fractures in weight-bearing long bones are challenging. This study was conducted to evaluate the effect of a scaffold composed of chitosan fiber and calcium phosphate ceramics (CF/CPC scaffold) on stability and fracture repair in weight-bearing long bones. MATERIAL/METHODS: Comminuted fractures of paired radiuses were created in 36 healthy, mature dogs. The left radius of each dog was classified in the experimental group and treated with CF/CPC scaffold, and the right one was not filled, and was used as a blank control. Of the 12 animals in each group that were killed at week 4, 8, and 12 after the operation, 6 were used for histological analysis, and the other 6 used were for biomechanical studies. Both radiuses from each animal were dissected free and stored for these analyses. All the animals underwent X-ray radiograph pre- and post-operatively. Computer-aided rapid-prototyping technologies were adopted for the fabrication of three-dimensional scaffolds with precise geometric control. RESULTS: X-ray showed that the bone fracture area in the experimental group was filled with callus at week 12 after surgery. Histological examination detected slow resorption of the cement and new bone formation since week 4. At week 12, the scaffold material partially degraded and was still present in all specimens. Mechanical testing revealed that the failure strength of the radiuses treated with CF/CPC scaffolds was about 3 times that of the radiuses without implanted scaffolds. CONCLUSIONS: The effect of using CF/CPC scaffold in treating comminuted weight-bearing long bone fractures is satisfactory.

The use of external fixation combined with vacuum sealing drainage to treat open comminuted fractures of tibia in the Wenchuan earthquake.

PURPOSE: The purpose of this study was to review the results of external fixation combined with vacuum sealing drainage (VSD) to treat patients who sustained tibial and fibular fractures in the Wenchuan earthquake. METHODS: We retrospectively analysed 179 cases (of which 85 were classified as Gustilo grade III) of open comminuted fracture of the tibia and fibula caused by the Wenchuan earthquake. The patients were followed up for an average of 15 months; detailed records were kept on their function and recovery. RESULTS: After caring for the life-threatening injuries; fractures were treated by external fixation, with VSD used on the surface or in the cavity of the wound after debridement. Antibiotics were administered on the basis of drug sensitivity test results. After the infection had been controlled and healthy granulation tissue had developed, the patients underwent secondary suture, free skin grafting, or skin flap transfer. CONCLUSION: Good results can be achieved when external fixation combined with vacuum sealing drainage were used to treat open comminuted fractures of tibia and fibula in the Wenchuan earthquake.

Virtual reality hypnosis pain control in the treatment of multiple fractures: a case series.

This case series evaluated the use of virtual reality hypnosis (VRH) for the treatment of pain associated with multiple fractures from traumatic injuries. VRH treatment was administered on 2 consecutive days, and pain and anxiety were assessed each day before and after VRH treatment as well as on Day 3, which was 24 hours after the second treatment session. Pain reduction from baseline to Day 3 was from 70% to 30%, despite opioid analgesic use remaining stable. The subjective pain reduction reported by patients was encouraging, and the results of this case series suggest the importance of further study of VRH with larger samples using randomized controlled trials.

Computed tomography-guided cement augmentation for pain relief of a symptomatic sternal fracture.

The authors report a novel application of cement augmentation for treatment of a symptomatic sternal fracture. Sternal fractures often cause debilitating pain and can affect ventilation. Given the success of vertebroplasty in patients in treating back pain, the authors used a similar technique in a 56-year-old woman with chronic obstructive pulmonary disease and an acute comminuted sternal fracture refractory to conservative management. The authors used computed tomography guidance and cement augmentation for the fracture. The patient subsequently reported good pain relief and improved breathing. Sternoplasty may be a viable alternative for patients with sternal fractures and refractory pain.

Pediatric nasal fractures: evaluation and management.

Nasal fractures have been reported as 1 of the 3 most commonly encountered pediatric facial bone fractures. The most common causes of nasal fractures in this age group are auto accidents (40%), sports injuries (25%), intended injuries (15%), and home injuries (10%). Nasal fractures are usually treated with closed reduction (Higuera S, Lee EI, Stal S. Nasal trauma and the deviated nose. Plast Reconstr Surg 2007;120:64S-75S). This results in a significant incidence of posttraumatic deformities, often requiring secondary surgical treatment. For this reason, it is paramount to pay careful attention to the underlying structural nasal anatomy during the initial diagnosis and management.

[Optimization of the diagnostics and treatment of the comminuted intraarticular fractures].

The diagnostic and treatment algorithm of the comminuted intraarticular fractures of the long tubular bones was worked out. It included laser Doppler flowmetry, thermography, artroscopy, osteoreplacing and external fixation methods. Bench tests of the innovated external fixation apparate proved the possibility of early postoperative rehabilitation of patients.