Strategies in Trauma and Limb Reconstruction

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2013 | August | Volume 8 | Issue 2

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Monique M. J. Walenkamp, Abdelali Bentohami, M. Suzan H. Beerekamp, Rolf W. Peters, Remy van der Heiden, J. C. Goslings, Niels W. L. Schep

Functional outcome in patients with unstable distal radius fractures, volar locking plate versus external fixation: a meta-analysis

[Year:2013] [Month:August] [Volume:8] [Number:2] [Pages:9] [Pages No:67 - 75]

Keywords: Meta-analysis, Unstable distal radius fracture, Volar locking plate, Bridging external fixator, Functional outcome

   DOI: 10.1007/s11751-013-0169-4  |  Open Access |  How to cite  | 


The aim of this study was to compare bridging external fixation with volar locked plating in patients with unstable distal radial fractures regarding functional outcome. A systematic search was performed in the Cochrane Central Register of Controlled Trials, Medline and EMBASE. All randomized controlled trials that compared bridging external fixation directly with volar locked plating in patients with distal radial fractures were considered. Three reviewers extracted data independently from eligible studies using a data collection form. Studies in which the primary endpoint was measured on the disabilities of the arm shoulder and hand (DASH) score at 3, 6 and 12 months were included in the analysis. To this end, mean scores and standard deviations were extracted. The software package Revman 5 provided by the Cochrane Collaboration was used for data analysis. Three studies involving 174 patients were analyzed. Ninety patients were treated with an (augmented) bridging external fixator and 84 with a volar locking plate. Data were analyzed with the random effects model. The robustness of the results was explored using a sensitivity analysis. Patients treated with a volar locking plate showed significantly lower DASH scores at all times. A difference of 16 (p = 0.006), six (p = 0.008) and eight points (p = 0.06) was found at 3, 6 and 12 months follow-up, respectively. Patients treated with a volar locking plate showed significantly better functional outcome throughout the entire follow-up. However, this difference was only clinically relevant during the early postoperative period (3 months).



Matthijs P. Somford, Michel P. J. van den Bekerom, Peter Kloen

Operative treatment for femoral shaft nonunions, a systematic review of the literature

[Year:2013] [Month:August] [Volume:8] [Number:2] [Pages:12] [Pages No:77 - 88]

Keywords: Nonunion, Pseudarthrosis, Review, Femur

   DOI: 10.1007/s11751-013-0168-5  |  Open Access |  How to cite  | 


The objective of this article is to systematically review the currently available literature to formulate evidence-based guidelines for the treatment of femoral shaft nonunions for clinical practice and to establish recommendations for future research. Articles from PubMed/MEDLINE, Cochrane Clinical Trial Register, and EMBASE, that presented data concerning treatment of nonunions of femoral shaft fractures in adult humans, were included for data extraction and analysis. The search was restricted to articles from January 1970 to March 2011 written in the English, German, or Dutch languages. Articles containing data that were thought to have been presented previously were used once. Reports on nonunion after periprosthetic fractures, review articles, expert opinions, abstracts from scientific meetings, and case reports on 5 or fewer patients were excluded. The data that were extracted from the relevant articles included: type of nonunion, type of initial and secondary treatments, follow-up, union rate, and general complications. Most studies had different inclusion criteria and outcome measures, thus prohibiting a proper meta-analysis. Therefore, only the union rate and number of complications were compared between the different treatments. Methodological quality was assessed by assigning levels of evidence as previously defined by the Centre for Evidence-Based Medicine. This systematic review provides evidence in favour of plating if a nail is the first treatment; after failed plate fixation, nailing has a 96 % union rate. After failed nailing, augmentative plating results in a 96 % union rate compared to 73 % in the exchange nailing group.


Original Article

Mohamed F. Mostafa

Treatment of distal radial fractures with antegrade intra-medullary Kirschner wires

[Year:2013] [Month:August] [Volume:8] [Number:2] [Pages:7] [Pages No:89 - 95]

Keywords: Distal, Radial, Colles, Antegrade, K-wire

   DOI: 10.1007/s11751-013-0161-z  |  Open Access |  How to cite  | 


The treatment of unstable Colles-type distal radial fractures remains a challenge. A prospective study was conducted to evaluate the outcomes of the treatment of unstable distal radial fractures using antegrade intra-medullary K-wires. Twenty-eight Colles-type distal radial fractures were selected excluding comminuted intra-articular and Barton's fractures. The blunt tips of intra-medullary K-wires were introduced in an antegrade direction to support the subchondral bone of the distal fragment. The scoring system of Green and O'Brien modified by Cooney et al. was used for the final clinical evaluation. The radiological outcomes were evaluated using the scale proposed by Stewart et al. After a mean follow-up of 34 months (range 14–46), 17 patients were rated clinically excellent, seven good, three fair and one poor. The mean loss of radial height, radial inclination, volar tilt and ulnar variance was 0.9 mm, 1.9°, 0.5° and 0.4 mm, respectively. These results were comparable with the values reported in other pinning studies. Only one patient complained of skin irritation and painful bursitis in the forearm; otherwise, no complications related to tendon or nerve injury were encountered. One patient had protrusion of K-wire into the wrist joint. The technique proved to be effective in maintaining reduction in distal radial fracture with low rate of soft tissue complications.


Original Article

Timour F. EL-Husseini, Nabil A. M. Ghaly, Mahmoud A. Mahran, Mohamed Ahmed Al Kersh, Khaled M. Emara

Comparison between lengthening over nail and conventional Ilizarov lengthening: a prospective randomized clinical study

[Year:2013] [Month:August] [Volume:8] [Number:2] [Pages:5] [Pages No:97 - 101]

Keywords: Ilizarov, Bone lengthening, Intramedullary nail, Distraction osteogenesis

   DOI: 10.1007/s11751-013-0163-x  |  Open Access |  How to cite  | 


The aim of this study is to compare lengthening over an intramedullary nail to the conventional Ilizarov method with regard to percentage length increase, external fixation index, consolidation index and incidence of complications. This is a prospective randomized controlled study. Thirty-one limbs in 28 patients were included in the study; 15 were lengthened over an intramedullary nail, and 16 limbs were lengthened conventionally. The mean duration of external fixation in the lengthening over nail group was 52.2 days compared to 180.4 days in the conventional group. There was higher incidence of complications in the conventional method group. In comparison with conventional Ilizarov lengthening, lengthening over an intramedullary nail offers a shorter period of external fixation and fewer complications overall, but there is a high incidence of deep intramedullary infection which is serious.


Original Article

Melih Güven, Emrah Ceviz, Murat Demirel, Turhan Özler, Onur Kocadal, Ayberk Önal

Minimally invasive osteosynthesis of adult tibia fractures by means of rigid fixation with anatomic locked plates

[Year:2013] [Month:August] [Volume:8] [Number:2] [Pages:7] [Pages No:103 - 109]

Keywords: Tibia fracture, Minimally invasive, Osteosynthesis, Biological, Locked plate, Screw

   DOI: 10.1007/s11751-013-0164-9  |  Open Access |  How to cite  | 


Main principle of biological fixation by minimally invasive locked plate osteosynthesis (MILPO) in lower extremity long bone fractures is relative stability which is provided by using long plate with limited number of screws. Some biomechanical studies have been reported about this issue. However, clinical studies are still missing. The aims of this retrospective extended case series were to evaluate the clinical and radiological results of adult tibia fractures treated by MILPO and the effect of plate length and screw density on complication rates. Twenty tibia fractures in 19 patients (mean age 42.3 years) operated by MILPO were reviewed. According to the AO classification, diaphyseal and metaphyseal fractures without intraarticular extensions were simple and wedge-type fractures, whereas all intraarticular fractures were comminuted. Number of screws, cortices and empty screw holes proximal and distal to the fracture, plate-span ratio (plate length divided by overall fracture length), plate-screw density (number of inserted screws divided by number of plate holes), fixation failures, delayed or nonunion, malalignment and leg length discrepancy were documented. Mean follow-up was 16 (range 12–26) months. On average, 4 screws with 6 cortices were used both proximally and distally in all fractures. Only in diaphyseal fractures, one screw hole close to the fracture was omitted. Average plate-screw density and plate-span ratio were 0.68 and 4, respectively. Mean union time was 3 months. There were no cases of delayed or nonunion on the final follow-up. Plate bending was observed in one patient who had fair result. The remaining 18 (94.8 %) patients showed good and excellent results. Satisfactory results can be achieved despite low plate-span ratio and high plate-screw density in simple and wedge-type diaphyseal fractures of the tibia. Additionally, plate-screw density can be higher at metaphysis in intraarticular fractures, in which essential point is a perfectly stable fixation that provides early motion.


Original Article

L. Vaienti, A. Marchesi, G. Palitta, R. Gazzola, P. C. Parodi, F. Leone

Limb trauma: the use of an advanced wound care device in the treatment of full-thickness wounds

[Year:2013] [Month:August] [Volume:8] [Number:2] [Pages:5] [Pages No:111 - 115]

Keywords: Upper limb, Lower limb, Hyaluronic acid, Full-thickness wound

   DOI: 10.1007/s11751-013-0165-8  |  Open Access |  How to cite  | 


This is an observational case series of 15 patients with full-thickness traumatic wound defects treated with a dermal substitute. There were 8 male and 7 female patients with a mean age of 36.6 years. Eight patients had trauma to the lower limbs and 7 were of the upper limbs, with the average lesion size 104.4 cm2 (range 6–490 cm2). The time to complete healing had a mean average time of 26.8 days (range 16–60 days). All patients went on to successful repair with 6 patients requiring a second application of the substitute and 5 patients needing split thickness skin grafts. Infection was recorded in one patient.


Original Article

Ram Chander Siwach, Rajesh Rohilla, Roop Singh, Rohit Singla, Sukhbir Singh Sangwan, Paritosh Gogna

Radiological and functional outcome in unstable, osteoporotic trochanteric fractures stabilized with dynamic helical hip system

[Year:2013] [Month:August] [Volume:8] [Number:2] [Pages:6] [Pages No:117 - 122]

Keywords: Dynamic helical hip system, Osteoporosis, Unstable fracture, Pertrochanteric fracture, DHS

   DOI: 10.1007/s11751-013-0166-7  |  Open Access |  How to cite  | 


A dynamic hip screw (DHS) remains the implant of choice for stabilization of trochanteric fractures because of its favourable results and low rate of non-union or hardware failure, but complication rates of the DHS are higher in unstable and osteoporotic trochanteric fractures. The proponents of the dynamic helical hip system (DHHS) report that it has the potential to decrease the cut-out rates in such fractures as helical blade allows compaction in osteoporotic femoral head which in itself improves anchorage. The purpose of the present study was to evaluate the radiological and functional outcome of DHHS in unstable and osteoporotic trochanteric fractures. This was a prospective observational study. The mean age of the 51 patients (24 men and 27 women) was 72.8 years. Fractures were type AO31A2.2 in 28 patients and AO31A2.3 in 23 patients. According to DEXA scans, 41 patients had osteoporosis and 10 patients had osteopenia. Osteoporosis was grade 3 in 36 patients and grade 2 in 15 patients according to Singh's index. The mean follow-up was 1.84 years. The average sliding of the lag screw was 3.6 mm (range 2–10 mm). The mean operative time was 54.74 (range 48–65) min. The average tip–apex distance was 20.24 mm (range 12–28 mm). All but one fractures united. The average time to union was 13.14 (range 11–24) weeks. There were four mechanical complications namely late helical blade migration (n = 1), late medialization of shaft (n = 2) and varus collapse with cut through (n = 1). No patient was noted to have a plate pull-out. The average Harris hip score was 92.87 (range 76–97). The use of a DHHS for stabilization of unstable(AO31A2), osteoporotic trochanteric fractures in the elderly patients was associated with reliable rates of union and functional outcome and a decreased incidence of screw cut-out and side plate pull-out.



Nipun Jindal, Parmanand Gupta, Ravi Kumar Gupta

Pucker sign in proximal humeral fractures: implications on management

[Year:2013] [Month:August] [Volume:8] [Number:2] [Pages:4] [Pages No:123 - 126]

Keywords: Surgical neck humerus fracture, Puckering, Dimpling, Buttonholing, Open reduction

   DOI: 10.1007/s11751-013-0162-y  |  Open Access |  How to cite  | 


Fracture of the surgical neck of humerus in young patients is a relatively rare injury. We reviewed the available material on the topic and identified puckering at the shoulder in high-energy fracture of the surgical neck as a finding which has been reported infrequently but signifies a need for open reduction. We present a review of the literature on the subject and our similar experience in two young males who had puckering and ecchymosis at the shoulder.



Fatih Parmaksızoğlu, Eren Cansü, Mehmet Bekir Ünal, A. Yener Ince

Acute emergency tibialization of the fibula: reconstruction of a massive tibial defect in a type IIIC open fracture

[Year:2013] [Month:August] [Volume:8] [Number:2] [Pages:5] [Pages No:127 - 131]

Keywords: Acute tibialization, Emergency tibialization, Tibial defect, Type IIIC open tibial fracture, Lower-extremity reconstruction

   DOI: 10.1007/s11751-013-0167-6  |  Open Access |  How to cite  | 


Gustilo type IIIC open fractures of the tibia are high-energy injuries necessitating long treatment periods and usually multiple surgical procedures and eventually resulting in high morbidity rates and even amputations. We present here a case involving a type IIIC open tibial fracture with massive loss of the entire tibial diaphysis, which we treated by performing acute tibialization of the fibula after revascularization of the posterior tibial artery in a single-stage emergency operation.



Hemant Sharma, T. Nunn

Conversion of open tibial IIIb to IIIa fractures using intentional temporary deformation and the Taylor Spatial Frame

[Year:2013] [Month:August] [Volume:8] [Number:2] [Pages:8] [Pages No:133 - 140]

Keywords: Open fracture, Wound closure, Taylor Spatial Frame, Deformity correction

   DOI: 10.1007/s11751-013-0160-0  |  Open Access |  How to cite  | 


The closure of small-to-moderate-sized soft tissue defects in open tibial fractures can be successfully achieved with acute bony shortening. In some instances, it may be possible to close soft tissue envelope defects by preserving length and intentionally creating a deformity of the limb. As the soft tissue is now able to close, this manoeuvre converts an open IIIb to IIIa fracture. This obviates the need for soft tissue reconstructive procedures such as flaps and grafts, which have the potential to cause donor-site morbidity and may fail. In this article, the authors demonstrate the technique for treating anterior medial soft tissue defects by deforming the bone at the fracture site, permitting temporary malalignment and closure of the wound. After healing of the envelope, the malalignment is gradually corrected with the use of the Taylor Spatial Frame. We present two such cases and discuss the technical indications and challenges of managing such cases.


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