Dynamic Hip Screw for the Treatment of Femoral Neck Fractures: A Prospective Study with 96 Patients

Objectives. To study the correlation between avascular necrosis and the demographics, time elapsed from fracture to surgery, quality of reduction, Garden classification, and the position of the screw following use of the dynamic hip screw (DHS) in the treatment of subcapital neck fractures. Methods. A prospective study of 96 patients with subcapital neck fractures was carried out in a faculty hospital. Patients underwent surgery with closed reduction and internal fixation with DHS. Results. There were 58% male and 42% female patients, with a mean age of 53 years (+/−14). In terms of Garden classification, 60% were Garden IV, 26% were Garden III, and 14% were Garden II. Nonunion was observed in three cases (3%) and was treated with valgus intertrochanteric osteotomy, in all cases leading to successful healing. Avascular necrosis was observed in 16% of patients. The positioning of the screw into the femoral head showed a significant correlation with necrosis. Conclusions. The incidence of necrosis in patients under the age of 50 years is twice as high as that in older patients. Displacement is a predictive factor regarding osteonecrosis and is associated with a high and anterior position of the screw in the femoral head. Level II of evidence. Study Type: therapeutic study.

A Staged Surgical Treatment Outcome of Type 3 Open Tibial Fractures

Aim. In these case series which are about type 3 open tibial fractures formed with three different high energy trauma etiologies in different parts of tibia. We aimed to assess our three-stage treatment approach and discuss final results of our elective surgery management with three different fixation methods. Patients and Methods. We assessed 19 patients with type 3 open tibial fractures between 2009 and 2012. Our treatment protocol consisted of three stages. Early intervention in operating room, which including vascular repairs or soft tissue closure, was done if necessary. Definitive surgery was performed using internal or external fixation in the first 15 days. Patients were followed up for at least one year. Last conditions of all our cases were evaluated according to modified Johner and Wruhs criteria. Results. Nine cases were type 3A, seven cases were type 3B, and three cases were type 3C in terms of fracture typing. All patients were followed up for at least one year and mean follow up time was 15 months. In terms of functional and clinical outcome, six cases were evaluated as excellent, eight cases as good, two cases as fair, and three cases as poor. Discussion. Staged treatment option in type 3 open tibial fractures seems to be a good method in reducing complication and achieving the best result. We think that definitive staged treatment protocol including internal fixation with plating or intramedullary nailing (IMN) of the fractures is a reliable method, especially to avoid complications as a result of external fixator and to provide patient rapport.

Treatment Options for Brachial Plexus Injuries

The incidence of brachial plexus injuries is rapidly growing due to the increasing number of high-speed motor-vehicle accidents. These are devastating injuries leading to significant functional impairment of the patients. The purpose of this review paper is to present the available options for conservative and operative treatment and discuss the correct timing of intervention. Reported outcomes of current management and future prospects are also analysed.

Normal Range of Thoracic Kyphosis in Male School Children

Background. Although there are frequent studies about normal range of thoracic kyphosis, there is still a controversy about the exact values of this curve. In nine reported studies on 10 to 20 years of age boys, the value ranged from 25.1° to 53.3°. Objective for the Study. The aim of the present research was investigation of normal ranges of thoracic kyphosis in school children in Kermanshah, western Iran. Methods. 582 male students aged 13 to 18 years old using cluster random sampling were recruited from schools in Kermanshah city, 97 students for each age. Thoracic curves were measured using the flexicurve method. Results. Mean thoracic kyphosis for whole population was 35.49° SD 7.83 and plus or minus two standard deviations ranged from 19.83° to 51.15°. It increased gradually from 13 to 16 and then there was a little decrease to 18 years. Mean values for each age (13–16) were 13 (34.41 SD 7.47°), 14 (34.86 SD 8.29°), 15 (35.79 SD 7.93°), 16 (36.49 SD 7.85°), 17 (35.84 SD 8.33°), and 18 (35.55 SD 7.07°). Conclusions. Our results are in agreement with previous reports and can be used as normal values for local and regional purposes.

Comparison of Functional Outcomes of Tibial Plateau Fractures Treated with Nonlocking and Locking Plate Fixations: A Nonrandomized Clinical Trial

Fixation of tibial plateau fractures with plate has been widely used. This prospective study was planned to compare locking plate fixation of tibial plateau fracture with nonlocking methods in terms of their functional outcomes. The subjects of the study were selected from consecutive patients suffering from tibial plateau fractures referred to Kashani Hospital in Isfahan, Iran, between 2012 and 2013 and were candidate for surgery. The final included patients were assigned to two groups, those who were treated with locking plate (n=20) and those who were treated with nonlocking plates (N=21). The mean duration of follow-up was 13.4 months (ranging between 10 and 17 months). The mean of knee scores was significantly higher in locking plate group than in nonlocking plate group at the follow-up time (80.20±10.21 versus 72.52±14.75, P=0.039). Also, the mean VAS pain severity score was significantly lower in locking plate group compared with nonlocking plate group (4.45±2.50 versus 6.00±2.59, P=0.046). This study confirmed superiority of the locking plate method over nonlocking plate method with regard to knee score as well as VAS pain score.

Plate on Plate Osteosynthesis for the Treatment of Nonhealed Periplate Fractures

Purpose. The purpose of this paper is to present our technique for the treatment of periplate fractures. Methods. From 2009 to 2012 we treated three patients. In all cases the existing plate was left and the new one placed over the existing. Locking screws were placed through both plates. The other screws in the new plate were used as best suited the fracture. Results. In all cases less than 6 months had passed between fractures. None of the original fractures had healed. Mean followup was 2 years. All fractures proceeded to union within 7 months. No complications were recorded. All the patients returned to their normal activities and were satisfied with the results of their treatment. Conclusion. Our plate on plate technique is effective for the treatment of periplate fractures. A solid fusion can be achieved at the new fracture site without disturbing the previous fixation.

Distal Radial Fractures in the Superelderly: Does Malunion Affect Functional Outcome?

Purpose. The management of unstable distal radial fractures in the superelderly (≥80 years old) remains controversial. The aim of this study was to compare the functional outcome of super-elderly patients with and without malunion after a distal radial fracture. Methods. We identified 51 superelderly patients living independently with displaced fractures from a prospective database of 4024 patients with distal radial fractures. Activities of daily living, presence of wrist pain, whether the wrist had returned to its normal level function, grip strength and ROM were recorded. The dorsal angulation was measured radiographically. Results. There were 17 (33.3%) patients defined to have a malunion. The outcomes of the independent patients with and without malunion were compared at a mean follow-up of 15 months. No difference was observed in activities of daily living P=0.28, wrist pain P=0.14, whether the wrist had returned to its normal level function P=0.25, grip strength P=0.31, or ROM P=0.41. An increasing degree of dorsal angulation correlated with diminished ROM (P=0.038), but did not correlate with activities of daily living (P=0.10). Conclusions. Malunion of the distal radius does not influence the functional outcome of independent superelderly patients.

The Role of Fascia Iliaca Blocks in Hip Fractures: A Prospective Case-Control Study and Feasibility Assessment of a Junior-Doctor-Delivered Service

Hip fractures are common and the incidence is expected to increase. Systemic analgesics, often prescribed to relieve pain after hip fractures, have huge side effects and can delay surgery. We analyse the role and efficacy of alternative forms of analgesia like fascia-iliac blocks (FIB) and assess the feasibility of a service delivered by junior doctors. 104 consecutive hip fracture patients were prospectively recruited and equally divided into cases (patients receiving FIB) and controls (patients receiving systemic analgesia). Outcome measures included time of initial analgesia, total preoperative dose of analgesia, pain scores from admission to 24 hours preoperatively, and complications. The pain scores were significantly lower (P≤0.05) in patients receiving FIB at 2 and 8 hours preoperatively. The timing of initial analgesia was also quicker in patients with FIB (25 compared to 40 minutes). FIB patients required fewer doses of systemic analgesia. The block was successful in 67% of patients. There were no complications. The implementation of EWTD, HAN, and shift-system and the reduction in the number of medical staff have increased the burden on emergency departments. This study demonstrates that FIB performed by junior doctors are not only safe and effective analgesia but also provide an opportunity for junior doctors to improve current clinical practice.

Distal Tibial Metaphyseal Fractures: Does Blocking Screw Extend the Indication of Intramedullary Nailing?

Aim. To evaluate the clinical use of blocking screws as a supplement to stability in distal tibial metaphyseal fractures treated with statically locked intramedullary nail. Main Outcome Measurement. Alignment and reduction preoperatively, postoperatively, and at healing were the main outcome measured with an emphasis on maintenance of initial reduction on followup. Patients and Methods. This was a prospective study of 20 consecutive cases of distal tibial metaphyseal fractures treated with statically locked intramedullary nailing with supplementary blocking screw between August 2006 and September 2007 with a maximum followup of 3 years. Medullary canal diameter was measured at the levels of fracture and isthmus. Results. The mean diameter of tibia at the level of isthmus was 11.9 mm and at the fracture site was 22.9 mm. Mean length of distal fracture segment was 4.6 cm. Mean varus/valgus alignment was 10.3 degrees preoperatively and 1.7 degrees immediatly postoperatively and was maintained till union. Using Karlstrom-Olerud score the outcome was excellent to good in 90%. Conclusion. We conclude that the use of blocking screw as a supplement will aid in achieving and maintaining the reduction of distal tibial metaphyseal fractures when treated with intramedullary nailing thereby extending the indication of intramedullary nailing.

Brachial Plexus Injuries in Adults: Evaluation and Diagnostic Approach

The increased incidence of motor vehicle accidents during the past century has been associated with a significant increase in brachial plexus injuries. New imaging studies are currently available for the evaluation of brachial plexus injuries. Myelography, CT myelography, and magnetic resonance imaging (MRI) are indicated in the evaluation of brachial plexus. Moreover, a series of specialized electrodiagnostic and nerve conduction studies in association with the clinical findings during the neurologic examination can provide information regarding the location of the lesion, the severity of trauma, and expected clinical outcome. Improvements in diagnostic approaches and microsurgical techniques have dramatically changed the prognosis and functional outcome of these types of injuries.