Purpose: To describe the pattern of injury, surgical technique and outcomes of Monteggia type IID fracture dislocations.

Method: Design: Retrospective review of prospectively collected clinical and radiographic patient data in orthopaedic trauma database with prospectively collected outcome scores. Setting: Level 1 university based trauma center. Patients / Participants: All patients with Monteggia type IID fracture dislocations admitted from January 2000 to July 2005. Intervention: Review of patient demographics, fracture pattern, method of fixation, complications, additional surgical procedures, and clinical and radiographic outcome measures. Main Outcome Measurements: Clinical outcomes: elbow range of motion, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand), PREE (Patient Rated Elbow Evaluation), complications. Radiographic outcomes: quality of fracture reduction, healing time, degenerative change and heterotopic ossification.

Results: Sixteen patients were included in the study. All fractures united. There were seven complications in 6 patients including 3 contractures with associated heterotopic ossification, 1 pronator syndrome and late radial nerve palsy, 1 radial head collapse and a DVT in the same patient and 1 with prominent hardware. Outcome scores were obtained on 11 patients at an average of 49 months (range 25 – 82 months) post-operatively. The average Quickdash score was 11 (range 0–43) and the average PREE score was 13 (range 0–34).

Conclusion: Monteggia IID fracture dislocations are complex injuries with a recurring pattern. Rigid anatomic fixation, early range of motion and avoidance of complications leads to a good outcome.

Purpose: To compare locking and non-locking single and dual plating constructs in maintaining posteromedial fragment reduction in a bicondylar tibial plateau fracture model. We hypothesized that posteromedial fragment fixation with medial and lateral non-locked constructs would tolerate higher loads than lateral locked constructs alone.

Method: Thirty adult-sized composite tibiae were identically fractured into an AO 41-C1.3 pattern. Six plate constructs were tested:

lateral 8-hole 3.5 mm conventional non-locking proximal tibial plate [CP];

Specimens were cyclically loaded to failure or a maximum load of 4000N. Load at posteromedial fragment failure was recorded.

Results: Fragment failure occurred at the posteromedial fragment first. The CP + 1/3 tubular construct had the highest average load to failure (3040 N). In two instances, the CP + 1/3 tubular construct did not fail under the highest loads applied and was the only construct to have specimens that did not fail by 4000 N. The CP + 1/3 tubular plating construct demonstrated significantly higher load at failure compared with the PTLP (p=0.036), the LCP (p=0.004), and the LISS (p=0.012). The CP + 1/3 tubular group did not demonstrate a significant difference in load at failure when compared with the CP (p=0.093) or the CP + LCDCP (p=0.108). The LISS demonstrated a significantly higher load at failure compared to the LCP (p=0.046) but not to the PTLP (p=0.800).

Conclusion: The posteromedial fragment tolerated higher loads with the CP + 1/3 tubular plate construct. The superiority of the dual plate construct may in part be due to the unreliable penetrance of the posteromedial fragment by the laterally applied locking screws.

Purpose: Non-union and secondary reduction loss complicate open distal femur fractures with bone loss. We hypothesize that locking plates decrease subsequent bone grafting in these injuries, yet maintain alignment; immediate post-fixation radiographic features predict primary union.

Method: From 2001 to 2004 inclusive, 34 adults with 36 open AO/OTA C-type distal femur fractures were reviewed. All were treated with locking plates and 3-month minimum follow-up. Union required radiographic bridging callus on 2/4 cortices combined with lack of symptoms. Alignment was assessed on initial and united radiographs. Antibiotic beads within a metaphyseal defect defined clinically important bone loss.

Results: Eleven of 20 fractures with bone loss (55%) underwent staged bone grafting to achieve union, versus two of 16 fractures without bone loss (13%). The presence of antibiotic beads was significantly associated with staged bone grafting (p< 0.01). Of those with bone loss and staged grafting, three had posterior cortical bone loss, and only three had medial and posterior cortical bone loss, and five had segmental defects. Of nine fractures with bone loss not requiring grafting, all had radiographic posterior cortical contact; seven had radiographic medial cortical contact. Posterior (p< 0.001) and medial (p< 0.025) cortical continuity were associated with injuries not requiring bone graft. Thirty-four had accurate frontal plane reductions; thirty-five had accurate sagittal plane reductions. Complications included two non-unions, and one reduction loss.

Conclusion: Despite metaphyseal bone loss, locking plates obviate the need for routine bone grafting of some open distal femur fractures. Those with radiographic posterior cortical contact and/or medial cortical contact are strongly correlated with primary union.