Conservative treatment is not always possibile because it needs anatomic reduction of the fractures and to prevent the functional difficulties. There’s inherent tendency loss of reduction after non-operative treatment. According to criteria of instability of Cooney et al. as dorsal angulation >
20° degrees, loss radial length>
10 mm, intraarticular extension, etc. or if we had fractures A3, B, C of A.O. classification, open, bilateral fractures in polytrauma, will be useful to operate with internal or external fixation. We need to respect the morphology of three columns. We compare two different types of devices usually used in the last ten years in our hospital as the external fixation with Pennig and the plates and screws in internal fixation, underlining the advantages and the disadvantages. Between January 1997 and December 2006 215 patients with comminuted and unstable fractures complicated with different clinical aspects of exposure or vasculopathy or neurological acute entrapment or lesion, of severe displacement were treated by external fixator of Pennig. They were evaluated according to Gartland e Werley system, Sarmiento modified. Pain, disability and functional disease of articulation, radiological criteria of instability. To follow up average 12,4 months (range 5 to 24 months) the patients were distinguished as excellent, good, in 76% and fair good and bad in 24%. Complications of treatment were 3 osteitis and trombosis. In the same period we applied 142 plates the most in the volar side as DCP, LCP in association when it needs with graft, pinning and platelet gel after centrifugation of blood of the patient useful to bone healing. These patients were evaluated regarding to anatomy and function after reduction as strength of punch by Jamar dynamometer, pain, range of motion. After three months the patients operated with plates showed a ROM and a strength of punch better than those operated by external fixator. On the contrary after six months, more and more after twelve months the clinical and radiological results that is anatomical and functional outcomes were the same. At one year the Dash score was the same in the both of groups and there was not a difference between them. So we are authorized to use the external fixator of Pennig in unstable fracture A3 of wrist after failure of closed reduction, higher energy fractures and dislocations, unstable articular methaepiphiseal and comminuted fractures, exposed fractures, bilateral and complicated in politrauma. We applied volar plate and screws when there are extraarticular displaced fractures (A3.3), articular displaced fracture (B, C), corrected osteotomies, particularly in fracture type B (internal osteosintesis with plate + eventual volar graft), type C (internal osteosintesis volar plate associated with dorsal approach and pinning) + possible graft.
Today there is a great interest in the use of the autol-ogous platelet growth factors (APGF) in the field of orthopaedic surgery. The platelets are like a cellular laboratory and secrete, store, and leave many growth factors. These APGF are able to increase the reproduction of futtock, mesenchymal, fibroblast, osteoblast, and endothelial cells, which have a homothetic effect on macrophages and mono- and polymorphonuclear cells. Between 2001 and 2003 about 60 patients were treated with APGF in the form of gel. It was used for osteosynthesis of high energy fractures with soft tissue and bone loss, in arthrodesis of scoliotic spine, and in the emergency treatment of hand trauma. The platelet gel was used for 4 weeks. The average time for recovery was about 1 month for the soft tissue lesions. The use of APGF enables a speedy recovery and quick resumption of work. The healing time of the fractures decreases by 50% and the fingertip lesions with exposed bone can be treated with APGF without shortening or plastic surgery being necessary. It is possible to use platelet gel for replacement of soft tissue, for osteosynthesis of fractures, and to fill up defect cavities. Thus, this opens new perspectives for treatment in orthopaedic surgery. The patients could return to normal daily activity in a short time and it is possible to reach good results, offering a better quality of life.
