Summary

Biomechanically, a 2° screw deviation from the nominal axis in the PFLCP leads to significantly earlier implant failure. Screw deviation relies on a technical error on insertion, but in our opinion cannot be controlled intraoperatively with the existing instrumentation devices.

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: Pilon fractures demonstrate complex osseous and soft tissue injury. Protocols involving immediate tibial reduction and external fixation, with or without fibular fixation, then delayed definitive fixation result in decreased complications. Our purpose was to evaluate the treatment course of pilon fractures provisionally stabilised at outside institutions and subsequently transferred, focusing on the incidence and reasons for revision procedures, and subsequent complication rates.

Method: An institutional trauma database was retrospectively reviewed, demonstrating 668 pilon fractures treated at our institution between 2000–2007. Of these, 39 patients with 42 fractures had a temporising surgical procedure prior to referral. Demographics, injury characteristics, reason for revision, and subsequent complications were determined. Clinical follow-up averaged 60 weeks (range, 1 to 281).

Results: Mean age was 41 years (range, 18–78). Twenty-two fractures (52%) were open; 38 (90%) demonstrated a fractured fibula. Referral occurred an average of 5.8 days (range, 1–20) after initial stabilization. Pre-transfer fixation was revised in 40 fractures (95%). Reasons for revision included tibial malreduction (33 fractures, 83%), fibular malreduction (4 fractures, 10%), pins in the proposed incision (5 fractures, 13%), or loose pins (3 fractures, 8%). Of the 34 fractures with distal pins, 24 (71%) required revision for pin malposition, loosening, drainage, talar placement, or extraosseous placement. Late complications occurred in 14 fractures (33%), including deep infection in 10 (24%), and non-union in 3 (7%). Twenty-three patients (55%) required additional procedures following definitive fixation, including 9 soft tissue coverage procedures and 3 amputations.

Conclusion: The majority of patients with pilon fractures treated with provisional stabilisation followed by referral to our institution required revision prior to definitive fixation. This resulted in many avoidable additional procedures, and a higher complication rate than recent contemporary controls. The authors recommend that, when possible, the initial and definitive management of these injuries be performed at the accepting institution.

Retrospective review of eighteen patients with sacral fracture dislocations and cauda equina deficits treated with posterior sacral decompression and lumbopelvic fixation. At mean nineteen-month follow-up, all fractures healed without loss of alignment despite immediate full weight-bearing. Fifteen patients (83%) improved neurologically, and ten patients (56%) had full bowel/ bladder recovery. Complications consisted mainly of infection (17%) and asymptomatic rod breakage (33%). This series demonstrates the clinical effectiveness of lumbopelvic fixation, allowing the application to sacral injuries of decompression and fixation principles commonly used in fractures with neurologic deficits that occur in more rostral areas of the spine.

To evaluate the results of sacral decompression and lumbopelvic fixation for sacral fracture-dislocations with neurologic deficits.

Lumbopelvic fixation provided the stability necessary for full weight-bearing without loss of fracture reduction despite extensive sacral decompression. The functional neurologic improvement in most patients and complete neurologic recovery in all but one patient with intact lumbosacral roots are encouraging. The effectiveness of lumbopelvic fixation facilitates the application of principles of early decompression and stabilization to sacral fracture-dislocations.

Sacral fractures healed in all eighteen patients without loss of reduction. Average sacral kyphosis improved from forty-one to twenty-four degrees. Fifteen patients (83%) had normalization or improvement of bowel and bladder deficits, although only ten patients (56%) had improved Gibbons scores. Average Gibbons type improved from four to 2.8 at nineteen-month average follow-up. Rod breakage (33%) and infection (17%) were the most common complications. Recovery of bowel and bladder function was less likely in patients with disruption of any lumbosacral root (36% vs. 86%, p=.066) and complete deficits (47% vs. 100%, p=.241) although the small cohort size precluded statistical significance.

Retrospective review of medical records, radiographs, and prospectively collected data of eighteen consecutive patients with sacral fracture-dislocations and cauda equina deficits identified between 1997 and 2002 through institutional databases. Treatment consisted of open reduction, sacral decompression and lumbopelvic fixation. Radiographic and clinical results of treatment were evaluated. Neurologic outcome was measured by Gibbons’ criteria.

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Pilon injuries without fibula fractures may be associated with increased tibial plafond fracture severity. To evaluate this, we used the rank order technique, with traumatologists blinded to the fibular injury, who ranked the radiographic severity of forty pilon injuries with and without fibula fractures.

Pilon injuries with fibular fractures were ranked as more severe than those without. C-type injuries were ranked as more severe than B-type. Fibular fracture was more frequently associated with C-type injury than B-type. The presence of an intact fibula is not predictive of a more severe injury to the tibial pilon.

To determine if the absence of a fibular fracture is predictive of tibial pilon fracture severity.

Fibular status is not predictive of a more severe injury to the tibial pilon, and is more commonly associated with the less severe B-type injuries.

Absence of an ipsilateral fibular fracture in patients with tibial pilon injuries may predict a more severe tibial plafond injury pattern. Presumably, the energy is completely absorbed by the tibia resulting in more severe epimetaphyseal injury. The reverse relationship, however, was identified. This fact may aid in prognosis and treatment strategies.

Twenty consecutive pilon injuries without associated fibular fractures were matched 1:1 to an age/gender-matched cohort of pilon injuries with fibular fractures. Initial radiographs were digitized, the fibular image concealed, and then independently ranked (One, least severe; forty, most severe) by three orthopaedic traumatologists according to tibial plafond fracture severity. Injuries were classified using AO/OTA guidelines.

Inter-observer agreement was moderate (κ =0.6). Mean rank for pilon injuries with fibula fractures was 24.4 versus 16.7 for those without (t = 0.02). C-type injuries demonstrated a mean of 10.3 for those with fibular fractures versus 8.7 for those without (t = 0.5). Mean rank for B-type injuries was 11.1 versus 24.5 for C-type injuries (t = 0.001).

Overall, tibial pilon injuries with fibular fractures are more severe than those without. C-type injuries with or without fibular fractures are equally severe. C-type injuries were ranked significantly more severe than B-type. Fibular fracture was more frequently associated with C-type injury than B-type.