Extract
This article summarizes current advances in fracture care and is designed to provide the practicing orthopaedic surgeon with an overview of recent presentations and publications in the field of orthopaedic trauma. Information presented at the 2001 Annual Meeting of the Orthopaedic Trauma Association and the 2002 Annual Meeting of the American Academy of Orthopaedic Surgeons is reviewed. In addition, selected noteworthy manuscripts published in The Journal of Bone and Joint Surgery, Journal of Orthopaedic Trauma, Clinical Orthopaedics and Related Research, The Journal of Trauma, and Injury between May 2001 and May 2002 have also been analyzed and their contributions to orthopaedic traumatology are summarized.
This article summarizes current advances in fracture care and is designed to provide the practicing orthopaedic surgeon with an overview of recent presentations and publications in the field of orthopaedic trauma. Information presented at the 2001 Annual Meeting of the Orthopaedic Trauma Association and the 2002 Annual Meeting of the American Academy of Orthopaedic Surgeons is reviewed. In addition, selected noteworthy manuscripts published in The Journal of Bone and Joint Surgery, Journal of Orthopaedic Trauma, Clinical Orthopaedics and Related Research, The Journal of Trauma, and Injury between May 2001 and May 2002 have also been analyzed and their contributions to orthopaedic traumatology are summarized.
The evaluation and treatment of hemorrhage following high-energy pelvic fractures remains a subject of considerable debate. Treatment alternatives include angiography, external fixation, specially designed pelvic clamps, pneumatic anti-shock garments, and laparotomy with pelvic packing. The decision to perform angiography and the timing of the procedure were investigated in a series of 150 patients with unstable fractures of the pelvis 1 . Angiography was performed in twenty-three patients (15%) with uncontrolled hypotension. The authors noted that the morphology of the fracture was not a reliable guide to an associated vascular injury. Ten patients died, six of whom had had angiography as a first therapeutic intervention. Five of these patients had a fracture that was associated with an increase in pelvic volume and theoretically could have been stabilized with an external fixator. The authors concluded that skeletal stabilization remains the treatment of choice in these difficult cases and that laparotomy and pelvic packing, if indicated, should be performed before resorting to pelvic angiography. Embolization of pelvic arterial bleeding may be worthwhile in patients with hypotension that is unresponsive to these interventions.
Laparotomy and packing of the pelvic retroperitoneum has been suggested as a therapeutic alternative for the treatment of catastrophically injured patients but until recently was not commonly practiced in North America. Two recent publications from Europe demonstrated improved survival rates when a pelvic C-clamp or external fixator was combined with pelvic packing for the treatment of multiply injured patients who had pelvic ring disruptions and hemorrhagic shock. Nevertheless, until further confirmatory data are published, it is likely to be indicated only for a small subgroup of patients with severe refractory hypotension who have an imminent prospect of death 2,3 .
Iliosacral screw placement has become the standard means of internal fixation for fractures and fracture-dislocations of the sacral and sacroiliac joints. Nevertheless, there have been few reports in the literature regarding functional outcomes after iliosacral screw fixation. Rozen et al. reviewed the Toronto experience in a report on eighty patients with unstable posterior ring disruptions that were treated with this method. Functional outcomes were measured with the use of the Musculoskeletal Function Assessment (MFA) and Short Form-36 (SF-36) questionnaires. The authors demonstrated that physical function remains substantially compromised after posterior pelvic ring fixation and emphasized that every effort should be made to obtain an anatomic reduction because residual displacement is associated with compromised outcomes and function.
Nerve injury, deep venous thrombosis, and heterotopic bone formation are well-known complications following acetabular fractures. Patient satisfaction and functional outcome may be compromised when complications develop. Haidukewych et al., in a retrospective, nonrandomized study of 256 consecutive patients, investigated the prevalence of nerve injury during monitored and unmonitored procedures that were performed for the treatment of an acetabular fracture and found that the use of intraoperative monitoring did not decrease the rate of iatrogenic sciatic nerve palsies 4 .
It has been well established that patients with pelvic and acetabular fractures, particularly those with severe associated injuries, are at increased risk for the development of deep venous thrombosis. In the multiply injured patient, classic anticoagulation is often contraindicated because of the risk of bleeding. Mechanical lower limb compression has been recommended as an alternative to pharmacological prophylaxis in this high-risk subpopulation of patients. In a prospective, randomized, blinded study of 107 patients, Stannard et al. compared two methods of mechanical prophylaxis against deep venous thrombosis 5 . They found that pulsatile limb compression was associated with fewer deep-vein thromboses than sequential compression was, but the difference was not significant.
There is conflicting information regarding the most effective method of preventing heterotopic bone formation following internal fixation of an acetabular fracture. Burd et al. compared indomethacin with localized irradiation for the prevention of heterotopic ossification following the surgical treatment of acetabular fractures 6 . The authors found that both methods of treatment were effective for prophylaxis against heterotopic ossification in the population that was studied.
The functional outcome of acetabular fracture treatment, as determined on the basis of limb-specific or joint-specific outcome measures and the physical function components of general-health status, have become a major focus of interest. Borrelli et al. demonstrated that hip flexion and extension strength are negatively affected following open reduction and internal fixation of an acetabular fracture 7 . Anglen et al. found that the functional outcomes of operative treatment of acetabular fractures in geriatric patients were comparable with those in an age-matched cohort without a history of acetabular fracture, with good to excellent results in two-thirds of the patients studied.
Open reduction and internal fixation is thought to offer the highest likelihood of a favorable outcome for patients with displaced acetabular fractures. However, acetabular fractures associated with extensive impaction or erosion of the acetabulum or femoral articular cartilage or with marked comminution and osteopenia have an intrinsically poor prognosis. In patients with a low likelihood of a favorable outcome after fracture treatment, combined internal fixation and total hip arthroplasty may be indicated to achieve a painless, mobile hip. Mears and Velyvis reported the results for fifty-seven patients who had an acute total hip arthroplasty for the treatment of an acetabular fracture 8 . The mean Harris hip score was 89 points (range, 69 to 100 points), and 79% of the patients had an excellent or good outcome. In another study, twenty-four elderly patients underwent combined internal fixation and total hip replacement. Although complications were seen in 50% of the patients, only two required further surgical intervention.
Previous studies of patients who have undergone total hip arthroplasty for the treatment of posttraumatic arthritis after an acetabular fracture have shown inferior results compared with the results for patients who have undergone the procedure for the treatment of nontraumatic arthritis. The prevalence of symptomatic posttraumatic arthritis following acetabular fractures has been reported to be as high as 30%. Total hip arthroplasty remains, for many patients, a favorable alternative to arthrodesis. The outcome of total hip arthroplasty performed after a previous acetabular fracture was compared with the outcome of total hip arthroplasty performed for the treatment of arthritis in a matched-cohort study. Ninety-two patients with a previous acetabular fracture that later required total hip arthroplasty were matched according to gender, age, and year with patients who had had a total hip arthroplasty for the treatment of osteoarthritis. After a mean duration of follow-up of 7.4 years, the authors concluded that patients who had had a total hip replacement after a previous acetabular fracture had worse function than those who had had a total hip replacement for the treatment of osteoarthritis.
Bellabarba et al. studied the results of cementless acetabular reconstruction in patients who had posttraumatic arthritis following an acetabular fracture 9 . They found that the intermediate-term clinical results for these patients were similar to those for patients in whom the same procedure was performed for the treatment of nontraumatic arthritis, regardless of whether or not the acetabular fracture had been internally fixed. However, total hip arthroplasty performed after an acetabular fracture was a more extensive procedure and was associated with greater blood loss, especially in patients with previous internal fixation. Previous open reduction and internal fixation predisposed the hip to more intraoperative instability but less bone deficiency.
Hip fractures in the elderly are a burden to both society and the individual and are associated with substantial morbidity and cost. Despite considerable research, the optimal method of treatment for both femoral neck and intertrochanteric fractures continues to be hotly debated. In a prospective, randomized trial in which internal fixation was compared with arthroplasty for the treatment of displaced fractures of the femoral neck, Rogmark et al. reviewed the functional outcomes for 409 patients after an average duration of follow-up of two years 10 . Patients who were seventy years of age or older and had a Garden type-III or IV femoral neck fracture were randomized to treatment with internal fixation or arthroplasty. After two years, the rate of failure was 43% in the internal fixation group and 6% in the arthroplasty group (p < 0.001). In the internal fixation group, 36% of the patients had impaired walking ability and 6% had severe pain, compared with 25% and 1.5%, respectively, in the arthroplasty group. Because of the high rate of failure and the poor functional outcomes after internal fixation, the authors recommended primary arthroplasty for the treatment of displaced femoral neck fractures in patients who are more than seventy years of age.
While hemiarthroplasty is a widely accepted method for the treatment of displaced femoral neck fractures in geriatric patients, there are differences of opinion about the choice of implant. Ong et al. reviewed the functional outcomes for 149 patients who were followed for a minimum of thirty-six months after the treatment of a femoral neck fracture with either unipolar or bipolar hemiarthroplasty 11 . The authors concluded that there was no advantage associated with the use of a bipolar endoprosthesis for the treatment of femoral neck fractures in the elderly. Tidermark et al. assessed the relationship between quality of life and fracture displacement in a prospective clinical study of ninety elderly patients in whom a femoral neck fracture had been treated with internal fixation 12 . The authors found a major difference in outcomes between patients with undisplaced and displaced fractures. The rate of fracture-healing complications in patients with undisplaced fractures was low, and patients with healed fractures regained their preinjury quality-of-life level. In contrast, the rate of fracture-healing complications and reoperations in patients with displaced fractures was high, and even patients with uneventful fracture-healing had a substantial decrease in the quality of life.
For nearly forty years, the sliding hip screw and plate has been the standard treatment for intertrochanteric fractures of the femur. In patients with stable fractures, the implant produces excellent results. However, in patients with unstable fractures, the implant is associated with a greater prevalence of complications, particularly cut-out and subsequent loss of reduction. For these reasons, there has been a sustained interest in the use of an intramedullary nail to treat intertrochanteric hip fractures. Biomechanical studies have shown that an intramedullary device shortens the lever arm, provides more load-sharing, and can be inserted through limited incisions. To test this hypothesis, Adams et al. performed a prospective, randomized, controlled trial in which an intramedullary nail was compared with a dynamic hip screw and plate for the treatment of intertrochanteric fractures of the femur 13 . Two hundred and three patients received a short gamma nail, and 197 received a sliding hip screw and plate. The patients were followed for one year or until death. The authors found that the use of an intramedullary device was associated with a higher, but not a significantly higher, risk of postoperative complications. For this reason, the routine use of a gamma nail for the treatment of intertrochanteric fractures was not recommended. In a similar study of 206 patients with peritrochanteric fractures, Stern and colleagues found that the use of a proximal femoral nail offered no advantage compared with the use of a dynamic hip screw. The nail has a greater cost, and there is no evidence that it is associated with a decreased rate of complications or improved patient outcomes.
Two recent studies focused on the reverse obliquity fracture of the proximal part of the femur, an uncommon but distinct fracture pattern. In one series, reverse oblique fractures accounted for 2% of all hip fractures and 5% of all intertrochanteric and subtrochanteric femoral fractures. Haidukewych et al. recently reported on the Mayo Clinic experience with forty-seven reverse oblique fractures of the hip 14 . Thirty-two (68%) of the forty-seven hips that were treated with internal fixation healed without additional surgery, while the other fifteen hips (32%) failed to heal or had a failure of fixation. Ninety-five-degree fixed-angle devices performed substantially better than sliding hip screws. The results of treatment were also worse for patients with poor fracture reduction and those with a poorly placed implant. The use of an intramedullary device was not evaluated.
The use of an intramedullary nail or a 95°ree; screw-plate for the treatment of reverse oblique and transverse intertrochanteric fractures was evaluated in a prospective, randomized study by Sadowski et al. 15 . Nineteen patients received a 95°ree; dynamic condylar screw, and twenty patients received a proximal femoral nail. Implant failure or nonunion occurred in seven of the nineteen patients who had been treated with a 95°ree; screw-plate. Only one of the twenty fractures that had been treated with an intramedullary nail did not heal. Although the numbers were small, the authors concluded that an intramedullary nail rather than a 95°ree; screw-plate should be employed for the fixation of reverse oblique and transverse intertrochanteric fractures in the elderly.
Locked intramedullary nail fixation is the treatment of choice for the vast majority of femoral shaft fractures in adults. A large body of literature has shown classic antegrade nailing to be safe and effective. Nevertheless, in certain clinical situations (e.g., displaced ipsilateral fractures of the femoral neck and shaft), an antegrade nail may be less effective. For this reason, intramedullary nailing through a retrograde approach has been developed. Initially, retrograde nailing was limited to specific fracture problems that are not apt to be well addressed with an antegrade nail. Following the initial success of retrograde nailing, the obvious question became, "is it as effective as antegrade nailing for fractures involving the middle third of the femur?" Huebner and Ostrum, in a prospective study of 195 patients, compared the results of antegrade and retrograde reamed femoral nailing with respect to fracture union, knee and hip function, operative time, blood loss, and secondary procedures. The authors found no significant differences in the rate of union, the time to union, knee pain, or the range of knee motion. Blood loss and operative time were decreased in the group treated with retrograde nailing. Hip pain was more common following antegrade nailing, and pain from prominent distal interlocking screws was more prominent after retrograde nailing. The authors concluded that retrograde nailing represents a viable alternative to antegrade nailing in the treatment of femoral shaft fractures.
Despite the increased popularity of retrograde femoral nailing, questions about potential problems with proximal interlocking in the subtrochanteric region, such as the risk of peritrochanteric fractures, remain. In a biomechanical study involving both synthetic and cadaveric femora, McLaurin et al. evaluated the optimal proximal interlocking location for retrograde femoral interlocking nails. Nails of various lengths with locking screws placed proximal and distal to the lesser trochanter were tested. The authors offered biomechanical evidence that hardware in the subtrochanteric region does act as a stress-riser, supporting the use of longer nails proximal to the lesser trochanter.
Little attention has been paid to insertion-site morbidity associated with antegrade femoral nailing. However, residual peritrochanteric pain after nailing is not uncommon. Entry-point tissue damage associated with antegrade femoral nailing was assessed in a cadaveric study by Dora et al. 16 . Reamed nailing with use of an AO universal femoral nail was performed on sixteen adult cadavers, followed by dissection of the proximal part of the femur to assess possible damage to the soft tissue. Three entry portals were defined. To select the best nail-entry portal, the ease of nail insertion must be weighed against the resulting soft-tissue damage at the insertion site. The nail-entry portal at the piriformis fossa, although geometrically ideal, caused the most substantial damage to the muscles and tendons as well as to the blood supply to the femoral head. A nail-entry portal anterior to the longitudinal axis of the femoral neck, although better with respect to soft-tissue damage, had the worst geometric and biomechanical disadvantages. An entry portal through the greater trochanter was associated with the least soft-tissue damage and was favored by the authors.
Roberts et al. assessed the fracture-site motion associated with different types of second-generation intramedullary nails that were used to fix subtrochanteric fractures of the proximal part of the femur with and without femoral neck fractures in a fiberglass composite model 17 . For simple, well-reduced fractures, the choice of implant was not crucial. As the fracture severity increased (i.e., for comminution, gap, and combined neck fractures), the choice of implant, particularly with reference to proximal nail dimensions and implant materials, was a substantial factor in reducing motion at the fracture site.
The appropriate method and timing of treatment for patients with traumatic knee dislocations is still controversial, with numerous factors influencing the outcome. Mills and Tejwani, in a prospective study of thirty-five patients, assessed the utility of the Injury Severity Score in predicting the formation of clinically important heterotopic ossification after knee dislocation. The Injury Severity Score was calculated at the time of admission. Stratification of the data revealed that an Injury Severity Score of 26 points was a distinct tidemark for determining which patients are at risk for heterotopic ossification after knee dislocation and ligament reconstruction. An Injury Severity Score of 26 points had a sensitivity of 100%, a specificity of 97%, and a positive predictive value of 86%. In a detailed study of eighty-nine patients with a dislocation of the knee, Richter et al. found that cruciate ligament reconstruction or repair was superior to nonoperative treatment but that reconstruction was not better than repair alone. The best results were achieved in patients following repair or reconstruction that provided sufficient stability to allow early range of motion of the knee.
Klatt et al. reported on thirty-one traumatic knee dislocations that were treated with a standard surgical approach and followed for an average of forty-four months. Patients who were treated acutely had higher subjective scores and better objective restoration of knee stability than did patients whose treatment was delayed. Nearly all patients were able to perform activities of daily living with few problems. However, the ability to return to high-demand sports and strenuous manual labor was less predictable.
Internal fixation is widely used for the treatment of low and intermediate-energy fractures of the tibial plateau. Recently, the use of lower-profile and smaller implants as well as the use of bone-graft substitutes has been proposed as a means of reducing wound complications and bone graft donor site morbidity. Karunakar et al. found no significant differences in overall construct stiffness in a recent biomechanical study in which a classic L-buttress plate was compared with four 3.5-mm screws that were placed into a "raft construct" for the fixation of a cadaveric simulated split-depression tibial plateau fracture 18 . Westmoreland et al. compared the pull-out strength of large-fragment and small-fragment screws that had been inserted into the tibial plateau of human cadavers 19 . They found no significant difference in pull-out strength between the large-fragment and small-fragment screws in subchondral and metadiaphyseal bone. However, large-fragment screws were substantially stronger than their smaller counterparts in diaphyseal bone. The authors stated that the results of the study lent support to the use of small-fragment fixation in the treatment of tibial plateau fractures.
Various techniques have been recommended to fill metaphyseal cancellous bone defects resulting from operative reduction of impacted tibial plateau fractures. Lobenhoffer et al. evaluated the use of an injectable calcium-phosphate bone cement (Norian SRS; Synthes, Paoli, Pennsylvania) in a study of twenty-six patients with tibial plateau fractures 20 . Two patients required irrigation and débridement because of wound drainage. Two patients had partial loss of reduction, and one of them required revision. There were no other complications, and all of the other fractures healed without displacement. The authors concluded that injectable mineral bone cement was a useful adjunct in the treatment of depressed tibial plateau fractures that required surgery.
Few studies have documented the functional outcomes for patients with tibial plateau fractures with use of modern statistically validated outcome measures. In the study by Stevens et al., forty-seven displaced fractures of the tibial plateau that had been treated with open reduction and internal fixation were followed for an average of 8.3 years 21 . A general health status scale (the SF-36) and a disability scale relating to knee osteoarthritis (the Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) were used to assess functional outcome. The authors found that age at the time of the injury was the main factor influencing functional outcome. Ninety-two percent of the patients who were less than forty years old at the time of the injury showed no significant functional differences compared with age-matched controls, regardless of fracture type. Conversely, only 57% of the patients who were more than forty years old at the time of the injury scored as well functionally as age-matched controls.
There is little information in the literature regarding the outcomes of total knee arthroplasty following open reduction and internal fixation of a tibial plateau fracture. Saleh et al. reviewed fifteen such patients after a minimum duration of follow-up of five years 22 . On the basis of the Hospital for Special Surgery knee score, the SF-36 score, and radiographs of the knee, the authors concluded that total knee arthroplasty after open reduction and internal fixation of a tibial plateau fracture decreases pain and improves knee function but that the procedure is technically demanding and is associated with a high failure rate.
Recent emphasis on the preservation of osseous vascularity with the use of indirect reduction and fixation techniques involving the insertion of a submuscular or percutaneous plate has led to increased rates of union with fewer complications in selected tibial fractures. However, the use of submuscular fixation is not without risk. In a cadaveric study, Kregor et al. assessed the neurovascular risks associated with submuscular fixation of the proximal part of the tibia with use of the Less Invasive Stabilization System (LISS; Synthes, Paoli, Pennsylvania). Twenty-six fresh-frozen whole-leg cadaveric specimens were used. A thirteen-hole tibial fixator was slid submuscularly beneath the anterior compartment of the leg. Following distal screw insertion, the plate and drill sleeves were exposed. In thirteen of the twenty-six specimens, the distal aspect of the fixator tented the anterior tibial artery and/or vein or the deep peroneal nerve or was in direct contact with these structures. In three additional specimens, the anterior tibial artery and/or vein was transected or injured. The superficial peroneal nerve was injured in three of the twenty-six specimens. On the basis of these results, the authors concluded that a formal open approach to the middle or distal part of the tibia should be used for the placement of distal tibial submuscular screws and plates.
The etiology of anterior knee pain after intramedullary nailing of the tibia remains uncertain. In a retrospective study of 248 patients (251 knees) who were followed for more than five years after closed intramedullary nailing of the tibia, anterior knee pain persisted in 47% of the patients. The authors recommended that all patients should be advised of this problem prior to the surgical procedure.
Unreamed nailing with use of small-diameter locked tibial nails is widely used for the stabilization of both open and closed tibial fractures. A multicenter analysis of 467 tibial fractures was performed to investigate the prevalence of complications following this procedure 23 . The infection rate was 1.1% overall and 5.4% among patients with grade-III fractures. Delayed union occurred in 9.2% of the patients, and nonunion occurred in 2.6% of the patients. Compartment syndrome occurred in sixty-two patients (13.3%), screw failure occurred in forty-seven patients (10.1%), and nail failure occurred in three patients (0.6%). Fracture distraction of >3 mm was associated with a twelvefold increase in the time to fracture-healing.
Advances in molecular biology and tissue-engineering related to orthopaedic trauma are moving slowly from the laboratory to the clinical arena. In a prospective, randomized, controlled study of 450 patients with open tibial fractures that were treated with intramedullary nailing, the role of recombinant human bone morphogenetic protein-2 (rhBMP-2) was evaluated. Patients were randomized into three groups: the control group underwent standard soft-tissue management, and the other two groups received rhBMP-2 at a dose of either 0.75 mg/ml or 1.5 mg/ml. The rhBMP-2 was implanted at the fracture site on an absorbable collagen sponge at the time of definitive wound closure. Ninety-four percent of the patients completed the twelve-month follow-up evaluation. The results of the study demonstrated that the implantation of rhBMP-2 on an absorbable collagen sponge at a dose of 1.5 mg/ml improved the probability and rate of bone and soft-tissue healing. The technique was safe and well tolerated, and it reduced the need for secondary interventions to promote fracture-healing.
Internal fixation of displaced ankle fractures is one of the most common, least controversial, and most gratifying orthopaedic procedures. Nevertheless, the optimal method for stabilizing ankle fractures associated with syndesmotic injuries remains controversial. In a prospective study, sixty-seven patients with ankle fractures were evaluated with plain radiographs and magnetic resonance images to determine the presence or absence of interosseous membrane tears. Twenty-eight of the sixty-seven ankle fractures were associated with intraosseous membrane tears as identified on magnetic resonance imaging. Of the forty-three ankles that had an adequate magnetic resonance imaging evaluation proximal to the fibular fracture, four had an interosseous membrane tear proximal to the fibular fracture. The authors concluded that it was difficult to estimate the integrity of the interosseous membrane and the subsequent need for syndesmotic fixation solely at the level of the fibular fracture. That study supports the need for intraoperative testing of the ankle syndesmosis at the time of surgery.
Tornetta et al. reported on fifty-seven patients in whom a Weber type-C ankle fracture was treated with fixation of the syndesmosis only. The operative technique included percutaneous reduction and clamp stabilization of the syndesmosis followed by the addition of a 3.5-mm cortical screw for twelve weeks. Forty-nine patients were followed for an average of 2.7 years. There were thirty-eight excellent, nine good, and two poor results. The authors concluded that the technique obviates the need for internal fixation of the fibula with its attendant morbidity and leads to good or excellent results in 96% of patients. In a complementary study, Tornetta et al. investigated the position of the ankle at the time of syndesmotic screw insertion in nineteen cadaveric ankles 24 . The authors showed that maximal dorsiflexion of the ankle during syndesmotic fixation is not required in order to avoid loss of dorsiflexion. Rather, the most important aspect of syndesmotic fixation is achieving an anatomic reduction of the syndesmosis.
The treatment of syndesmotic disruptions of the ankle with use of bioabsorbable screws was studied prospectively by Hovis et al. 25 . Twenty-three consecutive patients with a syndesmotic disruption were managed with standard metallic plate-and-screw fixation of the malleoli and a 4.5-mm polylevolactic acid screw, with purchase in four cortices, for fixation of the syndesmosis. After an average duration of follow-up of thirty-four months, all of the malleolar fractures had healed and there was no displacement of the syndesmosis or widening of the medial clear space. There was no osteolysis or late inflammation secondary to the bioabsorbable screw. Nineteen patients had an excellent result, and four had a good result. All patients returned to their preinjury level of activity. The authors concluded that the use of a polylevolactic acid screw is effective for stabilizing disruptions of the syndesmosis. The screw was well tolerated, and there was no need for a second operation to remove it.
Talar neck fractures, although uncommon, are associated with substantial patient morbidity. Fleuriau Chateau et al. reported on the use of minifragment plates for the fixation of talar neck fractures in twenty-three patients 26 . The plates were placed on the side with the most comminution. All fractures healed, and there were no varus malunions. However, the prevalence of avascular necrosis was not reported. Sanders reviewed the Vanderbilt experience with the treatment of displaced talar neck fractures. Of 108 eligible patients, sixty-six were available for review after two to ten years of follow-up. The authors found that the need for late salvage surgery was common and that subtalar arthrodesis was the most common cause of late morbidity. Outcome was dependent on comminution, a high Hawkins classification, and associated ipsilateral lower extremity injuries. In contrast, variables such as the time to surgery, patient age, and the number of surgical approaches were not associated with an increased rate of salvage surgery.
A prospective, randomized, multicenter Canadian study of displaced intra-articular calcaneal fractures has improved our understanding of this difficult injury. In a recent presentation, the authors analyzed the rates of complications associated with internal fixation and nonoperative treatment. A major complication developed in forty-two (19%) of the 218 patients in the nonoperatively treated group, compared with seventy-six (35%) of the 218 patients treated with open reduction and internal fixation. The authors emphasized the need for careful selection of patients for open calcaneal fracture treatment.
Shoulder Fractures
Displaced ipsilateral fractures of the clavicle and the glenoid neck (floating shoulder fractures) are complex injuries and usually are the result of high-energy trauma. Until recently, most were thought to be unstable injuries requiring operative stabilization. However, there were few data to support this recommendation. The mechanical, clinical, and functional outcomes of patients with "floating shoulders" were carefully analyzed and reviewed in three recent studies, one biomechanical and two clinical 27-29 . In the study by Williams et al., a standardized scapular neck fracture was created in human cadaveric shoulders and resistance to medial displacement was determined following sequential creation of an ipsilateral clavicle fracture, coracoacromial ligament disruption, and acromioclavicular capsular disruption 27 . The authors showed that ipsilateral fractures of the scapular neck and the clavicle do not produce an unstable floating shoulder without additional disruption of the coracoacromial and acromioclavicular capsular ligaments. Egol et al. evaluated the clinical and functional outcomes for nineteen patients with ipsilateral fractures of the scapula and clavicle, twelve of whom had been treated nonoperatively and seven of whom had been treated operatively 28 . The authors found no significant differences between the groups with regard to three different validated objective functional outcome measures. They concluded that good results may be obtained both with and without operative fixation and that treatment must be individualized. Van Noort et al., in a multicenter study from the Netherlands, reviewed the outcomes for thirty-five patients with a floating shoulder 29 . Thirty-one patients had initially been treated nonoperatively, and four had been treated operatively. The authors concluded that the injury is not inherently unstable and, in the absence of caudal displacement of the glenoid, nonoperative treatment provides a good functional outcome.
The management of displaced two-part and three-part fractures of the proximal part of the humerus is still controversial. Closed reduction and percutaneous pinning is an increasingly popular technique that minimizes soft-tissue dissection and is thought to reduce operative morbidity. The risk to the neurovascular structures following percutaneous pinning was studied by Rowles and McGrory in a cadaveric model 30 . In ten fresh-frozen cadavers, the intact proximal part of the humerus was pinned under fluoroscopic control with use of a standardized technique. The shoulders were subsequently dissected to determine the distance of each pin from adjacent neurovascular structures as well as key anatomic relationships. The authors clearly showed that percutaneous pinning may be associated with a risk to important anatomic structures around the shoulder, including the anterior branch of the axillary nerve, the cartilage of the humeral head, the cephalic vein, the biceps tendon, and the musculocutaneous nerve.
Haddad et al. reviewed the outcomes for sixty-six consecutive patients in whom a proximal humeral fracture was treated with percutaneous pin fixation with use of three or four wires. Although satisfactory reduction and alignment were achieved, there were high rates of complications, including pin migration (50%), stiffness (41%), pain (33%), infection (25%), nonunion (8%), and radial nerve palsy (8%). The complication rate increased in patients who were more than fifty years old and in those with osteopenia.
Humerus
Antegrade humeral nailing is commonly used for the treatment of displaced humeral shaft fractures. However, shoulder pain and weakness are common postoperative complaints. While the cause of these problems may be multifactorial, one possible explanation may be injury to the axillary nerve during the insertion of proximal interlocking screws. To test this hypothesis, twenty human cadaveric shoulders were treated with a Synthes titanium nail that was locked with two proximal screws. Following intramedullary nailing, the deltoid muscle was dissected and the relationship between the axillary nerve and the interlocking screws was recorded. The mean distance between the locking screw and the axillary nerve was only 2.47 mm, and five screws actually pierced the nerve. The authors concluded that the distal aspect of the axillary nerve is at substantial risk during proximal interlocking humeral nailing and that design alterations in the Synthes nail are necessary to minimize neurological injury.
In an effort to improve outcomes following humeral fractures, Stannard retrospectively reviewed the results associated with forty-three humeral shaft fractures that had been treated with a locking flexible nail that had been inserted through either an antegrade or a retrograde approach. Antegrade nailing had been done through the greater tuberosity, lateral to the rotator cuff insertion. Eighty-one percent of patients had a good or excellent result. The average Constant score for all patients in the series was 88 points. There were five complications (prevalence, 12%), including two nonunions, two instances of hardware failure, and one wound infection.
Elbow
Displaced intraarticular fractures of the distal part of the humerus are difficult to manage, particularly in elderly patients with comminution and osteopenia. Gambirasio et al. reviewed the outcomes for ten elderly patients who had had a total elbow replacement for the treatment of a complex fracture of the distal part of the humerus 31 . After a minimum duration of follow-up of one year, the mean range of motion was 125°ree; and the mean loss of extension was 23.5°ree;. The mean Mayo score was 94 points, and the level of patient satisfaction was high. The authors believed that total elbow replacement was a viable alternative to open reduction and internal fixation in the management of complex intra-articular fractures of the distal part of the humerus in the elderly.
The "terrible triad" is the name given to an elbow dislocation that is associated with fractures of the radial head and coronoid. McKee et al. reviewed the treatment of twenty-four patients who had this constellation of injuries and found that initial primary surgical reconstruction consisting of fixation or replacement of the radial head, fixation or repair of the coronoid process, repair of the lateral collateral ligament complex, and use of an adjuvant hinged external fixator led to ten excellent, five good, seven fair, and two poor results. After an average duration of follow-up of eighteen months, the mean arc of flexion-extension was 103°ree; and the mean arc of pronation-supination was 110°ree;.
Open reduction and internal fixation is the treatment of choice for most displaced fractures of the olecranon because it restores articular integrity, allows early motion, and prevents elbow contracture. Both plate osteosynthesis and tension-band wiring are widely accepted methods of treatment. Ikeda et al. reviewed the outcomes for ten patients in whom a comminuted olecranon fracture was treated with a corticocancellous iliac crest bone graft and multiple tension-band wires 32 . In that series, all fractures healed and no patient reported difficulties with activities of daily living or symptomatic elbow instability after an average duration of follow-up of 28.5 months. The mean range of motion of the elbow was from 15°ree; to 135°ree;. There were five excellent and five good results according to the Broberg-Morrey index. Alternatively, Bailey et al. reviewed the outcomes for twenty-five patients who underwent plate fixation for the treatment of an olecranon fracture 33 . After an average duration of follow-up of thirty-four months, physical capability measures indicated nonsignificant side-to-side differences in strength and motion (except for supination motion). Functional outcome measures showed a high level of patient satisfaction and almost normal physical function. However, 20% of the patients required removal of a prominent plate.
Forearm and Wrist
Fractures of the distal part of the radius are common injuries. Despite considerable research, there is no consensus regarding the optimal method of treatment. Nevertheless, most authors have believed that accurate reduction and adequate immobilization improve radiographic and functional outcomes. The most common method of treatment is closed reduction and immobilization in a splint or cast. In a prospective trial, 223 patients with 225 displaced Colles fractures were randomized to treatment with closed reduction with either finger-trap traction (112 patients) or manual manipulation (111 patients) 34 . The fractures were assessed radiographically by measurement of the radial angle, dorsal tilt, and radial shortening before, immediately after, and at one and five weeks after reduction. Both techniques produced an 87% rate of satisfactory initial reductions. However, the percentage of fractures in acceptable alignment was only 57% and 50% at one week after finger-trap traction and manual manipulation, respectively, and only 27% and 32% at five weeks. The two methods of fracture reduction did not differ with regard to the eventual position of the fracture or the rate of failure. Although closed reduction was successful for the majority of fractures, most fractures redisplaced substantially during the period of cast immobilization.
Haddad and colleagues investigated the fate of the radiographic and clinical deformity after the traditional six weeks of treatment for most distal radius fractures. One hundred consecutive unilateral Colles fractures were treated either with reduction and casting or with percutaneous pinning and casting once an acceptable reduction had been achieved. All patients were followed for one year to assess radial length, distal radial inclination, and volar tilt. Eighty percent of the patients showed loss of radial length and inclination beyond the position seen at six weeks after the injury. Thirty-four percent of the patients who had had manipulation of the fracture showed a progressive late regression of the deformity to the pretreatment position. On the basis of these results, the authors recommended methods of treatment that are able to safely hold the fracture for periods of longer than six weeks and that can resist deforming forces.
One method that has been used to improve stability following the reduction of displaced distal radial fractures is the addition of calcium-phosphate bone cement (Norian SRS; Synthes). In a cadaveric study, Higgins et al. evaluated the stability of intra-articular fractures that had been treated with calcium-phosphate bone cement alone, with external fixation augmented with cement, and with Kirschner-wire fixation alone when exposed to physiological loads and range of motion. Fixation with calcium-phosphate bone cement alone failed at the bone-cement interface at physiologic loads in all specimens and was insufficient to withstand wrist flexion-extension motion without supplemental wire fixation. Fractures that were treated with cement supplemented with three Kirschner wires were more stable than those fixed with Kirschner wires alone but were still substantially less stable than those fixed with a combination of external fixation and Kirschner wires.
For some displaced intra-articular fractures, manipulation, with or without percutaneous pins or external fixation, is insufficient to restore or maintain articular congruity, radial length, radial tilt angle, and volar inclination. Several authors have recommended open reduction and internal fixation to restore anatomy in these difficult cases. In the study by Rogachefsky et al., seventeen patients with severely comminuted intraarticular fractures of the distal part of the radius were treated with open reduction and combined internal and external fixation 35 . After an average duration of follow-up of thirty months, the average arc of flexion-extension was 72% of that on the uninjured side and the average grip strength was 73% of that on the uninjured side. Ten patients had an excellent or good result according to the system of Gartland and Worley, and five had an excellent or good result according to the modified system of Green and O'Brien. The authors believed that combined internal and external fixation of AO type-C3 fractures can restore anatomy, maintain reduction throughout the period of healing, and provide satisfactory functional results.
Ring et al. reported on forty-one patients in whom a complex fracture of the distal part of the radius was treated with combined dorsal and volar plate fixation. After an average duration of follow-up of twenty-two months, all of the fractures had healed. No patient had mechanical failure or loss of reduction. According to the rating system of Gartland and Worley, there were five excellent, thirty-four good, and two fair results. The authors concluded that fragment-specific fixation with use of combined dorsal and volar fixation provided a good functional result in patients with this severe injury.
Twenty years ago, the introduction of locked intramedullary nailing revolutionized the treatment of femoral and tibial shaft fractures. The use of load-sharing intramedullary nails that were inserted with a closed technique decreased blood loss while preserving the surrounding soft-tissue envelope, which substantially decreased the risk of contamination at the fracture site. The technique also allowed early patient mobilization and protected weight-bearing, thereby reducing the duration of hospitalization.
The recent introduction of a new generation of locking plates holds great promise for improving the treatment of selected periarticular, metaphyseal, periprosthetic, and osteoporotic fractures and nonunions. Locking plates, inserted either percutaneously or through open incisions, dramatically increase fracture stability, allowing earlier joint mobilization and rehabilitation of the injured limb. With this method of treatment, fixation failures and subsequent loss of reduction may be diminished. Recent studies in which the LISS plating system (Synthes) was used to treat supracondylar femoral and proximal tibial fractures have shown improved outcomes compared with other methods of treatment. From this experience, typical small and large-fragment plates have been modified to allow a conventional or locking screw to be inserted.
Several single-center and multicenter studies are underway to investigate the mechanical and clinical application of these new locking plates. Hopefully, these studies will lead to improved reduction and fixation techniques for common but difficult fractures, resulting in better clinical and functional outcomes.
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