Search

Navicular stress fractures are multifactorial injuries due to chronic overload on the navicular, particularly in young athletes. The navicular is subject to unique stresses and has a complex blood supply, making it susceptible to stress fractures and potentially delayed union or nonunion. Expeditious diagnosis is critical to prevent a delay in treatment and a poor outcome. Advanced imaging is essential in making the diagnosis and monitoring healing. Both nonsurgical and surgical treatments have demonstrated good results. Nonsurgical management consists of a period of immobilization and nonweight bearing, and surgical management typically involves open reduction and internal fixation. Patients need to be appropriately counseled regarding expectations for these challenging injuries.

Introduction The most feared and challenging complication in treating patients with musculoskeletal trauma is infection after fracture fixation, which can delay healing and, in turn, result in permanent functional loss of limbs or even amputation. Case presentation Here, we describe a case in which a patient presented with stage 4 chronic osteomyelitis on the right tibia and fibula. To treat the late infection by eradicating or reducing the infection, it was recommended to replace the internal fixation with surgical debridement for 6 weeks and antibiotics for 6–12 weeks until the internal fixation device could be removed. Conclusion Delayed union and chronic osteomyelitis are possible complications of IAFF., Highlights • Infection after fracture fixation is the most feared and challenging complication in treating patients with musculoskeletal trauma. • We report the rare case of a male suffering stage 4 chronic osteomyelitis due to Staphylococcus epidermidis. • Disruption of fracture healing is a clinical symptom that often arises in late infections caused by microorganisms such as Staphylococcus epidermidis.

Elastic intramedullary nailing is the main treatment method in the surgical treatment of pediatric forearm fractures. In this study, we compared the clinical outcomes of intramedullary nailing of forearm fractures with leaving the tips exposed and with placing the tip of the nails under the skin. We aimed to present the clinical outcomes of intramedullary nailing and determine the advantages and disadvantages of leaving the tips of the nails exposed. One hundred and ninety-two children with both-bone forearm fracture who were treated with titanium elastic nailing (TEN) in the Department of Orthopedics at Erzurum Regional Training and Research Hospital between January 2009 and December 2016 were included in the study. All cases had been followed up for at least 1 year. The tips of the TENs were left exposed in 74 and buried subcutaneously in 118 children. Union was achieved in all cases. Delayed union was observed in just one case. Skin irritation was observed in 11 (5.7%) of the exposed TEN cases. Superficial infection developed in two (1%) cases with exposed TEN tips. Migration developed during the follow-up of 11 (5.7%) cases with buried tips. The mean time to removal of TEN was 7.9 weeks in cases with exposed and 26.2 weeks in cases with buried cases. Refracture was observed in six buried (3.1%) cases and four exposed TEN (2.1%) cases in the first year after the removal of the nails. Perfect outcomes were achieved in 146 (76%) cases and good outcomes in 36 (19%) cases in our study. On comparing the rate of complications and clinicaloutcomes, leaving the TEN exposed seems to be safe.

Bone grafts are the second most common tissue transplanted in the United States, and they are an essential treatment tool in the field of acute and reconstructive traumatic orthopaedic surgery. Available in cancellous, cortical, or bone marrow aspirate form, autogenous bone graft is regarded as the gold standard in the treatment of posttraumatic conditions such as fracture, delayed union, and nonunion. However, drawbacks including donor-site morbidity and limited quantity of graft available for harvest make autograft a less-than-ideal option for certain patient populations. Advancements in allograft and bone graft substitutes in the past decade have created viable alternatives that circumvent some of the weak points of autografts. Allograft is a favorable alternative for its convenience, abundance, and lack of procurement-related patient morbidity. Options include structural, particulate, and demineralized bone matrix form. Commonly used bone graft substitutes include calcium phosphate and calcium sulfate synthetics-these grafts provide their own benefits in structural support and availability. In addition, different growth factors including bone morphogenic proteins can augment the healing process of bony defects treated with grafts. Autograft, allograft, and bone graft substitutes all possess their own varying degrees of osteogenic, osteoconductive, and osteoinductive properties that make them better suited for different procedures. It is the purpose of this review to characterize these properties and present clinical evidence supporting their indications for use in the hopes of better elucidating treatment options for patients requiring bone grafting in an orthopaedic trauma setting.

NSAIDs inhibit osteogenesis and may result in delayed union or nonunion. The purpose of this meta-analysis was to determine whether their use leads to delayed union or nonunion.We systematically reviewed the literature reporting the effect of NSAIDs on bone healing. We included studies of pediatric and adult patients NSAID exposure and healing bone. The outcomes of interest were delayed union, nonunion, or pseudarthrosis with at least six months of follow-up. A maximum likelihood random-effects model was used to conduct meta-analysis and meta-regression.NSAID exposure increased delayed union or nonunion (odds ratio [OR], 2.07; confidence interval [CI], 1.19 to 3.61). No effect was noted in pediatrics (OR, 0.58; CI, 0.27 to 1.21) or low dose/short duration of exposure (OR, 1.68; CI, 0.63 to 4.46).Analysis of the literature indicates a negative effect of NSAIDs on bone healing. In pediatric patients, NSAIDs did not have a significant effect. The effect may be dose or time dependent because low-dose/short-duration exposure did not affect union rates.

Principles of Conservative Management The treatment of most isolated humeral shaft fractures is commonly with a functional orthosis. Indications for functional brace application include closed diaphyseal fractures without marked distraction between the fragments with or without an initial radial nerve palsy. As well, low-grade open fractures without significant soft tissue damage are also suitable for treatment by closed measures. The early introduction of function, especially flexion and active extension of the elbow helps to prevent distraction of the fracture. The functional compression of the soft tissues provided by the brace satisfactorily aligns the fragments in most instances. The brace must be adjustable and tightened with Velcro straps to maintain constant compression of the soft tissues and to prevent distal displacement of the fracture. The compression of the soft tissues by the adjustable brace and the dependency of the extremity encourage the correction of angular deformity. Deformity is more likely to develop in transverse, nondisplaced fractures. As such, patients treated with bracing can expect a possible varus deformity of up to 10 degrees, which is very common. However, valgus and sagittal plane malalignment is rare.1,2 Failure to obtain acceptable alignment of the fragments calls for abandoning the closed functional treatment modality. This includes fractures that present with and maintain a progressive distraction gap that continues to increase despite active range of motion at the elbow. Residual deformity of up to 20 degrees has been noted by most authors to be cosmetically and functionally acceptable. Fracture malalignment greater than 20 degrees is unsatisfactory and an alternative treatment should be undertaken.1

A nonunion represents a significant clinical challenge for the orthopedic surgeon. The classic treatments for delayed union and nonunion are not always successful. Many alternatives and adjuncts to osteosynthesis currently exist, including electrical and electromagnetic stimulation. This review artic

➤ Cigarette smoking decreases bone mineral density and increases the risk of sustaining a fracture or tendon injury, with partial reversibility of these risks with long-term cessation of smoking. ➤ Cigarette smoking increases the risk for perioperative complications, nonunion and delayed union of fractures, infection, and soft-tissue and wound-healing complications. ➤ Brief preoperative cessation of smoking may mitigate these perioperative risks. ➤ Informed-consent discussions should include notification of the higher risk of perioperative complications with cigarette smoking and the benefits of temporary cessation of smoking.

Durability of plate fixation is important in delayed union. Although locking plates result in stronger constructs, it is not known if locking affects the fatigue life of a plate. Two locking screws on either side of the nonunion could decrease working length and increase strain in the plate. However, the reinforcing effect of the locking head on the plate may compensate, so that it is unclear whether locking reduces fatigue life.We determined whether locking screws, compression screws, and locking buttons reduce or increase the fatigue life of a plate.We tested fatigue life of four constructs using an eight-hole locking plate in a segmental defect model: (1) all locking screws (Locked; n = 5); (2) all compression screws (Unlocked; n = 5); (3) six compression screws with two locking buttons in the central holes (Button; n = 6); and (4) six compression screws with two open central holes (Open; n = 6).The Button group had the longest fatigue life (1.3 million cycles). There was no difference between the Locked and Unlocked groups. All of the constructs failed by fracture of the plates through a screw hole adjacent to the defect.Locking screws did not improve fatigue life, however a locking button increased the fatigue life of a locking plate in a segmental bone defect model.Locking buttons in holes adjacent to a defect may improve durability, which is important when delayed union is a possibility.

Cigarette smoking inhibits fracture healing and places the patient at a higher risk of delayed union and nonunion. Nicotine has been implicated as the primary ingredient responsible for these effects. However, an analysis of current published investigations reveals conflicting data, with some evidence that nicotine alone does not significantly affect healing. We undertook an animal study of the effects of transdermal nicotine on fracture healing.Twenty-two adult male New Zealand white rabbits were randomly assigned to the nicotine group or the control group. A midshaft tibial osteotomy was performed on the left tibiae of all 22 rabbits. The nicotine rabbits were exposed using a 10.5-mg transdermal patch applied daily to the ear. Radiographs were obtained, and the area of fracture callus was assessed. Rabbits were euthanized at 21 days. Fractures were stressed to failure, and load/deformation curves were recorded.The average area of callus formation was greater in the control group (0.158 cm, Nicotine: 0.124 cm), but the difference was not statistically significant (P = 0.30). There was a significant difference between the 2 groups for mean normalized torque to failure (Nicotine: 36% of nonfractured side,69% of nonfractured side, P = 0.028). The control group mean normalized stiffness was significantly greater than that for the nicotine rabbits (87%, Nicotine: 43%, P = 0.036). There were 3 nonunions in the nicotine group (27%) compared with none in the control group (P = 0.062).In a rabbit model of fracture healing, transdermal nicotine exposure resulted in decreased mechanical strength of healing fractures at 21 days and a higher rate of nonunion at 21 days compared with that of controls.

BACKGROUND Despite technical advances, nonunion or delayed union remains an important clinical problem when segmental allografts are used to repair diaphyseal defects after bone tumor resection. Using an ovine rib model, the authors studied whether the addition of a vascularized periosteum or bone flap improved healing compared with a segmental allograft alone. METHODS A 4-cm segment of rib was resected from four consecutive ribs of 15 sheep. Three different reconstructions were compared within the same sheep: allograft alone, allograft and vascularized periosteum, and allograft and vascularized bone. One defect was not reconstructed and served as a control. Five sheep were humanely killed at each of the following time points: 9, 12, and 15 weeks. The host-allograft junctions were analyzed using plain radiographs, micro-computed tomography, and histologic examination. RESULTS Micro-computed tomographic analysis showed significant improvement with each reconstruction technique over time. Plain radiographs and histologic analyses demonstrated earlier bridging of the host-allograft junction when either vascularized periosteum or vascularized bone was used compared with allograft alone. CONCLUSION Use of vascularized periosteum or bone may facilitate healing of the host-allograft junction after intercalary allograft reconstruction.

My part in this symposium is to discuss the end results of fractures of the femur. In order to gain the proper perspective, I have reviewed the literature of the past five years and have carefully, with the assistance of Dr. J. I. Mitchell, studied the records of 222 consecutive cases in the Mayo Clinic. The literature on the subject is so abundant that I shall not attempt to discuss it, but proceed at once with the discussion of data concerning the patients who have been under our care. Fifty-seven of the 222 patients had sustained fractures recently; the remaining 165 presented the end results of treatment which they had received elsewhere. These patients came to the Clinic because of malunion, delayed union, nonunion, chronic osteomyelitis, stiff joint, and so forth.

BACKGROUND: We are aware of no reports on the surgical results of posterior lumbar interbody fusion in elderly patients. The purpose of this study was to investigate the clinical and radiographic results of posterior lumbar interbody fusion with pedicle screws in patients older than seventy years of age and compare them with results in younger patients. We also investigated the association between the clinical and radiographic results. METHODS: The study included 101 patients who had been followed for at least three years after posterior lumbar interbody fusion with pedicle screws for the treatment of L4-L5 degenerative spondylolisthesis. The average follow-up period was fifty months. The patients were divided into two groups according to their age at the time of the operation: Group 1 included thirty-one patients who were seventy years of age or older (average age, seventy-four years) at the time of the operation, and Group 2 included seventy patients who were less than seventy years old (average age, fifty-nine years). Preoperative and postoperative status (according to the Japanese Orthopaedic Association scoring system) and postoperative complications were compared between the two groups. Postoperative radiographic features, including fusion status and segmental lordosis, were also examined. RESULTS: No significant differences in preoperative and postoperative scores were observed between the two age groups, with the numbers available. General complications were found in Group 1. However, the prevalence of adjacent segment degeneration in Group 1 was lower than that in Group 2. The radiographic results revealed no significant difference in the prevalence of segmental lordosis, with the numbers available. There was no nonunion in either group. Although the prevalence of either collapsed union or delayed union in Group 1 was significantly higher than that in Group 2 (p = 0.034), the fusion results such as union in situ, collapsed union, and delayed union did not appear to affect the postoperative clinical results in this study. CONCLUSIONS: No obvious differences in the clinical results were observed between the age groups with the numbers available. Postoperative adjacent segment degeneration was less frequent and collapsed union and delayed union were more common in the elderly group. The fusion results did not appear to affect the postoperative clinical results in this study. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence. ORIGINAL ABSTRACT CITATION: “Surgical Outcomes of Posterior Lumbar Interbody Fusion in Elderly Patients” (2006;88:[2714-20][1]). [1]: /lookup/volpage/88/2714

Osteoarticular allografts can be used for limb reconstruction following tumor excision. Most commonly, the distal femur, proximal tibia and distal radius have been studied, while distal tibial allografts receive only sporadic mention in the literature. We evaluated the functional outcomes of distal tibial allografts used in tumor reconstruction. Following FDA guidelines and using a questionnaire, we surveyed operating surgeons on the outcomes of 29 distal tibial allografts used to reconstruct osseous defects secondary to benign and malignant tumors. Twelve patient questionnaires were returned revealing nine complications in eight patients. These included nonunions (three), fracture (two), arthrosis (two), and delayed union (two). There were no reported infections. Two patients died of their disease. The average rating using the Musculoskeletal Tumor Society (MSTS) score was 67.3%. The 10 living patients had an average rating of 72.4%. Distal tibial osteoarticular allografts offer acceptable functional results when used in tumor reconstruction. Difficulties achieving union (delayed or nonunion) between the host and the graft appears the most common complication of this technique.

I am both honored and delighted to be here today. Whatever contributions that I have made to the American Academy of Orthopaedic Surgeons (AAOS) would have been impossible without a serious commitment—my wife's. With a professional plate fuller than my own and with the daunting responsibility of raising our three teenage daughters, she has nevertheless encouraged and supported me in my Academy activities. Marybeth, thank you. I would also like to thank you, the Academy fellowship, for giving me the privilege to serve as President. The last two years have been incredibly interesting and challenging, and I have no doubt that this next year will be even more so. My story of involvement in this remarkable organization is probably quite similar to many of yours. Nearly twenty years ago, when I was a fledgling academician, I was unexpectedly asked to serve on a task force of the Committee on Trauma. The United States Food and Drug Administration had approached the Academy to assist the government in defining what was a delayed union and what was a nonunion of a fracture. These definitions would be used in deciding when the federal government approved and funded the use of various electrical stimulation devices. The governmental agencies consulted the Academy—not scientific articles or textbooks, not industry sources, not their in-house consultants—but the Academy, since we were viewed as the source of expert opinion and musculoskeletal knowledge. Chaired by Mike Chapman and assisted by a well-prepared staff, the task force deliberated for an entire day. While the group reached its conclusions, the real value of the exercise emerged. The task force of orthopaedic surgeons unselfishly volunteered their experience, time, and analytical skills to the Academy to further our knowledge and understanding of an important subject. What drove the process was the unrelenting desire to …

During the past two decades, a number of physical modalities have been approved for the management of nonunions and delayed unions. Implantable direct current stimulation is effective in managing established nonunions of the extremities and as an adjuvant in achieving spinal fusion. Pulsed electromagnetic fields and capacitive coupling induce fields through the soft tissue, resulting in low-magnitude voltage and currents at the fracture site. Pulsed electromagnetic fields may be as effective as surgery in managing extremity nonunions. Capacitive coupling appears to be effective both in extremity nonunions and lumbar fusions. Low-intensity ultrasound has been used to speed normal fracture healing and manage delayed unions. It has recently been approved for the management of nonunions. Despite the different mechanisms for stimulating bone healing, all signals result in increased intracellular calcium, thereby leading to bone formation.

Fracture-healing slows with age. While six-week-old rats regain normal bone biomechanics at four weeks after a fracture, one-year-old rats require more than twenty-six weeks. The objective of this study was to examine the possible role of altered mRNA gene expression in this delayed union.Closed midshaft femoral fractures were created in six-week-old and one-year-old Sprague-Dawley female rats. The animals were killed at zero-time (unfractured) or at 0.4, one, two, three, four, or six weeks after the fracture. mRNA levels were measured by reverse transcription-polymerase chain reaction in the fracture callus for twenty-seven matrix, cytokine, and cytokine-receptor genes for the seven animals per time-point per age-group.The younger rats healed radiographically by four weeks after the fracture, whereas none of the older rats had healed by the sixth week. Despite the difference in healing rates, the levels of mRNA gene expression, in general, followed the same pattern in both age-groups. The mRNA expression levels increased to a peak at one to two weeks after the fracture and then decreased to very low or undetectable levels at four and six weeks after the fracture for both age-groups. Significantly lower levels of mRNA for Indian hedgehog (Ihh) and bone morphogenetic protein-2 (BMP-2) were detected in the fracture calluses of the older rats (p0.01 and p0.05, respectively).All genes studied were up-regulated by the fracture in both age-groups. Thus, the failure of the older rats to heal promptly was not due to the lack of expression of any of the studied genes. The increase in mRNA for Ihh and BMP-2 in the older rats was smaller than that in the younger rats, which may contribute to slower fracture repair. The return of mRNA gene expression to baseline in the older rats prior to healing may contribute to the delayed union. The slower healing response of the older rats did not stimulate a negative-feedback increase in the mRNA expression of stimulatory cytokines.

Although fractures of the radial head traditionally are not associated with healing problems, delayed union and nonunion are being seen more frequently after operative and nonoperative treatment. Given the tenuous blood supply to the head of the radius, problems with healing are not surprising. As the current review of five patients with nonunion of nonoperatively treated radial head fractures treated during a 6-year period shows, healing problems rarely are symptomatic and often may go unrecognized. Even when the fracture still is apparent on radiographs obtained more than 1 year after the injury, healing still may occur. Operative treatment, although rarely necessary, achieved union in one of the current patients.

The treatment of delayed unions, malunions, and nonunions requires restoration of alignment, stable fixation, and in many cases adjunctive measures such as bone-grafting or use of bone-graft substitutes.Bone-graft materials usually have one or more components: an osteoconductive matrix, which suppor

Fracture repair is a complex, specialized process whereby bone regenerates to restore pre-injury function to the skeleton. Despite successful healing in the majority of cases, a significant number of fractures require further treatment for delayed union or nonunion. As our knowledge of the molecular mechanisms that govern fracture repair continues to improve, new strategies for developing biologically based therapies will follow. This review examines the molecular aspects of adult skeletogenesis.

Objective: To determine whether poorly healing tibial shaft fractures exhibit a serological response of bone-specific alkaline phosphatase (BsALP), collagen I carboxy-terminal propeptide (PICP), collagen III amino-terminal propeptide (PIIINP), and collagen I carboxy-terminal telopeptide (ICTP) different from that of normally healing fractures. Design: Prospective. Participants: Twenty consecutive patients with isolated tibial shaft fractures with or without fracture of the fibula. Main Outcome Measurements: Assays of BsALP, PICP, PIIINP, and ICTP were performed with serum samples taken at standard intervals from twenty-four hours to twenty weeks after fracture. Fracture healing was assessed at five, ten, fourteen, and twenty weeks for clinical and radiological evidence of union. Results: Seventeen fractures united within the twenty-week study period. The three fractures exhibiting delayed union demonstrated significantly lower PICP levels and marginally lower BsALP levels at twenty weeks. PIIINP levels were significantly higher in these three fractures at ten weeks. There was no difference in ICTP between the seventeen united and the three un-united fractures. Conclusions: This study identified three serological features of a poor healing response in tibial shaft fractures. First, matrix collagen I and III production in the first ten weeks of healing was adequate, with evidence of significantly increased production of type III collagen. Second, there was no serological evidence of a deficient osteoblast response, as indicated by normal levels of BsALP and PICP, during this early period. Third, evidence of a deficient osteoblast response appeared only at twenty weeks after injury.

Laboratory and clinical scientists and practicing clinicians need definitions of union, delayed union, and nonunion. Fracture union is a gradual process, so quantitative measures are the most meaningful. However, end point definitions also are useful, but they need empirical validation. The measure that has received the best validation in human fractures is bending stiffness. Quantitative radiologic assessment of healing is difficult because varying patterns of bone bridging can occur, including periosteal, endosteal, and intercortical patterns. Natural fracture healing was studied in 43 cases of isolated, closed, conservatively treated tibial shaft fracture with serial measurements of bending stiffness and standard radiographs. Three healing groups were defined on the basis of stiffness recovery patterns. Four cases showed delayed union, defined as failure to reach a stiffness of 7 N-m per degree by 20 weeks from fracture. The remaining cases had normal union, but at differing rates. Callus index was used as a measure of periosteal new bone formation. Stiffness measurements correlated more strongly than callus index with injury severity and functional outcome at 6 months. However, the callus index predicted behavior in those fractures that showed no tendency to heal at the 10-week stage. That is, absence of periosteal new bone in these cases presaged delayed union. These delayed union cases all eventually healed, still without producing periosteal callus, but other fractures in the series healed very rapidly, also without periosteal callus. The implication is that endosteal healing is capable of very rapid fracture bridging if conditions are right, but it also can occur late, after the periosteal healing response has ceased. These observations suggest a more rational approach to the definition of union, delayed union, and nonunion than that provided by the selection of arbitrary times. For conservatively treated fractures at least, delayed union can be defined as the cessation of the periosteal response before the fracture successfully has been bridged. Nonunion is the cessation of both the periosteal and endosteal healing responses without bridging.

This study was performed to compare the effects of direct current with ultrasound on fracture healing. Thirty-two rats were subjected to the experiment. Each rat's right legs were used as the experimental sample, and their left legs were used as the control. Four groups were formed, each consisting of 16 ultrasound, 16 electrostimulation, 16 ultrasound control, and 16 electrostimulation control animals. Fibular osteotome was applied to the rats under anesthesia. In the electrostimulation and electrostimulation control groups, a stainless steel cathode electrode was installed in the fractured side. In the electrostimulation group, 10 microA of direct current for 30 min, using a semi-invasive method, was given one day after fracture, for 15 days. On the control side, the aforementioned protocol was followed but sham treated. The ultrasound group was treated with 0.1 W/cm2 ultrasound for 2 min every second day for 6 days after fracture (4 times). Rats were killed on the 7th and 14th days to investigate the macroscopic, radiologic, and histopathologic parameters of fracture healing. There was a difference (P < 0.05) between the electrostimulation and the electrostimulation control groups on the 7th day. There was a difference (P < 0.05) between the ultrasound and ultrasound control groups on the 14th day. After statistical evaluation of the experimental results, it was found that in both the ultrasound and the electrostimulation groups, the fracture healing had been accelerated more so than in the control groups. There was no observed statistical difference between ultrasound and electrostimulation effects.

External fixation was compared to crossed Steinman pins and plaster for fixation after osteotomy about the knee in children. A group of 26 patients treated by external fixation was compared to a control group of 26 patients fixed with crossed Steinman pins and casting. The groups were matched for age, height, and weight. Overall there was a 100% union rate. Preoperative deformity and postoperative correction were similar in the two groups. The time to union was significantly longer, and there were significantly more complications in the external fixator group. There were 16 complications (62%) in the external fixator group and five (19%) in the control group. Complications included pin tract infections, peroneal nerve palsy, and delayed union. External fixation provides certain advantages for fixation after osteotomies about the knee in children but is associated with a variety of complications.

Methylmethacrylate has been used as an external fixator on 52 bones in 36 children and adolescents. There were 36 osteotomies and 16 selected fractures of long bones. The application of the acrylic cement onto 229 half-pins was performed with the use of flexible plastic tubes, in all but two patients. Union in the desired position was achieved in 51 bones. Delayed union occurred in one and required internal fixation. In the rest of the cases, there were only a few minor complications. The methylmethacrylate appears to be a stable fixator for osteotomized and fractured bones in young patients. The method is practical, easily performed, and of low cost.

Introduction In adult phalanx fractures with delayed union, we obtained good results from low-intensity pulsed ultrasound (LIPUS) fracture treatment. Methods The subjects were 10 patients (7 male and 3 female) presenting with adult phalanx fracture with delayed union. The average age was 38.3-year-old. Eight cases presented with distal phalanx fracture and 2 with proximal phalanx fracture. Six cases involved a closed fracture and 4 cases an open fracture. The average LIPUS start time was 3.1 months, and the average treatment period was 5.1 months. Results Bone union was obtained in 9 cases (90%). The single case in which bone union was not obtained involved nail deficient severe open fracture. The ratios of joint range of motion on the other side were 50%-100% (average 78.5%). Although a mild skin disorder was seen on the LIPUS treatment site in one case as a complication, it was effectively treated by medication. Discussion LIPUS demonstrated significant effects in adult phalanx fractures when the maximum gap was small. We saw a bone union 90% of the cases without additional surgery, and confirmed the validity of LIPUS.

Although recombinant human bone morphogenetic protein-2 (rhBMP-2) is approved for treatment of open tibial fractures and anterior lumbar interbody fusion, off-label use has been associated with complications such as local inflammation, osteolysis, and dysphagia. This case report describes a patient treated with rhBMP-2 for an atrophic delayed union of a clavicular fracture who subsequently developed a profound motor and sensory brachial plexopathy.Use of rhBMP-2 near peripheral nerves may cause neuropathy. This should be considered prior to its use in surgical sites with peripheral nerves in proximity.

Case: In recent years, atypical femoral fractures (AFFs) associated with bisphosphonate use have increasingly been reported, but current definitions limit their diagnosis to native femora. Atypical periprosthetic fractures are rare. We present a case of a Vancouver type-C periprosthetic fracture that was recognized as an AFF following nonunion. Conclusion: Bisphosphonate-associated AFFs can present as periprosthetic fractures. Delayed recognition of the role of bisphosphonates in a periprosthetic fracture may lead to a worse outcome, including a delay in diagnosis, delayed union, and failure of fixation.

Extracorporal shock wave therapy (ESWT) has been postulated as an additional therapeutic option in nonunion after fracture treatment. We have reexamined patients with nonunions treated at our institution to evaluate the efficacy of the method. In a prospective nonrandomized study patients were investigated with a minimum duration of nonunion of 6 months. Following 2 cycles of ESWT with 2000 impulses/18 kV, the reevaluation was performed at 1, 3 and 6 months after treatment. A total of 27 pseudarthroses was reevaluated, in 11 one or more reosteosyntheses had been performed prior to ESWT. Following ESWT we found a success rate of 41 % (n = 11). The clinical evidence of subjective, clinical improvement was found in 5 of these patients within 1 month, in all of these patients within a period of 3 months. Radiologic evidence of improvement occurred in none of these patients within 1 month, in all of these patients within 6 months. ESWT appears to represent an additional treatment option in patients with longstanding nonunion. If no improvement occurs, the maximum delay of reosteosynthesis is three months.

The prevalence of implant failure in small diameter tibial nails has not been well characterized. In a series of 130 tibial fractures stabilized with 8-mm and 9-mm nails, implant failure occurred in 18 fractures (13.8%): 4 nails (3%) broke and 16 (12.3%) screws failed. All nail failures occurred in open, unstable fractures with delayed union, and all of the nails that broke were dynamically locked during the failure. Of the 130 fractures, 128 (98.5%) eventually united. Delayed union, degree of comminution, metaphyseal location, and dynamic locking of unstable fractures contribute to hardware failure. Based on these findings, dynamization could be used to treat delayed union only in axially stable diaphyseal fractures. Exchange nailing is recommended to treat delayed union in comminuted or metaphyseal fractures to prevent hardware failure. Bone grafting should be performed at 6 to 12 weeks for fractures with > 50% bone loss.

One hundred thirty-four acute unstable fractures of the tibia were treated with a reamed intramedullary nail with locking capabilities. There were 101 closed and 33 open fractures (20 Grade 1 fractures, 12 Grade 2 fractures, and 1 fracture from a gunshot wound). Patients were seen in followup for an average of 16 months after nailing. The time to fracture union averaged 28 weeks in closed fractures and 39 weeks in open fractures. Delayed union (> 6 months) developed in 14 fractures (8%): 11 closed (11%) and 3 open (9%) fractures. Eleven of the 14 delayed unions healed spontaneously, or after dynamization of statistically locked nails. Seven fractures (5%) were not healed by 9 months and were classified as nonunion (2 closed, 5 open). All fractures required major additional procedures to obtain union. Infection developed in 13 fractures (10%). In closed fractures, there were 2 superficial (2%) and 3 deep (3%) infections; in open fractures there was 1 superficial (3%) and 7 deep (21%) infections. The authors conclude that reamed intramedullary nails should be restricted to unstable, closed tibial shaft fractures. Its use in open fractures even on a delayed basis cannot be recommended because of unacceptably high infection rates.

Between February 1988 and May 1989, 17 consecutive patients with 18 tibial fractures were treated using the Ilizarov method and apparatus. Injuries included four closed fractures and 14 open fractures. There were three Grade I open, four Grade II open, and seven Grade III open tibial fractures. Indications for application of the Ilizarov frame included fractures that were determined to need surgical management primarily, or fractures that had failed to heal by other treatment methods, either operative or nonoperative. Patients averaged 17.7 months of follow-up treatment. One patient was lost to follow-up treatment after the fracture healed and the device was removed. To date, all fractures are healed. There was one delayed union, which subsequently healed with a second application of the device. Complications included two late wound infections, both in Grade III open fractures. These occurred after removal of the Ilizarov apparatus. The average time from application of the device to complete fracture healing was 5.6 months, with a range of 3.25 to 13 months. This compares favorably with the results described for other treatment modalities. These results indicate that the Ilizarov method is indeed a useful adjunct in the orthopedic armamentarium for the treatment of either open or closed tibial fractures. No practical contraindications to the use of the Ilizarov device in the management of tibial fractures were encountered.

A ten-year clinical and roentgenographic review was conducted on the patients in the original Australian multicenter trial that evaluated use of an implantable bone growth stimulator for delayed union and nonunion. Of the original 81 patients, 38 patients were located, seven patients had died from unrelated causes, and 36 were unlocatable. Of the 38 patients located, 37 patients (representing 38 fractures) participated in a detailed clinical review and had a roentgenographic assessment. All fractures had remained united, and normal bone remodeling had occurred. There were no adverse effects of the generator or cathode wire. Six patients initially reported as failures had healed after further surgical intervention. Thus, normal osteogenesis occurs in association with electrical stimulation using an implantable bone growth stimulator. This ten-year review supports the long-term safety and effectiveness of this technique in treating nonuniting fractures.

Lateral condylar fractures of the humerus in children are common injuries that can lead to many potential complications if not treated appropriately. Displaced fractures require open reduction and internal fixation. Undisplaced fractures can be treated nonoperatively in casts, but they must be watched closely for signs of delayed union. Nonunion of a lateral condylar fracture, although uncommon, can be very difficult to manage successfully. If a nonunion is diagnosed early, open reduction, internal fixation, and grafting are recommended. Early signs of tardy ulnar nerve palsy should be treated by ulnar nerve transposition.

Twelve stress fractures of the pubic arch were seen in eleven patients who were joggers, long-distance runners, or marathoners. In two of the fractures there were complications of healing; that is, delayed union or refracture. With two exceptions, the lesions occurred in women between the ages of nineteen and forty-eight. In all of the patients the fracture was in the inferior pubic ramus near the symphysis pubis, and caused pain in the groin, buttock, or thigh. All fractures were non-displaced and easy to overlook on the initial radiographic examination; when a fracture of the pubic arch was clinically suspected but the radiographs were normal, a radionuclide bone scan was diagnostic. After identification of the fracture, running had to be curtailed until the symptoms disappeared in order for healing to occur.

Thirty-seven (20 per cent) of 186 children who had myelomeningocele whose records were reviewed had sustained a total of seventy-six fractures. The frequency with which the fractures occurred was related directly to the level of neurological involvement. Thirteen (41 per cent) of the patients who had involvement at the thoracic level, fifteen (36 per cent) who had involvement at the upper lumbar level, eight (10 per cent) who had involvement at the lower lumbar level, and one (3 per cent) who had involvement at the sacral level sustained fractures. Sixty-five (86 per cent) of the fractures occurred before the child was nine years old, fifty-eight (76 per cent) were judged to be secondary to the limb being in a cast, and seventy-four (97 per cent) involved the lower extremity. Eleven patients, all of whom had thoracic or upper lumbar involvement, sustained fractures of multiple extremities. All fractures of the lower extremity were distal to the level of neurological involvement; they occurred predominantly in the femur in patients who had thoracic involvement and in the tibia in patients who had lumbar involvement. All of the metaphyseal and diaphyseal fractures healed satisfactorily, whether they were treated by immobilization in a plaster cast or in a bulky Webril dressing, although there were fewer complications in the latter group. The seven fractures that involved the physeal plate were a major problem, as three (43 per cent) had delayed union and two (29 per cent) developed premature growth arrest.

Between 1966 and 1975, we performed a fusion of the hip by the Thompson method in fifteen children with non-tuberculous, non-paralytic conditions. An attempt was made to position the hip in 30 degrees of flexion, neutral rotation, and neutral abduction. Fourteen patients were followed for an average of 4.5 years (range, one to ten years) postoperatively. A fibrous pseudarthrosis developed in one patient. The remainder had solid arthrodeses. None had delayed union. At follow-up, all patients were free of pain and had returned to normal activities. There was no significant increase in adduction with growth.

Nonunion occurs in less than 1% of phalangeal fractures. Despite this rarity we have accumulated a series of 14 proximal and middle phalangeal delayed unions, nonunions, and malunions. All patients but 1 were initially treated by a physician other than the senior author. All patients developed loss of active motion following their primary treatment. Secondary treatment was by open reduction and internal fixation with Kirschner wires. The mean and median total active motion before secondary treatment were 130 and 90 degrees, respectively. Following secondary treatment, the total active motion increased significantly (p less than 0.05) to a mean of 215 degrees and a median of 255 degrees. We recommend secondary treatment of delayed union, nonunion, and malunion of phalanges of the hand. Open reduction and internal fixation followed by early (two to three weeks) active motion leads to a significant improvement in finger function.

In this paper we document seventy fractures of the humeral shaft that were treated by intramedullary fixation between 1970 and 1981. Complications developed in forty-seven (67 per cent) of the fractures, and forty-five (64 per cent) required at least one additional operative procedure. Of the sixty fractures that were internally fixed within six weeks after injury, nine (15 per cent) had a delayed union and five (8.3 per cent) had a non-union, two of which persisted despite subsequent surgery. Three of the ten fractures that were internally fixed more than six weeks after injury never united despite additional procedures that were done to secure union. Delayed union and non-union were more common in open fractures (33 per cent) than in closed fractures (21 per cent), and with open reduction (39 per cent) than with closed or so-called semi-open reduction (9 per cent). Deep infection occurred in three (5 per cent) of the fractures and was more common in open (17 per cent) than in closed fractures (2 per cent). One of the three open fractures that were treated by immediate fixation became infected, as compared with only one of the nine open fractures treated by delayed fixation. Painful adhesive capsulitis of the shoulder developed in thirty-four (56 per cent) of the patients who had fractures treated with distally directed pins, but motion of the elbow was not restricted in the nine patients with fractures treated with proximally directed pins.

Closed Ender nailing was used in sixty fractures of the femoral shaft. Follow-up examination in fifty-two cases is reported. There were only two failures of the method, both in fractures with supracondylar extension. Simple transverse and short oblique fractures and those with unicortical comminution were shown to be stable after nailing, while long oblique fractures and lesions with bicortical comminution had a tendency to shorten and often required cerclage wiring, cast-bracing, or traction. The average hospital stay was 23.7 days. The operations were simple and quick. There was one case of osteomyelitis, one of clinically apparent thrombophlebitis, and one of fat-embolism syndrome in a patient with multiple fractures and multisystem injuries. There were no cases of breakage of the nail, delayed union, or non-union. In most cases knee motion returned to the preinjury level, although in five knees removal of the nails was necessary. The two failures of nailing which required plate fixation occurred in fractures extending into the supracondylar region. Therefore, these fractures are not suitable for Ender nailing.

Twenty-one patients with isolated avulsion fracture of the tibial attachment of the posterior cruciate ligament were treated in our hospital during the period 1965 to 1976. Twelve of the patients had fresh injuries and nine, injuries with delayed union or non-union. Twelve of the twenty-one patients were treated conservatively and nine, by surgical repair by means of staple fixation. Detachment of the posterior horn of the meniscus with an avulsed and displaced bone fragment was found in five of the nine patients operated on. All the patients were followed for an average of four years and eight months. Satisfactory results were obtained in every instance.