Femoral fractures are one of the commonest fractures encountered in orthopaedic practice. Over the years, treatment of this injury has evolved tremendously. The initial non-operative methods of reduction and stabilization have largely been replaced by operative fixation. There are currently three basic modes of internal fixation of femoral diaphyseal fractures in the adult age group: plate and screws, intramedullary Kuntscher nailing, and interlocking nailing. The objective of this study is to determine whether the so-called more ‘technologically advanced’ interlocking nailing results in better outcome compared to the more ‘traditional’ plate and screws, and Kuntscher nailing. It is found that, in terms of time to union and final function after an average of just under 2 years post-operative period, the group of patients who had interlocking nailing fared poorer. A review of relevant literature will then be presented.
In comminuted patellar fractures, a combination of cerclage wiring and tension band fixation is said to provide good mechanical stability. This is a retrospective review of four patients treated with this method. All fractures described herein were classified as 45-C3 (based on Orthopaedic Trauma Association classification) and were fixed with a 1.25mm cerclage wire and tension band wire proximally looped through the quadriceps tendon and distally through the patellar ligament in a figure-of-eight configuration. The average follow-up period was 10 months. The Activity of Daily Living Scale (ADLS) of the Knee Outcome Survey was used to assess symptoms and functional capability of the knee. In all the cases, fracture union was achieved at an average of 11 weeks. The average ADLS score was good (92.5 %). Full range of knee motion was achieved by end of the third postoperative month. None of the patients had complications, such as infection and implant failure.
Maxillofacial trauma in children is not common worldwide. Domestic injuries are frequently seen in younger children while older children are mostly involved in motor vehicle accidents (MVA). The objective of this study was to analyze the pattern of maxillofacial injuries in pediatric patients referred to three government main hospitals in different areas of West Malaysia.
Matched MeSH terms: Fracture Fixation, Internal/statistics & numerical data
Reduction of a malunited femoral diaphyseal fracture can be achieved by osteotomy and immediate internal fixation or gradual skeletal traction followed by delayed internal fixation. We retrospectively reviewed 27 patients with malunited and shortened femur. Nine patients with mean shortening of 4.7 cm (2.5-10.0) underwent acute one-stage reduction and gained 2.5 to 5.0 cm length. Eighteen patients with mean shortening of 5.3 cm (3.5 to 9.0) underwent twostage reduction and gained 2.0 to 5.0 cm length. There was no paralysis in either group. No infection occurred in the one-stage procedure. Intramedullary fixation demonstrated superior results compares to plate fixation.
Treatment of radius or ulna nonunion requires both osteogenic environment and mechanical stability. We would like to report three radial and six ulnar diaphyseal nonunions treated with 3.5 mm locking compression plate (LCP) fixation. To assess the effectiveness of 3.5 mm LCP in treating diaphyseal nonunion of the forearm bones, we prospectively reviewed nine patients with the mean age of 33 years with diaphyseal nonunion of the radius or ulna. All patients were treated with 3.5 mm LCP. Bone grafting was only performed for atrophic nonunion. Surgical and functional outcome were evaluated. There were three atrophic nonunion of the radius, four atrophic nonunion of the ulna and two hypertrophic nonunion of the ulna. All nonunion united successfully with satisfactory functional outcome. 3.5 mm LCP is effective in the treatment of nonunion of ulna or radius.
Fracture of the femur is most commonly treated with interlocking nailing. We conducted this study to describe and analyze the size of femoral interlocking nails used in our local population. This is a retrospective study on reamed intramedullary interlocking nailing procedures performed between 1st July 1998 and 30th June 2003. Demographic data, the diameter and length of femoral nails used were obtained from patient's medical record. A total of 267 procedures were included. The most common diameter used was 10 mm (56.9%), followed by 11 mm (27.0%) and 12 mm (13.1%). Only 2.6% of the nails were less than 10 mm in diameter. The most common nail length was 38 cm (31.1%), followed by 36 cm (24.9%) and 40 cm (19.5%). The longest nail used was 46 cm while the shortest 32 cm. The most commonly used femoral nails were of 10 mm diameter with the length ranging from 36 to 40 cm, which is smaller than those reported in the English literature. Nails with diameter smaller than 10 mm were required in 2.6% of patients.
In this issue of the Journal, there are two articles addressing relevant clinical problems that we may encounter in our practice. The main issue related to the occurrence of the inevitability of the avascular necrosis (AVN) following treatment of two different major types of capital femoral epiphyseal 'injury'.
Trend towards changing the face of management for pediatric femoral fractures tends to advocate operative treatment. This study was undertaken to review our current practice in the wake of recent progress in the management of pediatric femoral fractures. Fifty patients with femoral diaphyseal fracture treated in Sarawak General Hospital were reviewed retrospectively after an average follow-up of 2.6 years. There were 36 boys and 14 girls, with a mean age of 6.2 years (range five months to 14 years). Children under six years of age constituted the majority of the patients. Half of the fractures were caused by road traffic accident. Nine patients had associated injuries. The most common site of fracture was at the middle third (N=31). The treatment regimens were delayed hip spica (DHS) in 16, immediate hip spica (IHS) in 24, plate osteosynthesis (PO) in five, titanium elastic nailing (TEN) in five, and external fixation (EF) in one. The minimum hospital stay was two days, and the maximum 33 days (mean, 9.7 days). Malunion was the commonest complication. Conservative treatment is the preferred option for children under six years of age. It is cost-effective with minimal complication. The other treatment options are reserved for specific indication in older children. Diaphyseal fractures of the femur in children can be adequately managed non-operatively.
Slipped capital femoral epiphysis (SCFE) is a relatively uncommon hip disorder in adolescents and its prevalence in Malaysia has not been studied. This retrospective study is undertaken to provide an overview of a 12-year review of SCFE treated in our institution. Fourteen patients (19 hips) with slipped capital femoral epiphysis (SCFE) admitted to Hospital UKM from 1990 to 2002 were reviewed with respect to demographic profile, functional outcome according to the Iowa Hip Score, and complications. There were ten boys (average age, 12.5 years) and four girls (average age, 12 years). Eight were Malays and six were Indians. The average body mass index was 26.1 verweight). The left hips (11 hips) were affected more than the right hips (eight hips). Five patients had bilateral slips. Thirteen hips were considered stable while the other six hips were unstable. The majority of cases were moderate slips (12 hips), four hips had severe slips while three hips had mild slips. Several methods of treatment were instituted. These include in situ cannulated screw fixation (11 hips), Knowles pin fixation (three hips) and gentle closed manipulative reduction with cannulated screw fixation (three hips). One patient with bilateral slips refused surgical treatment. Based on the Iowa Hip Score, most patients (nine) had satisfactory results (excellent or good), three had fair results while one patient had a poor result. Avascular necrosis developed in five hips while chondrolysis occurred in one hip. In situ cannulated screw fixation is the treatment of choice. SCFE is an uncommon condition in Malaysia.
Acute traumatic transphyseal fracture of the capital femoral epiphysis is a rare but serious injury. The injury is typically inflicted by a severe trauma. Because of the vulnerability and predisposed anatomy of the femoral epiphysis in relation to its blood supply, the fracture has been designated to have poor prognosis with inevitable osteonecrosis and eventual deformity of the hip. We report a case of such fracture in a 13-year-old child in view to highlight some of the anticipated problems in the management of such injury.
We report a case of a 14-year-old Malay male who fell at school and sustained bilateral olecranon fractures. He had undergone an open reduction and tension band wiring to stabilize the fracture. Three months after the surgery, the movement of both his elbows was satisfactory.
This is a prospective study on infection following fixation of closed fractures done in Hospital Tengku Ampuan Afzan ,Kuantan from May 2003 to May 2005. There were 23 cases in this study. The mean age of patient was 32.9 years (range 15 to 77). Twenty one were males and 2 females. Twenty (87%) infections occurred in the lower limb and only 3(13%) occurred in the upper limbs. Twenty two patients (91%) had plating done for the fracture. Infection following internal fixation is commonly a deep seated (96%) and florid (78%) infection in which 70% occur after the surgical wound has healed. Staphylococcus aureus is the commonest organism isolated in which 43% are Methicillin resistant (MRSA). Overall infection caused by gram negative organisms is more common than gram positive organisms.
A retrospective study was done in 30 patients with infected closed fractures treated initially by open reduction and internal fixation. Nineteen fractures involved the femur, 8 the tibia, 2 the radius and 1 the ulna. Twenty-five were diaphyseal and 5 metaphyseal. Twenty-two fractures had initially been treated with plating and 8 with intramedullary nailing. Thirteen patients presented in the acute phase and 17 in the subacute phase of infection. Twenty-two patients presented with low grade infection and 8 with florid infection. The commonest organism isolated was Staphylococcus aureus (80%), of which fifty four percent was resistant to Methicillin (MRSA). This study showed that 77% of infected fractures with a stable implant united even in the presence of infection.
To conduct a prospective randomised controlled study to compare the stability and risk of nerve injury between fractures treated by medial-lateral pin fixation and those treated by 2-lateral pin fixation.
Management of severe open tibial fracture with neurovascular injury is difficult and controversial. Primary amputation is an acceptable option as salvaging the injured, insensate, and ischaemic limb may result in chronic osteomyelitis and non-functional limb. We report a case of open tibial fracture associated with segmental bone and soft tissue loss, posterior tibial nerve and artery injuries, which was further complicated by chronic osteo-myelitis treated with composite vascularised osteocutaneous fibula and sural nerve graft. Functional outcome of the injured limb at one-year follow-up was satisfactory: the patient was capable of achieving full weightbearing and was able to appreciate crude touch, pain, proprioception, and temperature at the plantar aspect of the foot. There was no pressure sore or ulceration.
Failure analysis was performed to investigate the failure of the femur fixation plate which was previously fixed on the femur of a girl. Radiography, metallography, fractography and mechanical testing were conducted in this study. The results show that the failure was due to the formation of notches on the femur plate. These notches act as stress raisers from where the cracks start to propagate. Finally fracture occurred on the femur plate and subsequently, the plate failed.
Fracture neck of the femur is rare in children and occurs following severe trauma. Several recommendations have been made for the treatment of displaced transcervical fracture type 11 (Delbet classification). However there are no recommendations when such a fracture occurs after recent acute osteomyelits of the neck of the femur. The management of a case is described with the outcome after 36 months.
We studied 60 intertrochanteric fractures of the femur fixed with Dynamic Hip Screw (DHS). There were 10 cases (16.7%) with cutting-out of device through femoral head and neck. Stable fracture pattern, postero-inferior and central position of screw in the femoral neck and head produced high percentage of good result, whereas anterior or superior position of screw produced higher incidence of cut-out. We found osteoporosis and distance of screw tip to subchondral bone to have no influence on the final outcome.