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Changing Patterns in Fracture Management Emphasizing Early Motion and Function
Symposium on Surgery at the Lahey Clinic
Changing Patterns in Fracture Management Emphasizing Early Motion and Function
Howard G. Parker, M.D.,* and Harold K. Reitman, M.D.t
Because of the advent of improved casting, bracing, and surgical techniques in the past several years, many fractures formerly treated by prolonged immobilization and inadequate internal fixation devices are now treated by methods that promote quicker healing of fractures and earlier joint motion. Consequently, patients can return to normal activity much sooner.
FRACTURES OF THE ANKLE The best means of ensuring normal function in the ankle after fracture is to obtain good reduction of the joint surfaces. 4 , 6 In most instances, this can be accomplished by closed manipulation and plaster casting, which sometimes requires repeated manipulations and plaster changes as the dimensions of the ankle change. 3 , 8, 17 Prolonged casting may promote ankle and subtalar joint stiffness and a high incidence of traumatic osteoarthritis. 4 , 29 Unstable ankle fractures that are difficult to reduce and maintain by closed means and comminuted fractures that have considerable intraarticular involvement may require opening of the fractures to attain accurate reduction. The instrumentation introduced by the Association for the Study ofInternal Fixation (ASIF) from Switzerland has made it possible to fix these fractures anatomically, making prolonged external immobilization unnecessary.1 9 With good fixation, early [lctive range of motion exercises can be started within a few days of injury. In my experience with 10 unstable ankle fractures treated by rigid fixation and early mobilization, full painless motion and normal function were possible within 10 weeks after injury. "Department of Orthopedic Surgery, Lahey Clinic Foundation, Boston, Massachusetts tResident, Boston University School of Medicine, Boston, Massachusetts
Surgical Clinics of North America-Vol. 56, No.3, June 1976
667
668
HOWARD
G.
PARKER AND HAROLD
K.
REITMAN
FRACTURES OF THE TIBIA The most significant advances in management of tibial fractures have been nonoperative treatment and early weightbearing. Dehne's9 original approach was to obtain a reasonably accurate anatomic reduction, to place the patient in a long leg cast, and to encourage early weightbearing. Sarmiento25 • 26 introduced a functional below-the-knee cast which he recently improved by instituting the same so-called total contact concept Dehne used and by employing a functional below-theknee brace. Functional bracing allows knee and ankle motion and yet immobilizes the fracture, and weightbearing on these fractures appears to promote faster healing. 9, 25, 26 A lower incidence of delayed union or nonunion is reported; infections do not occur. 9. 25, 26 These advantages seem to outweigh such problems as rotatory stress at the fracture site, shortening, and moderate angulation.
FRACTURES OF THE PATELLA An intact, smoothly articulating patellofemoral joint benefits the knee by acting as a lever system that potentiates the mechanical advantage of the quadriceps mechanism, and fracture of the patella obviously interferes with this function. Using the concepts of accurate anatomic reduction and firm fixation, the ASIF group developed a technique of threading a wire through the quadriceps mechanism above the patella and through the patella ligament below in such a manner that the tension created by the pull of the quadriceps muscle helps to hold the patella fragments in place. Because the technique employs a dynamic method of fixation, early motion of the knee is possible. The patella is not indispensable; however, a severely comminuted fracture may be treated by patellectomy. I used aN o. IB-gauge stainless steel wire in three comminuted patella fractures to appose the quadriceps tendon to the patella ligament after patellectomy. Immediate postoperative range of motion exercises were begun, and after six weeks, the patients had flexion greater than 90 no extensor lag, and no pain. 0
,
FRACTURES OF THE KNEE Intra-articular fractures in the region of the knee, particularly displaced intra-articular fractures, are difficult to manage, and, if the joint surfaces are not reduced anatomically and held in position, traumatic osteoarthritis is almost certain to ensue. 24 New internal fixation devices, such as buttress plates, cancellous screws, and blade plate fixation devices, make it easier to fix these fractures more rigidly and to promote early joint motion. 19
FRACTURE MANAGEMENT
669
FRACTURES OF THE FEMUR The femur is the largest bone in the body and is subject to action of the most powerful muscles in the body. Skeletal traction, intramedullary fixation, and various types of compression plates are commonly used to treat femoral fractures. Two significant advances in management of femoral fractures are so-called blind intramedullary nailing and cast bracing. Intramedullary nailing is usually performed by opening the fracture site. The blind technique is performed under fluoroscopic control and avoids surgical maneuvers at the fracture site. 16 Intramedullary nailing is an advance in management of femoral fractures because it allows patients to ambulate much sooner than does skeletal traction. However, most series of open intramedullary fixation operations report infection in a small number of patients. 2. 28 Gross and Giebink 14 reported no infection and healing of all fractures in 21 patients in whom the blind technique was used. Management of femoral fractures with a cast brace was first reported by Mooney and his colleagues 18 in 1970. They reported no infections and healing time shorter than with any other method. Hip, knee, and ankle motions were preserved. Brown and Preston5 recently reported impressive results in management of both open and closed femoral fractures by the ambulatory cast branching technique. Subtrochanteric fractures are not commonly encountered but they are difficult to manage. ZickeP1 reported early promising results with a new device that uses an intramedullary rod transfixed by a femoral neck pin. Patients are encouraged to ambulate early, and, in Zickel's hands, this technique lowered the normally high incidence of malunion, nonunion, shortening, and other problems associated with subtrochanteric fractures.
FRACTURES OF THE HIP Internal fixation and early ambulation of most hip fractures, both intertrochanteric and cervical, are now established methods of management for fractures in this region. Pneumonia, congestive heart failure, thrombophlebitis, bed sores, and other complications associated with prolonged bed rest in the elderly prompted surgeons to find methods of treating these fractures. The newer so-called sliding devices, such as the Pugh nail and compression screw, appear to improve results of both intracapsular and intertrochanteric fractures not only by fixing the fragments rigidly but also by allowing for continuous impaction during the early postoperative weightbearing periodY' 12 Fielding et al 12 reported a 90 per cent union rate with the Pugh nail.
670
HOWARD
G.
PARKER AND HAROLD
K.
REITMAN
FRACTURES OF THE SPINE The Harrington rod, which is normally used in the surgical management of scoliosis, is now employed to stabilize unstable thoracolumbar spine fractures. 13 The fixation makes nursing care easier in paralytics as these patients can be turned and cared for more easily than if they were in a plaster bed or in other forms of external immobilization. In the patient who is not paralytic but has an unstable thoracic or lumbar fracture, the physiologic benefits of early mobilization are obvious. The halo apparatus can be incorporated into a body cast and allows good external fixation during the healing phase of cervical fractures. 22 With this technique patients ambulate and avoid many of the complications of prolonged bed rest. 23
FRACTURES OF THE HUMERUS Neer's20 classification of proximal humeral fractures, based on the presence or absence of displacement of the four major fragments, has helped to crystallize current thinking. Most proximal humeral fractures are not displaced and usually require only a sling for support and early motion exercises. 20 Occasionally open reduction and wire loop fixation are necessary to salvage these fractures. The most important advance in management of three-part and four-part fractures (designated by Neer as "badly fractured") is the N eer prosthesis, which is essentially a replacement of the humeral head with an endoprosthesis. 21 Patients are encouraged to pursue a physical therapy program after operation, and good range of motion without much pain is usually possible. Fractures of the humeral diaphysis can be troublesome. Plaster spicas are often cumbersome, hanging casts frequently cause distraction in the fragments, and close supervision is mandatory (particularly for transverse fractures)' The compression plate is a reasonable alternative to closed methods if concomitant injury, obesity, difficulty in maintaining reduction by external means, or other obstacles interfere with closed management.
FRACTURES OF THE ELBOW The earlier active motion is instituted, the better the end result. This is particularly true for intra-articular elbow fractures. Early operation, anatomic reduction, and stable fixation are important for early active motion and good end results in complex elbow fractures. 7 • 15 In the six instances of intercondylar distal humeral fractures I have treated in which the elbow was approached posteriorly and the fragments were anatomically reduced and fixed by means of well~placed cancellous screws, patients were able to begin active assisted range of motion exercises within a few days of operation. Within four months, functional range of motion was possible, and, within nine months, the elbows were used for normal daily activities with little or no pain.
FRACTURE MANAGEMENT
671
Young30 described a technique of treating badly shattered elbows by excision of the comminuted fragments within the ulnar humeral articulation and transference of the triceps to the head of the radius. His results are impressive considering the severity of this injury.
FRACTURES OF THE FOREARM Fractures of the diaphysis of the radius and ulna are difficult to manage. Restoration oflength and maintenance of apposition and alignment must be achieved iffunctional range of supination and pronation is to be restored. I, 10 Although reasonable reduction is often possible, maintenance of the reduction with external immobilization is frequently difficult. Consequently, most fractures involving the midportion of the radius and ulna and single fractures in the distal portion of the radius in adults require open reduction and internal fixation. Appliances, such as plates, intramedullary devices, and percutaneous wires incorporated in plaster, have been used with mixed success. In the late 1950's the ASIF group developed a compression plate which has undergone several technical improvements and which allows anatomic alignment and rigid internal fixation. I, 10, 19 The value of rigid internal fixation in ankle and diaphyseal humeral fractures has been discussed, but it is even more valuable in the forearm because of the forearm's complex motor groups, its propensity to become malaligned, and the tendency of the shoulder, elbow, wrist, and hand to become stiff with prolonged immobilization. I, 10 Patients are encouraged to begin mobilizing the joints above and below the fracture early after operation. I, 10, 19 The early functional bracing technique developed by Sarmient027 is an exciting innovation; forearm fractures are treated with a functional below-the-elbow brace. Fractures are reduced by closed means, and reduction is then maintained in an orthoplast brace which allows elbow flexion of approximately 100°, limited extension of approximately 20°, and prevention of pronation and supination. Dorsiflexion and volar flexion of the wrist are permitted by a hinge joint connecting the wrist and hand to the brace. Results with this technique are impressive. In Sarmiento's series, the average healing time was 15 weeks (with a median of 11 weeks) when ~oth radius and ulna were fractured. Isolated radial fractures healed in approximately 14 weeks, and healing time of isolated ulnar fractures averaged approximately 10 weeks. Return of pronation and supination was equally impressive. Patients with isolated ulnar fractures had loss of pronation averaging less than 10° and loss of supination averaging 10°. Patients with isolated radial fractures had an average loss of pronation of 4 ° and an average loss of supination of 5°. When both bones were fractured and when the fractures occurred in the middle third of the forearm, average loss of motion was 5° of pronation and 4° of supination. These results are equal to or better than results from other series including those employing the compression plating technique. The obvious advantages of this method are that the fracture sites are unopened and the risks of operation (infection and neurovascular damage) are avoided.
672
HOWARD
G.
PARKER AND HAROLD
K.
REITMAN
REFERENCES 1. Anderson, L. D., Sisk, T. D., Tooms, R. E., et al: Compression·plate fixation in acute diaphyseal fractures of the radius and ulna. J. Bone Joint Surg., 57A:287-297 (April) 1975. 2. Bohler, J.: Closed intramedullary nailing of the femur. Clin. Orthop., 60:51-67 (Sept.Oct.) 1968. 3. Bonnin, J. G.: Injuries to the Ankle. New York, Grune & Stratton, 1950,412 pp. 4. Brodie, 1. A. O. D., Denham, R. A.: The treatment of unstable ankle fractures. J. Bone Joint Surg., 56B :256-262 (May) 1974. 5. Brown, P. E., Preston, E. T.: Ambulatory treatment of femoral shaft fractures with a cast-brace. J Trauma, 15:860-868 (Oct.) 1975. 6. Burwell, H. N., Charnley, A. D.: The treatment of displaced fractures at the ankle by rigid internal fixation and early joint movement. J. Bone Joint Surg., 47:634-660(Nov.) 1965. 7. Cassebaum, W. H.: Open reduction ofT & Y fractures of the lower end of the humerus. J. Trauma, 9 :915-925 (Nov.) 1969. 8. Cedell, C. A., Wiberg, G.: Treatment of eversion-supination fracture of the ankle (2nd degree). Acta. Chir. Scand., 124:41-44 (July) 1962. 9. Dehne, E.: Treatment of fractures of the tibial shaft. Clin. Orthop., 66:159-173 (Sept.Oct.) 1969. 10. Dodge, H. S., Cady, G. W.: Treatment offractures of the radius and ulna with compression plates. J. Bone Joint Surg., 54: 1167-1176 (Sept.) 1972. 11. Ecker, M. L., Joyce, J. J., Kohl, E. J.: The treatment of trochanteric hip fractures using a compression screw. J. Bone Joint Surg., 57A:23-27 (Jan.) 1975. 12. Fielding, J. W., Wilson, S. A., Ratzan, S.: A continuing end-result study of displaced intracapsular fractures of the neck ofthe femur treated with the Pugh nail. J Bone Joint Surg., 56:1464-1472 (Oct.) 1974. 13. Flesch, J R., Leider, L. 1,., Bradford, D. S.: Harrington instrumentation ofthora9ic and lumbar spinal injuries (abstract). J. Bone Joint Surg., 56:1763 (Dec.) 1974. 14. Gross, H. P., Giebink, R. R.: Blind nailing of the femur. A technique for closed intramedullary nailing ofthe femur using Polaroid radiography. J Trauma, 7 :591-598 (July) 1967. 15. Kelly, R. P., Griffin, T. W.: Open reduction of T-condylar fractures of the humerus through an anterior approach. J. Trauma, 9:901-914 (Nov.) 1969. 16. Kuntscher, G., Bick, E. M.: The intramedullary nailing of fractures By G. Kuntscher. Translation of article in Archiv. FUr Klinische Chirurgie, 200 :443, 1940. Clin. Orthop., 60:5-12 (Sept.-Oct.) 1968. 17. Mitchell, C. L., Fleming, J. L.: Fractures and fracture-dislocations of the ankle. Postgrad. Med., 26:773-782 (Dec.) 1959. 18. Mooney, V., Nickel, V. L., Harvey, J. P., Jr., et al.: Cast-brace treatment for fractures of the distal part of the femur. A prospective controlled study of one hundred and fifty patients. J. Bone Joint Surg., 52: 1563-1578 (Dec.) 1970. 19. Muller, M. E., Allgower, M., Willenegger, H.: Manual of Internal Fixation. Techniques Recommended by the AO-Groups. New York, Springer-Verlag, 1970, p. 297. 20. N eer, C. S., 2d: Displaced proximal humeral fractures. 1. Classification and evaluation. J. Bone Joint Surg., 52:1077-1089 (Sept.) 1970. 21. Neer, C. S., II: Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement. J. Bone Joint Surg., 52: 1090-1103 (Sept.) 1970. 22. Parker, H. G.: Management of cervical spine fractures. Unpublished data. 23. Quigley, T. B., Banks, H.: Progress in the treatment of fractures and dislocations, 1950-1960. N. Engl. J Med., 263 :493-501 concl. (Sept. 8) 1960. 24. Rasmussen, P. S.: Tibial condylar fractures. Impairment of knee joint stability as an indication for surgical treatment. J. Bone Joint Surg., 55: 1331-1350 (Oct.) 1973. 25. Sarmiento, A.: A functional below-the-knee cast for tibial fractures. J. Bone Joint Surg., 49:855-875 (July) 1967. 26. Sarmiento, A.: A functional below-the-knee brace for tibial fractures. A report on its use in one hundred thirty-five cases. J Bone Joint Surg., 52:295-311 (March) 1970. 27. Sarmiento, A., Cooper, J. S., Sinclair, W. F.: Forearm fractures. Early functional bracing-a preliminary report. J. Bone Joint Surg., 57A:297-304 (April) 1975. 28. Wickstrom, J., Corban, M. S.: Intramedullary fixation for fractures of the femoral shaft. A study of complications in 298 operations. J. Trauma, 7:551-583, 1967. 29. Wilson, F. C., Skilbred, L. A.: Long-term results in the treatment of displaced bimalleolar fractures. J Bone Joint Surg., 48:1065-1078 (Sept.) 1966. 30. Young, C., Jr.: Primary elbow arthroplasty. A posttraumatic procedure with follow-up of ten years. Arch. Surg., 101 :78-81 (July) 1970. 31. Zickel, R. E.: A new fixation device for subtrochanteric fractures of the femur. A preliminary report. Clin. Orthop., 54: 115-123 (Sept.-Oct.) 1957. Lahey Clinic Foundation 605 Commonwealth Avenue Boston, Massachusetts 02215
Changing Patterns in Fracture Management Emphasizing Early Motion and Function
Howard G. Parker, M.D.,* and Harold K. Reitman, M.D.t
Because of the advent of improved casting, bracing, and surgical techniques in the past several years, many fractures formerly treated by prolonged immobilization and inadequate internal fixation devices are now treated by methods that promote quicker healing of fractures and earlier joint motion. Consequently, patients can return to normal activity much sooner.
FRACTURES OF THE ANKLE The best means of ensuring normal function in the ankle after fracture is to obtain good reduction of the joint surfaces. 4 , 6 In most instances, this can be accomplished by closed manipulation and plaster casting, which sometimes requires repeated manipulations and plaster changes as the dimensions of the ankle change. 3 , 8, 17 Prolonged casting may promote ankle and subtalar joint stiffness and a high incidence of traumatic osteoarthritis. 4 , 29 Unstable ankle fractures that are difficult to reduce and maintain by closed means and comminuted fractures that have considerable intraarticular involvement may require opening of the fractures to attain accurate reduction. The instrumentation introduced by the Association for the Study ofInternal Fixation (ASIF) from Switzerland has made it possible to fix these fractures anatomically, making prolonged external immobilization unnecessary.1 9 With good fixation, early [lctive range of motion exercises can be started within a few days of injury. In my experience with 10 unstable ankle fractures treated by rigid fixation and early mobilization, full painless motion and normal function were possible within 10 weeks after injury. "Department of Orthopedic Surgery, Lahey Clinic Foundation, Boston, Massachusetts tResident, Boston University School of Medicine, Boston, Massachusetts
Surgical Clinics of North America-Vol. 56, No.3, June 1976
667
668
HOWARD
G.
PARKER AND HAROLD
K.
REITMAN
FRACTURES OF THE TIBIA The most significant advances in management of tibial fractures have been nonoperative treatment and early weightbearing. Dehne's9 original approach was to obtain a reasonably accurate anatomic reduction, to place the patient in a long leg cast, and to encourage early weightbearing. Sarmiento25 • 26 introduced a functional below-the-knee cast which he recently improved by instituting the same so-called total contact concept Dehne used and by employing a functional below-theknee brace. Functional bracing allows knee and ankle motion and yet immobilizes the fracture, and weightbearing on these fractures appears to promote faster healing. 9, 25, 26 A lower incidence of delayed union or nonunion is reported; infections do not occur. 9. 25, 26 These advantages seem to outweigh such problems as rotatory stress at the fracture site, shortening, and moderate angulation.
FRACTURES OF THE PATELLA An intact, smoothly articulating patellofemoral joint benefits the knee by acting as a lever system that potentiates the mechanical advantage of the quadriceps mechanism, and fracture of the patella obviously interferes with this function. Using the concepts of accurate anatomic reduction and firm fixation, the ASIF group developed a technique of threading a wire through the quadriceps mechanism above the patella and through the patella ligament below in such a manner that the tension created by the pull of the quadriceps muscle helps to hold the patella fragments in place. Because the technique employs a dynamic method of fixation, early motion of the knee is possible. The patella is not indispensable; however, a severely comminuted fracture may be treated by patellectomy. I used aN o. IB-gauge stainless steel wire in three comminuted patella fractures to appose the quadriceps tendon to the patella ligament after patellectomy. Immediate postoperative range of motion exercises were begun, and after six weeks, the patients had flexion greater than 90 no extensor lag, and no pain. 0
,
FRACTURES OF THE KNEE Intra-articular fractures in the region of the knee, particularly displaced intra-articular fractures, are difficult to manage, and, if the joint surfaces are not reduced anatomically and held in position, traumatic osteoarthritis is almost certain to ensue. 24 New internal fixation devices, such as buttress plates, cancellous screws, and blade plate fixation devices, make it easier to fix these fractures more rigidly and to promote early joint motion. 19
FRACTURE MANAGEMENT
669
FRACTURES OF THE FEMUR The femur is the largest bone in the body and is subject to action of the most powerful muscles in the body. Skeletal traction, intramedullary fixation, and various types of compression plates are commonly used to treat femoral fractures. Two significant advances in management of femoral fractures are so-called blind intramedullary nailing and cast bracing. Intramedullary nailing is usually performed by opening the fracture site. The blind technique is performed under fluoroscopic control and avoids surgical maneuvers at the fracture site. 16 Intramedullary nailing is an advance in management of femoral fractures because it allows patients to ambulate much sooner than does skeletal traction. However, most series of open intramedullary fixation operations report infection in a small number of patients. 2. 28 Gross and Giebink 14 reported no infection and healing of all fractures in 21 patients in whom the blind technique was used. Management of femoral fractures with a cast brace was first reported by Mooney and his colleagues 18 in 1970. They reported no infections and healing time shorter than with any other method. Hip, knee, and ankle motions were preserved. Brown and Preston5 recently reported impressive results in management of both open and closed femoral fractures by the ambulatory cast branching technique. Subtrochanteric fractures are not commonly encountered but they are difficult to manage. ZickeP1 reported early promising results with a new device that uses an intramedullary rod transfixed by a femoral neck pin. Patients are encouraged to ambulate early, and, in Zickel's hands, this technique lowered the normally high incidence of malunion, nonunion, shortening, and other problems associated with subtrochanteric fractures.
FRACTURES OF THE HIP Internal fixation and early ambulation of most hip fractures, both intertrochanteric and cervical, are now established methods of management for fractures in this region. Pneumonia, congestive heart failure, thrombophlebitis, bed sores, and other complications associated with prolonged bed rest in the elderly prompted surgeons to find methods of treating these fractures. The newer so-called sliding devices, such as the Pugh nail and compression screw, appear to improve results of both intracapsular and intertrochanteric fractures not only by fixing the fragments rigidly but also by allowing for continuous impaction during the early postoperative weightbearing periodY' 12 Fielding et al 12 reported a 90 per cent union rate with the Pugh nail.
670
HOWARD
G.
PARKER AND HAROLD
K.
REITMAN
FRACTURES OF THE SPINE The Harrington rod, which is normally used in the surgical management of scoliosis, is now employed to stabilize unstable thoracolumbar spine fractures. 13 The fixation makes nursing care easier in paralytics as these patients can be turned and cared for more easily than if they were in a plaster bed or in other forms of external immobilization. In the patient who is not paralytic but has an unstable thoracic or lumbar fracture, the physiologic benefits of early mobilization are obvious. The halo apparatus can be incorporated into a body cast and allows good external fixation during the healing phase of cervical fractures. 22 With this technique patients ambulate and avoid many of the complications of prolonged bed rest. 23
FRACTURES OF THE HUMERUS Neer's20 classification of proximal humeral fractures, based on the presence or absence of displacement of the four major fragments, has helped to crystallize current thinking. Most proximal humeral fractures are not displaced and usually require only a sling for support and early motion exercises. 20 Occasionally open reduction and wire loop fixation are necessary to salvage these fractures. The most important advance in management of three-part and four-part fractures (designated by Neer as "badly fractured") is the N eer prosthesis, which is essentially a replacement of the humeral head with an endoprosthesis. 21 Patients are encouraged to pursue a physical therapy program after operation, and good range of motion without much pain is usually possible. Fractures of the humeral diaphysis can be troublesome. Plaster spicas are often cumbersome, hanging casts frequently cause distraction in the fragments, and close supervision is mandatory (particularly for transverse fractures)' The compression plate is a reasonable alternative to closed methods if concomitant injury, obesity, difficulty in maintaining reduction by external means, or other obstacles interfere with closed management.
FRACTURES OF THE ELBOW The earlier active motion is instituted, the better the end result. This is particularly true for intra-articular elbow fractures. Early operation, anatomic reduction, and stable fixation are important for early active motion and good end results in complex elbow fractures. 7 • 15 In the six instances of intercondylar distal humeral fractures I have treated in which the elbow was approached posteriorly and the fragments were anatomically reduced and fixed by means of well~placed cancellous screws, patients were able to begin active assisted range of motion exercises within a few days of operation. Within four months, functional range of motion was possible, and, within nine months, the elbows were used for normal daily activities with little or no pain.
FRACTURE MANAGEMENT
671
Young30 described a technique of treating badly shattered elbows by excision of the comminuted fragments within the ulnar humeral articulation and transference of the triceps to the head of the radius. His results are impressive considering the severity of this injury.
FRACTURES OF THE FOREARM Fractures of the diaphysis of the radius and ulna are difficult to manage. Restoration oflength and maintenance of apposition and alignment must be achieved iffunctional range of supination and pronation is to be restored. I, 10 Although reasonable reduction is often possible, maintenance of the reduction with external immobilization is frequently difficult. Consequently, most fractures involving the midportion of the radius and ulna and single fractures in the distal portion of the radius in adults require open reduction and internal fixation. Appliances, such as plates, intramedullary devices, and percutaneous wires incorporated in plaster, have been used with mixed success. In the late 1950's the ASIF group developed a compression plate which has undergone several technical improvements and which allows anatomic alignment and rigid internal fixation. I, 10, 19 The value of rigid internal fixation in ankle and diaphyseal humeral fractures has been discussed, but it is even more valuable in the forearm because of the forearm's complex motor groups, its propensity to become malaligned, and the tendency of the shoulder, elbow, wrist, and hand to become stiff with prolonged immobilization. I, 10 Patients are encouraged to begin mobilizing the joints above and below the fracture early after operation. I, 10, 19 The early functional bracing technique developed by Sarmient027 is an exciting innovation; forearm fractures are treated with a functional below-the-elbow brace. Fractures are reduced by closed means, and reduction is then maintained in an orthoplast brace which allows elbow flexion of approximately 100°, limited extension of approximately 20°, and prevention of pronation and supination. Dorsiflexion and volar flexion of the wrist are permitted by a hinge joint connecting the wrist and hand to the brace. Results with this technique are impressive. In Sarmiento's series, the average healing time was 15 weeks (with a median of 11 weeks) when ~oth radius and ulna were fractured. Isolated radial fractures healed in approximately 14 weeks, and healing time of isolated ulnar fractures averaged approximately 10 weeks. Return of pronation and supination was equally impressive. Patients with isolated ulnar fractures had loss of pronation averaging less than 10° and loss of supination averaging 10°. Patients with isolated radial fractures had an average loss of pronation of 4 ° and an average loss of supination of 5°. When both bones were fractured and when the fractures occurred in the middle third of the forearm, average loss of motion was 5° of pronation and 4° of supination. These results are equal to or better than results from other series including those employing the compression plating technique. The obvious advantages of this method are that the fracture sites are unopened and the risks of operation (infection and neurovascular damage) are avoided.
672
HOWARD
G.
PARKER AND HAROLD
K.
REITMAN
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