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Distal humeral intra-articular fractures often result in functional impairment if treated conservatively. These fractures are particularly challenging due to osteoporosis and severe comminution. A 32-year-old female with a grade three open distal humerus intra-articular fracture presented with a 5 cm x 5 cm open wound on her right elbow. The patient underwent open reduction and internal fixation (ORIF) using the BB Joshi external fixator and a local flap for skin coverage, achieving stable fixation and early mobilization. The patient regained a near-normal range of movements and adequate skin coverage of the wound at follow-up. Compared to traditional ORIF, it showed lower infection rates and comparable union rates, leading to better functional outcomes when compared with the studies reported earlier. The BB Joshi external fixator effectively treats grade three open distal humerus intra-articular fractures, minimizing complications and promoting functional recovery.

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Proximal phalanx fractures of the big toe involving angulation or dislocation of the articular surface require repositioning and fixation. We treated a patient with such a fracture using a novel wire-connected external fixator, the ICHI-FIXATOR® system. A 45-year-old male sustained an injury when slipping down the stairs and impacting his left big toe. Plain radiography and computed tomography revealed a proximal phalangeal fracture of the left big toe with dislocation of the articular surface and comminution. The surgical intervention was performed using 1.1-mm diameter C-wires and an external fixator. The patient regained ambulation and resumed work immediately after surgery. Four weeks postoperatively, all wires were removed on an outpatient basis. Eight months postoperatively, the patient experienced no pain during strenuous activities or exercises. This novel wire-connected external fixator provides reliable and secure fixation, facilitating a prompt return to normal daily activities. This technique may be an effective option for managing toe fractures.

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Introduction: Securing stable internal fixation for fractures in osteoporotic intra-articular distal femur proves to be a demanding task due to thin cortices, a wide medullary canal, diminished bone stock, and fracture comminution. No singular therapeutic approach has successfully tackled all facets of this injury. Consequently, we now introduce a pioneering fixation method in our report, aiming to offer a holistic solution to the intricate challenges associated with this scenario. Case Report: A 60-year-old female presented with an intra-articular distal femur fracture, and underwent a combination fixation of distal femur plate and intramedullary interlocking nailing. The patient was rehabilitated with active knee range of motion on post-operative day 7 and has now attained full knee range of motion. Conclusion: The utilization of anatomical plates with locking mechanisms, in tandem with intramedullary interlocking nailing, holds promise for the secure stabilization and fixation of osteoporotic distal femur fractures, potentially leading to an expedited recovery process.

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Glenoid fossa fractures are rare injuries accounting for 10 to 29% of all intra-articular scapula fractures. They are usually the result of high-energy trauma, and concomitant injuries are not uncommon. Patients with glenoid fractures are admitted with shoulder pain and restricted range of motion. Although shoulder plain radiographs could establish the diagnosis, a computed tomography scan is necessary to adequately define the fracture pattern and characteristics. The most commonly used classification system is that of Ideberg (modified by Goss), which includes five glenoid fossa fracture types according to the location, extension, and complexity of the lesion. Articular surface displacement and step-off are the most important factors that should be taken under consideration when deciding for conservative or surgical management. Operative treatment includes open reduction and internal fixation through a posterior or anterior approach depending on fracture morphology and displacement. However, open surgical techniques are related to extensive soft-tissue disruption, risk of neurovascular injury, and inadequate exposure of the entire glenoid cavity. Introduction of arthroscopy could facilitate better visualization of the glenoid articular surface and improved fracture reduction. However, it is a technically demanding procedure with many challenges and pitfalls. The aim of this review is to summarize the current evidence regarding the treatment of glenoid fossa fractures and present the beneficial effect of arthroscopy in improving the quality of fracture fixation and overall functional outcomes.

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Background: The pins and rubber traction system (PRTS) has proven effective in managing intra-articular fractures of the proximal interphalangeal joint. However, there is scant evidence in the literature regarding its efficacy in treating distal interphalangeal joint (DIPJ). This study aims to investigate the outcomes of PRTS in the treatment of comminuted intra-articular fractures of the DIPJ. Methods: We conducted a retrospective review of patients with comminuted intra-articular fractures of the DIPJ treated with PRTS between 2017 and 2021. At the final follow-up, we measured and compared the active range of motion (ROM) in both affected and non-injured contralateral fingers. The subjective evaluation utilised the Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) questionnaire and the Visual Analogue Scale (VAS). Results: Ten patients with a mean follow-up of 13.2 months (range: 12-17) were included in the study. Fracture locations included the base of the distal phalanx in two patients, the condyle of the middle phalanx in seven and both in one patient. At the final follow-up, the average VAS score was 0.5 (range: 0-2). The average active motion of the DIPJ was 61° (range: 50°-70°) for the injured side and 76° (range: 75°-80°) for the opposite side. The mean range of DIPJ movement was 80% (range: 68%-87%) of the non-injured side. Extension deficits were observed in five patients, with a median deficit value of 10° (range: 5°-10°). The average Quick-DASH score was 2.9 (range: 0-11.3). Conclusions: The PRTS can be considered as an effective surgical technique in managing comminuted intra-articular fractures of the DIPJ. Level of Evidence: Level IV (Therapeutic).

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Fractures of the distal radius show a wide spectrum of different fracture patterns. Although standard X­ray images are sufficient for extra-articular fractures, the exact analysis of intra-articular fractures requires the use of computed tomography (CT) with coronal, sagittal and axial sectional images. The classification is based on the Working Group for Osteosynthesis Questions (AO) criteria. The treatment strategy can be more precisely defined by a CT-based classification. Special attention must be paid to the presence of the key corners, as they have a high risk for primary or secondary dislocation if they not adequately stabilized.

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Penetrating injuries to the musculoskeletal system pose common challenges for orthopedic surgeons in emergency departments (EDs). The complexity escalates when a joint is affected, increasing the risk of severe complications such as infection and post-traumatic arthritis. Given the potential importance of these injuries, early diagnosis and a meticulous treatment plan are crucial. In this paper, we present a unique case of penetrating trauma, resulting in an intra-articular defect on the lateral femoral condyle of an adolescent girl. This case underscores the importance of tailored interventions in managing complex musculoskeletal injuries.

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INTRODUCTION: Fractures of the distal femur with metaphyseal comminution and complete intra-articular involvement (AO/OTA classifications 33C2 and 33C3) present challenges for reduction and fixation. However, an optimal fixation method remains unknown. This study aimed to compare the clinical and radiographic outcomes of locking extramedullary plating (LEP) and retrograde intramedullary nailing (RIN) for complete distal femoral intra-articular fractures with metaphyseal comminution. MATERIALS AND METHODS: Between January 2016 and May 2022, 80 patients (45 men and 35 women; average age, 56.7 years) diagnosed with AO/OTA 33C2 and 33C3 were treated with either LEP or RIN and followed up for at least one year. Post-operative evaluations included radiographic assessments of bone union rate, timing, and alignment. Clinically, the knee joint range of motion (ROM), lower extremity functional scale (LEFS), and Kellgren and Lawrence (KL) grade were analyzed. The complications were also compared. RESULTS: 36 underwent LEP and 44 underwent RIN. Bone union was observed in 69.4% and 63.6% of the patients in the LEP and RIN groups, respectively (p = 0.64). The average union time was 6.9 months for the LEP group and 6.6 months for the RIN group (p = 0.51). A tendency toward varus deformity was observed in the RIN group, although the difference was not statistically significant. No significant differences were observed in knee ROM, LEFS, or KL grade. Complications included non-union (33.8%; RIN, 11; LEP, 16), varus deformity (5%; RIN, 4; LEP, 0), infection (1.3%; RIN, 0; LEP, 1), heterotrophic ossification (1.3%; RIN, 0; LEP, 1), and wound dehiscence (2.5%; RIN, 2; LEP, 0). CONCLUSIONS: The surgical fixation methods, RIN and LEP, for complete distal femoral intra-articular fractures with metaphyseal comminution showed similar clinical and radiological outcomes. However, regardless of the type of fixation device used, there was a reduced rate of bone union owing to high energy and a less favorable prognosis.

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The most prevalent long bone fracture is that of the distal radius, and it affects all age groups. These fractures can present after low-energy or high-energy trauma, and their configuration often varies depending on the mechanism of injury. Their management can be operative or non-operative, and the scientific literature is abundant in studies comparing these two treatment modalities. There is also a healthy scientific debate as to the indications that should guide surgery for these injuries. A male patient sustained a high-energy fracture to his distal radius and presented to our unit soon after the injury. His fracture presented significant surgical challenges due to its complexity. It was stabilised surgically, and the patient recovered good function after rehabilitation. This case aims to demonstrate a surgical treatment protocol and the relevant surgical considerations when dealing with significant injuries, such as the one presented in this paper, where traditional fixation techniques may not yield a satisfactory outcome.

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Background Distal radius fractures are common fractures. Treatment of intra-articular fractures is controversial, with treatment modalities including closed reduction and casting, open reduction and plating, and closed reduction and fixation with an external fixator. In this study, we compared the clinical and radiological outcomes of our patients treated with three different methods for intra-articular distal radius fractures. We hypothesize that open reduction and plate application are superior. Methodology Adult patients with intra-articular (AO type B and C) fractures of the distal radius and treated with closed reduction-casting, volar locking plate, and external fixator were identified. Radiologically, joint stepping at the end of treatment, radial inclination, radial height, volar tilt, and distal ulna fracture were examined. For clinical scoring, Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) scores were computed. Obtained data were compared statistically between groups. Results A total of 164 patients were included in the study. Overall, the treatment modality was conservative in 61, volar with plating in 78, and external fixation in 25. The mean age of the patients was 53.7 years (range = 20-82 years). Overall, 39.6% of the patients were male and 60.4% were female. The mean follow-up period of the patients was 16.7 months (range = 12-28 months). No statistically significant difference was found between Q-DASH scores in the statistical evaluation (p > 0.05). There was a statistically significant difference between the groups in the radiological evaluation. When conservative treatment and the volar plate group were compared, the volar plate was superior in all radiological parameters (p < 0.05). Compared with conservative treatment and external fixation, only volar tilt and radial inclination angle were different. External fixation was better (p < 0.05). Radial length, volar compared to plate and external fixation tilt, and ulnar variance were better in the plate group (p < 0.05). Regarding joint stepping and radial, there was no difference in inclination between the two groups (p > 0.05). Reflex sympathetic dystrophy was seen in a total of 10 (6.1%) patients. Pin-site infection was seen in three (12%) patients in the external fixator group. Implant removal was performed in seven (9.0%) patients who developed plaque due to irritation and tenosynovitis. Early arthrosis was seen in three (4.3%) patients. Conclusions The treatment of distal radius intra-articular fractures should be evaluated and decided individually for each patient. No single method is directly superior to other methods. However, in some cases, the best results radiologically in the treatment of comminuted intra-articular fractures have been obtained in patients with volar plates.

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BACKGROUND: Distal humerus fractures are a challenge to treat, and the current standard of care, open reduction internal fixation with a double-plate, has a high rate of complications. We proposed a novel internal fixation configuration, lateral intramedullary nail and medial plate (LINMP) and verified its rigidity through biomechanical tests and finite element analysis. METHODS: The study involved biomechanical testing of 30 synthetic humerus models to compare 2 different fixation systems for an AO 13C-2.3 type fracture. The orthogonal double-plate (ODP) group and the LINMP group were compared through biomechanical testing to measure stiffness and failure load fewer than 3 working conditions. Based on the results, we optimized the intramedullary nail by eliminating the holes at the distal end of the nail and incorporating a 2-hole external locking plate. The Finite element analysis was also conducted to further compare the modified LINMP configuration with the previous 2 fixation configurations. RESULTS: In biomechanical tests, the ODP group exhibited lower stiffness under bending and compression forces compared to the LINMP group, but higher stiffness and failure loads under torsion force. In finite element analysis, the modified LINMP reduces the maximum stress of the fixation structure without significantly reducing the stiffness under bending stress and axial compression conditions. In torsion stress conditions, the modified LINMP enhances both the maximum stress and the stiffness, although it remains marginally inferior to the ODP structure. CONCLUSION: Our study demonstrates that the innovative LINMP presents comparable or slightly superior concerning bending and axial loading compared to orthogonal double-plate osteosynthesis for distal humeral intra-articular fractures, which might become a minimally invasive option for these fractures.

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Background: We treated distal radius fractures (DRFs) beyond the watershed line without fracture of the lunate volar rim using a volar locking plate (VLP) and report the radiological and clinical outcomes at least 3 years after surgery. Methods: In 41 consecutive patients between January 2012 and August 2017, the fragment was composed of the radial styloid process (distal to the watershed line) and the lunate volar rim was intact. We evaluated demographic factors, radiological features and radiological/clinical outcomes at the final follow-up. Results: Twenty-nine patients were followed and evaluated. The mean follow-up period was 5.7 years. The mean patient age was 52.7 years and 24 patients had intracapsular intra-articular fractures. The fracture line was present in the lunate fossa in all patients. Twenty patients were classified as Soong grade 2, and five and four patients were grades 1 and 0, respectively. No radiological parameter (volar tilt, radial inclination, step-off and ulnar variance) was significantly different between the affected and contralateral normal sides. The mean visual analogue scale pain score and Disabilities of the Arm, Shoulder and Hand score, as well as the range of movement of the wrist, were not different between the affected and contralateral normal wrists. Finally, the grip strength on the affected side was 92% of the contralateral value. Major complications, such as nonunion, malunion and tendon rupture, were absent. Conclusions: DRFs distal to the watershed line with an intact lunate volar rim are rare and easy to miss. Careful inspection of 3D-CT images is necessary to determine these injuries, and the optimal choice for proper fixation of the fragment amongst the commercial VLPs would result in satisfactory radiological and clinical outcomes. Level of Evidence: Level IV (Therapeutic).

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INTRODUCTION: Concerning rates of nonunion in articular distal humerus fractures indicate an unsolved problem. The fixation principles of O'Driscoll describe linking the fractured articular segment to the distal humerus columns with compression screws which creates a stable fixed angle construct. A novel device has been introduced which utilizes an interlocking beam through the articular segment to connect the distal aspect of the medial and lateral plates, creating a linked construct. We sought to evaluate the stability of this linked construct using an articular model of distal humerus fracture. MATERIALS AND METHODS: Ten matched pair specimens of 65 years of age or older were randomized to the use (LB group) or non-use (NLB group) of an interlocking beam to link the medial and lateral locking plates in fixation of an AO Type C3 fracture model. Outside of the linking beam, fixation between the matched pairs was consistent using 2.7 mm locking screws distally with fixed trajectories and +/- 2 mm lengths. RESULTS: Mean stiffness was 273 Newtons/mm in the LB group and 225 Newtons/mm in the NLB group (p = 0.001). Mean maximum displacement was 0.28 in the LB group and 0.93 mm in the NLB group (p = 0.006). Mean load to failure was 277 pounds in the LB group and 280 pounds in the NLB group (p = 0.94). DISCUSSION: Our results indicate that an interlocking beam which links the medial and lateral plates provides greater stability compared to a similar construct without an interlocking beam. We attribute this finding to the beam's double supported design which resists cantilever bending and provides robust compression of the fractured fragments.

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Post-traumatic osteoarthritis (PTOA) develops secondary to a joint injury and accounts for 12 % of all osteoarthritis. These injuries, often of the lower extremity joints, occur due to trauma or accidents related to athletic or military activities. They primarily affect younger individuals although PTOA can occur across the spectrum of age. Pain and functional disability caused by PTOA confer a heavy economic toll on patients, in addition to detrimentally affecting their quality of life. Both high energy injuries that cause articular surface fracture with or without subchondral bone disruption and low-energy injuries involving joint dislocations or ligamentous injury cause PTOA, albeit through different mechanisms. Regardless, chondrocyte death, mitochondrial dysfunction, reactive oxygen species production, subchondral bone remodeling, inflammation and cytokine release in the cartilage and synovium play integral roles in the pathogenesis of PTOA. Evolving surgical methods are focused on stabilizing articular surface and joint structure congruity. However, to date there are no disease modifying medical therapies against PTOA. Increased recent understanding of the pathogenesis of the subchondral bone and synovial inflammation as well as that of chondrocyte mitochondrial dysfunction and apoptosis have led to the investigation of new therapeutics targeting these mechanisms to prevent or delay PTOA. This review discusses new advances in our understanding of cellular mechanisms underlying PTOA, and therapeutic approaches that are potentially effective in reducing the self-propagating cycle of subchondral bone alterations, inflammation, and cartilage degradation. Within this context, we focus therapeutic options involving anti-inflammatory and anti-apoptotic candidates that could prevent PTOA.

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OBJECTIVE: Surgical treatment of intra-articular calcaneus fractures via a minimally invasive approach. INDICATIONS: Intra-articular dislocated calcaneus fractures. CONTRAINDICATIONS: Fracture older than 14 days; poor soft tissue quality in the surgical area. SURGICAL TECHNIQUE: Patient in lateral position. Identifying the anatomic landmarks. Incision (3-5 cm) from the tip of the fibula to metatarsal IV. Preparation through the subcutis. Retraction of the peroneal tendons. Preparation of the lateral calcaneal wall and later plate position via raspatory. Placement of a Schanz screw in the calcaneal tuberosity from lateral or posterior as a reduction aid for restoring of the calcaneal length and reduction of the hindfoot varus. Reduction of the sustentaculum fragment with the help of fluoroscopy from lateral. Elevation of the subtalar articular surface. Positioning of the calcaneal plate and fixation of the sustentaculum fragment by placing a cannulated screw through the long hole. Afterwards, definite internal fixation of the reduction with locking screws. Completion of the operation with final X­rays and, if available, an intraoperative computed tomography. Wound closure with closing of the peroneal sheath. POSTOPERATIVE MANAGEMENT: Lower leg-foot orthoses. Mobilization with partial weight-bearing of the injured foot with 15 kg for 6-8 weeks; subsequently increased load bearing. RESULTS: Due to the smaller incision and the associated lower soft tissue trauma, the risk of wound healing complications can be reduced. Radiographic and functional outcomes are comparable to the outcomes of calcaneal fractures treated via the extended lateral approach.

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INTRODUCTION AND IMPORTANCE: Plastic deformities usually occur in skeletally immature bones not completely ossified due to longitudinal forces on their distal ends, especially the forearm and lower legs. Pediatric lateral humeral condylar fractures (LHCFs) constitute the second most common intra-articular fracture in the upper extremity. Nevertheless, plastic deformities accompanied by other traumatic injuries, including LHCFs, are atypical and rare. This study presents an exceedingly rare case of the concurrence of a plastic deformity and an ipsilateral fracture of the lateral condyle of the humerus in a 6-year-old Persian boy. CASE PRESENTATION: The 6-year-old Persian injured boy referred to orthopedic clinic with an obvious deformity in the right upper limb with a limited motion range in the ipsilateral elbow. The patient underwent open-fixation surgery for LHCF fixation and suitable maneuvers to rectify the ulnar plastic deformity. Our findings indicated an acceptable outcome for this approach. His injured limb was reformed without deformities, and the complete union of the fractured area was accomplished eight weeks after surgery. CLINICAL DISCUSSION: The case is remarkable as reminding that we have to care concomitant "minor" injuries to the main fracture and to correctly treat them. Furthermore, open fixation surgery for LHCF rectification before fixing the ulnar deformity with the aid of a suitable maneuver led to good outcome and acceptable rehabilitation in a case of concurrent ulnar plastic deformity and an ipsilateral fracture of the external condyle of the humerus. CONCLUSION: Our approach helps to avoid further tissue damage and prevent the 2-stage surgical process.

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Introduction: Proximal tibial plateau fractures are one of the major problems in orthopaedic surgery and are associated with high complication rates. Intra-articular proximal tibia plateau fractures represent approximately 1% of fractures in adults. Various modalities of proximal tibial plateau fracture management have been considered, ranging from simple external fixators in impending compartment syndrome to periarticular proximal tibia plates and inter-locking nails with poller screws. Purpose of this study is to determine clinical outcomes of proximal tibial plateau fractures treated with plate. Materials and methods: We did this study of proximal tibial plateau fracture according to Schatzker's classification treated with proximal tibial periarticular plates in 53 patients prospectively admitted at the author's institute from June 2018 to May 2020 with follow-up period of 6 months. Results: In our study, the average knee score was 89.30 (ranging from 79 to 93) and functional knee score was 97.92 (ranging from 75 to 100). Fifty-one (51) patients (96.23%) showed excellent results and 2 patients (3.77%) showed good results according to Knee Society Score, which suggest that internal fixation of proximal tibia plateau fracture with plating provides better results. Out of 53 patients, 9 patients had post-operative complications. Average radiological union was seen at 14 weeks. Conclusion: Locking compression plate in proximal tibia plateau fractures act as a good biological fixation provide stable fixation, articular reduction and limb alignment even in difficult fracture situations. Fixation of proximal tibia plateau fractures with plate gives excellent to good knee society score, with satisfactory functional and radiological outcome.

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BACKGROUND: Unlike articular shear fractures of the distal radius, radiocarpal fracture-dislocations defined as complete dislocation of the lunate from its articular facet of the radius are relatively uncommon. The management principles of these fractures have not been defined and there is no consensus on approach to management of these injuries. The aim of this study is to review our series of radiocarpal fracture-dislocations and propose a radiographic classification to guide surgical management. METHODS: This study is reported based on STROBE guidelines. A total of 12 patients underwent open reduction and internal fixation. All the fracture-dislocations were dorsal and satisfactory objective outcomes achieved were comparable to literature. Injury morphology-specific management approach was used based on the size of dorsal lip fragment and the volar teardrop fragment attached to the short radiolunate ligament assessed by preoperative CT scans. RESULTS: All patients with known outcome (n = 10) went on to resume their prior occupation and hobbies that included high-demand activities and manual labour at mean follow-up of 27 weeks. Average wrist flexion was 43° and wrist extension was 41° while radial and ulnar deviation were 14° and 18° respectively. Average forearm pronation was 76° and supination was 64° at final follow-up. CONCLUSION: We describe four injury patterns of radiocarpal fracture-dislocations based on preoperative CT scans that guide fixation. We believe that early recognition of radiocarpal fracture-dislocations and appropriate management can yield satisfactory outcomes.

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PURPOSE: Volar locking plate fixation for distal radius fractures (DRFs) is a technically demanding procedure with a risk of distal screw penetration through the dorsal cortex or the articular surface. This study aimed to investigate the incidence and details of distal screw penetration after volar locking plate fixation for intra-articular DRFs using a CT scan and to evaluate the relationship between the incidence of screw penetration and fracture comminution severity and the clinical complications of screw penetration. METHODS: This was a retrospective case series of 91 adult patients (mean age, 63 years; 27 men) who underwent volar locking plate fixation for intra-articular DRFs from 2015 to 2018. The positioning of the distal screws was evaluated using a postoperative CT scan, and radiological outcomes were compared between the AO C1 and C3 groups. At the final follow-up, tendon rupture and arthritis severity were assessed as clinical complications of dorsal and intra-articular screw penetration. RESULTS: Distal screw penetration was observed in 44 wrists (48%), dorsal cortex screw penetration in 34, intra-articular screw penetration in 13, and both dorsal cortex and intra-articular screw penetration in three. The incidence of intra-articular screw penetration was significantly higher in the C3 group than in the C1 group. No tendon rupture was observed. Multivariable analysis revealed that intra-articular screw penetration was significantly related to high severity of arthritis. CONCLUSIONS: Approximately half of the study patients with intra-articular DRFs had distal screw penetration. The incidence of intra-articular screw penetration was associated with the severity of fracture comminution, and the intra-articular screw penetration was associated with the incidence of early radiocarpal arthritis. Intra-articularly penetrating screws should be replaced as soon as they are discovered, regardless of the length of penetrated screw or absence of patients' subjective symptoms. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

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