[A 56-year-old patient with Gaucher's disease sustaining a pathologic subcapital fracture of the humerus]

We present a case of a pathologic humerus fracture in a patient with the initial diagnosis of Gaucher's disease, which is the most frequent form of lipidosis transmitted as an autosomal recessive trait. It often results in orthopaedic complications with pain, osteonecrosis, fractures and joint infractions. If there is cause for suspicion, beta-glucocerebrosidase in white blood cells should be measured because of the important consequences for treatment. Therapy with a modified enzyme is effective in managing the disease.

Lateral external fixation: a new surgical technique for displaced unreducible supracondylar humeral fractures in children

BACKGROUND: Percutaneous Kirschner wire fixation represents the classic treatment for displaced supracondylar humeral fractures in childhood. This type of treatment first requires satisfactory reduction of the fracture. Failure to achieve a satisfactory reduction or inadequate stabilization can result in instability of the fracture fragments, which can result in either an unsatisfactory cosmetic or functional outcome. In our experience, these problems can be overcome with the use of a small lateral external fixator. METHODS: Between 1999 and 2005, thirty-one of 170 Gartland type-III supracondylar humeral fractures were treated with a lateral external fixator. The outcome of treatment was analyzed with regard to limb alignment, elbow movement, cosmetic appearance, and patient satisfaction. RESULTS: In twenty-eight of the thirty-one patients, a satisfactory reduction was achieved with closed methods. All children except one had a normal or good range of movement. The cosmetic result was excellent in all cases. All of the children and their parents stated that they would choose this treatment again. CONCLUSIONS: The use of a small lateral external fixator seems to be a safe alternative for the treatment of displaced supracondylar fractures of the humerus when a closed reduction appears to be unattainable by means of manipulation alone or when sufficient stability is not achieved with standard methods of Kirschner wire fixation.

Treatment of posttraumatic cubitus varus in children and adolescents. Supracondylar humeral osteotomy using radial external fixation

OBJECTIVE Precise adaptable fixation of a supracondylar humerus osteotomy with a radial/lateral external fixator to correct posttraumatic cubitus varus. INDICATIONS Acquired, posttraumatic cubitus varus as a result of a malhealed and unsatisfactorily treated supracondylar humerus fracture. Idiopathic, congenital cubitus varus (very seldom) if the child (independent of age and after complete healing) is cosmetically impaired; stability of the elbow is reduced due to malalignment (hyperextension); secondary problems and pain (e. g., irritation of the ulnar nerve) are expected or already exist; or there is an explicit wish of the child/parents (relative indication). CONTRAINDICATIONS In principle there are no contraindications provided that the indication criteria are filled. The common argument of age does not represent a contraindication in our opinion, since angular remodeling at the distal end of the humerus is practically nonexistent. SURGICAL TECHNIQUE Basically, the surgical technique of the radial external fixator is used as previously described for stabilization of complex supracondylar humeral fractures. With the patient in supine position, the arm is placed freely on an arm table. Using a 4-5 cm long skin incision along the radial, supracondylar, the extracapsular part of the distal humerus is prepared, whereby great caution regarding the radial nerve is advised. In contrast to the procedure used in radial external fixation for supracondylar humeral fracture treatment, two Schanz screws are always fixed in each fragment at a distance of 1.5-2 cm. The osteotomy must allow the fragment to freely move in all directions. The proximal and distal two Schanz screws are then connected with short 4 mm carbon or stainless steel rods. These two rods are connected with each other over another rod using the tub-to-tub technique. Now the preliminary correction according the clinical situation can be performed and the clamps are tightened. Anatomical axis and function are checked. If these are radiologically and clinically perfect, all clamps are definitively tightened; if the alignment or the function is not perfect, then further adjustments can be made. POSTOPERATIVE MANAGEMENT Due to the excellent stability, further immobilization not necessary. Immediate functional follow-up treatment performed according to pain. RESULTS Adequate healing is usually expected within 6 weeks. At this time the external fixator can be removed in the fracture clinic. Because the whole operation is performed in an extraarticular manner and the mobility of the elbow is not affected, deterioration of function has never been observed. Also regarding the cosmetic/anatomical situation, good results are expected because they were already achieved intraoperatively.

[The AO/ASIF Flexnail : A flexible intramedullary nail for the treatment of humeral shaft fractures]

BACKGROUND: The use of conventional implants for intramedullary nailing of humeral shaft fractures is associated with specific difficulties. During antegrade implantation structures of the rotator cuff can be affected leading to a reduced functional result of the shoulder. If the nail is implanted in a retrograde manner problems arise due to a relatively large hole close to or within the olecranon fossa, which is necessary for insertion of the nail. Supracondylar fractures as well as persistent elbow pain and loss of function are reported in the literature. To overcome these disadvantages a flexible nail has been developed that can be stiffened and locked after implantation. METHOD: Between October 2000 and February 2002, 34 patients were treated with the flexible nail at our institution; 29 were available for follow-up. Fracture healing was documented on radiographs and clinical outcome was evaluated with use of the Constant as well as the Kwasny score. RESULTS: Median duration until fracture consolidation was 10 weeks. In two patients fracture union was not achieved within the follow-up period. The median outcome measured with the Constant score was 93 points and 2.5 with the Kwasny score. Both values correspond to a very good functional outcome. CONCLUSION: We conclude that the flexible humeral nail is an excellent treatment option for humeral shaft fractures. Damage to the rotator cuff and the distal humerus can be avoided due to its unique flexible construction, improving the functional outcome of intramedullary nailing for the treatment of humeral shaft fractures.

Remaining lifetime and absolute 10-year probabilities of osteoporotic fracture in Swiss men and women

SUMMARY: Remaining lifetime and absolute 10-year probabilities for osteoporotic fractures were determined by gender, age, and BMD values. Remaining lifetime probability at age 50 years was 20.2% in men and 51.3% in women and increased with advancing age and decreasing BMD. The study validates the elements required to populate a Swiss-specific FRAX model. INTRODUCTION: Switzerland belongs to high-risk countries for osteoporosis. Based on demographic projections, burden will still increase. We assessed remaining lifetime and absolute 10-year probabilities for osteoporotic fractures by gender, age and BMD in order to populate FRAX algorithm for Switzerland. METHODS: Osteoporotic fracture incidence was determined from national epidemiological data for hospitalised fractured patients from the Swiss Federal Office of Statistics in 2000 and results of a prospective Swiss cohort with almost 5,000 fractured patients in 2006. Validated BMD-associated fracture risk was used together with national death incidence and risk tables to determine remaining lifetime and absolute 10-year fracture probabilities for hip and major osteoporotic (hip, spine, distal radius, proximal humerus) fractures. RESULTS: Major osteoporotic fractures incidence was 773 and 2,078 per 100,000 men and women aged 50 and older. Corresponding remaining lifetime probabilities at age 50 were 20.2% and 51.3%. Hospitalisation for clinical spine, distal radius, and proximal humerus fractures reached 25%, 30% and 50%, respectively. Absolute 10-year probability of osteoporotic fracture increased with advancing age and decreasing BMD and was higher in women than in men. CONCLUSION: This study validates the elements required to populate a Swiss-specific FRAX model, a country at highest risk for osteoporotic fractures.

Radialer externer Fixateur zur geschlossenen Behandlung problematischer suprakondylärer Humerusfrakturen Typ III und IV bei Kindern und Jugendlichen

Operationsziel Geschlossene, anatomische Reposition und sichere Fixation von problematischen suprakondylären Typ-III- und Typ-IV-Humerusfrakturen, die mit den herkömmlichen Operationsmethoden nur schwierig geschlossen zu behandeln sind. Indikationen Gemäß der AO-Kinderklassifikation der suprakondylären Humerusfrakturen vom Typ III und IV: Frakturen, welche nicht geschlossen mittels üblicher Repositionsmethoden reponierbar sind sowie Frakturen, die nicht mittels der üblichen, gekreuzten perkutanen Kirschner-Draht-Technik zu fixieren sind. Bei schweren Schwellungszuständen, offener Fraktur oder initial neurologischen und/oder vaskulären Problemen („pulseless pink hand“) sowie bei mehrfachverletzten Kindern, welche eine optimale Rehabilitation benötigen und die Extremität gipsfrei sein sollte. Bei Kindern mit Komorbiditäten (z. B. Anfälle, Spastizität), die eine bessere Stabilität benötigen. Kontraindikationen Prinzipiell keine Kontraindikationen Operationstechnik Im nichtreponierten Zustand unter Durchleuchtungskontrolle Einbringen einer einzelnen Schanz-Schraube in den lateralen (radialen) Aspekt des distalen Fragments, welches sich in der streng seitlichen Röntgenprojektion als „Sand-Uhr“- bzw. Kreisform des Capitulum humeri darstellt. Je nach Größe dieses distalen Fragments kann die Schanz-Schraube rein epiphysär oder metaphysär liegen. Danach in absolut streng seitlicher Projektion des distalen Humerus im Bereich des meta-diaphysären Übergangs Einbohren einer 2. Schanz-Schraube unabhängig von der Ersten, die möglichst rechtwinklig zur Längsachse des Humerus in der a.-p.-Ebene zu liegen kommen sollte, um spätere Manipulationen mittels „Joy-Stick“-Technik zu erleichtern. Sind die beiden Schanz-Schrauben mehr oder weniger in beiden Ebenen parallel, so ist die Fraktur praktisch anatomisch reponiert. Nach erreichter Reposition Feinjustierung aller Achskomponenten. Sicherung der Flexion/Extension mittels einem von radial, distal eingebrachten sog. Anti-Rotations-Kirschner-Drahts, der die Stabilität signifikant erhöht und eine Drehung des distalen Fragments um die einzelne Schanz-Schraube verhindert. Postoperative Behandlung Keine zusätzliche Gipsruhigstellung notwendig. Es sollte eine funktionelle Nachbehandlung erfolgen. Ergebnisse Gemäß unserer Langzeitstudien bewegen die meisten Kinder bereits zum Zeitpunkt der ambulanten Pin-Entfernung in der Frakturambulanz ihren Ellbogen weitgehend normal. Bei einer Follow-up-Zeit über 40 Monate hatten 30/31 Kindern eine seitengleiche Achse und Beweglichkeit.

FRAX® assessment of osteoporotic fracture probability in Switzerland

A Swiss-specific FRAX model was developed. Patient profiles at increased probability of fracture beyond currently accepted reimbursement thresholds for bone mineral density (BMD) measurement by dual X-ray absorptiometry (DXA), and osteoporosis treatment were identified.

Teeth restored using fiber-reinforced posts: in vitro fracture tests and finite element analysis

In dentistry the restoration of decayed teeth is challenging and makes great demands on both the dentist and the materials. Hence, fiber-reinforced posts have been introduced. The effects of different variables on the ultimate load on teeth restored using fiber-reinforced posts is controversial, maybe because the results are mostly based on non-standardized in vitro tests and, therefore, give inhomogeneous results. This study combines the advantages of in vitro tests and finite element analysis (FEA) to clarify the effects of ferrule height, post length and cementation technique used for restoration. Sixty-four single rooted premolars were decoronated (ferrule height 1 or 2 mm), endodontically treated and restored using fiber posts (length 2 or 7 mm), composite fillings and metal crowns (resin bonded or cemented). After thermocycling and chewing simulation the samples were loaded until fracture, recording first damage events. Using UNIANOVA to analyze recorded fracture loads, ferrule height and cementation technique were found to be significant, i.e. increased ferrule height and resin bonding of the crown resulted in higher fracture loads. Post length had no significant effect. All conventionally cemented crowns with a 1-mm ferrule height failed during artificial ageing, in contrast to resin-bonded crowns (75% survival rate). FEA confirmed these results and provided information about stress and force distribution within the restoration. Based on the findings of in vitro tests and computations we concluded that crowns, especially those with a small ferrule height, should be resin bonded. Finally, centrally positioned fiber-reinforced posts did not contribute to load transfer as long as the bond between the tooth and composite core was intact.

Surgical hip dislocation for osteochondral transplantation as a salvage procedure for a femoral head impaction fracture

Obturator anterior hip dislocation is very rare. Poor results are described in patients with additional large transchondral fractures and treatment of these injuries remains challenging. Appropriate treatment recommendations are missing in the literature. This case report introduces surgical hip dislocation for osteochondral autograft transplantation with graft harvest from the nonweightbearing area of the head-neck junction as a salvage procedure in a large femoral head defect. We report the treatment and outcome of a 48-year-old man who sustained an anterior dislocation of the left hip after a motorcycle accident. After initial closed reduction in the emergency room, imaging analysis revealed a large osteochondral defect of the femoral head within the weightbearing area (10 × 20 mm, depth: 5 mm). The hip was exposed with a surgical hip dislocation using a trochanteric osteotomy. An osteochondral autograft was harvested from a nonweightbearing area of the femoral head and transferred into the defect. The patient was prospectively examined clinically and radiologically. Two years postoperatively, the patient was free of pain and complaints. The function of the injured hip was comparable to that of the contralateral, healthy hip and showed satisfying radiologic results. Surgical hip dislocation with a trochanteric flip osteotomy is a simple, one-step technique that allows full inspection of the hip to treat osteochondral femoral defects by osteochondral transplantation. The presented technique, used as a salvage procedure in a large femoral head defect, yielded good clinical and satisfying radiologic outcomes at the midterm.

[Intramedullary claw for stabilization of proximal humerus fractures: a comparison with other semirigid techniques]

Proximal humerus fractures (pHF) are common. In this retrospective study intra-operative and postoperative data and complications of patients stabilized with conventional semirigid techniques (pins, n=30; helix wire, n=19) or a novel semirigid technique, the intramedullary claw (IMC, n=82) were compared. The type and frequency of postoperative complications differed between the groups (p<0.001). The IMC is a novel semirigid technique to stabilize pHF and seems to result in fewer complications than pins or helix wire. The frequency and relevance of a loss of repositioning in patients after IMC implantation need to be elucidated in long-term studies.

Fracture hospitalizations between years 2000 and 2007 in Switzerland: a trend analysis

In Switzerland, the total number and incidence of hospitalizations for major osteoporotic fractures increased between years 2000 and 2007, while hospitalizations due to hip fracture decreased. The cost impact of shorter hospital stays was offset by the increasing cost per day of hospitalization.