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CÍL PRÁCE: Zlomeniny metakarpu patří mezi velmi časté úrazy ruky. Cílem této práce je zhodnotit naše zkušenosti s použitím zevního fixátoru. MATERIÁL A METODY: Od února 2009 do listopadu 2012 bylo 60 pacientů se subkapitální zlomeninou a zlomeninou diafýzy V. metakarpu léčeno s použitím zevního fixátoru Ellis mini-fixator (LINK, Hamburg, Německo). Do studie bylo zařazeno 5 žen a 55 mužů. Průměrný věk v době operace byl 29 let (od 14 do 96 let). Zevní fixátor je tvořen originálními Kirschnerovými dráty (K-dráty) se závitem a tyto jsou spojeny tělem fixátoru. Dva K dráty byly umístěny do distálního fragmentu, dva do proximálního fragmentu a po zavřené repozici byly propojeny tělem fixátoru. Ve všech případech byla zajištěna náležitá pooperační péče. Pooperační kontroly zahrnovaly klinické a radiografické hodnocení. VÝSLEDKY: Zevní fixátor byl ambulantně odstraněn průměrně za 8 týdnů (od 6 do 12 týdnů). V průběhu kontrol byly zaznamenány 2 typy komplikací. V pěti případech (8,3 %) byla zaznamenána pin track infekce, která byla zcela vyhojena po odstranění fixátoru v kombinaci s perorálním podáním antibiotik. Druhým typem zaznamenané komplikace byla refraktura. Ta se vyskytla v jednom případě (1,6 %), čtyři měsíce po odstranění fixátoru. ZÁVĚR: Mezi hlavní výhody použití zevního fixátoru Ellis v léčbě zlomenin metakarpů patří miniinvazivita, jednoduché odstranění osteosyntetického materiálu, nízké ekonomické náklady a nižší riziko poškození šlach než při otevřené osteosyntéze. Naše zkušenost s použitím fixátoru jsou uspokojivé, výskyt komplikací nepřesahuje počet komplikací udávaných v literatuře.

INTRODUCTION: Metacarpal fractures are the most common injuries of the hand. The aim of this study is to presented our experience with the external fixator. MATERIALS AND METHODS: From February 2009 to November 2012 we treated 60 patients with subcapital or diaphyseal fifth metacarpal closed fractures by using external fixator according to Ellis (Link, Hamburg, Germany). There were 5 women and 55 men. Average age at the time of surgery was 29 years (range from 14 to 96). The external fixation was provided by original K-wires with thread placed transversely through the fractured metacarpal. Two K-wires were placed to the distal fragment of the fracture and other two K-wires were inserted in the proximal fragment. The wires were connected with the body of fixator. Appropriate post-operative care about external fixator was regularly provided. RESULTS: The external fixator was remove in outpatient ward after 8 weeks on average (range, 6 to 12). Two types of complication occured. Superficial pin track infection was found in five cases (8,3 %). In these cases were antibiotics administered orally. The infection spontaneously resolved after fixator removal after bone healing. The second complication we observed was refracture. The refracture after removal of external fixation was observed in one case (1,6 %). CONCLUSIONS: The advantages of the treatment of metacarpal fractures with external fixation are less invasivity, simple removal of the osteosynthetic material, low economy cost and the lower risk of the injury of tendons. Our experience is satisfying and the incidence of complication is comparable literature sources.

Článek

Inveterované zadní glenohumerální luxace a jejich operační řešení předním přístupem
[Inveterated posterior glenohumeral dislocation treated surgically from the anterior approach]

Acta chirurgiae orthopaedicae et traumatologiae Čechoslovaca. 2011 ; 78 (1) : 34-40.

Medvik
Zdroj

PURPOSE OF THE STUDY The aim of the study is to remind the medical community of the occurrence of rare dorsal glenohumeral dislocations and of the need to pay increased attention to radiographic and clinical examination in the patients in whom signs of this injury are also supported by medical history. When this dislocation becomes a chronic disorder, it can frequently be managed only by surgical intervention. The treatment algorithm used at the authors' institutions is described. MATERIAL In the period from 2000 to 2008, a total of 17 patients (9 women and 8 men) with an average age of 65.5 years (51 to 89 years) had surgery for inveterated dorsal glenohumeral dislocation. The average injury-surgery interval was 5.6 weeks (1 to 18 weeks). The average follow-up was 38 months (101 to 13 months). METHODS Surgery was performed via an anterior deltoideopectoral approach. Under pathological conditions, the subscapular muscle was identified. When a large reverse Hill-Sachs defect was present, the lesser tuberosity with the subscapular tendon was osteomited (10 patients). After scar and granulation tissue had been removed, the humeral head was reduced. Using Neer's modification of the McLaughlin procedure, the excised lesser tuberosity fragment was transfered into the anteromedial defect in the humeral head and fastened with a screw. In the case of an unstable humeral head, this was held in the reduced position by two Kirschner wires either passed through the acromion or fixed to the glenoid (11 patients). The arm was immobilized in a brace for four weeks. Then the wires were removed and rehabilitation was started with avoidance of internal rotation. RESULTS None of the patients had recurrent dislocation. All were satisfied with the outcome and capable of resuming their daily activities sufficiently. Six patients complained of occasional pain. The average value of active elevation was 113° (40° to 160°). Reduced muscle strength in abduction, as compared with the contralateral arm, was observed in two patients. Injury to the axillary vein was recorded in one patient. Two patients had a large haematoma of the arm with swelling of the whole extremity. Two of the 11 patients treated with Kirschner wires developed infection around the wires that healed after their removal at four weeks after surgery. DISCUSSION The open reduction and stabilization of a posterior inveterated glenohumeral dislocation can be regarded as a rare procedure performed only occasionally even in specialized institutions. The international literature also provides information on only a few tens of such cases over a number of years. Causal procedures, performed through both an anterior and posterior approach, as well as extrafocal (rotational) osteotomy have been recommended. Currently, surgery from an anterior approach is preferred, because a reverse Hill-Sachs defect, if present, can be managed either by transfer of the lesser tuberosity with the subscapular tendon or by massive allograft. CONCLUSIONS The authors' experience suggests that Neer´s modification of the McLaughlin procedure is the optimal treatment for posterior inveterated glenohumeral dislocation with an anteromedial defect of the humeral head. The excision of the lesser tuberosity with the subscapular tendon provides good access to the shoulder joint and thus allows for its reliable reduction. The fastening of a tuberosity fragment into the compression defect resolves one of the major risks for recurrent dislocation, without necessity to use allogenic material. Transfixation of the humeral head with Kirschner wires for four weeks is a reliable method of holding the head in the glenoid without risk of significantly restricting shoulder motion in the future.