Historically rib fractures have been managed conservatively but over recent years evidence has continued to grow in support of fixation in select cases. Rib fractures can affect patients’ ability to adequately ventilate and increase the morbidity and mortality of patients with multiple injuries. There is increasing evidence that rib fracture fixation in certain patients is of benefit, reducing length of stay both in the Intensive Care Unit (ICU) and overall hospital stay, as well as resulting in a decreased rate of tracheostomy and pneumonia. We commenced rib fracture fixation two years ago as a combined procedure between Trauma Orthopaedics and Cardiothoracic surgery for carefully identified patients. We instituted a multi-disciplinary decision making process involving the Orthopaedic, Cardiothoracic and ICU teams. We present the initial results for these patients. Fourteen patients with a total of 49 ribs were fixed between November 2015 and August 2017. Nine patients were acute and multiply injured, with five patients treated with delayed fixation for ventilation problems following non-union of existing fractures. The average length of stay was 13 days. Follow up is ongoing with a mean follow up of 192 days. There have been no deep infections or acute complications and no incidence of peri-operative pneumothorax in this initial cohort. There have been no deaths, and all of these patients have since been discharged to their own home. The initial outcomes following the introduction of this new procedure to our unit have been encouraging, although the long term results are awaited.
Despite the variety of implants or techniques that exist to treat displaced distal radial fractures, the majority fail to provide sufficient stability to permit early functional recovery. However, locking plates have the advantage over other implants in that locking screws add considerably to the overall stability. The aim of this study was to assess the functional outcome of patients with displaced distal radial fractures treated with a volar distal radial locking plate (Synthes). During a two year period, details of 98 patients admitted to our unit with inherently unstable dorsally displaced distal radial fractures treated with volar locking plates were collected prospectively. For the purpose of this analysis, only those patients (55) with unilateral fracture, able to attend the study clinic at 6 months post-injury were considered. Patients were immobilised in wool and crepe for a 2 week period. The group consisted of 15 males and 40 females with an average age of 54 (28 to 83). At 6 months, patients' perceived functional recovery averaged 80%. Objective assessment was considered in relation to the uninjured side: grip strength 73%; pinch strength 83%; palmarflexion 77%, dorsiflexion 80%; radial deviation 74%; ulnar deviation 74%; pronation 93%, and supination 92%. Seven patients complained of symptoms relating to prominent metalwork. Good/excellent early subjective and objective functional recovery was made following open reduction and internal fixation using volar locking plates of dorsally displaced distal radial fractures. We suggest that objective assessment of grip strength and dorsiflexion can be used as a measure of patient perception of function.
Chondrosarcoma is an uncommon primary malignancy of cartilage. This tumour tends to be resistant to both chemotherapy and radiotherapy making surgical resection the primary treatment. These tumours can present on the chest wall, requiring multidisciplinary team input at the time of surgery, involving orthopaedic, cardiothoracic and plastic surgeons. Complete excision, ensuring adequate resection margins, requires removal of ribs and pleura resulting in a full thickness chest wall defect. Complex reconstruction techniques are necessary to prevent post-operative morbidity of chest wall indrawing and reduced pulmonary function. Reconstruction can be considered in two parts, the reconstruction of the rigid support and the necessary soft tissue cover. In the past a number of options have been available to provide the rigid support, marlex sandwich, prolene mesh and autologous bone grafting. Each of these techniques has potential disadvantages. We describe two patients who underwent resection of chest wall chondrosarcomas. These patients had reconstruction of the rigid chest wall support using STRATOS (STRASBOURG Thoracic Osteosyntheses System). This system utilises clamps around the cut ends of the ribs to provide the necessary rigid support, eliminating some of the disadvantages of the older techniques. Both patients made an uncomplicated post-operative recovery. The STRATOS implant was easily used and versatile, providing an immediately secure and rigid fixation in chest wall reconstruction.
Five patients with recurrent disease were treated prior to establishment of the sarcoma network. Two patients, before the establishment of the network underwent resection and staging in another unit and the exact time to recurrence is unknown. One patient is currently under investigation for recurrence. The average time to recurrence was 29.2 months (Range 12–48 months). Three of the five patients with original pathology available had complete resection with mean margins of 6.25mm (range 5–7.5mm). Two had incomplete excisions carried out by other specialities, only presenting to our unit with recurrent disease.
