Innovative Callus Release Technique for Closed Reduction in Old Fractures: Case Studies and Methodology

Introduction

Current limb fracture management, especially in children, relies on image-guided closed reduction and percutaneous fixation of many types of fractures, including fractures of the neck of the radius, and most hand and foot fractures [1–4]. This protocol decreases morbidity and facilities postoperative recovery. Instead of extensive dissection of soft tissue around the fracture site, percutaneous techniques have unique advantages, including preservation of soft tissues, less blood loss, lower risk of complications, and minimal scar formation and stiffness, which enables earlier functional rehabilitation [5,6]. However, for late and old (missed or neglected) displaced fractures, closed reduction can be difficult or even impossible, and most cases need open reduction, which has higher rates of complications, as previously reported with open reduction of fracture neck of the radius [7].

Yin et al [8] presented a method of percutaneous callus release followed by dynamic distraction external fixation (DDEF) to manage delayed presentation fracture-dislocations of the proximal interphalangeal (PIP) joint and treated 3 patients with this manner. Recently, Wu et al [9] reported the treatment of 16 pediatric patients with supracondylar humeral fractures who presented ≥14 days after trauma. All cases were treated by closed reduction and percutaneous K wire fixation after undergoing a “percutaneous K wire drill-and-pry” operation. We used the same technique of callus release in 2 patients with old fractures – one in the radial neck and the other in the proximal phalanx of the little finger. The fractures were fixed after reduction by percutaneous K wires.

Case Reports

CASE 1:

A 10-year-old girl presented to our department 10 days after sustaining left elbow trauma. An above-elbow plaster splint was applied to her left upper limb at a peripheral hospital. She presented to our hospital for a second opinion 10 days after the trauma. Plain radiographs showed a fully displaced fracture of the neck of the left radius, Judet type III (Figure 1A). The posterior splint was removed and a trial of closed reduction under conscious sedation failed to achieve reduction. Her parents were counselled on the need for a trial of intraoperative closed reduction under general anesthesia, and if that failed, open reduction might be required, to be followed in either case by K wire fixation. Her father accepted the treatment plan and signed an informed consent form. Closed reduction in the operating room under general anesthesia failed to achieve reduction. We then tried reduction using the Metaizeau method [1], in which a K wire was inserted into the medullary canal of the radius from the distal radial metaphysis and was hammered upwards until its point reached the inferior surface of the displaced epiphysis. Unfortunately, the trial for manipulation of the displaced epiphysis under C-arm control failed. Therefore, 2 K wire were inserted percutaneously at the callus site and were used to fragment the early callus. The 2 percutaneous K wires with the help of the intra-medullary K wire were used to push the epiphysis into its correct anatomical position. The intramedullary K wire was used for fixation of the reduced epiphysis while the other 2 K wires were removed (Figure 1B, 1C). The elbow was fixed in 90 degrees of flexion on a posterior splint. Postoperative plain radiographs show excellent reduction of the radial head in its normal position (Figure 1D) The patient was discharged from the hospital after 24 hours and was followed up in the outpatient clinic by plain radiographs at 1, 2, 3, and 6 weeks after the operation. The intramedullary K wire was removed after 6 weeks. The patient received physiotherapy to achieve full elbow range of motion. Three months after the operation, she had full range of elbow flexion-extension, as well as full range of supination-pronation movements of the forearm, and plain radiographs showed fully healed and remodelled fracture callus (Figure 2A, 2B).

CASE 2:

A 50-year-old woman presented to the emergency department after right-hand trauma caused by a heavy object falling on her finger. On examination, there was severe tenderness, discoloration, and deformity of the right little finger, but the sensation and vascularity of the finger were intact. Plain radiographs showed a displaced fracture at the base of the proximal phalanx of the little finger. Closed reduction and cast immobilization were done and the anatomical position was seen as acceptable. She was lost to follow-up and presented 2 weeks after the original trauma with a fully displaced fracture (Figure 3). Closed reduction under ring anesthesia failed to achieve the correct anatomical positioning of the displaced fracture. Under general anesthesia, callus release was performed using a K wire inserted at the fracture site and used for fragmentation of the formed soft callus and reduction of the fracture (Figure 4A, 4B). Percutaneous fixation by 2 K wires was done (Figure 4C). Postoperative plain radiographs (Figure 5) showed excellent reduction and fixation of the fracture. The patient was discharged from the hospital after 24 hours and was followed up in the outpatient clinic by plain radiographs at 1 and 3 weeks after the operation. She received physiotherapy to achieve full range of motion of the little finger. Three months after the operation, she had full range of motion in all joints of the little finger.

Discussion

Using our technique of callus release, we were able to free the displaced fracture fragment from the early formed callus, which enables closed reduction of the fractured fragment to its original position. Percutaneous fixation in a good/excellent position was achieved by K wires. According to our hospital protocol, plain radiographs were sufficient to plan surgery and there was no indication for pre- or postoperative computed tomography (CT) scans. Both surgeries were performed under C-arm control.

Our cases have some similarities to the 3 patients with fracture-dislocations of the (PIP) joint reported by Yin et al [8], who were treated by callus release followed by external fixator application. However, because the nature of the fractures was different in our cases, percutaneous K wire fixation was the best option. In 2023, Wu et al [9], reported clinical outcomes of 16 patients who underwent closed reduction with percutaneous K wire drill-and-pry technique for the delayed treatment of pediatric patients with supracondylar humeral fractures who presented ≥14 days after trauma with bony callus formation. Our technique has similarities to techniques used by Yin et al [8], but none of their patients had fractures of the neck of the radius or fingers. Also, patient 2 in our report was an adult.

In case 1, after callus release, reduction of the fracture of the neck of the radius was achieved using the Metaizeau method [1], in which a K wire was inserted into the medullary canal of the radius from the distal radial metaphysis and hammered upwards until its point reached the inferior surface of the displaced epiphysis. Under C-arm control, the displaced epiphysis was manipulated to reduce it. As reduction was difficult with the intramedullary K wire alone, 2 percutaneous K wires were used to release the callus and push the epiphysis to its correct anatomical position. The intramedullary K wire was used for fixation of the reduced epiphysis [4,10].

Our report has limitations. First, it consists of only 2 cases from a single center. Second, the follow-up period was short. However, in some selected cases, percutaneous callus release of late fractures followed by percutaneous fixation by K wires is a promising technique as a salvage operation to avoid all the hazards of open reduction. From the previously reported cases in addition to our 2 cases, it seems that the technique is applicable in various peri-articular late, old, and displaced fractures in pediatric as well as adult patients. In conclusion, the technique of callus release followed by percutaneous K wire fixation for old displaced fractures of the radial neck and proximal phalanx of the little finger enables closed reduction and internal fixation of late-displaced fractures at these 2 periarticular locations.

Conclusions

The technique of callus release and closed reduction followed by percutaneous K wire fixation for late-displaced fractures of the radial neck and proximal phalanx of the little finger enables closed reduction and internal fixation of neglected displaced fractures at these 2 peri-articular locations. Further level 1 and 2 studies are needed on this topic.