Complications of intra-articular fractures of the calcaneus

Most complications of calcaneal fractures are due to the combination of the dynamic nature and the mechanism of the injury itself. Complications are usually secondary to three integral parts of this complex fracture pattern: 1) fracture and depression of the subtalar joint, 2) loss of the height of the calcaneal body with varus rotation, and 3) expansion of the lateral wall of the calcaneus. Other complications occur with less frequency. This article describes the complications and sequelae of old, malunited intra-articular calcaneal fractures in relation to the nature and the components of these unique fractures.

Transcranial Motor Evoked Potential Recording in a Case of Kernohan's Notch Syndrome: Case Report

OBJECTIVE AND IMPORTANCE

Compression of the cerebral peduncle against the tentorial incisura contralateral to a supratentorial mass lesion, the so-called Kernohan-Woltman notch phenomenon, can be an important cause of false localizing motor signs. Here, we demonstrate a case in which clinical, radiological, and electrophysiological findings were used together to define this syndrome.

CLINICAL PRESENTATION

A 21-year-old man sustained a left temporal depressed cranial fracture from a motor vehicle accident. Serial computed tomographic examinations demonstrated no evolution of hematomas or contusions, and he was managed nonsurgically with ventriculostomy for intracranial pressure control. Throughout his course in the neurosurgical intensive care unit, he displayed persistent left hemiparesis.

INTERVENTION

Further radiological and electrophysiological studies were undertaken in an attempt to explain his left hemiparesis. Brain magnetic resonance imaging demonstrated T2 prolongation in the central portion of the right cerebral peduncle extending to the right internal capsule. Electrophysiological studies using transcranial electrical motor evoked potentials revealed both a marked increase in voltage threshold, as well as a reduction in the complexity of the motor evoked potential waveform on the hemiparetic left side. This contrasted to significantly lower voltage threshold as well as a highly complex motor evoked potential waveform recorded on the relatively intact contralateral side.

CONCLUSION

This is the first time that clinical, radiological, and electrophysiological findings have been correlated in a case of Kernohan's notch syndrome. Compression of the contralateral cerebral peduncle against the tentorial incisura can lead to damage and ipsilateral hemiparesis. The anatomic extent of the lesion can be defined by magnetic resonance imaging and the physiological extent by electrophysiological techniques.

Management of ipsilateral pilon and calcaneal fractures: a report of 2 cases

Although uncommon, the management of ipsilateral pilon and calcaneal fractures is a challenging problem for foot and ankle surgeons. There are several issues that may affect the outcome. Aside from damage to the soft-tissue envelope, technical issues such as positioning of the patient, application of traction, and tourniquet time may complicate surgical intervention. The authors present their experience with 2 patients who sustained this fracture pattern and highlight the mechanism, management, and possible complications of these injuries.

Trochanteric osteotomy for incarcerated hip dislocation due to interposed posterior wall fragments

A series of 12 patients was retrospectively reviewed to evaluate the use of sliding trochanteric osteotomy for reduction of hip dislocations that were irreducible due to interposed posterior wall fragments. Compared to similar patients who did not have irreducible dislocation or trochanteric osteotomy, the 12 patients had significantly longer operations with more blood loss. Patients with osteotomy tended toward a higher incidence of posttraumatic arthritis, but Harris hip scores at 2 years were identical to matched comparisons. No adverse effects of trochanteric osteotomy were identified.

Use of Wagner cementless self-locking stems for massive bone loss in hip arthroplasty

OBJECTIVE

To assess the use of Wagner cementless self-locking stems for massive bone loss in hip arthroplasty.

METHODS

22 patients with severe proximal femoral bone loss either due to prosthetic loosening or comminuted fracture were treated by Wagner cementless self-locking revision stems between November 1993 and June 1995.

RESULTS

Radiographic evidence of early bony incorporation was found by 1 month in most cases. At a mean follow-up of 7.1 years, the mean Harris hip score increased from 30 to 84 points. It was less than 80 points in 4 patients, 2 of whom experienced severe thigh pain due to marked progressive subsidence of the stems (by 13 mm and 20 mm), which were revised 2 and 3 years later respectively.

CONCLUSION

Implantation of a Wagner cementless self-locking revision stem provided satisfactory results for 82% of patients. Hence, in some difficult conditions, this device is a good choice of management.

Primary fusion as salvage following talar neck fracture: a case report

For a 29-year-old man with a three-week-old Hawkins Type IV talar neck fracture, intra-operative reduction and fixation were not possible due to soft tissue contractures and severe comminution. A primary talonavicular and subtalar arthrodesis with the use of iliac crest bone graft was performed. Postoperative follow-up at 16 months demonstrated solid fusions, no avascular necrosis of the talus and a functional range of motion at the ankle. He was not capable of returning to his job of roof maintenance.

Sonography of ankle tendon impingement with surgical correlation

OBJECTIVE

This report describes sonography of ankle tendon impingement due to osteophytes, fracture fragments, and orthopedic hardware.

CONCLUSION

Sonography can be helpful in identifying ankle tendon impingement due to osteophytes, fracture fragments, and orthopedic hardware. In such cases, dynamic sonography can aid assessment.

Severe Lisfrancs injuries: primary arthrodesis or ORIF?

Twenty-eight patients, with severe, acute Lisfranc dislocations, requiring operative intervention, were treated between 1989 and 1992 in a level one Trauma Center. Different treatment protocols were used by the two senior staff surgeons. This allowed ORIF to be compared to complete arthrodesis and partial arthrodesis. Twelve patients were treated with primary arthrodesis after open reduction of the dislocation. Partial (5) or complete arthrodesis (6) (depending on the type of fracture) was performed in these 12 patients. Sixteen patients were treated with open reduction and temporary fixation with stabilization and compression screw fixation (ORIF group). The subgroups were identical in age (mean 30.5 years), follow-up (30.1 months), type of fracture, type of injury and time to intervention. Anatomical reduction was achieved in eight of the 12 patients in the arthrodesis groups and in 12 of the 16 patients in the ORIF group. The Baltimore Painful foot Score (PFS) was higher in the ORIF group then in the complete arthrodesis group meaning the ORIF group had less pain. No difference in the PFS was found between the ORIF group and the partial arthrodesis group. Subsequent revision surgery was necessary in two cases in the arthrodesis groups and two cases in the ORIF group. Stiffness of the forefoot, loss of metatarsal arch, and sympathetic dystrophy occurred more frequently in the complete arthrodesis group. Open reduction and internal fixation with screws or partial arthrodesis is the treatment of choice in severe tarsometatarsal fracture dislocations. Primary complete arthrodesis should be reserved as a salvage procedure.

[Inferior subluxation of humerus after surgery of fractures of proximal humerus]

Posttraumatic inferior subluxation of the humerus can be a possible cause of nerve injury and is therefore an alarming symptom. Etiology and frequency of subluxation after surgery of fractures of proximal humerus in group of 53 patients, including 4 cases of nerve injuries were studied. X-rays performed during treatment of this patients were analyzed. We confirmed high rate (41.5%) of this subluxation in our patients, 4 times more often in comminuted fractures, as result of deltoid atony, impaction of bony fragments and distention of the joint by hematoma. Surgical trauma and heavy cast immobilization were additional factors. We remarked after bone plating subluxation more frequent (62.5-75%) and duration longer than after nailing (13.6-34%). We concluded subluxation is secondary to many factors, needs meticulous evaluation for excluding injury of nerves, and for avoiding surgical trauma and cast immobilization should be minimized.

Conjoined fracture-dislocation of the forearm at the elbow

Conjoined fracture-dislocation of the elbow were first described by Marotte in 1982. In this study, a total of 41 patients treated between 1975 and 1995 at the Rizzoli Orthopaedic Institute and 4 patients treated between 1997 and 2000 at the Division of Orthopaedics at the Maggiore Hospital are evaluated. Based on the Marotte classification, the patients are divided into 4 groups, by site of dislocation of the radial capitellum and amount of comminution of the fracture of the ulna. A clinical and radiographic evaluation was made after a mean follow-up of 5.3 years based on Anderson criteria. The results obtained were excellent in 17 patients (37.8%) satisfactory in 13 (28.9%), dissatisfactory in 12 (26.7%); 3 patients were considered to be failures (6.7%), the best results were obtained in type I anterior dislocations.

Transcalcaneal talonavicular dislocation

BACKGROUND

The combination of dorsal dislocation of the navicular from the talus and an associated comminuted fracture of the calcaneus (transcalcaneal talonavicular dislocation) is an unusual and severe injury. Six cases have been described previously. The purposes of this study were to report the prevalence of this injury and the variations in injury pattern and to characterize methods of treatment and patient outcomes.

METHODS

Eight patients with nine cases of transcalcaneal talonavicular dislocation were treated by the senior author between January 1, 1990, and February 28, 1998. The comminuted fracture of the calcaneus was apparently caused by plantar flexion of the talus through the anterior portion of the calcaneus. There were five open Grade-III injuries and three associated lacerations of the posterior tibial artery. After initial provisional stabilization of the hindfoot and management of the soft tissues, all injuries were treated with delayed open reduction and internal fixation of the calcaneus and fusion of the subtalar joint. At the last follow-up examination, the outcomes were rated with the Maryland foot score, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot rating score, and the Creighton-Nebraska score for all patients who had not had an amputation.

RESULTS

The duration of follow-up ranged from 1.1 to eight years. Chronic osteomyelitis developed in four patients, and three of them ultimately had an amputation. The Creighton-Nebraska scores for the remaining six feet ranged from 33 to 92 points, with only one having a good or excellent result. Five of the six patients had a limp, difficulty with shoe wear, limitation with regard to walking, and moderate pain.

CONCLUSIONS

Transcalcaneal talonavicular dislocation is a severe injury that often leads to osteomyelitis and amputation. Patients who do not lose the leg as a result of uncontrolled infection should be counseled to expect severe functional limitations and/or chronic pain.

Contamination of ballistic fractures: an in vitro model

This study allowed the development of an in vitro model of a high-energy ballistic fracture. Direct fractures are more heavily contaminated than indirect fractures, and the spread of contamination is more extensive than examination of the wounds, particularly the entry wounds, would suggest. The major spread of contamination is along tissue planes, and we would recommend that these are thoroughly lavaged in the management of the fracture. The fracture site is heavily contaminated, with endosteal spread in direct fractures. However, there appears to be relatively little bony contamination beyond the fracture site.

[Brachial plexus injury due to unhealed or wrongly healed clavicular fracture]

Two men, aged 65 and 27 years, had persistent dysesthesia of digits IV and V 18 and 8 months, respectively, after conservative treatment of dislocated comminuted clavicular fractures. In both patients, the fracture was found to have healed poorly. There was pseudoarthrosis, shortening and malrotation. Following surgical decompression of the neurogenic structures by elongation and internal fixation of the clavicle, motor and sensory functions recovered completely. The incidence of clavicular fractures is high, but complications are rare. Symptom recognition and timely treatment can prevent irreversible nerve damage.

Proximal ulna shaft fractures and associated compartment syndromes

In 1996, 6 (7%) of 84 ulna shaft fractures treated at our institution developed compartment syndrome. These 6 isolated, comminuted, proximal-third ulna fractures were secondary to low-velocity gunshot (5) or high-velocity blunt trauma (1). The 5 gunshot-induced fractures did not initially require immediate surgical intervention, but increasing compartment pressure prompted fasciotomy and open reduction and internal fixation. The blunt trauma fracture developed compartment syndrome while the patient awaited surgery; emergent fasciotomy and open reduction and internal fixation were performed. Three patients had vascular injury (interosseus system). The orthopedist must have a high index of suspicion for compartment syndrome in association with isolated, comminuted, proximal-third ulna fractures.

Broad ligament hematoma causing fetal death in a case of fracture pelvis

Although motor ventricular accidents complicates 6-7% of all pregnancies, the experience of pelvic fractures in near term gravid patients is limited. We present a unique case of fetal death caused by bilateral broad ligament hematomas following maternal pelvic fracture which improved our understanding of management of such cases.

Long-term physical impairment and functional outcomes after complex facial fractures

To develop an understanding of the expected functional outcomes after facial trauma, a retrospective cohort study of patients with complex facial fractures was conducted. A cohort of adults aged 18 to 55 years who were admitted to the R. Adams Cowley Shock Trauma Center between July of 1986 and July of 1994 for treatment of a Le Fort midface fracture (resulting from blunt force) was retrospectively identified. Outcomes of interest included measures of general health status and psychosocial well being in addition to self-reported somatic symptoms. General health status was ascertained using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). The Body Satisfaction Scale was used to define patient concerns about altered body image and shape. To determine whether complex maxillofacial trauma and facial fractures contributed to altered social interactions, the Social Avoidance and Distress scale was used. In addition, information about a patient, his or her injury, and its treatment were ascertained from the medical records. Using the methods described above, 265 patients with Le Fort fractures were identified. These individuals were matched to a similar group of 242 general injury patients. A total of 190 of the Le Fort patients (72 percent of those eligible for the study) and 144 (60 percent) general injury patients were successfully located, and long-term interview data were acquired.Le Fort fracture patients as a group had similar health status outcomes when compared with the group of general injury patients. However, when outcomes were examined by the complexity of the Le Fort fracture, the authors found that study subjects with severe, comminuted Le Fort injuries (group D) had significantly lower SF-36 scores (worse outcomes) for the two dimensions related to role limitations: role limitations due to physical problems and role limitations due to emotional problems (p < 0.05). SF-36 scores for all other dimensions except physical function were also lower for comminuted versus less complex Le Fort fractures, although differences were not statistically significant.Specifically, there was a direct relationship between severity of facial injury and patients reporting work disability. Of group C and D Le Fort patients (severely comminuted fractures) only 55 and 58 percent, respectively, had returned to work at the time of follow-up interview. These figures are significantly lower than the back-to-work percentage of patients with less severe facial injury (70 percent). When study participants were asked if they were experiencing specific somatic symptoms at the time of the interview that they had not experienced before the injury, a significantly larger percent of the Le Fort fracture patients (compared with the general injury patients) responded in the affirmative. Differences between the Le Fort fracture and general injury groups were statistically significant (p < 0.05) for all 11 symptoms. The percentage of patients reporting complaints increased with increasing complexity of facial fracture in the areas of visual problems, alterations in smell, difficulty with mastication, difficulty with breathing, and epiphora, and these differences reached statistical significance. Patients sustaining comminuted Le Fort facial fractures report poorer health outcomes than patients with less severe facial injury and substantially worse outcomes than population norms. It is also this severely injured population that reports the greatest percentage of injury-related disability, preventing employment at long-term follow-up. The long-term goal of centralized tertiary trauma treatment centers must be to return the patient to a productive, active lifestyle.

Secondary ulnar nerve palsy in adults after elbow trauma: a report of two cases

Secondary ulnar nerve palsy, an unusual condition in which the onset of ulnar nerve dysfunction occurs 1 to 3 months after elbow trauma, can be the cause of sudden deterioration of elbow function. Initially recognized in 1899, this condition has not been reported often. We describe 2 patients who had no subjective or objective evidence of ulnar nerve dysfunction after elbow trauma but had a sudden loss of motion, pain, and clinical and electrophysiologic evidence of ulnar nerve compression at the elbow 4 to 5 weeks after trauma. Marked improvement occurred after ulnar nerve subcutaneous transposition and contracture release.

[Comminutive fracture of the trapezium treated by ligamentotaxis. A case report]

We report a case of trapezium fracture treated by continuous traction. The fracture involved the trapezium alone and was associated with scapho-trapezium subluxation. Three percutaneously inserted pins were used for traction, one scapho-capitate pin and two pins in the first and second metacarpal bones. This allowed distraction of the entire first row. Good anatomic reconstruction of the trapezium was evidenced radiographically. The functional outcome was quite satisfactory with mobility strictly the same as the healthy side and complete pain relief.

Trimalleolar fracture with a double fragment of the posterior malleolus: a case report and modified operative approach to internal fixation

Fractures of the medial and lateral malleoli are frequently associated with fractures of the posterior malleolus, comprising trimalleolar fractures. The posterior fragment may be posteromedial or posterolateral and its size determines the necessity for surgical or non-surgical treatment. The authors describe a case of trimalleolar fracture with double involvement of the posterior malleolus, both a posteromedial and posterolateral fragment. A modified transmalleolar operative approach for internal fixation is recommended when dealing with such complex trimalleolar fractures of the ankle.

Diastasis with low distal fibula fractures: an anatomic rationale

Tibiofibular diastasis occurs infrequently in displaced ankle fractures that include a low fibula fracture. This is because the interosseous ligament, the major ligament resisting diastasis, lies above the level of the fracture. The anatomic study of the syndesmotic complex of the ankle reported here showed that the interosseous ligament has a variable attachment on the fibula, differing between specimens in its distance above the synovial reflection or joint line. Although most specimens had attachments approximately 1 cm or greater above the joint line, one of 18 specimens attached just above the synovial reflection. In such a case, a low fibula fracture would disrupt the interosseous ligament, which explains the anatomic basis for the infrequent diastasis in these ankle fractures.

[Occipital condyle fractures and clivus epidural hematoma. Case report]

A 47-year-old woman presented with a rare case of epidural hematoma of the clivus. The patient had bilateral occipital condyle fractures (a comminuted fracture on the right side, an avulsion fracture on left side and a lower clivus fracture). On admission the patient was tetraparetic with left abducens palsy. Preoperative imaging showed no atlanto-axial or occipito-atlantal dislocation. The patient was operated with a posterior approach. An occipital craniectomy with C1 laminectomy was achieved without atlanto-occipital fusion. Two years after the trauma, the patient had mild left hemiparesis but was able to walk normally. Head motion was normal, but just mildly decreased by pain in flexion and extension. Imaging control did not show any occipito-atlantal instability. We describe the imaging features allowing precise diagnosis and discuss the management of a rare entity: bilateral occipital condyle fractures and epidural hematoma of the clivus.