Mapping of scapular fractures with three-dimensional computed tomography

BACKGROUND

Fractures of the scapula involve a unique and challenging set of considerations, which must be understood to provide optimal treatment. The primary goal of this study was to create a frequency map of a series of surgically treated scapular fractures that specifically involved the scapular body and/or neck.

METHODS

A prospective database was used in the collection of consecutive radiographic imaging studies of patients undergoing operative treatment of scapular fractures. Scanned three-dimensional computed tomography images were superimposed and oriented to fit a model scapular template. Size dimensions were normalized by aligning specific scapular landmarks. Fracture lines were identified and traced over the combined three-dimensional computed tomography model to create a scapular fracture map.

RESULTS

Of ninety fractures that met the criteria for inclusion, 68% involved the inferior aspect of the glenoid neck and 71% involved the superior vertebral border. Seventeen percent of the patterns included articular extension, and 22% of the fractures entered the spinoglenoid notch. Of fractures involving the inferior aspect of the glenoid neck at the lateral scapular border, 84% traversed medially to exit just inferior to the medial extent of the scapular spine, and 59% of these inferior neck fractures also had propagation to the inferior third of the vertebral border. Among the fractures involving the spinoglenoid notch, the most common pattern was demonstrated by coexisting fracture lines; 60% of the fractures of the spinoglenoid notch exited just inferior to the glenoid, 65% extended to the superior-medial vertebral border, and 45% extended to the inferior-medial vertebral border. In contrast, articular fractures did not follow predictable patterns; they demonstrated the greatest variability in trajectory, which was almost random, and there was a wide distribution of exit points along the vertebral border.

CONCLUSIONS

Surgically treated scapular fractures display very common patterns. The most common pattern is the lateral border fracture immediately inferior to the glenoid, which extends to the superior vertebral border in more than two-thirds of cases. A smaller proportion of scapular fractures enter the spinoglenoid notch or the articular surface. There is great variation in the patterns of fractures involving the articular surface.

Case report: reconstruction of a recalcitrant scapular neck nonunion and literature review

We present the first reported treatment failure of a reconstructed scapula body that proceeded to nonunion. This is a unique case report of an otherwise healthy patient who underwent open reduction and internal fixation of a scapula fracture nonunion, which is very rare. Failure of internal fixation in this application has not been reported, and, to our knowledge, this is only the fifth case report of a scapula body nonunion that was reconstructed. Of 159 reported cases of open reduction and internal fixation for treatment of scapula neck and body fractures (with or without intraarticular glenoid fractures), there is not one reported case of a nonunion. Our case is described in detail, including the method of surgical reconstruction, and a review of the literature regarding surgical treatment of scapula nonunions after nonoperative treatment also is presented.

Activity level in young patients with primary total hip arthroplasty: a 5-year minimum follow-up

Increased activity level after total hip arthroplasty (THA) is considered a risk factor for early prosthetic failure in young patients. Forty-one primary total hip arthroplasties in 34 patients were evaluated. Walking activity was measured using a pedometer to record gait cycles. Patients completed a University of California, Los Angeles (UCLA) activity questionnaire. Linear wear rates were measured. Mean ages at surgery and final follow-up were 42 and 50.3 years, respectively (mean gait cycles per year, 1.2 million; mean UCLA score, 6; mean linear wear, 0.16 mm/y). Increased body mass index and age correlated with decreased gait cycles per year. Patients with systemic disease were less active than patients with localized hip conditions. Femoral head diameter was a predictor of linear wear. The average gait cycles per year and wear rate for this population do not appear accelerated relative to average values reported in older populations.

Operative treatment of acute distal femur fractures: systematic review of 2 comparative studies and 45 case series (1989 to 2005)

BACKGROUND

The incidence of distal femur fractures is approximately 37 per 100,000 person-years. Typically, distal femur fractures are caused by a high-energy injury mechanism in young men or a low-energy mechanism in elderly women. Managing these fractures can be a challenging task. Most surgeons agree that distal femur fractures need to be treated operatively to achieve optimal patient outcomes. The articular fracture component is usually treated with open reduction and internal lag screw fixation or external tension wire fixation (Illizarov). However, there is no consensus on the type of implant for the fixation of the metaphyseal-diaphyseal fracture component.

OBJECTIVE

The aim of this study is to systematically summarize and compare the results of different fixation techniques (traditional compression plating, antegrade nailing, retrograde nailing, submuscular locked internal fixation, and external fixation) in the operative management of acute nonperiprosthetic distal femur fractures (AO/OTA type 33A and C) and the characteristics of the fractures for each treatment (articular/nonarticular and open/closed). Additionally an attempt was made to evaluate the impact of surgical experience on nonunion rate, fixation failure rate, deep infection rate, and secondary surgical procedure rate. In the context of this article compression plating relates to techniques/implants that require compression of the implant to the femoral shaft-it does not relate to interfragmentary compression.

The application of dermatotraction for primary skin closure

Management of an open wound is a problem frequently encountered in the treatment of fractures. Skin grafting, rotational flaps, free flaps, and healing by secondary intention add a considerable amount of morbidity and cost to the patient. Therefore, it is ideal to obtain primary closure when possible. This communication describes a technique that uses spinal needles, using towel clips and the natural stretching ability of the skin to enable primary closure of wounds. The technique described uses dermatotraction to stretch the skin is a cost-effective way to achieve primary closure of large wounds with supplies that are readily available in every operating room.

Capsaicin-sensitive adrenal sensory fibers participate in compensatory adrenal growth in rats

Compensatory adrenal growth, in which one gland undergoes hyperplasia after removal of the other, is mediated by a neural reflex. In the present studies, a method employing capsaicin to selectively remove adrenal sensory fibers was developed and applied to determine whether adrenal capsaicin-sensitive fibers participate in compensatory adrenal growth. The splanchnic nerves of anesthetized male rats were treated with capsaicin or vehicle. Capsaicin treatment selectively removed adrenal calcitonin gene-related peptide-positive fibers. One week after drug treatment, rats underwent left adrenalectomy or sham surgery and recovered for 5 days. Capsaicin treatment bilaterally or to the left splanchnic nerve alone (i.e., the afferent nerve in the reflex) impaired compensatory adrenal growth at 5 days compared with vehicle controls, whereas capsaicin treatment to the right splanchnic nerve alone did not affect growth. Moreover, left adrenalectomy induced c-Fos immunolabeling in ipsilateral dorsal spinal cord that was prevented by capsaicin treatment. These data suggest that adrenal capsaicin-sensitive afferent nerves participate in compensatory adrenal growth and that this effect is primarily on the afferent limb of the reflex.

Pulmonary microvascular fracture in a patient with acute respiratory distress syndrome

OBJECTIVE

To present electron micrographs of lung tissue obtained from a patient exposed to high ventilatory pressures in the context of pulmonary dysfunction and pulmonary hypertension.

DESIGN

Case report.

SETTING

Adult intensive care unit of a university-affiliated teaching hospital.

PATIENTS

A patient exposed to high-pressure mechanical ventilation during support for acute respiratory distress syndrome; the acute respiratory distress syndrome in this case was secondary to septic shock.

MEASUREMENTS AND MAIN RESULTS

Scanning electron micrographs of lung tissue, focusing on the internal alveolar surfaces.

FINDINGS

Multiple gross disruptions of the alveolar walls, suggestive of stress fractures.

CONCLUSION

High-pressure mechanical ventilation may promote fracturing of the alveolar blood:airspace barrier.