Landmine Injury Resulting in Comminuted Lumbar Facet Fracture as a Cause of Lumbar Stenosis and Spondylolisthesis

Lumbar facet fractures are rarely reported and have been linked to sports and spine surgery. We describe the case of a 77-year-old patient who sustained an injury from multiple landmine blasts during the Vietnam War. He had low back pain since that time, which was initially managed conservatively. However, the pain progressed over decades to severe neurogenic claudication that greatly restricted his quality of life. Neuroimaging revealed the presence of bone fragments impinging on the spinal canal at the L5/6 level (transitional anatomy) that resulted from a comminuted fracture of the lumbar facet at the inferior articular process. We performed an L5/6 decompressive laminectomy, with removal of these fragments, and posterior instrumented fusion, with substantial improvement in symptoms. This case illustrates a unique mechanism of lumbar facet fracture and the biomechanic origination, natural history, and optimal treatment of this entity. We expand on the spectrum of lumbosacral injuries associated with the combat blast injury that have only increased in prevalence in recent conflicts.

Comminuted lunate fracture combined with distal radius fracture and scaphoid fracture: A case report

RATIONALE

Incidence of lunate fractures is very low, less than 1% of all fractures. Lunate fractures generally come from high-energy injuries, often combined with other wrist fractures. Simple lunate fractures can be fixed with screws or Kirschner wires. However, Comminuted lunate fractures are difficult to reduce and fixe by conventional methods.

PATIENT CONCERNS

Here we report a 42-year-old male construction worker who was crushed by an excavator bucket and presented with comminuted lunate fracture combined with distal radius fracture and scaphoid fracture.

DIAGNOSES

Comminuted lunate fracture, distal radius fracture, and scaphoid fracture.

INTERVENTIONS

The posterior approach was used to reconstruct the radial lunate bone with polymethylmethacrylate cement, and cannulated screws were used to fix the scaphoid and distal radius fractures.

OUTCOMES

At the 3rd month after surgery, the movement of the right wrist joint improved. At the sixth month after surgery, the patient returned to the building site and began working at the same intensity as before the injury.

LESSONS

Although the incidence of comminuted lunate fractures is very low, they occur sometimes. For comminuted lunate fractures, early identification and intervention can preserve most of the function of the wrist joint.

Geriatric Patients Presenting With Isolated Pubic Rami Fractures and Inability to Mobilize May Have Occult Lateral Compression Pelvic Ring Injuries With Dynamic Instability

OBJECTIVES

To determine the incidence of patients with isolated pubic rami fractures on computed tomography scans who have dynamic instability secondary to occult lateral compression pelvic ring injuries.

DESIGN

Retrospective comparison study.

SETTING

Urban level 1 trauma center.

PATIENTS/PARTICIPANTS

This study included geriatric patients with isolated pubic rami fractures and inability to mobilize secondary to pain.

INTERVENTION

Lateral stress radiographs of pelvis to evaluate for ≥1 cm dynamic instability.

MAIN OUTCOME MEASUREMENTS

Physical therapy clearance, hospital length of stay, and discharge location.

RESULTS

A total of 19 patients were identified over 12 months. Patients were predominantly geriatric (median age: 75 years, interquartile range: 67 to 90), woman (11/19), with unilateral (17/19) comminuted distal rami fractures (12/19) sustained in ground-level falls (12/19). Dynamic instability was identified in 42% of patients (8/19). Magnetic resonance imaging, obtained in 6 of these patients, demonstrated occult posterior ring fractures in all cases. Patients with dynamic instability were more likely to have comminuted distal rami fractures (Nakatani type 1b) and a longer hospital length of stay. There was also a trend for these patients to be unable to clear physical therapy by discharge (63% (5/8) versus 36% (4/11)). The 90-day mortality rate of the cohort was 16% (3/19).

CONCLUSIONS

Patients presenting with seemingly isolated pubic rami fractures on radiographs and computed tomography scans who are unable to mobilize may have occult lateral compression injuries with dynamic instability.

LEVEL OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Essex-Lopresti Injury

The Essex-Lopresti injury is caused by a high energy mechanism and consists of a characteristic triad: a comminuted radial head fracture, disruption of the distal radioulnar joint, and tearing of the interosseous membrane. These injuries are often difficult to diagnosis on initial evaluation, and the majority are missed acutely. Chronic Essex-Lopresti injuries lead to radioulnar longitudinal instability, proximal radius migration, ulnocarpal impaction, and chronic elbow pain. These injuries present a challenging problem for the treating surgeon.

[Surgical stabilization of multiple rib fractures can shorten inpatient stay]

Flail chest is a common complication in patients with blunt chest wall traumas resulting in high mortality rates. In this case report a 43-year-old woman was stepped on by a horse, thereby receiving multiple rib fractures and pneumohaemothorax. She was not able to wean from epidural analgesia after ten days and maintained a "thoracic floating feeling". In opposition to the non-operative management previously preferred, a surgical stabilization was then performed in the patient, who was discharged only five days later. Thus, surgical fixation of multiple rib fractures may reduce inpatient stay.

Hawkins' type-II talar fracture with subtalar dislocation: A very unusual combination

We report the unusual case of a 16-year-old young man who sustained a rare association of a Hawkins' type-II talar neck fracture with a complete medial subtalar dislocation (Hawkins type-IIB) that occurred as an isolated injury after indirect trauma during a soccer game. Following closed reduction of the subtalar dislocation, standard radiographs and computed tomography (CT) demonstrated a comminuted fracture of the talus involving the base of the talar neck. Open reduction was performed and the fracture was stabilized by ORIF. At 1-year follow-up, functional and radiographic outcomes were graded as excellent, with no radiographic evidence of talar osteonecrosis.

Tibialis Posterior Tendon Entrapment Within Posterior Malleolar Fracture Fragment

Management of posterior malleolus fractures continues to be controversial, with respect to both need for fixation and fixation methods. Fixation methods include an open posterior approach to the ankle as well as percutaneous reduction and fixation with or without arthroscopy for visualization of the articular surface. Plain radiographs are unreliable in identifying fracture pattern and intraoperative reduction, making arthroscopy a valuable adjunct to posterior malleolus fracture management. In this article, we report a case of tibialis posterior tendon entrapment within a posterior malleolus fracture, as identified by arthroscopy and managed with open reduction. Tibialis posterior tendon entrapment within a posterior malleolus has not been previously reported. Ankle arthroscopy for posterior malleolus fractures provides an opportunity to identify soft-tissue or tendinous entrapment, articular surface reduction, and articular cartilage injuries unlikely to be identified with fluoroscopy alone and should be considered in reduction and fixation of posterior malleolus fractures.

Is Skin Tenting Secondary to Displaced Clavicle Fracture More Than a Theoretical Risk? A Report of 2 Adolescent Cases

While one traditional indication for open reduction and internal fixation (ORIF) of clavicle fractures was tenting of the skin because of concern for an impending open fracture, recent review materials indicate that this complication may only be theoretical. To the best of the authors' knowledge, this complication has never been reported for a midshaft clavicle fracture. We report 2 adolescent cases of displaced, comminuted clavicle fractures in which the skin was initially intact. Both were managed nonoperatively and both secondarily presented with open lesions at the fracture site requiring urgent irrigation and débridement and ORIF. In displaced midshaft clavicle fractures, tenting of the skin sufficient to cause subsequent violation of the soft-tissue envelope is possible and is more than a theoretical risk. At-risk patients (ie, those with a vertically angulated sharp fragment of comminution) should be counseled appropriately and observed closely or considered for primary ORIF.

Assessing leg length after fixation of comminuted femur fractures

BACKGROUND

Nailing comminuted femur fractures may result in leg shortening, producing significant complications including pelvic tilt, narrowing of the hip joint space, mechanical and functional changes in gait, an increase in energy expenditures, and strains on spinal ligaments, leading to spinal deformities. The frequency of this complication in patients managed with an intramedullary (IM) nail for comminuted diaphyseal fractures is unknown.

QUESTIONS/PURPOSES

We therefore determined (1) the frequency of LLDs, (2) whether a specific fracture pattern was associated with LLDs, (3) the frequency of reoperation, and (4) whether revision fixation ultimately corrected the LLD.

METHODS

We studied 83 patients with 91 AO/OTA Type B or Type C fractures fixed with either an antegrade or retrograde IM nail from July 2002 through December 2005. There were 60 males and 23 females, with a mean age of 30 years (range, 15-79 years). All underwent a digitized CT scan in the immediate postoperative period. Measurements of both legs were performed. Any fixation producing a discrepancy and requiring a return to surgery was identified.

RESULTS

An mean LLD of 0.58 cm was found in 98% of the patients, but only six (7%) patients had an LLD of greater than 1.25 cm. No fracture pattern or the presentation of bilateral injuries demonstrated a greater incidence of LLD. Of the patients with LLD, two patients refused further surgery while the remaining four patients, two Type B and two Type C fractures, ultimately underwent revision fixation. Repeat CT scans after revision surgery of all four patients demonstrated a residual LLD of only 0.2 cm.

CONCLUSIONS

Postoperative CT scans appear to be an efficient method to measure femoral length after IM nailing. Although residual LLDs may be common in comminuted femurs treated with IM nails, most LLDs do not appear to be functionally relevant. When an LLD of greater than 1.5 cm is identified, it should be discussed with the patient, who should be told that potential complications may occur with larger LLDs and that sometimes patients may benefit from repeat surgery.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

[Operative treatment of anterior olecranon fracture-dislocation]

OBJECTIVE

To investigate the method and effectiveness of operative treatment of anterior olecranon fracture-dislocation.

METHODS

Between January 2007 and December 2010, 10 cases of anterior olecranon fracture-dislocation were treated. There were 6 males and 4 females with an average age of 46.1 years (range, 27-68 years). The injury was caused by traffic accident in 7 cases, falling from height in 2 cases, and falling in 1 case. Nine cases were fresh fracture and 1 case was old fracture. There were 9 cases of ulnar olecranon comminuted fracture and 1 case of simple oblique fracture. Associated fractures were Regan-Morrey type III coronoid process fractures in 5 cases, Mason type II radial head fracture in 1 case, and Mason type III radial head fracture in 1 case. Open reduction and internal fixation were performed in all cases: reconstruction plates were used in 4 cases, tension band and reconstruction plates in 5 cases, and tension band and one-third tubular plate in 1 case; bone graft was performed in 2 cases.

RESULTS

All incisions healed by first intention. The patients were followed up 12-26 months (mean, 19.8 months). The X-ray films showed that fractures healing was achieved at 12-24 weeks (mean, 16.4 weeks). No failure of internal fixation, ulnohumeral joint instability, or traumatic arthritis occurred. At last follow-up, the elbow function score was 69-100 (mean, 89.1) according to the Broberg-Morrey evaluation criteria; the results were excellent in 4 cases, good in 4 cases, and fair in 2 cases with an excellent and good rate of 80%. The Disability of Arm-Shoulder-Hand (DASH) score was 0-22 (mean, 9). The visual analogue score (VAS) was 0-3 (mean, 0.5).

CONCLUSION

For anterior olecranon fracture-dislocation, an early and stable anatomic reconstruction of the trochlear notch of the ulna with plates and early active mobilization are given, the good functional results can be obtained.

Pneumomediastinum, pneumopericardium, orbital subcutaneous emphysema as consequence of low energy impact facial trauma

Although not an uncommon occurrence from displaced zygomaticomaxillary complex fractures, localized air emphysema tends to resolve without consequence. Nevertheless, when accentuated by nose blowing or other forms of positive pressure soon after trauma, local air emphysema can spread via fascial planes into distant sites.

Mid-term outcomes of contoured plating for comminuted fractures of the olecranon

OBJECTIVE

To evaluate the mid-term outcomes of contoured plating for comminuted fractures of the olecranon.

METHODS

Twenty eight patients were available for analysis. Their mean age was 41 years (range, 25 to 61 years). Associated fractures were of the coronoid process in three, radial head in four, and both in three patients. A plate and screw system was used to stabilize comminuted fractures of the olecranon in all cases. Coronoid fractures were stabilized according to the fracture patterns. Displaced radial head fractures were treated with either mini-screw fixation or radial head replacement. Because of the severity of their fractures, 12 patients underwent primary bone grafting.

RESULTS

Primary stability was achieved in 25 of 28 cases. There were no cases of non-union. The mean time to union was 15 weeks (range, 12-22 weeks). The mean range of flexion of the elbow was from 14° to 125°, with 65° of pronation and 74° of supination. The end results were 6 excellent, 16 good, 4 fair and 2 poor, based on the Broberg and Morrey scale. The excellent plus good rate was 78.6%.

CONCLUSION

Favorable mid-term outcomes can be achieved by contoured plating of complex, comminuted fractures of the olecranon.

Growing skull fracture in a 5-month old child: a case report

Growing skull fractures are a rare complication of linear skull fractures in children. The authors report a case of a growing skull fracture in a 5-month-old patient with a review of the literature. CT and MRI scans revealed a growing skull fracture with complication of leptomeningeal cyst formation. Surgical removal of the cyst, duraplasty and cranial reconstruction were performed. Follow up showed that the patient was stable neurologically and had improving left upper extremity weakness.

[Treatment of distal comminuted humeral fracture with serious osteoporosis by total elbow arthroplasty]

OBJECTIVE

To analyse short-term clinical effect of total elbow arthroplasty in treatment of distal comminuted humeral fracture with serious osteoporosis in geratic patients.

METHODS

From April 2006 to October 2007, five cases of distal comminuted humeral fractures were treated by total elbow arthroplasty with bone cement. Of them, there were 2 males and 3 females, aging 50-76 years old (mean 67.6 years old), including 4 cases of closed fracture and 1 case of open fracture (II type Gustilo-Anderson). All fractures were caused by tumbling. According to classification of AO, there were 2 cases of type C1, 2 cases of type C2 and 1 case of type C3. The Barnett index of osteoporosis was 0.40-0.45. The time from injury to operation was 4 to 18 days (mean 7.2 days). The rehabilitation exercise of function was done after 2 days of operation.

RESULTS

The operative time was from 120 to 180 minutes (mean 150 minutes), the bleeding amount was from 150 to 250 mL (mean 200 mL). All incision achieved primary healing. No complication occurred. Five cases were followed up for 19 to 36 months (mean 24.5 months). The mean motion range of elbow joint include 141.6 degrees for flection, 6.5 degrees for extention, 10.2 degrees for the degree of ectropion, 81.7 degrees for revolve forward, and 73.8 degrees for revolve behind respectively after 4 months of operation. The length discrepancy of upper limb was less than 1.5 cm, the muscle force for flexion and extention of finger and wrist was normal. The X-ray films showed that the position of artificial joint was satisfactory without prosthesis dislocation or loosening. According to Mayo elbow performance score, the excellent and good rate was 80% (excellent in 1 case, good in 3 cases, and fair in 1 case).

CONCLUSION

Total elbow arthroplasty with bone cement is an effective method in treatment of distal comminuted humeral fracture with serious osteoporosis obviously in the geratic patients, but indication and technique of operation should be mastered strictly.

Hoffa fracture: should precautions be taken during fixation and rehabilitation?

A coronal fracture of a femoral condyle (Hoffa fracture) is an unusual injury and there are only a handful of reports discussing it. We report a case of a 52-year-old worker who fell from a height, suffering lower limb injuries, including a Hoffa fracture with comminution, and had problems with malunion during the postoperative period. Clinicians should be aware that rehabilitation programmes need to be tailored to the method of fixation used to manage this uncommon fracture pattern.

Management of posttraumatic arthritis of the wrist with radiolunate fusion enhanced with a sliding autograft: a case report and description of a novel technique

Although in rheumatoid cases radiolunate fusion presents with satisfying results, in cases with posttraumatic carpal distortion, the variability of injury pattern can influence the type of fixation and the rate of bony union. In this case report, we present an alternative technique of radiolunate fusion for the management of posttraumatic arthritis, which combines the traditional procedure with a corticocancellous autograft, created from the dorsal side of the radius that slides over the bones to be fused. That procedure provides the best environment for the bones to heal and an additional stabilizing effect on the radiolunate construct, thus better preserving the normal intercarpal relationships and wrist height. Patient's clinical and radiological outcome was very satisfactory until the last follow-up.

[Outcomes of prolonged anticoagulant prevention of thrombosis of deep veins of the crus in closed comminuted fractures of tibial bones]

Analysed herein are the outcomes of treating a total of 96 patients with closed comminuted fractures of crural bones. By the duration of antithrombotic prevention, the patients were subdivided into two groups: the Comparison Group comprising 45 patients with a brief course of anticoagulant treatment (mean 5.8 +/- 1.3 days) and the Study Group consisting of 51 patients receiving anticoagulant treatment till achieving full restoration of the supporting function of the limb (averagely 21.2 +/- 2.1 days). In the Comparison Group, thrombosis of the deep veins localizing exclusively on the crus was registered by the results of duplex scanning in 13 patients (28.9%). In two thirds of the cases (10 cases, 76.9%) thrombosis occurred predominantly on days 6 - 14, while in 3 cases (7.7%) it occurred on days 15 -21 after the injury. In the Study Group patients with protracted anticoagulation prevention, thrombosis of the deep veins was revealed in 9.8% of cases (5 patients). Of the five Study Group patients with thromboses of tibial veins four were subjected to prolonged prevention with indirect anticoagulants and only one - with fraxiparine. It was found that the development of venous thrombi in fractures significantly (p <0.05) makes the terms of consolidation 1.6-fold longer. A conclusion was made that because a high risk of the development of thrombosis of the deep veins preserves during the whole period of restoration of the supporting function of the extremity in fractures of the crural bones, the patients concerned should, based on early (within the first 3-7 days) stable osteosynthesis making it possible to activate the patient and to restore the function of the limb, be subjected to a prolonged course of anticoagulant preventive treatment till the final changeover of the patient to the full load on the affected extremity.

Arthrodesis for ankle osteoarthritis after harvesting of free vascularized fibular bone: a case report

INTRODUCTION

Although free vascularized fibular bone grafting is a good method for the reconstruction of large bone defects, it might cause morbidity of the donor leg. Progression of ankle osteoarthritis, valgus deformity and instability of the donor leg subsequently leading to arthrodesis has rarely been reported.

MATERIALS AND METHODS

A 53-year-old man suffered from a left tibial comminuted and Gustilo type IIIb open fracture. A folded free vascularized osteoseptocutaneous flap was harvested from the right fibula and transferred to the left tibial bone defect. After the reconstructive surgery, the patient obtained a solid union of the left tibial shaft uneventfully. Ten years later, he suffered intermittent pain on his right ankle. Plain radiographs revealed progressive tibiotalar osteoarthritis. Right ankle arthrodesis with crossed cannulated screws fixation and osteosynthesis of the fibula to the tibia and talus were performed. However, this procedure failed due to a deep infection and osteomyelitis. A revision of the failed ankle fusion was performed by using a vascularized iliac bone flap to strut the anterolateral aspect of the tibiotalar bone defect. A ventral plate fixation and supplementary onlay bone grafting were applied across the anterior aspect of the tibiotalar joint. At the 2-year follow-up, the patient had no pain and resumed his regular daily activities.

CONCLUSIONS

Harvesting of the fibula may cause longterm ankle osteoarthritis that requires ankle arthrodesis. In revision arthrodesis a ventral plate fixation and vascularized iliac bone flap may be the treatment of choice, neutralizing the large moment due to the long lever arms.

[Surgical treatment of acute coronoid process fractures]

OBJECTIVES

This study was designed to assess the results of surgical treatment for type 2-3 coronoid process fractures and to identify factors that might influence the outcome.

METHODS

Thirteen male patients (mean age 35 years; range 17 to 53 years) were treated with open reduction and internal fixation for displaced coronoid fractures. According to the Regan-Morrey classification, the fractures were type 2 in nine patients (69.2%), and type 3 in four patients (30.8%). Nine patients had associated injuries (elbow dislocation, radial head or olecranon fractures, and/or ligamentous injuries). The mean duration to treatment was 2.3 days (range 1 to 7 days). Functional results were assessed according to the Mayo elbow performance score (MEPS), and signs of arthritis were assessed according to the Broberg-Morrey criteria. The mean follow-up was 41.1 months (range 12 to 96 months).

RESULTS

A functional range of motion of the elbow joint was achieved in 10 patients (76.9%). The mean elbow range of motion was 110.7 degrees (range 85 degrees to 130 degrees ) and the mean forearm rotation was 134.2 degrees (range 120 degrees to 155 degrees ). Three patients who had comminuted fractures and associated elbow injuries had decreased range of motion. None of the patients exhibited signs of instability. The mean MEPS was 86.5 (range 75 to 100). The results were excellent in four patients (30.8%; the mean MEPS 98.8) having isolated or noncomminuted coronoid fractures, and good in nine patients (69.2%) with comminuted fractures and/or associated bone or ligament injuries. Post-traumatic arthritis was detected in seven patients (53.9%) whose mean MEPS was 81.4. Patients with an excellent functional result did not develop arthritis. All the patients returned to preinjury activity levels.

CONCLUSION

Coronoid fractures are the most important component of complex elbow injuries. The presence of comminuted fractures, associated bone and ligament injuries, and post-traumatic arthritis affect the outcome adversely.

[Reconstruction of the medial collateral ligament of elbow]

OBJECTIVE

To evaluate the clinical effect of excising the radial head, repairing or reconstructing the medial collateral ligament (MCL) in treating comminuted fracture of the radial head accompanying by MCL injury.

METHODS

From September 2000 to April 2006, 18 patients with comminuted fractures of radial head accompanying by MCL injury were treated by excision of the radial head, repair or reconstruction of the MCL. Of them, there were 12 males and 6 females, aged 21 to 57 years. Injury was caused by high falling in 10 cases and by traffic accidents in 8 cases. According to Mason classifications, 13 fractures were of type III and 5 of type IV. Fifteen cases of fresh fractures were operated within 2 weeks, 3 cases of old fractures at 4, 6, and 14 months after injury respectively. Four cases underwent MCL repair and 14 cases underwent MCL reconstruction.

RESULTS

All the 18 cases were followed up 1-5 years (mean 3 years). According to Broberg and Morrey scoring system, 4 patients were rated as excellent, 12 as good, 1 as fair, and 1 as poor. The excellent and good rate was 88.9%. Three patients had light pain of elbow, 1 patient had moderate pain and the other 14 had no pain. The range of elbow motion was from 110 to 140 degrees (mean 130 degrees). The pronation averaged 75 degrees (35-85 degrees). The supination averaged 80 degrees (65-89 degrees). Compared with normal limbs, the grip strength decreased by 3% to 28% (mean 15%); the extension strength decreased by 8% to 39% (mean 30%); the flexion strength decreased by 7% to 29% (mean 18%); the pronation strength decreased by 7% to 31% (mean 20%); the supination strength decreased by 15% to 45% (mean 25%). The X-ray films showed that carrying angle increased by 0 to 11 degrees (mean 5 degrees) under two-newton-meter valgus torque. There were significant differences between injured limbs and normal limbs (P < 0.05).

CONCLUSION

The MCL was the primary valgus stabilizer of the elbow. If the radial head replacement could not be carried out, the repair or reconstruction of the medial collateral ligament was effective.

Ostéosynthèse par plaque antérieure verrouillée des fractures complexes de l’extrémité distale du radius

PURPOSE OF THE STUDY

Maintaining radial length, likely to be the main challenge in the treatment of complex distal radius fractures, is necessary for complete grip-strength and pro-supination range recovery. In spite of frequent secondary displacements, bridging external-fixation has remained the reference method, either isolated or in association with additional percutaneous pins or volar plating. Also, there seems to be a relation between algodystrophy and the duration of traction applied on the radio-carpal joint. Fixed-angle volar plating offers the advantage of maintaining the reduction until fracture healing, without bridging the joint.

MATERIAL AND METHODS

In a prospective study, forty-three consecutive fractures of the distal radius with a positivated ulnar variance were treated with open reduction and fixed-angle volar plating. Results were assessed with special attention to the radial length and angulation obtained and maintained throughout treatment, based on repeated measurements of the ulnar variance and radial angulation in the first six months postoperatively.

RESULTS

The correction of the ulnar variance was maintained until complete recovery, independently of initial metaphyseal comminution, and of the amount of radial length gained at reduction. Only 3 patients lost more than 1 mm of radial length after reduction. The posterior tilt of the distal radial epiphysis was incompletely reduced in 13 cases, whereas reduction was partially lost in 6 elderly osteoporotic female patients. There was 8 articular malunions, all of them less than 2 mm. Secondary displacements were found to be related to a deficient locking technique. Eight patients developed an algodystropy. The risk factors for algodystrophy were articular malunion, associated posterior pining, and associated lesions of the ipsilateral upper limb.

CONCLUSION

Provided that the locking technique was correct, this type of fixation appeared efficient in maintaining the radial length in complex fractures of the distal radius. The main challenge remains the reduction of displaced articular fractures. Based on these results, it is not possible to conclude that this method is superior to external fixation.

Low back pain after unstable extracapsular hip fractures: randomized control trial on a specific training

AIM

This study compares the efficacy of a walking recovery rehabilitation program with or without specific back exercises in patients affected by unstable extracapsular hip fractures and secondary back pain. Further, it reports data and images about analysed tomographic changes of the psoas muscle ipsilateral to fractures.

METHODS

A prospective, randomized, parallel treatment trial was carried out. Patients admitted for rehabilitation after fractures were evaluated for secondary back pain. If clinically indicated, patients were further scheduled for a computed tomography (CT) scan of the lumbar spine by which we evaluated cross-sectional changes in density and fibroadipose degeneration of the body of the psoas muscle. When back pain matched cross-sectional changes in psoas density, the patient was eligible for our study, enrolled and randomly assigned to 1 of 2 study groups. Both groups were scheduled for hip rehabilitation and walking training plus a back protocol for the study group only. Pain was evaluated subjectively with a visual analog scale to calculate treatment effectiveness and Harris hip score was used to assess the outcome after surgery.

RESULTS

Thirty-seven patients out of about hundred were enrolled. In all cases CT scans showed age-related changes commonly seen in the lumbar spine and significant fibroadipose degeneration and altered density in the ipsilateral psoas muscles. With back exercises added to the standard rehabilitation protocol, all study patients recovered significantly better than control group patients (P<0.04) in only 4 weeks of treatment.

CONCLUSION

Results show how hip fractures may cause psoas changes that can be of relevance for a more rational choice of physical exercises. Causes of back pain may be more complex than described by the textbooks and prognosis is more favourable following specific back training.

Calcanisation of tibia using Ilizarov fixator in crush injuries of hindfoot: a new method

Crush injuries of the foot are one of the most difficult and challenging tasks for a trauma surgeon to manage in terms of limb salvage and provision of a painless functional foot. Injuries to the foot, especially the hindfoot, account for almost 24.6% of all the warfare injuries in Afghanistan, of which more than 70% end in amputation for various reasons. We devised a method using the principles of Ilizarov's distraction osteosynthesis to salvage limbs with bony defects in the hindfoot which otherwise were candidates for amputation. The procedure is done in two stages. Initially, the ring fixator is applied for the soft tissue reconstruction and infection control, and the next stage consists of percutaneous "inverted L"-shaped osteotomy in the posterior half of the lower tibia. The study included 32 patients with hindfoot crush injuries involving talus, calcaneum, a combination of both, or even involving the adjacent tarsal bones. All these crush injuries were classified using the Gustilo and Anderson classification. The postoperative functional assessment of the feet was done using the Maryland Foot Score system with a minimum follow-up of four years. We had good results in 53%, fair in 34% and failure in 13% of our cases. The complications of this procedure were the same as with the use of the ring fixator elsewhere in the body. This method provides a technique to salvage the foot and produce a painless, stable, fused foot in one of the most difficult settings of a hindfoot crush injury.

Flexor carpi radialis tendon rupture as a complication of a closed distal radius fracture: a case report

Although extensor pollicis longus tendon ruptures have been noted as a complication of distal radius fractures, flexor tendon ruptures in association with acute fractures of the distal radius are rare. We report a rupture of the flexor carpi radialis tendon as a complication of an acute distal radius fracture that was discovered during operative management of the fracture.

Blow-out fractures in children: six years’ experience

OBJECTIVES

To present and analyze our experience in treating blow-out fractures in children, over a 6-year period.

STUDY DESIGN

The study was retrospective with 16 consecutive cases of blow-out fractures in children aged 5 to 15 years. All patients presented with impairment of eye motility and diplopia together with radiological findings. Treatment included fracture reduction, release of entrapped periorbital soft tissues, and placement of an alloplastic membrane on the orbital floor. Fractures were linear in 11 cases (trapdoor) and severe or comminuted in 5 cases.

RESULTS

Clinical symptoms subsided in all cases. Complete recovery of eye motility was achieved after surgical procedure in 13 cases; 2 patients presented late but had full recovery, and 1 patient, 4 years postoperatively, still had slight motility impairment.

CONCLUSIONS

Surgical treatment of blow-out fractures, including periorbital tissue release and placement of a membrane lining on the orbital floor, presented satisfactory results in our cases.

Ipsilateral dislocation of the shoulder and elbow joints with contralateral comminuted humeral fracture

Ipsilateral dislocation of the shoulder and elbow joints is a rare and complex injury. During the last 25 years, only 3 cases have been reported in the literature. We report a 50-year-old woman who suffered ipsilateral elbow and shoulder dislocation with contralateral comminuted humeral fracture. Both shoulder and elbow joints were reduced, but the elbow was dislocated subsequently at follow-up. The reduction in the elbow was stabilized by a Kirschner wire that was removed at 3 weeks, and the elbow was then stable. A U-shaped coaptation splint was applied for the contralateral comminuted humeral fracture. At 6 months, she had acquired a nearly full range of motion of both shoulder and elbow with complete healing in the contralateral humerus. Although rare and complex, ipsilateral shoulder and elbow dislocation, which is the result of a high-energy trauma, can be treated conservatively.

Prediction of instability in distal radial fractures

BACKGROUND

Effective methods of treating an unstable distal radial fracture are described in the literature, but there is no reliable method of identifying an unstable fracture in time to initiate appropriate treatment. The purposes of this study were to identify the predictors of fracture instability and to construct a method of prospectively predicting the radiographic outcome.

METHODS

Data on approximately 4000 distal radial fractures were prospectively recorded over a 5.5-year period. The database was validated by reexamining a sample of it. Demographic data on the patients and mode of injury, as well as the fracture classification and measurements, were recorded at the time of presentation. Outcome measures consisted of radiographic measurements made at one week and six weeks and assessment of carpal alignment at six weeks. Univariate and multiple logistic regression analyses were performed to identify the significance of the data obtained at presentation in the prediction of early and late instability as well as the risk of malunion and carpal malalignment.

RESULTS

The predictors of early and late instability and malunion differed according to the displacement of the fracture at presentation. Patient age, metaphyseal comminution of the fracture, and ulnar variance were the most consistent predictors of radiographic outcome. Dorsal angulation was not found to be significant in the prediction of radiographic outcome for displaced fractures. The degree to which the patient was independent was predictive of malunion in minimally displaced and displaced fractures. Formulas that are predictive of each of the seven radiographic outcome measurements were constructed.

CONCLUSIONS

The study succeeded in identifying the factors that are prognostic of the radiographic outcome for distal radial fractures. Formulas to predict the radiographic outcome were constructed as the independent prognostic significance of these factors was quantified. These formulas can be used to inform the surgeon's decision about the nature of primary treatment of fractures of the distal aspect of the radius. However, they must be validated by further studies before they are used to impact the management of distal radial fractures.

LEVEL OF EVIDENCE

Prognostic Level I.

Spinal cord–fragment interactions following burst fracture: an in vitro model

Object

The purpose of the study was to develop an in vitro model of the bone fragment and spinal cord interactions that occur during a burst fracture and further the understanding of how the velocity of the bone fragment and the status of the posterior longitudinal ligament (PLL) affect the deformation of the cord.

Methods

An in vitro model was developed such that high-speed video and pressure measurements recorded the impact of a simulated bone fragment on sections of explanted bovine spinal cord. The model simulated the PLL and the posterior elements.

The status of the PLL had a significant effect on both the maximum occlusion of the spinal cord and the time for occlusion to occur. Raising the fragment velocity led to an overall increase in the spinal cord deformation. Interestingly the dura mater appeared to have little or no effect on the extent of occlusion.

Conclusions

These findings may indicate the importance of the dura’s interaction with the cerebrospinal fluid in protecting the cord during this type of impact.

Functional outcome following treatment of transolecranon fracture-dislocation of the elbow

Elbow fracture-dislocations are considered as difficult injuries to treat. Anterior olecranon fracture-dislocation consist an uncommon pattern which is likely to be under-diagnosed. Eight patients identified as anterior fracture-dislocation of the elbow were retrospectively reviewed. There were seven men and one woman with an average age of 35 years (range, 22-58 years). Proximal ulna fracture was comminuted in seven and simple oblique in one patient. Associated fractures were of coronoid in four and radial head in two. Reconstruction plate was used in seven patients and tension band wiring in just one. Nevertheless, tension wiring failed and was successfully revised to plate fixation combined with bone graft. Patients were followed for an average of 37.4 months (range, 10-50 months). The end results were two excellent, five good and one fair, based on Broberg and Morrey scale. An average score of 89 points was obtained using American Shoulder and Elbow Surgeons elbow scoring system. Treatment of anterior olecranon fracture dislocation is mostly satisfactory if contour and dimension of greater sigmoid notch is accurately restored.

Intraarticular distal humerus fracture complicated by osteogenesis imperfecta treated with primary total elbow arthroplasty: a case report

Intraarticular fractures of the distal humerus are challenging problems for the treating surgeon. When these fractures are complicated by severe comminution and poor bone quality, open reduction and internal fixation may lead to poor clinical outcomes when compared with those treated with primary total elbow arthroplasty. The population in which this clinical scenario most often arises is the elderly. An unusual case is presented in which a 38-year-old individual was successfully treated with primary total elbow arthroplasty for a highly comminuted, intraarticular distal humerus fracture with severe osteopenia due to osteogenesis imperfecta in which standard plate osteosynthesis was unlikely to provide sufficient stable fixation.

Comparison of radiologic and arthroscopic diagnoses of distal tibiofibular syndesmosis disruption in acute ankle fracture

PURPOSE

The purpose of this study was to compare intraoperative stress radiography and ankle arthroscopy in the evaluation of distal tibiofibular syndesmosis disruption in acute ankle fracture.

TYPE OF STUDY

Prospective study.

METHODS

We treated 53 Weber type B or C ankle fractures without radiographic evidence of frank syndesmosis diastasis. Intraoperative stress radiography and ankle arthroscopy were performed. Syndesmotic screws were inserted in those patients with syndesmosis diastasis. Screws were removed 12 weeks later and second-look ankle arthroscopy was performed at the same time.

RESULTS

Sixteen cases (30.2%) had positive intraoperative stress radiographs; 35 cases (66.0%) had positive arthroscopic findings of syndesmosis diastasis, including various combinations of coronal, sagittal, and rotational planes of instability. During second-look arthroscopy, 31 of 34 patients with syndesmotic screws showed healing of the syndesmotic ligaments and the syndesmosis became stable.

CONCLUSIONS

Ankle arthroscopy excels intraoperative stress radiography in detecting syndesmosis disruption. It also provides assessment of different planes of instability and assists anatomic reduction of the syndesmosis. Intraoperative radiography still does play an important role in assessing fracture reduction and proper restoration of fibular length and longitudinal orientation of the syndesmosis.

LEVEL OF EVIDENCE

Level 2.

Conservative treatment vs prosthetic replacement surgery to treat 3- and 4-fragment fractures of the proximal epiphysis of humerus in the elderly patient

Several previous studies have revealed a significant difference in the functional results obtained between conservative treatment and prosthetic replacement surgery to treat complex fractures of the proximal end of the humerus. Thus, prosthesis is the gold standard in treatment of such fractures. It is the purpose of this study to analyze the functional results obtained with the conservative treatment of 18 consecutive patients, mean age 78 years, affected with 3- and 4-fragment fractures of the proximal epiphysis of humerus. A comparison of functional results that may be obtained when prosthetic replacement is performed does not show significant differences in this category of patients. Thus, in order to limit complications, when the patient is elderly, complex fracture of the proximal epiphysis of humerus should be treated conservatively.

The metal prosthesis in radial head fracture: indications and preliminary results

Radial head displaced irreparable fracture is an indication for prosthesis; it becomes elective also when there are associated injuries of the skeletal and ligamentous stabilization systems. A retrospective study was conducted to evaluate the functional and radiographic results in 10 patients (mean age 39.6 yrs; minimum 20, maximum 80) submitted to radial head replacement. There were 4 Mason-Johnston type IV Rochwerger subtype "b" fractures, 7 type III fractures (1 associated with an Essex-Lopresti injury and 1 with fracture of the ulnar proximal metaepiphysis). Mean follow-up was 24.6 months (minimum 18, maximum 32). Postoperative functional evaluation of the elbow and ipsilateral wrist was carried out using the ESSSE/SECEC form (mean score 80.7/100; minimum 63, maximum 96) and the PRWE (mean score 11.1; minimum 0, maximum 36) respectively. Radiographically there were postoperative calcifications in 30% of cases and periprosthetic lucency in 40%. The results of this study encourage the use of a metal prosthesis, but a longer follow-up is needed for a better evaluation.

Lumbar burst fracture associated with bowel, bladder, and sexual dysfunction: case study

Lumbar burst fractures occur when unusual force and flexion are placed on the spine, causing the vertebral body to rupture and possibly protrude into the spinal canal. A resulting conus medullaris injury is possible, but not common. In this case presentation, a young man suffered bowel, bladder, and sexual dysfunction after a 25-foot fall that caused a burst fracture of the first lumbar vertebra. The presentation's primary focus is the nursing education needed to care for patients who experience the unusual side effect of conus medullaris injury. The psychosocial aspects attributable to age, developmental stage, and stigma for a young man with these dysfunctions also are explored.

COMMINUTED FRACTURE OF THE DISTAL SESAMOID BONE AND DISTAL RUPTURE OF THE DEEP DIGITAL FLEXOR TENDON

A 10-year-old show jumper was evaluated for an acute severe lameness (grade 4 of 5) of the right foreleg. During weight bearing, the toe of the affected limb rotated dorsally suggesting rupture of the deep digital flexor tendon (DDFT). Upon radiographic examination of the hoof, a severe erosion at the flexor surface and a parasagittal fracture of the distal sesamoid bone were found. Ultrasonographic examination confirmed rupture of the DDFT. These findings were confirmed on post-mortem examination. Prior to the acute lameness, the horse was treated with corticosteroid injections into the podotrochlear bursa. Repeated intra-bursal injections of corticosteroids as a possible cause for DDFT rupture are discussed as well as the possible association between a degenerative distal sesamoid bone, a distal sesamoid bone fracture and a DDFT rupture.

Multisegmental open sacral fracture due to impalement: a case report

We report on an unusual impalement injury to the sacrum in a 15-year-old adolescent patient. This open pelvic fracture resulted in a shattered sacrum with neurologic impairment including clinically absent anal sphincter tone and perineal sensation. Early debridement, wound revision, neural decompression, fracture reduction, and stable fixation using lumbopelvic fixation according to the principles of triangular osteosynthesis resulted in a favorable outcome with primary wound healing, return of bowel and bladder control, as well as immediate patient mobilization.

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.