A case of translunate luxation of the carpus

A rare case of carpal injury is presented in which a longitudinal fracture of the lunate bone was associated with a volar dislocation of the capitate bone. The injury was treated closed. Ten months after the trauma, there was nonunion of the lunate fracture and an instability of the capitate-lunate joint.

The nonoperative treatment of burst fractures of the thoracolumbar junction

Treatment of thoracolumbar spine burst fracture with a neurologically intact patient is controversial, with advocates of operative and nonoperative approaches. Of 404 patients in a prospective spinal trauma study, 21 had burst fractures, were neurologically intact, and had greater than 1-year followup. This group was analyzed to evaluate treatment with early mobilization using a thoracolumbar total contact orthosis. The average time in a brace was 6 months. Two patients had pulmonary embolus treated successfully with anticoagulants. No patient required subsequent surgery for increasing kyphosis or neurologic deficit. Change in K angle at followup was 4.6 degrees (+/- 5.7) and change in anterior vertebral height was 6.1 degrees (+/- 10). All patients had a satisfactory pain score and most individuals returned to full employment. It is concluded that it is not necessary to routinely treat patients operatively with burst fractures if they fulfill the following criteria: 1) neurologically intact; 2) kyphosis angle less than 35 degrees; 3) other injuries do not preclude the use of a total contact orthosis; and 4) the patient is capable of understanding and cooperating with the treatment regime. These criteria are irrespective of the CT findings of posterior vertebral retropulsion and spinal canal narrowing.

Effects of electrical stimulation on the biomechanical properties of fracture healing in rabbits

One hundred fifteen white rabbits with an average weight of 2.0 kg were used to study the influence of electrical stimulation on osteogenesis. They were divided into three groups: Group I was electrically stimulated with a constant direct current of 20 microamperes delivered to the fracture site; Group II was the control group having the same protocol as Group I except that the stimulator was not switched on; and Group III was the normal fracture healing group (no introduction of electrodes to the fracture site). Roentgenologic and histologic assessment showed that new bone formation in the electrical stimulation group was more exuberant than those in the other two groups in observation periods from three to eight weeks. However, at 12 weeks no difference was observed among the three groups. Biomechanical analysis showed definite increases in the breaking strength and bending stiffness of the fracture healing tibia in Group I, especially at six weeks after surgery. However, at 12 weeks no significant difference was observed among the three groups. Therefore, electrical stimulation of fracture healing has a positive effect only at the midphase of the healing process, and it does not lead to faster fracture healing.

Morphology and treatment of occipital condyle fractures

During the last 4 years, the authors have had six cases of occipital condyle fractures, a very rare injury. Medline search yielded reports of 20 occipital condyle fractures in the literature. Of the six treated by the authors, one death (by pontine hemorrhage) occurred in a patient with a displaced avulsion fracture on the right occipital condyle (Type III). All others attained solid union with appropriate immobilization. Morphologically, one presented with an impacted fracture of the occipital condyle (Type I), one with a basilar skull fracture that included an occipital condyle fracture (Type II), and four had avulsion fractures of the occipital condyle. The latter are potentially unstable since loss of integrity of alar ligaments may coexist. Type I and II are stable, and the authors recommend treatment with a semiconstrained cervical orthosis. Type III injuries, which are potentially unstable, require rigid immobilization.

Management of post-traumatic cervical spine instability: operative fusion versus halo vest immobilization. Analysis of 49 cases

A 5-year retrospective analysis was conducted for all cervical spine fractures associated with neurologic deficit initially treated at the University of Michigan Hospitals. Forty-nine cases of lower cervical spine fracture (C3-C7) were reviewed. Twenty-eight patients underwent early operative fusion followed by immobilization with either halo vests, or hard cervical collars, and 20 patients were initially immobilized in halo vests only. One patient refused treatment and was kept in a hard cervical collar. The average period of immobilization was 3 months. Eight patients in the halo vest group demonstrated radiographic evidence of spinal instability following immobilization (40%). Five of these eight patients subsequently required operative stabilization. Two of these five suffered progression of neurologic deficit secondary to loss of reduction while immobilized. Spinal instability occurred in two of the 28 patients initially fused (7%) (p less than 0.01), and in the patient treated in a collar. The findings indicate: 1) the halo vest does not protect patients with cervical instability from neurological injury, nor does it absolutely immobilize the cervical spine; 2) surgery may be required to provide spinal stability, even after a 3-month orthotic treatment period; and 3) there appears to be an increased rate of spinal stability with fusion and immobilization versus immobilization alone.

Acute traumatic atlas fractures: management and long term outcome

Fractures of the 1st cervical vertebra (C1) represent 7% of all acute cervical spine fractures. Isolated atlas fractures are most commonly bilateral or multiple fractures through the ring of C1. Frequently (44% of cases), the atlas will be fractured in combination with the axis. Treatment of isolated C1 fractures should be governed by the rules of Spence. The treatment of combination C1-C2 fractures is dictated by the type and severity of the C2 fracture. Experience with 57 cases of acute atlas fractures is reviewed. Nonoperative external immobilization was used in 53 patients (with 1 failure), and early surgical wiring and fusion were performed in 4 patients. The long term outcome from an atlas fracture is good (median follow-up, 40 months).

Complications of fractures of the cervical spine in ankylosing spondylitis

Five patients with ankylosing spondylitis who suffered severe neurologic complications after fracture of the cervical spine are presented. All developed delayed neurologic complications, ranging from 2 to 35 days after the initial injury (mean, 15.8 days). The diagnosis was delayed in four, and in three this delay contributed to morbidity. All fractures occurred in the lower cervical spine (C5 to C7). In three patients, the fracture was the result of minor trauma. A high index of suspicion, an appreciation of the extreme instability of these fractures, and prompt rigid immobilization with a halo vest or case in the alignment of preexisting kyphosis are all important factors in preventing neurologic complications.

A biomechanical evaluation of cervical spinal stabilization methods in a bovine model. Static and cyclical loading

A bovine model was developed for biomechanical evaluation of surgical procedures stabilizing traumatic cervical injuries disrupting the anterior and posterior spinal column. Cervical spinal segments and C4-5 functional spinal units were tested statically, and C4-5 functional spinal units were tested cyclically in evaluation of 1) the intact cervical spine, 2) Rogers' wiring method, 3) Bohlman's triple-wire technique, 4) sublaminar wiring, 5) anterior cervical plate instrumentation, and 6) posterior hook plate stabilization. Anterior cervical plate instrumentation proved inadequate, and was the least rigid, with axial and flexural loading (P less than 0.05). There was no significant difference between each of the three posterior wiring methods, and all generally restored stability to equal that of the uninjured intact cervical spine. Posterior hook plating with an interspinous bone graft serving as an extension block was the most effective method in reducing flexural stress across the injured C4-5 segment (P less than 0.05). Cyclical in vitro testing was the most sensitive method in highlighting mechanical differences between instrumentation systems, particularly with "on-line" continuous measurement of anterior and posterior strains. Anterior cervical plate stabilization does not appear to confer enough stability in cervical facet injuries to obviate the need for posterior cervical stabilization procedures. The recently developed posterior hook plate technique offers biomechanical advantages that should be weighed against the greater technical precision needed for insertion and the increased potential for neurologic and vascular complications.

Identification of epiphyseal ankle injuries

Physeal plate injuries are unique to children and young adults. They present special problems in treatment and diagnosis. This manuscript will review these fractures: their classification, diagnosis, prognosis, and treatment principles.

The young athlete's knee: recent advances

The understanding and treatment of the young athlete's knee has improved and continues to do so as arthroscopy and good long-term follow-up studies guide the process. In the management of epiphyseal fractures about the knee the presence of associated ligament injury and the high likelihood of a growth plate injury is now well documented. In the management of ligament injuries and internal derangements, arthroscopy has profoundly changed diagnosis and treatment. Pathology can be precisely identified and the appropriate treatment initiated to preserve an athletic career and possibly prevent degenerative arthritis in adulthood. Lastly, patellofemoral pain continues to be a difficult problem to treat, but a more scientific approach is evolving. This has been facilitated by a better understanding of the varied etiologies for anterior knee pain, and a trend away from classifying all such conditions as chondromalacia.

Propagation of a dorsal cortical fracture of the third metacarpal bone in two horses

Seemingly, propagation of a dorsal cortical fracture in the third metacarpal bone developed after continued race performance in 2 horses. Historically, both horses had intermittent lameness that had responded to nonsteroidal anti-inflammatory drugs and brief rest periods. However, lameness in both horses had increased in severity. Radiography revealed a dorsal cortical fracture of the third metacarpal bone, with propagation of the fracture plane proximally. Fractures were incomplete and healed with stall rest in both horses.

Treatment in fractures of the odontoid process

Fifty-eight cases of odontoid fractures treated at Keio University Hospital and affiliate hospitals from 1965 through 1985 were reviewed. Six patients under age 7 years (group A), were characterized as having epiphysiolysis. Among 52 patients over 8 years of age (group B), there were two Type I, 31 Type II and 19 Type III fractures. All cases in group A were treated conservatively by a plaster cast or a neck brace, and achieved bony union in 6 to 27 weeks. Five of 24 fractures in group B, treated conservatively, failed to unite. Nineteen cases of Type II and six cases of Type III were treated surgically. Transoral fusion was performed in six cases, internal fixation using a compression screw in ten, bone peg fixation in one, posterior fusion in eight, and posterior decompression in one. Two cases treated with transoral fusion and two with screw fixation failed to unite. We recommend conservative treatment of group A patients, Type I, and acute cases of Type III with minimal displacement in group B. Surgery should be performed in acute cases of Type II, Type III with significant displacement, and nonunion cases in Type II and Type III.

[Conservative treatment of fractures of the scaphoid bone--indications]

Healing-up of the bone is achieved by immobilization in 96 to 98% of all recent scaphoid fractures. The average immobilization period is eleven weeks. Different methods of immobilization are used. The majority of authors apply an upper arm plaster cast including the thumb for a period of six weeks and then a forearm plaster cast. Even fractures showing a delayed healingup of the bone can be cured in more than two thirds of the cases by prolonged immobilization. In case of dislocated and not reducible fractures as well as fractures with great fragment diastases, conservative treatment with a fist plaster cast should only be performed exceptionally, for example if there is an increased anesthesia risk. In case of negative X-ray findings (four planes) and only clinical suspicion of scaphoid fracture, an initial fracture therapy is recommended with repeated X-ray examination 14 days later. Most of the fractures which have not healed up are vertical oblique fractures within the proximal third, fractures with great diastases, or fractures which have not been immobilized long enough.

Cervical spine injury. Stabilization and management

The results of a spinal cord injury may be irreversible, or many months of rehabilitation may be required to restore a meaningful, functional lifestyle to the patient. Complications of the injury are numerous, and the financial burden of treatment can be overwhelming. The incidence of debilitating injury has decreased, however, since the advent of intensive education on emergency treatment and preventive methods. With continuing research, aggressive medical care, and innovative surgical methods, the prognosis for these patients, once dismal and devastating, may be greatly improved.

Simultaneous fractures of the distal radius and scaphoid

Simultaneous fractures of the distal radius and scaphoid are uncommon injuries for which the treatment is controversial. Nine patients with these fractures are presented. Five patients were available for long-term followup. In the series, there were five Colles and four Smith's fractures of the distal radius. All scaphoid fractures occurred at the anatomic waist. All injuries resulted from falls of considerable force producing hyperextension at the wrist. The ages of the patients ranged from 21 to 90 years (median, 34). All fractures were placed in a thumb spica cast with the wrist in neutral position. Five fractures required a second reduction of the radius and were placed in external skeletal fixation. No scaphoid fracture was displaced by this treatment, and all scaphoid fractures progressed to union. The principal deformity at followup was an average 16 degrees loss of volar tilt. Residual pain or functional disability was not noted. We conclude that these fractures can be successfully treated by reduction of the radius and immobilization by whatever means necessary to maintain an acceptable position. Scaphoid reduction and healing seemed unaffected by the method of treatment used to treat the distal radius fracture in this series.