Ipsilateral femoral neck and shaft fractures

Ipsilateral femoral neck and shaft fractures are uncommon injuries that present a surgical challenge. Patients are relatively young, are usually victims of high-energy trauma, and have frequently sustained multisystem injuries. A comminuted midshaft femoral fracture secondary to axial loading should alert the treating physician to the possibility of an associated femoral neck fracture. This is important in light of the frequency of unrecognized ipsilateral femoral neck fractures. Several treatment options are described in the literature, but no clear consensus exists regarding the optimal treatment of these complex fractures. The authors contend that, given the potentially devastating complications of the femoral neck fracture in young patients (e.g., avascular necrosis, nonunion, and malunion), the neck fracture should be treated first and the shaft fracture second. The authors present an algorithm for the diagnosis and management of this injury based on a review of the literature, an understanding of the biology and severity of this injury, and the technical aspects of surgical treatment.

Transolecranon fracture-dislocation of the elbow

OBJECTIVE

To characterize the prevalence, morphology, and prognosis of anterior (transolecranon) fracture-dislocations of the elbow.

DESIGN

Retrospective case series.

SETTING

A consecutive series of thirteen patients from a single level-one trauma center, plus four patients from the practices of two of the senior authors.

PATIENTS

Three of seventeen patients had simple, oblique fractures of the olecranon, and fourteen had complex, comminuted fractures of the proximal ulna, including fragmentation of the olecranon in seven patients, large coronoid fragments in eight patients, and segmental fractures of the ulna in six patients. Fourteen patients were male and three were female, with an average age of thirty-eight years (range, 18 to 78 years).

INTERVENTION

All fractures were treated by open reduction and internal fixation. Two one-third tubular plates had to be revised to 3.5-millimeter dynamic compression plates within six weeks of the initial operation.

MAIN OUTCOME MEASURE

Elbow performance rating of Broberg and Morrey.

RESULTS

At an average follow-up of twenty-five months, overall outcome was rated as excellent in seven patients, good in eight, and fair in two. Mild posttraumatic arthritis was noted in only two patients. Large coronoid fragments and extensive comminution of the trochlear notch did not preclude a good result provided that stable, anatomic fixation was achieved.

CONCLUSIONS

Anterior elbow dislocations occur most often as a fracture-dislocation in which the distal humerus is driven through the olecranon, thereby causing a complex, comminuted fracture of the proximal ulna. This injury is frequently confused with anterior Monteggia lesions by virtue of the readily apparent radiocapitellar dislocation. Stable restoration of the appropriate contour and dimensions of the trochlear notch of the ulna will lead to a good result in most cases.

Surgical treatment of a comminuted articular fracture of the accessory carpal bone in a thoroughbred horse

The clinical, radiographic and ultrasonographic findings in a case of a comminuted articular fracture of the accessory carpal bone of a thoroughbred chaser are described, and its surgical treatment and aftercare are detailed. The horse made an uneventful recovery and successfully returned to racing.

Vertebral compression fractures in multiple myeloma. Part I. Distribution and appearance at MR imaging

PURPOSE

To study the appearance and distribution of vertebral compression fractures on magnetic resonance (MR) images in patients with multiple myeloma.

MATERIALS AND METHODS

Two hundred twenty-four vertebral compression fractures were studied on 216 sagittal T1-weighted spin-echo and T2*-weighted gradient-echo MR images of the thoracolumbar spine obtained before and during treatment in 37 patients with multiple myeloma. Vertebral compression fractures observed at diagnosis and during follow-up were determined as being benign- or malignant-appearing at MR imaging according to literature criteria, and their distribution along the spine was recorded.

RESULTS

One hundred forty-nine (67%) of the 224 vertebral compression fractures appeared benign; 75 (33%) appeared malignant. Of the 37 patients, 14 (38%) had only benign-appearing vertebral compression fractures at diagnosis. One hundred five fractures (87%) were observed between T-6 and L-4, and 112 (50%) occurred between T-11 and L-3. Eight (4%) vertebral compression fractures involved the upper three thoracic vertebrae.

CONCLUSION

Most vertebral compression fractures in patients with multiple myeloma appear benign at MR imaging, and their distribution is similar to that observed in osteoporotic fractures. The possibility of multiple myeloma should not be excluded in patients with benign-appearing vertebral compression fractures at MR imaging.

Vertebral compression fractures in multiple myeloma. Part II. Assessment of fracture risk with MR imaging of spinal bone marrow

PURPOSE

To determine the utility of bone marrow magnetic resonance (MR) imaging in the assessment of risk of vertebral compression fractures in patients with multiple myeloma.

MATERIALS AND METHODS

In 50 patients with stage III multiple myeloma, 280 MR examinations of the thoracolumbar spine obtained at diagnosis and during treatment (mean follow-up, 28 months) were analyzed to determine MR patterns of bone marrow involvement before treatment and the occurrence of vertebral compression fracture at follow-up. Four MR patterns of marrow involvement were determined: A, normal marrow appearance; B, fewer than 10 focal lesions; C, more than 10 focal lesions; and D, diffuse infiltration. Fracture-free survival was compared according to these patterns.

RESULTS

During follow-up, 131 vertebral compression fractures appeared in 37 patients. Patients with pattern A (n = 10) or B (n = 16) had significantly longer fracture-free survival before occurrence of the first, second, and third fractures than those with pattern C or D (P < 10(-5)). Relative risks of first, second, and third fracture occurrence for patients with pattern C or D compared with those with pattern A or B were 6.2, 9.1, and 11.0, respectively.

CONCLUSION

Determination of MR patterns of spinal bone marrow involvement is a potential relevant factor to predict the risk of vertebral fractures in patients with stage III multiple myeloma.

Multifocal malignant fibrous histiocytoma of the spine

A 40-year-old patient was seen because of a three-month history of low back pain unresponsive to standard therapy. Crush fractures of T12 and L2 were seen on plain radiographs. A magnetic resonance imaging study disclosed lesions of all the vertebral bodies from T12 to the sacrum sparing the disks and epidural space. Histologic features of a vertebral biopsy specimen was consistent with malignant fibrous histiocytoma of the bone. The multifocal distribution caused some reluctance to accept this diagnosis, which was, however, confirmed by detailed immunohistochemical studies and reevaluation of the histologic slides by independent observers who were unaware of the initial diagnosis. Chemotherapy with doxorubicin and cisplatin was started but the patient died 15 months after the diagnosis. Malignant fibrous histiocytoma mainly affects the metaphyses of the long tubular bones. The spine is a very uncommon site of localization of this tumor. The multifocal spinal lesions in our patient may have been produced by metastases from an unidentified primary or by direct spread via the perivertebral soft tissues of a primary located in a vertebral body. The management of malignant fibrous histiocytoma relies on a combination of surgery and chemotherapy. Although complete excision of the tumor can be followed by prolonged survival, the prognosis is bleak in unresectable forms.