Coronal split fracture of the proximal tibia epiphysis through a partially closed physis: a new fracture pattern

SUMMARY

A comminuted coronal split fracture of the proximal tibial epiphysis is an uncommon injury in children. The authors evaluated and treated two patients who sustained an epiphyseal fracture through a partially closed proximal tibial epiphysis. Plain radiography and computed tomography with three-dimensional reconstruction showed a comminuted coronal split fracture of the proximal tibial epiphysis. Each patient underwent definitive operative fixation of the fracture and was followed at least 1 year after clinical union. A mechanism consisting of three-point bending on the tibial plateau is proposed.

[The middle period outcome of partial patellectomy for the treatment of comminuted patella fractures]

The fracture of the biggest sesamoid bone patella is encountered at a rate of 1% of all skeletal injuries. Partial patellectomy is advised in the treatment of comminuted fractures of patella. In this retrospective study, we evaluated 18 of 25 patients who had partial patellectomy in our clinic between 1986-1997. Five patients were female (%27.8) and 13 were male (%72.2). The mechanisms of injuries were as follows: 11 (%61) motor vehicle accidents; 4 (%22) falls from flat-roofed house; 2 (%11) gunshot; and 1 (%5) subsidence. The mean age of the patients was 34.3 (range, 13-65). Ten left (%55) and eight right (%45) partial patellectomy were performed. Ten (%55) patients had also additional pathologies. The median follow-up time was 5.2 years (range, 2-11 years). Patients were very well in the last follow-up. According to Cincinnati Knee Score, which was improved by Noyes, 5 patients (%30) had excellent, 8 (%42) good 3(%17) moderate and 2 (%11) bad results. In conclusion, in the following years, enlargement in patellar articular surface and ossification, which is developed compensationally in the extensor mechanism may be detected and misevaluated as osteoarthrosis. Hence, we determined that they had not restricted knee joint functions in our cases.

Traumatic posterior rotatory fracture-dislocation of lumbo-sacral spine

Fracture-dislocation of the lumbo-sacral spine was an unusual injury and was divided into anterior, posterior and lateral types depending on the displacement of the cephalad portion of the spine over the caudal portion. According to the authors' knowledge, only 31 cases of traumatic fracture-dislocation of the lumbo-sacral spine were reported in the English literature. Only 3 previous reports referred to this injury with a posterior displacement, which was an even rarer injury. This was the fourth report of this type of injury.

Occult craniocerebral injuries from dog bites in young children

Although dog bite injuries to the head and scalp of children occur frequently, penetrating dog bite wounds to the cranial vault occur only occasionally and may go unnoticed on initial examination. Substantial morbidity and mortality can ensue if these penetrating injuries are not detected and treated. The authors detail the evaluation of dog bites of the scalp in young children. They highlight the ease with which puncture wounds of the calvarium may be missed during physical examination as a result of scalp displacement at the time of puncture. The cranial puncture may not be large and may later be covered by scalp that returns to its native position. Well-scrutinized skull films and a careful, methodical physical examination are advocated. Recognized craniocerebral injuries should be explored. Depressed cranial fractures should be irrigated, debrided, and elevated. Dural tears should be repaired. Expedient management is necessary to prevent meningitis and its associated sequelae.

Extensor tendon rupture secondary to the AO/ASIF titanium distal radius plate without associated plate failure: a case report

Complications with open reduction and internal fixation of distal radius fractures have led to the development of the AO/titanium Pi-plate. This was designed to be a low-profile plate to decrease its intrusion into surrounding soft tissues. Recent case reports are revealing an association of tendon ruptures with failures of this plate. This case report demonstrates extensor tendon rupture without plate failure or prominent screw heads.

Treatment of complex mandibular fractures using titanium mesh

INTRODUCTION

The treatment of complex fractures with miniplates is often difficult and unsatisfactory. Such fractures include extremely atrophic mandibles, discontinuity defects, and marked comminuted fractures.

AIM

With this paper we want to call to mind once more that titanium mesh is useful for the treatment of such fractures and its use can reduce the number of complications.

PATIENTS

Between January 1996 and December 1998 we treated with titanium mesh 17 patients with fractures of extremely atrophic mandibles, mandibular discontinuity defects or comminuted fractures.

RESULTS

Union occurred without complication in 70% of fractures treated with titanium mesh. In 20% there were minor complications such as postoperative haematoma. In only one case did infection occur, a more severe complication.

CONCLUSION

Because of its geometry and the excellent physical and biomechanical properties, titanium mesh helps to achieve better stabilization of complex mandibular fractures than conventional miniplates do. Complications such as infection and non union can largely be avoided and bony continuity of the mandible can be restored.

Accidental and nonaccidental femur fractures in children

A retrospective review of 207 patients younger than 6 years of age who sustained nonpathologic diaphyseal femur fractures was done, which emphasized the characteristics of accidental versus nonaccidental injury. There were 214 fractures in 123 boys and 83 girls (the gender of one patient was unknown). The average age of the patients was 2.73 years. Mechanisms of injury were pedestrian struck by a car (62 patients), falls (92 patients), and motor vehicle accidents (10 patients). Nineteen patients did not have a history of trauma. Seventy-six cases were investigated for child abuse. The results of 13 investigations were positive. Overall, the morphologic features of the fractures were transverse (38%), spiral (27%), and oblique (17%). In the investigated group, 27% of the fractures were transverse, 39% were spiral, and 15% were oblique. In those cases with positive results of the investigation, 36% of the fractures were transverse, 36% were spiral, and 7% were oblique. Although transverse fractures are most common in accidental and nonaccidental injuries, many practitioners think spiral fractures are pathognomonic of abuse. The current data show that although spiral fractures were less common than transverse fractures overall, and no more common in the cohort of patients in whom the results of the child abuse investigations were positive, they were overrepresented in the cohort that was investigated. This suggests that spiral fractures are viewed as particularly suspicious, which may lead to missed cases of nonaccidental injury in children with transverse fractures.

Comminuted pelvic ring disruption in toddlers: management of a rare injury

Pediatric pelvic fractures are rare injuries. The clinical management, classification, and operative treatment of this type of injury was presented in two toddlers ranging in age from 1 to 3 years. The CT examination proved to be the most reliable diagnostic tool for the assessment of the fracture morphology. The findings of the CT examination provide the possibility for an exact classification and operative planning. The surgical treatment was performed with the AO instrumentation for small fragments by using the approved standard approaches of adult surgery. The postoperative management has to be adapted to the physiology of the children. It is important to remove the osteosynthesis material in due time to avoid the risk of epiphysiodesis at the pelvis. To detect late sequelae of the trauma, follow-up should be performed regularly until growth is completed.

Gunshot wounds to the lower extremity. A comprehensive review

A thorough knowledge of the mechanisms by which penetrating projectiles disrupt tissue can assist the physician in evaluating and treating the wound in a rational manner. Projectile mass, velocity, shape, construction, and the characteristics and anatomic constraints of the tissue penetrated determine the amount, type, and location of tissue disruption. The possibility of additional injuries caused by secondary missiles and cavitation must be understood to distinguish between conservative versus surgical care of the patient. Adherence to the principles of treatment discussed aids the physician in judgment when treating gunshot wound victims. Furthermore, the authors present a classification system to facilitate the identification and treatment of lower-extremity gunshot wounds. Regardless of the expertise in understanding wound ballistics, the unknown and unexpected variables create a challenge in treating the gunshot victim. A surgeon who believes in wide excision of tissue from all sides of the wound path in any high-velocity wound probably does more harm than that done by the bullet alone. A surgeon treating gunshot wound victims should follow the dictum: "Treat the wound, not the weapon."

Periprosthetic fractures about the elbow

As total elbow replacements are being performed more frequently, more periprosthetic fractures are occurring. Although this is a frequent topic of discussion for hips and knees, the literature contains little information to guide treatment of such fractures around the elbow. This article outlines the principles of classification and treatment based on the authors' clinical experience with more than 1000 total elbow arthroplasties.

Treatment of complex calcaneal fractures with bony defects from land mine blast injuries with a circular external fixator

Four calcanei, which were massively destroyed as a result of blasting injuries from land mines, and 18 severely comminuted calcaneal fractures with bony defects (in one patient, both feet), also from land mines, were treated using a circular external fixator for reconstruction by osteogenic distraction. Because of the severe destruction of tissue to be treated, definitive orthopaedic treatment was delayed for 3 to 28 months (average, 10.1 months) after injury. Time from first use of the circular external fixator to removal of the apparatus ranged from 110 to 175 days (average, 143.7 days). Mean follow-up was 18 months. Of the 22 calcaneal injuries, 4 had excellent results, 11 good, 5 fair, and 2 had poor results. Better results were achieved in cases with lesser defects in bone and where definitive orthopaedic treatment was delayed until problems in soft tissue could be treated.

Airbag-induced fracture in a patient with osteoporosis

Since the introduction of automotive airbag technology, patterns of airbag-induced injuries have emerged. Various types of upper-extremity trauma including fractures have been described. Previous reports have focused on the location of the forearm before deployment as the major determinant of fracture. We describe a case of forearm fracture resulting from an airbag deployment in a lupus patient with documented osteoporosis. Bone strength has recently been determined in laboratory testing to be an important factor determining airbag-induced fracture risk. An airbag-induced forearm fracture in an otherwise healthy individual may be an indicator of reduced bone strength.

Intramedullary fibular graft for supracondylar fracture of the femur following total knee arthroplasty

We describe a successful treatment, intramedullary fibular grafting, for a patient with a supracondylar fracture of the femur following total knee arthroplasty in which the fracture region was comminuted and a segmental large bone defect was present. Free autogenous fibular was inserted into the medullary cavity from the intercondylar region and fixed to the proximal fragment of the femur with augmented fixation using a small plate and screws. Our procedure makes it easy to perform large segmental bone grafting and internal fixation at the same time for such a condition.

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.

Significant roentgenographic parameters for evaluating the flexibility of acute thoracolumbar burst fractures. An in vitro study

Plain lateral radiographs in a neutral position were studied in ten acute thoracolumbar burst fractures produced by high speed impact on three vertebrae human cadaveric spine segments. Six linear geometric parameters were measured on each film. The ratio of each value in the neutral injured to the intact condition was correlated linearly with the motion parameters obtained from post-traumatic three-dimensional flexibility data (neutral zone NZ; range of motion ROM). Anterior unit height (vertebra+adjacent discs) had the highest correlation with the neutral zone and flexibility in all directions, especially flexion-extension (NZ, R2 = 0.93; flexion ROM, R2 = 0.86; extension ROM, R2 = 0.79) lateral bending (NZ, R2 = 0.83; ROM, R2 = 0.90) and right axial rotation (NZ, R2 = 0.53; ROM, R2 = 0.86). The deformation ratio (average height to depth) correlated most with the neutral zone in left axial rotation (R2 = 0.91) and right lateral bending (R2 = 0.92). Due to the high correlations obtained, these parameters should be evaluated in clinical situations to assess their effectiveness in predicting the instability of burst fractures. Ultimately, prospective clinical studies are required to verify their clinical utility.

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.

A new case of insufficiency fracture in a patient with tabes dorsalis

A new case of insufficiency fracture in a patient with tabes dorsalis is reported. Whereas the osteoarthropathies and bone lesions due to tabes dorsalis are well known, only one other case responsible for bone loss has been reported in the medical literature.

Skull fracture caused by vacuum extraction

BACKGROUND

The vacuum extractor is being increasingly advocated as the instrument of first choice for assisted vaginal delivery. It is widely believed that the vacuum cup will dislodge before causing serious fetal trauma.

CASE

Rotational delivery of a term infant was effected using a vacuum extractor. A 6-cm Malmström metal cup with a paramedian application was in place for 12 minutes. The vacuum pressure developed was 0.8 kg/cm2. Four traction efforts with contractions were required to deliver the fetal head. A neonatal skull x-ray the following day showed a comminuted parietal bone fracture at the vacuum cup application site. Management was conservative, and the infant's neurologic behavior remained normal.

CONCLUSION

The vacuum extractor exerts considerable traction force. Fetal skull fracture can result, and its true incidence may be higher than expected, considering that few neonates with normal neurologic behavior undergo skull x-ray.

Unilateral comminuted and complicated fracture of the mandible due to dog attack

Fractures of the mandible and their management are discussed in detail in textbooks and articles dealing with facial trauma. This paper presents the management and treatment of a case of a unilateral comminuted and complicated fracture of the mandible due to dog attack on a geriatric patient. The attack also severed the patient's right arm. Due to the severity of the trauma, an emergency surgery was performed on the mandible and arm.

Gunshot fractures of the humeral shaft treated with external fixation

In a prospective study, we assessed 38 consecutive gunshot fractures of the humeral shaft treated between 1 April 1990 and 30 June 1994. The average age was 34 (range, 16-60) years. Average follow-up was 31 (range, 8-50) months. Low-velocity fractures occurred in 35 patients. All fractures were comminuted and displaced. Nerve injuries (radial and/or median) occurred in eight and vascular injuries in three patients. All three vascular injuries had combined nerve injuries. The arteries and nerves were explored; only one artery was found severed and required repair; two arteries and all explored nerves were in continuity. All patients had minimal debridement, antibiotic therapy and stabilization of the fracture with an external fixator. The wounds healed by granulation in 27 patients; seven had secondary closure, and four had split skin grafts. The external fixator was left in place for 6-24 (average, 16) weeks. In 34 patients union occurred between 12 and 24 (average, 16) weeks. Two patients with delayed union required bone grafting. Nonunion occurred in two patients (5%). Full recovery of the nerve palsy without further intervention was observed in seven of the eight cases. Superficial pin track infection was present in five patients; two had deep wound sepsis, and one had bone sepsis. We recommend this treatment for low-velocity humeral shaft fractures.

Big cat attack: a case study

A 28-year-old man was attacked by a large female tiger at an exotic animal farm, sustaining penetrating injuries to the neck and pharynx as well as a cervical spine fracture. This case and review of the literature demonstrates the ability of these animals to cause significant trauma and occult injuries. Furthermore, this case demonstrates the need for a high index of suspicion when treating these patients, as serious underlying bony and soft tissue damage can easily be overlooked.

Dynamic responses of the head and cervical spine to axial impact loading

This study explores the inertial effects of the head and torso on cervical spine dynamics with the specific goal of determining whether the head mass can provide a constraining cervical spine end condition. The hypothesis was tested using a low friction impact surface and a pocketing foam impact surface. Impact orientation was also varied. Tests were conducted on whole unembalmed heads and cervical spines using a drop track system to produce impact velocities on the order of 3.2 m s-1. Data for the head impact forces and the reactions at T1 were recorded and the tests were also imaged at 1000 frames s-1. Injuries occurred 2-19 ms following head impact and prior to significant head motion. Average compressive load a failure was 1727 +/- 387 N. Decoupling was observed between the head and T1. Cervical spine loading due to head rebound constituted up to 54 +/- 16% of the total axial neck load for padded impacts and up to 38 +/- 30% of the total axial neck load for rigid impacts. Dynamic buckling was also observed; including first-order modes and transient higher-order modes which shifted the structure from a primarily compressive mode of deformation to various bending modes. These experiments demonstrate that in the absence of head pocketing, the head mass can provide sufficient constraint to cause cervical spine injury. The results also show that cervical spinal injury dynamics are complex, and that a large sample size of experimentally produced injuries will be necessary to develop comprehensive neck injury models and criteria.

[Bicoronal approach in the management of frontal sinus fractures]

The frontal sinus is located at the level of the junction between the naso-ethmoido-orbital region, the cranial vault and the skull base and plays a particularly important role in the biomechanics of the centro-facial region. It represents a locus minoris resistentiae placed between the fronto-orbital frame, whose resistance to trauma is good, and the thin posterior fronto-ethmoidal structures. Fractures of the frontal sinus more frequently involve the anterior wall of the frontal sinus and, occasionally, also the posterior wall and the base of the sinus. Where the fracture involves the anterior sinsu wall alone, surgical reduction is indicated to correct cosmetic defects arising from an altered bone profile, either via bicoronal access or by direct attack when there are skin lesions too. If the fracture extends to the posterior wall of the sinus without causing bone displacement or dural lesion, most authors agree that only the fractures of the anterior wall should be treated to avoid obliterating the sinus cavity. When the fracture of the posterior wall is comminuted with displacement of bone fragments, there are usually dural lesions too; in this event, once dural plasty has been performed, it is necessary to cranialize the frontal sinus by demolishing its posterior wall. Fractures of the skull base, associated with a high frequency of lesion or obstruction of the sinusal ostio and severe infective complication, require cranialization of the sinus that is also separated from the cranial cavity using a median-pedicled pericranial flap. To control the point of fracture, a rigid fixation system can be employed (microplates) or osteosynthesis with metal wires that restore the eurhythm of the frontal-orbital region and simultaneously guarantee good stability of the repositioned fragments.

Operative treatment of acute displaced intra-articular calcaneus fractures

A retrospective study of 18 operatively treated calcaneal fractures was conducted. The fractures were all type II and type III fractures according to the classification system of Crosby et al. The average follow-up was 32 months and consisted of subjective and objective criteria. The findings were compared with the results of nonoperative treatment reported by Crosby et al. The findings suggests that type II fractures have a similar outcome when either operative or nonoperative treatment is used. Type III fractures, however, fared considerably better with operative intervention when compared with those treated with nonoperative techniques.

Reconstructive amputation after grade IIIC open tibial fracture. One method of preserving residual limb length

A high percentage of patients with grade IIIC open tibial fractures eventually undergo amputation. Maintaining an adequate residual limb length is advantageous with regard to biomechanics, energy expenditure, and prosthetic fitting. This case report presents new considerations for maintaining residual limb length in the presence of comminuted proximal tibial fractures. These considerations include (a) using an autogenous fibular strut graft for stabilizing the reconstructed residual limb and (b) determining the level of amputation based on soft-tissue integrity rather than on fracture level. We present one technique for preserving an adequate residual limb length in the face of significant proximal tibia comminution.