Mapping of scapular fractures with three-dimensional computed tomography

Posterior Wall Fragments in Acetabular Both-Column Fractures: Morphology, Type, and the Significance of its Projection

OBJECTIVE

Most both-column acetabular fractures are combined with posterior wall fragments. However, the morphology of this posterior wall is varied, and how to fix this posterior wall remains a controversial topic. To investigate the morphological characteristics of posterior wall fragments of both-column acetabular fractures and select corresponding fixation methods.

METHODS

Data from 352 patients with acetabular fractures admitted to the level one trauma centre in our hospital between January 2006 and December 2022 were collected. The morphology of posterior wall fragments was observed and analyzed in 83 cases of both-column acetabular fractures and classified according to the consistency of posterior wall morphology. A fracture map of the posterior wall was created on a normal template according to the three morphological types of posterior wall fragments. Finally, the high-incidence area of the posterior wall fracture was projected onto the iliac fossa and the medial side of the posterior column to guide the fixation of the posterior wall fragment using the anterior intrapelvic approach.

RESULTS

Fractures were divided into four types: I, large posterior wall fragment which was high in the ilium bone (34 cases, 41.0%); II, posterior wall fragment in the acetabular parietal region (18 cases, 21.7%); III, posterior wall marginal fracture (10 cases, 12.0%); and IV, non-combined posterior wall fracture (21 cases, 25.3%). The most common morphologies of the posterior wall fragments of the first two types were mapped and projected onto the anterior iliac inner plate and medial side of the posterior column, where the corresponding area could be used to guide the insertion of the internal fixation.

CONCLUSION

Both-column acetabular fractures combined with posterior wall fractures can be divided into four types according to the morphology of the posterior wall fragment. Understanding the corresponding three-dimensional morphology and projection position of different types of these fragments can help surgeons determine the position and orientation of internal fixation of posterior wall fractures.

Endopelvic zones and constant fragment mapping in acetabular fractures

OBJECTIVE

This study aims to characterize the constant fragment (CF) in acetabular fractures and to provide a novel nomenclature of anatomic zones from the vantage point of the endopelvic approach.

DESIGN

Retrospective clinical study SETTING: Urban Level I trauma center, Patients/participants: One hundred and eleven consecutive acetabular fractures eligible for an AIP approach and treated surgically.

INTERVENTION

3D mapping of the CF line of fractures using a novel endopelvic anatomical zoning system.

MAIN OUTCOME MEASUREMENT

Correlation of Letournel's fracture types to the size of the CF and its location based on precise anatomical nomenclature.

RESULTS

The average age of patients was 47 years (range, 12 to 88 years), predominantly comprising male patients (78 %, n = 87) and female patients (22 %, n = 24). Fractures were grouped into 3 categories based on the size of the CF and its location from anterior to posterior. Group 1 included AC fractures which demonstrated the largest CF. The CF nearly always spared Zone 4. Group 2 included transverse fractures, T-Type fractures, and T-Type with posterior wall fractures. The CF was of intermediate size, and it often spared Zone 4. Group 3 included anterior column posterior hemitransverse fractures and associated both column fractures. The CF was the smallest of all categories and rarely spared Zone 4.

CONCLUSION

Our analysis suggests consistent and repeatable patterns and sizes of constant fragments. These findings can serve as an endopelvic roadmap for the AIP approach based on fracture types, guiding placement of reduction clamps, vectors of reduction and hardware position.

The Scapular Skiver Screw: A Useful Fixation Technique for Inferior Glenoid and Scapular Neck Fractures

SUMMARY

The inferior glenoid and scapular neck are common locations for scapular fractures. Operative exposures for reduction and fixation can be challenging, and frequently, the proximal fracture planes are not conducive to optimal fixation with a plate alone. The purpose of this article was to describe a new technique for enhancing fixation in specific inferior glenoid fractures using a single cortical lag screw.

Fracture pattern analysis of fractures to the diaphysis of the fifth metatarsal

BACKGROUND

Fractures to the fifth's metatarsal (MT-V) diaphysis are common. These are inconsistently referred to as diaphyseal-, shaft-, or Dancer's fractures. A comprehensive analysis of the MT-V fracture morphology is missing. The aim was to qualitatively and quantitatively analyze fracture patterns of MT-V diaphyseal fractures.

HYPOTHESIS

Fractures to the shaft of the fifth metatarsal feature specific fracture morphologies.

MATERIALS AND METHODS

Retrospective, radiologic database study. Included were all acute, isolated MT-V shaft fractures (including the proximal [Lawrence and Botte (L&B) III] and distal meta-diaphysis). Demographics and fracture characteristics were assessed. Each proximal fracture line was drawn, scaled, and a qualitative and quantitative fracture line analysis was conducted. The quantitative fracture line analysis aimed at identifying dens clusters with arbitrary shape using the DBSCAN algorithm. Data are presented as mean±standard deviation.

RESULTS

Out of 704 eligible MT-V fractures, 156 met the inclusion criteria. Patient's mean age was 46±19 years and 94% suffered a low energy trauma. Qualitative and quantitative fracture line analysis revealed three distinct fracture patterns. The proximal (30%) and distal (5%) meta-diaphyseal clusters showed a predominant transverse fracture pattern. The vast majority of diaphyseal fractures (56%) were spiral/oblique fractures, progressing from the proximal lateral meta-diaphyseal region in an oblique course at 61±9° to the medial distal diaphyseal cortex. Seven percent of diaphyseal fractures showed a transverse fracture pattern.

DISCUSSION

Based on a qualitative and quantitative analysis of all MT-V shaft fractures, three distinct fracture clusters were identified with homogeneous fracture patterns. MT-V shaft fractures should therefore be classified as proximal meta-diaphyseal (L&B Type III), diaphyseal (oblique or transverse) and distal meta-diaphyseal.

LEVEL OF PROOF

IV; retrospective database study.

Three-Dimensional Mapping of Scapular Body, Neck, and Glenoid Fractures

OBJECTIVES

The purpose of this study was to report patterns of scapular fractures and define them with a contemporary methodology.

METHODS

.

DESIGN

Retrospective study, 2015-2021.

SETTING

Single, academic, Level 1 trauma center.

PATIENT SELECTION CRITERIA

Consecutive patients ≥18 years, presenting with unilateral scapula fracture, with thin-slice (≤0.5-mm) bilateral computed tomography (CT) scans of the entirety of both the injured and uninjured scapulae.

OUTCOME MEASURES AND COMPARISONS

Thin-slice (0.5-mm) CT scans of injured and normal scapulae were obtained to create three-dimensional (3D) virtual models. 3D modeling software (Stryker Orthopedics Modeling and Analytics, Stryker Trauma GmbH, Kiel, Germany aka SOMA) was used to create a 3D map of fracture location and frequency. Fracture zones were delineated using anatomic landmarks to characterize fracture patterns.

RESULTS

Eighty-seven patients were identified with 75 (86%) extra-articular and 12 (14%) intra-articular fractures. The dominant fracture pattern emanated from the superior lateral border (zone E) to an area inferior to the spinomedial angle (zone B) and was present in 80% of extra-articular fractures. A second-most common fracture line propagated from the primary (most-common) line toward the inferior medial scapular border with a frequency of 36%. Bare zones (with 1 or no fractures present) were identified in 4 unique areas. Furthermore, intra-articular fractures were found to be heterogenous.

CONCLUSIONS

The 3D fracture map created in this study confirmed that extra-articular scapular fractures occur in certain patterns with a relatively high frequency. Results provide greater insight into scapular fracture locations and may help to study prognosis of injury and improve treatment strategy including operative approaches and surgical tactics.

CT-based five-segment classification in Freiberg's infarction: Evaluation of its intraobserver and interobserver reliability

BACKGROUND

According to the location and frequency of osteonecrosis zone of metatarsal head, a map of osteonecrosis zone was drawn for Freiberg's infarction. The objective of the current study is to develop a new computed tomography-based Five-Segment classification system for Freiberg's infarction and testify if it has good intra- and interobserver reliability or not.

METHODS

According to the location and its frequency of osteonecrosis zone of metatarsal head, a map of osteonecrosis zone was drawn. According to the distribution of osteonecrosis zones of metatarsal heads, we proposed the Five-Segment classification system. Four evaluators evaluated each radiography and computed tomography (CT) twice at 8-week intervals. To test the reproducibility of the Five-Segment classification system, the interobserver and intraobserver reliability of this classification system comparing with that of the Smillie classification by four observers using the kappa statistic.

RESULTS

The 80 cases were classified into five reproducible types by using Five-Segment classification system: type Ⅰ, two (2.5%) cases; type Ⅱ, ten (12.5%) cases; type Ⅲ, 42 (52.5) cases; type Ⅳ, 24 (30.0%) cases; type Ⅴ, two (2.5%) cases. The mean kappa value for interobserver reliability using Smillie classification systems was 0.562 (95% CI: 0.531-0.585), whereas the mean kappa value was 0.828 (95% CI: 0.801-0.852), by using Five-Segment classification; the mean kappa values for intraobserver reliability by using Smillie classification and Five-Segment classification were 0.777 (95% CI: 0.762-0.792) and 0.860 (95% CI: 0.843-0.895), respectively.

CONCLUSIONS

The new Five-Segment classification system demonstrated perfect interobserver and intraobserver agreement between evaluators in the management of Freiberg's infarction. Prospective studies should be done to evaluate its prognostic value and utility in clinical practice.

LEVEL OF EVIDENCE

Level IV, retrospective.

[Scapular fractures]

Scapular fractures are rare injuries that require different treatment strategies. Nondisplaced fractures and the majority of scapular body fractures can be treated conservatively, while surgical treatment should be considered for displaced fractures involving the glenoid. Displaced glenoid fractures of appropriate size and intra-articular step formation should be treated surgically. Different classification systems for scapular fractures can support the treatment decision. Postoperative and posttraumatic management should include early mobilization to achieve a good functional outcome. Clear recommendations and treatment algorithms at the evidence level are not available and long-term outcomes of scapular fractures are the subject of further investigation. The results published so far show good to excellent results for surgical and conservative treatment, depending on the type of fracture. Individual patient factors should be considered when planning treatment.

Outcomes of conservative treatment of acromial and scapular spine stress fracture post reverse shoulder arthroplasty: a systematic review with meta-analysis

INTRODUCTION

Acromial and scapular spine stress fractures are common complications post reverse shoulder arthroplasty. A systematic review with meta-analysis was conducted to evaluate the clinical outcomes of conservatively treated acromial and scapular spine stress fractures post reverse shoulder arthroplasty in comparison to nonfracture control.

METHODS

Embase, MEDLINE, and Web of Science were searched on September 9, 2022, using various terms related to fracture, acromion, scapula, and reverse shoulder arthroplasty. Meta-analysis using a random effects model was performed on common outcome scores. Risk of bias was assessed using the Joanna Briggs Institute tools for case-controlled studies. Sensitivity analysis was performed for imputed standard deviations and studies with <20 participants.

RESULTS

Thirteen studies with a total of 339 fracture and 3142 control patients were included in the systematic review. Meta-analysis was performed on 12 studies assessing active forward flexion, abduction, external rotation, Constant-Murley score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, pain score, Simple Shoulder Test, and Single Assessment Numeric Evaluation. Fracture patients experienced significantly poorer functional outcome compared with control patients when the fractures were managed conservatively. Levy III fractures tend to experience worse outcomes. Pain score did not demonstrate a statistically significant difference between the fracture and nonfracture cohort.

DISCUSSION

Currently, literature regarding surgical management is lacking, partially because of a dearth of high-quality literature but also hindered by a lack of standardized techniques. This review was limited by inclusion of studies of low evidence, small sample sizes, and inconsistency in outcome measurement and follow-up period. Overall, patients with acromial and scapular spine stress fractures treated conservatively are expected to have reduced shoulder function compared to nonfracture patients, with the spine of scapula fracture patients suffering the poorest outcomes. Future studies should aim to use the same sets of outcomes parameters to assess the patients at fixed time intervals and report outcomes stratified by Levy classification. This will enable interinstitutional collaboration and pooling of results.

Analysis of Potential Risk Factors for Cement Leakage into Paraspinal Veins after Vertebroplasty for Acute Osteoporotic Vertebral Fractures Based on a 3D Reconstruction Technique: A Retrospective Matched Case-Control Study

OBJECTIVE

Pulmonary embolism, cardiac embolism, and even cerebral embolism due to paraspinal vein leakage (PVL) are increasingly reported, and their risk factors need to be adequately investigated for prevention. To this end, this study investigated the correlation of the distribution and morphological characteristics of fracture lines with the occurrence of PVL after percutaneous vertebroplasty (PVP), which has not been previously reported.

METHODS

Patients with acute single-segment thoracolumbar osteoporotic vertebral compression fractures (OVCFs) treated with PVP at our institution from January 2019 to July 2022 were selected for a matched case-control study. The case and control groups included those with and without PVL, respectively, matched at a 1:1 ratio based on general clinical characteristics. Additionally, fracture map and heatmap analysis was performed in both groups. In addition to the general clinical characteristics, the vertebral height ratio, puncture angle, delivery rate, and indexes were assessed via the three-dimensional CT reconstruction fracture line mapping technique, namely, the distribution of fracture lines, fracture line length, main fracture line shape, location of fracture line involvement, and number of fracture line branches, were compared between the two groups. The Wilcoxon rank-sum test, t tests, analysis of variance, and conditional logistic regression were used for statistical analysis.

RESULTS

Among 658 patients with OVCFs, 54 who did and 54 who did not develop PVL were included in this study. Significant differences in the puncture angle, fracture line distribution (MR-1, ML-2, MM-2, MR-2, ML-3, MM-3, LL-1, LM-1, LL-2, LM-2), fracture line involvement of the posterior wall, total fracture line length, and main fracture line length were found between the two groups (p < 0.05). Logistic univariate analysis showed significant differences in the puncture angle, fracture line distribution (MR-1, ML-2, MM-2, MR-2, ML-3, MM-3, LL-1, LL-2, LM-2, LL-3), total fracture line length, main fracture line length, and fracture line involvement of the posterior wall between the two groups (p < 0.05). Logistic multifactorial analysis showed that the fracture line distribution (UR-3, ML-3, LM-2, LR-2) and main fracture line length were independent risk factors for the development of PVL in both groups. In addition, the fracture maps and heatmaps showed a greater degree of fracture line encapsulation and more extensive involvement in the middle and lower regions of the vertebral body in the PVL group than in the control group.

CONCLUSIONS

Through a three-dimensional computed tomography reconstruction-based fracture line mapping technique, this study revealed for the first time that the distribution of fracture lines (UR-3, ML-3, LM-2, LR-2) and main fracture line length were independent risk factors for PVL after PVP in patients with acute single-segment thoracolumbar OVCFs. In addition, we hypothesized that the fracture line-vein traffic branch that may appear within 2 weeks after injury in acute OVCF patients may be one of the mechanisms influencing the above potential independent risk factors associated with PVL.

Triplane ankle fracture patterns in paediatric patients

Aims

Triplane ankle fractures are complex injuries typically occurring in children aged between 12 and 15 years. Classic teaching that closure of the physis dictates the overall fracture pattern, based on studies in the 1960s, has not been challenged. The aim of this paper is to analyze whether these injuries correlate with the advancing closure of the physis with age.

Methods

A fracture mapping study was performed in 83 paediatric patients with a triplane ankle fracture treated in three trauma centres between January 2010 and June 2020. Patients aged younger than 18 years who had CT scans available were included. An independent Paediatric Orthopaedic Trauma Surgeon assessed all CT scans and classified the injuries as n-part triplane fractures. Qualitative analysis of the fracture pattern was performed using the modified Cole fracture mapping technique. The maps were assessed for both patterns and correlation with the closing of the physis until consensus was reached by a panel of six surgeons.

Results

Fracture map grouped by age demonstrates that, regardless of age (even at the extremes of the spectrum), the fracture lines consolidate in a characteristic Y-pattern, and no shift with closure of the physis was observed. A second fracture map with two years added to female age also did not show a shift. The fracture map, grouped by both age and sex, shows a Y-pattern in all different groups. The fracture lines appear to occur between the anterior and posterior inferior tibiofibular ligaments, and the medially fused physis or deltoid ligament.

Conclusion

This fracture mapping study reveals that triplane ankle fractures have a characteristic Y-pattern, and acknowledges the weakness created by the physis, however it also challenges classic teaching that the specific fracture pattern at the level of the joint of these injuries relies on advancing closure of the physis with age. Instead, this study observes the importance of ligament attachment in the fracture patterns of these injuries.

3D mapping: has the mystery of proximal tibia fractures been solved?

PURPOSE

One of the major limitations of the 2D fracture evaluation (Schatzker classification) is its failure to adequately assess fracture lines in the frontal plane and fracture displacement in the antero-posterior direction. 3D fracture line mapping includes steric assessment which can aid decision making with regards to the surgical approach and fixation scheme. We hypothesized that there are consistent fracture patterns and zones of comminution for proximal tibial fractures.

METHODS

Radiographic data of 228 proximal tibia fractures were retrospectively included in this study. Fracture lines and zones of comminution were graphically superimposed onto a 3D template of an intact tibia after virtual reduction and normalization to identify major patterns of fracture and comminution.

RESULTS

Out of 206 male and 21 female patients, 89 had a fracture of the lateral condyle only (Schatzker I and II), 53 involved the medial plateau only (Schatzker IV) and 86 had a high-grade fracture involving both the condyles (Schatzker V and VI). 64.5% of the fracture lines involving the medial plateau alone were in the coronal plane, and this number was even lesser (44.2%) in medial plateau involvement of bicondylar fractures. In bicondylar fractures, lines were usually not seen to pass directly through the posteromedial region.

CONCLUSIONS

Medial tibial plateau fractures have a mix of coronal or sagittal fracture alignment. A clearer understanding of the 3D orientations of fractures based on CT scans can aid in diagnosing the pattern of fracture and adequate positioning of plates can be done to eventually improve operative outcomes.

Fracture Line Morphology of Greater Tuberosity Fragments of Neer Three- and Four-Part Proximal Humerus Fractures

OBJECTIVE

In complicated Neer three- and four-part proximal humerus fracture (PHF), greater tuberosity (GT) fragments are often comminuted, and the currently widely used locking plate may not fix GT fragments effectively. A further understanding of morphological characteristics of the GT fragments may help explore new fixation devices. This study aimed to determine the fracture line morphology of the GT fragment of Neer three- or four-part PHF and analyze the location relationship between the locking plate and the GT fragment.

METHODS

Seventy-one three-dimensional computed tomography scans of Neer three- and four-part PHF were retrospectively reviewed between January 2014 and June 2019. Fracture fragments were reconstructed and virtually reduced in the Mimics software, and fracture lines of GT fragments were depicted on a humerus template in the 3-matic software and then were superimposed altogether. The common sites of the GT fracture were identified, and the location relationship between the locking plate and GT fragments was analyzed in a computer-simulated scenario.

RESULTS

The fracture line morphology of GT fragments was similar between Neer three- and four-part PHF. The overall morphology of GT fragments was in a fan shape, which could be summarized as anterior, superior, posterior, and middle lines. Of these, we identified 51 split and 29 avulsion type GT fragments based on the Mutch classification, and they could occur simultaneously in a PHF. The overall morphology of split type fragments was in a fan shape, and avulsion type fragments showed a quite distinguishable distribution pattern. A GT fragment could be classified as anterior-split, posterior-split, complete-split, anterior -avulsion, and posterior-avulsion type based on its morphology and location. The median percentage of fragment area covered by the plate was 32.3% in all of the fragments, and it was 69.4%, 23.0%, 37.2%, 21.8%, 0.0% in anterior-split, posterior-split, complete-split, anterior-avulsion, and posterior-avulsion type GT fragments. We defined the posterior-split, anterior-avulsion, and posterior-avulsion type GT fragments as the risky GT fragments, and they occurred in 43 (60.6%) Neer three- and four-part PHFs.

CONCLUSION

The fracture line morphology of GT fragments of Neer three- and four-part PHF was in a fan shape. GT fragments could be classified based on their location and morphology. The extent of GT fragment coverage provided by the locking plate differed in various fragment types, and we identified the anterior-avulsion, posterior-avulsion, and posterior-split type fragments as the risky GT fragments with a high incidence rate in Neer three- and four-part PHFs.

Morphological Analysis of Fractures of the Proximal Humerus by the Fracture Mapping Technique

OBJECTIVE

Fractures of different parts of the proximal humerus may lead to different postoperative functional deficits, but there are few studies on the morphology and related functions of the proximal humerus. The purpose of this study was to analyze the fracture pattern of the proximal humerus by the three-dimensional (3-D) fracture mapping technique and to further evaluate its clinical utility.

METHODS

Patients with proximal humeral fractures admitted to Pudong Hospital, Fudan University, from January 2018 to December 2020, were analyzed. Three surgeons divided the fractures into groups according to the 3-D CT imaging technique and mapped the fractures on a 3-D template according to the fracture line of each fracture. Finally, the humeral head inversion angle and the functional score were recorded in different fracture types.

RESULTS

A total of 312 cases of humeral fractures were included. Among them, there were 90 patients (28.8%) in the simple greater tuberosity + lesser tuberosity + medial cortex group, with typical fracture features of surgical neck fractures of the humerus + greater tuberosity fractures. Eighty-seven patients (27.9%) in the greater tuberosity + isolated fragment lesser tuberosity + medial cortex group had typical "four-part fractures." There were 45 patients (14.4%) in the greater tuberosity + lesser tuberosity + medial isolated fragment group. Moreover, more patients in this group had medial comminution due to varus displacement of the femoral head. There were 66 patients (21.1%) in the isolated greater tuberosity group, 21 patients (6.7%) in the greater tuberosity + lesser tuberosity group, and three patients (1.0%) in the greater tuberosity + medial cortex group. In addition, the humeral head inversion angle and other statistical differences were observed in the greater tuberosity + lesser tuberosity + medial isolated fragment group.

CONCLUSIONS

This morphological study helps to further identify the characteristics of proximal humerus fracture patterns, which may be closely related to different clinical outcomes. Further relevant studies are needed to verify the reliability of their clinical application and the potential value in surgical planning and postoperative functional rehabilitation.

Three-dimensional computed tomography mapping techniques in the morphometric analysis of AO/OTA 33A and 33C distal femoral fractures: a retrospective single-center study

Purpose: Complex distal femoral fractures involve a challenging set of considerations that must be known to provide optimal management. This study aimed to determine the location and frequency of fracture lines and comminution zones in AO/OTA types 33A and 33C distal femoral fractures using three-dimensional computed tomography mapping. Methods: Seventy-four consecutive eligible patients were included. Fracture fragments for each patient were reconstructed, virtually reduced, and adjusted to match the distal femoral template. Then, all fracture lines and comminuted areas were extracted in transparent mode, and corresponding heat maps were constructed. Finally, these maps, along with the quantitative analysis findings of the counts and volumes of each fragment, were used to summarize the characteristics of the fractures. Results: Thirty-four females and 40 males [average age, 58 years (range, 18-92 years)] presented with a distal femoral fracture. There were 53 AO/OTA type 33A fractures, and 21 AO/OTA type 33C fractures. These two patterns differed significantly on fracture fragment count, comminuted zone fracture fragment count, and mean comminuted zone fracture fragment volume (p < 0.05). Most of the fracture line heat zones were in the femoral epiphysis, intercondylar notch of the femur, and patellofemoral joint. The comminuted area heat regions were mostly found on the lateral, anterior, and posterior femoral diaphysis, with less involvement on the medial side. Conclusion: Our findings may serve as a guide for the surgical approach selection of complex distal femur fractures, the placement strategy of the internal fixation, and the optimization of the osteotomy plan for biomechanical studies.

Differences in Pilon Fractures According to Ipsilateral Fibular Injury Patterns: A Clinical Computed Tomography-Based Mapping Study

Background

Preoperative verification of fracture morphology is essential for determining the definitive fixation strategy in the management of a pilon fracture. This study aimed to determine the correlation between fibular injury patterns and fracture morphologies and introduce clinical implications.

Methods

Computed tomography scans of 96 pilon fractures were retrospectively analyzed and divided into three types: intact fibula, simple fracture, and multifragment fracture. The principal fracture line and comminution zones were illustrated on a plafond template and diagrammatized on a 6 × 6 grid using PowerPoint software as fracture mapping. Correlations between fibular injury patterns and fracture morphologies, including comminution zones and principal fracture lines, were analyzed.

Results

The thickest comminution zone was most often located in the anterolateral quadrant. According to fibular injury patterns, the comminution zone of the multifragment group was placed two grids more lateral than that of other groups. Lateral exits of the principal fracture line in the multifragment group were much more concentrated within the fibular incisura.

Conclusions

In pilon fractures, a more complex fibular fracture pattern was related to the valgus position. Moreover, the articular fracture pattern of pilon fractures differed according to coronal angulation and fibular fracture pattern. These differences should influence the operative approach and placement of the plate.

3D mapping of intra-articular calcaneal fractures

To determine the pattern of intra-articular calcaneal fractures (ICFs) by a three-dimensional (3D) mapping and determine whether there were consistent fracture patterns and comminution zones. In this study, 67 patients with ICFS by CT scan were included. The calcaneal fractures fragments in CT were multiplanar reconstructed and virtual reduced. 3D heat mapping was subsequently created by graphically superimposing all fracture lines onto a standard calcaneal template. The cohort included 26 (38.8%) left calcaneal fractures, 27 (40.30%) right calcaneal fractures, and 14 (20.9%) cases with bilateral fractures. Comminuted fractures accounted for 92.5%. Sagittal 3D mapping shows that the fracture line is mainly concentrated at the critical angle of Gissane and extending rear to the posterior of the tuberosity of the lateral wall and the anterior of the medial process of the calcaneus tuberosity but with more significant variation in the medial wall. The average angle of fracture lines concerning the long calcaneal axis (LCA) was 29.1° and 19.2° in the lateral and medial walls. Axial 3D mapping shows that fracture lines were primarily concentrated in the anterior area to the posterior joint facet and extending along the rear joint facet and calcaneus sulcus to the posteriorly of the tuberosity. The mean angle of fracture lines concerning the LAC was 11° in the axial wall. Our data provided elucidated that ICFs have consistent characteristic fracture patterns and comminution zones. This study provides visual guidelines for understanding fracture morphology, which may assist with fracture classification, preoperative planning, development of fixation concepts.

Rib Fracture Map in High-Energy Injuries

OBJECTIVES

To use a novel rib unfurling technology to investigate the locations of multiple rib fractures occurring from high-energy trauma to discern if there are reproducible rib fracture patterns.

METHODS

Patients between the ages of 18 and 48 years presenting to a Level 1 academic trauma center with ≥2 rib fractures after a high-energy mechanism of injury between 2017 and 2019 were identified. Curved planar reformatting of CT scans was used to create two-dimensional unfurled rib images by flattening out the view of the ribs from a CT scan. Rib fractures were placed on a template map using a standardized measurement method, and subsequent frequency and heat maps were created.

RESULTS

Among 100 consecutive patients, 534 fractures on 454 ribs were identified. The most common high-energy mechanism of injury was motor vehicle accidents (41%). Flail chest occurred in 8% of patients. The mean number of ribs fractured per patient was 4.54 ± 3.14 and included a mean of 5.34 ± 4.38 total fractures. Among all fractures, 50.9% were located on ribs 4 through 7. The most common fracture location was located in the lateral or anterolateral zone of the rib cage.

CONCLUSIONS

Patients with multiple rib fractures from high-energy trauma have rib fractures with locations of common occurrence. An understanding of location and frequency of rib fractures can help inform surgical approaches, prognosis, indications, classifications, and implant design in the management of a complex population of patients with chest wall injury after trauma.

LEVEL OF EVIDENCE

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

Deltoid-Sparing Modified Judet Approach: Technique and Clinical Series

SUMMARY

Posterior approaches provide the mainstay for treatment in most of the scapula body and neck fractures, even those associated with many intraarticular variants. Several posterior approach modifications for minimizing soft-tissue damage and limiting muscular detachment, have previously been described in the literature; however, little or no clinical evidence is available specifically applied to the various approaches.In this study, we describe complete sparing of the deltoid muscle origin during the "modified Judet" approach. The modified approach as previously described detaches the deltoid origin. Deltoid sparing allows for satisfactory visualization and fixation of extra-articular scapula fractures and even some intraarticular variants. The purpose of this article was to describe the deltoid-sparing modified Judet approach and report clinical outcomes for 23 patients after surgical treatment.

Fracture mapping of adult femoral neck fractures with three dimensional computed tomography

PURPOSE

Femoral neck fractures (FNFs) are a commonly encountered injury in orthopaedic practice. It is essential that surgeons recognize specific fracture patterns to effectively manage these fractures. The purpose of this study was to analyze the fracture morphology of FNFs by three-dimensional (3D) mapping of the fracture.

METHODS

The fracture line location and distribution of 120 FNFs were identified using computed tomography reconstructions. After segmentation and virtual reduction, the fracture line was revealed. The femoral neck region was divided into zones according to anatomical localization, and the zones through which the fracture lines passed were recorded. All fracture lines are superimposed on the standard model to create fracture mapping.

RESULTS

A total of 120 patients with FNFs were analyzed. The mean age of the patients was 67 (18-96) years. Of all patients, 59 were male, and 61 were female. The most affected region was Zone 4. The least affected region was Zone 6. The displacement in Zone 1 and Zone 4 was found to be significantly higher. The displacement in patients under 65 years was found to be significantly higher. Zone 2 and Zone 5 involvement was significantly higher in patients under 65 years.

CONCLUSION

The fracture map showed fracture patterns of FNFs. It was found that fracture displacement and transcervical region involvement were more common in patients under 65 years. It was also found that the displacement rate was high in fractures of the subcapital region.

Statistical Morphology and Fragment Mapping of Complex Proximal Humeral Fractures

Background and Objectives: Proximal humerus fractures (PHFs) are common in the elderly, but the treatment results are often poor. A clear understanding of fracture morphology and distribution of cortical bone loss is important for improved surgical decision making, operative considerations, and new implant designs. The aim of this study was to develop a 3D segmentation fracture mapping technique to create a statistical description of the spatial pattern and cortical bone loss of complex PHFs. Materials and Methods: Fifty clinical computed tomography (CT) scans of complex PHFs and their contralateral intact shoulders were collected. In-house software was developed for semi-automated segmentation and fracture line detection and was combined with manual fracture reduction to the contralateral template in a commercial software. A statistical mean model of these cases was built and used to describe probability maps of the fracture lines and cortical fragments. Results: The fracture lines predominantly passed through the surgical neck and between the tuberosities and tendon insertions. The superior aspects of the tuberosities were constant fragments where comminution was less likely. Some fracture lines passed through the bicipital sulcus, but predominantly at its edges and curving around the tuberosities proximally and distally. Conclusions: A comprehensive and systematic approach was developed for processing clinical CT images of complex fractures into fracture morphology and fragment probability maps and applied on PHFs. This information creates an important basis for better understanding of fracture morphology that could be utilized in future studies for surgical training and implant design.

Fracture edge features of diaphyseal clavicular fractures: a morphologic study

BACKGROUND

Previous researchers used transverse fractures centered over the midpoint of the clavicle as the diaphyseal clavicular fracture models. However, as a result of shear stress concentration in sigmoid-shaped structures, most diaphyseal clavicular fractures have coronal fracture edges and are located distal to the midpoint. The purpose of this study was to quantify the morphology and utilize these parameters to establish clinically relevant fracture models.

METHODS

The computed tomographic DICOM data of 100 consecutive patients were included. We investigated the morphologic characteristics of the fracture edges after virtual fracture reduction. The fracture orientation was determined based on the normal vectors of the best-fit plane of the fracture edges. The fracture location was measured by the extreme points of the edges. The fracture configuration was evaluated using fracture maps.

RESULTS

There were 28 simple, 43 wedge, and 29 multifragmentary types. Coronal oriented fracture edges accounted for more than 70% of the simple, wedge, and multifragmentary types. The most proximal point of the proximal edge was located at 46.7% (42.0%-56.5%), 47.6% (42.5%-50.1%), and 46.3% (42.0%-49.3%) of the endpoint line in the simple, wedge, and multifragmentary types, respectively (P = .548). The most distal point of the distal edge was located at 72.2% (68.4%-75.0%), 73.2% (69.5%-76.9%), and 74.0% (69.6%-77.1%) of the endpoint line (P = .353). The longest proximal main fragments occurred in the simple types at 71.9% (66.3%-75.4%) of the endpoint line (P < .001), and the shortest distal main fragments occurred in the multifragmentary types at 55.8% (49.8%-59.3%) of the endpoint line (P = .001). The heatmaps showed a high concentration of anteriorly distributed wedge fragments (88%; n = 38/43) and coronally distributed multifragmentary fragments (62%; n = 18/29).

CONCLUSIONS

We showed that typical diaphyseal clavicular fractures have coronal fracture edges and are located within the distal half of the diaphyseal segment. The fractured fragments were initiated anteriorly in the wedge types and then propagated coronally in the multifragmentary types. The features of these fracture edges could be useful in designing osteotomy models and provide different perspectives of anterior and superior plating techniques.

Fracture mapping of intra-articular calcaneal fractures

BACKGROUND

Calcaneal fractures have complex morphology, which brings great challenges to clinical treatment. The primary fracture lines could help us simplify the fracture. Fracture mapping technology can help surgeons understand the fracture morphology more intuitively. This study aims to develop a further understanding of calcaneal fractures by delineating the primary fracture lines through the fracture mapping technology.

METHODS

Ninety cases of intra-articular calcaneal fractures were reviewed between March 2016 and January 2019 at a level 1 trauma centre. The CT data of these cases were reconstructed and reduced using software. We superimposed the primary fracture lines on a standard model and created the distribution and heat map of the intra-articular calcaneal fractures. SPSS 18.0 was used to count the differences between the different groups.

RESULTS

The primary fracture lines concentrated at the Gissane angle and the posterior articular surface, which could be summarized in two ring structures. There were 43 cases of fracture involving calcaneocuboid joint, including 32 cases of joint-depression fracture and 11 cases of tongue-type fracture. The area ratio of lateral fragment of simple tongue-type fracture is larger than joint-depression fracture.

CONCLUSION

The primary fracture lines of calcaneus were distributed in two rings on the surface of calcaneus. Based on the distribution of primary fracture rings, we integrated the classification of calcaneal fracture and proposed some treatment recommendations.

Mapping of Orthopaedic Fractures for Optimal Surgical Guidance

Orthopaedic fractures may be difficult to treat surgically if accurate information on the fracture propagation and its exit points are not known. Even with two-dimensional (2D) radiographic images, it is difficult to be completely certain of the exact location of the fracture site, the fracture propagation pattern and the exit points of the fracture. Three-dimensional (3D) computerised tomographic models are better in providing surgeons with the extent of bone fractures, but they may still not be sufficient to allow surgeons to plan open reduction and internal fixation (ORIF) surgery.Fracture patterns and fracture maps are developed to be visual tools in 2D and 3D. These tools can be developed using fractured bones either before or after fracture reduction. Aside from being beneficial to surgeons during pre-surgical planning, these maps aid bioengineers who design fracture fixation plates and implants for these fractures, as well as represent fracture classifications.Fracture maps can be either created ex silico or in silico. Ex silico models are created using 3D printed bone models, onto which fracture patterns are marked. In silico fracture models are created by tracing the fracture lines from a fractured bone to a healthy bone template on a computer. The points of interest in both of these representations are the path of fracture propagation on the bone's surface and exit zones, which eventually determine the surgeon's choice of plate and fracture reduction. Both ex silico and in silico fracture maps are used for pre-surgical planning by the surgeons where they can plan the best way to reduce the fracture as well as template various implants in a low-risk environment before performing the surgery.Recently, fracture maps have been further digitised into heat maps. These heat maps provide visual representations of critical regions of fractures propagating through the bone and identify the weaker zones in the bone structure. These heat maps can allow engineers to develop optimal surgical plates to fix an array of fracture patterns propagating through the bone. Correlation of fractured regions with the mechanisms of injury, age, gender, etc. may improve fracture predictability in the future and optimise the intervention, along with making sure that surgeons do not miss fractures of the bone that may otherwise be hidden from plain sight.

Three-dimensional mapping of sternum fractures from high-energy trauma

BACKGROUND

Sternum fractures are relatively uncommon injuries, which generally occur as a result of a high-energy mechanism and are often associated with significant concomitant injuries. These injuries may result in decreased quality of life if not properly addressed and yet are rarely operated on. The purpose of this project is to evaluate high-energy sternum fracture patterns using a previously published three-dimensional (3D) computed tomography (CT) reconstruction process to produce fracture frequency maps.

METHODS

Patients 18 years and older presenting to a Level I trauma center with sternum fractures due to high-energy trauma between October 2013 and January 2022 were included. A 3D reconstruction and reduction was performed for each sternum using medical image processing software (Materialize NV, Leuven, Belgium). The reconstructions were subsequently overlaid onto a template sternum and normalized using bony landmarks. Fracture lines for each injured sternum were transferred onto the template, creating 3D frequency maps.

RESULTS

A total of 120 patients met inclusion criteria. The study population had a uniform age distribution and 57.5% were male. The most common mechanism of injury was motor vehicle collision (64.2%). The breakdown of sternum fractures were isolated sternal body (55.8%), isolated manubrium (31.7%), and combined sternal body and manubrium fractures (12.5%). No xiphoid fractures were observed. Sternal body fractures were a near even mix of transverse (31.7%), oblique (32.9%), and comminuted (35.4%), while 75.5% of manubrium fractures were oblique. The most common associated injuries included rib fractures (80.8%) and traumatic brain injury (61.7%).

CONCLUSION

This study presents the fractures from sternum injuries in 3D, and provides insight into reproducible sternum injury patterns that have not previously been analyzed in this format. This fracture mapping technique presents numerous injury patterns simultaneously, such that more frequent morphologies can be appreciated for different patient groups.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level V.

Osteosynthesis of scapular fractures: a retrospective cohort study

PURPOSE

In recent years a trend from conservative to operative treatment of displaced scapula fractures has evolved. The aim of this study was to assess surgical and patient-based radiological and functional outcome after open reduction and internal fixation (ORIF) of displaced scapula fractures following predefined operative indications.

METHODS

We retrospectively analyzed data of a consecutive series of patients with displaced scapula fractures following operative fixation at our institution between 06/2010 and 02/2020. The primary endpoint was a functional outcome using the QuickDASH score. Secondary outcomes were the Subjective Shoulder Value (SSV), numeric rating scale (NRS) for pain, Activities of Daily Living score (ADL) and complications.

RESULTS

Twenty-six male patients were treated operatively. Twenty-three of whom were available for follow-up after a median follow-up time of 33 months (interquartile range [IQR] 8-70 months). In 18 (69%) cases a standard open approach and in 8 (31%) cases a minimal invasive (MI) approach was used. The median QuickDASH was 0 (IQR 0-0) with a median SSV of 95 (IQR 90-98). Patients reported a median NRS of 0 (IQR 0-1) and a median ADL score of 1 (IQR 1-1). Radiological fracture union was 100% without the occurrence of implant failure or mal-union. Two patients (7.7%) required early correction osteosynthesis, one patient (3.8%) developed a frozen shoulder 3 months postoperatively, and one patient (3.8%) presented with a superficial wound infection.

CONCLUSION

Following previously published indications for ORIF of displaced scapula body and neck fractures a good functional outcome and a low rate of complications could be achieved.

The automized fracture edge detection and generation of three-dimensional fracture probability heat maps

With proven impact of statistical fracture analysis on fracture classifications, it is desirable to minimize the manual work and to maximize repeatability of this approach. We address this with an algorithm that reduces the manual effort to segmentation, fragment identification and reduction. The fracture edge detection and heat map generation are performed automatically. With the same input, the algorithm always delivers the same output. The tool transforms one intact template consecutively onto each fractured specimen by linear least square optimization, detects the fragment edges in the template and then superimposes them to generate a fracture probability heat map. We hypothesized that the algorithm runs faster than the manual evaluation and with low (< 5 mm) deviation. We tested the hypothesis in 10 fractured proximal humeri and found that it performs with good accuracy (2.5 mm ± 2.4 mm averaged Euclidean distance) and speed (23 times faster). When applied to a distal humerus, a tibia plateau, and a scaphoid fracture, the run times were low (1-2 min), and the detected edges correct by visual judgement. In the geometrically complex acetabulum, at a run time of 78 min some outliers were considered acceptable. An automatically generated fracture probability heat map based on 50 proximal humerus fractures matches the areas of high risk of fracture reported in medical literature. Such automation of the fracture analysis method is advantageous and could be extended to reduce the manual effort even further.

3D Mapping of the Lateral Malleolus Fractures for Predicting Syndesmotic Injuries in Supination External Rotation Type Ankle Fractures

Supination external rotation (SER) type ankle fracture is the most common ankle fracture in the Lauge-Hansen classification and is often accompanied with syndesmotic injury. However, the mechanism of this injury is indistinct and a suggestive role can be given by preoperative imaging. This study was to preoperatively predict whether SER type ankle fractures are accompanied with syndesmotic injuries by the means of lateral malleolus fracture mapping. One hundred and forty-eight patients diagnosed with SER type ankle fractures were retrospectively enrolled in this study. The baseline data were collected and computed tomography data were reconstructed in 3-dimensional (3D) model. Patients were divided into stable and unstable groups according to intraoperative Cotton test and whether the inferior tibiofibular screw was placed. All fracture lines were superimposed on the ankle template to create a fracture map, and the data on the fracture map were further measured. Logistic regression was conducted to identify relevant factors and the cutoff values were given using receiver operating characteristic curves. Forty-one patients were enrolled in the unstable group and 107 patients were enrolled in the stable group. The lateral malleolus fracture lines of the unstable group were higher and steeper than that in the stable group on lateral and posterior views. The fracture height of the posterior cortex and peak height were the significant contributing factors, and the cut-off values of posterior cortex, peak height and inclination angle were 40.35 mm (sensitivity: 78%, specificity: 82%), 55.34 mm (sensitivity: 85%, specificity: 70%) and 55.6° (sensitivity: 66%, specificity: 86%), respectively. In general, when the fracture lines of the lateral malleolus were high and steep, it was usually indicative of a syndesmotic injury and can be predicted by the preoperative 3D reconstruction of fracture height of posterior cortex, peak height and inclination angle. If the cut-off values of these indicators are exceeded, the syndesmotic injuries may be presented and need to be verified in the intraoperative Cotton test to decide whether to insert an inferior tibiofibular screw.

[Characteristics of femoral neck fractures in young and middle-aged adults based on fracture mapping technology]

OBJECTIVE

To analyze the characteristics of femoral neck fractures in young and middle-aged adults by means of medical image analysis and fracture mapping technology to provide reference for fracture treatment.

METHODS

A clinical data of 159 young and middle-aged patients with femoral neck fractures who were admitted between December 2018 and July 2019 was analyzed. Among them, 99 patients were male and 60 were female. The age ranged from 18 to 60 years, with an average age of 47.9 years. There were 77 cases of left femoral neck fractures and 82 cases of right sides. Based on preoperative X-ray film and CT, the fracture morphology was observed and classified according to the Garden classification standard and Pauwels' angle, respectively. Mimics19.0 software was used to reconstruct the three-dimensional models of femoral neck fracture, measure the angle between the fracture plane and the sagittal plane of the human body, and observe whether there was any defect at the fracture end and its position on the fracture surface. Through reconstruction, virtual reduction, and image overlay, the fracture map was established to observe the fracture line and distribution.

RESULTS

According to Garden classification standard, there were 6 cases of type Ⅰ, 61 cases of type Ⅱ, 54 cases of type Ⅲ, and 38 cases of type Ⅳ. According to the Pauwels' angle, there were 12 cases of abduction type, 78 cases of intermediate type, and 69 cases of adduction type. The angle between fracture plane and sagittal plane of the human body ranged from -39° to +30°. Most of them were Garden type Ⅱ, Ⅳ and Pauwels intermediate type. The fracture blocks were mainly in the form of a triangle with a long base and mainly distributed below the femoral head and neck junction area. Twenty-six cases (16.35%) were complicated with bone defects, which were mostly found in Garden type Ⅲ, Ⅳ, and Pauwels intermediate type, located at the back of femoral neck and mostly involved 2-4 quadrants. The fracture map showed that the fracture line of the femoral neck was distributed annularly along the femoral head and neck junction. The fracture line was dense above the femoral neck and scattered below, involving the femoral calcar.

CONCLUSION

The proportion of displaced fractures (Garden type Ⅲ, Ⅳ) and unstable fractures (Pauwels intermediate type, adduction type) is high in femoral neck fractures in young and middle-aged adults, and comminuted fractures and bone defects further increase the difficulty of treatment. In clinical practice, it is necessary to choose treatment plan according to fracture characteristics. Anatomic reduction and effective fixation are the primary principles for the treatment of femoral neck fracture in young and middle-aged adults.

Classification of avulsion fractures of the fifth metatarsal base using three-dimensional CT mapping and anatomical assessment: a retrospective case series study

Background

To clarify the injury mechanism of the avulsion fracture of the fifth metatarsal combining 3-dimensional (3D) fracture mapping with anatomical measurements.

Methods

Two hundred twenty-two patients with the avulsion fractures of the fifth metatarsal base, who were admitted to our hospital from August 2015 to August 2020. The computed tomography (CT) scans were used to generate the 3-D images of all mapped fracture lines for the avulsion fractures of the fifth metatarsal base were compiled in an overall 3D image. The fifth metatarsal base of 8 unpaired lower limbs of adult Asian frozen cadaveric specimens were also dissected to observe and measure the specific locations of the attachment points of the peroneus brevis, lateral band of the plantar fascia, and peroneus tertius to the fifth metatarsal base.

Results

Based on the type of fracture line produced and the specific locations of the attachment points of the tendons or fascia, the avulsion fractures of the fifth metatarsal base can be classified into three types: type I predominantly involves the action of the lateral band of the plantar fascia; type II predominantly involves the action of the peroneus brevis; type IIIA involves the joint action of the peroneus brevis and lateral band of the plantar fascia with one fracture line, and type IIIB involves the joint action of the peroneus brevis and lateral band of the plantar fascia with two fracture lines.

Conclusion

The lateral band of the plantar fascia and peroneus brevis play a major role, either separately or together, in avulsion fractures of the fifth metatarsal base. With this knowledge, we propose a novel classification based on the injury mechanism, which can serve as a reference for clinical treatment and diagnosis.

Level of evidence

Level III, retrospective case series.

Fracture lines and comminution zones in acetabular fractures based on three dimensional computed tomography

PURPOSE

To characterize the fracture patterns of acetabular fractures and create fracture maps and comminution zones based on three-dimensional (3D) computed tomography (CT) images.

METHODS

Sixty-eight computed tomography images of 67 patients (47 male [70.1%] and 20 female [29.9%], mean age: 45.2 ± 17.2 [range, 18-85 years] with the diagnosis of intra-articular acetabulum fracture were analyzed. Individual fracture lines were drawn and superimposed to a healthy acetabular template according to Judet-Letournel and simplified fracture classification systems. Fracture line, comminution zone, and heat maps were created using the computed tomography mapping technique.

RESULTS

Fracture lines were distributed mainly in a horizontal and oblique orientation, which concentrated in the anteroinferior part of the joint in anterior fractures. Posterior fractures mostly had an oblique orientation, which lied between the acetabular dome and middle part of the posterior wall. In complex fractures, fracture lines were concentrated just above the cotyloid fossa, acetabular dome, and posterosuperior part of the acetabulum. The most common comminuted zones were around the central area of the articular surface and the anterior wall in anterior fractures, between the cotyloid fossa and dome in complex fractures, and the upper half posterior wall.

CONCLUSION

Fracture patterns and comminution zones of acetabular fractures displayed certain characteristics. Some areas had higher comminution zones, and some areas remained intact in repeatable fracture patterns. These results may help surgeons in fixing acetabular fractures, designing new implants, and placement of acetabular component while performing THA after acetabular fractures.

Circumflex arterial sulcus of the scapula (sulcus arteriae circumflexae scapulae): its anatomy and clinical relevance

INTRODUCTION

The circumflex scapular artery (CSA) has been described in detail in the literature, but the groove, i.e., the circumflex sulcus (CFS), formed by the artery on the lateral pillar of the scapula has been completely neglected. The aim of the present study was to describe the variability and anatomy of the CFS.

MATERIALS AND METHODS

The study was based on the examination of 103 pairs of dry bone specimens of adult scapulae, i.e., 206 specimens, including 92 (46 pairs) male and 114 (57 pairs) female specimens. In the first step, quantitative criteria were defined for assessment of the CFS presence and type. Subsequently, statistical analysis of the obtained data was performed.

RESULTS

The study revealed considerable variability of the arterial groove, which was well developed in 33% (type A), shallow in 40% (type B), and absent in 27% (type C) of cases. The mean distance between CFS and the infraglenoid tubercle was 3.3 cm CI_0.95 (3.1-3.3), which corresponds to the proximal third of the lateral border of the scapula.

CONCLUSION

The study has confirmed variability of the arterial groove (CFS) and its localization in relation to the inferior glenoid rim. The findings are clinically important, particularly in relation to the Judet approach to scapular fractures (localization of the CSA course).

Tibial plateau fractures: three dimensional fracture mapping and morphologic measurements

Purpose

The injury mechanisms and classifications of tibial plateau fractures (TPFs) are still controversial. The aim of this study is to show 3D fracture mapping of different types of tibial plateau fractures. Moreover, combined with Schatzker and ten-segment classification, we aimed to analyze the injury frequency and characteristics of different segments.

Methods

In total, 346 patients with TPFs treated at level I trauma centres from 2017 to 2021 were reviewed. The CT files of the included cases were typed and categorized. 3D reconstruction of TPFs patients’ CT files were performed using software. All fracture lines were superimposed on the standard model by the software to create TPFs 3D fracture mapping.

Results

This study included 204 male and 142 female patients (average age, 47 years [range, 18 to 83 years]) with a tibial plateau fracture. Using the Schatzker classification, we found 39 type I (11.27%), 103 type II (29.77%), nine type III (2.60%), 71 type IV (20.52%), 52 type V (15.03%), 59 type VI (17.05%) fractures, and 13 others (3.76%). The density areas of fracture lines are mainly located in the ALC and PLC segments (74.3%, 69.1%). In different views, fracture lines of different Schatzker types showed distinct distribution characteristics.

Conclusions

Schatzker classification combined with 3D fracture mapping provides a new presentation of tibial plateau fracture morphology. According to the 3D fracture mapping, different types of TPFs have distinctly different distribution characteristics of fracture lines. There are significant differences between different types of fracture injury segments.

Three-dimensional mapping study of pure transverse acetabular fractures

BACKGROUND

To describe and analyze the morphological characteristics, location and frequency of pure transverse acetabular fracture lines through fracture mapping and quantitative measurements.

METHODS

Transverse fractures were retrospectively reviewed and analyzed. All computed tomography (CT) data were used for reconstruction and manual reduction. The reductive fracture fragments were graphically overlaid onto a three-dimensional (3D) right hemipelvis template. Then, the fracture lines were accurately depicted onto the surface of the 3D template. The fracture lines were overlapped onto the model to create the 3D fracture map and heatmap. All cases were subdivided into infratectal (62-B1.1), juxtatectal (62-B1.2), and transtectal (62-B1.3) types based on the AO Foundation/Orthopedic Trauma Association (AO/OTA) classification. Some anatomic parameters of the transverse fractures were also analyzed in these 3 groups.

RESULTS

Our study included forty-nine transverse fractures from 32 male and 17 female patients (mean age, 42 years; range 21-74 years) and included 19 type 62-B1.1, 17 type 62-B1.2, and 13 type 62-B1.3 fractures. The average anterior rim fracture angle was 70.0° (± 11.6°), and the posterior rim fracture angle was 92.4° (± 28.5°). The anterior rim fracture angles in 40 cases (40/49, 81.6%) fell within a wide range between 63° and 80°. On the heatmap, the hot zones were located on the highest position of the cotyloid fossa and the narrowed region, and the cold zone was on the inferior third of the articular surface. For type 62-B1.3 fractures, the hot zone was located on the posterior of the acetabular dome. There were no significant differences in anterior rim fracture angle and anterior height among the three patterns (P = 0.071, P = 0.072). Post hoc tests of the posterior rim fracture angle and the posterior height revealed significant differences among fracture subtypes (P < 0.01). The posterior intra-articular fracture line was significantly longer than the anterior intra-articular fracture line in type 62-B1.1 and type 62-B1.2 fractures (P < 0.01).

CONCLUSION

The fracture lines of transverse fractures through the anterior rim were concentrated on the narrowed zone, and the posterior fracture lines were diffusely distributed. The intra-articular fracture line distribution was focused on the superior and middle thirds of the joint surface. The recurrent fracture lines involving the weight-bearing dome mainly converged on the posterior region of the roof.

Fracture Mapping of Both-Column Acetabular Fractures

OBJECTIVES

To characterize the location and frequency of the fracture lines and comminution zones of both-column fractures using fracture mapping.

METHODS

Both-column fractures were retrospectively reviewed in 4 Level 1 trauma centers. Mimics software was used to reconstruct the both-column fractures and simulate the fracture reduction. Then, the fracture lines and the intra-articular and extra-articular comminution zones were drawn on a 3-dimensional innominate bone template. The distribution of fracture lines and fracture fragments were also mapped on the two-dimensional template of the acetabulum. All the included patients were divided into low-variety group and high-variety group according to the anterior column fracture line above or below the anterior superior spine. The anatomical characteristics of the posterior wall fragment were also analyzed in these 2 groups.

RESULTS

Seventy-eight patients with both-column fracture were included. The T type or inverted Y type main fracture lines divided the innominate bone into low-variety (n = 11) and high-variety (n = 67) both-column fractures. The extra-articular comminution zones are usually distributed between the posterior iliac fragment and anterior column fragment. High-variety type both-column fractures are usually combined with high and sharp posterior wall fragments, whereas low-variety type both-column fractures are usually accompanied by low and flat posterior wall fragments. The comminution zones in the acetabulum are mostly concentrated in the anterior and inferior parts of the acetabulum.

CONCLUSIONS

The innominate bone is divided into 3 major parts in the both-column fracture, and the fracture center is located at the proximal of the acetabular dome. The both-column fractures are divided into low-variety and high-variety patterns. The location of the anterior column fracture determined the characteristics of the posterior wall fragment.

3D Mapping of Bone Channel of Blood Supply to Femoral Head in Proximal Femur

Background

A detailed depiction of nutrient foramina is useful for defining guidelines and minimising iatrogenic damage during hip surgery. Therefore, this study aimed to define the location and frequency of nutrient foramina in the proximal femur using mapping techniques.

Methods

One hundred dry human cadaveric proximal femurs, comprising 56 left and 44 right femurs, were scanned using a three-dimensional scanner, with scanning distance 200 mm, precision 0.01 mm, and measuring point 0.04 mm. The image resolution of 1,310,000 pixels was obtained. Digital imaging models were acquired from the proximal femur surface. All the nutrient foramina in each model were identified and marked. The nutrient foramina models were superimposed on one another and oriented to fit a standard template of the femur’s proximal aspect. Three-dimensional mapping in the proximal femur’s nutrient foramina was performed.

Results

The nutrient foramina’s location and dense zones were identified. The dense zones were distributed along the vascular course and gaps between the muscle attachment sites. Eighteen dense zones were identified and found to be location-dependent. They were located in the central part of the fovea capitis femoris, subcapital and basicervical areas of the femoral neck, and muscle attachment gaps of the femoral trochanter.

Conclusions

The terminal branch of the nutrient vessels entering the nutrient foramina is at risk for iatrogenic damage during hip surgeries, especially in cases of close bone exposures. There are 18 dense zones that need to be considered for a safer approach to the proximal femur. To minimise iatrogenic damage to the nutrient vessels entering the nutrient foramina, the dense areas should be avoided when technically possible.

Morphological Characteristics of the Posterior Wall Associated with Complex Acetabular Fractures: A Radiological Study Using 3D Software and Fracture Mapping Technique

Background

The aim of the study was to compare the morphological distinctions of the posterior wall (PW) in different complex acetabular fractures using 3D software and fracture mapping technique and ultimately to provide for improved clinical treatment.

Methods

One hundred and fourteen patients with complex acetabular fracture associated with PW were recruited. All patients were divided into two groups according to the injury mechanism of the PW: Group A (both-column and PW) and Group B (including posterior column and PW; T shape and PW; and transverse and PW). Fracture mapping was generated on the intra- and extrasurface of a standard template. The radiological parameters including spatial displacement, articular surface area, articular range, marginal impaction, and multifragments of the two groups were compared.

Results

The spatial displacement, intra-/extra-articular surface area, and start and end point in Group A were 10.9 mm (IQR, 8.4-15.2), 8.2 ± 2.6 cm², 17.9 ± 5.3 cm², 0.8° (IQR, -6.0-16.2), and 107.5° (IQR, 97.2-116.9), respectively. The results in Group B were 30.4 mm (IQR, 16.8-48.7), 4.1 ± 2.0 cm², 10.6 ± 4.4 cm², 29.5° (IQR, 19.2-38.0), and 117.5° (IQR, 98.2-127.2), respectively. Marginal impaction was defined by Letournel et al. All the differences between two groups were significant (P < 0.05). The fracture map in Group A showed an “L”-shaped pattern and a “cusp” on the ilium, and the PW was located at 1/5 to 1/4 of the posterosuperior part of the acetabulum. The fracture maps in Group B were scattered and lacked consistency, and the PWs were confined to 1/10 to 1/8 of the posterior acetabulum.

Conclusions

Quantitative measurements and fracture mapping represented the differences in morphological characteristics of PWs associated with complex acetabular fractures.

Identification of recurring scapular fracture patterns using 3-dimensional computerized fracture mapping

BACKGROUND

Scapular fracture fixation and implant selection are guided by the fracture pattern and classification, which requires accurate understanding and interpretation of the fracture lines. Three-dimensional (3D) computed tomography (CT)-based fracture pattern analysis enhances a more accurate understanding of the scapular fracture patterns. The purpose of this study was to create scapular fracture maps and identify the frequent fracture patterns using 3D reconstructed CT images.

METHOD

Seventy patients treated for scapular fractures, in a single hospital, were considered for this study. Their CT images were reconstructed into 3D models and the fracture fragments were virtually reduced. The reduced 3D models were first aligned on a 3D template and 2D images were captured on the anterior, posterior, and lateral views. Then each fracture image was aligned on a corresponding 2D template and the fracture lines were transferred to the template. The 3 separate views were used to accurately capture the propagation and exit of the fractures through the scapular anatomy. These fracture lines were compiled and heat maps were generated to identify the frequent fracture zones of the scapula.

RESULT

The observed scapular fractures propagated through multiple regions of the bone. Overall, the 3 most common exit zones in the scapula were the lateral (69%), medial (67%), and superior borders (60%). More specifically, the superior lateral border, medial base of the scapula spine, spinoglenoid notch, and mid-superior border were the most frequent zones of fracture in the scapular body. Simple intra-articular fractures (transverse or oblique type) were the most common (92%) fracture type in the glenoid region.

CONCLUSION

Scapular fractures reveal repeatable patterns. The zones of recurrent fracture patterns can be identified from fracture and heat maps. Graphical plots of fracture and heat maps may assist surgical planning and implant design optimization.

Arthroscopy-Assisted Reduction and Internal Fixation versus Open Reduction and Internal Fixation for Glenoid Fracture with Scapular Involvement: A Retrospective Cohort Study

Background: We investigated the superiority of arthroscopy-assisted reduction and internal fixation (ARIF) to open reduction and internal fixation (ORIF) for treating glenoid fracture with scapular involvement. Methods: We retrospectively enrolled patients with glenoid fracture who underwent ARIF or ORIF from 2010–2020. Radiographic outcomes were assessed, and clinical outcomes (active range of motion [ROM], visual analog scale [VAS], Constant, and Disabilities of the Arm, Shoulder and Hand [DASH]) were evaluated 12 months postoperatively. Results: Forty-four patients with Ideberg type II–VI glenoid fractures (ARIF: 20; ORIF: 24; follow-up 12–22 months) were included. Union was achieved in all patients. Active ROM values were comparable between the approaches. Constant and DASH scores were non-significantly better with ARIF (90.9 ± 9.2 vs. 86.6 ± 18.1 [p = 0.341] and 6.8 ± 9.4 vs. 9.3 ± 21.3 [p = 0.626], respectively). However, VAS scores were significantly lower with ARIF (1.5 ± 0.6 vs. 2.7 ± 1.4, p = 0.001). Associated intra-articular lesions (articular depressions [80%], superior labral anterior-posterior tear [20%], labral tears [30%]) were found in most ARIF cases and were repaired during ARIF. Conclusions: For glenoid fracture with scapular involvement, ARIF allows accurate diagnosis of fracture pattern and the management of associated intra-articular lesions, with better pain control outcomes than ORIF. Thus, arthroscopy-assistant surgery should be considered in patient with glenoid fracture.

Calcaneal fracture maps and their determinants

Background

Calcaneal fractures are associated with numerous complications and a poor prognosis with significant long-term quality-of-life issues, regardless of treatment. Therefore, in-depth research into the underlying mechanism of calcaneal fracture is still of great interest, with the goal of improving treatment for patients suffering from this condition. This study aimed to investigate the relationship between the distribution of calcaneal fracture lines and their determinants, especially those related to the internal structure of the calcaneus. This goal was achieved by fracture maps created by copying and stacking fracture lines as viewed from six surfaces of the calcaneus.

Methods

A total of 210 consecutive patients with 226 calcaneal fractures were retrospectively analyzed. Fracture lines were copied from a reduced 3D calcaneal fracture model and stacked on calcaneal templates to generate fracture maps. The stacked images of six calcaneus surfaces were also converted into spectrograms with MATLAB to highlight the fracture frequency at specific locations.

Results

There were four concentrated bands of fracture lines and two fracture hot spots on the superior surface. Three dense bands of fractures were observed on the medial surface, and four fracture bands were observed lateral to the calcaneus. Vertical fracture lines dominated the anterior calcaneal fracture map. On the posterior surface, the fracture lines appeared to be centered superiorly. All fracture locations coincided with the interfaces between the trabecular groups.

Conclusions

The fracture maps showed fracture patterns and recurrent fracture zones on all calcaneal surfaces. The shape of the talus and calcaneus and the architecture within the calcaneus, especially the arrangement of the trabeculae, are essential factors for calcaneal fractures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-02930-y.

Influence of coracoglenoid space on scapular neck fracture stability: biomechanical study

Background

The anatomical variation of the coracoglenoid space has the potential to influence the stability of scapular neck fractures. This paper aimed to investigate the mechanical mechanism underlying the influence of different coracoglenoid space types on scapular neck fractures by morphometric analysis and biomechanical experiments.

Methods

The morphology of 68 dried scapulae (left: 36; right: 32) was studied. Two variables, the length of the coracoglenoid distance (CGD) and the coracoglenoid notch (CGN), were measured. The distribution of CGN/CGD × 100% was used to identify the morphology of the coracoglenoid space. Each specimen was tested for failure under static axial compression loading. The average failure load, stiffness, and energy were calculated.

Results

Two coracoglenoid space types were identified. The incidence of Type I (‘‘hook’’ shape) was 53%, and that of Type II (‘‘square bracket’’ shape) was 47%. The CGD and CGN were significantly higher for type I than type II (13.81 ± 0.74 mm vs. 11.50 ± 1.03 mm, P < 0.05; 4.74 ± 0.45 mm vs. 2.61 ± 0.45 mm, P < 0.05). The average maximum failure load of the two types was 1270.82 ± 318.85 N and 1529.18 ± 467.29 N, respectively (P = 0.011). The stiffness and energy were significantly higher for type II than type I (896.75 ± 281.14 N/mm vs. 692.91 ± 217.95 N/mm, P = 0.001; 2100.38 ± 649.54 N × mm vs. 1712.71 ± 626.02 N × mm, P = 0.015).

Conclusions

There was great interindividual variation in the anatomical morphology of the coracoglenoid space. Type I (hook-like) spaces bore lower forces, were less stiff, and bore less energy, which may constitute an anatomical predisposition to scapular neck fractures.

Mapping of common rib fracture patterns and the subscapular flail chest associated with operative scapula fractures

BACKGROUND

Rib fractures occur in approximately 10% of trauma patients and are associated with more than 50% of patients with scapula fractures. This study investigates the location and patterns of rib fractures and flail chest occurring in patients with operatively treated scapula fractures. Novel frequency mapping techniques of rib fracture patterns in patients who also injure the closely associated scapula can yield insight into surgical approaches and fixation strategies for complex, multiple injuries patients. We hypothesize that rib fractures have locations of common occurrence when presenting with concomitant scapula fracture that requires operative treatment.

METHODS

Patients with one or more rib fractures and a chest computed tomography scan between 2004 and 2018 were identified from a registry of patients having operatively treated scapula fractures. Unfurled rib images were created using Syngo-CT Bone Reading software (Siemens Inc., Munich, Germany). Rib fracture and flail segment locations were marked and measured for standardized placement on a two-dimensional chest wall template. Location and frequency were then used to create a gradient heat map.

RESULTS

A total of 1,062 fractures on 686 ribs were identified in 86 operatively treated scapula fracture patients. The mean ± SD number of ribs fractured per patient was 8.0 ± 4.1 and included a mean ± SD of 12.3 ± 7.2 total fractures. Rib fractures ipsilateral to the scapula fracture occurred in 96.5% of patients. The most common fracture and flail segment location was ipsilateral and subscapular; 51.4% of rib fractures and 95.7% of flail segments involved ribs 3 to 6.

CONCLUSION

Patients indicated for operative treatment of scapula fractures have a substantial number of rib fractures that tend to most commonly occur posteriorly on the rib cage. There is a pattern of subscapular rib fractures and flail chest adjacent to the thick bony borders of the scapula. This study enables clinicians to better evaluate and diagnose scapular fracture patients with concomitant rib fractures.

LEVEL OF EVIDENCE

Diagnostic test, level IV.

Mapping of Vertical Femoral Neck Fractures in Young Patients Using Advanced 2 and 3-Dimensional Computed Tomography

OBJECTIVE

To better describe the pathoanatomy of young patients' femoral neck fractures with the goal of improving surgeons' decisions for treatment including reduction and fixation.

DESIGN

This is a retrospective study of patient records, plain radiographs, and the modern computed tomography scans to study the pathoanatomy of Pauwels II and III femoral neck fractures (coronal angle >30 degrees) in young adults.

SETTING

One American College of Surgeons Level 1 trauma center.

PATIENTS

All patients 18-49 years of age with a surgically repaired Pauwels' II and III (>30 degrees) femoral neck fracture between 2013 and 2017.

METHODS

Fifty-six adult patients younger than 50 years were identified with a femoral neck fracture in the study period, of whom 30 met study criteria. We evaluated plain radiography and computed tomography data including fracture orientation, characteristics of fracture morphology including size, shape, and dimensions, comminution, displacement, and deformity.

RESULTS

Fracture morphology typically included a wide-based caudal head-neck segment (80%) that ends at a variable location along the medial calcar, sometimes as caudal as the lesser trochanter. Comminution was present in 90% of cases mostly located in the inferior quadrant, but anterior or posterior to the void left by the head-neck's caudal segment. The fractures orientations and deformities were reported by means and ranges.

CONCLUSIONS

We investigated and reported on the pathoanatomy of high-energy femoral neck fractures in young adults with the goal of increasing understanding of the injury and improving surgeons' ability to provide for improved treatment decisions and quality fracture repair.

LEVEL OF EVIDENCE

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

Bone defect map of the true acetabulum in hip dysplasia (Crowe type II and III) based on three-dimensional image reconstruction analysis

The high hip center technique (HHC) is considered to be feasible for acetabular reconstruction in patients with DDH, but there is little in-depth study of its specific impact on Crowe type II and III DDH. The purpose of this study was to simultaneously analyze the effect of HHC on bone coverage of the cup (CC) in the acetabular reconstruction of type II and III DDH patients and to propose a map of acetabular bone defects from the perspective of the cup. Forty-nine hip CT data of 39 patients with DDH (Crowe type II and III) were collected to simulate acetabular reconstruction by cup models of different sizes (diameter 38mm–50 mm, 2 mm increment) with the HHC technique. The frequency distribution was plotted by overlapping the portions of the 44 mm cups that were not covered by the host bone. The mean CC of cups with sizes of 38 mm, 40 mm, 42 mm, 44 mm, 46 mm, 48 mm, and 50 mm at the true acetabula were 77.85%, 76.71%, 75.73%, 74.56%, 73.68%, 72.51%, and 71.75%, respectively, and the maximum CC increments were 21.24%, 21.58%, 20.86%, 20.04%, 18.62%, 17.18%, and 15.42% (P < 0.001), respectively, after the cups were elevated from the true acetabula. The bone defect map shows that 95% of type II and III DDH acetabula had posterosuperior bone defects, and approximately 60% were located outside the force line of the hip joint. Acetabular cups can meet a CC of more than 70% at the true acetabulum, and approximately 60% of Crowe type II and III DDH patients can obtain satisfactory CC at the true acetabulum by using a 44-mm cup without additional operations.

Multifragmentary patellar fracture has a distinct fracture pattern which makes coronal split, inferior pole, or satellite fragments

The present study aimed to map the location and frequency of fracture lines on the coronal articular and sagittal planes in multifragmentary patellar fractures. 66 multifragmentary patellar fractures were digitally reconstructed using the 3D CT mapping technique. The coronal articular surface and midsagittal fracture maps were produced by superimposing each case over a single template. Each fracture line was classified based on the initial displacement and orientation. We evaluated the frequency and direction of the fracture line, coronal split fragment area, and satellite and inferior pole fragment presence. Coronal articular surface fracture mapping identified primary horizontal fracture lines between the middle and inferior one-third of the articular surface in 63 patients (95.4%). Secondary horizontal fracture lines running on the inferior border of the articular facet were confirmed (83.3%). Secondary vertical fracture lines creating satellite fragments were mostly located on the periphery of the bilateral facet. Midsagittal fracture mapping of primary and secondary horizontal fracture lines with the main coronal fracture line revealed a predominantly X-shaped fracture map. The consequent coronal split fragment and inferior pole fracture were combined in most cases. In conclusion, the multifragmentary patellar fracture has a distinct pattern which makes coronal split, inferior pole, or satellite fragments.

Fracture patterns in midshaft clavicle fractures

Current classifications of midshaft clavicle fractures are based on radiography. The aim of the study was to evaluate the fracture pattern of clavicle fractures using 3-dimensional computed tomography (3D CT). A retrospective analysis was performed on CT scans of 65 acute clavicle fractures. Using quantitative 3D CT reconstruction techniques, the fracture of the clavicle was virtually reduced. Based on these reconstructions, a group-based fracture heat map and small fragment heat map, and the location of the most common fracture line were determined. Also, the direction and amount of displacement were evaluated. Three fracture patterns could be distinguished. The primary fracture line in type 1 is going from posteromedial to anterolateral and located between 50% and 68% of the clavicle’s length. In type 2, a transverse fracture line is located around 55%, and in type 3, a superolateral to inferomedial line is located between 47% and 56%. Wedged fracture fragments can be seen in types 1 and 2 and are mainly situated inferiorly. The displacement is similar in all types, but the main direction of displacement is specific for the different types (posterior, anterior, inferior). We can conclude that several fracture patterns can be seen in clavicle fractures. Most fractures are located laterally at the midshaft of the clavicle. Wedged segments are mainly located inferiorly, and at the posterior part of the clavicle, no comminution is ever seen. The direction of displacement depends on the fracture pattern.

Case report of an unusual extra-articular scapular malunion: Rare indication for surgery

INTRODUCTION

Scapular fractures are relatively rare injuries usually associated with high-energy trauma and multiple concomitant injuries. Most of scapular fractures do not require surgical intervention.

PATIENT AND CLINICAL HISTORY

A 42-year-old male sustained an extra-articular scapular body fracture along with multiple rib fractures with flail segments and right pneumothorax treated with intercostal drain. The scapula fracture was treated non-operatively initially, which resulted in very poor outcome. Operative intervention was planned following scans which showed a bony spike from the ventral surface impinging on the chest wall.

SURGICAL TECHNIQUE

Bony spur was approached from dorsal side using a three-dimensional anatomical model as a guide for accurate localization.

RESULTS

The patient's symptoms including shoulder stiffness and pain on deep inspiration settled down completely following removal of the spur.

DISCUSSION

This case presents a new indication for surgical intervention in scapular body fracture which has not been published before. All the relevant measurements related to the fracture namely gleno-polar angle, lateral border offset and angulation were within published limits of indications for conservative treatment. Despite this, it resulted in poor outcome necessitating surgical intervention.

Three-dimensional mapping of distal humerus fracture

Background

Distal humerus fractures (DHFs) constitute one-third of elbow fractures approximately. In this study, we aim to define and analyze the fracture lines and morphological features of DHFs using mapping technique.

Methods

One hundred and two DHFs were retrospectively reviewed. All the computed tomography (CT) data were used to manually reconstruct and virtually reduce the DHF fragments to fit a standard 3D model. Smooth curves were depicted accurately onto the surface of the template to represent the fracture lines. All the curves were overlapped onto the model to create the 3D fracture map and heat map.

Results

Our analysis was based on 102 CT images of DHFs, contributed by 59 male and 43 female patients (mean age, 46 years; range, 18-93 years), and included 15 type A, 25 type B, and 62 type C fractures. On mapping, the hot zones were located in the radial fossa, coronoid fossa, olecranon fossa, and the external part of the trochlear. Conversely, the cold zones were noted in medial condyle, the medial side of the trochlear, and the anterolateral area on the supracondylar ridge.

Conclusions

Our study firstly shows the fracture lines and morphological features of distal humeral fractures by three-dimensional mapping technology. Distal humerus fracture lines are characteristic and highly related to the micro-architecture difference of distal humerus, which may provide some guidance for the treatment plan selection and surgical fixation design.

Structures Endangered During Minimally Invasive Plate Osteosynthesis of the Upper Extremity

Minimally invasive plate osteosynthesis is a surgical technique that is becoming increasingly common because radiographic images and implant technologies advance in capabilities. It is imperative for surgeons to enhance their understanding of the surgical anatomy related to new approaches for fracture fixation. While performing minimally invasive plate osteosynthesis, there is a danger of injuring structures in the common percutaneous and submuscular pathways. We describe the critical anatomical structures in these pathways and tips for injury avoidance when operating on the clavicle, scapula, humerus, and wrist.

Evaluation of Sanders Type 2 Joint Depression Calcaneal Fractures in 197 Patients from a Single Center Using Three-Dimensional Mapping

BACKGROUND This study aimed to evaluate Sanders type 2 calcaneal fractures in 197 patients from a single center using the 3D (three-dimensional) CT (computed tomography) mapping method. MATERIAL AND METHODS A consecutive series of 197 Sanders type 2 joint depression calcaneal fractures was used. The segment and split functions were used to create each calcaneal fragment using Mimics Research 20.0 software. The fracture fragments were reduced in 3-matic Research 12.0 software. In the E-3D Medical 18.01 software, after superimposing the fractured calcaneus entity with the calcaneus template, we drew the fracture line on the template. Finally, the heatmap was obtained by fracture statistical analysis function. Simultaneously, the distribution of the fracture lines in the anterior part of the calcaneus (APC) and middle talar joint was recorded. RESULTS There were 109 cases of Sanders type 2A, 46 cases of Sanders type 2B, and 42 cases of Sanders type 2C. Based on the data, we drew the characteristic fracture map of type 2A 2B and 2C. This study found that the most common types of Sanders type 2A in APC and middle talar articular surface are type AC and type AD. In Sanders type 2B, the most common type is type AC, and in Sanders type 2C it is type ACD. CONCLUSIONS The findings from this study showed that 3D CT imaging and reconstruction of the calcaneus was a useful diagnostic method to evaluate and classify joint depression calcaneal fractures. The calcaneal fracture map can be used to guide surgical planning and optimize the design of internal fixation.