Stabilization of Comminuted Fractures of the Proximal Humerus with Intramedullary Nails and Angularly Stable Locking Plates—Functional Results before and during the SARS-COVID-19 Pandemics

Background and Objectives: Intramedullary nailing (IMN) and angularly stable plating (ASP) are the most popular techniques for the stabilization of comminuted fractures of the proximal humerus, without either one being obviously superior. The aim of the study was to validate the functional outcomes of both stabilization techniques in the COVID-19 pandemic by comparing them with data obtained just before the pandemic, because the limitations of the COVID-19 pandemic are affecting several aspects of social and medical life—being afraid of the transmission of the infection, patients reduce their exposure to healthcare to absolutely essential emergencies. Moreover, working conditions in the operating theater have also become more restrictive. Materials and Methods: Investigations were performed on 112 adult patients with Neer’s three- and four-fragment fractures stabilized with IMN (64) and ASP (48). Treatment effects were validated six months after surgery based on radiographs for evidence of bone union, humeral neck–shaft angle (NSA) and implant placement. Limb function was assessed with the QuickDash and Constant–Murley scores. Data obtained from patients treated in the COVID-19 pandemic were compared with those obtained before the pandemic. Results: The healing of all fractures was satisfactory, but complications developed in six cases. Three patients required secondary interventions due to inadequate repositioning: one after IMN and two after ASP. Additionally, one ASP was complicated by the secondary destabilization of a primarily properly stabilized major tubercle, and in two cases by conflict of the protruding implant with the acromion. ASP was noted to provide better functional results during the COVID-19 pandemic according to the Constant–Murley score (p = 0.0048; Student’s t-test). No significant differences were observed in the pre-COVID-19 pandemic. Conclusions: Our results suggest that ASP is more beneficial for the stabilization of comminuted fractures of the proximal humerus during the COVID-19 pandemic.

THE RELATIONSHIP OF CLINICAL AND MORPHOLOGICAL DATA IN COMMINUTED FRACTURES OF THE LOWER JAW

OBJECTIVE

The aim is to establish the relationship between some clinical, physiological and morphological parameters in patients with the consequences of an acute injury considering the features of pathological and reparative changes in the bone fragments of the lower jaw formed during a fracture using clinical and morphological methods.

PATIENTS AND METHODS

Materials and methods: The material of the study was bone fragments of the lower jaw, removed during osteosynthesis operations in 20 patients with traumatic comminuted fractures. Also, the material of the study was the data obtained during the examination of the above patients. Morphological parameters characterizing the state of the fragments tissues removed during surgical treatment of fractures of the lower jaw and clinical parameters characterizing the patient's condition in cases of traumatic fractures of the lower jaw treatment were identified for frequency and correlation analysis. Different of frequency of individual indicators' gradations cases was determined by the χ-square test, correlations between parameters (correlations of pairs of parameters "clinic - morphology", "clinical and laboratory data - morphology") - by calculating the Pearson association coefficient.

RESULTS

Results: The main pathological and reparative changes are determined in the bone fragments of the lower jaw after a traumatic fracture: osteomedullary ischemic necrosis (traumatic bone infarction), nonspecific productive inflammation, endosteal and periosteal bone regenerates. The severity and frequency of pathological and reparative changes in the bone fragments of the lower jaw vary, leading to various correlations between clinical and morphological indicators of the fragment tissues conditions. Reliable correlations were established between individual clinical and morphological indicators of the state of bone fragments corresponding to the values of the association coefficient in the range of 0.3-0.7, in particular: in the pair "age of the patient" - "endosteal regenerates" - the dependence is negative, of medium strength, significant (p<0.05); in the pair "age of the patient" - "periosteal regenerates" - the dependence is negative, of medium strength, significant (p<0.05); in the pair "fragment surface area" - "osteonecrosis" - the relationship is negative, weak, significant with the probability of error in assessing the value |ra| p<0.1; in the pair "locus of a fracture in the lower jaw" - "type of inflammation in the bone marrow" - the dependence is positive, of medium strength, highly reliable (p<0.01).

CONCLUSION

Conclusions: A comprehensive clinical and morphological examination made it possible to calculate quantitative data that characterize the frequency parameters of the occur¬rence of certain pathological changes in the bone fragments of the lower jaw after a fracture and the features of individual clinical and morphological parameters conjugation in patients with the consequences of a mechanical jaw injury. The obtained data on the correlation dependences of the type "clinic - morphology" can be used to predict the severity of morphological parameters according to the known values of clinical parameters in patients with the consequences of mandibular fractures.

The use of 3D-printed titanium mesh tray in treating complex comminuted mandibular fractures: A case report

RATIONALE

Precise bony reduction and reconstruction of optimal contour in treating comminuted mandibular fractures is very difficult using traditional techniques and devices. The aim of this report is to introduce our experiences in using virtual surgery and three-dimensional (3D) printing technique in treating this clinical challenge.

PATIENT CONCERNS

A 26-year-old man presented with severe trauma in the maxillofacial area due to fall from height.

DIAGNOSIS

Computed tomography images revealed middle face fractures and comminuted mandibular fracture including bilateral condyles.

INTERVENTIONS AND OUTCOMES

The computed tomography data was used to construct the 3D cranio-maxillofacial models; then the displaced bone fragments were virtually reduced. On the basis of the finalized model, a customized titanium mesh tray was designed and fabricated using selective laser melting technology. During the surgery, a submandibular approach was adopted to repair the mandibular fracture. The reduction and fixation were performed according to preoperative plan, the bone defects in the mental area were reconstructed with iliac bone graft. The 3D-printed mesh tray served as an intraoperative template and carrier of bone graft. The healing process was uneventful, and the patient was satisfied with the mandible contour.

LESSONS

Virtual surgical planning combined with 3D printing technology enables surgeon to visualize the reduction process preoperatively and guide intraoperative reduction, making the reduction less time consuming and more precise. 3D-printed titanium mesh tray can provide more satisfactory esthetic outcomes in treating complex comminuted mandibular fractures.

Facial fractures caused by less-lethal rubber bullet weapons: case series report and literature review

PURPOSE

The present study aims to describe three cases of patients inflicted by rubber bullets with severe facial fractures.

METHODS

In addition, a review of English-language literature involving facial fractures by rubber bullets from 1975 to 2016 was performed.

RESULTS

This current study demonstrated that the use of the LLRBW is unsafety even when applied by police enforcements exclusively.

CONCLUSIONS

Management of facial fractures caused by LLRBW is done in a usual manner with closed or open reduction associated with bone mini-plates or reconstruction plates when indicated. Special initial wound care should be done to avoid secondary infection and additional procedures.

Multiple mandibular fractures. Treatment outlines

Multiple mandibular comminuted fractures usually occur in high energy traumas. The authors describe the management and treatment of multiple mandibular fractures in a young patient after a suicide attempt.

Complications in the treatment of adolescent clavicle fractures

This study evaluated the complications associated with the treatment of clavicle fractures in adolescents. All cases of clavicle fractures were identified during an 8-year period between January 2005 and January 2013. During the study period, 153 clavicle fractures occurred in patients between the ages of 14 and 17 years who were treated at the authors' center. Medical records and radiographs were reviewed to determine injury mechanism, fracture pattern, treatment, and complications. Injury severity was assessed as high, medium, and low. Patients with medial or distal metaphyseal fractures and intra-articular fractures were excluded. Of the 153 clavicle fractures, 23 (15.0%) were treated surgically. Compared with the fractures treated nonsurgically, the surgical fractures had greater shortening (mean, 2.0 vs 0.9 cm; P<.001) and were more likely to be comminuted (65.2% vs 23.1%; P<.001). Complications occurred in 21.7% of fractures treated surgically, including refracture (n=2), implant removal for prominence (n=2), and nonunion with implant failure (n=1). One complication was associated with intramedullary nailing, whereas the other 4 complications occurred in clavicles treated with plate fixation. In the non-surgical group, no patients sustained a refracture or malunion who required delayed surgical intervention. Pediatric fellowship-trained orthopedic surgeons treated 78 displaced fractures, resulting in 8 (10.3%) surgeries. Nonpediatric orthopedic specialists treated 46 displaced fractures, 15 (32.6%) of which were treated surgically (P=.0035).

Facial Dog Bite Injuries of a 19-Month-Old Child: A Case Report

It is estimated that 4.5 million Americans are bitten by dogs each year, and half of those are children. One in five dog bites results in injuries that require some form of medical attention. Children between 5 and 9 years of age are the most affected age group for this type of injury. A 19-month-old boy was admitted to the emergency department of Children's Hospital of Michigan for treatment of injuries due to a dog attack. Injuries were limited to the face of the child. Dental injuries included avulsion of upper lateral incisors, severe luxation of upper central incisors, and fracture of the facial alveolus bone. Surgical management of facial wounds was accomplished through irrigation, debridement and suturing. Dental treatment included extraction of central incisors and suturing soft tissues.

An adjustable Kirchner wire frame traction method for the treatment of dorsal fracture-dislocation of the distal interphalangeal joint

We applied an adjustable traction method which enables early range of motion exercise for the dorsal fracture-dislocation of the distal interphalangeal joint, and obtained satisfactory results. The reduction of comminuted fragments or depression of the joint is unnecessary using the traction method, because early exercise accelerates the remodelling of the injured soft tissue, followed by the development of joint stability. This traction mechanism is independent of the vector force of the traction applied due to the frame-structure construction. Our method makes it easy to adjust the traction force in millimetre increments of the glove-finger length, and has broad range of traction force. In cases where the dislocation is persistent even after strengthening the traction force, a transverse-transfixing Kirschner wire (K-wire) can be inserted to hold the reduction securely against subluxation.

Elbow arthroplasty for distal humeral fractures

The treatment of comminuted, distal humeral fractures in elderly patients with osteoporotic bone is challenging. Total elbow arthroplasty or hemiarthroplasty are reliable treatment options with favorable outcomes for fractures that are not amenable to open reduction and internal fixation. Total elbow arthroplasty is a reliable option for a comminuted distal humeral fracture in an elderly patient with osteoporosis and low functional demands. Longer-term studies have shown good to excellent results and a low risk of complications. Specific indications for hemiarthroplasty are evolving, but include comminuted coronal shear or low transverse fractures in patients who have higher functional demands than those that can be met by total elbow arthroplasty. Further studies with longer-term follow-ups are needed to compare the benefits of hemiarthroplasty with total elbow arthroplasty.

[Forensic identification of 50 phalangeal fracture cases]

OBJECTIVE

To study the characteristics of forensic identification of phalangeal fracture and to use a combination of medical records, imaging materials, and forensic examination data in identification.

METHODS

Fifty cases of phalangeal fracture involved in the forensic identification were collected from 2009 to 2011. The general situation, the distribution of fracture, the fracture morphology, the injury-causing objects and the results of identification were analyzed retrospectively.

RESULTS

Majority of the cases of phalangeal fracture were young and middle-aged men. The index finger and distal phalanx fractures were common. There was no difference in the number of phalangeal fracture between left and right hand. Most of the injury-causing objects were knives and sticks, followed by bricks and stones.

CONCLUSION

The injury-causing objects and modes are related to the morphology of fracture, the distribution of fracture and the severity of the injury. The comprehensive analysis is helpful in forensic identification of phalangeal fracture.

The clinical presentation and management of zygomatic complex fractures in a Nigeria Teaching Hospital

BACKGROUND

Fractures of the zygomatic complex occur worldwide and are a component part of injuries that can be sustained in the maxillofacial region. The objective was to analyze the clinical presentation and management ofzygomatic complex fractures.

METHODS

This was a prospective study carried out over a period of five years at the University of Calabar Teaching Hospital, Nigeria. Data documented were patients' age, gender, time of presentation, cause and type of fracture, associated head and maxillofacial injuries, clinical features, types of plain radiographs, treatment methods, duration of follow-up and complications.

RESULTS

Majority of the patients (n = 81, 63.3%) were in their third and fourth decades of life while the male to female ratio was 20.3:1. Road traffic accident (n = 111, 86.7%) was the most common cause of fracture. Fractures of the zygomatic complex alone (n = 105, 82.0%) were more common than isolated fractures of the arch (n = 13, 10.2%) and combined fractures of the zygomatic complex and arch (n = 10, 7.8%).

CONCLUSION

While multi-disciplinary approach to treatment is important, majority of the fractures were treated by simple elevation and transosseous wire osteosynthesis. Delay in presentation, associated injuries and non-availability of mini-plating technique contributed to the development of complications.

Bilateral four-part anterior fracture dislocation of the shoulder--a case report and review of literature

Although bilateral anterior dislocation of shoulder is not that uncommon, there have been only 12 published reports on bilateral anterior fracture dislocation of shoulder. The associated fractures have mostly been greater tuberosity fractures with bilateral three part fractures being reported in only two cases. To our knowledge, a bilateral four part anterior fracture dislocation of the shoulder has not yet been reported in the English literature. We here report a case of bilateral anterior fracture dislocation with four part fracture of both proximal humeri in a 60-year-old male due to electrocution. Considering the comparatively old age of the patient and excessive comminution of both the fractures, a bilateral hemiarthroplasty was done. At the last follow-up after more than 2 years, the patient was pain free with ability to comfortably carry out most of the activities of daily life. Through our case report, we highlight the rarity of the condition and review the available literature on the subject. We also emphasize the importance of meticulous perioperative planning when dealing with such cases to ensure a satisfactory long-term outcome.

Comparison of two biological internal fixation techniques in the treatment of adult femur shaft fractures (plate-screws and locked intramedullary nail)

BACKGROUND

We aimed to compare two (plate-screws and locked intramedullary nail) biological internal fixation techniques in the treatment of adult femur shaft fractures.

METHODS

Group I included 28 patients operated with biological internal fixation with plate and screws. Group II consisted of 31 patients operated with locked intramedullary nailing technique. During the follow-up period in Group I, 1 patient died and 3 patients dropped out of the study, so the results of 24 patients were evaluated. During the follow-up period in Group II, 2 patients died and 3 patients dropped out of the study, so the results of 26 patients were evaluated in this group.

RESULTS

Age, sex, injury mechanism, fracture type, time to operation, duration of operation, amount of bleeding, fluoroscopy usage time, early and late complications, duration of hospitalization, fracture union time, and functional results of all patients were comparatively evaluated.

CONCLUSION

According to our results, no superiority of either technique was demonstrated with respect to fracture union time, complication rate and functional results. Biological internal fixation with plate and screws is an alternative technique to locked intramedullary nailing in patients with multi-trauma or compromised pulmonary or cardiac function, or in complex comminuted or segmented diaphyseal or metaphyseal fractures.

[A comparative study between humeral head prosthesis replacement and internal fixation for treatment of comminuted proximal humeral fractures]

OBJECTIVE

To compare the clinical efficacies of humeral head prosthesis and internal fixation in the treatment of comminuted proximal humeral fractures.

METHODS

The clinical data were analyzed for the patients with comminuted proximal humeral fractures undergoing surgeries for humeral head replacement or open reduction plus internal fixation in our hospital between January 2002 and January 2009. Constant scores were used to determine the excellent clinical outcome rates in the two groups, and the operating time, blood loss and postoperative motor scores of the shoulder were compared.

RESULTS

Forty patients in the humeral head replacement group were evaluated. According to the Constant scores, excellent outcomes were achieved in 16 patients, good outcomes in 18 patients, moderate in 3 patients, and poor in 3 patients, with an excellent outcome rate of 85%. In the 40 cases receiving open reduction plus internal fixation, excellent outcomes were achieved in 11 cases, good in 13 cases, moderate in 8 cases, and poor in 8 cases, with an excellent clinical outcome rate of 60%. Compared with open reduction plus internal fixation, humeral head replacement was associated with shortened operating time, reduced blood loss and better motor function recovery of the shoulder.

CONCLUSIONS

Replacement of humeral head prosthesis produces better clinical outcomes than open reduction and internal fixation in patients with comminuted proximal humeral fractures, and can promote the short-term functional recovery of the shoulder with minimal surgical complications.

[Different surgical methods for treatment of senile osteoporotic comminuted proximal humerus fracture]

OBJECTIVE

To compare the efficacy and indication of the three different surgical methods in the treatment of the senile osteoporotic comminuted proximal humerus fracture.

METHODS

From January 2006 to April 2008, 70 senile patients with osteoporotic comminuted proximal humerus fracture were randomly divided into three groups to receive different surgical methods. There were 21 patients in the group A receiving Kirschner tension band or screw internal fixation, 37 patients in group B receiving internal fixation of locking proximal humeral plate, and 12 patients in group C receiving humeral head replacement. There were 36 males and 34 females aged 53-76 years old (average 61.9 years old). All the fractures were closed, osteoporotic, and III and IV-part according to Neer classification. The disease course was 1-8 days (average 2.8 days). There was no significant difference among three groups in terms of baseline information (P > 0.05). The effective anti-osteoporosis therapy was given during perioperative period.

RESULTS

All the incision healed by first intention. All patients reached anatomical or almost anatomical reduction without complications such as postoperative infection, neurovascular injury, and nonunion of bone. Seventy patients were followed up for 9-20 months (average 11.5 months). The healing time of the fracture was 8-12 weeks in group A and group B, the average healing time was 10.5 weeks in group A and 10 weeks in group B, and there was no significant difference between two groups (P > 0.05). Group C presented with no sign of prosthesis loosening or shoulder dislocation. Six cases in group A suffered from frozen shoulder, pain or acromion impingement syndrome 6 months after operation and obtained various degrees of improvement via functional exercises. One of them had humeral head avascular necrosis 12 months later and achieved fair recovery after performing humeral head replacement. Two cases in group B had frozen and painful shoulder 6 months after operation and achieved fair recovery after functional exercises. One cases in group C had frozen shoulder and poor performance of abduction and uplifting and achieved improvement after exercises. The rest patients achieved satisfactory curative effects. The incidence of complication was 28.6% in group A, 5.4% in group B, and 8.3% in group C. The incidence of complication in group A was significantly higher than that of group B and group C (P < 0.05), and there was no significant difference between group B and group C (P > 0.05). Neer scale system was adopted to evaluate the postoperative shoulder function, the excellent and good rate was 66.7% in group A, 78.4% in group B, and 83.3% in group C. The excellent and good rate in group A was significantly less than that of group B and group C (P < 0.05), and there was no significant difference between group B and group C (P > 0.05).

CONCLUSION

The senile osteoporotic comminuted proximal humerus fracture treated by surgery can obtain satisfied results. Most patients can use locking plate fixation. Those with poor general condition can use Kirschner wire fixation with tension band or screws, but this method is subject to certain constraints. For some elder patients with humeral head necrosis and humeral head crushed, priority should be given to the use of humeral head replacement.

Endoprosthetic replacement of unstable, comminuted intertrochanteric fracture of the femur in the elderly, osteoporotic patient: A review

PURPOSE

To summarize currently existing evidence regarding prosthetic replacement for the treatment of intertrochanteric (extracapsular) hip fractures and their complications.

METHOD

Report of a clinical investigation program conducted at one academic institution and literature review.

RESULTS

Although the majority of intertrochanteric fractures can be successfully managed with operative reduction and fixation, some patients may benefit from prosthetic replacement. For older patients with severe osteoporosis or comminution there are some definite advantages of prosthetic replacement over reduction and fixation. If the prosthetic replacement has been properly performed, there is very little concern over immediate ambulation and weight-bearing. This decreases the incidence of postoperative complications, such as pulmonary infection, atelectasis, and pressure sores. In addition, acute prosthetic replacement eliminates the possibility of excessive collapse compromising walking function, mal-union, as well as the uncommon problems of non-union and avascular necrosis. Likewise, hip arthroplasty is an effective salvage procedure after the failed internal fixation of an intertrochanteric fracture in an older patient. Most patients report good pain relief, and surprisingly few serious orthopaedic complications are associated with this procedure.There are, however, a number of methodological concerns regarding previous studies which have examined the use of prosthetic replacement for the treatment of comminuted intertrochanteric fractures or non-union in the elderly patient. Many have been small case series without a control group. There are few comparative studies and even fewer prospective, randomized controlled trials which have compared prosthetic replacement surgery with standard internal fixation techniques in the long run.

CONCLUSIONS

Older patients with severe osteoporosis or comminution may benefit from prosthetic replacement to treat intertrochanteric fractures and non-unions. Overall, rigorously conducted prospective randomized clinical trials with long-term follow-up are lacking. Despite these methodological reservations, several authors have reported successful prosthetic replacement for treating intertrochanteric fractures and their complications in elderly patients. Few serious orthopaedic complications are associated with these procedures, and most patients have good pain relief.

Treatment of complex proximal femoral fractures with the proximal femur locking compression plate

The PF-LCP represents a feasible alternative for the treatment of unstable inter- and subtrochanteric fractures.

[Fracture due to bilateral avulsion of the tuberosity of the shin bone (tibia). A case report]

INTRODUCTION

The avultion-fracture of the tibial tuberosity is a rare injury, one which appears in adolescents, predominantly male and happens in a zone in which the conditions of bone immaturity are favorable, so that an abrupt traction of the patellar tendon generates the injury. The reports of simultaneous fractures in both knees are rare.

CLINICAL CASE

A 14-year-old masculine patient, who had suffered indirect trauma in both knees while playing soccer. The injuries correspond to a 3-A and one 3-B of Ogden's classification for the right and left knee respectively. Both injuries were treated in the same surgical act using screws and wire. The recovery of the patient was satisfactory.

CONCLUSION

The avultion-fracture of the tibial tuberosity is a rare injury. The bilateral presentation in simultaneous form is even rarer. Generally they are injuries of type 3 that require surgical handling. Preexisting conditions such as Osgood-Schlatter disease and the type of athletic training must be considered.

Alumina femoral head fracture in uncemented total hip arthroplasty with a ceramic sandwich cup

In total hip arthroplasty, insertion of a UHMWPE-coated ceramic sandwich liner dramatically reduces any risk related to the stiffness of the ceramic-ceramic coupling. We present a case of an alumina ceramic head fracture with a ceramic sandwich cup. The fracture occurred 16 months after the initial operation, without trauma. Impingement between the neck and posteroinferior portion of the liner rim had occurred. This was related to the traditional cross-legged sitting position of Koreans, which caused impingement between the neck and liner rim. Consequently, the taper became loose, and the resulting force bent the taper and fractured the head. We examined a peculiar case of ceramic femoral head fracture after implantation of an uncemented total hip arthroplasty with a ceramic sandwich cup and investigated the underlying cause.

[Treatment of comminuted intra-articular fractures of the distal radius by open reduction and volar plating in adults]

BACKGROUND

We herein present the mid-term results of the adult patients with comminuted intra-articular fractures of the distal radius who were treated by palmar plating.

METHODS

Between 1999 and 2003, open reduction and palmar plating were performed in 23 of the patients who had surgical treatment for comminuted intra-articular fractures of the distal radius. Nineteen patients (11 females, 8 males; mean age 34; range 22 to 54 years) with regular follow-up were included in the study. In the majority of patients only one wrist was involved (7 dominant - 12 nondominant). Preoperative evaluation included patient's history, physical examination, and radiological studies (plain radiographs, computed tomography). The patients were classified according to AO classification as 7 type B [B1 (1); B2 (3); B3 (3)] and 12 type C [C1 (7); C2 (5)]. The surgical procedure included internal fixation by using plates and screws with palmar approach. Range of motion exercises were started immediately after the operations. The patients were followed clinically and radiographically, with an average follow-up time of 28 months (range, 13-47 months). Complications were recorded.

RESULTS

Union was achieved in all patients. Radiographic parameters including the radial height, radial inclination, palmar tilt, and articular congruency have been corrected in the operation and remained unchanged until the last follow-up. According to the Gartland and Werley's classification, there were 9 (47%) excellent, 7 (37%) good, and 3 (16%) fair results. No perioperative and postoperative complications were recorded, except for three wound problems and one prolonged scar tenderness.

CONCLUSION

Palmar plating is a safe and effective treatment for comminuted intraarticular fractures of the distal radius, regardless of direction of displacement of the distal fragment.

Comminuted femur fracture secondary to stress during the Boston marathon

We report a case of a comminuted femur fracture secondary to repetitive stress in a healthy marathon runner. Stress fractures are common orthopedic injuries that result from normal muscular activity on deficient bone ("insufficiency fractures") or excessive, repetitive stresses on normal bone ("fatigue fractures"). Of recreational and professional sports, running accounts for a higher incidence of stress fractures, which have been reported to cause up to 15% of all injuries to runners. We report a case of a sub-trochanteric comminuted femoral stress fracture in a female marathon runner.

[External fixation of war injuries of the proximal femur]

Seventeen patients with open fractures of the upper third of the femur were treated using a pelvifemoral external fixation device. All of them had grade III open fractures resulting from high-velocity missile and explosive injuries with massive foreign body contamination. Sciatic nerve injury was present in five (29.4%); abdominal viscera and thoracic wall injuries were present in two patients (11.8%). There were no major arterial injuries. Full weight bearing was allowed after clinical and radiological bone healing (average 11.5 months). Chronic osteitis with fistula and sequestra developed in two (11.8%) patients. There were no nonunions and no refractures. Minor painless limitation of hip motion persisted in all patients. Upper-third femoral open fractures due to firearms are a unique type of open fractures. They are usually highly comminuted; therefore, stable fixation is difficult or impossible to achieve using external fixation with transfixation of the fracture site. On the other hand, the risk of infection is high following intramedullary nailing. Pelvifemoral external fixation allows adequate management of the soft tissue wounds, provides stable bone fixation and allows early patient mobilization.

Blindness after Le Fort I osteotomy: a possible complication associated with pterygomaxillary separation

INTRODUCTION

Visual loss after Le Fort I osteotomy is a devastating complication the mechanism of which is not always clear.

METHODS

A case report of blindness following Le Fort I osteotomy is presented. The literature on the various skull base complications associated with Le Fort I osteotomies is reviewed and the mechanisms of these complications discussed.

CONCLUSION

The radiological findings in this case are similar to those previously reported. They strongly support the hypothesis that an adverse transmission of forces associated with pterygomaxillary separation via the sphenoid bone to the intra- and extracranial portions of the skull base is the main reason for injury to the optic and other cranial nerves as well as to the branches of the carotid artery.

Use of an External Fixation Combined with the Buttress-Maintain Pinning Method in Treating Comminuted Distal Radius Fractures in Osteoporotic Patients

BACKGROUND

It is difficult to keep the alignment of a distal radius fracture in patients with osteoporosis and prevent malunion. Therefore, we hoped to design better method to maintain alignment.

METHODS

Thirty-two patients over 65 years old with a displaced unstable distal radius fracture were treated by the external fixator combined with buttress-maintain pinning method and were compared with a group of 66 patients less than 60 years old treated by the same method.

RESULT

The radiologic results demonstrated that postoperative and final radial length and volar tilt were not statistically different between both groups. The functional result (excellent and good) in the elderly group was 87.5% and 89% to that of the control group. There was only one complication of pin tract infection in the elderly group.

CONCLUSIONS

External fixation for unstable distal radius fracture combined with buttress-maintain pinning method can be used in the osteoporotic bone of older adults with results similar to those for young adults at 18 months follow-up.

Head injury caused by an ostrich: A rare entity

Human injuries caused by animals are not uncommon and have been reported in the literature on many occasions. Most of the animals commonly involved are dogs, cats, cows, horses and camels. Injuries are usually on the trunk or limbs and sometimes on the face. Human injuries caused by an ostrich are rare and only three cases have been reported with severe ocular injury. To our knowledge, this is the first reported case of head injury caused by an ostrich in a child.

Comminuted refracture of the distal femur and condyles in patients with an intramedullary nail: a report of 5 cases

Patients with in situ intramedullary nails sustaining a second distal femoral fracture following high-velocity trauma are infrequently reported in the literature. We report 5 such patients who sustained a second injury after 6 to 24 months, resulting in another fracture at the nail-tip level. These second fractures severely comminuted the femoral condyles. These patients required removal of the intramedullary nail, reconstruction of the comminuted femoral condyles, and stabilisation using an angled or buttress plate. Four of the 5 patients were followed up for a mean period of 36 months and were evaluated for knee status and outcome using Judet's criteria. Postoperative knee stiffness was common, and further interventions such as manipulation, hardware removal, arthrolysis, and quadricepsplasty were needed. One patient was lost to follow-up. The final results of the knees were good, with more than 100 degrees range of movement. It is important to adhere to established internal fixation protocols in the treatment of these complex nail tip fractures.

Multisegmental open sacral fracture due to impalement: a case report

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

Cruciate ligament avulsion fractures

PURPOSE

The objective of this study was to assess the variability of cruciate avulsion fractures.

TYPE OF STUDY

Retrospective observational study.

METHODS

Standardized radiographs and computed tomography (CT) examinations were performed in 40 patients (31 male, 9 female; age range, 10 to 77 years) with cruciate avulsion fractures.

RESULTS

The average age of patients with anterior cruciate ligament (ACL) avulsion fractures was 21.5 years and that of patients with posterior cruciate ligament (PCL) avulsion fractures was 42.9 years. Two basic patterns of avulsion fracture emerged. ACL fractures were either partial (62%) (with avulsion of anteromedial bundle) or extended (38%) and were comminuted in 25%. PCL fractures were either complete (47%) or extended (53%) and were comminuted in 50%. CT helped delineate fracture margins, comminution and extent.

CONCLUSIONS

Although there is considerable variability in fracture type, 2 basic patterns of ACL and PCL avulsion fractures exist. CT helps delineate these features as a prelude to surgical fixation.

LEVEL OF EVIDENCE

Level III.

Kyphoplasty: report of eighty-two thoracolumbar osteoporotic vertebral fractures

OBJECTIVES

Document initial outcomes of balloon kyphoplasty.

DESIGN

Retrospective analysis of the first 52 patients with 82 painful vertebral body compression fractures secondary to osteoporosis treated at our institution.

SETTING

Operation on subacute painful fractures with office follow-up.

PATIENTS/PARTICIPANTS

First 82 fractures in 52 patients treated. All patients had failed nonoperative treatment and had magnetic resonance imaging scans documenting edematous changes of the vertebral body. Forty-nine out of 52 patients presented for follow-up at an average of 37 weeks.

INTERVENTION

Minimally invasive balloon reduction via bilateral transpedicular or extrapedicular approaches followed by polymethyl methacrylate fixation.

MAIN OUTCOME MEASURES

Vertebral body height, Cobb angle, visual analogue pain scale, Roland-Morris Disability Survey, and complication rate.

RESULTS

Mean length of follow-up was 9 months (37 weeks, range 4-99 weeks); improved height 4.6 and 3.9 mm in the anterior and medial columns, respectively (P > 0.05); Cobb angle increased 14% (P < 0.05), visual analogue pain scale score improved 7 points (P < 0.05); Roland-Morris Disability Survey improved 11 points (P < 0.05); no adverse medical or procedural complications; 9.8% cement leakage rate.

CONCLUSION

Balloon kyphoplasty safely improves vertebral body height and patient quality of life.

Unusual presentation of blunt laryngeal injury with cricotracheal disruption by attempted hanging: a case report

The management of a patient with traumatic disruption of the cricotracheal junction in an attempted suicide by hanging is described. Such injury is uncommon, and many patients die at the scene; detailed radiologic imaging is rare because of the urgency of airway management. The delayed complete disruption of the major airway in this patient allowed adequate imaging and corrective management. Associated soft-tissue injuries of the great vessels of the neck are also described.

Evaluation of a Technique for Collection of Cancellous Bone Graft from the Proximal Humerus in Horses

OBJECTIVES

To describe a technique for collecting cancellous bone graft from the proximal humerus in horses.

STUDY DESIGN

Prospective evaluation of an experimental bone graft collection technique.

ANIMAL POPULATION

Eight horses, 3-15 years, weighing 495-605 kg.

METHODS

Horses were anesthetized and positioned in lateral recumbency. The lateral aspect of the proximal humerus was exposed by a 7-10-cm incision extending distally from the greater humeral tubercle, followed by sharp dissection through the omotransversarius muscle and between the infraspinatus and deltoideus muscles. A 12-mm cortical defect was incrementally created in the lateral proximal humerus. Human bone graft harvesting equipment (Acumed, Beaverton, OR) was drilled through this defect to collect a core of cancellous bone. In five horses additional cancellous bone was then collected with conventional instruments. Bone samples were weighed and histologically examined. Horses were monitored and graded for quality of anesthetic recovery, incisional complications, and postoperative lameness.

RESULTS

Total mean (+/-SD) surgical time for harvesting bone with the Acumed system and traditional techniques (n=5) was 38+/-6 minutes (range, 32-47 minutes). Mean cancellous bone weight collected with the Acumed system was 3.6+/-0.8 g (range, 2.0-4.6 g), and cancellous bone collected conventionally was 25.6+/-7.5 g (range, 16.8-34.2 g). Minimal incisional complications or postoperative lameness were observed. Mortality was 12.5%; one horse fractured the operated humerus during anesthetic recovery.

CONCLUSION

The Acumed system provided limited cancellous bone when used with the technique described. However, the quantity of cancellous bone collected with traditional harvesting instruments was comparable to other sites used in horses. The procedure was associated with minimal postoperative incisional complications or lameness, but because one horse suffered a catastrophic humeral fracture further research is required to assess the effects of this procedure on humeral breaking strength.

CLINICAL RELEVANCE

Based on the risk of catastrophic fracture, this technique cannot be recommended for use in clinical cases, especially if an unassisted recovery from general anesthesia is planned.

Treatment of comminuted trochanteric fractures and non-union of trochanteric osteotomy in revision total hip arthroplasty

OBJECTIVE

To explore the clinical efficacy of the treatment of comminuted trochanteric fractures and trochanteric osteotomy non-union in revision total hip arthroplasty with tension-band fixation.

METHODS

A retrospective review of 295 revision total hip operations performed between 1992 and 1998 was undertaken. Twenty hips of 19 patients with comminuted fractures or nonunion of the greater trochanter were stabilized with tension band technique. Multiple 2.0 mm k-wires and tension-band wires were placed through the intact cortex distally and the abductor tendon proximally in the pattern "8".

RESULTS

The average follow-up was 30 months. The Harris Hip Score improved on average from 45 preoperatively to 89 at follow-up. Sixteen hips with intra-operative trochanteric fracture through osteolytic bone and four hips with symptomatic trochanteric nonunion were approached with tension band fixation. Perioperative loss of fixation in one patient required a repeated surgery. The same fixation at the second operation achieved an uneventful healing. Two patients had a 2 cm proximal migration of one K-wire without loss of bony fixation. The trochanteric fractures healed with no further proximal wire migration. One patient had loss of fixation with trochanteric escape at 6 weeks post-operatively. The patient has abductor weakness with Trendleburg limp but without pain. On average, radiographic examination showed that healing occurred at 16.6 weeks postoperatively. Six patients developed grade 1 heterotopic ossification and two patients grade 3. All were asymptomatic. None of the 19 patients experienced a dislocation during the follow-up.

CONCLUSIONS

Tension-band fixation for greater trochanter can enhance the success rate of revision total hip arthroplasty without a deficient abductor mechanism.

Treatment results for open comminuted distal humerus intra-articuler fractures with Ilizarov circular external fixator

In open, intra-articular distal humerus fracture caused by gunshot injury, full functional recovery is difficult to obtain. Three basic treatment methods are available: minimal internal fixation, open reduction-internal fixation, and external fixation. In Gülhane Military Medical Academy Department of Orthopedics and Traumatology, 19 of 20 cases of gunshot injuries were treated with circular external fixator between the January 1995 and December 2000. Nine (45%) cases were type III-A, eight (40%) were type III-B, and three (15%] were type III-C. Eight (40%) cases were brought to the hospital 6 to 8 hours after the injury and 12 (60%) were in late stage. An amputation was done in one case. Mean follow-up period was 34.3 (14-55) months. Union was achieved in all 19 of the cases, and circular external fixator was taken out in a mean period of 4.6 (3-7) months. In the early treatment group, three (42.9%) were good, three (42.9%) were moderate, and one (14.2%) was unsatisfactory. In the late treatment group, five (41.7%) were good, four (33.3) were moderate, and three (25%) were unsatisfactory. Circular external fixator can be preferred as a treatment alternative in selected cases of distal humerus intra-articular open communited fractures because it protects the soft tissue connections and blood circulation of bone fractured, permits early elbow movements, and allows the patient to return to daily life very early.

Comminuted fracture of the ulnar sesamoid of the metacarpophalangeal joint of the thumb: an uncommon injury

Fracture of the ulnar sesamoid of the metacarpophalangeal joint of the thumb is rare. Injury may be caused as a result of hyperextension or, less frequently, direct trauma. A sesamoid may be incompletely ossified, making it difficult to diagnose the fracture on radiographs. Early recognition of this entity leads to appropriate management. The case of a 26-year-old man who sustained a hyperextension injury of the thumb is presented. Radiographs demonstrated a fracture of the ulnar sesamoid of the thumb metacarpophalangeal joint. The literature regarding this uncommon injury is discussed.

Classification of gunshot injuries in civilians

Gunshot injuries have become extremely prevalent among the United States civilian population because of increasing urban violence and the availability of handguns. However, the increasing prevalence of gunshot injuries in civilians dramatically contrasts with the paucity of scientific literature pertaining to the diagnosis, classification, and treatment of these injuries. The objective of the current study was to delineate the principal factors associated with gunshot injury severity in civilians, designate their importance in various injury patterns, and propose a new comprehensive classification system that may establish more uniform treatment approaches. The authors critically review existing gunshot injury classification systems with emphasis on the ballistic and clinical parameters that compose each system. The authors propose a new classification system based on five gunshot injury parameters: energy, vital structures involved, wound characteristics, fracture, and degree of contamination. This new classification scheme is applicable to all firearm injuries in civilians and assists with proper treatment selection. The proposed classification system is based on the authors' clinical experience in a Level I urban trauma center, and will require validation in a prospective clinical setting.

Results of surgical treatment of intra-articular (ao-c3) distal humeral fractures in adults

BACKGROUND

The results of intra-articular comminuted distal humeral fractures, which have been treated by open reduction and dual plate fixation, are compared in this study with previously published results.

METHODS

At Uludag University Faculty of Medicine Department of Orthopaedics and Traumatology, between 1995 and 2002, the results of 20 cases were evaluated in patients with intra-articular comminuted distal humer- alfractures, who had been treated by open reduction and internal jixation.

RESULTS

Eleven (55%) cases were male, nine (45%) were female and mean age was 40.6 (range; 18 to 76). All fractures were C3 type according to AO/ASIF classification. Eight (40%) cases were open fractures and of these, six ( 30% ) were type 3A and 2 ( 1 0% ) were type 3B on the Gustilo-Anderson classification. All the fractures were jixed with dual plate after open reduction. In 25% ~f the cases, superficial wound infection was observed and in 5% heterotopic ossification.

CONCLUSION

In adult distal humeral. fractures of type C3, stabilization by dual plate, following open reduction and early commencement of joint movements, has fewer complications and should he the preferred method of treatment. Key Words: Distal humeral, fracture, intra-articular, dual plate. fixation.

[Treatment of fragmented femur fracture following unilateral hip hemiarthroplasty and total knee arthroplasty]

In this paper is presented a case of the 80 years old patient with femur fracture after unilateral hip arthroplasty because of femur neck fracture and knee arthroplasty following osteoarthritis. First was done the stabilization of the fracture using a plate. Because of second fracture and damage the plate stabilization next operation was done using intramedullary Küntscher nail which was non typically inserted and with additional fixation by bone cement. The result were good stabilization and healing of the fracture after 4 months.

Gut barrier function damage following multiple firearm injuries in a porcine model

OBJECTIVE

To study the characteristics and pathogenesis of gut barrier damage following multiple firearm injuries in a porcine model.

METHODS

Twenty-four small pigs were divided into 4 groups: control group (n = 6, group C), group H (n = 6, gunshot-induced tangential fracture of parietal bone), group L (n = 6, gunshot-induced comminuted fracture of bilateral femora) and group M (n = 6, combined group H + L). Gastric intramucosal pH (pHi), plasma endotoxin levels in portal vein, and plasma D-lactate levels were measured and blood samples were cultured at different intervals after trauma. The animals were sacrificed at 72 h following trauma and intestinal tissues were harvested for pathological examination and diamine oxidase (DAO) activity measurement.

RESULTS

In group M at 72 h, pHi was significantly lower than that of group H and L ( P < 0.01), and plasma endotoxin level was significantly higher than that of group H (P < 0.01) and group L (P < 0.05). Simultaneously, in group M, D-lactate level was markedly higher than that of group H ( P < 0.01), and incidence of positive blood culture was much higher than that of group H and L ( P < 0.05). Necrosis and exfoliation were revealed at ileum villus top in all trauma groups, especially in group M, in which ileum DAO activity declined most significantly as well.

CONCLUSION

Multiple trauma is prone to cause gastrointestinal ischemia even without hemorrhagic shock. The damage of gut barrier in multiple trauma appears to be more severe than that in one-site trauma, thereby promoting gut-derived endotoxemia and bacterial translocation and contributing to the development of endogenous infection.

Activation of blood coagulation in pigs following lower limb gunshot trauma

A standardized, quantifiable gunshot trauma to one hind leg of fourteen anaesthetized and sedated pigs was used to investigate the extent to which an isolated gunshot trauma causes activation of blood coagulation. The traumatized pigs were mechanically ventilated in intensive care for 48 h before they were euthanized. Blood samples were drawn at baseline (t = 0), 24, 27 and 48 h after trauma to examine the late effects on haemostasis. The median energy absorption in the pigs was 27.57 (22.6-31.7) J/kg. This gunshot injury caused increased creatine kinase and body temperature and led to a combined metabolic and respiratory alkalosis; the pigs remained circulatory stable. Within the haemostatic system the trauma caused increased activated partial thromboplastin time at 48 h (P < 0.05), prothrombin time at 24 and 27 h (P < 0.05), fibrinogen and soluble fibrin concentration at 48 h (P < 0.05), and 24 h (P < 0.05), respectively. The platelet count, protein C activity, tissue factor concentration and trombin-antithrombin concentration decreased throughout the experiment (P < 0.05); the changes of antithrombin activity did not reach statistical significance. In conclusion, this study in pigs demonstrates that a standardized gunshot trauma to a hind leg activates blood coagulation without signs of organ failure or disseminated intravascular coagulation within 48 h.

Predictors of outcome of floating knee injuries in adults: 89 patients followed for 2-12 years

Of the 98 floating knee injuries that were consecutively treated from 1987 to 1997, 89 patients were available for analysis. There were 80 males and 9 females, ranging from 15 to 70 years old. Average follow-up was 5 (2-12) years. Injury severity scores ranged from 18 to 45. 21 fractures were intra-articular. 55 fractures were open. Substantial comminuted and segmental fractures occurred in 57 cases and 35 cases, respectively. Multivariate analysis showed that increasing age was associated with delays in bony union and full weight bearing ability. An increase in the number of pack years smoked at the time of injury predicted the likelihood of knee stiffness, delays in bony union and full weight bearing ability. Higher injury severity scores were associated with delayed full weight bearing ability. The presence of open fractures predicted the likelihood of knee stiffness and delayed full weight bearing ability. Comminuted fractures were associated with malunion, and segmental fractures with delayed bony union. Using the outcome of floating knee injuries as fair or poor, according to Karlström and Olerud's criteria, we constructed a preoperative prognostic scoring scale which showed a sensitivity of 0.72 and a specificity of 0.90.

Percutaneous pin fixation of intercondylar fractures in young children

T-condylar fractures of the distal humerus are very rare in children. When they do occur they tend to affect those approaching skeletal maturity. Most agree that the undisplaced fracture can be managed conservatively. With increasing displacement and comminution the opinions tend to differ. As an alternative to open reduction and internal fixation we report the use of closed reduction and percutaneous pin fixation for displaced and comminuted T-condylar fractures in a series of three young children. In addition to the classical medial and lateral column fixation we report the use of a transcondylar wire to stabilise the distal fragments and discuss the use of intra-operative arthrography in low supracondylar fractures to exclude a missed intercondylar extension on plain xrays. Although small this series represents the largest series of children less than eight years of age.