Partial articular fractures of the radial head: How to understand them using computed tomography

BACKGROUND

The optimal treatment for different types of displaced partial articular radial head fractures is still debatable. Fractures involving the articulating portion of the radial head can be defined also as bi-articular and are often underestimated. Moreover, the complete loss of periosteal contact between fracture fragments is a marker of instability. Available classifications do not emphasize these aspects. The purpose of the present study is to describe two assessment methods to identify fractures involving the articulating portion of the radial head and complete loss of periosteal contact with the help of 2D-3D CT scan. The second purpose is to propose a classification of the displaced partial articular radial head fractures basing on these two assessment methods.

HYPOTHESIS

We hypothesize that the proposed classification is reliable.

PATIENTS AND METHODS

By observing the position of the bicipital tuberosity with respect to the ulna in reference to the coronal plane in the 3D-CT scan and by observing the location of the fracture fragment in the 2D axial scan, it is possible to understand if a displaced partial articular fracture involves the articulating portion of the radial head. Also, it is possible to understand the presence or absence of a complete loss of periosteal contact between the two fracture fragments by observing the coronal and sagittal 2D-CT scans. We identified 20 displaced partial articular radial head fractures on a series of 149 patients with radial head fractures. Following the above-described assessment methods, these 20 fractures were classified in three subgroups. Also, seven evaluators were asked to use these assessment methods to classify these 20 fractures in the three subgroups, in order to evaluate inter- and intra-observer agreement.

RESULTS

Eight fractures involved the non-articulating portion of the radial head with complete loss of periosteal contact, eight involved the non-articulating portion of the radial head without complete loss of periosteal contact, and four involved the articulating portion of the radial head with or without complete loss of periosteal contact. The kappa for intra-observer reliability ranged from 0.46 to 0.84. The average kappa for inter-observer reliability was 0.570 (range: 0.526 to 0.676). The Kendall's coefficient for inter-observer concordance was 0.673.

DISCUSSION

Prognostically, displaced partial fractures of the articulating portion of the radial head could differ from the other types, regardless of whether or not there is a complete loss of periosteal contact. Underestimating this fracture pattern can lead to poor results due to risk of forearm rotation blockage. Moreover, underestimating complete loss of periosteal contact in displaced partial fractures of the non-articulating portion of the radial head could lead to poor results. The described evaluation methods have moderate reliability, but can represent, along with other described methods, a good starting point to better understand and treat these insidious fractures.

LEVEL OF EVIDENCE

III; retrospective study.

Distal radius nonunion after epiphyseal plate fracture in a 15 years old young rider

BACKGROUND AND AIM OF THE WORK

Radius and ulna fractures are the most common long bone fractures in children and adolescents. The majority of these injuries involve the distal metaphyseal portion of the radius associated or not to physeal plate injuries. Because of the high remodelling potential of the distal radius in growing children most injuries heal without complication after closed reduction and immobilization in a long arm cast. Nonunions of closed distal radius fracture are an extremely rare occurrence especially in paediatric population. Methods: In this report, we describe a rare case of distal radius fracture nonunion in a 15-years old male rider treated conservatively with cast immobilization. Eight months later he underwent surgical closed reduction and fixation with kirschner wire and cannulated screw. Results: Follow-up at 2 years showed satisfying radiological and functional outcomes. The patient ultimately returned to ride 3 months following surgery. Conclusions: Nonunion is rarely seen in distal radius fractures in healthy children and adolescents, and there are few studies in the literature. Treatment of the nonunion must be individualized and the results are not entirely predictable.

Atypical use of pediatric flexible nails in the treatment of diaphyseal fractures in adults

Background and aim of the work:

Elastic intramedullary nails are commonly used for the treatment of diaphyseal fractures in adolescents and children. The major advantages are the minimally invasive nature of the technique, the short operation time, and the preservation of the growth plate and periosteum thus allowing bone healing within a closed and intact biological environment. Elastic nails are rarely applied to the adult fractures.

Methods:

Five selected adult patients affected by diaphyseal fractures were treated using paediatric flexible nails T2 Kids (Stryker®, Mahwah, NJ, USA) as consequence of their poor clinical conditions, high risk of neurovascular injuries and skin/soft tissues problems. All patients were monthly clinically and radiographically evaluated after surgery until fracture healing.

Results:

Radiological and clinical outcomes were satisfying. All fractures healed after a mean period of 3 months. No losses of reduction as well as mobilization/breakage of implant were observed. Conclusions: Use of pediatric elastic nails is a valid surgical option in treatment of diaphyseal fractures in selected adult patients who request fast and minimally invasive surgery as consequence of precarious clinical or soft tissues conditions. (www.actabiomedica.it)

Grice subtalar arthrodesis of bilateral adult flatfoot in a professional dancer: a case report

BACKGROUND AND AIM

Adult acquired flatfoot deformity (AAFD) is a common pathology and an important cause of pain and disability. This deformity causes a progressive flattening of the foot arch which has traditionally been associated with posterior tibialis tendon (PTT) dysfunction. Operative treatment is indicated after the failure of conservative management aiming to achieve proper alignment of the hindfoot and to maintain as much flexibility as possible. If subtalar osteoarthritis is present, subtalar arthrodesis is usually the best therapeutic option. Grice-Green subtalar arthrodesis is a widely used procedure.

METHODS

This report describes a case of bilateral painful AAFD in a 39-years old female professional dancer treated with Grice-Green subtalar arthrodesis with an autologous corticocancellous graft harvested from the ipsilateral proximal tibia. Surgeries were performed 3 years apart from each other.

RESULTS

The patient followed had good clinical and radiological outcomes. She returned to dance 4 months after surgery with no referred pain or limitations.  Conclusions: Due to its versatility and capability to restore the shape and thickness of the hindfoot Grice-Green procedure is a simple and effective technique for the treatment of AAFD with subtalar osteoarthritis and a valid option to solve professional disabilities as it happened in this case with a professional dancer.

A rare case of complicated pure posterior sternoclavicular dislocation in a young athlete

Sternoclavicular joint dislocation (SCJD) is a rare injury, generally classified in anterior and posterior. The posterior SCJD is very infrequent yet potentially associated with life-threatening complications. In patients with unfused medial clavicle physis, SCJD can be associated with fracture-dislocation (Salter type I or II). We hereby present the case of a 12-year-old basketball player with severe pain in sternoclavicular region and arising dysphagia after a fall and tackle by another player. A SCJ injury was hypothesised and the CT scan detected the presence of a true posterior SCJD with no associated fracture, which was also confirmed during open reduction. As the patient complained dysphagia, it was also necessary to study other possible mediastinal compressions by a contrast medium CT scan of the great vessels. The CT scanned brachiocephalic vein compression without additional clinical evidence or signs. Twenty hours after the trauma the patient underwent an unsuccessful closed reduction; for this reason, surgical treatment with open reduction and fixation was mandatory. After 12 weeks of therapy she returned to her previous sport activity. (www.actabiomedica)

Surgical or conservative treatment in ARGP syndrome? A systematic review

BACKGROUND AND AIM OF THE WORK

The rectus-adductor syndrome is a common cause of groin pain. In literature the adductor longus is reported as the most frequent site of injury so that the syndrome can be fitted into the adductor related groin pain (ARGP) group. The aim of this study was to define what is the best treatment between surgical and conservative in athletes affected by ARGP in terms of healing and return to play (RTP) time.

METHODS

A systematic review was performed searching for articles describing studies on RTP time for surgical or conservative interventions for ARGP. A qualitative synthesis was performed. Only 10 out 7607 articles were included in this systematic review. An exploratory meta-analysis was carried out. Due to high heterogeneity of the included studies, raw means of surgery and conservative treatment groups were pooled separately. A random effects model was used.

RESULTS

The results showed quicker RTP time for surgery when pooled raw means were compared to conservative treatments: 11,23 weeks (CI 95%, 8.18,14.28, p<0.0001, I^2=99%) vs 14,9 weeks (CI 95%, 13.05,16.76, p<0.0001, I^2 = 77%). The pooled results showed high statistical heterogeneity (I^2), especially in the surgical group.

CONCLUSIONS

Surgical interventions are associated with quicker RTP time in athletes affected by ARGP, but due to the high heterogeneity of the available studies and the lack of dedicated RCTs this topic needs to be investigated with dedicated high quality RCT studies.

A proposal for computed tomography-based algorithm for the management of radial head and neck fractures: the Proximal and Articular Radial fractures Management (PARMa) classification

Background

Owing to the great variety of fracture patterns and limitations of the standard radiographic investigation, all the already available classification systems for radial head and neck fractures (RHNFs) are limited by a poor-to-moderate degree of intraobserver and interobserver reliability. Although computed tomography (CT) is being increasingly used to better understand the fracture characteristics, a CT-based classification system of RHNFs is still lacking. Therefore, in this agreement study, we aimed to propose a classification system based on two-dimensional and three-dimensional (2D/3D) CT to test the hypothesis that this classification has good intraobserver and interobserver reliability. We have also provided a treatment algorithm.

Methods

Our proposed classification-Proximal and Articular Radial fractures Management (PARMa)-is based on 2D/3D CT imaging. It is divided into four types based on different fractures patterns. The 2D/3D scans of 90 RHNFs were evaluated in a blinded fashion by eight orthopedic and one radiology consultant, according to the proposed classification. The first phase of observation aimed to estimate the interobserver agreement. The second phase involved a new observation, 4 weeks after the first analysis, and estimated the intraobserver reliability. The standard radiographs of these 90 fractures were also evaluated by the same observers, with the same timing and methods, based on the same classification. Cohen's Kappa was applied for intraobserver agreement. Fleiss's Kappa was used both within and among the evaluators. Kendall's coefficient of concordance was employed to determine the strength of association among the appraisers' rankings. Furthermore, Krippendorff's alpha was chosen as an adjunctive analysis to assess between evaluators' agreement.

Results

For the intraobserver agreement, Fleiss' Kappa statistics confirmed the consistency (overall kappa values: 0.70-0.82). Cohen's Kappa statistics aligned with Fleiss' Kappa, with similar kappa values and significant P values (P < .001). For interobserver agreement, Fleiss' Kappa statistics for between appraisers showed moderate-to-substantial agreement, with kappa values ranging from 0.54 to 0.82 for different responses. The results relating to the appraisers' observation of standard radiographs showed that the overall Fleiss' Kappa values for intraobserver agreement ranged from 0.34 to 0.82, whereas Fleiss' Kappa statistics for interobserver agreement ranged from 0.40 to 0.69.

Conclusions

The proposed classification system is expected to be reliable, reproducible, and useful for preoperative planning and surgical management. Both 2D and 3D CT allow the identification of the magnitude and position of displacement and articular surface involvement.