Medial Hoffa Fracture: A Case Report and Literature Review of Approach and Management

BACKGROUND Hoffa fractures are an uncommon form of coronal fracture that impact the femoral condyle. As a result, they are not very prevalent. It is necessary to perform anatomical reduction and rigorous fixation on these fractures; however, there is no consensus among medical professionals on the surgical procedure and implant that would be the most successful in treating these fractures. CASE REPORT A 50-year-old woman who had poliomyelitis in her right lower limb presented with a displaced medial Hoffa fracture of her left knee. She had fallen and was suffering from poliomyelitis. The trauma that caused this fracture had a modest energy level. Open reduction and internal fixation with 2 retrograde cannulated screws were included in her surgical procedure. An approach known as the medial parapatellar route was used for this treatment. As part of her postoperative rehabilitation, she participated in physiotherapy, exercises that did not require weight bearing, exercises that used passive and active assistance, activities that involved partial and full weight bearing, and exercises that involved complete weight bearing. At the 2-year follow-up, the patient's left knee continued to be painless and stable, and it had unrestricted range of motion across the whole extremity. It was determined via radiographs that the fracture had healed without any problems or arthritic changes developing. She was able to walk without help and carry out her daily tasks since she was able to walk with the use of a cane. CONCLUSIONS Retrograde cannulated screws can be a reliable and successful choice for treatment of medial Hoffa fractures, with positive results according to both clinical and radiographic characteristics. Further research is needed to analyze the outcomes over a longer period of time and make comparisons between this technique and others.

Hemi-hamate arthroplasty outcomes: a single-centre experience

This retrospective observational study evaluated outcomes after hemi-hamate arthroplasty. A palmar cortical step caused by the osteochondral graft was associated with reduced proximal interphalangeal joint range of motion compared to a flush palmar cortex at early follow-up (62° vs. 83°; p = 0.006).

Reported Outcome Measures in Complex Fracture Elbow Dislocations: A Systematic Review

BACKGROUND

Complex elbow fracture dislocations, dislocation with fracture of one or several surrounding bony stabilizers, are difficult to manage and associated with poor outcomes. While many studies have explored treatment strategies but a lack of standardization of patient-reported outcome measures (PROMs) makes cross-study comparison difficult. In this systematic review, we aim to describe what injury patterns, measured outcomes, and associated complications are reported in the complex elbow fracture dislocation literature to provide outcome reporting recommendations that will facilitate improved future cross-study comparison.

METHODS

A systematic review was performed per PRISMA guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles published between 2010 and 2022 reporting on adult patients who had a complex elbow fracture dislocation. Pathologic fractures were excluded. A bias assessment using the methodological index for non-randomized studies criteria was conducted. For each article, patient demographics, injury pattern, outcome measures, and complications were recorded.

RESULTS

Ninety-one studies reporting on 3664 elbows (3654 patients) with an elbow fracture and dislocation (weighted mean age 44 years, follow-up of 30 months, 41% female) were evaluated. Of these, the injury pattern was described in 3378 elbows and included 2951 (87%) terrible triad injuries and 72 (2%) transolecranon fracture-dislocations. The three most commonly reported classification systems were: Mason classification for radial head fractures, Regan and Morrey coronoid classification for coronoid fractures, and O'Driscoll classification for coronoid fractures. Range of motion was reported in 87 (96%) studies with most reporting flexion (n=70), extension (n=62), pronation (n=68), or supination (n=67). Strength was reported in 11 (12%) studies. PROMs were reported in 83 (91%) studies with an average of 2.6 outcomes per study. There were 14 outcome scores including the Mayo Elbow Performance Score (MEPS) (n=69 [83%]), the Disabilities of Arm, Shoulder and Hand (DASH) score (n=28 [34%]), the visual analog scale for pain (VAS) (n=27 [33%]), QuickDASH score (n=13 [15.7%]), and Oxford Elbow score (n=5 [6.0%]). No significance was found between the number of PROMs used per article and the year of publication (P=.313), study type (P=.689), complex fracture pattern (P=.211), or number of elbows included (P=.152).

CONCLUSION

There is great heterogeneity in reported PROMs in the complex elbow fracture dislocation literature. Although there is no gold standard PROM for assessing complex elbow fracture dislocations, we recommend the use of at least the MEPS and DASH outcomes measures as well as VAS pain rating scale in future studies to facilitate cross-study comparisons.

Cervical corpectomy in delayed presentation of irreducible cervical dislocation: experience with eight cases

OBJECTIVE

To describe a single-staged procedure for the management of neglected subaxial cervical spine injuries.

METHODS

Between January 2012 and December 2014, 12 patients presented to us with healed cervical sub axial dislocations. The deformities could not be reduced using skull traction. Eight were operated with anterior cervical corpectomy. American spinal injury Association (ASIA) grade, Neck Disability index (NDI), and Visual analog scale (VAS) score were recorded throughout the patient course and CT was done at 12 months for assessment of fusion.

RESULTS

Four patients improved from ASIA C to ASIA D, two patients improved from ASIA B to ASIA E, one patient improved from ASIA D to ASIA E and one patient remained static at ASIA B. All patients except one showed evidence of fusion on CT scan at 12 months. NDI improved from preoperative range (18-32, mean 25) to postoperative range (8-16 mean, 11.25), VAS from preoperative range (3-6, mean 4.25) to postoperative range (1-3, mean 1.75).

CONCLUSIONS

Single-stage in situ fixation does not disrupt ongoing natural healing and has good clinical and radiological outcomes.

Reconstruction of Delayed Proximal Interphalangeal Joint Fracture-Dislocation Using Hemi-Hamate Arthroplasty: A Case Report

This case report aims to delineate the clinical outcomes and technical considerations of hemi-hamate arthroplasty in the reconstruction of a delayed proximal interphalangeal (PIP) joint fracture-dislocation. It underscores the procedure's viability as a reconstructive option for complex finger injuries with delayed presentation. A 23-year-old male presented six weeks post-injury with a PIP joint fracture-dislocation of the left index finger. Traditional management options were limited due to the delayed presentation and the nature of the injury. A surgical intervention was performed using an autologous osteochondral hemi-hamate graft to reconstruct the articular surface. Herein, we describe the detailed surgical steps, postoperative care, and rehabilitation protocols. Over a five-month follow-up period, the patient demonstrated significant functional improvement. The range of motion in the PIP joint increased substantially, with a notable reduction in pain levels. Radiographic assessments showed successful graft incorporation and joint alignment. The patient reported satisfaction with the aesthetic and functional outcome, highlighting an enhanced quality of life post-surgery. Hemi-hamate arthroplasty emerges as a favorable surgical option for delayed PIP joint fracture-dislocations, offering improved articular congruity, joint stability, and functional outcomes. This case contributes to the growing body of evidence supporting the procedure's effectiveness and underscores the importance of considering innovative approaches in complex hand injuries.

Strategies for the planning of complex shoulder arthroplasty: Use of a custom-made glenoid component in reverse shoulder arthroplasty for a neglected posterior fracture dislocation of the shoulder with malunited scapula fractures and severe eccentric glenoid bone loss

Glenoid bone loss associated with abnormal glenoid morphology can be encountered in complex primary and revision reverse shoulder arthroplasty. Strategies to deal with this include allografts, augments and custom-made prostheses. We describe a unique case of a long-standing neglected posterior fracture dislocation of the shoulder with severe glenoid bone loss and retroversion. The patient also had malunited acromial and scapula fractures and an associated rotator cuff tear. The primary challenges were access to the shoulder joint due to the malunited fractures, reconstruction of the dysplastic glenoid and providing joint stability. A reverse shoulder replacement was planned using a custom-made glenoid component and patient-specific instrumentation (PSI). The custom base plate was manufactured based on the pre-operative computerised tomography (CT) scan and conformed to the native glenoid. A post-operative CT scan confirmed adequate positioning of the implants. 30 months following surgery, there was a significant improvement in pain and range of motion with an Oxford Shoulder Score (OSS) of 39/48, compared to a pre-operative score of 12/48. Plain radiographs did not show any evidence of loosening or osteolysis. This case report highlights the approach for planning a complex reverse shoulder arthroplasty and the use of custom-made prostheses and PSI in such scenarios.

Transscaphoid Transcapitate Perilunate Fracture-dislocation with Inferior Arc Injury and Acute Ulnar Nerve Compression: A Case Report

Introduction

Perilunate dislocations and perilunate fracture-dislocations (PLFD) are relatively uncommon injuries, comprising <10% of wrist injuries. Perilunate injuries are often complicated by median neuropathy reported in 23-45% of cases, whereas there are very few reported cases of associated ulnar neuropathy. Combined greater arc and inferior arc injuries are also rare. We report an unusual PLFD pattern with associated inferior arc injury and acute ulnar nerve compression.

Case Report

A 34-year-old male sustained a wrist injury after a motorcycle collision. Computed tomography scan revealed a trans-scaphoid, transcapitate, perilunate fracture-dislocation, and a distal radius lunate facet volar rim fracture with radiocarpal subluxation. Examination revealed acute ulnar neuropathy without median neuropathy. He underwent urgent nerve decompression and closed reduction, followed by open reduction internal fixation the next day. He recovered without complication.

Conclusion

This case emphasizes the importance of a thorough neurovascular examination to rule out less commonly seen neuropathies. With up to 25% of perilunate injuries misdiagnosed, surgeons should have a low threshold for advanced imaging in high-energy injuries.

Delayed Sub-axial Fracture Dislocation Surgical Management: Technical Notes and Review of the Literature

The surgical treatment of delayed, unstable sub-axial cervical spine injuries is challenging. Multiple treatment regimens have been described in the literature, although there is no consensus regarding the best treatment approach. This report presents a 35-year-old obese woman who experienced a delayed sub-axial fracture-dislocation following a motor vehicle accident (MVA) and was successfully managed after three weeks via pre-operative traction followed by a novel single-surgery, single-approach technique with pedicle screws and tension-band wiring as a reduction method. A 35-year-old obese woman with a body mass index (BMI) of 30.1 sustained a frontal impact MVA and suffered from complete quadriplegia below C5 (American Spinal Cord Association Injury A) three weeks prior to presentation. She was intubated and presented with a Glasgow Coma Scale score of 11/15. Trauma computed tomography (CT) showed an isolated spine injury. Moreover, whole-spine CT showed an isolated cervical spine injury involving a basin tip fracture, a comminuted C1 arch fracture, a C2 fracture, and a C6-C7 fracture-dislocation. In addition, magnetic resonance imaging revealed cord contusion at the same level, with C1-C2 left atlantoaxial joint instability. Neck magnetic resonance angiograms and carotid CT angiograms showed left vertebral artery attenuation. She was admitted to the intensive care unit and taken for C6-C7 reduction and instrumentation using only a posterior approach after medical optimization and the application of sufficient traction. Delayed cervical spine fracture-dislocation imposes a challenge for surgical reduction. However, a proper reduction can be achieved through a sufficient duration of pre-operative traction and an isolated anterior or posterior approach.

Bilateral Radial Head Fractures in a Young Patient: A Rare and Unique Presentation

Introduction

Bilateral radial head fractures are a unique and rare presentation. Few studies are available in the literature documenting these type of injuries. We present a rare case of bilateral radial head fractures (Mason type 1) and managed conservatively with full functional recovery.

Case Report

A 20-year-old male sustained bilateral radial head fractures (Mason type 1) following a roadside accident. The patient was managed conservatively with above elbow slab for 2 weeks followed by range of motion exercises. The patient had uneventful follow-up with full range of motion at elbow.

Conclusion

Bilateral radial head fractures in a patient are a discreet clinical entity. A high index of suspicion, meticulous history, clinical examination, and appropriate imaging is essential in patients with history of fall on outstretched hands to avoid missing diagnosis. Early diagnosis, proper management, and appropriate physical rehabilitation lead to complete functional recovery.

Functional outcomes of elbow injuries managed according to the Wrightington classification of elbow fracture-dislocations

Background

This study aims to review the functional outcomes of patients managed by the application of the Wrightington elbow fracture-dislocation classification system and its corresponding management algorithms.

Methods

This is a retrospective consecutive case series of patients over the age of 16 with an elbow fracture-dislocation managed according to the Wrightington classification. The primary outcome was the Mayo Elbow Performance Score (MEPS) at the last follow-up. Range of movement (ROM) and complications were collected as a secondary outcome.

Results

Sixty patients qualified for inclusion (32 female, 28 male) with a mean age of 48 years (19-84). Fifty-eight (97%) patients completed a minimum of three months follow-up. Mean follow-up was six months (3-18). The median MEPS at the final follow-up was 100 (interquartile range [IQR] 85-100) and median ROM of 123° (IQR 101-130) degrees. Four patients underwent secondary surgery and had improved outcomes with the average MEPS score improving from 65 to 94 following the second surgery.

Conclusions

The results of this study show that good outcomes can be achieved for complex elbow fracture-dislocations through pattern recognition and management with an anatomically based reconstruction algorithm as described by the Wrightington classification system.

Correlation of Lisfranc Injuries With Regional Bone Density

Lisfranc injuries present a challenge due to their ubiquity though frequent missed diagnoses. A paucity of data exists associating the contribution of bone density to injury type. This investigation compares the regional bone density between Lisfranc injury types using computed-tomography (CT)-derived Hounsfield units. A retrospective chart review identified patients with gross ligamentous and avulsion-type Lisfranc injuries determined by CT examination of the second metatarsal base and medial cuneiform. Regional bone density was assessed by averaging the Hounsfield units of the first metatarsal base, navicular, cuboid, calcaneus, and talus between 2 reviewers. Density was compared between injury type, isolated concomitant forefoot, and mid/hindfoot fractures. One hundred thirty-four patients were separated into avulsion (n = 85) and ligamentous (n = 49) groups. No statistically significant difference in patient body mass index, age, smoking status, or Quenu and Kuss injury pattern was observed between groups. The regional bone density of the cuboid (p = .03) and talus (p = .04) was greater in the ligamentous group. Lower extremity concomitant mid/hindfoot fracture patients exhibited greater regional bone density in the ligamentous group in all assessed bones (p ≤ .04) except the calcaneus. Ligamentous injuries of the Lisfranc complex are associated with increased regional bone density among patients sustaining concomitant mid/hindfoot fractures. This study expands the utility of regional bone density analysis in foot and ankle trauma.

Bilateral locked posterior shoulder dislocation overlooked for 15 months treated with the modified McLaughlin procedure: A case report

Neglected bilateral posterior shoulder dislocation is a rare injury caused primarily by an epileptic seizure. The injury is usually associated with a reverse Hill-Sachs lesion in the anteromedial aspect of the humeral head. The modified McLaughlin technique may avoid instability and osteoarthritis when 20 to 40% of the articular surface is affected by reverse Hill-Sachs. In this article, we present the clinical results of a case overlooked in the literature for the longest time, i.e., for 15 months. A 46-year-old male patient was receiving treatment for epilepsy for five years. There was no fall or trauma in the four seizures he had during this time. The last seizure was 15 months ago. When the patient presented to our clinic, both shoulders were symmetrically deformed, the anterior shoulder contour disappeared (empty socket sign), and there was a loss of upper contour. The computed tomography (CT) scan revealed a posteriorly locked dislocation with a reverse Hill-Sachs lesion in 32% of the left shoulder and 36% of the right shoulder. We applied the modified McLaughlin procedure to the dominant right shoulder and, two months later, we used it to the left shoulder (with a graft taken from the anterior superior iliac spine). At one-year of follow-up, both shoulders were moderately functional: forward elevation left 70° and right 50°, abduction left 40° and right 60°, and internal rotation: the back of the hand could touch the fifth lumbar vertebra. Meanwhile, the patient did not suffer from recurrent dislocation. The pre- and postoperative Constant-Murley Scores for the right and left shoulder were 30/52 and 11/48, respectively. Although the operational outcomes using the modified McLaughlin technique were not ideal, with no recurrence, the patient seemed to be satisfied with this outcome. In conclusion, in neglected locked shoulder fracture-dislocations, the modified McLaughlin technique is a method that can respond to the pathophysiology by eliminating reverse Hill-Sachs lesion.

Does displacement of cervical and thoracolumbar dislocation-translation injuries predict spinal cord injury or recovery?

OBJECTIVE

For patients with cervical and thoracolumbar AO Spine type C injuries, the authors sought to 1) identify whether preoperative vertebral column translation is predictive of a complete spinal cord injury (SCI) and 2) identify whether preoperative or postoperative vertebral column translation is predictive of neurological improvement after surgical decompression.

METHODS

All patients who underwent operative treatment for cervical and thoracolumbar AO Spine type C injuries at the authors' institution between 2006 and 2021 were identified. CT and MRI were utilized to measure vertebral column translation in millimeters prior to and after surgery. A receiver operating characteristic (ROC) curve was generated to predict the probability of sustaining a complete SCI on the basis of the amount of preoperative vertebral column translation. ROC curves were then used to predict the probability of neurological recovery on the basis of preoperative and postoperative vertebral column translation.

RESULTS

ROC analysis of 67 patients identified 6.10 mm (area under the curve [AUC] 0.77, 95% CI 0.650-0.892) of preoperative vertebral column translation as predictive of complete SCI. Additionally, ROC curve analysis found that 10.4 mm (AUC 0.654, 95% CI 0.421-0.887) of preoperative vertebral column translation was strongly predictive of no postoperative neurological improvement. Residual postoperative vertebral column translation after fracture reduction and instrumentation had no predictive value on neurological recovery (AUC 0.408, 95% CI 0.195-0.622).

CONCLUSIONS

For patients with cervical and thoracolumbar AO Spine type C injuries, the amount of preoperative vertebral column translation is highly predictive of complete SCI and the likelihood of postoperative neurological recovery.

The Syringe External Fixator: Short- and Medium-Term Functional Outcomes From This Inexpensive and Customizable Treatment for Comminuted Intra-Articular Fractures of the Hand

PURPOSE

Comminuted intra-articular fractures and fracture dislocations of the metacarpophalangeal (MCP) and interphalangeal joints are challenging. Dynamic external fixation, permitting early joint motion while still minimizing forces across the healing joint, can result in acceptable postoperative active range of motion (AROM). However, some fractures are not initially stable enough for early dynamic motion; further, many available dynamic external fixation systems are costly and cumbersome. We reviewed our experience using an external fixator made from a 1-mL syringe and K-wires and report outcomes using it as a static fixator, dynamic fixator, or configured as a static fixator and then converted to a dynamic fixator in the clinic.

METHODS

Patients with intra-articular fractures and fracture dislocations of the MCP and proximal interphalangeal (PIP) joints treated between 2014 and 2020 using syringe external fixators were retrospectively reviewed. We reviewed demographics, mechanisms, treatment types and durations, and postoperative AROM, as well as complications including infection, pin loosening, nonunion, hardware failure, and need for further surgery. Patients were analyzed by the level of joint injury (MCP versus PIP) and by treatment pattern.

RESULTS

After excluding 23 patients with 25 joint injuries who were lost to follow-up or had inadequate outcome data, 27 patients with 29 joint injuries were reviewed. The average follow-up was 171 days after surgery. The postoperative AROM at the MCP level averaged 55° for static fixation and 30° for static-to-dynamic fixation. The postoperative AROM at the PIP level averaged 64° for static fixation, 66° for static-to-dynamic fixation, and 80° for dynamic fixation. Three pin site infections and 2 loose pins were reported.

CONCLUSIONS

The syringe external fixator is an inexpensive, effective, and customizable treatment for intra-articular MCP and interphalangeal fractures and fracture dislocations, and results in acceptable postoperative AROM outcomes and complication rates.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A Systematic Review of Acute Irreducible Shoulder Dislocations in the 21st Century

Background

Rarely, closed reduction cannot be achieved in patients with acute shoulder dislocation, necessitating open management. A paucity of literature exists regarding these cases.

Purpose

To perform a systematic review on the mechanism, management, and outcome data of acute irreducible shoulder dislocations.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review of the literature was performed using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE between 2000 and 2020. Inclusion criteria were as follows: human participants, acute irreducible shoulder dislocation requiring open management, English language, and publication within the past 20 years. We excluded basic science articles, technique articles, reviews, editorials, and studies of chronic shoulder dislocations or dislocations with ipsilateral humeral shaft fractures.

Results

Twelve articles fit the inclusion criteria and were considered for review. All studies were single case reports (level 4 evidence). Ten of the 12 studies were of male patients. The direction of dislocation included 7 anterior/anteroinferior, 2 posterior, 1 inferior, 1 bilateral inferior, and 1 superolateral. Most dislocations were irreducible owing to a mechanical block to reduction. The most common type of block was an incarcerated long head of the biceps tendon, followed by interposition of 1 of the rotator cuff tendons. The axillary and musculocutaneous nerves, displaced fracture fragments, and Hill-Sachs and bony Bankart lesions were other causes of blocks to reduction. Eleven patients were treated with open surgery, while 1 patient was treated arthroscopically. Procedures performed were dependent on concurrent pathology. Final follow-up ranged from 6 weeks to 2 years, with no repeat dislocation episodes reported. Complications after open reduction included 1 case of brachial plexopathy (posterior cord) and 1 case of musculocutaneous nerve palsy.

Conclusion

There is a paucity of literature on the management of irreducible acute shoulder dislocations. The most common irreducible dislocation found in this systematic review was anterior with a mechanical block attributed to interposition of the long head of the biceps tendon. When patients were treated with an open or arthroscopic procedure, recurrence was low, with none reporting recurrent dislocation in limited follow-up.

Single versus dual operative spine fractures in ankylosing spondylitis

OBJECTIVE

Ankylosing spondylitis, the most common spondyloarthritis, fuses individual spinal vertebrae into long segments. The unique biomechanics of the ankylosed spine places patients at unusually high risk for unstable fractures secondary to low-impact mechanisms. These injuries are unique within the spine trauma population and necessitate thoughtful management. Therefore, the authors aimed to present a richly annotated data set of operative AS spine fractures with a significant portion of patients with simultaneous dual noncontiguous fractures.

METHODS

Patients with ankylosing spondylitis with acute fractures who received operative management between 2012 and 2020 were reviewed. Demographic, admission, surgical, and outcome parameters were retrospectively collected and reviewed.

RESULTS

In total, 29 patients were identified across 30 different admissions. At admission, the mean age was 71.7 ± 11.8 years. The mechanism of injury in 77% of the admissions was a ground-level fall; 30% also presented with polytrauma. Of admissions, 50% were patient transfers from outside hospitals, whereas the other half presented primarily to our emergency departments. Fifty percent of patients sustained a spinal cord injury, and 35 operative fractures were identified and treated in 32 surgeries. The majority of fractures clustered around the cervicothoracic (C4-T1, 48.6%) and thoracolumbar (T8-L3, 37.11%) junctions. Five patients (17.2%) had simultaneous dual noncontiguous operative fractures; these patients were more likely to have presented with a higher-energy mechanism of injury such as a bicycle or motor vehicle accident compared with patients with a single operative fracture (60% vs 8%, p = 0.024). On preoperative MRI, 56.3% of the fractures had epidural hematomas (EDHs); 25% were compressive of the underlying neural elements, which dictated the number of laminectomy levels performed (no EDH, 2.1 ± 2.36; noncompressive EDH, 2.1 ± 1.85; and compressive EDH, 7.4 ± 4 [p = 0.003]). The mean difference in instrumented levels was 8.7 ± 2.6 with a mean estimated blood loss (EBL) of 1183 ± 1779.5 mL. Patients on a regimen of antiplatelet therapy had a significantly higher EBL (2635.7 mL vs 759.4 mL, p = 0.015). Overall, patients had a mean hospital length of stay of 15.2 ± 18.5 days; 5 patients died during the same admission or after transfer to an outside hospital. Nine of 29 patients (31%) had died by the last follow-up (the mean follow-up was 596.3 ± 878.9 days).

CONCLUSIONS

Patients with AS who have been found to have unstable spine fractures warrant a thorough diagnostic evaluation to identify secondary fractures as well as compressive EDHs. These patients experienced prolonged inpatient hospitalizations with significant morbidity and mortality.

Neurologically Asymptomatic Lumbar Traumatic Dislocation With Vascular Compression in a Patient With Ankylosing Spondylitis: Case Report

BACKGROUND

Ankylosing spondylitis (AS) is associated with high rates of severe thoracolumbar fractures, in many cases with neurological deficits. It is currently a point of debate as to whether the optimal surgical treatment is posterior fixation and fusion or combined approaches. Vascular injuries in this kind of fracture are a challenging issue to solve in the management of these patients.

METHODS

We are reporting the case of a 65-year-old man who presented an L4 traumatic fracture-dislocation. He had a long history of symptomatic AS. No neurological deficits were detected during the initial exploration. During the preoperative work-up, a lumbar spine computed tomography (CT) scan was taken with vascular reconstruction of the abdominal vessels. It confirmed the compression of the abdominal aorta, which had caused more than 90% stenosis. A posterior approach, an open reduction, and fixation with pedicle screws were performed, without hemodynamic or neurological changes. A postoperative angiography demonstrated a complete recovery of the vessel caliber, without contrast leaks.

RESULTS

After a 2-year follow-up, the patient was pain free and the CT scan revealed bone fusion.

CONCLUSIONS

The vascular structures involved in severe thoracolumbar fractures present a dangerous situation that should be considered in the choice of the surgical approach. The posterior approach alone may be a good option in the absence of vascular damage. However, due to risk of vessel rupture during the fracture reduction, vascular surgeons must take part in the surgery.

LEVEL OF EVIDENCE

5.

CLINICAL RELEVANCE

The article provides help for surgeons who have to treat severe fractures in the context of ankylosing spondylitis.

Clinical characteristics and treatment of fracture-dislocation of thoracic spine with or without minimal spinal cord injury

BACKGROUND

It is important to evaluate clinical efficacy and safety of posterior internal fixation using pedicle screw system.

OBJECTIVES

To investigate clinical characteristics of patients diagnosed with fracture-dislocation of the thoracic spine with or without minimal spinal cord.

METHODS

Twenty-eight patients with fracture-dislocation of thoracic spine with or without minimal spinal cord injury were retrospectively analyzed. All patients received posterior reduction and internal fixation using pedicle screw system.

RESULTS

The mean follow-up duration was 11.4 months. Among 28 patients, 24 cases were complicated with bilateral pedicle or laminal fracture. Preoperatively, the percentage of vertebral displacement was (32.1 ± 20.6)%, significantly declined to (7.5 ± 6.0)% (t= 4.575, P= 0.001) and maintained at (7.9 ± 6.3)% at the final follow-up. Preoperative local kyphosis angle was measured as (16.2 ± 11.3)∘, restored to (15.4 ± 5.9)∘ postoperatively and (15.8 ± 5.4)∘ during the final follow-up. No statistical significance was observed at three time points (all P> 0.05). The remaining 25 patients were evaluated with normal and complete neurological function. No severe complications were observed intra- and postoperatively.

CONCLUSIONS

Posterior internal fixation using pedicle screw is an efficacious and safe therapy which achieves proper reduction and preserves spinal cord function.

Neglected Monteggia Fracture Dislocations in Children: A Case Series

INTRODUCTION

Monteggia fracture dislocations are a relatively rare entity and they represent less than 2% of forearm fractures, the diagnosis can be missed in up to 50% of the time. The gold standard of treatment in adults has been open reduction and internal fixation, and closed reduction and cast immobilization in pediatrics.

CASE REPORT

We present three cases series of neglected Monteggia fractures in a 5-, 4-, and 9-year-old patients. The patients presented 10, 20, and 25 days post-injury, respectively. Each case was treated differently with the last case requiring open reduction and annular ligament reconstruction. All the three cases showed excellent results on follow-up.

CONCLUSION

To avoid missing these injuries, each patient should undergo a comprehensive clinical approach and adequate radiological imaging. Various treatment methods exist for neglected Monteggia fracture and each option should be exhausted to salvage the radial head starting with the less invasive approaches.

Galeazzi Fracture Dislocations: An Illustrated Review

Galeazzi fracture dislocations are a fracture of the distal one third of the radius shaft with a concomitant dislocation of the distal radioulnar joint (DRUJ). These injuries usually occur by axial loading on an outstretched arm with pronation or supination of the wrist which determines the angulation of the fracture. Surgical treatment has been historically by the anterior (volar) approach to the forearm with plate fixation with or without pinning of the distal radioulnar joint. Failed or inadequate treatment may lead to complications including chronic pain, malunion or instability of the DRUJ that may warrant salvage procedures.

Mid-lumbar traumatic spondyloptosis without neurological deficit: A case report and literature review

INTRODUCTION

Spondyloptosis is a form of vertebral dislocation and the most advanced form of spondylolisthesis. Traumatic spondyloptosis is usually caused by high-energy impact and results in unstable spine deformity and spinal canal deformation, which lead to severe spinal cord injury. Traumatic spondyloptosis is mostly reported in the lumbo-sacral junction, while it is rarely documented in mid-lumbar segments. To the best of the authors' knowledge, only 16 cases of mid-lumbar spondyloptosis have been described previously. Herein, we present a L3 to L4 spondyloptosis case that did not involve neurological deficit.

PATIENT CONCERNS

A 42-year-old man presented to the emergency department after an accident involving a fall. The patient developed severe back pain and spinal deformity, while his neurologic function remained intact. Radiological examinations indicated complete posterior vertebral dislocation at L3 to L4 and a fracture at the bilateral pelvic ischial tuberosity without major vessel injury or severe dura sac compression.

DIAGNOSES

L3 to L4 complete vertebral dislocation, pelvic ischial tuberosity fracture.

INTERVENTIONS

For treatment, the patient underwent fracture reduction, L3 to L4 intervertebral fusion, and internal fixation 7 days post-injury.

OUTCOMES

Postoperative digital radiography showed the correction of the spinal deformity. The patient was pain-free and fully rehabilitated 3 months after the surgery. At the 1-year follow-up, the patient was completely asymptomatic and had achieved normal alignment.

CONCLUSIONS

We reported an L3 to L4 traumatic spondyloptosis case that involved intact neurology, which is the first-ever reported mid-lumbar spondyloptosis case that involved complete posterior column and neural sparing. For the treatment of traumatic spondyloptosis without neurological deficit, restoring stability and preventing secondary cord injury should be taken into consideration.

Peroneal Tendon Lengthening as an Adjunct Procedure to Aid in the Reduction of the Lateral Malleolus in Diabetic Ankle Fractures: 2 Case Reports

It is well-documented that individuals with longstanding diabetes mellitus are at risk for specific metabolic abnormalities; this includes but is not limited to increased glycation of collagenous soft-tissue structures. It is also apparent that such changes can manifest as thickening and increased stiffness of tendinous structures. What remains unknown are the biomechanical ramifications of these changes and how they should affect the surgical management of lower extremity injuries. Previous research suggests that the Achilles tendon demonstrates increased stiffness in the presence of diabetes. It is therefore reasonable to presume that increased collagen glycation and the resultant tendon stiffness can also lead to decreased extensibility and shortening of the peroneus longus and brevis tendons. The significance of this leads us to the conclusion that glycation of the peroneal tendons can create a deforming force in displaced lateral malleolar fractures because of the adjacent position of the peroneal tendons relative to the lateral malleolus. Complications stemming from this can lead to increased difficulty in reducing fibular fractures and subsequent shortening of the fibula. For the purpose of this article, we present 2 cases, 1 using open reduction with internal fixation and the other with external fixation. We will demonstrate that, in both reduction methods, lengthening of the peroneal tendons can be a useful adjunct procedure to aid in restoration of fibular length in diabetic ankle fractures.

Incidence of and risk factors for the development of asymptomatic heterotopic ossification after elbow fracture fixation

OBJECTIVE

This study was performed to investigate the incidence of and risk factors for asymptomatic heterotopic ossification (HO) after open reduction and internal fixation of elbow fractures.

METHODS

This retrospective analysis involved 197 patients with elbow fractures treated operatively from 2014 to 2017 at our institution. Patient-related and clinical variables were recorded. Univariate analysis and multivariate logistic regression were performed to reveal independent risk factors for postoperative HO. In addition, a receiver operating characteristic (ROC) curve was performed to assess the ability of risk factors to predict the development of postoperative HO.

RESULTS

The overall rate of asymptomatic HO after surgery was 18.78%. The incidence was highest in terrible triad injuries and lowest in capitellum fractures. Independent predictors of asymptomatic HO identified by the multivariate analysis were underlying diseases, fracture dislocation, and a prolonged operative time. The area under the ROC curve for underlying diseases, fracture dislocation, and a prolonged operative time were 0.593, 0.596, and 0.694, respectively.

CONCLUSIONS

The incidence of postoperative asymptomatic HO in patients with elbow fractures is high. Clinicians should employ prophylaxis to avoid HO when treating patients with elbow fractures who have underlying diseases, fracture dislocation, or a prolonged operative time.

Isolated Partial Intra-Articular Volar Ulnar Fractures of the Distal Radius: The Tetrahedron Variant

PURPOSE

The aim of this study was to assess the treatment and complications of a distinct type of partial intra-articular distal radius fracture.

METHODS

Seven patients treated by the senior author between 2008 and 2013 for a partial intra-articular distal radius fracture with isolated involvement of the volar lunate facet were included. All fragments had the distinctive shape of a triangular-base pyramid (tetrahedron) extending from the metaphysis distally. All fractures were preoperatively assessed with computed tomography (CT) scans. Patients underwent surgical treatment using a standard flexor carpi radialis approach (2 patients) or a volar ulnar approach (5 patients) and were followed postoperatively for a minimum of 12 months.

RESULTS

Patient age ranged from 33 to 66 years. On average, fragments measured 34 ± 6 mm in length (range, 27-43 mm) and were 48% as wide as the distal radius (range, 40% to 56%) and 58% as deep as the anterior-posterior dimension of the lesser sigmoid notch (range, 33% to 83%). Loss of reduction requiring revision surgery occurred at 4 weeks in 1 patient who underwent internal fixation through the flexor carpi radialis approach. The remaining cases healed uneventfully. At the final follow-up, all, except the patient requiring revision surgery, had a painless wrist. Average total wrist motion measured 87% of the opposite side. Radiographic healing with anatomic wrist alignment was observed in all except the patient requiring revision. This patient had persistent joint subluxation. The remaining patients all achieved good or excellent functional outcomes.

CONCLUSIONS

Isolated tetrahedron volar lunate facet fractures of the distal radius are rare. In our experience, the use of a volar ulnar approach leads to satisfactory fixation and outcomes, yielding excellent radiographic and clinical outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Two-Stage Surgery for the Malleolar Fracture-Dislocation With Severe Soft Tissue Injuries Does Not Affect the Functional Results

Soft tissue injuries associated with malleolar fracture-dislocations may increase postoperative rates of wound complication. Ankle-spanning frame plays a fundamental role in the local damage control orthopedics while gaining time for definitive surgery. The objective of this study was to evaluate the effect of a 2-stage surgery for the unstable malleolar fracture-dislocations with severe soft tissue injuries compared to a 1-stage surgery in terms of the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle and Olerud-Molander ankle scores (OMAS). We analyzed 45 patients who met our study criteria. The patients were divided into 2 groups according to staged surgeries. Demographic data of patients, comorbidities, alcohol and tobacco use, Tscherne soft tissue injury scores, the AOFAS hindfoot-ankle and OMAS, postoperative complications, total hospitalization times, waiting time between stages, and waiting time from admission to surgery times were investigated. There was a statistically significant difference between the groups in terms of the mean total hospitalization times (p = .007), waiting time from admission to surgery (p < .001), gender (p = .005), and Tscherne soft tissue injury scores (p < .001). The mean AOFAS hindfoot-ankle and OMAS of the groups did not differ statistically at a minimum of 12 months of the follow-up period (p = .094 and p = .126, respectively). A 2-stage surgery can be performed safely in the carefully selected patients with the unstable malleolar fracture-dislocations with Tscherne grades 2 and 3 soft tissue injuries, and this surgery does not affect the postoperative AOFAS hindfoot-ankle and OMAS statistically compared to a 1-stage surgery at a minimum of 12 months of the follow-up period.

Rock Climbing Injuries Treated in US Emergency Departments, 2008-2016

INTRODUCTION

Previous research identified a trend for increasing numbers of injuries sustained while rock climbing. This study investigates whether that trend continued and describes characteristics of climbing injuries.

METHODS

The National Electronic Injury Surveillance System registry was searched for rock climbing injuries in US emergency departments in 2008 through 2016 among patients aged ≥7 y. Variables included each patient's age, diagnosis, injured body part, mechanism of injury, and disposition. Injuries were graded using International Mountaineering and Climbing Federation injury grades. National estimates were generated using sample weighting.

RESULTS

An estimated 34,785 rock climbing injuries were seen in emergency departments nationally, a mean of 3816 per year (SD 854). The median age of injured climbers was 24 y (range 7-77), with those aged 20 to 39 y accounting for 60% and males for 66%, respectively. Fractures (27%) and sprains and strains (26%) were the most common types of injuries. The most frequently injured body parts were lower extremities (47%), followed by upper extremities (25%). The most commonly fractured body part (27%) was the ankle. The knee and lower leg accounted for 42% of all lacerations and were 5.8 times as likely as lacerations to other body parts. Falls were the most common mechanism, accounting for 60% of all injuries.

CONCLUSIONS

This study reports continued increase in annual numbers of climbing injuries. Whether this is based on a higher injury rate or on a higher number of climbers overall cannot be stated with certainty because no denominator is presented to estimate the injury rate among climbers.

Comparison of outcomes between axial radial and axial ulnar carpal injuries

Axial carpal injuries are rare entities where a traumatic force transmits through the intermetacarpal space, dissociating the carpometacarpal joint and disrupting the distal carpal row in an axial radial or axial ulnar pattern via true axial force or compressive crush mechanism. Differences in outcomes remain unclear with regard to the specific type of axial carpal injury pattern. A retrospective case series identified 37 wrists (in 37 patients) over 25 years who presented to a Level 1 trauma centre, with 20 wrists experiencing an axial radial injury and 17 wrists experiencing an axial ulnar injury. Of all the variables evaluated, only axial radial injuries were identified as predictors of poor outcome as defined by Mayo Wrist scores with univariate analysis demonstrating 6 times increased risk and multivariate analysis demonstrating 15 times increased risk of a poor outcome compared with axial ulnar injuries. This knowledge will provide prognostic information to surgeons managing patients with these severe injuries.

LEVEL OF EVIDENCE

IV.

Outcomes following surgical management of complex terrible triad injuries of the elbow: a single surgeon case series

BACKGROUND

Terrible triad injuries of the elbow are complex injuries to treat and we report our outcomes following surgical management.

METHODS

Twenty-two consecutive patients who underwent fixation of terrible triad injuries between 2007 and 2012 were identified. Clinical outcomes were assessed by examination, visual analogue scores (VAS), Oxford Elbow Score (OES), Mayo Elbow Performance Index (MEPI) and QuickDash score (QD).

RESULTS

The mean age of patients was 47 years, with a mean follow-up of 32 months. All patients underwent lateral ligament repair, with additional medial ligament repair in four cases. Thirteen patients required repair of the coronoid and 18 patients required surgery to the radial head. The mean flexion-extension arc was 113°, with mean prono-supination of 136°. The functional elbow scores revealed good outcomes in the majority (mean OES of 37, MEPI of 79 and QD of 21). The overall complication rate was 41%. In total, 23% required reoperation, with one patient requiring fasciotomy for acute compartment syndrome and four requiring subsequent removal of metalwork as a result of stiffness.

CONCLUSIONS

Recognition of this complex injury pattern and appropriate restoration of the joint stability are the prerequisites. Systematic surgical approach is effective and can provide both stability and good function, in most cases.

External fixation combined with delayed internal fixation in treatment of tibial plateau fractures with dislocation

The aim of this study was to evaluate the clinical efficacy of external fixation, delayed open reduction, and internal fixation in treating tibial plateau fracture with dislocation.Clinical data of 34 patients diagnosed with tibial plateau fracture complicated with dislocation between January 2009 and May 2015 were retrospectively analyzed. Fifteen patients in group A underwent early calcaneus traction combined with open reduction and internal fixation and 19 in group B received early external fixation combined with delayed open reduction and internal fixation. Operation time, postoperative complication, bone healing time, knee joint range of motion, initial weight-bearing time, Rasmussen tibial plateau score, and knee function score (HSS) were statistically compared between 2 groups.The mean follow-up time was 18.6 months (range: 5-24 months). The mean operation time in group A was 96 minutes, significantly longer than 71 minutes in group B (P < .05). In group A, 5 cases had postoperative complications and 1 in group B (P < .05). The mean bone healing time in group A was 6.9 months (range: 5-9 months) and 6.0 months (range: 5-8 months) in group B (P > .05). In group A, initial weight-bearing time in group A was (14.0 ± 3.6) weeks, significantly differing from (12.9 ± 2.8) weeks in group B (P < 0.05). In group A, the mean knee joint range of motion was 122° (range: 95°-150°) and 135° (range: 100°-160°) in group B (P > 0.05). Rasmussen tibial plateau score in group A was slightly lower than that in group B (P > .05). The excellent rate of knee joint function in group A was 80% and 84.21% in group B (P > .05).External fixation combined with delayed open reduction and internal fixation is a safer and more efficacious therapy of tibial plateau fracture complicated with dislocation compared with early calcaneus traction and open reduction and internal fixation.

Interposition of Tibialis Posterior and Flexor Digitorum Longus Tendons Resulted in Irreducible Ankle Fracture-Dislocation

Irreducible ankle fracture-dislocations are very rare entities. The present case report demonstrates an unusual finding of tibialis posterior and flexor digitorum longus tendons interposed in the tibiofibular joint impairing successful closed reduction of ankle fracture-dislocation. A 45-year-old patient presented with a bimalleolar pronation-external rotation ankle fracture-dislocation after a motorcycle accident. Attempts to perform closed reduction before surgery were unsuccessful. Subsequent urgent open reduction and internal fixation surgical management revealed interposition of the tibialis posterior and flexor digitorum longus tendons in the tibiofibular joint. In irreducible fracture-dislocation of the ankle with severe lateral displacement of the talus, one should be aware of the possibility of soft tissue interposition of the tibialis posterior and flexor digitorum longus tendons in the tibiofibular joint.

A Rare Case Report of an Unusual Dislocation of Fractured Mandibular Condyle

Several cases have been reported regarding superolateral, posterior, or superior dislocation of mandibular condyle. The anteromedial dislocation of fractured condyle is the most common among all. This article reports an unusual and unique case of dislocated fractured mandibular condyle wherein the fractured left condylar head was dislocated to the left anatomic angle of mandible. We have not found a single such case in the world English literature published till date. The presented case falls in the rarest of the rare category that will add to our previous knowledge about the types and extent of fracture dislocation of mandibular condyle.

The management of bilateral posterior fracture dislocations of the shoulder: a case series illustrating management options

BACKGROUND

Although dislocation of the shoulder is a relatively common event, the overwhelming majority of injuries are anterior. Posterior shoulder dislocation is more uncommon, comprising between 3% and 5% of all shoulder dislocations. One percent of shoulder dislocations involve a fracture, whereas only 0.9% of the 1500 cases reported by Neer (J Bone Joint Surg Am 1970; 52:1077-89; J Bone Joint Surg Am 1970; 52:1090-103) concerned posterior fracture dislocations. Bilateral posterior fracture dislocation is an even rarer event, comprising just 5% of all posterior fracture dislocations. Given the rarity and relative poor outcome often observed after these severe injuries, it is important that upper limb function is optimized.

METHODS

Bilateral posterior fracture dislocations of the shoulder pose a difficult clinical challenge that requires careful management planning. To date, there have been three isolated case reports of using contralateral osteochondral humeral autograft and hemiarthroplasty. We report our experiences and clinical outcomes in managing four such cases using a variety and combination of treatments, including the first reported use of reverse shoulder arthroplasty with contralateral osteochondral humeral autografting.

RESULTS

Shoulders reconstructed with humeral autograft demonstrated superior Oxford Shoulder Scores and an improved range of motion, as measured by a markerless machine vision system, compared to hemiarthroplasty.

CONCLUSIONS

Our results support the use of a contralateral humeral autograft in bilateral posterior shoulder fracture dislocation.

Extension Block Pinning for Unstable Proximal Interphalangeal Joint Dorsal Fracture Dislocations

PURPOSE

To evaluate the outcomes of extension block pinning used to treat unstable dorsal fracture dislocations of the proximal interphalangeal (PIP) joint. The factors affecting the functional outcome were analyzed.

METHODS

A series of 53 patients with 55 dorsal fracture dislocations of the PIP joint treated with closed reduction and extension block pinning were retrospectively reviewed. Additional percutaneous intramedullary fracture reduction (16 cases) or open fracture reduction (4 cases) had been performed. The radiological and clinical evaluations were included.

RESULTS

At a mean follow-up of 5.2 years (range, 1.0-10.6 years), 39 patients with 41 injured fingers were evaluated. The fracture fragments involved 30% to 69% (mean, 50%) of the articular surface of the middle phalanx. The mean range of motion was 80° (range, 35° to 115°) at the PIP joint with a mean extension loss of 6° (range, 0° to 50°) excluding 2 joints that were salvaged with arthrodesis. The mean range of motion of the distal interphalangeal joint was 68° (range, 5° to 90°). The mean visual analog scale for digit pain was 1.5/10. The reduction of the joint was achieved intraoperatively in all cases. However, after the hardware removal, recurrent minimal subluxation was observed in 12 cases (29%). Recurrent subluxation was associated with increased residual pain. The length of follow-up time had a positive correlation, whereas the patient age had a negative correlation with the range of motion of the injured PIP joint.

CONCLUSIONS

The extension block pinning technique is a simple and valuable technique for treating unstable dorsal PIP fracture-dislocation injuries producing satisfactory long-term results.

Results of Perilunate Dislocations and Perilunate Fracture Dislocations With a Minimum 15-Year Follow-Up

PURPOSE

To evaluate the long-term clinical, functional, and radiological outcomes in 30 patients with at least 15 years of follow-up.

METHODS

We performed a retrospective study that identified 73 patients. Thirty patients agreed to participate and were included. The mean follow-up was 18 years (range, 15-24 years). There were 14 cases of perilunate dislocation and 16 cases of perilunate fracture-dislocation (including 13 transscaphoid perilunate fracture-dislocations). At the last follow-up, the clinical and functional evaluation was based on the range of motion, grip strength, the Mayo wrist score, the Quick Disabilities of the Arm Shoulder and Hand score, and the Patient-Rated Wrist Evaluation score. Radiological abnormalities, according to the Herzberg classification, were 5 type A1 cases, 7 type B, 16 type B1, and 2 type C.

RESULTS

The mean flexion-extension arc, radial-ulnar abduction arc, and pronation-supination arc were, respectively, 68%, 67%, and 80%, relative to the contralateral side. The mean grip strength was 70%, relative to the contralateral side. The mean Mayo wrist score was 70, and the mean Quick Disabilities of the Arm Shoulder and Hand and Patient-Rated Wrist Evaluation scores were, respectively, 20 and 21. Five patients had secondary procedure. Six patients had a complex regional pain syndrome type 1.

CONCLUSIONS

Although arthritis occurred in 70% of cases, its clinical and functional impact appeared to be low. However, the 2 lowest Mayo wrist scores corresponded to the patients with the most advanced arthritis. Complex regional pain syndrome appeared to have an impact on long-term outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Traumatic L5 Posterolateral Spondyloptosis: A Case Report and Review of the Literature

Traumatic retrolisthesis of the lumbar spine is a rare clinical entity. Only a few case reports have shown retrolisthesis of the fractured fragment over the inferior vertebral body. Fracture dislocations of the spine are unstable injuries that require operative fixation to restore alignment and prevent progressive deformity.

We present the case of a traumatic L5-S1 fracture dislocation with retrolisthesis of the L5 vertebral body over the superior aspect of S1 managed with anterior, middle, and posterior column reconstruction. The patient presented with paraplegia and bowel and bladder incontinence.

Retrolisthesis fracture dislocations injuries are rare, and as such, there are no guidelines regarding their management. In our case, we performed an L5 vertebrectomy with anterior, middle, and posterior column reconstruction via a posterior approach using a lumbosacral-pelvic construct. The patient did not regain function in his distal lower extremities postoperatively.

Staged treatment of high energy midfoot fracture dislocations

BACKGROUND

Staged care with interval external fixation is a successful established treatment strategy for high energy periarticular fractures with often extensive soft tissue damage such as the tibial plateau and plafond. The aim of the current study was to determine whether staged care of high energy midfoot fracture/dislocation with interval external fixation prior to definitive open reconstruction in the polytraumatized patient was both safe and efficacious.

METHODS

One hundred twenty-three patients were operated on for high energy midfoot fracture/dislocation during the 8-year study period. Eighteen polytrauma patients were selectively treated with a staged protocol. Radiographic assessment was utilized to determine if the fixator achieved gross skeletal alignment. Further, final alignment after definitive reconstruction and postoperative complications were analyzed.

RESULTS

The fixator improved both length and alignment of all high energy midfoot fracture/dislocations. Loss of acceptable reduction while in the temporary frame occurred in only 1 case. Final alignment after definitive reconstruction was anatomic in all cases. No cases of wound-related complication and/or deep infection occurred.

CONCLUSION

Delayed reconstruction of high energy midfoot fracture/dislocation using interval external fixation should be an accepted care paradigm in selected polytrauma patients.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Extensor pollicis longus dysfunction associated with non-united fracture of the trapezium

A 26 year old man was referred to us with extensor pollicis longus dysfunction (EPL), and investigation revealed a fracture of the trapezium (left) and carpo-metacarpal joint dislocation of the thumb. Operative exploration revealed mechanical displacement of the tendon secondary to fracture dislocation of the trapezium as the cause for EPL dysfunction. The lesion was managed with an open reduction and screw fixation resulting in good functional outcome.

Fracture dislocations of the cervical spine: a review of 106 conservatively and operatively treated patients

We compared clinical outcomes following conservative treatment of subaxial fracture dislocations of the cervical spine and posterior fusion using bone grafts and interspinous Roger's wiring (Bohlman modification). We reviewed 106 patients: 51 were treated primarily surgically, and 55 treated conservatively served as historical controls. Those patients who neurologically recovered at least one Frankel grade had on average less displacement on discharge (1.3 mm vs 3.1 mm, p=0.04). Although anatomical outcomes were better in the operatively treated group (1.6 mm vs 2.9 mm displacement at end of follow-up, p=0.001), there was no difference in neurological recovery. Late neck pain correlated with residual displacement ( p=0.04) and was more common in the conservatively treated patients ( p=0.01). Time in hospital was shorter in the group with posterior fusions, and complication rates were similar to those found after conservative treatment. A significant number of the conservatively treated patients developed kyphotic deformity, and 29% needed later surgery because of chronic instability or unacceptable anatomical results.