Golf and racquet sports injuries.

PubMed

Jacobson, Jon A; Miller, Bruce S; Morag, Yoav

2005-12-01

There are specific injuries that are common in golf and racquet sports. These abnormalities have a predilection for specific structures as well and can be divided into two categories on the basis of etiology as either chronic repetitive injury or acute trauma. With golf injuries, upper extremity abnormalities prevail and include rotator cuff disease, epicondylitis, wrist tenosynovitis, and hamate hook fracture. Thoracolumbar spine pain can also occur. The order of frequency of these ailments is different for professional and recreational athletes. With racquet injuries, as in tennis, lower extremity injuries are more common and include medial gastrocnemius and Achilles tendon abnormalities, although shoulder, elbow, and wrist abnormalities may also occur. Knowledge of the biomechanics behind each sport is also helpful in understanding the pathophysiology of injury and in part explains the findings seen at imaging.

Medial epicondylitis - golfer's elbow

MedlinePlus

... Golf Baseball and other throwing sports, such as football and javelin Racquet sports, such as tennis Weight ... herein should not be used during any medical emergency or for the diagnosis or treatment of any ...

Overuse injuries of the upper extremity in the competitive athlete: magnetic resonance imaging findings associated with repetitive trauma.

PubMed

Banks, Kevin P; Ly, Justin Q; Beall, Douglas P; Grayson, David E; Bancroft, Laura W; Tall, Michael A

2005-01-01

Overuse injuries are a very common cause of pain in athletes, accounting for a significant loss of training time and missed competitions. Magnetic resonance imaging (MRI) is playing an increasing role in facilitating the expeditious and safe return of these individuals to their preinjury level of physical performance by allowing accurate diagnosis. Sports physicians are increasingly relying on the exquisite anatomic detail afforded by this technique to formulate diagnoses that assist with the optimal management of these athletic injuries. Some upper extremity overuse entities are well recognized; two examples are medial epicondylitis, classically appearing in baseball pitchers, and lateral epicondylitis, in tennis players. Other less well-known injuries of the upper extremity, such as intersection syndrome in rowers and distal clavicular stress fractures in weightlifters, are frequent occurrences in certain circles of athletes. The following article is a pictorial review of the MRI findings of upper extremity overuse injuries encountered in the competitive athlete, with an emphasis on the sports scenarios in which they occur. We will depict mechanisms of injury and applicable anatomy and show characteristic imaging findings. A wide range of entities are addressed, including but not limited to overuse injuries occurring in baseball, swimming, gymnastics, weightlifting, bowling, and cycling.

Surgical anatomy of the radial nerve at the elbow.

PubMed

Artico, M; Telera, S; Tiengo, C; Stecco, C; Macchi, V; Porzionato, A; Vigato, E; Parenti, A; De Caro, R

2009-02-01

An anatomical study of the brachial portion of the radial nerve with surgical implications is proposed. Thirty specimens of arm from 20 fresh cadavers (11 male, 9 female) were used to examine the topographical relations of the radial nerve with reference to the following anatomical landmarks: acromion angle, medial and lateral epicondyles, point of division between the lateral and long heads of the triceps brachii, lateral intermuscular septum, site of division of the radial nerve into its superficial and posterior interosseous branches and entry and exit point of the posterior interosseous branch into the supinator muscle. The mean distances between the acromion angle and the medial and lateral levels of crossing the posterior aspect of the humerus were 109 (+/-11) and 157 (+/-11) mm, respectively. The mean length and calibre of the nerve in the groove were 59 (+/-4) and 6 (+/-1) mm, respectively. The division of the lateral and long heads of the triceps was found at a mean distance of 126 (+/-13) mm from the acromion angle. The mean distances between the lateral point of crossing the posterior aspect of the humerus and the medial and lateral epicondyles were 125 (+/-13) and 121 (+/-13) mm, respectively. The mean distance between the lateral point of crossing the posterior aspect of the humerus and the entry point in the lateral intermuscular septum (LIS) was 29 (+/-6) mm. The mean distances between the entry point of the nerve in the LIS and the medial and lateral epicondyles were 133 (+/-14) and 110 (+/-23) mm, respectively. Our study provides reliable and objective data of surgical anatomy of the radial nerve which should be always kept in mind by surgeons approaching to the surgery of the arm, in order to avoid iatrogenic injuries.

Psychological factors at work and musculoskeletal disorders: a one year prospective study.

PubMed

Bugajska, Joanna; Zołnierczyk-Zreda, Dorota; Jędryka-Góral, Anna; Gasik, Robert; Hildt-Ciupińska, Katarzyna; Malińska, Marzena; Bedyńska, Sylwia

2013-12-01

The etiology of musculoskeletal disorders is complex, with physical and psychosocial working conditions playing an important role. This study aimed to determine the relationship between psychosocial work conditions, such as psychological job demands, decision latitude, social support and job insecurity and musculoskeletal complains (MSCs) and (repetitive strain injuries (RSIs) in a 1-year prospective study. The job content questionnaire, the Nordic musculoskeletal questionnaire and provocation tests were used to study 725 employees aged 20-70 years. Pain in the lower back (58 % of subjects), neck (57 %), wrists/hands (47 %) and upper back (44 %) was most frequent. The carpal tunnel syndrome (CTS) (33.6 %), rotator cuff tendinitis (15.4 %), Guyon's canal syndrome (13.4 %), lateral epicondylitis (7.6 %), medial epicondylitis (5.3 %), tendinitis of forearm-wrist extensors (7.8 %) and tendinitis of forearm-wrist flexors (7.3 %) were the most frequent RSIs. Logistic analysis showed that increased psychological job demands statistically significantly increased the probability of lateral and medial epicondylitis, and increased control (decision latitude) statistically significantly decreased the risk of CTS. There was no relationship between job insecurity, social support and the studied RSIs. Psychosocial factors at work predict prevalence of MSCs and RSIs, irrespectively of demographic factors, e.g., age or gender, and organizational and physical factors.

A reliable technique for ultrasound-guided perineural injection in ulnar neuropathy at the elbow.

PubMed

Hamscha, Ulrike M; Tinhofer, Ines; Heber, Stefan; Grisold, Wolfgang; Weninger, Wolfgang J; Meng, Stefan

2017-08-01

Ulnar neuropathy at the elbow (UNE) is a common peripheral compression neuropathy and, in most cases, occurs at 2 sites, the retroepicondylar groove or the cubital tunnel. With regard to a potential therapeutic approach with perineural corticosteroid injection, the aim of this study was to evaluate the distribution of injection fluid applied at a standard site. We performed ultrasound-guided (US-guided) perineural injections to the ulnar nerve halfway between the olecranon and the medial epicondyle in 21 upper limbs from 11 non-embalmed cadavers. In anatomic dissection we investigated the spread of injected ink. Ink was successfully injected into the perineural sheath of the ulnar nerve in all 21 cases (cubital tunnel: 21 of 21; retroepicondylar groove: 19 of 21). US-guided injection between the olecranon and the medial epicondyle is a feasible and safe method to reach the most common sites of ulnar nerve entrapment. Muscle Nerve 56: 237-241, 2017. © 2016 Wiley Periodicals, Inc.

Episodic snapping of the medial head of the triceps due to weightlifting.

PubMed

Spinner, R J; Wenger, D E; Barry, C J; Goldner, R D

1999-01-01

We describe two patients who had episodic elbow snapping and ulnar nerve dysesthesias only after weightlifting. These symptoms would disappear soon afterward. The episodic nature of their complaints and findings led to misdiagnosis. We documented by repeated clinical examinations and magnetic resonance imaging that the presence of these symptoms correlated directly with the finding of intermittent, activity-related snapping of the medial triceps. In both patients, the symptoms disappeared when the medial portion of the triceps migrated medially but did not dislocate over the medial epicondyle with elbow flexion. Thus, a minor change in the configuration of the medial portion of the triceps (fluid accumulation) in the same individual at different times can cause intermittent dislocation of the medial triceps. Previous papers dealing with patients with snapping of the medial triceps describe symptoms exacerbated by athletic activities, but the constant finding of snapping on sequential examinations.

Lateral epicondylitis and beyond: imaging of lateral elbow pain with clinical-radiologic correlation.

PubMed

Kotnis, Nikhil A; Chiavaras, Mary M; Harish, Srinivasan

2012-04-01

The diagnosis of lateral epicondylitis is often straightforward and can be made on the basis of clinical findings. However, radiological assessment is valuable where the clinical picture is less clear or where symptoms are refractory to treatment. Demographics, aspects of clinical history, or certain physical signs may suggest an alternate diagnosis. Knowledge of the typical clinical presentation and imaging findings of lateral epicondylitis, in addition to other potential causes of lateral elbow pain, is necessary. These include entrapment of the posterior interosseous and lateral antebrachial cutaneous nerves, posterolateral rotatory instability, posterolateral plica syndrome, Panner's disease, osteochondritis dissecans of the capitellum, radiocapitellar overload syndrome, occult fractures and chondral-osseous impaction injuries, and radiocapitellar arthritis. Knowledge of these potential masquerades of lateral epicondylitis and their characteristic clinical and imaging features is essential for accurate diagnosis. The goal of this review is to provide an approach to the imaging of lateral elbow pain, discussing the relevant anatomy, various causes, and discriminating factors, which will allow for an accurate diagnosis.

Medial joint space widening of the ankle in displaced Tillaux and Triplane fractures in children.

PubMed

Gourineni, Prasad; Gupta, Asheesh

2011-10-01

Tillaux and Triplane fractures occur in children predominantly from external rotation mechanism. We hypothesized that in displaced fractures, the talus would shift laterally along with the distal fibula and the distal tibial epiphyseal fragment increasing the medial joint space. Consecutive cases evaluated retrospectively. Level I and Level II centers. Twenty-two skeletally immature patients with 14 displaced Triplane fractures and eight displaced Tillaux fractures were evaluated for medial joint space widening. Measurement of fracture displacement and medial joint space widening before and after intervention. Thirteen Triplane and six Tillaux fractures (86%) showed medial space widening of 1 to 9 mm and equal to the amount of fracture displacement. Reduction of the fracture reduced the medial space to normal. There were no known complications. Medial space widening of the ankle may be a sign of ankle fracture displacement. Anatomic reduction of the fracture reduces the medial space and may improve the results in Tillaux and Triplane fractures.

The ulnar collateral ligament of the human elbow joint. Anatomy, function and biomechanics.

PubMed Central

Fuss, F K

1991-01-01

The posterior portion of the ulnar collateral ligament, which arises from the posterior surface of the medial epicondyle, is taut in maximal flexion. The anterior portion, which takes its origin from the anterior and inferior surfaces of the epicondyle, contains three functional fibre bundles. One of these is taut in maximal extension, another in intermediate positions between middle position and full flexion while the third bundle is always taut and serves as a guiding bundle. Movements of the elbow joint are checked by the ligaments well before the bony processes forming the jaws of the trochlear notch lock into the corresponding fossae on the humerus. Images Fig. 1 Fig. 2 Fig. 3 Fig. 4 PMID:2050566

Variation of the latissimus dorsi

PubMed Central

Shah, Ishani P; Yadav, Amit; Mehta, Rujuta; Thatte, Mukund

2014-01-01

A typical muscle variation of latissimus dorsi — the axillary arch is represented by the muscular or fibromuscular slip detached from the anteroinferior border of the musculus latissimus dorsi passing over the axilla under the axillary fascia crossing the medial side of the brachial plexus to continue as a septum intermusculare mediale brachii distally to the medial epicondyle of humerus. The full extent of the muscle is rarely present. Slips of muscle extend from the latissimus dorsi at the inferior angle of scapula to insert into pectoralis major (Langer), coracobrachilis, biceps or coracoid process forming what is described as a common variant - the muscular axillary arch. We report three cases of variants of latissimus dorsi, one of which has not been reported in the literature before. PMID:25593441

Variation of the latissimus dorsi.

PubMed

Shah, Ishani P; Yadav, Amit; Mehta, Rujuta; Thatte, Mukund

2014-01-01

A typical muscle variation of latissimus dorsi - the axillary arch is represented by the muscular or fibromuscular slip detached from the anteroinferior border of the musculus latissimus dorsi passing over the axilla under the axillary fascia crossing the medial side of the brachial plexus to continue as a septum intermusculare mediale brachii distally to the medial epicondyle of humerus. The full extent of the muscle is rarely present. Slips of muscle extend from the latissimus dorsi at the inferior angle of scapula to insert into pectoralis major (Langer), coracobrachilis, biceps or coracoid process forming what is described as a common variant - the muscular axillary arch. We report three cases of variants of latissimus dorsi, one of which has not been reported in the literature before.

Lateral Patellofemoral Ligament: An Anatomic Study.

PubMed

Shah, Kalpit N; DeFroda, Steven F; Ware, James Kristopher; Koruprolu, Sarath C; Owens, Brett D

2017-12-01

Medial instability of the patellofemoral joint is a rare but known phenomenon that may result from an incompetent lateral patellofemoral ligament (LPFL). Surgical reconstruction of the LPFL has been described. However, anatomic details of the ligament have not been the subject of scrutiny. To describe the anatomic origin and insertion of the LPFL. Descriptive laboratory study. Ten fresh-frozen, unpaired human cadaveric knees (mean age, 57 years) were dissected to identify the LPFL. The dissection was carried out by elevating the iliotibial band to expose the deep capsular layer of the knee joint, followed by a medial parapatellar approach to the knee. Then the quadriceps and patellar tendons were sectioned, and the LPFL was isolated by visualization and palpation. The LPFL was dissected to reveal its origin and insertion; these were measured with respect to the lateral epicondyle and the superior-inferior axis of the lateral patella, respectively. On average, the LPFL had a variable point of origin in location as well as width about the lateral epicondyle. The LPFL originated, on average, 2.6 mm distal (range, 13.1 mm proximal to 11.4 mm distal) and 10.8 mm anterior (range, 7.3 mm posterior to 14.9 mm anterior) to the lateral epicondyle. The LPFL insertion on the patella was more reliably found to be about 45% (range, 23.7%-58.4%) of its lateral articular surface. The insertion on the patella was found to be in the middle third of the lateral patella. The LPFL has an origin that is variable but, on average, was found to be distal and anterior to the lateral epicondyle. The patella insertion was more reliably found to be in the middle third of the lateral patella. These anatomic relationships can help the surgeon reconstruct the LPFL in a more anatomic fashion. Surgeons who are tasked with reconstruction of the LPFL of a patient with idiopathic medial instability or a previous aggressive lateral release of the knee may reference this article to perform an anatomic reconstruction of the LPFL. We hope that having anatomic landmarks for the reconstruction of this ligament permits the surgeon to operate in an efficient manner that allows for the optimal outcome. This is a rare surgical issue, and no studies are available that provide this information. The little information present in the literature does not provide measurements for anatomic reconstruction; rather, it is limited to descriptions of reconstruction techniques that indirectly provide stability on the lateral aspect of the knee.

Medial tibial plateau morphology and stress fracture location: A magnetic resonance imaging study.

PubMed

Yukata, Kiminori; Yamanaka, Issei; Ueda, Yuzuru; Nakai, Sho; Ogasa, Hiroyoshi; Oishi, Yosuke; Hamawaki, Jun-Ichi

2017-06-18

To determine the location of medial tibial plateau stress fractures and its relationship with tibial plateau morphology using magnetic resonance imaging (MRI). A retrospective review of patients with a diagnosis of stress fracture of the medial tibial plateau was performed for a 5-year period. Fourteen patients [three female and 11 male, with an average age of 36.4 years (range, 15-50 years)], who underwent knee MRI, were included. The appearance of the tibial plateau stress fracture and the geometry of the tibial plateau were reviewed and measured on MRI. Thirteen of 14 stress fractures were linear, and one of them stellated on MRI images. The location of fractures was classified into three types. Three fractures were located anteromedially (AM type), six posteromedially (PM type), and five posteriorly (P type) at the medial tibial plateau. In addition, tibial posterior slope at the medial tibial plateau tended to be larger when the fracture was located more posteriorly on MRI. We found that MRI showed three different localizations of medial tibial plateau stress fractures, which were associated with tibial posterior slope at the medial tibial plateau.

Elbow tendinopathy.

PubMed

Pitzer, Michael E; Seidenberg, Peter H; Bader, Dov A

2014-07-01

Overuse injuries of the lateral and medial elbow are common in sport, recreational activities, and occupational endeavors. They are commonly diagnosed as lateral and medial epicondylitis; however, the pathophysiology of these disorders demonstrates a lack of inflammation. Instead, angiofibroblastic degeneration is present, referred to as tendinosis. As such, a more appropriate terminology for these conditions is epicondylosis. This is a clinical diagnosis, and further investigations are only performed to rule out other clinical entities after conventional therapy has failed. Yet, most patients respond to conservative measures with physical therapy and counterforce bracing. Corticosteroid injections are effective for short-term pain control but have not demonstrated long-term benefit. Copyright © 2014 Elsevier Inc. All rights reserved.

Medial tibial plateau morphology and stress fracture location: A magnetic resonance imaging study

PubMed Central

Yukata, Kiminori; Yamanaka, Issei; Ueda, Yuzuru; Nakai, Sho; Ogasa, Hiroyoshi; Oishi, Yosuke; Hamawaki, Jun-ichi

2017-01-01

AIM To determine the location of medial tibial plateau stress fractures and its relationship with tibial plateau morphology using magnetic resonance imaging (MRI). METHODS A retrospective review of patients with a diagnosis of stress fracture of the medial tibial plateau was performed for a 5-year period. Fourteen patients [three female and 11 male, with an average age of 36.4 years (range, 15-50 years)], who underwent knee MRI, were included. The appearance of the tibial plateau stress fracture and the geometry of the tibial plateau were reviewed and measured on MRI. RESULTS Thirteen of 14 stress fractures were linear, and one of them stellated on MRI images. The location of fractures was classified into three types. Three fractures were located anteromedially (AM type), six posteromedially (PM type), and five posteriorly (P type) at the medial tibial plateau. In addition, tibial posterior slope at the medial tibial plateau tended to be larger when the fracture was located more posteriorly on MRI. CONCLUSION We found that MRI showed three different localizations of medial tibial plateau stress fractures, which were associated with tibial posterior slope at the medial tibial plateau. PMID:28660141

Transcaruncular Approach for Treatment of Medial Wall and Large Orbital Blowout Fractures.

PubMed

Nguyen, Dennis C; Shahzad, Farooq; Snyder-Warwick, Alison; Patel, Kamlesh B; Woo, Albert S

2016-03-01

We evaluate the safety and efficacy of the transcaruncular approach for reconstruction of medial orbital wall fractures and the combined transcaruncular-transconjunctival approach for reconstruction of large orbital defects involving the medial wall and floor. A retrospective review of the clinical and radiographic data of patients who underwent either a transcaruncular or a combined transcaruncular-transconjunctival approach by a single surgeon for orbital fractures between June 2007 and June 2013 was undertaken. Seven patients with isolated medial wall fractures underwent a transcaruncular approach, and nine patients with combined medial wall and floor fractures underwent a transcaruncular-transconjunctival approach with a lateral canthotomy. Reconstruction was performed using a porous polyethylene implant. All patients with isolated medial wall fractures presented with enophthalmos. In the combined medial wall and floor group, five out of eight patients had enophthalmos with two also demonstrating hypoglobus. The size of the medial wall defect on preoperative computed tomography (CT) scan ranged from 2.6 to 4.6 cm(2); the defect size of combined medial wall and floor fractures was 4.5 to 12.7 cm(2). Of the 11 patients in whom postoperative CT scans were obtained, all were noted to have acceptable placement of the implant. All patients had correction of enophthalmos and hypoglobus. One complication was noted, with a retrobulbar hematoma having developed 2 days postoperatively. The transcaruncular approach is a safe and effective method for reconstruction of medial orbital floor fractures. Even large fractures involving the orbital medial wall and floor can be adequately exposed and reconstructed with a combined transcaruncular-transconjunctival-lateral canthotomy approach. The level of evidence of this study is IV (case series with pre/posttest).

A rare type of ankle fracture: Syndesmotic rupture combined with a high fibular fracture without medial injury.

PubMed

van Wessem, K J P; Leenen, L P H

2016-03-01

High fibular spiral fractures are usually caused by pronation-external rotation mechanism. The foot is in pronation and the talus externally rotates, causing a rupture of the medial ligaments or a fracture of the medial malleolus. With continued rotation the anterior and posterior tibiofibular ligament will rupture, and finally, the energy leaves the fibula by creating a spiral fracture from anterior superior to posterior inferior. In this article we demonstrate a type of ankle fracture with syndesmotic injury and high fibular spiral fractures without a medial component. This type of ankle fractures cannot be explained by the Lauge-Hansen classification, since it lacks injury on the medial side of the ankle, but it does have the fibular fracture pattern matching the pronation external rotation injury (anterior superior to posterior inferior fracture). We investigated the mechanism of this injury illustrated by 3 cases and postulate a theory explaining the biomechanics behind this type of injury. Copyright © 2016 Elsevier Ltd. All rights reserved.

Medial malleolar stress fracture secondary to chronic ankle impingement.

PubMed

Jowett, Andrew J L; Birks, Christopher L; Blackney, Mark C

2008-07-01

Medial malleolar stress fractures are uncommon even in the sporting population. We believe that stress fractures of the medial malleolus may be the end stage of chronic anteromedial ankle impingement in elite running and jumping athletes. We present five cases of elite athletes who presented to our institution with stress fractures of the medial malleolus over a 3-year period (2004 to 2007). In each case preoperative imaging revealed an anteromedial bony spur on the tibia. All fractures were internally fixed and at the same sitting had arthroscopic debridement of the bony spur. All fractures united without further intervention, average time to union was 10.2 (range, 6 to 16) weeks. At most recent review (average, 18 months; range, 8 to 37 months), all patients had resumed sporting activity to their previous level. No patient had suffered a recurrent fracture of the medial malleolus. We believe this region of impingement to be important in the development of the stress fracture and should be addressed at the time of fracture fixation.

Injuries of the Medial Clavicle: A Cohort Analysis in a Level-I-Trauma-Center. Concomitant Injuries. Management. Classification.

PubMed

Bakir, Mustafa Sinan; Merschin, David; Unterkofler, Jan; Guembel, Denis; Langenbach, Andreas; Ekkernkamp, Axel; Schulz-Drost, Stefan

2017-01-01

Introduction: Although shoulder girdle injuries are frequent, those of the medial clavicle are widely unexplored. An applied classification is less used just as a standard management. Methods: A retrospective analysis of medial clavicle injuries (MCI) during a 5-year-term in a Level-1-Trauma-Center. We analyzed amongst others concomitant injuries, therapy strategies and the classification following the AO standards. Results: 19 (2.5%) out of 759 clavicula injuries were medial ones (11 A, 6 B and 2 C-Type fractures) thereunder 27,8% were displaced and thus operatively treated Locked plate osteosynthesis was employed in unstable fractures and a reconstruction of the ligaments at the sternoclavicular joint (SCJ) in case of their disruption. 84,2% of the patients sustained relevant concomitant injuries. Numerous midshaft fractures were miscoded as medial fracture, which limited the study population. Conclusions: MCI resulted from high impact mechanisms of injury, often with relevant dislocation and concomitant injuries. Concerning medial injury's complexity, treatment should occur in specialized hospitals. Unstable fractures and injuries of the SCJ ligaments should be considered for operative treatment. Midshaft fractures should be clearly distinguished from the medial ones in ICD-10-coding. Further studies are required also regarding a subtyping of the AO classification for medial clavicle fractures including ligamental injuries. Celsius.

The Effects of a Functional Elbow Brace on Medial Joint Stability: A Case Study

PubMed Central

Pincivero, Danny M.; Rijke, Arie M.; Heinrichs, Kristinn; Perrin, David H.

1994-01-01

Medical elbow ligament sprains in athletics can be traumatic and disabling. In this case report, we outline the effect of a prototype functional elbow brace on joint stability in a female collegiate javelin thrower with an ulnar collateral ligament sprain. A valgus force to both elbows was applied using graded stress radiography (Telos GA-II/E stress device) at 0, 5, 10, and 15 kiloPascals (kPa) of pressure. The increase in gap width between the coronoid process and the medial epicondyle was measured from anteroposterior radiographs to determine medial displacement. The brace resulted in less displacement in both injured and noninjured ulnar collateral ligament; injured ulnar collateral ligament demonstrated greater displacement regardless of condition. The brace restored medial stability to the elbow joint by 49%, 38%, and 35% at 5, 10, and 15 kPa of pressure, respectively. The application of the brace may be useful in athletes with ulnar collateral ligament injuries. ImagesFig 1Fig 2 PMID:16558285

Comminuted supracondylar femoral fractures: a biomechanical analysis comparing the stability of medial versus lateral plating in axial loading.

PubMed

Briffa, Nikolai; Karthickeyan, Raju; Jacob, Joshua; Khaleel, Arshad

2016-11-01

The aim of this study was to compare the biomechanical properties of medial and lateral plating of a medially comminuted supracondylar femoral fracture. A supracondylar femoral fracture model comparing two fixation methods was tested cyclically in axial loading. One-centimetre supracondylar gap osteotomies were created in six synthetic femurs approximately 6 cm proximal to the knee joint. There were two constructs investigated: group 1 and group 2 were stabilized with an 8-hole LC-DCP, medially and laterally, respectively. Both construct groups were axially loaded. Global displacement (total length), wedge displacement, bending moment and strain were measured. Medial plating showed a significantly decreased displacement, bending moment and strain at the fracture site in axial loading. Medial plating of a comminuted supracondylar femur fracture is more stable than lateral plating.

Modified tension band wiring of medial malleolar ankle fractures.

PubMed

Georgiadis, G M; White, D B

1995-02-01

Twenty-two displaced medial malleolar ankle fractures that were treated surgically using the modified tension band method of Cleak and Dawson were retrospectively reviewed at an average follow-up of 25 months. The technique involves the use of a screw to anchor a figure-of-eight wire. There were no malreductions and all fractures healed. Problems with the technique included technical errors with hardware placement, medial ankle pain, and asymptomatic wire migration. Despite this, modified tension band wiring remains an acceptable method for fixation of selected displaced medial malleolar fractures. It is especially suited for small fracture fragments and osteoporotic bone.

Does medial tenderness predict deep deltoid ligament incompetence in supination-external rotation type ankle fractures?

PubMed

DeAngelis, Nicola A; Eskander, Mark S; French, Bruce G

2007-04-01

To identify whether medial tenderness is a predictor of deep deltoid ligament incompetence in supination-external rotation ankle fractures. All Weber B lateral malleolar fractures with normal medial clear space over a 9 month period were prospectively included in the study. Fracture patterns not consistent with a supination-external rotation mechanism were excluded. High-volume tertiary care referral center and Level I trauma center. Fifty-five skeletally mature patients with a Weber B lateral malleolar fracture and normal medial clear space presenting to our institution were included. All study patients had ankle anteroposterior, lateral, and mortise radiographs. Each patient was seen and evaluated by an orthopedic specialist and the mechanism of injury was recorded. Each patient was assessed for tenderness to palpation in the region of the deltoid ligament and then had an external rotation stress mortise radiograph. Correlating medial tenderness with deep deltoid competence as measured by stress radiographs. Thirteen patients (23.6%) were tender medially and had a positive external rotation stress radiograph. Thirteen patients (23.6%) were tender medially and had a negative external rotation stress radiograph. Nineteen patients (34.5%) were nontender medially and had a negative external rotation stress radiograph. Ten patients (18.2%) were nontender medially and had a positive external rotation stress radiograph. We calculated a chi statistic of 2.37 as well as the associated P value of 0.12. Medial tenderness as a measure of deep deltoid ligament incompetence had a sensitivity of 57%, a specificity of 59%, a positive predictive value of 50%, a negative predictive value of 66%, and an accuracy of 42%. There was no statistical significance between the presence of medial tenderness and deep deltoid ligament incompetence. There is a 25% chance of the fracture in question with medial tenderness having a positive external rotation stress and a 25% chance the fracture with no medial tenderness having a positive stress test. Medial tenderness in a Weber B lateral ankle fracture with a normal clear space on standard plain radiographs does not ensure the presence of a positive external rotation stress test.

Orbital blowout fracture location in Japanese and Chinese patients.

PubMed

Sun, Michelle T; Wu, Wencan; Watanabe, Akihide; Kakizaki, Hirohiko; Chen, Ben; Ueda, Kosuke; Katori, Nobutada; Takahashi, Yasuhiro; Selva, Dinesh

2015-01-01

To characterize the location of orbital blowout fractures in Asian individuals. This was a retrospective review of 470 consecutive Asian patients with orbital blowout fractures who presented to four tertiary care hospitals in Japan and China. Computed tomography (CT) characterized the location and severity of fractures involving the medial wall, the orbital floor, and/or the maxilloethmoidal strut. A total of 475 orbital blowout fractures were identified. More than one fracture location was involved in 19% of all cases. The medial orbital wall was the most commonly involved location, presenting in 29 cases (61%), of which 204 (43%) were isolated medial blowout fractures. The orbital floor was the second most common location involved, present in 226 cases (48%) with 150 isolated orbital floor fractures (32%), while the maxilloethmoidal strut was involved in 45 cases (9%) with 30 of those being isolated strut fractures (6%). The majority of fractures (62%) were classified as moderately severe, whilst 14% were mild, and 24% were severe. Associated nasal fractures were present in 16% of the cases. Orbital blowout fractures in Japanese and Chinese individuals occur most commonly in the medial wall. This is in contrast to previous reports on white individuals, who tend to sustain fractures involving the orbital floor rather than the medial wall.

A clinical evaluation of alternative fixation techniques for medial malleolus fractures.

PubMed

Barnes, Hayley; Cannada, Lisa K; Watson, J Tracy

2014-09-01

Medial malleolus fractures have traditionally been managed using partially threaded screws and/or Kirschner wire fixation. Using these conventional techniques, a non-union rate of as high as 20% has been reported. In addition too many patients complaining of prominent hardware as a source of pain post-fixation. This study was designed to assess the outcomes of medial malleolar fixation using a headless compression screw in terms of union rate, the need for hardware removal, and pain over the hardware site. Saint Louis University and Mercy Medical Center, Level 1 Trauma Centers, St. Louis, MO. After IRB approval, we used billing records to identify all patients with ankle fractures involving the medial malleolus. Medical records and radiographs were reviewed to identify patients with medial malleolar fractures treated with headless compression screw fixation. Our inclusion criteria included follow-up until full weight bearing and a healed fracture. Follow-up clinical records and radiographs were reviewed to determine union, complication rate and perception of pain over the site of medial malleolus fixation. Sixty-four ankles were fixed via headless compression screws and 44 had adequate follow-up for additional evaluation. Seven patients had isolated medial malleolar fractures, 23 patients had bimalleolar fractures, and 14 patients had trimalleolar fractures. One patient (2%) required hardware removal due to cellulitis. One patient (2%) had a delayed union, which healed without additional intervention. Ten patients (23%) reported mild discomfort to palpation over the medial malleolus. The median follow-up was 35 weeks (range: 12-208 weeks). There were no screw removals for painful hardware and no cases of non-union. Headless compression screws provide effective compression of medial malleolus fractures and result in good clinical outcomes. The headless compression screw is a beneficial alternative to the conventional methods of medial malleolus fixation. Copyright © 2014 Elsevier Ltd. All rights reserved.

Inverted distal clavicle anatomic locking plate for displaced medial clavicle fracture.

PubMed

Wang, Yong; Jiang, Jiannong; Dou, Bin; Zhang, Panjun

2015-09-01

Fractures of the medial clavicle are rare injuries. Recently, open reduction and internal fixation has been recommended for displaced medial clavicle fractures in order to prevent non-union and dysfunction. Because of the rarity of this injury, the optimal fixation device has not yet been established. In this report, we describe a case of a 40-year-old male patient who sustained a significantly displaced medial clavicle fracture treated by open reduction and internal fixation using an inverted distal clavicle anatomic locking plate. At the 12 months follow-up, the patient recovered well, had returned to pre-injury job, and was quite satisfied with the outcome. Internal fixation of medial clavicle fracture using an inverted distal clavicle anatomic locking plate of the ipsilateral side appears to be a good treatment option.

A Biomechanical Comparison Of Pin Configurations Used For Percutaneous Pinning Of Distal Tibia Fractures In Children.

PubMed

Brantley, Justin; Majumdar, Aditi; Jobe, J Taylor; Kallur, Antony; Salas, Christina

2016-01-01

Percutaneous pin fixation is often used in conjunction with closed-reduction and cast immobilization to treat pediatric distal tibia fractures. The goal of this procedure is to maintain reduction and provide improved stabilization, in effort to facilitate a more anatomic union. We conducted a biomechanical study of the torsional and bending stability of three commonly used pin configurations in distal tibia fracture fixation. A transverse fracture was simulated at the metaphyseal/diaphyseal junction in 15 synthetic tibias. Each fracture was reduced and fixed with two Kirschner wires, arranged in one of three pin configurations: parallel, retrograde, medial to lateral pins entering at the medial malleolus distal to the fracture (group A); parallel, antegrade, medial to lateral pins entering at the medial diaphysis proximal to the fracture (group B); or a cross-pin configuration with one retrograde, medial to lateral pin entering the medial malleolus distal to the fracture and the second an antegrade, medial to lateral pin entering at the medial diaphysis proximal to the fracture (group C). Stability of each construct was assessed by resistance to torsion and bending. Resistance to external rotation stress was significantly higher in group A than group B (P = 0.044). Resistance to internal rotation stress was significantly higher in group C than group B (P = 0.003). There was no significant difference in torsional stiffness when comparing group A with group C. Under a medial-directed load, group B and C specimens were significantly stiffer than those in group A (28 N/mm and 24 N/mm vs. 14 N/mm for A; P = 0.001 and P = 0.009, respectively). None of the three pin configurations produced superior results with respect to all variables studied. Group A configuration provided the highest resistance to external rotation forces, which is the most clinically relevant variable under short-cast immobilization. Parallel, retrograde, medial to lateral pins entering at the medial malleolus provide the greatest resistance to external rotation of the foot while minimizing the potential for iatrogenic injury to soft tissue structures.

Comparison of Clinical Efficacy of Lateral and Lateral and Medial Double-plating Fixation of Distal Femoral Fractures.

PubMed

Bai, Zhibiao; Gao, Shichang; Hu, Zhenming; Liang, Anlin

2018-03-20

The present study was performed to compare the clinical efficacy of lateral plate and lateral and medial double-plating fixation of distal femoral fractures and explore the indication of lateral and medial double-plating fixation of the distal femoral fractures. From March 2006 to April 2014, 48 and 12 cases of distal femoral fractures were treated with lateral plate (single plate) and lateral and medial plates (double plates), respectively. During the surgery, after setting the lateral plate for the distal femoral fractures, if the varus stress test of the knee was positive and the lateral collateral ligament rupture was excluded, lateral and medial double-plating fixation was used for the stability of the fragments. All the patients were followed up at an average period of 15.9 months. The average operation time, the intraoperative hemorrhage and the fracture union time of the two groups were compared. One year after operation, knee function was evaluated by the Kolmert's standard. There was no significant difference in the average operation time, intraoperative hemorrhage, fracture healing time and excellent and good rates of postoperative knee function between two groups. Positive Varus stress test during operation can be an indication for lateral and medial double-plating fixation of distal femoral fractures.

Anatomically precontoured LCP for delayed union of a medial third clavicle fracture. Case report with review of the literature.

PubMed

Siebenlist, S; Sandmann, G; Kirchhoff, C; Biberthaler, P; Neumaier, M

2013-01-01

Fractures of the medial clavicle third are rare injuries. Even in case of significant fracture displacement, their therapeutic management has been nonoperative. Recently, surgical intervention has become mandatory for displaced fractures types to prevent non-union and functional complaints, but the optimal operative strategy is being discussed controversially. We describe the case of a 63-year-old male patient with a significantly displaced medial clavicle fracture after failed conservative treatment resulting in restricted, painful shoulder function. The patient underwent open reduction and osteosynthesis with an anatomically precontoured locking compression plate (LCP). One year after surgery the patient is free of complaints and has returned to his preinjury activity level without any functional restrictions. As a not yet reported operative approach, anatomically preshaped locking plating seems to be an effective fixation method for displaced fractures of the medial clavicle third. The operative management is described in detail and discussed with the current literature. Based on the presented case, we underline the statement that displaced medial clavicle fractures should be surgically addressed to avoid late damage.

Medial tibial pain. A prospective study of its cause among military recruits.

PubMed

Milgrom, C; Giladi, M; Stein, M; Kashtan, H; Margulies, J; Chisin, R; Steinberg, R; Swissa, A; Aharonson, Z

1986-12-01

In a prospective study of 295 infantry recruits during 14 weeks of basic training, 41% had medial tibial pain. Routine scintigraphic evaluation in cases of medial tibial bone pain showed that 63% had abnormalities. A stress fracture was found in 46%. Only two patients had periostitis. None had ischemic medial compartment syndrome. Physical examination could not differentiate between cases with medial tibial bone pain secondary to stress fractures and those with scintigraphically normal tibias. When both pain and swelling were localized in the middle one-third of the tibia, the lesion most likely proved to be a stress fracture.

Evaluation of the Risk for Work-Related Upper Extremity Musculoskeletal Symptoms in USAF Air Traffic Controllers: A Pilot Feasibility Study

DTIC Science & Technology

1997-07-11

interest to this study. One was suffering from (being diagnosed and in treatment for) medial epicondylitis , and the other had tenderness related to...rest forearms and hands, excessive lateral deviation of the hands operating the keyboard, and a pronounced inclination or turning of the head. Their...equal to or greater than 2.0. A similar relative risk was noted for neck, shoulder, arm and elbow disorders in 9 of 16 studies. The magnitude of the

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zilkha, A.

Computed tomographic (CT) findings in four patients with isolated blow-out fracture of the medial orbital wall are reported. CT delineated the fracture site and its extent in each case, and clearly demonstrated medial rectus muscle entrapment in two. This was confirmed by surgery. CT was found superior to polytomography and proved to be the best radiologic means for the diagnosis of medial orbital wall fracture and muscle entrapment.

Natural history of medial clavicle fractures.

PubMed

Salipas, Andrew; Kimmel, Lara A; Edwards, Elton R; Rakhra, Sandeep; Moaveni, Afshin Kamali

2016-10-01

Fractures of the medial third of the clavicle comprise less than 3% of all clavicle fractures. The natural history and optimal management of these rare injuries are unknown. The aim of our study is to describe the demographics, management and outcomes of patients with medial clavicle fractures treated at a Level 1 Trauma Centre. A retrospective review was conducted of patients presenting to our institution between January 2008 and March 2013 with a medial third clavicle fracture. Clinical and radiographic data were recorded including mechanism of injury, fracture pattern and displacement, associated injuries, management and complications. Functional outcomes were assessed using the Glasgow Outcome Scale Extended (GOS-E) scores from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Shoulder outcomes were assessed using two patient reported outcomes scores, the American Shoulder and Elbow Society Score (ASES) and the Subjective Shoulder Value (SSV). Sixty eight medial clavicle fractures in 68 patients were evaluated. The majority of patients were male (n=53), with a median age of 53.5 years (interquartile range (IQR) 37.5-74.5 years). The most common mechanism of injury was motor vehicle accident (n=28). The in-hospital mortality rate was 4.4%. The fracture pattern was almost equally distributed between extra articular (n=35) and intra-articular (n=33). Fifty-five fractures (80.9%) had minimal or no displacement. Associated injuries were predominantly thoracic (n=31). All fractures were initially managed non-operatively, with a broad arm sling. Delayed operative fixation was performed for painful atrophic delayed union in two patients (2.9%). Both patients were under 65 years of age and had a severely displaced fracture of the medial clavicle. One intra-operative vascular complication was seen, with no adverse long-term outcome. Follow-up was obtained in 85.0% of the surviving cohort at an average of three years post injury (range 1-6 years). The mean ASES score was 80.3 (SD 24.8, range 10-100,), and the mean SSV score was 77.0 (SD 24.6, range 10-100). Sixty eight patients with medial clavicle fractures were identified over a 5year period, with excellent functional results seen following conservative management. Copyright © 2016 Elsevier Ltd. All rights reserved.

[Surgical approaches to tibial plateau fractures].

PubMed

Krause, Matthias; Müller, Gunnar; Frosch, Karl-Heinz

2018-06-06

Intra-articular tibial plateau fractures can present a surgical challenge due to complex injury patterns and compromised soft tissue. The treatment goal is to spare the soft tissue and an anatomical reconstruction of the tibial articular surface. Depending on the course of the fracture, a fracture-specific access strategy is recommended to provide correct positioning of the plate osteosynthesis. While the anterolateral approach is used in the majority of lateral tibial plateau fractures, only one third of the joint surface is visible; however, posterolateral fragments require an individual approach, e. g. posterolateral or posteromedial. If necessary, osteotomy of the femoral epicondyles can improve joint access for reduction control. Injuries to the posterior columns should be anatomically reconstructed and biomechanically correctly addressed via posterior approaches. Bony posterior cruciate ligament tears can be refixed via a minimally invasive posteromedial approach.

Tibial avulsion fracture of the posterior root of the medial meniscus in children.

PubMed

Iversen, Jonas Vestergård; Krogsgaard, Michael Rindom

2014-01-01

Few reports have described avulsion fractures of the posterior root of the medial meniscus in skeletally immature patients. This lesion should not be overlooked as it damages the load absorptive (distributive) function of the meniscus, increasing the risk of cartilage degeneration. Two cases of displaced avulsion fractures of the posterior root of the medial meniscus in children are presented along with a concise report of the literature regarding avulsion fractures of the posterior root of the medial meniscus. Both avulsions were reattached arthroscopically by trans-tibial pull-out sutures with a good clinical result at 2-years follow-up, and in one case, the avulsion was found at re-arthroscopy after 6 weeks to have healed.

Baseball and softball injuries.

PubMed

Wang, Quincy

2006-05-01

Baseball and softball injuries can be a result of both acute and overuse injuries. Soft tissue injuries include contusions, abrasions, and lacerations. Return to play is allowed when risk of further injury is minimized. Common shoulder injuries include those to the rotator cuff, biceps tendon, and glenoid labrum. Elbow injuries are common in baseball and softball and include medial epicondylitis, ulnar collateral ligament injury, and osteochondritis dissecans. Typically conservative treatment with relative rest, medication, and a rehabilitation program will allow return to play. Surgical intervention may be needed for certain injuries or conservative treatment failure.

Treatment of Medial Malleolus or Pure Deltoid Ligament Injury in Patients with Supination-External Rotation Type IV Ankle Fractures.

PubMed

Wang, Xu; Zhang, Chao; Yin, Jian-Wen; Wang, Chen; Huang, Jia-Zhang; Ma, Xin; Wang, Cheng-Wei; Wang, Xue

2017-02-01

To investigate the effect of internal fixation on postoperative ankle function in patients with supination-external rotation type IV ankle fractures, including medial malleolus fractures and deltoid ligament injury. Between January 2012 and June 2014, patients with medial structure injuries were enrolled in this study and assigned to the medial malleolus fracture group or the deltoid ligament group. The surgical procedures for the two groups were documented. The follow-up endpoint was the time point when the steel plate or screw was removed from the lateral ankle. The Olerud-Molander ankle scoring system was used to assess ankle function. A total of 84 patients with supination-external rotation type IV ankle fractures had complete medical records and were included in this study. The average age of the patients was 44.16 years (range, 15-75). The patient sample included 39 males and 45 females. Overall, 49 patients (19 males and 30 females) suffered a medial malleolus fracture. The average age of these patients was 40.20 years (range, 15-75). Patients with a posterior malleolar fracture fragment >25% of the articular surface accounted for 81.6% (40 patients) of these patients. Overall, 35 patients (20 males and 15 females) experienced a deltoid ligament injury. The average age of these patients was 44.21 years (range, 17-73). Patients with a posterior malleolar fracture fragment >25% of the articular surface accounted for 11.5% (four patients) of these patients. Open reduction was performed in patients with medial malleolus fractures, and two 4.0-mm cannulated screws were used to fixate the posterior malleolus and the medial malleolus. The suture-anchor technique was used to repair the ligaments in patients with deltoid ligament injuries. The follow-up endpoint was the time point when the steel plate and screws were removed from the lateral ankle in patients. The average follow-up period was 13.4 months (range, 11-17). The Olerud-Molander ankle scoring system was used to assess postoperative ankle function. The average score for the patients in the medial malleolus fracture group was 90.3 points (range, 85-95). The average score for the patients in the deltoid ligament injury group was 87.7 points (range, 80-95). No significant differences were found in the scores between the two groups. Medial malleolus fracture and deltoid ligament injury are two different presentations of supination-external rotation type IV ankle fractures. Anatomic reduction of the articular surface concurrent with restoration of ankle stability can achieve favorable results for these two injuries. © 2017 Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.

Treatment strategy and long-term functional outcome of traumatic elbow dislocation in childhood: a single centre study.

PubMed

Nussberger, G; Schädelin, S; Mayr, J; Studer, D; Zimmermann, P

2018-04-01

Traumatic elbow dislocation (TED) is the most common injury of large joints in children. There is an ongoing debate on the optimal treatment for TED. We aimed to assess the functional outcome after operative and nonoperative treatment of TED. We analysed the medical records of patients with TED treated at the University Children's Hospital, Basel, between March 2006 and June 2015. Functional outcome was assessed using the Mayo Elbow Performance Score (MEPS) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) Sport and Music Module score. These scores were compared between nonoperatively and operatively treated patients. A total of 37 patients (mean age 10.2 years, 5.2 to 15.3) were included. Of these, 21 (56.8%) children had undergone nonoperative treatment, with 16 (43.2%) patients having had operative treatment. After a mean follow-up of 5.6 years (1.2 to 5.9), MEPS and QuickDASH Sport and Music Module scores in the nonoperative group and operative group were similar: MEPS: 97.1 points (SD 4.6) versus 97.2 points (SD 2.6); 95% confidence interval (CI)-2.56 to 2.03); p = 0.53; QuickDASH Sport and Music Module score: 3.9 points (SD 6.1) versus 3.1 points (SD 4.6); 95% CI 2.60 to 4.17; p = 0.94. We noted no significant differences regarding the long-term functional outcome between the subgroup of children treated operatively versus those treated nonoperatively for TED with accompanying fractures of the medial epicondyle and medial condyle. Functional outcome after TED was excellent, independent of the treatment strategy. If clear indications for surgery are absent, a nonoperative approach for TED should be considered. Level III - therapeutic, retrospective, comparative study.

A new genus and species of Planopinae (Xenarthra: Tardigrada) from the Miocene of Santa Cruz Province, Argentina.

PubMed

Carlini, Alfredo A; Brandoni, Diego; Dal Molin, Carlos N

2013-01-01

Prepoplanops boleadorensis, a new genus and species of Planopinae (Xenarthra, Tardigrada), is described herein. The new taxon is based on a nearly complete specimen recovered from the Cerro Boleadoras Formation (Miocene, Rio Zeballos Group), in northwestern Santa Cruz Province, Argentina. The shape and length of the predentary region of the skull and the length of the diastema of Prepoplanops boleadorensis differ from those present in the species of Planops. The posterolateral opening of the mandibular canal and the position of the posterior margin of the mandibular symphysis differ from those of species of Prepotherium. In addition, Prepoplanops boleadorensis differs from Planops martini in the size of the humeral tuberosities, the development of the deltoid crest, the position of the distal margin of the humeral trochlea, the shape and position of the olecranon, the development of the femoral epicondyles, and the shape of the medial margins of the patellar trochlea and medial condyle. On the other hand, it differs from Prepotherium potens in the shape of the medial margin of the medial condyle. The recognition of Prepoplanops boleadorensis increases the diversity of Planopinae for the Miocene of Patagonia, Argentina.

Clarification of Eponymous Anatomical Terminology: Structures Named After Dr Geoffrey V. Osborne That Compress the Ulnar Nerve at the Elbow.

PubMed

Wali, Arvin R; Gabel, Brandon; Mitwalli, Madhawi; Tubbs, R Shane; Brown, Justin M

2017-05-01

In 1957, Dr Geoffrey Osborne described a structure between the medial epicondyle and the olecranon that placed excessive pressure on the ulnar nerve. Three terms associated with such structures have emerged: Osborne's band, Osborne's ligament, and Osborne's fascia. As anatomical language moves away from eponymous terminology for descriptive, consistent nomenclature, we find discrepancies in the use of anatomic terms. This review clarifies the definitions of the above 3 terms. We conducted an extensive electronic search via PubMed and Google Scholar to identify key anatomical and surgical texts that describe ulnar nerve compression at the elbow. We searched the following terms separately and in combination: "Osborne's band," "Osborne's ligament," and "Osborne's fascia." A total of 36 papers were included from 1957 to 2016. Osborne's band, Osborne's ligament, and Osborne's fascia were found to inconsistently describe the etiology of ulnar neuritis, referring either to the connective tissue between the 2 heads of the flexor carpi ulnaris muscle as described by Dr Osborne or to the anatomically distinct fibrous tissue between the olecranon process of the ulna and the medial epicondyle of the humerus. The use of eponymous terms to describe ulnar pathology of the elbow remains common, and although these terms allude to the rich history of surgical anatomy, these nonspecific descriptions lead to inconsistencies. As Osborne's band, Osborne's ligament, and Osborne's fascia are not used consistently across the literature, this research demonstrates the need for improved terminology to provide reliable interpretation of these terms among surgeons.

Influence of medial parapatellar nail insertion on alignment in proximal tibia fractures--special consideration of the fracture level.

PubMed

Weninger, Patrick; Tschabitscher, Manfred; Traxler, Hannes; Pfafl, Veronika; Hertz, Harald

2010-04-01

Although a lateral starting point for tibial nailing is recommended to avoid valgus misalignment, higher rates of intra-articular damage were described compared with a medial parapatellar approach. The aim of this anatomic study was to evaluate the fracture level allowing for a safe medial nail entry point without misalignment or dislocation of fragments. Thirty-two fresh-frozen cadaver lower extremities were used to create 1-cm osteotomies at four different levels (n = 8) from 2 cm to 8 cm below the tibial tuberosity. Nine-millimeter unreamed solid titanium tibial nails (Connex, I.T.S. Spectromed, Lassnitzhohe, Austria) were inserted from a medial parapatellar incision. Misalignment (degree) and dislocation of the distal fragment were measured in the frontal and sagittal plane. A medial parapatellar approach for tibial nail insertion mainly caused valgus and anterior bow misalignment and ventral and medial fragment displacement. Mean misalignment and fragment displacement did not exceed 0.5 degree if the osteotomy was performed 8 cm to 9 cm below the tibial tuberosity. According to the results of this study, a medial parapatellar approach can be performed without misalignment and fragment dislocation in proximal tibia fractures extending 8 cm or more below the tibial tuberosity.

Preoperative Radiographic and CT Findings Predicting Syndesmotic Injuries in Supination-External Rotation-Type Ankle Fractures.

PubMed

Choi, Young; Kwon, Soon-Sun; Chung, Chin Youb; Park, Moon Seok; Lee, Seung Yeol; Lee, Kyoung Min

2014-07-16

The Lauge-Hansen classification system does not provide sufficient data related to syndesmotic injuries in supination-external rotation (SER)-type ankle fractures. The aim of the present study was to investigate factors helpful for the preoperative detection of syndesmotic injuries in SER-type ankle fractures using radiographs and computed tomography (CT). A cohort of 191 consecutive patients (104 male and eighty-seven female patients with a mean age [and standard deviation] of 50.7 ± 16.4 years) with SER-type ankle fractures who had undergone operative treatment were included. Preoperative ankle radiographs and CT imaging scans were made for all patients, and clinical data, including age, sex, and mechanism of injury (high or low-energy trauma), were collected. Patients were divided into two groups: the stable syndesmotic group and the unstable syndesmotic group, with a positive intraoperative lateral stress test leading to syndesmotic screw fixation. Fracture height, fracture length, medial joint space, extent of fracture, and bone attenuation were measured on radiographs and CT images and were compared between the groups. Binary logistic regression analysis was performed to identify the factors that significantly contributed to unstable syndesmotic injuries. Receiver operating characteristic curves were calculated, and cutoff values were suggested to predict unstable syndesmotic injuries on preoperative imaging measurements. Of the 191 patents with a SER-type ankle fracture, thirty-eight (19.9%) had a concurrent unstable syndesmotic injury. Age, sex, mechanism of injury, fracture height, medial joint space, and bone attenuation were significantly different between the two groups. In the binary logistic analysis, fracture height, medial joint space, and bone attenuation were found to be significant factors contributing to unstable syndesmotic injuries. The cutoff values for predicting unstable syndesmotic injuries were a fracture height of >3 mm and a medial joint space of >4.9 mm on CT scans, and a fracture height of >7 mm and medial joint space of >4.5 mm on radiographs. Fracture height, medial joint space, and bone attenuation were useful factors for the preoperative detection of unstable syndesmotic injuries in SER-type ankle fractures. Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.

[Stable ankle joint fractures. Indication for surgical or conservative management?].

PubMed

Richter, J; Schulze, W; Muhr, G

1999-06-01

In German literature, ankle joint fractures are mostly classified in three groups according to Weber. In cases of the type A, the fracture line runs below, in cases of type B at height of the syndesmotic ligaments. C-type fractures are typically seen above this region. However, this practical and simple classification allows no inferences at accompanying injuries which in turn influence the functional outcome. We observed isolated fractures of the lateral malleolus in more than 60% of all type B-fractures, as soon as in the majority the type A-fractures. Since isolated medial ankle fractures occur very rarely, careful exclusion of further injuries is advisable here. In order to differentiate stable ones from unstable type B ankle injuries, we carry out a manual stress test, if there is less than 2 mm fracture dislocation and a congruent ankle mortise. In this manner we could find that stable lateral ankle fractures are characterized with a combination of an intact dorsal syndesmotic and medial ligament. Stable type B and undisplaced type A fractures were treated conservatively with an ankle brace (Aircast?). Unstable ankle injuries were treated by ORIF. Conservative treatment for undisplaced medial malleolar fractures is recommended, if x-rays showed less than 2 mm dislocation which allows a tibio-talare impingement. Biomechanical investigations could prove a significant increase in ankle joint stability, when an axial load of 300 N was applied to various horizontal loads. The talus does not follow automatically a displaced fibular fracture. The dorsal syndesmotic and the medial deltoid ligaments control ankle joint stability.

Evaluation of Fibular Fracture Type vs Location of Tibial Fixation of Pilon Fractures.

PubMed

Busel, Gennadiy A; Watson, J Tracy; Israel, Heidi

2017-06-01

Comminuted fibular fractures can occur with pilon fractures as a result of valgus stress. Transverse fibular fractures can occur with varus deformation. No definitive guide for determining the proper location of tibial fixation exists. The purpose of this study was to identify optimal plate location for fixation of pilon fractures based on the orientation of the fibular fracture. One hundred two patients with 103 pilon fractures were identified who were definitively treated at our institution from 2004 to 2013. Pilon fractures were classified using the AO/OTA classification and included 43-A through 43-C fractures. Inclusion criteria were age of at least 18 years, associated fibular fracture, and definitive tibial plating. Patients were grouped based on the fibular component fracture type (comminuted vs transverse), and the location of plate fixation (medial vs lateral) was noted. Radiographic outcomes were assessed for mechanical failures. Forty fractures were a result of varus force as evidenced by transverse fracture of the fibula and 63 were due to valgus force with a comminuted fibula. For the transverse fibula group, 14.3% mechanical complications were noted for medially placed plate vs 80% for lateral plating ( P = .006). For the comminuted fibular group, 36.4% of medially placed plates demonstrated mechanical complications vs 16.7% for laterally based plates ( P = .156). Time to weight bearing as tolerated was also noted to be significant between groups plated medially and laterally for the comminuted group ( P = .013). Correctly assessing the fibular component for pilon fractures provides valuable information regarding deforming forces. To limit mechanical complications, tibial plates should be applied in such a way as to resist the original deforming forces. Level of Evidence Level III, comparative study.

The 'trampoline ankle': severe medial malleolar physeal injuries in children and adolescents secondary to multioccupant use of trampolines.

PubMed

Blumetti, Francesco C; Gauthier, Luke; Moroz, Paul J

2016-03-01

The purpose of this study was to describe a series of patients presenting with medial malleolus Salter-Harris types III and IV fractures (MacFarland fractures) related to trampoline use. In total, 11 patients were reviewed retrospectively (mean age: 11.8 years; four boys and seven girls). Salter-Harris type III fractures were more commonly seen (n=7). Undisplaced fractures were more prevalent (n=6). Six children underwent surgical treatment. Average follow-up time was 17.8 months. A medial physeal bar with subsequent growth arrest and ankle deformity was observed in two patients. More than one user was present on the trampoline at the time of the injury in nine of the reported cases. Medial malleolus growth-plate injuries can be seen after trampoline injuries where multiple users were involved. Potential complications including growth arrest can occur.

The operative outcomes of displaced medial-end clavicle fractures.

PubMed

Sidhu, Verinder S; Hermans, Deborah; Duckworth, David G

2015-11-01

Nonoperative treatment of displaced medial clavicle fractures often leads to poor functional outcomes and painful nonunions. This study investigates the functional outcomes of patients undergoing operative fixation of these fractures. We investigated 27 patients undergoing operative fixation of a medial clavicle fracture; 24 had an acute, displaced fracture and 3 had fixation for nonunions. Preoperative radiographs or computed tomography scans were obtained, and data collected included age, sex, mechanism of injury, and fixation method. Follow-up included physical examination and radiographs for assessment of union; Disabilities of the Arm, Shoulder, and Hand scores at 12 months; and the recording of complications. The median age was 37 years (interquartile range, 17-47 years). There were 26 male patients and one female patient included, with 7 physeal injuries and 20 adult injuries. The most common mechanism of fracture was vehicular accident (n = 15). Three patients had operations for nonunions and 2 for a periprosthetic fracture medial to an existing plate. The fracture was fixed with plate and screws in 19 cases and with transosseous sutures in 8 cases. The median Disabilities of the Arm, Shoulder, and Hand score at 12 months was 0.4 (interquartile range, 0-5.0), with a union rate of 100% at 12 months. All patients had full shoulder range of motion at final follow-up and were able to return to preinjury occupational activities. There were no significant complications. Operative fixation of displaced medial clavicle fractures results in anatomic reconstruction and excellent functional outcomes, even in the setting of fixation performed for symptomatic nonunion. Early intervention can minimize the risk of painful nonunion. Crown Copyright © 2015. Published by Elsevier Inc. All rights reserved.

[Progress on treatment and research of quadrilateral plate fractures of acetabular].

PubMed

Peng, Ye; Zhang, Li-hai; Tang, Pei-fu

2015-05-01

Acetabular is an important human joint for weight bearing. Quadrilateral plate is a crucial structure of medial acetabulum with special morphology and important function. Quadrilateral plate fractures are common fracture in acetabulum. Quadrilateral plate fracture is hard to expose and reduction because it is in the medial of acetabulum. At the same time,the bone in the quadrilateral plate is not easy to fixed for thinning bones and adjacent to the articular cavity. The operator should know well about the anatomy and choose the suitable internal fixation. After quadrilateral plate fractures, the femur head maybe displace medially even break into pelvis. That make reduction and treatment always be a challenge. With different kinds of fractures,the efficacy of treatment is not the same. This paper intend to review the relation of anatomic features,approaches, internal fixations, key point of treatment and efficacy.

[Elbow tendinopathy].

PubMed

Dumusc, A; Zufferey, P

2015-03-11

The lateral and medial epicondylitis is often manifested in a professional or in a sport context leading to repetitive wrist movements. The diagnosis is primarily clinical. Additional tests are indicated in chronic evolution and in searching for differential diagnoses. Elbow X-ray can be completed with ultrasound or MRI, the most efficient but expensive diagnostic procedure. There is no consensus on treatment. After a period of rest, stretching then strengthening exercises are recommended. Corticosteroid injections may provide a short-term beneficial effect. Platelet-Rich Plasma injections have recently gained notoriety. In case of failure of treatment, surgery is possible, but only in a minority of patients.

Endoscopic transnasal approach for the treatment of isolated medial orbital blow-out fractures: a prospective study of preoperative and postoperative orbital volume change.

PubMed

Kim, KyoungHoon; Song, KyeongHo; Choi, SooJong; Bae, YongChan; Choi, ChiWon; Oh, HeungChan; Lee, JaeWoo; Nam, SuBong

2012-02-01

Endoscopic transnasal reduction is a safe and effective technique for the treatment of blow-out fractures of the medial orbital wall. However, because this approach does not use rigid permanent material for reconstruction of the fractured medial orbital wall, some degree of herniation of the orbital contents may occur after the intraethmoidal packing material is removed. The purpose of this study was to evaluate the change in orbital volume in patients with medial orbital wall fractures treated through an endoscopic transnasal approach. This study was a prospective analysis that includes 20 patients who underwent endoscopic transnasal reduction of medial orbital wall fractures between April 2007 and December 2008. Computer-assisted orbital volume measurements were made using axial computed tomography. The mean (standard deviation [SD]) volume increase was 2.00 (0.92) cm(3) and the mean (SD) dimension of the fractured orbital wall was 2.76 (0.83) cm(2). After endoscopic surgery, an average (SD) volume decrease of 2.15 (0.91) cm(3) was achieved with ethmoid sinus packing. After removal of the packing materials, 1.14 (0.78) cm(3) increase of the orbital volume was observed. The dimension of the orbital wall fracture significantly correlated with the increased preoperative orbital volume (P = 0.002, r = 0.609); the preoperative increase in the orbital volume also significantly correlated with volume relapse after removal of the packing (P = 0.023, r = 0.452). These findings suggest that in broad orbital wall fractures, reconstruction of the orbital wall by rigid materials or prolongation of the packing period should be considered, because orbital volume can increase again after packing removal, and may thus lead to postoperative complications.

Comparison of surgical techniques of 111 medial malleolar fractures classified by fracture geometry.

PubMed

Ebraheim, Nabil A; Ludwig, Todd; Weston, John T; Carroll, Trevor; Liu, Jiayong

2014-05-01

Evaluation of operative techniques used for medial malleolar fractures by classifying fracture geometry has not been well documented. One hundred eleven patients with medial malleolar fractures (transverse n = 63, oblique n = 29, vertical n = 7, comminuted n = 12) were included in this study. Seventy-two patients had complicating comorbidities. All patients were treated with buttress plate, lag screw, tension band, or K-wire fixation. Treatment outcomes were evaluated on the basis of radiological outcome (union, malunion, delayed union, or nonunion), need for operative revision, presence of postoperative complications, and AOFAS Ankle-Hindfoot score. For transverse fractures, tension band fixation showed the highest rate of union (79%), highest average AOFAS score (86), lowest revision rate (5%), and lowest complication rate (16%). For oblique fractures, lag screws showed the highest rate of union (71%), highest average AOFAS score (80), lowest revision rate (19%), and lowest complication rate (33%) of the commonly used fixation techniques. For vertical fractures, buttress plating was used in every case but 1, achieving union (whether normal or delayed) in all cases with an average AOFAS score of 84, no revisions, and a 17% complication rate. Comminuted fractures had relatively poor outcomes regardless of fixation method. The results of this study suggest that both tension bands and lag screws result in similar rates of union for transverse fractures of the medial malleolus, but that tension band constructs are associated with less need for revision surgery and fewer complications. In addition, our data demonstrate that oblique fractures were most effectively treated with lag screws and that vertical fractures attained superior outcomes with buttress plating. Level III, retrospective comparative series.

The medial femoral wall can play a more important role in unstable intertrochanteric fractures compared with lateral femoral wall: a biomechanical study.

PubMed

Nie, Boyuan; Chen, Xueying; Li, Jing; Wu, Dou; Liu, Qiang

2017-12-28

The major objective of the present study is to investigate the differences in the load and strain changes in the intertrochanteric region of human cadaveric femora between the loss of medial or lateral wall and after treatment with proximal femoral nail antirotation (PFNA). After measuring the geometry of the proximal femur region and modeling the medial or lateral wall defect femoral models, six pairs of freshly frozen human femora were randomly assigned in the medial or lateral wall group. According to a single-leg stance model, an axial loading was applied, and the strain distribution was measured before and after PFNA implantation. The strains of each specimen were recorded at load levels of 350, 700, and 1800 N and the failure load. Paired t test was performed to assess the differences between two groups. The failure mode of almost all defect model femora was consistent with that of the simulated type of intertrochanteric fractures. After the PFNA implantation, the failure mode of almost all stabilized femora was caused by new lateral wall fractures. The failure load of the lateral wall group for defect model femora was significantly higher than that of the medial wall group (p < 0.001). However, the difference disappeared after the PFNA was implanted (p = 0.990). The axial stiffness in all defect model femora showed the same results (p < 0.001). After the PFNA implantation, the axial stiffness of the lateral wall group remained higher than that of the medial wall group (p = 0.001). However, the axial stiffness of the lateral wall group showed that the femora removed from the lateral wall were higher than the PFNA-stabilized femora (p = 0.020). For the axial strain in the anterior wall after the PFNA implantation, the strain of the lateral wall group was significantly lower than that of the medial group (p = 0.003). Nevertheless, for the axial strain of the posterior wall after the PFNA implantation, the strain of the medial wall group was significantly lower than that of the lateral group (p < 0.001). In summary, this study demonstrated that PFNA is an effective intramedullary fixation system for treating unstable intertrochanteric fractures. Compared with the lateral wall, the medial femoral wall is a more important part in the intertrochanteric region. We suggest that in treating intertrochanteric femoral fractures with medial wall fractures, the medial wall fragment should be reset and fixed as much as possible.

Arthroscopic Pullout Fixation for a Small and Comminuted Avulsion Fracture of the Posterior Cruciate Ligament from the Tibia

PubMed Central

Nakagawa, Shuji; Arai, Yuji; Hara, Kunio; Inoue, Hiroaki; Hino, Manabu; Kubo, Toshikazu

2017-01-01

We describe a patient who underwent arthroscopic pullout fixation for a posterior cruciate ligament (PCL) avulsion fracture. A 46-year-old female, injured in a fall while riding a motorcycle, was diagnosed with a right knee PCL tibial attachment avulsion fracture and underwent arthroscopic osteosynthesis. A Kirschner wire was drilled to a point just medial to the medial border of the anterior tibial bony bed. A suture wire was folded into a loop and introduced into the posteromedial compartment via the bone tunnel. A fixation thread was inserted from the posteromedial portal, through the medial and lateral loop wires, and into the posteromedial compartment. The lateral and medial loop wires attached to the thread were pulled to the outside, and the thread was fixed onto the tibia. Three months post-surgery, she returned to her job. This procedure represents a minimally invasive method of treating avulsion fractures of the tibial attachment of the PCL. PMID:29172392

Pure Varus Injury to the Knee Joint.

PubMed

Yoo, Jae Ho; Lee, Jung Ha; Chang, Chong Bum

2015-06-01

A 30-year-old male was involved in a car accident. Radiographs revealed a depressed marginal fracture of the medial tibial plateau and an avulsion fracture of the fibular head. Magnetic resonance imaging showed avulsion fracture of Gerdy's tubercle, injury to the posterior cruciate ligament (PCL), posterior horn of the medial meniscus, and the attachments of the lateral collateral ligament and the biceps femoris tendon. The depressed fracture of the medial tibial plateau was elevated and stabilized using a cannulated screw and washer. The injured lateral and posterolateral corner (PLC) structures were repaired and augmented by PLC reconstruction. However, the avulsion fracture of Gerdy's tubercle was not fixed because it was minimally displaced and the torn PCL was also not repaired or reconstructed. We present a unique case of pure varus injury to the knee joint. This case contributes to our understanding of the mechanism of knee injury and provides insight regarding appropriate treatment plans for this type of injury.

Postero-medial approach for complex tibial plateau injuries with a postero-medial or postero-lateral shear fragment.

PubMed

Berber, Reshid; Lewis, Charlotte P; Copas, David; Forward, Daren P; Moran, Christopher G

2014-04-01

This study demonstrates the utility of a modified postero-medial surgical approach to the knee in treating a series of patients with complex tibial plateau injuries with associated postero-medial and postero-lateral shear fractures. Posterior coronal shear fractures are underappreciated and their clinical relevance has recently been characterised. Less-invasive surgery and indirect reduction techniques are inadequate for treating these coronal plane fractures. Our approach includes an inverted 'L'-shaped incision situated within the posterior flexor knee crease, followed by the retraction or incision of the medial head of the gastrocnemius tendon, while protecting the neurovascular structures. This provides a more extensile exposure, as far as the postero-lateral corner, than previously described. Our case series included eight females and eight males. The average age was 53 years. The majority of these injuries were sustained through high-energy trauma. All patients' fractures were classified as Schatzker grade 4, or above, with a postero-medial split depression. Eight patients had associated postero-lateral corner fractures. Two were open, two had vascular compromise and one had neurological injury. The average time to surgery was 6.4 days (range 0-12), operative time 142 min (range 76-300) and length of stay 17 days (range 7-46). A total of 11 patients were treated using the postero-medial approach alone and in five the treatment was combined with an antero-lateral approach. Two patients suffered a reduced range of movement requiring manipulation and physiotherapy, and three patients had a 5-degree fixed flexion deformity. Two patients developed superficial wound infections treated with antibiotics alone. Anatomical reduction and fracture union was achieved in 15 patients. These are complex fractures to treat, and our modified posterior approach allows direct reduction and optimal positioning of plates to act as buttress devices. It can be extended across the midline to the postero-lateral corner and also allows excellent exposure of the popliteal vessels should concurrent vascular repair be required. Copyright © 2013 Elsevier Ltd. All rights reserved.

[Anatomy of fractures of the inferior scapular angle].

PubMed

Bartoníček, J; Tuček, M; Malík, J

2018-01-01

The aim of this study is to describe the anatomy of fractures of the inferior angle and the adjacent part of the scapular body, based on 3D CT reconstructions. In a series of 375 scapular fractures, we identified a total of 20 fractures of the inferior angle of the scapular body (13 men, 7 women), with a mean patient age of 50 years (range 3373). In all fractures, 3D CT reconstructions were obtained, allowing an objective evaluation of the fracture pattern with a focus on the size and shape of the inferior angle fragment, propagation of the fracture line to the lateral and medial borders of the infraspinous part of the scapular body, fragment displacement and any additional fracture of the ipsilateral scapula and the shoulder girdle. We identified a total of 5 types of fracture involving the distal half of the infraspinous part of the scapular body. The first type, recorded in 5 cases, affected only the apex of the inferior angle, with a small part of the adjacent medial border. The second type, occurring in 4 cases, involved fractures separating the entire inferior angle. The third type, represented by 4 cases, was characterized by a fracture line starting medially close above the inferior angle and passing proximolaterally. The separated fragment had a shape of a big drop, carrying also the distal half of the lateral pillar in addition to the inferior angle. In the fourth type identified in 5 fractures, the separated fragment was formed both by the inferior angle and a variable part of the medial border. The fifth type, being by its nature a transition to the fracture of the infraspinous part of the body, was recorded in 2 cases, with the same V-shaped fragment. Fractures of the inferior angle and the adjacent part of the scapular body are groups of fractures differing from other infraspinous fractures of the scapular body. Although these fractures are highly variable in terms of shape, they have the same course of fracture line and the manner of displacement.Key words: scapula scapula fractures scapular body fractures inferior angle classification of scapular body fractures.

Posterior medial meniscus root ligament lesions: MRI classification and associated findings.

PubMed

Choi, Ja-Young; Chang, Eric Y; Cunha, Guilherme M; Tafur, Monica; Statum, Sheronda; Chung, Christine B

2014-12-01

The purposes of this study were to determine the prevalence of altered MRI appearances of "posterior medial meniscus root ligament (PMMRL)" lesions, introduce a classification of lesion types, and report associated findings. We retrospectively reviewed 419 knee MRI studies to identify the presence of PMMRL lesions. Classification was established on the basis of lesions encountered. The medial compartment was assessed for medial meniscal tears in the meniscus proper, medial meniscal extrusion, insertional PMMRL osseous changes, regional synovitis, osteoarthritis, insufficiency fracture, and cruciate ligament abnormality. PMMRL abnormalities occurred in 28.6% (120/419) of the studies: degeneration, 14.3% (60/419) and tear, 14.3% (60/419). Our classification system included degeneration and tearing. Tearing was categorized as partial or complete with delineation of the point of failure as entheseal, midsubstance, or junction to meniscus. Of all tears, 93.3% (56/60) occurred at the meniscal junction. Univariate analysis revealed significant differences between the knees with and without PMMRL lesions in age, medial meniscal tear, medial meniscal extrusion, insertional PMMRL osseous change, regional synovitis, osteoarthritis, insufficiency fracture (p=0.017), and cruciate ligament degeneration (p<0.001). PMMRL lesions are commonly detected in symptomatic patients. We have introduced an MRI classification system. PMMRL lesions are significantly associated with age, medial meniscal tears, medial meniscal extrusion, insertional PMMRL osseous change, regional synovitis, osteoarthritis, insufficiency fracture, and cruciate ligament degeneration.

EXTRA-ARTICULAR FRACTURE OF THE MEDIAL END OF THE CLAVICLE ASSOCIATED WITH TYPE IV ACROMIOCLAVICULAR DISLOCATION: CAAE REPORT

PubMed Central

Correa, Mário Chaves; Gonçalves, Lucas Braga Jacques; Vilela, Jose Carlos Souza; Leonel, Igor Lima; Costa, Lincoln Paiva; de Andrade, Ronaldo Percopi

2015-01-01

Fractures of the clavicle and acromioclavicular dislocations are very common injuries when they occur separately. The combination of an acromioclavicular dislocation and a fracture of the lateral third of the clavicle is not rare. However, there are very few reported cases of acromioclavicular dislocations associated with fractures of the middle third of the clavicle; those associated with fractures of the medial third are even rarer. We report the case of an adult male who suffered an acromioclavicular dislocation (type IV) associated with a displaced extra-articular fracture of the medial end of the clavicle (Almann group 3) in a cycling accident. The patient was treated during the acute phase with open reduction and internal fixation of the two lesions. At the clinical evaluation 12 months after the surgery, the patient was asymptomatic, with full active and passive mobility, and normal strength and endurance of the shoulder girdle. Radiographs and a three-dimensional CT scan showed persistent posterosuperior subluxation of the acromioclavicular joint and anatomical consolidation of the clavicular fracture. PMID:27027060

EXTRA-ARTICULAR FRACTURE OF THE MEDIAL END OF THE CLAVICLE ASSOCIATED WITH TYPE IV ACROMIOCLAVICULAR DISLOCATION: CAAE REPORT.

PubMed

Correa, Mário Chaves; Gonçalves, Lucas Braga Jacques; Vilela, Jose Carlos Souza; Leonel, Igor Lima; Costa, Lincoln Paiva; de Andrade, Ronaldo Percopi

2011-01-01

Fractures of the clavicle and acromioclavicular dislocations are very common injuries when they occur separately. The combination of an acromioclavicular dislocation and a fracture of the lateral third of the clavicle is not rare. However, there are very few reported cases of acromioclavicular dislocations associated with fractures of the middle third of the clavicle; those associated with fractures of the medial third are even rarer. We report the case of an adult male who suffered an acromioclavicular dislocation (type IV) associated with a displaced extra-articular fracture of the medial end of the clavicle (Almann group 3) in a cycling accident. The patient was treated during the acute phase with open reduction and internal fixation of the two lesions. At the clinical evaluation 12 months after the surgery, the patient was asymptomatic, with full active and passive mobility, and normal strength and endurance of the shoulder girdle. Radiographs and a three-dimensional CT scan showed persistent posterosuperior subluxation of the acromioclavicular joint and anatomical consolidation of the clavicular fracture.

[Conventional X-Rays of Ankle Joint Fractures in Older Patients are Not Always Predictive].

PubMed

Jubel, A; Faymonville, C; Andermahr, J; Boxberg, S; Schiffer, G

2017-02-01

Background: Ankle fractures are extremely common in the elderly, with an incidence of up to 39 fractures per 100,000 persons per year. We found a discrepancy between intraoperative findings and preoperative X-ray findings. It was suggested that many relevant lesions of the ankle joint in the elderly cannot be detected with plain X-rays. Methods: Complete data sets and preoperative X-rays of 84 patients aged above 60 years with ankle fractures were analysed retrospectively. There were 59 women and 25 men, with a mean age of 69.9 years. Operation reports and preoperative X-rays were analysed with respect to four relevant lesions: multifragmentary fracture pattern of the lateral malleolus, involvement of the medial malleolus, posterior malleolar fractures and bony avulsion of anterior syndesmosis. Sensitivity, specificity, positive predictive value, negative predictive value, accuracy and prevalence were calculated. Results: The prevalence of specific ankle lesions in the analyzed cohort was 24 % for the multifragmentary fracture pattern of the lateral malleolus, 38 % for fractures of the medial malleolus, 25 % for posterior malleolar fractures and 22.6 % for bony avulsions of the anterior syndesmosis. Multifragmentary fracture patterns of the lateral malleolus (sensitivity 0 %) and bony avulsions of the anterior syndesmosis (sensitivity 5 %) could not be detected in plain X-rays of the ankle joint at all. Fractures of the medial malleolus and involvement of the dorsal tibial facet were detected with a sensitivity of 96.8 % and 76.2 %, respectively, and specificity of 100 % in both cases. Conclusions: This study confirms that complex fracture patterns, such as multifragmentary involvement of the lateral malleolus, additional fracture of the medial malleolus, involvement of the dorsal tibial facet or bony avulsion of the anterior syndesmosis are common in ankle fractures of the elderly. Therefore, CT scans should be routinely considered for primary diagnosis, in addition to plain X-rays. Georg Thieme Verlag KG Stuttgart · New York.

An interesting radiological picture of post traumatic TMJ ankylosis due to sagittal condylar fracture.

PubMed

Kumar L K, Surej; Manuel, Suvy; Kurien, Nikhil M; Khalam, Sherin A; P Menon, Varun

2015-01-01

In a condylar fracture whether to intervene or to go for conservative management still remains a dilemma. Studies and hypothesis suggests that it's medially dislocated condylar fracture segment that is more likely to ankylose, moreover no consensus have been put forth as to whether to remove the medially displaced fracture segment. The current article describes a case of unilateral temporomandibular joint (TMJ) ankylosis, which resulted as a sequlae from conservative management of a bilateral condylar fracture of which, the ankylosed side had a sagittal fracture of condyle. In our case the post trauma CT shows the lateral segment abutting with the arch and that the area has become ankylotic in a span of 2 years. Here we report a case of posttraumatic unilateral TMJ ankylosis resulting from closed reduction of a bilateral condylar fracture with interesting radiological findings. We have tried to discuss a rather interesting radiological picture of posttraumatic TMJ ankylosis which resulted as a sequlae from conservative management of a bilateral condylar fracture. The dilemma for a clinician as to whether to intervene in a condylar fracture or to go for conservative management still remains at large. As in this case the medial fracture segment was intact and the lateral segment was resulting in ankylosis. Copyright © 2015. Published by Elsevier Ltd.

Comorbidities in rotator cuff disease: a case-control study.

PubMed

Titchener, Andrew G; White, Jonathan J E; Hinchliffe, Sally R; Tambe, Amol A; Hubbard, Richard B; Clark, David I

2014-09-01

Rotator cuff disease is a common condition in the general population, but relatively little is known about its associated risk factors. We have undertaken a large case-control study using The Health Improvement Network database to assess and to quantify the relative contributions of some constitutional and environmental risk factors for rotator cuff disease in the community. Our data set included 5000 patients with rotator cuff disease who were individually matched with a single control by age, sex, and general practice (primary care practice). The median age at diagnosis was 55 years (interquartile range, 44-65 years). Multivariate analysis showed that the risk factors associated with rotator cuff disease were Achilles tendinitis (odds ratio [OR] = 1.78), trigger finger (OR = 1.99), lateral epicondylitis (OR = 1.71), and carpal tunnel syndrome (OR = 1.55). Oral corticosteroid therapy (OR = 2.03), oral antidiabetic use (OR = 1.66), insulin use (OR = 1.77), and "overweight" body mass index of 25.1 to 30 (OR = 1.15) were also significantly associated. Current or previous smoking history, body mass index of greater than 30, any alcohol intake, medial epicondylitis, de Quervain syndrome, cubital tunnel syndrome, and rheumatoid arthritis were not found to be associated with rotator cuff disease. We have identified a number of comorbidities and risk factors for rotator cuff disease. These include lateral epicondylitis, carpal tunnel syndrome, trigger finger, Achilles tendinitis, oral corticosteroid use, and diabetes mellitus. The findings should alert the clinician to comorbid pathologic processes and guide future research into the etiology of this condition. Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.

Role for Primary Repair of Deltoid Ligament Complex in Ankle Fractures.

PubMed

Rigby, Ryan B; Scott, Ryan T

2018-04-01

Acute deltoid injuries may occur with ankle fractures. They are often left to heal without repair, possibly leading to chronic medial ankle instability. Stress radiographs identify the need for surgical repair of fractures or soft tissue damage. Gravity stress views have benefits over manually stressing the ankle. MRI can explore the extent of medial soft tissue injuries. Arthroscopy can evaluate and potentially treat deltoid injuries. Interposition of the deltoid may preclude adequate fracture reduction. Except with deltoid tear, fractures should be reduced and fixated, then the deltoid assessed. With persistent instability, primary repair may prevent long-term sequelae. Copyright © 2017 Elsevier Inc. All rights reserved.

Arthroscopic fixation of the clavicle shaft fracture.

PubMed

Kim, Yang-Soo; Lee, Hyo-Jin; Kim, Jong-Ick; Yang, Hyo; Jin, Hong-Ki; Patel, Hiren Kirtibhai; Kim, Jong-Ho; Park, In

2017-01-01

This article describes an arthroscopic technique for the fixation of clavicle shaft fractures. A viewing portal is made 2 cm anterior to the fracture site, and a working portal is made 2 cm lateral to the fracture site. The guide wire for a 4.0-mm cannulated screw is inserted through the fracture site to the medial fracture fragment under arthroscopic guidance. Through the medial fragment, the guide wire is delivered through the skin anteriorly. The fracture is reduced, and then, the guide wire is drilled back across the fracture site to the lateral fracture fragment. After confirming the reduction under arthroscopy, the appropriately sized cannulated screw is inserted after reaming. This arthroscopic technique would be useful for the precise reduction and minimal invasive fixation of clavicle shaft fractures. Preliminary results are encouraging, and further studies with long-term follow-up are needed to determine the precise indications and limitations of the procedure.

Elbow arthroscopy.

PubMed

Dodson, Christopher C; Nho, Shane J; Williams, Riley J; Altchek, David W

2008-10-01

Arthroscopy of the elbow was originally considered to be an unsafe procedure because of the small size of the elbow joint capsule and its proximity to several crucial neurovascular structures. Over the past decade, however, the procedure has become safer and more effective. These improvements can be attributed to a better understanding of elbow anatomy and of the disorders about the elbow as well as to advances in arthroscopic equipment and surgical technique. The most common indications for elbow arthroscopy include removal of loose bodies, synovectomy, débridement and/or excision of osteophytes, capsular release, and the assessment and treatment of osteochondritis dissecans. More recent advances have expanded the indications of elbow arthroscopy to include fracture management (eg, radial head fractures) and the treatment of lateral epicondylitis.

Early Weightbearing After Operatively Treated Ankle Fractures: A Biomechanical Analysis.

PubMed

Tan, Eric W; Sirisreetreerux, Norachart; Paez, Adrian G; Parks, Brent G; Schon, Lew C; Hasenboehler, Erik A

2016-06-01

No consensus exists regarding the timing of weightbearing after surgical fixation of unstable traumatic ankle fractures. We evaluated fracture displacement and timing of displacement with simulated early weightbearing in a cadaveric model. Twenty-four fresh-frozen lower extremities were assigned to Group 1, bimalleolar ankle fracture (n=6); Group 2, trimalleolar ankle fracture with unfixed small posterior malleolar fracture (n=9); or Group 3, trimalleolar ankle fracture with fixed large posterior malleolar fracture (n=9) and tested with axial compressive load at 3 Hz from 0 to 1000 N for 250 000 cycles to simulate 5 weeks of full weightbearing. Displacement was measured by differential variable reluctance transducer. The average motion at all fracture sites in all groups was significantly less than 1 mm (P < .05). Group 1 displacement of the lateral and medial malleolus fracture was 0.1±0.1 mm and 0.4±0.4 mm, respectively. Group 2 displacement of the lateral, medial, and posterior malleolar fracture was 0.6±0.4 mm, 0.5±0.4 mm, and 0.5±0.6 mm, respectively. Group 3 displacement of the lateral, medial, and posterior malleolar fracture was 0.1±0.1 mm, 0.5±0.7 mm, and 0.5±0.4 mm, respectively. The majority of displacement (64.0% to 92.3%) occurred in the first 50 000 cycles. There was no correlation between fracture displacement and bone mineral density. No significant fracture displacement, no hardware failure, and no new fractures occurred in a cadaveric model of early weightbearing in unstable ankle fracture after open reduction and internal fixation. This study supports further investigation of early weightbearing postoperative protocols after fixation of unstable ankle fractures. © The Author(s) 2016.

Simultaneous avulsion fracture of the posterior medial and posterior lateral meniscus root: a case report and review of the literature.

PubMed

Feucht, Matthias J; Salzmann, Gian M; Pestka, Jan M; Südkamp, Norbert P; Niemeyer, Philipp

2014-04-01

Injuries of the meniscus roots are increasingly recognized as a serious knee joint pathology. An avulsion fracture of the meniscus root is a rare variant of this injury pattern. In this article, a case of a traumatic simultaneous avulsion fracture of both the posterior medial and posterior lateral meniscus root associated with a tear of the anterior cruciate ligament is presented. Both avulsion fractures were treated by indirect arthroscopic transtibial pullout fixation of the bony fragment. Based on the findings of our literature review, root avulsion fractures seem to be more common in young male patients after an acute trauma to the knee joint.

Medial orbital wall reconstruction with flexible Ethisorb patches.

PubMed

Pohlenz, P; Adler, W; Li, L; Schmelzle, R; Klatt, J

2013-03-01

The aim of this study was to analyse the long-term result after reconstruction of the medial orbital wall with a flexible, biodegradable material (Ethisorb). During a period of almost 8 years, 31 patients with a medial orbital wall fracture were analysed retrospectively. Inclusion criteria were patients with a maximum size fracture of the orbital medial wall measuring 1.5-2 cm(2). Exophthalmos, enophthalmos, bulbus motility, diplopia and skin sensation were investigated over a period of 6 months. In all patients, the medial orbital wall was reconstructed with Ethisorb patches. No significant intraoperative complications were detected. No postoperative infection, abscess or seroma was found in any of the patients receiving an Ethisorb patch. The advantage of the semiflexibility of the Ethisorb patch is that it supplies an anatomically correct fit to the orbital medial wall but does not require fixation by screws or the use of sutures. The low rate of reported bulbus motility disturbance, diplopia, exophthalmos and enophthalmos demonstrates acceptable results after medial orbital wall reconstruction using the Ethisorb patch.

Fracture of the medial intercondylar eminence of the tibia in horses treated by arthroscopic fragment removal (21 horses).

PubMed

Rubio-Martínez, L M; Redding, W R; Bladon, B; Wilderjans, H; Payne, R J; Tessier, C; Geffroy, O; Parker, R; Bell, C; Collingwood, F A

2018-01-01

Fractures of the medial intercondylar eminence of the tibia (MICET) are scarcely reported in horses. To report the clinical and diagnostic findings, surgical treatment and outcome in a series of horses presented with MICET fracture and treated with arthroscopic fragment removal. Multicentre retrospective case series. Case records of horses diagnosed with MICET fractures that had undergone surgical treatment were reviewed. Follow-up information was obtained from re-examination visits and/or owners. Twenty-one cases were identified at 9 equine hospitals between 2004 and 2016. A history of trauma and acute onset of lameness was reported in 12 horses. All cases underwent fracture removal via arthroscopy of the medial femorotibial joint. The cranial cruciate ligament was intact in 6 horses and damaged in 15 horses (damage was ≤25% [n = 9], 25-50% [n = 4] or ≥50% [n = 2] of the cross-sectional area). The cranial ligament of the medial meniscus was damaged in 11 horses (≤25% [n = 8], 25-50% [n = 3]). The medial meniscus was damaged in 5 horses and articular cartilage damage was identified in 14 horses (mild [n = 8], moderate [n = 6]). Follow-up information (median 14 months; 4 months-6 years) was available for 20 cases; 2 horses were sound but convalescing; 13 horses were sound and returned to their previous or expected use. Of the 4 horses with the most severe changes to the articular soft tissue structures, 2 remained lame and 2 were subjected to euthanasia because of persistent lameness. The retrospective, multicentre nature of this study and the limited number of horses are the main limitations. Fractures of the MICET are commonly associated with a traumatic event. Prompt diagnosis and early arthroscopic removal of the fracture are recommended. © 2017 The Authors. Equine Veterinary Journal published by John Wiley & Sons Ltd on behalf of EVJ Ltd.

An evidence-based evaluation on the use of platelet rich plasma in orthopedics – a review of the literature

PubMed Central

Hussain, Nasir; Johal, Herman; Bhandari, Mohit

2017-01-01

Within orthopedics, the use of platelet-rich plasma (PRP) has been rapidly increasing in popularity, however, its true effectiveness has yet to be fully established. Several studies find that injecting PRP to the site of injury does not provide any significant benefit with respect to clinical outcomes; however, many others report the contrary. Due to the conflicting evidence and multiple meta-analyses conducted on the topic, a literature review of high-quality evidence on the use of PRP for common orthopaedic conditions was performed. Thus far, the evidence appears to suggest that PRP may provide some benefit in patients who present with knee osteoarthritis or lateral epicondylitis. On the other hand, evidence appears to be inconsistent or shows a minimal benefit for PRP usage in rotator cuff repair, patellar and Achilles tendinopathies, hamstring injuries, anterior cruciate ligament (ACL) repair, and medial epicondylitis. There is limited confidence in the conclusions from the published meta-analyses due to issues with statistical pooling, and limited subgroup analyses exploring the substantial heterogeneity across studies. Evidence-based clinicians considering the use of PRP in their patients with musculoskeletal injuries should be weary that the literature appears to be inconsistent and thus far, inconclusive. PMID:28990574

Foot fractures frequently misdiagnosed as ankle sprains.

PubMed

Judd, Daniel B; Kim, David H

2002-09-01

Most ankle injuries are straightforward ligamentous injuries. However, the clinical presentation of subtle fractures can be similar to that of ankle sprains, and these fractures are frequently missed on initial examination. Fractures of the talar dome may be medial or lateral, and they are usually the result of inversion injuries, although medial injuries may be atraumatic. Lateral talar process fractures are characterized by point tenderness over the lateral process. Posterior talar process fractures are often associated with tenderness to deep palpation anterior to the Achilles tendon over the posterolateral talus, and plantar flexion may exacerbate the pain. These fractures can often be managed nonsurgically with nonweight-bearing status and a short leg cast worn for approximately four weeks. Delays in treatment can result in long-term disability and surgery. Computed tomographic scans or magnetic resonance imaging may be required because these fractures are difficult to detect on plain films.

Gravity versus manual external rotation stress view in evaluating ankle stability: a prospective study.

PubMed

LeBa, Thu-Ba; Gugala, Zbigniew; Morris, Randal P; Panchbhavi, Vinod K

2015-06-01

The purpose of this prospective study was to determine whether gravity versus manual external rotation stress testing effectively detects widening of the medial clear space in isolated ankle fractures when compared with the uninjured contralateral side. Manual external rotation stress and gravity stress tests were performed on injured and uninjured ankles of ankle fracture patients in a clinic setting. Medial clear space measurements were recorded and differences between gravity and manual stress views were determined. Twenty consecutive patients with ankle injury were enrolled in the study. When compared with the uninjured side, gravity stress views showed a statistically significant (P = .017) increase in medial clear space widening (1.85 ± 1.07 mm) compared with manual stress view widening (1.35 ± 1.04 mm). This study suggests that gravity stress views are as effective as manual external rotation stress views in detecting medial clear space widening in isolated fibular fractures. Diagnostic, Level II: Prospective, comparative trial. © 2014 The Author(s).

Case report: multifocal subchondral stress fractures of the femoral heads and tibial condyles in a young military recruit.

PubMed

Yoon, Pil Whan; Yoo, Jeong Joon; Yoon, Kang Sup; Kim, Hee Joong

2012-03-01

Subchondral stress fractures of the femoral head may be either of the insufficiency-type with poor quality bone or the fatigue-type with normal quality bone but subject to high repetitive stresses. Unlike osteonecrosis, multiple site involvement rarely has been reported for subchondral stress fractures. We describe a case of multifocal subchondral stress fractures involving femoral heads and medial tibial condyles bilaterally within 2 weeks. A 27-year-old military recruit began having left knee pain after 2 weeks of basic training, without any injury. Subsequently, right knee, right hip, and left hip pain developed sequentially within 2 weeks. The diagnosis of multifocal subchondral stress fracture was confirmed by plain radiographs and MR images. Nonoperative treatment of the subchondral stress fractures of both medial tibial condyles and the left uncollapsed femoral head resulted in resolution of symptoms. The collapsed right femoral head was treated with a fibular strut allograft to restore congruity and healed without further collapse. There has been one case report in which an insufficiency-type subchondral stress fracture of the femoral head and medial femoral condyle occurred within a 2-year interval. Because the incidence of bilateral subchondral stress fractures of the femoral head is low and multifocal involvement has not been reported, multifocal subchondral stress fractures can be confused with multifocal osteonecrosis. Our case shows that subchondral stress fractures can occur in multiple sites almost simultaneously.

Lower limb stress fractures in sport: Optimising their management and outcome

PubMed Central

Robertson, Greg A J; Wood, Alexander M

2017-01-01

Stress fractures in sport are becoming increasing more common, comprising up to 10% of all of sporting injuries. Around 90% of such injuries are located in the lower limb. This articles aims to define the optimal management of lower limb stress fractures in the athlete, with a view to maximise return rates and minimise return times to sport. Treatment planning of this condition is specific to the location of the injury. However, there remains a clear division of stress fractures by “high” and “low” risk. “Low risk” stress fractures are those with a low probability of fracture propagation, delayed union, or non-union, and so can be managed reliably with rest and exercise limitation. These include stress fractures of the Postero-Medial Tibial Diaphysis, Metatarsal Shafts, Distal Fibula, Medial Femoral Neck, Femoral Shaft and Calcaneus. “High risk” stress fractures, in contrast, have increased rates of fracture propagation, displacement, delayed and non-union, and so require immediate cessation of activity, with orthopaedic referral, to assess the need for surgical intervention. These include stress fractures of the Anterior Tibial Diaphysis, Fifth Metatarsal Base, Medial Malleolus, Lateral Femoral Neck, Tarsal Navicular and Great Toe Sesamoids. In order to establish the optimal methods for managing these injuries, we present and review the current evidence which guides the treatment of stress fractures in athletes. From this, we note an increased role for surgical management of certain high risk stress fractures to improve return times and rates to sport. Following this, key recommendations are provided for the management of the common stress fracture types seen in the athlete. Five case reports are also presented to illustrate the application of sport-focussed lower limb stress fracture treatment in the clinical setting. PMID:28361017

Medial malleolar fractures: a biomechanical study of fixation techniques.

PubMed

Fowler, T Ty; Pugh, Kevin J; Litsky, Alan S; Taylor, Benjamin C; French, Bruce G

2011-08-08

Fracture fixation of the medial malleolus in rotationally unstable ankle fractures typically results in healing with current fixation methods. However, when failure occurs, pullout of the screws from tension, compression, and rotational forces is predictable. We sought to biomechanically test a relatively new technique of bicortical screw fixation for medial malleoli fractures. Also, the AO group recommends tension-band fixation of small avulsion type fractures of the medial malleolus that are unacceptable for screw fixation. A well-documented complication of this technique is prominent symptomatic implants and secondary surgery for implant removal. Replacing stainless steel 18-gauge wire with FiberWire suture could theoretically decrease symptomatic implants. Therefore, a second goal was to biomechanically compare these 2 tension-band constructs. Using a tibial Sawbones model, 2 bicortical screws were compared with 2 unicortical cancellous screws on a servohydraulic test frame in offset axial, transverse, and tension loading. Second, tension-band fixation using stainless steel wire was compared with FiberWire under tensile loads. Bicortical screw fixation was statistically the stiffest construct under tension loading conditions compared to unicortical screw fixation and tension-band techniques with FiberWire or stainless steel wire. In fact, unicortical screw fixation had only 10% of the stiffness as demonstrated in the bicortical technique. In a direct comparison, tension-band fixation using stainless steel wire was statistically stiffer than the FiberWire construct. Copyright 2011, SLACK Incorporated.

Ankle stress test for predicting the need for surgical fixation of isolated fibular fractures.

PubMed

Egol, Kenneth A; Amirtharajah, Mohana; Amirtharage, Mohana; Tejwani, Nirmal C; Capla, Edward L; Koval, Kenneth J

2004-11-01

The purpose of this study was to confirm the prevalence of medial ankle widening among patients with an isolated fibular fracture and to determine the functional outcome of nonoperative treatment despite a diagnosis of a supination-external rotation stage-IV injury based on stress radiography. One hundred and one patients with evidence of an isolated fibular fracture and an intact mortise seen on a standard ankle trauma radiograph series were evaluated with stress radiographs. Clinical signs were recorded at the time of presentation. A positive stress test was defined as > or =4 mm of widening of the medial clear space. Patients with a negative stress test were treated nonoperatively, those with a positive stress test and clinical signs of medial injury were treated surgically, and those with a positive stress test and no signs of medial injury were treated according to the preference of the surgeon and patient. The patients were followed prospectively with radiographs and ankle outcome scores. Sixty-six (65%) of the 101 patients had a positive stress radiograph. Thirty-six of them had signs of medial injury, and thirty had no medial injury. With regard to predicting a positive stress radiograph, medial tenderness had a sensitivity of 56% and a specificity of 80%, swelling had a sensitivity of 55% and a specificity of 71%, and ecchymosis had a sensitivity of 26% and a specificity of 91%. Of the subset of patients without signs of medial injury, twenty were treated nonoperatively (group I) and ten were treated operatively (group II). Two of the twenty patients in group I had evidence of persistent widening of the medial clear space at the time of the latest follow-up (mean, 7.4 months); only one of those patients was symptomatic. The average American Orthopaedic Foot and Ankle Society (AOFAS) score was 94 points in group I and 93 points in group II. We found a high rate of positive stress radiographs for patients who presented with an isolated fibular fracture and an intact ankle mortise on the initial radiographs. Medial tenderness, swelling, and ecchymosis were not sensitive with regard to predicting widening of the medial clear space on stress radiographs. All of the patients with a positive stress radiograph and no clinical symptoms who were treated without surgery had a good or excellent clinical result.

Ability of modern distal tibia plates to stabilize comminuted pilon fracture fragments: Is dual plate fixation necessary?

PubMed

Penny, Phillip; Swords, Michael; Heisler, Jason; Cien, Adam; Sands, Andrew; Cole, Peter

2016-08-01

The purpose of this study was to examine the screw trajectory of ten commercially available distal tibia plates and compare them to common fracture patterns seen in OTA C type pilon fractures to determine their ability to stabilize the three most common fracture fragments while buttressing anterolateral zones of comminution. We hypothesized that a single plate for the distal tibia would fail to adequately stabilize all three main fracture fragments and zones of comminution in complex pilon fractures. Ten synthetic distal tibia sawbones models were used in conjunction with ten different locking distal tibia plate designs from three manufacturers (Depuy Synthes, J&J Co, Paoli, PA; Smith & Nephew, Memphis, TN; and Stryker, Mawa, NJ). Both medial and anterolateral plates from each company were utilized and separately applied to an individual sawbone model. Three implants allowing variable angle screw placement were used. The location of the locking screws and buttress effect 1cm above the articular surface was noted for each implant using axial computed tomography (CT). The images were then compared to a recently published "pilon fracture map" using an overlay technique to establish the relationship between screw location and known common fracture lines and areas of comminution. Each of the three main fragments was considered "captured" by a screw if it was purchased by at least two screws thereby controlling rotational forces on each fragment. Three of four anterolateral plates lacked stable fixation in the medial fragment. Of the 4 anterolateral plates used, only the variable angle anterolateral plate by Depuy Synthes captured the medial fragment with two screws. All four anterolateral plates buttressed the area of highest comminution and had an average of 1.25 screws in the medial fragment and an average of 3 screws in the posterolateral fragment. All five direct medial plates had variable fixation within anterolateral and posterolateral fragments with an average of 1.8 screws in the anterolateral fragment and an average of 1.3 screws in the posterolateral fragment. The Depuy Synthes variable angle anterolateral plate allowed for fixation of the medial fragment with two screws while simultaneously buttressing the zone of highest comminution and capturing both the anterolateral and posterolateral fragments with five and three screws respectively. The variable angle anteromedial plate by Depuy Synthes captured all three main fracture fragments but it did not buttress the anterolateral zone of comminution. In OTA 43C type pilon fractures, 8 out of 10 studied commercially available implants precontoured for the distal tibia, do not adequately stabilize the three primary fracture fragments typically seen in these injuries. Anterolateral plates were superior in addressing the coronal primary fracture line across the apex of the plafond, and buttressing the zone of comminution. None of the available plates can substitute for an understanding of the fracture planes and fragments typically seen in complex intra-articular tibia fractures and the addition of a second plate is necessary for adequate stability. Level IV. Copyright © 2016 Elsevier Ltd. All rights reserved.

[Intramedullary nailing in diaphyseal clavicle fractures using minimally invasive percutaneous reduction].

PubMed

Müller, M; Freude, T; Stöckle, U; Kraus, T M

2017-02-01

Closed reduction and intramedullary nailing is common in diaphyseal clavicle fractures. The aim of this report is to demonstrate a surgical method with minimally invasive percutaneous reduction in cases where closed reduction fails. The procedure is associated with good cosmetic results. Percutaneous reduction using two reduction forceps enables intramedullary nailing without an open procedure. Open, multifragmented or non-dislocated fractures, oblique fractures due to postoperative dislocation or shortening risk, fracture having potential to become compound fractures, neurovascular complications, pseudoarthroses. The patient is in beach-chair position. After an incision, the nail is entered from medial, two reduction forceps are mounted percutaneously at the lateral and medial fragment. After reduction the nail is pushed forward into the lateral fragment. Thereby, the fracture hematoma is not disturbed for the most part. Early functional rehabilitation with maximal abduction and anteversion of 90° for 6 weeks. Anatomic reduction can be achieved with mild cosmetic impairment.

Snapping plicae associated with radiocapitellar chondromalacia.

PubMed

Antuna, S A; O'Driscoll, S W

2001-05-01

Painful snapping of the elbow joint is usually attributed to intra-articular loose bodies, instability, or medial dislocation of the triceps muscle over the medial epicondyle. We report our experience with 14 patients who were treated arthroscopically for snapping elbow that was found to be caused by hypertrophic synovial folds associated with radiocapitellar chondromalacia. Case series. The records of 14 patients who were treated arthroscopically for painful snapping elbows caused by intra-articular plicae were reviewed. There were 6 women and 8 men with an average age of 36 years (range, 27 to 48 years). Nine patients had had some type of trauma to the joint. Four patients had been previously diagnosed with lateral epicondylitis and 5 with intra-articular loose bodies. The average time from initial onset of symptoms to treatment was 13 months (range, 8 to 36 months). Average follow-up was 24 months (range, 6 to 66 months). All patients complained of painful snapping in the posterolateral or anterolateral aspect of the elbow. The snapping occurred between 90 degrees and 110 degrees of flexion with the forearm in pronation. In 7 patients, the snapping was reproducible by passively flexing the pronated elbow, which we refer to as the flexion-pronation test. At the time of arthroscopic surgery, all patients had a thickened synovial plica that would snap back and forward over the radial head, usually associated with a chondromalacic area on the radial head. Twelve patients had complete relief of their snapping after surgery. One patient in whom there was associated posterolateral rotatory elbow instability did not improve. One patient became asymptomatic for 4 years but then had recurrence of her symptoms, which persisted despite 2 subsequent arthroscopies. The presence of synovial plicae in the radiocapitellar joint must be considered in the differential diagnosis of painful snapping elbow. Arthroscopy confirms the diagnosis and allows excision of the plica.

Osteosynthesis of fractures of the femur with flexible metallic intramedullary nails.

PubMed

Firica, A; Troianescu, O; Petre, M

1978-04-01

The authors discuss their use of Ender's method in the treatment of fractures of the femur. The diameter and length of the nails depends on the type of fracture. 1) Three nails of 4 mm diameter are introduced in parallel from the medial condyle in fractures of the femoral neck; 2) 5 mm nails are used, in similar fashion, for the fixation of intertrochanteric and subtrochanteric fractures; 3) 5 mm nails are used for diaphyseal, supracondylar and intercondylar fractures, introduced in crossed fashion ("Eiffel Tower" technique) from both medial and lateral condyles. This method of fixation has proved to be extremely stable. The operation itself is quick, with no blood loss or shock. The patient can resume partial weight bearing after a week in stabilised intertrochanteric and shaft fractures, after a month in less stable types, and after three to four months in fractures of the neck of the femur. This report is based on the first 250 cases treated by this method.

Role of Ankle Arthroscopy in Management of Acute Ankle Fracture.

PubMed

Chan, Kwok Bill; Lui, Tun Hing

2016-11-01

To report the operative findings of ankle arthroscopy during open reduction and internal fixation of acute ankle fractures. This was a retrospective review of 254 consecutive patients with acute ankle fractures who were treated with open reduction and internal fixation of the fractures, and ankle arthroscopy was performed at the same time. The accuracy of fracture reduction, the presence of syndesmosis disruption and its reduction, and the presence of ligamentous injuries and osteochondral lesions were documented. Second-look ankle arthroscopy was performed during syndesmosis screw removal 6 weeks after the key operation. There were 6 patients with Weber A, 177 patients with Weber B, 51 patients with Weber C, and 20 patients with isolated medial malleolar fractures. Syndesmosis disruption was present in 0% of patients with Weber A fracture, 52% of patients with Weber B fracture, 92% of patients with Weber C fracture, and 20% of the patients with isolated medial malleolar fracture. Three patients with Weber B and one patient with Weber C fracture have occult syndesmosis instability after screw removal. Osteochondral lesion was present in no patient with Weber A fracture, 26% of the Weber B cases, 24% of the Weber C cases, and 20% of isolated medial malleolar fracture cases. The association between the presence of deep deltoid ligament tear and syndesmosis disruption (warranting syndesmosis screw fixation) in Weber B cases was statistically significant but not in Weber C cases. There was no statistically significant association between the presence of posterior malleolar fracture and syndesmosis instability that warrant screw fixation. Ankle arthroscopy is a useful adjuvant tool to understand the severity and complexity of acute ankle fracture. Direct arthroscopic visualization ensures detection and evaluation of intra-articular fractures, syndesmosis disruption, and associated osteochondral lesions and ligamentous injuries. Level IV, case series. Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

[Antero-medial incision of knee joint for the treatment of intercondylar fracture of femur].

PubMed

Yin, Zi-Fei; Sun, Bin-Feng; Yang, Xiao-Hai; Wang, Qing; Qian, Ping-Kang; Wu, Xiao-Feng; Xu, Feng

2017-12-25

To explore the clinical effect of antero-medial incision of knee joint in treating intercondylar fracture of femur. From September 2012 to March 2015, 24 patients with intercondylar fracture of femur were selected, including 17 males and 7 females, aged from 20 to 65 years old with an average of(38.3±9.5) years old. Among them, 12 cases were caused by traffic accident, 8 cases were caused by falling injury and 4 cases were caused by falling down. All patients were closed fractures. The time from injury to hospital was from 30 min to 8 h with an average of(2.2±0.3) h. According to AO classification, 4 cases were type B1, 3 type B2, 2 type B3, 5 type C1, 6 type C2 and 4 type C3. All patients were treated with antero-medial incision of knee joint. Operative time, blood loss and postoperative complications were observed and recovery of keen function was evaluated by Kolmert scoring. All patients were followed-up from 6 to 12 months with average of (9.0±1.7) months. Operative time ranged from 50 to 90 min with an average of (70.0±8.2) min; blood loss ranged from 90 to 400 ml with an average of (180±36) ml; negative pressure flow was from 30 to 90 ml, with an average of (50.0±7.1) ml. All fracture were healed at stage I without loosening of internal fixator, fracture nonunion, and deep vein thrombosis. According to Kolmert scoring, 16 patients got excellent result, 5 patients good and 3 fair. Antero-medial incision of knee joint in treating intercondylar fracture of femur, which has advantages of good fracture reduction, less injury of soft tissue and simple operation, could obtain good clinical results.

Magnetic resonance imaging signs of iliotibial band friction in patients with isolated medial compartment osteoarthritis of the knee.

PubMed

Vasilevska, Violeta; Szeimies, Ulrike; Stäbler, Axel

2009-09-01

The purpose of this retrospective study was to assess the frequency of magnetic resonance imaging (MRI) signs of iliotibial band friction (ITBF) in patients with advanced medial compartment knee osteoarthritis. Proton density-weighted (PDw) fat-saturated (fatsat) MR images (1.5 T, slice thickness (SL) 2.5-3 mm, eight-channel phased array coil) of 128 patients with isolated advanced osteoarthritis of the medial knee compartment and complete or subtotal (>80%) loss of cartilage were evaluated. There were 41 men and 87 women. Mean age was 63 years, range 34-89 years. The control group consisted of 94 patients with medial meniscus degeneration without cartilage loss (56 men and 38 women, mean age 50 years, range 16-89 years). MRI signs of ITBF were evaluated in both groups [poorly defined abnormalities of signal intensity and localized fluid collection lateral, distal or proximal to the lateral epicondyle; signal intensity abnormalities superficial to or deep by the iliotibial band (ITB)]. Transverse images were evaluated separately. Consensus evaluation using all imaging planes was performed. Of 128 patients with osteoarthritis, 95 had moderate or advanced MRI signs of ITBF (74.2%). Eighty-nine patients (69.5%) had advanced degeneration of the meniscus. In the control group, 26 of 94 patients had only moderate MRI signs of ITBF. There was a statistically significant difference between both groups for the presence of MR signs of ITBF (P

A comparative study of cranial, blunt trauma fractures as seen at medicolegal autopsy and by Computed Tomography

PubMed Central

2009-01-01

Background Computed Tomography (CT) has become a widely used supplement to medico legal autopsies at several forensic institutes. Amongst other things, it has proven to be very valuable in visualising fractures of the cranium. Also CT scan data are being used to create head models for biomechanical trauma analysis by Finite Element Analysis. If CT scan data are to be used for creating individual head models for retrograde trauma analysis in the future we need to ascertain how well cranial fractures are captured by CT scan. The purpose of this study was to compare the diagnostic agreement between CT and autopsy regarding cranial fractures and especially the precision with which cranial fractures are recorded. Methods The autopsy fracture diagnosis was compared to the diagnosis of two CT readings (reconstructed with Multiplanar and Maximum Intensity Projection reconstructions) by registering the fractures on schematic drawings. The extent of the fractures was quantified by merging 3-dimensional datasets from both the autopsy as input by 3D digitizer tracing and CT scan. Results The results showed a good diagnostic agreement regarding fractures localised in the posterior fossa, while the fracture diagnosis in the medial and anterior fossa was difficult at the first CT scan reading. The fracture diagnosis improved during the second CT scan reading. Thus using two different CT reconstructions improved diagnosis in the medial fossa and at the impact points in the cranial vault. However, fracture diagnosis in the anterior and medial fossa and of hairline fractures in general still remained difficult. Conclusion The study showed that the forensically important fracture systems to a large extent were diagnosed on CT images using Multiplanar and Maximum Intensity Projection reconstructions. Difficulties remained in the minute diagnosis of hairline fractures. These inconsistencies need to be resolved in order to use CT scan data of victims for individual head modelling and trauma analysis. PMID:19835570

A Medial Malleolar "Fleck Sign" May Predict Ankle Instability in Ligamentous Supination External Rotation Ankle Fractures.

PubMed

Nwosu, Kenneth; Schneiderman, Brian Andrew; Shymon, Stephen Joseph; Harris, Thomas

2018-06-01

Ankle joint stability dictates treatment in ligamentous supination external rotation ankle injuries (LSERAI). Investigation of the medial structures that support the ankle mortise is critical, and a small avulsion fracture, or "fleck", of the medial malleolus is occasionally encountered. This study aimed to assess the utility of this medial malleolus fleck sign (MMFS) in diagnosing instability requiring surgery in LSERAI. This retrospective observational study examined 166 LSERAI at a single level I trauma center. A standardized diagnostic and treatment protocol for ankle fractures was followed. LSERAI at presentation were reported as having a normal, dynamically wide, or statically wide medial clear space. Patient demographics, MMFS characteristics, and the use of operative management were recorded. MMFS incidence in the cohort was 16 (10%) of 166 and was present in 25% of patients with unstable LSERAI. Fifteen (94%) of 16 patients with a MMFS were deemed to have an unstable LSERAI (P < .005). MMFS had a 25% sensitivity and 99% specificity in diagnosing an unstable LSERAI. For the subgroup of patients without a statically wide medial clear space, MMFS had a 50% sensitivity and 99% specificity in determining instability. A MMFS may be indicative of an unstable LSERAI. With previous MRI studies demonstrating complete deltoid disruption in unstable LSERAI, we deduce the MMFS may be associated with extensive deltoid incompetence. The MMFS may help to diagnose a complete deltoid injury in LSERAI with a normal medial clear space, which could influence treatment and reduce patient morbidity, radiation exposure, and healthcare costs. Level III: Retrospective Cohort Study.

Risk factors in lateral epicondylitis (tennis elbow): a case-control study.

PubMed

Titchener, A G; Fakis, A; Tambe, A A; Smith, C; Hubbard, R B; Clark, D I

2013-02-01

Lateral epicondylitis is a common condition, but relatively little is known about its aetiology and associated risk factors. We have undertaken a large case-control study using The Health Improvement Network database to assess and quantify the relative contributions of some constitutional and environmental risk factors for lateral epicondylitis in the community. Our dataset included 4998 patients with lateral epicondylitis who were individually matched with a single control by age, sex, and general practice. The median age at diagnosis was 49 (interquartile range 42-56) years . Multivariate analysis showed that the risk factors associated with lateral epicondylitis were rotator cuff pathology (OR 4.95), De Quervain's disease (OR 2.48), carpal tunnel syndrome (OR 1.50), oral corticosteroid therapy (OR 1.68), and previous smoking history (OR 1.20). Diabetes mellitus, current smoking, trigger finger, rheumatoid arthritis, alcohol intake, and obesity were not found to be associated with lateral epicondylitis.

Antero-medial approach to the wrist: anatomic basis and new application in cases of fracture of the lunate facet.

PubMed

Uzel, A-P; Bulla, A; Laurent-Joye, M; Caix, P

2011-08-01

The Henry approach is the classical anterolateral surgical exposure of the volar aspect of the distal radius. This approach does not allow good access to the medial side of the volar distal radius (lunate facet) and the distal radio-ulnar joint, unless it is extended proximally, retracting the tendons and the median nerve medially, which can cause some trauma. The purpose of our study was to investigate the anatomic basis and to outline the advantages of the unusual anteromedial approach, reporting our experience in the treatment of 4 distal radius fractures, with a 90° or 180° twist of the lunate facet, and 10 wrist dissections on cadavers. The average follow-up was 68.8 months (range 18 to 115 months). In our series, this approach did not cause any nerve injuries or any sensory loss of the distal forearm and the palm. All the fractures of the lunate facet and of the radial styloid process healed. One patient with an ulnar styloid process fracture associated showed pseudarthrosis, but with no instability of the distal radio-ulnar joint or pain on the ulnar side. Using the criteria of Green and O'Brien, modified by Cooney, the results were: excellent in two cases, good in one case, and average in another. The evaluation of arthritis according to Knirk and Jupiter's classification showed grade 0 in three cases and grade 3 in one case with osteochondral sclerosis. We showed that the anteromedial approach is reliable and convenient in the case of fractures situated in the antero-medial portion of the radius, for the double objective of reducing the fracture under direct control and checking the congruence of the distal radio-ulnar joint.

A Surgical Model of Posttraumatic Osteoarthritis With Histological and Gait Validation.

PubMed

Zahoor, Talal; Mitchell, Reed; Bhasin, Priya; Schon, Lew; Zhang, Zijun

2016-07-01

Posttraumatic osteoarthritis (PTOA) is secondary to an array of joint injuries. Animal models are useful tools for addressing the uniqueness of PTOA progression in each type of joint injury and developing strategies for PTOA prevention and treatment. Intra-articular fracture induces PTOA pathology. Descriptive laboratory study. Through a parapatellar incision, the medial tibial plateau was exposed in the left knees of 8 Sprague-Dawley rats. Osteotomy at the midpoint between the tibial crest and the outermost portion of the medial tibial plateau, including the covering articular cartilage, was performed using a surgical blade. The fractured medial tibial plateau was fixed with 2 needles transversely. The fractured knees were not immobilized. Before and after surgery, rat gait was recorded. Rats were sacrificed at week 8, and their knees were harvested for histology. After intra-articular fracture, the affected limbs altered gait from baseline (week 0). In the first 2 weeks, the gait of the operated limbs featured a reduced paw print intensity and stride length but increased maximal contact and stance time. Reduction of maximal and mean print area and duty cycle (the percentage of stance phase in a step) was present from week 1 to week 5. Only print length was reduced in weeks 7 and 8. At week 8, histology of the operated knees demonstrated osteoarthritic pathology. The severity of the PTOA pathology did not correlate with the changes of print length at week 8. Intra-articular fracture of the medial tibial plateau effectively induced PTOA in rat knees. During PTOA development, the injured limbs demonstrated characteristic gait. Intra-articular fracture represents severe joint injury and associates with a high rate of PTOA. This animal model, with histologic and gait validations, can be useful for future studies of PTOA prevention and early diagnosis.

Etiology and Treatment of Delayed-Onset Medial Malleolar Pain Following Total Ankle Arthroplasty.

PubMed

Lundeen, Gregory A; Dunaway, Linda J

2016-08-01

Total ankle arthroplasty (TAA) has become a successful treatment for end-stage ankle arthritis. Some patients may still have pain or may present with new pain. Suggested sources of medial pain include tibialis posterior tendonitis, impingement, or medial malleolar stress fracture. Etiology and treatment remain unclear. The objective of our study was to evaluate patients with delayed-onset medial malleolar pain following TAA who underwent treatment with percutaneous medial malleolar screw placement and propose an etiology. Patients who had undergone TAA at our institution were reviewed and those with medial malleolar pain were identified. Clinical and radiographic examinations were performed pre- and postoperatively. Radiographs were compared with those from a cohort of controls without a history of medial pain. All affected patients failed conservative therapy and were treated with percutaneous placement of medial malleolar screws positioned from the malleolar tip and extending proximally beyond the tibial component. Postoperatively, patients were placed in an ace wrap and allowed to be weightbearing to tolerance, except for 1 patient initially restricted to partial weightbearing. Visual analog scale (VAS) scores were recorded. Seventy-four (74) patients underwent TAA by the corresponding author. All (100%) were female with an average age of 66 (range, 57-73) years. Average follow-up since screw placement was 21.4 (range, 10-41) months. Six (8.1%) underwent placement of 2 percutaneous medial malleolar screws. Patients presented with pain an average of 12 (range, 4-24) months postoperatively and underwent screw placement an average of 2.8 (range, 1-6) months after presentation. At the time of TAA, none had a coronal plane deformity and none underwent a deltoid ligament release as part of balancing. All (100%) patients had pain and swelling directly over the medial malleolus prior to screw placement. Postoperatively, 1 (17%) had mild pain clinically at this site and 2 (33%) had occasional pain medially with activity. Average VAS scores improved from 5.7 (range, 4-6) preoperatively to 1.3 (range, 0-3) postoperatively (P < .05). Three (50%) patients had a bone density test and all were normal. Prior to screw placement, radiographs demonstrated no signs of stress fracture or misalignment. Average minimum width of the medial malleolus at the level of the tibial component was 10.2 mm (range, 9.2-11.0), which was significantly less (P < .05) than the control group of 19 patients whose distance measured 12.2 mm (range, 8.5-14.8). Patients who present with new-onset medial malleolar pain with normal radiographs following TAA may have medial malleolar insufficiency fracture. These patients can be treated successfully with minimal morbidity by placement of percutaneous medial malleolar screws. Etiology may be related to deltoid traction, subacute stress fracture, and/or impingement of the talus component on the medial malleolus. Medial malleolar pain may be misdiagnosed as tibialis posterior tendonitis, impingement, or implant failure. This diagnosis should be considered in patients who have pain at the medial malleolus, particularly if they are female or have medial malleolus thickness less than 11 mm at the level of the tibial implant. Placement of prophylactic medial malleolar screws may be considered at the time of TAA when these conditions exist. Level IV, case series. © The Author(s) 2016.

Ankle fractures have features of an osteoporotic fracture.

PubMed

Lee, K M; Chung, C Y; Kwon, S S; Won, S H; Lee, S Y; Chung, M K; Park, M S

2013-11-01

We report the bone attenuation of ankle joint measured on computed tomography (CT) and the cause of injury in patients with ankle fractures. The results showed age- and gender-dependent low bone attenuation and low-energy trauma in elderly females, which suggest the osteoporotic features of ankle fractures. This study was performed to investigate the osteoporotic features of ankle fracture in terms of bone attenuation and cause of injury. One hundred ninety-four patients (mean age 51.0 years, standard deviation 15.8 years; 98 males and 96 females) with ankle fracture were included. All patients underwent CT examination, and causes of injury (high/low-energy trauma) were recorded. Mean bone attenuations of the talus, medial malleolus, lateral malleolus, and distal tibial metaphysis were measured on CT images. Patients were divided into younger age (<50 years) and older age (≥50 years) groups, and mean bone attenuation and causes of injury were compared between the two groups in each gender. Proportion of low-energy trauma was higher in the older age group than in the younger age group, but the difference was only significant in female gender (p = 0.011). The older age group showed significantly lower bone attenuation in the talus, medial malleolus, lateral malleolus, and distal tibial metaphysis than the younger age group in both genders. The older age group showed more complex pattern of fractures than the younger age group. With increasing age, bone attenuations tended to decrease and the difference of bone attenuation between the genders tended to increase in the talus, medial malleolus, lateral malleolus, and distal tibial metaphysis. Ankle fracture had features of osteoporotic fracture that is characterized by age- and gender-dependent low bone attenuation. Ankle fracture should not be excluded from the clinical and research interest as well as from the benefit of osteoporosis management.

Research and application of absorbable screw in orthopedics: a clinical review comparing PDLLA screw with metal screw in patients with simple medial malleolus fracture.

PubMed

Tang, Jin; Hu, Jin-feng; Guo, Wei-chun; Yu, Ling; Zhao, Sheng-hao

2013-01-01

To observe the therapeutic effect of absorbable screw in medial malleolus fracture and discuss its clinical application in orthopedics. A total of 129 patients with simple medial malleolus fracture were studied. Among them, 64 patients were treated with poly-D, L-lactic acid (PDLLA) absorbable screws, while the others were treated with metal screws. All the patients were followed up for 12-20 months (averaged 18.4 months) and the therapeutic effect was evaluated according to the American Orthopaedic Foot and Ankle Society clinical rating systems. In absorbable screw group, we obtained excellent and good results in 62 cases (96.88%); in steel screw group, 61 cases (93.85%) achieved excellent and good results. There was no significant difference between the two groups. In the treatment of malleolus fracture, absorbable screw can achieve the same result compared with metal screw fixation. Absorbable screw is preferred due to its advantages of safety, cleanliness and avoiding the removal procedure associated with metallic implants.

Results of step-cut medial malleolar osteotomy.

PubMed

Thordarson, David B; Kaku, Shawn K

2006-12-01

Treatment of certain complex ankle pathology, such as a talar body fracture or osteochondral lesion requiring grafting, can necessitate medial malleolar osteotomy for adequate operative exposure. This paper evaluates the step-cut medial malleolar osteotomy for exposure of the ankle joint. Fourteen patients with intra-articular pathology, including talar body fractures or osteochondral lesions necessitating extensive intra-articular exposure had step-cut malleolar osteotomy. The average age of the patients was 37 (range 20-90) years, and the average followup was 8 months. All 14 patients had an uncomplicated intraoperative course, with excellent exposure of the ankle joint. All patients had prompt healing of the osteotomy by 6 weeks after surgery without loss of reduction. None of the patients had pain at the osteotomy site. Step-cut medial malleolar osteotomy is an excellent, reproducible method for extensive exposure of the talar dome.

[Internal screwed plate for recent fractures of the humeral diaphysis in adults].

PubMed

Dayez, J

1999-06-01

Can medial plating of the humerus, through an antero lateral approach, diminish incidence of iatrogenic radial palsies? We carried out a prospective study of medial plating of humeral shaft fractures through an antero lateral approach between 1988 and 1997. 41 fractures were fixed, 36 were followed up for a mean period of 5.8 years. The indications were multiple injuries (10), displaced fractures (23), and failure of conservative treatment (3). Road traffic accidents and sports injuries were the cause in 68 per cent of cases. Two fractures were open and in 9 cases there was a radial palsy. Bone graft was never used. The approach to the medial aspect of the humerus an antero lateral incision was the essential feature of the technique. After a slightly curved incision on the antero lateral aspect of the arm, the space between biceps and brachialis anterior was bluntly dissected. The assistant holded the elbow flexed in order to relax the biceps and rotated il laterally to expose the medial aspect of the bone. Splitting brachialis fibres longitudinally exposed the fracture site. It was easy to check if the radial nerve was trapped and, if not, the nerve seen during the operation. Postoperatively patients were given a simple sling and mobilised freely, including rotation. We had no intra-operative complications, no infections, no fixation failure, no post operative radial palsies and no non-unions. Results were excellent in 89 per cent of cases (full recovery of pain free range of movement). Four patient had a restriction of elbow movements of 10 degrees but without any discomfort. The mean time to union was 80 days. All radial nerve palsies recovered between 24 hours and 1 year. The plate was removed in 11 cases. Iatrogenic complications of humeral plating have led to the increased popularity of intramedullary nailing. Even if secondary radial palsies and non-unions have decreased, union of the humeral shafts is often difficult. Placing the plate into the medial surface allowed to preserve the radial nerve, but still permitted to check its continuity when it was trapped in the fracture site. Restoration of the length and rotational alignment of the humerus puts the radial nerve in the best condition for its recovery. An antero lateral approach and a medially placed plate allowed to avoid secondary radial plasies and non-unions, which can complicate internal fixation of the humeral shaft.

Comminuted Distal Radial Fracture with Large Rotated Palmar Medial Osteochondral Fragment in the Joint.

PubMed

Gökkus, Kemal; Sagtas, Ergin; Kesgin, Engin; Aydin, Ahmet Turan

2018-01-01

Intra-articular distal radius fractures have long been massively discussed in the literature, but regarding to fractures that possess rotated volar medial fragment in the joint a few amount papers has been written. In this article, we would like to emphasize the significance of the rotated palmar medial (lunate facet) fragment. A 39-year-old man fell from a height of about 3 m and landed on his right outstretched hand; within 40 min, he arrived at our clinic presenting with a severe pain and swelling in his right wrist. Initial X-rays of the wrist revealed dorsal subluxation of the radiocarpal joint with dorsal comminution of the radial articular surface and fracture of the radial styloid process, with (nearly inverted) ~ 140-150° rotation of the palmar medial fragment. With an additional volar approach, the fragment reduced and stabilized with two K-wires and wrist immobilized in external fixator. The patient returned to daily activities without any discomfort and pain after the 1 year from the surgery. Overlooking of palmar rotated osteochondral fragment will cause deficiency to build proper pre-operative strategy to approach the reduction of the fragment. The incompetence of reduction will deteriorate the articular surface and lead to early osteoarthritis of the wrist. The surgeon should detect this fragment and should be familiar with volar approaches of the wrist. Above average surgical experience would be needed for successful reduction.

Functional outcome of Schatzker type V and VI tibial plateau fractures treated with dual plates

PubMed Central

Prasad, G Thiruvengita; Kumar, T Suresh; Kumar, R Krishna; Murthy, Ganapathy K; Sundaram, Nandkumar

2013-01-01

Background: Dual plate fixation in comminuted bicondylar tibial plateau fractures remains controversial. Open reduction and internal fixation, specifically through compromised soft tissues, has historically been associated with major wound complications. Alternate methods of treatment have been described, each with its own merits and demerits. We performed a retrospective study to evaluate the functional outcome of lateral and medial plate fixation of Schatzker type V and VI fractures through an anterolateral approach, and a medial minimally invasive approach or a posteromedial approach. Materials and Methods: We treated 46 tibial plateau fractures Schatzker type V and VI with lateral and medial plates through an anterolateral approach and a medial minimal invasive approach over an 8 years period. Six patients were lost to followup. Radiographs in two planes were taken in all cases. Immediate postoperative radiographs were assessed for quality of reduction and fixation. The functional outcome was evaluated according to the Oxford Knee Score criteria on followup. Results: Forty patients (33 men and 7 women) who completed the followup were included in the study. There were 20 Schatzker type V fractures and 20 Schatzker type VI fractures. The mean duration of followup was 4 years (range 1-8 years). All patients had a satisfactory articular reduction defined as ≤2 mm step-off or gap as assessed on followup. All patients had a good coronal and sagittal plane alignment, and articular width as assessed on supine X-rays of the knee in the anteroposterior (AP) and lateral views. The functional outcome, as assessed by the Oxford Knee Score, was excellent in 30 patients and good in 10 patients. All patients returned to their pre-injury level of activity and employment. There were no instances of deep infection. Conclusions: Dual plate fixation of severe bicondylar tibial plateau fractures is an excellent treatment option as it provides rigid fixation and allows early knee mobilization. Careful soft tissue handling and employing minimal invasive techniques minimizes soft tissue complications. PMID:23682182

Stress Fractures of the Pelvis and Legs in Athletes

PubMed Central

Behrens, Steve B.; Deren, Matthew E.; Matson, Andrew; Fadale, Paul D.; Monchik, Keith O.

2013-01-01

Context: Stress fractures are common injuries in athletes, often difficult to diagnose. A stress fracture is a fatigue-induced fracture of bone caused by repeated applications of stress over time. Evidence Acquisition: PubMed articles published from 1974 to January 2012. Results: Intrinsic and extrinsic factors may predict the risk of stress fractures in athletes, including bone health, training, nutrition, and biomechanical factors. Based on their location, stress fractures may be categorized as low- or high-risk, depending on the likelihood of the injury developing into a complete fracture. Treatment for these injuries varies substantially and must account for the risk level of the fractured bone, the stage of fracture development, and the needs of the patient. High-risk fractures include the anterior tibia, lateral femoral neck, patella, medial malleolus, and femoral head. Low-risk fractures include the posteromedial tibia, fibula, medial femoral shaft, and pelvis. Magnetic resonance is the imaging test of choice for diagnosis. Conclusions: These injuries can lead to substantial lost time from participation. Treatment will vary by fracture location, but most stress fractures will heal with rest and modified weightbearing. Some may require more aggressive intervention, such as prolonged nonweightbearing movement or surgery. Contributing factors should also be addressed prior to return to sports. PMID:24427386

Elbow arthroscopy: indications, techniques, outcomes, and complications.

PubMed

Adams, Julie E; King, Graham J W; Steinmann, Scott P; Cohen, Mark S

2015-01-01

Elbow arthroscopy is a tool useful for the treatment of a variety of pathologies about the elbow. The major indications for elbow arthroscopy include débridement for septic elbow arthritis, synovectomy for inflammatory arthritis, débridement for osteoarthritis, loose body extraction, contracture release, treatment of osteochondral defects and selected fractures or instability, and tennis elbow release. To achieve favorable outcomes after elbow arthroscopy, the surgeon should be aware of contraindications, technical considerations, anatomic principles, and the need for proper patient positioning and portal selection. Elbow arthroscopy is an effective procedure for the treatment of inflammatory arthritis, osteoarthritis, and lateral epicondylitis.

[Social, demographic and laboral factors associated with the presence of lateral elbow epicondylitis].

PubMed

Zamudio-Muñoz, Laura Angélica; Urbiola-Verdejo, Marcos; Sánchez-Vizcaíno, Pedro Miguel

2011-01-01

To determine the social and demographic factors associated with laboral activities and the presence of lateral epicondylitis of elbow in workers. We conducted an observational, descriptive, cross-sectional sampling for convenience. We included 34 patients with a diagnosis of lateral epicondylitis, both sexes between 20 and 55 years, with occupations requiring repetitive movements of the wrist. They answered a questionnaire with 21 questions. We applied descriptive statistic. Lateral epicondylitis occurs predominantly in women, aged 42.4 years with a schooling of 8.8 years; the main laboral activities were as cleaning staff (12%), packaging (12%) and mechanical (12%). Thirty five percent of participants made at least two breaks for health. Nine percent were exposed to low temperatures. Lateral epicondylitis is a condition that occurs in greater proportion in women. It is situated more frequently in the fifth decade of life. Epicondylitis has not been thoroughly studied in our environment, perhaps it is more prevalent in women who work at home.

Morphology of the posteromedial fragment in pertrochanteric fractures: A three-dimensional computed tomography analysis.

PubMed

Sharma, Gaurav; Gn, Kiran Kumar; Khatri, Kavin; Singh, Ravijot; Gamanagatti, Shivanand; Sharma, Vijay

2017-02-01

In this study we describe the morphology of the posteromedial fragment in pertrochanteric fractures using 3D CT scans and answer two questions 1) Do differences exist between the 3D CT appearances of posteromedial fragments and the depictions made in the AO classification 2) Does the posteromedial fragment affect stability in pertrochanteric fractures, in terms of fracture collapse? Preoperative CT scans of eight 31-A1 and fifty 31-A2 fractures were analysed. The presence of PM fragment, its fragmentation, greater trochanter (GT) involvement, lesser trochanter (LT) fragment size (in terms of its posterior and medial extent as well as LT length), LT fragment displacement (in terms of medial displacement and rotation) were determined. All fractures were treated with a DHS. Fracture collapse was determined on postoperative radiographs. The relationship between fracture collapse and patient factors including age, gender, fracture type (A1 versus A2), characteristics of the posteromedial fragment, and the presence of a lateral wall fracture were determined. Three out of eight 31-A1 fractures demonstrated a separate GT fragment (three part fracture). Out of the 50 31-A2 fractures, 12 had a single PM fragment, which included the LT and GT in continuity. The more common four part fractures seem to form by further fragmentation of this basic form. In A2 fractures, the GT was almost always broken and the broken fragment comprised a mean 56% of normal GT. The LT fragment involved an average of 74% of the posterior wall, and an average of 36% of the medial wall of the proximal femur. Larger LT fragments were less displaced as compared to smaller fragments. Univariate regression analyses revealed that fracture collapse was significantly correlated with fracture type (A1 versus A2, p 0.036), GT size (p 0.002) and the presence of a lateral wall fracture (p<0.001). This study revealed some important differences between the 3D CT appearances and AO classification of pertrochanteric fractures. Further, neither fragmentation of the posteromedial fragment, nor the size of the lesser trochanter fragment was found to predict stability in pertrochanteric fractures. A perioperative lateral wall fracture is the main determinant of stability in these fractures. Copyright © 2016 Elsevier Ltd. All rights reserved.

Management of comminuted proximal ulna fracture-dislocations using a multiplanar locking intramedullary nail.

PubMed

Edwards, Scott G; Argintar, Evan; Lamb, Joshua

2011-06-01

Intramedullary nails have been used for the fixation of olecranon fractures in an attempt to reduce the soft tissue irritation and resulting need for hardware removal seen with plating and tension banding. Further benefits include preservation of vascular supply, and increase stability and improved compression over some alternative techniques. Most intramedullary nails have been limited to simple olecranon fractures or osteotomies. One novel multiplanar, locking intramedullary nail, however, is indicated to stabilize all fracture patterns of the proximal ulna, including the coronoid. This particular locking nail has screws that radiate in multiple planes and form a fixed-angle lattice throughout the bone. The nail also has fixed-angle screws dedicated to the 3 parts of the coronoid: process tip, medial facet, and medial wall. This allows the nail to secure multiple fragments regardless of the fracture pattern's extent of instability. The objective of this article is to illustrate the recommended steps in reducing and stabilizing a comminuted proximal ulna fracture-dislocation using this multiplanar locking intramedullary nail.

Persistent medial foot pain in an adolescent athlete.

PubMed

Hensley, Craig P; Reischl, Stephen F

2013-03-01

The patient was a 15-year-old adolescent male who was referred to a physical therapist for a chief complaint of worsening right medial foot pain. Given the worsening nature of the patient's right medial foot pain, palpatory findings, and a prior recommendation for computed tomography from a radiologist, the patient was referred to his physician. Subsequent computed tomography imaging of the right foot revealed a nondisplaced fracture through the dorsal-medial aspect of the navicular.

Subtalar dislocation without associated fractures: Case report and review of literature

PubMed Central

Giannoulis, Dionisios; Papadopoulos, Dimitrios V; Lykissas, Marios G; Koulouvaris, Panagiotis; Gkiatas, Ioannis; Mavrodontidis, Alexandros

2015-01-01

Isolated subtalar dislocations are unusual injuries due to the inherent instability of the talus. Subtalar dislocations are frequently associated with fractures of the malleoli, the talus, the calcaneus or the fifth metatarsal. Four types of subtalar dislocation have been described according to the direction of the foot in relation to the talus: medial, lateral posterior and anterior. It has been shown that some of these dislocations may spontaneously reduce. A rare case of a 36-year-old male patient who sustained a closed medial subtalar dislocation without any associated fractures of the ankle is reported. The patient suffered a pure closed medial subtalar dislocation that is hardly reported in the literature. Six months after injury the patient did not report any pain, had a satisfactory range of motion, and no signs of residual instability or early posttraumatic osteoarthritis. The traumatic mechanism, the treatment options, and the importance of a stable and prompt closed reduction and early mobilization are discussed. PMID:25893182

Open reduction and internal fixation of osteoporotic acetabular fractures through the ilio-inguinal approach: use of buttress plates to control medial displacement of the quadrilateral surface.

PubMed

Peter, Robin E

2015-01-01

The number of acetabular fractures in the geriatric population requiring open reduction and internal fixation is increasing. Fractures with medial or anterior displacement are the most frequent types, and via the ilio-inguinal approach buttress plates have proved helpful to maintain the quadrilateral surface or medial acetabular wall. Seven to ten hole 3.5 mm reconstruction plates may be used as buttress plates, placed underneath the usual pelvic brim plate. This retrospective study presents our results with this technique in 13 patients at a minimum follow-up of 12 months (average, 31 months). 85% of the patients had a good result. The early onset of post-traumatic osteoarthritis necessitated total hip arthroplasty in two patients (15%) at 12 and 18 months follow-up, respectively. This treatment option should be considered in the surgeon's armamentarium when fixing these challenging cases. Copyright © 2015 Elsevier Ltd. All rights reserved.

Compartment syndrome of the foot.

PubMed

Andermahr, J; Helling, H J; Tsironis, K; Rehm, K E; Koebke, J

2001-05-01

The hindfoot compartment syndrome occurs in 10% of cases after calcaneal fracture. We analyzed the pathological anatomical reasons for this syndrome using the 10 feet from cadavers plastinated and cut into 4-mm thick sequential sections. CT scans of patients with calcaneal fractures were then compared with the anatomical findings. The key component of this compartment syndrome is the quadratus plantae muscle. The sustentacular calcaneal fragment causes bleeding from the bone or the medial calcaneal arteries into this compartment. The medial and lateral plantar nerves and vessels are then compressed between the quadratus plantae muscle and the short flexor digitorum muscle. Relieving pressure by surgical decompression of the quadratus plantae compartment via a medial or plantar approach is the recommended treatment. Copyright 2001 Wiley-Liss, Inc.

Patient-specific puzzle implant preformed with 3D-printed rapid prototype model for combined orbital floor and medial wall fracture.

PubMed

Kim, Young Chul; Min, Kyung Hyun; Choi, Jong Woo; Koh, Kyung S; Oh, Tae Suk; Jeong, Woo Shik

2018-04-01

The management of combined orbital floor and medial wall fractures involving the inferomedial strut is challenging due to absence of stable cornerstone. In this article, we proposed surgical strategies using customized 3D puzzle implant preformed with Rapid Prototype (RP) skull model. Retrospective review was done in 28 patients diagnosed with combined orbital floor and medial wall fracture. Using preoperative CT scans, original and mirror-imaged RP skull models for each patient were prepared and sterilized. In all patients, porous polyethylene-coated titanium mesh was premolded onto RP skull model in two ways; Customized 3D jigsaw puzzle technique was used in 15 patients with comminuted inferomedial strut, whereas individual 3D implant technique was used in each fracture for 13 patients with intact inferomedial strut. Outcomes including enophthalmos, visual acuity, and presence of diplopia were assessed and orbital volume was measured using OsiriX software preoperatively and postoperatively. Satisfactory results were achieved in both groups in terms of clinical improvements. Of 10 patients with preoperative diplopia, 9 improved in 6 months, except one with persistent symptom who underwent extraocular muscle rupture. 18 patients who had moderate to severe enophthalmos preoperatively improved, and one remained with mild degree. Orbital volume ratio, defined as volumetric ratio between affected and control orbit, decreased from 127.6% to 99.79% (p < 0.05) in comminuted group, and that in intact group decreased from 117.03% to 101.3% (p < 0.05). Our surgical strategies using the jigsaw puzzle and individual reconstruction technique provide accurate restoration of combined orbital floor and medial wall fractures. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Stress and stability of plate-screw fixation and screw fixation in the treatment of Schatzker type IV medial tibial plateau fracture: a comparative finite element study.

PubMed

Huang, Xiaowei; Zhi, Zhongzheng; Yu, Baoqing; Chen, Fancheng

2015-11-25

The purpose of this study is to compare the stress and stability of plate-screw fixation and screw fixation in the treatment of Schatzker type IV medial tibial plateau fracture. A three-dimensional (3D) finite element model of the medial tibial plateau fracture (Schatzker type IV fracture) was created. An axial force of 2500 N with a distribution of 60% to the medial compartment was applied to simulate the axial compressive load on an adult knee during single-limb stance. The equivalent von Mises stress, displacement of the model relative to the distal tibia, and displacement of the implants were used as the output measures. The mean stress value of the plate-screw fixation system was 18.78 MPa, which was significantly (P < 0.001) smaller than that of the screw fixation system. The maximal value of displacement (sum) in the plate-screw fixation system was 2.46 mm, which was lower than that in the screw fixation system (3.91 mm). The peak stress value of the triangular fragment in the plate-screw fixation system model was 42.04 MPa, which was higher than that in the screw fixation model (24.18 MPa). But the mean stress of the triangular fractured fragment in the screw fixation model was significantly higher in terms of equivalent von Mises stress (EVMS), x-axis, and z-axis (P < 0.001). This study demonstrated that the load transmission mechanism between plate-screw fixation system and screw fixation system was different and the stability provided by the plate-screw fixation system was superior to the screw fixation system.

Tibial avulsion fracture of the posterior root of the medial meniscus in a skeletally-immature child - a case report.

PubMed

Matava, Matthew J; Kim, Young-Mo

2011-01-01

It has been theorized that a traumatic tibial avulsion fracture of the posterior root of the medial meniscus (MM) is the cause of the so-called meniscus ossicle (MO). We report the delayed appearance of a tibial avulsion fracture of the posterior root of the MM after a valgus, twisting injury in a 12-year-old boy with open physes. Magnetic resonance imaging (MRI) scans performed 3 days after the injury did not demonstrate a definitive tibial avulsion fracture of the posterior root of the MM; whereas, a repeat MRI for 3 months post-injury did. Medial extrusion of the MM was also noted on the 3 month MRI. Arthroscopic reattachment of the avulsed posterior root of the MM using a trans-physeal nonabsorbable suture tied over a proximal tibia staple was performed. Follow-up MRI at 6 months postoperatively demonstrated healing of the tibial avulsion fracture of the posterior root of the MM in an anatomic position. The patient had a complete resolution of symptoms and there was no angular deformity or limb-length discrepancy at 2 years postoperatively. To our knowledge, this is the first report describing a tibial avulsion fracture of the posterior root of the MM in a skeletally-immature patient successfully treated by a trans-physeal arthroscopic suture. This case also illustrates the development of the MO of the posterior root of the MM. Copyright © 2010 Elsevier B.V. All rights reserved.

Earliest colobine skeletons from Nakali, Kenya.

PubMed

Nakatsukasa, Masato; Mbua, Emma; Sawada, Yoshihiro; Sakai, Tetsuya; Nakaya, Hideo; Yano, Wataru; Kunimatsu, Yutaka

2010-11-01

Old World monkeys represent one of the most successful adaptive radiations of modern primates, but a sparse fossil record has limited our knowledge about the early evolution of this clade. We report the discovery of two partial skeletons of an early colobine monkey (Microcolobus) from the Nakali Formation (9.8-9.9 Ma) in Kenya that share postcranial synapomorphies with extant colobines in relation to arboreality such as mediolaterally wide distal humeral joint, globular humeral capitulum, distinctly angled zona conoidea, reduced medial trochlear keel, long medial epicondyle with weak retroflexion, narrow and tall olecranon, posteriorly dislocated fovea on the radial head, low projection of the femoral greater trochanter, wide talar head with a greater rotation, and proximodistally short cuboid and ectocuneiform. Microcolobus in Nakali clearly differs from the stem cercopithecoid Victoriapithecus regarding these features, as Victoriapithecus is postcranially similar to extant small-sized terrestrial cercopithecines. However, degeneration of the thumb, a hallmark of modern colobines, is not observed, suggesting that this was a late event in colobine evolution. This discovery contradicts the prevailing hypothesis that the forest invasion by cercopithecids first occurred in the Plio-Pleistocene, and shows that this event occurred by the late Miocene at a time when ape diversity declined. © 2010 Wiley-Liss, Inc.

Optimal Measurement Level and Ulnar Nerve Cross-Sectional Area Cutoff Threshold for Identifying Ulnar Neuropathy at the Elbow by MRI and Ultrasonography.

PubMed

Terayama, Yasushi; Uchiyama, Shigeharu; Ueda, Kazuhiko; Iwakura, Nahoko; Ikegami, Shota; Kato, Yoshiharu; Kato, Hiroyuki

2018-06-01

Imaging criteria for diagnosing compressive ulnar neuropathy at the elbow (UNE) have recently been established as the maximum ulnar nerve cross-sectional area (UNCSA) upon magnetic resonance imaging (MRI) and/or ultrasonography (US). However, the levels of maximum UNCSA and diagnostic cutoff values have not yet been established. We therefore analyzed UNCSA by MRI and US in patients with UNE and in controls. We measured UNCSA at 7 levels in 30 patients with UNE and 28 controls by MRI and at 15 levels in 12 patients with UNE and 24 controls by US. We compared UNCSA as determined by MRI or US and determined optimal diagnostic cutoff values based on receiver operating characteristic curve analysis. The UNCSA was significantly larger in the UNE group than in controls at 3, 2, 1, and 0 cm proximal and 1, 2, and 3 cm distal to the medial epicondyle for both modalities. The UNCSA was maximal at 1 cm proximal to the medial epicondyle for MRI (16.1 ± 3.5 mm 2 ) as well as for US (17 ± 7 mm 2 ). A cutoff value of 11.0 mm 2 for MRI and US was found to be optimal for differentiating between patients with UNE and controls, with an area under the receiver operating characteristic curve of 0.95 for MRI and 0.96 for US. The UNCSA measured by MRI was not significantly different from that by US. Intra-rater and interrater reliabilities for UNCSA were all greater than 0.77. The UNCSA in the severe nerve dysfunction group of 18 patients was significantly larger than that in the mild nerve dysfunction group of 12 patients. By measuring UNCSA with MRI or US at 1 cm proximal to the ME, patients with and without UNE could be discriminated at a cutoff threshold of 11.0 mm 2 with high sensitivity, specificity, and reliability. Diagnostic III. Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Biological approach to treatment of intra-articular proximal tibial fractures with double osteosynthesis.

PubMed

Singh, Saurabh; Patel, Pankaj R; Joshi, Anil Kumar; Naik, Rajnikant N; Nagaraj, Chethan; Kumar, Sudeep

2009-02-01

The treatment of intra-articular proximal tibial fractures is associated with complications, and much conflicting literature exists concerning the treatment of choice. In our study, an attempt has been made to develop an ideal and adequate treatment protocol for these intra-articular fractures. The principle of double osteosynthesis, i.e., lateral minimally invasive plate osteosynthesis (MIPO), was combined with a medial external fixator to treat 22 intra-articular proximal tibial fractures with soft tissue injury with a mean follow-up of 25 months. Superficial pin track infection was observed in one case, and no soft tissue breakdown was noted. Loss of articular reconstruction was reported in one case. Bridging callus was seen at 12 weeks (8 weeks-7 months). The principle of substitution or double osteosynthesis, i.e., lateral MIPO, was combined with a medial external fixator and proved to be a fairly good method of fixation in terms of results and complications.

Value of lateral blood pool imaging in patients with suspected stress fractures of the tibia.

PubMed

Mohan, Hosahalli K; Clarke, Susan E M; Centenara, Martin; Lucarelli, Amanda; Baron, Daniel; Fogelman, Ignac

2011-03-01

To critically evaluate the use of lateral blood pool imaging in athletes with lower limb pain and with a clinical suspicion of stress fracture. Two experienced nuclear medicine physicians evaluated 3-phase bone scans using 99mTc-methylene diphosphonate performed in 50 consecutive patients referred from a specialist sports injury clinic for suspected tibial stress fracture. The vascularity to the tibia as seen on the blood pool (second phase) images in the anterior/posterior views was compared with the lateral/medial view assessments. Stress fractures were presumed to be present when on the delayed images (third phase) there was a focal or fusiform area of increased tracer uptake involving the tibial cortex. Shin splints which are a recognized cause of lower limb pain in athletes mimicking stress fracture were diagnosed if increased tracer uptake was seen extending along the posterior tibial surface with no significant focal or fusiform area of uptake within this. Inter-reviewer agreement for the assessment of vascularity was also assessed using Cohen's Kappa scores. Twenty-four stress fractures in 24 patients and 66 shin splints in 40 patients were diagnosed. In 18 patients stress fracture and shin splints coexisted. In 10 patients no tibial pathology was identified. Of the 24 patients diagnosed with stress fractures, lateral/medial blood pool imaging was superior in the assessment of blood pool activity (P < 0.001) identifying increased vascularity in 21 cases compared with the anterior/posterior views positive in only 11 cases. The inter-reviewer agreement was near perfect for lateral/medial views, κ = 0.86 while very good for anterior/posterior views, κ = 0.68. In patients with suspected tibial stress fractures, lateral views of the tibia provide the optimal method for evaluation of vascularity. Prospective studies with quantitative or semi-quantitative assessment of skeletal vascularity could provide supplementary information relating to the pathophysiology of stress fractures, for example, the time scale of vascular changes after a tibial stress fracture, and potentially could have clinical relevance as to the assessment of the severity of stress fractures and their prognosis.

Anatomy of the collateral ligaments of the feline elbow joint: functional implications.

PubMed

Engelke, E; Pfarrer, C; Waibl, H

2011-04-01

Cats show a higher capability to supinate their forearms than dogs. This suggests a special arrangement of the collateral ligaments of the feline elbow joint. Therefore, the course of the ligaments was examined in 13 adult cats. The size of the ligaments was measured, and effects of passive joint movements were studied. Ligaments of five additional cats were examined histologically. The lateral collateral ligament (LCL) had a superficial and deep part, both originating from the humerus. The free humeral portion of the LCL was short and contained fibrous cartilage. Fibre bundles of the deep part inserted into the annular ligament, while the remaining deep fibres and the superficial part inserted with a long antebrachial portion on the radius. The medial collateral ligament (MCL) originated from the humeral epicondyle and divided into cranial and caudal parts. The caudal part inserted medioproximally on the ulna, while the cranial part attached primarily with a long thin part to the caudal aspect of the radius. During supination, the MCL loosened thus allowing medial widening of the joint space, up to 2 mm. A specific feature of the feline elbow is the long thin part of the MCL. Its course through a special furrow distal to the medial coronoid causes the tightening of the feline MCL during pronation. Apart from that, the feline collateral ligaments combine the features of both human and canine cubital anatomy. This explains the range of supination in cats, which is intermediate between humans and dogs. © 2010 Blackwell Verlag GmbH.

Repair of Acute Superficial Deltoid Complex Avulsion During Ankle Fracture Fixation in National Football League Players.

PubMed

Hsu, Andrew R; Lareau, Craig R; Anderson, Robert B

2015-11-01

Infolding and retraction of an avulsed deltoid complex after ankle fracture can be a source of persistent increased medial clear space, malreduction, and postoperative pain and medial instability. The purpose of this descriptive case series was to analyze the preliminary outcomes of acute superficial deltoid complex avulsion repair during ankle fracture fixation in a cohort of National Football League (NFL) players. We found that there is often complete avulsion of the superficial deltoid complex off the proximal aspect of the medial malleolus during high-energy ankle fractures in athletes. Between 2004 and 2014, the cases of 14 NFL players who underwent ankle fracture fixation with open deltoid complex repair were reviewed. Patients with chronic deltoid ligament injuries or ankle fractures more than 2 months old were excluded. Average age for all patients was 25 years and body mass index 34.4. Player positions included 1 wide receiver, 1 tight end, 1 safety, 1 running back, 1 linebacker, and 9 offensive linemen. Average time from injury to surgery was 7.5 days. Surgical treatment for all patients consisted of ankle arthroscopy and debridement, followed by fibula fixation with plate and screws, syndesmotic fixation with suture-button devices, and open deltoid complex repair with suture anchors. Patient demographics were recorded with position played, time from injury to surgery, games played before and after surgery, ability to return to play, and postoperative complications. Return to play was defined as the ability to successfully participate in at least 1 full regular-season NFL game after surgery. All NFL players were able to return to running and cutting maneuvers by 6 months after surgery. There were no significant differences in playing experience before surgery versus after surgery. Average playing experience before surgery was 3.3 seasons, 39 games played, and 22 games started. Average playing experience after surgery was 1.6 seasons, 16 games played, and 15 games started. Return to play was 86% for all players. There were no intraoperative or postoperative complications noted, and no players had clinical evidence of medial pain or instability at final follow-up with radiographic maintenance of anatomic mortise alignment. Superficial deltoid complex avulsion during high-energy ankle fractures in athletes is a distinct injury pattern that should be recognized and may benefit from primary open repair. The majority of NFL players treated surgically for this injury pattern are able to return to play after surgery with no reported complications or persistent medial ankle pain or instability. Level IV, retrospective case series. © The Author(s) 2015.

Open versus closed reduction: diacapitular fractures of the mandibular condyle.

PubMed

Chrcanovic, Bruno Ramos

2012-09-01

The purpose of the study was to review the literature regarding the evolution of current thoughts on management of diacapitular fractures (DFs) of the mandibular condyle. An electronic search in PubMed was undertaken in March 2012. The titles and abstracts from these results were read to identify studies within the selection criteria. Eligibility criteria included studies reporting clinical series of DFs, including both animal and human studies, without date or language restrictions. The search strategy initially yielded 108 references. Twenty-eight studies were identified without repetition within the selection criteria. Additional hand-searching of the reference lists of selected studies yielded three additional papers. The current indications for open reduction and internal fixation (ORIF) of DFs described in the literature are: (a) fractures affecting the lateral condyle with reduction of mandibular height; (b) fractures in which the proximal fragment dislocates laterally out of the glenoid fossa, which cannot be reduced by closed or open treatment of another part of the mandibular fracture. The indications for conservative treatment are: (a) fractures that do not shorten the condylar height (a fracture with displacement of the medial parts of the condyle); (b) undisplaced fractures; (c) comminution of the condylar head, when the bony fragments are too small for stable fixation; and (d) fractures in children. As the temporomandibular joint disk plays an important role as a barrier preventing ankylosis, it is important to reposition the disk (if displaced/dislocated) during the surgical treatment of DFs. The lateral pterygoid muscle should never be stripped from the medially displaced fragment because its desinsertion disrupts circulation to the medial bony fragment, and also because this muscle helps to restore the muscle function after surgery. ORIF of selected DFs improves prognosis by anatomical bone and soft tissue recovery when combined with physical therapy. If conducted properly, surgical treatment of DFs is a safe and predictable procedure and yields good results.

Weightbearing vs Gravity Stress Radiographs for Stability Evaluation of Supination-External Rotation Fractures of the Ankle.

PubMed

Seidel, Angela; Krause, Fabian; Weber, Martin

2017-07-01

Isolated lateral malleolar fractures may result from a supination-external rotation (SER) injury of the ankle. Stable fractures maintain tibiotalar congruence due to competent medial restraints and can be treated nonoperatively with excellent functional results and long-term prognosis. Stability might be assessed with either stress radiographs or weightbearing radiographs. A consecutive series of patients with closed SER fractures (presumed AO 44-B1) were prospectively enrolled from 2008 to 2015. Patients with clearly unstable fractures (medial clear space more than 7 mm) on the initial nonweightbearing radiograph were excluded and operated on. All other patients were examined with a gravity stress and a weightbearing anteroposterior radiograph. Borderline instability of the fracture was assumed when the medial clear space was 4 to 7 mm. Those were treated nonoperatively. Of 104 patients with isolated lateral malleolar fractures of the SER type, 14 patients were treated operatively because of clear instability (displacement) on the initial radiographs. Of the nonoperative patients, 44 patients demonstrated borderline instability on the gravity stress but stability on the weightbearing radiograph ("gravity borderline"); the remaining 46 were stable in both tests ("gravity stable"). At an average follow-up of 23 months, no significant differences were seen in the American Orthopaedic Foot & Ankle Society hindfoot score (92 points gravity-borderline group vs 93 points gravity-unstable group), the Foot Functional Index score (11 vs 10 points), the Short Form 36 (SF-36) physical component (86 vs 85 points), and SF-36 mental component (84 vs 81 points). Radiographically, all fractures had healed with anatomic congruity of the ankle. Weightbearing radiographs provided a reliable basis to decide about stability and nonoperative treatment in isolated lateral malleolar fractures of the SER type with excellent clinical and radiographic outcome at short-term follow-up. Gravity stress radiographs appear to overrate the need for operative treatment. Level III, prospective comparative study.

Magnetic resonance imaging in stress fractures and shin splints.

PubMed

Aoki, Yoshimitsu; Yasuda, Kazunori; Tohyama, Harukazu; Ito, Hirokazu; Minami, Akio

2004-04-01

The purpose of the current study was to determine whether stress fractures and shin splints could be discriminated with MRI in the early phase. Twenty-two athletes, who had pain in the middle or distal part of their leg during or after sports activity, were evaluated with radiographs and MRI scans. Stress fractures were diagnosed when consecutive radiographs showed local periosteal reaction or a fracture line, and shin splints were diagnosed in all the other cases. In all eight patients with stress fractures, an abnormally wide high signal in the localized bone marrow was the most detectable in the coronal fat-suppressed MRI scan. In 11 patients with shin splints, the coronal fat-suppressed MRI scans showed a linear abnormally high signal along the medial posterior surface of the tibia, and in seven patients with shin splints, the MRI scans showed a linear abnormally high signal along the medial bone marrow. No MRI scans of shin splints showed an abnormally wide high signal in the bone marrow as observed on MRI scans of stress fractures. This study showed that fat-suppressed MRI is useful for discrimination between stress fracture and shin splints before radiographs show a detectable periosteal reaction in the tibia.

Association between findings on palmarodorsal radiographic images and detection of a fracture in the proximal sesamoid bones of forelimbs obtained from cadavers of racing Thoroughbreds.

PubMed

Anthenill, Lucy A; Stover, Susan M; Gardner, Ian A; Hill, Ashley E; Lee, Christina M; Anderson, Mark L; Barr, Bradd C; Read, Deryck H; Johnson, Bill J; Woods, Leslie W; Daft, Barbara M; Kinde, Hailu; Moore, Janet D; Farman, Cynthia A; Odani, Jenee S; Pesavento, Patricia A; Uzal, Francisco A; Case, James T; Ardans, Alex A

2006-05-01

To determine the distribution for limbs and bones in horses with fractures of the proximal sesamoid bones and relationships with findings on palmarodorsal radiographic images. Proximal sesamoid bones obtained from both forelimbs of cadavers of 328 racing Thoroughbreds. Osteophytes; large vascular channels; and fracture location, orientation, configuration, and margin distinctness were categorized by use of high-detail contact palmarodorsal radiographs. Distributions of findings were determined. Relationships between radiographic findings and fracture characteristics were examined by use of chi2 and logistic regression techniques. Fractures were detected in 136 (41.5%) horses. Biaxial fractures were evident in 109 (80%) horses with a fracture. Osteophytes and large vascular channels were evident in 266 (81%) and 325 (99%) horses, respectively. Medial bones typically had complete transverse or split transverse simple fractures, indistinct fracture margins, > 1 vascular channel that was > 1 mm in width, and osteophytes in abaxial wing and basilar middle or basilar abaxial locations. Lateral bones typically had an oblique fracture and distinct fracture margins. Odds of proximal sesamoid bone fracture were approximately 2 to 5 times higher in bones without radiographic evidence of osteophytes or large vascular channels, respectively. Biaxial fractures of proximal sesamoid bones were common in cadavers of racing Thoroughbreds. Differences between medial and lateral bones for characteristics associated with fracture may relate to differences in fracture pathogeneses for these bones. Osteophytes and vascular channels were common findings; however, fractures were less likely to occur in bones with these features.

Tennis elbow

MedlinePlus

Epitrochlear bursitis; Lateral epicondylitis; Epicondylitis - lateral; Tendonitis - elbow ... Philadelphia, PA: Elsevier; 2017:chap 25. Biundo JJ. Bursitis, tendinitis, and other periarticular disorders and sports medicine. ...

Section modulus is the optimum geometric predictor for stress fractures and medial tibial stress syndrome in both male and female athletes.

PubMed

Franklyn, Melanie; Oakes, Barry; Field, Bruce; Wells, Peter; Morgan, David

2008-06-01

Various tibial dimensions and geometric parameters have been linked to stress fractures in athletes and military recruits, but many mechanical parameters have still not been investigated. Sedentary people, athletes with medial tibial stress syndrome, and athletes with stress fractures have smaller tibial geometric dimensions and parameters than do uninjured athletes. Cohort study; Level of evidence, 3. Using a total of 88 subjects, male and female patients with either a tibial stress fracture or medial tibial stress syndrome were compared with both uninjured aerobically active controls and uninjured sedentary controls. Tibial scout radiographs and cross-sectional computed tomography images of all subjects were scanned at the junction of the midthird and distal third of the tibia. Tibial dimensions were measured directly from the films; other parameters were calculated numerically. Uninjured exercising men have a greater tibial cortical cross-sectional area than do their sedentary and injured counterparts, resulting in a greater value of some other cross-sectional geometric parameters, particularly the section modulus. However, for women, the cross-sectional areas are either not different or only marginally different, and there are few tibial dimensions or geometric parameters that distinguish the uninjured exercisers from the sedentary and injured subjects. In women, the main difference between the groups was the distribution of cortical bone about the centroid as a result of the different values of section modulus. Last, medial tibial stress syndrome subjects had smaller tibial cross-sectional dimensions than did their uninjured exercising counterparts, suggesting that medial tibial stress syndrome is not just a soft-tissue injury but also a bony injury. The results show that in men, the cross-sectional area and the section modulus are the key parameters in the tibia to distinguish exercise and injury status, whereas for women, it is the section modulus only.

Appropriate hinge position for prevention of unstable lateral hinge fracture in open wedge high tibial osteotomy.

PubMed

Nakamura, R; Komatsu, N; Fujita, K; Kuroda, K; Takahashi, M; Omi, R; Katsuki, Y; Tsuchiya, H

2017-10-01

Open wedge high tibial osteotomy (OWHTO) for medial-compartment osteoarthritis of the knee can be complicated by intra-operative lateral hinge fracture (LHF). We aimed to establish the relationship between hinge position and fracture types, and suggest an appropriate hinge position to reduce the risk of this complication. Consecutive patients undergoing OWHTO were evaluated on coronal multiplanar reconstruction CT images. Hinge positions were divided into five zones in our new classification, by their relationship to the proximal tibiofibular joint (PTFJ). Fractures were classified into types I, II, and III according to the Takeuchi classification. Among 111 patients undergoing OWHTOs, 22 sustained lateral hinge fractures. Of the 89 patients without fractures, 70 had hinges in the zone within the PTFJ and lateral to the medial margin of the PTFJ (zone WL), just above the PTFJ. Among the five zones, the relative risk of unstable fracture was significantly lower in zone WL (relative risk 0.24, confidence interval 0.17 to 0.34). Zone WL appears to offer the safest position for the placement of the osteotomy hinge when trying to avoid a fracture at the osteotomy site. Cite this article: Bone Joint J 2017;99B10:1313-18. ©2017 The British Editorial Society of Bone & Joint Surgery.

In Situ Splitting of a Rib Bone Graft for Reconstruction of Orbital Floor and Medial Wall.

PubMed

Uemura, Tetsuji; Yanai, Tetsu; Yasuta, Masato; Harada, Yoshimi; Morikawa, Aya; Watanabe, Hidetaka; Kurokawa, Masato

2017-06-01

In situ splitting of rib bone graft was conducted in 22 patients for the repair of orbital fracture with no other complicating fractures. A bone graft was harvested from the sixth or seventh rib in the right side. The repair of the orbital floor and medial wall was successful in all the cases. Ten patients had bone grafting to the orbital floor, eight had it done onto medial wall, and 4 onto both floor and wall after reduction. The mean length of in situ rib bone graft was 40.9 mm (range, 20-70 mm), the mean width of these was 14.9 mm (range, 8-20 mm). The bone grafting was done by one leaf for 15 cases and two leafs for 7 cases in size of defects. The technique of in situ splitting of a rib bone graft for the repair of the orbital floor and medial wall is a simple and safe procedure, easily taking out the in situ splitting of a rib, and less pain in donor site. It has proved to be an optimal choice in craniofacial reconstruction, especially the defects of orbital floor and medial wall.

Acquired simulated brown syndrome following surgical repair of medial orbital wall fracture.

PubMed

Hwang, Jong-uk; Lim, Hyun Taek

2005-03-01

Simulated Brown syndrome is a term applied to a myriad of disorders that cause a Brown syndrome-like motility. We encountered a case of acquired simulated Brown syndrome in a 41-year-old man following surgical repair of fractures of both medial orbital walls. He suffered from diplopia in primary gaze, associated with hypotropia of the affected eye. We performed an ipsilateral recession of the left inferior rectus muscle as a single-stage intraoperative adjustment procedure under topical anesthesia, rather than the direct approach to the superior oblique tendon. Postoperatively, the patient was asymptomatic in all diagnostic gaze positions.

A new surgical technique for traumatic dislocation of posterior tibial tendon with avulsion fracture of medial malleolus.

PubMed

Jeong, Soon-Taek; Hwang, Sun-Chul; Kim, Dong-Hee; Nam, Dae-Cheol

2015-01-01

We introduce a case of traumatic dislocation of the posterior tibial tendon with avulsion fracture of the medial malleolus in a 52-year-old female patient who was treated surgically with periosteal flap and suture anchor fixation. Based in the posteromedial ridge of the distal tibia, a quadrilateral periosteal flap was created and folded over the tendon, followed by fixation on the lateral aspect of the groove by use of multiple suture anchors. Clinical and radiological findings 25 months postoperatively showed well-preserved function of the ankle joint with stable tendon gliding.

An unusual variety of simultaneous fracture dislocation pattern: medial swivel dislocation of talonavicular joint with displaced fractures of the fourth and fifth metatarsals.

PubMed

Inal, Sermet; Inal, Canan

2013-01-01

In published studies, a very rare, special type of Chopart dislocation termed a swivel dislocation has been reported. This injury is characterized by dislocation of the talonavicular joint, but the calcaneocuboid joint remains intact. The foot creates a typical rotational movement without inversion or eversion. The axis of rotation is the interosseous talocalcaneal ligament, which remains intact. We report the case of an 18-year-old male who had experienced a medial swivel dislocation of the talonavicular joint associated with displaced fractures of the fourth and fifth metatarsals. The occurrence, features, and method of treatment of this rare injury are presented. Copyright © 2013 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

Comparison of Local Injection of Platelet Rich Plasma and Corticosteroids in the Treatment of Lateral Epicondylitis of Humerus.

PubMed

Yadav, Raman; Kothari, S Y; Borah, Diganta

2015-07-01

Lateral epicondylitis or Tennis Elbow is one of the most common causes of upper extremity pain with various treatment options. Platelet-rich plasma (PRP) offers a new option for the treatment of lateral epicondylitis. This study was conducted with an aim to compare the efficacy of PRP versus methyl-prednisolone local injection in patients with lateral epicondylitis. Sixty five patients with lateral epicondylitis were included in the study and randomized into two groups. Group A was treated with single injection of 1ml PRP with absolute platelet count of at least 1 million platelets/ mm(3). Group B was treated with single injection of 1ml (40mg) methyl-prednisolone. Pain, grip strength and functional improvements were assessed using visual analogue scale, dynamometer and quick Disabilities of the Arm, Shoulder and Hand scale respectively at baseline, 15 days, 1 month and 3 months. Sixty patients completed the follow up. All assessment parameters improved significantly in both the Groups at each follow up compared to baseline. At the end of three months group A showed significantly better improvement as compared to Group B. PRP and methyl-prenisolone both are effective in the treatment of lateral epicondylitis. However, PRP is a superior treatment option for longer duration efficacy.

Athletes' leg pains.

PubMed Central

Orava, S.; Puranen, J.

1979-01-01

The frequency and nature of exertion pains of the leg in athletes were studied in 2,750 cases of overuse injuries treated at the Sports Clinic of the Deaconess Institute of Oulu, Finland, during the years 1972-1977. 465 cases of exertion pain (18%) were located in the shin. The medial tibial syndrome was the most common overuse injury among these athletes, comprising 9.5% of all exertion injuries and 60% of the leg exertion pains. Together with stress fracture of the tibia, the second most common exertion pain of the leg, it accounted for 75% of the total leg pains. There are certain difficulties in differentiating between the medial tibial syndrome and stress fracture of the tibia. They both occur at the same site with similar symptoms. Radiological examination and isotope scanning are needed. The medial tibial syndrome is an overuse injury at the medial tibial border caused by running exercises. The pain is elicited by exertional ischaemia. The pathogenesis is explained by increased pressure in the fascial compartment of the deep flexor muscles due to prolonged exercise. Similar chronic ischaemic pains from exercise are also found in other fascial compartments of the leg, especially in the anterior compartment. The only treatment needed for stress fractures is rest from training. Fascial compartment pains also usually subside. If chronic fascial syndromes prevent training, fasciotomy is recommended as a reliable method to restore the athlete to normal training without pains. PMID:486888

Split Fracture of the Posteromedial Tubercle of the Talus: Case Report and Proposed Classification System.

PubMed

Watanabe, Hiroshi; Majima, Tokifumi; Takahashi, Kenji; Kawaji, Hidemi; Takai, Shinro

We describe a rare case of a fracture of the medial tubercle of the posterior process of the talus in a 16-year-old male athlete who fell during basketball practice. The patient presented to our orthopedic clinic when pain and swelling had persisted despite 2 weeks of anti-inflammatory medication and rest. Computed tomography and magnetic resonance imaging scans revealed a fracture of the posteromedial tubercle of the talus and a small amount of retained fluid in the joint. Immobilization with a below-the-knee cast and non-weightbearing for 4 weeks, with a gradual return to full activity, was successful. At the 1-year follow-up evaluation, the patient expressed no complaints. Fracture of the posteromedial tubercle of the talus will usually result in a misdiagnosis or delayed diagnosis owing to the insidious onset of symptoms. We believe the present fracture configuration resulted from the vertical compression force that occurred on landing by posterior medial ankle impingement in plantarflexion-supination, modifying the conventional concept of the posteromedial tubercle fracture. We also present a suggested classification with a flowchart diagram. Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

Elbow arthroscopy: indications, techniques, outcomes, and complications.

PubMed

Adams, Julie E; King, Graham J W; Steinmann, Scott P; Cohen, Mark S

2014-12-01

Elbow arthroscopy is a tool useful for the treatment of a variety of pathologies about the elbow. The major indications for elbow arthroscopy include débridement for septic elbow arthritis, synovectomy for inflammatory arthritis, débridement for osteoarthritis, loose body extraction, contracture release, treatment of osteochondral defects and selected fractures or instability, and tennis elbow release. Contraindications, technical considerations, and favorable outcomes following treatment with elbow arthroscopy require careful patient evaluation, a thorough understanding of anatomic principles, and proper patient positioning and portal selection to guide preoperative planning and overall patient care. Elbow arthroscopy is an effective procedure for the treatment of inflammatory arthritis, osteoarthritis, and lateral epicondylitis. Copyright 2014 by the American Academy of Orthopaedic Surgeons.

An Atypical Variant of Superolateral Dislocation of the Mandibular Condyle: A Case Report.

PubMed

Malik, Kapil; Debnath, Subhas C; Adhyapok, Apurba K; Hazarika, Kriti

2017-10-01

Dislocation of the mandibular condyle from the glenoid fossa can occur in anterior, posterior, lateral, and superior directions. Posterior, lateral, and superior dislocations are rare. Superolateral dislocation is seldom encountered in clinical practice. It is generally associated with fracture of the anterior or contralateral side of the mandible. The occurrence of superolateral dislocation of the condyle hooked above the zygomatic arch with an associated fracture of the medial pole of the condyle is rare and has been reported only once in the literature. This report describes another case in which the patient had superolateral dislocation of the mandibular condyle with a fractured medial pole without any associated fracture of the anterior or contralateral side of the mandible. The condyle was hooked laterally above the zygomatic arch. Open reduction of the dislocated condyle was performed and a good outcome was obtained. Copyright © 2017 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Subchondral Impaction Fractures of the Medial Femoral Condyle in Weightlifters: A Report of 5 Cases.

PubMed

Grzelak, Piotr; Podgórski, Michał Tomasz; Stefańczyk, Ludomir; Krochmalski, Marek; Domżalski, Marcin

2016-01-01

Although subchondral impaction fractures have already been reported in the non-weight-bearing portion of the lateral femoral condyle, this study reveals the presence of an intra-articular impaction fracture of the postero-superior region of the non-weight-bearing portion of the medial femoral condyle recognized in 5 of a group of 22 representatives of the Polish national Olympic weightlifting team, who underwent 1.5T magnetic resonance imaging examination. Articular cartilage lesions varied with regard to the type of injury and its severity ranging from healed or subchronic injuries to acute trauma. All described individuals had no clinical history of acute knee trauma and only 3 of them had minor pain symptoms. The accumulation of microtraumas occurring during participation in particular activities associated with weightlifting training seems to be responsible for the development of this type of contusion. This is the first description of impaction fracture observed in this location in professional weightlifters.

Ankle syndesmotic injury.

PubMed

Zalavras, Charalampos; Thordarson, David

2007-06-01

Ankle syndesmotic injury does not necessarily lead to ankle instability; however, the coexistence of deltoid ligament injury critically destabilizes the ankle joint. Syndesmotic injury may occur in isolation or may be associated with ankle fracture. In the absence of fracture, physical examination findings suggestive of injury include ankle tenderness over the anterior aspect of the syndesmosis and a positive squeeze or external rotation test. Radiographic findings usually include increased tibiofibular clear space decreased tibiofibular overlap, and increased medial clear space. However, syndesmotic injury may not be apparent radiographically; thus, routine stress testing is necessary for detecting syndesmotic instability. The goals of management are to restore and maintain the normal tibiofibular relationship to allow for healing of the ligamentous structures of the syndesmosis. Fixation of the syndesmosis is indicated when evidence of a diastasis is present. This may be detected preoperatively, in the absence of fracture, or intraoperatively, after rigid fixation of the medial malleolus and fibula fractures. Failure to diagnose and stabilize syndesmotic disruption adversely affects outcome.

Middle and long term radiologic and functional results of childhood supracondylar humeral fractures operated in first 24 hours with limited medial approach.

PubMed

Dost, Abdulkadir; Yilmaz, Baris; Komur, Baran; Mutlu, Serhat; Mutlu, Harun; Ozkan, Korhan; Eren, Abdullah

2016-04-01

To investigate the middle- and long-term radiological and functional results of children with type III supracondylar humerus fractures treated with a limited medial approach and internal fixation. The retrospective study was conducted at Department of Orthopaedics in Goztepe Training and Research Hospital, Istanbul, Turkey, and comprised data of children who underwent surgery between April 1991 and June 2009. Patients in group I underwent surgery within the first 8 hours after admission, and those in group II did so 8-24 hours after admission. Patients were evaluated according to the Flynn scoring system. Of the 79 patients, 52(65.8%) were male and 27(34.2%) were female. Fractures involved the left side in 49(62%) patients. Group I had 39(49.4%) patients and group II 40(50.6%). The overall mean age was 6.2±2.95 years (range: 2-13 years), and the mean follow-up was 53.2±14.9 months (range: 26-193 months). Functional scores were satisfactory (excellent, good and fair results) in all cases in both groups (100%), and the cosmetic results were satisfactory in 37(95%) in group I, and 39(97.5%) in group II (p>0.05). Limited medial approach to the treatment of supracondylar humerus fractures yielded successful functional and cosmetic results.

[Outcome of operative treatment for supination-external rotation Lauge-Hansen stage IV ankle fractures].

PubMed

Kołodziej, Łukasz; Boczar, Tomasz; Bohatyrewicz, Andrzej; Zietek, Paweł

2010-01-01

Ankle fractures are among the most common musculoskeletal injures. These fractures occur with an overall age- and sex-adjusted incidence rate around 180 per 100 000 person-years. The most frequent mechanism is considered to be supination-external rotation (60 to 80% of all ankle fractures) consisting of pathologic external rotation of the foot initially placed in some degree of supination. According to Lauge-Hansen classification, ankle joint structures are damaged in a sequence where the final, stage IV injuries, represents transverse fracture of the medial malleolus or its equivalent-rupture of the deltoid ligament. The aim of this study is to compare the results of two subtypes of supination-external rotation stage IV fractures. 43 patients treated surgically in 2006 to 2007 at Authors institution because of stage IV supination-external rotation ankle fracture were submitted to retrospective analysis. There were 25 patients with bimalleolar fracture (type 1) and in 18 patients with lateral malleolar fracture with accompanying rupture of the deltoid ligament (type 2). The mean age was 46 years (from 20 to 82 years). Average follow up period was 37 months (from 24 to 46 months). For the evaluation of treatment AOFAS hind-foot score (American Orthopedic Foot and Ankle Society) was used. The mean AOFAS score scale for Type 1 fractures was 85 points and for type 2 was significantly higher and amounted to 91 points (p < 0.05). Supination-external rotation stage IV ankle fractures with medial malleolar fracture, requires the implementation of additional diagnostic and therapeutic strategies and procedures in order to improve the outcome of results.

FLOATING ELBOW IN CHILDREN: A DESCRIPTIVE STUDY OF 31 CASES ATTENDED IN A REFERENCE CENTER FOR PEDIATRIC TRAUMA.

PubMed

Malheiros, Dorotea Starling; Bárbara, Gustavo Henrique Silva; Mafalda, Leandro Gonçalves; Madureira, João Lopo; Braga, Gilberto Ferreira; Terra, Dalton Lopes

2011-01-01

To conduct a descriptive analysis on 31 cases of children with floating elbow who were attended at our clinic between 1994 and 2009, and to review the literature relating to this topic. Data were obtained through examining the medical records. The following variables were used: age, gender, side, mechanism, type of fracture, classification, treatment and complications. Twenty-four patients (77.4%) were male and seven (22.6%) were female. The mean age was 8.5 (± 3.2) years, ranging from one to 14 years. The left side was predominantly affected (67.7%). The commonest injury mechanism was a fall from a height (74.2%). All the supracondylar fractures were Gartland type III. Distal radius fractures alone, of Salter-Harris type II, were diagnosed in 22 patients (71%). Open fractures occurred in 22 cases (71%). Closed reduction and application of a plaster cast for a closed fracture of the distal radius was performed in two patients (6.45%). Simultaneous conservative treatment for two fractures was not used. Sixteen supracondylar fractures (54.8%) were fixed using crossed wires, at 90° to each other, and in 14 cases (45.16%), an intramedullary wire was used together with another wire introduced through the lateral epicondyle at 45°. The following complications were observed: deformed consolidation (10%), nerve injuries (6%), compartment syndrome (3%) and pin path infection (16%). This is an uncommon injury that in most cases results from high-energy trauma. Surgical treatment for both fractures is recommended by most authors. Ulnar nerve injuries were correlated with the fixation method, but no neurological injuries were triggered by the initial trauma.

FLOATING ELBOW IN CHILDREN: A DESCRIPTIVE STUDY OF 31 CASES ATTENDED IN A REFERENCE CENTER FOR PEDIATRIC TRAUMA

PubMed Central

Malheiros, Dorotea Starling; Bárbara, Gustavo Henrique Silva; Mafalda, Leandro Gonçalves; Madureira, João Lopo; Braga, Gilberto Ferreira; Terra, Dalton Lopes

2015-01-01

Objective: To conduct a descriptive analysis on 31 cases of children with floating elbow who were attended at our clinic between 1994 and 2009, and to review the literature relating to this topic. Methods: Data were obtained through examining the medical records. The following variables were used: age, gender, side, mechanism, type of fracture, classification, treatment and complications. Results: Twenty-four patients (77.4%) were male and seven (22.6%) were female. The mean age was 8.5 (± 3.2) years, ranging from one to 14 years. The left side was predominantly affected (67.7%). The commonest injury mechanism was a fall from a height (74.2%). All the supracondylar fractures were Gartland type III. Distal radius fractures alone, of Salter-Harris type II, were diagnosed in 22 patients (71%). Open fractures occurred in 22 cases (71%). Closed reduction and application of a plaster cast for a closed fracture of the distal radius was performed in two patients (6.45%). Simultaneous conservative treatment for two fractures was not used. Sixteen supracondylar fractures (54.8%) were fixed using crossed wires, at 90° to each other, and in 14 cases (45.16%), an intramedullary wire was used together with another wire introduced through the lateral epicondyle at 45°. The following complications were observed: deformed consolidation (10%), nerve injuries (6%), compartment syndrome (3%) and pin path infection (16%). Conclusions: This is an uncommon injury that in most cases results from high-energy trauma. Surgical treatment for both fractures is recommended by most authors. Ulnar nerve injuries were correlated with the fixation method, but no neurological injuries were triggered by the initial trauma. PMID:27027045

Locking plate fixation in distal metaphyseal tibial fractures: series of 79 patients.

PubMed

Gupta, Rakesh K; Rohilla, Rajesh Kumar; Sangwan, Kapil; Singh, Vijendra; Walia, Saurav

2010-12-01

Open reduction and internal fixation in distal tibial fractures jeopardises fracture fragment vascularity and often results in soft tissue complications. Minimally invasive osteosynthesis, if possible, offers the best possible option as it permits adequate fixation in a biological manner. Seventy-nine consecutive adult patients with distal tibial fractures, including one patient with a bilateral fracture of the distal tibia, treated with locking plates, were retrospectively reviewed. The 4.5-mm limited-contact locking compression plate (LC-LCP) was used in 33 fractures, the metaphyseal LCP in 27 fractures and the distal medial tibial LCP in the remaining 20 fractures. Fibula fixation was performed in the majority of comminuted fractures (n = 41) to maintain the second column of the ankle so as to achieve indirect reduction and to prevent collapse of the fracture. There were two cases of delayed wound breakdown in fractures fixed with the 4.5-mm LC-LCP. Five patients required primary bone grafting and three patients required secondary bone grafting. All cases of delayed union (n = 7) and nonunion (n = 3) were observed in cases where plates were used in bridge mode. Minimally invasive plate osteosynthesis (MIPO) with LCP was observed to be a reliable method of stabilisation for these fractures. Peri-operative docking of fracture ends may be a good option in severely impacted fractures with gap. The precontoured distal medial tibial LCP was observed to be a better tolerated implant in comparison to the 4.5-mm LC-LCP or metaphyseal LCP with respect to complications of soft tissues, bone healing and functional outcome, though its contour needs to be modified.

Posttraumatic tibia valga: a case demonstrating asymmetric activity at the proximal growth plate on technetium bone scan

DOE Office of Scientific and Technical Information (OSTI.GOV)

Zionts, L.E.; Harcke, H.T.; Brooks, K.M.

1987-07-01

Posttraumatic tibia valga is a well-recognized complication following fracture of the upper tibial metaphysis in young children. We present a case of a child who developed a valgus deformity following fracture of the proximal tibia and fibula in which quantitative bone scintigraphy at 5 months after injury demonstrated increased uptake at the proximal tibial growth plate with proportionally greater uptake on the medial side. This finding suggests that the valgus deformity in this patient was due to a relative increase in vascularity and consequent overgrowth of the medial portion of the proximal tibial physis.

The comparison of femoral component rotational alignment with transepicondylar axis in mobile bearing TKA, CT-scan study.

PubMed

Witoolkollachit, Polawat; Seubchompoo, Onuma

2008-07-01

The tibial axis referencing method with a balanced tension flexion gap at 90 degrees knee flexion provides adequate femoral component rotation usually in external rotation, the trans-epicondylar line being parallel to the proximal tibial cut. The LCS mobile bearing TKA uses this technique to automatically determine the femoral component rotation with desired tension. The determination of the epicondyles may lead to some confusion. On the lateral side, the prominence of the lateral condyle makes it easy to define. However on the medial side, some surgeons use the prominent part of the medial epicondyle (well recognized on CT scan as the most proximal ridge that gives insertion to the superficial collateral ligament) and use the anatomical transepicondylar axis (aTEA). Other surgeons use the depression below called sulcus that defines the surgical transepicondylar axis (sTEA). The authors evaluated 40 clinically successful mobile bearing TKA in 33 patients. All the knees were performed by single surgeon and the rotational alignment of the femoral component was applied with balanced flexion gap technique. Post-op CT-scans were done in all knees with 2-mm interval and measurement of the different angles (between aTEA and the prosthetic posterior condylar line and between the sTEA and the prosthetic posterior condylar line) with the UTHSCSA Imagetool (IT) version 3 from the University of Texas Health Science Center at San Antonio. The authors found that the mean femoral implant angle was in 2.39 degrees (SD = 2.80) of internal rotation with reference to the aTEA and in 1.34 degrees (SD = 1.57 degrees) of external rotation with reference to the sTEA when the medial sulcus was perfectly detected (nine knees, 22.5%). The angle between the aTEA and the sTEA was -3.98 degrees (SD = 1.05 degrees). No patella subluxation was identified. Nineteen or 47.5% of the femoral components were in internal or external femoral rotation of more than 3 degrees to the aTEA. When sTEA was detected, no knee was in internal or external rotation more than 3 degrees to sTEA. The balanced flexion gap technique positions the femoral component in external rotation with the LCS TKA. Within 3 degrees to aTEA or sTEA, this technique produced femoral rotational angle closer to sTEA when the sulcus was detected and produced a wide range of different angles when compared to aTEA. However sTEA is not the consistent bony landmark. This technique is a reliable method to determine femoral rotational alignment.

Supracondylar process syndrome: two cases of median nerve neuropathy due to compression by the ligament of Struthers.

PubMed

Shon, Hyun-Chul; Park, Ji-Kang; Kim, Dong-Soo; Kang, Sang-Woo; Kim, Kook-Jong; Hong, Seok-Hyun

2018-01-01

The supracondylar process is a beak-shaped bony process on the anteromedial aspect of the distal humerus. The ligament of Struthers is a fibrous band extending from the tip of the process to the medial epicondyle. The median nerve and brachial artery pass under the ligament of Struthers and consequently can be compressed, causing supracondylar process syndrome. As a rare cause of proximal median nerve entrapment, supracondylar process syndrome is triggered when the median nerve is located in the superficial or deep layer of the ligament of Struthers as a result of anatomical variation. The supracondylar process can be easily detected on X-ray images obtained in oblique views but may not be identified in only anteroposterior or lateral views. In this article, we present 2 cases of supracondylar process syndrome and describe the process of diagnosis and treatment and results of a literature review.

Avascular Necrosis of Trochlea After Supracondylar Humerus Fractures in Children.

PubMed

Etier, Brian E; Doyle, J Scott; Gilbert, Shawn R

2015-10-01

Avascular necrosis (AVN) is a rare but important complication after supracondylar humerus fractures. Posttraumatic humerus deformity was first reported in 1948 and sporadically thereafter. AVN deformity has been classified as type A (AVN of the lateral ossification center) and type B (AVN of the entire medial crista and a metaphyseal portion). In this article, we present 5 cases of AVN after supracondylar humerus fracture, discuss the importance of late clinical findings, and postulate a mechanism of AVN in nondisplaced fractures. Five cases of AVN after supracondylar humerus fracture were reviewed from the Children's of Alabama database. Four of the 5 patients were female. Four patients sustained a Gartland type III fracture, and 1 patient sustained a nondisplaced Gartland type I fracture. Age at time of injury ranged from 5 years to 10 years. All patients had an asymptomatic clinical period after treatment and re-presented 6 months to 7 years later with elbow pain or loss of motion. All patients were treated symptomatically. AVN of the trochlea has a late clinical presentation. The cause of this complication is interruption of the trochlea blood supply. In displaced fractures, the medial and/or lateral vessels are injured, leading to type A or type B deformity. In nondisplaced fractures, the lateral vessels are interrupted by tamponade because of encased fracture hematoma; this presents as a type A deformity. Both type A and type B deformities can be clinically significant. AVN of the trochlea should be considered in patients with late presentation of pain or loss of motion after treatment of supracondylar humerus fractures.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Hammeschlag, S.B.; Hughes, S.; O'Reilly, G.V.

Orbital blow-out fractures were experimentally created in eight human cadavers. Each orbit underwent conventional radiographic studies, complex motion tomography, and computed tomographic examinations. A comparison of the three modalities was made. Anatomical correlation was obtained by dissecting the orbits. The significance of medial-wall fractures and enophthalmos is discussed. Limitation of inferior rectus muscle mobility is thought to be a result of muscle kinking associated with orbital fat-pad prolapse at the fracture site, rather than muscle incarceration. Blow-out fractures should be evaluated by computed tomographic computer reformations in the oblique sagittal plane.

[Cannulated lag screw combined with lateral supporting plate for treatment of Hoffa fracture of Letenneur type I and type III].

PubMed

Lin, Tao; Yang, Shuhua; Xiao, Baojun; Fu, Dehao

2013-09-01

To investigate the effectiveness of cannulated lag screws combined with lateral supporting plates in the treatment of Hoffa fracture of Letenneur type I and type III. Between May 2004 and April 2011, 11 patients with Hoffa fracture of Letenneur type I and type III were treated, including 6 males and 5 females with an average age of 36 years (range, 25-47 years). Factures were caused by traffic accident in 8 cases, by falling in 2 cases, and by the other in 1 case. Fracture involved the left knee in 7 patients and the right knee in 4 patients. According Letenneur's classification criteria, there were 7 type I fractures (6 lateral condyle fractures and 1 medial condyle fracture) and 4 type III fractures (3 lateral condyle fractures and 1 medial condyle fracture). Of 11 fractures, 9 were fresh fractures and 2 were old fractures. Two 6.5 mm cannulated lag screws combined with lateral supporting plates were used to fix fractures by anterolateral or anteromedial incision. All incisions achieved primary healing with no early complication. All patients were followed up 12-26 months (mean, 15 months). X-ray films showed bone healing with an average healing time of 15 weeks (range, 10-18 weeks). No loosening or breaking of internal fixator was observed; the removal time of internal fixation was 9-15 months (mean, 12 months). Accoding to Letenneur's functional assessment system, the results were excellent in 7 cases, good in 3 cases, and poor in 1 case at last follow-up. Cannulated lag screws combined with lateral supporting plates fixation is effective in treatment of Hoffa fracture of Letenneur type I and type III with a high union rate; anterolateral or anteromedial approach is the first choice for Hoffa fracture of type I and type III, especially for complicating by tibial plateau fracture or patella fracture.

The vascularization of the os calcaneum and the clinical consequences.

PubMed

Andermahr, J; Helling, H J; Rehm, K E; Koebke, Z

1999-06-01

This study was conducted to analyze extraosseous and intraosseous vascularization of the os calcaneum and to elucidate possible clinical manifestations. The arteries of 13 lower leg and foot specimens of human cadavers were injected with a polymer and subjected to maceration or were embedded in plastic. The examination revealed that 45% of the bone is vascularized via medial arteries and 45% via lateral arteries, whereas the remaining 10% is supplied by the sinus tarsi artery. From the medial side, two or three vessels branch off the posterior tibial artery, penetrate the calcaneus below the sustentaculum, and supply the medial part of the posterior joint. The lateral calcaneal artery normally is a branch from the posterior tibial artery. In two of 13 specimens, this lateral supply comes from the peroneal artery. The medial and lateral intraosseous arterial supply for the calcaneus is equal. Inside the bone there is a water-shed zone where the medial and lateral arterial supply meet in the midline. Only 10% of the blood flow is supplied by vessels in the sinus tarsi. Clinically, interruption of the lateral calcaneal artery during the conventional lateral surgical approach for a calcaneus fracture may result in ischemic bone necrosis. The lateral calcaneal artery could supply a local microvascular flap to cover soft tissue defects of the heel. A compartment syndrome after a calcaneus fracture may be caused by bleeding from the medial calcaneal arteries into the quadratus plantae compartment.

Elastic interactions between single microcrack and single osteon microstructure of human femur cortical bone

NASA Astrophysics Data System (ADS)

Mansor, N. N.; Daud, R.; Basaruddin, K. S.; Mat, F.; Bajuri, Y.; Ariffin, A. K.

2017-09-01

Inmultiscale Haversian system of cortical bone fracture, a homogenous bone modeling consideration is limited to only one Young modulus was significant for each cortex without having any constituents in that bone. A two dimension model of human femur cortical bone is presented by considering the anatomical positions of four cortices, e.g anterior, posterior, medial and lateral. The Haversian system is modeled under tensile loading by considering the interstitial matrix, osteon and cement line mechanical properties. The interaction between single microcrack and single osteon is evaluated using linear elastic fracture mechanics theory, and was determined using of stress intensity factor, strain energy release rate, and the critical stress intensity factor and critical strain energy release rate parameter. The results indicate that the medial cortex has the highest SIFs while the lowest was posterior cortex. The Young modulus of material was greatly influence the fracture parameters. More stiff the material, the SIF was reduced.

Anatomic and isometric points on femoral attachment site of popliteus muscle-tendon complex for the posterolateral corner reconstruction.

PubMed

Yang, Jae-Hyuk; Lim, Hong Chul; Bae, Ji Hoon; Fernandez, Harry; Bae, Tae Soo; Wang, Joon Ho

2011-10-01

Descriptive laboratory study. The femoral anatomic insertion site and the optimal isometric point of popliteus tendon for posterolateral reconstruction are not well known. Purpose of this study was to determine the relative relationship between the femoral anatomic insertion and isometric point of popliteus muscle-tendon complex with the lateral epicondyle of femur. Thirty unpaired cadaveric knees were dissected to determine the anatomic femoral insertion of the popliteus tendon. The distance and the angle from the lateral epicondyle of femur to the center of the anatomic insertion of the popliteus tendon were measured using digital caliper and goniometer. Eight unpaired fresh cadaveric knees were examined to determine the optimal isometric point of femoral insertion of popliteus tendon using computer-controlled motion capture analysis system (Motion Analysis, CA, USA). Distances from targeted tibial tunnel for popliteus tendon reconstruction to the 35 points gained on the lateral surface of femur were recorded at 0, 30, 60, 90, and 120° knee flexion. A point with the least excursion (<2.0 mm) was determined as the isometric point. The center of anatomic insertion points and the optimal isometric point for the main fibers of popliteus tendon were found to be posterior and distal to the lateral epicondyle of femur. The distance from the lateral epicondyle of femur to the center of anatomic femoral insertion of popliteus tendon was 11.3 ± 1.2 mm (mean ± SD). The angle between long axis of femur and the line from lateral epicondyle of femur to anatomic femoral insertion of popliteus tendon was 31.4 ± 5.3°. The isometric points for the femoral insertion of popliteus muscle-tendon complex were situated posterior and distal to the lateral epicondyle in all 8 knees. The distance between the least excursion point and the lateral epicondyle was calculated as 10.4 ± 1.7 mm. The angle between the long axis of femur and the line from lateral epicondyle of femur to optimum isometric point of popliteus tendon was calculated as 41.3 ± 14.9°. The optimal isometric point for the femoral insertion of popliteus muscle-tendon complex is situated posterior and distal to the lateral epicondyle of femur. Femoral tunnel for "posterolateral corner sling procedure" should be placed at this point to achieve least amount of graft excursion during knee motion.

Fracture of supracondylar process of the humerus.

PubMed

Suresh, S S

2008-07-01

The supracondylar process of the humerus is a rare skeletal anomaly, which is usually an incidental finding while an X-ray is done for some other purpose. The process can fracture resulting in pain and tender mobile swelling over the medial aspect of the arm, and consequent neurovascular symptoms, or entrapment neuropathies. The anomaly, which fractured in a clinical situation, is described, followed by a review of the literature.

Percutaneous locking plates for fractures of the distal tibia: our experience and a review of the literature.

PubMed

Ahmad, Mudussar Abrar; Sivaraman, Alagappan; Zia, Ahmed; Rai, Amarjit; Patel, Amratlal D

2012-02-01

Distal tibial metaphyseal fractures pose many complexities. This study assessed the outcomes of distal tibial fractures treated with medial locking plates. Eighteen patients were selected based on the fracture pattern and classified using the AO classification and stabilized with an AO medial tibial locking plate. Time to fracture union, complications, and outcomes were assessed with the American Orthopedic Foot and Ankle Society Ankle score at 12 months. Sixteen of the 18 patients achieved fracture union, with 1 patient lost to follow-up. Twelve fractures united within 24 weeks, with an average union time of 23.1 weeks. Three delayed unions, two at 28 weeks and one at 56 weeks. The average time to union was 32 weeks in the smokers and 15.3 weeks in the nonsmokers. Five of the 18 patients (27%) developed complications. One superficial wound infection, and one chronic wound infection, resulting in nonunion at 56 weeks, requiring revision. Two patients required plate removal, one after sustaining an open fracture at the proximal end of the plate 6 months after surgery (postfracture union)and the other for painful hardware. One patient had implant failure of three proximal diaphyseal locking screws at the screwhead/neck junction, but successful fracture union. The average American Orthopedic Foot and Ankle Society ankle score was 88.8 overall, and 92.1 in fractures that united within 24 weeks. Distal tibial locking plates have high fracture union rates, minimum soft tissue complications, and good functional outcomes. The literature shows similar fracture union and complication rates in locking and nonlocking plates. Copyright © 2012 by Lippincott Williams & Wilkins

Analysis of functional outcome of Hoffa fractures: A retrospective review of 32 patients.

PubMed

Trikha, Vivek; Das, Saubhik; Gaba, Sahil; Agrawal, Prabhat

2017-01-01

Hoffa fractures are uncommon intra-articular fractures of femoral condyle in coronal plane. The purpose of our study is to assess radiologic and functional outcome in operatively treated Hoffa fractures. We retrospectively reviewed 32 patients of isolated Hoffa fracture from January 2010 to March 2015. All were treated with open reduction and internal fixation using lateral approach for lateral Hoffa and medial approach for medial Hoffa fracture. Cancellous screws in lag mode and/or antiglide plate were employed for fixation in accordance with fracture anatomy. All patients were subjected to aggressive physical therapy postoperatively. Knee Society Score (KSS), International Knee Documentation Committee Score (IKDC), and Knee range of motion (ROM) were documented at final follow-up for functional evaluation. All fractures united by mean time of 11.56 ± 1.5 weeks. No evidence of subsequent displacement or fixation failure, arthritis, Avascular necrosis (AVN) of femoral condyle was elicited in any of the patients. Documented mean KSS and mean IKDC Score at final follow-up were 83.19 ± 8.43 and 81.62± 6.95, respectively. ROM at final follow-up was ranging from 0° to mean 116.41° ± 13.98°. Complications included stiffness of the involved knee in four patients, including one patient who developed infection and had to undergo implant removal after fracture union. Operative treatment of Hoffa fractures yields fairly good functional outcome. One must endeavor to achieve adequate intraoperative exposure and stable congruous articular reconstruction. Early aggressive physical therapy is a harbinger of optimal outcome.

Avulsion fracture of an ossified pes anserinus tendon post-lateral patellar dislocation.

PubMed

Albtoush, Omar M; Taib, Abtehag A; Horger, Marius; Springer, Fabian

2018-05-01

The pes anserinus is a common tendon comprising the tendinous insertions of the sartorius, gracilis, and semitendinosus muscles. It inserts at the anteromedial aspect of the tibia and plays a significant role in stabilization of the medial side of the knee joint. The current article presents a case with recurrent lateral patellar dislocations causing chronic stress along the medial knee stabilizers and consecutive enthesophyte formation at the insertion of the pes anserinus tendon that showed a transverse fracture upon a subsequent incident of traumatic lateral patellar dislocation. Avulsion injuries of the pes anserinus tendon are rarely encountered, and to our knowledge, association with recurrent lateral patellar dislocations has not been described before.

Open-wedge high tibial osteotomy: incidence of lateral cortex fractures and influence of fixation device on osteotomy healing.

PubMed

Dexel, Julian; Fritzsche, Hagen; Beyer, Franziska; Harman, Melinda K; Lützner, Jörg

2017-03-01

Open-wedge high tibial osteotomy (HTO) is an established treatment for young and middle-aged patients with medial compartment knee osteoarthritis and varus malalignment. Although not intended, a lateral cortex fracture might occur during this procedure. Different fixation devices are available to repair such fractures. This study was performed to evaluate osteotomy healing after fixation with two different locking plates. Sixty-nine medial open-wedge HTO without bone grafting were followed until osteotomy healing. In patients with an intact lateral hinge, no problems were noted with either locking plate. A fracture of the lateral cortex occurred in 21 patients (30.4 %). In ten patients, the fracture was not recognized during surgery but was visible on the radiographs at the 6-week follow-up. Lateral cortex fracture resulted in non-union with the need for surgical treatment in three out of eight (37.5 %) patients using the newly introduced locking plate (Position HTO Maxi Plate), while this did not occur with a well-established locking plate (TomoFix) (0 out of 13, p = 0.023). With regard to other adverse events, no differences between both implants were observed. In cases of lateral cortex fracture, fixation with a smaller locking plate resulted in a relevant number of non-unions. Therefore, it is recommended that bone grafting, another fixation system, or an additional lateral fixation should be used in cases with lateral cortex fracture. III.

Hemodynamic Deterioration in Lateral Compression Pelvic Fracture After Prehospital Pelvic Circumferential Compression Device Application.

PubMed

Garner, Alan A; Hsu, Jeremy; McShane, Anne; Sroor, Adam

Increased fracture displacement has previously been described with the application of pelvic circumferential compression devices (PCCDs) in patients with lateral compression-type pelvic fracture. We describe the first reported case of hemodynamic deterioration temporally associated with the prehospital application of a PCCD in a patient with a complex acetabular fracture with medial displacement of the femoral head. Active hemorrhage from a site adjacent to the acetabular fracture was subsequently demonstrated on angiography. Caution in the application of PCCDs to patients with lateral compression-type fractures is warranted. Copyright © 2017 Air Medical Journal Associates. All rights reserved.

Short- and long-term results following standing fracture repair in 34 horses.

PubMed

Payne, R J; Compston, P C

2012-11-01

Standing fracture repair in the horse is a recently described surgical procedure and currently there are few follow-up data. This case series contains 2 novel aspects in the standing horse: repair of incomplete sagittal fractures of the proximal phalanx and medial condylar repair from a lateral aspect. To describe outcome in a case series of horses that had lower limb fractures repaired under standing sedation at Rossdales Equine Hospital. Case records for all horses that had a fracture surgically repaired, by one surgeon at Rossdales Equine Hospital, under standing sedation and local anaesthesia up until June 2011, were retrieved. Hospital records, owner/trainer telephone questionnaire and the Racing Post website were used to evaluate follow-up. Thirty-four horses satisfied the inclusion criteria. Fracture sites included the proximal phalanx (incomplete sagittal fracture, n = 14); the third metacarpal bone (lateral condyle, n = 12, and medial condyle, n = 7); and the third metatarsal bone (lateral condyle, n = 1). One horse required euthanasia due to caecal rupture 10 days post operatively. Twenty horses (66.7% of those with available follow-up) have returned to racing. Where available, mean time from operation to return to racing was 226 days (range 143-433 days). Standing fracture repair produced similar results to fracture repair under general anaesthesia in terms of both the number of horses that returned to racing and the time between surgery and race. Repair of lower limb fracture in the horse under standing sedation is a procedure that has the potential for tangible benefits, including avoidance of the inherent risks of general anaesthesia. The preliminary findings in this series of horses are encouraging and informative when discussing options available prior to fracture repair. © 2012 EVJ Ltd.

Novel Semiquantitative Bone Marrow Oedema Score and Fracture Score for the Magnetic Resonance Imaging Assessment of the Active Charcot Foot in Diabetes

PubMed Central

Meacock, L.; Donaldson, Ana; Isaac, A.; Briody, A.; Ramnarine, R.; Edmonds, M. E.; Elias, D. A.

2017-01-01

There are no accepted methods to grade bone marrow oedema (BMO) and fracture on magnetic resonance imaging (MRI) scans in Charcot osteoarthropathy. The aim was to devise semiquantitative BMO and fracture scores on foot and ankle MRI scans in diabetic patients with active osteoarthropathy and to assess the agreement in using these scores. Three radiologists assessed 45 scans (Siemens Avanto 1.5T, dedicated foot and ankle coil) and scored independently twenty-two bones (proximal phalanges, medial and lateral sesamoids, metatarsals, tarsals, distal tibial plafond, and medial and lateral malleoli) for BMO (0—no oedema, 1—oedema < 50% of bone volume, and 2—oedema > 50% of bone volume) and fracture (0—no fracture, 1—fracture, and 2—collapse/fragmentation). Interobserver agreement and intraobserver agreement were measured using multilevel modelling and intraclass correlation (ICC). The interobserver agreement for the total BMO and fracture scores was very good (ICC = 0.83, 95% confidence intervals (CI) 0.76, 0.91) and good (ICC = 0.62; 95% CI 0.48, 0.76), respectively. The intraobserver agreement for the total BMO and fracture scores was good (ICC = 0.78, 95% CI 0.6, 0.95) and fair to moderate (ICC = 0.44; 95% CI 0.14, 0.74), respectively. The proposed BMO and fracture scores are reliable and can be used to grade the extent of bone damage in the active Charcot foot. PMID:29230422

Accuracy of radiographs in assessment of displacement in lateral humeral condyle fractures.

PubMed

Knutsen, Ashleen; Avoian, Tigran; Borkowski, Sean L; Ebramzadeh, Edward; Zionts, Lewis E; Sangiorgio, Sophia N

2014-02-01

Determining the magnitude of displacement in pediatric lateral humeral condyle fractures can be difficult. The purpose of this study was to (1) assess the effect of forearm rotation on true fracture displacement using a cadaver model and to (2) determine the accuracy of radiographic measurements of the fracture gap. A non-displaced fracture was created in three human cadaveric arms. The specimens were mounted on a custom apparatus allowing forearm rotation with the humerus fixed. First, the effect of pure rotation on fracture displacement was simulated by rotating the forearm from supination to pronation about the central axis of the forearm, to isolate the effects of muscle pull. Then, the clinical condition of obtaining a lateral oblique radiograph was simulated by rotating the forearm about the medial aspect of the forearm. Fracture displacements were measured using a motion-capture system (true-displacement) and clinical radiographs (apparent-displacement). During pure rotation of the forearm, there were no significant differences in fracture displacement between supination and pronation, with changes in displacement of <1.0 mm. During rotation about the medial aspect of the forearm, there was a significant difference in true displacements between supination and pronation at the posterior edge (p < 0.05). Overall, true fracture displacement measurements were larger than apparent radiographic displacement measurements, with differences from 1.6 to 6.0 mm, suggesting that the current clinical methods may not be sensitive enough to detect a displacement of 2.0 mm, especially when positioning the upper extremity for an internal oblique lateral radiograph.

Factors associated with regional rheumatic pain disorders in a population of Puerto Ricans with diabetes mellitus

PubMed Central

Font, Yvonne M.; Castro-Santana, Lesliane E.; Nieves-Plaza, Mariely; Maldonado, Mirna; Mayor, Ángel M.

2015-01-01

The aim of the study was to determine the prevalence and factors associated with bursitis/tendonitis disorders in Puerto Ricans with diabetes mellitus (DM). A cross-sectional study was performed in 202 adult Puerto Ricans (100 DM patients and 102 non-diabetic subjects). For each participant, a complete medical history and a musculoskeletal exam were systematically performed. Socio-demographic parameters, health-related behaviors, comorbidities, and pharmacotherapy were determined for all subjects. For DM patients, disease duration, glycemic control, and DM long-term complications were also examined. Multivariate logistic regression analyses were used to determine the factors associated with bursitis/tendonitis disorders. The mean (SD) age for DM patients and non-diabetic controls were 53.3 (12.9) and 50.0 (13.1) years; 64.0 and 64.7 % of DM patients and controls were females, respectively. Overall, the prevalence of bursitis/tendonitis was higher in DM patients than among non-diabetics (59.0 % vs. 29.4 %, p<0.01). In multivariate analyses, DM patients had 2.47 (95 % CI 1.05, 5.84) the odds of having bursitis/tendonitis as compared to non-diabetics. Specifically, DM patients had a higher frequency of flexor tenosynovitis, De Quervain’s tenosynovitis, lateral epicondylitis, medial epicondylitis, trochanteric bursitis, and anserine bursitis than non-diabetic subjects (p<0.05). Among DM patients, multivariate analyses showed that those with bursitis/tendonitis were more likely to be female [OR (95 % CI) 4.55 (1.42, 14.55)] and have peripheral vascular disease [OR (95 % CI) 8.48 (1.71, 41.93)]. In conclusion, bursitis/tendonitis disorders were common in this population of Hispanics with DM. Among DM patients, bursitis/tendonitis disorders were more frequent in women and those with long-term complications such as peripheral vascular disease. PMID:24522480

Indirect reduction with a condylar blade plate for osteosynthesis of subtrochanteric femoral fractures.

PubMed

Siebenrock, K A; Müller, U; Ganz, R

1998-01-01

Subtrochanteric fractures frequently occur as high energy trauma usually in younger patients and may lead to severe comminution of the medial cortex. The medial cortex of the proximal femur is exposed to high compressive forces which make fracture stabilization a difficult problem. Bone healing may be seriously compromised due to extensive comminution and fragment devitalization. This requires reduction techniques which do not cause additional damage to the vitality of the bone. With indirect reduction techniques and the use of a condylar blade plate the results have been significantly improved in these fracture types in our department (1). In this report the essential aspects of indirect reduction for subtrochanteric fractures using a condylar blade plate and the treatment results from our department from earlier years (1) and from the last 2 1/2 years will be presented. In the latter period, fifteen patients with a mean age of 49 years (19-87 years) were treated with this method. Fractures resulted from traffic incidents or falls from a great height in 11 cases (73%). Union was achieved in 14 cases (93%) with full weight-bearing after a mean of 3 months (1-4 1/2 months). Malunion was seen in two cases (13%) without the need for further surgery. Non union occurred in one patient (7%) with a III B open injury due to early infection. After repeated debridements, bone grafting and decortication, the fracture was stabilized with a replacement condylar blade plate and healed uneventfully.

Shoulder joint abduction motion test bench: a new shoulder test bench for in vitro experiments with active muscle force simulation.

PubMed

Onder, Ursula; Blauth, Michael; Kralinger, Franz; Schmoelz, Werner

2012-05-30

In our society the average age is increasing, as are the number of proximal humeral head fractures. For fixation of these fractures, an increasing number of implants are available. New fixation devices should be compared biomechanically with established methods in a standardized fashion. The test bench that was designed was intended to simulate abduction motion of the humerus actively induced by muscle forces. We used three pneumatic muscles to apply forces to the tendons of the musculus supraspinatus and the bifid musculus deltoideus. Thus, it was possible to create an active abduction in the scapular plane. Two different fracture models (with and without medial support) were stabilised with an angular stable plate in sawbone models to reproduce a known clinical outcome with the newly designed test setup. The resultant force acting on the proximal humerus reached approximately 47% BW (per cent body weight), which amounted to 329.0 N (SD: 21.76). The supraspinatus reached maximum forces of 254.7 N (SD: 20.1) and the deltoid muscle 258.9 N (SD: 16.5). Fracture gap instrumentation with medial support resulted in a significantly reduced per-cycle fracture gap motion. The performance evaluation showed that the simulator produced predicable, reproducible movements with physiological muscle force magnitudes.

Stress fractures about the tibia, foot, and ankle.

PubMed

Shindle, Michael K; Endo, Yoshimi; Warren, Russell F; Lane, Joseph M; Helfet, David L; Schwartz, Elliott N; Ellis, Scott J

2012-03-01

In competitive athletes, stress fractures of the tibia, foot, and ankle are common and lead to considerable delay in return to play. Factors such as bone vascularity, training regimen, and equipment can increase the risk of stress fracture. Management is based on the fracture site. In some athletes, metabolic workup and medication are warranted. High-risk fractures, including those of the anterior tibial diaphysis, navicular, proximal fifth metatarsal, and medial malleolus, present management challenges and may require surgery, especially in high-level athletes who need to return to play quickly. Noninvasive treatment modalities such as pulsed ultrasound and extracorporeal shock wave therapy may have some benefit but require additional research.

Anatomical predisposition of the ankle joint for lateral sprain or lateral malleolar fracture evaluated by radiographic measurements.

PubMed

Lee, Kyoung Min; Chung, Chin Youb; Sung, Ki Hyuk; Lee, SeungYeol; Kim, Tae Gyun; Choi, Young; Jung, Ki Jin; Kim, Yeon Ho; Koo, Seung Bum; Park, Moon Seok

2015-01-01

Injury mechanism and the amount of force are important factors determining whether a fracture or sprain occurs at the time of an ankle inversion injury. However, the anatomical differences between the ankle fracture and sprain have not been investigated sufficiently. This study was performed to investigate whether an anatomical predisposition of the ankle joint results in a lateral malleolar fracture or lateral ankle sprain. Two groups of consecutive patients, one with lateral malleolar fracture (274 patients, mean age 49.0 years) and the other with lateral ankle sprain (400 patients, mean age 38.4 years), were evaluated. Ankle radiographs were examined for 7 measures: distal tibial articular surface (DTAS) angle, bimalleolar tilt (BT), medial malleolar relative length (MMRL), lateral malleolar relative length (LMRL), medial malleolar slip angle (MMSA), anterior inclination of tibia (AI), and fibular position (FP). After an interobserver reliability test, the radiographic measurements were compared between the 2 groups. Linear regression analysis was performed to correct for age and sex effects between the groups. The fracture group and the sprain group showed significant differences in BT (P = .001), MMSA (P < .001), AI (P = .023), and FP (P < .001). In multiple regression analysis, after adjusting for age and sex effects, fracture and sprain groups showed a significant difference in BT (P = .001), MMRL (P < .001), MMSA (P < .001), and FP (P < .001). The lateral malleolar fracture group tended to show more bony constraint than that of the lateral ankle sprain group. Further 3-dimensional assessment of the bony structure and subsequent biomechanical studies are needed to elucidate the mechanism of injury according to the various types of ankle fractures and ankle sprain. Level III, retrospective comparative study. © The Author(s) 2014.

Combined Orbital Fractures: Surgical Strategy of Sequential Repair

PubMed Central

Hur, Su Won; Kim, Sung Eun; Chung, Kyu Jin; Lee, Jun Ho; Kim, Tae Gon

2015-01-01

Background Reconstruction of combined orbital floor and medial wall fractures with a comminuted inferomedial strut (IMS) is challenging and requires careful practice. We present our surgical strategy and postoperative outcomes. Methods We divided 74 patients who underwent the reconstruction of the orbital floor and medial wall concomitantly into a comminuted IMS group (41 patients) and non-comminuted IMS group (33 patients). In the comminuted IMS group, we first reconstructed the floor stably and then the medial wall by using separate implant pieces. In the non-comminuted IMS group, we reconstructed the floor and the medial wall with a single large implant. Results In the follow-up of 6 to 65 months, most patients with diplopia improved in the first-week except one, who eventually improved at 1 year. All patients with an EOM limitation improved during the first month of follow-up. Enophthalmos (displacement, 2 mm) was observed in two patients. The orbit volume measured on the CT scans was statistically significantly restored in both groups. No complications related to the surgery were observed. Conclusions We recommend the reconstruction of orbit walls in the comminuted IMS group by using the following surgical strategy: usage of multiple pieces of rigid implants instead of one large implant, sequential repair first of the floor and then of the medial wall, and a focus on the reconstruction of key areas. Our strategy of step-by-step reconstruction has the benefits of easy repair, less surgical trauma, and minimal stress to the surgeon. PMID:26217562

Treatment of the external epicondylitis of the humerus with a magnetic field

NASA Technical Reports Server (NTRS)

Degen, I. L.

1974-01-01

The therapeutic effect of a constant and varying magnetic field on epicondylitis of the humerus is studied on ninety patients. Good results are obtained from the treatment (recovery of 80%, considerable improvement in 14.5%). The method is recommended for clinical application.

Pulsed radiofrequency on radial nerve under ultrasound guidance for treatment of intractable lateral epicondylitis.

PubMed

Oh, Dae Seok; Kang, Tae Hyung; Kim, Hyae Jin

2016-06-01

Lateral epicondylitis is a painful and functionally limiting disorder. Although lateral elbow pain is generally self-limiting, in a minority of people symptoms persist for a long time. When various conservative treatments fail, surgical approach is recommended. Surgical denervation of several nerves that innervate the lateral humeral epicondyle could be considered in patients with refractory pain because it denervates the region of pain. Pulsed radiofrequency is a minimally invasive procedure that improves chronic pain when applied to various neural tissues without causing any significant destruction and painful complication. This procedure is safe, minimally invasive, and has less risk of complications relatively compared to the surgical approach. The radial nerve can be identified as a target for pulsed radiofrequency lesioning in lateral epicondylitis. This innovative method of pulsed radiofrequency applied to the radial nerve has not been reported before. We reported on two patients with intractable lateral epicondylitis suffering from elbow pain who did not respond to nonoperative treatments, but in whom the ultrasound-guided pulsed radiofrequency neuromodulation of the radial nerve induced symptom improvement. After a successful diagnostic nerve block, radiofrequency probe adjustment around the radial nerve was performed on the lateral aspect of the distal upper arm under ultrasound guidance and multiple pulsed treatments were applied. A significant reduction in pain was reported over the follow-up period of 12 weeks.

Moore I postero-medial articular tibial fracture in alpine skiers: Surgical management and return to sports activity.

PubMed

Morin, Vincent; Pailhé, Régis; Sharma, Akash; Rouchy, René-Christopher; Cognault, Jérémy; Rubens-Duval, Brice; Saragaglia, Dominique

2016-06-01

Over the past 10 years, like many authors, we observed an increasing number of Moore I tibial plateau fractures related to alpine skiing for which the surgeon may face difficult choices regarding surgical approach and fixation means. Some authors have recently been suggesting a posterior approach associated to open reduction and osteosynthesis by a buttress plate. But in our knowledge there is no specific study on sports activity recovery after Moore I tibial fractures. The aim of this work was to assess sports activities and clinical outcomes after surgically treated Moore I tibial plateau fractures in an athletic population of skiers. We conducted a prospective case series between 2012 and 2014. This included fifteen patients aged 39.6±7 years whom presented with a Moore I tibial plateau fracture during a skiing accident. 12 cases (80%) presented with an associated tibial spine fracture. Treatment consisted of a standard antero-medial approach, with a medial para patellar arthrotomy to allow direct visualisation of articular reduction and spinal fixation. Two or three 6.5mm long cancellous bone screws were placed antero-posteriorly so as to ensure perfect compression of the fracture site. Radiological and functional results were assessed by an independent observer (Lysholm-Tegner, UCLA, KOOS scores) at the longest follow-up. Mean follow-up was 18.2±6 months (12-28). An immediate postoperative anatomical reduction was achieved in all cases and remained stable in time. At last follow-up Lysholm mean score was 85±14 points (59-100), UCLA score was 7.3±1.6 (4-10) and Tegner score was 4.6±1.3 (3-6). Mean KOOS score was 77±15 (54-97). 87% of patients had resumed their skiing activity and 93% were satisfied or very satisfied from their post-operative surgical outcome. We observed no pseudarthrosis or secondary varus displacement. In our series 87% of patients had resumed back to their sporting activities. Surgical management of Moore I tibial plateau fractures by isolated antero-posterior screwing provides excellent clinical and radiological results. The anteromedial incision has a dual advantage of anatomical reduction, tibial spine fixation (in 80% of our cases) and posteromedial fragment reduction. Copyright © 2016 Elsevier Ltd. All rights reserved.

Acute traumatic open posterolateral dislocation of the ankle without tearing of the tibiofibular syndesmosis ligaments: a case report.

PubMed

Demiralp, Bahtiyar; Komurcu, Mahmut; Ozturk, Cagatay; Ozturan, Kutay; Tasatan, Ersin; Erler, Kaan

2008-01-01

Pure open dislocation of the ankle, or dislocation not accompanied by rupture of the tibiofibular syndesmosis ligaments or fractures of the malleoli or of the posterior border of the tibia, is an extremely rare injury. A 62-year-old man injured his right ankle in a motor vehicle accident. Besides posterolateral ankle dislocation, there was a 7-cm transverse skin cut on the medial malleolus, and the distal end of the tibia was exposed. After reduction, we made a 2- to 2.5-cm longitudinal incision on the lateral malleolus; the distal fibular fracture was exposed. Two Kirschner wires were placed intramedullary in a retrograde manner, and the fracture was stabilized. The deltoid ligament and the medial capsule were repaired. The tibiofibular syndesmosis ligaments were intact. At the end of postoperative year 1, right ankle joint range of motion had a limit of approximately 5 degrees in dorsiflexion, 10 degrees in plantarflexion, 5 degrees in inversion, and 0 degrees in eversion. The joint appeared normal on radiographs, with no signs of osteoarthritis or calcification. The best result can be obtained with early reduction, debridement, medial capsule and deltoid ligament restoration, and early rehabilitation. Clinical and radiographic features at long-term follow-up also confirm good mobility of the ankle without degenerative change or mechanical instability.

Molecular Identification of Human Fungal Pathogens

DTIC Science & Technology

2011-03-01

of the right lower tibia and fibula revealed nonenhancing edema of the skin and subcutaneous fat involving the medial distal right lower leg without...military hospital in Iraq and taken immediately to the operating room for complex pelvic fracture debridement and fixation, right lower extremity...patient’s comorbidities—which included acute kidney injury secondary to rhabdomyolysis, multiple fractures requiring surgical intervention, and pro

Foreign-body reaction and the course of osteolysis after polyglycolide implants for fracture fixation: experimental study in sheep.

PubMed

Weiler, A; Helling, H J; Kirch, U; Zirbes, T K; Rehm, K E

1996-05-01

Foreign-body reaction to polyglycolide (PGA) implants has been described in man. Many animal experiments have verified the mechanical properties of fixation devices made from PGA, but a significant foreign-body reaction has not been described. We studied the effect of PGA rods in 12 sheep with standardised osteochondral fractures of the medial femoral condyle fixed with uncoloured, self-reinforced PGA rods (Biofix). Radiographs were taken at intervals ranging from two weeks to two years, and the sheep were killed at intervals ranging from six to 24 months. All knees were examined histologically. Eleven of the 12 fractures healed radiologically and histologically. Moderate to severe osteolysis was seen at four to six weeks with maximum changes at 12 weeks in ten animals. Six knees showed fistula-like connections between the implant site and the joint space. Three developed synovitis, one with inflammatory changes involving the whole cartilage and one with destruction of the medial condyle. Although in our study osteochondral fractures fixed with PGA rods healed reliably, there were frequent, significant foreign-body reactions. Caution is needed when considering the use of PGA fixation devices in vulnerable regions such as the knee.

Defining the lateral and accessory views of the patella: an anatomic and radiographic study with implications for fracture treatment.

PubMed

Berkes, Marschall B; Little, Milton T M; Pardee, Nadine C; Lazaro, Lionel E; Helfet, David L; Lorich, Dean G

2013-12-01

The majority of orthopaedic surgeons rely on a lateral fluoroscopic image to assess reduction during patella fracture osteosynthesis. However, a comprehensive radiographic description of the lateral view of the patella has not been performed previously, and no accessory views to better visualize specific anatomic features have been developed. The purpose of this study was to provide a detailed anatomic description of all radiographic features of the true lateral of the patella, describe reproducible accessory views for assessing specific features of the patella, and demonstrate their utility in a fracture model. Twelve cadaver knee specimens free of patellofemoral pathology were used, and imaging was performed using standard C-arm fluoroscopy. For each specimen, a true lateral radiographic projection of the patella was obtained and distinct features were noted. Next, an arthrotomy was made and steel wire was contoured and fixed to various anatomic regions of the patella so as to obliterate the radiographic densities on the true lateral projection, thus confirming their anatomic correlation. Ideal views of the lateral and medial facets themselves were determined using radiographic markers and varying amounts of internal or external rotation of the specimen. Last, a transverse osteotomy was created in each patella and the ability of the true lateral and accessory views to detect malreduction was assessed. The true lateral projection of the patella was obtained with the limb in neutral alignment. Constant radiographic features of the lateral view of the patella include the articular tangent, a secondary articular density of variable length, and a dorsal cortical density. The articular tangent was produced by the central ridge between the medial and lateral facets in all specimens. The secondary articular density was created by a confluence of the edge of the lateral and edge of the medial facets in 5 patellas, a confluence of the edge of the lateral facet and the intersection of the odd and medial facets in 6 patellas, and the edge of the lateral facet alone in 1 patella. The edge of the lateral facet gave a constant contribution to the appearance of the secondary articular density in all cases. A distinct accessory view of the tangent of the lateral facet could be seen with an average of 17 degrees of patella external rotation (range, 12-35 degrees), and the tangent of the medial facet with an average of 26.5 degrees of internal rotation (range, 15-45 degrees). These accessory views were better able to visualize malreduction than the single lateral projection in a fracture model in all specimens. Described here is a comprehensive description of the true lateral radiographic view of the patella and accessory views. These views can be used in the evaluation of minimally displaced patella fractures if a computerized tomography is not desired to better assess the true amount of displacement and when assessing intraoperative reduction during patella fracture osteosynthesis.

Complete dislocation of the ulnar nerve at the elbow: a protective effect against neuropathy?

PubMed

Leis, A Arturo; Smith, Benn E; Kosiorek, Heidi E; Omejec, Gregor; Podnar, Simon

2017-08-01

Recurrent complete ulnar nerve dislocation has been perceived as a risk factor for development of ulnar neuropathy at the elbow (UNE). However, the role of dislocation in the pathogenesis of UNE remains uncertain. We studied 133 patients with complete ulnar nerve dislocation to determine whether this condition is a risk factor for UNE. In all, the nerve was palpated as it rolled over the medial epicondyle during elbow flexion. Of 56 elbows with unilateral dislocation, UNE localized contralaterally in 17 elbows (30.4%) and ipsilaterally in 10 elbows (17.9%). Of 154 elbows with bilateral dislocation, 26 had UNE (16.9%). Complete dislocation decreased the odds of having UNE by 44% (odds ratio = 0.475; P =  0.028), and was associated with less severe UNE (P = 0.045). UNE occurs less frequently and is less severe on the side of complete dislocation. Complete dislocation may have a protective effect on the ulnar nerve. Muscle Nerve 56: 242-246, 2017. © 2016 Wiley Periodicals, Inc.

A Novel Fixation System for Acetabular Quadrilateral Plate Fracture: A Comparative Biomechanical Study

PubMed Central

Zha, Guo-Chun; Sun, Jun-Ying; Dong, Sheng-Jie; Zhang, Wen; Luo, Zong-Ping

2015-01-01

This study aims to assess the biomechanical properties of a novel fixation system (named AFRIF) and to compare it with other five different fixation techniques for quadrilateral plate fractures. This in vitro biomechanical experiment has shown that the multidirectional titanium fixation (MTF) and pelvic brim long screws fixation (PBSF) provided the strongest fixation for quadrilateral plate fracture; the better biomechanical performance of the AFRIF compared with the T-shaped plate fixation (TPF), L-shaped plate fixation (LPF), and H-shaped plate fixation (HPF); AFRIF gives reasonable stability of treatment for quadrilateral plate fracture and may offer a better solution for comminuted quadrilateral plate fractures or free floating medial wall fracture and be reliable in preventing protrusion of femoral head. PMID:25802849

Open Reduction in Pediatric Condylar Fracture.

PubMed

Barbosa, Alexandre Agostini; Mariano, Ronaldo Célio

2017-05-01

Facial fractures in children are rare. Lack of pneumatization, fat pockets, mixed dentition, contribute to the elasticity and bone stability. When mandibular fractures occur in children, most often involve the condyle by indirect trauma. Such fractures are the center of discussion on the form of treatment if this should be performed conservatively, or held the reduction and fixation of the fracture with surgical exposure of the fragments. In condylar fractures in children, in most patients, the proposed treatment is closed reduction. Treatment with open reduction and fixation has its specific indications. In this case, the authors report a patient cycling accident victim, with cut-contusion injury in ment with limited mouth opening and left condylar fracture with medial rotation. The treatment was the reduction and fixation of fragments by open process.

[Application of lateral malleolus hook-plate in treatment of stage II supination-adduction type medial malleolus fracture].

PubMed

Chen, Yu; Zhang, Hui; Huang, Fuguo; Xiang, Zhuo; Fang, Yue; Liu, Lei; Cen, Shiqiang

2014-09-01

To investigate the application of lateral malleolus hook-plate for the treatment of stage II supination-adduction type medial malleolus fractures. Between January 2011 and June 2013, 21 patients with stage II supination-adduction type ankle fractures were treated with lateral malleolus hook-plate, including 12 males and 9 females with an average age of 55.5 years (range, 27-65 years). The injury causes were sprain in 17 cases and traffic accident in 4 cases. The mean time between injury and admission was 12.4 hours (range, 2-72 hours). The tibial distal medial articular surface collapse was found in 7 cases by CT examination and in 3 cases by X-ray film. Of 21 cases, there were 12 cases of low transverse fractures of lateral malleolus, 7 cases of short oblique fractures of lateral malleolus, and 2 cases of ankle joint lateral collateral ligament injury without fractures of lateral malleolus. After operation, the clinical outcome was evaluated according to the talus-leg angle, the recovery of Coin-sign continuity, inside-outside and top ankle gap, talus slope, American Orthopedic Foot and Ankle Society (AOFAS) score, Olerud-Molander score, Kofoed evaluation standards, and patient satisfaction. Seventeen cases were followed up 18.7 months on average (range, 12-25 months). Primary healing was obtained in 16 cases except 1 case of delayed healing. Fracture healed at an average of 14.6 weeks (range, 12-16 weeks). All cases achieved anatomical reduction, the continuity of Coin-sign, and consistency of inside and outside joint gap; no talus tilt occurred. There was no complication of reduction loss, loosening or breakage of internal fixation, or osteoarthritis during follow-up. The talus-leg angle of the affected side was significantly improved to (83.4 ± 1.8)° at 1 week after operation from preoperative (74.8 ± 7.1)° (t = 5.370, P = 0.000), but no significant difference was found when compared with normal side (83.8 ± 2.3)° (t = 0.676, P = 0.509). The AOFAS score, Olerud-Molander score, and range of motion at 1 week, 3 months, and 1 year after operation were significantly improved when compared with preoperative ones (P < 0.05). According to Kofoed evaluation standard, the outcome was excellent in 15 cases and good in 2 cases; the excellent and good rate was 100%. According to patient satisfaction, the outcome was excellent in 13 cases, good in 3 cases, and poor in 1 case; the excellent and good rate was 94.1%. The use of lateral malleolus hook-plate for fixation of stage II supination-adduction type medial malleolus fracture not only can effectively maintain anatomical reduction and supporting function, but also can prevent re-collapsing of the reset joint surface. The surgical method can not increase soft tissue complication, so it is a safe and effective method.

Applications of 3D orbital computer-assisted surgery (CAS).

PubMed

Scolozzi, P

2017-09-01

The purpose of the present report is to describe the indications for use of 3D orbital computer-assisted surgery (CAS). We analyzed the clinical and radiological data of all patients with orbital deformities treated using intra-operative navigation and CAD/CAM techniques at the Hôpitaux Universitaires de Genève, Switzerland, between 2009 and 2016. We recorded age and gender, orbital deformity, technical and surgical procedure and postoperative complications. One hundred and three patients were included. Mean age was 39.5years (range, 5 to 84years) and 85 (87.5%) were men. Of the 103 patients, 96 had intra-operative navigation (34 for primary and 3 for secondary orbito-zygomatic fractures, 15 for Le Fort fractures, 16 for orbital floor fractures, 10 for combined orbital floor and medial wall fractures, 7 for orbital medial wall fractures, 3 for NOE (naso-orbito-ethmoidal) fractures, 2 for isolated comminuted zygomatic arch fractures, 1 for enophthalmos, 3 for TMJ ankylosis and 2 for fibrous dysplasia bone recontouring), 8 patients had CAD/CAM PEEK-PSI for correction of residual orbital bone contour following craniomaxillofacial trauma, and 1 patient had CAD/CAM surgical splints and cutting guides for correction of orbital hypertelorism. Two patient (1.9%) required revision surgery for readjustment of an orbital mesh. The 1-year follow-up examination showed stable cosmetic and dimensional results in all patients. This study demonstrated that the application of 3D orbital CAS with regards to intra-operative navigation and CAD/CAM techniques allowed for a successful outcome in the patients presented in this series. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Osteoligamentous injuries of the medial ankle joint.

PubMed

Lötscher, P; Lang, T H; Zwicky, L; Hintermann, B; Knupp, M

2015-12-01

Injuries of the ankle joint have a high incidence in daily life and sports, thus, playing an important socioeconomic role. Therefore, proper diagnosis and adequate treatment are mandatory. While most of the ligament injuries around the ankle joint are treated conservatively, great controversy exists on how to treat deltoid ligament injuries in ankle fractures. Missed injuries and inadequate treatment of the medial ankle lead to inferior outcome with instability, progressive deformity, and ankle joint osteoarthritis.

[ANALYSIS OF CLINICAL EFFECT IN SURGICAL TREATMENT OF Maisonneuve FRACTURE].

PubMed

Zhang, Zhiwen; Cai, Xianhua; Wei, Shijun; Liu, Ximing

2015-03-01

To investigate the operative method and short-term effectiveness in the surgical treatment of Maisonneuve fracture. Between January 2010 and February 2013, 23 patients with Maisonneuve fracture were treated. There were 14 males and 9 females with an average age of 40.3 years (range, 30-68 years). The causes of injuries were falling injury in 11 patients, sports related injury in 5 patients, traffic accident injury in 4 patients, and falling injury from height in 3 patients. The interval between injury and operation was 7-10 days (mean, 8.5 days). All of fractures were closed. Three patients had combined injury of deltoid ligament. The surgical procedures included surgical reduction and fixation of medial malleolus fracture and posterior malleolus fracture, repair of the deltoid ligament with ground anchor suture, and fixation of the disrupted distal tibiofibular syndesmosis. All incisions achieved primary healing, no postoperative complications such as infection occurred. Twenty-one patients were followed up 24-36 months (mean, 26.5 months). No patients complained of pain, tenderness, and obvious swelling of the ankle. At 3-6 months (mean, 4.6 months) after operation, X-ray films showed bony union of fractures and normal mortises in 21 patients. And no traumatic arthritis was observed with reliable fixation. The range of motion of ankle dorsi flexion and plantar flexion was 30-40 degrees) (mean, 34.5 degrees) Baird-Jackson anide functional score was 85-100 (mean, 94); 16 cases were rated as excellent, 4 as good, and 1 as fair with an excellent and good rate of 95.2%. Surgical treatments of Maisonneuve fracture include surgical reduction and fixation of the medial malleolus and posterior malleolus, repair of the deltoid ligament and fixation of the disrupted distal tibiofibular syndesmosis, and good effectiveness can be achieved.

LATERAL EPICONDYLITIS OF THE ELBOW

PubMed Central

Cohen, Marcio; da Rocha Motta Filho, Geraldo

2015-01-01

Lateral epicondylitis, also known as tennis elbow, is a common condition that is estimated to affect 1% to 3% of the population. The word epicondylitis suggests inflammation, although histological analysis on the tissue fails to show any inflammatory process. The structure most commonly affected is the origin of the tendon of the extensor carpi radialis brevis and the mechanism of injury is associated with overloading. Nonsurgical treatment is the preferred method, and this includes rest, physiotherapy, cortisone infiltration, platelet-rich plasma injections and use of specific immobilization. Surgical treatment is recommended when functional disability and pain persist. Both the open and the arthroscopic surgical technique with resection of the degenerated tendon tissue present good results in the literature. PMID:27047843

Clinical Comparison of Extensile Lateral Approach and Sinus Tarsi Approach Combined with Medial Distraction Technique for Intra-Articular Calcaneal Fractures.

PubMed

Zhou, Hai-Chao; Yu, Tao; Ren, Hao-Yang; Li, Bing; Chen, Kai; Zhao, You-Guang; Yang, Yun-Feng

2017-02-01

To study and compare the clinical outcomes of open reduction and internal fixation via extensile L-shape incision and limited open reduction via the sinus tarsi approach using the medial distraction technique for intra-articular calcaneal fractures. We performed a retrospective review of 65 intra-articular calcaneal fractures treated operatively between March 2012 and February 2015. Patients were divided into two groups: 28 were in the sinus tarsi approach group and 37 were in the extensile lateral approach group. All patients were asked to return for a research visit that included radiography and clinical evaluation. The postoperative function was evaluated using the ankle and hindfoot score of the American Orthopaedic Foot and Ankle Society (AOFAS) and the visual analogue scale (VAS). No significant difference was found in demographics between the two groups. The corrected value of the calcaneal varus angle between the two groups is statistically significant (P < 0.05). The overall wound complication rate was 3.6% in the minimally invasive group versus 13.5% in the extensile group. Four patients in the extensile lateral approach group had developed hindfoot varus deformity at last follow-up. At the last follow-up, the average AOFAS ankle and the hindfoot score of the minimal group was 88.4 ± 6.6, and the VAS score was 1.9 ± 0.7, while that of the extensile lateral approach group was 83.2 ± 5.6 and 2.3 ± 1.0, respectively. Limited open reduction via the sinus tarsi approach for intra-articular calcaneal fractures could reduce the incidence of wound complications effectively, and the medial distraction technique is helpful for correcting the calcaneus varus deformity. © 2017 Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.

Modification of elastic stable intramedullary nailing with a 3rd nail in a femoral spiral fracture model - results of biomechanical testing and a prospective clinical study.

PubMed

Kaiser, Martin M; Stratmann, Christine; Zachert, Gregor; Schulze-Hessing, Maaike; Gros, Nina; Eggert, Rebecca; Rapp, Marion

2014-01-08

Elastic stable intramedullary nailing (ESIN) is the standard treatment for displaced diaphyseal femoral fractures in children. However, high complication rates (10-50%) are reported in complex fractures. This biomechanical study compares the stiffness with a 3rd nail implanted to that in the classical 2C-shaped configuration and presents the application into clinical practice. For each of the 3 configurations of ESIN-osteosynthesis with titanium nails eight composite femoral grafts (Sawbones®) with an identical spiral fracture were used: 2C configuration (2C-shaped nails, 2 × 3.5 mm), 3CM configuration (3rd nail from medial) and 3CL configuration (3rd nail from lateral). Each group underwent biomechanical testing in 4-point bending, internal/external rotation and axial compression. 2C and 3CM configurations showed no significant differences in this spiroid type fracture model. 3CL had a significantly higher stiffness during anterior-posterior bending, internal rotation and 9° compression than 2C, and was stiffer in the lateral-medial direction than 3CM. The 3CL was less stable during p-a bending and external rotation than both the others. As biomechanical testing showed a higher stability for the 3CL configuration in two (a-p corresponding to recurvation and 9° compression to shortening) of three directions associated with the most important clinical problems, we added a 3rd nail in ESIN-osteosynthesis for femoral fractures. 11 boys and 6 girls (2.5-15 years) were treated with modified ESIN of whom 12 were '3CL'; due to the individual character of the fractures 4 patients were treated with '3CM' (third nail from medial) and as an exception 1 adolescent with 4 nails and one boy with plate osteosynthesis. No additional stabilizations or re-operations were necessary. All patients achieved full points in the Harris-Score at follow-up; no limb length discrepancy occurred. The 3CL configuration provided a significantly higher stiffness than 2C and 3CM configurations in this biomechanical model. These results were successfully transmitted into clinical practice. All children, treated by 3CL or 3CM according to the individual character of each fracture, needed no additional stabilization and had no Re-Do operations. As a consequence, at our hospital all children with femoral diaphyseal fractures with open physis are treated with this modified ESIN-technique.

Two-View Gravity Stress Imaging Protocol for Nondisplaced Type II Supination External Rotation Ankle Fractures: Introducing the Gravity Stress Cross-Table Lateral View.

PubMed

Boffeli, Troy J; Collier, Rachel C; Gervais, Samuel J

Assessing ankle stability in nondisplaced Lauge-Hansen supination external rotation type II injuries requires stress imaging. Gravity stress mortise imaging is routinely used as an alternative to manual stress imaging to assess deltoid integrity with the goal of differentiating type II from type IV injuries in cases without a posterior or medial fracture. A type II injury with a nondisplaced fibula fracture is typically treated with cast immobilization, and a type IV injury is considered unstable and often requires operative repair. The present case series (two patients) highlights a standardized 2-view gravity stress imaging protocol and introduces the gravity stress cross-table lateral view. The gravity stress cross-table lateral view provides a more thorough evaluation of the posterior malleolus owing to the slight external rotation and posteriorly directed stress. External rotation also creates less bony overlap between the tibia and fibula, allowing for better visualization of the fibula fracture. Gravity stress imaging confirmed medial-sided injury in both cases, confirming the presence of supination external rotation type IV or bimalleolar equivalent fractures. Open reduction and internal fixation was performed, and both patients achieved radiographic union. No further treatment was required at 21 and 33 months postoperatively. Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

Medial submuscular plating of the femur in a series of paediatric patients: a useful alternative to standard lateral techniques.

PubMed

Nayagam, S; Davis, B; Thevendran, G; Roche, A J

2014-01-01

We describe the technique and results of medial submuscular plating of the femur in paediatric patients and discuss its indications and limitations. Specifically, the technique is used as part of a plate-after-lengthening strategy, where the period of external fixation is reduced and the plate introduced by avoiding direct contact with the lateral entry wounds of the external fixator pins. The technique emphasises that vastus medialis is interposed between the plate and the vascular structures. A total of 16 patients (11 male and five female, mean age 9.6 years (5 to 17)), had medial submuscular plating of the femur. All underwent distraction osteogenesis of the femur with a mean lengthening of 4.99 cm (3.2 to 12) prior to plating. All patients achieved consolidation of the regenerate without deformity. The mean follow-up was 10.5 months (7 to 15) after plating for those with plates still in situ, and 16.3 months (1 to 39) for those who subsequently had their plates removed. None developed a deep infection. In two patients a proximal screw fractured without loss of alignment; one patient sustained a traumatic fracture six months after removal of the plate. Placing the plate on the medial side is advantageous when the external fixator is present on the lateral side, and is biomechanically optimal in the presence of a femoral defect. We conclude that medial femoral submuscular plating is a useful technique for specific indications and can be performed safely with a prior understanding of the regional anatomy.

Management of complications of open reduction and internal fixation of ankle fractures.

PubMed

Ng, Alan; Barnes, Esther S

2009-01-01

The management of complications resulting from the open reduction and internal fixation of ankle fractures is discussed in detail. The initial radiographic findings of the most common postsurgical complications of ankle fracture reduction are briefly discussed, namely lateral, medial, and posterior malleolar malunion or nonunion, syndesmotic widening, degenerative changes, and septic arthritis with or without concomitant osteomyelitis. Emphasis is placed on the management of these complications, with a review of the treatment options proposed in the literature, a detailed discussion of the authors' recommendations, and an inclusion of different case presentations.

[Treatment of calcaneal fractures using the medial approach for open reduction].

PubMed

Vanĕcek, L; Malkus, T; Dungl, P

2003-01-01

A comprehensive evaluation of the treatment of calcaneal fractures by open reduction is presented. The long-term results are compared with the relevant literature data. In the period from 1987 to 2000, 60 displaced fractures of the calcaneus were treated in 51 patients. Of these, 49 patients suffered the fracture by falling from a height, which is generally the most common cause. Only two patients were injured during sports activities. Thirty eight injuries were classified as fractures of the joint depression type and 22 as fractures of the tongue type. The patients had surgery on the day they sustained the injury or after edema had subsided, if this was present on admission. The interval between injury and surgery was 4.6 days on the average. The fracture was fixed with Kirschner's wires (Kw) in 53 cases, a Kirshcner's wire and a hook-nail in five cases and a Kirchner's wire and a spongious screw in two patients. In May 2001, 23 patients were available for evaluation after a follow-up period of 6 to 120 months. The patients underwent clinical and radiographic examination and filled a questionnaire. The fracture type was defined on the basis of the Essex-Lopresti classification system. Outcomes were scored according to the Creighton-Nebraska Health Foundation rating system that assessed pain, range of motion, edema, a change in shoe size, patient's activity after therapy termination and return to a job. In May 2001, 23 patients, with a follow-up ranging from 6 to 120 months were checked up. Of them, 20 (86.9%) had neither clinical manifestations nor subjective complaints. Three patients retired because of persisting complaints, two with disability pensions and one with an old-age pension. A total of 19 patients were evaluated by the Creighton-Nebraska Health Foundation rating system. The average score was 90.8 points. The results were excellent in 15 patients, good in three and poor in one patient. The complications reported by the patients included superficial infection in two, thromboembolic disease in one, and hypesthesia on the medial side of the leg in two patients. The optimal mode of treatment in dislocated intra-articular fractures of the calcaneus still remains open to discussion. Should conservative or surgical therapy be used? In agreement with others, the authors preferred early surgical intervention. This facilitated a better congruence of the dorsal articular surface. The average remaining dislocation of the articular surface was 1.1 mm in surgically treated as against the average of 4.7 mm in conservatively treated patients. It was possible to restore the length, height and width, and the correct axial position of the calcaneus by this surgery from the medial approach. However, in indicated cases, the procedure required an additional intervention from the lateral approach through a mini-incision. As reported in the literature, other authors have achieved comparable, or even better results but on the basis of either the lateral or the plantar approach. The application of primary spongioplasty or primary arthrodesis of the subtalar joint is discussed. The advantages of preoperative examination by computer-assisted tomography are emphasized. Good outcomes of the treatment of intra-articular, dislocated calcaneal fractures depend on a correct shape and position of the dorsal articular surface of the calcaneus. The open reduction procedure from the medial approach based on the principles of McReynold's technique allowed us to accomplish both these criteria.

Lateral epicondylitis of the elbow.

PubMed

Tosti, Rick; Jennings, John; Sewards, J Milo

2013-04-01

Lateral epicondylitis, or "tennis elbow," is a common musculotendinous degenerative disorder of the extensor origin at the lateral humeral epicondyle. Repetitive occupational or athletic activities involving wrist extension and supination are thought to be causative. The typical symptoms include lateral elbow pain, pain with wrist extension, and weakened grip strength. The diagnosis is made clinically through history and physical examination; however, a thorough understanding of the differential diagnosis is imperative to prevent unnecessary testing and therapies. Most patients improve with nonoperative measures, such as activity modification, physical therapy, and injections. A small percentage of patients will require surgical release of the extensor carpi radialis brevis tendon. Common methods of release may be performed via percutaneous, arthroscopic, or open approaches. Copyright © 2013 Elsevier Inc. All rights reserved.

Clinics in diagnostic imaging (163). Transient lateral patellar dislocation with trochlear dysplasia

PubMed Central

Zhang, Junwei; Lee, Chin Hwee

2015-01-01

A 14-year-old girl presented with left knee pain and swelling after an injury. Magnetic resonance (MR) imaging showed a transient lateral patellar dislocation with patellar osteochondral fracture, medial patellofemoral ligament tear and underlying femoral trochlear dysplasia. Open reduction and internal fixation of the osteochondral fracture, plication of the medial patellar retinaculum and lateral release were performed. As lateral patellar dislocation is often clinically unsuspected, an understanding of its characteristic imaging features is important in making the diagnosis. Knowledge of the various predisposing factors for patellar instability may also influence the choice of surgical management. We also discuss signs of acute injury and chronic instability observed on MR imaging, and the imaging features of anatomical variants that predispose an individual to lateral patellar dislocation. Treatment options and postsurgical imaging appearances are also briefly described. PMID:26512145

Successful application of endoscopic modified medial maxillectomy to orbital floor trapdoor fracture in a pediatric patient.

PubMed

Matsuda, Yasunori; Sakaida, Hiroshi; Kobayashi, Masayoshi; Takeuchi, Kazuhiko

2016-10-01

Although surgical treatment of orbital floor fractures can be performed by many different approaches, the application of endoscopic modified medial maxillectomy (EMMM) for this condition has rarely been described in the literature. We report on a case of a 7-year-old boy with a trapdoor orbital floor fracture successfully treated with the application of EMMM. The patient suffered trauma to the right orbit floor and the inferior rectus was entrapped at the orbital floor. Initially, surgical repair via endoscopic endonasal approach was attempted. However, we were unable to adequately access the orbital floor through the maxillary ostium. Therefore, an alternative route of access to the orbital floor was established by EMMM. With sufficient visualization and operating space, the involved orbital content was completely released from the entrapment site and reduced into the orbit. To facilitate wound healing, the orbital floor was supported with a water-inflated urethral balloon catheter for 8 days. At follow-up 8 months later, there was no gaze restriction or complications associated with the EMMM. This case illustrates the efficacy and safety of EMMM in endoscopic endonasal repair of orbital floor fracture, particularly for cases with a narrow nasal cavity such as in pediatric patients. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

The influence of muscle fatigue on electromyogram and plantar pressure patterns as an explanation for the incidence of metatarsal stress fractures.

PubMed

Weist, Roger; Eils, Eric; Rosenbaum, Dieter

2004-12-01

Stress fractures are common overuse injuries in runners and appear most frequently in the metatarsals. To investigate fatigue-related changes in surface electromyographic activity patterns and plantar pressure patterns during treadmill running as potential causative factors for metatarsal stress fractures. Prospective cohort study with repeated measurements. Thirty experienced runners volunteered to participate in a maximally exhaustive run above the anaerobic threshold. Surface electromyographic activity was monitored for 14 muscles, and plantar pressures were measured using an in-shoe monitoring system. Fatigue was documented with blood lactate measurements. The results demonstrated an increased maximal force (5%, P < .01), peak pressure (12%, P < .001), and impulse (9%, P < .01) under the second and third metatarsal head and under the medial midfoot (force = 7%, P < .05; pressure = 6%, P < .05; impulse = 17%, P < .01) toward the end of the fatiguing run. Contact area and contact time were only slightly affected. The mean electromyographic activity was significantly reduced in the medial gastrocnemius (-9%, P < .01), lateral gastrocnemius (-12%, P < .01), and soleus (-9%, P < .001) muscles. The demonstrated alteration of the rollover process with an increased forefoot loading may help to explain the incidence of stress fractures of the metatarsals under fatiguing loading conditions.

[Surgical treatment of pronation and supination external rotation trimalleolar fractures].

PubMed

Xu, Ye-qing; Zhan, Bei-lei; He, Fei-xiong; Wei, Hong-da

2008-04-01

To explore the operative method and its clinical effects of pronation and supination external rotation trimalleolar fractures. From March 2000 to July 2006,42 patients of the pronation and supination external rotation trimalleolar fractures treated with open reduction and internal fixation. Thirty-one were males and 11 were females,with an average age of 40.5 years (from 19 to 76 years). Four cases were open fractures and 38 cases close fractures. The fractures were classified as pronation-external rotation (grade IV) injury in 18 cases and supination-external rotation (grade IV)in 24 cases according to the system of Lauge-Hansen. The time of injury to operation was 2 hours to 27 days. The medial, lateral and posterior malleolus were exposed by standard anteromedial and Gatellier-Chastang approaches. The reduction and internal fixation started with the posterior,then the medial and the lateral malleolus and distal tibiofibular syndesmosis in sequence. The anteroposterior, lateral and mostise X-ray films were taken after operation. All the patients were followed up for an average time of 13.5 months(from 6 to 24 months). The time of union was from 12 to 16 weeks. The results were excellent in 20,good in 16, fair in 4 and poor in 2 cases according to Baird-Jackson ankle scoring system based on pain, stability, walking ability,range of motion and radiological manifestations. The excellent and good rate was 85.7%. There were no infection,malunion and nonunion of the fractures except that the inserted screw to distal tibiofibular syndesmosis was broken in 1 case. The key of operative treatment is to restore the anatomy of ankle and to regain the ankle function maximally.

Second generation locked plating for complex proximal humerus fractures in very elderly patients.

PubMed

Gavaskar, Ashok S; Karthik B, Bhupesh; Tummala, Naveen C; Srinivasan, Parthasarathy; Gopalan, Hitesh

2016-11-01

Humeral head sacrificing procedures are more favored in elderly patients with complex proximal humerus fractures because of high incidence of failures and complications with osteosynthesis. The purpose of this study is to assess the outcome of second generation locked plating techniques in 3 and 4 part fractures in active elderly patients >70years with an emphasis on function and complications. 29 patients with displaced 3 and 4 part proximal humerus fractures were treated using the principles of second-generation proximal humerus locked plating. Fixed angle locked plating (PHILOS) using the anterolateral deltoid spilt approach augmented with traction cuff sutures was performed. Minimum of 7 locking head screws including 2 calcar screws were used. In cases with a comminuted medial calcar, an endosteal fibular strut was used. Subchondral metaphyseal bone voids were filled with injectable calcium phosphate cement. Radiological outcome (union, head - shaft angle, tuberosity reduction), functional outcome assessment (Constant and ASES scores) and complications (loss of reduction, nonunion and osteonecrosis) were assessed. The fracture united in 24 of the 26 patients available for follow up at a mean of 27 months (12-40 months). 3 patients developed complications that required arthroplasty (fixation failure in 2 patients and osteonecrosis in 1 patient). Follow up age adjusted Constant (63.1±11.9) and ASES scores (62.58±7.5) showed the extent of functional improvement post surgery. Patients with fractures having a non-comminuted medial calcar and valgus displacement of the humeral head had better functional scores and fewer complications. Osteosynthesis with second generation locked plating techniques provide satisfactory outcome in very elderly patients with complex proximal humerus fractures with minimal complications. Copyright © 2016 Elsevier Ltd. All rights reserved.

Regional bone geometry of the tibia in triathletes and stress reactions--an observational study.

PubMed

Newsham-West, Richard J; Lyons, Brett; Milburn, Peter D

2014-03-01

The association between tibial morphology and tibial stress fractures or tibial stress syndrome was examined in triathletes with an unusually high incidence of these injuries. A cross-sectional study design examined associations between tibial geometry from MRI images and training and injury data between male and female triathletes and between stress fracture (SF) and non-stress fracture (NSF) groups. Fifteen athletes (7 females, 8 males) aged 17-23 years who were currently able to train and race were recruited from the New Zealand Triathlete Elite Development Squad. Geometric measurements were taken at 5 zones along the tibia using MRI and compared between symptomatic and asymptomatic tibiae subjects. SF tibiae displayed either oedema within the cancellous bone and/or stress fracture on MRI. When collapsed across levels, symptomatic tibiae had thicker medial cortices (F1,140=9.285, p=0.003), thicker lateral cortices (F1,140=10.129, p=0.002) and thinner anterior cortices (F1,140=14.517, p=0.000) than NSF tibiae. Only medial cortex thickness in SF tibia was significantly different (F4,140=3.358, p=0.012) at different levels. Follow-up analysis showed that athletes showing oedema within the cancellous bone and/or stress fracture on MRI had, within 2 years of analysis, subsequently taken time off training and racing due a tibial stress fracture. The thinner anterior cortex in SF tibiae is associated with a stress reaction in these triathletes. Copyright © 2013 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Internal derangement of the knee after ipsilateral femoral shaft fracture: MR imaging findings.

PubMed

Blacksin, M F; Zurlo, J V; Levy, A S

1998-08-01

This study uses magnetic resonance (MR) imaging to delineate the types and frequencies of injuries seen in the knee after ipsilateral femoral shaft fracture. We also compare the results of the orthopedic knee examination with the MR findings. MR imaging of the ipsilateral knee was performed on 34 patients with closed femoral shaft fractures. Indications for knee MR imaging included knee pain at the time of fracture, soft tissue swelling or an effusion of the knee, or a positive knee examination under anesthesia. The patients had a mean age of 27 years and all were stabilized with intramedullary nails. Imaging was performed a mean time of 2.5 days after surgery. All patients had knee examinations done under anesthesia, and the MR results were compiled and compared with the clinical examinations. Ninety-seven percent of patients demonstrated knee effusions. Twenty-seven percent of patients demonstrated meniscal tears, with the posterior horn of the medial meniscus most frequently torn. The medial collateral ligament was the most frequent site of ligamentous injury (38%) followed by the posterior cruciate ligament (21%). Fifty percent of patients had injuries of the extensor mechanism. Bone bruises were noted in 32% of patients. Articular cartilage injuries were confined to the patella in four cases. One occult tibial plateau fracture and one meniscocapsular separation were seen. There is a common incidence of both ligamentous and meniscal injury to the knee after ipsilateral femoral shaft fracture. MR imaging can be useful in assessing the extent of injury, and may reveal findings unsuspected after clinical examination of the knee.

Bone stress in runners with tibial stress fracture.

PubMed

Meardon, Stacey A; Willson, John D; Gries, Samantha R; Kernozek, Thomas W; Derrick, Timothy R

2015-11-01

Combinations of smaller bone geometry and greater applied loads may contribute to tibial stress fracture. We examined tibial bone stress, accounting for geometry and applied loads, in runners with stress fracture. 23 runners with a history of tibial stress fracture & 23 matched controls ran over a force platform while 3-D kinematic and kinetic data were collected. An elliptical model of the distal 1/3 tibia cross section was used to estimate stress at 4 locations (anterior, posterior, medial and lateral). Inner and outer radii for the model were obtained from 2 planar x-ray images. Bone stress differences were assessed using two-factor ANOVA (α=0.05). Key contributors to observed stress differences between groups were examined using stepwise regression. Runners with tibial stress fracture experienced greater anterior tension and posterior compression at the distal tibia. Location, but not group, differences in shear stress were observed. Stepwise regression revealed that anterior-posterior outer diameter of the tibia and the sagittal plane bending moment explained >80% of the variance in anterior and posterior bone stress. Runners with tibial stress fracture displayed greater stress anteriorly and posteriorly at the distal tibia. Elevated tibial stress was associated with smaller bone geometry and greater bending moments about the medial-lateral axis of the tibia. Future research needs to identify key running mechanics associated with the sagittal plane bending moment at the distal tibia as well as to identify ways to improve bone geometry in runners in order to better guide preventative and rehabilitative efforts. Copyright © 2015 Elsevier Ltd. All rights reserved.

Qualitative assessment of bone density at the distal articulating surface of the third metacarpal in Thoroughbred racehorses with and without condylar fracture.

PubMed

Loughridge, A B; Hess, A M; Parkin, T D; Kawcak, C E

2017-03-01

Changes in subchondral bone density, induced by the repetitive cyclical loading of exercise, may potentiate fatigue damage and the risk of fracture. To use computed tomography (CT) to characterise bone density patterns at the articular surface of the third metacarpal bone in racehorses with and without lateral condylar fractures. Case control METHODS: Computed tomographic images of the distal articulating surface of the third metacarpal bone were obtained from Thoroughbred racehorses subjected to euthanasia in the UK. Third metacarpal bones were divided into 3 groups based on lateral condyle status; fractured (FX, n = 42), nonfractured contralateral condyle (NFX, n = 42) and control condyles from horses subjected to euthanasia for reasons unrelated to the third metacarpal bone (control, n = 94). Colour CT images were generated whereby each colour represented a range of pixel values and thus a relative range of bone density. A density value was calculated qualitatively by estimating the percentage of each colour within a specific region. Subchondral bone density was assessed in 6 regions from dorsal to palmar and 1 mm medial and lateral to the centre of the lateral parasagittal groove in NFX and control condyles and 1 mm medial and lateral to the fracture in FX condyles. Bone density was significantly higher in the FX and NFX condyles compared with control condyles for all 6 regions. A significantly higher bone density was observed in FX condyles relative to NFX condyles in the lateral middle and lateral palmar regions. Fractured condyles had increased heterogeneity in density among the 6 regions of interest compared with control and NFX condyles. Adjacent to the fracture, a focal increase in bone density and increased heterogeneity of density were characteristic of limbs with lateral condylar fractures compared with control and NFX condyles. These differences may represent pathological changes in bone density that increase the risk for lateral condylar fractures in racehorses. © 2015 EVJ Ltd.

A Scapholunate Ligament-Sparing Technique Utilizing the Medial Femoral Condyle Corticocancellous Free Flap to Reconstruct Scaphoid Nonunions With Proximal Pole Avascular Necrosis.

PubMed

Kazmers, Nikolas H; Thibaudeau, Stephanie; Levin, L Scott

2016-09-01

This article demonstrates a technique for the treatment of scaphoid fracture waist and proximal pole nonunions with avascular necrosis using a free vascularized medial femoral condyle flap. We present our surgical technique and representative case examples in which the scapholunate ligament, a key structure required to preserve carpal kinematics, is spared. Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Percutaneous Soft Tissue Release for Treating Chronic Recurrent Myofascial Pain Associated with Lateral Epicondylitis: 6 Case Studies

PubMed Central

Lin, Ming-Ta; Chou, Li-Wei; Chen, Hsin-Shui; Kao, Mu-Jung

2012-01-01

Objective. The purpose of this pilot study is to investigate the effectiveness of the percutaneous soft tissue release for the treatment of recurrent myofascial pain in the forearm due to recurrent lateral epicondylitis. Methods. Six patients with chronic recurrent pain in the forearm with myofascial trigger points (MTrPs) due to chronic lateral epicondylitis were treated with percutaneous soft tissue release of Lin's technique. Pain intensity (measured with a numerical pain rating scale), pressure pain threshold (measured with a pressure algometer), and grasping strength (measured with a hand dynamometer) were assessed before, immediately after, and 3 months and 12 months after the treatment. Results. For every individual case, the pain intensity was significantly reduced (P < 0.01) and the pressure pain threshold and the grasping strength were significantly increased (P < 0.01) immediately after the treatment. This significant effectiveness lasts for at least one year. Conclusions. It is suggested that percutaneous soft tissue release can be used for treating chronic recurrent lateral epicondylitis to avoid recurrence, if other treatment, such as oral anti-inflammatory medicine, physical therapy, or local steroid injection, cannot control the recurrent pain. PMID:23243428

A Newly Designed Tennis Elbow Orthosis With a Traditional Tennis Elbow Strap in Patients With Lateral Epicondylitis

PubMed Central

Saremi, Hossein; Chamani, Vahid; Vahab-Kashani, Reza

2016-01-01

Background Lateral epicondylitis is a common cause of pain and upper limb dysfunction. The use of counterforce straps for treatment of lateral epicondylitis is widespread. This kind of orthosis can be modified to have a greater effect on relieving pain by reducing tension on the origin of the extensor pronator muscles. Objectives To determine the immediate effects of a newly designed orthosis on pain and grip strength in patients with lateral epicondylitis. Materials and Methods Twelve participants (six men and six women) were recruited (mean age = 41 ± 6.7 years) and evaluated for pain and grip strength in three sessions. A 48-hour break was taken between each session. The first session was without any orthosis, the second session was with the new modified tennis elbow orthosis, and the third session was with a conventional tennis elbow strap. Results Both counterforce straps were effective. However, significantly more improvement was observed in pain and grip strength after using the newly modified orthosis (P < 0.05). Conclusions The newly designed strap reduces pain more effectively and improves grip strength by causing greater localized pressure on two regions with different force applications (two component vectors versus one). PMID:28180116

Conservative orthodontic treatment of mandibular bilateral condyle fracture.

PubMed

Gašpar, Goran; Brakus, Ivan; Kovačić, Ivan

2014-09-01

Maxillofacial trauma is rare in children younger than the age of 5 years (range 0.6%-1.2%), and they can require different clinical treatment strategies compared with fractures in the adult population because of concerns regarding mandibular growth and development of dentition. A 5-year-old girl with a history of falling from a bicycle 7 hours earlier was referred to the department of oral and maxillofacial surgery. Multislice computed tomographic examination demonstrated a bilateral fracture of the mandibular condyle neck associated with minimal fracture of the alveolar ridge of the maxilla. The multislice computed tomographic scan also demonstrated dislocation on the right condyle neck and, on the left side, a medial inclination of approximately 45 degrees associated with greenstick fracture of the right parasymphysis region. In this particular case, orthodontic rubber elastics in combination with fixed orthodontic brackets provided good results in the treatment of bilateral condyle neck fractures associated with greenstick fracture of parasymphysis.

[Comparative study of proximal femoral shortening after the third generation of Gamma nail versus proximal femoral nail anti-rotation in treatment of intertrochanteric fracture].

PubMed

Hou, Yu; Yao, Qi; Zhang, Gen'ai; Ding, Lixiang

2018-03-01

To explore the difference of the proximal femoral shortening (PFS) between the third generation of Gamma nail (TGN) and the proximal femoral nail anti-rotation (PFNA) in treating intertrochanteric fracture of femur. The clinical data of 158 patients with intertrochanteric fracture of femur who were treated with TGN internal fixation or PFNA internal fixation between January 2014 and December 2015 were retrospectively analysed. The patients were divided into TGN group (69 cases) and PFNA group (89 cases) according to surgical operation. There was no significant difference in gender, age, bone mineral density, causes of injury, AO/Association for the Study of Internal Fixation (AO/ASIF) classification, accompanied disease, and the time from injury to operation between 2 groups ( P >0.05). The result of fracture reduction was divided into 3 types: positive medial cortex support, neutral position cortex support, and negative medial cortex support according to the method of Chang et al . At 18 months postoperatively, bilateral hip anteroposterior X-ray films were taken to measure horizontal PFS values (marked as X), vertical PFS values (marked as Y), and calculate the total PFS values (marked as Z). The PFS values were divided into 4 grades according to the criteria (≤1.0 mm, 1.0-4.9 mm, 5.0-9.9 mm, and ≥10.0 mm), and the constituent ratio was calculated and compared between 2 groups. The X, Y, and Z values and the collodiaphyseal angles of 2 groups at 18 months postoperatively were compared. The X, Y, and Z values of 2 groups of patients with failed fixation and normal healing within 18 months after operation were recorded and compared. The X, Y, and Z values of 2 groups of the patients with different cortex support types were also compared. There were 34 cases of positive medial cortex support, 30 cases of neutral position cortex support, and 5 cases of negative medial cortex support in TGN group, and there were 45, 33, and 11 cases in PFNA group respectively, showing no significant difference between 2 groups ( Z =-1.06, P =0.29). All patients were followed up 18 months after operation. At 18 months after operation, the constituent ratios of PFS values (X, Y, Z) had significant differences between 2 groups ( P <0.05). The patients of shortening of 1.0-4.9 mm and 5.0-9.9 mm were obviously more in TGN group than in PFNA group; the patients of shortening of ≥10.0 mm were obviously more in PFNA group than in TGN group. There were significant differences in X, Y, and Z values between 2 groups ( P <0.05), but no significant difference of the collodiaphysial angle was found between 2 groups ( t =0.47, P =0.64). Six cases of internal fixation failed in TGN group and PFNA group respectively within 3 months after operation, and there was no significant difference of X, Y, and Z values between failed fixation and normal healing patients within 2 groups ( P >0.05). When the reposition effect was the positive medial cortex support, the X, Y, and Z values were significantly lower in TGN group than in PFNA group ( P <0.05); but no significant difference was found between 2 groups when the reposition effect was the neutral position cortex support or negative medial cortex support ( P >0.05). At 18 months after operation, the X, Y, and Z values of the negative medial cortex support patients were significantly higher than those of the positive medial cortex support or the neutral position cortex support patients within 2 groups ( P <0.05). PFS is a common complication of the intertrochanteric fracture of the femur after internal fixation. During operation, the selection of internal fixation should be based on the results of intraoperative reduction. TGN should be applied to reduce PFS if positive medial cortex support happened.

Stress fractures of the foot and ankle.

PubMed

Welck, M J; Hayes, T; Pastides, P; Khan, W; Rudge, B

2017-08-01

Stress fractures occur as a result of microscopic injuries sustained when bone is subjected to repeated submaximal stresses. Overtime, with repeated cycles of loading, accumulation of such injuries can lead to macro-structural failure and frank fracture. There are numerous stress fractures about the foot and ankle of which a trauma and orthopaedic surgeon should be aware. These include: metatarsal, tibia, calcaneus, navicular, fibula, talus, medial malleolus, sesamoid, cuneiform and cuboid. Awareness of these fractures is important as the diagnosis is frequently missed and appropriate treatment delayed. Late identification can be associated with protracted pain and disability, and may predispose to non-union and therefore necessitate operative intervention. This article outlines the epidemiology and risk factors, aetiology, presentation and management of the range of stress fractures in the foot and ankle. Copyright © 2015 Elsevier Ltd. All rights reserved.

The Valgus Inclination of the Tibial Component Increases the Risk of Medial Tibial Condylar Fractures in Unicompartmental Knee Arthroplasty.

PubMed

Inoue, Shinji; Akagi, Masao; Asada, Shigeki; Mori, Shigeshi; Zaima, Hironori; Hashida, Masahiko

2016-09-01

Medial tibial condylar fractures (MTCFs) are a rare but serious complication after unicompartmental knee arthroplasty. Although some surgical pitfalls have been reported for MTCFs, it is not clear whether the varus/valgus tibial inclination contributes to the risk of MTCFs. We constructed a 3-dimensional finite elemental method model of the tibia with a medial component and assessed stress concentrations by changing the inclination from 6° varus to 6° valgus. Subsequently, we repeated the same procedure adding extended sagittal bone cuts of 2° and 10° in the posterior tibial cortex. Furthermore, we calculated the bone volume that supported the tibial component, which is considered to affect stress distribution in the medial tibial condyle. Stress concentrations were observed on the medial tibial metaphyseal cortices and on the anterior and posterior tibial cortices in the corner of cut surfaces in all models; moreover, the maximum principal stresses on the posterior cortex were larger than those on the anterior cortex. The extended sagittal bone cuts in the posterior tibial cortex increased the stresses further at these 3 sites. In the models with a 10° extended sagittal bone cut, the maximum principal stress on the posterior cortex increased as the tibial inclination changed from 6° varus to 6° valgus. The bone volume decreased as the inclination changed from varus to valgus. In this finite element method, the risk of MTCFs increases with increasing valgus inclination of the tibial component and with increased extension of the sagittal cut in the posterior tibial cortex. Copyright © 2016 Elsevier Inc. All rights reserved.

Quadriceps Tendon Autograft Medial Patellofemoral Ligament Reconstruction.

PubMed

Fink, Christian; Steensen, Robert; Gföller, Peter; Lawton, Robert

2018-06-01

Critically evaluate the published literature related to quadriceps tendon (QT) medial patellofemoral ligament (MPFL) reconstruction. Hamstring tendon (HT) MPFL reconstruction techniques have been shown to successfully restore patella stability, but complications including patella fracture are reported. Quadriceps tendon (QT) reconstruction techniques with an intact graft pedicle on the patella side have the advantage that patella bone tunnel drilling and fixation are no longer needed, reducing risk of patella fracture. Several QT MPFL reconstruction techniques, including minimally invasive surgical (MIS) approaches, have been published with promising clinical results and fewer complications than with HT techniques. Parallel laboratory studies have shown macroscopic anatomy and biomechanical properties of QT are more similar to native MPFL than hamstring (HS) HT, suggesting QT may more accurately restore native joint kinematics. Quadriceps tendon MPFL reconstruction, via both open and MIS techniques, have promising clinical results and offer valuable alternatives to HS grafts for primary and revision MPFL reconstruction in both children and adults.

Factors associated with regional rheumatic pain disorders in a population of Puerto Ricans with diabetes mellitus.

PubMed

Font, Yvonne M; Castro-Santana, Lesliane E; Nieves-Plaza, Mariely; Maldonado, Mirna; Mayor, Angel M; Vilá, Luis M

2014-07-01

The aim of the study was to determine the prevalence and factors associated with bursitis/tendonitis disorders in Puerto Ricans with diabetes mellitus (DM). A cross-sectional study was performed in 202 adult Puerto Ricans (100 DM patients and 102 non-diabetic subjects). For each participant, a complete medical history and a musculoskeletal exam were systematically performed. Socio-demographic parameters, health-related behaviors, comorbidities, and pharmacotherapy were determined for all subjects. For DM patients, disease duration, glycemic control, and DM long-term complications were also examined. Multivariate logistic regression analyses were used to determine the factors associated with bursitis/tendonitis disorders. The mean (SD) age for DM patients and non-diabetic controls were 53.3 (12.9) and 50.0 (13.1) years; 64.0 and 64.7 % of DM patients and controls were females, respectively. Overall, the prevalence of bursitis/tendonitis was higher in DM patients than among non-diabetics (59.0 % vs. 29.4 %, p < 0.01). In multivariate analyses, DM patients had 2.47 (95 % CI 1.05, 5.84) the odds of having bursitis/tendonitis as compared to non-diabetics. Specifically, DM patients had a higher frequency of flexor tenosynovitis, De Quervain's tenosynovitis, lateral epicondylitis, medial epicondylitis, trochanteric bursitis, and anserine bursitis than non-diabetic subjects (p < 0.05). Among DM patients, multivariate analyses showed that those with bursitis/tendonitis were more likely to be female [OR (95 % CI) 4.55 (1.42, 14.55)] and have peripheral vascular disease [OR (95 % CI) 8.48 (1.71, 41.93)]. In conclusion, bursitis/tendonitis disorders were common in this population of Hispanics with DM. Among DM patients, bursitis/tendonitis disorders were more frequent in women and those with long-term complications such as peripheral vascular disease.

Managing type II and type IV Lauge-Hansen supination external rotation ankle fractures: current orthopaedic practice.

PubMed

Kosuge, D D; Mahadevan, D; Chandrasenan, J; Pugh, H

2010-11-01

Differentiating supination external rotation (SER) type II and IV ankle injuries is challenging in the absence of a medial malleolar fracture or talar shift on radiographs. The accurate differentiation between a stable SER-II from an unstable SER-IV injury would allow implementation of the appropriate management plan from diagnosis. The aim of this study was to ascertain the practice of orthopaedic surgeons in dealing with these injuries. A postal survey was undertaken on 216 orthopaedic consultants from three regions. In the presence of medial-sided clinical signs (tenderness, swelling, ecchymosis), 22% of consultants would perform surgical fixation. 53% would choose non-operative treatment and the majority would monitor these fractures through serial radiographs. The remaining 25% of consultants would perform an examination under anaesthesia (EUA; 15%), request stress radiographs (9%) or an MRI scan (1%). Without medial-sided signs, 85% would advocate non-operative treatment and, of these, 74% would perform weekly radiographs. Interestingly, 6% would perform immediate surgical fixation. Stress radiographs (6%) and EUAs (2%) were advocated in the remaining group of consultants. Foot and ankle surgeons utilised stress radiographs more frequently and were more likely to proceed to surgical fixation should talar shift be demonstrated. Clinical practice is varied amongst the orthopaedic community. This may lead to unnecessary surgery in SER-II injuries and delay in diagnosis and operative management of SER-IV injuries. We have highlighted the various investigative modalities available that may be used in conjunction with clinical signs to make a more accurate diagnosis.

Intra-articular pathology associated with isolated posterior cruciate ligament injury on MRI.

PubMed

Ringler, Michael D; Shotts, Ezekiel E; Collins, Mark S; Howe, B Matthew

2016-12-01

Unlike with anterior cruciate ligament injury, little is known about the prevalence of intra-articular pathology associated with isolated posterior cruciate ligament (PCL) injury in the knee. The objectives of this study were to characterize and identify the frequency of meniscal tears and osteochondral injuries in these patients, and to see if management might be affected. Altogether, 48 knee MRI exams with isolated PCL tears were evaluated for the presence of: grade and location of PCL tear, meniscal tear, articular chondral lesion, bone bruise, and fracture. Comparisons between PCL tear grade and location, as well as mechanism of injury when known, with the presence of various intra-articular pathologies, were made using the chi-square or Fisher's exact test as appropriate. In all, 69 % of isolated PCL tears occur in the midsubstance, 27 % proximally. Meniscal tears were seen in 25 % of knees, involving all segments of both menisci, except for the anterior horn medial meniscus. Altogether, 23 % had focal cartilage lesions, usually affecting the central third medial femoral condyle and medial trochlea, while 12.5 % of knees had fractures, and 48 % demonstrated bone bruises, usually involving the central to anterior tibiofemoral joint. The presence of a fracture (p = 0.0123) and proximal location of PCL tear (p = 0.0016) were both associated with the hyperextension mechanism of injury. There were no statistically significant associations between PCL tear grade and presence of intra-articular abnormality. Potentially treatable meniscal tears and osteochondral injuries are relatively prevalent, and demonstrable on MRI in patients with isolated acute PCL injury of the knee.

Platelet-rich plasma for chronic lateral epicondylitis: is one injection sufficient?

PubMed

Glanzmann, Michael C; Audigé, Laurent

2015-12-01

Chronic lateral epicondylitis is generally treated using nonsurgical methods including physiotherapy and infiltrations of cortisone or platelet-rich plasma (PRP). The latter is known for its simple application as well as associated low risk of adverse events, which lend to its widespread use in treating various musculoskeletal conditions. There is limited evidence on the effectiveness of PRP injections to optimally treat chronic lateral epicondylitis. This study explored the effectiveness of single or repeated injections for patients with symptoms that spanned 6 months or more and were unresponsive to alternate conservative measures. Patients with chronic lateral epicondylitis received PRP injections in 4-week intervals that were complemented with standardized physical therapy. Patient-reported outcomes based on the patient-rated elbow evaluation (PREE), quick disabilities of the arm, shoulder and hand (qDASH), and EuroQol (five dimensions) 3-level version (EQ5D3L) questionnaires were documented at each visit including 6 months after the first injection. These outcomes were compared between patients receiving 1 vs. 2 or 3 PRP injections. Sixty-two patients received one (n = 36) or more (n = 26) PRP injections. The mean baseline to 6-month follow-up scores of the PREE and qDASH questionnaires improved significantly from 54.0 to 23.0 and 50.3 to 20.7, respectively. The mean baseline EQ5D3L-visual analogue scale score improved from 62.5 to 82.9 by 6 months post-injection. These outcomes did not significantly differ between the patients who received varying numbers of injections. Patients with chronic lateral epicondylitis reported significant pain relief and gain in function as well as quality of life 6 months after localized PRP treatment. A single PRP injection may be sufficient.

Transcatheter arterial embolization of abnormal vessels as a treatment for lateral epicondylitis refractory to conservative treatment: a pilot study with a 2-year follow-up.

PubMed

Iwamoto, Wataru; Okuno, Yuji; Matsumura, Noboru; Kaneko, Takao; Ikegami, Hiroyasu

2017-08-01

Abnormal vessels and accompanying nerves are possible sources of pain with lateral epicondylitis. The purpose of this study was to describe the safety and efficacy of transcatheter arterial embolization (TAE) for lateral epicondylitis resistant to conservative treatment. This prospective study was conducted in 24 patients with lateral epicondylitis resistant to conservative treatments for more than 3 months, with a symptom duration longer than 6 months, and with moderate to severe pain who were treated with TAE between March 2013 and October 2014. Two patients were lost to follow-up, and the remaining 22 patients were followed up for 2 years after TAE. Abnormal vessels were identified in all of the patients. No major adverse events were observed. The Quick Disabilities of the Arm, Shoulder and Hand scores at baseline significantly decreased at 1, 3, 6, and 24 months after treatment (50.8 vs 23.4, 8.3, 5.3, and 2.7, respectively; all P < .001). There was a statistically significant (P < .001) change from baseline to the last observed value in all of the clinical parameters, including visual analog scale pain score, Patient-Rated Tennis Elbow Evaluation score, and pain-free grip strength. Magnetic resonance images obtained 2 years after TAE showed an improvement in tendinosis and tear scores compared with baseline, and no patients showed bone marrow necrosis, obvious cartilage loss, or muscle atrophy. TAE could be one possible treatment option for patients with lateral epicondylitis that fails to improve with conservative treatments. Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

A Biomechanical Study of Posteromedial Tibial Plateau Fracture Stability: Do They All Require Fixation?

PubMed

Cuéllar, Vanessa G; Martinez, Danny; Immerman, Igor; Oh, Cheongeun; Walker, Peter S; Egol, Kenneth A

2015-07-01

Although the posteromedial fragment in tibial plateau fractures is often considered unstable, biomechanical evidence supporting this view is lacking. We aimed to evaluate the stability of the fragment in a cadaver model. Our hypothesis was that under the expected small axial force during rehabilitation and the combined effects of this force with shear force, internal rotation torque, and varus moment, the most common posteromedial tibial fragment morphology could maintain stability in early flexion. Axial compression force alone or combined with posterior shear, internal rotation torque, or varus moment was applied to the femurs of 5 fresh cadaveric knees. A Tekscan pressure mapping system was used to measure pressure and contact area between the femoral condyles, meniscus, and tibial plateau. A Microscribe 3D digitizer was used to define the 3-dimensional positions of the femur and tibia. A 10-mm and then a 20-mm osteotomy was created with a saw at an angle of 30 degrees in the axial plane with respect to the tangent of the posterior tibial plateau and 75 degrees in the sagittal plane, representing a typical posteromedial fracture fragment. At each flexion angle (15, 30, 60, 90, and 120 degrees) and loading condition (axial compression only, compression with shear force, torque, and varus moment), distal displacement of the medial femoral condyle and the tibial fracture fragments was determined. For the 10-mm fragment, medial femoral condyle displacement was little affected up to approximately 30-degree flexion, after which it increased. For the 20-mm fragment, there was progressive medial femoral condyle displacement with increasing flexion from baseline. However, for the 10- and 20-mm fragments themselves, displacements were noted at every flexion angle, starting at 1.7 mm inferior displacement with 15 degrees of flexion and internal rotation torque and up to 10.2 mm displacement with 90 degrees of flexion and varus bending moment. In this cadaveric model of a posteromedial tibial plateau fracture, both fracture fragments studied displaced with knee flexion, even at low flexion angles. Although such fragments may initially seem nondisplaced after injury, posteromedial fragments similar to these tested are likely to displace during knee range of motion exercises in non-weight-bearing conditions.

Favorable Responsiveness of the Hand10 Questionnaire to Assess Treatment Outcomes for Lateral Epicondylitis.

PubMed

Nishizuka, Takanobu; Iwatsuki, Katsuyuki; Kurimoto, Shigeru; Yamamoto, Michiro; Onishi, Tetsuro; Hirata, Hitoshi

2018-06-01

The aim of our study was to compare the responsiveness of the Hand10 questionnaire and the Pain visual analogue scale (VAS) for the assessment of lateral epicondylitis. The standardized response mean and effect size were used as indicators of responsiveness, measured at baseline and after 6 months of treatment. Among the 54 patients enrolled, 28 were treated using a forearm band, compress and stretching, with the other 26 patients treated using compress and stretching. The standardized response mean and the effect size were 1.18 and 1.38, respectively, of the Hand10 and 1.39 and 1.75, respectively, for the Pain VAS. The responsiveness of both tests was considered to be large, based on Cohen's classification of effect size, supporting the use of the Hand10 questionnaire to assess treatment outcomes for lateral epicondylitis.

The Influence of Physical Forces on Progenitor Cell Migration, Proliferation and Differentiation in Fracture Repair

DTIC Science & Technology

2007-11-01

accelerated healing patterns in the loaded specimens. Periosteal callus formation appears more robust with more chondrocytes present in loaded... periosteal callus formation on one side of the fracture gap. It is hypothesized that callus development may occur first on the medial side of the femoral...Figure 10: Comparison of periosteal callus formation (trichrome stain) between a loaded limb at section levels 1 (a), 3 (b), and 5 (c), and

The initial safe range of motion of the ankle joint after three methods of internal fixation of simulated fractures of the medial malleolus.

PubMed

Shimamura, Yoshio; Kaneko, Kazuo; Kume, Kazuhiko; Maeda, Mutsuhiro; Iwase, Hideaki

2006-07-01

Previous studies have demonstrated the safe passive range of ankle motion for inter-bone stiffness after internal fixation under load but there is a lack of information about the safe range of ankle motion for early rehabilitation in the absence of loading. The present study was designed to assess the effect of ankle movement on inter-bone displacement characteristics of medial malleolus fractures following three types of internal fixation to determine the safe range of motion. Five lower legs obtained during autopsy were used to assess three types of internal fixation (two with Kirschner-wires alone; two with Kirschner-wires plus tension band wiring; and, one with an AO/ASIF malleolar screw alone). Following a simulated fracture by sawing through the medial malleolus the displacement between the fractured bone ends was measured during a passive range of movement with continuous monitoring using omega (Omega) shaped transducers and a biaxial flexible goniometer. Statistical analysis was performed with repeated measures analysis of variance. Inter-bone displacement was not proportional to the magnitude of movement throughout the range of ankle motion as, when separation exceeded 25 microm, there was increasingly wide separation as plantar-flexion or dorsal-flexion was increased. There was no statistical significant difference between the small amount of inter-bone displacement observed with three types of fixation within the safe range of dorsal-flexion and plantar-flexion for early rehabilitation. However the inter-bone separation when fixation utilized two Kirschner-wires alone tended to be greater than when using the other two types of fixation during dorsal-flexion and eversion. The present study revealed a reproducible range of ankle motion for early rehabilitation which was estimated to be within the range of 20 degrees of dorsal-flexion and 10 degrees of plantar-flexion without eversion. Also, internal fixation with two Kirschner-wires alone does not seem to provide stability achieved by the other two forms of fixation.

Accuracy and predictability in use of AO three-dimensionally preformed titanium mesh plates for posttraumatic orbital reconstruction: a pilot study.

PubMed

Scolozzi, Paolo; Momjian, Armen; Heuberger, Joris; Andersen, Elene; Broome, Martin; Terzic, Andrej; Jaques, Bertrand

2009-07-01

The aim of this study was to prospectively evaluate the accuracy and predictability of new three-dimensionally preformed AO titanium mesh plates for posttraumatic orbital wall reconstruction.We analyzed the preoperative and postoperative clinical and radiologic data of 10 patients with isolated blow-out orbital fractures. Fracture locations were as follows: floor (N = 7; 70%), medial wall (N = 1; 1%), and floor/medial wall (N = 2; 2%). The floor fractures were exposed by a standard transconjunctival approach, whereas a combined transcaruncular transconjunctival approach was used in patients with medial wall fractures. A three-dimensional preformed AO titanium mesh plate (0.4 mm in thickness) was selected according to the size of the defect previously measured on the preoperative computed tomographic (CT) scan examination and fixed at the inferior orbital rim with 1 or 2 screws. The accuracy of plate positioning of the reconstructed orbit was assessed on the postoperative CT scan. Coronal CT scan slices were used to measure bony orbital volume using OsiriX Medical Image software. Reconstructed versus uninjured orbital volume were statistically correlated.Nine patients (90%) had a successful treatment outcome without complications. One patient (10%) developed a mechanical limitation of upward gaze with a resulting handicapping diplopia requiring hardware removal. Postoperative orbital CT scan showed an anatomic three-dimensional placement of the orbital mesh plates in all of the patients. Volume data of the reconstructed orbit fitted that of the contralateral uninjured orbit with accuracy to within 2.5 cm(3). There was no significant difference in volume between the reconstructed and uninjured orbits.This preliminary study has demonstrated that three-dimensionally preformed AO titanium mesh plates for posttraumatic orbital wall reconstruction results in (1) a high rate of success with an acceptable rate of major clinical complications (10%) and (2) an anatomic restoration of the bony orbital contour and volume that closely approximates that of the contralateral uninjured orbit.

Temporary Fixation Using a Long Femoral-tibial Nail to Treat a Displaced Medial Tibial Plateau Fracture in a 90-year-old Patient: A Case Report

PubMed Central

Batta, V; Sinha, S; Trompeter, A

2017-01-01

Introduction: Tibial plateau fractures are complex injuries in the elderly population. When traditional methods of fixation are not suitable, an alternative method needs to be chosen for a favorable outcome. We demonstrate a previously undescribed treatment for displaced tibial plateau fractures in the very elderly with poor soft-tissue integrity. Case Report: A 90-year-old woman suffered an open, Gustilo Grade IIIA, displaced fracture of the tibial plateau. An intramedullary knee arthrodesis, the femoral-tibial nail was used to temporarily stabilize her fracture. She was able to weight bear immediately postfixation. Conclusion: A long femoral-tibial nail allows favorable fracture and soft tissue healing, ease of nursing and immediate full weight-bearing. It shows good promise and should be considered as a management option when traditional methods are not applicable in select patients. PMID:29181350

Temporary Fixation Using a Long Femoral-tibial Nail to Treat a Displaced Medial Tibial Plateau Fracture in a 90-year-old Patient: A Case Report.

PubMed

Batta, V; Sinha, S; Trompeter, A

2017-01-01

Tibial plateau fractures are complex injuries in the elderly population. When traditional methods of fixation are not suitable, an alternative method needs to be chosen for a favorable outcome. We demonstrate a previously undescribed treatment for displaced tibial plateau fractures in the very elderly with poor soft-tissue integrity. A 90-year-old woman suffered an open, Gustilo Grade IIIA, displaced fracture of the tibial plateau. An intramedullary knee arthrodesis, the femoral-tibial nail was used to temporarily stabilize her fracture. She was able to weight bear immediately postfixation. A long femoral-tibial nail allows favorable fracture and soft tissue healing, ease of nursing and immediate full weight-bearing. It shows good promise and should be considered as a management option when traditional methods are not applicable in select patients.

'Trampoline fracture' of the proximal tibia in children: report of 3 cases and review of literature.

PubMed

Bruyeer, E; Geusens, E; Catry, F; Vanstraelen, L; Vanhoenacker, F

2012-01-01

We present three cases of fracture of the proximal tibia in young children who were jumping on a trampoline. The typical radiological findings and the underlying mechanism of trauma are discussed. The key radiological features are: a transverse hairline fracture of the upper tibia often accompanied by a buckle fracture of the lateral or medial tibial cortex, buckling of the anterior upper tibial cortex and anterior tilting of the epiphyseal plate. New types of injuries related to specific recreational activities are recognized. It is often helpful to associate a typical injury with a particular activity. Trampoline related injuries have increased dramatically over the last years. The most common lesions are fractures and ligamentous injuries, in particular a transverse fracture of the proximal tibia. However the radiological findings can be very subtle and easily overlooked. It is therefore important to be aware of the typical history and radiological findings.

[MRI in chronic epicondylitis humeri radialis using 1.0 T equipment--contrast medium administration necessary?].

PubMed

Herber, S; Kalden, P; Kreitner, K F; Riedel, C; Rompe, J D; Thelen, M

2001-05-01

Evaluation of the diagnostic value and confidence of contrast-enhanced MR imaging in patients with lateral epicondylitis in comparison to clinical diagnosis. 42 consecutive patients with clinically proven chronic lateral epicondylitis and 10 elbow joints of healthy controls have been examined on a 1.0 T MR-unit. Criteria for inclusion in the prospective study were: persistent pain and a failed conservative therapy. The MR protocol included STIR sequence, a native, T2-weighted, fat-suppressed TSE sequence, and a Flash-2-D sequence. Also, fat-suppressed, T1-weighted SE sequences before and after administration of Gd-DTPA contrast media have been recorded. In 39/42 patients the STIR sequence showed an increased SI of the common extensor tendon. Increased MR signal of the lateral collateral ligament combined with a thickening and a partial rupture or a full thickness tear have been observed in 15/42 cases. A bone marrow edema at the lateral epicondilus was noticed in 6 of the studied patients and a joint effusion in 18/42 patients. After administration of contrast media we noticed an average increase of SI by about 150%. However, enhanced MR imaging did not provide additional information. In MR imaging of chronic epicondylitis administration of gadolinium-DTPA does not provide additional information.

Common Occupational Disorders: Asthma, COPD, Dermatitis, and Musculoskeletal Disorders.

PubMed

Bepko, Jennifer; Mansalis, Katherine

2016-06-15

An occupational illness is an event or exposure that occurs in the workplace that causes or contributes to a condition or worsens a preexisting condition. If an occupational disorder is suspected, a directed history should be taken with particular attention to establishing a temporal relationship of symptoms and exposure at work. Occupational asthma is the most prevalent occupational lung disorder in industrialized countries and presents with classic asthma symptoms (cough, difficulty breathing, chest tightness, wheezing). Occupational chronic obstructive pulmonary disease has been linked with exposure to nonspecific vapors, gases, dusts, fumes, and cigarette smoke. Occupational contact dermatitis is the most common dermal exposure. It can be caused by exposure to a variety of agents, including primary irritants or sensitizers, physical agents, mechanical trauma, and biologic agents. Occupational musculoskeletal disorders include many common repetitive injuries such as carpal tunnel syndrome and medial or lateral epicondylitis. Treatment of occupational disorders is generally the same as for nonoccupational disorders. Ideally, the exposure should be controlled to protect the worker. The impact of an occupational injury reaches beyond lost wages and can have a negative impact on quality of life.

An isolated dorso-medial dislocation of navicular bone: A case report.

PubMed

Singh, Varun Kumar; Kashyap, Abhishek; Vargaonkar, Gauresh; Kumar, Ramesh

2015-03-01

An isolated dislocation of tarsal navicular is extremely rare injury. Usually it is associated with fracture of navicular itself or other tarsal bones of foot along with disruption of medial or lateral column of foot. Mechanism of injury is complex but usually a severe abduction force is required to produce such injury in a planter flexed foot. A 30 year old male presented with isolated navicular dislocation. Management required open reduction and fixation with k-wires. These injuries have specific complications including avascular necrosis of navicular and post-traumatic arthritis.

The Hydraulic Mechanism in the Orbital Blowout Fracture Because of a High-Pressure Air Gun Injury.

PubMed

Kang, Seok Joo; Chung, Eui Han

2015-10-01

There are 2 predominant mechanisms that are used to explain the pathogenesis of orbital blowout fracture; these include hydraulic and buckling mechanisms. Still, however, its pathophysiology remains uncertain. To date, studies in this series have been conducted using dry skulls, cadavers, or animals. But few clinical studies have been conducted to examine whether the hydraulic mechanism is involved in the occurrence of pure orbital blowout fracture. The authors experienced a case of a 52-year-old man who had a pure medial blowout fracture after sustaining an eye injury because of a high-pressure air gun. Our case suggests that surgeons should be aware of the possibility that the hydraulic mechanism might be involved in the blowout fracture in patients presenting with complications, such as limitation of eye movement, diplopia, and enophthalmos.

Fractures of the distal tibia treated with polyaxial locking plating.

PubMed

Gao, Hong; Zhang, Chang-Qing; Luo, Cong-Feng; Zhou, Zu-Bin; Zeng, Bing-Fang

2009-03-01

We evaluated the healing rate, complications, and functional outcomes in 32 adult patients with very short metaphyseal fragments in fractures of the distal tibia treated with a polyaxial locking system. The average distance from the distal extent of the fracture to the tibial plafond was 11 mm. All fractures healed and the average time to union was 14 weeks. Six patients (19%) reported occasional local disturbance over the medial malleolus. There were two cases of postoperative superficial infections and evidence of delayed wound healing. Using the American Orthopaedic Foot and Ankle Society ankle score, the average functional score was 87.3 points (of 100 total possible points). Our results show the polyaxial locking plates, which offer more fixation versatility, may be a reasonable treatment option for distal tibia fractures with very short metaphyseal segments.

Joint Mobilization Enhances Mechanisms of Conditioned Pain Modulation in Individuals With Osteoarthritis of the Knee.

PubMed

Courtney, Carol A; Steffen, Alana D; Fernández-de-Las-Peñas, César; Kim, John; Chmell, Samuel J

2016-03-01

An experimental laboratory study with a repeated-measures crossover design. Treatment effects of joint mobilization may occur in part by decreasing excitability of central nociceptive pathways. Impaired conditioned pain modulation (CPM) has been found experimentally in persons with knee and hip osteoarthritis, indicating impaired inhibition of central nociceptive pathways. We hypothesized increased effectiveness of CPM following application of joint mobilization, determined via measures of deep tissue hyperalgesia. To examine the effect of joint mobilization on impaired CPM. An examination of 40 individuals with moderate/severe knee osteoarthritis identified 29 (73%) with impaired CPM. The subjects were randomized to receive 6 minutes of knee joint mobilization (intervention) or manual cutaneous input only, 1 week apart. Deep tissue hyperalgesia was examined via pressure pain thresholds bilaterally at the knee medial joint line and the hand at baseline, postintervention, and post-CPM testing. Further, vibration perception threshold was measured at the medial knee epicondyle at baseline and post-CPM testing. Joint mobilization, but not cutaneous input intervention, resulted in a global increase in pressure pain threshold, indicated by diminished hyperalgesic responses to pressure stimulus. Further, CPM was significantly enhanced following joint mobilization. Diminished baseline vibration perception threshold acuity was enhanced following joint mobilization at the knee that received intervention, but not at the contralateral knee. Resting pain was also significantly lower following the joint intervention. Conditioned pain modulation was enhanced following joint mobilization, demonstrated by a global decrease in deep tissue pressure sensitivity. Joint mobilization may act via enhancement of descending pain mechanisms in patients with painful knee osteoarthritis.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ball, J.B. Jr.

Direct oblique sagittal CT was used to evaluate trauma to 77 orbits. Sixty-seven orbital wall fractures with intact orbital rims (36 floor, 22 medial wall, nine roof) were identified in 47 orbits. Since persistent diplopia and/or enophthalmos may warrant surgical repair of orbital floor fractures, optimal imaging should include an evaluation of extraocular muscle status, the nature and amount of displaced orbital contents, and an accurate definition of fracture margins. For orbital floor fractures, a combination of the direct oblique sagittal and direct coronal projections optimally displayed all fracture margins, the fracture's relationship to the inferior orbital rim and medialmore » orbital wall, and the amount of displacement into the maxillary sinus. Inferior rectus muscle status with 36 floor fractures was best seen on the direct oblique sagittal projection in 30 fractures (83.3%) and was equally well seen on sagittal and coronal projections in two fractures (5.5%). Floor fractures were missed on 100% of axial, 5.5% of sagittal, and 0% of coronal projections. Since the direct oblique sagittal projection complements the direct coronal projection in evaluating orbital floor fractures, it should not be performed alone. A technical approach to the CT evaluation or orbital wall fractures is presented.« less

Robot-Assisted Medial Compartment Arthroplasty Following Remote Patellectomy: A Case Report

PubMed Central

Kouk, Shalen; Kalbian, Irene; Wolfe, Elizabeth; Strickland, Sabrina M

2018-01-01

Introduction: Total patellectomies are uncommon procedures that are reserved as salvage treatment for severely comminuted fractures of the patella. Due to the alteration of normal joint mechanics, these patients present later on in life with degenerative cartilage damage to the femorotibial joint and altered extensor mechanism. There are very few reports of unicondylar knee arthroplasties following previous patellectomy and none that specifically address robot-assisted unicompartmental knee arthroplasty. A recent case report by Pang et al. described the use of minimally invasive fixed-bearing unicondylar knee arthroplasty in a patellectomized patient with moderate medial compartment osteoarthritis. Our report details a case with more significant chondral loss along with patellar tendon subluxation. Case Report: This is a case report of a patient with severe medial compartment osteoarthritis after a patellectomy following a motor vehicle collision. After failing conservative treatment, the patient underwent a medial MAKOplasty with complete resolution of arthritic pain. Conclusion: Significant pain relief and improved knee function can be achieved with MAKOPlasty partial knee resurfacing system in a previously patellectomized patient with severe medial compartment osteoarthritis. PMID:29854684

Prevalence of musculoskeletal disorders among immigrant Latino farmworkers and non-farmworkers in North Carolina

PubMed Central

Mora, Dana C.; Miles, Christopher M.; Chen, Haiying; Quandt, Sara A.; Summers, Phillip; Arcury, Thomas A.

2015-01-01

Background This manuscript evaluates the variability in the prevalence of epicondylitis, rotator cuff syndrome, low back pain, and lower extremity pathology among immigrant Latino farmworkers and non-farmworkers. Methods Data were collected from a study among 272 farmworkers and non-farmworkers. Participants were recruited in eastern and central North Carolina. A physical exam was conducted by trained physicians. Results Prevalence of MSDs among Latino manual workers is high compared other workers in similar occupations. Non-farmworkers (49%) had a higher prevalence of MSDs than farmworkers (35%). Epicondylitis (20.2%) and rotator cuff syndrome (19.1%) were most prevalent. Age was found to be significant among those who had epicondylitis (AOR = 1.04) and lower extremity pathology (AOR = 1.07). Conclusions Latino immigrant manual workers have high prevalence of MSDs. Further studies are needed to identify possible factors that make these populations more vulnerable to MSDs. PMID:25454715

Prevalence of musculoskeletal disorders among immigrant Latino farmworkers and non-farmworkers in North Carolina.

PubMed

Mora, Dana C; Miles, Christopher M; Chen, Haiying; Quandt, Sara A; Summers, Phillip; Arcury, Thomas A

2016-05-03

This paper evaluates the variability in the prevalence of epicondylitis, rotator cuff syndrome, low back pain, and lower extremity pathology among immigrant Latino farmworkers and non-farmworkers. Data were collected from a study among 272 farmworkers and non-farmworkers. Participants were recruited in eastern and central North Carolina. A physical examination was conducted by trained physicians. Prevalence of musculoskeletal disorders (MSDs) among Latino manual workers is high compared with other workers in similar occupations. Non-farmworkers (49%) had a higher prevalence of MSDs than farmworkers (35%). Epicondylitis (20.2%) and rotator cuff syndrome (19.1%) were most prevalent. Age was found to be significant among those who had epicondylitis (adjusted odds ratio [AOR] = 1.04) and lower extremity pathology (AOR = 1.07). Latino immigrant manual workers have high prevalence of MSDs. Further studies are needed to identify possible factors that make these populations more vulnerable to MSDs.

Musculoskeletal and neurological injuries associated with work organization among immigrant Latino women manual workers in North Carolina.

PubMed

Arcury, Thomas A; Cartwright, Michael S; Chen, Haiying; Rosenbaum, Daryl A; Walker, Francis O; Mora, Dana C; Quandt, Sara A

2014-04-01

This analysis examines the associations of work organization attributes among Latino women in manual occupations with musculoskeletal and neurological injuries. Participants included 234 women in western North Carolina. Outcome measures included epicondylitis, rotator cuff syndrome, back pain, and carpal tunnel syndrome. Independent measures included indicators of job demand, job control, and job support, as well as personal characteristics. Latina workers commonly experienced epicondylitis, rotator cuff syndrome, back pain, and CTS. Awkward posture and decision latitude were associated with epicondylitis. Rotator cuff syndrome was associated with awkward posture and psychological demand. Awkward posture and psychological demand, and decreased skill variety and job control were related to CTS. Work organization factors are potentially important for musculoskeletal and neurological injury among vulnerable workers. Research is required to understand the associations of work and health outcomes of these women. Policy initiatives need to consider how work organization affects health. © 2014 Wiley Periodicals, Inc.

Lateral epicondylitis of the elbow

PubMed Central

Vaquero-Picado, Alfonso; Barco, Raul; Antuña, Samuel A.

2016-01-01

Lateral epicondylitis, also known as ‘tennis elbow’, is a very common condition affecting mainly middle-aged patients. The pathogenesis remains unknown but there appears to be a combination of local tendon pathology, alteration in pain perception and motor impairment. The diagnosis is usually clinical but some patients may benefit from additional imaging for a specific differential diagnosis. The disease has a self-limiting course of between 12 and 18 months, but in some patients, symptoms can be persistent and refractory to treatment. Most patients are well-managed with non-operative treatment and activity modification. Many surgical techniques have been proposed for patients with refractory symptoms. New non-operative treatment alternatives with promising results have been developed in recent years. Cite this article: Vaquero-Picado A, Barco R, Antuña SA. Lateral epicondylitis of the elbow. EFORT Open Rev 2016;1:391-397. DOI: 10.1302/2058-5241.1.000049. PMID:28461918

Unilateral lag screw fixation of isolated non-union atlas lateral mass fracture: a new technical note.

PubMed

Farrokhi, Majid Reza; Kiani, Arash; Rezaei, Hamid

2018-01-15

We describe a novel and new technique of posterior unilateral lag screw fixation of non-union atlas lateral mass fracture. A 46-year-old man presented with cervical pain and tenderness after a vehicle turn over accident and he was diagnosed to have left atlas lateral mass fracture. He was initially treated by immobilization using Minerva orthosis. About 2 months later, he developed severe neck pain and limitation of motion and thus he was scheduled for operation due to non-union atlas lateral mass fracture. A 28 mm lag screw was inserted under anterior-posterior and lateral fluoroscopic views. The entrance point was at the dorsal aspect of left atlas posterior arc at its junction to the lateral mass, and by using the trajectory of 10 degrees medial and 22 degrees cephalad fracture reduction was achieved. Unilateral lag screw fixation of atlas fractures is an appropriate, safe and effective surgical technique for the management of unilateral atlas fractures.

Diagnostic accuracy of the gravity stress test and clinical signs in cases of isolated supination-external rotation-type lateral malleolar fractures.

PubMed

Nortunen, S; Flinkkilä, T; Lantto, I; Kortekangas, T; Niinimäki, J; Ohtonen, P; Pakarinen, H

2015-08-01

We prospectively assessed the diagnostic accuracy of the gravity stress test and clinical findings to evaluate the stability of the ankle mortise in patients with supination-external rotation-type fractures of the lateral malleolus without widening of the medial clear space. The cohort included 79 patients with a mean age of 44 years (16 to 82). Two surgeons assessed medial tenderness, swelling and ecchymosis and performed the external rotation (ER) stress test (a reference standard). A diagnostic radiographer performed the gravity stress test. For the gravity stress test, the positive likelihood ratio (LR) was 5.80 with a 95% confidence interval (CI) of 2.75 to 12.27, and the negative LR was 0.15 (95% CI 0.07 to 0.35), suggesting a moderate change from the pre-test probability. Medial tenderness, both alone and in combination with swelling and/or ecchymosis, indicated a small change (positive LR, 2.74 to 3.25; negative LR, 0.38 to 0.47), whereas swelling and ecchymosis indicated only minimal changes (positive LR, 1.41 to 1.65; negative LR, 0.38 to 0.47). In conclusion, when gravity stress test results are in agreement with clinical findings, the result is likely to predict stability of the ankle mortise with an accuracy equivalent to ER stress test results. When clinical examination suggests a medial-side injury, however, the gravity stress test may give a false negative result. ©2015 The British Editorial Society of Bone & Joint Surgery.

[Sinus tarsi approach combined with medial distraction technique for treatment of intra-articular calcaneus fractures].

PubMed

Zhou, Haichao; Ren, Haoyang; Li, Bing; Yu, Tao; Yang, Yunfeng

2016-07-08

?To discuss the effectiveness of limited open reduction via sinus tarsi approach using medial distraction technique in the treatment of intra-articular calcaneus fractures by comparing with open reduction and internal fixation via extensile L-shaped incision. ?A retrospective analysis was made on the clinical data of 21 patients with intra-articular calcaneus fractures treated by sinus tarsi approach combined with medial distraction technique between April 2013 and November 2014 (minimally invasive group), and 32 patients treated by extensile L-shaped incision approach between June 2012 and September 2014 (extensile incision group). No significant difference was found in gender, age, injury pattern, fracture classification, time from injury to operation, preoperative Böhler angle, Gissane angle, calcaneal varus angle, the ankle and hind-foot score of American Orthopaedic Foot and Ankle Society (AOFAS), and visual analogue scale (VAS) score between 2 groups (P>0.05), which was comparable. The operation time, wound complications, and bone healing time were recorded. The postoperative function was also evaluated by AOFAS score and VAS score. The pre-and post-operative Böhler angle, Gissane angle, and calcaneal varus angle were measured on the X-ray films, and the corrective angle was calculated. ?Sixteen patients were followed up 6-18 months (mean, 11.5 months) in the minimally invasive group, and 23 patients for 6-24 months (mean, 13.5 months) in the extensile incision group. Difference was not significant in operation time between 2 groups (t=0.929, P=0.796). No complication occurred in the minimally invasive group; partial skin flap necrosis occurred in 3 cases of the extensile incision group, was cured after dressing change. There was no loosening of implants or reduction loss in 2 groups at last follow-up. Subtalar joint stiffness occurred in 1 case of the minimally invasive group and 4 cases of the extensile incision group, and 1 patient had discomfort for the implants in the extensile incision group. The bone healing time was (9.9±0.8) weeks in the minimally invasive group, and was (10.1±0.7) weeks in the extensile incision group, showing no significant difference (t=0.613, P=0.845 ). Böhler angle, Gissane angle, calcaneal varus angle, AOFAS score, and VAS score were significantly improved at last follow-up when compared with preoperative values in 2 groups (P<0.05), but there was no significant difference between 2 groups (P>0.05), and the corrective value of angle showed no significant difference between 2 groups (P>0.05). ?Limited open reduction via sinus tarsi approach for intra-articular calcaneus fractures could reduce the incidence of wound complications effectively. Meanwhile, the medial distraction technique is helpful to correct the heel varus deformity.

Factors associated with recurrent fifth metatarsal stress fracture.

PubMed

Lee, Kyung-tai; Park, Young-uk; Jegal, Hyuk; Kim, Ki-chun; Young, Ki-won; Kim, Jin-su

2013-12-01

Many surgeons agree that fifth metatarsal stress fractures have a tendency toward delayed union, nonunion, and possibly refracture. Difficulty healing seems to be correlated with fracture classification. However, refracture sometimes occurs after low-grade fracture, even long after apparent resolution. The records of 168 consecutive cases of fifth metatarsal stress fracture (163 patients) treated by modified tension band wiring from March 2002 to June 2011 were evaluated retrospectively. Mean length of follow-up was 23.6 months (range, 10-112 months). Forty-nine cases classified as Torg III were bone grafted initially also. All enrolled patients were elite athletes. Eleven patients experienced nonunion and 18 refracture. The 11 nonunion cases were bone grafted. The 157 patients (excluding nonunion cases) were allocated to either a refracture group or a union group. Clinical features, such as age, weight, fracture classification, time to union, and reinjury history, were compared. Radiological parameters representing cavus deformity and fifth metatarsal head protrusion were compared to evaluate the influence of structural abnormalities. Mean group weights were significantly different (P = .041), but mean ages (P = .879), fracture grades (P = .216, P = .962), and time from surgery to rehabilitation (P = .539) were similar. No significant intergroup differences were found for talocalcaneal (TC) angle (P = .470), calcaneal pitch (CP) angle (P = .847), or talo-first metatarsal (T-MT1) angle (P = .407) on lateral radiographs; for fifth metatarsal lateral deviation (MT5-LD) angle (P = .623) on anteroposterior (AP) radiographs; or for MT5-LD angle (P = .065) on the 30-degree medial oblique radiographs. However, the mean fourth-fifth intermetatarsal (IMA4-5) angle on AP radiographs was significantly greater in the refracture group, and for Torg II cases, mean weight (P = .042), IMA4-5 angle on AP radiographs (P = .014), and MT5-LD angle (P = .043) on 30-degree medial oblique radiographs were significantly greater in the refracture group. For B2 cases (incomplete fracture and a plantar gap of 1 mm or larger), mean weight (P = .046), IMA4-5 angle on AP radiographs (P = .019), and MT5-LD angle (P = .045) on 30-degree medial oblique radiographs were significantly greater in the refracture group. All cases of refracture had a traumatic history after bone union. Refracture developed within 6 months of starting rehabilitation in 13 cases and within 3 months in 8 cases. The development of refracture after the surgical treatment of fifth metatarsal stress fractures was found to be associated with higher body mass index (BMI) and with radiological parameters (IMA4-5 on AP radiographs, MT5-LD on oblique radiographs) associated with protrusion of the fifth metatarsal head. The study indicates that patients with a protruding fifth metatarsal head and a high BMI should approach rehabilitation with care before considering a return to previous sporting activity levels. Level III, retrospective comparative series.

Clavicle fractures.

PubMed

Ropars, M; Thomazeau, H; Huten, D

2017-02-01

Management of clavicle fracture has progressed over the last decade, notably with wider use of surgery in midshaft fracture, and new techniques for lateral fracture. Midshaft clavicle fracture treatment needs to be personalized and adapted to the patient's activity level. Whichever the segment involved, treatment for non-displaced fracture is functional; elbow-to-body sling immobilization seems the best tolerated. Apart from regular surgical indications (shoulder impaction, floating shoulder, open fracture or fracture with neurovascular complications), surgery is recommended in case of bone shortening exceeding 1.5cm in young active patients. The technique needs to take account of clavicle anatomy: notably periosteal vascularization in midshaft fracture and acromioclavicular ligament integrity and location in case of lateral fracture. Plate osteosynthesis should take account of bone diameter and 3D curvature; intramedullary fixation should take account of intramedullary canal morphology. Although iatrogenic vascular complications are rare, vessel relations and variants need to be known, especially in the medial end of the clavicle and midshaft. Lateral segment fractures are a particular entity. Large-scale randomized studies are needed to assess indications and results for the various possible internal fixation techniques: isolated or associated to ligament reconstruction, rigid or flexible, and open or arthroscopic. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Mini-Fragment Fixation Is Equivalent to Bicortical Screw Fixation for Horizontal Medial Malleolus Fractures.

PubMed

Wegner, Adam M; Wolinsky, Philip R; Robbins, Michael A; Garcia, Tanya C; Amanatullah, Derek F

2018-05-01

Horizontal fractures of the medial malleolus occur through application of valgus or abduction force through the ankle that creates a tension failure of the medial malleolus. The authors hypothesize that mini-fragment T-plates may offer improved fixation, but the optimal fixation construct for these fractures remains unclear. Forty synthetic distal tibiae with identical osteotomies were randomized into 4 fixation constructs: (1) two parallel unicortical cancellous screws; (2) two parallel bicortical cortical screws; (3) a contoured mini-fragment T-plate with 2 unicortical screws in the fragment and 2 bicortical screws in the shaft; and (4) a contoured mini-fragment T-plate with 2 bicortical screws in the fragment and 2 unicortical screws in the shaft. Specimens were subjected to offset axial tension loading on a servohydraulic testing system and tracked using high-resolution video. Failure was defined as 2 mm of articular displacement. Analysis of variance followed by a Tukey-Kramer post hoc test was used to assess for differences between groups, with significance defined as P<.05. The mean stiffness (±SD) values of both mini-fragment T-plate constructs (239±83 N/mm and 190±37 N/mm) and the bicortical screw construct (240±17 N/mm) were not statistically different. The mean stiffness values of both mini-fragment T-plate constructs and the bicortical screw construct were higher than that of a parallel unicortical screw construct (102±20 N/mm). Contoured T-plate constructs provide stiffer initial fixation than a unicortical cancellous screw construct. The T-plate is biomechanically equivalent to a bicortical screw construct, but may be superior in capturing small fragments of bone. [Orthopedics. 2018; 41(3):e395-e399.]. Copyright 2018, SLACK Incorporated.

Femoral fracture repair and postoperative management in new zealand white rabbits.

PubMed

Reuter, Jon D; Ovadia, Shira; Howell, Paula; Jaskwich, David H

2002-07-01

Low bone density and large muscle mass predispose rabbits to femoral fractures. However, there are few reports describing treatment and prognosis. Two New Zealand White rabbits presented with unilateral left rear limb abduction and lateral rotation of the distal left rear limb 2 and 17 days after experimental surgery to create a "stair step" in the patellar groove of the left medial femoral chondyle. This procedure was performed after approval by the Institutional Animal Care and Use Committee. Radiography revealed a spiral oblique mid-shaft fracture of the left femur in both rabbits. Open fracture reduction was undertaken. Because of the presence of screws and Kirschner-wires in the medial femoral condyle, a lateral approach to surgical correction was chosen. Intramedullary fixation was used to reduce and stabilize the fractures. A 0.062" Kirschner wire was selected for the intramedullary device, because it was sufficiently flexible to allow easy passage into the femoral canal while being sufficiently stiff to promote reduction of the fracture. In addition, the ends of the fracture were secured with a 0.032" Kirschner cerclage wire to provide additional control of rotation and angulation. Then we assessed the range of motion of the knee joint to determine fracture stability and ensure that the hardware did not impinge on soft-tissue elements. After closure and application of sterile dressing, the hind legs were hobbled proximal to the hock by using elastic veterinary wrap in a figure-eight pattern to maintain limb alignment and prevent formation of pressure ulcers. Intraoperative fluoroscopic evaluation and postoperative radiographs confirmed fracture reduction. Bruising and seroma formation occurred at the surgical site, and transient anorexia developed. Rabbits were treated with fluids, analgesics, antibiotics, and fitted with Elizabethan collars. They were housed in isolation to limit excessive environmental stimulation, which could alarm them and provoke "thumping" of the rear legs. Muscular weakness and atrophy developed in the affected legs, but the fractures remained immobilized. Radiographs obtained 21 days after surgery confirmed marked callus formation and integrity of the implanted hardware. Four weeks after surgical fixation, both rabbits showed increased muscle development in the repaired leg and were ambulating normally. The long-term prognosis was excellent. These cases demonstrate that repair of femoral fractures in rabbits can be achieved by using basic orthopedic techniques and diligent post-operative management.

Deep Friction Massage Versus Steroid Injection in the Treatment of Lateral Epicondylitis.

PubMed

Yi, Rosemary; Bratchenko, Walter W; Tan, Virak

2018-01-01

The aim of the study was to determine the efficacy of deep friction massage in the treatment of lateral epicondylitis by comparing outcomes with a control group treated with splinting and therapy and with an experimental group receiving a local steroid injection. A randomized clinical trial was conducted to compare outcomes after recruitment of consecutive patients presenting with lateral epicondylitis. Patients were randomized to receive one of 3 treatments: group 1: splinting and stretching, group 2: a cortisone injection, or group 3: a lidocaine injection with deep friction massage. Pretreatment and posttreatment parameters of visual analog scale (VAS) pain ratings, Disabilities of the Arm, Shoulder and Hand (DASH) scores, and grip strength were measured. Outcomes were measured at early follow-up (6-12 weeks) and at 6-month follow-up. There was a significant improvement in VAS pain score in all treatment groups at early follow-up. DASH score and grip strength improved in the cortisone injection group and the deep friction massage group at early follow-up; these parameters did not improve in the splinting and stretching group. At 6-month follow-up, only patients in the deep friction massage group demonstrated a significant improvement in all outcome measures, including VAS pain score, DASH score, and grip strength. Deep friction massage is an effective treatment for lateral epicondylitis and can be used in patients who have failed other nonoperative treatments, including cortisone injection.

Brachial Plexus Injury in a 6-Year-Old Boy with 100% Displaced Proximal Humeral Metaphyseal Fracture: A Case Presentation.

PubMed

Jovanovich, Elizabeth Nora; Howard, James F

2017-12-01

Posttraumatic brachial plexopathies can occur following displaced proximal humeral fractures, causing profound functional deficits. Described here is an unusual case of a displaced proximal humeral metaphyseal fracture in a young child. The patient underwent closed reduction and serial casting, but hand weakness and forearm sensory loss persisted. Needle electromyography localized the injury to the mid/proximal arm near the fracture site, resulting in damage to the posterior and medial cords of the brachial plexus with profound involvement of the radial, ulnar, and median nerves and sparing of the axillary nerve. After months of occupational therapy, hand strength improved, with a nearly full return of function. V. Copyright © 2017 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.

Real Time Navigation-Assisted Orbital Wall Reconstruction in Blowout Fractures.

PubMed

Shin, Ho Seong; Kim, Se Young; Cha, Han Gyu; Han, Ba Leun; Nam, Seung Min

2016-03-01

Limitation in performing restoration of orbital structures is the narrow, deep, and dark surgical field, which makes it difficult to view the operative site directly. To avoid perioperative complications from this limitation, the authors have evaluated the usefulness of computer-assisted navigation techniques in surgical treatment of blowout fracture. Total 37 patients (14 medial orbital wall fractures and 23 inferior orbital wall fractures) with facial deformities had surgical treatment under the guide of navigation system between September 2012 and January 2015. All 37 patients were treated successfully and safely with navigation-assisted surgery without any complications, including diplopia, retrobulbar hematoma, globe injury, implant migration, and blindness. Blowout fracture can be treated safely under guidance of a surgical navigation system. In orbital surgery, navigation-assisted technology could give rise to improvements in the functional and aesthetic outcome and checking the position of the instruments on the surgical site in real time, without injuring important anatomic structures.

Common Leg Injuries of Long-Distance Runners

PubMed Central

Gallo, Robert A.; Plakke, Michael; Silvis, Matthew L.

2012-01-01

Context Long-distance running (greater than 3000 m) is often recommended to maintain a healthy lifestyle. Running injury rates increase significantly when weekly mileage extends beyond 40 miles cumulatively. With the development of running analysis and other diagnostic tests, injuries to the leg secondary to bone, musculotendinous, and vascular causes can be diagnosed and successfully managed. Evidence Acquisition Searches used the terms running, injuries, lower extremity, leg, medial tibial stress syndrome, compartment syndrome, stress fractures, popliteal artery entrapment, gastrocnemius soleus tears, and Achilles tendinopathy. Sources included Medline, Google Scholar, and Ovid from 1970 through January 2012. Results Tibial stress fractures and medial tibial stress syndrome can sometimes be prevented and/or treated by correcting biomechanical abnormalities. Exertional compartment syndrome and popliteal artery entrapment syndrome are caused by anatomic abnormalities and are difficult to treat without surgical correction. Conclusion Leg pain due to bone, musculotendinous, and vascular causes is common among long-distance runners. Knowledge of the underlying biomechanical and/or anatomic abnormality is necessary to successfully treat these conditions. PMID:24179587

Catastrophic complication following injection and extracorporeal shock wave therapy of a medial femoral condyle subchondral cystic lesion in a 14 year old Arabian mare.

PubMed

Moser, Darla K; Schoonover, Mike J; Sippel, Kate M; Dieterly, Alix M; Ritchey, Jerry W; Wall, Corey R

2017-01-01

This report describes fibrous cyst lining injection and extracorporeal shock wave therapy (ESWT) of a medial femoral condyle (MFC) subchondral cystic lesion (SCL) resulting in catastrophic MFC fracture in an Arabian mare. The mare was presented for evaluation of a severe hind limb lameness of approximately 4 months duration. On presentation, a non-weight bearing lameness of the left hind limb with severe effusion and soft tissue swelling of the stifle region was noted. Radiographic evaluation of the stifle revealed a large SCL of the MFC with associated osteoarthritis. Arthroscopic guided intra-lesional injection of the SCL with corticosteroids and autologous bone marrow concentrate was performed followed by ESWT of the MFC. The mare was discharged walking comfortably 48-hours post-operatively. An acute increase in lameness was noted 14 days post-operatively. Imaging revealed catastrophic fracture of the left MFC. Possible mechanisms leading to failure of the MFC secondary to the described treatment are discussed.

Posterior tibial tendon displacement behind the tibia and its interposition in an irreducible isolated ankle dislocation: a case report and literature review

PubMed Central

ORTOLANI, ALESSANDRO; BEVONI, ROBERTO; RUSSO, ALESSANDRO; MARCACCI, MAURILIO; GIROLAMI, MAURO

2016-01-01

Isolated posteromedial ankle dislocation is a rare condition thanks to the highly congruent anatomical configuration of the ankle mortise, in which the medial and lateral malleoli greatly reduce the rotational movement of the talus, and the strength of the ligaments higher than the malleoli affords protection against fractures. However, other factors, like medial malleolus hypoplasia, laxity of the ligaments, peroneal muscle weakness and previous ankle sprains, could predispose to pure dislocation. In the absence of such factors, only a complex high-energy trauma, with a rotational component, can lead to this event. Irreducibility of an ankle dislocation, which is rarely encountered, can be due to soft tissue interposition. Dislocation of the posterior tibial tendon can be the cause of an irreducible talar dislocation; interposition of this tendon, found to have slid posteriorly to the distal tibia and then passed through the tibioperoneal syndesmosis, is reported in just a few cases of ankle fracture-dislocation. PMID:27900312

Treatment of mandibular symphyseal fracture combined with dislocated intracapsular condylar fractures.

PubMed

Xu, Xiaofeng; Shi, Jun; Xu, Bing; Dai, Jiewen; Zhang, Shilei

2015-03-01

To evaluate the treatment methods of mandibular symphyseal fracture combined with dislocated intracapsular condylar fractures (MSF&DICF) and to compare the effect of different treatment methods of condylar fractures. Twenty-eight patients with MSF&DICF were included in this study. Twenty-two sites were treated by open reduction, and all the medial condylar fragments were fixed with titanium screws; whereas the other 22 sites underwent close treatment. The surgical effect between these 2 groups was compared based on clinical examination and radiographic examination results. Seventeen of 22 condyle fractures were repositioned in the surgery group, whereas 4 of 22 condyle fractures were repositioned in the close treatment group. Statistical difference was observed between these 2 groups (P < 0.01). Functional outcomes of the patients treated in the surgical treatment group also were better than those in the close treatment group. The dislocated intracapsular condyle fractures should be treated by surgical reduction with the maintenance of the attachment of lateral pterygoid muscle, which is beneficial to repositioning the dislocated condyle to its original physiological position, to closure of the mandibular lingual gap, to restore the mandibular width.

The "safe zone" in medial percutaneous calcaneal pin placement.

PubMed

Gamie, Zakareya; Donnelly, Leo; Tsiridis, Eleftherios

2009-05-01

Percutaneous pin insertion into the medial calcaneus places a number of structures at risk. Evidence suggests that the greatest risk is to the medial calcaneal nerve (MCN). The medial calcaneal region of 24 cadavers was dissected to determine the major structures at risk. By using four palpable anatomical landmarks, the inferior tip of the medial malleolus (point A), the posterior superior portion of the calcaneal tuberosity (point B), the navicular tuberosity (point C), and the medial process of the calcaneal tuberosity (point D), we attempted to define the safe zone taking into account all possible variables in our dissections including ankle position, side, gender, and possible anatomical variations of the MCN. The commonest arrangement of the MCN was two MCNs that arose independently, one arising before the bifurcation of the tibial nerve and the other arising from the medial plantar nerve. A zone could be defined posterior to 75% of the distance along the lines AB, CD, AD, and CB which would avoid most structures. The posterior branches of the MCN, however, would still be at risk and placing the pin too far posteriorly risks an avulsion fracture. This is the first study to employ four palpable anatomical landmarks to identify a zone to minimize damage to neurovascular structures. It may not be possible, however, to avoid injury of the MCN and consequent sensory loss to the sole of the foot.

Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up.

PubMed

Peerbooms, Joost C; Sluimer, Jordi; Bruijn, Daniël J; Gosens, Taco

2010-02-01

Platelet-rich plasma (PRP) has shown to be a general stimulation for repair. Purpose To determine the effectiveness of PRP compared with corticosteroid injections in patients with chronic lateral epicondylitis. Randomized controlled trial; Level of evidence, 1. The trial was conducted in 2 teaching hospitals in the Netherlands. One hundred patients with chronic lateral epicondylitis were randomly assigned in the PRP group (n = 51) or the corticosteroid group (n = 49). A central computer system carried out randomization and allocation to the trial group. Patients were randomized to receive either a corticosteroid injection or an autologous platelet concentrate injection through a peppering technique. The primary analysis included visual analog scores and DASH Outcome Measure scores (DASH: Disabilities of the Arm, Shoulder, and Hand). Successful treatment was defined as more than a 25% reduction in visual analog score or DASH score without a reintervention after 1 year. The results showed that, according to the visual analog scores, 24 of the 49 patients (49%) in the corticosteroid group and 37 of the 51 patients (73%) in the PRP group were successful, which was significantly different (P <.001). Furthermore, according to the DASH scores, 25 of the 49 patients (51%) in the corticosteroid group and 37 of the 51 patients (73%) in the PRP group were successful, which was also significantly different (P = .005). The corticosteroid group was better initially and then declined, whereas the PRP group progressively improved. Treatment of patients with chronic lateral epicondylitis with PRP reduces pain and significantly increases function, exceeding the effect of corticosteroid injection. Future decisions for application of the PRP for lateral epicondylitis should be confirmed by further follow-up from this trial and should take into account possible costs and harms as well as benefits.

The effect of platelet-rich plasma on clinical outcomes in lateral epicondylitis.

PubMed

Ahmad, Zafar; Brooks, Roger; Kang, Sertaz-Niel; Weaver, Holly; Nunney, Ian; Tytherleigh-Strong, Graham; Rushton, Neil

2013-11-01

To evaluate the evidence for application of platelet-rich plasma (PRP) in lateral epicondylitis. We carried out a systematic review of the current evidence on the effects of PRP in lateral epicondylitis on clinical outcomes. We performed a comprehensive search of the PubMed, Medline, Cochrane, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase databases using various combinations of the commercial names of each PRP preparation and "lateral epicondylitis" (with its associated terms), looking specifically at human studies. Data validity was assessed and collected on clinical outcome. Nine studies met the inclusion criteria, of which 5 were randomized controlled trials. Two cohort studies showed that PRP improved clinical satisfaction scores. One case-control study showed that PRP yielded a significantly greater improvement in symptoms compared with bupivacaine. Two randomized controlled trials compared the effect of injections of PRP and blood. Only 1 of the studies noted a significant difference at the 6-week time point. Three randomized controlled trials compared corticosteroids with PRP. Two of the smaller trials, which had follow-up periods of 6 weeks and 3 months, showed no significant difference between treatment groups. The largest randomized controlled trial found that PRP had significant benefit compared with corticosteroids with regard to pain and Disabilities of the Arm, Shoulder and Hand scores at 1- and 2-year time points. This review highlights the limited but evolving evidence for the use of PRP in lateral epicondylitis; however, further research is required to understand the concentration and preparation that facilitate the best clinical outcome. Characterizing the timing of the intervention would optimize the health economics behind the decision to treat for the patient and health care provider. Level III, systematic review of Level I to III studies. Copyright © 2013 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up.

PubMed

Gosens, Taco; Peerbooms, Joost C; van Laar, Wilbert; den Oudsten, Brenda L

2011-06-01

Platelet-rich plasma (PRP) has been shown to be a general stimulation for repair and 1-year results showed promising success percentages. This trial was undertaken to determine the effectiveness of PRP compared with corticosteroid injections in patients with chronic lateral epicondylitis with a 2-year follow-up. Randomized controlled trial; Level of evidence, 1. The trial was conducted in 2 Dutch teaching hospitals. One hundred patients with chronic lateral epicondylitis were randomly assigned to a leukocyte-enriched PRP group (n = 51) or the corticosteroid group (n = 49). Randomization and allocation to the trial group were carried out by a central computer system. Patients received either a corticosteroid injection or an autologous platelet concentrate injection through a peppering needling technique. The primary analysis included visual analog scale (VAS) pain scores and Disabilities of the Arm, Shoulder and Hand (DASH) outcome scores. The PRP group was more often successfully treated than the corticosteroid group (P < .0001). Success was defined as a reduction of 25% on VAS or DASH scores without a reintervention after 2 years. When baseline VAS and DASH scores were compared with the scores at 2-year follow-up, both groups significantly improved across time (intention-to-treat principle). However, the DASH scores of the corticosteroid group returned to baseline levels, while those of the PRP group significantly improved (as-treated principle). There were no complications related to the use of PRP. Treatment of patients with chronic lateral epicondylitis with PRP reduces pain and increases function significantly, exceeding the effect of corticosteroid injection even after a follow-up of 2 years. Future decisions for application of PRP for lateral epicondylitis should be confirmed by further follow-up from this trial and should take into account possible costs and harms as well as benefits.

Effect of simultaneous stretching of the wrist and finger extensors for lateral epicondylitis: a gross anatomical study of the tendinous origins of the extensor carpi radialis brevis and extensor digitorum communis.

PubMed

Shirato, Rikiya; Wada, Takuro; Aoki, Mitsuhiro; Iba, Kousuke; Kanaya, Kohei; Fujimiya, Mineko; Yamashita, Toshihiko

2015-11-01

Pulling the wrist into flexion with the elbow in extension and forearm in pronation has been used as the stretching technique of wrist extensors for lateral epicondylitis. Simultaneous stretching of the fingers in addition to the wrist flexion has also been applied. However, the mechanism of this simultaneous stretching has not been clarified. This study is designed to clarify the mechanism underlying this simultaneous stretching technique based on the anatomical features of the origins of the extensor carpi radialis brevis (ECRB) and extensor digitorum communis (EDC). Thirty-nine arms from formalin-embalmed Japanese human specimens were dissected. The features of the origins of the ECRB and EDC were macroscopically observed, and the locations of each origin on the lateral epicondyle were measured. The ECRB had a long and wide, purely tendinous origin which originated from the anterior slope of the lateral epicondyle. The tendinous origin of the index finger of the EDC (EDC-IF) arose from the posterior aspect of the ECRB tendinous origin, with a coexisting muscular portion observed at the level of the proximal forearm. The middle finger of the EDC (EDC-MF) had a short tendinous origin with an associated muscular portion and originated proximo-laterally to the origin of the ECRB on the lateral epicondyle. In addition, the muscular origin of the EDC-MF arose on the superficial and posterior aspect of the ECRB tendinous origin. In contrast, the ring and little fingers of the EDC originated from the tendinous septum of the extensor digiti minimi and extensor carpi ulnaris, and had no connection with the ECRB tendinous origin. On the basis of our anatomical findings, simultaneous stretching of the wrist extensors by wrist, index and middle fingers flexion could provide stretching force to both the tendinous origins of the ECRB and EDC through the EDC-IF and EDC-MF.

Anatomical and Functional Recovery of Intracapsular Fractures of the Mandibular Condyle: Analysis of 124 Cases after Closed Treatment

PubMed Central

Lee, Jong-Sung; Jeon, Eun-Gyu; Seol, Guk-Jin; Choi, So-Young; Kim, Jin-Wook; Kwon, Tae-Geon; Paeng, Jun-Young

2014-01-01

Purpose: The purpose of this study is to evaluate the influence of intracapsular fracture lines of the mandibular condyle on the anatomical and functional recovery after non-surgical closed treatment. Methods: Clinical and radiological follow-up of 124 patients with intracapsular fractures of the mandibular condyle was performed after closed treatment between 2005 and 2012. The intracapsular fractures were classified into three categories: type A (medial condylar pole fracture), type B (lateral condylar pole fracture with loss of vertical height) and type M (multiple fragments or comminuted fracture). Results: By radiological finding, fracture types B and M lost up to 24% vertical height of the mandibular condyle compared to the height on the opposite side. In Type M, moderate to severe dysfunction was observed in 33% of the cases. Bilateral fractures were significantly associated with the risk of temporomandibular joint (TMJ) dysfunction in fracture types A and B. Bilateral fracture and TMJ dysfunction were not statistically significantly associated in type M fractures. Conclusion: Most of the mandibular intracapsular condylar fractures recovered acceptably after conservative non-surgical treatment with functional rehabilitation, even with some anatomical shortening of the condylar height. The poor functional recovery encountered in type M fractures, especially in cases with additional fracture sites and bilateral fractures, points up the limitation of closed treatment in such cases. PMID:27489844

Fatigue Failure in Extra-Articular Proximal Tibia Fractures: Locking Intramedullary Nail Versus Double Locking Plates-A Biomechanical Study.

PubMed

Kandemir, Utku; Herfat, Safa; Herzog, Mary; Viscogliosi, Paul; Pekmezci, Murat

2017-02-01

The goal of this study is to compare the fatigue strength of a locking intramedullary nail (LN) construct with a double locking plate (DLP) construct in comminuted proximal extra-articular tibia fractures. Eight pairs of fresh frozen cadaveric tibias with low bone mineral density [age: 80 ± 7 (SD) years, T-score: -2.3 ± 1.2] were used. One tibia from each pair was fixed with LN, whereas the contralateral side was fixed with DLP for complex extra-articular multifragmentary metaphyseal fractures (simulating OTA 41-A3.3). Specimens were cyclically loaded under compression simulating single-leg stance by staircase method out to 260,000 cycles. Every 2500 cycles, localized gap displacements were measured with a 3D motion tracking system, and x-ray images of the proximal tibia were acquired. To allow for mechanical settling, initial metrics were calculated at 2500 cycles. The 2 groups were compared regarding initial construct stiffness, initial medial and lateral gap displacements, stiffness at 30,000 cycles, medial and lateral gap displacements at 30,000 cycles, failure load, number of cycles to failure, and failure mode. Failure metrics were reported for initial and catastrophic failures. DLP constructs exhibited higher initial stiffness and stiffness at 30,000 cycles compared with LN constructs (P < 0.03). There were no significant differences between groups for loads at failure or cycles to failure. For the fixation of extra-articular proximal tibia fractures, a LN provides a similar fatigue performance to double locked plates. The locked nail could be safely used for fixation of proximal tibia fractures with the advantage of limited extramedullary soft tissue damage.

Weight-Bearing Cone-Beam CT Scan Assessment of Stability of Supination External Rotation Ankle Fractures in a Cadaver Model.

PubMed

Lawlor, Mark C; Kluczynski, Melissa A; Marzo, John M

2018-03-01

The utility of computed tomography (CT) for measuring medial clear space (MCS) for determination of the stability of supination external rotation (SER) ankle fractures and in comparison to standard radiographs is unknown. We compared MCS on gravity stress (GS) radiographs to GS and weight bearing (WB) cone-beam CT (CBCT). An AO SER 44B3.1 ankle fracture was simulated in 10 human cadavers, also serving as controls. MCS was measured on GS radiographs, GS CBCT, and a simulated WB CBCT scan. Specimens were stable if MCS was <5 mm and unstable if MCS was ≥5 mm. Paired t tests were used to compare MCS from each imaging modality for controls versus SER injuries and stable versus unstable specimens. Compared with controls assessed by GS radiographs, MCS was greater for an SER injury when assessed by GS radiograph and GS CBCT scan within the stable group. Compared with controls assessed by GS radiographs, MCS was greater for SER injuries when assessed by GS radiograph, GS CBCT scan, and WB CBCT within the unstable group. MCS was reduced for stable versus unstable SER injuries assessed by WB CBCT. In a cadaveric model of SER ankle fracture, the medial clear space was statistically significantly greater for the experimental condition when assessed by gravity stress radiograph and gravity stress CBCT scan. Under weight-bearing conditions, the cone-beam CT scanner distinguished between stable and unstable ankles in the experimental condition. This study suggests that a WB cone-beam CT scan may be able to distinguish between stable and unstable SER ankle fractures and influence operative decision making.

Double plating of intra-articular multifragmentary C3-type distal femoral fractures through the anterior approach.

PubMed

Imam, Mohamed A; Torieh, Ahmed; Matthana, Ahmed

2018-01-01

In this prospective case series, we report a mean of 12-month follow-up of the utilization of a dual plating of distal femoral fractures. Our technique included a lateral distal femoral locked plate with a low-contact-locked medial plate and bone graft through an extended medial parapatellar anterior approach for the fixation of C3-type distal femoral fractures. Sixteen patients (11 males and 5 females) presented with supracondylar femoral fracture type C3, according to Müller long-bone classification system and its revision OA/OTA classification. These were treated using dual plating through extended anterior approach and bone grafting. Our outcomes included clinical and radiological outcomes. Secondary outcomes included postoperative complications. The mean time of complete radiological union in the studied population was 6.0 ± 3.5 months with a range of 3-14 months. We have not observed postoperative varus or valgus deformity in our cohort. The majority (68.75%) of the studied patients showed significant improvement in range of motion (90°-120°) during follow-up. Eleven out of sixteen patients (68.75%) had well-to-excellent functional outcome. Poor outcome was reported in only two patients (12.50%). Dual plating fixation using anterior approach for type C3 distal femoral fractures is an efficient method of management. It has several advantages such as precise exposure, easy manipulation, anatomical reduction and stable fixation. However, operative indications and instructions should be strictly followed. The surgical technique must be rigorous, and the biomechanical qualities of these implants must be understood to prevent the development of major complications.

Decision Making in the Management of Extracapsular Fractures of the Proximal Femur - is the Dynamic Hip Screw the Prevailing Gold Standard?

PubMed

Jacob, Joshua; Desai, Ankit; Trompeter, Alex

2017-01-01

Currently, approximately half of all hip fractures are extracapsular, with an incidence as high as 50 in 100,000 in some countries. The common classification systems fail to explain the logistics of fracture classification and whether they all behave in the same manner. The Muller AO classification system is a useful platform to delineate stable and unstable fractures. The Dynamic hip screw (DHS) however, has remained the 'gold standard' implant of choice for application in all extracapsular fractures. The DHS relies on the integrity and strength of the lateral femoral wall as well as the postero-medial fragment. An analysis of several studies indicates significant improvements in design and techniques to ensure a better outcome with intramedullary nails. This article reviews the historical trends that helped to evolve the DHS implant as well as discussing if the surgeon should remain content with this implant. We suggest that the gold standard surgical management of extracapsular fractures can, and should, evolve.

Calcific periarthritis of the elbow presenting as acute tennis elbow.

PubMed

Jawad, F; Jawad, A S M

2014-01-01

A 28-year-old woman presented with sudden acute lateral epicondylitis. There was no history of preceding trauma or repetitive use of the arm. Because of the acute onset and signs of acute inflammation, an X-ray was arranged. The X-ray showed a hyperdense calcified elongated globule distal to the lateral epicondyle. A diagnosis of calcific periarthritis (calcium apatite) of the elbow was made. Calcific periarthritis has rarely been reported as a cause of acute elbow pain.

Dynamic Stress Testing Is Unnecessary for Unimalleolar Supination-External Rotation Ankle Fractures with Minimal Fracture Displacement on Lateral Radiographs.

PubMed

Nortunen, Simo; Leskelä, Hannu-Ville; Haapasalo, Heidi; Flinkkilä, Tapio; Ohtonen, Pasi; Pakarinen, Harri

2017-03-15

This study aimed to identify factors from standard radiographs that contributed to the stability of the ankle mortise in patients with isolated supination-external rotation fractures of the lateral malleolus (OTA/AO 44-B). Non-stress radiographs of the mortise and lateral views, without medial clear space widening or incongruity, were prospectively collected for 286 consecutive patients (mean age, 45 years [range, 16 to 85 years]), including 144 female patients (mean age, 50 years [range, 17 to 85 years]) and 142 male patients (mean age, 40 years [range, 16 to 84 years]) from 2 trauma centers. The radiographs were analyzed for fracture morphology by 2 orthopaedic surgeons, who were blinded to each other's measurements and to the results of external rotation stress radiographs (the reference for stability). Factors significantly associated with ankle mortise stability were tested in multiple logistic regression. Receiver operating characteristic analyses were performed for continuous variables to determine optimal thresholds. A sensitivity of >90% was used as the criterion for an optimal threshold. According to external rotation stress radiographs, 217 patients (75.9%) had a stable injury, defined as that with a medial clear space of <5 mm. Independent factors that predicted stable ankle mortise were female sex (odds ratio [OR], 2.5 [95% confidence interval (CI), 1.4 to 4.6]), a posterior diastasis of <2 mm (corresponding with a sensitivity of 0.94 and specificity of 0.39) on lateral radiographs (OR, 10.8 [95% CI, 3.7 to 31.5]), and only 2 fracture fragments (OR, 7.3 [95% CI, 2.1 to 26.3]). When the posterior diastasis was <2 mm and only 2 fracture fragments were present, the probability of a stable ankle mortise was 0.98 for 48 female patients (16.8%) and 0.94 for 37 male patients (12.9%). Patients with noncomminuted lateral malleolar fractures (85 patients [29.7%]) could be diagnosed with a stable ankle mortise without further stress testing, when the fracture line widths were <2 mm on lateral radiographs. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

[Operative treatment of displaced intra-articular calcaneal fractures].

PubMed

Zwipp, H; Rammelt, S; Amlang, M; Pompach, M; Dürr, C

2013-12-01

Anatomic reduction of displaced intra-articular calcaneal fractures with restoration of height, length, and axial alignment and reconstruction of the subtalar and calcaneocuboid joints. Displaced intra-articular calcaneal fractures with incongruity of the posterior facet of the subtalar joint, loss of height, and axial malalignment. High perioperative risk, soft tissue infection, advanced peripheral arterial disease (stage III), neurogenic osteoarthropathy, poor patient compliance (e. g., substance abuse). Extended lateral approach with the patient placed on the uninjured side. Reduction of the anatomic shape and joint surfaces according to the preoperative CT-based planning. Reduction of the medial wall and step-wise reconstruction of the posterior facet from medial to lateral. Reduction of the tuberosity and anterior process fragments to the posterior joint block and temporary fixation with Kirschner wires. Internal fixation with an anatomic lateral plate in a locking or nonlocking mode. Alternatively less invasive internal fixation with a calcaneus nail over a sinus tarsi approach for less severe fracture types. The lower leg is immobilized in a brace until the wound is healed. Range of motion exercises of the ankle and subtalar joints are initiated on the second postoperative day. Patients are mobilized in their own shoe with partial weight bearing of 20 kg for 6-12 weeks depending on fracture severity and bone quality. Over a 4-year period, 163 patients with 184 displaced, intra-articular calcaneal fractures were treated with a lateral plate via an extended approach. In all, 102 patients with 116 fractures were followed for a mean of 8 years. A surgical revision was necessary in 4 cases (3.4%) of postoperative hematoma, 2 (1.7%) superficial and 5 (4.3%) deep infections. Of the latter, 2 patients needed a free flap for definite wound coverage, no calcanectomy or amputation was needed. Secondary subtalar fusion for symptomatic posttraumatic arthritis was performed in 9 cases (7.8%). At follow-up, the AOFAS Ankle/Hindfoot Score averaged 70.2, the Zwipp Score averaged 76.0, the German versions of the Foot Function Index and SF-36 physical component averaged 32.8 and 42.2, respectively. Scores were significantly lower with increasing fracture severity according to the Sanders and Zwipp classifications, bilateral fractures, open fractures, and with work-related injuries. With less invasive fixation using a calcaneal nail, superficial wound edge necrosis was seen in 2 of 75 cases (2.7%).

Major complications of tibial tuberosity advancement in 1613 dogs.

PubMed

Costa, Mario; Craig, Diane; Cambridge, Tony; Sebestyen, Peter; Su, Yuhua; Fahie, Maria A

2017-05-01

To report major postoperative complications in 1613 dogs with tibial tuberosity advancement (TTA). Retrospective case series. Dogs (n = 1613) with cranial cruciate ligament deficiency treated with TTA. Medical records of TTAs performed between December 2007-2013 were reviewed for age, sex, weight, contralateral stifle surgery, surgical approach, duration of preoperative lameness, presence of meniscal damage, concurrent patellar luxation and simultaneous bilateral TTA. Major postoperative complications were defined as surgical site infection (SSI) (superficial, deep, or organ/space), implant failure, fracture, patellar luxation, and meniscal tear. Major complications were recorded in 13.4% of cases. Superficial SSI (incisional irritation) was diagnosed in 6.9% cases, requiring only antimicrobial therapy. Other complications included postliminary medial meniscal tear (2% incidence), deep SSI (incisional dehiscence, 1.1%), implant failure (1%), patellar luxation (1.2%), fracture (0.9%), and organ/space SSI (septic arthritis, 0.4%). Dogs with normal menisci were less likely to develop postliminary meniscal tears if the medial meniscus was released at the time of TTA (P < .0001). No association was detected between recorded parameters and complications, although dogs >8 years old approached significance (P = .05) in terms of predisposition to major complications. Major complications after TTA are uncommon, even in dogs with concurrent patellar luxation or bilateral simultaneous procedures. In spite of its morbidity, medial meniscal release may prevent postliminary meniscal tears. © 2017 The American College of Veterinary Surgeons.

Common extensor origin release in recalcitrant lateral epicondylitis - role justified?

PubMed Central

2010-01-01

The aim of our study was to analyse the efficacy of operative management in recalcitrant lateral epicondylitis of elbow. Forty patients included in this study were referred by general practitioners with a diagnosis of tennis elbow to the orthopaedic department at a district general hospital over a five year period. All had two or more steroid injections at the tender spot, without permanent relief of pain. All subsequently underwent simple fasciotomy of the extensor origin. Of forty patients thirty five had improvement in pain and function, two had persistent symptoms and three did not perceive any improvement. Twenty five had excellent, ten had well, two had fair and three had poor outcomes (recurrent problem; pain at rest and night). Two patients underwent revision surgery. Majority of the patients had improvement in pain and function following operative treatment. In this study, an extensor fasciotomy was demonstrated to be an effective treatment for refractory chronic lateral epicondylitis; however, further studies are warranted. PMID:20459701

Chronic shin splints. Classification and management of medial tibial stress syndrome.

PubMed

Detmer, D E

1986-01-01

A clinical classification and treatment programme has been developed for chronic medial tibial stress syndrome. Medial tibial stress syndrome has been reported to be either tibial stress fracture or microfracture, tibial periostitis, or distal deep posterior chronic compartment syndrome. Three chronic types exist and may coexist: Type I (tibial microfracture, bone stress reaction or cortical fracture); type II (periostalgia from chronic avulsion of the periosteum at the periosteal-fascial junction); and type III (chronic compartment syndrome syndrome). Type I disease is treated nonoperatively. Operations for resistant types II and III medial tibial stress syndrome were performed in 41 patients. Bilaterality was common (type II, 50% type III, 88%). Seven had coexistent type II/III; one had type I/II. Preoperative symptoms averaged 24 months in type II, 6 months in type III, and 33 months in types II/III. Mean age was 22 years (15 to 51). Resting compartment pressures were normal in type II (mean 12 mm Hg) and elevated in type III and type II/III (mean 23 mm Hg). Type II and type II/III patients received fasciotomy plus periosteal cauterisation. Type III patients had fasciotomy only. All procedures were performed on an outpatient basis using local anaesthesia. Follow up was complete and averaged 6 months (2 to 14 months). Improved performance was as follows: type II, 93%, type III, 100%; type II/III, 86%. Complete cures were as follows: type II, 78%; type III, 75%; and type II/III, 57%. This experience suggests that with precise diagnosis and treatment involving minimal risk and cost the athlete has a reasonable chance of return to full activity.

Is fibular fracture displacement consistent with tibiotalar displacement?

PubMed

van den Bekerom, Michel P J; van Dijk, C Niek

2010-04-01

We believed open reduction with internal fixation is required for supination-external rotation ankle fractures located at the level of the distal tibiofibular syndesmosis (Lauge-Hanssen SER II and Weber B) with 2 mm or more fibular fracture displacement. The rationale for surgery for these ankle fractures is based on the notion of elevated intraarticular contact pressures with lateral displacement. To diagnose these injuries, we presumed that in patients with a fibular fracture with at least 2 mm fracture displacement, the lateral malleolus and talus have moved at least 2 mm in a lateral direction without medial displacement of the proximal fibula. We reviewed 55 adult patients treated operatively for a supination-external rotation II ankle fracture (2 mm or more fibular fracture displacement) between 1990 and 1998. On standard radiographs, distance from the tibia to the proximal fibula, distance from the tibia to the distal fibula, and displacement at the level of the fibular fracture were measured. These distances were compared preoperatively and postoperatively. We concluded tibiotalar displacement cannot be reliably assessed at the level of the fracture. Based on this and other studies, we believe there is little evidence to perform open reduction and internal fixation of supination-external rotation II ankle fractures. Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Tibial Stress Injuries: Decisive Diagnosis and Treatment of "Shin Splints."

ERIC Educational Resources Information Center

Couture, Christopher J.; Karlson, Kristine A.

2002-01-01

Tibial stress injuries, commonly called shin splints, often result when bone remodeling processes adopt inadequately to repetitive stress. Physicians who are caring for athletic patients must have a thorough understanding of this continuum of injuries, including medial tibial stress syndrome and tibial stress fractures, because there are…

The Thrower's Elbow: Arthroscopic Treatment of Valgus Extension Overload Syndrome

PubMed Central

Altchek, David W.

2006-01-01

Injury to the medial collateral ligament of the elbow (MCL) can be a career-threatening injury for an overhead athlete without appropriate diagnosis and treatment. It has been considered separately from other athletic injuries due to the unique constellation of pathology that results from repetitive overhead throwing. The past decade has witnessed tremendous gains in understanding of the complex interplay between the dynamic and static stabilizers of the athlete's elbow. Likewise, the necessity to treat these problems in a minimally invasive manner has driven the development of sophisticated techniques and instrumentation for elbow arthroscopy. MCL injuries, ulnar neuritis, valgus extension overload with osteophyte formation and posteromedial impingement, flexor pronator strain, medial epicondyle pathology, and osteochondritis dissecans (OCD) of the capitellum have all been described as sequelae of the overhead throwing motion. In addition, loose body formation, bony spur formation, and capsular contracture can all be present in conjunction with these problems or as isolated entities. Not all pathology in the thrower's elbow is amenable to arthroscopic treatment; however, the clinician must be familiar with all of these problems in order to form a comprehensive differential diagnosis for an athlete presenting with elbow pain, and he or she must be comfortable with the variety of open and arthroscopic treatments available to best serve the patient. An understanding of the anatomy and biomechanics of the thrower's elbow is critical to the care of this population. The preoperative evaluation should focus on a thorough history and physical examination, as wellas on specific diagnostic imaging modalities. Arthroscopic setup, including anesthesia, patient positioning, and portal choices will be discussed. Operative techniques in the anterior and posterior compartments will bereviewed, as well as postoperative rehabilitationandsurgical results. Lastly, complications will be reviewed. PMID:18751853

Mandibular fracture patterns consistent with posterior maxillary fractures involving the posterior maxillary sinus, pterygoid plate or both: CT characteristics.

PubMed

Imai, T; Sukegawa, S; Kanno, T; Fujita, G; Yamamoto, N; Furuki, Y; Michizawa, M

2014-01-01

The aim of this study was to determine the incidence of posterior maxillary fractures involving the posterior maxillary sinus wall, pterygoid plate or both, unrelated to major midface fractures in patients with mandibular fractures, and to characterize associated fractures. A CT study was performed in patients with mandibular fractures to identify posterior maxillary fractures. Patients aged under 16 years, those with mandibular fractures involving only dentoalveolar components and those with concurrent major midfacial fractures were excluded. 13 (6.7%) of 194 patients with mandibular fractures also had posterior maxillary fractures (case group). The injury pattern correlated with the external force directed to the lateral side of the mandible (p < 0.001), alcohol consumption (p = 0.049), the presence of multifocal fractures (p = 0.002) and the fracture regions in the symphysis/parasymphysis (p = 0.001) and the angle/ramus (p = 0.001). No significant difference between the case and non-case groups was seen for age, sex or cause of trauma. Non-displaced fractures in the ipsilateral posterior mandible occurred with significant frequency (p = 0.001) when the posterior maxillary fractures involved only the sinus. Mandibular fractures accompanied by posterior maxillary fractures are not rare. The finding of a unilateral posterior maxillary fracture on CT may aid the efficient radiological examination of the mandible based on possible patterns of associated fractures, as follows: in the ipsilateral posterior region as a direct fracture when the impact is a medially directed force, and in the symphysis/parasymphysis or contralateral condylar neck as an indirect fracture.

Complications in the treatment of adolescent clavicle fractures.

PubMed

Luo, T David; Ashraf, Ali; Larson, A Noelle; Stans, Anthony A; Shaughnessy, William J; McIntosh, Amy L

2015-04-01

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). Copyright 2015, SLACK Incorporated.

Design and fuzzy logic control of an active wrist orthosis.

PubMed

Kilic, Ergin; Dogan, Erdi

2017-08-01

People who perform excessive wrist movements throughout the day because of their professions have a higher risk of developing lateral and medial epicondylitis. If proper precautions are not taken against these diseases, serious consequences such as job loss and early retirement can occur. In this study, the design and control of an active wrist orthosis that is mobile, powerful and lightweight is presented as a means to avoid the occurrence and/or for the treatment of repetitive strain injuries in an effective manner. The device has an electromyography-based control strategy so that the user's intention always comes first. In fact, the device-user interaction is mainly activated by the electromyography signals measured from the forearm muscles that are responsible for the extension and flexion wrist movements. Contractions of the muscles are detected using surface electromyography sensors, and the desired quantity of the velocity value of the wrist is extracted from a fuzzy logic controller. Then, the actuator system of the device comes into play by conveying the necessary motion support to the wrist. Experimental studies show that the presented device actually reduces the demand on the muscles involved in repetitive strain injuries while performing challenging daily life activities including extension and flexion wrist motions.

Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options.

PubMed

Matcuk, George R; Mahanty, Scott R; Skalski, Matthew R; Patel, Dakshesh B; White, Eric A; Gottsegen, Christopher J

2016-08-01

Stress fracture, in its most inclusive description, includes both fatigue and insufficiency fracture. Fatigue fractures, sometimes equated with the term "stress fractures," are most common in runners and other athletes and typically occur in the lower extremities. These fractures are the result of abnormal, cyclical loading on normal bone leading to local cortical resorption and fracture. Insufficiency fractures are common in elderly populations, secondary to osteoporosis, and are typically located in and around the pelvis. They are a result of normal or traumatic loading on abnormal bone. Subchondral insufficiency fractures of the hip or knee may cause acute pain that may present in the emergency setting. Medial tibial stress syndrome is a type of stress injury of the tibia related to activity and is a clinical syndrome encompassing a range of injuries from stress edema to frank-displaced fracture. Atypical subtrochanteric femoral fracture associated with long-term bisphosphonate therapy is also a recently discovered entity that needs early recognition to prevent progression to a complete fracture. Imaging recommendations for evaluation of stress fractures include initial plain radiographs followed, if necessary, by magnetic resonance imaging (MRI), which is preferred over computed tomography (CT) and bone scintigraphy. Radiographs are the first-line modality and may reveal linear sclerosis and periosteal reaction prior to the development of a frank fracture. MRI is highly sensitive with findings ranging from periosteal edema to bone marrow and intracortical signal abnormality. Additionally, a brief description of relevant clinical management of stress fractures is included.

Fixation of osteochondral fractures in rabbit knees. A comparison of Kirschner wires, fibrin sealant, and polydioxanone pins.

PubMed

Plaga, B R; Royster, R M; Donigian, A M; Wright, G B; Caskey, P M

1992-03-01

We compared fibrin sealant, polydioxanone (PDS) pins and Kirschner wires in the fixation of osteochondral fractures in rabbit knees. Standardised osteochondral fractures of the right medial femoral condyle were made in 56 adult New Zealand white rabbits. There were equal groups of control knees, and those which had Kirschner-wire, fibrin-sealant or PDS-pin fixation. No external immobilisation was used. One animal from each group was killed at two, three and four weeks. The remaining rabbits were killed at six weeks. A fracture which healed with less than 1 mm of displacement was considered a success. There was successful healing in 29% of the control group, in all of the Kirschner-wire group, in 50% of the fibrin-sealant group, and in 86% of the PDS-pin group. The use of PDS pins appears to be a reliable alternative to the use of metal in the fixation of osteochondral fractures in rabbits.

[Particular posteromedial and posterolateral approaches for the treatment of tibial head fractures].

PubMed

Lobenhoffer, P; Gerich, T; Bertram, T; Lattermann, C; Pohlemann, T; Tscheme, H

1997-12-01

Tibial plateau fractures with depression of posterior aspects of the proximal tibia cause significant therapeutic problems. Posterior fractures on the medial side are mainly highly instable fracture-dislocations (Moore type I). Posterolateral fractures usually cause massive depression and destruction of the chondral surface. Surgical exposure of these fractures from anterior requires major soft tissue dissection and has a significant complication rate. However, incomplete restoration of the joint surface results in chronic postero-inferior joint subluxation, osteoarthritis and pain. We present new specific approaches for posterior fracture types avoiding large skin incisions, but allowing for atraumatic exposure, reduction and fixation. Posteromedial fracture-dislocations are exposed by a direct posteromedial skin incision and a deep incision between medial collateral ligament and posterior oblique ligament. The posteromedial pillar and the posterior flare of the proximal tibia are visualized. The inferior extent of the joint fragment can be reduced by indirect techniques or direct manipulation of the fragment. Fixation is achieved with subchondral lag screws and an anti-glide plate at the tip of the fragment. Posterolateral fractures are exposed by a transfibular approach: the skin is incised laterally, the peroneal nerve is dissected free. The fibula neck is osteotomized, the tibiofibular syndesmosis is divided and the fibula neck is reflected upwards in one layer with the meniscotibial ligament and the iliotibial tract attachment. Reflexion of the fibula head relaxes the lateral collateral ligament, allows for lateral joint opening and internal rotation of the tibia and thus exposes the posterolateral and posterior aspect of the tibial plateau. Fixation and buttressing on the posterolateral side can be achieved easily with this approach. In closure, the fibula head is fixed back with a lag screw or a tension-band system. These two exposures can be combined in bicondylar posterior fracture situations. 168 cases with tibial plateau fractures had ORIF in the authors' institution from 1988 to 1994. 26 of these patients had a total of 29 posterior exposures to treat their fractures (9 posteromedial, 12 posterolateral, 3 combined posteromedial/posterolateral and 2 posterior/anterior exposures). No specific complications occurred related to these exposures, i.e. no skin slough, no infection, no nerve palsy. The mean duration of follow-up was 4 years. Twenty-one cases healed uneventfully: 12 were excellent in Rasmussen's clinical score, 8 were good and 1 was fair. Seven patients were excellent in the radiological score, 13 good and 1 fair. Five of the 26 cases had revision surgery: 3 patients developed valgus or retrocurvatum deformity and were successfully treated by an osteotomy. They obtained a good result at follow-up. Two fractures in elderly patients were revised to an endoprosthesis.

Tibial stress injuries: decisive diagnosis and treatment of 'shin splints'.

PubMed

Couture, Christopher J; Karlson, Kristine A

2002-06-01

Tibial stress injuries, commonly called 'shin splints,' often result when bone remodeling processes adapt inadequately to repetitive stress. Physicians who care for athletic patients need a thorough understanding of this continuum of injuries, including medial tibial stress syndrome and tibial stress fractures, because there are implications for appropriate diagnosis, management, and prevention.

Operative versus nonoperative treatment of unstable lateral malleolar fractures: a randomized multicenter trial.

PubMed

Sanders, David W; Tieszer, Christina; Corbett, Bradley

2012-03-01

To compare clinical and functional outcomes after operative and nonoperative treatment of undisplaced, unstable, isolated fibula fractures. Randomized multicenter clinical trial. Six level 1 trauma centers. Eighty-one patients with undisplaced, unstable, isolated fibula fractures as confirmed by an external rotation stress examination demonstrating an increase in medial clear space to 5 mm or greater were followed for 12 months after treatment. Forty-one patients were treated operatively by open reduction and internal fixation of the fibula. Forty patients underwent nonoperative treatment, which included the use of a short leg cast or brace and protected weight bearing for 6 weeks. Functional outcomes determined using the Olerud-Molander Ankle Score and the Short Form 36. Radiographic outcomes included measurement of union and displacement at each visit. There were no statistically significant differences in functional outcome scores or pace of recovery between the operative and nonoperative groups at any time interval (β = -0.28, 3.49; P = 0.936). Complications in the nonoperative group included 8 patients with a medial clear space ≥5 mm and 8 patients with delayed union or nonunion. In the operative group, 5 patients had a surgical site infection and 5 patients required hardware removal. Patients managed operatively had equivalent functional outcomes compared with nonoperative treatment; however, the risk of displacement and problems with union was substantially lower in patients managed with surgery.

[Operative treatment and curative effects of the deltoid ligament injuries of the ankle joint].

PubMed

Cong, Pei-Jun; Liu, Bai-Hong; Wang, Ji-Ping; Qiao, Yong-Ping

2009-12-01

To explore the operative methods and curative effects of the deltoid ligament injuries. From 2002 to 2008, all 61 patients with ankle fractures complicated with deltoid ligament injuries were treated with open reduction and firm internal fixation. Among the patients, 39 patients were male and 22 patients were female, ranging in age from 14 to 71 years, with an average of 41 years. During the operation, the deltoid ligament was reconstructed to restore the medial and lateral stability of ankle joint. All the patients were followed up ranged from 5 to 30 months, with an average of 17 months. Fifty-nine patients had incision healed at the first stage; 2 patients had superficial infections at lateral malleolus, and healed at the 3rd week after changing dressings. The incisions at the internal medial malleolus were all healed at the first stage. According to Qi evaluation criteria, 35 patients got an excellent result, 13 good and 13 fair. The deltoid ligament should be treated properly in the treatment of ankle joint fractures when open reduction and firm internal fixation were emphasized.

Analysis of anatomic periarticular tibial plate fit on normal adults.

PubMed

Goyal, Kanu S; Skalak, Anthony S; Marcus, Randall E; Vallier, Heather A; Cooperman, Daniel R

2007-08-01

Implant manufacturers are producing anatomically contoured periarticular plates to improve the treatment of proximal tibia fractures. We assessed the accuracy of the designation anatomic. We applied eight-hole medial and lateral anatomically contoured periarticular plates to 101 cadaveric tibiae. The tibiae and the plate fits were mapped, quantified, and analyzed using a MicroScribe G2LX digitizer, Rhinoceros software, and MATLAB software. By corresponding the clinical appearance of good fit with our digital findings, we created numerical criteria for plate fit in three planes: coronal (volume of free space between the plate and bone), sagittal (alignment with the tibial plateau and shaft), and axial (match in curvature between the proximal horizontal part of the plate and the tibial plateau). An anatomic fit should mirror the shape of the tibia in all three planes, and only four medial and four lateral plate fits qualified. Recognizing and understanding the substantial variations in fit that exist between anatomically contoured plates and the tibia may help lead to a more stable fixation and prevent malreduction of the fracture and/or soft tissue impingement.

Extracorporeal shock wave therapy without local anesthesia for chronic lateral epicondylitis.

PubMed

Pettrone, Frank A; McCall, Brian R

2005-06-01

The use of extracorporeal shock wave therapy for the treatment of lateral epicondylitis is controversial. The purpose of this study was to evaluate the use of extracorporeal shock wave therapy without local anesthesia to treat chronic lateral epicondylitis. One hundred and fourteen patients with a minimum six-month history of lateral epicondylitis that was unresponsive to conventional therapy were randomized into double-blind active treatment and placebo groups. The protocol consisted of three weekly treatments of either low-dose shock wave therapy without anesthetic or a sham treatment. Patients had a physical examination, including provocation testing and dynamometry, at one, four, eight, and twelve weeks and at six and twelve months after treatment. Radiographs, laboratory studies, and electrocardiograms were also evaluated prior to participation and at twelve weeks. A visual analog scale was used to evaluate pain, and an upper extremity functional scale was used to assess function. Crossover to active treatment was initiated for nonresponsive patients who had received the placebo and met the inclusion criteria after twelve weeks. A total of 108 of the 114 randomized patients completed all treatments and the twelve weeks of follow-up required by the protocol. Sixty-one patients completed one year of follow-up, whereas thirty-four patients crossed over to receive active treatment. A significant difference (p = 0.001) in pain reduction was observed at twelve weeks in the intent-to-treat cohort, with an improvement in the pain score of at least 50% seen in 61% (thirty-four) of the fifty-six patients in the active treatment group who were treated according to protocol compared with 29% (seventeen) of the fifty-eight subjects in the placebo group. This improvement persisted in those followed to one year. Functional activity scores, activity-specific evaluation, and the overall impression of the disease state all showed significant improvement as well (p < 0.05). Crossover patients also showed significant improvement after twelve weeks of active treatment, with 56% (nineteen of thirty-four) achieving an improvement in the pain score of at least 50% (p < 0.0001). These results demonstrate that low-dose shock wave therapy without anesthetic is a safe and effective treatment for chronic lateral epicondylitis.

Comparison of the effects of sodium hyaluronate-chondroitin sulphate and corticosteroid in the treatment of lateral epicondylitis: a prospective randomized trial.

PubMed

Tosun, Haci Bayram; Gumustas, Seyitali; Agir, Ismail; Uludag, Abuzer; Serbest, Sancar; Pepele, Demet; Ertem, Kadir

2015-09-01

Hyaluronic acid and glycosaminoglycans have shown positive effects in improving lateral epicondylitis and other tendinosis conditions. Therefore, we designed a prospective, randomized study to compare the effects of a combined sodium hyaluronate and chondroitin sulfate (HA + CS) injection versus a triamcinolone injection in the treatment of lateral epicondylitis. In total, 57 consecutive patients with clinically diagnosed lateral epicondylitis were divided randomly into two groups. In the HA + CS group, 25 patients received a single injection of a solution containing an HA + CS combination and prilocaine HCl, while the 32 patients in the triamcinolone group received a single injection of a solution of triamcinolone and prilocaine HCl. We evaluated the pain and function outcome measures using the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire at the beginning of the study, and 3 and 6 months after the injection. Additionally, the Minimum Clinically Important Difference values and percentage changes in the PRTEE subscale scores between the assessments were calculated. No serious adverse events were reported throughout the study. The mean pain and function scores for the HA + CS and triamcinolone groups had significantly improved at 3 months, but the mean function scores in the HA + CS group were statistically significantly better when compared to the triamcinolone group. At 6 months, both groups had significantly improved mean pain and function scores, compared to the baseline scores; however, the mean pain and function scores in the 6-month HA + CS treatment group were better than in the 6-month triamcinolone group. The relative change for the mean total score in the HA + CS group was much better when compared with the triamcinolone group, and the HA + CS treatment group showed clinically significant improvement when compared with triamcinolone group at 3 and 6 months. This study supports the idea that for a single injection treatment of patients with lateral epicondylitis, a combination injection of HA + CS may offer better pain benefits for 6 months after injection, when compared to triamcinolone. Level II, Randomized Clinical Trial, Prospective Comparative Study.

Decision Making in the Management of Extracapsular Fractures of the Proximal Femur – is the Dynamic Hip Screw the Prevailing Gold Standard?

PubMed Central

Jacob, Joshua; Desai, Ankit; Trompeter, Alex

2017-01-01

Currently, approximately half of all hip fractures are extracapsular, with an incidence as high as 50 in 100,000 in some countries. The common classification systems fail to explain the logistics of fracture classification and whether they all behave in the same manner. The Muller AO classification system is a useful platform to delineate stable and unstable fractures. The Dynamic hip screw (DHS) however, has remained the ‘gold standard’ implant of choice for application in all extracapsular fractures. The DHS relies on the integrity and strength of the lateral femoral wall as well as the postero-medial fragment. An analysis of several studies indicates significant improvements in design and techniques to ensure a better outcome with intramedullary nails. This article reviews the historical trends that helped to evolve the DHS implant as well as discussing if the surgeon should remain content with this implant. We suggest that the gold standard surgical management of extracapsular fractures can, and should, evolve. PMID:29290858

Management of Chronic Lateral Epicondylitis With Manual Therapy and Local Cryostimulation: A Pilot Study.

PubMed

Richer, Nadia; Marchand, Andrée-Anne; Descarreaux, Martin

2017-12-01

The purpose of this pilot study was to evaluate the feasibility and efficacy of adding cryostimulation to manual therapy in patients with chronic lateral epicondylitis. The control group (n = 19) was treated with manual therapy consisting of soft-tissue therapy and radial head mobilizations. The experimental group (n = 18) received cryostimulation in addition to manual therapy care similar to that for the control group. Both protocols consisted of 8 treatments over a 4-week period. Outcome measures included pain intensity (visual analog scale), pain-free grip strength (handheld dynamometer), and functional index (Patient-Rated Tennis Elbow Evaluation questionnaire). Assessments were performed at baseline, postintervention, and 3-month follow-up. Adherence and dropout rates were also considered. Both groups exhibited significant improvements in pain intensity and functional index at postintervention assessments, which were maintained at follow-up. All participants attended the prescribed number of treatments, but 27% were lost at follow-up. Minor adverse events were reported after cryostimulation in 4 cases. This study indicated that it is feasible to complete a clinical trial evaluating the efficacy of adding cryostimulation to manual therapy in patients with chronic lateral epicondylitis. On the basis of these preliminary data, the combination of cryostimulation and manual therapy care did not provide any additional benefits in both the short term and the long term. Manual myofascial point treatment and mobilization techniques yielded positive outcomes in chronic lateral epicondylitis. Further studies should focus on the sole therapeutic effect of cryostimulation in both patients with acute and those with chronic conditions.

The reverse Segond fracture: not associated with knee dislocation and rarely with posterior cruciate ligament tear.

PubMed

Peltola, Erno K; Lindahl, Jan; Koskinen, Seppo K

2014-06-01

The aims of this study were to assess the incidence of reverse Segond fracture, to examine the associated ligamentous injuries, and to examine how often reverse Segond fracture coexists with a knee dislocation. At a level 1 trauma center, an 11-year period of emergency department multidetector-row computed tomography (MDCT) examinations for knee trauma was evaluated for reverse Segond and Segond fractures. Surgical findings served as the reference standard for intra-articular injuries. The hospital discharge register was searched for the diagnosis of knee dislocation from August 2000 through the end of August 2011. A total of 1,553 knee MDCT examinations were evaluated. Ten patients with a reverse Segond fracture were found, comprising 0.64 % of emergency room acute knee trauma MDCT examinations. Seven patients who had a reverse Segond fracture were operated: Three had an avulsion fracture of the anterior cruciate ligament, one had an avulsion fracture of posterior cruciate ligament, two had a lateral meniscal tear, and two had a medial collateral ligament tear. The ratio of reverse Segond fractures to Segond fractures was 1:4. None of the 71 knee dislocation patients had a reverse Segond fracture. Reverse Segond fracture is a rare finding even in a level 1 trauma center. Cruciate ligament injuries appear to be associated with avulsion fracture, but every patient does not have PCL injury, as previously reported. Our results do not support the association of knee dislocation with reverse Segond fracture.

Does a positive ankle stress test indicate the need for operative treatment after lateral malleolus fracture? A preliminary report.

PubMed

Koval, Kenneth J; Egol, Kenneth A; Cheung, Yvonne; Goodwin, Douglass W; Spratt, Kevin F

2007-08-01

At our institution, a standardized protocol using magnetic resonance imaging (MRI) to evaluate ankle stability and need for surgery following a positive manual stress test for isolated lateral malleolus fractures has been used. The purpose of this study was to evaluate the results using this standardized protocol. Retrospective review. University teaching hospital. : Twenty-one patients who had a positive ankle stress test (>or=5 mm clear space widening) after isolated Weber B lateral malleolus fracture were further evaluated by MRI to determine the status of the deep deltoid ligament. If the MRI showed the deltoid ligament was completely disrupted, the patient was advised to have operative ankle repair. However, if the MRI demonstrated that the deep deltoid was intact or only partially disrupted, the patient was treated nonoperatively in a walking boot with weightbearing as tolerated ambulation. Patients were followed until fracture union and contacted at 12-month minimum follow-up to determine outcomes by radiographic evaluation, health related quality of life (HRQOL) based on Short Form (SF)-36 results and functional outcomes based on the American Orthopaedic Foot and Ankle (AOFAS) and patient report of treatment satisfaction. Twenty-one patients had an MRI after a positive ankle stress test and comprised the study group. There were 12 men and 9 women with an average age of 27 years (range, 16-62 years). Absolute medial clear space measurement on stress testing ranged from 5 to 8 mm. In all, 19 of 21 patients (90%) had evidence of partially torn deep deltoid ligament on MRI and were treated nonoperatively, whereas two patients had MRI findings of a complete deep deltoid injury and underwent surgical treatment. There were no statistically significant correlations between the medial clear space measurements and MRI documentation of complete deltoid ligament rupture. All fractures united without evidence of residual medial clear space widening or posttraumatic joint space narrowing. Of the 15 patients who were available for 1 year minimum follow-up and agreed to come back for clinical and radiographic evaluation, 14 had an AOFAS score of 100, with the remaining patient having a score of 85. HRQOL based on SF-36 results indicated all patients were above or at normal levels, and all patients reported that they were satisfied with their treatment; 93% (14/15) indicated that they would make the same treatment decision again. Using our protocol, we were able to identify and provide effective nonoperative care to 19 patients who otherwise might have underwent operative treatment after an isolated lateral malleolus fracture. Further work is needed to identify the subset of patients who could be treated nonoperatively without a need for MRI scanning.

Mandibular fracture patterns consistent with posterior maxillary fractures involving the posterior maxillary sinus, pterygoid plate or both: CT characteristics

PubMed Central

Sukegawa, S; Kanno, T; Fujita, G; Yamamoto, N; Furuki, Y; Michizawa, M

2014-01-01

Objectives: The aim of this study was to determine the incidence of posterior maxillary fractures involving the posterior maxillary sinus wall, pterygoid plate or both, unrelated to major midface fractures in patients with mandibular fractures, and to characterize associated fractures. Methods: A CT study was performed in patients with mandibular fractures to identify posterior maxillary fractures. Patients aged under 16 years, those with mandibular fractures involving only dentoalveolar components and those with concurrent major midfacial fractures were excluded. Results: 13 (6.7%) of 194 patients with mandibular fractures also had posterior maxillary fractures (case group). The injury pattern correlated with the external force directed to the lateral side of the mandible (p < 0.001), alcohol consumption (p = 0.049), the presence of multifocal fractures (p = 0.002) and the fracture regions in the symphysis/parasymphysis (p = 0.001) and the angle/ramus (p = 0.001). No significant difference between the case and non-case groups was seen for age, sex or cause of trauma. Non-displaced fractures in the ipsilateral posterior mandible occurred with significant frequency (p = 0.001) when the posterior maxillary fractures involved only the sinus. Conclusions: Mandibular fractures accompanied by posterior maxillary fractures are not rare. The finding of a unilateral posterior maxillary fracture on CT may aid the efficient radiological examination of the mandible based on possible patterns of associated fractures, as follows: in the ipsilateral posterior region as a direct fracture when the impact is a medially directed force, and in the symphysis/parasymphysis or contralateral condylar neck as an indirect fracture. PMID:24336313

[External stability of the elbow after surgical treatment of epicondylitis. Presentation of a case].

PubMed

Llop-Corbacho, A; Romero-Ruiz, J; Denia-Alarcón, N

2014-01-01

Elbow instability is a difficult to diagnose condition in certain cases, and could lead to some problems that limit daily functioning, such as joint blocks, bumps, projections, muscle weakness, and persistent pain. A case is presented of a patient with a clinical picture of epicondylitis, with a previous history of a fall on the affected arm. As there was no improvement after performing conventional non-aggressive treatment, surgery was performed on the affected tendon. The outcome of this was persistent pain and clinical instability of the elbow that ended up requiring surgery to reconstruct the ligament over the external complex. In follow-up 6 months after the operation, the clinical instability had disappeared, but there was still external discomfort and a 30° extension deficit. When faced with a picture of epicondylitis with a previous injury that does not respond to conventional therapies, it is important to take into account the possibility of an underlying elbow instability, ruling this out with a correct physical examination and, where necessary, with the appropriate complementary tests. Copyright © 2013 SECOT. Published by Elsevier Espana. All rights reserved.

Increased plantar force and impulse in American football players with high arch compared to normal arch

PubMed Central

Carson, Daniel W.; Myer, Gregory D.; Hewett, Timothy E.; Heidt, Robert S.; Ford, Kevin R.

2014-01-01

Background Risk of overuse injury among athletes is high due in part to repeated loading of the lower extremities. Compared to individuals with normal arch (NA) structure, those with high (HA) or low arch (LA) may be at increased risk of specific overuse injuries, including stress fractures. A high medial longitudinal arch may result in decreased shock absorbing properties due to increased rigidity in foot mechanics. While the effect of arch structure on dynamic function has been examined in straight line walking and running, the relationship between the two during multi-directional movements remains unstudied. Objective The purpose of this study was to determine if differences in plantar loading in football players occur during both walking and pivoting movements. Method Plantar loading was examined in 9 regions of the foot for 26 participants (16 NA, 10 HA). Results High arch athletes demonstrated increased maximum force in the lateral rear foot and medial forefoot, and force time integral in the medial forefoot while walking. HA athletes also demonstrated increased maximum force in the medial rear foot and medial and central forefoot during rapid pivoting. Conclusions The current findings demonstrate that loading patterns differ between football players with high and normal arch structure, which could possibly influence injury risk in this population. PMID:23141809

Complications after pinning of supracondylar distal humerus fractures.

PubMed

Bashyal, Ravi K; Chu, Jennifer Y; Schoenecker, Perry L; Dobbs, Matthew B; Luhmann, Scott J; Gordon, J Eric

2009-01-01

Supracondylar distal humerus fractures are one of the most common skeletal injuries in children. The current treatment of choice in North America is closed reduction and percutaneous pin fixation. Often surgeons leave the pins exposed beneath a cast but outside the skin. Great variation exists with respect to preoperative skin preparation, and perioperative antibiotic administration. Few data exist regarding the rate of infection and other complications. The purpose of this study is to review a large series of children to evaluate the rate of infection and other complications. A retrospective review was carried out of all patients treated at our institution over an 11-year period. A total of 622 patients were identified that were followed for a minimum of 2 weeks after pin removal. Seventeen patients had flexion-type fractures, 294 had type II fractures, and 311 had type III fractures. Seventy-four fractures (11.9%) had preoperative nerve deficits with anterior interosseous palsies being the most common (33 fractures, 5.3%). Preoperative antibiotics were given to 163 patients (26.2%). Spray and towel draping were used in 362 patients, paint and towel draping were used in 65 patients, alcohol paint and towel draping were used in 146 patients, and a full preparation and draping were used in 13 patients. The pins were left exposed under the cast in 591 fractures (95%), and buried beneath the skin in 31 fractures (5.0%). A medial pin was placed in 311 fractures with a small incision made to aid placement in 18 of these cases. The most common complication was pin migration necessitating unexpected return to the operating room for pin removal in 11 patients (1.8%). One patient developed a deep infection with septic arthritis and osteomyelitis (0.2%). Five additional patients had superficial skin infections and were treated with oral antibiotics for a total infection rate of 6 of 622 patients (1.0%). One patient ultimately had a malunion and 4 others returned to the operating room for repeat reduction and pinning. Three patients developed compartment syndromes. Ulnar nerve injury was rare with only 1 postoperative ulnar nerve injury occurring in 311 patients treated with a medial pin (0.3%). Closed reduction with percutaneous pinning is effective and has a low complication rate with a very low rate of infection even when simple betadine preparation and towel draping are used. Preoperative antibiotics seem to have little effect on infection rate. Level III retrospective comparative study.

The anatomy of the palpebral branch of the infraorbital artery relating to midface lift.

PubMed

Hwang, Kun; Kim, Dong Hyun; Huan, Fan; Nam, Yong Seok; Han, Seung Ho

2011-07-01

The aim of this study was to elucidate a branch of the infraorbital artery (IOA) crossing the arcus marginalis into the orbit that might be vulnerable during a procedure of midface lift or fat sliding or a transposition in lower blepharoplasty.Eleven orbits of 6 Korean cadavers were dissected after injecting red latex into the external carotid artery. The IOA and nerve were identified. A branch of the IOA running upward was traced. In 28 cases of blow-out fracture, a branch of the IOA crossing the arcus marginalis into the orbit was identified, and the location was measured from each medial and lateral canthus.The palpebral branch of the IOA (PIOA) emerged from the infraorbital foramen and ran superior and lateral to the orbital septum. After passing through the orbital septum near the arcus marginalis, PIOA was distributed to the orbital fat. The palpebral branch of the IOA was identified in 21 (75.0%) of 28 fractured orbits. Twenty orbits had 1 PIOA, and 1 orbit had 2 PIOAs. The location of PIOA from the medial canthus (49.0%) was approximately half of the eye width in average. Most of the PIOAs (91%, 20 of 22 arteries found) were included in the range of 40% to 80% of the eye width from the medial canthus.Knowledge of the anatomic course of the PIOA crossing the arcus marginalis is conducive to cauterizing the vessels, as needed, in the subciliary or transconjunctival approach for lower blepharoplasty.

Fracture mechanics of shear crack propagation and dissection in the healthy bovine descending aortic media.

PubMed

Haslach, Henry W; Siddiqui, Ahmed; Weerasooriya, Amanda; Nguyen, Ryan; Roshgadol, Jacob; Monforte, Noel; McMahon, Eileen

2018-03-01

This experimental study adopts a fracture mechanics strategy to investigate the mechanical cause of aortic dissection. Inflation of excised healthy bovine aortic rings with a cut longitudinal notch that extends into the media from the intima suggests that an intimal tear may propagate a nearly circumferential-longitudinal rupture surface that is similar to the delamination that occurs in aortic dissection. Radial and 45°-from-radial cut notch orientations, as seen in the thickness surface, produce similar circumferential crack propagation morphologies. Partial cut notches, whose longitudinal length is half the width of the ring, measure the influence of longitudinal material on crack propagation. Such specimens also produce circumferential cracks from the notch root that are visible in the thickness circumferential-radial plane, and often propagate a secondary crack from the base of the notch, visible in the intimal circumferential-longitudinal plane. Inflation of rings with pairs of cut notches demonstrates that a second notch modifies the propagation created in a specimen with a single notch. The circumferential crack propagation is likely a consequence of the laminar medial structure. These fracture surfaces are probably due to non-uniform circumferential shear deformation in the heterogeneous media as the aortic wall expands. The qualitative deformation morphology around the root of the cut notch during inflation is evidence for such shear deformation. The shear apparently results from relative slip in the circumferential direction of collagen fibers. The slip may produce shear in the longitudinal-circumferential plane between medial layers or in the radial-circumferential plane within a medial lamina in an idealized model. Circumferential crack propagation in the media is then a shear mechanical process that might be facilitated by disease of the tissue. An intimal tear of an apparently healthy aortic wall near the aortic arch is life-threatening because it may lead to full rupture or to wall dissection in which delamination of the medial layer extends around most of the aortic circumference. The mechanical events underlying dissection are not definitively established. This experimental fracture mechanics study provides evidence that shear rupture is the main mechanical process underlying aortic dissection. The commonly performed tensile strength tests of aortic tissue are not clinically useful to predict or describe aortic dissection. One implication of the study is that shear tests might produce more fruitful simple assessments of the aortic wall strength. A clinical implication is that when presented with an intimal tear, those who guide care might recommend steps to reduce the shear load on the aorta. Copyright © 2017 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.

The second fracture of the same clavicle: prevalence and fracture configurations.

PubMed

Asavamongkolkul, Apichat; Harnroongroj, Thos; Suteeraporn, Wuttipon; Sudjai, Narumol; Harnroongroj, Thossart

2012-12-01

To study second fracture at the same clavicle including prevalence, fracture configurations related to malunion types of the first fracture, and healing. Between 2008 and 2011, the authors reviewed medical records and radiographs of the clavicles of patients who sustained acute clavicular fractures from motorcycle accident. Second fracture at the same clavicle and prevalence were studied. Malunion of the first fracture of the same clavicle were typed and configurations of the second fracture at the same clavicles were described related to type of the malunion. There were 552 clavicular fractures. Four cases of which sustained a second fracture at the same clavicles. Malunion of the first clavicular fracture of the four cases were typed: type I, extension, type II, flexion, and type III, bayonet. There were one, two, and one case of second clavicular fractures of the type I, II, and III clavicular malunion. The configuration of second clavicular fracture of the type I malunion clavicle is located at lateral fragment, inferior displacement, and dorsal angulation with dorsal cortex conminution. The type II malunion clavicle is located at lateral fragment with minimal displacement. For the type III malunion clavicle, the second fracture is located at medial fragment with mild inferior displacement and inferior angulation. The four cases of the second fractures of the same clavicles healed within two months without complication. The prevalence of second fracture at the same clacicles was 7.2:1000. The three types of the first fracture malunion were extension, flexion, and bayonet. The configuration of the second fracture at the same clavicles depends on malunion types of the first clavicular fracture. They healed without complication.

Acupuncture for lateral epicondylitis (tennis elbow): study protocol for a randomized, practitioner-assessor blinded, controlled pilot clinical trial.

PubMed

Shin, Kyung-Min; Kim, Joo-Hee; Lee, Seunghoon; Shin, Mi-Suk; Kim, Tae-Hun; Park, Hyo-Ju; Lee, Min-Hee; Hong, Kwon-Eui; Lee, Seungdeok; Choi, Sun-Mi

2013-06-14

Lateral epicondylitis is the most frequent cause of pain around the elbow joint. It causes pain in the region of the elbow joint and results in dysfunction of the elbow and deterioration of the quality of life. The purpose of this study is to compare the effects of ipsilateral acupuncture, contralateral acupuncture and sham acupuncture on lateral epicondylitis. Forty-five subjects with lateral epicondylitis will be randomized into three groups: the ipsilateral acupuncture group, contralateral acupuncture group and the sham acupuncture group. The inclusion criteria will be as follows: (1) age between 19 and 65 years with pain due to one-sided lateral epicondylitis that persisted for at least four weeks, (2) with tenderness on pressure limited to regions around the elbow joint, (3) complaining of pain during resistive extension of the middle finger or the wrist, (4) with average pain of NRS 4 or higher during the last one week at a screening visit and (5) voluntarily agree to this study and sign a written consent. Acupuncture treatment will be given 10 times in total for 4 weeks to all groups. Follow up observations will be conducted after the completion of the treatment, 8 weeks and 12 weeks after the random assignment. Ipsilateral acupuncture group and contralateral acupuncture group will receive acupuncture on LI4, TE5, LI10, LI11, LU5, LI12 and two Ashi points. The sham acupuncture group will receive treatment on acupuncture points not related to the lateral epicondylitis using a non-invasive method. The needles will be maintained for 20 minutes. The primary outcome will be differences in the visual analogue scale (VAS) for elbow pain between the groups. The secondary outcome will be differences in patient-rated tennis elbow evaluation (PRTEE), pain-free/maximum grip strength (Dynamometer), pressure pain threshold, clinically relevant improvement, patient global assessment, and the EQ-5D. The data will be analyzed with the paired t-test and ANCOVA (P <0.05). The results of this study will allow evaluation of contralateral acupuncture from two aspects. First, if the contralateral acupuncture shows the effects similar to ipsilateral acupuncture, this will establish clinical basis for contralateral acupuncture. Second, if the effects of contralateral acupuncture are not comparable to the effects of ipsilateral acupuncture, but are shown to be similar to the effects of the sham acupuncture, we can establish the basis for using the same acupoints of the unaffected side as a control in acupuncture clinical studies. This trial has been registered with the 'Clinical Research Information Service (CRIS)', Republic of Korea: KCT0000628.

Acupuncture for lateral epicondylitis (tennis elbow): study protocol for a randomized, practitioner-assessor blinded, controlled pilot clinical trial

PubMed Central

2013-01-01

Background Lateral epicondylitis is the most frequent cause of pain around the elbow joint. It causes pain in the region of the elbow joint and results in dysfunction of the elbow and deterioration of the quality of life. The purpose of this study is to compare the effects of ipsilateral acupuncture, contralateral acupuncture and sham acupuncture on lateral epicondylitis. Methods/design Forty-five subjects with lateral epicondylitis will be randomized into three groups: the ipsilateral acupuncture group, contralateral acupuncture group and the sham acupuncture group. The inclusion criteria will be as follows: (1) age between 19 and 65 years with pain due to one-sided lateral epicondylitis that persisted for at least four weeks, (2) with tenderness on pressure limited to regions around the elbow joint, (3) complaining of pain during resistive extension of the middle finger or the wrist, (4) with average pain of NRS 4 or higher during the last one week at a screening visit and (5) voluntarily agree to this study and sign a written consent. Acupuncture treatment will be given 10 times in total for 4 weeks to all groups. Follow up observations will be conducted after the completion of the treatment, 8 weeks and 12 weeks after the random assignment. Ipsilateral acupuncture group and contralateral acupuncture group will receive acupuncture on LI4, TE5, LI10, LI11, LU5, LI12 and two Ashi points. The sham acupuncture group will receive treatment on acupuncture points not related to the lateral epicondylitis using a non-invasive method. The needles will be maintained for 20 minutes. The primary outcome will be differences in the visual analogue scale (VAS) for elbow pain between the groups. The secondary outcome will be differences in patient-rated tennis elbow evaluation (PRTEE), pain-free/maximum grip strength (Dynamometer), pressure pain threshold, clinically relevant improvement, patient global assessment, and the EQ-5D. The data will be analyzed with the paired t-test and ANCOVA (P <0.05). Discussion The results of this study will allow evaluation of contralateral acupuncture from two aspects. First, if the contralateral acupuncture shows the effects similar to ipsilateral acupuncture, this will establish clinical basis for contralateral acupuncture. Second, if the effects of contralateral acupuncture are not comparable to the effects of ipsilateral acupuncture, but are shown to be similar to the effects of the sham acupuncture, we can establish the basis for using the same acupoints of the unaffected side as a control in acupuncture clinical studies. Trial registration This trial has been registered with the ‘Clinical Research Information Service (CRIS)’, Republic of Korea: KCT0000628. PMID:23768129

Clothing increases the risk of indirect ballistic fractures

PubMed Central

2013-01-01

Background Current literature has shown the mechanism of how indirect fractures occur but has not determined what factors increase the risks of such fractures. The objective of this study is thus to determine the effect of clothing and soft tissue thickness on the risk of indirect fracture formation. Methods Twenty-five fresh red deer femora embedded in ballistic gelatine were shot with varying distances off their medial cortex with a 5.56 × 45 mm North Atlantic Treaty Organization (NATO) bullet while being filmed with a slow-motion video. We compared the effect of two different gelatine depths and the effect of denim cloth laid onto the impact surface of the moulds. Results Bullet passage in thinner moulds failed to cause fracture because the bullet exited the mould before a large expanding temporary cavity was produced. Clothing dramatically altered the size and depth of the expanding cavity, as well as increased lateral pressures, resulting in more severe fractures with greater bullet distances from the bone that can cause fracture. Conclusions Clothing increases the risk of indirect fracture and results in larger, more superficial temporary cavities, with greater lateral pressures than are seen in unclothed specimens, resulting in more comminuted fractures. Greater tissue depth affords the 5.56 × 45 mm NATO a chance to yaw and thus develop an enlarging temporary cavity that is sufficient to cause fracture. PMID:24267379

Treatment of Medial Tibial Stress Syndrome With Radial Soundwave Therapy in Elite Athletes: Current Evidence, Report on Two Cases, and Proposed Treatment Regimen.

PubMed

Saxena, Amol; Fullem, Brian; Gerdesmeyer, Ludger

Two case reports of high-level athletes with medial tibial stress syndrome (MTSS), 1 an Olympian with an actual stress fracture, are presented. Successful treatment included radial soundwave therapy, pneumatic leg braces, relative rest using an antigravity treadmill, and temporary foot orthoses. Radial soundwave therapy has a high level of evidence for treatment of MTSS. We also present recent evidence of the value of vitamin D assessment. Both patients had a successful outcome with minimal downtime. Finally, a suggested treatment regimen for MTSS is presented. Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

Facial nerve injuries associated with the retromandibular transparotid approach for reduction and fixation of mandibular condyle fractures.

PubMed

Shi, Dan; Patil, Pavan Manohar; Gupta, Ritika

2015-04-01

To document facial nerve (FN) injuries after surgical treatment of mandibular condylar fractures using the retromandibular transparotid approach and to identify risk factors associated with these injuries. A retrospective study of patients surgically treated for mandibular condylar fractures using the retromandibular transparotid approach over seven years was conducted. The primary study variable was the postoperative change in FN function after fracture fixation. Risk factors were categorized as demographic, anatomic, experience of the operator, fracture displacement/dislocation and number of miniplates placed at the fracture site. Appropriate statistics were computed. Ninety patients with 102 fractures were analysed. Thirty two fractures (31%) were located in the condylar neck and 70 fractures (69%) were subcondylar (located below the sigmoid notch). The condylar segment was undisplaced in twelve cases (12%), displaced medially in thirty five (34%), laterally displaced in thirty (29%) and dislocated in 25 (24.5%). In 18 fractures (18%), postoperative examination revealed various degrees of damage to the FN. All nerve injuries recovered completely in 8-24 weeks. In a multivariate model, condylar neck fractures, fracture dislocation and operator inexperience were associated with a statistically significant risk of postoperative deterioration of FN function (P ≤ 0.05). The majority of facial nerve injuries after surgical treatment of condylar fractures by the retromandibular transparotid approach are transient in nature. Condylar neck fractures, fracture dislocation and operator inexperience were associated with an increased risk for FN injury. Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Bone microarchitecture of the tibial plateau in skeletal health and osteoporosis.

PubMed

Krause, Matthias; Hubert, Jan; Deymann, Simon; Hapfelmeier, Alexander; Wulff, Birgit; Petersik, Andreas; Püschel, Klaus; Amling, Michael; Hawellek, Thelonius; Frosch, Karl-Heinz

2018-05-07

Impaired bone structure poses a challenge for the treatment of osteoporotic tibial plateau fractures. As knowledge of region-specific structural bone alterations is a prerequisite to achieving successful long-term fixation, the aim of the current study was to characterize tibial plateau bone structure in patients with osteoporosis and the elderly. Histomorphometric parameters were assessed by high-resolution peripheral quantitative computed tomography (HR-pQCT) in 21 proximal tibiae from females with postmenopausal osteoporosis (mean age: 84.3 ± 4.9 years) and eight female healthy controls (45.5 ± 6.9 years). To visualize region-specific structural bony alterations with age, the bone mineral density (Hounsfield units) was additionally analyzed in 168 human proximal tibiae. Statistical analysis was based on evolutionary learning using globally optimal regression trees. Bone structure deterioration of the tibial plateau due to osteoporosis was region-specific. Compared to healthy controls (20.5 ± 4.7%) the greatest decrease in bone volume fraction was found in the medio-medial segments (9.2 ± 3.5%, p < 0.001). The lowest bone volume was found in central segments (tibial spine). Trabecular connectivity was severely reduced. Importantly, in the anterior and posterior 25% of the lateral and medial tibial plateaux, trabecular support and subchondral cortical bone thickness itself were also reduced. Thinning of subchondral cortical bone and marked bone loss in the anterior and posterior 25% of the tibial plateau should require special attention when osteoporotic patients require fracture fixation of the posterior segments. This knowledge may help to improve the long-term, fracture-specific fixation of complex tibial plateau fractures in osteoporosis. Copyright © 2018 Elsevier B.V. All rights reserved.

Plantar loading during cutting while wearing a rigid carbon fiber insert.

PubMed

Queen, Robin M; Abbey, Alicia N; Verma, Ravi; Butler, Robert J; Nunley, James A

2014-01-01

Stress fractures are one of the most common injuries in sports, accounting for approximately 10% of all overuse injuries. Treatment of fifth metatarsal stress fractures involves both surgical and nonsurgical interventions. Fifth metatarsal stress fractures are difficult to treat because of the risks of delayed union, nonunion, and recurrent injuries. Most of these injuries occur during agility tasks, such as those performed in soccer, basketball, and lacrosse. To examine the effect of a rigid carbon graphite footplate on plantar loading during 2 agility tasks. Crossover study. Laboratory. A total of 19 recreational male athletes with no history of lower extremity injury in the past 6 months and no previous metatarsal stress fractures were tested. Seven 45° side-cut and crossover-cut tasks were completed in a shoe with or without a full-length rigid carbon plate. Testing order between the shoe conditions and the 2 cutting tasks was randomized. Plantar-loading data were recorded using instrumented insoles. Peak pressure, maximum force, force-time integral, and contact area beneath the total foot, the medial and lateral midfoot, and the medial, middle, and lateral forefoot were analyzed. A series of paired t tests was used to examine differences between the footwear conditions (carbon graphite footplate, shod) for both cutting tasks independently (α = .05). During the side-cut task, the footplate increased total foot and lateral midfoot peak pressures while decreasing contact area and lateral midfoot force-time integral. During the crossover-cut task, the footplate increased total foot and lateral midfoot peak pressure and lateral forefoot force-time integral while decreasing total and lateral forefoot contact area. Although a rigid carbon graphite footplate altered some aspects of the plantar-pressure profile during cutting in uninjured participants, it was ineffective in reducing plantar loading beneath the fifth metatarsal.

Is Augmented LISS Plating Biomechanically Advantageous Over Conventional LISS Plating In Unstable Osteoporotic Distal Femoral Fractures?

PubMed

Todorov, Dimitar; Zderic, Ivan; Richards, R Geoff; Lenz, Mark; Knobe, Matthias; Enchev, Dian; Baltov, Asen; Gueorguiev, Boyko; Stoffel, Karl

2018-05-10

Treatment of complex osteoporotic distal femur fractures with the Less Invasive Stabilization System (LISS) has been associated with high complication rates. The aim of this study was to investigate the biomechanical competence of two different techniques of augmented versus conventional LISS plating. Unstable distal femoral fracture AO/OTA 33-A3 was created via osteotomies in artificial femora simulating osteoporotic bone. Three study groups, consisting of 10 specimens each, were created for instrumentation with either LISS plate, LISS plate with additional polylactide intramedullary graft, or LISS plate plus medial locking plate (double plating). All specimens were non-destructively tested under axial (20-150N) and torsional (0-4Nm) quasi-static loading. Each construct was tested with two different working length (WL) configurations (long and short) of the LISS plate. Relative movements between the most medial superior and inferior osteotomy aspects were investigated via three-dimensional motion tracking analysis. Double plating revealed significantly smaller longitudinal and shear displacement than the other two techniques (P≤0.001). In addition, LISS plus graft fixation was with significantly less longitudinal displacement in comparison to conventional LISS plating (P < 0.001). Long WL resulted in significantly higher longitudinal and shear displacement compared to short WL for LISS and LISS plus graft (P≤0.032), but not for double plating (P > 0.999). In conclusion, intramedullary grafting resulted in significantly increased fracture stability under axial loading in comparison to conventional LISS plating. Although it was not efficient enough to provide comparable stability to double plating, intramedullary grafting may be considered as a useful biological alternative to the latter in a surgeon's armamentarium. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

A pilot hole does not reduce the strains or risk of fracture to the lateral cortex during and following a medial opening wedge high tibial osteotomy in cadaveric specimens.

PubMed

Bujnowski, K; Getgood, A; Leitch, K; Farr, J; Dunning, C; Burkhart, T A

2018-02-01

It has been suggested that the use of a pilot-hole may reduce the risk of fracture to the lateral cortex. Therefore the purpose of this study was to determine the effect of a pilot hole on the strains and occurrence of fractures at the lateral cortex during the opening of a high tibial osteotomy (HTO) and post-surgery loading. A total of 14 cadaveric tibias were randomized to either a pilot hole (n = 7) or a no-hole (n = 7) condition. Lateral cortex strains were measured while the osteotomy was opened 9 mm and secured in place with a locking plate. The tibias were then subjected to an initial 800 N load that increased by 200 N every 5000 cycles, until failure or a maximum load of 2500 N. There was no significant difference in the strains on the lateral cortex during HTO opening between the pilot hole and no-hole conditions. Similarly, the lateral cortex and fixation plate strains were not significantly different during cyclic loading between the two conditions. Using a pilot hole did not significantly decrease the strains experienced at the lateral cortex, nor did it reduce the risk of fracture. The nonsignificant differences found here most likely occurred because the pilot hole merely translated the stress concentration laterally to a parallel point on the surface of the hole. Cite this article : K. Bujnowski, A. Getgood, K. Leitch, J. Farr, C. Dunning, T. A. Burkhart. A pilot hole does not reduce the strains or risk of fracture to the lateral cortex during and following a medial opening wedge high tibial osteotomy in cadaveric specimens. Bone Joint Res 2018;7:166-172. DOI: 10.1302/2046-3758.72.BJR-2017-0337.R1.

Anatomy and classification of the posterior tibial fragment in ankle fractures.

PubMed

Bartoníček, Jan; Rammelt, Stefan; Kostlivý, Karel; Vaněček, Václav; Klika, Daniel; Trešl, Ivo

2015-04-01

The aim of this study was to analyze the pathoanatomy of the posterior fragment on the basis of a comprehensive CT examination, including 3D reconstructions, in a large patient cohort. One hundred and forty one consecutive individuals with an ankle fracture or fracture-dislocation of types Weber B or Weber C and evidence of a posterior tibial fragment in standard radiographs were included in the study. The mean patient age was 49 years (range 19-83 years). The exclusion criteria were patients below 18 years of age, inability to provide written consent, fractures of the tibial pilon, posttraumatic arthritis and pre-existing deformities. In all patients, post-injury radiographs were obtained in anteroposterior, mortise and lateral views. All patients underwent CT scanning in transverse, sagittal and frontal planes. 3D CT reconstruction was performed in 91 patients. We were able to classify 137 cases into one of the following four types with constant pathoanatomic features: type 1: extraincisural fragment with an intact fibular notch, type 2: posterolateral fragment extending into the fibular notch, type 3: posteromedial two-part fragment involving the medial malleolus, type 4: large posterolateral triangular fragment. In the 4 cases it was not possible to classify the type of the posterior tibial fragment. These were collectively termed type 5 (irregular, osteoporotic fragments). It is impossible to assess the shape and size of the posterior malleolar fragment, involvement of the fibular notch, or the medial malleolus, on the basis of plain radiographs. The system that we propose for classification of fractures of the posterior malleolus is based on CT examination and takes into account the size, shape and location of the fragment, stability of the tibio-talar joint and the integrity of the fibular notch. It may be a useful indication for surgery and defining the most useful approach to these injuries.

The Posterior Bundle's Effect on Posteromedial Elbow Instability After a Transverse Coronoid Fracture: A Biomechanical Study.

PubMed

Shukla, Dave R; Golan, Elan; Weiser, Mitch C; Nasser, Philip; Choueka, Jack; Hausman, Michael

2018-04-01

There has been increased interest in the role of the posterior bundle of the medial collateral ligament (pMUCL) in the elbow, particularly its effects on posteromedial rotatory stability. The ligament's effect in the context of an unfixable coronoid fracture has not been the focus of any study. The purposes of this biomechanical study were to evaluate the stabilizing effect of the pMUCL with a transverse coronoid fracture and to assess the effect of graft reconstruction of the ligament. We simulated a varus and internal rotatory subluxation in 7 cadaveric elbows at 30°, 60°, and 90° elbow flexion. The amount of ulnar rotation and medial ulnohumeral joint gapping were assessed in the intact elbow after we created a transverse coronoid injury, after we divided the pMUCL, and finally, after we performed a graft reconstruction of the pMUCL. At all angles tested, some stability was lost after cutting the pMUCL once the coronoid had been injured, because mean proximal ulnohumeral joint gapping increased afterward by 2.1, 2.2, and 1.3 mm at 90°, 60°, and 30°, respectively. Ulnar internal rotation significantly increased after pMUCL transection at 90°. At 60° and 30° elbow flexion, ulnar rotation increased after resection of the coronoid but not after pMUCL resection. An uninjured pMUCL stabilizes against varus internal rotatory instability in the setting of a transverse coronoid fracture at higher flexion angles. Further research is needed to optimize graft reconstruction of the pMUCL. The pMUCL is an important secondary stabilizer against posteromedial instability in the coronoid-deficient elbow. In the setting of an unfixable coronoid fracture, the surgeon should examine for posteromedial instability and consider addressing the pMUCL surgically. Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Functional and Radiological Outcome of Schatzker type V and VI Tibial Plateau Fracture Treatment with Dual Plates with Minimum 3 years follow-up: A Prospective Study

PubMed Central

Suri, Harpreet Singh; Gangrade, Kewal

2016-01-01

Introduction High energy intra-articular fractures involving the tibial plateau causes various problems related to management like wound dehiscence, severe comminution leading to malalignment and delayed complications like varus collapse, implant failure and arthritis of knee joint. Aim This study was done to determine functional, radiological outcome and the complications of Schatzker V and VI tibial plateau fractures treated with bipillar plating with dual plates with a regular follow-up of atleast 3 years. Materials and Methods Total 34 cases of tibial plateau fracture type V and VI treated with dual plating were studied from January 2011 to December 2013 in KIMS Hospital were followed for minimum of 3 years. The patients were operated through an anterolateral approach for lateral plate and a medial column plate was put through a minimally invasive medial approach or an open posteromedial approach. Results Total 34 patients were evaluated postoperatively thoroughly for functional outcome using The Knee Society Score and radiological outcomes by Modified Rasmussen Assessment criteria which showed 29 patients (85.29%) had excellent and 5 patients (14.71%) had good objective knee society score. 24 patients (70.59%) had excellent, 8 patients (23.53%) had good and 1patient (2.94%) were each of poor and fair functional knee society score. Eleven patients (32.35%) had excellent, 21patients (61.76%) had good and 2 patients (5.88%) had fair radiological outcome. Conclusion We conclude that open reduction and internal fixation of high-energy tibial plateau fractures with dual plates via 2 incisions gives excellent to good functional outcome with minimal soft tissue complications. Thus, a minimally invasive approach should be used which helps in preventing soft tissue problems and helps in early wound healing. Fixation done by bipillar plating is important for early mobilization of knee joint. Early mobilization leads to better range of movements and thereby better functional outcome. PMID:27437315

Similarity in Bilateral Isolated Internal Orbital Fractures.

PubMed

Chen, Hung-Chang; Cox, Jacob T; Sanyal, Abanti; Mahoney, Nicholas R

2018-04-13

In evaluating patients sustaining bilateral isolated internal orbital fractures, the authors have observed both similar fracture locations and also similar expansion of orbital volumes. In this study, we aim to investigate if there is a propensity for the 2 orbits to fracture in symmetrically similar patterns when sustaining similar trauma. A retrospective chart review was performed studying all cases at our institution of bilateral isolated internal orbital fractures involving the medial wall and/or the floor at the time of presentation. The similarity of the bilateral fracture locations was evaluated using the Fisher's exact test. The bilateral expanded orbital volumes were analyzed using the Wilcoxon signed-rank test to assess for orbital volume similarity. Twenty-four patients with bilateral internal orbital fractures were analyzed for fracture location similarity. Seventeen patients (70.8%) had 100% concordance in the orbital subregion fractured, and the association between the right and the left orbital fracture subregion locations was statistically significant (P < 0.0001). Fifteen patients were analyzed for orbital volume similarity. The average orbital cavity volume was 31.2 ± 3.8 cm on the right and 32.0 ± 3.7 cm on the left. There was a statistically significant difference between right and left orbital cavity volumes (P = 0.0026). The data from this study suggest that an individual who suffers isolated bilateral internal orbital fractures has a statistically significant similarity in the location of their orbital fractures. However, there does not appear to be statistically significant similarity in the expansion of the orbital volumes in these patients.

A double-plating approach to distal femur fracture: A clinical study.

PubMed

Steinberg, Ely L; Elis, Jacov; Steinberg, Yohai; Salai, Moshe; Ben-Tov, Tomer

2017-10-01

Locked plating is one of the latest innovative options for treating supracondylar femur fractures with relatively low failure rates. Single lateral plating was often found to have a relative higher failure rate. No clinical studies of double-plating distal femur fixation have thus far been reported. The aim of this study is to present our clinical experience with this surgical approach. Thirty-two patients (26 females and 6 males, mean age 76 years, range 44-101) were included in the study. Eight of them patients had a periprosthetic stable implant fracture and two patients were treated for a nonunion. All fractures, excluding one that needed bone grafting and one refracture, healed within 12 weeks. One patient needed bone grafting for delayed union and one patient needed fixation exchange due to femur re-fracture at the site of the most proximal screw. Two patients developed superficial wound infection and one patient required medial plate removal after union due to deep infection. Based on these promising results, we propose that the double-plating technique should be considered in the surgeon's armamentarium for the treatment of supracondylar femur fractures, particularly in patients with poor bone quality, comminuted fractures and very low periprosthetic fractures. Copyright © 2017 Elsevier Ltd. All rights reserved.

Ultrasound-guided percutaneous needle electrolysis in chronic lateral epicondylitis: short-term and long-term results

PubMed Central

Valera-Garrido, Fermín; Minaya-Muñoz, Francisco; Medina-Mirapeix, Francesc

2014-01-01

Background Ultrasound (US)-guided percutaneous needle electrolysis (PNE) is a novel minimally invasive approach which consists of the application of a galvanic current through an acupuncture needle. Objective To evaluate the clinical and ultrasonographic effectiveness of a multimodal programme (PNE, eccentric exercise (EccEx) and stretching) in the short term for patients with chronic lateral epicondylitis, and to determine whether the clinical outcomes achieved decline over time. Methods A one-way repeated measures study was performed in a clinical setting in 36 patients presenting with lateral epicondylitis. The patients received one session of US-guided PNE per week over 4–6 weeks, associated with a home programme of EccEx and stretching. The main outcome measures were severity of pain, disability (Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire), structural tendon changes (US), hypervascularity and patients’ perceptions of overall outcome. Measurements at 6, 26 and 52 weeks follow-up included recurrence rates (increase in severity of pain or disability compared with discharge), perception of overall outcome and success rates. Results All outcome measures registered significant improvements between pre-intervention and discharge. Most patients (n=30, 83.3%) rated the overall outcome as ‘successful’ at 6 weeks. The ultrasonographic findings showed that the hypoechoic regions and hypervascularity of the extensor carpi radialis brevis changed significantly. At 26 and 52 weeks, all participants (n=32) perceived a ‘successful’ outcome. Recurrence rates were null after discharge and at follow-up at 6, 26 and 52 weeks. Conclusions Symptoms and degenerative structural changes of chronic lateral epicondylitis are reduced after US-guided PNE associated with EccEx and stretching, with encouragingly low recurrences in the mid to long term. Trial registration number ClinicalTrials.gov identifier: NCT02085928. PMID:25122629

Short-term evaluation of arthroscopic management of tennis elbow; including resection of radio-capitellar capsular complex.

PubMed

Babaqi, AbdulRahman A; Kotb, Mohammed M; Said, Hatem G; AbdelHamid, Mohamed M; ElKady, Hesham A; ElAssal, Maher A

2014-06-01

There has been controversy regarding the pathogenesis and treatment of lateral epicondylitis. Different surgical techniques for the treatment of lateral epicondylitis prescribed. The purpose of this study was to evaluate the short-term outcomes of arthroscopic management including resection of the radio-capitellar capsular complex, using different validated scores. In this study, arthroscopic resection of a capsular fringe complex was done beside debridement of the undersurface of Extensor Carpi Radialis Brevis (ECRB). Thirty-one patients with recalcitrant lateral epicondylitis for a minimum of 6 months had surgery. In all patients, a collar-like band of radio-capitellar capsular complex was found to impinge on the radial head and subluxate into the radio-capitellar joint with manipulation under direct vision. Outcomes were assessed using Mayo Elbow Performance Index (MEPI), the Patient-Rated Tennis Elbow Evaluation (PRTEE), and the Disability of the Arm, Shoulder, and Hand (DASH), beside visual analog scale (VAS) for pain and satisfaction criteria. After arthroscopic surgery, overall satisfaction was extremely positive, over the 31 patients, 93.5% of the patients are satisfied. The mean score for pain improved from 8.64 to 1.48 points. The total PRTEE improved from 55.53 to 10.39 points. The mean MEPI score was improved from 61.82 to 94.10 points. DASH score also improved from 24.46 to 4.81 points. All improvements are statistically significant (P < 0.05). Arthroscopic release of ECRB in patients with chronic lateral epicondylitis is a reproducible method with a marked improvement in function within a short period, with special consideration for resection of radio-capitellar capsular complex.

Stress fractures: diagnosis, treatment, and prevention.

PubMed

Patel, Deepak S; Roth, Matt; Kapil, Neha

2011-01-01

Stress fractures are common injuries in athletes and military recruits. These injuries occur more commonly in lower extremities than in upper extremities. Stress fractures should be considered in patients who present with tenderness or edema after a recent increase in activity or repeated activity with limited rest. The differential diagnosis varies based on location, but commonly includes tendinopathy, compartment syndrome, and nerve or artery entrapment syndrome. Medial tibial stress syndrome (shin splints) can be distinguished from tibial stress fractures by diffuse tenderness along the length of the posteromedial tibial shaft and a lack of edema. When stress fracture is suspected, plain radiography should be obtained initially and, if negative, may be repeated after two to three weeks for greater accuracy. If an urgent diagnosis is needed, triple-phase bone scintigraphy or magnetic resonance imaging should be considered. Both modalities have a similar sensitivity, but magnetic resonance imaging has greater specificity. Treatment of stress fractures consists of activity modification, including the use of nonweight-bearing crutches if needed for pain relief. Analgesics are appropriate to relieve pain, and pneumatic bracing can be used to facilitate healing. After the pain is resolved and the examination shows improvement, patients may gradually increase their level of activity. Surgical consultation may be appropriate for patients with stress fractures in high-risk locations, nonunion, or recurrent stress fractures. Prevention of stress fractures has been studied in military personnel, but more research is needed in other populations.

Broken Pieces of Circlage Wire Lying in Soft Tissue Envelope Around Knee Joint: A Case Report and Review of Literature

PubMed Central

Kalia, Anoop; Khatri, Kavin; Singh, Jagdeep; Bansal, Kapil; Sagy, Mohammed

2016-01-01

Introduction: The migration of circlage wires used in tension band wiring construct of patella fractures in the posterior soft tissue envelope surrounding the knee joint has been rarely reported. Case Presentation: A 60-year-old woman presented to us with pain over medial aspect of right knee joint. She underwent open reduction and internal fixation for a patellar fracture which she sustained 4 years back and subsequently underwent kirschner wire(k wire) removal for the same around 2 years back. X-rays of the knee joint shows that the circlage wire used in tension band construct which was left in place had broken into multiple pieces and was lying in the soft tissue envelope surrounding the knee joint and one piece migrate to the popliteal fossa. On examination patient did not had distal neuro-vascular deficit. The pain of the patient was due to the osteo-arthritic changes in her medial side of knee joint rather than broken wire pieces. Patient was advised to undergo total knee replacement along with subsequent removal of broken wires but patient refused for any type of surgery and is kept on regular follow up Conclusion: This case report summarizes a rare complication resulting from hardware failure used for fixing patella fractures and throws a light on potential unwarned complications due to broken wires along with early recogonition and removal of broken hardware by surgeons. PMID:28116277

Diagnostic imaging in a patient with an acute knee injury.

PubMed

Sago, Carrie E; Labuda, Craig S

2013-01-01

The patient was a 23-year-old man, currently serving in a military airborne operations unit. During a jump training exercise, the patient's right lower extremity became entangled in his parachute equipment upon exiting the aircraft, which caused hyperextension and valgus forces upon his right knee. Due to concern for a fracture, the patient was transported to an emergency department, where conventional radiographs were completed and interpreted by a radiologist as negative for a fracture. Following further physical examination by a physical therapist, magnetic resonance imaging of the right knee was ordered, revealing ruptures of the anterior cruciate ligament and medial collateral ligament.

The effect of platelet-rich plasma injection on lateral epicondylitis following failed conservative management.

PubMed

Brkljac, Milos; Kumar, Shyam; Kalloo, Dale; Hirehal, Kiran

2015-12-01

We assessed the effect PRP injection on pain and function in patients with lateral epicondylitis where conservative management had failed. We prospectively reviewed 34 patients. The mean follow-up was 26 weeks (range 6-114 weeks). We used the Oxford Elbow Score (OES) and progression to surgery to assess outcomes. 88.2% improved their OES. 8.8% reported symptom progression. One patient had no change. No patients suffered adverse reactions. Two patients underwent an open release procedure. One had the injection repeated. An injection of PRP improves pain and function in patients suffering from LE where conservative management has failed.

Tennis elbow: a biomechanical and therapeutic approach.

PubMed

Schnatz, P; Steiner, C

1993-07-01

Lateral epicondylitis, one of the most common lesions of the arm, affects some 50% of tennis players. This condition poses a problem in clinical management because treatment is dependent not only on proper medical therapy but also on correction of the improper on-court biomechanics. The most common flaw is a late contact on the backhand groundstroke, forcing the player to extend the wrist with the extensor muscles. This action predisposes to trauma of the tendon fibers at the lateral epicondyle. Understanding the biomechanics will better prepare the physician to advise the patient and to communicate with a tennis teaching professional to facilitate long-term relief.

Effects of platelet-rich plasma on lateral epicondylitis of the elbow: prospective randomized controlled trial.

PubMed

Palacio, Evandro Pereira; Schiavetti, Rafael Ramos; Kanematsu, Maiara; Ikeda, Tiago Moreno; Mizobuchi, Roberto Ryuiti; Galbiatti, José Antônio

2016-01-01

To evaluate the effects of platelet-rich plasma (PRP) infiltration in patients with lateral epicondylitis of the elbow, through analysis of the Disabilities of the Arm, Shoulder and Hand (DASH) and Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaires. Sixty patients with lateral epicondylitis of the elbow were prospectively randomized and evaluated after receiving infiltration of three milliliters of PRP, or 0.5% neocaine, or dexamethasone. For the scoring process, the patients were asked to fill out the DASH and PRTEE questionnaires on three occasions: on the day of infiltration and 90 and 180 days afterwards. Around 81.7% of the patients who underwent the treatment presented some improvement of the symptoms. The statistical tests showed that there was evidence that the cure rate was unrelated to the substance applied (p = 0.62). There was also intersection between the confidence intervals of each group, thus demonstrating that the proportions of patients whose symptoms improved were similar in all the groups. At a significance level of 5%, there was no evidence that one treatment was more effective than another, when assessed using the DASH and PRTEE questionnaires.

[Design of a multicenter study for assessing the effectiveness of extracorporeal shockwave therapy in epicondylitis humeri radialis].

PubMed

Haake, M; Jensen, K; Prinz, H; Willenberg, T

2000-01-01

Previously published studies concerning, extracorporeal shock-wave therapy (ESWT) in the treatment of lateral epicondylitis do not fulfil the biometric standards of modern clinical research. The objective of the trial is to show that ESWT is effective in the treatment of chronic LE. A prospective, randomized, placebo-controlled, single-blinded, multicenter trial with an independent blinded observer was designed. The effectiveness of ESWT is evaluated by comparison with a control group in which sham-ESWT is performed, both under local anaesthesia. Outcome is determined on the basis of the Roles/Maudsley-Score. Inclusion criteria are a history of at least 6 months of LE and failure of conventional treatment. The therapy includes 3 sessions of low energy ESWT with 2000 impulses (energy flux density 0.07-0.09 mJ/mm2). Sample size is 272 patients. Randomisation started in October 1998 and is planned over a period of two and a half years. Only a randomised clinical trial with adequate control of placebo effects and observer bias can provide the required evidence for the efficiency of ESWT in the treatment of lateral epicondylitis of the elbow.

Comparison of Effectiveness of Supervised Exercise Program and Cyriax Physiotherapy in Patients with Tennis Elbow (Lateral Epicondylitis): A Randomized Clinical Trial

PubMed Central

Viswas, Rajadurai; Ramachandran, Rejeeshkumar; Korde Anantkumar, Payal

2012-01-01

Objective. To compare the effectiveness of supervised exercise program and Cyriax physiotherapy in the treatment of tennis elbow (lateral epicondylitis). Design. Randomized clinical trial. Setting. Physiotherapy and rehabilitation centre. Subjects. This study was carried out with 20 patients, who had tennis elbow (lateral epicondylitis). Intervention. Group A (n = 10) had received supervised exercise program. Group B (n = 10) was treated with Cyriax physiotherapy. All patients received three treatment sessions per week for four weeks (12 treatment sessions). Outcome measures. Pain was evaluated using a visual analogue scale (VAS), and functional status was evaluated by completion of the Tennis Elbow Function Scale (TEFS) which were recorded at base line and at the end of fourth week. Results. Both the supervised exercise program and Cyriax physiotherapy were found to be significantly effective in reduction of pain and in the improvement of functional status. The supervised exercise programme resulted in greater improvement in comparison to those who received Cyriax physiotherapy. Conclusion. The results of this clinical trial demonstrate that the supervised exercise program may be the first treatment choice for therapist in managing tennis elbow. PMID:22629225

IMpact of Platelet Rich plasma OVer alternative therapies in patients with lateral Epicondylitis (IMPROVE): protocol for a multicenter randomized controlled study: a multicenter, randomized trial comparing autologous platelet-rich plasma, autologous whole blood, dry needle tendon fenestration, and physical therapy exercises alone on pain and quality of life in patients with lateral epicondylitis.

PubMed

Chiavaras, Mary M; Jacobson, Jon A; Carlos, Ruth; Maida, Eugene; Bentley, Todd; Simunovic, Nicole; Swinton, Marilyn; Bhandari, Mohit

2014-09-01

Lateral epicondylitis, commonly known as tennis elbow, is the most common cause of lateral elbow pain and the second most frequently diagnosed musculoskeletal disorder in the neck and upper limb in a primary care setting. Many therapeutic options, including conservative, surgical, and minimally invasive procedures, have been advocated for the treatment of lateral epicondylitis. Although numerous small studies have been performed to assess the efficacy of various treatments, there are conflicting results with no clear consensus on the optimal treatment. In an economic environment with limited health care resources, it is paramount that optimal cost-effective therapies with favorable patient-important outcomes be identified. This is a protocol paper which outlines a multicenter, multidisciplinary, single-blinded, four-arm randomized controlled trial, comparing platelet-rich plasma (PRP), whole blood injection, dry needle tendon fenestration, and sham injection with physical therapy alone for the treatment of lateral epicondylitis. Patients are screened based on pre-established eligibility criteria and randomized to one of the four study groups using an Internet-based system. The patients are followed at 6-week, 12-week, 24-week, and 52-week time points to assess the primary and secondary outcomes of the study. The primary outcome is pain. Secondary outcomes include health-related quality of life and ultrasound appearance of the common extensor tendon. Two university centers (McMaster University and the University of Michigan) are currently recruiting patients. We have planned a sample size of 100 patients (25 patients per arm) to ensure over 80% power to detect a three-point difference in pain scores at 52 weeks of follow-up. This study has ethics approval from the McMaster University Research Ethics Board (REB# 12-146) and the University of Michigan Institutional Review Board (IRB# HUM00067750). Successful completion of this proposed study will significantly impact clinical practice and enhance patients' lives. More broadly, this trial will develop a network of collaboration from which further high-quality trials in ultrasound-guided interventions will follow. Copyright © 2014 AUR. Published by Elsevier Inc. All rights reserved.

Clinical outcome and complications using a polyaxial locking plate in the treatment of displaced proximal humerus fractures. A reliable system?

PubMed

Königshausen, M; Kübler, L; Godry, H; Citak, M; Schildhauer, T A; Seybold, D

2012-02-01

The surgical treatment of displaced proximal humeral fractures (ORIF) is a perpetual challenge to the surgeon. For this reason, the principle of polyaxiality was developed to provide an improved primary stability of the fracture through better anchorage of the screws, especially in osteoporotic bone. The aim of this study was to present clinical results with the polyaxial locking plate in the operative treatment of proximal humerus fractures in order to determine whether the technique of polyaxiality leads to better functional outcome and lower complication rates in comparison to monoaxial plates in the literature. Seventy-three patients with displaced proximal humeral fractures were treated surgically with the polyaxial locking Suture Plate™ (Arthrex(®)) between 03/2007 and 06/2009. Fifty-two of the patients (mean age, 69.9 ± 12.1) were included in a radiographical and clinical examination using the Constant score (CS) and the Disabilities of the Arm, Shoulder and Hand score (DASH). The follow-up examinations were on average 13.9 ± 4.5 months (10-27 months) after surgical treatment. The mean CS of the patients was 66.0 ± 13.7 points, the age- and gender-related CS was 90.9% ± 20.0% and the mean DASH score was 23.8 ± 19.8 points for the injured side. The patients with a nearly anatomical reduction of their fracture (n = 13) reached a significantly higher CS (75.1 ± 8.5; p = 0.004) and DASH-score (13.6 ± 11.6; p = 0.043) and none of these patients had a complication. The complications were identified in 12 (23.1%) cases, 5 of which involved loss of reduction. All of these 5 cases were lacking of initial medial column support and 4 of which were type C2.3 AO-Classification. The data show that the combination of angular stability with the possibility of variable polyaxial screw direction is a good concept for reduction and fixation of displaced proximal humeral fractures, but anatomical reduction and medial support remain important preconditions for a good outcome. However, a significantly lower rate of complications or better clinical outcome than that reported in the literature could not be found. Copyright © 2011 Elsevier Ltd. All rights reserved.

Isolated avulsion fracture of the first metatarsal base at the peroneus longus tendon attachment: a case report.

PubMed

Weinberg, Maxwell W; Krähenbühl, Nicola; Davidson, Nathan P; Hanrahan, Christopher J; Barg, Alexej

2018-05-01

Avulsion fractures of the first metatarsal (MT1) base at the peroneus longus (PL) tendon attachment are rare and may be undiagnosed during an emergency visit. If the injury is not treated properly, chronic pain or persistent impairment for inversion and plantar-flexion of the first ray may occur. This case report presents a 30-year-old woman who presented 10 weeks post trauma to a foot and ankle surgeon due to a swollen right midfoot with diffuse tenderness over the medial Lisfranc joint. Further evaluation showed an isolated avulsion fracture of the first metatarsal, which was undiagnosed during the emergent visit following the accident. In this case, the patient was successfully treated conservatively. The goal of this article is to raise awareness of this rare injury for radiologists and orthopedic surgeons.

Posterior Root Meniscal Tears: Preoperative, Intraoperative, and Postoperative Imaging for Transtibial Pullout Repair.

PubMed

Palisch, Andrew R; Winters, Ronald R; Willis, Marc H; Bray, Collin D; Shybut, Theodore B

2016-10-01

The menisci play an important biomechanical role in axial load distribution of the knees by means of hoop strength, which is contingent on intact circumferentially oriented collagen fibers and meniscal root attachments. Disruption of the meniscal root attachments leads to altered biomechanics, resulting in progressive cartilage loss, osteoarthritis, and subchondral edema, with the potential for development of a subchondral insufficiency fracture. Identification of meniscal root tears at magnetic resonance (MR) imaging is crucial because new arthroscopic surgical techniques (transtibial pullout repair) have been developed to repair meniscal root tears and preserve the tibiofemoral cartilage of the knee. An MR imaging classification of posterior medial meniscal root ligament lesions has been recently described that is dedicated to the posterior root of the medial meniscus. An arthroscopic classification of meniscal root tears has been described that can be applied to the anterior and posterior roots of both the medial meniscus and the lateral meniscus. This arthroscopic classification includes type 1, partial stable root tears; type 2, complete radial root tears; type 3, vertical longitudinal bucket-handle tears; type 4, complex oblique tears; and type 5, bone avulsion fractures of the root attachments. Knowledge of these classifications and the potential contraindications to meniscal root repair can aid the radiologist in the preoperative reporting of meniscal root tear types and the evaluation of the tibiofemoral cartilage. As more patients undergo arthroscopic repair of meniscal root tears, familiarity with the surgical technique and the postoperative radiographic and MR imaging appearance is important to adequately report the imaging findings. © RSNA, 2016.

Nontraumatic Fracture of the Femoral Condylar Prosthesis in a Total Knee Arthroplasty Leading to Mechanical Failure

PubMed Central

Swamy, Girish N.; Quah, Conal; Bagouri, Elmunzar; Badhe, Nitin P.

2014-01-01

This paper reports a case of fatigue fracture of the femoral component in a cruciate-retaining cemented total knee arthroplasty (TKA). A 64-year-old man had undergone a primary TKA for osteoarthritis 10 years previously at another institution using the PFC-Sigma prosthesis. The patient recovered fully and was back to his regular activities. He presented with a history of sudden onset pain and locking of the left knee since the preceding three months. There was no history of trauma, and the patient was mobilizing with difficulty using crutches. Radiographs revealed fracture of the posterior condyle of the femoral prosthesis. Revision surgery was performed as an elective procedure revealing the broken prosthesis. The TC3RP-PFC revision prosthesis was used with a medial parapatellar approach. The patient recovered fully without any squeal. Mechanical failure of the knee arthroplasty prosthesis is rare, and nontraumatic fracture of the femoral metallic component has not been reported before. PMID:24587928

Nontraumatic fracture of the femoral condylar prosthesis in a total knee arthroplasty leading to mechanical failure.

PubMed

Swamy, Girish N; Quah, Conal; Bagouri, Elmunzar; Badhe, Nitin P

2014-01-01

This paper reports a case of fatigue fracture of the femoral component in a cruciate-retaining cemented total knee arthroplasty (TKA). A 64-year-old man had undergone a primary TKA for osteoarthritis 10 years previously at another institution using the PFC-Sigma prosthesis. The patient recovered fully and was back to his regular activities. He presented with a history of sudden onset pain and locking of the left knee since the preceding three months. There was no history of trauma, and the patient was mobilizing with difficulty using crutches. Radiographs revealed fracture of the posterior condyle of the femoral prosthesis. Revision surgery was performed as an elective procedure revealing the broken prosthesis. The TC3RP-PFC revision prosthesis was used with a medial parapatellar approach. The patient recovered fully without any squeal. Mechanical failure of the knee arthroplasty prosthesis is rare, and nontraumatic fracture of the femoral metallic component has not been reported before.

Subchondral impaction fractures of the non-weight-bearing portion of the lateral femoral condyle.

PubMed

Depasquale, Ruben; Fotiadou, Anastasia; Kumar, Dalavaye Suresh; Lalam, Radhesh; Tins, Bernhard; Tyrrell, Prudencia N M; Singh, Jaspreet; Cassar-Pullicino, Victor N

2013-02-01

To document the first report of intra-articular, non-weight-bearing, impaction fractures of the lateral femoral condyle. Institutional Review Board and Regional Ethics Committee approval for this study was obtained and patient informed consent deemed unnecessary. We prospectively documented all potential cases of non-weight-bearing posterior subchondral impaction fractures of the femoral condyles diagnosed on magnetic resonance imaging (MRI) of the knee performed at our institution between January 2006 and December 2011. The cases were reviewed and discussed by three experienced musculoskeletal radiologists and only cases satisfying pre-defined MRI criteria were included. Sixteen cases of intra-articular impaction fractures in a posterior, non-weight-bearing area of the lateral femoral condyle were diagnosed in patients with a mean age of 40. Eight were associated with recreational sports activities and 4 with repeated kneeling. There were no fractures documented in the non-weight-bearing aspect of the medial femoral condyles. Proposed underlying mechanisms for development of this type of fracture are presented. Awareness, along with a high level of suspicion, that non-specific knee pain, especially in patients involved in athletic activities, could be due to intra-articular impaction fractures of the non-weight-bearing posterior aspect of the lateral femoral condyle is essential and MRI is the mainstay of diagnosis.

Stress fractures of the foot and ankle in athletes.

PubMed

Mayer, Stephanie W; Joyner, Patrick W; Almekinders, Louis C; Parekh, Selene G

2014-11-01

Stress fractures of the foot and ankle are a common problem encountered by athletes of all levels and ages. These injuries can be difficult to diagnose and may be initially evaluated by all levels of medical personnel. Clinical suspicion should be raised with certain history and physical examination findings. Scientific and review articles were searched through PubMed (1930-2012) with search terms including stress fractures and 1 of the following: foot ankle, medial malleolus, lateral malleolus, calcaneus, talus, metatarsal, cuboid, cuneiform, sesamoid, or athlete. Clinical review. Level 5. Stress fractures of the foot and ankle can be divided into low and high risk based upon their propensity to heal without complication. A wide variety of nonoperative strategies are employed based on the duration of symptoms, type of fracture, and patient factors, such as activity type, desire to return to sport, and compliance. Operative management has proven superior in several high-risk types of stress fractures. Evidence on pharmacotherapy and physiologic therapy such as bone stimulators is evolving. A high index of suspicion for stress fractures is appropriate in many high-risk groups of athletes with lower extremity pain. Proper and timely work-up and treatment is successful in returning these athletes to sport in many cases. Low-risk stress fracture generally requires only activity modification while high-risk stress fracture necessitates more aggressive intervention. The specific treatment of these injuries varies with the location of the stress fracture and the goals of the patient.

Stress fractures of the foot and ankle, part 2: site-specific etiology, imaging, and treatment, and differential diagnosis.

PubMed

Mandell, Jacob C; Khurana, Bharti; Smith, Stacy E

2017-09-01

Stress fractures of the foot and ankle are a commonly encountered problem among athletes and individuals participating in a wide range of activities. This illustrated review, the second of two parts, discusses site-specific etiological factors, imaging appearances, treatment options, and differential considerations of stress fractures of the foot and ankle. The imaging and clinical management of stress fractures of the foot and ankle are highly dependent on the specific location of the fracture, mechanical forces acting upon the injured site, vascular supply of the injured bone, and the proportion of trabecular to cortical bone at the site of injury. The most common stress fractures of the foot and ankle are low risk and include the posteromedial tibia, the calcaneus, and the second and third metatarsals. The distal fibula is a less common location, and stress fractures of the cuboid and cuneiforms are very rare, but are also considered low risk. In contrast, high-risk stress fractures are more prone to delayed union or nonunion and include the anterior tibial cortex, medial malleolus, navicular, base of the second metatarsal, proximal fifth metatarsal, hallux sesamoids, and the talus. Of these high-risk types, stress fractures of the anterior tibial cortex, the navicular, and the proximal tibial cortex may be predisposed to poor healing because of the watershed blood supply in these locations. The radiographic differential diagnosis of stress fracture includes osteoid osteoma, malignancy, and chronic osteomyelitis.

Opening the medial tibiofemoral compartment by pie-crusting the superficial medial collateral ligament at its tibial insertion: a cadaver study.

PubMed

Roussignol, X; Gauthe, R; Rahali, S; Mandereau, C; Courage, O; Duparc, F

2015-09-01

Arthroscopic treatment of tears in the middle and posterior parts of the medial meniscus can be difficult when the medial tibiofemoral compartment is tight. Passage of the instruments may damage the cartilage. The primary objective of this cadaver study was to perform an arthroscopic evaluation of medial tibiofemoral compartment opening after pie-crusting release (PCR) of the superficial medial collateral ligament (sMCL) at its distal insertion on the tibia. The secondary objective was to describe the anatomic relationships at the site of PCR (saphenous nerve, medial saphenous vein). We studied 10 cadaver knees with no history of invasive procedures. The femur was held in a vise with the knee flexed at 45°, and the medial aspect of the knee was dissected. PCR of the sMCL was performed under arthroscopic vision, in the anteroposterior direction, at the distal tibial insertion of the sMCL, along the lower edge of the tibial insertion of the semi-tendinosus tendon. Continuous 300-N valgus stress was applied to the ankle. Opening of the medial tibiofemoral compartment was measured arthroscopically using graduated palpation hooks after sequential PCR of the sMCL. The compartment opened by 1mm after release of the anterior third, 2.3mm after release of the anterior two-thirds, and 3.9mm after subtotal release. A femoral fracture occurred in 1 case, after completion of all measurements. Both the saphenous nerve and the medial saphenous vein were located at a distance from the PCR site in all 10 knees. PCR of the sMCL is chiefly described as a ligament-balancing method during total knee arthroplasty. This procedure is usually performed at the joint line, where it opens the compartment by 4-6mm at the most, with some degree of unpredictability. PCR of the sMCL at its distal tibial insertion provides gradual opening of the compartment, to a maximum value similar to that obtained with PCR at the joint space. The lower edge of the semi-tendinosus tendon is a valuable landmark for PCR of the distal sMCL. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Thoracic limb morphology of the red panda (Ailurus fulgens) evidenced by osteology and radiography.

PubMed

Makungu, Modesta; Groenewald, Hermanus B; du Plessis, Wencke M; Barrows, Michelle; Koeppel, Katja N

2015-07-15

The red panda (Ailurus fulgens) is distributed primarily in the Himalayas and southern China. It is classified as a vulnerable species by the International Union for Conservation of Nature. The aim of this study was to describe the normal osteology and radiographic anatomy of the thoracic limb of the red panda. Radiography of the right thoracic limb was performed in seven captive adult red pandas. Radiographic findings were correlated with bone specimens from three adult animals. The scapula was wide craniocaudally and presented with a large area for the origin of the teres major muscle. The square-shaped major tubercle did not extend proximal to the head of the humerus. The medial epicondyle was prominent. A supracondylar foramen was present. The radial tuberosity and sesamoid bone for the abductor digiti I longus were prominent. The accessory carpal bone was directed palmarolaterally. Metacarpal bones were widely spread. The thoracic limb morphology of the red panda evidenced by osteology and radiography indicated flexibility of the thoracic limb joints and well-developed flexor and supinator muscles, which are important in arboreal quadrupedal locomotion. Knowledge gained during this study may prove useful in identifying skeletal material or remains and diagnosing musculoskeletal diseases and injuries of the thoracic limb.

Anatomic factors related to the cause of tennis elbow.

PubMed

Bunata, Robert E; Brown, David S; Capelo, Roderick

2007-09-01

The pathogenesis of lateral epicondylitis remains unclear. Our purpose was to study the anatomy of the lateral aspect of the elbow under static and dynamic conditions in order to identify bone-to-tendon and tendon-to-tendon contact or rubbing that might cause abrasion of the tissues. Eighty-five cadaveric elbows were examined to determine details related to the bone structure and musculotendinous origins. We identified the relative positions of the musculotendinous units and the underlying bone when the elbow was in different degrees of flexion. We also recorded the contact between the extensor carpi radialis brevis and the lateral edge of the capitellum as elbow motion occurred, and we sought to identify the areas of the capitellum and extensor carpi radialis brevis where contact occurs. The average site of origin of the extensor carpi radialis brevis on the humerus lay slightly medial and superior to the outer edge of the capitellum. As the elbow was extended, the undersurface of the extensor carpi radialis brevis rubbed against the lateral edge of the capitellum while the extensor carpi radialis longus compressed the brevis against the underlying bone. The extensor carpi radialis brevis tendon has a unique anatomic location that makes its undersurface vulnerable to contact and abrasion against the lateral edge of the capitellum during elbow motion.

Ideal tibial intramedullary nail insertion point varies with tibial rotation.

PubMed

Walker, Richard M; Zdero, Rad; McKee, Michael D; Waddell, James P; Schemitsch, Emil H

2011-12-01

The aim of the study was to investigate how superior entry point varies with tibial rotation and to identify landmarks that can be used to identify suitable radiographs for successful intramedullary nail insertion. The proximal tibia and knee were imaged for 12 cadaveric limbs undergoing 5° increments of internal and external rotation. Medial and lateral arthrotomies were performed, the ideal superior entry point was identified, and a 2-mm Kirschner wire inserted. A second Kirschner wire was sequentially placed at the 5-mm and then the 10-mm position, both medial and lateral to the initial Kirschner wire. Radiographs of the knee were obtained for all increments. The changing position of the ideal nail insertion point was recorded. A 30° arc (range, 25°-40°) provided a suitable anteroposterior radiograph. On the neutral anteroposterior radiograph, the Kirschner wire was 54% ± 1.5% (range, 51-56%) from the medial edge of the tibial plateau. For every 5° of rotation, the Kirschner wire moved 3% of the plateau width. During external rotation, a misleading medial entry point was obtained. A fibular bisector line correlated with an entry point that was ideal or up to 5 mm lateral to this but never medial. The film that best showed the fibular bisector line was between 0° and 10° of internal rotation of the tibia. The fibula head bisector line can be used to avoid choosing external rotation views and, thus, avoid medial insertion points. The current results may help the surgeon prevent malalignment during intramedullary nailing in proximal tibial fractures.

Fishtail deformity--a delayed complication of distal humeral fractures in children.

PubMed

Narayanan, Srikala; Shailam, Randheer; Grottkau, Brian E; Nimkin, Katherine

2015-06-01

Concavity in the central portion of the distal humerus is referred to as fishtail deformity. This entity is a rare complication of distal humeral fractures in children. The purpose of this study is to describe imaging features of post-traumatic fishtail deformity and discuss the pathophysiology. We conducted a retrospective analysis of seven cases of fishtail deformity after distal humeral fractures. Seven children ages 7-14 years (five boys, two girls) presented with elbow pain and history of distal humeral fracture. Four of the seven children had limited range of motion. Five children had prior grade 3 supracondylar fracture treated with closed reduction and percutaneous pinning. One child had a medial condylar fracture and another had a lateral condylar fracture; both had been treated with conservative casting. All children had radiographs, five had CT and three had MRI. All children had a concave central defect in the distal humerus. Other imaging features included joint space narrowing with osteophytes and subchondral cystic changes in four children, synovitis in one, hypertrophy or subluxation of the radial head in three and proximal migration of the ulna in two. Fishtail deformity of the distal humerus is a rare complication of distal humeral fractures in children. This entity is infrequently reported in the radiology literature. Awareness of the classic imaging features can result in earlier diagnosis and appropriate treatment.

[Surgery of ipsilateral Hawkins Ⅲ talus neck and ankle joint fractures via internal and lateral approaches with Herbert screws].

PubMed

Zhang, P; Dong, Q R; Wang, Z Y; Chen, B; Wan, J H; Wang, L

2016-11-08

Objective: To explore the manual operation skills of operative treatment of ipsilateral Hawkins Ⅲ talus neck and ankle joint fractures via internal and lateral approaches with Herbert screws, and to study the clinical results. Method: From Jan 2009 to Dec 2014, the clinical data of 13 patients with ipsilateral Hawkins Ⅲ talus neck and ankle joint fractres via internal and lateral approaches with Herbert screws were retrospectively analyzed in our department.There were 10 males and 3 female, ranging in age from 20 to 60 years with an average age of 31.5 years.The fractures occurred on the right side in 9 patients and on the left side in 4 patients.Three cases had the complication of medial malleolar fracture.Ten cases had the complication of medial and lateral malleolar fracture. Totally 11 cases were made calcaneal skeletal traction, and all the were made CT with three-dimensional image reconstruction.Two cases were treated with emergency operation.Eleven cases were treated with selective operation.The operation time was 5 hours-10 days after injury. The functional results were evaluated by American Orthopaedic Foot and Ankle Society (AOFAS). Result: The average duration of follow-up was 22.6 months (range, 14-65 months). There was skin necrosis in one cases, no incision infection, malunion and nonunion of the fractures and loss of reduction. At final follow-up, AOFAS ankle score was 75.2 (range, 42 to 93), higher than preoperative 39.2 (range, 23 to 60), the difference was statistically significant ( P =0.023). The result was excellent in 4 cases, good in 5 cases, fair in 3 cases and 1 cases in poor, and the overall excellent or good rate was 69.2%. Avascular necrosis occurred in 3 cases (23.1%, 3/13). Traumatic arthritis was found in 5 cases (38.5%, 5/13), involved tibial astragaloid joint in 2 cases, involved subtalar joint in 1 case, involved tibial astragaloid joint and subtalar joint in 2 cases. Conclusion: The effect of surgical treatment for ipsilateral Hawkins Ⅲ talus neck and ankle joint fractures via internal and lateral approaches with Herbert screws is satisfactory.Correct operative approach and pay more attention to protect blood circulation of intraoperative, anatomical precision and strong reduction and fixation are the key to achieve and gain better long-term results for the surgical treatment of ipsilateral Hawkins Ⅲ talus neck and ankle joint fractures.

A comparison of bone density and bone morphology between patients presenting with hip fractures, spinal fractures or a combination of the two

PubMed Central

2013-01-01

Background Currently it is uncertain how to define osteoporosis and who to treat after a hip fracture. There is little to support the universal treatment of all such patients but how to select those most in need of treatment is not clear. In this study we have compared cortical and trabecular bone status between patients with spinal fractures and those with hip fracture with or without spinal fracture with the aim to begin to identify, by a simple clinical method (spine x-ray), a group of hip fracture patients likely to be more responsive to treatment with current antiresorptive agents. Methods Comparison of convenience samples of three groups of 50 patients, one with spinal fractures, one with a hip fracture, and one with both. Measurements consist of bone mineral density at the lumbar spine, at the four standard hip sites, number, distribution and severity of spinal fractures by the method of Genant, cortical bone thickness at the infero-medial femoral neck site, femoral neck and axis length and femoral neck width. Results Patients with spinal fractures alone have the most deficient bones at both trabecular and cortical sites: those with hip fracture and no spinal fractures the best at trabecular bone and most cortical bone sites: and those with both hip and spinal fractures intermediate in most measurements. Hip axis length and neck width did not differ between groups. Conclusion The presence of the spinal fracture indicates poor trabecular bone status in hip fracture patients. Hip fracture patients without spinal fractures have a bone mass similar to the reference range for their age and gender. Poor trabecular bone in hip fracture patients may point to a category of patient more likely to benefit from therapy and may be indicated by the presence of spinal fractures. PMID:23432767

Paratrooper's Ankle Fracture: Posterior Malleolar Fracture

PubMed Central

Young, Ki Won; Cho, Jae Ho; Kim, Hyung Seuk; Cho, Hun Ki; Lee, Kyung Tai

2015-01-01

Background We assessed the frequency and types of ankle fractures that frequently occur during parachute landings of special operation unit personnel and analyzed the causes. Methods Fifty-six members of the special force brigade of the military who had sustained ankle fractures during parachute landings between January 2005 and April 2010 were retrospectively analyzed. The injury sites and fracture sites were identified and the fracture types were categorized by the Lauge-Hansen and Weber classifications. Follow-up surveys were performed with respect to the American Orthopedic Foot and Ankle Society ankle-hindfoot score, patient satisfaction, and return to preinjury activity. Results The patients were all males with a mean age of 23.6 years. There were 28 right and 28 left ankle fractures. Twenty-two patients had simple fractures and 34 patients had comminuted fractures. The average number of injury and fractures sites per person was 2.07 (116 injuries including a syndesmosis injury and a deltoid injury) and 1.75 (98 fracture sites), respectively. Twenty-three cases (41.07%) were accompanied by posterior malleolar fractures. Fifty-five patients underwent surgery; of these, 30 had plate internal fixations. Weber type A, B, and C fractures were found in 4, 38, and 14 cases, respectively. Based on the Lauge-Hansen classification, supination-external rotation injuries were found in 20 cases, supination-adduction injuries in 22 cases, pronation-external rotation injuries in 11 cases, tibiofibular fractures in 2 cases, and simple medial malleolar fractures in 2 cases. The mean follow-up period was 23.8 months, and the average follow-up American Orthopedic Foot and Ankle Society ankle-hindfoot score was 85.42. Forty-five patients (80.36%) reported excellent or good satisfaction with the outcome. Conclusions Posterior malleolar fractures occurred in 41.07% of ankle fractures sustained in parachute landings. Because most of the ankle fractures in parachute injuries were compound fractures, most cases had to undergo surgical repairs. PMID:25729514

Paratrooper's ankle fracture: posterior malleolar fracture.

PubMed

Young, Ki Won; Kim, Jin-su; Cho, Jae Ho; Kim, Hyung Seuk; Cho, Hun Ki; Lee, Kyung Tai

2015-03-01

We assessed the frequency and types of ankle fractures that frequently occur during parachute landings of special operation unit personnel and analyzed the causes. Fifty-six members of the special force brigade of the military who had sustained ankle fractures during parachute landings between January 2005 and April 2010 were retrospectively analyzed. The injury sites and fracture sites were identified and the fracture types were categorized by the Lauge-Hansen and Weber classifications. Follow-up surveys were performed with respect to the American Orthopedic Foot and Ankle Society ankle-hindfoot score, patient satisfaction, and return to preinjury activity. The patients were all males with a mean age of 23.6 years. There were 28 right and 28 left ankle fractures. Twenty-two patients had simple fractures and 34 patients had comminuted fractures. The average number of injury and fractures sites per person was 2.07 (116 injuries including a syndesmosis injury and a deltoid injury) and 1.75 (98 fracture sites), respectively. Twenty-three cases (41.07%) were accompanied by posterior malleolar fractures. Fifty-five patients underwent surgery; of these, 30 had plate internal fixations. Weber type A, B, and C fractures were found in 4, 38, and 14 cases, respectively. Based on the Lauge-Hansen classification, supination-external rotation injuries were found in 20 cases, supination-adduction injuries in 22 cases, pronation-external rotation injuries in 11 cases, tibiofibular fractures in 2 cases, and simple medial malleolar fractures in 2 cases. The mean follow-up period was 23.8 months, and the average follow-up American Orthopedic Foot and Ankle Society ankle-hindfoot score was 85.42. Forty-five patients (80.36%) reported excellent or good satisfaction with the outcome. Posterior malleolar fractures occurred in 41.07% of ankle fractures sustained in parachute landings. Because most of the ankle fractures in parachute injuries were compound fractures, most cases had to undergo surgical repairs.

The new intra-articular calcaneal fracture classification system in term of sustentacular fragment configurations and incorporation of posterior calcaneal facet fractures with fracture components of the calcaneal body.

PubMed

Harnroongroj, Thossart; Harnroongroj, Thos; Suntharapa, Thongchai; Arunakul, Marut

2016-10-01

The aim of this study was to develop a new calcaneal fracture classification system which will consider sustentacular fragment configuration and relation of posterior calcaneal facet to calcaneal body. The new classification system used sustentacular fragment configuration and relation of posterior calcaneal facet fracture with fracture components of calcaneal body as key aspects of main types and subtypes. Between 2000 and 2014, 126 intraarticular calcaneal fractures were classified according to the new classification system by using computed tomography images. The new classification system was studied in term of reliability, correlation to choices of treatment, implant fixation and quality of fracture reduction. Types of sustentacular fragment comprised type A, B and C. Type A sustentacular fragment included sustentacular tali containing middle calcaneal facet. In Type B and C fractures sustentacular fragment included medial aspect and entire posterior calcaneal facet as a single unit, respectively. The fractures with type A, B and C sustentacular fragments were classified as main type A, B and C intra-articular calcaneal fractures. The main type A and B comprised 4 subtypes. Subtypes A1, A3, B1, and B3 associated with avulsion and bending fragments of calcaneal body. Subtype A2, B2, and B4 associated with burst calcaneal body. Subtype B4 was not found in the study. Main type C had no subtype and associated with burst calcaneal body. The data showed good reliability. The study showed that our new intra-articular calcaneal fracture classification system correlates to choices of treatment, implant fixation and quality of fracture reduction. Level IV, Study of Diagnostic Test. Copyright © 2016 Turkish Association of Orthopaedics and Traumatology. Production and hosting by Elsevier B.V. All rights reserved.

High-Risk Stress Fractures: Diagnosis and Management.

PubMed

McInnis, Kelly C; Ramey, Lindsay N

2016-03-01

Stress fractures are common overuse injuries in athletes. They occur during periods of increased training without adequate rest, disrupting normal bone reparative mechanisms. There are a host of intrinsic and extrinsic factors, including biochemical and biomechanical, that put athletes at risk. In most stress fractures, the diagnosis is primarily clinical, with imaging indicated at times, and management focused on symptom-free relative rest with advancement of activity as tolerated. Overall, stress fractures in athletes have an excellent prognosis for return to sport, with little risk of complication. There is a subset of injuries that have a greater risk of fracture progression, delayed healing, and nonunion and are generally more challenging to treat with nonoperative care. Specific locations of high-risk stress fracture include the femoral neck (tension side), patella, anterior tibia, medial malleolus, talus, tarsal navicular, proximal fifth metatarsal, and great toe sesamoids. These sites share a characteristic region of high tensile load and low blood flow. High-risk stress fractures require a more aggressive approach to evaluation, with imaging often necessary, to confirm early and accurate diagnosis and initiate immediate treatment. Treatment consists of nonweight-bearing immobilization, often with a prolonged period away from sport, and a more methodic and careful reintroduction to athletic activity. These stress fractures may require surgical intervention. A high index of suspicion is essential to avoid delayed diagnosis and optimize outcomes in this subset of stress fractures. Copyright © 2016 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.

Sonographic measurements of the ulnar nerve at the elbow with different degrees of elbow flexion.

PubMed

Patel, Prutha; Norbury, John W; Fang, Xiangming

2014-05-01

To determine whether there were differences in the cross-sectional area (CSA) and the flattening ratio of the normative ulnar nerve as it passes between the medial epicondyle and the olecranon at 30° of elbow flexion versus 90° of elbow flexion. Bilateral upper extremities of normal healthy adult volunteers were evaluated with ultrasound. The CSA and the flattening ratio of the ulnar nerve at the elbow as it passes between the medial epicondyle and the olecranon were measured, with the elbow flexed at 30° and at 90°, by 2 operators with varying ultrasound scanning experience by using ellipse and direct tracing methods. The results from the 2 different angles of elbow flexion were compared for each individual operator. Finally, intraclass correlations for absolute agreement and consistency between the 2 raters were calculated. An outpatient clinic room at a regional rehabilitation center. Twenty-five normal healthy adult volunteers. The mean CSA and the mean flattening ratio of the ulnar nerve at 30° of elbow flexion and at 90° of elbow flexion. First, for the ellipse method, the mean CSA of the ulnar nerve at 90° (9.93 mm(2)) was slightly larger than at 30° (9.77 mm(2)) for rater 1. However, for rater 2, the mean CSA of the ulnar nerve at 90° (6.80 mm(2)) was slightly smaller than at 30° (7.08 mm(2)). This was found to be statistically insignificant when using a matched pairs t test and the Wilcoxon signed-rank test, with a significance level of .05. Similarly, the difference between the right side and the left side was not statistically significant. The intraclass correlations for absolute agreement between the 2 raters were not very high due to different measurement locations, but the intraclass correlations for consistency were high. Second, for the direct tracing method, the mean CSA at 90° (7.26 mm(2)) was slightly lower than at 30° (7.48 mm(2)). This was found to be statistically nonsignificant when using the matched pairs t test and the Wilcoxon signed-rank test with a significance level of .05. There was no significant difference in the average flattening ratio between the 2 angles for the left arm (0.54 at 30° vs 0.56 at 90°; P = .619 for the matched pairs t test and .274 for the Wilcoxon signed-rank test). However, for the right arm, the flattening ratio at 90° was significantly higher than that at 30° (0.58 at 90° vs 0.50 at 30°; P = .007 for both the matched pairs t test and the Wilcoxon signed-rank test). The mean CSA of the ulnar nerve at the elbow at 30° was not significantly different than at 90°. However, the average flattening ratio at 90° was found to be significantly higher than at 30° for the right arm. Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.

Elbow arthroscopy: valgus extension overload.

PubMed

Ahmad, Christopher S; Conway, John E

2011-01-01

Valgus torque combined with deceleration produces high compression and shear forces acting on the posteromedial olecranon and the posteromedial trochlea. This valgus extension overload process may cause posteromedial trochlea chondromalacia, chondral flap formation, osteochondrosis, subchondral erosion, a subchondral insufficiency fracture, and marginal exostosis formation. Olecranon pathologies include proximal stress reaction, a posteromedial tip stress fracture, a transverse proximal process stress fracture, exostosis formation, exostosis fragmentation, and intra-articular loose bodies. Symptoms include posteromedial elbow pain during the deceleration phase of the throwing motion. The extension impingement test reproduces posterior or posteromedial pain similar to that experienced while throwing. Special radiographic techniques and CT scans can show loose bodies and osteophyte fragmentation. Surgical treatment is indicated when symptoms persist despite nonsurgical management. Based on clinical and basic science research, all patients with valgus extension overload should be comprehensively evaluated for medial ulnar collateral ligament insufficiency. Surgical treatment is limited to the resection of osteophytes only; normal olecranon should not be resected.

Valgus extension overload syndrome and stress injury of the olecranon.

PubMed

Ahmad, Christopher S; ElAttrache, Neal S

2004-10-01

Basic science studies have improved our understanding of the pathomechanics for valgus extension overload and olecranon stress fractures. These disorders result from repetitive abutment of the olecranon into the olecranon fossa combined with valgus torques, resulting in impaction and shear along the posteromedial olecranon. The patient history and physical examination are similar for each disorder. Imaging studies including plain radiographs, computed tomography, MRI or bone scan may be necessary for accurate diagnosis. Clinical and basic science support mandatory and careful assessment of the medial collateral ligament when valgus extension overload is identified and limited debridement of the olecranon when surgery is indicated. For stress fractures that fail nonoperative management, treatment with internal fixation provides good results.

Biomechanics of forearm rotation: force and efficiency of pronator teres.

PubMed

Ibáñez-Gimeno, Pere; Galtés, Ignasi; Jordana, Xavier; Malgosa, Assumpció; Manyosa, Joan

2014-01-01

Biomechanical models are useful to assess the effect of muscular forces on bone structure. Using skeletal remains, we analyze pronator teres rotational efficiency and its force components throughout the entire flexion-extension and pronation-supination ranges by means of a new biomechanical model and 3D imaging techniques, and we explore the relationship between these parameters and skeletal structure. The results show that maximal efficiency is the highest in full elbow flexion and is close to forearm neutral position for each elbow angle. The vertical component of pronator teres force is the highest among all components and is greater in pronation and elbow extension. The radial component becomes negative in pronation and reaches lower values as the elbow flexes. Both components could enhance radial curvature, especially in pronation. The model also enables to calculate efficiency and force components simulating changes in osteometric parameters. An increase of radial curvature improves efficiency and displaces the position where the radial component becomes negative towards the end of pronation. A more proximal location of pronator teres radial enthesis and a larger humeral medial epicondyle increase efficiency and displace the position where this component becomes negative towards forearm neutral position, which enhances radial curvature. Efficiency is also affected by medial epicondylar orientation and carrying angle. Moreover, reaching an object and bringing it close to the face in a close-to-neutral position improve efficiency and entail an equilibrium between the forces affecting the elbow joint stability. When the upper-limb skeleton is used in positions of low efficiency, implying unbalanced force components, it undergoes plastic changes, which improve these parameters. These findings are useful for studies on ergonomics and orthopaedics, and the model could also be applied to fossil primates in order to infer their locomotor form. Moreover, activity patterns in human ancient populations could be deduced from parameters reported here.

Mechanical solution for a mechanical problem: Tennis elbow.

PubMed

Rothschild, Bruce

2013-07-18

Lateral epicondylitis is a relatively common clinical problem, easily recognized on palpation of the lateral protuberance on the elbow. Despite the "itis" suffix, it is not an inflammatory process. Therapeutic approaches with topical non-steroidal anti-inflammatory drugs, corticosteroids and anesthetics have limited benefit, as would be expected if inflammation is not involved. Other approaches have included provision of healing cytokines from blood products or stem cells, based on the recognition that this repetitive effort-derived disorder represents injury. Noting calcification/ossification of tendon attachments to the lateral epicondyle (enthesitis), dry needling, radiofrequency, shock wave treatments and surgical approaches have also been pursued. Physiologic approaches, including manipulation, therapeutic ultrasound, phonophoresis, iontophoresis, acupuncture and exposure of the area to low level laser light, has also had limited success. This contrasts with the benefit of a simple mechanical intervention, reducing the stress on the attachment area. This is based on displacement of the stress by use of a thin (3/4-1 inch) band applied just distal to the epicondyle. Thin bands are required, as thick bands (e.g., 2-3 inch wide) simply reduce muscle strength, without significantly reducing stress. This approach appears to be associated with a failure rate less than 1%, assuming the afflicted individual modifies the activity that repeatedly stresses the epicondylar attachments.

Mechanical solution for a mechanical problem: Tennis elbow

PubMed Central

Rothschild, Bruce

2013-01-01

Lateral epicondylitis is a relatively common clinical problem, easily recognized on palpation of the lateral protuberance on the elbow. Despite the “itis” suffix, it is not an inflammatory process. Therapeutic approaches with topical non-steroidal anti-inflammatory drugs, corticosteroids and anesthetics have limited benefit, as would be expected if inflammation is not involved. Other approaches have included provision of healing cytokines from blood products or stem cells, based on the recognition that this repetitive effort-derived disorder represents injury. Noting calcification/ossification of tendon attachments to the lateral epicondyle (enthesitis), dry needling, radiofrequency, shock wave treatments and surgical approaches have also been pursued. Physiologic approaches, including manipulation, therapeutic ultrasound, phonophoresis, iontophoresis, acupuncture and exposure of the area to low level laser light, has also had limited success. This contrasts with the benefit of a simple mechanical intervention, reducing the stress on the attachment area. This is based on displacement of the stress by use of a thin (3/4-1 inch) band applied just distal to the epicondyle. Thin bands are required, as thick bands (e.g., 2-3 inch wide) simply reduce muscle strength, without significantly reducing stress. This approach appears to be associated with a failure rate less than 1%, assuming the afflicted individual modifies the activity that repeatedly stresses the epicondylar attachments. PMID:23878775

Early results for treatment of two- and three-part fractures of the proximal humerus using Contours PHP (proximal humeral plate).

PubMed

Biazzo, Alessio; Cardile, Carlo; Brunelli, Luca; Ragni, Paolo; Clementi, Daniele

2017-04-28

The management of displaced 2- and 3-part fractures of the proximal humerus is controversial, both in younger and in elderly patients. The purpose of this paper is to evaluate the functional results of the Contours Proximal Humerus Plate (OrthofixR, Bussolengo,Verona, Italy), for the treatment of displaced 2- and 3-part fractures of the proximal humerus. We retrospectively reviewed 55 patients with proximal humerus fractures, who underwent osteosynthesis with Contours Proximal Humerus Plate from December 2011 to March 2015. We had 21 patients with 2-part fractures and with an average age of 67.1 years and 34 patients with 3-part fractures, with average age of 63.6 years. The average union time was 3 months. The mean Constant score was 67 for 2-part fracture group and 64.9 for 3-part fracture group. The difference was not statistically significant (p = 0.18). The overall complication rate was 14.5 %. Six patients underwent additional surgery (10.9%). The most frequent major complication was secondary loss of reduction following varus collapse of the fracture (2 cases). In these patients, there was loss of medial hinge integrity due to impaction and osteoporosis. The placement of the main locking screw in the calcar area to provide inferomedial support is the rational of the Contours Proximal Humerus Plate. Osteosynthesis with Contours Proximal Humerus Plate is a safe system for treating displaced 2- and 3-part fractures of the proximal humerus, with good functional results and complication rates comparable to those reported in the literature.

Stress Fractures of the Foot and Ankle in Athletes

PubMed Central

Mayer, Stephanie W.; Joyner, Patrick W.; Almekinders, Louis C.; Parekh, Selene G.

2014-01-01

Context: Stress fractures of the foot and ankle are a common problem encountered by athletes of all levels and ages. These injuries can be difficult to diagnose and may be initially evaluated by all levels of medical personnel. Clinical suspicion should be raised with certain history and physical examination findings. Evidence Acquisition: Scientific and review articles were searched through PubMed (1930-2012) with search terms including stress fractures and 1 of the following: foot ankle, medial malleolus, lateral malleolus, calcaneus, talus, metatarsal, cuboid, cuneiform, sesamoid, or athlete. Study Design: Clinical review. Level of Evidence: Level 5. Results: Stress fractures of the foot and ankle can be divided into low and high risk based upon their propensity to heal without complication. A wide variety of nonoperative strategies are employed based on the duration of symptoms, type of fracture, and patient factors, such as activity type, desire to return to sport, and compliance. Operative management has proven superior in several high-risk types of stress fractures. Evidence on pharmacotherapy and physiologic therapy such as bone stimulators is evolving. Conclusion: A high index of suspicion for stress fractures is appropriate in many high-risk groups of athletes with lower extremity pain. Proper and timely work-up and treatment is successful in returning these athletes to sport in many cases. Low-risk stress fracture generally requires only activity modification while high-risk stress fracture necessitates more aggressive intervention. The specific treatment of these injuries varies with the location of the stress fracture and the goals of the patient. PMID:25364480

Overestimation of femoral tunnel length during anterior cruciate ligament reconstruction using the retrograde outside-in drilling technique.

PubMed

Okazaki, Ken; Osaki, Kanji; Nishikawa, Kazutaka; Matsubara, Hirokazu; Tashiro, Yasutaka; Iwamoto, Yukihide

2016-08-01

When the femoral tunnel socket is reamed in an oblique direction from the wall of inter-condylar notch in anterior cruciate ligament (ACL) reconstruction, the tunnel length can be shorter at the periphery than at the centre. Because surgeons can manipulate the direction of tunnel in the outside-in femoral tunnel drilling technique, this length mismatch would vary depending on the direction of the tunnel. The purpose of this study was to investigate this length mismatch when reamed in various directions. In total of thirteen points were defined as femoral drilling entry points on concentric lines with 0, 1, 2, and 3 cm radius from the lateral epicondyle of a three-dimensional bone model from 40 subjects. Femoral tunnel drilling was simulated on the models by connecting the centre of the ACL footprint with each defined point on the lateral femoral surface. The mismatch length was measured between the centre and the shortest peripheral side of the tunnel socket. When the distance between the drilling entry point on the lateral femoral surface and the lateral epicondyle was increased to anterior proximal direction, there was a significant increase in the mismatch length. The mismatch length became more than 2 mm when the entry point was located more than 2 cm away from the lateral epicondyle. When the drilling entry point is set far away from the lateral epicondyle, a significant increase was observed in tunnel length mismatch between the centre of the tunnel and its shortest peripheral side. Because the tunnel length is measured with a guide pin introduced at the centre of the tunnel before reaming in retrograde outside-in technique, this length mismatch could cause an overestimation of the tunnel length. Surgeons should recognise this mismatch when preparing the length of graft and socket to optimise the graft insertion length into the socket.

Ultrasound-guided percutaneous needle electrolysis in chronic lateral epicondylitis: short-term and long-term results.

PubMed

Valera-Garrido, Fermín; Minaya-Muñoz, Francisco; Medina-Mirapeix, Francesc

2014-12-01

Ultrasound (US)-guided percutaneous needle electrolysis (PNE) is a novel minimally invasive approach which consists of the application of a galvanic current through an acupuncture needle. To evaluate the clinical and ultrasonographic effectiveness of a multimodal programme (PNE, eccentric exercise (EccEx) and stretching) in the short term for patients with chronic lateral epicondylitis, and to determine whether the clinical outcomes achieved decline over time. A one-way repeated measures study was performed in a clinical setting in 36 patients presenting with lateral epicondylitis. The patients received one session of US-guided PNE per week over 4-6 weeks, associated with a home programme of EccEx and stretching. The main outcome measures were severity of pain, disability (Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire), structural tendon changes (US), hypervascularity and patients' perceptions of overall outcome. Measurements at 6, 26 and 52 weeks follow-up included recurrence rates (increase in severity of pain or disability compared with discharge), perception of overall outcome and success rates. All outcome measures registered significant improvements between pre-intervention and discharge. Most patients (n=30, 83.3%) rated the overall outcome as 'successful' at 6 weeks. The ultrasonographic findings showed that the hypoechoic regions and hypervascularity of the extensor carpi radialis brevis changed significantly. At 26 and 52 weeks, all participants (n=32) perceived a 'successful' outcome. Recurrence rates were null after discharge and at follow-up at 6, 26 and 52 weeks. Symptoms and degenerative structural changes of chronic lateral epicondylitis are reduced after US-guided PNE associated with EccEx and stretching, with encouragingly low recurrences in the mid to long term. ClinicalTrials.gov identifier: NCT02085928. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Intramedullary osteosynthesis versus plate osteosynthesis in subtrochanteric fractures.

PubMed

Burnei, C; Popescu, Gh; Barbu, D; Capraru, F

2011-11-14

Due to an ever-aging population and a growing prevalence of osteoporosis and motor vehicle accidents, the number of subtrochanteric fractures is increasing worldwide. The choice of the appropriate implant continues to be critical for fixation of unstable hip fractures. The subtrochanteric region has certain anatomical and biomechanical features that can make fractures in this region difficult to treat. The preferred type of device is a matter of debate. Increased understandings of biomechanical characteristics of the hip and improvement of the implant materials have reduced the incidence of complications. The surgeons choose between the two methods according to Seinsheimer's classification and also to their personal preferences. As a general principle, the open reduction and internal fixation were performed in stable fractures, and the closed reduction and internal fixation were performed in unstable fractures. The advantages of intramedullary nailing consist in a small skin incision, lower operating times, preservation of fracture hematoma and the possibility of early weight bearing. The disadvantages consist in a difficult closed reduction due to important muscular forces, although the nail can be used as a reduction instrument, and higher implant cost. In open reduction internal fixation techniques, the advantage is represented by anatomical reduction which, in our opinion, is not necessary. The disadvantages are represented by: higher operating time, demanding surgery, large devascularization, higher infection rates, late weight bearing, medial instability, refracture after plate removal and inesthetic approach.

Intramedullary osteosynthesis versus plate osteosynthesis in subtrochanteric fractures

PubMed Central

Burnei, C; Popescu, Gh; Barbu, D; Capraru, F

2011-01-01

Due to an ever-aging population and a growing prevalence of osteoporosis and motor vehicle accidents, the number of subtrochanteric fractures is increasing worldwide. The choice of the appropriate implant continues to be critical for fixation of unstable hip fractures. The subtrochanteric region has certain anatomical and biomechanical features that can make fractures in this region difficult to treat. The preferred type of device is a matter of debate. Increased understandings of biomechanical characteristics of the hip and improvement of the implant materials have reduced the incidence of complications. The surgeons choose between the two methods according to Seinsheimer's classification and also to their personal preferences. As a general principle, the open reduction and internal fixation were performed in stable fractures, and the closed reduction and internal fixation were performed in unstable fractures. The advantages of intramedullary nailing consist in a small skin incision, lower operating times, preservation of fracture hematoma and the possibility of early weight bearing. The disadvantages consist in a difficult closed reduction due to important muscular forces, although the nail can be used as a reduction instrument, and higher implant cost. In open reduction internal fixation techniques, the advantage is represented by anatomical reduction which, in our opinion, is not necessary. The disadvantages are represented by: higher operating time, demanding surgery, large devascularization, higher infection rates, late weight bearing, medial instability, refracture after plate removal and inesthetic approach. PMID:22514563

Bovine xenograft application for treatment of a metatarsal nonunion fracture in an alpaca (Vicugna pacos).

PubMed

Longo, F; Finotti, L; Bellini, L; Zavan, B; Busetto, R; Isola, M

2016-05-01

A 15-year-old female huacaya alpaca (Vicugna pacos) was referred because of a non-weight-bearing lameness (4/4) in the left pelvic limb caused by a grade three open metatarsal fracture. The referring veterinarian treated the fracture with conservative management using bandages, but it progressively evolved to a non-union. Clinical examination revealed external wounds on the medial and lateral surfaces of the metatarsus. Radiographs confirmed an open, nonarticular, displaced, diaphyseal fracture of the left metatarsus. Cancellous bone was sourced from bovine proximal and distal femur epiphyses, followed by a thermal shock procedure to achieve decellularisation, to produce a xenograft. Open reduction and internal fixation of the fracture using locking plates was performed. Alignment of the fracture fragments was corrected and the xenograft was placed at the debrided fracture site to stimulate and harness osteogenesis in situ. Clinical and radiographic follow-up was performed up to 40 weeks postoperatively. Clinical evaluations revealed that the alpaca gradually increased weight bearing following bandage removal 10 days after surgery. Serial radiographs showed correct alignment of the left metatarsus, progressive bone modelling and, complete bone union at 12 weeks. Ten months postoperatively the alpaca showed no signs of lameness and resumed normal activity. For management of a metatarsal non-union, a combination of bovine xenograft application and angular stable internal fixation progressed toward an excellent long-term recovery.

Lateral and posterior dynamic bending of the mid-shaft femur: fracture risk curves for the adult population.

PubMed

Kennedy, Eric A; Hurst, William J; Stitzel, Joel D; Cormier, Joseph M; Hansen, Gail A; Smith, Eric P; Duma, Stefan M

2004-11-01

The purpose of this study was to develop injury risk functions for dynamic bending of the human femur in the lateral-to-medial and posterior-to-anterior loading directions. A total of 45 experiments were performed on human cadaver femurs using a dynamic three-point drop test setup. An impactor of 9.8 kg was dropped from 2.2 m for an impact velocity of 5 m/s. Five-axis load cells measured the impactor and support loads, while an in situ strain gage measured the failure strain and subsequent strain rate. All 45 tests resulted in mid-shaft femur fractures with comminuted wedge and oblique fractures as the most common fracture patterns. In the lateral-to-medial bending tests the reaction loads were 4180 +/- 764 N, and the impactor loads were 4780 +/- 792 N. In the posterior-to-anterior bending tests the reaction loads were 3780 +/- 930 N, and the impactor loads were 4310 +/- 1040 N. The difference between the sum of the reaction forces and the applied load is due to inertial effects. The reaction loads were used to estimate the mid-shaft bending moments at failure since there was insufficient data to include the inertial effects in the calculations. The resulting moments are conservative estimates (lower bounds) of the mid-shaft bending moments at failure and are appropriate for use in the assessment of knee restraints and pedestrian impacts with ATD measurements. Regression analysis was used to identify significant parameters, and parametric survival analysis was used to estimate risk functions. Femur cross-sectional area, area moment of inertia (I), maximum distance to the neutral axis (c), I/c, occupant gender, and occupant mass are shown to be significant predictors of fracture tolerance, while no significant difference is shown for loading direction, bone mineral density, leg aspect and age. Risk functions are presented for femur cross-sectional area and I/c as they offer the highest correlation to peak bending moment. The risk function that utilizes the most highly correlated (R2 = 0.82) and significant (p = 0.0001) variable, cross-sectional area, predicts a 50 percent risk of femur fracture of 240 Nm, 395 Nm, and 562 Nm for equivalent cross-sectional area of the 5(th) percentile female, 50(th) percentile male, and 95(th) percentile male respectively.

Plantar Loading During Cutting While Wearing a Rigid Carbon Fiber Insert.

PubMed

Queen, Robin M; Abbey, Alicia N; Verma, Ravi; Butler, Robert J; Nunley, James A

2014-02-12

Context : Stress fractures are one of the most common injuries in sports, accounting for approximately 10% of all overuse injuries. Treatment of fifth metatarsal stress fractures involves both surgical and nonsurgical interventions. Fifth metatarsal stress fractures are difficult to treat because of the risks of delayed union, nonunion, and recurrent injuries. Most of these injuries occur during agility tasks, such as those performed in soccer, basketball, and lacrosse. Objective : To examine the effect of a rigid carbon graphite footplate on plantar loading during 2 agility tasks. Design :  Crossover study. Setting : Laboratory. Patients or Other Participants : A total of 19 recreational male athletes with no history of lower extremity injury in the past 6 months and no previous metatarsal stress fractures were tested. Main Outcome Measure(s) :  Seven 45° side-cut and crossover-cut tasks were completed in a shoe with or without a full-length rigid carbon plate. Testing order between the shoe conditions and the 2 cutting tasks was randomized. Plantar-loading data were recorded using instrumented insoles. Peak pressure, maximum force, force-time integral, and contact area beneath the total foot, the medial and lateral midfoot, and the medial, middle, and lateral forefoot were analyzed. A series of paired t tests was used to examine differences between the footwear conditions (carbon graphite footplate, shod) for both cutting tasks independently (α = .05). Results : During the side-cut task, the footplate increased total foot and lateral midfoot peak pressures while decreasing contact area and lateral midfoot force-time integral. During the crossover-cut task, the footplate increased total foot and lateral midfoot peak pressure and lateral forefoot force-time integral while decreasing total and lateral forefoot contact area. Conclusions : Although a rigid carbon graphite footplate altered some aspects of the plantar- pressure profile during cutting in uninjured participants, it was ineffective in reducing plantar loading beneath the fifth metatarsal.

Plantar Loading During Cutting While Wearing a Rigid Carbon Fiber Insert

PubMed Central

Queen, Robin M.; Abbey, Alicia N.; Verma, Ravi; Butler, Robert J.; Nunley, James A.

2014-01-01

Context Stress fractures are one of the most common injuries in sports, accounting for approximately 10% of all overuse injuries. Treatment of fifth metatarsal stress fractures involves both surgical and nonsurgical interventions. Fifth metatarsal stress fractures are difficult to treat because of the risks of delayed union, nonunion, and recurrent injuries. Most of these injuries occur during agility tasks, such as those performed in soccer, basketball, and lacrosse. Objective: To examine the effect of a rigid carbon graphite footplate on plantar loading during 2 agility tasks. Design:  Crossover study. Setting: Laboratory. Patients or Other Participants: A total of 19 recreational male athletes with no history of lower extremity injury in the past 6 months and no previous metatarsal stress fractures were tested. Main Outcome Measure(s):  Seven 45° side-cut and crossover-cut tasks were completed in a shoe with or without a full-length rigid carbon plate. Testing order between the shoe conditions and the 2 cutting tasks was randomized. Plantar-loading data were recorded using instrumented insoles. Peak pressure, maximum force, force-time integral, and contact area beneath the total foot, the medial and lateral midfoot, and the medial, middle, and lateral forefoot were analyzed. A series of paired t tests was used to examine differences between the footwear conditions (carbon graphite footplate, shod) for both cutting tasks independently (α = .05). Results: During the side-cut task, the footplate increased total foot and lateral midfoot peak pressures while decreasing contact area and lateral midfoot force-time integral. During the crossover-cut task, the footplate increased total foot and lateral midfoot peak pressure and lateral forefoot force-time integral while decreasing total and lateral forefoot contact area. Conclusions: Although a rigid carbon graphite footplate altered some aspects of the plantar-pressure profile during cutting in uninjured participants, it was ineffective in reducing plantar loading beneath the fifth metatarsal. PMID:24955620

Evaluation of the diagnostic accuracy of four-view radiography and conventional computed tomography analysing sacral and pelvic fractures in dogs.

PubMed

Stieger-Vanegas, S M; Senthirajah, S K J; Nemanic, S; Baltzer, W; Warnock, J; Bobe, G

2015-01-01

The purpose of our study was (1) to determine whether four-view radiography of the pelvis is as reliable and accurate as computed tomography (CT) in diagnosing sacral and pelvic fractures, in addition to coxofemoral and sacroiliac joint subluxation or luxation, and (2) to evaluate the effect of the amount of training in reading diagnostic imaging studies on the accuracy of diagnosing sacral and pelvic fractures in dogs. Sacral and pelvic fractures were created in 11 canine cadavers using a lateral impactor. In all cadavers, frog-legged ventro-dorsal, lateral, right and left ventro-45°-medial to dorsolateral oblique frog leg ("rollover 45-degree view") radiographs and a CT of the pelvis were obtained. Two radiologists, two surgeons and two veterinary students classified fractures using a confidence scale and noted the duration of evaluation for each imaging modality and case. The imaging results were compared to gross dissection. All evaluators required significantly more time to analyse CT images compared to radiographic images. Sacral and pelvic fractures, specifically those of the sacral body, ischiatic table, and the pubic bone, were more accurately diagnosed using CT compared to radiography. Fractures of the acetabulum and iliac body were diagnosed with similar accuracy (at least 86%) using either modality. Computed tomography is a better method for detecting canine sacral and some pelvic fractures compared to radiography. Computed tomography provided an accuracy of close to 100% in persons trained in evaluating CT images.

Comparison between Closing-Wedge and Opening-Wedge High Tibial Osteotomy in Patients with Medial Knee Osteoarthritis: A Systematic Review and Meta-analysis.

PubMed

Sun, Hao; Zhou, Lin; Li, Fengsheng; Duan, Jun

2017-02-01

Young active patients with medial knee osteoarthritis (OA) combined with varus leg alignment can be treated with high tibial osteotomy (HTO) to stop the progression of OA and avoid or postpone total knee arthroplasty (TKA). Closing-wedge osteotomy (CWO) and opening-wedge osteotomy (OWO) are the most commonly used osteotomy techniques. The purpose of this study was to compare the clinical and radiologic outcomes and complications between OWO and CWO. We retrospectively evaluated 23 studies including 17 clinical trials from published databases from their inception to May 2015. We evaluated the clinical outcomes including operation time, visual analog scale (VAS), maximal flexion, and hospital for special surgery knee (HSS) score. The radiologic outcomes included patellar height measured by posterior tibial slope angle, hip-knee-ankle (HKA) angle, femorotibial (FT) axis, and limb length. Complications recorded included the incidence of deep vein thrombosis (DVT), common peroneal nerve injury, opposite cortical fracture, etc. There were no differences in most of the clinical outcomes except the operation time. OWO increased the posterior slope angle and limb length, decreased the patellar height, and provided higher accuracy of correction. CWO led to a higher incidence of opposite cortical fracture. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Reconstruction of the pelvic brim and its role in the reduction accuracy of displaced T-shaped acetabular fracture.

PubMed

Harnroongroj, T; Asavamongkolkul, A; Chareancholvanich, K

2000-05-01

Open reduction of the displaced T-shaped acetabular fracture has a problem of accuracy of the fracture reduction. This study was carried out to demonstrate that the reconstruction of the pelvic brim by approaching the pubo-acetabular fragment plays a role in the accuracy of the reduction of displaced T-shaped acetabular fractures. From 1975 to 1990, a retrospective study was carried out of 22 patients who sustained a displaced T-shaped acetabular fracture. The patients were operated on by open reduction and internal fixation of the ischio-acetabular fragment to the posterior column without restoration of the pelvic brim. Radiographs of the pelvis were reviewed. The result showed that there was displacement of the pubo-acetabular fragment including the medial wall in all cases. As the result of this study, a prospective study between 1990 and 1997 was carried out of 15 patients who sustained displaced T-shaped acetabular fractures including 3 cases with medial displacement of the femoral head. The pubo-acetabular fragment was anatomically reduced and fixed to the anterior column of the acetabulumn as the first approach to restore a disrupted pelvic brim. There, patterns of the acetabular fracture were subsequently re-evaluated especially the ischio-acetabular fragment including the position of the femoral head by using an intraoperative portable X-ray technique. The stability of the hip joint was assessed by hip flexion. The intraoperative radiograph appearances of the ischio-acetabular fragment were visually confirmed by a second surgical exposure. The results showed that the intraoperative radiographs gave spontaneous reduction of the ischio-acetabular fragment in all patients except one. There was a reduction of the displaced femoral head into the hip socket in the three patients. The hip joints were stable in all patients. The second surgical exposure showed that there was good spontaneous reduction of the ischio-acetabular fragment to the posterior column by ligamentotaxis in 14 patients. Therefore, it is not necessary to address the ischio-acetabular fragment. In the exceptional case, the ischio-acetabular fragment was displaced as a free bone which could not be reduced by ligamentotaxis. However, reduction and internal fixation of the ischio-acetabular fragment to the posterior column for complete re-application of the hip joint onto the pelvic ring of this case was facilitated. Postoperative 2 year and 5 year follow-up showed that the fracture had healed without heterotrophic ossification or premature osteoarthrosis of the hip joint. The exceptional case had a broken plate at the anterior column of the acetabulum. Hip function was evaluated clinically using Merle D' Aubigne's hip score. All patients had a "very good score". The study showed that reconstruction of the pelvic brim by anatomical reduction and fixation of the pubo-acetabular fragment to the anterior column plays an important role in the accuracy of fracture reduction of a displaced T-shaped acetabular fracture.

Orbital fracture and eyeball rupture caused by golf-club injury.

PubMed

Hwang, Kun; Kim, Joo Ho

2014-05-01

We report a case of an orbital fracture and an eyeball rupture caused by a golf-club injury. A 75-year-old man was struck in his right eye by a golf club while watching behind his son swinging a hybrid-type golf club at his home. A 70-mm muscle-depth laceration was present in the infraorbital area with active bleeding. Computed tomographic imaging of the face revealed a rupture of the right eyeball; fractures in the superior, medial, lateral, and inferior wall of the right orbit; a fracture in the right zygomaticofrontal junction; and a small amount of pneumocephalus in the parafalx region. Under general anesthesia, evisceration of the right eyeball was performed. Not only golfers but also people just watching or passing by can be injured by an errantly struck golf ball or swung golf club. Elderly people as well as children should be instructed in technique and safety and also be supervised when playing golf. Also, the public should be educated about the risk of eye injuries and the benefits of wearing a protective eyewear.

Cell-stimulation therapy of lateral epicondylitis with frequency-modulated low-intensity electric current.

PubMed

Aliyev, R M; Geiger, G

2012-03-01

In addition to the routine therapy, the patients with lateral epicondylitis included into experimental group were subjected to a 12-week cell-stimulation therapy with low-intensity frequency-modulated electric current. The control group received the same routine therapy and sham stimulation (the therapeutic apparatus was not energized). The efficiency of this microcurrent therapy was estimated by comparing medical indices before therapy and at the end of a 12-week therapeutic course using a 10-point pain severity numeric rating scale (NRS) and Roles-Maudsley pain score. The study revealed high therapeutic efficiency of cell-stimulation with low-intensity electric current resulting probably from up-regulation of intracellular transmitters, interleukins, and prostaglandins playing the key role in the regulation of inflammation.

[Application of pie-crusting the medial collateral ligament release in arthroscopic surgery for posterior horn of 
medial meniscus in knee joint].

PubMed

Zhu, Weihong; Tang, Qi; Liao, Lele; Li, Ding; Yang, Yang; Chen, You

2017-09-28

To explore the effectiveness and safety of pie-crusting the medial collateral ligament release (MCL) in treating posterior horn of medial meniscus (PHMM) tear in tight medial tibiofemoral compartment of knee joint.
 Methods: Thirty-two consecutive patients with PHMM tear in tight medial tibiofemoral compartment of knee joint were admitted to our department from January, 2013 to December, 2014. All patients were performed pie-crusting the MCL release at its tibial insertion with 18-gauge intravenous needle. All patients were evaluated by valgus stress test and bilateral valgus stress radiograph at postoperative 1st day, 4th week and 12th week. Visual Analogue Scales (VAS), Lysholm scores, Tegner scores and International Knee Documentation Committee (IKDC) scores were recorded at the 1st, 3th, 6th month follow-up, then follow-up every 6 months.
 Results: The mean follow-up was 28 (24-36) months. All cases were negative in valgus stress test. MCL rupture, femoral fracture, articular cartilage lesion and neurovascular injury were not found at the last follow-up. The median medial joint space width of affected side and unaffected side for valgus stress radiographs were 6.8 mm and 4.3 mm (P<0.05) at the 1st day, 5.5 mm and 4.2 mm 
(P<0.05) in the 4th week and 4.8 mm and 4.3 mm (P>0.05) at the 12th week, respectively. VAS scores was changed from 4.5±1.5 preoperatively to 1.7±1.0 at the final follow-up (t=16.561, P<0.05). Lysholm scores was changed from 52.3±5.8 preoperatively to 93.2±6.3 at the final follow-up (t=-41.353, P<0.05). Tegner scores was changed from 4.1±1.1 preoperatively to 5.5±0.6 at the final follow-up (t=-18.792, P<0.05). IKDC scores was changed from 54.5±6.2 preoperative to 93.8±4.5 at the final follow-up (t=-38.253, P<0.05).
 Conclusion: Pie-crusting the medial collateral ligament release is a safe, minimal invasive and effective surgical option for posterior horn of medial meniscus tear in tight medial tibiofemoral compartment of knee joint.

Prospective Computed Tomographic Analysis of Osteochondral Lesions of the Ankle Joint Associated With Ankle Fractures.

PubMed

Nosewicz, Tomasz L; Beerekamp, M Suzan H; De Muinck Keizer, Robert-Jan O; Schepers, Tim; Maas, Mario; Niek van Dijk, C; Goslings, J Carel

2016-08-01

Osteochondral lesions (OCLs) associated with ankle fracture correlate with unfavorable outcome. The goals of this study were to detect OCLs following ankle fracture, to associate fracture type to OCLs and to investigate whether OCLs affect clinical outcome. 100 ankle fractures requiring operative treatment were prospectively included (46 men, 54 women; mean age 44 ± 14 years, range 20-77). All ankle fractures (conventional radiography; 71 Weber B, 22 Weber C, 1 Weber A, 4 isolated medial malleolus and 2 isolated posterior malleolus fractures) were treated by open reduction and internal fixation. Multidetector computed tomography (CT) was performed postoperatively. For each OCL, the location, size, and Loomer OCL classification (CT modified Berndt and Harty classification) were determined. The subjective Foot and Ankle Outcome Scoring (FAOS) was used for clinical outcome at 1 year. OCLs were found in 10/100 ankle fractures (10.0%). All OCLs were solitary talar lesions. Four OCLs were located posteromedial, 4 posterolateral, 1 anterolateral, and 1 anteromedial. There were 2 type I OCLs (subchondral compression), 6 type II OCLs (partial, nondisplaced fracture) and 2 type IV OCLs (displaced fracture). Mean OCL size (largest diameter) was 4.4 ± 1.7 mm (range, 1.7 mm to 6.2 mm). Chi-square analysis showed no significant association between ankle fracture type and occurrence of OCLs. OCLs did occur only in Lauge-Hansen stage III/IV ankle fractures. There were no significant differences in FAOS outcome between patients with or without OCLs. Ten percent of investigated ankle fractures had associated OCLs on CT. Although no significant association between fracture type and OCL was found, OCLs only occurred in Lauge-Hansen stage III/IV ankle fractures. With the numbers available, OCLs did not significantly affect clinical outcome at 1 year according to FAOS. Level IV, observational study. © The Author(s) 2016.

Morel-Lavallée Lesions of the Knee: MRI Findings Compared With Cadaveric Study Findings.

PubMed

Vassalou, Evangelia E; Zibis, Aristeidis H; Raoulis, Vasileios A; Tsifountoudis, Ioannis P; Karantanas, Apostolos H

2018-05-01

The purpose of this study is to describe the MRI findings and treatment decisions and outcome for Morel-Lavallée lesions (MLLs) of the knee and to investigate whether evidence exists to support an increased frequency of such lesions on the medial or lateral side by performing a cadaveric experiment. In a 4-year period, 24 MRI studies of 24 consecutive patients (16 male patients and eight female patients) with knee MLLs were retrospectively reviewed. Patient demographic characteristics, treatment decisions and outcome, and associated injuries were recorded. The location of the MLL was categorized as medial, lateral, or global. Lesions were categorized according to an established MRI classification. During the cadaveric experiment, the compartmental pressures of the medial or lateral aspect of the knee were monitored in 20 cadaveric knees. The chi-square test, t test, and Pearson correlation were used for statistical analysis. MLLs were located medially in 16 patients, laterally in two patients, and globally in six patients. The medial location was significantly more common than a lateral or global location (p < 0.05). MLLs were classified as type I in 14 patients, type II in eight patients, and type III in two patients. MRI type was correlated with the chronicity of injury (r 2 = 0.614; p = 0.0014). Fractures were the most common associated injuries, occurring in seven of 24 patients. In 17 patients, all of whom had conservatively treated type I or type II lesions, complete resolution of the MLL occurred. The maximum compartmental pressures were significantly higher on the lateral side than on the medial side (p < 0.0001). Knee MLLs have a predilection for the medial side, which may be attributed to the lower resistance in this location, and they have variable patterns on MRI, which correlate with chronicity. Conservative treatment of type I and II lesions seems effective.

Anterolateral Ligament Expert Group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament - deficient knee.

PubMed

Sonnery-Cottet, Bertrand; Daggett, Matthew; Fayard, Jean-Marie; Ferretti, Andrea; Helito, Camilo Partezani; Lind, Martin; Monaco, Edoardo; de Pádua, Vitor Barion Castro; Thaunat, Mathieu; Wilson, Adrian; Zaffagnini, Stefano; Zijl, Jacco; Claes, Steven

2017-06-01

Purpose of this paper is to provide an overview of the latest research on the anterolateral ligament (ALL) and present the consensus of the ALL Expert Group on the anatomy, radiographic landmarks, biomechanics, clinical and radiographic diagnosis, lesion classification, surgical technique and clinical outcomes. A consensus on controversial subjects surrounding the ALL and anterolateral knee instability has been established based on the opinion of experts, the latest publications on the subject and an exchange of experiences during the ALL Experts Meeting (November 2015, Lyon, France). The ALL is found deep to the iliotibial band. The femoral origin is just posterior and proximal to the lateral epicondyle; the tibial attachment is 21.6 mm posterior to Gerdy's tubercle and 4-10 mm below the tibial joint line. On a lateral radiographic view the femoral origin is located in the postero-inferior quadrant and the tibial attachment is close to the centre of the proximal tibial plateau. Favourable isometry of an ALL reconstruction is seen when the femoral position is proximal and posterior to the lateral epicondyle, with the ALL being tight upon extension and lax upon flexion. The ALL can be visualised on ultrasound, or on T2-weighted coronal MRI scans with proton density fat-suppressed evaluation. The ALL injury is associated with a Segond fracture, and often occurs in conjunction with acute anterior cruciate ligament (ACL) injury. Recognition and repair of the ALL lesions should be considered to improve the control of rotational stability provided by ACL reconstruction. For high-risk patients, a combined ACL and ALL reconstruction improves rotational control and reduces the rate of re-rupture, without increased postoperative complication rates compared to ACL-only reconstruction. In conclusion this paper provides a contemporary consensus on all studied features of the ALL. The findings warrant future research in order to further test these early observations, with the ultimate goal of improving the long-term outcomes of ACL-injured patients. Level of evidence Level V-Expert opinion.

The influence of impact direction and axial loading on the bone fracture pattern.

PubMed

Cohen, Haim; Kugel, Chen; May, Hila; Medlej, Bahaa; Stein, Dan; Slon, Viviane; Brosh, Tamar; Hershkovitz, Israel

2017-08-01

The effect of the direction of the impact and the presence of axial loading on fracture patterns have not yet been established in experimental 3-point bending studies. To reveal the association between the direction of the force and the fracture pattern, with and without axial loading. A Dynatup Model POE 2000 (Instron Co.) low energy pendulum impact machine was utilized to apply impact loading on fresh pig femoral bones (n=50). The bone clamp shaft was adjusted to position the bone for three-point bending with and without additional bone compression. Four different directions of the force were applied: anterior, posterior, lateral, and medial. The impacted aspect can be distinguished from the non-impacted aspects based on the fracture pattern alone (the most fractured one); the impact point can be identified on bare bones (the area from which all oblique lines radiate and/or the presence of a chip fragment). None of our experiments (with and without compression) yielded a "true" butterfly fracture, but instead, oblique radiating lines emerged from the point of impact (also known as "false" butterfly). Impacts on the lateral and anterior aspects of the bones produce more and longer fracture lines than impacts on the contralateral side; bones subjected to an impact with axial loading are significantly more comminuted and fragmented. Under axial loading, the number of fracture lines is independent of the impact direction. Our study presents an experimental model for fracture analysis and shows that the impact direction and the presence of axial loading during impact significantly affect the fracture pattern obtained. Copyright © 2017 Elsevier B.V. All rights reserved.

Partial proximal tibia fractures

PubMed Central

Raschke, Michael J.; Kittl, Christoph; Domnick, Christoph

2017-01-01

Partial tibial plateau fractures may occur as a consequence of either valgus or varus trauma combined with a rotational and axial compression component. High-energy trauma may result in a more complex and multi-fragmented fracture pattern, which occurs predominantly in young people. Conversely, a low-energy mechanism may lead to a pure depression fracture in the older population with weaker bone density. Pre-operative classification of these fractures, by Müller AO, Schatzker or novel CT-based methods, helps to understand the fracture pattern and choose the surgical approach and treatment strategy in accordance with estimated bone mineral density and the individual history of each patient. Non-operative treatment may be considered for non-displaced intra-articular fractures of the lateral tibial condyle. Intra-articular joint displacement ⩾ 2 mm, open fractures or fractures of the medial condyle should be reduced and fixed operatively. Autologous, allogenic and synthetic bone substitutes can be used to fill bone defects. A variety of minimally invasive approaches, temporary osteotomies and novel techniques (e.g. arthroscopically assisted reduction or ‘jail-type’ screw osteosynthesis) offer a range of choices for the individual and are potentially less invasive treatments. Rehabilitation protocols should be carefully planned according to the degree of stability achieved by internal fixation, bone mineral density and other patient-specific factors (age, compliance, mobility). To avoid stiffness, early functional mobilisation plays a major role in rehabilitation. In the elderly, low-energy trauma and impression fractures are indicators for the further screening and treatment of osteoporosis. Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160067. Originally published online at www.efortopenreviews.org PMID:28630761

Arthroscopic evaluation of soft tissue injuries in tibial plateau fractures: retrospective analysis of 98 cases.

PubMed

Abdel-Hamid, Mohamed Zaki; Chang, Chung-Hsun; Chan, Yi-Sheng; Lo, Yang-Pin; Huang, Jau-Wen; Hsu, Kuo-Yao; Wang, Ching-Jen

2006-06-01

This investigation arthroscopically assesses the frequency of soft tissue injury in tibial plateau fracture according to the severity of fracture patterns. We hypothesized that use of arthroscopy to evaluate soft tissue injury in tibial plateau fractures would reveal a greater number of associated injuries than have previously been reported. From March 1996 to December 2003, 98 patients with closed tibial plateau fractures were treated with arthroscopically assisted reduction and osteosynthesis, with precise diagnosis and management of associated soft tissue injuries. Arthroscopic findings for associated soft tissue injuries were recorded, and the relationship between fracture type and soft tissue injury was then analyzed. The frequency of associated soft tissue injury in this series was 71% (70 of 98). The menisci were injured in 57% of subjects (56 in 98), the anterior cruciate ligament (ACL) in 25% (24 of 98), the posterior cruciate ligament (PCL) in 5% (5 of 98), the lateral collateral ligament (LCL) in 3% (3 of 98), the medial collateral ligament (MCL) in 3% (3 of 98), and the peroneal nerve in 1% (1 of 98); none of the 98 patients exhibited injury to the arteries. No significant association was noted between fracture type and incidence of meniscus, PCL, LCL, MCL, artery, and nerve injury. However, significantly higher injury rates for the ACL were observed in type IV and VI fractures. Soft tissue injury was associated with all types of tibial plateau fracture. Menisci (peripheral tear) and ACL (bony avulsion) were the most commonly injured sites. A variety of soft tissue injuries are common with tibial plateau fracture; these can be diagnosed with the use of an arthroscope. Level III, diagnostic study.

Is posterior synovial plica excision necessary for refractory lateral epicondylitis of the elbow?

PubMed

Rhyou, In Hyeok; Kim, Kang Wook

2013-01-01

Arthroscopic treatments for lateral epicondylitis including débridement of the extensor carpi radialis brevis (ECRB) origin (Baker technique) or resection of the radiocapitellar synovial plica reportedly improve symptoms. However the etiology of the disease and the role of the plica remain unclear. We asked if posterior radiocapitellar synovial plica excision made any additional improvement in pain or function after arthroscopic ECRB release. We retrospectively reviewed 38 patients who had arthroscopic treatment for refractory lateral epicondylitis between November 2003 and October 2009. Twenty patients (Group A) underwent the Baker technique and 18 patients (Group B) underwent a combination of the Baker technique and posterior synovial plica excision. The minimum followup was 36 months (mean, 46 months; range, 36-72 months) for Group A and 25 months (mean, 30 months; range, 25-36 months) for Group B. Postoperatively we obtained VAS pain and DASH scores for each group. Two years postoperatively, we found no differences in the VAS pain score or DASH: the mean VAS pain scores were 0.3 points in Group A and 0.4 points in Group B, and the DASH scores were 5.1 points and 6.1 points respectively. The addition of débridement of the posterior synovial fold did not appear to enhance either pain relief or function compared with the classic Baker technique without decortication.

The Use of Superselective Arteriography in the Evaluation of the Influence of Intracapsular Hip Joint Pressure on the Blood Flow of the Femoral Head.

PubMed

Wu, Kai; Huang, Jianhua; Wang, Qiugen

2016-01-01

We aimed to analyze the intracapsular pressure of the hip joint following femoral neck fracture and its relationship to the position of the hip or to traction and (using superselective arteriography) to evaluate the blood supply to the femoral head and the influence of traction and hip position on the blood supply. Twenty-six cases of fresh Garden type I-III femoral neck fractures were enrolled. After being placed in the neutral position, in internal rotation or with traction of 3 and 5 kg, respectively, intracapsular manometric changes were measured. Eight cases underwent superselective arteriography of the medial circumflex femoral artery and its branches under the manometric changes of the hip joint capsule. Twenty-four to 48 h after the injury, the intracapsular pressure was significantly higher on the fractured side than on the normal side. The mean pressure was 28.41 ± 9.339 mm Hg in fully extended hips in the neutral position, 79.92 ± 12.80 mm Hg in internally rotated hips, 51.39 ± 15.41 mm Hg in hips with 3 kg of traction and 64.81 ± 13.56 mm Hg in hips with 5 kg of traction. The arteriographic findings revealed that traction and internal rotation reduced the perfusion of the femoral head at the medial circumflex femoral artery and its branches, and also negatively influenced venous reflux. Traction and internal rotation both caused the intracapsular pressure of the hip joint to rise considerably, which reduced the femoral head perfusion and impeded venous reflux. This could lead to avascular necrosis of the femoral head. © 2015 S. Karger AG, Basel.

Tennis elbow surgery - discharge

MedlinePlus

Lateral epicondylitis surgery - discharge; Lateral tendinosis surgery - discharge; Lateral tennis elbow surgery - discharge ... Soon after surgery, severe pain will decrease, but you may have mild soreness for 3 to 6 months.

Can a semi-automated surface matching and principal axis-based algorithm accurately quantify femoral shaft fracture alignment in six degrees of freedom?

PubMed

Crookshank, Meghan C; Beek, Maarten; Singh, Devin; Schemitsch, Emil H; Whyne, Cari M

2013-07-01

Accurate alignment of femoral shaft fractures treated with intramedullary nailing remains a challenge for orthopaedic surgeons. The aim of this study is to develop and validate a cone-beam CT-based, semi-automated algorithm to quantify the malalignment in six degrees of freedom (6DOF) using a surface matching and principal axes-based approach. Complex comminuted diaphyseal fractures were created in nine cadaveric femora and cone-beam CT images were acquired (27 cases total). Scans were cropped and segmented using intensity-based thresholding, producing superior, inferior and comminution volumes. Cylinders were fit to estimate the long axes of the superior and inferior fragments. The angle and distance between the two cylindrical axes were calculated to determine flexion/extension and varus/valgus angulation and medial/lateral and anterior/posterior translations, respectively. Both surfaces were unwrapped about the cylindrical axes. Three methods of matching the unwrapped surface for determination of periaxial rotation were compared based on minimizing the distance between features. The calculated corrections were compared to the input malalignment conditions. All 6DOF were calculated to within current clinical tolerances for all but two cases. This algorithm yielded accurate quantification of malalignment of femoral shaft fractures for fracture gaps up to 60 mm, based on a single CBCT image of the fractured limb. Copyright © 2012 IPEM. Published by Elsevier Ltd. All rights reserved.

Assessment of Lower Limb Prosthesis through Wearable Sensors and Thermography

PubMed Central

Cutti, Andrea Giovanni; Perego, Paolo; Fusca, Marcello C.; Sacchetti, Rinaldo; Andreoni, Giuseppe

2014-01-01

This study aimed to explore the application of infrared thermography in combination with ambulatory wearable monitoring of temperature and relative humidity, to assess the residual limb-to-liner interface in lower-limb prosthesis users. Five male traumatic transtibial amputees were involved, who reported no problems or discomfort while wearing the prosthesis. A thermal imaging camera was used to measure superficial thermal distribution maps of the stump. A wearable system for recording the temperature and relative humidity in up to four anatomical points was developed, tested in vitro and integrated with the measurement set. The parallel application of an infrared camera and wearable sensors provided complementary information. Four main Regions of Interest were identified on the stump (inferior patella, lateral/medial epicondyles, tibial tuberosity), with good inter-subject repeatability. An average increase of 20% in hot areas (P < 0.05) is shown after walking compared to resting conditions. The sensors inside the cuff did not provoke any discomfort during recordings and provide an inside of the thermal exchanges while walking and recording the temperature increase (a regime value is ∼+1.1 ± 0.7 °C) and a more significant one (∼+4.1 ± 2.3%) in humidity because of the sweat produced. This study has also begun the development of a reference data set for optimal socket/liner-stump construction. PMID:24618782

[Trochanteric femoral fractures: anatomy, biomechanics and choice of implants].

PubMed

Bonnaire, F; Lein, T; Bula, P

2011-06-01

The objective of any surgical care of a trochanteric femoral fracture should be the achievement of a stable osteosynthesis that allows early full weight-bearing mobilisation of the patient, because long-term immobilisation soon becomes a vital threat to the affected patients who are usually elderly with correlating comorbidities. The anatomical references of the proximal femur and the structure of the hip joint contain some specifics that play an essential role in the incurrence of a trochanteric femoral fracture and the planning of the osteosynthesis as well. With reposition and fracture stabilisation particular importance must be attached to the collo-diaphyseal and the antetorsion angle so that they do not interfere with the functional interaction of the hip and knee joint. Uncomplex trochanteric fractures ordinarily stabilise sufficiently after reposition so that even an extramedullary implant can ensure full weight-bearing stability. With evermore distal fracture course and intertrochanteric comminution zone, rotational instability and pivot transfer of the fracture area to lateral and caudal are followed by an increase of the dislocating forces. These kinds of fractures (A2 and A3 according to the AO/ASIF classification) profit from an intramedullary and rotationally stable osteosynthesis. Basically primary total hip arthroplasty is a potential option for surgical care of a trochanteric fracture in elderly patients with relevant coxarthrosis. However this procedure can only be recommended in cases of a stable uncomplex fracture. The more the medial interlocking of the proximal femur is destroyed the more difficult it will be to primarily implant a total hip prosthesis with good offset and without a varus and rotational failure in the fracture zone.The current studies in the main show disadvantages due to increased complications in these patients, so that in cases of an unstable trochanteric fracture a primary osteosynthesis should be performed followed by total hip arthroplasty after fracture consolidation has occurred.

Extracorporeal shock wave treatment for chronic lateral epicondylitis (tennis elbow).

PubMed

Ho, C

2007-01-01

(1) Electrohydraulic, electromagnetic, or piezoelectric devices are used to translate energy into acoustic waves during extracorporeal shock wave treatment (ESWT) for chronic lateral epicondylitis (CLE) of the elbow (elbow tendonitis or tennis elbow). These waves may help to accelerate the healing process via an unknown mechanism. (2) Results from randomized controlled trials have been conflicting. Half of the studies showed statistically significant improvement in pain in the treatment group, and half of the studies had data showing no benefit over placebo for any measured outcomes. (3) Limited evidence shows that ESWT is cheaper than arthroscopic surgery, open surgery, and other conservative therapies, such as steroid infiltrations and physiotherapy, that continue for more than six weeks. (4) The lack of convincing evidence regarding its effectiveness does not support the use of ESWT for CLE.

Tennis elbow surgery

MedlinePlus

Lateral epicondylitis - surgery; Lateral tendinosis - surgery; Lateral tennis elbow - surgery ... Surgery to repair tennis elbow is often an outpatient surgery. This means you will not stay in the hospital overnight. You will be given ...

Complex proximal humerus fractures: Hertel's criteria reliability to predict head necrosis.

PubMed

Campochiaro, G; Rebuzzi, M; Baudi, P; Catani, F

2015-09-01

The risk of post-traumatic humeral head avascular necrosis (AVN), regardless of the treatment, has a high reported incidence. In 2004, Hertel et al. stated that the most relevant predictors of ischemia after intracapsular fracture treated with osteosynthesis are the calcar length, medial hinge integrity and some specific fracture types. Based on Hertel's model, the purpose of this study is to evaluate both its reliability and weaknesses in our series of 267 fractures, assessing how the anatomical configuration of fracture, the quality of reduction and its maintenance were predictive of osteonecrosis development, and so to suggest a treatment choice algorithm. A retrospective study, level of evidence IV, was conducted to duly assess the radiographic features of 267 fractures treated from 2004 to 2010 following Hertel's criteria treated with open reduction and internal fixation by angular stability plates and screws. The average age was 65.2 years. The average follow-up was 28.3 ± 17.0 months. The percentage of AVN, the quality and maintenance of reduction obtained during surgery were evaluated. The AVN incidence was 3.7 %. No significant correlation with gender, age and fracture type was found. At the last follow-up X-ray, only 30 % presented all Hertel's good predictors in the AVN group, 4.7 % in the non-AVN group (p < 0.05). About quality of reduction in the AVN group, it was poor in 50 %; while in the non-AVN group, it was poor in 3.4 % (p < 0.05). Four patients with AVN were symptomatic, and three needed a second surgery. Hertel's criteria are important in the surgical planning, but they are not sufficient: an accurate evaluation of the calcar area fracture in three planes is required. All fractures involving calcar area should be studied with CT.

Short frontal plane fractures involving the dorsoproximal articular surface of the proximal phalanx: Description of the injury and a technique for repair.

PubMed

Wright, I M; Minshall, G J

2018-01-01

Chip fractures of the dorsoproximal articular margin of the proximal phalanx are common injuries in racehorses. Large fractures can extend distal to the joint capsule insertion and have been described as dorsal frontal fractures. To report the location and morphology of short frontal plane fractures involving the dorsoproximal articular surface of the proximal phalanx and describe a technique for repair under arthroscopic and radiographic guidance. Single centre retrospective case study. Case records of horses with frontal plane fractures restricted to the dorsoproximal epiphysis and metaphysis of the proximal phalanx referred to Newmarket Equine Hospital were retrieved, images reviewed and lesion morphology described. A technique for repair and the results obtained are reported. A total of 22 fractures in 21 horses commencing at the proximal articular surface exited the dorsal cortex of the proximal phalanx distal to the metacarpophalangeal/metatarsophalangeal joint capsule in 17 hind- and five forelimbs. All were in Thoroughbred racehorses. In 16 cases these were acute racing or training injuries; 20 fractures were medial, one lateral and one was midline. All were repaired with a single lag screw using arthroscopic and radiographically determined landmarks. A total of 16 horses raced after surgery with performance data similar to their preinjury levels. The study demonstrates substantial morphological similarities between individual lesions supporting a common pathophysiology, but does not identify precise causation. There are no cases managed differently that might permit assessment of the comparative efficacy of the treatment described. Short frontal plane fractures involving the dorsoproximal margin of the proximal phalanx that exit the bone distal to the metacarpophalangeal/metatarsophalangeal joint capsule have substantial morphological similarities, are amenable to minimally invasive repair and carry a good prognosis for return to training and racing. © 2017 EVJ Ltd.

FRACTURES OF THE FEMUR NECK RESULTING FROM RADIATION DAMAGE (in German)

DOE Office of Scientific and Technical Information (OSTI.GOV)

Koschitz-Kosic, H.

Fractures of the neck of the femur following radiation therapy may involve three interrelated factors: age of the patient, archetectonic phylogenesis of the femur neck, and onset of radionecrosis. Up to now approximates 144 cases of femur neck fracture have been reported in the literature. Of the 10 cases reported here there was no clear relation between the time of irradiation and the fracture. One fracture followed 35 months after 17,400 r, and another 15 months after 4000 r of x ray, but both of these patients had also received Ra therapy. The average time span between irradiation and fracturemore » was 21 months. Only x ray had been given to five patients, but five had received combined x-ray and Ra treatment. One of the patients with a medial femur neck fracture became ambulatory after three weeks bed rest. The other nine fractures were nailed without any fatality. Subsequently, two cases were practically free of difficulties 12 and 18 months later, three cases exhibited slight fatigue 2, 5, and 63 months later, and five cases limped and required a cane 1, 3, 14, 17, and 76 months later. So far none of the nails have been removed. In no case was there complete recalcification of the fracture, and the ability of the ambulatory patients to walk depended on a combination of callus formation and the support of the nail. The fractures never gave any contraindication for use of the nails. Their use reduced the time for bed rest needed to an average of approximates 5 weeks. Treatment of this type of patient should also include appropriate geriatric and physical therapy measures. (BBB)« less

Proximal tibia stress fracture with Osteoarthritis of knee − Radiological and functional analysis of one stage TKA with long stem

PubMed Central

Soundarrajan, Dhanasekaran; Rajkumar, Natesan; Dhanasekararaja, Palanisamy; Rajasekaran, Shanmuganathan

2018-01-01

Introduction: Proximal tibia stress fractures with knee osteoarthritis pose a challenging situation. We evaluated the radiological and functional outcome of one-stage total knee arthroplasty (TKA) and long stem for patients with varied grades of knee arthritis and proximal tibia stress fractures.  Methods: We analysed 20 patients from April 2012 to March 2017 with proximal tibia stress fractures associated with knee osteoarthritis of varied grades. Out of 20 patients, five were acute fresh fractures. The mean age was 64 years (range, 52–78) which includes three men and 17 women. Previous surgery in the same limb, rheumatoid arthritis, valgus deformity were excluded. All patients were treated with posterior stabilised TKA with long stem, of which, four patients had screw augmentation for medial tibial bone defect and two patients with malunited fracture at stress fracture site required osteotomy, plating and bone grafting. Two patients had two level stress fracture of tibia in the same leg. Results: The mean follow-up period was 28 (range, 6–60) months. The mean tibiofemoral angle improved from 18.27° varus to 1.8° valgus. The mean knee society score improved from 21.9 (range, −10 to 45) to 82.8 (range, 15–99) [p < 0.05]. The mean Knee Society functional score improved from 15.5 (range, −10 to 40) to 76.8 (range, 10–100) [p < 0.05]. All fractures got united at the last follow-up. One patient had infection and wound dehiscence at six months for which debridement done and had poor functional outcome. Conclusion: TKA with long stem gives excellent outcome, irrespective of severity of arthritis associated with stress fracture. By restoring limb alignment and bypassing the fracture site, it facilitates fracture healing. Early detection and prompt intervention is necessary to prevent the progression to recalcitrant non-union or malunion. PMID:29667926

Proximal tibia stress fracture with Osteoarthritis of knee - Radiological and functional analysis of one stage TKA with long stem.

PubMed

Soundarrajan, Dhanasekaran; Rajkumar, Natesan; Dhanasekararaja, Palanisamy; Rajasekaran, Shanmuganathan

2018-01-01

Proximal tibia stress fractures with knee osteoarthritis pose a challenging situation. We evaluated the radiological and functional outcome of one-stage total knee arthroplasty (TKA) and long stem for patients with varied grades of knee arthritis and proximal tibia stress fractures.  Methods: We analysed 20 patients from April 2012 to March 2017 with proximal tibia stress fractures associated with knee osteoarthritis of varied grades. Out of 20 patients, five were acute fresh fractures. The mean age was 64 years (range, 52-78) which includes three men and 17 women. Previous surgery in the same limb, rheumatoid arthritis, valgus deformity were excluded. All patients were treated with posterior stabilised TKA with long stem, of which, four patients had screw augmentation for medial tibial bone defect and two patients with malunited fracture at stress fracture site required osteotomy, plating and bone grafting. Two patients had two level stress fracture of tibia in the same leg. The mean follow-up period was 28 (range, 6-60) months. The mean tibiofemoral angle improved from 18.27° varus to 1.8° valgus. The mean knee society score improved from 21.9 (range, -10 to 45) to 82.8 (range, 15-99) [p < 0.05]. The mean Knee Society functional score improved from 15.5 (range, -10 to 40) to 76.8 (range, 10-100) [p < 0.05]. All fractures got united at the last follow-up. One patient had infection and wound dehiscence at six months for which debridement done and had poor functional outcome. TKA with long stem gives excellent outcome, irrespective of severity of arthritis associated with stress fracture. By restoring limb alignment and bypassing the fracture site, it facilitates fracture healing. Early detection and prompt intervention is necessary to prevent the progression to recalcitrant non-union or malunion. © The Authors, published by EDP Sciences, 2018.

Biomechanics important to interpret radiographs of the hip

DOE Office of Scientific and Technical Information (OSTI.GOV)

Rosenthal, D.I.; Scott, J.A.

1983-02-01

Biomechanic principles have important implications to film interpretation. Angulation of the femoral neck results in four different types of forces: compression on the medial side, tension on the lateral side, shear stress in the center, and torque forces at the neck-shaft angle. The body's response to these forces results in recognicable trabecular patterns which respond in a predictable manner to disease states. Surgical intervention in the form of hip replacement or fracture fixation must reflect these engineering consideration.

Assessment of Biomarkers Associated with Joint Injury and Subsequent Post-Traumatic Arthritis

DTIC Science & Technology

2014-10-01

histological assessment. Subchondral bone thickening was significantly increased in the C57BL/6 mice compared to the MRL/MpJ mice in the medial femur (p...human knee following articular injury. Biomarkers will be correlated to joint pathology that will be assessed from microCT and histology . The human...fracturing, sacrificing, and collection of biosamples. MicroCT and histologic analyses have also been completed for the short-term cohort. We have

The origin of channels and associated deposits in the Elysium region of Mars

NASA Technical Reports Server (NTRS)

Christiansen, Eric H.; Hoppin, Richard A.

1987-01-01

Photogeological studies of the Elysium volcanic province of Mars show that its sinuous channels are part of a large deposit which probably was emplaced as a series of huge volcanic debris flows or lahars. The suggestion is based on evidence that the lahars were : (1) gravity-driven mass flow deposits (lobate outlines, steep snouts, smooth medial channels and rough lateral deposits--the deposits narrow and widen in accord with topography, and they extend downslope); (2) wet (channeled surfaces, drainage features); and (3) associated with volcanism (the deposits and channels extend from a system of fractures which fed lava flows). It is conceivable that heat associated with magmatism melted ground ice below the Elysium volcanoes, formed a muddy slurry which issued out of regional fractures and spread over the adjoining plain.

Treatment of a Femur Nonunion with Microsurgical Corticoperiosteal Pedicled Flap from the Medial Femoral Condyle

PubMed Central

Guzzini, Matteo; Guidi, Marco; Civitenga, Carolina; Ferri, Germano; Ferretti, Andrea

2016-01-01

Introduction. The vascularized corticoperiosteal flap is harvested from the medial femoral condyle and it is nourished by the articular branch of the descending genicular artery and the superomedial genicular artery. This flap is usually harvested as a free flap for the reconstruction of bone defects at forearm, distal radius, carpus, hand, and recently at lower limb too. Case Report. A 50-year-old Caucasian man referred to our department for hypertrophic nonunion of the distal femur, refractory to the conservative treatments. The first surgical choice was the revision of the nail and the bone reconstruction with a corticoperiosteal pedicled flap from the medial femoral condyle. We considered union to have occurred 3.5 months after surgery when radiographs showed bridging of at least three of the four bony cortices and clinically the patient was able to walk with full weight bearing without any pain. At the last follow-up (25 months), the patient was completely satisfied with the procedure. Discussion. The corticoperiosteal flap allows a faster healing of fractures with a minimal morbidity at the donor site. We suggest that the corticoperiosteal pedicled flap graft is a reliable and effective treatment for distal femur nonunion. PMID:27064589

Acute Pelvic Fractures: II. Principles of Management.

PubMed

Tile

1996-05-01

The past two decades have seen many advances in pelvic-trauma surgery. Provisional fixation of unstable pelvic-ring disruptions and open-book fractures with a pelvic clamp or an external frame with a supracondylar pin has proved markedly beneficial in the resuscitative phase of management. In the completely unstable pelvis, external clamps and frames can act only as provisional fixation and should be combined with skeletal traction. The traction pin is usually used only until a definitive form of stabilization can be applied to keep the pelvic ring in a reduced position. If the patient is too ill to allow operative intervention, the traction pin can remain in place with the external frame as definitive treatment. Symphyseal disruptions and medial ramus fractures should be plated at the time of laparotomy. Lateral ramus fractures can usually be controlled with external frames. A role has been suggested for percutaneous retrograde fixation of the superior pubic ramus; however, the benefits to be gained may not be enough to outweigh the serious risks of penetrating the hip, and this technique should therefore be used only by surgeons trained in its performance. The techniques for posterior fixation are becoming more standardized, but all still carry significant risks, especially to neurologic structures.

Posttraumatic Bone Marrow Lesion Volume and Knee Pain Within 4 Weeks After Anterior Cruciate Ligament Injury

PubMed Central

Lohmander, Stefan; Frobell, Richard B.

2017-01-01

Context:  After an anterior cruciate ligament (ACL) injury, a majority of patients have a traumatic bone marrow lesion (BML, or bone bruise). The clinical relevance of posttraumatic lesions remains unclear. Objective:  To explore the cross-sectional associations between traumatic BML volume and self-reported knee pain and symptoms among individuals within 4 weeks of ACL injury. Design:  Cross-sectional exploratory analysis of a randomized clinical trial. Setting:  Orthopaedic departments at 2 hospitals in Sweden. Patients or Other Participants:  As part of a randomized trial (knee anterior cruciate ligament nonoperative versus operative treatment [KANON] study), 121 young active adults (74% men, age = 26 ± 5 years, height = 1.8 ± 0.1 m, weight = 76 ± 13 kg) with an ACL tear were studied. Main Outcome Measure(s):  The BML volume in the proximal tibia and distal femur was segmented using magnetic resonance images obtained within 4 weeks of injury. A radiologist evaluated the presence of depression fractures on the images. Pain and symptoms of the injured knee (Knee Injury and Osteoarthritis Outcome Score [KOOS] pain and symptoms subscales) were obtained the same day as imaging. We used linear regression models to assess the associations. Results:  Most knees had at least 1 BML (96%), and the majority (57%) had a depression fracture. Whole-knee BML volume was not related to knee pain for the entire cohort (β = −0.09, P = .25). Among those without a depression fracture, larger whole-knee BML volume was associated with increased knee pain (β = –0.46, P = .02), whereas no association was found for those with a depression fracture (β = 0.0, P = .96). Larger medial (β = –0.48, P = .02) but not lateral (β = –0.03, P = .77) tibiofemoral BML volume was associated with greater pain. We found no association between BML volume and knee symptoms. Conclusions:  We confirmed the absence of relationships between whole-knee BML volume and pain and symptoms within 4 weeks of ACL injury. Our findings extend previous reports in identifying weak associations between larger BML volume in the medial compartment and greater pain and between BML volume and greater pain among those without a depression fracture. PMID:28653872

[One case report: removal of foreign body in ethmoidal sinus-medial orbital wall through nose assisted by endoscope].

PubMed

Yang, Zeyin; Yang, Xiaohong

2013-07-01

The patient was male, 20 years old, and complained of pain, bleeding and decreased vision after the right eye was injured by nail for an hour. right exophthalmos, conjunctival edema, skin laceration at the lower eyelid of right eye, limitation of eye movement, asymmetric eyes and weak light-reflecting. X-ray showed: metallic foreign body shadow in the right orbit, 0.5 cm x 0.4 cm approximately. Orbit and paranasal sinus CT showed: 1 hematoma of the right eye and inside. 2 high density foreign body embedded in the bone wall of the inside of right orbit and ethmoid. 3 medial wall fracture of right eye orbit. 4 bilateral maxillary sinus and right ethmoidal sinus effusion. 5 slightly left side of nasal septum. The patient was initially diagnosed as foreign body in right ethmoidal sinus, skin laceration of right lower eyelid, retrobulbar hematoma.

The specific scintigraphic pattern of "shin splints in the lower leg": concise communication.

PubMed

Holder, L E; Michael, R H

1984-08-01

The clinical entity, "shin splints," is now being recognized, and more specifically characterized by the findings of exercise-induced pain and tenderness to palpation along the posterior medial border of the tibia. In this prospective study, ten patients with this syndrome were evaluated using three-phase bone scintigrams, and a specific scintigraphic pattern was determined. Radionuclide angiograms and blood-pool images were all normal. On delayed images, tibial lesions involved the posterior cortex, were longitudinally oriented, were long, involving one third of the length of the bone, and often showed varying tracer uptake along that length. Obtaining both lateral and medial views was crucial. The location of activity suggested that this entity is related to the soleus muscle. These scintigraphic findings can be used to differentiate shin splints from stress fractures or other conditions causing pain in the lower leg in athletes.

Treatment of recurrent patellar dislocation via knee arthroscopy combined with C-arm fluoroscopy and reconstruction of the medial patellofemoral ligament.

PubMed

Li, Li; Wang, Hongbo; He, Yun; Si, Yu; Zhou, Hongyu; Wang, Xin

2018-06-01

Recurrent patellar dislocations were treated via knee arthroscopy combined with C-arm fluoroscopy, and reconstruction of the medial patellofemoral ligaments. Between October 2013 and March 2017, 52 cases of recurrent patellar dislocation [27 males and 25 females; age, 16-47 years (mean, 21.90 years)] were treated. Arthroscopic exploration was performed and patellofemoral joint cartilage injuries were repaired. It was subsequently determined whether it was necessary to release the lateral patellofemoral support belt. Pre-operative measurements were used to decide whether tibial tubercle osteotomy was required. Medial patellofemoral ligaments were reconstructed using autologous semitendinosus tendons. Smith and Nephew model 3.5 line anchors were used to double-anchor the medial patellofemoral margin. On the femoral side, the medial patellofemoral ligament was fixed using 7-cm, absorbable, interfacial compression screws. All cases were followed for 1-40 months (average, 21 months). The Q angle, tibial tuberosity trochlear groove distance, Insall-Salvati index, patellofemoral angle, lateral patellofemoral angle and lateral shift were evaluated on X-Ray images using the picture archiving and communication system. Subjective International Knee Documentation Committee (IKDC) knee joint functional scores and Lysholm scores were recorded. Post-operative fear was absent, and no patellar re-dislocation or re-fracture was noted during follow-up. At the end of follow-up, the patellofemoral angle (0.22±4.23°), lateral patellofemoral angle (3.44±1.30°), and lateral shift (0.36+0.14°) differed significantly from the pre-operative values (all, P<0.05). Furthermore, IKDC and Lysholm scores (87.84+3.74 and 87.48+3.35, respectively) differed significantly from the pre-operative values (both, P<0.05). These findings suggest that, in the short term, recurrent patellar dislocation treatment via knee arthroscopy combined with C-arm fluoroscopy and reconstruction of the medial patellofemoral ligament was effective.

Joint capsule attachment to the extensor carpi radialis brevis origin: an anatomical study with possible implications regarding the etiology of lateral epicondylitis.

PubMed

Nimura, Akimoto; Fujishiro, Hitomi; Wakabayashi, Yoshiaki; Imatani, Junya; Sugaya, Hiroyuki; Akita, Keiichi

2014-02-01

To identify the unique anatomical characteristic of the extensor carpi radialis brevis (ECRB) origin and points of differentiation from other extensors and to clarify the specific relationship of the ECRB to the underlying structures. We studied the origin of each extensor macroscopically for its muscular and tendinous parts; to identify the relationship between the ECRB origin and the deeper structures, we also examined the attachment of the joint capsule under the ECRB origin. The ECRB simply originated as a tendon without any muscle, whereas other extensors originated as a mixture of tendon and muscle. At the anterior part of the ECRB origin, the thin attachment of the joint capsule (average width, 3.3 mm) lay deep to the ECRB and was distinct. However, at the posterodistal portion, the joint capsule, annular ligament, and supinator were intermingled and originated as a single wide sheet from the humerus (average width, 10.7 mm). The anterior part of the ECRB origin was delicate, because the ECRB origin was purely tendinous, and the attachment of the articular capsule was thin compared with that of the posterodistal attachment. This thin attachment could be an initial factor leading to the development of lateral epicondylitis. The results of the current study may enhance magnetic resonance imaging understanding and may help clarify the etiology of the lateral epicondylitis. Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Ultrasound-guided percutaneous bone drilling for the treatment of lateral epicondylitis.

PubMed

Yoo, Sang Ho; Cha, Jang Gyu; Lee, Bo Ra

2018-01-01

To determine the clinical efficacy of sonographically-guided percutaneous bone drilling of the lateral epicondyle (LE) for the treatment of patients with LE. We included 24 patients with LE who reported pain in this study. All patients underwent sonographically-guided percutaneous bone drilling of the lateral epicondyle. Follow-up sonography and physical examinations were performed 1, 3 and 6 months after the procedure. The outcome measures included sonographic findings, visual analogue scale (VAS) score, maximum voluntary grip strength (MVGS) and patient-related tennis elbow evaluation (PRTEE) score. None of the patients had immediate complications during the procedure. The area of the extensor carpi radialis brevis (ECRB) tears decreased significantly at 1 month and declined gradually over the remaining 5 months of the study (p < 0.001). The mean pain VAS score was significantly lower at 6 months than preoperatively (respectively; p < 0.001). The mean MVGS increased significantly between pretreatment and 6 months post-treatment (p < 0.001), whereas the PRTEE score decreased significantly during the same period (p < 0.001). Sonographically-guided percutaneous drilling is a quick and safe treatment option for LE that can be performed in an outpatient setting. • Percutaneous drilling of the lateral condyle is effective for the treatment of LE. • The area of ECRB tears can be measured by US-guided saline injection. • US-guided percutaneous drilling is a quick and safe treatment option for LE.

Evaluation of stability of osteosynthesis with K-wires on an artificial model of tibial malleolus fracture.

PubMed

Bumči, Igor; Vlahović, Tomislav; Jurić, Filip; Žganjer, Mirko; Miličić, Gordana; Wolf, Hinko; Antabak, Anko

2015-11-01

Paediatric ankle fractures comprise approximately 4% of all paediatric fractures and 30% of all epiphyseal fractures. Integrity of the ankle "mortise", which consists of tibial and fibular malleoli, is significant for stability and function of the ankle joint. Tibial malleolar fractures are classified as SH III or SH IV intra-articular fractures and, in cases where the fragments are displaced, anatomic reposition and fixation is mandatory. Type SH III-IV fractures of the tibial malleolus are usually treated with open reduction and fixation with cannulated screws that are parallel to the physis. Two K-wires are used for temporary stabilisation of fragments during reduction. A third "guide wire" for the screw is then placed parallel with the physis. Considering the rules of mechanics, it is assumed that the two temporary pins with the additional third pin placed parallel to the physis create a strong triangle and thus provide strong fracture fixation. To prove this hypothesis, an experiment was conducted on the artificial models of the lower end of the tibia from the company "Sawbones". Each model had been sawn in a way that imitates the fracture of medial malleoli and then reattached with 1.8mm pins in various combinations. Prepared models were then tested for tensile and pressure forces. The least stable model was that in which the fractured pieces were attached with only two parallel pins. The most stable model comprised three pins, where two crossed pins were inserted in the opposite compact bone and the third pin was inserted through the epiphysis parallel with and below the growth plate. A potential method of choice for fixation of tibial malleolar fractures comprises three K-wires, where two crossed pins are placed in the opposite compact bone and one is parallel with the growth plate. The benefits associated with this method include shorter operating times and avoidance of a second operation for screw removal. Copyright © 2015 Elsevier Ltd. All rights reserved.

Intramedullary nailing of clavicular midshaft fractures in adults using titanium elastic nail.

PubMed

Chen, Qing-Yu; Kou, Dong-Quan; Cheng, Xiao-Jie; Zhang, Wei; Wang, Wei; Lin, Zhang-Qin; Cheng, Shao-Wen; Shen, Yue; Ying, Xiao-Zhou; Peng, Lei; Lv, Chuan-Zhu

2011-01-01

Studies showed elastic stable intramedullary nailing (ESIN) of displaced midclavicular fractures has excellent outcomes, as well as high complication rates and specific problems. The aim was to discuss ESIN of midshaft clavicular fractures. Totally 60 eligible patients (aged 18-63 years) were randomized to either ESIN group or non-operative group between January 2007 and May 2008. Clavicular shortening was measured after trauma and osseous consolidation. Radiographic union and complications were assessed. Function analysis including Constant shoulder scores and disabilities of the arm, shoulder and hand (DASH) scores were performed after a 15-month follow-up. ESIN led to a signifcantly shorter time to union, especially for simple fractures. In ESIN group, all patients got fracture union, of which 5 cases had medial skin irritation and 1 patient needed revision surgery because of implant failure. In the nonoperative group, there were 3 nonunion cases and 2 symptomatic malunions developed requiring corrective osteotomy. At 15 months after intramedullary stabilization, patients in the ESIN group were more satisfied with the appearance of the shoulder and overall outcome, and they benefited a lot from the great improvement of post-traumatic clavicular shortening. Furthermore, DASH scores were lower and Constant scores were significantly higher in contrast to the non-operative group. ESIN is a safe minimally invasive surgical technique with lower complication rate, faster return to daily activities, excellent cosmetic and better functional results, restoration of clavicular length for treating mid-shaft clavicular fractures, resulting in high overall satisfaction, which can be regard as an alternative to plate fixation or nonoperative treatment of mid-shaft clavicular fractures.

Radiography versus computed tomography for displacement assessment in calcaneal fractures.

PubMed

Ogawa, Brent K; Charlton, Timothy P; Thordarson, David B

2009-10-01

Coronal computed tomography (CT) scans are commonly used in fracture classification systems for calcaneus fractures. However, they may not accurately reflect the amount of fracture displacement. The purpose of this paper was to determine whether lateral radiographs provide superior assessment of the displacement of the posterior facet compared to coronal CT scans. Lateral radiographs of calcaneus fractures were compared with CT coronal images of the posterior facet in 30 displaced intra-articular calcaneus fractures. The average patient age was 39 years old. Using a Picture Archiving and Communication System (PACS), measurements were obtained to quantify the amount of displacement on the lateral radiograph and compared with the amount of depression on corresponding coronal CT scans. On lateral radiographs, the angle of the depressed portion of the posterior facet relative to the undersurface of the calcaneus averaged 28.2 degrees; Bohler's angle averaged 12.7 degrees. These numbers were poorly correlated (r = 0.25). In corresponding CT images from posterior to anterior, the difference in the amount of displacement of the lateral portion of the displaced articular facet versus the nondisplaced medial, constant fragment, was minimal and consistently underestimated the amount of displacement. Underestimation of the amount of depression and rotation of the posterior facet fragment was seen on the coronal CT scan. We attribute this finding to the combined rotation and depression of the posterior facet which may not be measured accurately with the typical semicoronal CT orientation. While sagittal reconstructed images would show this depression better, if they are unavailable we recommend using lateral radiographs to better gauge the amount of fracture displacement.

Polyaxial Screws in Locked Plating of Tibial Pilon Fractures.

PubMed

Yenna, Zachary C; Bhadra, Arup K; Ojike, Nwakile I; Burden, Robert L; Voor, Michael J; Roberts, Craig S

2015-08-01

This study examined the axial and torsional stiffness of polyaxial locked plating techniques compared with fixed-angle locked plating techniques in a distal tibia pilon fracture model. The effect of using a polyaxial screw to cross the fracture site was examined to determine its ability to control relative fracture site motion. A laboratory experiment was performed to investigate the biomechanical stiffness of distal tibia fracture models repaired with 3.5-mm anterior polyaxial distal tibial plates and locking screws. Sawbones Fourth Generation Composite Tibia models (Pacific Research Laboratories, Inc, Vashon, Washington) were used to model an Orthopaedic Trauma Association 43-A1.3 distal tibia pilon fracture. The polyaxial plates were inserted with 2 central locking screws at a position perpendicular to the cortical surface of the tibia and tested for load as a function of axial displacement and torque as a function of angular displacement. The 2 screws were withdrawn and inserted at an angle 15° from perpendicular, allowing them to span the fracture and insert into the opposing fracture surface. Each tibia was tested again for axial and torsional stiffness. In medial and posterior loading, no statistically significant difference was found between tibiae plated with the polyaxial plate and the central screws placed in the neutral position compared with the central screws placed at a 15° position. In torsional loading, a statistically significant difference was noted, showing greater stiffness in tibiae plated with the polyaxial plate and the central screws placed at a 15° position compared with tibiae plated with the central screws placed at a 0° (or perpendicular) position. This study showed that variable angle constructs show similar stiffness properties between perpendicular and 15° angle insertions in axial loading. The 15° angle construct shows greater stiffness in torsional loading. Copyright 2015, SLACK Incorporated.

[Medial versus lateral plating in distal tibial fractures: a prospective study of 40 fractures].

PubMed

Encinas-Ullán, C A; Fernandez-Fernandez, R; Rubio-Suárez, J C; Gil-Garay, E

2013-01-01

Tibial plafond fractures are one of the most challenging injuries in orthopaedic surgery. Their results could be improved by following the new guidelines for the management, and modern plating techniques. The results and complication rate between anteromedial and anterolateral approach for open reduction and internal fixation of these fractures were compared. A study was conducted on 40 patients treated by open reduction an internal fixation between 2007 and 2008. The surgical approach was selected by the surgeon in charge, depending on fracture pattern and skin situation. Patients were evaluated clinically and radiographically by an independent orthopaedic surgeon, not involved in the surgical procedure, using clinical (American Orthopaedic Foot and Ankle Society score) and radiological criteria at a minimum of two years. The appearance of complications after both approaches was recorded. Forty patients were included. The mean age was 53 years, with 24 males and 16 females. Seventeen of the injuries were of high energy, and there were 8 open fractures (3 of type i, 4 type ii and one type iii), and 12 of the closed injuries were grade ii or iii in the Tscherne classification. Six patients (15%) had associated injuries. At final follow-up there were 33 (82%) excellent or good results. No statistical differences were found between either surgical approach regarding time to bone union, rate of delayed union and infection rate. Three plates of the anteromedial group and none of the anterolateral group needed to be removed. Open reduction and internal fixation of distal tibia fractures produced reliable results, with no statistical differences found between anteromedial and anterolateral surgical approaches. Clinical and radiological results and complication rate were mainly related to the fracture type. Copyright © 2012 SECOT. Published by Elsevier Espana. All rights reserved.

Increase of cortical bone after a cementless long stem in periprosthetic fractures.

PubMed

García-Rey, Eduardo; García-Cimbrelo, Eduardo; Cruz-Pardos, Ana; Madero, Rosário

2013-12-01

Healing and functional recovery have been reported using an extensively porous-coated stem in Vancouver B2 and B3 periprosthetic fractures; however, loss of cortical bone has been observed when using these stems in revision surgery for aseptic loosening. However, it is unclear whether this bone loss influences subsequent loosening. We analyze the healing fracture rate and whether the radiographic changes observed around and extensively porous-coated stem used for periprosthetic fractures affect function or loosening. We retrospectively reviewed 35 patients with periprosthetic fractures (20 Vancouver B2 and 15 Vancouver B3). Patients' mean age at surgery was 80 years (range, 51-86 years). No cortical struts were used in this series. We evaluated radiographs for signs of loosening or subsidence. The cortical index and the femoral cortical width were measured at different levels on the immediate pre- and postoperative radiographs and at different periods of followup. The minimum followup was 3 years (mean, 8.3 years; range, 3-17 years). All fractures had healed, and all stems were clinically and radiographically stable at the end of followup. Nineteen hips showed nonprogressive radiographic subsidence during the first 3 postoperative months without clinical consequences. The cortical index and the lateral and medial cortical thickness increased over time. Increase of femoral cortex thicknesses was greater in cases with moderate preoperative osteoporosis and in cases with stems less than 16 mm in thickness. Our data suggest an extensively porous-coated stem for Vancouver B2 and B3 periprosthetic fractures leads to a high rate of union and stable fixation. Cortical index and lateral cortex thickness increased in these patients with periprosthetic fractures. Patients with moderate osteoporosis and those using thin stems showed a major increase in femoral cortex thickness over time.

Lateral unicompartmental knee arthroplasty through a lateral parapatellar approach has high early survivorship.

PubMed

Berend, Keith R; Kolczun, Michael C; George, Joseph W; Lombardi, Adolph V

2012-01-01

The literature suggests lateral unicompartmental knee arthroplasties are associated with low revision rates. However, there are fewer reports describing techniques for lateral unicompartmental arthroplasty and whether technique influences ROM and function compared to reports for medial unicompartmental arthroplasty. We report our indications for lateral unicompartmental arthroplasty, how we perform this procedure, and the subsequent Knee Society scores, ROM, and revision and reoperation rates. From a retrospective review of electronic records from 2004 through 2008, we identified 93 patients who had 100 lateral unicompartmental arthroplasties. Indications were complete lateral bone-on-bone arthrosis with a correctible deformity and maintenance of the medial joint space on varus stress radiographs or isolated lateral disease by diagnostic arthroscopy. Average age was 68 years. Seventy percent of patients were women. At followup, we obtained Knee Society scores and ROM. Minimum followup was 24 months (average, 39 months; range, 24-81 months). At followup, Knee Society scores averaged 46 for pain, 94 for clinical, and 89 for function, and ROM averaged 124°. Three patients had reoperations: one an open reduction and internal fixation for fracture at 2 years postoperatively, one an arthroscopy for a medial meniscal tear, and one a revision for pain. Based on our observations, we believe complete cartilage loss laterally and correctible deformity with maintenance of the medial joint on varus stress radiographs are reasonable indications for lateral unicompartmental arthroplasty. We recommend a lateral parapatellar approach can be utilized. The early reoperation and revision rates were low.

The effect of methotrexate on the bone healing of mandibular condylar process fracture: an experimental study in rats.

PubMed

Cavalcanti, Samantha Cristine Santos X B; Corrêa, Luciana; Mello, Suzana Beatriz Veríssimo; Luz, João Gualberto C

2014-10-01

Methotrexate (MTX) is an anti-metabolite used in rheumatology and oncology. High doses are indicated for oncological treatment, whereas low doses are indicated for chronic inflammatory diseases. This study evaluated the effect of two MTX treatment schedules on the bone healing of the temporomandibular joint fracture in rats. Seventy-five adult male Wistar rats were used to generate an experimental unilateral medially rotated condylar fracture model that allows an evaluation of bone healing and the articular structures. The animals were subdivided into three groups that each received one of the following treatments intraperitoneally: saline (1 mL/week), low-dose MTX (3 mg/kg/week) and high-dose MTX (30 mg/kg). The histological study comprised fracture site and temporomandibular joint evaluations and bone neoformation was evaluated by histomorphometric analysis. A biochemical parameter of bone formation was also assessed. When compared with saline, high-dose MTX delayed bone fracture repairs. In this latter group, after 90 days, the histological analysis revealed atrophy of the fibrocartilage and the presence of fibrous tissue in the joint space. The histomorphometric analysis revealed diminished bone neoformation. The alkaline phosphatase levels also decreased after MTX treatment. It was concluded that high-dose MTX impaired mandibular condyle repair and induced degenerative articular changes. Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Arthroscopic-assisted Locking Compression Plate clavicular hook fixation for unstable fractures of the lateral end of the clavicle: a prospective study

PubMed Central

Lee, Kwang Won; Kim, Kap Jung; Kim, Yong In; Kwon, Won Cho; Choy, Won Sik

2009-01-01

The aim of this prospective study was to assess the clinical outcomes of an unstable fracture of the lateral end of the clavicle treated with an arthroscopic-assisted locking compressive plate (LCP) clavicular hook plate. Twenty-three patients underwent arthroscopic assisted LCP clavicular hook plate fixation for these fractures. All patients achieved clinical and radiological union over a mean of 4.2 months (range, 3.4–5 months). Four patients (17%) showed some degree of acromial osteolysis. Three patients (13%) showed radiological signs of arthrosis of the acromioclavicular joint. In one patient, a second fracture (stress) was observed between the medial two screws of the plate without an additional injury. Five patients (22%) showed subacromial bursitis on dynamic ultrasonography. The mean Constant and Murley score was 91 points (range, 81–98). The average level of pain in the shoulder at rest and on abduction was 1 (range, 0–2) and 2.4 (range, 0–4), respectively. Based on our experience, arthroscopic-assisted LCP hook plate fixation for the treatment of unstable fractures of the lateral end of the clavicle is not without complications. However, it is an acceptable alternative method that is easy to apply with good results. Furthermore, it prevents rotator cuff impingement, allows early mobilisation and maintains the acromioclavicular joint biomechanics. PMID:19998033

Traumatic globe luxation associated with orbital fracture in a child: a case report and literature review.

PubMed

Amaral, Márcio Bruno Figueiredo; Carvalho, Matheus Furtado; Ferreira, André Baptista; Mesquita, Ricardo Alves

2015-03-01

Orbital fracture associated with traumatic globe luxation is rare, as it generally requires trauma with high energy for this to occur. The present case report focused on a child who had been hit by a motorcycle, leading to a globe luxation of the left eye and fractures of the superolateral orbital walls. The patient presented initial cosmetic and psychological benefits from the repositioning of the intact globe and the reduction of the orbital fractures. However, a subsequent evisceration of the globe was required due to persistent proptosis and pain. An ocular prosthesis was also implanted, thus recovering the patient's aesthetics. Thirty-four well-documented cases of traumatic globe luxation could be found in the English literature since 1970. The mean age of patients presenting traumatic globe luxation was 29.5 years. The male gender proved to be more prevalent, with traffic collisions representing the most common accident etiology. Direct orbital trauma with fractures of medial and floor walls displacing the globe into the maxillary sinus represented the most common injury mechanism (38.2 %), followed by an elongated object entering the orbit (26.5 %). Optical nerve avulsion is the most serious complication seen in association with traumatic globe luxation, with the repositioning of the initial globe, with no enucleation or evisceration, representing the main form of management.

Proximal Humerus Fractures: Evaluation and Management in the Elderly Patient

PubMed Central

Grawe, Brian

2018-01-01

Introduction: Proximal humerus fractures are common in the elderly. The evaluation and management of these injuries is often controversial. The purpose of this study is to review recent evidence and provide updated recommendations for treating proximal humerus fractures in the elderly. Methods: A literature review of peer-reviewed publications related to the evaluation and management of proximal humerus fractures in the elderly was performed. There was a focus on randomized controlled trials and systematic reviews published within the last 5 years. Results: The incidence of proximal humerus fractures is increasing. It is a common osteoporotic fracture. Bone density is a predictor of reduction quality and can be readily assessed with anteroposterior views of the shoulder. Social independence is a predictor of outcome, whereas age is not. Many fractures are minimally displaced and respond acceptably to nonoperative management. Displaced and severe fractures are most frequently treated operatively with intramedullary nails, locking plates, percutaneous techniques, or arthroplasty. Discussion: Evidence from randomized controlled trials and systematic reviews is insufficient to recommend a treatment; however, most techniques have acceptable or good outcomes. Evaluation should include an assessment of the patient’s bone quality, social independence, and surgical risk factors. With internal fixation, special attention should be paid to medial comminution, varus angulation, and restoration of the calcar. With arthroplasty, attention should be paid to anatomic restoration of the tuberosities and proper placement of the prosthesis. Conclusion: A majority of minimally displaced fractures can be treated conservatively with early physical therapy. Treatment for displaced fractures should consider the patient’s level of independence, bone quality, and surgical risk factors. Fixation with percutaneous techniques, intramedullary nails, locking plates, and arthroplasty are all acceptable treatment options. There is no clear evidence-based treatment of choice, and the surgeon should consider their comfort level with various procedures during the decision-making process. PMID:29399372

Do Tibial Plateau Fractures Worsen Outcomes of Knee Ligament Injuries? A Matched Cohort Analysis

PubMed Central

Cinque, Mark E.; Godin, Jonathan A.; Moatshe, Gilbert; Chahla, Jorge; Kruckeberg, Bradley M.; Pogorzelski, Jonas; LaPrade, Robert F.

2017-01-01

Background: Tibial plateau fractures account for a small portion of all fractures; however, these fractures can pose a surgical challenge when occurring concomitantly with ligament injuries. Purpose/Hypothesis: The purpose of this study was to compare 2-year outcomes of soft tissue reconstruction with or without a concomitant tibial plateau fracture and open reduction internal fixation. We hypothesized that patients with a concomitant tibial plateau fracture at the time of soft tissue surgery would have inferior outcomes compared with patients without an associated tibial plateau fracture. Study Design: Cohort study; Level of evidence, 3. Methods: Forty patients were included in this study: 8 in the fracture group and 32 in the matched control group. Inclusion criteria for the fracture group included patients who were at least 18 years old at the time of surgery and sustained a tibial plateau fracture and a concomitant injury of the anterior cruciate ligament, posterior cruciate ligament, medial collateral ligament, or fibular collateral ligament in isolation or any combination of cruciate or collateral ligaments and who subsequently underwent isolated or combined ligament reconstruction. Patients were excluded if they underwent prior ipsilateral knee surgery, sustained additional bony injuries, or sustained an isolated extra-articular ligament injury at the time of injury. Each patient with a fracture was matched with 4 patients from a control group who had no evidence of a tibial plateau fracture but underwent the same soft tissue reconstruction procedure. Results: Patients in the fracture group improved significantly from preoperatively to postoperatively with respect to Short Form–12 (P < .05) and Western Ontario and McMaster Universities Osteoarthritis Index total scores (P < .05). The Lysholm (P = .075) and Tegner scores (P = .086) also improved, although this was not statistically significant. Patients in the control group improved significantly from preoperatively to postoperatively across all measured scores. A comparison of the postoperative results between the 2 groups showed no statistically significant difference. Conclusion: The presence of a tibial plateau fracture in conjunction with a ligamentous knee injury did not have a negative effect on postoperative patient-reported outcomes. Patient-reported outcome scores after surgery in both the fracture and control groups improved beyond the minimally clinically important difference, indicating that the presence of a fracture did not detract from the outcomes observed in patients without fractures undergoing concomitant ligament reconstruction. PMID:28840154

The effects of work organization on the health of immigrant manual workers: A longitudinal analysis.

PubMed

Arcury, Thomas A; Chen, Haiying; Mora, Dana C; Walker, Francis O; Cartwright, Michael S; Quandt, Sara A

2016-01-01

This analysis uses a longitudinal design to examine the associations of work organization and health outcomes among Latino manual workers. Participants included 247 Latino workers who completed baseline and 1-year follow-up interviews and clinical examinations. Health outcome measures were epicondylitis, rotator cuff syndrome, back pain, and depressive symptoms. Independent measures were measures of job demand, job control, and job support. Workers commonly experienced rotator cuff syndrome (6.5%), back pain (8.9%), and depressive symptoms (11.2%); fewer experienced epicondylitis (2.4%). Psychological demand was associated with rotator cuff syndrome; awkward position and decision latitude were associated with back pain. Decreased skill variety but increased decision latitude was associated with elevated depressive symptoms. Work context factors are important for health outcomes among vulnerable workers. Further research is needed to expand upon this work, particularly cultural perspectives on job support.

EFFICACY OF TENNIS ELBOW (EPICONDYLITIS HUMERI RADIALIS) TREATMENT IN CBR “PRAXIS”

PubMed Central

Pecar, Džemal; Avdić, Dijana

2009-01-01

Tennis elbow (Epicondylitis humeri radialis) is the most frequent reason that patients with elbow pain report to a physician. The exact cause of elbow pain is still unclear. However, it is certainly causally connected with connective intersection between forearm muscle and bone in the elbow region. In this paper, we analyzed patients that, over the period of 15 years, reported to “Praxis” clinic for elbow pain treatment (Epicondylitis humeri radialis). Of the total number of 228 patients, 126 were male, 101 female while one patient was younger than 14. Initial analysis established that average overall health condition grade was 2,87 at the onset of treatment. Following the treatment completion that grade was 4,48. Of the total number of 223 patients who were treated by combined method of manipulation and local corticosteroid instillation, eight patients received physical therapy as well. Thus, surgical treatment was not necessary in any patient. The patients’ treatment included: Application of manipulative methods in order to reestablish mobility in the “blocked” radio-humeral and the upper radio-ulnar joints. Local instillation of corticosteroid depot in order to control inflammation (enthesitis) and thus, eliminate pain and establish physiological conditions for functioning of joint and local structures. Unlike conservative method which includes initial immobilization due to irritation and inflammation development prevention with concomitant analgesic and antirheumatic therapy, initial application of manipulation with reinstatement of joint mobility instead of immobilization with subsequent instillation of steroid preparations achieves functional restitution and fast reinstatement of full working ability, as a rule. PMID:19284391

Efficacy of tennis elbow (epicondylitis humeri radialis) treatment in CBR "Praxis".

PubMed

Pecar, Dzemal; Avdić, Dijana

2009-02-01

Tennis elbow (Epicondylitis humeri radialis) is the most frequent reason that patients with elbow pain report to a physician. The exact cause of elbow pain is still unclear. However, it is certainly causally connected with connective intersection between forearm muscle and bone in the elbow region. In this paper, we analyzed patients that, over the period of 15 years, reported to "Praxis" clinic for elbow pain treatment (Epicondylitis humeri radialis). Of the total number of 228 patients, 126 were male, 101 female while one patient was younger than 14. Initial analysis established that average overall health condition grade was 2,87 at the onset of treatment. Following the treatment completion that grade was 4,48. Of the total number of 223 patients who were treated by combined method of manipulation and local corticosteroid instillation, eight patients received physical therapy as well. Thus, surgical treatment was not necessary in any patient. The patients' treatment included: 1. Application of manipulative methods in order to reestablish mobility in the "blocked" radio-humeral and the upper radio-ulnar joints. 2. Local instillation of corticosteroid depot in order to control inflammation (enthesitis) and thus, eliminate pain and establish physiological conditions for functioning of joint and local structures. Unlike conservative method which includes initial immobilization due to irritation and inflammation development prevention with concomitant analgesic and antirheumatic therapy, initial application of manipulation with reinstatement of joint mobility instead of immobilization with subsequent instillation of steroid preparations achieves functional restitution and fast reinstatement of full working ability, as a rule.

Percutaneous Needle Tenotomy for the Treatment of Lateral Epicondylitis: A Systematic Review of the Literature.

PubMed

Mattie, Ryan; Wong, Joseph; McCormick, Zachary; Yu, Sloane; Saltychev, Mikhail; Laimi, Katri

2017-06-01

To analyze the literature to determine whether controlled studies on percutaneous tenotomy have been published, and if so, to systematically assess the efficacy of percutaneous tenotomy for the treatment of tendinosis at the lateral epicondyle of the elbow. Systematic review of the available literature. Cochrane Controlled Trials Register (CENTRAL), MEDLINE, EMBASE, CINAHL, and Web of Science databases were searched in November 2015, unrestricted by date. After the initial search, we excluded conference proceedings, theses, reviews, expert opinions, and publications written in languages other than English. Next, 2 independent reviewers screened all of the remaining records with regard to their titles and abstracts, and subsequently, the full texts of identified publications potentially relevant to the present study. Six articles focused on percutaneous tenotomy, none of which were controlled against a placebo or conservative treatment group. The absence of true randomized controlled trials created a great deal of heterogeneity between the studies; thus we could not include any of our studies in the intended final quantitative analysis with meta-analysis tools. We describe all 6 studies identified by this systematic review with a detailed analysis of the procedural methods, outcome measures, and conclusions of each study. Percutaneous tenotomy presents an alternative to surgical release of the common extensor tendon for the treatment of chronic tendinosis at the lateral epicondyle of the elbow. Current research supporting the efficacy of this procedure, however, is of low quality (level II to level IV). III. Copyright © 2017 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.

Anatomical considerations of fascial release in ulnar nerve transposition: a concept revisited.

PubMed

Mahan, Mark A; Gasco, Jaime; Mokhtee, David B; Brown, Justin M

2015-11-01

Surgical transposition of the ulnar nerve to alleviate entrapment may cause otherwise normal structures to become new sources of nerve compression. Recurrent or persistent neuropathy after anterior transposition is commonly attributable to a new distal compression. The authors sought to clarify the anatomical relationship of the ulnar nerve to the common aponeurosis of the humeral head of the flexor carpi ulnaris (FCU) and flexor digitorum superficialis (FDS) muscles following anterior transposition of the nerve. The intermuscular septa of the proximal forearm were explored in 26 fresh cadaveric specimens. The fibrous septa and common aponeurotic insertions of the flexor-pronator muscle mass were evaluated in relation to the ulnar nerve, with particular attention to the effect of transposition upon the nerve in this region. An intermuscular aponeurosis associated with the FCU and FDS muscles was present in all specimens. Transposition consistently resulted in angulation of the nerve during elbow flexion when this fascial septum was not released. The proximal site at which the nerve began to traverse this fascial structure was found to be an average of 3.9 cm (SD 0.7 cm) from the medial epicondyle. The common aponeurosis encountered between the FDS and FCU muscles represents a potential site of posttransposition entrapment, which may account for a subset of failed anterior transpositions. Exploration of this region with release of this structure is recommended to provide an unconstrained distal course for a transposed ulnar nerve.

Imaging three-dimensional innervation zone distribution in muscles from M-wave recordings

NASA Astrophysics Data System (ADS)

Zhang, Chuan; Peng, Yun; Liu, Yang; Li, Sheng; Zhou, Ping; Zev Rymer, William; Zhang, Yingchun

2017-06-01

Objective. To localize neuromuscular junctions in skeletal muscles in vivo which is of great importance in understanding, diagnosing and managing of neuromuscular disorders. Approach. A three-dimensional global innervation zone imaging technique was developed to characterize the global distribution of innervation zones, as an indication of the location and features of neuromuscular junctions, using electrically evoked high-density surface electromyogram recordings. Main results. The performance of the technique was evaluated in the biceps brachii of six intact human subjects. The geometric centers of the distributions of the reconstructed innervation zones were determined with a mean distance of 9.4  ±  1.4 cm from the reference plane, situated at the medial epicondyle of the humerus. A mean depth was calculated as 1.5  ±  0.3 cm from the geometric centers to the closed points over the skin. The results are consistent with those reported in previous histology studies. It was also found that the volumes and distributions of the reconstructed innervation zones changed as the stimulation intensities increased until the supramaximal muscle response was achieved. Significance. Results have demonstrated the high performance of the proposed imaging technique in noninvasively imaging global distributions of the innervation zones in the three-dimensional muscle space in vivo, and the feasibility of its clinical applications, such as guiding botulinum toxin injections in spasticity management, or in early diagnosis of neurodegenerative progression of amyotrophic lateral sclerosis.

Understanding the etiology of the posteromedial tibial stress fracture.

PubMed

Milgrom, Charles; Burr, David B; Finestone, Aharon S; Voloshin, Arkady

2015-09-01

Previous human in vivo tibial strain measurements from surface strain gauges during vigorous activities were found to be below the threshold value of repetitive cyclical loading at 2500 microstrain in tension necessary to reduce the fatigue life of bone, based on ex vivo studies. Therefore it has been hypothesized that an intermediate bone remodeling response might play a role in the development of tibial stress fractures. In young adults tibial stress fractures are usually oblique, suggesting that they are the result of failure under shear strain. Strains were measured using surface mounted unstacked 45° rosette strain gauges on the posterior aspect of the flat medial cortex just below the tibial midshaft, in a 48year old male subject while performing vertical jumps, staircase jumps and running up and down stadium stairs. Shear strains approaching 5000 microstrain were recorded during stair jumping and vertical standing jumps. Shear strains above 1250 microstrain were recorded during runs up and down stadium steps. Based on predictions from ex vivo studies, stair and vertical jumping tibial shear strain in the test subject was high enough to potentially produce tibial stress fracture subsequent to repetitive cyclic loading without necessarily requiring an intermediate remodeling response to microdamage. Copyright © 2015 Elsevier Inc. All rights reserved.

Secure Screw Placement in Management of Acetabular Fractures Using the Suprapectineal Quadrilateral Buttress Plate.

PubMed

Egli, R J; Keel, M J B; Cullmann, J L; Bastian, J D

2017-01-01

Acetabular fractures involving predominantly the anterior column associated with a disruption of the quadrilateral surface can be treated with instrumentation implementing the stabilization of the quadrilateral surface. The recently introduced suprapectineal quadrilateral buttress plate is specifically designed to prevent secondary medial subluxation of the femoral head, especially in elderly patients with reduced ability for partial weight bearing. Whereas there are guidelines available for safe screw fixation for the anterior and posterior columns, there might be a concern for intra-articular placement of screws placed through the infrapectineal part of the quadrilateral buttress plate. Within this report we analyzed retrospectively screw placement in 30 plates in postoperative CT scans using algorithms for metal artifact reduction. None of the screws of the buttress plate penetrated the hip joint. We describe the placement, length, and spatial orientation of the screws used for fracture fixation and suggest that the use of intraoperative image intensifiers with a combined inlet-obturator view of 30-45° best projects the screws and the hip joint. Preoperative knowledge of approximate screw placement and information for accurate intraoperative imaging may contribute to safe acetabular fracture fixation and may reduce operating time and limit radiation exposure to the patient and the personnel. This trial is registered with KEK-BE: 266/2014.

Less-invasive stabilization of rib fractures by intramedullary fixation: a biomechanical evaluation.

PubMed

Bottlang, Michael; Helzel, Inga; Long, William; Fitzpatrick, Daniel; Madey, Steven

2010-05-01

This study evaluated intramedullary fixation of rib fractures with Kirschner wires and novel ribs splints. We hypothesized that rib splints can provide equivalent fixation strength while avoiding complications associated with Kirschner wires, namely wire migration and cutout. The durability, strength, and failure modes of rib fracture fixation with Kirschner wires and rib splints were evaluated in 22 paired human ribs. First, intact ribs were loaded to failure to determine their strength. After fracture fixation with Kirschner wires and rib splints, fixation constructs were dynamically loaded to 360,000 cycles at five times the respiratory load to determine their durability. Finally, constructs were loaded to failure to determine residual strength and failure modes. All constructs sustained dynamic loading without failure. Dynamic loading caused three times more subsidence in Kirschner wire constructs (1.2 mm +/- 1.4 mm) than in rib splint constructs (0.4 mm +/- 0.2 mm, p = 0.09). After dynamic loading, rib splint constructs remained 48% stronger than Kirschner wire constructs (p = 0.001). Five of 11 Kirschner wire constructs failed catastrophically by cutting through the medial cortex, leading to complete loss of stability and wire migration through the lateral cortex. The remaining six constructs failed by wire bending. Rib splint constructs failed by development of fracture lines along the superior and interior cortices. No splint construct failed catastrophically, and all splint constructs retained functional reduction and fixation. Because of their superior strength and absence of catastrophic failure mode, rib splints can serve as an attractive alternative to Kirschner wires for intramedullary stabilization of rib fractures, especially in the case of posterior rib fractures where access for plating is limited.

[A new type sternoclavicular hook plate for unstable sternoclavicular joint dislocation and fracture].

PubMed

Zhang, Chuan-Yi; Lin, Lie; Liang, Jun-Bo; Wang, Bin; Chen, Guo-Fu; Chen, Hai-Xiao

2016-11-25

To evaluate the therapeutic effect of a new type sternoclavicular hook plate fixation in treating unstable sternoclavicular joint dislocation and fracture. From June 2011 to December 2013, 32 patients with sternoclavicular joint dislocation and fracture were treated with a new type sternoclavicular hook plate fixation, including 24 males and 8 females with an average age of 42 years ranging from 25 to 76 years;12 patients were anterior dislocation, 5 pations were posterior dislocation, 10 patients were internal extremity of clavicle fracture and 5 patients were sternoclavicular joint dislocation combined with fracture. The anterior fracture dislocation of the sternoclavicular joint adopted standard sternoclavicular joint hook plate, and the posterior dislocation was at the distal end of the hook of the steel plate, that is, the front part of the handle of the breast was added with a nut and a gasket to prevent the re-dislocation after operation. The results were evaluated according to Rockwood score. No complication happened in all patients. X-ray and CT showed that the dislocation and fracture of the sternoclavicular joint was well reduced and the plate was on right position. All patients were followed up for 6 to 24 months with an average of 10 months. At 6 to 3 months after operation, the fracture was healing without re-dislocation of the sternoclavicular joint, the medial end of the clavicle anatomical structure were restored, functional satisfaction, in which 9 patients with the swelling around sternoclavicular joint, but no pain and other symptoms. The total Rockwood score was 12.78±1.43; the results were excellent in 24 cases, good in 8 cases. The use of the new type of locking hook plate for the treatment of unstable fracture of the sternoclavicular joint, internal fixation is reliable, high security, easy to operate, to provide a reliable method for the treatment of such trauma.

Fixation of 4-part fractures of the proximal humerus: Can we identify radiological criteria that support locking plates or IM nailing? Comparative, retrospective study of 107 cases.

PubMed

Gadea, F; Favard, L; Boileau, P; Cuny, C; d'Ollone, T; Saragaglia, D; Sirveaux, F

2016-12-01

No objective criteria exist to help surgeons choose between IM nailing and plate fixation for 4-part fractures of the proximal humerus. The goal of this study was to identify radiological criteria that would make one technique a better choice than the other. This was a comparative, multicentre, retrospective study of 54 cases of antegrade nailing and 53 cases of plating performed between 1st January 2009 and 31 December 2011 for 4-part fractures of the proximal humerus. All patients had a minimum radiological and clinical follow-up of 18 months. The functional outcomes were evaluated using the weighted Constant score; a poor result was defined as a weighted Constant score<70%. The following radiological criteria were evaluated during the preoperative assessment and at the last follow-up: initial displacement and reduction of humeral head and tuberosities; morphology of the medial column (i.e. calcar comminution, posteromedial hinge, size of metaphyseal head extension); occurrence of avascular necrosis (AVN). After an average follow-up of 42 months, the weighted Constant scores and rate of poor outcomes were 77% and 48% in the nail group and 81% and 38% in the plate group, respectively (ns). The humeral head was reduced into an anatomical position, valgus or varus in 57%, 30% and 13% of cases in the nail group, and 58%, 29% and 13% in the plate group, respectively. The tuberosities healed in an anatomical position in 72% of nail cases and 70% of plate cases (ns). Only the presence of a medial hinge preoperatively had an effect on the functional outcomes in the nail and plate groups: the weighted Constant scores (P=0.05) and rate of poor outcomes (P=0.02) were 82% and 52% in the nail group and 97% and 9% in the plate group, respectively. The complication rates were comparable: the rates of AVN and articular screw penetration were 17% and 11% in the nail group, and 15% and 11% in the plate group, respectively. The surgical revision rate was 18.5% in the nail group and 30% in the plate group. If the medial hinge is preserved, we recommend locking plate fixation. In other cases, either technique can be used as long as the general rules of internal fixation are applied: reduction of the tuberosities, varus correction and stabilization of the calcar area. IV, retrospective study. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

The use of weightbearing radiographs to assess the stability of supination-external rotation fractures of the ankle.

PubMed

Weber, Martin; Burmeister, Helge; Flueckiger, Gerhard; Krause, Fabian G

2010-05-01

Isolated lateral malleolar fractures usually result from a supination-external rotation (SER) injury and may include a deltoid ligament rupture. The necessity of operative treatment is based on the recognition of a relevant medial soft-tissue disruption. Currently used tests to assess ankle stability include manual stress radiographs and gravity stress radiographs, but seem to overestimate the need for fracture fixation. We investigated the use of weightbearing radiographs to distinguish stable and unstable isolated lateral malleolar fractures induced by the SER mechanism in 57 patients. Patients with stable fractures (SER type II according to the Lauge-Hansen classification) were treated non-operatively with varying external support. Forty-seven patients were evaluated by questionnaire and AOFAS ankle-hindfoot score. Follow-up was 18-120 months (mean 62). Fifty-one of fifty-seven (90%) patients were found to have stable fractures (SER type II) and were treated nonoperatively. The AOFAS score was 96.1 points on average (range 85-100) at latest follow-up. Four patients reported minor complaints. A "moderate" correlation of risk factors (i.e. smoking) to delayed bone healing was found while the correlation of varying external support (i.e. bandage, cast) to the AOFAS score and delayed bone healing was "poor". The use of weightbearing radiographs is an easy, pain-free, safe and reliable method to exclude the need for operative treatment, with excellent clinical outcome in the majority of the patients seen at latest follow-up. The delay of 3-10 days until the decision about surgical treatment is well accepted by the patients.

Protruding anterior medial meniscus-An indirect sign of posterior cruciate ligament deficiency.

PubMed

Parkar, Anagha P; Bleskestad, Kristiane; Løken, Susanne; Adriaensen, Miraude E A P M; Solheim, Eirik

2018-02-01

to examine if PROTruding of the Anterior Medial Meniscus (PROTAMM) could be an indirect sign of PCL deficiency by comparing PROTAMM to passive posterior tibial sagging (PSS) for chronic PCL rupture on routine MRI. Patients with PCL reconstruction between 2011 and 2016 were included in a case control study. Primarily cases with combined ACL/PCL injury were excluded. Secondary exclusion criteria were bony fractures, medial meniscus pathology and poor quality MRIs. Three (blinded) observers reviewed the pre-operative MRIs according to a pre-defined protocol. After applying the inclusion and primary exclusion criteria 16 patients were identified in the PCL rupture group. The control group consisted of 15 patients. After reviewing the MRIs, 6 were excluded due to secondary exclusion criteria. Mean PPS measured 4.8 mm (± 4.4 mm) in the PCL rupture group and 1.8 mm (±2.9 mm) in the control group, p = 0.05. Mean PROTAMM was 3.6 mm (±0.6 mm) in the PCL rupture group and 0.7 mm (±0.9 mm) in the control group, p = 0.004. We found a mean PROTAMM of 3.6 mm in patients with PCL rupture. We suggest that this sign, after knee injury in an otherwise normal medial meniscus, is a promising indirect sign of PCL deficiency compared to PPS. Implementation of this sign in clinical practice may improve the sensitivity of routine non-weight bearing MRI in identifying PCL deficient knees. Copyright © 2018 Elsevier B.V. All rights reserved.

Elbow Synovial Fold Syndrome

DTIC Science & Technology

2007-12-01

inflammation are not present. In the first reported cases of this syndrome, diagnosis was made by arthroscopy after the patient had failed all non...osteoarthritis, and snapping triceps tendon. Lateral epicondylitis appears to be the leading mis-diagnosis before proper imaging or arthroscopy is

Does the Watson-Jones or Modified Smith-Petersen Approach Provide Superior Exposure for Femoral Neck Fracture Fixation?

PubMed

Lichstein, Paul M; Kleimeyer, John P; Githens, Michael; Vorhies, John S; Gardner, Michael J; Bellino, Michael; Bishop, Julius

2018-07-01

A well-reduced femoral neck fracture is more likely to heal than a poorly reduced one, and increasing the quality of the surgical exposure makes it easier to achieve anatomic fracture reduction. Two open approaches are in common use for femoral neck fractures, the modified Smith-Petersen and Watson-Jones; however, to our knowledge, the quality of exposure of the femoral neck exposure provided by each approach has not been investigated. (1) What is the respective area of exposed femoral neck afforded by the Watson-Jones and modified Smith-Petersen approaches? (2) Is there a difference in the ability to visualize and/or palpate important anatomic landmarks provided by the Watson-Jones and modified Smith-Petersen approaches? Ten fresh-frozen human pelvi underwent both modified Smith-Petersen (utilizing the caudal extent of the standard Smith-Petersen interval distal to the anterosuperior iliac spine and parallel to the palpable interval between the tensor fascia lata and the sartorius) and Watson-Jones approaches. Dissections were performed by three fellowship-trained orthopaedic traumatologists with extensive experience in both approaches. Exposure (in cm) was quantified with calibrated digital photographs and specialized software. Modified Smith-Petersen approaches were analyzed before and after rectus femoris tenotomy. The ability to visualize and palpate seven clinically relevant anatomic structures (the labrum, femoral head, subcapital femoral neck, basicervical femoral neck, greater trochanter, lesser trochanter, and medial femoral neck) was also recorded. The quantified area of the exposed proximal femur was utilized to compare which approach afforded the largest field of view of the femoral neck and articular surface for assessment of femoral neck fracture and associated femoral head injury. The ability to visualize and palpate surrounding structures was assessed so that we could better understand which approach afforded the ability to assess structures that are relevant to femoral neck fracture reduction and fixation. After controlling for age, body mass index, height, and sex, we found the modified Smith-Petersen approach provided a mean of 2.36 cm (95% confidence interval [CI], 0.45-4.28 cm; p = 0.015) additional exposure without rectus femoris tenotomy (p = 0.015) and 3.33 cm (95% CI, 1.42-5.24 cm; p = 0.001) additional exposure with a tenotomy compared with the Watson-Jones approach. The labrum, femoral head, subcapital femoral neck, basicervical femoral neck, and greater trochanter were reliably visible and palpable in both approaches. The lesser trochanter was palpable in all of the modified Smith-Petersen and none of the Watson-Jones approaches (p < 0.001). All modified Smith-Petersen approaches (10 of 10) provided visualization and palpation of the medial femoral neck, whereas visualization of the medial femoral neck was only possible in one of 10 Watson-Jones approaches (p < 0.001) and palpation was possible in eight of 10 Watson-Jones versus all 10 modified Smith-Petersen approaches (p = 0.470). In the hands of surgeons experienced with both surgical approaches to the femoral neck, the modified Smith-Petersen approach, with or without rectus femoris tenotomy, provides superior exposure of the femoral neck and articular surface as well as visualization and palpation of clinically relevant proximal femoral anatomic landmarks compared with the Watson-Jones approach. Open reduction and internal fixation of a femoral neck fracture is typically performed in a young patient (< 60 years old) with the objective of obtaining anatomic reduction that would not be possible by closed manipulation, thus enhancing healing potential. In the hands of surgeons experienced in both approaches, the modified Smith-Petersen approach offers improved direct access for reduction and fixation. Higher quality reductions and fixation are expected to translate to improved healing potential and outcomes. Although our experimental results are promising, further clinical studies are needed to verify if this larger exposure area imparts increased quality of reduction, healing, and improved outcomes compared with other approaches. The learning curve for the exposure is unclear, but the approach has broad applications and is frequently used in other subspecialties such as for direct anterior THA and pediatric septic hip drainage. Surgeons treating femoral neck fractures with open reduction and fixation should familiarize themselves with the modified Smith-Petersen approach.

Reverse total shoulder arthroplasty

PubMed Central

Familiari, Filippo; Rojas, Jorge; Nedim Doral, Mahmut; Huri, Gazi; McFarland, Edward G.

2018-01-01

Since the introduction of reverse total shoulder arthroplasty (RTSA) in 1987 (in Europe) and 2004 (in the United States), the number of RTSAs performed annually has increased. Although the main indication for RTSA has been rotator cuff tears, indications have expanded to include several shoulder conditions, many of which involve dysfunction of the rotator cuff. RTSA complications have been reported to affect 19% to 68% of patients and include acromial fracture, haematoma, infection, instability, mechanical baseplate failure, neurological injury, periprosthetic fracture and scapular notching. Current controversies in RTSA include optimal baseplate positioning, humeral neck-shaft angle (135° versus 155°), glenosphere placement (medial, lateral or bony increased offset RTSA) and subscapularis repair. Improvements in prosthesis design, surgeon experience and clinical results will need to occur to optimize this treatment for many shoulder conditions. Cite this article: EFORT Open Rev 2018;3:58–69 DOI: 10.1302/2058-5241.3.170044 PMID:29657846

Common Ice Hockey Injuries and Treatment: A Current Concepts Review.

PubMed

Mosenthal, William; Kim, Michael; Holzshu, Robert; Hanypsiak, Bryan; Athiviraham, Aravind

Injuries are common in ice hockey, a contact sport where players skate at high speeds on a sheet of ice and shoot a vulcanized rubber puck in excess of one hundred miles per hour. This article reviews the diagnoses and treatment of concussions, injuries to the cervical spine, and lower and upper extremities as they pertain to hockey players. Soft tissue injury of the shoulder, acromioclavicular joint separation, glenohumeral joint dislocation, clavicle fractures, metacarpal fractures, and olecranon bursitis are discussed in the upper-extremity section of the article. Lower-extremity injuries reviewed in this article include adductor strain, athletic pubalgia, femoroacetabular impingement, sports hernia, medial collateral and anterior cruciate ligament tears, skate bite, and ankle sprains. This review is intended to aid the sports medicine physician in providing optimal sports-specific care to allow their athlete to return to their preinjury level of performance.

Treatment of open tibial fracture with bone defect caused by high velocity missiles: a case report.

PubMed

Golubović, Zoran; Vukajinović, Zoran; Stojiljković, Predrag; Golubović, Ivan; Visnjić, Aleksandar; Radovanović, Zoran; Najman, Stevo

2013-01-01

Tibia fracture caused by high velocity missiles is mostly comminuted and followed by bone defect which makes their healing process extremely difficult and prone to numerous complications. A 34-year-old male was wounded at close range by a semi-automatic gun missile. He was wounded in the distal area of the left tibia and suffered a massive defect of the bone and soft tissue. After the primary treatment of the wound, the fracture was stabilized with an external fixator type Mitkovic, with convergent orientation of the pins. The wound in the medial region of the tibia was closed with the secondary stitch, whereas the wound in the lateral area was closed with the skin transplant after Thiersch. Due to massive bone defect in the area of the rifle-missile wound six months after injury, a medical team placed a reconstructive external skeletal fixator type Mitkovic and performed corticotomy in the proximal metaphyseal area of the tibia. By the method of bone transport (distractive osteogenesis), the bone defect of the tibia was replaced. After the fracture healing seven months from the secondary surgery, the fixator was removed and the patient was referred to physical therapy. Surgical treatment of wounds, external fixation, performing necessary debridement, adequate antibiotic treatment and soft and bone tissue reconstruction are essential in achieving good results in patients with the open tibial fracture with bone defect caused by high velocity missiles. Reconstruction of bone defect can be successfully treated by reconstructive external fixator Mitkovic.

Mitral valve plasty for mitral regurgitation after blunt chest trauma.

PubMed

Kumagai, H; Hamanaka, Y; Hirai, S; Mitsui, N; Kobayashi, T

2001-06-01

A 21 year-old woman was admitted to our hospital because of chest and back pain after blunt chest trauma. On admission, consciousness was clear and a physical examination showed labored breathing. Her vital signs were stable, but her breathing gradually worsened, and artificial respiration was started. The chest roentgenogram and a subsequent chest computed tomographic scans revealed contusions, hemothorax of the left lung and multiple rib fractures. A transthoracic echocardiography (TTE) revealed normal left ventricular wall motion and mild mitral regurgitation (MR). TTE was carried out repeatedly, and revealed gradually progressive MR and prolapse of the posterior medial leaflet, although there was no congestive heart failure. After her general condition had recovered, surgery was performed. Intraoperative transesophageal echocardiography (TEE) revealed torn chordae at the posterior medial leaflet. The leaflet where the chorda was torn was cut and plicated, and posterior mitral annuloplasty was performed using a prosthetic ring. One month later following discharge, the MR had disappeared on TTE.

Plantar pressure asymmetry and risk of stress injuries in the foot of young soccer players.

PubMed

Azevedo, Renato R; da Rocha, Emmanuel S; Franco, Pedro S; Carpes, Felipe P

2017-03-01

Asymmetries in the magnitude of plantar pressure are considered a risk factor for stress fracture of the fifth metatarsal in soccer athletes. To investigate the presence of plantar pressure asymmetries among young soccer athletes. Observational. Laboratory. Thirty young adolescents divided into a soccer player group (n = 15) or a matched control group (n = 15). Mean plantar pressure was determined for seven different regions of the foot. Data were compared between the preferred and non-preferred foot, and between the groups, during barefoot standing on a pressure mat system. Higher pressure was found in the hallux, 5th metatarsal and medial rearfoot of the non-preferred foot in the young soccer players. These asymmetries were not observed in the control group. Magnitudes of plantar pressure did not differ between the groups. Young soccer players present asymmetries in plantar pressure in the hallux, 5th metatarsal and medial rearfoot, with higher pressure observed in the non-preferred foot. Copyright © 2016 Elsevier Ltd. All rights reserved.

Pseudo-Duane's retraction syndrome.

PubMed Central

Duane, T D; Schatz, N J; Caputo, A R

1976-01-01

Five patients presented with signs that were similar to but opposite from Duane's retraction syndrome. Most had a history of orbital trauma. On attempted abduction a narrowing of the palpebral fissure and retraction of the globe was observed. Diplopia with lateral gaze was present. Roentgenograms (polytomograms) showed involvement of the medial orbital wall. Forced ductuin tests were positive. Surgical repair of the fracture and release of the entrapped muscle as determined by forced duction tests and by postoperative motility led to successful results. Images FIGURE 1 A FIGURE 1 B FIGURE 2 FIGURE 3 PMID:867622

Prevention of cement leakage into the hip joint by a standard cement plug during PFN-A cement augmentation: a technical note.

PubMed

Hanke, M; Djonov, V; Tannast, M; Keel, M J; Bastian, J D

2016-06-01

Medial penetration of the helical blade into the hip joint after fixation of trochanteric fractures using the proximal femur nail antirotation (PFN-A) is a potential failure mode. In low demand patients a blade exchange with cement augmentation may be an option if conversion to total hip arthroplasty is unfeasible to salvage the cut-through. This article describes a technique to avoid intraarticular cement leakage using a cement plug to close the defect in the femoral head caused by the cut-through.

Role of an anatomically contoured plate and metal block for balanced stability between the implant and lateral hinge in open-wedge high-tibial osteotomy.

PubMed

Jang, Young Woong; Lim, DoHyung; Seo, Hansol; Lee, Myung Chul; Lee, O-Sung; Lee, Yong Seuk

2018-07-01

Open-wedge high tibial osteotomy (OWHTO) is a well-established surgical option for medial compartment osteoarthritis of the varus knee. The initial strength of the fixation plate is critical for successful correction maintenance and healing of the osteotomy site. This study was conducted to verify if a newly designed anatomical plate (LCfit) improves the stability of both the medial implant and lateral hinge area, as well as to evaluate how the metal block contributes to both medial and lateral stability. A finite element (FE) tibial model was combined with TomoFix plate, a LCfit plate with and without a metal block. Data analysis was conducted to evaluate the balanced stability, which refers to the enforced lateral stability resulting from redistribution of overall stress. We assessed the balanced stability of the medial implant and lateral hinge area in three cases using the same Sawbones and loads using the tibia FE model. The LCfit plate reduced stress by 23.1% at the lateral hinge compared to the TomoFix plate (TomoFix vs. LCfit: 34.2 ± 23.3 MPa vs. 26.3 ± 17.5 MPa). The LCfit plate with a metal block reduced stress by 40.1% at the medial plate (210.1 ± 64.2 MPa vs. 125.8 ± 65.7 MPa) and by 31.2% (26.3 ± 17.5 MPa vs. 18.1 ± 12.1 MPa) at the lateral hinge area compared to the reduction using the LCfit plate without a metal block. The newly designed fixation system for OWHTO balanced the overall stress distribution and reduced stress at the lateral hinge area compared to that using a conventional fixation system. The addition of the metal block showed additional benefits for balanced stability between the medial implant and lateral hinge area. However, this conclusion could only be drawn using the FE model in this study. Therefore, further clinical studies are necessary to reveal the clinical effect of reduced lateral stress on the occurrence of the lateral hinge fracture and the biologic effect of the metal block on the healing of the medial cortex.

The effects of KinesioTape on the treatment of lateral epicondylitis.

PubMed

Shakeri, Hassan; Soleimanifar, Manijeh; Arab, A M; Hamneshin Behbahani, Shirin

Randomized clinical trial. KinesioTape (KT) is a noninvasive method to treat pain and muscular dysfunction. To investigate the effect of KT with and without tension on pain intensity, pain pressure threshold, grip strength and disability in individuals with lateral epicondylitis, and myofacial trigger points in forearm muscles. Thirty women with lateral epicondylitis and myofacial trigger point in forearm muscles were randomly assigned to KT with tension and placebo (KT without tension). The treatment was provided 3 times in one week, and outcome measures were assess pre-post treatment. The mean score of visual analogue scale (VAS) during activity decreased significantly from 6.4 and 6 pretest to 2.53 and 4.66 posttest, respectively, for the KT with and without tension groups. The mean score of Disabilities of the Arm, Shoulder and Hand decreased significantly from 16.82 and 22.79 pretest to 8.65 and 8.29 posttest, respectively, for the KT with and without tension groups. A paired t-test revealed a significant reduction in VAS during activity and Disabilities of the Arm, Shoulder and Hand before and after treatment in both groups (P < .05). Pain pressure threshold, grip strength, and VAS using an algometer revealed no significant differences. The study showed no significant difference in variables immediately after intervention. Improvements in functional disability were superior when KT was used with tension, than obtained with a placebo-no tension application. The application of KT produces an improvement in pain intensity and upper extremity disability in subjects with LE and MTP in forearm muscles, and KT with tension was more effective than placebo group. NA. 100-216. Copyright © 2017 Hanley & Belfus. Published by Elsevier Inc. All rights reserved.

Platelet-rich plasma versus corticosteroid injection for recalcitrant lateral epicondylitis: clinical and ultrasonographic evaluation.

PubMed

Gautam, V K; Verma, Saurabh; Batra, Sahil; Bhatnagar, Nidhi; Arora, Sumit

2015-04-01

To evaluate the clinical and ultrasonographic changes in the morphology and vascularity of the common extensor tendon after injecting platelet-rich plasma (PRP) or corticosteroid (CS) for recalcitrant lateral epicondylitis (LE). 30 patients aged 18 to 60 years with recalcitrant (>6 months) LE not responsive to oral medication or non-invasive treatment were randomised to receive PRP (n=15) or CS (n=15) injection. Patients were assessed using the visual analogue scale (VAS) for pain, Disabilities of the Arm, Shoulder and Hand Scale (DASH) score, Oxford Elbow Score, modified Mayo Clinic performance index for the elbow (modified Mayo score), and hand grip strength. Ultrasonography was performed by a musculoskeletal ultrasonologist to evaluate for tear at the common extensor origin, oedema at the common extensor origin, cortical erosion, probe-induced tenderness, and thickness of the tendon. The VAS for pain, DASH score, Oxford Elbow Score, modified Mayo score, and hand grip strength all improved significantly from pre-injection to the 6-month follow-up in the PRP and CS groups. However, in the CS group, the scores generally peaked at 3 months and then deteriorated slightly at 6 months indicating recurrence of symptoms, which involved 46.7% of the CS patients. At 6 months, the number of patients positive for various ulrasonographic findings generally decreased. However, in the CS group, the number of patients with reduced thickness of the common extensor tendon increased from 2 to 12, and the number of patients with cortical erosion at the lateral epicondyle increased from 9 to 11. PRP appeared to enable biological healing of the lesion, whereas CS appeared to provide short-term, symptomatic relief but resulted in tendon degeneration.

Does Kinesiotaping improve pain and functionality in patients with newly diagnosed lateral epicondylitis?

PubMed

Eraslan, Leyla; Yuce, Deniz; Erbilici, Arzu; Baltaci, Gul

2018-03-01

This study aimed to compare the short-term effects of kinesiotaping and extracorporeal shock wave therapy (ESWT) along with physiotherapy on pain, functionality, and grip strength in patients with newly diagnosed lateral epicondylitis undergoing rehabilitation. Forty-five voluntary patients (mean age 48 years) were randomly assigned to three groups. Patients in all groups received physiotherapy consisting of a cold pack and transcutaneous electrical nerve stimulation five times per week for a total of 15 sessions and a home exercise programme including stretching and eccentric strength exercises. In the second group, patients received kinesiotaping 5 days a week for 3 weeks. In the third group, ESWT was applied three times for 3 weeks. Patients were assessed by visual analogue scale for pain intensity, pain-free grip strength using a hand dynamometer, Cyriax Resisted Muscle Test, and Patient-Rated Tennis Elbow Evaluation Scale. All measurements were collected at baseline and after treatment. There were no significant differences in the demographic characteristics of the patients in all groups at baseline. Intra-group analysis revealed that pain intensity decreased, whereas maximum grip strength and functionality increased in all groups at the end of the treatment (p < 0.05). Inter-group analysis revealed that the kinesiotaping group yielded better results in decreasing pain intensity than the other groups (p < 0.05). The kinesiotaping group (p < 0.001) and ESWT group (p = 0.002) yielded better results in improving functionality than the physiotherapy group. There were significant differences in recovering pain-free grip strength in the kinesiotaping group (p < 0.05). Kinesiotaping was found to be effective for decreasing pain intensity, recovering grip strength, and improving functionality in patients with lateral epicondylitis undergoing rehabilitation. Therapeutic study, Level II.

Efficacy of peloid therapy in patients with chronic lateral epicondylitis: a randomized, controlled, single blind study

NASA Astrophysics Data System (ADS)

Ökmen, Burcu Metin; Eröksüz, Rıza; Altan, Lale; Aksoy, Meliha Kasapoğlu

2017-11-01

The aim of this study was to assess the effect of peloid on pain, functionality, daily life activities, and quality of life of lateral epicondylitis (LE) patients. In this randomized, controlled, single-blind study, 75 patients who were diagnosed with chronic LE were enrolled to the study. Patients were randomized into two groups using the random number table. The patients in the first group (group 1) ( n = 33), were given lateral epicondylitis band (LEB) (during the day for 6 weeks) + peloid therapy (five consecutive days a week for 2 weeks), and the second group (group 2) ( n = 32), received LEB treatment alone. The patients were assessed by using Patient Rated Tennis Elbow Evaluation (PRTEE) and Nottingham Health Profile (NHP). The data were obtained before treatment (W0), immediately after treatment (W2), and 1 month after treatment (W6). In analysis of the collected data, the Wilcoxon signed rank test for intra-group comparisons and Mann-Whitney U test for comparisons between groups were used. Both in groups 1 and 2, there was a statistically significant improvement in all the evaluation parameters at W2 and W6 when compared to W0 ( p < 0.05). In comparison of difference scores between groups, although there was no statistically significant difference between the two groups at W2 when compared to W0 ( p > 0.05), a statistically significant difference was found in favor of group 1 for all the evaluation parameters at W6 ( p < 0.05). Our results have shown that peloid treatment could be effective in providing improvement in pain relief, function, daily life activities, and quality of life in LE patients.

Comparative effectiveness of botulinum toxin versus non-surgical treatments for treating lateral epicondylitis: a systematic review and meta-analysis.

PubMed

Lin, Yu-Ching; Wu, Wei-Ting; Hsu, Yu-Chun; Han, Der-Sheng; Chang, Ke-Vin

2018-02-01

To explore the effectiveness of botulinum toxin compared with non-surgical treatments in patients with lateral epicondylitis. Data sources including PubMed, Scopus, Embase and Airity Library from the earliest record to February 2017 were searched. Study design, patients' characteristics, dosage/brand of botulinum toxin, injection techniques, and measurements of pain and hand grip strength were retrieved. The standardized mean differences (SMDs) in pain relief and grip strength reduction were calculated at the following time points: 2-4, 8-12, and 16 weeks or more after injection. Six randomized controlled trials (321 participants) comparing botulinum toxin with placebo or corticosteroid injections were included. Compared with placebo, botulinum toxin injection significantly reduced pain at all three time points (SMD, -0.729, 95% confidence interval [CI], -1.286 to -0.171; SMD, -0.446, 95% CI, -0.740 to -0.152; SMD, -0.543, 95% CI, -0.978 to -0.107, respectively). Botulinum toxin was less effective than corticosteroid at 2-4 weeks (SMD, 1.153; 95% CI, 0.568-1.737) and both treatments appeared similar in efficacy after 8 weeks. Different injection sites and dosage/brand did not affect effectiveness. Botulinum toxin decreased grip strength 2-4 weeks after injection, and high equivalent dose could extend its paralytic effects to 8-12 weeks. When treating lateral epicondylitis, botulinum toxin was superior to placebo and could last for 16 weeks. Corticosteroid and botulinum toxin injections were largely equivalent, except the corticosteroid injections were better at pain relief in the early stages and were associated with less weakness in grip in the first 12 weeks.

Surgical repair of propagating condylar fractures of the third metacarpal/metatarsal bones with cortical screws placed in lag fashion in 26 racehorses (2007-2015).

PubMed

Moulin, N; François, I; Coté, N; Alford, C; Cleary, O; Desjardins, M R

2018-01-19

Despite the recommendation of plate fixation for propagating condylar fractures of the third metacarpal (McIII) or third metatarsal bone (MtIII), lag screw fixation can be a viable surgical option. To evaluate short-term outcome and long-term racing performance of horses that underwent lag screw fixation of long condylar fractures of the McIII/MtIII. Retrospective case series. Medical records, post-surgical racing performance and outcome of 26 horses with propagating fractures of the medial and/or lateral condyle of McIII/MtIII were reviewed. Medical information included were age, breed, sex, physical examination at admission, circumstances of fracture, radiographic evaluation, anaesthesia and recovery records, surgical and post-operative management, as well as complications. Outcome included racing data and information from telephone interviews. Twenty-six horses (9 Standardbreds and 17 Thoroughbreds) were admitted with a long condylar fracture of the McIII/MtIII. Fore- and hindlimbs were equally represented with the left hindlimb being more frequently involved. Most of the fractures had a spiralling component (76%) and four (15%) were comminuted. Fifteen (58%) horses raced post-surgery including nine Standardbreds (100%) and six Thoroughbreds (35%). Twelve of them were placed in at least one race and 11 won at least once. One horse sustained a severe complication in recovery. No significant difference was observed in the racing performances before and after surgery. Follow-up method and duration were not standardised and there is a low number of cases with six surgeons. Long condylar fractures can be repaired using lag fashion technique combined with a half-limb or full-limb tight cast for recovery as a good surgical alternative. Similar results to plate fixation can be expected, with a return to racing of more than 50%, and the prognosis being even better for pacers. © 2018 EVJ Ltd.

Outcomes of coronoid-first repair in terrible triad injuries of the elbow.

PubMed

Zhang, Junren; Tan, Mark; Kwek, Ernest Beng Kee

2017-09-01

Clinical outcomes of terrible triad injuries (TTIs) of the elbow are historically poor. To date, it is still debatable whether the coronoid needs to be fixed and if so, how and in which sequence. Between 2010 and 2013, 13 patients were treated surgically for acute TTIs of the elbow at a Tertiary Level 1 Trauma Centre by a single surgeon, using a standardized protocol, which included coronoid-brachialis complex fixation via pull-through trans-osseous sutures, radial head fixation or prosthetic replacement and a repair of the lateral ulnar collateral ligament. Repair of the medial collateral ligament (MCL) was done if valgus-stress test demonstrated persistent instability. Patients were then followed-up with clinical and radiological evaluation by the senior author until fracture union and elbow range of motion reached a plateau. Outcomes measured were range of motion, DASH scores and MEPS, as well as surgical complications. Intraoperative stability was achieved in all 13 cases, MCL repair was required in 3 cases and application of external fixation was not required in any case. Patients were followed-up for an average length of 27.7 months and the minimum follow-up period was 12 months. The average age of patients was 46.4 years (range 35-79 years old) at the time of trauma. This included eight Regan-Morrey Type I and five Regan-Morrey Type II coronoid fractures, with ten Mason Type I/II and three Mason Type III radial head fractures. The average arc of ulno-humeral motion was 105.0° (range 80°-135°). The average flexion contracture was 15.0° (range 0°-40°). The average supination-pronation arc was 114.9° (range 0°-180°). The average MEPS was 85 of 100 (range 45-100) and the average DASH score was 21.2 of 100 (range 1.7-61.2). A single case of radio-ulnar synostosis, heterotropic ossification and two cases of recurrent elbow instability were noted. The coronoid-first surgical approach, using a suture-lasso fixation method, has technical benefits for us and showed good clinical success in our series. This is important with postero-medial rotatory instability being common in our series of TTIs. We emphasize not to miss a TTI in an apparently isolated low Mason class radial head fracture.

The Comprehensive AOCMF Classification System: Condylar Process Fractures - Level 3 Tutorial

PubMed Central

Neff, Andreas; Cornelius, Carl-Peter; Rasse, Michael; Torre, Daniel Dalla; Audigé, Laurent

2014-01-01

This tutorial outlines the detailed system for fractures of the condylar process at the precision level 3 and is organized in a sequence of sections dealing with the description of the classification system within topographical subdivisions along with rules for fracture coding and a series of case examples with clinical imaging. Basically, the condylar process comprises three fracture levels and is subdivided into the head region, the condylar neck, and the condylar base. Fractures of the condylar head show typical fracture lines either within the lateral pole zone, which may lead to loss of vertical height, or medially to the pole zone, with the latter ones usually not compromising the vertical condyle to fossa relation. In condylar head fractures, the morphology is further described by the presence of minor or major fragmentation, the vertical apposition of fragments at the plane of the head fracture, the displacement of the condylar head with regard to the fossa including a potential distortion of the condylar head congruency resulting in dystopic condyle to fossa relations and the presence or absence of a loss of vertical ramus height. A specific vertical fracture pattern extending from the head to the neck or base subregion is considered. Fractures of the condylar neck and base can be differentiated according to a newly introduced one-third to two-thirds rule with regard to the proportion of the fracture line above and below the level of the sigmoid notch, which is presented in the classification article, and are basically subdivided according to the presence or absence of displacement or dislocation. In both condylar neck and base fractures, the classification is again based on the above mentioned parameters such as fragmentation, displacement of the condylar head with regard to the fossa, including dystopic condyle to fossa relations and loss of vertical ramus height, that is, according to the measurement of the condylar process. In addition, the classification assesses a sideward displacement including the respective displacement sector at the neck or base fracture site as well as the angulation of the superior main fragment and also considers a potential displacement of the caudal fragment with regard to the fossa, which may occur in fractures affecting additional fracture locations in the mandible. The design of this classification is discussed along with a review of existing classification systems. The condylar process for fracture location was defined according to the level 2 system presented in a previous tutorial in this special issue. PMID:25489390

The Comprehensive AOCMF Classification System: Condylar Process Fractures - Level 3 Tutorial.

PubMed

Neff, Andreas; Cornelius, Carl-Peter; Rasse, Michael; Torre, Daniel Dalla; Audigé, Laurent

2014-12-01

This tutorial outlines the detailed system for fractures of the condylar process at the precision level 3 and is organized in a sequence of sections dealing with the description of the classification system within topographical subdivisions along with rules for fracture coding and a series of case examples with clinical imaging. Basically, the condylar process comprises three fracture levels and is subdivided into the head region, the condylar neck, and the condylar base. Fractures of the condylar head show typical fracture lines either within the lateral pole zone, which may lead to loss of vertical height, or medially to the pole zone, with the latter ones usually not compromising the vertical condyle to fossa relation. In condylar head fractures, the morphology is further described by the presence of minor or major fragmentation, the vertical apposition of fragments at the plane of the head fracture, the displacement of the condylar head with regard to the fossa including a potential distortion of the condylar head congruency resulting in dystopic condyle to fossa relations and the presence or absence of a loss of vertical ramus height. A specific vertical fracture pattern extending from the head to the neck or base subregion is considered. Fractures of the condylar neck and base can be differentiated according to a newly introduced one-third to two-thirds rule with regard to the proportion of the fracture line above and below the level of the sigmoid notch, which is presented in the classification article, and are basically subdivided according to the presence or absence of displacement or dislocation. In both condylar neck and base fractures, the classification is again based on the above mentioned parameters such as fragmentation, displacement of the condylar head with regard to the fossa, including dystopic condyle to fossa relations and loss of vertical ramus height, that is, according to the measurement of the condylar process. In addition, the classification assesses a sideward displacement including the respective displacement sector at the neck or base fracture site as well as the angulation of the superior main fragment and also considers a potential displacement of the caudal fragment with regard to the fossa, which may occur in fractures affecting additional fracture locations in the mandible. The design of this classification is discussed along with a review of existing classification systems. The condylar process for fracture location was defined according to the level 2 system presented in a previous tutorial in this special issue.

Quantitative analysis of the patella following the harvest of a quadriceps tendon autograft with a bone block.

PubMed

Ferrer, Gerald A; Miller, R Matthew; Murawski, Christopher D; Tashman, Scott; Irrgang, James J; Musahl, Volker; Fu, Freddie H; Debski, Richard E

2016-09-01

The objective of this study was to determine parameters associated with patellar fracture after quadriceps tendon autograft harvest. Thirteen non-fractured and five fractured patella surface models were created based on patient data obtained from a prospective randomized clinical trial in order to assess geometric parameters and bending stress. Measurements that describe the bone block harvest site geometry were used to calculate three normalized parameters. The relative depth parameter describes the thickness of the bone block harvest site with respect to the thickness of the patella at the harvest site. The asymmetry parameter defines the medial-lateral location of the bone bock harvest site. The normalized bending stress parameter assesses the bending stress experienced by the remaining bone beneath the bone block harvest site. The relative depth of the bone block harvest site in the non-fractured patellae was 27 ± 12 % and for the fractured patellae was 42 ± 14 % (p < 0.05). With a value <1 indicating a more lateral location of the harvest site, asymmetry for the non-fractured group was 1.0 ± 0.5 and 0.7 ± 0.4 for the fractured group (n.s.). The maximum bending stress experienced by the non-fractured patellae was (1.8 × 10(-3) ± 1.3 × 10(-3)) mm(-3) × M and for the fractured patellae was over three times greater (6.3 × 10(-3) ± 3.7 × 10(-3)) mm(-3) × M (p < 0.05). Based on the non-uniform geometry of the patella, an emphasis should be made on harvesting a standard percentage of patella thickness rather than a fixed depth. In order to minimize the incidence of a patellar fracture, bone blocks should not be taken laterally and should not exceed 30 % of the total patella thickness at the harvest site.

Surgical repair of humeral condylar fractures in New Zealand working farm dogs - long-term outcome and owner satisfaction.

PubMed

Nortje, J; Bruce, W J; Worth, A J

2015-03-01

To report the long-term outcome, return to work and owner satisfaction, for working farm dogs in New Zealand following surgical repair of humeral condylar fractures. A retrospective study of working dogs that had undergone surgical repair of one or more condylar fractures of the humerus was undertaken by searching the medical records of two referral veterinary clinics. The inclusion criteria were working dogs that had undergone open surgical reduction and internal fixation of a fracture of one or both humeral condyles. The ability of the dog to work after surgery, persistence of lameness and the owners' degree of satisfaction with the outcome were assessed from answers to a questionnaire. Sixteen dogs met the inclusion criteria and had owner questionnaires completed at a median follow-up interval of 54 (min 3, max 121) months. Fifteen were working farm dogs (13 Heading dogs, including Border Collies, and two New Zealand Huntaways) and one dog was a cross-breed used for pig hunting. Four dogs had two fractures on separate occasions, of which three underwent surgery on both elbows at a median interval of 19 months. Of the 20 humeral fractures, 10 were lateral condylar, one was a medial condylar fracture and nine were dicondylar fractures. Of the 16 repairs with follow-up data, seven (44%) dogs could perform all expected duties following surgical repair, whilst a further eight (50%) could perform most duties although some allowances had to be made for some limitation of their performance. Of the 15 owners responding, 13 (87%) were satisfied or very satisfied with the outcome of surgery and felt the surgery was worth the expense. Post-operative complications requiring a second surgery occurred in 7/20 (35%) dogs, and all six dogs that received appropriate surgical revision returned to work. In this small case series, surgical repair of humeral condylar fractures in working dogs had a good prognosis with 15/16 of treated dogs returning to full or substantial levels of work. These data provide veterinarians with relevant information regarding the outcome and prognosis of surgery for clients whose working dogs have fractured a humeral condyle.

THE TREATMENT OF IRRADIATION FRACTURE OF THE FEMORAL NECK

DOE Office of Scientific and Technical Information (OSTI.GOV)

Leabhart, J.W.; Bonfiglio, M.

1961-10-01

Treatment of 44 patients with 56 postirradiation fractures of the femoral neck is reported. Of 2612 patients who received pelvic irradiation for carcinoma of the uterine cervix, 40 developed fractures of the femoral neck, an incidence of 1.5%. Sixteen of the 40 patients had bilateral fractures. The average age of the patients was 58.5 yr at the time of irradiation. The average irradiation dose was approximates 3600 r (parametrial dose), the largest dose being 4235 r. The average interval from irradiation to the onset of pain in the hip was 36.6 months (3 to 240 months) and from the onsetmore » of pain to diagnosis, 3 months. Forty-six surgical procedures were performed: 36 as primary treatment and 9 because of failure or complications of the first procedure. The average follow-up time of these patients was 6.9 yr. The presenting complaint was usually spontaneous onset of pain in the groin and medial portion of the thigh. Initially the physical examination often revealed only restriction of internal rotation of the affected hip, and the roentgenograms appeared normal in some instances. Subsequently, a change in bone density was noted at the inferior aspect of the femoral neck, denoting an adduction type of fracture. The displaced fractures resembled the traumatic adduction fractures of the femoral neck seen in patients who had not received irradiation. Acetabular changes were also noted, characterized by marked osteoporosis and occasionally fracture of the acetabulum. Seven methods of primary therapy were used to treat these patients: no treatment, nonsurgical measures (crutches or bedrest), internal fixation, bone- grafting (with and without additional fixation), osteotomy, arthroplasty, and the insertion of a prosthesis. Early in situ internal fixation or internal fixation with bone grafts was the procedure of choice in fractures of the femorai neck secondary to irradiation. Reconstructive procedures, such as cup arthroplasty or insertion of a prosthesis, were effective treatment in selected cases. Osteotomy was not applicable for primary treatment of this type of fracture. (H.H.D.)« less

Elbow arthroscopy: setup, portal placement, and simple procedures.

PubMed

Ahmad, Christopher S; Vitale, Mark A

2011-01-01

Elbow arthroscopy has become an accepted treatment for numerous elbow conditions, including loose bodies, lateral epicondylitis, contractures, painful osteophytes, synovitis, osteochondritis dissecans, synovial plica, and osteoarthritis. It is absolutely necessary that the treating surgeon have complete knowledge of elbow anatomy. Three options exist for patient positioning: supine, prone, and lateral decubitus. Standard arthroscopic probes, grasping forceps, punches, and motorized shavers and burrs are used in the procedure. Retractors are essential for visualizing, exposing, and protecting nerves. Specially designed capsular biters can be used to develop a plane between the capsule and the surrounding soft tissues to facilitate capsulotomy and capsulectomy. Among elbow arthroscopists, the sequence of portal placement varies; however, there is little variation in the exact location of portal placement because of neurovascular constraints. Loose body removal and extensor carpi radialis brevis release for lateral epicondylitis are common procedures suitable for the beginning arthroscopist. For beginning and advanced procedures, the surgeon's skill and competence must be at a level consistent with the procedure to avoid complications.

The strain index and TLV for HAL: risk of lateral epicondylitis in a prospective cohort.

PubMed

Garg, Arun; Kapellusch, Jay M; Hegmann, Kurt T; Thiese, Matthew S; Merryweather, Andrew S; Wang, Ying-Chih; Malloy, Elizabeth J

2014-03-01

This study's objective was to quantify exposure-response relationships between job physical exposure (JPE) and incidence of lateral epicondylitis (LE). A cohort of 536 workers was enrolled from 10 manufacturing facilities and followed monthly for 6 years to ascertain changes in JPE and health status. JPE was individually measured and quantified using the Strain Index (SI) and TLV for HAL. Worker demographics, medical history, psychosocial factors, and current musculoskeletal disorders were obtained. Fifty-six workers developed LE. In multivariate models JPE, age, family problems, and swimming were associated with increased risk of LE. SI showed an exposure-response relationship with maximum hazard ratio (HR) of 4.5(P = 0.04). TLV for HAL showed a non-statistically significant trend for increased risk of LE (P = 0.19). JPE is associated with increased risk of LE. The SI and TLV for HAL are useful metrics for estimating JPE. © 2013 Wiley Periodicals, Inc.

Anatomical evidence for the anterior plate fixation of sacroiliac joint.

PubMed

Bai, Zhibiao; Gao, Shichang; Liu, Jia; Liang, Anlin; Yu, Weihua

2018-01-01

The iatrogenic injuries to the lumbar nerves during the fixation the sacroiliac (SI) joint fractures with anterior plates were often reported. No specific method had been reported to avoid it. This study was done to find a safer way of placing the anterior plates and screws for treating the sacroiliac (SI) joint fracture and/or dislocation. The research was performed using 8 male and 7 female normal corpse pelvic specimens preserved by 10% formalin solution. Try by measuring the horizontal distance from L4, L5 nerve roots to the sacroiliac joint and perpendicular distance from L4, L5 nerve roots to the ala sacralis, the length of L4, L5 nerve roots from intervertebral foramen to the edge of true pelvis, the diameter of L4, L5 nerve roots. The angles between the sacroiliac joint and sagittal plane were measured on the CT images. The horizontal distance between the lateral side of the anterior branches of L4, L5 nerve roots and the sacroiliac joint decreased gradually from the top to the bottom. The widest distances for L4,5 were 2.1 cm (range, 1.74-2.40) and 2.7 cm (range, 2.34-3.02 cm), respectively. The smallest distances for L4, 5 were 1.2 cm (range, 0.82-1.48 cm) and 1.5 cm (range, 1.08-1.74 cm), respectively. On CT images, the angle between the sacroiliac joint and sagittal plane was about 30°. If we use two anterior plates to fix the sacroiliac joint, It is recommended to place one plate on the superior one third part of the joint, with exposing medially no more than 2.5 cm and the other in the middle one third part of the joint, with elevating periosteum medially no more than 1.5 cm. The screws in the sacrum are advised to incline medially about 30° directing to the true pelvis. Copyright © 2017. Published by Elsevier B.V.

Finite element analysis of intramedullary nailing and double locking plate for treating extra-articular proximal tibial fractures.

PubMed

Chen, Fancheng; Huang, Xiaowei; Ya, Yingsun; Ma, Fenfen; Qian, Zhi; Shi, Jifei; Guo, Shuolei; Yu, Baoqing

2018-01-16

Proximal tibia fractures are one of the most familiar fractures. Surgical approaches are usually needed for anatomical reduction. However, no single treatment method has been widely established as the standard care. Our present study aims to compare the stress and stability of intramedullary nails (IMN) fixation and double locking plate (DLP) fixation in the treatment of extra-articular proximal tibial fractures. A three-dimensional (3D) finite element model of the extra-articular proximal tibial fracture, whose 2-cm bone gap began 7 cm from the tibial plateau articular surface, was created fixed by different fixation implants. The axial compressive load on an adult knee during single-limb stance was imitated by an axial force of 2500 N with a distribution of 60% to the medial compartment, while the distal end was fixed effectively. The equivalent von Mises stress and displacement of the model was used as the output measures for analysis. The maximal equivalent von Mises stress value of the system in the IMN model was 293.23 MPa, which was higher comparing against that in the DLP fixation model (147.04 MPa). And the mean stress of the model in the IMN model (9.25 MPa) was higher than that of the DLP fixation system in terms of equivalent von Mises stress (EVMS) (P < 0.0001). The maximal value of displacement (sum) in the IMN system was 8.82 mm, which was lower than that in the DLP fixation system (9.48 mm). This study demonstrated that the stability provided by the locking plate fixation system was superior to the intramedullary nails fixation system and served as an alternative fixation for the extra-articular proximal tibial fractures of young patients.

Morphomics of the Talus.

PubMed

Gorman, David; Handy, Ebram; Wang, Sikui; Irwin, Annette L; Wang, Stewart

2016-11-01

Previous studies of frontal crash databases reported that ankle fractures are among the most common lower extremity fractures. While not generally life threatening, these injuries can be debilitating. Laboratory research into the mechanisms of ankle fractures has linked dorsiflexion with an increased risk of tibia and fibula malleolus fractures. However, talus fractures were not produced in the laboratory tests and appear to be caused by more complex loading of the joint. In this study, an analysis of the National Automotive Sampling System - Crashworthiness Data System (NASS-CDS) for the years 2004-2013 was conducted to investigate foot-ankle injury rates in front seat occupants involved in frontal impact crashes. A logistic regression model was developed indicating occupant weight, impact delta velocity and gender to be significant predictors of talus fracture (p<0.05). Separately, a specific set of Computed Tomography (CT) scans from the International Center for Automotive Medicine (ICAM) scan database was used to characterize the talar dome. This control population consisted of 207 adults aged 18 to 84, with no foot or ankle trauma, and scans that had suitable coverage of the talus. Size of the talus was determined using medial-to-lateral width and anterior-to-posterior depth measurements. Geometry was assessed by evaluating the radius of the articulating talus and strength was assessed using a combination of cross sectional area and density. Demographics were studied to investigate correlation with talus measurements from the CT scan database. A multi-variable linear regression model of the morphomics showed gender to be statistically significant (p<0.05) for talus depth, width, cross-sectional area, radius and strength. Body Mass Index (BMI) was significant for depth and radius. Weight was significant for depth, width, density and strength. Stature was significant for depth, cross-sectional area, radius and strength. Age was significant for radius and density.

Fixed-angle plates in patella fractures - a pilot cadaver study

PubMed Central

2011-01-01

Objective Modified anterior tension wiring with K-wires and cannulated lag screws with anterior tension wiring are currently the fixation of choice for patellar fractures. Failure of fixation, migration of the wires, postoperative pain and resulting revision surgery, however, are not uncommon. After preliminary biomechanical testing of a new fixed-angle plate system especially designed for fixation of patella fractures the aim of this study was to evaluate the surgical and anatomical feasibility of implanting such a plate-device at the human patella. Methods In six fresh unfixed female cadavers without history of previous fractures around the knee (average age 88.8 years) a bilateral fixed-angle plate fixation of the patella was carried out after previous placement of a transverse central osteotomy. Operative time, intra-operative problems, degree of retropatellar arthritis (following Outerbridge), quality of reduction and existence of any intraarticular screw placement have been raised. In addition, lateral and anteroposterior radiographs of all specimens were made. Results Due to the high average age of 88.8 years no patella showed an unimpaired retropatellar articular surface and all were severely osteoporotic, which made a secure fixation of the reduction forceps during surgery difficult. The operation time averaged 49 minutes (range: 36-65). Although in postoperative X-rays the fracture gap between the fragments was still visible, the analysis of the retropatellar surface showed no residual articular step or dehiscence > 0.5 mm. Also in a total of 24 inserted screws not one intraarticular malposition was found. No intraoperative complications were noticed. Conclusions Osteosynthesis of a medial third patella fracture with a bilateral fixed-angle plate-device is surgically and anatomically feasible without difficulties. Further studies have to depict whether the bilateral fixed-angle plate-osteosynthesis of the patella displays advantages over the established operative procedures. PMID:21345769

The outcome of unstable proximal femoral fracture treated with reverse LISS plates.

PubMed

Lin, Shih-Jie; Huang, Kuo-Chin; Chuang, Po-Yao; Lee, Chien-Yin; Huang, Tsan-Wen; Lee, Mel S; Hsu, Robert Wen-Wei

2016-10-01

The Russel-Taylor type 2B fractures compromised the trochanteric region and medial buttress of proximal femur. This fracture pattern limits the choice of implants and raises the risk of adverse outcomes. We aimed to (i) determine the outcome of Russel-Taylor type 2B fractures treated using reverse less invasive stabilization system plates (LISS-DF) and to (ii) learn what factors affected outcomes after osteosynthesis with reverse LISS plates. A retrospective study SETTING: The study was conducted at a Level III trauma center in Taiwan. Twenty-five consecutive patients presenting with a Russel-Taylor type 2B fracture were enrolled. All cases were treated with reverse LISS plates. A Modified Radiographic Union Scale for Femur (RUSF), Radiographic parameters, functional scores, and complications were assessed. Union occurred in 21 cases at an average of 18.8 weeks. The average immediate postoperative neck-shaft angle was 130° (range: 122-135°) compared with 139° (range: 135-141°, p=0.05) on the contralateral side. Two cases had complications of proximal screws cutting out and two cases had broken implants. Finally, all 4 cases required repeated surgeries (16%). Malunion occurred in 4 patients and early mechanical failure (proximal screws cut out) occurred in 2. There was a significant difference in the purchase index of the proximal screws between cases with redisplacement and those without (26.4mm and 98.6mm, p=0.01). The use of reverse LISS plate appeared to be an alternative procedure for the specific pattern in the present study. We recommend using this reverse locking plate to treat unstable proximal femoral fractures with meticulous techniques of placing plates. Adequate purchase of the proximal locking screws might decrease the risks of complications. Copyright © 2016 Elsevier Ltd. All rights reserved.

Less invasive reduction and fusion of fresh A2 and A 3 traumatic L 1-L 4 fractures with a novel vertebral body augmentation implant and short pedicle screw fixation and fusion.

PubMed

Korovessis, Panagiotis; Vardakastanis, Konstantinos; Repantis, Thomas; Vitsas, Vasilios

2014-04-01

The aim of this clinical study was to report on the efficacy in reduction and safety in PMMA leakage of a novel vertebral augmentation technique with PEEK and PMMA, together with pedicle screws in the treatment of fresh vertebral fractures in young adults. Twenty consecutive young adults aged 45 ± 11 years with fresh burst A3/AO or severely compressed A2/AO fractures underwent via a less invasive posterior approach one-staged reduction with a novel augmentation implant and PMMA plus 3-vertebrae pedicle screw fixation and fusion. Radiologic parameters as segmental kyphosis (SKA), anterior (AVBHr) and posterior vertebral body height ratio (PVBHr), spinal canal encroachment (SCE), cement leakage and functional parameters as VAS, SF-36 were measured pre- and post-operatively. Hybrid construct restored AVBHr (P < 0.000), PVBHr (P = 0.02), SKA (P = 0.015), SCE (P = 0.002) without loss of correction at an average follow-up of 17 months. PMMA leakage occurred in 3 patients (3 vertebrae) either anteriorly to the fractured vertebral body or to the adjacent disc, but in no case to the spinal canal. Two pedicle screws were malpositioned (one medially, one laterally to the pedicle at the fracture level) without neurologic sequelae. Solid posterolateral spinal fusion occurred 8-10 months post-operatively. Pre-operative VAS and SF-36 scores improved post-operatively significantly. This study showed that this novel vertebral augmentation technique using PEEK implant and PMMA reduces and stabilizes via less invasive technique A2 and A3 vertebral fractures without loss of correction and leakage to the spinal canal.

Talocrural Dislocation With Associated Weber Type C Fibular Fracture in a Collegiate Football Player: A Case Report

PubMed Central

Ricci, R Daniel; Cerullo, James; Blanc, Robert O; McMahon, Patrick J; Buoncritiani, Anthony M; Stone, David A; Fu, Freddie H

2008-01-01

Objective: To present the case of a talocrural dislocation with a Weber type C fibular fracture in a National Collegiate Athletic Association Division I football athlete. Background: The athlete, while attempting to make a tackle during a game, collided with an opponent, who in turn stepped on the lateral aspect of the athlete's ankle, resulting in forced ankle eversion and external rotation. On-field evaluation showed a laterally displaced talocrural dislocation. Immediate reduction was performed in the athletic training room to maintain skin integrity. Post-reduction radiographs revealed a Weber type C fibular fracture and increased medial joint clear space. A below-knee, fiberglass splint was applied to stabilize the ankle joint complex. Differential Diagnosis: Subtalar dislocation, Maisonneuve fracture, malleolar fracture, deltoid ligament rupture, syndesmosis disruption. Treatment: The sports medicine staff immediately splinted and transported the athlete to the athletic training room to reduce the dislocation. The athlete then underwent an open reduction and internal fixation procedure to stabilize the injury: 2 syndesmosis screws and a fibular plate were placed to keep the ankle joint in an anatomically reduced position. With the guidance of the athletic training staff, the athlete underwent an accelerated physical rehabilitation protocol in an effort to return to sport as quickly and safely as possible. Uniqueness: Most talocrural dislocations and associated Weber type C fibular fractures are due to motor vehicle accidents or falls. We are the first to describe this injury in a Division I football player and to present a general rehabilitation protocol for a high-level athlete. Conclusions: Sports medicine practitioners must recognize that this injury can occur in the athletic environment. Prompt reduction, early surgical intervention, sufficient resources, and an accelerated rehabilitation protocol all contributed to a successful outcome in the patient. PMID:18523569

Hip abductor strength and lower extremity running related injury in distance runners: A systematic review.

PubMed

Mucha, Matthew D; Caldwell, Wade; Schlueter, Emily L; Walters, Carly; Hassen, Amy

2017-04-01

Determine the association between hip abduction strength and lower extremity running related injury in distance runners. Systematic review. Prospective longitudinal and cross sectional studies that quantified hip abduction strength and provided diagnosis of running related injury in distance runners were included and assessed for quality. Effect size was calculated for between group differences in hip abduction strength. Of the 1841 articles returned in the initial search, 11 studies matched all inclusion criteria. Studies were grouped according to injury: iliotibial band syndrome, patellofemoral pain syndrome, medial tibial stress syndrome, tibial stress fracture, and Achilles tendinopathy, and examined for strength differences between injured and non-injured groups. Meaningful differences were found in the studies examining iliotibial band syndrome. Three of five iliotibial band syndrome articles found weakness in runners with iliotibial band syndrome; two were of strong methodological rigor and both of those found a relationship between weakness and injury. Other results did not form associative or predictive relationships between weakness and injury in distance runners. Hip abduction weakness evaluated by hand held dynamometer may be associated with iliotibial band syndrome in distance runners as suggested by several cross sectional studies but is unclear as a significant factor for the development of patellofemoral pain syndrome, medial tibial stress syndrome, tibial stress fracture or Achilles tendinopathy according to the current literature. Future studies are needed with consistent methodology and inclusion of all distance running populations to determine the significance of hip abduction strength in relationship to lower extremity injury. Copyright © 2016 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Comparison of plantar flexor musculotendinous stiffness, geometry, and architecture in male runners with and without a history of tibial stress fracture.

PubMed

Pamukoff, Derek N; Blackburn, J Troy

2015-02-01

Greater lower extremity joint stiffness may be related to the development of tibial stress fractures in runners. Musculotendinous stiffness is the largest contributor to joint stiffness, but it is unclear what factors contribute to musculotendinous stiffness. The purpose of this study was to compare plantar flexor musculotendinous stiffness, architecture, geometry, and Achilles tendon stiffness between male runners with and without a history of tibial stress fracture. Nineteen healthy runners (age = 21 ± 2.7 years; mass = 68.2 ± 9.3 kg; height = 177.3 ± 6.0 cm) and 19 runners with a history of tibial stress fracture (age = 21 ± 2.9 years; mass = 65.3 ± 6.0 kg; height = 177.2 ± 5.2 cm) were recruited from community running groups and the university's varsity and club cross-country teams. Plantar flexor musculotendinous stiffness was estimated from the damped frequency of oscillatory motion about the ankle follow perturbation. Ultrasound imaging was used to measure architecture and geometry of the medial gastrocnemius. Dependent variables were compared between groups via one-way ANOVAs. Previously injured runners had greater plantar flexor musculotendinous stiffness (P < .001), greater Achilles tendon stiffness (P = .004), and lesser Achilles tendon elongation (P = .003) during maximal isometric contraction compared with healthy runners. No differences were found in muscle thickness, pennation angle, or fascicle length.

The anterior approach for the fixation of displaced talar neck fractures--a cadaveric study.

PubMed

Mullen, Michael; Pillai, Anand; Fogg, Quentin A; Kumar, C Senthil

2013-01-01

Talar neck fractures are rare and are associated with high complication rates. Adequate surgical exposure is essential in the operative management of these challenging injuries. The anterior approach is an alternative to the more commonly described and utilized anterolateral and anteromedial approaches. The main objective was to compare the surface area of talus visible and quality of exposure via the anterior approach, with the anteromedial and anterolateral approaches. An anterior approach was performed on five fresh frozen cadaveric specimens. The surface area of talus visible was measured using an Immersion Digital Microscribe and analyzed with the Rhinoceros 3D graphics package. Standard anterolateral and anteromedial approaches were performed in the same specimens and areas visible measured using the same method. The talar surface area visible using the anterior approach is significantly greater than that visible using the anterolateral approach or anteromedial, without and with medial malleolar osteotomy, as well as combination approaches. The anterior approach offers excellent visualization in the fixation of displaced talar neck fractures. Greater talar surface area is visible using this approach compared to traditional approaches. Copyright © 2013 Elsevier Ltd. All rights reserved.

Proximal humeral fractures: the role of calcium sulphate augmentation and extended deltoid splitting approach in internal fixation using locking plates.

PubMed

Somasundaram, K; Huber, C P; Babu, V; Zadeh, H

2013-04-01

The aim of our study is to analyse the results of our surgical technique for the treatment of proximal humeral fractures and fracture dislocations using locking plates in conjunction with calcium sulphate bone-substitute augmentation and tuberosity repair using high-strength sutures. We used the extended deltoid-splitting approach for fracture patterns involving displacement of both lesser and greater tuberosities and for fracture-dislocations. Optimal surgical management of proximal humeral fractures remains controversial. Locking plates have become a popular method of fixation. However, failure of fixation may occur if they are used as the sole method of fixation in comminuted fractures, especially in osteopenic bone. We retrospectively analysed 22 proximal humeral fractures in 21 patients; 10 were male and 11 female with an average age of 64.6 years (range 37-77). Average follow-up was 24 months. Eleven of these fractures were exposed by the extended deltoid-splitting approach. Fractures were classified according to Neer and Hertel systems. Preoperative radiographs and computed tomography (CT) scans in three- and four-part fractures were done to assess the displacement and medial calcar length for predicting the humeral head vascularity. According to the Neer classification, there were five two-part, six three-part, five four-part fractures and six fracture-dislocations (two anterior and four posterior). Results were assessed clinically with disabilities of the arm, shoulder and hand (DASH) scores, modified Constant and Murley scores and serial postoperative radiographs. The mean DASH score was 16.18 and the modified Constant and Murley score was 64.04 at the last follow-up. Eighteen out of twenty-two cases achieved good clinical outcome. All the fractures united with no evidence of infection, failure of fixation, malunion, tuberosity failure, avascular necrosis or adverse reaction to calcium sulphate bone substitute. There was no evidence of axillary nerve injury. Four patients had a longer recovery period due to stiffness, associated wrist fracture and elbow dislocation. The CaSO4 bone substitute was replaced by normal appearing trabecular bone texture at an average of 6 months in all patients. In our experience, we have found the use of locking plates, calcium sulphate bone substitute and tuberosity repair with high-strength sutures to be a safe and reliable method of internal fixation for complex proximal humeral fractures and fracture-dislocations. Furthermore, we have also found the use of the extended deltoid-splitting approach to be safe and to provide excellent exposure facilitating accurate reduction for fixation of the fracture patterns involving displacement of both lesser and greater tuberosities and for fracture-dislocations. Copyright © 2012 Elsevier Ltd. All rights reserved.

Accuracy and Measurement Error of the Medial Clear Space of the Ankle.

PubMed

Metitiri, Ogheneochuko; Ghorbanhoseini, Mohammad; Zurakowski, David; Hochman, Mary G; Nazarian, Ara; Kwon, John Y

2017-04-01

Measurement of the medial clear space (MCS) is commonly used to assess deltoid ligament competency and mortise stability when managing ankle fractures. Lacking knowledge of the true anatomic width measured, previous studies have been unable to measure accuracy of measurement. The purpose of this study was to determine MCS measurement error and accuracy and any influencing factors. Using 3 normal transtibial ankle cadaver specimens, deltoid and syndesmotic ligaments were transected and the mortise widened and affixed at a width of 6 mm (specimen 1) and 4 mm (specimen 2). The mortise was left intact in specimen 3. Radiographs were obtained of each cadaver at varying degrees of rotation. Radiographs were randomized, and providers measured the MCS using a standardized technique. Lack of accuracy as well as lack of precision in measurement of the medial clear space compared to a known anatomic value was present for all 3 specimens tested. There were no significant differences in mean delta with regard to level of training for specimens 1 and 2; however, with specimen 3, staff physicians showed increased measurement accuracy compared with trainees. Accuracy and precision of MCS measurements are poor. Provider experience did not appear to influence accuracy and precision of measurements for the displaced mortise. This high degree of measurement error and lack of precision should be considered when deciding treatment options based on MCS measurements.

Prevalence of and referred pain from myofascial trigger points in the forearm muscles in patients with lateral epicondylalgia.

PubMed

Fernández-Carnero, Josué; Fernández-de-Las-Peñas, César; de la Llave-Rincón, Ana Isabel; Ge, Hong-You; Arendt-Nielsen, Lars

2007-05-01

Referred pain and pain characteristics evoked from the extensor carpi radialis brevis, extensor carpi radialis longus, extensor digitorum communis, and brachioradialis muscles was investigated in 20 patients with lateral epicondylalgia (LE) and 20-matched controls. Both groups were examined for the presence of myofascial trigger points (TrPs) in a blinded fashion. The quality and location of the evoked referred pain, and the pressure pain threshold (PPT) at the lateral epicondyle on the right upper extremity (symptomatic side in patients, and dominant-side on controls) were recorded. Several lateral elbow pain parameters were also evaluated. Within the patient group, the elicited referred pain by manual exploration of 13 out of 20 (65%) extensor carpi radialis brevis muscles, 12/20 (70%) extensor carpi radialis longus muscles, 10/20 (50%) brachioradialis muscles, and 5/20 (25%) extensor digitorum communis muscles, shares similar pain patterns as their habitual lateral elbow and forearm pain. The mean number of muscles with TrPs for each patient was 2.9 [95% confidence interval (CI) 1,4] of which 2 (95% CI 1,3) were active, and 0.9 (95% CI 0,2) were latent TrPs. Control participants only had latent TrPs (mean: 0.4; 95% CI 0,2). TrP occurrence between the 2 groups was significantly different for active TrPs (P<0.001), but not for latent TrPs (P>0.05). The referred pain pattern was larger in patients than in controls, with pain referral to the lateral epicondyle (proximally) and to the dorso-lateral aspect of the forearm in the patients, and confined to the dorso-lateral aspect of the forearm in the controls. Patients with LE showed a significant (P<0.001) lower PPT (mean: 2.1 kg/cm; 95% CI 0.8, 4 kg/cm) as compared with controls (mean: 4.5 kg/cm; 95% CI 3, 7 kg/cm). Within the patient group, PPT at the lateral epicondyle was negatively correlated with both the total number of TrPs (rs=-0.63; P=0.003) and the number of active TrPs (rs=-0.5; P=0.02): the greater the number of active TrPs, the lower the PPT at the lateral epicondyle. Our results suggest that in patients with LE, the evoked referred pain and its sensory characteristics shared similar patterns as their habitual elbow and forearm pain, consistent with active TrPs. Lower PPT and larger referred pain patterns suggest that peripheral and central sensitization exists in LE.

Locked plating of comminuted distal femur fractures: does unlocked screw placement affect stability and failure?

PubMed

Cui, Shari; Bledsoe, J G; Israel, Heidi; Watson, J T; Cannada, Lisa K

2014-02-01

Locked plates provide greater stiffness, possibly at the expense of fracture healing. The purpose of this study is to evaluate construct stiffness of distal femur plates as a function of unlocked screw position in cadaveric distal femur fractures. Osteoporotic cadaveric femurs were used. Four diaphyseal bridge plate constructs were created using 13-hole distal femur locking plates, all with identical condylar fixation. Constructs included all locked (AL), all unlocked (AUL), proximal unlocked (PUL), and distally unlocked (DUL) groups. Constructs underwent cyclic axial loading with increasing force per interval. Data were gathered on axial stiffness, torsional stiffness, maximum torque required for 5-degree external rotation, and axial force to failure. Twenty-one specimens were divided into AL, AUL, PUL, and DUL groups. Axial stiffness was not significantly different between the constructs. AL and PUL demonstrated greater torsional stiffness, maximum torque, and force to failure than AUL and AL showed greater final torsional stiffness and failure force than DUL (P < 0.05). AL and PUL had similar axial, torsion, and failure measures, as did AUL and DUL constructs. All but 2 specimens fractured before medial gap closure during failure tests. Drop-offs on load-displacement curves confirmed all failures. Only the screw nearest the gap had significant effect on torsional and failure stiffness but not axial stiffness. Construct mechanics depended on the type of screw placed in this position. This screw nearest the fracture dictates working length stiffness when the working length itself is constant and in turn determines overall construct stiffness in osteoporotic bone.

Assessing joint line positions by means of the contralateral knee: a new approach for planning knee revision surgery?

PubMed

Maderbacher, Günther; Keshmiri, Armin; Zeman, Florian; Grifka, Joachim; Baier, Clemens

2015-11-01

Reconstructing the natural joint line in knee revision surgery improves clinical and functional outcome but may be challenging when both cartilage and bone were removed during previous operations. Assessing joint lines (JLs) by means of bony landmarks is inadvisable because of large variations in human anatomy. Because of the inherent symmetry of the human body, we hypothesised that JLs may be directly assessed by measuring the distances from the bony landmarks to the JL of the contralateral knee by means of radiographic images. Using scaled weight-bearing radiographs in anteroposterior view of both knees, two independent observers measured the distances from the fibular head, the medial and lateral epicondyle, and the adductor tubercle to the JL. A two-sided p value of ≤0.05 was considered statistically significant. Two hundred knees of 100 patients (50 men and 50 women) were examined. For the fibular head, the mean difference between the treated and the control knee was 0.0 mm with narrow confidence limits ranging from -1.1 to 1.1. As a new assessment method, we have suggested to assess the JL by means of radiographs of the contralateral knee. The most precise parameter was found to be the distance between the fibular head and the JL. The level of arthritis, age, gender, visibility of the landmarks, and misalignment did not influence measurement accuracy. This parameter is the first tibia-related landmark for assessing the JL, which advantageously corresponds to the tibia-first technique in revision surgery. Diagnostic Study, Level II.

[TREATMENT OF PRONATION EXTERNAL ROTATION ANKLE FRACTURE COMBINED WITH SEPARATION OF DISTAL TIBIOFIBULAR SYNDESMOSIS].

PubMed

Wu, Benwen; Ding, Zhenqi; Huang, Guofeng; Liu, Guojun; Cai, Zhemin; Ding, Luobin; Li, Xiang

2016-09-08

To evaluate the difference between using and not using syndesmotic screw to treat pronation external rotation (PER) ankle fracture combined with separation of distal tibiofibular syndesmosis. Between April 2011 and October 2014, 46 cases of PER ankle fracture combined with separation of distal tibiofibular syndesmosis were treated, and syndesmotic screw was used in 24 cases (fixation group) and syndesmotic screw was not used in 22 cases (non-fixation group). There was no significant difference in gender, age, weight, cause of injury, side, injury to operation time, and fracture type between 2 groups ( P >0.05). The time for full weight-bearing, fracture healing time, and complications were recorded after operation. Anteroposterior and lateral X-ray films were taken to measure the tibiofibular overlap (TBOL) and tibiofibular clear space (TBCS). Baird-Jackson score was used to evaluate functional recovery of the ankle. All incision healed by first intention without complications. The cases were followed up 13-18 months (mean, 15.2 months) in 2 groups. The time for full weight-bearing was 8-12 weeks (median, 11 weeks) in fixation group, which was significantly later than that in non-fixation group (range, 6-10 weeks; median, 8 weeks) ( Z =-5.049, P =0.000). X-ray examination showed reduction of separation of distal tibiofibular syndesmosis. All fractures healed. The fracture healing time was (13.83±1.37) weeks in fixation group, and was (13.91±1.31) weeks in non-fixation group, showing no significant difference ( t =-0.191, P =0.945). No separation of distal tibiofibular syndesmosis, delayed union, nonunion, loosening, or breakage of fixation devices was observed in 2 groups. There was no significant difference in TBOL, TBCS, Baird-Jackson score and the excellent and good rate between 2 groups ( P >0.05). If the medial, lateral, and posterior structures of the ankle could be repaired according to injury, no significant influence on functional outcome of ankle or radiologic findings could be detected whether syndesmotic fixation is given or not in treating PER ankle fracture (exclude Maisonneuve fracture) combined with separation of distal tibiofibular syndesmosis.

Monitoring tissue inflammation and responses to drug treatments in early stages of mice bone fracture using 50 MHz ultrasound

PubMed Central

Chen, Yen-Chu; Lin, Yi-Hsun; Wang, Shyh-Hau; Lin, Shih-Ping; Shung, K. Kirk; Wu, Chia-Ching

2014-01-01

Bone fracture induces moderate inflammatory responses that are regulated by cyclooxygenase-2 (COX-2) or 5-lipoxygenase (5-LO) for initiating tissue repair and bone formation. Only a handful of non-invasive techniques focus on monitoring acute inflammation of injured bone currently exists. In the current study, we monitored in vivo inflammation levels during the initial 2 weeks of the inflammatory stage after mouse bone fracture utilizing 50 MHz ultrasound. The acquired ultrasonic images were correlated well with histological examinations. After the bone fracture in the tibia, dynamic changes in the soft tissue at the medial-posterior compartment near the fracture site were monitored by ultrasound on the days of 0, 2, 4, 7, and 14. The corresponding echogenicity increased on the 2nd, 4th, and 7th day, and subsequently declined to basal levels after the 14th day. An increase of cell death was identified by the positive staining of deoxynucleotidyl transferase dUTP nick end-labeling (TUNEL) assay and was consistent with ultrasound measurements. The increases of both COX-2 and Leukotriene B4 receptor 1 (BLT1, 5- LO-relative receptor), which are regulators for tissue inflammation, in the immunohistochemistry staining revealed their involvement in bone fracture injury. Monitoring the inflammatory response to various non-steroidal anti-inflammatory drugs (NSAIDs) treatments was investigated by treating injured mice with a daily oral intake of aspirin (Asp), indomethacin (IND), and a selective COX-2 inhibitor (SC-236). The Asp treatment significantly reduced fracture-increased echogenicity (hyperechogenicity, p < 0.05) in ultrasound images as well as inhibited cell death, and expression of COX-2 and BLT1. In contrast, treatment with IND or SC-236 did not reduce the hyperechogenicity, as confirmed by cell death (TUNEL) and expression levels of COX-2 or BLT1. Taken together, the current study reports the feasibility of a noninvasive ultrasound method capable of monitoring post-fracture tissue inflammation that positively correlates with histological findings. Results of this study also suggest that this approach may be further applied to elucidate the underlying mechanisms of inflammatory processes and to develop therapeutic strategies for facilitating fracture healing. PMID:23871514

How bone quality may influence intraoperative and early postoperative problems after angular stable open reduction-internal fixation of proximal humeral fractures.

PubMed

Spross, Christian; Zeledon, Rebeca; Zdravkovic, Vilijam; Jost, Bernhard

2017-09-01

With the introduction of the deltoid tuberosity index (DTI), a simple radiographic tool has become available to measure bone mineral density of the proximal humerus. The aim of this study was to assess the influence of local bone mineral density on the early failure rate after angular stable open reduction-internal fixation of proximal humeral fractures (PHFs). We retrospectively followed up all patients treated with angular stable implants for PHFs from 2007 to 2014. The fractures were classified according to Neer, and the DTI, metaphyseal head extension (MHE), medial hinge displacement, and quality of reduction were assessed. Failures were defined as head screw cutouts. The study included 146 patients (mean age, 66 years; range, 20-94 years). The mean follow-up period was 11 months (range, 3-94 months). Of the fractures, 91% were classified as 2- or 3-part fractures and 9% as 4-part fractures. The mean DTI was 1.44 (range, 1.19-2.11), and the mean MHE was 12 mm (range, 0-48 mm). The reduction result was at least acceptable in 80% of fractures. Screw cutouts were found in 23%. The DTI and MHE were the most significant preoperative predictors for the reduction result. The DTI (P = .036) and age (P = .02) were independent preoperative factors, and a good reduction (P = .001) was the only intraoperative factor influencing cutout. This study proves that good bone quality and a long MHE are helpful for the reduction. Furthermore, good bone quality, a younger age, and a good reduction prevent later cutout. We conclude that local bone quality is a relevant factor in the treatment plan for PHFs. Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Posterior locked lateral compression injury of the pelvis in geriatric patients: an infrequent and specific variant of the fragility fracture of pelvis.

PubMed

Lee, Se-Won; Kim, Weon-Yoo; Koh, Sung-Jun; Kim, Young-Yul

2017-09-01

Posterior locked lateral compression injury (PLLCI) of the pelvic ring is an infrequent variant of lateral compression injury, a condition described in only eight reported cases since 2000. Lateral compression injury usually results from high-energy trauma and is characterized by locking between the medially translated fractured ilium and the anterior border of the sacrum, regardless of whether the fractured ilium involves the sacroiliac joint. However, in our experience, lateral compression injury can also result from low-energy trauma as a manifestation of pelvic fragility fracture. The aim of the present study was to describe this rare form of PLLCI in a case series of geriatric patients. A retrospective analysis of consecutive patients with pelvic ring injuries who were admitted to our hospital from January 2008 to April 2015 identified seven geriatric patients (1 male and 6 females; median age 81 years) with a form of PLLCI. All injuries were due to falls from a standing position onto the ground. All seven cases demonstrated characteristics of a locking fractured ilium over the anterior border of the sacrum on axial computed tomography images, but were not detected on plain radiographs. All underwent follow-up at 1 year or later with improved mean visual analogue scale scores (range 0-3). Regarding Koval walking ability scores, patients who underwent pelvic brim plating with anterior external fixation were more likely to regain their pre-injury walking ability than patients who only underwent anterior external fixation or conservative treatment. Geriatric patients can experience PLCCIs of the pelvis due to low-energy trauma. These fractures have different characteristics from those associated with severe injuries due to high-energy trauma, and they comprise an infrequent form of Rommens fragility fracture of the pelvis (type IIIa). In these cases, appropriate surgical management that includes sacroiliac plating combined with anterior external fixation can yield good outcomes.

[Effectiveness comparison of flexible fixation and rigid fixation in treatment of ankle pronation-external rotation fractures with distal tibiofibular syndesmosis].

PubMed

Li, Yuewei; Zhang, Minghui; Li, Xiaorong; Chen, Xiaoyong; Deng, Jianlong

2017-07-01

To compare the effectiveness of flexible fixation and rigid fixation in the treatment of ankle pronation-external rotation fractures with distal tibiofibular syndesmosis. A retrospective analysis was made on the clinical data of 50 patients with ankle pronation-external rotation fractures and distal tibiofibular syndesmosis treated between January 2013 and December 2015. Suture-button fixation was used in 23 patients (flexible fixation group) and cortical screw fixation in 27 patients (rigid fixation group). There was no significant difference in age, gender, weight, side, fracture type, and time from trauma to surgery between 2 groups ( P >0.05). The operation time, medial clear space (MCS), tibiofibular clear space (TFCS), tibiofibular overlap (TFO), American Orthopaedic Foot and Ankle Society (AOFAS) score, and Foot and Ankle Disability Index (FADI) score were compared between 2 groups. The operation time was (83.0±9.1) minutes in the flexible fixation group and was (79.6±13.1) minutes in the rigid fixation group, showing no significant difference ( t =1.052, P =0.265). All patients achieved healing of incision by first intention. The patients were followed up 12-20 months (mean, 14 months). The X-ray films showed good healing of fracture in 2 groups. There was no screw fracture, delayed union or nounion. The fracture healing time was (12.1±2.5) months in the flexible fixation group and was (11.3±3.2) months in the rigid fixation group, showing no significant difference between 2 groups ( t =1.024, P =0.192). Reduction loss occurred after removal of screw in 2 cases of the rigid fixation group. At last follow-up, there was no significant difference in MCS, TFCS, TFO, AOFAS score and FADI score between 2 groups ( P >0.05). Suture-button fixation has similar effectiveness to screw fixation in ankle function and imaging findings, and flexible fixation has lower risk of reduction loss of distal tibiofibular syndesmosis than rigid fixation.

Addition of a Medial Locking Plate to an In Situ Lateral Locking Plate Results in Healing of Distal Femoral Nonunions.

PubMed

Holzman, Michael A; Hanus, Bryan D; Munz, John W; O'Connor, Daniel P; Brinker, Mark R

2016-06-01

Nonunion of the distal femur after lateral plating is associated with axial malalignment, chronic pain, loss of ambulatory function, and decreased knee ROM. The addition of a medial locking plate with autogenous bone grafting can provide greater stability to allow bone healing and may be used to achieve union in these challenging cases. We wished to determine (1) the proportion of patients who achieve radiographic signs of osseous union for distal femoral nonunions with an in situ lateral plate after treatment with addition of a medial locking plate and autogenous bone grafting, and (2) the frequency and types of complications associated with this treatment. Between 2007 and 2013, we treated 22 patients for 23 distal femoral nonunions, defined as an unhealed fracture with no radiographic signs of osseous union at a mean of 16 months (SD, 13 months) after injury. During that time, we used a treatment algorithm consisting of treatment in one or two stages. The single-stage procedure performed in 16 aseptic nonunions with a stable lateral plate involved addition of a medial locking plate and autogenous bone graft. A two-stage treatment performed in seven nonunions with lateral plate failure involved placement of a new lateral locking plate followed by addition of a medial locking plate with autogenous bone graft at least 2 months after the first procedure. Of the 22 patients treated, 20 had a median followup of 18 months (SD, 6-94 months). We defined osseous union by bridging bone on three of four cortices with absence of a radiolucent line or more than 25% cross-sectional area of bridging bone via CT. Twenty of the 21 nonunions attained radiographic signs of osseous union by 12 months. Six of the 20 patients experienced complications: one patient had a persistent nonunion; four patients underwent removal of symptomatic hardware; and one patient experienced skin breakdown at the bone graft harvest site. A very high proportion of patients achieve union when using medial locking plates to treat distal femoral nonunions after lateral plating of the original injury. Addition of bone graft, staged reconstruction, and revision of the initial lateral plate is indicated when the nonunion is associated with fatigue failure of the initial lateral plate. Level IV, therapeutic study.

Femoral neck buttressing: a radiographic and histologic analysis.

PubMed

Dixon, T; Benjamin, J; Lund, P; Graham, A; Krupinski, E

2000-10-01

To examine the incidence, radiographic and histologic findings of medial femoral neck buttressing in a consecutive group of patients undergoing total hip arthroplasty. Biomechanical parameters were evaluated on standard anteroposterior pelvic radiographs of 113 patients prior to hip replacement surgery. Demographic information on all patients was reviewed and histologic evaluation was performed on specimens obtained at the time of surgery. The incidence of medial femoral neck buttressing was found to be 50% in a consecutive series of patients undergoing total hip arthroplasty. The incidence was slightly higher in women (56% vs. 41%). Patients with buttressing had increased neck-shaft angles and smaller femoral neck diameters than were seen in patients without buttressing. Histologic evaluation demonstrated that the buttress resulted from deposition bone by the periosteum on the femoral neck in the absence of any evidence of femoral neck fracture. It would appear that femoral neck buttressing occurs in response to increased joint reactive forces seen at the hip being transmitted through the femoral neck. The increased joint reactive force can be related to the increased neck shaft angle seen in patients with buttressing.

In vivo analysis of acromioclavicular joint motion after hook plate fixation using three-dimensional computed tomography.

PubMed

Kim, Yoon Sang; Yoo, Yon-Sik; Jang, Seong Wook; Nair, Ayyappan Vijayachandran; Jin, Hyonki; Song, Hyun-Seok

2015-07-01

The clavicle hook plate can be used to treat acromioclavicular and coracoclavicular ligament injury or distal clavicular fracture with comminution. However, the hook plate can induce subacromial impingement, resulting in discomfort from the hardware. Our inclusion criteria were (1) men and women aged older than 20 years and (2) the presence of comminuted distal clavicular fractures (Neer type IIB) fixed with a hook plate (Synthes, Oberdorf, Switzerland). Three-dimensional computed tomography was obtained before removal of the hook plate. Seven patients were enrolled prospectively. The mean age was 42 years (range, 24-60 years). Zero degree images and abduction images were obtained. The sagittal cut surface was obtained 5 mm medial from the distal clavicle. The equator of the cut surface of the clavicle was compared with the full abduction model to analyze rotation. The center of the cut surface of the clavicle was compared with the full abduction model to analyze translation. The average difference in rotation of the distal clavicle between both shoulders was 16° (range, 3°-22°; P = .001). The mean difference in anterior translation of the distal clavicle was 2.2 mm (range, -0.7 to 5.6 mm; P = .030). Hook plate fixation at the acromioclavicular joint causes decreased internal rotation and increased anterior translation of the distal clavicle with respect to the medial acromion, indicating that the scapula relative to the thorax has decreased posterior tilting and increased external rotation in shoulders fixed using a hook plate. Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

A micro-architectural evaluation of osteoporotic human femoral heads to guide implant placement in proximal femoral fractures.

PubMed

Jenkins, Paul J; Ramaesh, Rishikesan; Pankaj, Pankaj; Patton, James T; Howie, Colin R; Goffin, Jérôme M; Merwe, Andrew van der; Wallace, Robert J; Porter, Daniel E; Simpson, A Hamish

2013-10-01

The micro-architecture of bone has been increasingly recognized as an important determinant of bone strength. Successful operative stabilization of fractures depends on bone strength. We evaluated the osseous micro-architecture and strength of the osteoporotic human femoral head. 6 femoral heads, obtained during arthroplasty surgery for femoral neck fracture, underwent micro-computed tomography (microCT) scanning at 30 μm, and bone volume ratio (BV/TV), trabecular thickness, structural model index, connection density, and degree of anisotropy for volumes of interest throughout the head were derived. A further 15 femoral heads underwent mechanical testing of compressive failure stress of cubes of trabecular bone from different regions of the head. The greatest density and trabecular thickness was found in the central core that extended from the medial calcar to the physeal scar. This region also correlated with the greatest degree of anisotropy and proportion of plate-like trabeculae. In the epiphyseal region, the trabeculae were organized radially from the physeal scar. The weakest area was found at the apex and peripheral areas of the head. The strongest region was at the center of the head. The center of the femoral head contained the strongest trabecular bone, with the thickest, most dense trabeculae. The apical region was weaker. From an anatomical and mechanical point of view, implants that achieve fixation in or below this central core may achieve the most stable fixation during fracture healing.

Therapeutic objectives and surgical treatment of mandibular condyle fractures. Personal experience.

PubMed

Burlini, D

2004-10-01

A review of condylar fractures treated ''non-surgically'' and ''surgically'' over the last 5 years (1996-2001) at the Maxillofacial Surgery Division of the Brescia Civil Hospital (Italy) is presented. The non surgical and surgical treatments carried out, as well as their effectiveness and therapeutic aims, are illustrated. From June 1996 to June 2001, at the Maxillofacial Surgery Division of the Brescia Civil Hospital, 179 fractures of the mandibular condyle were treated. Of the 179 cases treated, a distinction was immediately made between ''non-surgical'' (103 cases) and ''surgical'' cases (76 cases). The 76 ''surgical'' cases were all treated with the same surgical technique. Out-patient follow-up was at days 20, 60, 90, and 1 year, together with a radiographic check-up at 60 days. Of the 76 condylar fractures treated surgically, 15 patients selected at random were re-examined; the medical history was investigated and clinical and radiological examinations performed. For each patient, the type of condylar fracture and whether this was associated with other mandibular fractures were recorded. The following data were also recorded: age of the patient; pain at the surgical site or at the mandible at the time of check-up; presence of normal occlusion and laterodeviation; any surgical sequelae at the facial nerve on the operated side; maximum mouth opening; any radiological defect; time since surgery. Then, the patient was asked to give his/her own evaluation of the surgical outcome, by expressing adequate, good or excellent result. In patients treated surgically the indication is almost absolute in the following cases: condylar fractures types II and IV of the Spiessl/Schroll classification, low or high condylar fractures with medial dislocation of the condyle; non-surgical treatment cannot be applied for reasons of patient's health; condylar fracture associated with other open fractures of the face. The use of rigid fixation also may help in the success of the technique adopted. In all the cases (surgical and non-surgical) it is important to achieve early mobilization of the mandible and carry out a rehabilitation program for masticatory function. The goals of condylar treatment may therefore be summarized as follows: to achieve a good occlusion; to eliminate pain; to achieve a proper mandibular symmetry; to achieve good mandibular movement in the 3 planes of space.

The role of tendinitis in fibromyalgia syndrome.

PubMed

Genç, Hakan; Saracoğlu, Meryem; Duyur, Burcu; Erdem, Hatice Rana

2003-08-30

Fibromyalgia Syndrome (FS) is a common disease characterized by diffuse, widespread pain and multiple tender points. The syndrome has been subclassified as primary (PFS) and secondary (SFS) fibromyalgia. The aim of this study was to evaluate the role of common tendinitis (rotator cuff tendinitis, bicipital tendinitis, lateral epicondylitis, De-Quervain's tendinitis and pes anserinus tendinitis) in FS. Twenty female patients with PFS, 20 with SFS and 20 female controls, matched by age and body mass index, participated in the study. Existence of common tendinitis was evaluated with specific examination methods. Right and left rotator cuff tendinitis, pes anserinus tendinitis and left lateral epicondylitis were significantly more common in patients with PFS and SFS than in control subjects. As a result, considering the central hyperexcitability present in the fibromyalgia patients, concomitant pathologies such as tendinitis which lead to shoulder, arm, and leg pain must be evaluated. Follow up and therapy for the disease must be planned according to these factors which are not only probable symptoms of FS, but also leading causes for the occurrence and continuity of the pain in this disease.

Outcome of Boyd-McLeod procedure for recalcitrant lateral epicondylitis of elbow.

PubMed

Reddy, V R M; Satheesan, K S; Bayliss, N

2011-08-01

Various surgical procedures including percutaneous and open release and arthroscopic procedures have been described to treat recalcitrant tennis elbow. We present the outcome of Boyd-McLeod surgical procedure for tennis elbow resistant to non-operative treatment in twenty-seven patients (twenty-nine limbs). Boyd McLeod procedure involves excision of the proximal portion of the annular ligament, release of the origin of the extensor muscles, excision of the bursa if present, and excision of the synovial fringe. The average time interval from the onset of symptoms of tennis elbow until surgery was 28 months (range 8-72 months). Of those patients, 91% reported complete relief of symptoms with return to full normal activities including sports. Average post-operative time for return to professional/recreational activity was 5 weeks. One case developed pain secondary to ectopic bone formation after surgery, which settled after excision, and in another there was no pain relief with Boyd McLeod procedure. Two patients had scar tenderness that did not affect the final outcome. We conclude that Boyd-McLeod procedure is an effective treatment option in patients with resistant lateral epicondylitis.

Claims incidence of work-related disorders of the upper extremities: Washington state, 1987 through 1995.

PubMed

Silverstein, B; Welp, E; Nelson, N; Kalat, J

1998-12-01

This study examined the claim incidence rate, cost, and industry distribution of work-related upper extremity disorders in Washington. Washington State Fund workers' compensation claims from 1987 to 1995 were abstracted and categorized into general and specific disorders of gradual or sudden onset. Accepted claims included 100,449 for hand/wrist disorders (incidence rate: 98.2/10,000 full-time equivalents; carpal tunnel syndrome rate: 27.3), 30,468 for elbow disorders (incidence rate: 29.7; epicondylitis rate: 11.7), and 55,315 for shoulder disorders (incidence rate: 54.0; rotator cuff syndrome rate: 19.9). Average direct workers' compensation claims costs (medical treatment and indemnity) were $15,790 (median: $6774) for rotator cuff syndrome, $12,794 for carpal tunnel syndrome (median: $4190), and $6593 for epicondylitis (median: $534). Construction and food processing were among the industries with the highest rate ratios for all disorders (> 4.0). Upper extremity disorders represent a large and costly problem in Washington State industry. Industries characterized by manual handling and repetitive work have high rate ratios. The contingent workforce appears to be at high risk.

N of 1, two contemporary arm, randomised controlled clinical trial for bilateral epicondylitis: a new study design

PubMed Central

Fante, Claudia Del; Perotti, Cesare; Pavesi, Claudio Francesco; Coscia, Davide; Scotti, Valeria; Tinelli, Carmine

2011-01-01

Objective To investigate the use of a novel study design in analysis of bilateral elbow pain. Design N of 1, two contemporary arm, open label, randomised controlled clinical trial. Setting A clinical epidemiologist at a university hospital in Pavia, Italy. Participants Two elbows with epicondylitis. Interventions Autologous platelet lysate versus “wait and see” strategy. Main outcome measures Visual analogue scale for pain on elbow extension and resisted wrist extension. Results Over six months’ follow-up, the patient experienced bilateral improvement in pain, but higher in the treated arm, with a drop in visual analogue scale for pain from 28 to 4 for right (control) arm (drop of 24 points) and from 67 to 10.5 for left (treated) arm (drop of 56.5 points). Conclusions Platelet lysate might (or might not) work. Competing interests and lack of blinding might be relevant issues in the interpretation of trial results. However, the new study design can be applied to a number of conditions such as bilateral sport or trauma injuries, bilateral otitis, or any condition affecting chiral organs or limbs. PMID:22187187

A CRITICAL REVIEW OF THE CURRENT CONSERVATIVE THERAPIES FOR TENNIS ELBOW (LATERAL EPICONDYLITIS)

PubMed Central

Viola, Leonardo

1998-01-01

The pathogenesis, pathology, natural course, and in particular the treatment of lateral epicondylitis (tennis elbow) remains controversial. An extensive review of the scientific literature with respect to the conservative treatment of tennis elbow, revealed that acceptable epidemiological techniques of the prospective randomised control trials or case controlled studies are scarce. While administration of steroid compounds has traditionally been the mainstay of conservative treatment of tennis elbow, the high recurrence rate of side effects and structural tissue changes associated with steroid therapy, leaves this modality as the most controversial approach in the treatment of tennis elbow. In contrast, in some studies evidence in favour of a role for classical acupuncture, ultrasound and low level laser as effective therapeutic means in the treatment of tennis elbow has been provided. As these modalities have not been associated with any side effects, in view of the ease of application, low cost and good curative effects, their increased application has been suggested by some authors. This proposition, however, remains rather conjectural until it could be convincingly substantiated by future studies with appropriate epidemiological design. PMID:17987156

Minimally invasive treatment of pilon fractures with a low profile plate: preliminary results in 17 cases.

PubMed

Borens, Olivier; Kloen, Peter; Richmond, Jeffrey; Roederer, Goetz; Levine, David S; Helfet, David L

2009-05-01

To determine the results of "biologic fixation" with a minimally invasive plating technique using a newly designed low profile "Scallop" plate in the treatment of pilon fractures. Retrospective case series. A tertiary referral center. Seventeen patients were treated between 1999 and 2001 for a tibial plafond fracture at the Hospital for Special Surgery with a newly designed low-profile plate. Eleven of the fractures (65%) were high-energy injuries. Two fractures were open. Staged surgical treatment with open reduction and fixation of the fibular fracture and application of an external fixator was performed in 12 cases. As soon as the soft tissues and swelling allowed, i.e. skin wrinkling, the articular surface was reconstructed and simply reduced, if necessary through an small incision, and the articular block was fixed to the diaphysis using a medially placed, percutaneously introduced flat scallop plate. In the remaining five cases the operation was performed in one session. Time to healing and complications including delayed union, non-union, instrument failure, loss of fixation, infection, quality of reduction and number of reoperations were evaluated. Quality of results and outcome were graded using the ankle-hindfoot-scale and a modified rating system. All patients went on to bony union at an average time of 14 weeks. There were no plate failures or loss of fixation/reduction. Two superficial wound-healing problems resolved with local wound care. At an average follow up of 17 months (range 6-29 months) eight patients (47%) had an excellent result; seven (41%) had a fair result whereas two (12%) had a poor result. The average ankle-hindfoot-score was 86.1 (range 61-100). Four patients have had the hardware removed and one of them is awaiting an ankle arthrodesis. Based on these initial results, it appears that a minimally invasive surgical technique including new low profile plate can decrease soft tissue problems while leading to fracture healing and obtaining results comparable with other more recent series. We believe that this new "Scallop Plate" is effective for the treatment of pilon fractures and should be used in conjunction with a staged procedure in the acute trauma setting.

Effects of varying pulsatile lavage pressure on cancellous bone structure and fracture healing.

PubMed

Polzin, Britton; Ellis, Thomas; Dirschl, Douglas R

2006-04-01

To study the effects of variations in pulsatile lavage irrigation pressure on the rate of new bone formation and the degree to which cellular elements are removed from cancellous bone after fracture. A previously described intraarticular fracture model was used for 29 New Zealand white rabbits that underwent osteotomy of the medial femoral condyle. Fractures were irrigated with high-pressure pulsatile lavage at a fixed distance and volume, but at nozzle pressures varying from 20 to 70 psi. Fractures were reduced and stabilized, and animals euthanized 14 days after fracture. Fluorescent bone staining was used to determine the rate of new bone formation in the osteotomy site. At the time of euthanasia, the nonoperated knees of 12 rabbits underwent osteotomy and irrigation using the same protocol. These specimens were sent for immediate scanning electron microscopy to determine the amount of cellular material removed from the bony trabeculae. In the first week after irrigation, there was no significant difference in the amount of new bone formation between the 20- and 30-psi groups, but there were significant differences between these groups and the 50- and 70-psi groups. There were no significant differences between any of the groups in the amount of new bone formed during the second week after irrigation. No structural damage to the bony trabeculae was observed in any specimen irrigated at any of the pressures used. There was a direct correlation between percentage of the trabecula completely cleared of cellular material and irrigation pressure; there were statistically significant differences between each of the groups. There are presently no recommended guidelines as to the optimal irrigation pressure, and this study is the first to address the effects of variations in pressure on bone healing. The results of this study indicate that early new bone formation in an intraarticular fracture rabbit model is inhibited by irrigation pressure of 50 psi or greater. Additionally, this study demonstrates a direct relationship between irrigation pressure and the amount of cellular material removed from the trabecula at the irrigation site. Surgeons should be aware of the potentially detrimental effects of using irrigation pressures at or above 50 psi in the treatment of fractures.

Variability of medial and posterior offset in patients with fourth-generation stemmed shoulder arthroplasty.

PubMed

Irlenbusch, Ulrich; Berth, Alexander; Blatter, Georges; Zenz, Peter

2012-03-01

Most anthropometric data on the proximal humerus has been obtained from deceased healthy individuals with no deformities. Endoprostheses are implanted for primary and secondary osteoarthritis, rheumatoid arthritis,humeral-head necrosis, fracture sequelae and other humeral-head deformities. This indicates that pathologicoanatomical variability may be greater than previously assumed. We therefore investigated a group of patients with typical shoulder replacement diagnoses, including posttraumatic and rheumatic deformities. One hundred and twenty-two patients with a double eccentrically adjustable shaft endoprosthesis served as a specific dimension gauge to determine in vivo the individual humeral-head rotation centres from the position of the adjustable prosthesis taper and the eccentric head. All prosthesis heads were positioned eccentrically.The entire adjustment range of the prosthesis of 12 mm medial/lateral and 6 mm dorsal/ventral was required. Mean values for effective offset were 5.84 mm mediolaterally[standard deviation (SD) 1.95, minimum +2, maximum +11]and 1.71 mm anteroposteriorly (SD 1.71, minimum −3,maximum 3 mm), averaging 5.16 mm (SD 1.76, minimum +2,maximum + 10). The posterior offset averaged 1.85 mm(SD 1.85, minimum −1, maximum + 6 mm). In summary, variability of the combined medial and dorsal offset of the humeral-head rotational centre determined in patients with typical underlying diagnoses in shoulder replacement was not greater than that recorded in the literature for healthy deceased patients.The range of deviation is substantial and shows the need for an adjustable prosthetic system.

Gender differences in plantar loading during three soccer-specific tasks.

PubMed

Sims, E L; Hardaker, W M; Queen, R M

2008-04-01

Examine the effect of gender on plantar loading during three football-specific tasks. Thirty-four athletes (17 men, 17 women) ran an agility course five times while wearing the Nike Vitoria hard ground cleat. Plantar loading data were recorded during a side cut, a cross-over cut and a forward acceleration task using Pedar-X insoles. Controlled laboratory study. No history of lower extremity injury in the past 6 months, no previous foot or ankle surgery, not currently wearing foot orthotics and play a cleated sport at least two times per week. Contact area, maximum force and the force-time integral (FTI) in the medial and lateral midfoot, medial, middle and lateral forefoot as well as the hallux. A univariate ANCOVA (alpha = 0.05) was performed on each dependent variable (covariate was course speed). Significant gender differences existed in the force and force-time integral beneath the lateral midfoot and forefoot during the cross-over cut task as well as in the middle forefoot during the side cut task with the men demonstrating an increased force. No significant differences existed in the loading on the medial side of the foot during any tasks. The results of this study indicate that the increase in plantar loading on the lateral portion of the midfoot and forefoot in men could be one possible explanation for the increased incidence of fifth metatarsal stress fractures in men. Gender differences in loading patterns need to be considered when comparing different movements as well as different footwear conditions.

A biomechanical evaluation to optimize the configuration of a hinged external fixator for the primary treatment of severely displaced intraarticular calcaneus fractures with soft tissue damage.

PubMed

Besch, Lutz; Schmidt, Ina; Mueller, Michael; Daniels-Wredenhagen, Mark; Hilgert, Ralf-Eric; Varoga, Deike; Seekamp, Andreas

2008-01-01

The purpose of this investigation was to develop an optimized hinged external fixator for the primary treatment of dislocated, intra-articular calcaneus fractures with associated soft tissue damage. To this end, a calcaneus model was made out of a polyurethane block, and a steel cylinder served as the ankle joint and was connected to a synthetic model of the tibia via a metal clamp. A saw cut served as the fracture in the model. A Steinmann nail and Schanz screw were placed in defined positions in the model and connected medially and laterally with longitudinal support rods. The fixator allowed a total of 20 degrees of plantar- and dorsiflexion, with rotation in the virtual axis of the upper ankle joint. Changes in the model fracture were measured during cyclical strain, and at different screw positions in the model tibia and calcaneus. Miniature force sensors located on the longitudinal support rods, and a plantar tension spring, were used to measure pressure and tension. Reproducible values were determined and, with the optimal configuration, shifting within the osteotomy was minimal. In the experimental configuration, optimal tibial screw placement was 70 mm proximal to the rotation axis of the upper ankle joint, and optimal placement of the Steinmann nail was in the posterior surface of the calcaneus. These findings indicated that the hinged fixator allows 20 degrees of ankle movement without alteration of the rotation axis, and suggest that this type of external fixator can be used in all types of calcaneal fracture regardless of the soft tissue damage. ACFAS Level of Clinical Evidence: 5c.

Development plates for stable internal fixation: Study of mechanical resistance in simulated fractures of the mandibular condyle.

PubMed

Celegatti Filho, Tóride Sebastião; Rodrigues, Danillo Costa; Lauria, Andrezza; Moreira, Roger William Fernandes; Consani, Simonides

2015-01-01

To develop Y-shaped plates with different thicknesses to be used in simulated fractures of the mandibular condyle. Ten plates were developed in Y shape, containing eight holes, and 30 synthetic polyurethane mandible replicas were developed for the study. The load test was performed on an Instron Model 4411 universal testing machine, applying load in the mediolateral and anterior-posterior positions on the head of the condyle. Two-way ANOVA with Tukey testing with a 5% significance level was used. It was observed that when the load was applied in the medial-lateral plate of greater thickness (1.5 mm), it gave the highest strength, while in the anteroposterior direction, the plate with the highest resistance was of the lesser thickness (0.6 mm). A plate with a thickness of 1.5 mm was the one with the highest average value for all displacements. In the anteroposterior direction, the highest values of resistance were seen in the displacement of 15 mm. After comparing the values of the biomechanical testing found in the scientific literature, it is suggested that the use of Y plates are suitable for use in subcondylar fractures within the limitations of the study. Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

[Surgical treatment for Lisfranc injuries accompanied by the base crashing of the second metatarsal bone].

PubMed

Huang, Jie-feng; Zheng, Yang; Chen, Xin; Zha, Kai; Du, Xi-wen; Chen, Jun-jie; Tong, Pei-jian

2015-02-01

To discuss the clinical effects of open reduction and internal fixation (ORIF) for treatment of patients with Lisfranc injury combined the second metatarsal base comminuted fracture. From March 2007 to June 2012, 7 patients with Lisfranc injury combined the second metatarsal base comminuted fracture were treated including 5 males and 2 female aged from 22 to 51 years old (means 42 years), 4 of sprain and 3 of traffic injury. According Myerson classification, there was 1 case of type A, 3 of type B and 3 of type C. Kirschner wire was used to fix Lisfranc ligament placing from the medial cuneiform bone to the second metatarsal base during the operation. After the operation American Orthopaedic Foot and Ankle Society (AOFAS) criteria system were applied to evaluate the foot and ankle function. Preoperative and postoperative AP, lateral and oblique X-ray and CT scan were collected for radiographic evaluation. All patients were followed up from 12 to 20 months (16.8 months in average). According to AOFAS criteria system, 3 cases were excellent result,3 good, 1 fair. All the wounds were primary healing without skin necrosis, infection, Kirschner loose,broken, or other complications. Kirschner wire had good clinical efficacy for fixing Lisfranc ligament injury with the second metatarsal base comminuted fracture, and could avoid arthrodesis.

Intra-articular findings in symptomatic minor instability of the lateral elbow (SMILE).

PubMed

Arrigoni, Paolo; Cucchi, Davide; D'Ambrosi, Riccardo; Butt, Usman; Safran, Marc R; Denard, Patrick; Randelli, Pietro

2017-07-01

Lateral epicondylitis is generally considered an extra-articular condition. The role of minor instability in the aetiology of lateral elbow pain has rarely been considered. The aim of this study was to evaluate the correlation of lateral ligamentous laxity with aspects of intra-articular lateral elbow pathology and investigate the role of minor instability in lateral elbow pain. Thirty-five consecutive patients aged between 20 and 60 years with recalcitrant lateral epicondylitis who had failed conservative therapy and had no previous trauma or overt instability, were included. The presence of three signs of lateral ligamentous patholaxity and five intra-articular findings were documented during arthroscopy. The relative incidence of each of these was calculated, and the correlation between patholaxity and intra-articular pathology was evaluated. At least one sign of lateral ligamentous laxity was observed in 48.6% of the studied cohort, and 85.7% demonstrated at least one intra-articular abnormal finding. Radial head ballottement was the most common sign of patholaxity (42.9%). Synovitis was the most common intra-articular aspect of pathology (77.1%), followed by lateral capitellar chondropathy (40.0%). A significant correlation was found between the presence of lateral ligamentous patholaxity signs and capitellar chondropathy (p = 0.0409), as well as anteromedial synovitis (p = 0.0408). Almost one half of patients suffering from recalcitrant lateral epicondylitis display signs of lateral ligamentous patholaxity, and over 85% demonstrate at least one intra-articular abnormality. The most frequent intra-articular findings are synovitis and lateral capitellar chondropathy, which correlate significantly with the presence of lateral ligamentous patholaxity. The fact that several patients demonstrated multiple intra-articular findings in relation to laxity provides support to a sequence of pathologic changes that may result from a symptomatic minor instability of the lateral elbow (SMILE) condition. III.

Modified Anterolateral Portals in Elbow Arthroscopy: A Cadaveric Study on Safety.

PubMed

Thon, Stephen; Gold, Peter; Rush, Lane; O'Brien, Michael J; Savoie, Felix H

2017-11-01

To evaluate the proximity to the radial nerve on cadaveric specimens of 2 modified anterolateral portals used for elbow arthroscopy. Ten fresh cadaveric elbow specimens were prepared. Four-millimeter Steinman pins were inserted into 3 anterolateral portal sites in relation to the lateral epicondyle: (1) the standard distal anterolateral portal, (2) a modified direct anterolateral portal, and (3) a modified proximal anterolateral portal. These were defined as follows: direct portals 2 cm directly anterior to the lateral epicondyle, and proximal portals 2 cm proximal and 2 cm directly anterior to the lateral epicondyle. Each elbow was then dissected to reveal the course of the radial nerve. Digital photographs were taken of each specimen, and the distance from the Steinman pin to the radial nerve was measured. The modified proximal anterolateral and direct anterolateral portals were found to be a statistically significant distance from the radial nerve compare to the distal portal site (P = .011 and P = .0011, respectively). No significant difference was found in the proximity of the radial nerve between the modified proximal and direct anterolateral portals (P = .25). Inadequate imaging was found at a single portal site for the proximal site; 9 specimens were used for analysis of this portal with 10 complete specimens for the other 2 sites. In cadaveric analysis, both the modified proximal and direct lateral portals provide adequate distance from the radial nerve and may be safe for clinical use. In this study, the distal anterolateral portal was in close proximity of the radial nerve and may result in iatrogenic injury in the clinical setting. This is a cadaveric analysis of 2 modified portal locations at the anterolateral elbow for use in elbow arthroscopy. Further clinical studies are needed prior to determining their absolute safety in comparison to previously identified portal sites. Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Shin-splints: common exercise-related syndromes affecting the lower leg.

PubMed

Williamson, B L; Arthur, C H C

2014-01-01

Lower leg pain is a common complaint of athletically active individuals, often limiting physical activities. As such, the group of lower leg conditions related to athletic pursuits and physical exercise confer considerable operational implications for the military. Whilst acute injuries to the lower limb are commonly encountered and are clearly of significance, this article focuses instead on chronic conditions related to physical activity. These include insults to bone such as stress fractures and medial tibial stress syndrome, and those related to the soft tissues such as chronic exertional compartment syndrome. In this article we will examine the presentation and management of these conditions.

Treatment of proximal humerus fractures with locking plates: a systematic review.

PubMed

Thanasas, Christos; Kontakis, George; Angoules, Antonios; Limb, David; Giannoudis, Peter

2009-01-01

Locking plates with special configuration for the anatomic region of the proximal humerus have been introduced recently to address the difficulties of stabilizing proximal humeral fractures. The purpose of this study was to carry out a systematic review of the literature on the efficacy and early to medium term functional results of locking plates for stabilization of proximal humeral fractures. Using the PubMed database, a systematic review of the English and German literature was carried out in order to assess the efficacy and complications related to the use of these plates and the patients' functional outcome, using the key words "locking plates proximal humeral fractures," "angular stability plates proximal humeral fractures," "PHILOS plate," and "LPHP plate." Our criteria for eligibility were clinical studies with more than ten cases followed-up, adult patients, and adequate data provided at least in terms of implant related complications. Articles written in English and German language were included. Exclusion criteria were: studies dealing exclusively with 2-part fractures (since this category has a more favorable outcome); experimental studies; case reports; and, literature other than English or German. Each one of the articles was evaluated for quality of the study using the Structured Effectiveness Quality Evaluation Scale (SEQES). Twelve studies including 791 patients met the inclusion criteria. Patients in these studies continued to improve up to one year, achieving a mean Constant score of 74.3. The incidence of the reported complications was: avascular necrosis 7.9%, screw cut-out 11.6% and re-operation rate 13.7%. The high incidence of cut-out may be secondary to the rigidity of the implant in combination with medial inadequate support, in cases compromised by severe underlying osteoporotic bone. Definition of indications for the use of locking plates and attention on technical aspects of applying them would help optimization of the results. Systematic Review.

Postoperative stroke after hemiarthroplasty for femoral neck fracture: a report of 2 cases and review of literature.

PubMed

Ding, David Yi; Christoforou, Dimitrios; Turner, Garth; Tejwani, Nirmal C

2014-06-01

Femoral neck fractures in the elderly comprise a significant number of orthopedic surgical cases at a major trauma center. These patients are immediately incapacitated, and surgical fixation can help increase mobility, restore independence, and reduce morbidity and mortality. However, operative treatment carries its own inherent risks including infections, deep vein thromboses, and intraoperative cardiovascular collapse. Cerebrovascular stroke is a relatively uncommon occurrence after hip fractures. We present 2 cases with unusual postoperative medical complication after cemented hip hemiarthroplasty for femoral neck fracture that will serve to illustrate an infrequent but very serious complication. Case 1 was a 73-year-old man with a Garden IV femoral neck fracture who underwent a right hip unipolar cemented hemiarthroplasty under general anesthesia. After uneventful surgery, he developed neurological deficits, and a postoperative noncontrast head computed tomography showed a right medial thalamic infarct. Case 2 was an 82-year-old man with a Garden IV femoral neck fracture who underwent a right hip unipolar cemented hemiarthroplasty under general anesthesia. After uneventful surgery, the patient became hemodynamically unstable. A postoperative noncontrast head computed tomography showed a large evolving left middle cerebral artery stroke. General anesthesia in the setting of decreased cardiac function (decreased ejection fraction and output) carries the risk for ischemic injury to the brain from decreased cerebral perfusion. Risk factors including advanced age, history of coronary artery disease, atherosclerotic disease, and atrial fibrillation increase the risk for perioperative stroke. Furthermore, it is known that during the cementing of implants, microemboli can be released, which must be considered in patients with preoperative heart disease. As a result, consideration of using a noncemented implant or cementing without pressurizing in this clinical scenario should be an important aspect of the preoperative plan in an at-risk patient. Further studies are needed that can elucidate a causal relationship.

Developing a shale heterogeneity index to predict fracture response in the Mancos Shale

NASA Astrophysics Data System (ADS)

DeReuil, Aubry; Birgenheier, Lauren; McLennan, John

2017-04-01

The interplay between sedimentary heterogeneity and fracture propagation in mudstone is crucial to assess the potential of low permeability rocks as unconventional reservoirs. Previous experimental research has demonstrated a relationship between heterogeneity and fracture of brittle rocks, as discontinuities in a rock mass influence micromechanical processes such as microcracking and strain localization, which evolve into macroscopic fractures. Though numerous studies have observed heterogeneity influencing fracture development, fundamental understanding of the entire fracture process and the physical controls on this process is still lacking. This is partly due to difficulties in quantifying heterogeneity in fine-grained rocks. Our study tests the hypothesis that there is a correlation between sedimentary heterogeneity and the manner in which mudstone is fractured. An extensive range of heterogeneity related to complex sedimentology is represented by various samples from cored intervals of the Mancos Shale. Samples were categorized via facies analysis consisting of: visual core description, XRF and XRD analysis, SEM and thin section microscopy, and reservoir quality analysis that tested porosity, permeability, water saturation, and TOC. Systematic indirect tensile testing on a broad variety of facies has been performed, and uniaxial and triaxial compression testing is underway. A novel tool based on analytically derived and statistically proven relationships between sedimentary geologic and geomechanical heterogeneity is the ultimate result, referred to as the shale heterogeneity index. Preliminary conclusions from development of the shale heterogeneity index reveal that samples with compositionally distinct bedding withstand loading at higher stress values, while texturally and compositionally homogeneous, bedded samples fail at lower stress values. The highest tensile strength results from cemented Ca-enriched samples, medial to high strength samples have approximately equivalent proportions of Al-Ca-Si compositions, while Al-rich samples have consistently low strength. Moisture preserved samples fail on average at approximately 5 MPa lower than dry samples of similar facies. Additionally, moisture preserved samples fail in a step-like pattern when tested perpendicular to bedding. Tensile fractures are halted at heterogeneities and propagate parallel to bedding planes before developing a through-going failure plane, as opposed to the discrete, continuous fractures that crosscut dry samples. This result suggests that sedimentary heterogeneity plays a greater role in fracture propagation in moisture preserved samples, which are more indicative of in-situ reservoir conditions. Stress-strain curves will be further analyzed, including estimation of an energy released term based on post-failure response, and an estimation of volume of cracking measure on the physical fracture surface.

Anterior and posterior bands of the anterior bundle in the elbow ulnar collateral ligament: ultrasound anatomy.

PubMed

Yoshida, Masahito; Goto, Hideyuki; Takenaga, Tetsuya; Tsuchiya, Atsushi; Sugimoto, Katsumasa; Musahl, Volker; Fu, Freddie; Otsuka, Takanobu

2017-10-01

The anterior oblique bundle (AOL) of the ulnar collateral ligament (UCL) is composed of anterior and posterior bands. This study evaluated the anatomy of the anterior and posterior bands in the AOL of the UCL for their separate visualization with ultrasound (US). We dissected 18 cadaveric elbow joints and recorded the direction of each band from the lateral view to determine the proper position for the US transducer. To determine the proper inclination of the transducer, we measured the inclinations of each band at the proximal and distal insertions from the transverse view. A paired t test was used for comparisons between both bands. Values of P < .05 were considered statistically significant. The mean angles of the directions in the anterior and posterior bands were 10° ± 4° and 24° ± 9°, respectively. At the medial epicondyle, the mean inclination angles of both bands were 61° ± 5° and 67° ± 5°, respectively. At the sublime tubercle, the mean inclination angles of both bands were 14° ± 7° and 44° ± 9°, respectively. The inclination angles at the proximal ulna and the directions in both bands were significantly different (P < .001). This study shows that the directions of both bands and inclination angles of the bony attachments in both bands can assist with correct placement of the US transducer and allow for separate visualization of each band. Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Weight bearing cone beam CT scan versus gravity stress radiography for analysis of supination external rotation injuries of the ankle.

PubMed

Marzo, John M; Kluczynski, Melissa A; Clyde, Corey; Anders, Mark J; Mutty, Christopher E; Ritter, Christopher A

2017-12-01

For AO 44-B2 ankle fractures of uncertain stability, the current diagnostic standard is to obtain a gravity stress radiograph, but some have advocated for the use of weight-bearing radiographs. The primary aim was to compare measures of medial clear space (MCS) on weight-bearing cone beam computed tomography (CBCT) scans versus gravity stress radiographs for determining the state of stability of ankle fractures classified as AO SER 44-B2 or Weber B. The secondary aim was to evaluate the details offered by CBCT scans with respect to other findings that may be relevant to patient care. Nine patients were enrolled in this cross-sectional study between April 2016 and February 2017 if they had an AO SER 44-B2 fracture of uncertain stability, had a gravity stress radiograph, and were able to undergo CT scan within seven days. The width of the MCS was measured at the level of the talar dome on all radiographs and at the mid coronal slice on CT. Wilcoxon signed-ranks tests were used to compare MCS between initial radiographs, gravity stress radiographs and weight-bearing CBCT scans. MCS on weight-bearing CBCT scan (1.41±0.41 mm) was significantly less than standard radiographs (3.28±1.63 mm, P=0.004) and gravity stress radiographs (5.82±1.93 mm, P=0.02). There was no statistically significant difference in MCS measured on standard radiographs versus gravity stress radiographs (P=0.11). Detailed review of the multiplanar CT images revealed less than perfect anatomical reduction of the fractures, with residual fibular shortening, posterior displacement, and fracture fragments in the incisura as typical findings. Similar to weight-bearing radiographs, weight-bearing CBCT scan can predict stability of AO 44-B2 ankle fractures by showing restoration of the MCS, and might be used to indicate patients for non-operative treatment. None of the fractures imaged in this study were perfectly reduced however, and further clinical research is necessary to determine if any of the detailed weight-bearing CBCT findings are related to patient outcomes.

Dual small fragment plating improves screw-to-screw load sharing for mid-diaphyseal humeral fracture fixation: a finite element study.

PubMed

Kosmopoulos, Victor; Luedke, Colten; Nana, Arvind D

2015-01-01

A smaller humerus in some patients makes the use of a large fragment fixation plate difficult. Dual small fragment plate constructs have been suggested as an alternative. This study compares the biomechanical performance of three single and one dual plate construct for mid-diaphyseal humeral fracture fixation. Five humeral shaft finite element models (1 intact and 4 fixation) were loaded in torsion, compression, posterior-anterior (PA) bending, and lateral-medial (LM) bending. A comminuted fracture was simulated by a 1-cm gap. Fracture fixation was modelled by: (A) 4.5-mm 9-hole large fragment plate (wide), (B) 4.5-mm 9-hole large fragment plate (narrow), (C) 3.5-mm 9-hole small fragment plate, and (D) one 3.5-mm 9-hole small fragment plate and one 3.5-mm 7-hole small fragment plate. Model A showed the best outcomes in torsion and PA bending, whereas Model D outperformed the others in compression and LM bending. Stress concentrations were located near and around the unused screw holes for each of the single plate models and at the neck of the screws just below the plates for all the models studied. Other than in PA bending, Model D showed the best overall screw-to-screw load sharing characteristics. The results support using a dual small fragment locking plate construct as an alternative in cases where crutch weight-bearing (compression) tolerance may be important and where anatomy limits the size of the humerus bone segment available for large fragment plate fixation.

Radiographic morphometry and densitometry predict strength of cadaveric proximal humeri more reliably than age and DXA scan density.

PubMed

Skedros, John G; Knight, Alex N; Pitts, Todd C; O'Rourke, Peter J; Burkhead, Wayne Z

2016-02-01

Methods are needed for identifying poorer quality cadaver proximal humeri to ensure that they are not disproportionately segregated into experimental groups for fracture studies. We hypothesized that measurements made from radiographs of cadaveric proximal humeri are stronger predictors of fracture strength than chronological age or bone density values derived from dual-energy x-ray absorptiometry (DXA) scans. Thirty-three proximal humeri (range: 39-78 years) were analyzed for: (1) bone mineral density (BMD, g/cm(2)) using DXA, (2) bulk density (g/cm(3)) using DXA and volume displacement, (3) regional bone density in millimeters of aluminum (mmAl) using radiographs, and (4) regional mean (medial+lateral) cortical thickness and cortical index (CI) using radiographs. The bones were then fractured simulating a fall. Strongest correlations with ultimate fracture load (UFL) were: mean cortical thickness at two diaphyseal locations (r = 0.71; p < 0.001), and mean mmAl in the humeral head (r = 0.70; p < 0.001). Weaker correlations were found between UFL and DXA-BMD (r = 0.60), bulk density (r = 0.43), CI (r = 0.61), and age (r = -0.65) (p values <0.01). Analyses between UFL and the product of any two characteristics showed six combinations with r-values >0.80, but none included DXA-derived density, CI, or age. Radiographic morphometric and densitometric measurements from radiographs are therefore stronger predictors of UFL than age, CI, or DXA-derived density measurements. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.

Dissection of the internal carotid artery and stroke after mandibular fractures: a case report and review of the literature.

PubMed

Tveita, Ingrid Aune; Madsen, Martin Ragnar Skjerve; Nielsen, Erik Waage

2017-06-02

We present a report of a patient with blunt trauma and mandibular fractures who developed a significant cerebral infarction due to an initially unrecognized injury of her left internal carotid artery. We believe that increased knowledge of this association will facilitate early recognition and hence prevention of a devastating outcome. A 41-year-old ethnic Norwegian woman presented to our Emergency Room after a bicycle accident that had caused a direct blow to her chin. At admittance, her Glasgow Coma Scale was 15. Initial trauma computed tomography showed triple fractures of her mandible, but no further pathology. She was placed in our Intensive Care Unit awaiting open reduction of her mandibular fractures. During the following 9 hours, she showed recurrent episodes of confusion and a progressive right-sided hemiparesis. Repeated cerebral computed tomography revealed no further pathology compared to the initial scan. She had magnetic resonance angiography 17 hours after admittance, which showed dissection and thrombus formation in her left internal carotid artery, total occlusion of her left medial cerebral artery, and left middle cerebral artery infarction was detected. Carotid artery dissection is a rare but life-threatening condition that can develop after trauma to the head and neck. There should be a high index of suspicion in patients with a mechanism of injury that places the internal carotid artery at risk because blunt vascular injury may show delayed onset with no initial symptoms of vascular damage. By implementing an algorithm for early detection and treatment of these injuries, serious brain damage may be avoided.

Technical and Clinical Results After Percutaneous Angioplasty in Nonmedial Fibromuscular Dysplasia: Outcome After Endovascular Management of Unifocal Renal Artery Stenoses in 30 Patients

DOE Office of Scientific and Technical Information (OSTI.GOV)

Barrier, Pierre, E-mail: p.barrier@gmail.com; Julien, Auriol; Guillaume, Canevet

2010-04-15

Although percutaneous transluminal renal angioplasty (PTRA) is associated with excellent results in medial fibromuscular dysplasia (FMD), the clinical and technical outcome in the less common nonmedial subtype of FMD is not clearly known. Angiographic PTRA results and clinical follow-up were documented, to report technical and clinical results in 30 patients with unifocal, nonmedial dysplastic stenoses. Balloon angioplasty was technically successful in only 65% of the lesions. Additional stenting, performed after PTRA failure in six patients, increased the initial technical success rate to 82%. Stenting was used in another lesion after restenosis, and long-term patency was achieved in only three ofmore » the seven stented lesions. Frequent restenoses and unusual complications were observed during follow-up. Stent fracture occurred in two cases. Overall, long-term clinical and technical successes were sustained in 70 and 76%, respectively. We conclude that nonmedial, unifocal renal artery dysplastic stenoses do not share the excellent prognosis of the medial type and that stenting should be avoided. Therefore, surgery should be considered in lesions remaining unresponsive to balloon dilatation, after a second PTRA attempt.« less

Lateral epicondylosis and calcific tendonitis in a golfer: a case report and literature review

PubMed Central

Yuill, Erik A.; Lum, Grant

2011-01-01

Objective To detail the progress of a young female amateur golfer who developed chronic left arm pain while playing golf 8 months prior to her first treatment visit. Clinical Features Findings included pain slightly distal to the lateral epicondyle of the elbow, decreased grip strength, and positive orthopedic testing. Diagnostic ultrasound showed thickening of the common extensor tendon origin indicating lateral epicondylosis. Radiographs revealed an oval shaped calcified density in the soft tissue adjacent to the lateral humeral epicondyle, indicating calcific tendonitis of the common extensor tendon origin. Intervention and Outcome Conventional care was aimed at decreasing the repetitive load on the common extensor tendon, specifically the extensor carpi radialis brevis. Soft tissue techniques, exercises and stretches, and an elbow brace helped to reduce repetitive strain. Outcome measures included subjective pain ratings, and follow up imaging 10 weeks after treatment began. Conclusion A young female amateur golfer with chronic arm pain diagnosed as lateral epicondylosis and calcific tendonitis was relieved of her pain after 7 treatments over 10 weeks of soft tissue and physical therapy focusing specifically on optimal healing and decreasing the repetitive load on the extensor carpi radialis brevis. PMID:22131570

Osteosynthesis in situ for lateral condyle nonunion in children.

PubMed

Park, Hoon; Hwang, Jin Ho; Kwon, Yong Uk; Kim, Hyun Woo

2015-06-01

This study investigated the efficacy of osteosynthesis in situ by evaluating the functional and cosmetic results in children with nonunion of lateral condyle fractures. Sixteen consecutive patients were treated with in situ fixation consisting of minimal curettage of fracture gap and screw compression of metaphyseal fragments without bone grafting. The mean age at the time of surgery was 5.6 years (range, 1 to 10 y). The mean interval between the initial lateral condylar fracture and surgery was 4.8 months (range, 3 to 12 mo). The average amount of displacement measured on radiographs was 6.6 mm medially and 7.4 mm laterally. Outcome was assessed by clinical and radiologic evaluation at the latest follow-up. All patients achieved bony union. The mean duration of follow-up was 45.4 months (range, 24 to 67 mo). The range of motion and flexion contracture improved postoperatively in all patients. There was no evidence of premature growth arrest, osteonecrosis, or fishtail deformity until last follow-up. The overall result was excellent in 5, good in 10, and fair in 1 patient. However, 3 patients developed valgus or varus deformities of >10 degrees. Osteosynthesis in situ can be an effective and safe treatment for achieving bone union and improved elbow motion and preventing avascular necrosis. However, valgus or varus deformities may occur after this procedure and corrective osteotomy may be necessary. Level IV - case series.

Clinical and radiological outcome following treatment of displaced lateral clavicle fractures using a locking compression plate with lateral extension: a prospective study.

PubMed

Beirer, Marc; Siebenlist, Sebastian; Crönlein, Moritz; Postl, Lukas; Huber-Wagner, Stefan; Biberthaler, Peter; Kirchhoff, Chlodwig

2014-11-19

Treatment of lateral fractures of the clavicle is challenging and has been controversially discussed for a long time due to high non-union rates in non-operative treatment and high complication rates in surgical treatment. Acromioclavicular joint instability due to the injury of the closely neighbored coraco-clavicular ligaments can result in a cranialization of the medial clavicle shaft. A recently developed implant showed a promising functional outcome in a small collective of patients. In this prospective study, 20 patients with a mean age of 40.7 ± 11.3 years with a dislocated fracture of the lateral clavicle (Jäger&Breitner I-III, Neer I-III) were enrolled. All patients were surgically treated using the locking compression plate (LCP) for the superior anterior clavicle (Synthes®). Functional outcome was recorded using the Munich Shoulder Questionnaire (MSQ) allowing for qualitative self-assessment of the Shoulder Pain and Disability Index (SPADI), of the Disability of the Arm, Shoulder and Hand (DASH) score and of the Constant Score. Acromioclavicular joint stability was evaluated using the Taft-Score. The mean follow-up was 14.2 ± 4.0 months. The mean MSQ was 87.0 ± 7.4 points, the mean SPADI 91.1 ± 11.3 points, the mean DASH score 7.6 ± 7.3 points and the mean normative age- and sex-specific Constant Score 85.6 ± 8.0 points. The mean Taft Score resulted in 10.7 ± 1.0 points. The mean Taft Score in lateral clavicular fractures with fracture gap between the coracoclavicular ligaments in combination with a rupture of the conoid ligament (J&B II a, Neer II B; n =11) was with 10.3 ± 0.9 points significantly lower than the mean Taft Score of all other types of lateral clavicle fractures (J&B I, II b, III; n =9) which resulted in 11.3 ± 0.9 points (p<0.05). The Synthes® LCP superior anterior clavicle plate allows for a safe stabilization and good functional outcome with high patient satisfaction in fractures of the lateral clavicle. However, in fractures type Jäger&Breitner II a, Neer II B a significant acromioclavicular joint instability was observed and additional reconstruction of the coracoclavicular ligaments should be performed. ClinicalTrials.gov NCT02256059. Registered 02 October 2014.

Radiographic follow-up of 84 operatively treated scapula neck and body fractures.

PubMed

Cole, Peter A; Gauger, Erich M; Herrera, Diego A; Anavian, Jack; Tarkin, Ivan S

2012-03-01

Certain scapula fractures may warrant surgical management to restore shoulder anatomy and promote optimal function. The purpose of this study is to determine the early radiographic follow-up of open reduction internal fixation (ORIF) for displaced, scapular fractures involving the glenoid neck and body. Eighty-four patients with a scapula body or neck fracture (with or without articular involvement) underwent ORIF between 2002 and 2010 at a single level I trauma centre. This study represents a retrospective review of data prospectively collected into a dedicated scapula fracture database. All patients met at least one of the following operative criteria: ≥20 mm medial/lateral (M/L) displacement (lateral border offset), ≥45° of angular deformity on a scapular-Y X-ray, the combination of angulation ≥30° plus M/L displacement ≥15 mm, double disruptions of the superior shoulder suspensory complex both displaced ≥10 mm, glenopolar angle (GPA) ≤22° and open fractures. Eighty-eight percent (74/84) had sufficient follow-up defined as at least 6 months. Measured outcomes included rates of scapula union and malunion, as well as surgical complications and re-operations. All fractures were caused by high-energy trauma with 24 (29%) resulting from motor-vehicle collisions. Associated injuries occurred in 94% of patients, most commonly involving the chest (70%) and ipsilateral shoulder girdle (43%). Forty-eight patients had M/L displacement as an operative indication with a mean displacement of 25.7 mm (range=20-40). Thirty-eight (45%) had ≥2 operative indications. A single surgeon performed ORIF in all patients using a posterior approach. Five patients also required an anterior (deltopectoral) approach. The fixation strategy included lateral and vertebral border stabilisation with dynamic compression and reconstruction plates, respectively. Union was achieved in all cases. There were three cases of malunion based on a GPA difference >10° from the uninjured shoulder. Re-operations included removal of hardware (seven patients) and manipulation under anaesthesia (three patients). There were no infections or wound dehiscence. ORIF for displaced scapula fractures is a relatively safe and effective procedure for restoration of anatomy and promotion of union. Therapeutic study, level IV. Copyright © 2011 Elsevier Ltd. All rights reserved.

Cycling injuries of the lower extremity.

PubMed

Wanich, Tony; Hodgkins, Christopher; Columbier, Jean-Allain; Muraski, Erika; Kennedy, John G

2007-12-01

Cycling is an increasingly popular recreational and competitive activity, and cycling-related injuries are becoming more common. Many common cycling injuries of the lower extremity are preventable. These include knee pain, patellar quadriceps tendinitis, iliotibial band syndrome, hip pain, medial tibial stress syndrome, stress fracture, compartment syndrome, numbness of the foot, and metatarsalgia. Injury is caused by a combination of inadequate preparation, inappropriate equipment, poor technique, and overuse. Nonsurgical management may include rest, nonsteroidal anti-inflammatory drugs, corticosteroid injection, ice, a reduction in training intensity, orthotics, night splints, and physical therapy. Injury prevention should be the focus, with particular attention to bicycle fit and alignment, appropriate equipment, proper rider position and pedaling mechanics, and appropriate training.

[Patellar instability : diagnosis and treatment].

PubMed

Ngo, Trieu Hoai Nam; Martin, Robin

2017-12-13

The aim of this paper is to present recent advances in surgical management of patellar instability. Several anatomical factors were reported to promote instability. We propose to classify them in two groups. Extra articular factors are valgus and torsion deformity. Articular factors include trochlea and patella dysplasia, tibial tubercle lateralization and medial patellofemoral ligament (MPFL) insufficiency. Acute patellar dislocations are treated conservatively, with exception for osteochondral and MPFL avulsion fractures that require acute reinsertion. Surgery is considered for recurrent instability. As we aim for a correction of all contributing elements, we prefer a two stages approach. Extra articular factors are treated first by osteotomy, followed by articular factors after 4-6 months. This allows separate rehabilitation protocols.