Treatment of type II and type III open tibia fractures in children.

PubMed

Bartlett, C S; Weiner, L S; Yang, E C

1997-07-01

To determine whether severe open tibial fractures in children behave like similar fractures in adults. A combined retrospective and prospective review evaluated treatment protocol for type II and type III open tibial fractures in children over a ten-year period from 1984 to 1993. Twenty-three fractures were studied in children aged 3.5 to 14.5 (18 boys and 5 girls). There were six type II, eight type IIIA, and nine type IIIB fractures. Type I fractures were not included. Seven fractures were comminuted with significant butterfly fragments or segmental patterns. Treatment consisted of adequate debridement of soft tissues, closure of dead space, and stabilization with external fixation. Bone debridement only included contaminated devitalized bone or devitalized bone without soft tissue coverage. Bone that could be covered despite periosteal stripping was preserved. Clinical and roentgenographic examinations were used to determine time to union. All fractures in this series healed between eight and twenty-six weeks. Wound coverage included two flaps, three skin grafts, and two delayed primary closures. No bone grafts were required. There were no deep infections, growth arrests, or malunions. Follow-up has ranged from six months to four years. Open tibia fractures in children differ from similar fractures in adults in the following ways: soft tissues have excellent healing capacity, devitalized bone that is not contaminated or exposed can be saved and will become incorporated, and external fixation can be maintained until the fracture has healed. Periosteum in young children can form bone even in the face of bone loss.

Tibia shaft fractures: costly burden of nonunions.

PubMed

Antonova, Evgeniya; Le, T Kim; Burge, Russel; Mershon, John

2013-01-26

Tibia shaft fractures (TSF) are common for men and women and cause substantial morbidity, healthcare use, and costs. The impact of nonunions on healthcare use and costs is poorly described. Our goal was to investigate patient characteristics and healthcare use and costs associated with TSF in patients with and without nonunion. We retrospectively analyzed medical claims in large U.S. managed care claims databases (Thomson Reuters MarketScan®, 16 million lives). We studied patients ≥ 18 years old with a TSF diagnosis (ICD-9 codes: 823.20, 823.22, 823.30, 823.32) in 2006 with continuous pharmaceutical and medical benefit enrollment 1 year prior and 2 years post-fracture. Nonunion was defined by ICD-9 code 733.82 (after the TSF date). Among the 853 patients with TSF, 99 (12%) had nonunion. Patients with nonunion had more comorbidities (30 vs. 21, pre-fracture) and were more likely to have their TSF open (87% vs. 70%) than those without nonunion. Patients with nonunion were more likely to have additional fractures during the 2-year follow-up (of lower limb [88.9% vs. 69.5%, P < 0.001], spine or trunk [16.2% vs. 7.2%, P = 0.002], and skull [5.1% vs. 1.3%, P = 0.008]) than those without nonunion. Nonunion patients were more likely to use various types of surgical care, inpatient care (tibia and non-tibia related: 65% vs. 40%, P < 0.001) and outpatient physical therapy (tibia-related: 60% vs. 42%, P < 0.001) than those without nonunion. All categories of care (except emergency room costs) were more expensive in nonunion patients than in those without nonunion: median total care cost $25,556 vs. $11,686, P < 0.001. Nonunion patients were much more likely to be prescribed pain medications (99% vs. 92%, P = 0.009), especially strong opioids (90% vs. 76.4%, P = 0.002) and had longer length of opioid therapy (5.4 months vs. 2.8 months, P < 0.001) than patients without nonunion. Tibia fracture patterns in men differed from those in women. Nonunions in TSF's are associated with substantial healthcare resource use, common use of strong opioids, and high per-patient costs. Open fractures are associated with higher likelihood of nonunion than closed ones. Effective screening of nonunion risk may decrease this morbidity and subsequent healthcare resource use and costs.

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.

Fate of combat nerve injury.

PubMed

Beltran, Michael J; Burns, Travis C; Eckel, Tobin T; Potter, Benjamin K; Wenke, Joseph C; Hsu, Joseph R

2012-11-01

Assess a cohort of combat-related type III open tibia fractures with peripheral nerve injury to determine the injury mechanism and likelihood for recovery or improvement in nerve function. Retrospective study. Three military medical centers. Out of a study cohort of 213 type III open tibia fractures, 32 fractures (in 32 patients) with a total of 43 peripheral nerve injuries (peroneal or tibial) distal to the popliteal fossa met inclusion criteria and were available for follow-up at an average of 20 months (range, 2-48 months). Clinical assessment of motor and sensory nerve improvement. There was a 22% incidence of peripheral nerve injury in the study cohort. At an average follow-up of 20 months (range, 2-48 months), 89% of injured motor nerves were functional, whereas the injured sensory nerves had function in 93%. Fifty percent and 27% of motor and sensory injuries demonstrated improvement, respectively (P = 0.043). With the numbers available, there was no difference in motor or sensory improvement based on mechanism of injury, fracture severity or location, soft tissue injury, or specific nerve injured. In the subset of patients with an initially impaired sensory examination, full improvement was related to fracture location (P = 0.0164). Type III open tibia fractures sustained in combat are associated with a 22% incidence of peripheral nerve injury, and the majority are due to multiple projectile penetrating injury. Despite the severe nature of these injuries, the vast majority of patients had a functional nerve status by an average of 2-year follow-up. Based on these findings, discussions regarding limb salvage and amputation should not be overly influenced by the patient's peripheral nerve status. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Does the Zone of Injury in Combat-Related Type III Open Tibia Fractures Preclude the Use of Local Soft Tissue Coverage?

DTIC Science & Technology

2010-11-01

delayed union , non- union , and deep infection.39 The large zone of injury surrounding the open fracture site led to the rationale that free flap coverage...also lower for the rotational flap cohort (7% versus 27%, P 0.08). The average time to fracture union for the free flap group was 9.5 months (range, 5...success of coverage, complication rates, visual pain scores, time to radiographic fracture union , and progression to amputation for local rotational

Open unstable metaphyseo-diaphyseal fractures of the tibia in adolescents: treatment by flexible intramedullary nails augmented by external fixator.

PubMed

Atef, Ashraf; El Tantawy, Ahmad

2015-05-01

The treatment of open and unstable metaphyseo-diaphyseal fractures of the tibia in adolescents is challenging. It is important to choose a fixation method that can maintain alignment, allow wound care and not violate the growth plate. The aim of this work was to evaluate the efficacy of using flexible intramedullary nails (FIN) augmented by external fixator (EF) in the management of such fractures. A total of 26 males, with a mean age of 14.08 years and average body weight of 49.8 kg, presented with open metaphyseo-diaphyseal tibial fractures. All cases were treated using FIN augmented by mono-lateral EF. The fractures were located at the upper third in 17 cases and at the lower third in nine cases. The fracture pattern was spiral in eight cases, oblique in seven and multi-fragmentary in 11. The results were evaluated according to the scoring system for femoral TENs. All fractures united primarily after an average eight to 12 weeks with no evident angular deformity or limb-length discrepancy. None of the cases required cast immobilization or revision procedure. Twenty patients had excellent results, six patients showed good results and none had poor results. Fracture characteristics as well as patients' characteristics had no statistically significant effect (p > 0.005) on the final end results. The use of FIN augmented by EF is a good alternative in the management of open metaphyseo-diaphyseal tibial fractures in adolescents. This fixation provides more stability, allows easy access to the wound and early patients' ambulation.

Tibia shaft fractures: costly burden of nonunions

PubMed Central

2013-01-01

Background Tibia shaft fractures (TSF) are common for men and women and cause substantial morbidity, healthcare use, and costs. The impact of nonunions on healthcare use and costs is poorly described. Our goal was to investigate patient characteristics and healthcare use and costs associated with TSF in patients with and without nonunion. Methods We retrospectively analyzed medical claims in large U.S. managed care claims databases (Thomson Reuters MarketScan®, 16 million lives). We studied patients ≥ 18 years old with a TSF diagnosis (ICD-9 codes: 823.20, 823.22, 823.30, 823.32) in 2006 with continuous pharmaceutical and medical benefit enrollment 1 year prior and 2 years post-fracture. Nonunion was defined by ICD-9 code 733.82 (after the TSF date). Results Among the 853 patients with TSF, 99 (12%) had nonunion. Patients with nonunion had more comorbidities (30 vs. 21, pre-fracture) and were more likely to have their TSF open (87% vs. 70%) than those without nonunion. Patients with nonunion were more likely to have additional fractures during the 2-year follow-up (of lower limb [88.9% vs. 69.5%, P < 0.001], spine or trunk [16.2% vs. 7.2%, P = 0.002], and skull [5.1% vs. 1.3%, P = 0.008]) than those without nonunion. Nonunion patients were more likely to use various types of surgical care, inpatient care (tibia and non-tibia related: 65% vs. 40%, P < 0.001) and outpatient physical therapy (tibia-related: 60% vs. 42%, P < 0.001) than those without nonunion. All categories of care (except emergency room costs) were more expensive in nonunion patients than in those without nonunion: median total care cost $25,556 vs. $11,686, P < 0.001. Nonunion patients were much more likely to be prescribed pain medications (99% vs. 92%, P = 0.009), especially strong opioids (90% vs. 76.4%, P = 0.002) and had longer length of opioid therapy (5.4 months vs. 2.8 months, P < 0.001) than patients without nonunion. Tibia fracture patterns in men differed from those in women. Conclusions Nonunions in TSF’s are associated with substantial healthcare resource use, common use of strong opioids, and high per-patient costs. Open fractures are associated with higher likelihood of nonunion than closed ones. Effective screening of nonunion risk may decrease this morbidity and subsequent healthcare resource use and costs. PMID:23351958

The anterior tilt angle of the proximal tibia epiphyseal plate: a significant radiological finding in young children with trampoline fractures.

PubMed

Stranzinger, Enno; Leidolt, Lars; Eich, Georg; Klimek, Peter Michael

2014-08-01

Evaluation of the anterior tilt angle of the proximal tibia epiphyseal plate in young children, which suffered a trampoline fracture in comparison with a normal population. 62 children (31 females, 31 males) between 2 and 5 years of age (average 2 years 11 months, standard deviation 11 months) with radiographs in two views of the tibia were included in this retrospective study. 25 children with proximal tibia fractures were injured with a history of jumping on a trampoline. All other causes for tibia fractures were excluded. A normal age-mapped control cohort of 37 children was compared. These children had neither evidence of a trampoline related injury nor a fracture of the tibia. The anterior tilt angle of the epiphyseal plate of the tibia was defined as an angle between the proximal tibia physis and the distal tibia physis on a lateral view. Two radiologists evaluated all radiographs for fractures and measured the anterior tilt angle in consensus. An unpaired Student's t-test was used for statistical analysis (SPSS). Original reports were reviewed and compared with the radiological findings and follow-up radiographs. In the normal control group, the average anterior tilt angle measured -3.2°, SD ± 2.8°. The children with trampoline fractures showed an anterior tilt of +4.4°, SD ± 2.9°. The difference was statistically significant, P<0.0001. In 6 patients (24% of all patients with confirmed fractures) the original report missed to diagnose the proximal tibial fracture. Young children between 2 and 5 years of age are at risk for proximal tibia fractures while jumping on a trampoline. These fractures may be very subtle and difficult to detect on initial radiographs. Measurement of the anterior tilt angle of the proximal tibia epiphyseal plate on lateral radiographs is supportive for interpreting correctly trampoline fractures. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Dynamic osteosynthesis by modified Kuntscher nail for the treatment of tibial diaphyseal fractures.

PubMed

Gadegone, Wasudeo M; Salphale, Yogesh S

2009-04-01

We evaluated a series of diaphyseal fractures of the tibia using low-cost, Indian-made modified Kuntscher nail (Daga nail) with the provision of distal locking screw for the management of the tibial diaphyseal fractures. One hundred and fifty one consecutive patients with diaphyseal fractures of tibia with 151 fractures who were treated by Daga nail were enrolled. One of the patients who had died because of cancer, and the two patients who were lost to follow-up at 3 months were excluded from the study.Therefore data of 148 patients with one hundred and fortyeight fractures is described. One hundred twenty closed fractures, 20 open Grade I fractures, and eight open Grade II fractures as per Gustilo and Anderson classification were included in this study. One hundred fourteen men and 34 women, with a mean age of 38.4 years, were studied. The result were analysed for Surgical time, duration of hospitalisation, union time, union rate, complication rate, functional recovery and crutch walking time. The fractures were followed at least until the time of solid union. The follow-up period averaged 15 months (range, 6-26 months). Union occurred in 140 cases (94.6%). The mean time to union was 13 weeks for closed fractures,17.8 weeks for Grade I open fractures, and 21.6 weeks for Grade II open fractures. Compartment syndrome occurred in two patients. Superficial infection occurred in five cases of Grade I and II compound fractures. Three closed fractures and one case of Grade I compound fracture required bone grafting for delayed union. Two cases of Grade II compound fracture with nonunion required revision surgery and bone grafting. Twelve cases resulted in acceptable malalignment due to operative technical error. In four cases, the distal screw breakage was seen, but none of these complications interfered with fracture healing. Recovery of joint motion was essentially normal in those patients without knee or ankle injury. Unreamed distally locked dynamic tibial nailing (modified Kuntscher nail/Daga nail) can produce excellent clinical results for diaphyseal tibial fractures. It has the advantages of technical simplicity, minimal cost, user-friendly instrumentation, and a short learning curve.

Surgical treatment of distal tibia fractures: open versus MIPO.

PubMed

Gülabi, Deniz; Bekler, Halil İbrahim; Sağlam, Fevzi; Taşdemir, Zeki; Çeçen, Gültekin Sıtkı; Elmalı, Nurzat

2016-01-01

Treatment of the distal tibial fractures are challenging due to the limited soft tissue, subcutaneous location and poor vascularity. In this control-matched study, it was aimed to compare the traditional open reduction and internal fixation with minimal invasive plating (MIPO). We hypothesized that superior results may be achieved with MIPO technique. 22 patients treated with traditional open reduction and internal fixation were matched with 22 patients treated with closed reduction and MIPO on the basis of age (±3), gender, and fracture pattern (AO classification). Evaluation was assed according to the wound problems, the American Orthopaedic Foot and Ankle surgery (AOFAS) scoring, radiological union, malunion, delayed union, hospitalisation time, time from injury to surgery, and operation time. There was no significant difference in the distribution of AO/OTA classification, age, gender, AOFAS score, time from injury to operation, follow-up, bone union time, delayed union, malunion and infection (p>0.05). The operation time was significantly longer in the open group than in the MIPO group: 69.59±7.21 min. for the ORIF, and 61.14±5.61 for the MIPO group (p<0.01).The hospitalisation time was significantly longer in the open group than in the MIPO group: 7.64±4.71 days for the MIPO, and 10.18±4.32 days for the ORIF group (p<0.05). MIPO technique can be beneficial for the treatment of distal tibia AO/OTA A and B type fractures with reduced hospital stay, cost-effectiveness, and infection rate.

Open tibial fractures grade IIIC treated successfully with external fixation, negative-pressure wound therapy and recombinant human bone morphogenetic protein 7.

PubMed

Babiak, Ireneusz

2014-10-01

The aim of the therapy in open tibial fractures grade III was to cover the bone with soft tissue and achieve healed fracture without persistent infection. Open tibial fractures grade IIIC with massive soft tissue damage require combined orthopaedic, vascular and plastic-reconstructive procedures. Negative-pressure wound therapy (NPWT), used in two consecutive cases with open fracture grade IIIC of the tibia diaphysis, healed extensive soft tissue defect with exposure of the bone. NPWT eventually allowed for wound closure by split skin graft within 21-25 days. Ilizarov external fixator combined with application of recombinant human bone morphogenetic protein-7 at the site of delayed union enhanced definitive bone healing within 16-18 months. © 2012 The Authors. International Wound Journal © 2012 Medicalhelplines.com Inc and John Wiley & Sons Ltd.

Composite Bone and Soft Tissue Loss Treated with Distraction Histiogenesis

DTIC Science & Technology

2010-01-01

their frames removed had healed docking sites, and the fourth whose frame remained in place had a healing fracture without evidence of delayed union ...interventions (3–8). The goals of limb salvage surgery in this setting are to restore length and alignment, regenerate bone loss, obtain fracture union ...angulation to manage composite bone and soft tissue loss associated with combat-related type IIIB open tibia fractures . Four patients underwent placement

External fixation of tibial pilon fractures and fracture healing.

PubMed

Ristiniemi, Jukka

2007-06-01

Distal tibial fractures are rare and difficult to treat because the bones are subcutaneous. External fixation is commonly used, but the method often results in delayed union. The aim of the present study was to find out the factors that affect fracture union in tibial pilon fractures. For this purpose, prospective data collection of tibial pilon fractures was carried out in 1998-2004, resulting in 159 fractures, of which 83 were treated with external fixation. Additionally, 23 open tibial fractures with significant > 3 cm bone defect that were treated with a staged method in 2000-2004 were retrospectively evaluated. The specific questions to be answered were: What are the risk factors for delayed union associated with two-ring hybrid external fixation? Does human recombinant BMP-7 accelerate healing? What is the role of temporary ankle-spanning external fixation? What is the healing potential of distal tibial bone loss treated with a staged method using antibiotic beads and subsequent autogenous cancellous grafting compared to other locations of the tibia? The following risk factors for delayed healing after external fixation were identified: post-reduction fracture gap of >3 mm and fixation of the associated fibula fracture. Fracture displacement could be better controlled with initial temporary external fixation than with early definitive fixation, but it had no significant effect on healing time, functional outcome or complication rate. Osteoinduction with rhBMP-7 was found to accelerate fracture healing and to shorten the sick leave. A staged method using antibiotic beads and subsequent autogenous cancellous grafting proved to be effective in the treatment of tibial bone loss. Healing potential of the bone loss in distal tibia was at least equally good as in other locations of the tibia.

Lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibia-fibula fractures.

PubMed

Parrett, Brian M; Matros, Evan; Pribaz, Julian J; Orgill, Dennis P

2006-04-01

Open lower leg fractures with exposed bone or tendon continue to be challenging for plastic surgeons. Microvascular free-tissue transfer increases the ability to close wounds, transfer vascularized bone, and prevent amputation, yet remains a complex, invasive procedure with significant complication rates, donor-site morbidity, and failure rates. This review documents the changing treatment protocol in the authors' institution for these injuries. Two hundred ninety consecutive open tibia-fibula fractures over a 12-year period (1992 to 2003) were retrospectively reviewed and methods and outcomes were compared by grouping the fractures into 4-year intervals. The number of open lower extremity fractures increased, whereas the distribution of Gustilo grade I to III fractures remained unchanged. Overall, free-tissue transfer was performed less frequently and constituted 20 percent of reconstructions in period 1 (1992 to 1995), 11 percent in period 2 (1996 to 1999), and 5 percent in period 3 (2000 to 2003). For the most severe fractures, Gustilo grade III, free-flap reconstruction has decreased significantly, constituting 42 percent, 26 percent, and 11 percent of procedures in periods 1, 2, and 3, respectively. Local flaps for grade III fractures have remained relatively constant throughout the study. In contrast, local wound care for grade III fractures, including skin grafts, delayed primary closures, and secondary intention closures has significantly increased from 22 percent to 49 percent of reconstructions from periods 1 through 3. In 1997, the authors began to use the vacuum-assisted closure device and now use it in nearly half of all open fractures. Despite this trend, there has been no change in infection, amputation, or malunion/nonunion rates and a decrease in reoperation rate with at least 1-year follow-up. These results demonstrate a change in practice, with a trend down the reconstructive ladder, currently using fewer free flaps and more delayed closures and skin grafts with frequent use of the vacuum-assisted closure sponge. Possible reasons for this change are a better understanding of lower leg vascular anatomy and better use of improved wound care technology.

Treatment of close-range, low-velocity gunshot fractures of tibia and femur diaphysis with consecutive compression-distraction technique: a report of 11 cases.

PubMed

Ateşalp, A Sabri; Kömürcü, Mahmut; Demiralp, Bahtiyar; Bek, Dogan; Oğuz, Erbil; Yanmiş, Ibrahim

2004-01-01

Lower extremity injuries secondary to close-range, low-velocity gunshot wounds are frequently seen in both civilian and military populations. A close-range, low-velocity injury produces high energy and often results in comminuted and complicated fractures with significant morbidity. In this study, four femoral, four tibial, and three combined tibia and fibular comminuted diaphyseal fractures secondary to close-range, low-velocity gunshot wounds in 11 military personnel were treated with debridement followed by compression-distraction lengthening using a circular external fixator frame. Fracture union was obtained in all without significant major complications. Fracture consolidation occurred at a mean of 3.5 months. At follow-up of 46.8 months, there were no delayed unions, nonunions, or malunions. Minor complications included four pin-tract infections and knee flexion limitation in two femur fractures. Osteomyelitis and deep soft tissue infection were not observed. This technique provided an alternative to casting, open reduction internal fixation, or intermedullary fixation with an acceptable complication rate.

Pathomorphism of spiral tibial fractures in computed tomography imaging.

PubMed

Guzik, Grzegorz

2011-01-01

Spiral fractures of the tibia are virtually homogeneous with regard to their pathomorphism. The differences that are seen concern the level of fracture of the fibula, and, to a lesser extent, the level of fracture of the tibia, the length of fracture cleft, and limb shortening following the trauma. While conventional radiographs provide sufficient information about the pathomorphism of fractures, computed tomography can be useful in demonstrating the spatial arrangement of bone fragments and topography of soft tissues surrounding the fracture site. Multiple cross-sectional computed tomography views of spiral fractures of the tibia show the details of the alignment of bone chips at the fracture site, axis of the tibial fracture cleft, and topography of soft tissues that are not visible on standard radiographs. A model of a spiral tibial fracture reveals periosteal stretching with increasing spiral and longitudinal displacement. The cleft in tibial fractures has a spiral shape and its line is invariable. Every spiral fracture of both crural bones results in extensive damage to the periosteum and may damage bellies of the long flexor muscle of toes, flexor hallucis longus as well as the posterior tibial muscle. Computed tomography images of spiral fractures of the tibia show details of damage that are otherwise invisible on standard radiographs. Moreover, CT images provide useful information about the spatial location of the bone chips as well as possible threats to soft tissues that surround the fracture site. Every spiral fracture of the tibia is associated with disruption of the periosteum. 1. Computed tomography images of spiral fractures of the tibia show details of damage otherwise invisible on standard radiographs, 2. The sharp end of the distal tibial chip can damage the tibialis posterior muscle, long flexor muscles of the toes and the flexor hallucis longus, 3. Every spiral fracture of the tibia is associated with disruption of the periosteum.

Multiple Tibial Insufficiency Fractures in the Same Tibia

PubMed Central

Defoort, Saartje; Mertens, Peter

2011-01-01

Stress fractures were first described by Briethaupt in 1855. Since then, there have been many discussions in the literature concerning stress fractures, which have been described in both weight-bearing and non-weight-bearing bones. Currently, the tibia is the most frequent location, but multiple stress fractures in the same tibia are rare. This paper presents an unusual case of a 60-year-old woman with multiple tibial stress fractures of spontaneous onset. PMID:23569673

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.

The effects of tibia profile, distraction angle, and knee load on wedge instability and hinge fracture: A finite element study.

PubMed

Weng, Pei-Wei; Chen, Chia-Hsien; Luo, Chu-An; Sun, Jui-Sheng; Tsuang, Yang-Hwei; Cheng, Cheng-Kung; Lin, Shang-Chih

2017-04-01

Several plate systems for high tibial osteotomy (HTO) have been developed to stabilize the opening wedge of an osteotomized tibia. Among them, the TomoFix system, having a quasi-straight and T-shaped design, has been widely adopted in the literature. However, this system is implemented by inserting a lag (i.e., cortical) screw through the proximal combi-hole, to deform the plate and pull the distal tibia toward the plate. This process potentially induces plate springback and creates an elastic preload on the osteotomized tibia, especially at the lateral hinge of the distracted wedge. Using the finite-element method, this study aims to investigate the contoured effect of lag-screw application on the biomechanical behavior of the tibia-plate construct. Two tibial profiles (normal and more concave), three distraction angles (6°, 9°, and 12°), and three knee loads (intraoperative: contouring plate; postoperative: weight and nonweight bearing) are systematically varied in this study. The wedge instability and fracture risk at the lateral hinge are chosen as the comparison indices. The results show the necessity of preoperative planning for a precontoured procedure, rather than elastic deformation using a lag screw. Within the intraoperative period, a more concave tibial profile and/or reduced distraction angle (i.e., 6° or 9°) necessitate a higher compressive load to elastically deform the plate, thereby deteriorating the lateral-hinge fracture risk. A precontoured plate is recommended in the case that the proximal tibia is highly concave and the distraction angle is insufficient to stretch the tibial profile. Copyright © 2017 IPEM. Published by Elsevier Ltd. All rights reserved.

[Clinical application of continuous douche and vacuum sealing drainage in refractory tissue, bone and joint infections after debridement].

PubMed

Yang, Ping-lin; He, Xi-jing; Li, Hao-peng; Wang, Guo-yu; Zang, Quan-jin

2010-01-01

To explore effect and the application value of continuous douche and vacuum sealing drainage (VSD) in refractory tissue, and joint infections after complete debridement. As retrospective analysis of treatment time and restoration or recurrence, from Jan. 2006 to Dec. 2007, 61 cases of refractory tissue, bone and joint infections underwent continuous douche and VSD combined with the treatment of anti-inflammatory and rehabilitation training after debridement in our hospital. The 61 patients included 39 males and 22 females with age ranging from 10 to 58 years with an average of (35 +/- 12) years, among whom 61 identified to have ankle ulcers combined with infections,open fracture combined with infections, sacrococcygeal pressure ulcers combined with infections, infections after hip replacement, infections after open fracture, and infections after skin avulsion postoperation were 11, 15, 9, 3, 5 and 18 cases respectively. The course was from 2 weeks to 11 months with an average of 4 months. In all 61 patients,the mean healing time was 17, 36, 42, 24, 32, 29 and 28 days in ankle ulcers and infections, tibia and fibula open fracture and infections, femoral shaft fracture and infections, sacrococcygeal pressure ulcers and infections, infections after hip replacement, infections after open fracture, and infections after skin avulsion postoperation respectively. The replacement of VSD was 1, 2-4, 3-5, 1-3, 2-4, 2-3 and 1-3 times in each group respectively. There was no wound recurrence except for 2 cases with recurrent in 61 cases with external fixation nail hole semi-pathological fracture in 1 case of femoral shaft fracture and infection and 1 case of tibia and fibula fracture and infection after follow-up at least one year. Application of continuous douche and VSD can effectively decrease incidence of complications and promote the refractory tissue, bone and joint infections wound growth, healing and considerably shorten the healing time.

The Contribution of SPECT/CT in the Diagnosis of Stress Fracture of the Proximal Tibia.

PubMed

Okudan, Berna; Coşkun, Nazım; Arıcan, Pelin

2018-02-01

Stress fractures are injuries most commonly seen in the lower limbs and are usually caused by repetitive stress. While the distal and middle third of the tibia is the most frequent site for stress fractures (almost 50%), stress fractures of the proximal tibia is relatively rare and could be confused with other types of tibial fractures, thus altering management plans for the clinician. Early diagnosis of stress fractures is also important to avoid complications. Imaging plays an important role in the diagnosis of stress fractures, especially bone scan. Combined with single-photon emission computed tomography/computed tomography (SPECT/CT) it is an important imaging technique for stress fractures in both upper and lower extremities, and is widely preferred over other imaging techniques. In this case, we present the case of a 39-year-old male patient diagnosed with stress fracture of the proximal tibia and demonstrate the contribution of CT scan fused with SPECT imaging in the early diagnosis of stress fracture prior to other imaging modalities.

Basic principles of fracture treatment in children.

PubMed

Ömeroğlu, Hakan

2018-04-01

This review aims to summarize the basic treatment principles of fractures according to their types and general management principles of special conditions including physeal fractures, multiple fractures, open fractures, and pathologic fractures in children. Definition of the fracture is needed for better understanding the injury mechanism, planning a proper treatment strategy, and estimating the prognosis. As the healing process is less complicated, remodeling capacity is higher and non-union is rare, the fractures in children are commonly treated by non-surgical methods. Surgical treatment is preferred in children with multiple injuries, in open fractures, in some pathologic fractures, in fractures with coexisting vascular injuries, in fractures which have a history of failed initial conservative treatment and in fractures in which the conservative treatment has no/little value such as femur neck fractures, some physeal fractures, displaced extension and flexion type humerus supracondylar fractures, displaced humerus lateral condyle fractures, femur, tibia and forearm shaft fractures in older children and adolescents and unstable pelvis and acetabulum fractures. Most of the fractures in children can successfully be treated by non-surgical methods.

Identification tibia and fibula bone fracture location using scanline algorithm

NASA Astrophysics Data System (ADS)

Muchtar, M. A.; Simanjuntak, S. E.; Rahmat, R. F.; Mawengkang, H.; Zarlis, M.; Sitompul, O. S.; Winanto, I. D.; Andayani, U.; Syahputra, M. F.; Siregar, I.; Nasution, T. H.

2018-03-01

Fracture is a condition that there is a damage in the continuity of the bone, usually caused by stress, trauma or weak bones. The tibia and fibula are two separated-long bones in the lower leg, closely linked at the knee and ankle. Tibia/fibula fracture often happen when there is too much force applied to the bone that it can withstand. One of the way to identify the location of tibia/fibula fracture is to read X-ray image manually. Visual examination requires more time and allows for errors in identification due to the noise in image. In addition, reading X-ray needs highlighting background to make the objects in X-ray image appear more clearly. Therefore, a method is required to help radiologist to identify the location of tibia/fibula fracture. We propose some image-processing techniques for processing cruris image and Scan line algorithm for the identification of fracture location. The result shows that our proposed method is able to identify it and reach up to 87.5% of accuracy.

Numerical simulations of human tibia osteosynthesis using modular plates based on Nitinol staples.

PubMed

Tarniţă, Daniela; Tarniţă, D N; Popa, D; Grecu, D; Tarniţă, Roxana; Niculescu, D; Cismaru, F

2010-01-01

The shape memory alloys exhibit a number of remarkable properties, which open new possibilities in engineering and more specifically in biomedical engineering. The most important alloy used in biomedical applications is NiTi. This alloy combines the characteristics of the shape memory effect and superelasticity with excellent corrosion resistance, wear characteristics, mechanical properties and a good biocompatibility. These properties make it an ideal biological engineering material, especially in orthopedic surgery and orthodontics. In this work, modular plates for the osteosynthesis of the long bones fractures are presented. The proposed modular plates are realized from identical modules, completely interchangeable, made of titanium or stainless steel having as connecting elements U-shaped staples made of Nitinol. Using computed tomography (CT) images to provide three-dimensional geometric details and SolidWorks software package, the three dimensional virtual models of the tibia bone and of the modular plates are obtained. The finite element models of the tibia bone and of the modular plate are generated. For numerical simulation, VisualNastran software is used. Finally, displacements diagram, von Misses strain diagram, for the modular plate and for the fractured tibia and modular plate ensemble are obtained.

Analysis of orthopedic injuries in an airplane landing disaster and a suggested mechanism of trauma.

PubMed

Mirzatolooei, Fardin; Bazzazi, Amirmohammad

2013-04-01

Survival after an airplane disaster is rare. We describe the injuries of survivors of an airplane accident and present a common mechanism of trauma for victims. Descriptive data were gathered by interviews with patients, physical examination. Review of charts and patients X-ray films. Informations regarding the flight characteristics were obtained from Iran air safety board. All dead patients were clinically examined by legal medicine department. The suggested mechanism of trauma was established according to present knowledge of mechanism of fractures. From 105 passengers, 27 survived. There was no mortality during hospital course. Between dead passengers, lower extremity fractures were the most common followed by chest wall fractures. Among the survivors, neurosurgical help was needed only in one case for shunt application. Brain concussions and effusions and one hematoma managed conservatively. Two laparotomies were performed for one splenectomy and two hepatoraphy. One pelvic fracture and two femur fractures were occurred. Tibia fractures were the most common (17) followed by spine (14) fractures. Ten tibial fractures were open, and 15 were in distal third. All tibia fractures were fixed with IM locking nails or locking plates. Eight posterior instrumentations were applied for seven burst and two fracture-dislocations. In this landing accident, a combination of vertical loading along with deceleration force produced burst fractures of spine and distal leg fractures.

Operative stabilization of open long bone fractures: A tropical tertiary hospital experience

PubMed Central

Ifesanya, Adeleke O.; Alonge, Temitope O.

2012-01-01

Background: Operative treatment of open fractures in our environment is fraught with problems of availability of theater space, appropriate hardware, and instrumentation such that high complication rates may be expected. Materials and Methods: We evaluated all open long bone fractures operatively stabilized at our center to determine the outcome of the various treatment modalities as well as the determinant factors. Result: A total of 160 patients with 171 fractures treated between December 1995 and December 2008 were studied. There were twice as many males; mean age was 35.0 years. About half were open tibia fractures. Gustilo IIIa and IIIb fractures each accounted for 56 cases (45.2%). Fifty-three percent were stabilized within the first week of injury. Interval between injury and operative fixation averaged 11.1 days. Anderson-Hutchin's technique was employed in 27 cases (21.8%), external fixation in 21 (16.9%), plate osteosynthesis in 50 (40.3%), and intramedullary nail 15 cases (12.1%). Mean time to union was 24.7 weeks. Fifty-two complications occurred in 50 fractures (40.3%) with joint stiffness and chronic osteomyelitis each accounting for a quarter of the complications. Union was delayed in grade IIIb open fractures and those fractures treated with external fixation. Conclusion: A significant proportion of open long bone fractures we operatively treated were severe. Severe open fractures (type IIIb) with concomitant stabilization using external fixation delayed fracture union. While we recommend intramedullary devices for open fractures, in our setting where locking nails are not readily available, external fixation remains the safest choice of skeletal stabilization particularly when contamination is high. PMID:23271839

When are CT angiograms indicated for patients with lower extremity fractures? A review of 275 extremities.

PubMed

Monazzam, Shafagh; Goodell, Parker B; Salcedo, Edgardo S; Nelson, Sandahl H; Wolinsky, Philip R

2017-01-01

Computed tomography angiogram (CTA) is frequently utilized to detect vascular injuries even without examination findings indicating a vascular injury. We had the following hypotheses: (1) a CTA for lower extremity fractures with no clinical signs of a vascular injury is not indicated, and (2) fracture location and pattern would correlate with the risk of a vascular injury. A retrospective review was conducted on patients who had an acute lower extremity fracture(s) and a CTA. Their charts were reviewed for multiple factors including the presence or absence of hard or soft signs of a vascular injury, soft tissue status, and fracture location/pattern. Every CTA radiology report was reviewed and any vascular intervention or amputation resulting from a vascular injury was recorded. Statistical analysis was performed. Of the 275 CTAs of fractured extremities reviewed, 80 (29%) had a positive CTA finding and 16 (6%) required treatment. A total of 109 (40%) of the extremities had no hard or soft signs; all had normal CTAs. Having at least one hard or soft sign was a significant risk factor for having a positive CTA. An open fracture, isolated proximal third fibula fracture, distal and shaft tibia fractures, and the presence of multiple fractures in one extremity were also associated with an increased risk for having a positive CTA. We found no evidence to support the routine use of CTAs to evaluate lower extremity fractures unless at least one hard or soft sign is present. The presence of an open fracture, distal tibia or tibial shaft fractures, multiple fractures in one extremity, and/or an isolated proximal third fibula fracture increases the risk of having a finding consistent with a vascular injury on a CTA. Only 6% of the cases required treatment, and all of them had diminished or absent distal pulses on presentation. Diagnostic test, level III.

Should fractures in massive intercalary bone allografts of the lower limb be treated with ORIF or with a new allograft?

PubMed

Aponte-Tinao, Luis A; Ayerza, Miguel A; Muscolo, D Luis; Farfalli, Germán L

2015-03-01

Massive bone allografts have been used for limb salvage of bone tumor resections as an alternative to endoprostheses, although they have different outcomes and risks. There is no general consensus about when to use these alternatives, but when it is possible to save the native joints after the resection of a long bone tumor, intercalary allografts offer some advantages despite complications, such as fracture. The management and outcomes of this complication deserve more study. The purposes of this study were to (1) analyze the fracture frequency in a group of patients treated with massive intercalary bone allografts of the femur and tibia; (2) compare the results of allografts treated with open reduction and internal fixation (ORIF) with those treated with resection and repeat allograft reconstruction; and (3) determine the likelihood that treatment of a fracture resulted in a healed intercalary reconstruction. We reviewed patients treated with intercalary bone allografts between 1991 and 2011. During this period, patients were generally treated with intercalary allografts when after tumor resection at least 1 cm of residual epiphysis remained to allow fixation of the osteotomy junction. To obtain a homogeneous group of patients, we excluded allograft-prosthesis composites and osteoarticular and hemicylindrical intercalary allografts from this study. We analyzed the fracture rate of 135 patients reconstructed with segmental intercalary bone allografts of the lower extremities (98 femurs and 37 tibias). In patients whose grafts fractured were treated either by internal fixation or a second allograft, ORIF generally was attempted but after early failures in femur fractures, these fractures were treated with a second allograft. Using a chart review, we ascertained the frequency of osseous union, complications, and reoperations after the treatment of fractured intercalary allografts. Followup was at a mean of 101 months (range, 24-260 months); of the original 135 patients, no patient was lost to followup. At latest followup, 19 patients (14%) had an allograft fracture (16 femurs [16%] and three tibias [8%]). Six patients were treated with internal fixation and addition of autologous graft (three femurs and three tibias) and 13 patients were treated with a second intercalary allograft (13 femurs). The three patients with femoral allograft fractures treated with internal fixation and autologous grafts failed and were treated with a second allograft, whereas those patients with tibia allograft fractures treated by the same procedure healed without secondary complications. When we analyzed the 16 patients with a second intercalary allograft (13 as primary treatment of the fracture and three as secondary treatment of the fracture), five failed (31%) and were treated with resection of the allograft and reconstructed with an endoprosthesis (four patients) or an osteoarticular allograft (one patient). Fractures of intercalary allografts of the tibia could successfully be treated with internal fixation and autologous iliac crest bone graft; however, this treatment failed when used for femur allograft fractures. Femoral fractures could be treated with resection and repeat allograft reconstruction, however, with a higher refracture frequency. The addition of a vascularized fibular graft in the second attempt should be considered. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

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.

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.

'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.

An unusual stress fracture: Bilateral posterior longitudinal stress fracture of tibia.

PubMed

Malkoc, Melih; Korkmaz, Ozgur; Ormeci, Tugrul; Oltulu, Ismail; Isyar, Mehmet; Mahirogulları, Mahir

2014-01-01

Stress fractures (SF) occur when healthy bone is subjected to cyclic loading, which the normal carrying range capacity is exceeded. Usually, stress fractures occur at the metatarsal bones, calcaneus, proximal or distal tibia and tends to be unilateral. This article presents a 58-year-old male patient with bilateral posterior longitudinal tibial stress fractures. A 58 years old male suffering for persistent left calf pain and decreased walking distance for last one month and after imaging studies posterior longitudinal tibial stress fracture was detected on his left tibia. After six months the patient was admitted to our clinic with the same type of complaints in his right leg. All imaging modalities and blood counts were performed and as a result longitudinal posterior tibial stress fractures were detected on his right tibia. Treatment of tibial stress fracture includes rest and modified activity, followed by a graded return to activity commensurate with bony healing. We have applied the same treatment protocol and our results were acceptable but our follow up time short for this reason our study is restricted for separate stress fractures of the posterior tibia. Although the main localization of tibial stress fractures were unilateral, anterior and transverse pattern, rarely, like in our case, the unusual bilateral posterior localization and longitudinal pattern can be seen. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.

Comparative investigation of percutaneous plating and intramedullary nailing effects on IL-6 production in patients with tibia shaft fracture.

PubMed

Ebrahimpour, Adel; Okhovatpour, Mohammad-Ali; Sadighi, Mehrdad; Sarejloo, Amir-Hossein; Sajjadi, Mohammad-Reza Minator

2017-12-01

The aim of this study was to analyze the effect of intramedullary nailing (IMN), open plating and percutaneous plating on the induction of IL-6 in patients with tibia fractures. A total of 30 patients with tibia shaft fracture underwent either intramedullary nailing (IMN, n = 15; 14 males and 1 female; mean age: 32.1 ± 15.6), ORIF plating (n = 8; 5 males and 3 females; mean age: 60.0 ± 17.8), or percutaneous plating (n = 7; 6 males and 1 female; mean age: 43.1 ± 21.4). Serum IL-6 cytokine levels were measured prior to, and 6 and 24 h after the surgery, using a special ELISA kit. The IL-6 concentration increased to peak levels at 6 h in both IMN and percutaneous plating groups, and at 24 h in ORIF plating group (p < 0.001). The mean IL-6 concentration of percutaneous plating group was significantly lower than that of the IMN group at 6 h following the surgery (p = 0.022). In addition, the mean IL-6 concentration of ORIF plating group was significantly higher than that of the percutaneous plating group at 24 h post operation (p = 0.009). Our results suggest that percutaneous plating compared to the IMN has lower effects on IL-6 production in patients with tibia fracture. Level III, therapeutic study. Copyright © 2017 Turkish Association of Orthopaedics and Traumatology. Production and hosting by Elsevier B.V. All rights reserved.

[Safety evaluation of secondary conversion from external fixation to internal fixation for open tibia fractures].

PubMed

Liu, Xi; Cen, Shiqiang; Xiang, Zhou; Zhong, Gang; Yi, Min; Fang, Yue; Liu, Lei; Huang, Fuguo

2017-06-01

To evaluate the safety of conversion from external fixation to internal fixation for open tibia fractures. Between January 2010 and December 2014, 94 patients (98 limbs) with open tibia fractures were initially treated with external fixators at the first stage, and the clinical data were retrospectively analyzed. In 29 cases (31 limbs), the external fixators were changed to internal fixation for discomfort, pin tract response, Schantz pin loosening, delayed union or non-union after complete wound healing and normal or close to normal levels of erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and the leucocyte count as well as the neutrophil ratio (trial group); in 65 cases (67 limbs), the external fixators were used as the ultimate treatment in the control group. There was no significant difference in gender, age, side of the limbs, interval from injury to the first debridement, initial pathogenic bacteria, the limbs that skin grafting or flap transferring for skin and soft tissue defect between the two groups ( P >0.05). The incidence of Gustilo type III fractures in the control group was significantly higher than that in the trial group ( P =0.000). The overall incidence of infection was calculated respectively in the two groups. The incidence of infection according to different fracture types and whether skin grafting or flap transferring was compared between the two groups. The information of the pathogenic bacteria was recorded in the infected patients, and it was compared with the results of the initial culture. The incidence of infection in the patients of the trial group using different internal fixation instruments was recorded. The overall incidences of infection for the trial and control groups were 9.7% (3/31) and 9.0% (6/67) respectively, showing no significant difference ( χ 2 =0.013, P =0.909). No infection occurred in Gustilo type I and type II patients. The incidence of infection for Gustilo type IIIA patients in the trial group and the control group were 14.3% (1/7) and 6.3% (2/32) respectively, showing no significant difference ( χ 2 =0.509, P =0.476); the incidence of infection for type IIIB patients in the two groups were 50.0% (2/4) and 14.3% (2/14) respectively, showing no significant difference ( χ 2 =2.168, P =0.141); and the incidence of infection for type IIIC patients in the two groups were 0 and 16.7% (2/12) respectively, showing no significant difference ( χ 2 =0.361, P =0.548). Of all the infected limbs, only 1 limb in the trial group had the same Staphylococcus Aureus as the result of the initial culture. In the patients who underwent skin grafting or flap transferring, the incidence of infection in the trial and control groups were 33.3% (2/6) and 13.3% (2/15) respectively, showing no significant difference ( χ 2 =1.059, P =0.303). After conversion to internal fixation, no infection occurred in the cases that fixed with nails (11 limbs), and infection occurred in 4 of 20 limbs that fixed with plates, with an incidence of infection of 20%. Conversion from external fixation to internal fixation for open tibia fractures is safe in most cases. However, for open tibia fractures with extensive and severe soft tissue injury, especially Gustilo type III patients who achieved wound heal after flap transfer or skin grafting, the choice of secondary conversion to internal fixation should carried out cautiously. Careful pre-operative evaluation of soft tissue status, cautious choice of fixation instrument and meticulous intra-operative soft tissue protection are essential for its safety.

Stress fracture as a complication of autogenous bone graft harvest from the distal tibia.

PubMed

Chou, Loretta B; Mann, Roger A; Coughlin, Michael J; McPeake, William T; Mizel, Mark S

2007-02-01

Autogenous bone graft from the distal tibia provides cancellous bone graft for foot and ankle operations, and it has osteogenic and osteoconductive properties. The site is in close proximity to the foot and ankle, and published retrospective studies show low morbidity from the procedure. One-hundred autografts were obtained from the distal tibia between 2000 and 2003. In four cases the distal tibial bone graft harvest resulted in a stress fracture. There were three women and one man. The average time of diagnosis of the stress fracture from the operation was 1.8 months. All stress fractures healed with a short course (average 2.4 months) of cast immobilization. This study demonstrated that a stress fracture from the donor site of autogenous bone graft of the distal tibia occurs and can be successfully treated nonoperatively.

Bilateral trampoline fracture of the proximal tibia in a child.

PubMed

Arkink, Enrico B; van der Plas, Annelies; Sneep, Ruth W; Reijnierse, Monique

2017-12-01

Trampoline fractures are transversely oriented impaction fractures of the proximal tibia sustained by young children jumping on a trampoline. Unaware of the mechanism of this specific nontraumatic fracture, physicians may fail to detect these fractures on plain radiographs, as radiological findings may be very subtle. In this case report, we present a rare case of bilateral trampoline fractures with an explanation of the trauma mechanism.

Post-traumatic cerebral fat embolism prior to operative repair of femoral and tibial fractures.

PubMed

Kim, Kyung-Cheon; Hwang, Deuk-Soo; Shin, Hyun-Dae

2008-02-01

Rare cases of primary cerebral fat embolism as a postoperative complication have been reported. In addition, cerebral fat embolism occurring before operative repair without shunt lesion are more rarely reported. We report a patient with a posttraumatic cerebral fat embolism resulting in severe neurologic dysfunction without right to left shunt. A 25-year-old man was brought to the hospital immediately after a traffic accident. He sustained a right segmental femoral shaft fracture and a left tibial shaft fracture. The patient was alert with no neurological deficits. Approximately 13 hours after injury, the patient developed acute mental status deterioration and dyspnea. Magnetic resonance imaging of the brain revealed extensive multifocal infarction owing to embolic showering throughout nearly the entire brain parenchyma. Computed tomography with intravenous contrast revealed no evidence of embolism in the lung, abdomen, and pelvis. Transthoracic and transesophageal echocardiogram revealed no circulating embolic particles or intracardiac shunt. The patient underwent closed reduction and internal fixation with a reamed intramedullary nail in the tibia and underwent open reduction and internal fixation with a reamed nail in the femur at 5 days after injury. We performed decompression of a hematoma containing a large number of lipid droplets via a small incision in the femur shaft fracture, established suction drainage of the tibia medullar cavity, and applied a tourniquet to the thigh in the tibia shaft fracture. Supportive medical treatment included endotracheal ventilatory support and tracheostomy. The patient was discharged from the hospital 50 days after admission. On follow-up 2 months later, he had returned to activities of daily living, however a speech disturbance remained.

The floating knee: epidemiology, prognostic indicators & outcome following surgical management

PubMed Central

Rethnam, Ulfin; Yesupalan, Rajam S; Nair, Rajagopalan

2007-01-01

Background Floating Knee injuries are complex injuries. The type of fractures, soft tissue and associated injuries make this a challenging problem to manage. We present the outcome of these injuries after surgical management. Methods 29 patients with floating knee injuries were managed over a 3 year period. This was a prospective study were both fractures of the floating knee injury were surgically fixed using different modalities. The associated injuries were managed appropriately. Assessment of the end result was done by the Karlstrom criteria after bony union. Results The mechanism of injury was road traffic accident in 27/29 patients. There were 38 associated injuries. 20/29 patients had intramedullary nailing for both fractures. The complications were knee stiffness, foot drop, delayed union of tibia and superficial infection. The bony union time ranged from 15 – 22.5 weeks for femur fractures and 17 – 28 weeks for the tibia. According to the Karlstrom criteria the end results were Excellent – 15, Good – 11, Acceptable – 1 and Poor – 3. Conclusion The associated injuries and the type of fracture (open, intra-articular, comminution) are prognostic indicators in the Floating knee. Appropriate management of the associated injuries, intramedullary nailing of both the fractures and post operative rehabilitation are necessary for good final outcome. PMID:18271992

Successful reimplantation of extruded long bone segments in open fractures of lower limb--a report of 3 cases.

PubMed

Shanmuganathan, Rajasekaran; Chandra Mohan, Arun Kamal; Agraharam, Devendra; Perumal, Ramesh; Jayaramaraju, Dheenadhayalan; Kulkarni, Sunil

2015-07-01

Extruded bone segments are rare complication of high energy open fractures. Routinely these fractures are treated by debridement followed by bone loss management in the form of either bone transport or free fibula transfer. There are very few reports in the literature about reimplantation of extruded segments of bone and there are no clear guidelines regarding timing of reimplantation, bone stabilisation and sterilisation techniques. Reimplantation of extruded bone is a risky procedure due to high chances of infection which determines the final outcome and can result in secondary amputations. We present two cases of successful reimplantation of extruded diaphyseal segment of femur and one case of reimplantation of extruded segment of tibia. Copyright © 2015 Elsevier Ltd. All rights reserved.

Natural tibialization of fibula in non-union tibia: Two cases.

PubMed

Prabhat, Vinay; Vargaonkar, Gauresh S; Mallojwar, Sunil R; Kumar, Ramesh

2016-01-01

Non-union of tibia is known to be a common complication after fracture both bones of leg treated conservatively. During the course of natural healing, fibula usually unites early as it had more soft tissue attachment and vascular supply. Due to early union of fibula and absence of axial force across the tibia, it undergoes non-union. Two cases, a 32-year-old male and 65-year-old female treated conservatively for fracture both bones of leg long years back, presented to us with mild calf pain on and off. On radiological examination, there was non-union of tibia along with compensatory fibular hypertrophy to the extent that fibula became main weight bearing bone. In both the cases, we observed gross fibular hypertrophy in presence of non-union of tibia. In conservatively treated cases of fracture, both bones of leg, non-union of tibia may coexist with compensatory hypertrophy of fibula to the extent that, it becomes main weight bearing bone of the leg. We are presenting here two cases of natural tibialization of fibula along with nonunion tibia. Our article supports the theory of Wolff's law.

Management of Gustilo Anderson III B open tibial fractures by primary fascio-septo-cutaneous local flap and primary fixation: The 'fix and shift' technique.

PubMed

Ramasamy, P R

2017-01-01

Open fractures of tibia have posed great difficulty in managing both the soft tissue and the skeletal components of the injured limb. Gustilo Anderson III B open tibial fractures are more difficult to manage than I, II, and III A fractures. Stable skeletal fixation with immediate soft tissue cover has been the key to the successful outcome in treating open tibial fractures, in particular, Gustilo Anderson III B types. If the length of the open wound is larger and if the exposed surface of tibial fracture and tibial shaft is greater, then the management becomes still more difficult. Thirty six Gustilo Anderson III B open tibial fractures managed between June 2002 and December 2013 with "fix and shift" technique were retrospectively reviewed. All the 36 patients managed by this technique had open wounds measuring >5 cm (post debridement). Under fix and shift technique, stable fixation involved primary external fixator application or primary intramedullary nailing of the tibial fracture and immediate soft tissue cover involved septocutaneous shift, i.e., shifting of fasciocutaneous segments based on septocutaneous perforators. Primary fracture union rate was 50% and reoperation rate (bone stimulating procedures) was 50%. Overall fracture union rate was 100%. The rate of malunion was 14% and deep infection was 16%. Failure of septocutaneous shift was 2.7%. There was no incidence of amputation. Management of Gustilo Anderson III B open tibial fractures with "fix and shift" technique has resulted in better outcome in terms of skeletal factors (primary fracture union, overall union, and time for union and malunion) and soft tissue factors (wound healing, flap failure, access to secondary procedures, and esthetic appearance) when compared to standard methods adopted earlier. Hence, "fix and shift" could be recommended as one of the treatment modalities for open III B tibial fractures.

Measurement of bone adjacent to tibial shaft fracture.

PubMed

Findlay, S C; Eastell, R; Ingle, B M

2002-12-01

Delayed union and non-union are common complications after fracture of the tibial shaft. Response of the surrounding bone as a fracture heals could be monitored using techniques currently used in the study of osteoporosis. The aims of our study were to: (1) evaluate the decrement in bone measurements made close to the fracture using dual-energy X-ray absorptiometry (DXA), quantitative ultrasound (QUS) and peripheral quantitative computed tomography (pQCT); (2) compare values for fractured versus non-fractured leg to determine the duration of decrement in bone measurements; and (3) calculate short-term precision in DXA, QUS and pQCT in order to calculate the ratio of decrement to precision (response ratio, RR) to determine the optimal test for monitoring changes after tibial fracture. The biggest decrement in bone measurements at the ipsilateral limb of 28 patients with tibial shaft fracture was observed at the pQCT tibial trabecular sites (distal = 19%, p<0.0001; proximal 5% = 21%, p<0.001; proximal 10% = 28%, p<0.001) and the ultradistal tibia/fibula measured by DXA (19%, p<0.0001). When comparing Z-scores, the magnitude of decrements at the ipsilateral limb was bigger for variables measured directly at the tibia, both proximal and distal to the fracture. The magnitude of the decrement in ultradistal tibia/fibula BMD decreased as the time since fracture increased ( r = 0.55). When response ratios are considered, pQCT measurements at the distal tibia (RR 6-8) and proximal 5% and 10% trabecular sites (RR 5 and 9 respectively) were found to be the most sensitive to change. Therefore, pQCT of the trabecular regions of either the proximal or distal tibia should prove the most sensitive measurement for monitoring changes in bone adjacent to a tibial shaft fracture.

Ultrasound-Diagnosed Tibia Stress Fracture: A Case Report.

PubMed

Amoako, Adae; Abid, Ayesha; Shadiack, Anthony; Monaco, Robert

2017-01-01

Stress fractures are a frequent cause of lower extremity pain in athletes, and especially in runners. Plain imaging has a low sensitivity. Magnetic resonance imaging (MRI) or bone scan scintigraphy is the criterion standard, but expensive. We present the case of a young female distance runner with left shin pain. Plain radiography was unremarkable. Ultrasound showed focal hyperechoic elevation of the periosteum with irregularity over the distal tibia and increased flow on Doppler. These findings were consistent with a distal tibia stress fracture and confirmed by MRI. Examination of our case will highlight the utility of considering an ultrasound for diagnosis of tibial stress fracture.

Ultrasound-Diagnosed Tibia Stress Fracture: A Case Report

PubMed Central

Amoako, Adae; Abid, Ayesha; Shadiack, Anthony; Monaco, Robert

2017-01-01

Stress fractures are a frequent cause of lower extremity pain in athletes, and especially in runners. Plain imaging has a low sensitivity. Magnetic resonance imaging (MRI) or bone scan scintigraphy is the criterion standard, but expensive. We present the case of a young female distance runner with left shin pain. Plain radiography was unremarkable. Ultrasound showed focal hyperechoic elevation of the periosteum with irregularity over the distal tibia and increased flow on Doppler. These findings were consistent with a distal tibia stress fracture and confirmed by MRI. Examination of our case will highlight the utility of considering an ultrasound for diagnosis of tibial stress fracture. PMID:28469488

The management of open tibial fractures in children: a retrospective case series of eight years' experience of 61 cases at a paediatric specialist centre.

PubMed

Nandra, R S; Wu, F; Gaffey, A; Bache, C E

2017-04-01

Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union. A retrospective review was performed on 61 children who between 2007 and 2015 presented with an open tibia fracture. Their mean age was nine years (2 to 16) and the median follow-up was ten months (interquartile range 5 to 18). Management involved IV antibiotics, early debridement and combined treatment of the skeletal and soft-tissue injuries in line with standards proposed by the British Orthopaedic Association. There were 36 diaphyseal fractures and 25 distal tibial fractures. Of the distal fractures, eight involved the physis. Motor vehicle collisions accounted for two thirds of the injuries and 38 patients (62%) arrived outside of normal working hours. The initial method of stabilisation comprised: casting in nine cases (15%); elastic nailing in 19 (31%); Kirschner (K)-wiring in 13 (21%); intramedullary nailing in one (2%); open reduction and plate fixation in four (7%); and external fixation in 15 (25%). Wound management comprised: primary wound closure in 24 (39%), delayed primary closure in 11 (18%), split skin graft (SSG) in eight (13%), local flap with SSG in 17 (28%) and a free flap in one. A total of 43 fractures (70%) were Gustilo-Anderson grade III. There were four superficial (6.6%) and three (4.9%) deep infections. Two deep infections occurred following open reduction and plate fixation and the third after K-wire fixation of a distal fracture. No patient who underwent primary wound closure developed an infection. All the fractures united, although nine patients required revision of a mono-lateral to circular frame for delayed union (two) or for altered alignment or length (seven). The mean time to union was two weeks longer in diaphyseal fractures than in distal fractures (13 weeks versus 10.8 weeks, p = 0.016). Children aged > 12 years had a significantly longer time to union than those aged < 12 years (16.3 weeks versus 11.4 weeks, p = 0.045). The length of stay in hospital for patients with a Gustilo-Anderson grade IIIB fracture was twice as long as for less severe injuries. Fractures in children heal better than those in adults. Based on our experience of deep infection we discourage the use of internal fixation with a plate for open tibial fractures in children. We advocate aggressive initial wound debridement in theatre with early definitive combined orthopaedic and plastic surgery in order to obtain skeletal stabilisation and soft-tissue cover. Cite this article: Bone Joint J 2017;99-B:544-53. ©2017 The British Editorial Society of Bone & Joint Surgery.

Microbiology and Injury Characteristics in Severe Open Tibia Fractures from Combat

DTIC Science & Technology

2012-01-01

cloacae 17 18.3 Klebsiella pneumoniae 13 14 Enterococcus faecium 13 14 Pseudomonas aeruginosa 13 14 Staphylococcus epidermidis 6 6.5 Infection cultures 57...baumannii 10 19.6 Staphylococcus epidermidis 10 19.6 Klebsiella pneumoniae 6 11.8 Enterococcus faecium 4 7.8 Burns et al. J Trauma Volume 72, Number 4 © 2012

Development of a Novel Synthetic Drug for Osteoporosis and Fracture Healing

DTIC Science & Technology

2015-11-01

Four-point bending setup for mechanical testing. (C & D) X-ray images of the fractured tibiae. Of note, a stainless steel rod was inserted in the...respectively. Figure 15. Mechanical strength 4 weeks after fracture induction for experiment 1. (A) Force- displacement relationship for the hydrogel...University Purdue University Indianapolis, Indianapolis, IN 46202, USA Keywords: bone fracture , tibia, salubrinal, hydrogel, mechanical test Running

Ipsilateral femur and tibia fractures in pediatric patients: A systematic review

PubMed Central

Anari, Jason B; Neuwirth, Alexander L; Horn, B David; Baldwin, Keith D

2017-01-01

AIM To better understand how pediatric floating knee injuries are managed after the wide spread use of new orthopaedic technology. METHODS We searched EMBASE, COCHRANE and MEDLINE computerized literature databases from the earliest date available in the databases to February 2017 using the following search term including variants and pleural counterparts: Pediatric floating knee. All studies were thoroughly reviewed by multiple authors. Reference lists from all articles were scrutinized to identify any additional studies of interest. A final database of individual patients was assembled from the literature. Univariate and multivariate statistical tests were applied to the assembled database to assess differences in outcomes. RESULTS The English language literature contains series with a total of 97 pediatric patients who sustained floating knee injuries. Patients averaged 9.3 years of age and were mostly male (73). Approximately 25% of the fractures were open injuries, more tibia (27) than femur (10). Over 75% of the fractures of both the tibia and the femur involved the diaphysis. More than half (52) of the patients were treated non-operatively for both fractures. As a sequela of the injury 32 (33%) patients were left with a limb length discrepancy, 24 (25%) patients had lengthening of the injured limb at follow up, while 8 (8%) had shortening of the affected limb. Infection developed in 9 patients and 3 had premature physeal closure. Younger patients were more likely to be treated non-operatively (P < 0.001) and patients treated with operative intervention had statistically significant shorter hospital length of stays (P = 0.001). CONCLUSION Given the predominance of non-operative management in published studies, the available literature is not clinically relevant since the popularization of internal fixation for pediatric long-bone fractures PMID:28875130

Ipsilateral femur and tibia fractures in pediatric patients: A systematic review.

PubMed

Anari, Jason B; Neuwirth, Alexander L; Horn, B David; Baldwin, Keith D

2017-08-18

To better understand how pediatric floating knee injuries are managed after the wide spread use of new orthopaedic technology. We searched EMBASE, COCHRANE and MEDLINE computerized literature databases from the earliest date available in the databases to February 2017 using the following search term including variants and pleural counterparts: Pediatric floating knee. All studies were thoroughly reviewed by multiple authors. Reference lists from all articles were scrutinized to identify any additional studies of interest. A final database of individual patients was assembled from the literature. Univariate and multivariate statistical tests were applied to the assembled database to assess differences in outcomes. The English language literature contains series with a total of 97 pediatric patients who sustained floating knee injuries. Patients averaged 9.3 years of age and were mostly male (73). Approximately 25% of the fractures were open injuries, more tibia (27) than femur (10). Over 75% of the fractures of both the tibia and the femur involved the diaphysis. More than half (52) of the patients were treated non-operatively for both fractures. As a sequela of the injury 32 (33%) patients were left with a limb length discrepancy, 24 (25%) patients had lengthening of the injured limb at follow up, while 8 (8%) had shortening of the affected limb. Infection developed in 9 patients and 3 had premature physeal closure. Younger patients were more likely to be treated non-operatively ( P < 0.001) and patients treated with operative intervention had statistically significant shorter hospital length of stays ( P = 0.001). Given the predominance of non-operative management in published studies, the available literature is not clinically relevant since the popularization of internal fixation for pediatric long-bone fractures.

Minimally invasive plate osteosynthesis with locking compression plate for distal diametaphyseal tibia fracture.

PubMed

Shrestha, D; Acharya, B M; Shrestha, P M

2011-01-01

Distal diametaphyseal tibia fracture though requires operative treatment is difficult to manage. Conventional osteosynthesis is not suitable because distal tibia is subcutaneous bone with poor vascularity. Closed reduction and minimally invasive plate osteosynthesis (MIPO) with locking compression plate (LCP) has emerged as an alternative treatment option because it respects biology of distal tibia and fracture hematoma and also provides biomechanicaly stable construct. To find out suitability of MIPO with LCP for distal diametaphyseal tibia fracture including union time and complicatios and compare wih other available management options in literature. Twenty patients with closed distal diametaphyseal tibia fracture with or without intra articular extension (AO classification: 12 type 43A1, 4 type 43A2, 2 type 43A3 and 2 type 43B1) treated with MIPO with LCP were prospectively followed for average duration of 18.45 months (range 5-30 months). Average duration of injury-hospital and injury-surgery interval was 12.8 hrs (range 2-44 hrs) and 4.45 days (range 1-10 days) respectively. All fractures got united with an average duration of 18.5 weeks (range14-28weeks) except one case of delayed union which was managed with percutaneous bone marrow injection. Two patients had union with valgus angulation less than 5 degees but no nonunion was found. There were two superficial and one deep post operative wound infection. All infections healed with extended period of intravenous antibiotics besides repeated debridemet for deep infection. Implants were removed in eight patients among whom six (30%) had malleolar skin irritation and pain due to prominent hardware. The present case series shows that MIPO with LCP is an effective treatment method in terms of union time and complications rate for distal diametaphyseal tibia fracture. Malleolar skin irritation is common problem because of prominent hardware.

The effect of retained intramedullary nails on tibial bone mineral density.

PubMed

Allen, J C; Lindsey, R W; Hipp, J A; Gugala, Z; Rianon, N; LeBlanc, A

2008-07-01

Intramedullary nailing has become a standard treatment for adult tibial shaft fractures. Retained intramedullary nails have been associated with stress shielding, although their long-term effect on decreasing tibial bone mineral density is currently unclear. The purpose of this study was to determine if retained tibial intramedullary nails decrease tibial mineral density in patients with successfully treated fractures. Patients treated with statically locked intramedullary nails for isolated, unilateral tibia shaft fractures were studied. Inclusion required that fracture had healed radiographically and that the patient returned to the pre-injury activity level. Data on patient demographic, fracture type, surgical technique, implant, and post-operative functional status were tabulated. Dual energy X-ray absorptiometry was used to measure bone mineral density in selected regions of the affected tibia and the contralateral intact tibia. Image reconstruction software was employed to ensure symmetry of the studied regions. Twenty patients (mean age 43; range 22-77 years) were studied at a mean of 29 months (range 5-60 months) following intramedullary nailing. There was statistically significant reduction of mean bone mineral density in tibiae with retained intramedullary nails (1.02 g/cm(2) versus 1.06 g/cm(2); P=0.04). A significantly greater decrease in bone mineral density was detected in the reamed versus non-reamed tibiae (-7% versus +6%, respectively; P<0.05). The present study demonstrates a small, but statistically significant overall bone mineral density decrease in healed tibiae with retained nails. Intramedullary reaming appears to be a factor potentiating the reduction of tibia bone mineral density in long-term nail retention.

Retrograde nail for tibiotalocalcaneal arthrodesis as a limb salvage procedure for open distal tibia and talus fractures with severe bone loss.

PubMed

Ochman, Sabine; Evers, Julia; Raschke, Michael J; Vordemvenne, Thomas

2012-01-01

The treatment of complex fractures of the distal tibia, ankle, and talus with soft tissue damage, bone loss, and nonreconstructable joints for which the optimal timing for reduction and fixation has been missed is challenging. In such cases primary arthrodesis might be a treatment option. We report a series of multi-injured patients with severe soft tissue damage and bone loss, who were treated with a retrograde tibiotalocalcaneal arthrodesis nail as a minimally invasive treatment option for limb salvage. After a median follow-up of 5.4 years, all patients returned to their former profession. The ankle and bone fusion was complete, with moderate functional results and quality of life. Calcaneotibial arthrodesis using a retrograde nail is a good treatment option for nonreconstructable fractures of the ankle joint with severe bone loss and poor soft tissue quality in selected patients with multiple injuries, in particular, those involving both lower extremities, as a salvage procedure. Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

[Clinical practice guideline on closed tibial plateau fractures in adulthood].

PubMed

Ocegueda-Sosa, Miguel Ángel; Valenzuela-Flores, Adriana Abigail; Aldaco-García, Víctor Daniel; Flores-Aguilar, Sergio; Manilla-Lezama, Nicolás; Pérez-Hernández, Jorge

2013-01-01

Closed tibiae plateau fractures are common injuries in the emergency room. The optimal treatment is not well defined or established. For this reason, there are several surgical management options: open reduction and internal fixation, closed reduction and percutaneous synthesis, external fixation, and even conservative treatment for this kind of fracture. The mechanism of production of this fracture is through large varus or valgus deformation to which is added a factor of axial load. The trauma may be direct or indirect. The degree of displacement, fragmentation and involvement of soft tissues like ligaments, menisci, vascular and nerve structures are determined by the magnitude of the force exerted. Any intra-articular fracture treatment can lead to an erroneous instability, deformity and limitation of motion with subsequent arthritic changes, leading to joint incongruity, limiting activity and significantly altering the quality of life. Open reduction and internal fixation with anatomic restitution is the method used in this type of fracture. However, the results of numerous publications can be questioned due to the inclusion in the same study of fractures treated with very different methods.

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.

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.

Lower Trabecular Volumetric BMD at Metaphyseal Regions of Weight-Bearing Bones is Associated With Prior Fracture in Young Girls

PubMed Central

Farr, Joshua N; Tomás, Rita; Chen, Zhao; Lisse, Jeffrey R; Lohman, Timothy G; Going, Scott B

2011-01-01

Understanding the etiology of skeletal fragility during growth is critical for the development of treatments and prevention strategies aimed at reducing the burden of childhood fractures. Thus we evaluated the relationship between prior fracture and bone parameters in young girls. Data from 465 girls aged 8 to 13 years from the Jump-In: Building Better Bones study were analyzed. Bone parameters were assessed at metaphyseal and diaphyseal sites of the nondominant femur and tibia using peripheral quantitative computed tomography (pQCT). Dual-energy X-ray absorptiometry (DXA) was used to assess femur, tibia, lumbar spine, and total body less head bone mineral content. Binary logistic regression was used to evaluate the relationship between prior fracture and bone parameters, controlling for maturity, body mass, leg length, ethnicity, and physical activity. Associations between prior fracture and all DXA and pQCT bone parameters at diaphyseal sites were nonsignificant. In contrast, lower trabecular volumetric BMD (vBMD) at distal metaphyseal sites of the femur and tibia was significantly associated with prior fracture. After adjustment for covariates, every SD decrease in trabecular vBMD at metaphyseal sites of the distal femur and tibia was associated with 1.4 (1.1–1.9) and 1.3 (1.0–1.7) times higher fracture prevalence, respectively. Prior fracture was not associated with metaphyseal bone size (ie, periosteal circumference). In conclusion, fractures in girls are associated with lower trabecular vBMD, but not bone size, at metaphyseal sites of the femur and tibia. Lower trabecular vBMD at metaphyseal sites of long bones may be an early marker of skeletal fragility in girls. © 2011 American Society for Bone and Mineral Research. PMID:20721933

Lower trabecular volumetric BMD at metaphyseal regions of weight-bearing bones is associated with prior fracture in young girls.

PubMed

Farr, Joshua N; Tomás, Rita; Chen, Zhao; Lisse, Jeffrey R; Lohman, Timothy G; Going, Scott B

2011-02-01

Understanding the etiology of skeletal fragility during growth is critical for the development of treatments and prevention strategies aimed at reducing the burden of childhood fractures. Thus we evaluated the relationship between prior fracture and bone parameters in young girls. Data from 465 girls aged 8 to 13 years from the Jump-In: Building Better Bones study were analyzed. Bone parameters were assessed at metaphyseal and diaphyseal sites of the nondominant femur and tibia using peripheral quantitative computed tomography (pQCT). Dual-energy X-ray absorptiometry (DXA) was used to assess femur, tibia, lumbar spine, and total body less head bone mineral content. Binary logistic regression was used to evaluate the relationship between prior fracture and bone parameters, controlling for maturity, body mass, leg length, ethnicity, and physical activity. Associations between prior fracture and all DXA and pQCT bone parameters at diaphyseal sites were nonsignificant. In contrast, lower trabecular volumetric BMD (vBMD) at distal metaphyseal sites of the femur and tibia was significantly associated with prior fracture. After adjustment for covariates, every SD decrease in trabecular vBMD at metaphyseal sites of the distal femur and tibia was associated with 1.4 (1.1-1.9) and 1.3 (1.0-1.7) times higher fracture prevalence, respectively. Prior fracture was not associated with metaphyseal bone size (ie, periosteal circumference). In conclusion, fractures in girls are associated with lower trabecular vBMD, but not bone size, at metaphyseal sites of the femur and tibia. Lower trabecular vBMD at metaphyseal sites of long bones may be an early marker of skeletal fragility in girls. Copyright © 2011 American Society for Bone and Mineral Research.

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.

Novel implant for peri-prosthetic proximal tibia fractures.

PubMed

Tran, Ton; Chen, Bernard K; Wu, Xinhua; Pun, Chung Lun

2018-03-01

Repair of peri-prosthetic proximal tibia fractures is very challenging in patients with a total knee replacement or arthroplasty. The tibial component of the knee implant severely restricts the fixation points of the tibial implant to repair peri-prosthetic fractures. A novel implant has been designed with an extended flange over the anterior of tibial condyle to provide additional points of fixation, overcoming limitations of existing generic locking plates used for proximal tibia fractures. Furthermore, the screws fixed through the extended flange provide additional support to prevent the problem of subsidence of tibial component of knee implant. The design methodology involved extraction of bone data from CT scans into a flexible CAD format, implant design and structural evaluation and optimisation using FEM as well as prototype development and manufacture by selective laser melting 3D printing technology with Ti6Al4 V powder. A prototype tibia implant was developed based on a patient-specific bone structure, which was regenerated from the CT images of patient's tibia. The design is described in detail and being applied to fit up to 80% of patients, for both left and right sides based on the average dimensions and shape of the bone structure from a wide range of CT images. A novel tibial implant has been developed to repair peri-prosthetic proximal tibia fractures which overcomes significant constraints from the tibial component of existing knee implant. Copyright © 2018 Elsevier Ltd. All rights reserved.

Increased Cortical Porosity in Type-2 Diabetic Postmenopausal Women with Fragility Fractures

PubMed Central

Patsch, Janina M.; Burghardt, Andrew J.; Yap, Samuel P.; Baum, Thomas; Schwartz, Ann V.; Joseph, Gabby B.; Link, Thomas M.

2012-01-01

The primary goal of this study was to assess peripheral bone microarchitecture and strength in diabetic postmenopausal women with fragility fractures (DMFx) and to compare them with diabetic women without fracture (DM). Secondary goals were to assess differences in non-diabetic women with (Fx) and without fragility fractures (Co) and in women with (DM) and without diabetes (Co). Eighty women (mean age 61.3±5.7 yrs) were recruited into these groups (n=20 per group). Participants underwent DXA and high-resolution peripheral quantitative computed tomography (HR-pQCT) of the ultradistal and distal radius and tibia. In the HR-pQCT images volumetric bone mineral density, cortical and trabecular structure measures, including cortical porosity, were calculated. Bone strength was estimated using micro-finite element analysis (μFEA). Differential strength estimates were obtained with and without open cortical pores. At the ultradistal and distal tibia, DMFx had greater intracortical pore volume (+52.6%, p=0.009; +95.4%, p=0.020), relative porosity (+58.1%; p=0.005; +87.9%, p=0.011) and endocortical bone surface (+10.9%, p=0.031; +11.5%, 0.019) than DM. At the distal radius DMFx had 4.7-fold greater relative porosity (p=0.000) than DM. At the ultradistal radius, intracortical pore volume was significantly higher in DMFx than DM (+67.8%, p=0.018). DMFx also displayed larger trabecular heterogeneity (ultradistal radius; +36.8%, p=0.035), and lower total and cortical BMD (ultradistal tibia: −12.6%, p=0.031; −6.8%, p=0.011) than DM. DMFx exhibited significantly higher pore-related deficits in stiffness, failure load and cortical load fraction at the ultradistal and distal tibia, and the distal radius than DM. Comparing non-diabetic Fx and Co, we only found a non-significant trend with increase in pore volume (+38.9%, p=0.060) at the ultradistal radius. The results of our study suggest that severe deficits in cortical bone quality are responsible for fragility fractures in postmenopausal diabetic women. PMID:22991256

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.

Fibular fixation as an adjuvant to tibial intramedullary nailing in the treatment of combined distal third tibia and fibula fractures: a biomechanical investigation.

PubMed

Morin, Paul M; Reindl, Rudolf; Harvey, Edward J; Beckman, Lorne; Steffen, Thomas

2008-02-01

Distal third tibia fractures have classically been treated with standard plating, but intramedullary (IM) nailing has gained popularity. Owing to the lack of interference fit of the nail in the metaphyseal bone of the distal tibia, it may be beneficial to add rigid plating of the fibula to augment the overall stability of fracture fixation in this area. This study sought to assess the biomechanical effect of adding a fibular plate to standard IM nailing in the treatment of distal third tibia and fibula fractures. Eight cadaveric tibia specimens were used. Tibial fixation consisted of a solid titanium nail locked with 3 screws distally and 2 proximally, and fibular fixation consisted of a 3.5 mm low-contact dynamic compression plate. A section of tibia and fibula was removed. Testing was accomplished with an MTS machine. Each leg was tested 3 times; with and without a fibular plate and with a repetition of the initial test condition. Vertical displacements were tested with an axial load up to 500 N, and angular rotation was tested with torques up to 5 N*m. The difference in axial rotation was the only statistically significant finding (p = 0.003), with fibular fixation resulting in 1.1 degrees less rotation through the osteotomy site (17.96 degrees v. 19.10 degrees ). Over 35% of this rotational displacement occurred at the nail-locking bolt interface with the application of small torsional forces. Fibular plating in addition to tibial IM fixation of distal third tibia and fibula fractures leads to slightly increased resistance to torsional forces. This small improvement may not be clinically relevant.

Towards valid 'serious non-fatal injury' indicators for international comparisons based on probability of admission estimates.

PubMed

Cryer, Colin; Miller, Ted R; Lyons, Ronan A; Macpherson, Alison K; Pérez, Katherine; Petridou, Eleni Th; Dessypris, Nick; Davie, Gabrielle S; Gulliver, Pauline J; Lauritsen, Jens; Boufous, Soufiane; Lawrence, Bruce; de Graaf, Brandon; Steiner, Claudia A

2017-02-01

Governments wish to compare their performance in preventing serious injury. International comparisons based on hospital inpatient records are typically contaminated by variations in health services utilisation. To reduce these effects, a serious injury case definition has been proposed based on diagnoses with a high probability of inpatient admission (PrA). The aim of this paper was to identify diagnoses with estimated high PrA for selected developed countries. The study population was injured persons of all ages who attended emergency department (ED) for their injury in regions of Canada, Denmark, Greece, Spain and the USA. International Classification of Diseases (ICD)-9 or ICD-10 4-digit/character injury diagnosis-specific ED attendance and inpatient admission counts were provided, based on a common protocol. Diagnosis-specific and region-specific PrAs with 95% CIs were calculated. The results confirmed that femoral fractures have high PrA across all countries studied. Strong evidence for high PrA also exists for fracture of base of skull with cerebral laceration and contusion; intracranial haemorrhage; open fracture of radius, ulna, tibia and fibula; pneumohaemothorax and injury to the liver and spleen. Slightly weaker evidence exists for cerebellar or brain stem laceration; closed fracture of the tibia and fibula; open and closed fracture of the ankle; haemothorax and injury to the heart and lung. Using a large study size, we identified injury diagnoses with high estimated PrAs. These diagnoses can be used as the basis for more valid international comparisons of life-threatening injury, based on hospital discharge data, for countries with well-developed healthcare and data collection systems. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Percutaneous or Open Reduction of Closed Tibial Shaft Fractures During Intramedullary Nailing Does Not Increase Wound Complications, Infection or Nonunion Rates.

PubMed

Auston, Darryl A; Meiss, Jordan; Serrano, Rafael; Sellers, Thomas; Carlson, Gregory; Hoggard, Timothy; Beebe, Michael; Quade, Jonathan; Watson, David; Simpson, Robert Bruce; Kistler, Brian; Shah, Anjan; Sanders, Roy; Mir, Hassan R

2017-04-01

To compare the incidence of complications (wound, infection, and nonunion) among those patients treated with closed, percutaneous, and open intramedullary nailing for closed tibial shaft fractures. Retrospective review. Multiple trauma centers. Skeletally mature patients with closed tibia fractures amenable to treatment with an intramedullary device. Intramedullary fixation with closed, percutaneous, or open reduction. Superficial wound complication, deep infection, nonunion. A total of 317 tibial shaft fractures in 315 patients were included in the study. Two-hundred fractures in 198 patients were treated with closed reduction, 61 fractures in 61 patients were treated with percutaneous reduction, and 56 fractures in 56 patients were treated with formal open reduction. The superficial wound complication rate was 1% (2/200) for the closed group, 1.6% (1/61) for the percutaneous group, and 3.6% (2/56) for the open group with no statistical difference between the groups (P = 0.179). The deep infection rate was 2% (4/200) for the closed group, 1.6% (1/61) for the percutaneous group, and 7.1% (4/56) for the open group with no significant difference between the groups (P = 0.133). Nonunion rate was 5.0% (10/200) for the closed group, 4.9% (3/61) for the percutaneous group, and 7.1% (4/56) for the open group, with no statistical difference between the groups (P = 0.492). This is the largest reported series of closed tibial shaft fractures nailed with percutaneous and open reduction. Percutaneous or open reduction did not result in increased wound complications, infection, or nonunion rates. Carefully performed percutaneous or open approaches can be safely used in obtaining reduction of difficult tibial shaft fractures treated with intramedullary devices. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Changes in biochemical markers after lower limb fractures.

PubMed

Stoffel, Karl; Engler, Hanna; Kuster, Markus; Riesen, Walter

2007-01-01

The bone remodeling sequence after bone fracture changes the concentrations of biochemical bone markers, but the relationships of fracture size and of healing time to changes in biomarkers are unclear. The present pilot study was undertaken to determine the changes found in serum bone markers after plate osteosynthesis of closed distal tibial and malleolar fractures during a study period of 24 weeks. We measured tatrate-resistant acid phosphatase (TRACP 5b), collagen type I C-terminal telopeptide (ICTP), bone-specific alkaline phosphatase (bone ALP), osteocalcin (OC), procollagen type I C-terminal propeptide (PICP), procollagen type III N-terminal propeptide (PIIINP), and human cartilage glycoprotein 39 (YKL-40) in 20 patients with lower limb fractures (10 malleolar, 10 tibia). A physical examination and radiographs were completed to assess evidence of union. All malleolar fractures healed within 6 weeks, whereas 2 tibial fractures did not show complete bone healing after 24 weeks. Changes were comparable but more pronounced in the tibia group, and marker concentrations remained increased at the end of study (bone ALP, 86 vs 74 U/L; OC, 14.9 vs 7.7 microg/L; ICTP: 5.6 vs 3.3 microg/L at day 84 after osteosynthesis, P <0.05 in tibia; 80 vs 70 U/L, 8 vs 5.2 microg/L, and 3.5 vs 3.2 microg/L, respectively, in the malleolar fracture group). In normal bone healing, changes in bone turnover markers were primarily dependent on the fracture size. Delayed tibia fracture healing may involve a disturbance in bone remodeling.

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.

Effect on dynamic mechanical stability and interfragmentary movement of angle-stable locking of intramedullary nails in unstable distal tibia fractures: a biomechanical study.

PubMed

Gueorguiev, Boyko; Wähnert, Dirk; Albrecht, Daniel; Ockert, Ben; Windolf, Markus; Schwieger, Karsten

2011-02-01

Unstable distal tibia fractures are challenging injuries that require surgery. Increasingly, intramedullary nails are being used. However, fracture site anatomy may cause distal-fragment stabilization and fixation problems and lead to malunion/nonunion. We studied the influence of angle-stable nail locking on fracture gap movement and other biomechanical parameters. Eight pairs of fresh human cadaver tibiae were used. The bone mineral density (BMD) was determined. All tibiae were nailed with a Synthes Expert tibial nail. Within each pair, one tibia was randomized to receive conventional locking screws; the other, angle-stable screws with sleeves. A 7-mm osteotomy was created 10 mm above the upper distal locking screw, to simulate an AO 42-A3 fracture. Biomechanical testing involved nondestructive mediolateral and anteroposterior pure bending, followed by cyclic combined axial and torsional loading to catastrophic failure. The neutral zone was determined. Fracture gap movement was monitored with 3-D motion tracking. The angle-stable locked constructs had a significantly smaller mediolateral neutral zone (mean: 0.04 degree; p=0.039) and significantly smaller fracture gap angulation (p=0.043). The number of cycles to failure did not differ significantly between the locking configurations. BMD was a significant covariate affecting the number of cycles to failure (p=0.008). However, over the first 20,000 cycles, there was no significant correlation in the angle-stable construct. Angle-stable locking of the Expert tibial nail was associated with a significant reduction in the mediolateral neutral zone and in fracture gap movement. Angle-stable fixation also reduced the influence of BMD over the first 20,000 cycles.

Management of neglected open extremity fractures in low-resource settings: Experience of the French Army Medical Service in Chad.

PubMed

Mathieu, L; Mottier, F; Bertani, A; Danis, J; Rongiéras, F; Chauvin, F

2014-11-01

The purpose of this study was to report the experience of the French Army Medical Service in the management of neglected open extremity fractures and related-complications in Chad. Delayed treatment of open extremity fractures is possible in a low-resource setting. An observational prospective study was performed in a French Forward Surgical Team deployed in N'Djamena for six months. Twenty-seven patients, 24 men and three women, mean age 30 years old with an open fracture that was managed more than 24 hours after it occurred were included. The mean treatment delay was 83 days. Fractures were located in the tibia in 20 cases. There were 15 non-infected and twelve infected fractures. The number of cases of debridement, flap coverage, and the overall number of procedures were higher in the group with infection, but the difference was not significant. Treatment of infected fractures was complicated by six early recurrent infections, while there were no complications in the group without infection. The mean follow-up was 4.4 months. Infection was controlled in eleven cases, however evaluation of fracture healing was limited because of the short follow-up in the group with infection. Functional outcome of the lower extremities was often complicated by knee stiffness. Delayed management of open fractures depends on the available resources. In low-resource settings, the goals of surgery should be modest. Treatment of non-infected injuries and osteomyelitis is possible. On the other hand, treatment of infected fractures and septic nonunions should be undertaken with caution if all the necessary aspects of treatment, in particular extended antibiotic treatment and sequential procedures are not possible. level IV. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Achieving interlocking nails without using an image intensifier

PubMed Central

Ogunlusi, Johnson D.; Ine, Henry R.

2006-01-01

Interlocking nails are commonly performed using an image intensifier. These are expensive and are not readily available in most resource-poor countries of the world. The aim of this study was to achieve interlocking nailing without the use of an image intensifier. This is a prospective descriptive analysis of 40 consecutive cases seen with shaft fractures of the humerus, femur, and tibia. Fracture fixation was done using Surgical Implant Generation Network (SIGN) nails. Forty limbs in 34 patients were studied. There were 12 females and 22 males, giving a ratio of 1:2. The mean age (years) was 35.75±13.16 and the range was 17–70 years. The studied bones were: humerus 10%, femur 65%, and tibia 25%. The fracture lines were: transverse 40%, oblique 15%, and communited 45%. Fracture grades were: closed 90%, grade I, 5%, grade II, 2.5%, and grade IIIA, 2.5%. Surgical approaches were: antegrade 62.5% and retrograde 37.5%. Indications for fixation were: recent fracture 92.5%, non-union 5%, and malunion 3%. Methods of reductions were: open 85% and closed 15%. The mean follow-up period (years) was 1.50±0.78. The union time averaged 3 months. Complication was mainly screw loosening due to severe osteoporoses in one case. It is, therefore, concluded that, with the aid of external jigs and slot finders, interlocking can be achieved without an image intensifier. PMID:17039384

[Disruption of the arteria nutricia tibiae by reamed and unreamed intramedullary nailing. Study of the vascular architecture of the human tibial intramedullary cavity].

PubMed

Paar, O; mon O'Dey, D; Magin, M N; Prescher, A

2000-01-01

By reason of the pseudarthrotic healing of fractures due to vascular complications after reamed and unreamed intramedullary nailing, the intraosseous course and branching of the tibial nutrient artery and its impairment by nailing procedures needs an actual analysis. The nutrient vessel of 24 tibiae taken from fresh corpses were prepared by injection of Technovit and lead oxide. After this procedure the medullary cavities of 12 bones were opened by a frontal cut. These specimens were subjected to routine maceration. The other 12 tibiae were naed with the unreamed (6) and the reamed nailing (6) techniques. X-rays were also taken routinely. After penetration of the tibial compact bone the main trunk of the nutrient vessel runs through a perforated osseous tunnel (pars tecta arteriae nutriciae tibiae). At its end the vessel divides into a descending branch (obligate) and two ascending branches (facultative). The descending branch lies near to the centromedial region of the medullary cavity which is termed as the pars liberal arteriae nutriciae tibiae. All branches pass through supporting horizontal osseous lamellas. Due to this topography the reamed nailing technique destroyed the nutrient vessel completely in all specimens. In contrast to this observation the unreamed nailing destroyed the vessel completely only in 1 (16.7%) and partially in 3 (50%) bones; 2 (33.3%) specimens exhibited no destruction of the vessel. The unreamed as well as the reamed nailing technique can destroy the intramedullary course of the tibial nutrient artery. Fractures as well as displacement osteotomies or corticotomies are able to diminish the medullary blood supply seriously, if they are localised within the area of the tactic an of the tibial nutrient artery.

Patient-Based Outcomes After Tibia Fracture in Children and Adolescents

PubMed Central

Sabatini, Coleen S; Curtis, Tracy A; Mahan, Susan T

2014-01-01

Introduction : Tibia fractures are common in pediatric patients and time necessary to return to normal function may be underappreciated. The purpose of this study was to assess functional recovery in pediatric patients who sustain tibia fractures, utilizing the Pediatrics Outcome Data Collection Instrument (PODCI), in order to provide evidence-based information on post-injury functional limitations and anticipated recovery times. Methods : 84patients (out of 264 eligible patients, response rate 32%) age 1.5-18 years treated for a tibia fracture at a large children's hospital between 1/07 and 4/08 completed a PODCI questionnaire at 6 and 12 months post-injury. PODCI questionnaires were compared to previously reportednormal controls using Student's t-test in six categories. Results : At 6 months after injury, the Sports functioning PODCI score was significantly less than healthy controls in both the parent reports for adolescent (mean 88.71 versus 95.4) and adolescent self-report (mean 90.44 versus 97.1); these showed no difference at 12 months. Discussion : For adolescents who sustain fractures of the tibia, there remains a negative impact on their sports functioning after 6 months that resolves by 12 months. Physicians can counsel their patients that although they may be limited in their sports function for some time after injury, it is anticipated that this will resolve by one year from the time of injury. Level of Evidence : Level II. PMID:24627732

Fixation orientation in ankle fractures with syndesmosis injury.

PubMed

Nimick, Craig J; Collman, David R; Lagaay, Pieter

2013-01-01

Accurate reduction of the syndesmosis has been shown to be an important prognostic factor for functional outcome in ankle injuries that disrupt the syndesmosis. The purpose of the present case series was to assess the fixation orientation and the position of the fibula within the tibial incisura after open reduction and internal fixation of ankle fractures with syndesmosis injury. Computed tomography was used to assess the accuracy of the reduction. Twelve patients were included in the present case series. A ratio representing the relationship between the tibia and fibula and the orientation of the syndesmotic fixation was measured preoperatively and postoperatively and compared with the uninjured contralateral ankle, representing the patient's normal anatomy. The measurements were accomplished electronically to one tenth of 1 mm using Stentor Intelligent Informatics, I-site, version 3.3.1 (Phillips Electronics; Andover, MA). Posteriorly oriented syndesmotic fixation caused posterior translation of the fibula with respect to the tibia and anteriorly oriented syndesmotic fixation caused anterior translation. Copyright © 2013. Published by Elsevier Inc.

Injury tolerance of tibia for the car-pedestrian impact.

PubMed

Mo, Fuhao; Arnoux, Pierre Jean; Jure, Jean Jaques; Masson, Catherine

2012-05-01

Lower limbs are normally the first contacted body region during car-pedestrian accidents, and easily suffer serious injuries. The previous tibia bending tolerances for pedestrian safety were mainly developed from three-point bending tests on tibia mid-shaft. The tibia tolerances of other locations are still not investigated enough. In addition, tibia loading condition under the car-pedestrian impact should be explored to compare with the three-point bending. This work aims to investigate the injury tolerance of tibia fracture with combined experimental data and numerical simulation. Eleven new reported quasi-static bending tests of tibia mid-shaft, and additional eleven dynamic mid-shaft bending test results in the previous literature were used to define injury risk functions. Furthermore, to investigate the influence of tibia locations on bending tolerance, finite element simulations with lower limb model were implemented according to three-point bending and pedestrian impact conditions. The regressive curve of tibia bending tolerance was obtained from the simulations on the different impact locations, and indicated that tibia fracture tolerance could vary largely due to the impact locations for the car-pedestrian crash. Copyright © 2011 Elsevier Ltd. All rights reserved.

Treatment of open tibial shaft fracture with soft tissue and bone defect caused by aircraft bomb--case report.

PubMed

Golubović, Zoran; Vidić, Goran; Trenkić, Srbobran; Vukasinović, Zoran; Lesić, Aleksandar; Stojiljković, Predrag; Stevanović, Goran; Golubović, Ivan; Visnjić, Aleksandar; Najman, Stevo

2010-01-01

Aircraft bombs can cause severe orthopaedic injuries. Tibia shaft fractures caused by aircraft bombs are mostly comminuted and followed by bone defects, which makes the healing process extremely difficult and prone to numerous complications. The goal of this paper is to present the method of treatment and the end results of treatment of a serious open tibial fracture with soft and bone tissue defects resulting from aircraft bomb shrapnel wounds. A 26-year-old patient presented with a tibial fracture as the result of a cluster bomb shrapnel wound. He was treated applying the method of external bone fixation done two days after wounding, as well as of early coverage of the lower leg soft tissue defects done on the tenth day after the external fixation of the fracture. The external fixator was removed after five months, whereas the treatment was continued by means of functional plaster cast for another two months. The final functional result was good. Radical wound debridement, external bone fixation of the fracture, and early reconstruction of any soft tissue and bone defects are the main elements of the treatment of serious fractures.

Outcome of Distal Both Bone Leg Fractures Fixed by Intramedulary Nail for Fibula & MIPPO in Tibia.

PubMed

Gupta, Anil; Anjum, Rashid; Singh, Navdeep; Hackla, Shafiq

2015-04-01

Fractures of the distal third of the tibia are mostly associated with a fibular fracture that often requires fixation. The preferred treatment of distal tibial fracture is the minimally invasive percutaneous plate osteosynthesis (MIPPO) procedure. However, there are no clear cut guidelines on fixation of the fibular fracture and currently most orthopedic surgeons use a plate osteosynthesis for the fibula as well. A common complication associated with dual plating is an increased chance of soft tissue necrosis, infection, and in some cases resulting in an exposed implant. We conducted a prospective study to analyze the results of fractures of the distal in both leg bones managed by the MIPPO procedure for tibial fractures and a rush nail for fibular fractures. The study was conducted in a tertiary care hospital from November 2012 to May 2014, a total of 30 fractures in 30 patients (18 males, 12 females) with a mean age of 42.4 years (26-60 years) were treated in our institution in the aforesaid time period with MIPPO for tibia and rush nail for fibular fractures. All the cases were operated on by a single surgeon in emergency within 24 hours. The patients with skin blistering and compound fractures were excluded from this study. Rehabilitative measures were proceeded as per patient's pain profile, isometric and isotonic exercises were started on the first post-operative day, with full weight bearing at 10-12 weeks after assessing clinical and radiological union. Regular follow up of patients was done, radiographs were taken at the immediate post-operative period and at 3, 6, 12 and 24 weeks. All the patients were available for regular follow up. Radiological and clinical union proceeded normally in all the patients, no patients had signs of any deep infection, delayed union or nonunion, three patients had a superficial infection of the tibial incision that healed with a change in antibiotic. The use of dual plating for fixation of the lower tibia and fibula fractures is often associated with soft tissue complications, exposed implant, and increased risk of infection. We conclude that in fractures of the distal tibia and fibula it is better to use a rush nail for the fibula with a concurrent MIPPO for the tibia for the reasons cited above. Moreover, with the use of rush nail the cost of implant is also reduced, which is a very important factor in developing countries.

MINERAL METABOLISM OF FRACTURES OF THE TIBIA IN MAN STUDIED WITH EXTERNAL COUNTING OF Sr$sup 8$$sup 5$

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

Wendberg, B.

1961-01-01

A study was made of 51 adult patients with tibial fractures by external counting with scintillation detectors over the thighs, knees, and tibias during a 14-day period after intravenous injection of 25 to 50 mu c Sr/sup 85/. The pattern of activity curves recorded over the fractured leg compared to those recorded over the control leg varied significantly with the age of the fracture (2 days to 9 yr). Increased uptake of Sr/sup 85/ was observed in all cases. The activity ratio fracture/control tibia obtained 14 days after injection rose during the 1st months after fracture to reach a peakmore » value 6 to 8 months after fracture. The mean 14-day fracture/ control ratios obtained 5 to 10 months after fracture was 15.5 plus or minus 7.2; then it dropped. Even 6 to 9 yr after fracture the counting rate over the fracture was higher than that over the intact tibia. No differences in activity uptake were observed between normally healing fractures and fractures showing delayed or nonunion. Activity curves obtained over the thigh, knee, and tibia of the fractured and intact legs 1 to l4 days after injection of Sr/sup 85/ could be simulated on the basis of a 2-compartment model for the kinetics of Sr in the body. Based on this kinetic analysis the externally recorded Sr/sup 85/ activity values may be interpreted as follows: The activity ratios fractured/intact leg obtained during early intervals after injection are mainly related to differences in the size of the exchangeable mineral spaces under the detector. The 14-day activity ratio of 2 anatomically comparable locations may be used as a relative index of the difference in the accretion rate (rate of irreversible deposition of bone mineral) in these locations, but is somewhat lower than the absolute dfference in the accretion rate. The bone salt laid down in the fracture callus is derived from the body fluids. The accretion rate in the fracture region is increased within a week of the fracture. It rapidly increases during the first months after fracture to reach a peak value at 6 to 8 months after fracture. The accretion rate in the entire fractured leg is increased some months after fracture. The traumatic osteopenia is caused by increased resorption and not by decreased accretion. (H.H.D.)« less

Secondary Radial Nerve Palsy after Minimally Invasive Plate Osteosynthesis of a Distal Humeral Shaft Fracture

PubMed Central

Bichsel, Ursina; Nyffeler, Richard Walter

2015-01-01

Minimally invasive plate osteosynthesis is a widely used procedure for the treatment of fractures of the femur and the tibia. For a short time it is also used for the treatment of humeral shaft fractures. Among other advantages, the ambassadors of this technique emphasize the lower risk of nerve injuries when compared to open reduction and internal fixation. We report the case of secondary radial nerve palsy caused by percutaneous fixation of a plate above the antecubital fold. The nerve did not recover and the patient needed a tendon transfer to regain active extension of the fingers. This case points to the importance of adequate exposure of the bone and plate if a humeral shaft fracture extends far distally. PMID:26558125

Distal tibia fractures: locked or non-locked plating? A systematic review of outcomes.

PubMed

Khalsa, Amrit S; Toossi, Nader; Tabb, Loni P; Amin, Nirav H; Donohue, Kenneth W; Cerynik, Douglas L

2014-06-01

Although plating is considered to be the treatment of choice in distal tibia fractures, controversies abound regarding the type of plating for optimal fixation. We conducted a systematic review to evaluate and compare the outcomes of locked plating and non-locked plating in treatment of distal tibia fractures. A systematic review was conducted using PubMed to identify articles on the outcomes of plating in distal tibia fractures that were published up to June 2012. We included English language articles involving a minimum of 10 adult cases with acute fractures treated using single-plate, minimally invasive techniques. Study-level binomial regression on the pooled data was conducted to determine the effect of locking status on different outcomes, adjusted for age, sex, and other independent variables. 27 studies met the inclusion criteria and were included in the final analysis of 764 cases (499 locking, 265 non-locking). Based on descriptive analysis only, delayed union was reported in 6% of cases with locked plating and in 4% of cases with non-locked plating. Non-union was reported in 2% of cases with locked plating and 3% of cases with non-locked plating. Comparing locked and non-locked plating, the odds ratio (OR) for reoperation was 0.13 (95% CI: 0.03-0.57) and for malalignment it was 0.10 (95% CI: 0.02-0.42). Both values were statistically significant. This study showed that locked plating reduces the odds of reoperation and malalignment after treatment for acute distal tibia fracture. Future studies should accurately assess causality and the clinical and economic impact of these findings.

Effect of strontium ranelate on fracture healing in rat tibia.

PubMed

Cebesoy, Oguz; Tutar, Ediz; Kose, Kamil Cagri; Baltaci, Yasemin; Bagci, Cahit

2007-12-01

Various anti-osteoporotic agents are available for clinical use. In contrast to other anti-osteoporotic drugs, strontium ranelate has anti-resorptive and bone-forming effects (dual action). Our objective in the present study is to investigate the efficacy of strontium ranelate (SR) on fracture healing in rat tibia. Forty-two male Wistar rats randomized into two groups (groups 1 and 2, n=21 for each). Left tibiae of all animals were broken in a closed manner using a manual three-point bending technique through mid-tibia following deep anesthesia with ketamine. The animals in group 1 were fed 25g/day specially produced food containing 450mg/kg SR starting from the first post-operative day. Group 2 were given 25g/day normal food. The animals were sacrificed on the 2nd, 3rd and 4th post-operative weeks (each week 7 animals were sacrificed from each group) and the broken tibiae were removed. The tibiae were examined first radiographically and second, histopathologically. Radiologically, callus maturity and bone union increased with time in both groups. But no significant differences were found regarding callus maturity and bone union in weekly comparisons (p=0.52, p=0.19, p=0.74). Histopathologically, it was seen that the fractures remarkably healed steadily in both groups on the 2nd, 3rd and 4th post-operative weeks. But no significant differences were found regarding the progression of fracture callus in weekly comparison (p=1.0, p=0.52, p=1.0). In the present study, we were unable to find any beneficial or harmful effects of strontium ranelate on fracture healing.

Insufficiency fractures of the distal tibia misdiagnosed as cellulitis in three patients with rheumatoid arthritis

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

Straaton, K.V.; Lopez-Mendez, A.; Alarcon, G.S.

We describe 3 patients with rheumatoid arthritis who presented with diffuse pain, swelling, and erythema of the distal aspect of the lower extremity, suggestive of either cellulitis or thrombophlebitis, but were found to have insufficiency fractures of the distal tibia. The value of technetium-99m diphosphonate bone scintigraphy in the early recognition of these fractures and a possible explanation for the associated inflammatory symptoms are discussed.

Evaluation of functional outcome of the floating knee injury using multivariate analysis.

PubMed

Yokoyama, Kazuhiko; Tsukamoto, Tatsuro; Aoki, Shinichi; Wakita, Ryuji; Uchino, Masataka; Noumi, Takashi; Fukushima, Nobuaki; Itoman, Moritoshi

2002-11-01

The objective of this study is to evaluate significant contributing factors affecting the functional prognosis of floating knee injuries using multivariate analysis. A total of 68 floating knee injuries (67 patients) were treated at Kitasato University Hospital from 1986 to 1999. Both the femoral fractures and the tibial fractures were managed surgically by various methods. The functional results of these injuries were evaluated using the grading system of Karlström and Olerud. Follow-up periods ranged from 2 to 19 years (mean 50.2 months) after the original injury. We defined satisfactory (S) outcomes as those cases with excellent or good results and unsatisfactory (US) outcomes as those cases with acceptable or poor results. Logistic regression analysis was used as a multivariate analysis, and the dependent variables were defined as a satisfactory outcome or as an unsatisfactory outcome. The explanatory variables were predicting factors influencing the functional outcome such as age at trauma, gender, severity of soft-tissue injury in the femur and the tibia, AO fracture grade in the femur and the tibia, Fraser type (type I or type II), Injury Severity Score (ISS), and fixation time after injury (less than 1 week or more than 1 week) in the femur and the tibia. The final functional results were as follows: 25 cases had excellent results, 15 cases good results, 16 cases acceptable results, and 12 cases poor results. The predictive logistic regression equation was as follows: Log 1-p/p = 3.12-1.52 x Fraser type - 1.65 x severity of soft-tissue injury in the tibia - 1.31 x fixation time after injury in the tibia - 0.821 x AO fracture grade in the tibia + 1.025 x fixation time after injury in the femur - 0.687 x AO fracture grade in the femur ( p=0.01). Among the variables, Fraser type and the severity of soft-tissue injury in the tibia were significantly related to the final result. The multivariate analysis showed that both the involvement of the knee joint and the severity grade of soft-tissue injury in the tibia represented significant risk factors of poor outcome in floating knee injuries in this study.

External fixation using locking plate in distal tibial fracture: a finite element analysis.

PubMed

Zhang, Jingwei; Ebraheim, Nabil; Li, Ming; He, Xianfeng; Schwind, Joshua; Liu, Jiayong; Zhu, Limei

2015-08-01

External fixation of tibial fractures using a locking plate has been reported with favorable results in some selected patients. However, the stability of external plate fixation in this fracture pattern has not been previously demonstrated. We investigated the stability of external plate fixation with different plate-bone distances. In this study, the computational processing model of external fixation of a distal tibial metaphyseal fracture utilizing the contralateral femoral less invasive stabilization system plate was analyzed. The plate was placed on the anteromedial aspect of tibia with different plate-bone distances: 1, 10, 20, and 30 mm. Under axial load, the stiffness of construct in all groups was higher than intact tibia. Under axial load with an internal rotational force, the stiffness of construct with 1 and 10 mm plate-bone distances was similar to that of an intact tibia and the stiffness of the construct with 20 and 30 mm distances was lower than that of an intact tibia. Under axial load with an external rotational force, the stiffness of the construct in all groups was lower than that of an intact tibia. The maximum plate stresses were concentrated at the two most distal screws and were highest in the construct with the 10 mm plate-bone distance, and least in the construct with a 1 mm plate-bone distance. To guarantee a stable external plate fixation in distal tibial fracture, the plate-bone distance should be less than 30 mm.

The healing stages of an intramedullary implanted tibia: A stress strain comparative analysis of the calcification process

PubMed Central

Filardi, Vincenzo

2015-01-01

Aims The extended usage of unreamed tibial nailing resulted in reports of an increased rate of complications, especially for the distal portion of the tibia. Unreamed nailing favours biology at the expense of the achievable mechanical stability, it is therefore of interest to define the limits of the clinical indications for this method. Extra-articular fractures of the distal tibial metaphysis, meta-diaphyseal junction, and adjacent diaphysis are distinct in their management from impaction derived ‘‘pilon’’ type fractures and mid-diaphyseal fractures. The goals of this work were to gain a thorough understanding of the load-sharing mechanism between unreamed nail and bones in a fractured tibia. With this purpose a complete model of the human leg was realised, simulating a mid-diaphyseal fracture, classified as A2 type 1, according to the AO classification. The analysis of the entire chain allows to have a complete picture of the stress distribution and of the most stressed bones and soft tissues, but, more importantly can overcome problems connected with boundary conditions imposed at single bony components. Methods Model consists of six bony structures: pelvis, femur, patella, fibula, tibia, and a simplified lump of the feet, configured in a standing up position. Their articular cartilage layers, were simulated by 3D membranes of opportune stiffness connecting the different segments. Moreover an unreamed intra-medullary nail Expert Tibial Nail (DePuy Synthes®) stabilized the fractured tibia. A load of 700 N has been applied at the top of pelvis and a part the feet, at the tip, was rigidly fixed. Five different contact interfaces have been imposed at the different bony surfaces in contact. Results Three different conditions were analysed: the initially healthy tibia, the A2 type 1 fractured tibia with the Expert tibial nail implanted, and the follow up stage after complete healing of tibia. Non-linear finite element analysis of the models were performed with Abaqus version 5.4 (Hibbitt, Karlsson and Sorensen, Inc., Pawtucket, RI) using the geometric non linearity and automatic time stepping options. Conclusion The obtained results reveal interesting consequences deriving by taking into account how the stress shielding can influence the integrity and resistance of bones, in order to identify the mechanical reasons for the unfavourable clinical results, and to identify borderline indications due to biomechanical factors. The evolution of treatment options for these fractures has been closely linked to developments in implant technology and surgical technique. Further developments in this area, particularly with respect to minimally invasive plating techniques and nail design are ongoing. PMID:26719629

Comparison of 3 Minimally Invasive Methods for Distal Tibia Fractures.

PubMed

Fang, Jun-Hao; Wu, Yao-Sen; Guo, Xiao-Shan; Sun, Liao-Jun

2016-07-01

This study compared the results of external fixation combined with limited open reduction and internal fixation (EF + LORIF), minimally invasive percutaneous plate osteosynthesis (MIPPO), and intramedullary nailing (IMN) for distal tibia fractures. A total of 84 patients with distal tibia shaft fractures were randomized to operative stabilization using EF + LORIF (28 cases), MIPPO (28 cases), or IMN (28 cases). The 3 groups were comparable with respect to patient demographics. Data were collected on operative time and radiation time, union time, complications, time of recovery to work, secondary operations, and measured joint function using the American Orthopaedic Foot and Ankle Society (AOFAS) score. There was no significant difference in time to union, incidence of union status, time of recovery to work, and AOFAS scores among the 3 groups (P>.05). Mean operative time and radiation time in the MIPPO group were longer than those in the IMN or EF + LORIF groups (P<.05). Wound complications after MIPPO were more common compared with IMN or EF + LORIF (P<.05). Anterior knee pain occurred frequently after IMN (32.1%), and irritation symptoms were encountered more frequently after MIPPO (46.4%). Although EF + LORIF was associated with fewer secondary procedures vs MIPPO or IMN, it was related with more pin-tract infections (14.3%). Findings indicated that EF + LORIF, MIPPO, and IMN all achieved similar good functional results. However, EF + LORIF had some advantages over MIPPO and IMN in reducing operative and radiation times, postoperative complications, and reoperation rate. [Orthopedics. 2016; 39(4):e627-e633.]. Copyright 2016, SLACK Incorporated.

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.

Uncontacted tire explosion causing trauma to bilateral lower extremities: A case report.

PubMed

Yu, Ming-Yang; Su, Yun; Meng, Xiang-Jun; Luan, Bo-Wu; Gu, Gui-Shan; Sun, Qiang; Zhao, De-Wei

2017-06-01

It is uncommon for tire explosion related injuries on the lower extremity. The bilateral lower extremities were injured by tire explosion when the patient was seated in a bus. She sustained an open fracture with partial bone loss in the right calcaneus (a comminuted fracture in the right ankle joint) and a closed comminuted fracture in the left tibia and fibula. This damage was caused by uncontacted tire explosion, thanks to a thick floor between the exploded tire and the patient's feet. This type of injury on lower extremity caused by uncontacted tire explosion was uncommon. Copyright © 2017 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. All rights reserved.

Distal tibia fractures: locked or non-locked plating?

PubMed Central

Khalsa, Amrit S; Toossi, Nader; Tabb, Loni P; Amin, Nirav H; Donohue, Kenneth W; Cerynik, Douglas L

2014-01-01

Background and purpose Although plating is considered to be the treatment of choice in distal tibia fractures, controversies abound regarding the type of plating for optimal fixation. We conducted a systematic review to evaluate and compare the outcomes of locked plating and non-locked plating in treatment of distal tibia fractures. Patients and methods A systematic review was conducted using PubMed to identify articles on the outcomes of plating in distal tibia fractures that were published up to June 2012. We included English language articles involving a minimum of 10 adult cases with acute fractures treated using single-plate, minimally invasive techniques. Study-level binomial regression on the pooled data was conducted to determine the effect of locking status on different outcomes, adjusted for age, sex, and other independent variables. Results 27 studies met the inclusion criteria and were included in the final analysis of 764 cases (499 locking, 265 non-locking). Based on descriptive analysis only, delayed union was reported in 6% of cases with locked plating and in 4% of cases with non-locked plating. Non-union was reported in 2% of cases with locked plating and 3% of cases with non-locked plating. Comparing locked and non-locked plating, the odds ratio (OR) for reoperation was 0.13 (95% CI: 0.03–0.57) and for malalignment it was 0.10 (95% CI: 0.02–0.42). Both values were statistically significant. Interpretation This study showed that locked plating reduces the odds of reoperation and malalignment after treatment for acute distal tibia fracture. Future studies should accurately assess causality and the clinical and economic impact of these findings. PMID:24758325

Geometry reconstruction method for patient-specific finite element models for the assessment of tibia fracture risk in osteogenesis imperfecta.

PubMed

Caouette, Christiane; Ikin, Nicole; Villemure, Isabelle; Arnoux, Pierre-Jean; Rauch, Frank; Aubin, Carl-Éric

2017-04-01

Lower limb deformation in children with osteogenesis imperfecta (OI) impairs ambulation and may lead to fracture. Corrective surgery is based on empirical assessment criteria. The objective was to develop a reconstruction method of the tibia for OI patients that could be used as input of a comprehensive finite element model to assess fracture risks. Data were obtained from three children with OI and tibia deformities. Four pQCT scans were registered to biplanar radiographs, and a template mesh was deformed to fit the bone outline. Cortical bone thickness was computed. Sensitivity of the model to missing slices of pQCT was assessed by calculating maximal von Mises stress for a vertical hopping load case. Sensitivity of the model to ±5 % of cortical thickness measurements was assessed by calculating loads at fracture. Difference between the mesh contour and bone outline on the radiographs was below 1 mm. Removal of one pQCT slice increased maximal von Mises stress by up to 10 %. Simulated ±5 % variation of cortical bone thickness leads to variations of up to 4.1 % on predicted fracture loads. Using clinically available tibia imaging from children with OI, the developed reconstruction method allowed the building of patient-specific finite element models.

Negative pressure wound therapy for Gustilo Anderson grade IIIb open tibial fractures.

PubMed

Park, Chul Hyun; Shon, Oog Jin; Kim, Gi Beom

2016-09-01

Traditionally, Gustilo Anderson grade IIIb open tibial fractures have been treated by initial wide wound debridement, stabilization of fracture with external fixation, and delayed wound closure. The purpose of this study is to evaluate the clinical and radiological results of staged treatment using negative pressure wound therapy (NPWT) for Gustilo Anderson grade IIIb open tibial fractures. 15 patients with Gustilo Anderson grade IIIb open tibial fractures, treated using staged protocol by a single surgeon between January 2007 and December 2011 were reviewed in this retrospective study. The clinical results were assessed using a Puno scoring system for severe open fractures of the tibia at the last followup. The range of motion (ROM) of the knee and ankle joints and postoperative complication were evaluated at the last followup. The radiographic results were assessed using time to bone union, coronal and sagittal angulations and a shortening at the last followup. The mean score of Puno scoring system was 87.4 (range 67-94). The mean ROM of the knee and ankle joints was 121.3° (range 90°-130°) and 37.7° (range 15°-50°), respectively. Bone union developed in all patients and the mean time to union was 25.3 weeks (range 16-42 weeks). The mean coronal angulation was 2.1° (range 0-4°) and sagittal was 2.7° (range 1-4°). The mean shortening was 4.1 mm (range 0-8 mm). Three patients had partial flap necrosis and 1 patient had total flap necrosis. There was no superficial and deep wound infection. Staged treatment using NPWT decreased the risks of infection and requirement of flap surgeries in Gustilo Anderson grade IIIb open tibial fractures. Therefore, staged treatment using NPWT could be a useful treatment option for Gustilo Anderson grade IIIb open tibial fractures.

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.

Effects of salmon calcitonin on fracture healing in ovariectomized rats.

PubMed

Li, Xiaolin; Luo, Xinle; Yu, Nansheng; Zeng, Bingfang

2007-01-01

To explore the effects of salmon calcitonin on the healing process of osteoporotic fractures in ovariectomized rats. We performed this study in The First Affiliated Hospital of Guangzhou Medical College, Guangzhou, China, during the period March 2002 to December 2004. We used 120 female adult Wistar rats in this experiment, among which 90 underwent ovariectomy (OVX) and the other 30 had sham-operation. All rats had their left tibias fractured 3 months later. The 90 OVX rats were randomly divided into 3 groups with 30 in each, while the 30 sham-operated rats served as control group. After the fracture the rats had subcutaneous injection of normal saline, salmon calcitonin and estrogen, respectively. X-ray film, histological examination, bone mineral density (BMD) measurement and biomechanics testing were carried out to evaluate the fracture healing. Compared with OVX rats treated with normal saline, the rats with salmon calcitonin had significantly higher BMD values in the left tibia, higher max torque, shear stress of the left tibia 8 weeks after fracture (p<0.05), and presented with stronger callus formation, shorter fracture healing time and faster normalization of microstructure of bone trabeculae. Salmon calcitonin can, not only increase BMD in osteoporotic bone, but also enhance the bone biomechanical properties and improve the process of fracture healing in fractured osteoporotic bone.

Military Medical Revolution: Military Trauma System

DTIC Science & Technology

2012-01-01

receive state-of-the-art physical therapy and occupational therapy , in- cluding demanding and challenging sports equipment and virtual reality systems...Knudson MM. Into the theater: perspectives from a civilian trauma sur- geon’s visit to the combat support hospital in Balad, Iraq. Bull Am Coll Surg...following type III open tibia fracture . J Orthop Trauma. 2012;26:43 47. 52. U.S Army Medical Research and Materiel Command. Armed Forces In- stitute of

Comparison of stress fractures of male and female recruits during basic training in the Israeli anti-aircraft forces.

PubMed

Gam, Arnon; Goldstein, Liav; Karmon, Yuval; Mintser, Igor; Grotto, Itamar; Guri, Alex; Goldberg, Avishay; Ohana, Nissim; Onn, Erez; Levi, Yehezkel; Bar-Dayan, Yaron

2005-08-01

In military basic training, stress fractures are a common orthopedic problem. Female recruits have a significantly higher incidence of stress fractures than do male recruits. Because the Israeli Defense Forces opened traditionally male roles in combat units to female recruits, their high risk for stress fractures is of concern. To compare the prevalence of stress fractures during Israeli Defense Forces anti-aircraft basic training among otherwise healthy young male and female recruits, in terms of anatomic distribution and severity. Ten mixed gender batteries, including 375 male recruits and 138 female recruits, carried out basic training in the Israeli anti-aircraft corps between November 1999 and January 2003. Each battery was monitored prospectively for 10 weeks of a basic training course. During that time, recruits who were suspected of having an overuse injury went through a protocol that included an orthopedic specialist physical examination followed by a radionuclide technetium bone scan, which was assessed by consultant nuclear medicine experts. The assessment included the anatomic site and the severity of the fractures, labeled as either high severity or low severity. Stress fractures were significantly more common among female recruits than among male recruits. A total of 42 male (11.2%) and 33 female (23.91%) recruits had positive bone scans for stress fractures (female:male relative ratio, 2.13; p < 0.001). Pelvic, femur, and tibia fractures were significantly more common among female recruits than among male recruits (p < 0.005). Female recruits had significantly more severe fractures in the tibia (p < 0.05). However, there was no significant difference in the severity of stress fractures in the femur or metatarsals between male and female recruits, as assessed by radionuclide uptake. We recommend that different training programs be assigned according to gender, in which female recruits would have a lower level of target strain or a more moderate incline of strain in the training program throughout basic training.

Evaluation of the Mangled Extremity Severity Score in Combat-Related Type III Tibia Fracture

DTIC Science & Technology

2014-09-01

Return to duty rates of amputee soldiers in the current conflicts in Afghanistan and Iraq. J Trauma. 2010; 68:1476–1479. 5. Johansen K, Daines M, Howey T...severity score (MESS) in combat related type III tibia fracture. J Orthop Trauma. 2013. 4. Johansen K, Daines M, Howey T, et al. Objective criteria

Prediction of risk of fracture in the tibia due to altered bone mineral density distribution resulting from disuse: a finite element study.

PubMed

Gislason, Magnus K; Coupaud, Sylvie; Sasagawa, Keisuke; Tanabe, Yuji; Purcell, Mariel; Allan, David B; Tanner, K Elizabeth

2014-02-01

The disuse-related bone loss that results from immobilisation following injury shares characteristics with osteoporosis in post-menopausal women and the aged, with decreases in bone mineral density leading to weakening of the bone and increased risk of fracture. The aim of this study was to use the finite element method to: (i) calculate the mechanical response of the tibia under mechanical load and (ii) estimate of the risk of fracture; comparing between two groups, an able-bodied group and spinal cord injury patients group suffering from varying degrees of bone loss. The tibiae of eight male subjects with chronic spinal cord injury and those of four able-bodied age-matched controls were scanned using multi-slice peripheral quantitative computed tomography. Images were used to develop full three-dimensional models of the tibiae in Mimics (Materialise) and exported into Abaqus (Simulia) for calculation of stress distribution and fracture risk in response to specified loading conditions - compression, bending and torsion. The percentage of elements that exceeded a calculated value of the ultimate stress provided an estimate of the risk of fracture for each subject, which differed between spinal cord injury subjects and their controls. The differences in bone mineral density distribution along the tibia in different subjects resulted in different regions of the bone being at high risk of fracture under set loading conditions, illustrating the benefit of creating individual material distribution models. A predictive tool can be developed based on these models, to enable clinicians to estimate the amount of loading that can be safely allowed onto the skeletal frame of individual patients who suffer from extensive musculoskeletal degeneration (including spinal cord injury, multiple sclerosis and the ageing population). The ultimate aim is to reduce fracture occurrence in these vulnerable groups.

[Structural changes in the tibial bones from an excessive load].

PubMed

Moshiashvili, B I

1977-10-01

80 cases of pathological reconstruction of the tibia in young men at the age of 18--20 are described. The pathology developed as a result of intense regular physical exercise. In 53 patients the process was localized in the upper third of the tibia, in 20--in the middle third and in 7--in the lower third of the bone. In 6 cases the fracture of the tibial proximal metaphysis happened against the background of pathological reconstruction of the tibia; 3 of them sustained simultaneously a fracture of the fibular head. Some recommendations of practical importance are suggested.

Intramedullary nailing in opening wedge high tibial osteotomy-in vitro test for validation of a method of fixation.

PubMed

Burchard, Rene; Katerla, Denise; Hammer, Marina; Pahlkötter, Anke; Soost, Christian; Dietrich, Gerhard; Ohrndorf, Arne; Richter, Wolfgang; Lengsfeld, Markus; Christ, Hans-Jürgen; Graw, Jan Adriaan; Fritzen, Claus-Peter

2018-02-01

Opening wedge high tibial osteotomy (HTO) as a treatment in unicompartimental osteoarthritis of the knee can significantly relieve pain and prevent or at least delay an early joint replacement. The fixation of the osteotomy has undergone development and refinements during the last years. The angle-stable plate fixator is currently one of the most commonly used plates in HTOs. The angular stable fixation between screws and the plate offers a high primary stability to retain the correction with early weight-bearing protocols. This surgical technique is performed as a standard of care and generally well tolerated by the patients. Nevertheless, some studies observed that many patients complained about discomfort related to the implant. Therefore, the stability of two different intramedullary nails, a short implant used in humeral fractures and a long device used in tibial fractures for stabilization in valgus HTOs, was investigated as an alternative fixation technique. The plate fixator was defined as reference standard. Nine synthetic tibia models were standardly osteotomized and stabilized by one of the fixation devices. Axial compression was realized using a special testing machine and two protocols were performed: a multi-step fatigue test and a load-to-failure test. Overall motion, medial, and lateral displacements were documented. Fractures always occurred at the lateral cortex. Axial cyclic loading up to 800 N was tolerated by all implants without failure. The tibia nail provided highest fatigue strength under the load-to-failure conditions. The results suggest that intramedullary nailing might be used as an alternative concept in HTO.

[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.

Minimally invasive locked plating of distal tibia fractures is safe and effective.

PubMed

Ronga, Mario; Longo, Umile Giuseppe; Maffulli, Nicola

2010-04-01

Distal tibial fractures are difficult to manage. Limited soft tissue and poor vascularity impose limitations for traditional plating techniques that require large exposures. The nature of the limitations for traditional plating techniques is intrinsic to the large exposure required to approach distal tibia, a bone characterized by limited soft tissue coverage and poor vascularity. The locking plate (LP) is a new device for treatment of fractures. We assessed the bone union rate, deformity, leg-length discrepancy, ankle range of motion, return to preinjury activities, infection, and complication rate in 21 selected patients who underwent minimally invasive osteosynthesis of closed distal tibia fractures with an LP. According to the AO classification, there were 12 Type A, 5 Type B, and 4 Type C fractures. The minimum followup was 2 years (average, 2.8 years; range, 2-4 years). Two patients were lost to followup. Union was achieved in all but one patient by the 24th postoperative week. Four patients had angular deformity less than 7 degrees . No patient had a leg-length discrepancy more than 1.1 cm. Five patients had ankle range of motion less than 20 degrees compared with the contralateral side. Sixteen patients had not returned to their preinjury sporting or leisure activities. Three patients developed a delayed infection. We judge the LP a reasonable device for treating distal tibia fractures. The level of physical activities appears permanently reduced in most patients. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Red Tides: Mass casualty and whole blood at sea Red Tides.

PubMed

Miller, Benjamin T; Lin, Andrew H; Clark, Susan C; Cap, Andrew P; Dubose, Joseph J

2018-02-13

The U.S. Navy's casualty-receiving ships provide remote damage control resuscitation (RDCR) platforms to treat injured combatants deployed afloat and ashore. We report a significant mass casualty incident aboard the USS Bataan, and the most warm fresh whole blood (WFWB) transfused at sea for traumatic hemorrhagic shock since the Vietnam War. Casualty-receiving ships have robust medical capabilities, including a frozen blood bank with packed red blood cells (pRBC) and fresh frozen plasma (FFP). The blood supply can be augmented with WFWB collected from a "walking blood bank" (WBB). Following a helicopter crash, six patients were transported by MV-22 Osprey to the USS Bataan. Patient 1 had a pelvic fracture, was managed with a pelvic binder, and received 4 units of pRBC, 2 units of FFP, and 6 units of WFWB. Patient 2, with a comminuted tibia and fibula fracture, underwent lower extremity four-compartment fasciotomy, and received 4 units of WFWB. Patient 3 underwent several procedures, including left anterior thoracotomy, aortic cross-clamping, exploratory laparotomy, small bowel resection, and tracheostomy. He received 8 units of pRBC, 8 units of FFP, and 28 units of WFWB. Patients 4 and 5 had suspected spine injuries and were managed non-operatively. Patient 6, with open tibia and fibula fractures, underwent lower extremity four-compartment fasciotomy with tibia external fixation and received 1 unit of WFWB. All patients survived aeromedical evacuation to a Role 4 medical facility and subsequent transfer to local hospitals. Maritime military mass casualty incidents are challenging, but the U.S. Navy's casualty-receiving ships are ready to perform RDCR at sea. Activation of the ship's WBB to transfuse WFWB is essential for hemostatic resuscitations afloat. V STUDY TYPE: Case series.

Lower-limb reconstruction with chimeric flaps: The quad flap.

PubMed

Azouz, Solomon M; Castel, Nikki A; Vijayasekaran, Aparna; Rebecca, Alanna M; Lettieri, Salvatore C

2018-05-07

Early soft-tissue coverage is critical for treating traumatic open lower-extremity wounds. As free-flap reconstruction evolves, injuries once thought to be nonreconstructable are being salvaged. Free-tissue transfer is imperative when there is extensive dead space or exposure of vital structures such as bone, tendon, nerves, or blood vessels. We describe 2 cases of lower-extremity crush injuries salvaged with the quad flap. This novel flap consists of parascapular, scapular, serratus, and latissimus dorsi free flaps in combination on one pedicle. This flap provides the large amount of soft-tissue coverage necessary to cover substantial defects from skin degloving, tibia and fibula fractures, and soft-tissue loss. In case 1, a 51-year-old woman was struck by an automobile and sustained bilateral tibia and fibula fractures, a crush degloving injury of the left leg, and a right forefoot traumatic amputation. She underwent reconstruction with a contralateral quad free flap. In case 2, a 53-year-old man sustained a right tibia plateau fracture with large soft-tissue defects from a motorcycle accident. He had a crush degloving injury of the entire anterolateral compartment over the distal and lower third of the right leg. The large soft-tissue defect was reconstructed with a contralateral quad flap. In both cases, the donor site was closed primarily and without early flap failures. There was one surgical complication, an abscess in case 2; the patient was taken back to the operating room for débridement of necrotic tissue. There have been no long-term complications in either case. Both patients achieved adequate soft-tissue coverage, avoided amputation, and had satisfactory aesthetic and functional outcomes. With appropriate surgical technique and patient selection, the quad-flap technique is promising for reconstructing the lower extremity. © 2018 Wiley Periodicals, Inc.

Fat Embolism Among Patients with Hip and Long Bone Fractures in Albania

PubMed Central

Hysa, Elida

2012-01-01

Objective: The aim of this study was to assess the incidence and the effectiveness of treatment of fat embolism in patients with hip and long bone fractures (femur and tibia) in Albania. Methods: 229 patients (68% men) with combined hip and long bone fractures (femur and tibia) hospitalized at the Orthopedics-Traumatology Services of the University Center “Mother Teresa” during 2004-2006 were included in the study. Patients were classified into three groups based on astrupogram data: PaO2<60mmHg, 65mmHg75mmHg. Chi square test was used to compare fracture differences between men and women and the effectiveness of combined use of metilprednisolon and anticoagulants vs. anticoagulants alone. Results: Poly traumas combined with femur fracture were more frequent in 2005. These combined poly traumas combined were more frequent among men than women (P<0.001). Remarkably, femur fractures were more frequent among men than women (9:1). Coli femur fractures peaked in the age-group 76-85 years. In general, poly traumas were less frequent in the older age groups, with a peak between 36-55 years, being more frequent among men, but the difference was not statistically significant. Fractures of coli femur and those of tibia were more frequent in 2006, while in 2004 femur fractures were more frequent. In almost all age groups fractures of coli femur were more frequent, followed by fractures of femur and tibia. In general, poly traumas were more frequent among men than women, ranging from 6:1 for fractures of femur to 2:1 for tibia fractures. The incidence of fat embolism ranged from 4.9% to 8.9% for the period 2004-2006. Among fat embolism patients, 100% of them had tachycardia, 88.2% had petechia, 84% tachipnea, 23.5% cyanosis and blood sputum, and 41.2% obnubilation. In general, during 2004-2006 the frequency of combined use of metilprednisolon and anticoagulants has increased. Conclusions: Clinical diagnosis remains the most important element for the detection of fat embolism syndrome. The incidence of fat embolism was 8-9 times higher than the rates reported in literature. This finding is linked with trauma gravity in Albania. Combined use of metilprednisolon with anticoagulants seems to be more effective than use of anticoagulants alone in preventing fat embolism (P<0.05) and patients using the combined therapy have experienced milder forms of disease. Therefore, the combined treatment should be preferred over the single treatment for the prevention of fat embolism. PMID:23678329

Fat embolism among patients with hip and long bone fractures in Albania.

PubMed

Hysa, Elida

2012-01-01

The aim of this study was to assess the incidence and the effectiveness of treatment of fat embolism in patients with hip and long bone fractures (femur and tibia) in Albania. 229 patients (68% men) with combined hip and long bone fractures (femur and tibia) hospitalized at the Orthopedics-Traumatology Services of the University Center "Mother Teresa" during 2004-2006 were included in the study. Patients were classified into three groups based on astrupogram data: PaO2<60mmHg, 65mmHg75mmHg. Chi square test was used to compare fracture differences between men and women and the effectiveness of combined use of metilprednisolon and anticoagulants vs. anticoagulants alone. Poly traumas combined with femur fracture were more frequent in 2005. These combined poly traumas combined were more frequent among men than women (P<0.001). Remarkably, femur fractures were more frequent among men than women (9:1). Coli femur fractures peaked in the age-group 76-85 years. In general, poly traumas were less frequent in the older age groups, with a peak between 36-55 years, being more frequent among men, but the difference was not statistically significant. Fractures of coli femur and those of tibia were more frequent in 2006, while in 2004 femur fractures were more frequent. In almost all age groups fractures of coli femur were more frequent, followed by fractures of femur and tibia. In general, poly traumas were more frequent among men than women, ranging from 6:1 for fractures of femur to 2:1 for tibia fractures. The incidence of fat embolism ranged from 4.9% to 8.9% for the period 2004-2006. Among fat embolism patients, 100% of them had tachycardia, 88.2% had petechia, 84% tachipnea, 23.5% cyanosis and blood sputum, and 41.2% obnubilation. In general, during 2004-2006 the frequency of combined use of metilprednisolon and anticoagulants has increased. Clinical diagnosis remains the most important element for the detection of fat embolism syndrome. The incidence of fat embolism was 8-9 times higher than the rates reported in literature. This finding is linked with trauma gravity in Albania. Combined use of metilprednisolon with anticoagulants seems to be more effective than use of anticoagulants alone in preventing fat embolism (P<0.05) and patients using the combined therapy have experienced milder forms of disease. Therefore, the combined treatment should be preferred over the single treatment for the prevention of fat embolism.

[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.

The effect of both a thoracic trauma and a soft-tissue trauma on fracture healing in a rat model

PubMed Central

2011-01-01

Background and purpose There is some clinical evidence that fracture healing is impaired in multiply injured patients. Nothing is known, however, about the effects of various types of injuries and their contribution to a possible disturbance of the fracture-healing process. We investigated the effect of a thoracic trauma and an additional soft-tissue trauma on fracture healing in a rat tibia model. Methods 3 groups of rats were operated: group A with a simple fracture of the tibia and fibula, group B with a fracture and an additional thoracic trauma, and group C with a fracture, thoracic trauma, and an additional soft-tissue trauma. The fracture and the soft-tissue injury were produced by a special guillotine-like device and the thoracic trauma by a blast wave generator. After one day, the serum level of IL-6 was quantified, and at the end of the study (28 days) the mechanical properties and the callus volume of the healed tibia were determined. Results Increasing the severity of the injury caused IL-6 levels to more than double 1 day after injury. It halved the load to failure in mechanical tests and led to reduced callus volume after 28 days of healing. Interpretation Fracture healing is impaired when additional thoracic trauma and soft tissue trauma occurs. PMID:21463222

Infection after fracture fixation of the tibia: Analysis of healthcare utilization and related costs.

PubMed

Metsemakers, Willem-Jan; Smeets, Bart; Nijs, Stefaan; Hoekstra, Harm

2017-06-01

One of the most challenging complications in musculoskeletal trauma surgery is the development of infection after fracture fixation (IAFF). It can delay healing, lead to permanent functional loss, or even amputation of the affected limb. The main goal of this study was to investigate the total healthcare costs and length-of-stay (LOS) related to the surgical treatment of tibia fractures and furthermore identify the subset of clinical variables driving these costs within the Belgian healthcare system. The hypothesis was that deep infection would be the most important driver for total healthcare costs. Overall, 358 patients treated operatively for AO/OTA type 41, 42, and 43 tibia fractures between January 1, 2009 and January 1, 2014 were included in this study. A total of 26 clinical and process variables were defined. Calculated costs were limited to hospital care covered by the Belgian healthcare financing system. The five main cost categories studied were: honoraria, materials, hospitalization, day care admission, and pharmaceuticals. Multivariate analysis showed that deep infection was the most significant characteristic driving total healthcare costs and LOS related to the surgical treatment of tibia fractures. Furthermore, this complication resulted in the highest overall increase in total healthcare costs and LOS. Treatment costs were approximately 6.5-times higher compared to uninfected patients. This study shows the enormous hospital-related healthcare costs associated with IAFF of the tibia. Treatment costs for patients with deep infection are higher than previously mentioned in the literature. Therefore, future research should focus more on prevention rather than treatment strategies, not only to reduce patient morbidity but also to reduce the socio-economic impact. Copyright © 2017 Elsevier Ltd. All rights reserved.

Stress Fractures of Tibia Treated with Ilizarov External Fixator.

PubMed

Górski, Radosław; Żarek, Sławomir; Modzelewski, Piotr; Górski, Ryszard; Małdyk, Paweł

2016-08-30

Stress fractures are the result of cyclic loading of the bone, which gradually becomes damaged. Most often they are treated by rest or plaster cast and, in rare cases, by internal fixation. There is little published data on initial reposition followed by stabilization with the Ilizarov apparatus in such fractures. Six patients were treated with an external fixator according to the Ilizarov method for a stress fracture of the tibia between 2007 and 2015. Three patients were initially treated conservatively. Due to increasing tibial deformation, they were qualified for surgical treatment with external stabilization. In the other patients, surgery was the first-line treatment. All patients demonstrated risk factors for a stress fracture. After the surgery, they fully loaded the operated limb. No patient developed malunion, nonunion, infection or venous thrombosis. The average time from the first operation to the removal of the external fixator was 19 weeks. Radiographic and clinical outcomes were satisfactory in all patients. 1. The Ilizarov method allows for successful stabilization of stress fractures of the tibia. 2. It may be a good alternative to internal stabilization, especially in patients with multiple comorbidities which affect bone quality and may impair soft tissue healing.

Bone mineral density, chemical composition and biomechanical properties of the tibia of female rats exposed to cadmium since weaning up to skeletal maturity.

PubMed

Brzóska, M M; Majewska, K; Moniuszko-Jakoniuk, J

2005-10-01

The influence of exposure to cadmium (Cd) during skeletal development on the risk of bone fractures at the stage of skeletal maturity was investigated on a female rat model of human exposure. The tibias of rats treated with 1, 5 or 50 mg Cd/l in drinking water for 3, 6, 9 and 12 months (since weaning) were used. The exposure to Cd dose- and time-dependently influenced the tibia bone mineral density (BMD) and chemical composition. In skeletally matured animals, at each level of the exposure to Cd, the BMD at the whole tibia and its diaphysis as well as the percentage of minerals content in the bone, including the content of zinc, copper and iron, were decreased compared to control. Moreover, in the 50 mg Cd/l group, the percentage of organic components content increased. The Cd-induced changes, at all levels of exposure, resulted in weakening in the yield strength and fracture strength of the tibia (a three-point bending test of the diaphysis and compression test with vertical loading) of the skeletally matured females. A very important and clinically useful finding of this study is that a decrease (even by several percent) in the tibia BMD results in weakness in the bone biomechanical properties and that the BMD may predict the risk of its fracture at the exposure to Cd. Moreover, the results together with our previous findings seem to suggest that tibia, due to higher vulnerability of its diaphysis, compared to the femoral diaphysis, to damage by Cd may be more useful than femur to investigate the effect of Cd on the cortical bone. The present study revealed that a low exposure to Cd (1 mg Cd/l), corresponding to low human environmental exposure, during the skeletal development affects the tibia mineral status leading to weakening in its mechanical properties at the skeletal maturity. The findings allow for the conclusion that environmental exposure to Cd during childhood and adolescence may enhance the risk of low BMD and fractures at adulthood.

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.

[CHANGES OF SEMAPHORIN 3A EXPRESSION IN HEALING OF TIBIA FRACTURE AFTER TRAUMATIC BRAIN INJURY].

PubMed

Li, Zhengzheng; Zhao, Junwei; Yi, Zhigang; Luo, Wei; Li, Kang; Wang, Yuliang; Wang, Jing; An, Liping; Ma, Jinglin

2016-10-08

To investigate the mechanism of Semaphorin 3A (Sema3A) in fracture healing after nerve injury by observing the expression of Sema3A in the tibia fracture healing after traumatic brain injury (TBI). A total of 192 Wistar female rats, 8-10 weeks old and weighing 220-250 g, were randomly divided into tibia fracture group (group A, n =48), TBI group (group B, n =48), TBI with tibia fracture group (group C, n =48), and control group (group D, n =48). The tibia fracture model was established at the right side of group A; TBI model was made in group B by the improved Feeney method; the TBI and tibia fracture model was made in group C; no treatment was given in group D. The tissue samples were respectively collected at 3, 5, 7, 14, 21, and 28 days after operation; HE staining, immunohistochemistry staining, and Western blot method were used for the location and quantitative detection of Sema3A in callus tissue. HE staining showed that no obvious changes were observed at each time point in groups B and D. At 3 and 5 days, there was no obvious callus growth at fracture site with inflammatory cells and fibrous tissue filling in groups A and C. At 7 and 14 days, fibrous tissue grew from periosteum to fracture site in groups A and C; the proliferation of chondrocytes in exterior periosteum gradually formed osteoid callus at fracture site in groups A and C. The chondrocyte had bigger size, looser arrangement, and more osteoid in group C than group A. Group B had disorder periosteum, slight subperiosteal bone hyperplasia, and no obvious change of bone trabecula in group B when compared with group D. At 21 and 28 days, cartilage callus was gradually replaced by new bone trabecula in groups A and C. Group C had loose arrange, disorder structure, and low density of bone trabecula, big callus area and few chondrocyte and osteoid when compared with group A; group B was similar to Group D. Immunohistochemistry staining showed that Sema3A expression in chondrocytes in group C was higher than that in group A, particularly at 7, 14, and 21 day. Sema3A was significantly higher in osteoblasts of new bone trabecula in group A than group C, especially at 14 and 21 days ( P <0.05). Western blot results showed that the Sema3A had the same expression trend during fracture healing in groups A and C. However, the expression of Sema3A protein was significantly higher in group C than group A ( P <0.05) and in group B than group D ( P <0.05) at 7, 14, 21, and 28 days. Abnormal expression of Sema3A may play a role in fracture healing after nerve injury by promoting the chondrocytes proliferation and reducing the distribution of sensory nerve fibers and osteoblast differentiation.

A New Device for Percutaneous Elevation of the Depressed Fractures of Tibial Condyles

PubMed Central

Ravindranath, V.S.; Kumar, Madhusudan; Murthy, G.V.S.

2012-01-01

Introduction: Monocondylar tibia plateau fractures with non-comminuted fragments can be treated using percutaneous screws. Currently indirect methods of reduction are used and thus the technique is limited to fragments with less than 5 mm depression. The first author has designed a device for direct elevation and reduction of the fragments thus potentially expanding the indications of percutaneous screws to fragments with >5mm depression Technical Note: A total of ten cases were treated by this method of percutaneous elevation of the depressed fractures of lateral condyles of the Tibia using this device. Device was inserted through a bony window on the anteromedial surface of tibia. The inner piston of the device in slowly hammered inside thus elevating the depressed fragment. Elevation of fragment could be achieved in all the cases. The fractures were fixed with cancellous screws applied percutaneously. There were no cases with loss of fixation or subsidence of the fragment. All cases achieved radiological union and have good knee function at follow up Conclusion: The new device is able to elevate unicondylar tibia plateau fragments with no subsidence or loss of fixation in our series. A longer follow up in a larger sample will be needed to establish the technique. PMID:27298860

Analysis of stress fractures in athletes based on our clinical experience

PubMed Central

Iwamoto, Jun; Sato, Yoshihiro; Takeda, Tsuyoshi; Matsumoto, Hideo

2011-01-01

AIM: To analyze stress fractures in athletes based on experience from our sports medicine clinic. METHODS: We investigated the association between stress fractures and age, sex, sports level, sports activity, and skeletal site in athletes seen at our sports medicine clinic between September 1991 and April 2009. Stress fractures of the pars interarticularis were excluded from this analysis. RESULTS: During this period (18 years and 8 mo), 14276 patients (9215 males and 5061 females) consulted our clinic because of sports-related injuries, and 263 patients (1.8%) [171 males (1.9%) and 92 females (1.8%)] sustained stress fractures. The average age of the patients with stress fractures was 20.2 years (range 10-46 years); 112 patients (42.6%) were 15-19 years of age and 90 (34.2%) were 20-24 years of age. Altogether, 90 patients (34.2%) were active at a high recreational level and 173 (65.8%) at a competitive level. The highest proportion of stress fractures was seen in basketball athletes (21.3%), followed by baseball (13.7%), track and field (11.4%), rowing (9.5%), soccer (8.4%), aerobics (5.3%), and classical ballet (4.9%). The most common sites of stress fractures in these patients were the tibia (44.1%), followed by the rib (14.1%), metatarsal bone (12.9%), ulnar olecranon (8.7%) and pelvis (8.4%). The sites of the stress fractures varied from sport to sport. The ulnar olecranon was the most common stress fracture site in baseball players, and the rib was the most common in rowers. Basketball and classical ballet athletes predominantly sustained stress fractures of the tibia and metatarsal bone. Track and field and soccer athletes predominantly sustained stress fractures of the tibia and pubic bone. Aerobics athletes predominantly sustained stress fractures of the tibia. Middle and long distance female runners who sustained multiple stress fractures had the female athlete triad. CONCLUSION: The results of this analysis showed that stress fractures were seen in high-level young athletes, with similar proportions for males and females, and that particular sports were associated with specific sites for stress fractures. Middle and long distance female runners who suffered from multiple stress fractures had the female athlete triad. PMID:22474626

Bilateral periprosthetic tibial stress fracture after total knee arthroplasty: A case report.

PubMed

Ozdemir, Guzelali; Azboy, Ibrahim; Yilmaz, Baris

2016-01-01

Periprosthetic fractures around the knee after total knee arthroplasty can be seen in the femur, tibia and patella. The tibial fractures are rare cases. Our case with bilateral tibial stress fracture developed after total knee arthroplasty (TKA) is the first of its kind in the literature. 75-year-old male patient with bilateral knee osteoarthritis had not benefited from conservative treatment methods previously applied. Left TKA was applied. In the second month postoperatively, periprosthetic tibial fracture was identified and osteosynthesis was implemented with locked tibia proximal plate-screw. Bone union in 12 weeks was observed in his follow-ups. After 15 months of his first operation, TKA was applied to the right knee. Postoperatively in the second month, as in the first operation, periprosthetic tibial fracture was detected. Osteosynthesis with locking plate-screw was applied and union in 12 weeks was observed in his follow-up. He was seen mobilized independently and without support in the last control of the case made in the 24th month after the second operation. The number of TKA applications is expected to increase in the future. The incidence of periprosthetic fractures should also be expected to increase in these cases. Periprosthetic tibial fractures after TKA are rarely seen. The treatment of periprosthetic fractures around the knee after TKA can be difficult. In the case of persistent pain in the upper end of the tibia after the surgery, stress fracture should be considered. Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.

Factors influencing interlocking screw failure in unreamed small diameter nails--a biomechanical study using a distal tibia fracture model.

PubMed

Weninger, Patrick; Schueller, Michael; Jamek, Michael; Stanzl-Tschegg, Stefanie; Redl, Heinz; Tschegg, Elmar K

2009-05-01

Unreamed tibia nails with small diameters are increasingly used for fracture fixation. However, little is known about the fatigue strength of proximal and distal interlocking screws in those nails. To date, no data are available reporting on mechanical differences of solid compared to cannulated tibial nails. The aim of this study was to assess the fatigue strength of proximal and distal interlocking screws of solid and cannulated small diameter tibia nails. We created a distal tibia fracture model (AO/OTA 43 A3) using 16 Sawbones. After fracture stabilization with one of four different nail types (Expert Tibial Nail, VersaNail, T2 Tibial Nailing System, Connex), mechanical testing was performed in three loading series (40,000 cycles each) with incremental loads. Timing and type of interlocking screw failure were assessed. Interlocking screw failure was observed significantly earlier (after a mean interval of 57,042 cycles) in cannulated tibial nails (VersaNail, T2) compared to solid nails (after a mean interval of 88,415 cycles; P < 0.001). Proximal interlocking screw failure was recorded if oblique screws were used proximally (VersaNail, T2, Connex). No distal interlocking screw failure was recorded in the Connex nail. Two- and three-part fractures of proximal or distal interlocking screws were observed in all specimen. Proximal and distal interlocking screw failure has to be considered in small diameter nails in case of delayed fracture healing. To support our results, further experimental studies and clinical series are necessary.

[Current status of surgical technique for unreamed nailing of tibial shaft fractures with the UTN (unreamed tibia nail)].

PubMed

Krettek, C; Schandelmaier, P; Rudolf, J; Tscherne, H

1994-11-01

Nailing technique has changed in recent years in some important aspects which are not limited to the omitted reaming procedure. These changes concern patient positioning, reduction technique, the use of temporary stabilizers such as the 'Pinless', and determination of implant length and diameter. Approach and exposure techniques have been modified to new, less invasive procedures, in order to fulfill technical, functional and aesthetic requirements. Techniques and tricks have been developed for avoidance of fragment diastasis and axial and torsional malalignment. Finally, simple algorithms are described for the management of large bone defects, bilateral tibia shaft or ipsilateral femoral shaft fractures, number and location of locking bolts, the 'when and how' of patient mobilization and load bearing, and primary and secondary dynamization. These algorithms, techniques and procedures were developed in a series of 152 tibia shafts, which were stabilized with the AO unreamed tibia nail (UTN) in a prospective study between March 1989 and June 1994. Of these, 75 cases with a mean follow-up of 19.4 +/- 6.3 (range 11-37) months after trauma were reviewed. Fractures were classified according to Müller (1990): 14 type A, 37 type B and 24 type C. Closed soft tissue damage was categorized according to our classification: C0/1, n = 5; C2, n = 12; C3, n = 9 (Tscherne 1982). Among 49 open fractures 8 were OI, 18 OII, 10 OIIIA and 13 OIIIB (Gustilo 1976). The main minor intraoperative complication was drill bit breakage (n = 10), most frequently at the proximal locking holes. The main postoperative complication was breakage of locking bolts (n = 16), mainly between weeks 6 and 20. Minor secondary reinterventions were, in most cases, secondary dynamization under local anaesthesia. Major reintervention were: soft tissue reconstructions (n = 5), isolated cancellous bone graft (n = 6), and change of treatment (n = 12). There were nine changes to a reamed nail, two changes, in very proximal fractures, to plate osteosyntheses. There were three deep infections. Mean time to union was 23.9 weeks (range 10-48 weeks, n = 73); in two cases non-union was observed. The overall result was judged with the Karlström-Olerud score, which was applicable in 66 of 75 cases; excellent, n = 2; good, n = 22; satisfactory, n = 24; fair, n = 9; poor, n = 9. In the remaining nine cases no scoring was attempted because of severe injuries around the knee or ankle.

Social inequalities in osteoporosis and fracture among community-dwelling older men and women: findings from the Hertfordshire Cohort Study.

PubMed

Syddall, Holly E; Evandrou, Maria; Dennison, Elaine M; Cooper, Cyrus; Sayer, Avan Aihie

2012-01-01

It is unknown whether osteoporosis is socially patterned. Using data from the Hertfordshire Cohort Study we found no consistent evidence for social inequalities in prevalent or incident fracture, bone mineral density or loss rates, or bone strength. Public health strategies for prevention of osteoporosis should focus on the whole population. Osteoporosis and osteoporotic fracture are major public health issues for society; the burden for the affected individual is also high. It is unclear whether osteoporosis and osteoporotic fracture are socially patterned. This study aims to analyse social inequalities in osteoporosis and osteoporotic fracture among the 3,225 community-dwelling men and women, aged 59-73 years, who participated in the Hertfordshire Cohort Study (HCS), UK. A panel of markers of bone health (fracture since 45 years of age; DXA bone mineral density and loss rate at the total femur; pQCT strength strain indices for the radius and tibia; and incident fracture) were analysed in relation to the social circumstances of the HCS participants (characterised at the individual level by: age left full time education; current social class; housing tenure and car availability). We found little strong or consistent evidence among men, or women, for social inequalities in prevalent or incident fracture, DXA bone mineral density, bone loss rates, or pQCT bone strength, with or without adjustment for age, anthropometry, lifestyle and clinical characteristics. Reduced car availability at baseline was associated with lower pQCT radius and tibia strength strain indices at follow-up among men only (p = 0.02 radius and p < 0.01 tibia unadjusted; p = 0.05 radius and p = 0.01 tibia, adjusted for age, anthropometry, lifestyle and clinical characteristics). Our results suggest that fracture and osteoporosis do not have a strong direct social gradient and that public health strategies for prevention and treatment of osteoporosis should continue to focus on the whole population.

Dual-energy X-ray absorptiometry derived structural geometry for stress fracture prediction in male U.S. Marine Corps recruits.

PubMed

Beck, T J; Ruff, C B; Mourtada, F A; Shaffer, R A; Maxwell-Williams, K; Kao, G L; Sartoris, D J; Brodine, S

1996-05-01

A total of 626 U.S. male Marine Corps recruits underwent anthropometric measurements and dual-energy X-ray absorptiometry (DXA) scans of the femoral midshaft and the distal third of the tibia prior to a 12 week physical training program. Conventionally obtained frontal plane DXA scan data were used to measure the bone mineral density (BMD) as well as to derive the cross-sectional area, moment of inertia, section modulus, and bone width in the femur, tibia, and fibula. During training, 23 recruits (3.7%) presented with a total of 27 radiologically confirmed stress fractures in various locations in the lower extremity. After excluding 16 cases of shin splints, periostitis, and other stress reactions that did not meet fracture definition criteria, we compared anthropometric and bone structural geometry measurements between fracture cases and the remaining 587 normals. There was no significant difference in age (p = 0.8), femur length (p = 0.2), pelvic width (p = 0.08), and knee width at the femoral condyles (p = 0.06), but fracture cases were shorter (p = 0.01), lighter (p = 0.0006), and smaller in most anthropometric girth dimensions (p < 0.04). Fracture case bone cross-sectional areas (p < 0.001), moments of inertia (p < 0.001), section moduli (p < 0.001), and widths (p < 0.001) as well as BMD (p < 0.03) were significantly smaller in the tibia and femur. After correcting for body weight differences, the tibia cross-sectional area (p = 0.03), section modulus (p = 0.05), and width (p = 0.03) remained significantly smaller in fracture subjects. We conclude that both small body weight and small diaphyseal dimensions relative to body weight are factors predisposing to the development of stress fractures in this population. These results suggest that bone structural geometry measurements derived from DXA data may provide a simple noninvasive methodology for assessing the risk of stress fracture.

Finite element analysis performed on radius and tibia HR-pQCT images and fragility fractures at all sites in men.

PubMed

Vilayphiou, Nicolas; Boutroy, Stephanie; Szulc, Pawel; van Rietbergen, Bert; Munoz, Francoise; Delmas, Pierre D; Chapurlat, Roland

2011-05-01

Few studies have investigated bone microarchitecture and biomechanical properties in men. This study assessed in vivo both aspects in a population of 185 men (aged 71 ± 10 years) with prevalent fragility fractures, compared to 185 controls matched for age, height, and weight, from the Structure of the Aging Men's Bones (STRAMBO) cohort. In this case-control study, areal BMD (aBMD) was measured by DXA, bone microarchitecture was assessed by high resolution (HR)-pQCT, and finite element (µFE) analysis was based on HR-pQCT images of distal radius and tibia. A principal component (PC) analysis (PCA) was used to study the association of synthetic PCs with fracture by computing their odds ratio (OR [95%CI]) per SD change. Specific associations with vertebral fracture (n = 100), and nonvertebral fracture (n = 85) were also computed. At both sites, areal and volumetric BMD, cortical thickness and trabecular number, separation, and distribution were significantly worse in cases than in controls, with differences ranging from -6% to 15%. µFE-derived stiffness and failure load were 8% to 9% lower in fractures (p < .01). No difference in load distribution was found between the two groups. After adjustment for aBMD, only differences of µFE-derived stresses, stiffness, and failure load at the tibia remained significant (p < .05). PCA resulted in defining 4 independent PCs, explaining 83% of the total variability of bone characteristics. Nonvertebral fractures were associated with PC1, reflecting bone quantity and strength at the radius (tibia) with OR = 1.64 [1.27-2.12] (2.21 [1.60-3.04]), and with PC2, defined by trabecular microarchitecture, with OR = 1.27 [1.00-1.61]. Severe vertebral fractures were associated with PC1, with OR = 1.56 [1.16-2.09] (2.21 [1.59-3.07]), and with PC2, with OR = 1.55 [1.17-2.06] (1.45 [1.06-1.98]). In conclusion, microarchitecture and biomechanical properties derived from µFE were associated with all types of fractures in men, showing that radius and tibia mechanical properties were relatively representative of distant bone site properties. Copyright © 2011 American Society for Bone and Mineral Research.

Arthroscopic Management of Tibial Spine Avulsion Fractures: Principles and Techniques.

PubMed

Strauss, Eric J; Kaplan, Daniel James; Weinberg, Maxwell E; Egol, Jonathan; Jazrawi, Laith M

2018-05-15

Tibial spine fractures are uncommon injuries affecting the insertion of the anterior cruciate ligament on the tibia. They typically occur in skeletally immature patients aged 8 to 14 years and result from hyperextension of the knee with a valgus or rotational force. Diagnosis is based on history, physical examination, and standard radiographs. The use of MRI can identify entrapped soft tissue that may prevent reduction. Open or arthroscopic repair is indicated in patients with partially displaced fractures (>5 mm) with one third to one half of the avulsed fragment elevated, in patients who have undergone unsuccessful nonsurgical reduction and long leg casting or bracing, and in patients with completely displaced fractures. Arthroscopy offers reduced invasiveness and decreased morbidity. Suture fixation and screw fixation have produced successful results. Suture fixation can eliminate the risk of fracture fragment comminution during screw insertion, the risk of neurovascular injury, and the need for hardware removal. Suture fixation is ideal in cases in which existing comminution prevents screw fixation.

Intramedullary nail fixation versus locking plate fixation for adults with a fracture of the distal tibia: the UK FixDT RCT.

PubMed

Costa, Matthew L; Achten, Juul; Hennings, Susie; Boota, Nafisa; Griffin, James; Petrou, Stavros; Maredza, Mandy; Dritsaki, Melina; Wood, Thomas; Masters, James; Pallister, Ian; Lamb, Sarah E; Parsons, Nick R

2018-05-01

The best treatment for fractures of the distal tibia remains controversial. Most of these fractures require surgical fixation, but the outcomes are unpredictable and complications are common. To assess disability, quality of life, complications and resource use in patients treated with intramedullary (IM) nail fixation versus locking plate fixation in the 12 months following a fracture of the distal tibia. This was a multicentre randomised trial. The trial was conducted in 28 UK acute trauma centres from April 2013 to final follow-up in February 2017. In total, 321 adult patients were recruited. Participants were excluded if they had open fractures, fractures involving the ankle joint, contraindication to nailing or inability to complete questionnaires. IM nail fixation ( n  = 161), in which a metal rod is inserted into the hollow centre of the tibia, versus locking plate fixation ( n  = 160), in which a plate is attached to the surface of the tibia with fixed-angle screws. The primary outcome measure was the Disability Rating Index (DRI) score, which ranges from 0 points (no disability) to 100 points (complete disability), at 6 months with a minimum clinically important difference of 8 points. The DRI score was also collected at 3 and 12 months. The secondary outcomes were the Olerud-Molander Ankle Score (OMAS), quality of life as measured using EuroQol-5 Dimensions (EQ-5D), complications such as infection, and further surgery. Resource use was collected to inform the health economic evaluation. Participants had a mean age of 45 years (standard deviation 16.2 years), were predominantly male (61%, 197/321) and had experienced traumatic injury after a fall (69%, 223/321). There was no statistically significant difference in DRI score at 6 months [IM nail fixation group, mean 29.8 points, 95% confidence interval (CI) 26.1 to 33.7 points; locking plate group, mean 33.8 points, 95% CI 29.7 to 37.9 points; adjusted difference, 4.0 points, 95% CI -1.0 to 9.0 points; p  = 0.11]. There was a statistically significant difference in DRI score at 3 months in favour of IM nail fixation (IM nail fixation group, mean 44.2 points, 95% CI 40.8 to 47.6 points; locking plate group, mean 52.6 points, 95% CI 49.3 to 55.9 points; adjusted difference 8.8 points, 95% CI 4.3 to 13.2 points; p  < 0.001), but not at 12 months (IM nail fixation group, mean 23.1 points, 95% CI 18.9 to 27.2 points; locking plate group, 24.0 points, 95% CI 19.7 to 28.3 points; adjusted difference 1.9 points, 95% CI -3.2 to 6.9 points; p  = 0.47). Secondary outcomes showed the same pattern, including a statistically significant difference in mean OMAS and EQ-5D scores at 3 and 6 months in favour of IM nail fixation. There were no statistically significant differences in complications, including the number of postoperative infections (13% in the locking plate group and 9% in the IM nail fixation group). Further surgery was more common in the locking plate group (12% in locking plate group and 8% in IM nail fixation group at 12 months). The economic evaluation showed that IM nail fixation provided a slightly higher quality of life in the 12 months after injury and at lower cost and, therefore, it was cost-effective compared with locking plate fixation. The probability of cost-effectiveness for IM nail fixation exceeded 90%, regardless of the value of the cost-effectiveness threshold. As wound dressings after surgery are clearly visible, it was not possible to blind the patients to their treatment allocation. This evidence does not apply to intra-articular (pilon) fractures of the distal tibia. Among adults with an acute fracture of the distal tibia who were randomised to IM nail fixation or locking plate fixation, there were similar disability ratings at 6 months. However, recovery across all outcomes was faster in the IM nail fixation group and costs were lower. The potential benefit of IM nail fixation in several other fractures requires investigation. Research is also required into the role of adjuvant treatment and different rehabilitation strategies to accelerate recovery following a fracture of the tibia and other long-bone fractures in the lower limb. The patients in this trial will remain in longer-term follow-up. Current Controlled Trials ISRCTN99771224 and UKCRN 13761. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 22, No. 25. See the NIHR Journals Library website for further project information.

Periprosthetic fracture of the proximal tibia after lateral unicompartmental knee arthroplasty.

PubMed

Kumar, Arun; Chambers, Iain; Wong, Paul

2008-06-01

We report a case of periprosthetic fracture of the proximal tibia after lateral unicompartmental knee arthroplasty following a trivial fall. At the time of surgery, the components were found to be loose; and there was a large uncontained tibial defect with bone loss and communition at the fracture site. The patient was treated by revision total knee arthroplasty and proximal structural tibial allograft, with a satisfactory result at 5-year follow up. Our case illustrates that a bone-conserving unicompartmental knee arthroplasty, if complicated by a periprosthetic fracture, can also present with a difficult surgical problem. Attention to preoperative planning and to availability of structural allograft for such difficult cases is recommended.

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.

Osteomalacia in a patient with Paget's bone disease treated with long-term etidronate.

PubMed

Hoppé, E; Masson, C; Laffitte, A; Chappard, D; Audran, M

2012-08-01

A 93 year-old woman with Paget's disease of bone had been treated with etidronate without interruption during 20 years. The daily dose was usual (5mg/kg/day) but this prescription had never been stopped by her physicians. Two fractures had already occurred in pagetic (right tibia) and non pagetic bones (right fibula) within the last 2 years, and she presented rib fractures, another right tibia fracture and right femur fracture during hospitalization time. X-rays films showed major osteolysis of left ulna and right tibia. Blood samples and technetium bone scan brought no evidence for sarcoma or lytic evolution of the disease. A transiliac bone biopsy on non pagetic bone site confirmed the diagnosis of osteomalacia (increased osteoid parameters), with secondary hyperparathyroidism (hook resorption). In Paget's disease of bone, continuous treatment by etidronate may induce generalized osteomalacia, and increase the risk of fracture in both pagetic and non-pagetic bones. Whereas physicians and pharmaceutical industry try to improve the observance of those drugs, this striking observation also points out that a prescription always needs to be updated. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

A Passive and Wireless Sensor for Bone Plate Strain Monitoring.

PubMed

Tan, Yisong; Hu, Jiale; Ren, Limin; Zhu, Jianhua; Yang, Jiaqi; Liu, Di

2017-11-16

This paper reports on a sensor for monitoring bone plate strain in real time. The detected bone plate strain could be used for judging the healing state of fractures in patients. The sensor consists of a magnetoelastic material, which can be wirelessly connected and passively embedded. In order to verify the effectiveness of the sensor, a tibia-bone plate-screw (TBS) model was established using the finite element analysis method. A variation of the bone plate strain was obtained via this model. A goat hindquarter tibia was selected as the bone fracture model in the experiment. The tibia was fixed on a high precision load platform and an external force was applied. Bone plate strain variation during the bone fracture healing process was acquired with sensing coils. Simulation results indicated that bone plate strain decreases as the bone gradually heals, which is consistent with the finite element analysis results. This validated the soundness of the sensor reported here. This sensor has wireless connections, no in vivo battery requirement, and long-term embedding. These results can be used not only for clinical practices of bone fracture healing, but also for bone fracture treatment and rehabilitation equipment design.

Incidence of infection after early intramedullary nailing of open tibial shaft fractures stabilized with pinless external fixators

PubMed Central

Kulshrestha, Vikas

2008-01-01

Background: A major drawback of conventional fixator system is the penetration of fixator pins into the medullary canal. The pins create a direct link between the medullary cavity and outer environment, leading to higher infection rates on conversion to intramedullary nailing. This disadvantage is overcome by the AO pinless fixator, in which the trocar points are clamped onto the outer cortex without penetrating it. This study was designed to evaluate the role of AO pinless fixators in primary stabilization of open diaphyseal tibial fractures that received staged treatment because of delayed presentation or poor general condition. We also analyzed the rate of infection on early conversion to intramedullary nail. Materials and Methods: This study is a retrospective review of 30 open diaphyseal fractures of tibia, which were managed with primary stabilization with pinless fixator and early exchange nailing. Outcome was evaluated in terms of fracture union and rate of residual infection. The data were compared with that available in the literature. Results: All the cases were followed up for a period of 2 years. The study includes Gustilo type 1 (n=10), 14 Gustilo type 2 (n=14), and type3 (n=6) cases. 6 cases (20%) had clamp site infection, 2 cases (6.7%) had deep infection, and in 28 cases (93%) the fracture healed and consolidated well. Conclusion: This study has highlighted the valuable role of pinless external fixator in the management of open tibial fractures in terms of safety and ease of application as well as the advantage of early conversion to intramedullary implant without the risk of deep infection. PMID:19753227

A Computational/Experimental Platform for Investigating Three-Dimensional Puzzle Solving of Comminuted Articular Fractures

PubMed Central

Thomas, Thaddeus P.; Anderson, Donald D.; Willis, Andrew R.; Liu, Pengcheng; Frank, Matthew C.; Marsh, J. Lawrence; Brown, Thomas D.

2011-01-01

Reconstructing highly comminuted articular fractures poses a difficult surgical challenge, akin to solving a complicated three-dimensional (3D) puzzle. Pre-operative planning using CT is critically important, given the desirability of less invasive surgical approaches. The goal of this work is to advance 3D puzzle solving methods toward use as a pre-operative tool for reconstructing these complex fractures. Methodology for generating typical fragmentation/dispersal patterns was developed. Five identical replicas of human distal tibia anatomy, were machined from blocks of high-density polyetherurethane foam (bone fragmentation surrogate), and were fractured using an instrumented drop tower. Pre- and post-fracture geometries were obtained using laser scans and CT. A semi-automatic virtual reconstruction computer program aligned fragment native (non-fracture) surfaces to a pre-fracture template. The tibias were precisely reconstructed with alignment accuracies ranging from 0.03-0.4mm. This novel technology has potential to significantly enhance surgical techniques for reconstructing comminuted intra-articular fractures, as illustrated for a representative clinical case. PMID:20924863

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.

Periprosthetic Fractures Following Total Knee Arthroplasty

PubMed Central

Kim, Nam Ki

2015-01-01

Periprosthetic fractures after total knee arthroplasty may occur in any part of the femur, tibia and patella, and the most common pattern involves the supracondylar area of the distal femur. Supracondylar periprosthetic fractures frequently occur above a well-fixed prosthesis, and risk factors include anterior femoral cortical notching and use of the rotational constrained implant. Periprosthetic tibial fractures are frequently associated with loose components and malalignment or malposition of implants. Fractures of the patella are much less common and associated with rheumatoid arthritis, use of steroid, osteonecrosis and malalignment of implants. Most patients with periprosthetic fractures around the knee are the elderly with poor bone quality. There are many difficulties and increased risk of nonunion after treatment because reduction and internal fixation is interfered with by preexisting prosthesis and bone cement. Additionally, previous soft tissue injury is another disadvantageous condition for bone healing. Many authors reported good clinical outcomes after non-operative treatment of undisplaced or minimally displaced periprosthetic fractures; however, open reduction or revision arthroplasty was required in displaced fractures or fractures with unstable prosthesis. Periprosthetic fractures around the knee should be prevented by appropriate technique during total knee arthroplasty. Nevertheless, if a periprosthetic fracture occurs, an appropriate treatment method should be selected considering the stability of the prosthesis, displacement of fracture and bone quality. PMID:25750888

How Does Ankle-foot Orthosis Stiffness Affect Gait in Patients With Lower Limb Salvage?

DTIC Science & Technology

2014-05-10

characteristics Group Age (years) Height Mass Months of IDEO use Diagnosis IDEO 1 28 1.92 96.4 3.9 R LE neuropathy 2 21 1.79 95.7 11.3 R paresis 3 30...1.78 97.3 7.5 R LE tissue loss/trauma 4 40 1.81 81.0 9.3 L ankle fracture and osteoarthritis 5 30 1.75 79.1 9.8 L tibia/fibula fracture 6 30 1.76 78.2...11.0 L LE neuropathy, crushed tibia/fibula 7 36 1.78 75.5 4.4 L LE talar fracture, multiple fractures 8 22 1.64 80.3 9.0 R LE tissue loss/trauma 9 27

Bone strength estimates relative to vertical ground reaction force discriminates women runners with stress fracture history.

PubMed

Popp, Kristin L; McDermott, William; Hughes, Julie M; Baxter, Stephanie A; Stovitz, Steven D; Petit, Moira A

2017-01-01

To determine differences in bone geometry, estimates of bone strength, muscle size and bone strength relative to load, in women runners with and without a history of stress fracture. We recruited 32 competitive distance runners aged 18-35, with (SFX, n=16) or without (NSFX, n=16) a history of stress fracture for this case-control study. Peripheral quantitative computed tomography (pQCT) was used to assess volumetric bone mineral density (vBMD, mg/mm 3 ), total (ToA) and cortical (CtA) bone areas (mm 2 ), and estimated compressive bone strength (bone strength index; BSI, mg/mm 4 ) at the distal tibia. ToA, CtA, cortical vBMD, and estimated strength (section modulus; Zp, mm 3 and strength strain index; SSIp, mm 3 ) were measured at six cortical sites along the tibia. Mean active peak vertical (pkZ) ground reaction forces (GRFs), assessed from a fatigue run on an instrumented treadmill, were used in conjunction with pQCT measurements to estimate bone strength relative to load (mm 2 /N∗kg -1 ) at all cortical sites. SSIp and Zp were 9-11% lower in the SFX group at mid-shaft of the tibia, while ToA and vBMD did not differ between groups at any measurement site. The SFX group had 11-17% lower bone strength relative to mean pkZ GRFs (p<0.05). These findings indicate that estimated bone strength at the mid-tibia and mean pkZ GRFs are lower in runners with a history of stress fracture. Bone strength relative to load is also lower in this same region suggesting that strength deficits in the middle 1/3 of the tibia and altered gait biomechanics may predispose an individual to stress fracture. Copyright © 2016. Published by Elsevier Inc.

Fractures in Relation to Menstrual Status and Bone Parameters in Young Athletes

PubMed Central

Ackerman, Kathryn E.; Cano Sokoloff, Natalia; Maffazioli, Giovana De Nardo; Clarke, Hannah; Lee, Hang; Misra, Madhusmita

2014-01-01

Introduction To compare fracture prevalence in oligo-amenorrheic athletes (AA), eumenorrheic athletes (EA), and non-athletes (NA) and determine relationships with bone density, structure and strength estimates. Methods 175 females (100 AA, 35 EA, and 40 NA) 14–25 yo were studied. Lifetime fracture history was obtained through participant interviews. Areal BMD was assessed by DXA at the spine, hip and whole body (WB). Bone structure was assessed by HRpQCT at the radius and tibia, and strength by finite element analysis. Results AA, EA, and NA did not differ in age, sexual maturity, or height. AA had lower BMI, and older menarchal age than EA and NA (p≤0.001). BMD Z-scores were lower in AA vs. EA at the total hip, femoral neck, spine, and whole body (p≤0.001). Lifetime fracture risk was higher in AA than EA and NA (47%, 25.7%, 12.5%, p≤0.001), largely driven by stress fractures in AA vs. EA and NA (32% vs. 5.9% vs. 0%). In AA, those who fractured had lower lumbar and WB BMD Z-scores, vBMD of outer trabecular region in radius and tibia, and trabecular thickness of the radius (p≤0.05). In AA, those who had 2 stress fractures had lower lumbar and WB BMD Z-scores, total cross-sectional area, trabecular vBMD, stiffness and failure load at radius; and lower stiffness and failure load at tibia versus those with <2 stress fracture (p≤0.05). Conclusion Weight-bearing athletic activity increases BMD, but may increase stress fracture risk in those with menstrual dysfunction. Bone microarchitecture and strength differences are more pronounced in AA with multiple stress fractures. This is the first study to examine fractures in relation to bone structure in adolescent female athletes. PMID:25397605

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.

Effects of local vibration and pulsed electromagnetic field on bone fracture: A comparative study.

PubMed

Bilgin, Hakkı Murat; Çelik, Ferhat; Gem, Mehmet; Akpolat, Veysi; Yıldız, İsmail; Ekinci, Aysun; Özerdem, Mehmet Siraç; Tunik, Selçuk

2017-07-01

The effectiveness of various therapeutic methods on bone fracture has been demonstrated in several studies. In the present study, we tried to evaluate the effect of local low-magnitude, high-frequency vibration (LMHFV) on rat tibia fracture in comparison with pulsed electromagnetic fields (PEMF) during the healing process. Mid-diaphysis tibiae fractures were induced in 30 Sprague-Dawley rats. The rats were assigned into groups such as control (CONT), LMHFV (15 min/day, 7 days/week), and PEMF (3.5 h/day, 7 days/week) for a three-week treatment. Nothing was applied to control group. Radiographs, serum osteocalcin levels, and stereological bone analyses of the three groups were compared. The X-rays of tibiae were taken 21 days after the end of the healing process. PEMF and LMHFV groups had more callus formation when compared to CONT group; however, the difference was not statistically significant (P = 0.375). Serum osteocalcin levels were elevated in the experimental groups compared to CONT (P ≤ 0.001). Stereological tests also showed higher osteogenic results in experimental groups, especially in LMHFV group. The results of the present study suggest that application of direct local LMHFV on fracture has promoted bone formation, showing great potential in improving fracture outcome. Bioelectromagnetics. 38:339-348, 2017. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

Application of fracture mechanics to failure in manatee rib bone.

PubMed

Yan, Jiahau; Clifton, Kari B; Reep, Roger L; Mecholsky, John J

2006-06-01

The Florida manatee (Trichechus manatus latirostris) is listed as endangered by the U.S. Department of the Interior. Manatee ribs have different microstructure from the compact bone of other mammals. Biomechanical properties of the manatee ribs need to be better understood. Fracture toughness (K(C)) has been shown to be a good index to assess the mechanical performance of bone. Quantitative fractography can be used in concert with fracture mechanics equations to identify fracture initiating defects/cracks and to calculate the fracture toughness of bone materials. Fractography is a standard technique for analyzing fracture behavior of brittle and quasi-brittle materials. Manatee ribs are highly mineralized and fracture in a manner similar to quasi-brittle materials. Therefore, quantitative fractography was applied to determine the fracture toughness of manatee ribs. Average fracture toughness values of small flexure specimens from six different sizes of manatees ranged from 1.3 to 2.6 MPa(m)(12). Scanning electron microscope (SEM) images show most of the fracture origins were at openings for blood vessels and interlayer spaces. Quantitative fractography and fracture mechanics can be combined to estimate the fracture toughness of the material in manatee rib bone. Fracture toughness of subadult and calf manatees appears to increase as the size of the manatee increases. Average fracture toughness of the manatee rib bone materials is less than the transverse fracture toughness of human and bovine tibia and femur.

Tibial tunnel aperture irregularity after drilling with 5 reamer designs: a qualitative micro-computed tomography analysis.

PubMed

Geeslin, Andrew G; Jansson, Kyle S; Wijdicks, Coen A; Chapman, Mark A; Fok, Alex S; LaPrade, Robert F

2011-04-01

There is limited information in the literature on comparisons of antegrade versus retrograde reaming techniques and the effect on the creation of anterior cruciate ligament (ACL) tibial tunnel entry and exit apertures. Proximal and distal apertures of ACL tibial tunnels, as created with different reamers, will be affected by type of reamer design. Controlled laboratory study. Forty skeletally mature porcine tibias with bone mineral density values comparable with a young athletic population were included in this study. Five 9-mm reamer models were used (3 antegrade: A1, smooth-bore reamer; A2, acorn-head reamer; A3, flat-head reamer; 2 retrograde: R1, retrograde acorn reamer; R2, single-blade retrograde reamer), and a new reamer was used for each tibia (8 reamer-tibia pairs per reamer model). All specimens underwent micro-computed tomography scanning, and images were reconstructed and analyzed using 3-dimensional image analysis software. Aperture rim fractures were graded on a 0-IV scale that described the proportion of the fractured aperture circumference. Specimens with incomplete apertures were also recorded. Because of the unique characteristics of various tunnels, intratunnel characteristics were observed and recorded. In sum, 1 proximal and 7 distal aperture rim fractures were found; 3, 0, and 4 distal aperture rim fractures were found with groups A1, A2, and A3, respectively. Incomplete apertures were more commonly found at the distal aperture (n = 15) than the proximal aperture (n = 8); there were no tibias with this finding at both apertures. All incomplete distal apertures occurred with the retrograde technique, and all incomplete proximal apertures occurred with the antegrade technique, most commonly with reamer design A3. An added finding of tunnel curvature at the distal aspect of the tunnel was observed in all 8 tibias with R1 reamers and 5 tibias with R2 reamers. This phenomenon was not observed in any of the tibias reamed with the antegrade technique. Anterior cruciate ligament tibial tunnel aperture characteristics were highly dependent on reamer design. Optimal proximal aperture characteristics were produced by the retrograde reamers, whereas optimal distal aperture characteristics were obtained with the antegrade reamers. In addition, a phenomenon of tunnel curvature in retrograde-type reamers was found, which may have effects on ACL graft or screw fixation. Differences in tunnel aperture shapes and fractures depend on reamer design. This information is important for the creation of ACL reconstruction tunnels with different reamer designs.

Advantages of the Ilizarov external fixation in the management of intra-articular fractures of the distal tibia

PubMed Central

Vasiliadis, Elias S; Grivas, Theodoros B; Psarakis, Spyridon A; Papavasileiou, Evangelos; Kaspiris, Angelos; Triantafyllopoulos, Georgios

2009-01-01

Background Treatment of distal tibial intra-articular fractures is challenging due to the difficulties in achieving anatomical reduction of the articular surface and the instability which may occur due to ligamentous and soft tissue injury. The purpose of this study is to present an algorithm in the application of external fixation in the management of intra-articular fractures of the distal tibia either from axial compression or from torsional forces. Materials and methods Thirty two patients with intra-articular fractures of the distal tibia have been studied. Based on the mechanism of injury they were divided into two groups. Group I includes 17 fractures due to axial compression and group II 15 fractures due to torsional force. An Ilizarov external fixation was used in 15 patients (11 of group I and 4 of group II). In 17 cases (6 of group I and 11 of group II) a unilateral hinged external fixator was used. In 7 out of 17 fractures of group I an additional fixation of the fibula was performed. Results All fractures were healed. The mean time of removal of the external fixator was 11 weeks for group I and 10 weeks for group II. In group I, 5 patients had radiological osteoarthritic lesions (grade III and IV) but only 2 were symptomatic. Delayed union occurred in 3 patients of group I with fixed fibula. Other complications included one patient of group II with subluxation of the ankle joint after removal of the hinged external fixator, in 2 patients reduction found to be insufficient during the postoperative follow up and were revised and 6 patients had a residual pain. The range of ankle joint motion was larger in group II. Conclusion Intra-articular fractures of the distal tibia due to axial compression are usually complicated with cartilaginous problems and are requiring anatomical reduction of the articular surface. Fractures due to torsional forces are complicated with ankle instability and reduction should be augmented with ligament repair, in order to restore normal movement of talus against the mortise. Both Ilizarov and hinged external fixators are unable to restore ligamentous stability. External fixation is recommended only for fractures of the ankle joint caused by axial compression because it is biomechanically superior and has a lower complication rate. PMID:19754962

Periprosthetic fractures of the femur after total knee arthroplasty.

PubMed

McGraw, Phil; Kumar, Arun

2010-09-01

Periprosthetic fracture following total knee arthroplasty is a potentially serious complication. This injury can involve the distal femur, proximal tibia or the patella. This review article analyzes the prevalence, risk factors, classification and treatment options for periprosthetic fractures of the femur.

Progressive migration of broken Kirschner wire into the proximal tibia following tension-band wiring technique of a patellar fracture--case report.

PubMed

Konda, Sanjit R; Dayan, Alan; Egol, Kenneth A

2012-01-01

Wire breakage and migration is a known complication of using a wire tension band construct to treat displaced patella fractures. We report a case of a broken K-wire that migrated from the patella completely into the proximal tibia without complication 9 years after the index surgery. This report highlights the fact that wire migration can occur long after fracture healing and be relatively asymptomatic. But because the complications of wire migration can be deadly, it requires diligence on the part of the physician to educate the patient that new knee pain after operative fixation requires formal evaluation by the treating surgeon.

Postoperative complications associated with external skeletal fixators in cats.

PubMed

Beever, Lee; Giles, Kirsty; Meeson, Richard

2017-07-01

The objective of this study was to quantify complications associated with external skeletal fixators (ESFs) in cats and to identify potential risk factors. A retrospective review of medical records and radiographs following ESF placement was performed. Case records of 140 cats were reviewed; fixator-associated complications (FACs) occurred in 19% of cats. The region of ESF placement was significantly associated with complication development. Complications developed most frequently in the femur (50%), tarsus (35%) and radius/ulna (33%). Superficial pin tract infection (SPTI) and implant failure accounted for 45% and 41% of all FACs, respectively. SPTI occurred more frequently in the femur, humerus and tibia, with implant failure more frequent in the tarsus. No association between breed, age, sex, weight, fracture type (open vs closed), ESF classification, number of pins per bone segment, degree of fracture load sharing, and the incidence or type of FAC was identified. No association between region of placement, breed, age, sex, weight, fracture type (open vs closed), ESF classification, number of pins per bone segment, fracture load sharing and the time to complication development was identified. Complication development is not uncommon in cats following ESF placement. The higher complication rate in the femur, tarsus and radius/ulna should be considered when reviewing options for fracture management. However, cats appear to have a lower rate of pin tract infections than dogs.

Diaphyseal long bone nonunions - types, aetiology, economics, and treatment recommendations.

PubMed

Rupp, Markus; Biehl, Christoph; Budak, Matthäus; Thormann, Ulrich; Heiss, Christian; Alt, Volker

2018-02-01

The intention of the current article is to review the epidemiology with related socioeconomic costs, pathophysiology, and treatment options for diaphyseal long bone delayed unions and nonunions. Diaphyseal nonunions in the tibia and in the femur are estimated to occur 4.6-8% after modern intramedullary nailing of closed fractures with an even much higher risk in open fractures. There is a high socioeconomic burden for long bone nonunions mainly driven by indirect costs, such as productivity losses due to long treatment duration. The classic classification of Weber and Cech of the 1970s is based on the underlying biological aspect of the nonunion differentiating between "vital" (hypertrophic) and "avital" (hypo-/atrophic) nonunions, and can still be considered to represent the basis for basic evaluation of nonunions. The "diamond concept" units biomechanical and biological aspects and provides the pre-requisites for successful bone healing in nonunions. For humeral diaphyseal shaft nonunions, excellent results for augmentation plating were reported. In atrophic humeral shaft nonunions, compression plating with stimulation of bone healing by bone grafting or BMPs seem to be the best option. For femoral and tibial diaphyseal shaft fractures, dynamization of the nail is an atraumatic, effective, and cheap surgical possibility to achieve bony consolidation, particularly in delayed nonunions before 24 weeks after initial surgery. In established hypertrophic nonunions in the tibia and femur, biomechanical stability should be addressed by augmentation plating or exchange nailing. Hypotrophic or atrophic nonunions require additional biological stimulation of bone healing for augmentation plating.

Post-junctional facilitation of substance P signaling in a tibia fracture rat model of complex regional pain syndrome type I

PubMed Central

Wei, Tzuping; Li, Wen-wu; Guo, Tian-Zhi; Zhao, Rong; Wang, Liping; Clark, David J; Oaklander, Ann Louise; Schmelz, Martin; Kingery, Wade S.

2009-01-01

Tibia fracture in rats evokes nociceptive, vascular, and bone changes resembling complex regional pain syndrome (CRPS). Substance P (SP) signaling contributes to the hindpaw warmth, increased vascular permeability, and edema observed in this model, suggesting that neurogenic inflammatory responses could be enhanced after fracture. Four weeks after tibia fracture we measured SP and calcitonin gene-related peptide (CGRP) protein levels in the sciatic nerve and serum. Hindpaw skin extravasation responses and SP receptor (NK1), CGRP receptor (calcitonin receptor-like receptor, CRLR) and neutral endopeptidase (NEP) protein levels were also determined. Gene expression levels of these peptides, receptors, and peptidase were examined in the DRG and skin. Spontaneous and intravenous SP-evoked extravasation responses were increased ipsilateral, but not contralateral to the fracture. Fracture increased SP and CGRP gene expression in the ipsilateral L4,L5 DRG and neuropeptide protein levels in the sciatic nerve and in serum, but had no effect on electrically-evoked SP and CGRP release. NK1 receptor expression was increased in the ipsilateral hindpaw skin keratinocytes and endothelial cells after injury, but CRLR and NEP expression were unchanged. Fracture also increased epidermal thickness, but had no effect on epidermal skin neurite counts. These results demonstrate that spontaneous and intravenous SP-evoked extravasation responses are enhanced in the ipsilateral hindlimb after fracture and that fracture chronically increases the expression of endothelial and keratinocyte NK1 receptors in the injured limb. We postulate that SP activation of these up-regulated NK1 receptors results in skin warmth, protein leakage, edema, and keratinocyte proliferation in the injured limb. PMID:19464118

Post-junctional facilitation of Substance P signaling in a tibia fracture rat model of complex regional pain syndrome type I.

PubMed

Wei, Tzuping; Li, Wen-Wu; Guo, Tian-Zhi; Zhao, Rong; Wang, Liping; Clark, David J; Oaklander, Anne Louise; Schmelz, Martin; Kingery, Wade S

2009-08-01

Tibia fracture in rats evokes nociceptive, vascular, and bone changes resembling complex regional pain syndrome (CRPS). Substance P (SP) signaling contributes to the hindpaw warmth, increased vascular permeability, and edema observed in this model, suggesting that neurogenic inflammatory responses could be enhanced after fracture. Four weeks after tibia fracture we measured SP and calcitonin gene-related peptide (CGRP) protein levels in the sciatic nerve and serum. Hindpaw skin extravasation responses and SP receptor (NK1), CGRP receptor (calcitonin receptor-like receptor, CRLR) and neutral endopeptidase (NEP) protein levels were also determined. Gene expression levels of these peptides, receptors, and peptidase were examined in the DRG and skin. Spontaneous and intravenous SP-evoked extravasation responses were increased ipsilateral, but not contralateral to the fracture. Fracture increased SP and CGRP gene expression in the ipsilateral L4,L5 DRG and neuropeptide protein levels in the sciatic nerve and in serum, but had no effect on electrically evoked SP and CGRP release. NK1 receptor expression was increased in the ipsilateral hindpaw skin keratinocytes and endothelial cells after injury, but CRLR and NEP expression were unchanged. Fracture also increased epidermal thickness, but had no effect on epidermal skin neurite counts. These results demonstrate that spontaneous and intravenous SP-evoked extravasation responses are enhanced in the ipsilateral hindlimb after fracture and that fracture chronically increases the expression of endothelial and keratinocyte NK1 receptors in the injured limb. We postulate that SP activation of these up-regulated NK1 receptors results in skin warmth, protein leakage, edema, and keratinocyte proliferation in the injured limb.

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

Treatment of high-energy pilon fractures using the ILIZAROV treatment.

PubMed

Osman, Walid; Alaya, Zeineb; Kaziz, Hamdi; Hassini, Lassad; Braiki, Meriem; Naouar, Nader; Ben Ayeche, Mohamed Laaziz

2017-01-01

The management of high-energy pilon fractures is still controversial. Open reduction and internal fixation are often associated with serious complications. Various methods have been used to treat these injuries, with variable results. The aim of this retrospective study was to analyze the clinical and radiographic outcome of the ILIZAROV technique in patients with high-energy pilon fractures. Thirty cases of distal tibia epiphysis fractures (pilon fractures) were managed from 1999 to 2012. The study group included 5 cases of open fractures. The mean age was 47 years. According to Rüedi and Algower classification; 11 fractures were type II, and 19 type III. All fractures were a consequence of high-energy trauma. Fractures of the lower fibula were present in 28 of the patients. An external Fixator was applied for open fractures. Closed injuries were operated on 3 to 13 days after injury, with an average of 8 days. The mean follow-up was 48 months. All fractures united. The external fixator was removed after a mean of 22 weeks (10 - 28 weeks). Two patients with a type III fracture had a delayed union and were treated with corticotomy and dynamisation of the ILIZAROV fixator. Only one secondary displacement of a type III fracture was noted after two months and was treated by adjuction of 2 olive wires. There were no cases of osteomyelitis or deep infections. Pin-tract infections occurred in ten patients. We had not any case of nervous injury due to introduction of the pins. Using radiological criteria for assessement of reduction of the articular fragments, there was excellent and good restoration of articular structure in 24 cases. The average American Orthopeadic Foot and Ankle Society ankle-hind foot score was excellent in 16, good in 6, fair in 6 and poor in 2. Soft tissue healing occurred without need for plastic surgery in all cases. The movements of the ankle ranged from 0 to 20° of dorsiflexion and 5° to 40° of plantar flexion. Twenty patients had gone back to their preinjury profession. The ILIZAROV technique is a safe and a very effective treatment for severe pilon fractures with minimum complications and good healing results.

Treatment of high-energy pilon fractures using the ILIZAROV treatment

PubMed Central

Osman, Walid; Alaya, Zeineb; Kaziz, Hamdi; Hassini, Lassad; Braiki, Meriem; Naouar, Nader; Ben Ayeche, Mohamed Laaziz

2017-01-01

The management of high-energy pilon fractures is still controversial. Open reduction and internal fixation are often associated with serious complications. Various methods have been used to treat these injuries, with variable results. The aim of this retrospective study was to analyze the clinical and radiographic outcome of the ILIZAROV technique in patients with high-energy pilon fractures. Thirty cases of distal tibia epiphysis fractures (pilon fractures) were managed from 1999 to 2012. The study group included 5 cases of open fractures. The mean age was 47 years. According to Rüedi and Algower classification; 11 fractures were type II, and 19 type III. All fractures were a consequence of high-energy trauma. Fractures of the lower fibula were present in 28 of the patients. An external Fixator was applied for open fractures. Closed injuries were operated on 3 to 13 days after injury, with an average of 8 days. The mean follow-up was 48 months. All fractures united. The external fixator was removed after a mean of 22 weeks (10 - 28 weeks). Two patients with a type III fracture had a delayed union and were treated with corticotomy and dynamisation of the ILIZAROV fixator. Only one secondary displacement of a type III fracture was noted after two months and was treated by adjuction of 2 olive wires. There were no cases of osteomyelitis or deep infections. Pin-tract infections occurred in ten patients. We had not any case of nervous injury due to introduction of the pins. Using radiological criteria for assessement of reduction of the articular fragments, there was excellent and good restoration of articular structure in 24 cases. The average American Orthopeadic Foot and Ankle Society ankle-hind foot score was excellent in 16, good in 6, fair in 6 and poor in 2. Soft tissue healing occurred without need for plastic surgery in all cases. The movements of the ankle ranged from 0 to 20° of dorsiflexion and 5° to 40° of plantar flexion. Twenty patients had gone back to their preinjury profession. The ILIZAROV technique is a safe and a very effective treatment for severe pilon fractures with minimum complications and good healing results. PMID:28904724

Surgical Management of Complex Lower-Extremity Trauma With a Long Hindfoot Fusion Nail: A Case Report.

PubMed

Jain, Nickul S; Lopez, Gregory D; Bederman, S Samuel; Wirth, Garrett A; Scolaro, John A

2016-08-01

High-energy injuries can result in complete or partial loss of the talus. Ipsilateral fractures to the lower limb increase the complexity of surgical management, and treatment is guided by previous case reports of similar injuries. A case of complex lower-extremity trauma with extruded and missing talar body and ipsilateral type IIIB open tibia fracture is presented. Surgical limb reconstruction and salvage was performed successfully with a single orthopaedic implant in a manner not described previously in the literature. The purpose of this case report is to present the novel use of a single orthopaedic implant for treatment of a complex, open traumatic injury. Previous case reports in the literature have described the management of complete or partial talar loss. We describe the novel use of a long hindfoot fusion nail and staged bone grafting to achieve tibiocalcaneal arthrodesis for the treatment of complex lower-extremity trauma. Therapeutic, Level IV: Case study. © 2015 The Author(s).

Immediate versus delayed intramedullary nailing for open fractures of the tibial shaft: a multivariate analysis of factors affecting deep infection and fracture healing.

PubMed

Yokoyama, Kazuhiko; Itoman, Moritoshi; Uchino, Masataka; Fukushima, Kensuke; Nitta, Hiroshi; Kojima, Yoshiaki

2008-10-01

The purpose of this study was to evaluate contributing factors affecting deep infection and fracture healing of open tibia fractures treated with locked intramedullary nailing (IMN) by multivariate analysis. We examined 99 open tibial fractures (98 patients) treated with immediate or delayed locked IMN in static fashion from 1991 to 2002. Multivariate analyses following univariate analyses were derived to determine predictors of deep infection, nonunion, and healing time to union. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type, fracture grade by AO type, fracture location, timing or method of IMN, reamed or unreamed nailing, debridement time (< or =6 h or >6 h), method of soft-tissue management, skin closure time (< or =1 week or >1 week), existence of polytrauma (ISS< 18 or ISS> or =18), existence of floating knee injury, and existence of superficial/pin site infection. The predictive variables of nonunion selected for analysis was the same as those for deep infection, with the addition of deep infection for exchange of pin site infection. The predictive variables of union time selected for analysis was the same as those for nonunion, excluding of location, debridement time, and existence of floating knee and superficial infection. Six (6.1%; type II Gustilo n=1, type IIIB Gustilo n=5) of the 99 open tibial fractures developed deep infections. Multivariate analysis revealed that timing or method of IMN, debridement time, method of soft-tissue management, and existence of superficial or pin site infection significantly correlated with the occurrence of deep infection (P< 0.0001). In the immediate nailing group alone, the deep infection rate in type IIIB + IIIC was significantly higher than those in type I + II and IIIA (P = 0.016). Nonunion occurred in 17 fractures (20.3%, 17/84). Multivariate analysis revealed that Gustilo type, skin closure time, and existence of deep infection significantly correlated with occurrence of nonunion (P < 0.05). Gustilo type and existence of deep infection were significantly correlated with healing time to union on multivariate analysis (r(2) = 0.263, P = 0.0001). Multivariate analyses for open tibial fractures treated with IMN showed that IMN after EF (especially in existence of pin site infection) was at high risk of deep infection, and that debridement within 6 h and appropriate soft-tissue managements were also important factor in preventing deep infections. These analyses postulated that both the Gustilo type and the existence of deep infection is related with fracture healing in open fractures treated with IMN. In addition, immediate IMN for type IIIB and IIIC is potentially risky, and canal reaming did not increase the risk of complication for open tibial fractures treated with IMN.

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

Bilateral stress fracture of the fibulae and periostitis of the tibiae.

PubMed

Tsuchie, Hiroyuki; Okada, Kyoji; Nagasawa, Hiroyuki; Chida, Shuichi; Shimada, Yoichi

2010-01-01

This study describes a unique case of bilateral stress fractures of the fibulae and provides a literature review. A 16-year-old female badminton player presented with pain around the bilateral distal lateral legs. She had mild bilateral varus deformity at the knee joint, and the bilateral ankles showed valgus deformity in standing posture. Radiographs and computed tomography showed periosteal reactions on the bilateral distal fibulae. Technetium-99m bone scintigraphy demonstrated increased uptake in the bilateral distal fibulae and the bilateral middle third of the tibiae. A diagnosis of bilateral distal fibular stress fractures was made. She was advised to stop playing badminton until the symptoms disappeared. Varus deformity of the knee and valgus deformity of the ankle may have influenced the mechanism underlying bilateral symmetric stress fractures. Copyright © 2010 S. Karger AG, Basel.

Novel management of distal tibial and fibular fractures with Acumed fibular nail and minimally invasive plating osteosynthesis technique: A case report.

PubMed

Wang, Tie-Jun; Ju, Wei-Na; Qi, Bao-Chang

2017-03-01

Anatomical characteristics, such as subcutaneous position and minimal muscle cover, contribute to the complexity of fractures of the distal third of the tibia and fibula. Severe damage to soft tissue and instability ensure high risk of delayed bone union and wound complications such as nonunion, infection, and necrosis. This case report discusses management in a 54-year-old woman who sustained fractures of the distal third of the left tibia and fibula, with damage to overlying soft tissue (swelling and blisters). Plating is accepted as the first choice for this type of fracture as it ensures accurate reduction and rigid fixation, but it increases the risk of complications. Closed fracture of the distal third of the left tibia and fibula (AO: 43-A3). After the swelling was alleviated, the patient underwent closed reduction and fixation with an Acumed fibular nail and minimally invasive plating osteosynthesis (MIPO), ensuring a smaller incision and minimal soft-tissue dissection. At the 1-year follow-up, the patient had recovered well and had regained satisfactory function in the treated limb. The Kofoed score of the left ankle was 95. Based on the experience from this case, the operation can be undertaken safely when the swelling has been alleviated. The minimal invasive technique represents the best approach. Considering the merits and good outcome in this case, we recommend the Acumed fibular nail and MIPO technique for treatment of distal tibial and fibular fractures.

[Case-control study on effects of external fixation combined with limited internal fixation for the treatment of Pilon fractures of Rüedi-Allgower type III].

PubMed

Duan, Da-Peng; You, Wu-Lin; Ji, Le; Zhang, Yong-Tao; Dang, Xiao-Qian; Wang, Kun-Zheng

2014-01-01

To analyze the effects of three surgical operations in the treatment of Pilon fracture of Rüedi-Allgower type III, and put forward the best therapeutic method. The clinical data of 33 patients with Pilon fracture who received surgical operations (plaster immobilization group, 10 cases; distal tibia anatomical plate group, 11 cases; external fixation with limited internal fixation group, 12 cases) from October 2009 to January 2012 were analyzed. There were 5 males and 5 females, ranging in age from 24 to 61 years in the plaster immobilization group. There were 7 males and 4 females, ranging in age from 21 to 64 years in the distal tibia anatomical plate group. There were 7 males and 5 females, ranging in age from 23 to 67 years in the external fixation with limited internal fixation group. The Ankle X-ray of Pilon fracture after operation, ankle score, early and late complications were collected. Bourne system was used to evaluate ankle joint function. After 8 months to 3 years follow-up, it was found that three kinds of treatment had significant differences in the outcomes and complications (P < 0.05): the external fixation with limited internal fixation group got the best results. The number of anatomic reduction cases in the external fixation with limited internal fixation group (7 cases) and the distal tibia anatomical plate group (8 cases) was more than the plaster immobilization group (2 cases). According to the ankle score, 8 patients got an excellent result, 3 good and 1 poor in the limited internal fixation group ,which was better than those of distal tibia anatomical plate group (5 excellent, 4 good and 2 poor) and the plaster immobilization group (3 excellent, 4 good and 3 poor). The number of early and late complications in the external fixation with limited internal fixation group was more than those in the plaster immobilization group and the distal tibia anatomical plate group (P< 0.05). Treatment of external fixation with limited internal fixation in the treatment of Pilon fracture of Rüedi-Allgower type III is effective and safe.

UK Fixation of Distal Tibia Fractures (UK FixDT): protocol for a randomised controlled trial of ‘locking’ plate fixation versus intramedullary nail fixation in the treatment of adult patients with a displaced fracture of the distal tibia

PubMed Central

Achten, Juul; Parsons, Nicholas R; McGuinness, Katie R; Petrou, Stavros; Lamb, Sarah E; Costa, Matthew L

2015-01-01

Introduction The treatment of displaced, extra-articular fractures of the distal tibia remains controversial. These injuries are difficult to manage due to limited soft tissue cover, poor vascularity of the area and proximity to the ankle joint. Surgical treatment options are expanding and include locked intramedullary nails, plate and screw fixation and external fixator systems. The nail and plate options are most commonly used in the UK, but controversy exists over which treatment is most clinically and cost-effective. In this multicentre randomised controlled trial we aim to assess ratings of disability 6 months postinjury in patients who have sustained a distal tibia fracture treated with either an intramedullary nail or plate and locking screw fixation. Methods and analysis Adult patients presenting at trial centres with an acute fracture of the distal tibia will be considered for inclusion. A total of 320 patients will provide 90% power to detect a difference of 8 points in Disability Rating Index (DRI) score at 6 months at the 5% level. The randomisation sequence is stratified by trial centre and age, and administered via web-based service with 1:1 treatment allocation. Baseline demographic and pre-injury functional data and radiographs will be collected using the DRI, Olerud and Molander, and EuroQol EQ-5D questionnaire. Clinical assessment, early complications and radiographs will be recorded at 6–8 weeks. Functional outcome, health-related quality of life and resource use will be collected at 3, 6 and 12 months postoperatively. The main analysis will investigate differences in DRI 6 months postsurgery, between the two treatment groups, on an intention-to-treat basis. Tests will be two-sided and considered to provide evidence for a significant difference if p values are <0.05. Ethics and dissemination NRES Committee West-Midlands, 6/11/2012 (ref:12/WM/0340). The results of the trial will be disseminated via peer-reviewed publications and presentations at relevant conferences. Trial registration number ISRCTN99771224. PMID:26384729

Character, Incidence, and Predictors of Knee Pain and Activity After Infrapatellar Intramedullary Nailing of an Isolated Tibia Fracture.

PubMed

Obremskey, William; Agel, Julie; Archer, Kristin; To, Philip; Tornetta, Paul

2016-03-01

To study the activity and incidence of knee pain after sustaining an isolated tibia fracture treated with an infrapatellar intramedullary nail at 1 year. Retrospective review of prospective cohort. Multicenter Academic and Community hospitals. Four hundred thirty-seven patients with an isolated tibia fracture completed a 12-month assessment on pain and self-reported activity. Infrapatellar intramedullary nail. Demographic information, comorbid conditions, injury characteristics, and surgical technique were recorded. Knee pain was defined on a 1-7 scale with 1 being "no pain" and 7 being a "very great deal of pain." Knee pain >4 was considered clinically significant. Patients reported if they were "able," "able with difficulty," or "unable" to perform the following activities: kneel, run, climb stairs, and walk prolonged. Variables were tested in multilevel multivariable regression analyses. In knee pain, 11% of patients reported a "good deal" to a "very great deal" of pain (>4), and 52% of patients reported "no" or "very little" pain at 12 months. In activity at 12 months, 26% and 29% of patients were unable to kneel or run, respectively, and 31% and 35% of patients, respectively, stated they were able with difficulty or unable to use stairs or walk. Clinically significant knee pain (>4/7) was present in 11% of patients 1 year after a tibia fracture. Of note, 31%-71% of patients had difficulty performing or were unable to perform routine daily activities of kneeling, running, and stair climbing, or walking prolonged distances. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Character, Incidence, and Predictors of Knee Pain and Activity after Infrapatellar Intramedullary Nailing of an Isolated Tibia Fracture

PubMed Central

Obremskey, William; Agel, Julie; Archer, Kristin; To, Philip; Tornetta, Paul

2015-01-01

Objective To study the activity and incidence of knee pain after sustaining a isolated tibia fracture treated with an infrapatellar intramedullary nail at one year. Design Retrospective review of prospective cohort Setting Multicenter Academic and Community hospitals Patients 437 patients with an isolated tibia fracture completed a 12 month assessment on pain and self-reported activity. Intervention Infrapatellar Intramedullary Nail Outcomes Demographic information co-morbid conditions, injury characteristics, and surgical technique were recorded. Knee pain was defined on a 1-7 scale with 1 being “no pain” and 7 being a “very great deal of pain.” Knee pain > 4 was considered clinically significant. Patients reported if they were “able”, “able with difficulty” or “unable” to perform the following activities: kneel, run, climb stairs, and walk prolonged. Variables were tested in multilevel multivariable regression analyses. Results Knee Pain: 11% percent of patients reported a “good deal” to a “very great deal” of pain (> 4). 52% of patients reported “no” or “very little” pain at 12 months. Activity at 12 months: 26% and 29% of patients were unable to kneel or run, respectively. 31% and 35% of patients respectively stated they were able with difficulty or unable to use stairs or walk. Conclusion Clinically significant knee pain (>4/7) was present in 11% of patients one year after a tibia fracture. 31%-71% of patients had difficulty performing or were unable to perform routine daily activities of kneeling, running, and stair climbing or walking prolonged distances. PMID:26496180

Fractures in Relation to Menstrual Status and Bone Parameters in Young Athletes.

PubMed

Ackerman, Kathryn E; Cano Sokoloff, Natalia; DE Nardo Maffazioli, Giovana; Clarke, Hannah M; Lee, Hang; Misra, Madhusmita

2015-08-01

This study was aimed to compare fracture prevalence in oligoamenorrheic athletes (AA), eumenorrheic athletes (EA), and nonathletes (NA) and determine relationships with bone density, structure, and strength estimates. One hundred seventy-five females (100 AA, 35 EA, and 40 NA) 14-25 yr old were studied. Lifetime fracture history was obtained through participant interviews. Areal bone mineral density (BMD) was assessed by DXA at the spine, hip, and whole body (WB). Bone structure was assessed by HRpQCT at the radius and tibia, and strength by finite element analysis. AA, EA, and NA did not differ in age, sexual maturity, or height. AA had lower BMI, and older menarchal age than EA and NA (P ≤ 0.001). Bone mineral density Z-scores were lower in AA versus EA at the total hip, femoral neck, spine, and whole body (P ≤ 0.001). Lifetime fracture risk was higher in AA than EA and NA (47%, 25.7%, 12.5%; P ≤ 0.001), largely driven by stress fractures in AA versus EA and NA (32% vs 5.9% vs 0%). In AA, those who fractured had lower lumbar and WB BMD Z-scores, volumetric BMD (vBMD) of outer trabecular region in radius and tibia, and trabecular thickness of the radius (P ≤ 0.05). In AA, those who had two or more stress fractures had lower lumbar and WB BMD Z-scores, total cross-sectional area, trabecular vBMD, stiffness, and failure load at radius; and lower stiffness and failure load at tibia versus those with fewer than two stress fractures (P ≤ 0.05). Weight-bearing athletic activity increases BMD but may increase stress fracture risk in those with menstrual dysfunction. Bone microarchitecture and strength differences are more pronounced in AA with multiple stress fractures. This is the first study to examine fractures in relation to bone structure in adolescent female athletes.

[Surgical treatment of tibial nonunion after wounding by high velocity missile and external fixators: a case report].

PubMed

Golubović, Ivan; Vukašinović, Zoran; Stojiljković, Predrag; Golubović, Zoran; Stojiljković, Danilo; Radovanović, Zoran; Ilić, Nenad; Najman, Stevo; Višnjić, Aleksandar; Arsić, Stojanka

2012-01-01

The missiles of modern firearms can cause severe fractures of the extremity. High velocity missile fractures of the tibia are characterized by massive tissue destruction and primary contamination with polymorphic bacteria. Treatment of these fractures is often complicated by delayed healing, poor position healing, nonhealing and bone tissue infection. We present the management of tibial nonunion after wounding by high velocity missile and primary treatment by external fixation in a 25-year-old patient. The patient was primarily treated with external fixation and reconstructive operations of the soft tissue without union of the fracture. Seven months after injury we placed a compression-distraction external fixator type Mitkovic and started with compression and distraction in the fracture focus after osteotomy of the fibula and autospongioplasty. We recorded satisfactory fracture healing and good functional outcome. Contamination and devitalization of the soft-tissue envelope increase the risk of infection and nonunion in fractures after wounding by high velocity missile. The use of the compression-distraction external fixator type Mitkovic may be an effective method in nonunions of the tibia after this kind of injury.

Trampoline fracture of the proximal tibial metaphysis in children may not progress into valgus: a report of seven cases and a brief review.

PubMed

Kakel, R

2012-06-01

Fracture of the proximal tibial metaphysis in children is a rare injury but notorious for carrying the risk of subsequent valgus deformity of the tibia. Trampoline-caused fracture of the proximal tibial metaphysis in children may not progress into valgus. We followed up six children who collectively sustained seven fractures of the proximal tibial metaphysis while trampolining with other heavier and/or older children. Initial and follow-up x-rays were reviewed by an orthopaedic surgeons and two radiologists. None of the patients developed valgus deformity with follow-up. Trampoline is associated with a specific type of injury to the proximal tibia when children are trampolining with other heavier children even without falling off the trampoline. This fracture is linear and complete, often non-displaced. Unlike "other" proximal tibial metaphyseal fractures, trampoline-associated proximal tibial metaphysical fracture in children is not associated with a risk of subsequent valgus deformity. Level 4. case series. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Factors Associated With Development of Nonunion or Delayed Healing After an Open Long Bone Fracture: A Prospective Cohort Study of 736 Subjects.

PubMed

Westgeest, Joseph; Weber, Donald; Dulai, Sukhdeep K; Bergman, Joseph W; Buckley, Richard; Beaupre, Lauren A

2016-03-01

To determine factors associated with developing nonunion or delayed healing after open fracture. Prospective cohort between 2001 and 2009. Three level 1 Canadian trauma centers. Seven hundred thirty-six (791 fractures) subjects were enrolled. Six hundred eighty-nine (94%) subjects (739 fractures) provided adequate outcome data. Subjects were followed until fracture(s) healed; phone interviews and chart reviews were conducted 1 year after fracture. Patient, fracture, and injury information, and time to surgery and antibiotics were recorded during hospitalization. Nonunion defined as unplanned surgical intervention after definitive wound closure or incomplete radiographic healing at 1 year and delayed healing defined as 2 consecutive clinical assessments showing no radiographic progression or incomplete radiographic healing between 6 months and 1 year. There were 413 (52%) tibia/fibular, 285 (36%) upper extremity, and 93 (13%) femoral fractures. Nonunion developed in 124 (17%) and delayed healing in 63 (8%) fractures. The median time to surgery was not different for fractures that developed nonunion compared with those who did not (P = 0.36). Deep infection [Odd ratio (OR) 12.75; 95% confidence interval (CI) 6.07-26.8], grade 3A fractures (OR 2.49; 95% CI, 1.30-4.78), and smoking (OR 1.73; 95% CI, 1.09-2.76) were significantly associated with developing a nonunion. Delayed healing was also significantly associated with deep infection (OR 4.34; 95% CI, 1.22-15.48) and grade 3B/C fractures (OR 3.69; 95% CI, 1.44-9.44). Multivariate regression found no association between nonunion and time to surgery (P = 0.15) or antibiotics (P = 0.70). Deep infection and higher Gustilo grade fractures were associated with nonunion and delayed healing. Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Anticipated Transfusion Requirements and Mortality in Patients with Orthopedic and Solid Organ Injuries.

PubMed

Callahan, Devon S; Ashman, Zane; Kim, Dennis Y; Plurad, David S

2016-10-01

Long bone fractures are cited as an etiology for significant blood loss; however, there is scant supporting literature. We examined the relationship between long bone fractures, blood transfusions, and solid organ injuries. We hypothesize that transfusions are rare with long bone fractures in the absence of a liver or splenic injury. We performed a retrospective analysis of patients admitted with femur, tibia, and humerus fractures. Outcomes included transfusion requirements and mortality. A total of 1837 patients were included. There were 182 patients with at least one solid organ injury. A greater portion of patients with femur fractures and a lower proportion of patients with tibia fractures required transfusion. Adjusting for solid organ injuries, there was no difference in transfusions for any patient with these fractures compared with the group, or when grouped by organ injury severity. A solid organ injury significantly increases the risk of death among patients with long bone fractures. Blood loss requiring transfusion in patients with orthopedic and solid organ injuries should not be attributed to the presence of fractures alone. The need for transfusions in these patients should lower the threshold for reimaging or intervention for the solid organ injury. Further study is warranted to quantify blood loss by fracture type with or without solid organ.

Fixation of a split fracture of the lateral tibial plateau with a locking screw plate instead of cannulated screws would allow early weight bearing: a computational exploration.

PubMed

Carrera, Ion; Gelber, Pablo Eduardo; Chary, Gaetan; González-Ballester, Miguel A; Monllau, Juan Carlos; Noailly, Jerome

2016-10-01

To assess, with finite element (FE) calculations, whether immediate weight bearing would be possible after surgical stabilization either with cannulated screws or with a locking plate in a split fracture of the lateral tibial plateau (LTP). A split fracture of the LTP was recreated in a FE model of a human tibia. A three-dimensional FE model geometry of a human femur-tibia system was obtained from the VAKHUM project database, and was built from CT images from a subject with normal bone morphologies and normal alignment. The mesh of the tibia was reconverted into a geometry of NURBS surfaces. A split fracture of the lateral tibial plateau was reproduced by using geometrical data from patient radiographs. A locking screw plate (LP) and a cannulated screw (CS) systems were modelled to virtually reduce the fracture and 80 kg static body-weight was simulated. While the simulated body-weight led to clinically acceptable interfragmentary motion, possible traumatic bone shear stresses were predicted nearby the cannulated screws. With a maximum estimation of about 1.7 MPa maximum bone shear stresses, the Polyax system might ensure more reasonable safety margins. Split fractures of the LTP fixed either with locking screw plate or cannulated screws showed no clinically relevant IFM in a FE model. The locking screw plate showed higher mechanical stability than cannulated screw fixation. The locking screw plate might also allow full or at least partial weight bearing under static posture at time zero.

Ketorolac administration does not delay early fracture healing in a juvenile rat model: a pilot study.

PubMed

Cappello, Teresa; Nuelle, Julia A V; Katsantonis, Nicolas; Nauer, Rachel K; Lauing, Kristen L; Jagodzinski, Jason E; Callaci, John J

2013-06-01

Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective at controlling pain in children, especially in the treatment of fractures. Adult animal and adult clinical studies demonstrate conflicting evidence for the inhibitory relationship between NSAIDs and fracture healing. Published pediatric orthopaedic clinical studies do not demonstrate an inhibitory effect of ketorolac on bone healing. Little is known about the effects of any NSAID on bone formation in juvenile animals. This study investigates the effects of the NSAID ketorolac on fracture healing in a juvenile rat model. Unilateral surgically induced and stabilized tibial shaft fractures were created in 45 juvenile (3 to 4 wk old) male Sprague-Dawley rats. Either ketorolac (5 mg/kg; n=24) or saline (0.9% normal saline; n=21) was then administered to the rats 6 d/wk by intraperitoneal injections. Animals were then randomly assigned into time groups and euthanized at 7 days (n=8 ketorolac, n=7 saline), 14 days (n=8 ketorolac, n=7 saline), or 21 days (n=8 ketorolac, n=7 saline) postfracture. Biomechanical analysis was performed using a custom-designed 4-point bending loading apparatus. Statistics for tibial stiffness and strength data were performed using software package Systat 11. Specimens were also evaluated histologically using hematoxylin and eosin staining. Strength and stiffness of all fractured tibiae increased over time from day 7 to day 21 regardless of treatment type. No statistical difference was found between the fractured tibiae strength or stiffness in the ketorolac or control-treated specimens at the same time point. In addition, the quality of the fracture callus was similar in both groups at each of the time points. In this study of a juvenile rat model with a stabilized tibia fracture, fracture callus strength, stiffness, and histologic characteristics were not affected by the administration of ketorolac during the first 21 days of fracture healing. The absence of inhibitory effects of ketorolac on early juvenile rat fracture healing supports the clinical practice of utilizing NSAIDs for analgesia in children with long bone fractures.

Ketorolac Administration Does Not Delay Early Fracture Healing in a Juvenile Rat Model

PubMed Central

Cappello, Teresa; Nuelle, Julia A.V.; Katsantonis, Nicolas; Nauer, Rachel K.; Lauing, Kristen L.; Jagodzinski, Jason E.; Callaci, John J.

2014-01-01

Background Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective at controlling pain in children, especially in the treatment of fractures. Adult animal and adult clinical studies demonstrate conflicting evidence for the inhibitory relationship between NSAIDs and fracture healing. Published pediatric orthopaedic clinical studies do not demonstrate an inhibitory effect of ketorolac on bone healing. Little is known about the effects of any NSAID on bone formation in juvenile animals. This study investigates the effects of the NSAID ketorolac on fracture healing in a juvenile rat model. Methods Unilateral surgically induced and stabilized tibial shaft fractures were created in 45 juvenile (3 to 4wk old) male Sprague-Dawley rats. Either ketorolac (5 mg/kg; n=24) or saline (0.9% normal saline; n=21) was then administered to the rats 6 d/wk by intraperitoneal injections. Animals were then randomly assigned into time groups and euthanized at 7 days (n=8 ketorolac, n=7 saline), 14 days (n=8 ketorolac, n=7 saline), or 21 days (n=8 ketorolac, n=7 saline) postfracture. Biomechanical analysis was performed using a custom-designed 4-point bending loading apparatus. Statistics for tibial stiffness and strength data were performed using software package Systat 11. Specimens were also evaluated histologically using hematoxylin and eosin staining. Results Strength and stiffness of all fractured tibiae increased over time from day 7 to day 21 regardless of treatment type. No statistical difference was found between the fractured tibiae strength or stiffness in the ketorolac or control-treated specimens at the same time point. In addition, the quality of the fracture callus was similar in both groups at each of the time points. Conclusions In this study of a juvenile rat model with a stabilized tibia fracture, fracture callus strength, stiffness, and histologic characteristics were not affected by the administration of ketorolac during the first 21 days of fracture healing. Clinical Relevance The absence of inhibitory effects of ketorolac on early juvenile rat fracture healing supports the clinical practice of utilizing NSAIDs for analgesia in children with long bone fractures. PMID:23653032

Does morbid obesity negatively affect the hospital course of patients undergoing treatment of closed, lower-extremity diaphyseal long-bone fractures?

PubMed

Baldwin, Keith D; Matuszewski, Paul E; Namdari, Surena; Esterhai, John L; Mehta, Samir

2011-01-03

Obesity is prevalent in the developed world and is associated with significant costs to the health care system. The effect of morbid obesity in patients operatively treated for long-bone fractures of the lower extremity is largely unknown. The National Trauma Data Bank was accessed to determine if morbidly obese patients (body mass index >40) with lower extremity fractures have longer length of hospital stay, higher cost, greater rehabilitation admission rates, and more complications than nonobese patients. We identified patients with operatively treated diaphyseal femur (6920) and tibia (5190) fractures. Polytrauma patients and patients younger than 16 years were excluded. Morbidly obese patients were identified by ICD-9 and database comorbidity designation (femur, 131 morbidly obese; tibia, 75 morbidly obese). Patients meeting these criteria who were not morbidly obese were used as controls. Sensitivity analyses were performed to analyze patients with isolated trauma to the tibia or femur. Morbidly obese patients were more likely to be admitted to a subacute facility. Length of stay trended higher in morbidly obese patients. There was no significant relationship between obesity and inpatient mortality or inpatient complications. These trends held true when considering patients with multiple injuries and patients who had isolated long-bone injuries. Our study showed that morbidly obese patients may have greater rehabilitation needs following long-bone fractures in the lower extremity. Our study showed no difference in mortality or complications, although further studies are needed to confirm these findings. Copyright 2011, SLACK Incorporated.

Limited Associations between Keel Bone Damage and Bone Properties Measured with Computer Tomography, Three-Point Bending Test, and Analysis of Minerals in Swiss Laying Hens

PubMed Central

Gebhardt-Henrich, Sabine G.; Pfulg, Andreas; Fröhlich, Ernst K. F.; Käppeli, Susanna; Guggisberg, Dominik; Liesegang, Annette; Stoffel, Michael H.

2017-01-01

Keel bone damage is a wide-spread welfare problem in laying hens. It is unclear so far whether bone quality relates to keel bone damage. The goal of the present study was to detect possible associations between keel bone damage and bone properties of intact and damaged keel bones and of tibias in end-of-lay hens raised in loose housing systems. Bones were palpated and examined by peripheral quantitative computer tomography (PQCT), a three-point bending test, and analyses of bone ash. Contrary to our expectations, PQCT revealed higher cortical and trabecular contents in fractured than in intact keel bones. This might be due to structural bone repair after fractures. Density measurements of cortical and trabecular tissues of keel bones did not differ between individuals with and without fractures. In the three-point bending test of the tibias, ultimate shear strength was significantly higher in birds with intact vs. fractured keel bones. Likewise, birds with intact or slightly deviated keel bones had higher mineral and calcium contents of the keel bone than birds with fractured keel bones. Calcium content in keel bones was correlated with calcium content in tibias. Although there were some associations between bone traits related to bone strength and keel bone damage, other factors such as stochastic events related to housing such as falls and collisions seem to be at least as important for the prevalence of keel bone damage. PMID:28848740

[Locked plating with minimally invasive percutaneous plate osteosynthesis versus intramedullary nailing of distal extra-articular tibial fracture: a retrospective study].

PubMed

Yao, Qi; Ni, Jie; Peng, Li-bin; Yu, Da-xin; Yuan, Xiao-ming

2013-12-17

To compare the efficacies of minimally invasive plate osteosynthesis (MIPPO) and interlocking intramedullary nailing (IMN) in the treatment of extra-articular fractures of distal tibia. Retrospective reviews were conducted for 126 patients with extra-articular distal tibia fractures. Treatment was either MIPPO (n = 61) or IMN (n = 65). The outcomes were assessed by comparing operating duration, time to union, the last follow-up American Orthopedic Foot and Ankle Society (AOFAS) score and complication rate. The average follow-up period was 23.7 (12-53) months. In the minimally invasive plate osteosynthesis group, there were deep infections (n = 2), superficial infections (n = 5), delayed union (n = 2), malunion (n = 2) and knee joint pain (n = 10) were observed. In addition, the average operating duration (85.9 ± 18.9 min), average time to union (17.3 ± 3.8 weeks) and average AOFAS (83.2 ± 11.9) were analyzed. In the interlocking intramedullary nailing group, there were delayed union (n = 3), malunion (n = 12) and knee joint pain (n = 22). And the average operating duration (83.3 ± 15.7 min), average time to union (16.5 ± 3.1 weeks) and average AOFAS (84.9 ± 12.0) were analyzed. No statistical significance existed in operating duration, time to union and the last follow-up AOFAS between two groups (P > 0.05). However, the rates of malformation and knee joint pain were higher in the intramedullary nail group than those in the plate group. And the difference was statistically significant (P = 0.015, P = 0.025). Both MIPPO and IMN are effective for extra-articular fractures of distal tibia. However, the former has the advantage of lowers rate of malformation and knee joint pain. Therefore a surgeon should consider the degree of injury while managing extra-articular fracture of distal tibia.

Hindfoot Valgus following Interlocking Nail Treatment for Tibial Diaphysis Fractures: Can the Fibula Be Neglected?

PubMed Central

Uzun, Metin; Kara, Adnan; Adaş, Müjdat; Karslioğlu, Bülent; Bülbül, Murat; Beksaç, Burak

2014-01-01

Purpose. We evaluated whether intramedullary nail fixation for tibial diaphysis fractures with concomitant fibula fractures (except at the distal one-third level) managed conservatively with an associated fibula fracture resulted in ankle deformity and assessed the impact of the ankle deformity on lower extremity function. Methods. Sixty middle one-third tibial shaft fractures with associated fibular fractures, except the distal one-third level, were included in this study. All tibial shaft fractures were anatomically reduced and fixed with interlocking intramedullary nails. Fibular fractures were managed conservatively. Hindfoot alignment was assessed clinically. Tibia and fibular lengths were compared to contralateral measurements using radiographs. Functional results were evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Foot and Ankle Disability Index Score (FADI). Results. Anatomic union, defined as equal length in operative and contralateral tibias, was achieved in 60 fractures (100%). Fibular shortening was identified in 42 fractures (68%). Mean fibular shortening was 1.2 cm (range, 0.5–2 cm). Clinical exams showed increased hindfoot valgus in 42 fractures (68%). The mean KOOS was 88.4, and the mean FADI score was 90. Conclusion. Fibular fractures in the middle or proximal one-third may need to be stabilized at the time of tibial intramedullary nail fixation to prevent development of hindfoot valgus due to fibular shortening. PMID:25544899

Early and late fracture following extensive limb lengthening in patients with achondroplasia and hypochondroplasia.

PubMed

Kitoh, H; Mishima, K; Matsushita, M; Nishida, Y; Ishiguro, N

2014-09-01

Two types of fracture, early and late, have been reported following limb lengthening in patients with achondroplasia (ACH) and hypochondroplasia (HCH). We reviewed 25 patients with these conditions who underwent 72 segmental limb lengthening procedures involving the femur and/or tibia, between 2003 and 2011. Gender, age at surgery, lengthened segment, body mass index, the shape of the callus, the amount and percentage of lengthening and the healing index were evaluated to determine predictive factors for the occurrence of early (within three weeks after removal of the fixation pins) and late fracture (> three weeks after removal of the pins). The Mann‑Whitney U test and Pearson's chi-squared test for univariate analysis and stepwise regression model for multivariate analysis were used to identify the predictive factor for each fracture. Only one patient (two tibiae) was excluded from the analysis due to excessively slow formation of the regenerate, which required supplementary measures. A total of 24 patients with 70 limbs were included in the study. There were 11 early fractures in eight patients. The shape of the callus (lateral or central callus) was the only statistical variable related to the occurrence of early fracture in univariate and multivariate analyses. Late fracture was observed in six limbs and the mean time between removal of the fixation pins and fracture was 18.3 weeks (3.3 to 38.4). Lengthening of the tibia, larger healing index, and lateral or central callus were related to the occurrence of a late fracture in univariate analysis. A multivariate analysis demonstrated that the shape of the callus was the strongest predictor for late fracture (odds ratio: 19.3, 95% confidence interval: 2.91 to 128). Lateral or central callus had a significantly larger risk of fracture than fusiform, cylindrical, or concave callus. Radiological monitoring of the shape of the callus during distraction is important to prevent early and late fracture of lengthened limbs in patients with ACH or HCH. In patients with thin callus formation, some measures to stimulate bone formation should be considered as early as possible. ©2014 The British Editorial Society of Bone & Joint Surgery.

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.

A Comparison of Two Surgical Techniques Using the Unity Knee™ Total Knee System

ClinicalTrials.gov

2018-04-24

Osteoarthritis, Knee; Rheumatoid Arthritis; Post-Traumatic Osteoarthritis of Knee; Varus Deformity, Not Elsewhere Classified, Knee; Valgus Deformity, Not Elsewhere Classified, Knee; Flexion Deformity, Knee; Fracture of Distal End of Femur; Fracture of Upper End of Tibia

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.

Avianca flight No. 052 accident: a plastic surgical perspective.

PubMed

Greenberg, B M; Brewer, B W

1991-09-01

The crash of Avianca Airlines flight no. 052 en route to JFK Airport on January 25, 1990, in Cove Neck, New York, resulted in the death of 72 passengers. Eighty-nine victims were admitted to 13 regional hospitals. Despite difficult access to the wooded crash site, early warning and prompt response by 37 volunteer fire and rescue units resulted in organized EMS triage and rapid hospital transport. This report reviews the specific injuries incurred, highlights the team management approach to a major aviation accident in a suburban area, and studies the likelihood of accidents of this magnitude. Thirty-eight patients triaged to two level I trauma centers, North Shore University Hospital-Cornell University Medical Center and Nassau County Medical Center, form the basis of this report. Seventeen patients were male; 21 were female. The average patient age was 33 years. Eight patients were children. The average length of stay was 30.9 days (range 2 to greater than 90 days). Twenty-six patients (including nonsurvivors) (68 percent) sustained significant multiple orthopedic injuries. The majority of fractures were open grade II to III tibia-fibula fractures. Bilaterality was commonly seen. Soft-tissue coverage of open long bone fractures was required in 10 patients (11 extremities) and included 3 microvascular muscle transfers, 7 muscle transposition flaps, and 3 skin grafts. Seven patients required open reduction and fixation of complex facial fractures (two of Le Fort II to III type, four of complex naso-orbital-ethmoid type). Plastic surgical repair of complex lacerations was common. Peripheral nerve exploration was required in three patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Return to Sport Following Surgery for a Complicated Tibia and Fibula Fracture in a Collegiate Women's Soccer Player with a Low Level of Kinesiophobia.

PubMed

Feigenbaum, Luis A; Baraga, Michael; Kaplan, Lee D; Roach, Kathryn E; Calpino, Kathryn M; Dorsey, Katie; Martorelli, Cristina; Sagarduy, Beatriz; King, Lesley-Anne; Scavo, Vincent A

2015-02-01

Much attention has been solely paid to physical outcome measures for return to sport after injury in the past. However, current research shows that the psychological component of these injuries can be more predictive of return to sport than physical outcome measures. The purpose of this case report is to describe the successful return to sport following surgery of a complicated tibia and fibula fracture of a Division I collegiate women's soccer player with a low level of kinesiophobia. A 22-year-old female sustained a closed traumatic mid-shaft fracture of her tibia and fibula. During a high velocity play she sustained a direct blow while colliding with an opposing player's cleats. As a result of the play, her distal tibia was displaced 908 to the rest of her leg. She underwent a closed reduction and tibial internal fixation with an intramedullary rod. Outcome scores were tracked using the IKDC and TSK-11. The IKDC measures symptoms, function, and sport activity related to knee injuries. The TSK-11 measures fear of movement and re-injury, which was important to assess during this case due to the gruesome nature of the injury. At 4 months, the subject became symptomatic over the fibula and was diagnosed with a fibular nonunion fracture. This was unexpected due to the low incidence of and usual asymptomatic nature of fibular nonunion fractures, which required an additional surgery. TSK-11 scores ranged from 19-20 throughout, signifying low levels of kinesiophobia. IKDC scores improved from 8.05 to 60.92. The subject ultimately signed a professional soccer contract. The rehabilitation of this subject was complex due to her low levels of kinesiophobia, self-guided overtraining, and the potential role they may have had in her fibular nonunion fracture. This case study demonstrates a successful outcome despite a unique injury presentation, multiple surgeries, and low levels of kinesiophobia. While a low level of kinesiophobia can be detrimental to rehabilitation compliance, it may have benefited her in the long-term. 5.

Management of knee rheumatoid arthritis and tibia nonunion with one-stage total knee arthroplasty and intramedullary nailing: A report of two cases.

PubMed

Erdogan, Fahri; Sarikaya, Ilker Abdullah; Can, Ata; Gorgun, Baris

2018-01-01

Total knee arthroplasty (TKA) is a surgical procedure which is widely used in the treatment of gonarthrosis secondary to rheumatoid arthritis (RA). The incidence of stress fractures in tibia in the patients with RA is higher compared to normal patients. In this study, we report two cases of TKA and intramedullary nailing in RA patients with severe knee arthritis and tibial nonunion. Both patients had a satisfactory clinical outcome with radiological healing of the tibial fracture. Copyright © 2017 Turkish Association of Orthopaedics and Traumatology. Production and hosting by Elsevier B.V. All rights reserved.

Autologous platelet lysates local injections for treatment of tibia non-union with breakage of the nickelclad: a case report.

PubMed

Jiang, Hong-Jiang; Tan, Xun-Xiang; Ju, Hai-Yang; Su, Jin-Ping; Yan, Wei; Song, Xiu-Gang; Qin, Li-Wu; Ju, Chang-Jun; Wang, Ling-Shuang; Zou, De-Bao

2016-01-01

Nonunions of the tibia represent challenging orthopedic problems, which require the surgeon to analyze numerous factors and choose an appropriate treatment. This article presents a case report of tibia and fibula fracture patient who failed the internal fixation surgery and successfully recovered after one course of percutaneous autologous platelet lysates injection. The patient received an internal nickelclad breakage at 9 months post-surgery but reluctant to accept a second surgery, then autologous platelet lysates (APL) injection which is a less invasive method was recommended. The injections were carried once a week for three times. Radiologic evaluation was conducted every month until recovery. To the best of our knowledge, this is the first reported case of tibia delayed union with breakage of the plate resolved with APL injection. Improved clinical evidence was observed at 4 and 6 months after injection. The patient got good bony union at 8 months post-injection. The patient didn't feel any discomfort postinjection, no complications such as infection, refracture etc. were observed. APL percutaneous injection could be a new therapeutic option for the treatment of nonunion or delayed healing fractures.

Deployment After Limb Salvage for High-Energy Lower-Extremity Trauma

DTIC Science & Technology

2012-01-01

idiopathic avascular necrosis of the talus, and one had an iatrogenic nerve injury after pelvic surgery. Six of the patients underwent circular external... avascular necrosis Unknown 10 40 Distal tibia fracture Fall from height 11 38 Calcaneus fracture, fifth metatarsal fracture, ankle fracture, talus...injury, and one fall from height). One patient developed idiopathic avascular ne- crosis of the talus without a precipitating injury, and one de

Time-Dependent Changes in T1 during Fracture Healing in Juvenile Rats: A Quantitative MR Approach

PubMed Central

Baron, Katharina; Neumayer, Bernhard; Amerstorfer, Eva; Scheurer, Eva; Diwoky, Clemens; Stollberger, Rudolf; Sprenger, Hanna; Weinberg, Annelie M.

2016-01-01

Quantitative magnetic resonance imaging (qMRI) offers several advantages in imaging and determination of soft tissue alterations when compared to qualitative imaging techniques. Although applications in brain and muscle tissues are well studied, its suitability to quantify relaxation times of intact and injured bone tissue, especially in children, is widely unknown. The objective observation of a fracture including its age determination can become of legal interest in cases of child abuse or maltreatment. Therefore, the aim of this study is the determination of time dependent changes in intact and corresponding injured bones in immature rats via qMRI, to provide the basis for an objective and radiation-free approach for fracture dating. Thirty-five MR scans of 7 Sprague-Dawley rats (male, 4 weeks old, 100 ± 5 g) were acquired on a 3T MRI scanner (TimTrio, Siemens AG, Erlangen, Germany) after the surgical infliction of an epiphyseal fracture in the tibia. The images were taken at days 1, 3, 7, 14, 28, 42 and 82 post-surgery. A proton density-weighted and a T1-weighted 3D FLASH sequence were acquired to calculate the longitudinal relaxation time T1 of the fractured region and the surrounding tissues. The calculation of T1 in intact and injured bone resulted in a quantitative observation of bone development in intact juvenile tibiae as well as the bone healing process in the injured tibiae. In both areas, T1 decreased over time. To evaluate the differences in T1 behaviour between the intact and injured bone, the relative T1 values (bone-fracture) were calculated, showing clear detectable alterations of T1 after fracture occurrence. These results indicate that qMRI has a high potential not only for clinically relevant applications to detect growth defects or developmental alterations in juvenile bones, but also for forensically relevant applications such as the dating of fractures in cases of child abuse or maltreatment. PMID:27832068

Lower limb fracture presentations at a regional hospital.

PubMed

Holloway, K L; Yousif, D; Bucki-Smith, G; Hosking, S; Betson, A G; Williams, L J; Brennan-Olsen, S L; Kotowicz, M A; Sepetavc, A; Pasco, J A

2017-08-28

We found that lower limb fractures, which were largely the result of minimal trauma, had high levels of hospitalisation, length of stay and surgery. It is therefore important to prevent fractures at all sites to avoid the associated morbidity and mortality. Hip fractures are a major cause of morbidity and mortality, particularly in older women. In comparison, less is known about the epidemiology and burden of other lower limb fractures. The study aimed to investigate the epidemiology and burden of these fractures. Incident fractures of the hip, femur, tibia/fibula, ankle and foot in women (≥ 20 years) managed through the University Hospital Geelong, Australia, were ascertained from 1 Jan. 2014 to 31 Dec. 2014 from radiology reports. Age, cause of fracture, post-fracture hospitalisation, surgery, length of stay and discharge location were ascertained from medical records. We identified 585 fractures of the lower limb (209 hip, 42 femur, 41 tibia/fibula, 162 ankle, 131 foot). Most fractures were sustained by women aged ≥ 50 years. Fractures were largely a result of minimal trauma. Most women with hip or femur fractures were hospitalised; fewer were hospitalised for fractures at other sites. Surgery for fracture followed the same pattern as hospitalisations. Length of stay was the highest for hip and femur fractures and the lowest for foot fractures. Women with hip or femur fractures were discharged to rehabilitation more often than home. Fractures at other sites were most commonly discharged home. Fractures of the lower limb occurred frequently in older women. Hospitalisation and subsequent surgery were common in cases of hip and femur fractures. It is important for prevention strategies to target fractures at a range of skeletal sites to reduce costs, hospitalisations, loss of independence and reduced quality of life.

Ultrasound elastography assessment of bone/soft tissue interface

NASA Astrophysics Data System (ADS)

Parmar, Biren J.; Yang, Xu; Chaudhry, Anuj; Shafeeq Shajudeen, Peer; Nair, Sanjay P.; Weiner, Bradley K.; Tasciotti, Ennio; Krouskop, Thomas A.; Righetti, Raffaella

2016-01-01

We report on the use of elastographic imaging techniques to assess the bone/soft tissue interface, a region that has not been previously investigated but may provide important information about fracture and bone healing. The performance of axial strain elastograms and axial shear strain elastograms at the bone/soft tissue interface was studied ex vivo on intact and fractured canine and ovine tibias. Selected ex vivo results were corroborated on intact sheep tibias in vivo. The elastography results were statistically analyzed using elastographic image quality tools. The results of this study demonstrate distinct patterns in the distribution of the normalized local axial strains and axial shear strains at the bone/soft tissue interface with respect to the background soft tissue. They also show that the relative strength and distribution of the elastographic parameters change in the presence of a fracture and depend on the degree of misalignment between the fracture fragments. Thus, elastographic imaging modalities might be used in the future to obtain information regarding the integrity of bones and to assess the severity of fractures, alignment of bone fragments as well as to follow bone healing.

Management of the Floating Knee in Polytrauma Patients

PubMed Central

Bertrand, M.L.; Andrés-Cano, P.

2015-01-01

Ipsilateral fracture of the femur and tibia, or floating knee, is a rare injury that is found almost exclusively in polytrauma or high-energy trauma patients. It presents a combination of diaphyseal, metaphyseal and intra-articular fractures of the femur and tibia, with a high incidence of neurovascular, ligamentous and soft-tissue injuries. The functional outcome and, in some cases, the life, of such polytrauma patients depends largely on a correct therapeutic approach being taken. In general, the treatment decided upon will depend on the individual characteristics present, regarding aspects such as the patient’s general condition, the fracture line and the state of the soft tissues. The treatment provided may be the same as when single fractures are presented, but it is often necessary to consider whether certain techniques or surgical approaches may interfere with other lines of treatment. It is essential at all times to take into consideration the associated injuries and complications before deciding upon a treatment strategy. Ligamentous injuries play an important role in these injuries, much more so than when fractures occur singly. Therefore, these injuries require management by an experienced multidisciplinary team. PMID:26312119

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

Ankle fusion for definitive management of non-reconstructable pilon fractures.

PubMed

Bozic, Vladimir; Thordarson, David B; Hertz, Jennifer

2008-09-01

Highly comminuted pilon fractures, especially with a compromised soft tissue envelope, present a challenging treatment scenario. This study presents our results for patients managed with ankle fusion rather than ORIF. Fourteen patients with ankle joint incongruence after non-reconstructable tibia pilon fractures were treated with primary tibiotalar arthrodesis using a fixed-angle cannulated blade plate. Delayed metaphyseal unions due to bone defects were treated concurrently. The subtalar joint was preserved in all cases. Metaphyseal healing and stable arthrodesis was obtained in each case. There was one case of blade plate breakage in a patient who still achieved successful arthrodesis without reoperation. Union was achieved at an average of 15 weeks. No secondary procedures were required to obtain union. All 14 patients were ambulatory at last followup. Average followup was 39 weeks. Primary ankle arthrodesis can be achieved using a cannulated blade plate to address a non-reconstructable articular surface and metaphyseal bone defects in complex tibia pilon fractures.

Radial and tibial fracture repair with external skeletal fixation. Effects of fracture type, reduction, and complications on healing.

PubMed

Johnson, A L; Kneller, S K; Weigel, R M

1989-01-01

Twenty-eight consecutive fractures of the canine radius and tibia were treated with external skeletal fixation as the primary method of stabilization. The time of fixation removal (T1) and the time to unsupported weight-bearing (T2) were correlated with: (1) bone involved; (2) communication of the fracture with the external environment; (3) severity of the fracture; (4) proximity of the fracture to the nutrient artery; (5) method of reduction; (6) diaphyseal displacement after reduction; and (7) gap between cortical fragments after reduction. The Kruskal-Wallis one-way analysis of variance was used to test the correlation with p less than .05 set as the criterion for significance. The median T1 was 10 weeks and the median T2 was 11 weeks. None of the variables correlated significantly with either of the healing times; however, there was a strong trend toward longer healing times associated with open fractures and shorter healing times associated with closed reduction. Periosteal and endosteal callus uniting the fragments were observed radiographically in comminuted fractures, with primary bone union observed in six fractures in which anatomic reduction was achieved. Complications observed in the treatment of these fractures included: bone lysis around pins (27 fractures), pin track drainage (27 fractures), pin track hemorrhage (1 fracture), periosteal reaction around pins (27 fractures), radiographic signs consistent with osteomyelitis (12 fractures), degenerative joint disease (2 dogs), and nonunion (1 fracture). Valgus or rotational malalignment resulted in 16 malunions of fractures. One external fixation device was replaced and four loose pins were removed before the fractures healed. One dog was treated with antibiotics during the postoperative period because clinical signs of osteomyelitis appeared.(ABSTRACT TRUNCATED AT 250 WORDS)

Dipyrone has no effects on bone healing of tibial fractures in rats

PubMed Central

Gali, Julio Cesar; Sansanovicz, Dennis; Ventin, Fernando Carvalho; Paes, Rodrigo Henrique; Quevedo, Francisco Carlos; Caetano, Edie Benedito

2014-01-01

OBJECTIVE: To evaluate the effect of dipyrone on healing of tibial fractures in rats. METHODS: Fourty-two Wistar rats were used, with mean body weight of 280g. After being anesthetized, they were submitted to closed fracture of the tibia and fibula of the right posterior paw through manual force. The rats were randomly divided into three groups: the control group that received a daily intraperitoneal injection of saline solution; group D-40, that received saline injection containing 40mg/Kg dipyrone; and group D-80, that received saline injection containing 80mg/Kg dipyrone. After 28 days the rats were sacrificed and received a new label code that was known by only one researcher. The fractured limbs were then amputated and X-rayed. The tibias were disarticulated and subjected to mechanical, radiological and histological evaluation. For statistical analysis the Kruskal-Wallis test was used at a significance level of 5%. RESULTS: There wasn't any type of dipyrone effect on healing of rats tibial fractures in relation to the control group. CONCLUSION: Dipyrone may be used safely for pain control in the treatment of fractures, without any interference on bone healing. Level of Evidence II, Controlled Laboratory Study. PMID:25246852

Onset of mandible and tibia osteoradionecrosis – a comparative pilot study in the rat

PubMed Central

Damek-Poprawa, Monika; Both, Stefan; Wright, Alexander C.; Maity, Amit; Akintoye, Sunday O.

2012-01-01

Objectives Osteoradionecrosis (ORN) is common in the jaws following radiotherapy. We hypothesized that mandible is more susceptible to ORN than tibia based on site-disparity in hypoxic-hypocellular-hypovascular tissue breakdown. Study Design Twelve rats received 50 Gy irradiation to mandible or tibia; 4 of 12 rats further received minor surgical trauma to the irradiated sites. Structural and cellular skeletal changes were assessed with computer tomography, histology and immunostaining. Results Mandible developed ORN with 70% mean bone loss 10 weeks post-irradiation (p < 0.05) while tibia was structurally and radiological intact for 20 weeks post-irradiation. Hypocellularity, hypoxia and oxidative stress were higher in irradiated mandible (p < 0.001) than tibia (p < 0.01) but vascular damage was similar at both skeletal sites. Combined effects of radiation and minor trauma promoted mandibular alveolar bone loss and tibial fracture Conclusion ORN has a more rapid onset in mandible relative to tibia in the rat PMID:23254371

Island osteoperiosteal flap vitality when isolated from basal bone by silicone interposition: an experimental study in rabbit tibia.

PubMed

Laviv, Amir; Ringeman, Jason; Debecco, Meir; Jensen, Ole T; Casap, Nardy

2014-01-01

This study sought to confirm, through histologic evaluation, the vitality and viability of the island osteoperiosteal flap (i-flap) in a rabbit tibia model. In four rabbits, an osteotomy was performed on the tibial aspect of the right leg. A bone flap was raised, but the periosteal attachment was kept intact. The free-floating i-flap was separated from the rest of the bone by a silicone sheet. The rabbits were to be sacrificed after 1, 2, 4, and 8 weeks and histologic samples examined. All surgeries were accomplished successfully; however, three animals showed fractured tibiae within a few days after surgery and were sacrificed immediately after the fractures were discovered. The fourth rabbit was sacrificed at 4 weeks. Histologic specimens showed vital new bone in the i-flap area and signs of remodeling in the transition zone and the original basal bone. The i-flap remained vital. This suggests potential for use in bone augmentation strategies, particularly for the alveolar split procedure.

Desmoplastic fibroma of the distal tibia: A case report of a minimally invasive histological diagnosis

PubMed Central

Levrini, Gabriele; Pattacini, Pierpaolo

2016-01-01

Desmoplastic fibroma (DF) is a benign, rare fibroblastic intraosseous neoplasm histologically resembling a desmoid soft tissue tumor. Although classified as benign, DF frequently exhibits an aggressive behavior, has a moderate-to-high recurrence rate, and often causes pathological fractures and extensive bone destruction. This case report presents an incidentally detected DF of the tibia, which was diagnosed using a minimally invasive approach. A 36-year-old African female patient was referred to the Department of Diagnostic Imaging of Arcispedale Santa Maria Nuova-IRCCS (Reggio Emilia, Italy), to be examined by a computed tomography scan on an outpatient basis, after an x-ray examination of the tibia, which was performed after an injury to exclude the presence of a fracture, revealed a hyperlucency of unknown origin. The aim of this study was to discuss the clinical, histological, immunohistochemical and radiographic characteristics of this rare neoplasm, with a focus on image-guided bone biopsy. PMID:27882239

Reconstruction of Traumatic Bone Defect With In Situ Implantation of Dropped Traumatic Segmental Bone Fragments.

PubMed

Lin, Dasheng; Luo, Deqing; Lian, Kejian; Zhai, Wenliang; Ding, Zhenqi

2016-01-01

This study was conducted to determine whether in situ implantation of a dropped traumatic segmental bone fragment is safe and whether the authors' method would reduce the incidence of infectious and related complications. The authors retrospectively reviewed 16 patients with open fractures, including 11 with Gustilo-Anderson type IIIA fractures and 5 with Gustilo-Anderson type IIIB fractures who had a dropped traumatic segmental bone fragment between January 2002 and January 2012. Mean patient age was 35.4 years (range, 19-47 years). There were 10 femurs and 6 tibias. Average postoperative follow-up was 26.8 months (range, 12-60 months). The dropped traumatic segmental bone fragments were cleaned with 3% hydrogen peroxide, placed in separate sterile cups, and soaked in 1% iodophor for 30 minutes. Initial treatment included surgical debridement, wound irrigation, in situ implantation of the dropped traumatic segmental bone fragment, and temporary external fixation. Approximately 4 to 8 weeks later, after successful reconstruction of the soft tissue envelope, minimally invasive plate osteosynthesis was performed. Mean duration of treatment was 8 weeks (range, 6-14 weeks). All patients had fracture union at final follow-up. Mean healing time was 21.8 weeks (range, 14-48 weeks). One patient did not achieve primary union and required bone grafting. One patient with a Gustilo-Anderson type IIIB fracture had deep infection and removal of the dropped traumatic segmental bone fragment and bone grafting. According to the Klemm and Börner classification, 11 patients had excellent results, 3 had good results, and 2 had poor results. With adequate soft tissue coverage, this method was acceptable for the management of open fractures with bone defects. Copyright 2016, SLACK Incorporated.

Are certain fractures at increased risk for compartment syndrome after civilian ballistic injury?

PubMed

Meskey, Thomas; Hardcastle, John; O'Toole, Robert V

2011-11-01

Compartment syndrome after ballistic fracture is uncommon but potentially devastating. Few data are available to help guide clinicians regarding risk factors for developing compartment syndrome after ballistic fractures. Our primary hypothesis was that ballistic fractures of certain bones would be at higher risk for development of compartment syndrome. A retrospective review at a Level I trauma center from 2001 through 2007 yielded 650 patients with 938 fractures resulting from gunshots. We reviewed all operative notes, clinic notes, discharge summaries, and data from our prospective trauma database. Cases in which the attending orthopedic surgeon diagnosed compartment syndrome and performed fasciotomy were considered cases with compartment syndrome. We excluded all prophylactic fasciotomies. Univariate analyses were conducted to identify risk factors associated with development of compartment syndrome. Twenty-six (2.8%) of the 938 fractures were associated with compartment syndrome. Only fibular (11.6%) and tibial (11.4%) fractures had incidence significantly higher than baseline for all ballistic fractures (p < 0.001). Fractures of the proximal third of the fibula were more likely to result in compartment syndrome than fractures of the middle or distal third (p = 0.03), as were fractures of the proximal third of the tibia (p = 0.01). No other demographic or injury parameters were associated with compartment syndrome. Ballistic fractures of the fibula and tibia are at increased risk for development of compartment syndrome over other ballistic fractures. We recommend increased vigilance when treating these injuries, particularly if the fracture is in the proximal aspect of the bone or is associated with vascular injury.

Inverse Dynamics Model for the Ankle Joint with Applications in Tibia Malleolus Fracture

NASA Astrophysics Data System (ADS)

Budescu, E.; Merticaru, E.; Chirazi, M.

The paper presents a biomechanical model of the ankle joint, in order to determine the force and the torque of reaction into the articulation, through inverse dynamic analysis, in various stages of the gait. Thus, knowing the acceleration of the foot and the reaction force between foot and ground during the gait, determined by experimental measurement, there was calculated, for five different positions of the foot, the joint reaction forces, on the basis of dynamic balance equations. The values numerically determined were compared with the admissible forces appearing in the technical systems of osteosynthesis of tibia malleolus fracture, in order to emphasize the motion restrictions during bone healing.

Tibial bone fractures occurring after medioproximal tibial bone grafts for oral and maxillofacial reconstruction.

PubMed

Kim, Il-Kyu; Cho, Hyun-Young; Pae, Sang-Pill; Jung, Bum-Sang; Cho, Hyun-Woo; Seo, Ji-Hoon

2013-12-01

Oral and maxillofacial defects often require bone grafts to restore missing tissues. Well-recognized donor sites include the anterior and posterior iliac crest, rib, and intercalvarial diploic bone. The proximal tibia has also been explored as an alternative donor site. The use of the tibia for bone graft has many benefits, such as procedural ease, adequate volume of cancellous and cortical bone, and minimal complications. Although patients rarely complain of pain, swelling, discomfort, or dysfunction, such as gait disturbance, both patients and surgeons should pay close attention to such after effects due to the possibility of tibial fracture. The purpose of this study is to analyze tibial fractures that occurring after osteotomy for a medioproximal tibial graft. An analysis was intended for patients who underwent medioproximal tibial graft between March 2004 and December 2011 in Inha University Hospital. A total of 105 subjects, 30 females and 75 males, ranged in age from 17 to 78 years. We investigated the age, weight, circumstance, and graft timing in relation to tibial fracture. Tibial fractures occurred in four of 105 patients. There were no significant differences in graft region, shape, or scale between the fractured and non-fractured patients. Patients who undergo tibial grafts must be careful of excessive external force after the operation.

Coupled external fixator and skin flap transposition for treatment of exposed and nonunion bone.

PubMed

Zhao, Yong-gang; Ding, Jing; Wang, Neng

2011-02-01

To discuss the effect of coupled external fixator and skin flap transposition on exposed and nonunion bones. The data of 12 cases of infected nonunion and exposed bone following open fracture treated in our hospital during the period of March 1998 to June 2008 were analysed. There were 10 male patients, 2 female patients, whose age were between 19-52 years and averaged 28 years. There were 10 tibial fractures and 2 femoral fractures. The course of diseases lasted for 12-39 months with the mean period of 19 months. All the cases were treated by the coupled external fixator and skin flap transposition. Primary healing were achieved in 10 cases and delayed healing in 2 cases in whom the tibia was exposed due to soft tissue defect and hence local flap transposition was performed. All the 12 cases had bony union within 6-12 months after operation with the average time of 8 months. They were followed up for 1-3 years and all fractures healed up with good function and no infection recurrence. The coupled external fixator and skin flap transposition therapy have shown optimal effects on treating infected, exposed and nonunion bones.

The floating knee: a review on ipsilateral femoral and tibial fractures

PubMed Central

Muñoz Vives, Josep; Bel, Jean-Christophe; Capel Agundez, Arantxa; Chana Rodríguez, Francisco; Palomo Traver, José; Schultz-Larsen, Morten; Tosounidis, Theodoros

2016-01-01

In 1975, Blake and McBryde established the concept of ‘floating knee’ to describe ipsilateral fractures of the femur and tibia.1 This combination is much more than a bone lesion; the mechanism is usually a high-energy trauma in a patient with multiple injuries and a myriad of other lesions. After initial evaluation patients should be categorised, and only stable patients should undergo immediate reduction and internal fixation with the rest receiving external fixation. Definitive internal fixation of both bones yields the best results in almost all series. Nailing of both bones is the optimal fixation when both fractures (femoral and tibial) are extra-articular. Plates are the ‘standard of care’ in cases with articular fractures. A combination of implants are required by 40% of floating knees. Associated ligamentous and meniscal lesions are common, but may be irrelevant in the case of an intra-articular fracture which gives the worst prognosis for this type of lesion. Cite this article: Muñoz Vives K, Bel J-C, Capel Agundez A, Chana Rodríguez F, Palomo Traver J, Schultz-Larsen M, Tosounidis, T. The floating knee. EFORT Open Rev 2016;1:375-382. DOI: 10.1302/2058-5241.1.000042. PMID:28461916

Intramedullary nailing versus plating for distal tibia fractures without articular involvement: a meta-analysis.

PubMed

Mao, Zhi; Wang, Guoqi; Zhang, Lihai; Zhang, Licheng; Chen, Shuo; Du, Hailong; Zhao, Yanpeng; Tang, Peifu

2015-06-16

The choice between intramedullary (IM) nailing or plating of distal tibia fractures without articular involvement remains controversial. A meta-analysis of randomized controlled trials (RCTs) and observational studies was performed to compare IM nailing with plating for distal tibia fractures without articular involvement and to determine the dominant strategy. The PubMed, Embase, Cochrane Library databases, Chinese Wan-Fang Database, and China National Knowledge Infrastructure were searched. Twenty-eight studies, which included 1863 fractures, met the eligible criteria. The meta-analysis did not identify a statistically significant difference between the two treatments in terms of the rate of deep infection, delayed union, removal of instrumentation, or secondary procedures either in the RCT or retrospective subgroups. IM nailing was associated with significantly more malunion events and a higher incidence of knee pain in the retrospective subgroup and across all the studies, but not significantly in the RCT subgroup, and a lower rate of delayed wound healing and superficial infection both in the RCT and retrospective subgroups relative to plating. A meta-analysis of the functional scores or questionnaires was not possible because of the considerable variation among the included studies, and no significant differences were observed. Evidence suggests that both IM nailing and plating are appropriate treatments as IM nailing shows lower rate of delayed wound healing and superficial infection and plating may avoid malunion and knee pain. These findings should be interpreted with caution, however, because of the heterogeneity of the study designs. Large, rigorous RCTs are required.

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.

Phosphaturic mesenchymal tumor of the tibia with oncogenic osteomalacia in a teenager.

PubMed

Farmakis, Shannon G; Siegel, Marilyn J

2015-08-01

Phosphaturic mesenchymal tumor is an uncommon cause of a paraneoplastic syndrome that can be associated with osteogenic osteomalacia. This tumor most commonly occurs in middle-aged men and women. We report a rare case of a phosphaturic mesenchymal tumor in a 16-year-old girl with multiple fractures as a result of severe osteoporosis. CT and MRI showed a mass arising from the tibia.

Resistance of equine tibiae and radii to side impact loads.

PubMed

Piskoty, G; Jäggin, S; Michel, S A; Weisse, B; Terrasi, G P; Fürst, A

2012-11-01

There are no detailed studies describing the resistance of equine tibiae and radii to side impact loads, such as a horse kick and a better understanding of the general long bone impact behavioural model is required. To quantify the typical impact energy required to fracture or fissure an equine long bone, as well as to determine the range and time course of the impact force under conditions similar to that of a horse kick. Seventy-two equine tibiae and radii were investigated using a drop impact tester. The prepared bones were preloaded with an axial force of 2.5 kN and were then hit in the middle of the medial side. The impact velocity of the metal impactor, weighting 2 kg, was varied within the range of 6-11 m/s. The impact process was captured with a high-speed camera from the craniomedial side of the bone. The videos were used both for slow-motion observation of the process and for quantifying physical parameters, such as peak force via offline video tracking and subsequent numerical derivation of the 'position vs. time' function for the impactor. The macroscopic appearance of the resultant bone injuries was found to be similar to those produced by authentic horse kicks, indicating a successful simulation of the real load case. The impact behaviours of tibiae and radii do not differ considerably in terms of the investigated general characteristics. Peak force occurred between 0.15-0.30 ms after the start of the impact. The maximum contact force correlated with the 1.45-power of the impact velocity if no fracture occurred (F(max) ≈ 0.926 · v(i) (1.45) ). Peak force scatter was considerably larger within the fractured sub-group compared with fissured bones. The peak force for fracture tended to lie below the aforementioned function, within the range of F(max) = 11-23 kN ('fracture load'). The impact energy required to fracture a bone varied from 40-90 J. The video-based measuring method allowed quantifying of the most relevant physical parameters, such as contact force and energy balance. The results obtained should help with the development of bone implants and guards, supporting theoretical studies, and in the evaluation of bone injuries. © 2012 EVJ Ltd.

High incidence of osteochondral lesions after open reduction and internal fixation of displaced ankle fractures: Medium-term follow-up of 100 cases.

PubMed

Regier, Marc; Petersen, Jan Philipp; Hamurcu, Ahmet; Vettorazzi, Eik; Behzadi, Cyrus; Hoffmann, Michael; Großterlinden, Lars G; Fensky, Florian; Klatte, Till Orla; Weiser, Lukas; Rueger, Johannes M; Spiro, Alexander S

2016-03-01

The incidence of osteochondral lesions (OCLs) in association with displaced ankle fractures has only been examined in two previous studies. In both studies magnetic resonance imaging (MRI) was performed prior to open reduction and internal fixation (ORIF). Because MRI may overdiagnose or overestimate the extent of OCLs in an acute trauma setting the aim of this study was to determine the incidence of OCLs after ORIF of displaced ankle fractures using MRI at medium-term follow-up, and to analyse if the severity of fracture or the clinical outcome correlates with the incidence of OCLs. Following institutional review board approval a total of 100 patients (mean age, 41.3 years; range, 17.9-64.3 years) with a displaced ankle fracture who had undergone ORIF according to the AO principles were included in this study. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was used to quantify the clinical outcome and MR images were evaluated for OCLs of the talus and distal tibia after a mean of 34.5 months (range, 17.5-54.1 months). OCLs were found in 40.4% of the patients. Logistic regression revealed a significant correlation between the severity of fracture and the incidence of OCLs. Patients with a trimalleolar fracture (p=0.04) or an ankle fracture dislocation (p=0.003) had a significantly higher risk for developing an OCL compared to those with a type B fracture. Logistic regression also demonstrated a significant correlation between the clinical outcome (AOFAS score) and the incidence of OCLs (p=0.01). The risk for developing an OCL increases up to 5.6% when the AOFAS score decreases by one point. OCLs were frequently found in association with acute ankle fractures at medium-term follow-up, and the severity of fracture was associated with an increased number of OCLs. Considering the disadvantages of MRI including the high cost and limited availability, the results of this study may help to explain why anatomic surgical realignment of displaced ankle fractures may still be associated with poor clinical outcomes. Copyright © 2015 Elsevier Ltd. All rights reserved.

Virtual stress testing of fracture stability in soldiers with severely comminuted tibial fractures.

PubMed

Petfield, Joseph L; Hayeck, Garry T; Kopperdahl, David L; Nesti, Leon J; Keaveny, Tony M; Hsu, Joseph R

2017-04-01

Virtual stress testing (VST) provides a non-invasive estimate of the strength of a healing bone through a biomechanical analysis of a patient's computed tomography (CT) scan. We asked whether VST could improve management of patients who had a tibia fracture treated with external fixation. In a retrospective case-control study of 65 soldier-patients who had tibia fractures treated with an external fixator, we performed VST utilizing CT scans acquired prior to fixator removal. The strength of the healing bone and the amount of tissue damage after application of an overload were computed for various virtual loading cases. Logistic regression identified computed outcomes with the strongest association to clinical events related to nonunion within 2 months after fixator removal. Clinical events (n = 9) were associated with a low tibial strength for compression loading (p < 0.05, AUC = 0.74) or a low proportion of failed cortical bone tissue for torsional loading (p < 0.005, AUC = 0.84). Using post-hoc thresholds of a compressive strength of four times body-weight and a proportional of failed cortical bone tissue of 5%, the test identified all nine patients who failed clinically (100% sensitivity; 40.9% positive predictive value) and over three fourths of those (43 of 56) who progressed to successful healing (76.8% specificity; 100% negative predictive value). In this study, VST identified all patients who progressed to full, uneventful union after fixator removal; thus, we conclude that this new test has the potential to provide a quantitative, objective means of identifying tibia-fracture patients who can safely resume weight bearing. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:805-811, 2017. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.

Locked compression plating for peri- and intra-articular fractures around the knee.

PubMed

Jain, Jitesh Kumar; Asif, Naiyer; Ahmad, Suhail; Qureshi, Owais; Siddiqui, Yasir Salam; Rana, Ashish

2013-11-01

To evaluate the role of locked compression plates (LCPs) in management of peri- and intra-articular fractures around the knee. Twenty distal femoral and 20 proximal tibial fractures were fixed with LCPs. The types of femoral fractures were A1 (four), A2 (three), A3 (two), C1 (one), C2 (seven) and C3 (three). The types of tibial fractures were A2 (one), A3 (two), B2 (two), C1 (four), C2 (five) and C3 (six). All patients were followed up for up to 18 months (mean, 12 months). Fourteen patients with distal femoral fractures and 19 with proximal tibial fractures underwent surgery using a minimally invasive percutaneous plate osteosynthesis (MIPPO) technique. The others were treated by open reduction. The average time of fixation was 8 days after injury (0-31 days). Knee Society scores were used for clinical and functional assessment. All fractures, except one of the distal femur and one of the proximal tibia, united. The mean union times for distal femoral and proximal tibial fractures were 15.2 and 14.9 weeks, respectively. One patient with a distal femoral fracture had implant failure. One patient was quadriplegic and did not recover the ability to walk. The average Knee Society scores of the remaining 18 patients were 82.66 (excellent) and 77.77 (functional score, good). There was one case of implant failure and one of screw breakage in distal femoral fractures. One case of nonunion occurred in a proximal tibial fracture. Provided it is applied with proper understanding of biomechanics, LCP is one of the best available options for management of challenging peri- and intra-articular fractures. © 2013 Chinese Orthopaedic Association and Wiley Publishing Asia Pty Ltd.

A controlled trial of glutamine effects on bone healing.

PubMed

Polat, Onur; Kilicoglu, Sibel Serin; Erdemli, Esra

2007-01-01

Glutamine is considered a nonessential amino acid, but it may be conditionally essential in patients with catabolic conditions. For centuries, researchers have looked for ways to promote and accelerate fracture healing. This controlled animal study examines the effects of glutamine on fracture healing. The left tibias of 10 standardized albino rats were broken at the distal third to produce a closed fracture. L-glutamine/L-alanyl solution (2.0 mL/kg) was administered through the tail veins of half the rats for the first 7 d, and physiologic serum alone was given to the control group. On the 21st day, all rats were euthanized and their left legs removed; after histologic observation, the tibias were examined under light microscopy. In the glutamine-injected group, development of primary callus was quicker and more regular than in the control group. The control group produced insufficient fibrous callus, and the glutamine group attained formed cartilaginous callus. Glutamine was noted to have positive effects on healing of traumatically fractured bone through attainment of positive nitrogen balance. This effect was minimal in enhancing the quality of fracture healing under conditions of stress, but some effect was noted on the speed of healing. Further research is needed in this area.

Slow Recovery of Weight Bearing After Stabilization of Long-Bone Fractures Using Elastic Stable Intramedullary Nails in Children

PubMed Central

Lardelli, Patrizia; Frech-Dörfler, Martina; Holland-Cunz, Stefan; Mayr, Johannes

2016-01-01

Abstract Stabilization of diaphyseal long-bone fractures using elastic stable intramedullary nails (ESIN) in children promises early mobilization and rapid resumption of full weight bearing. We evaluated the duration of postoperative functional rehabilitation after ESIN, measured by the time from stabilization until first partial weight bearing, full weight bearing, and resumption of school sports. Fifty children with unstable, displaced fractures of the femur or lower leg treated with ESIN between 2002 and 2012 were included in this retrospective analysis. We classified fractures according to the pediatric comprehensive classification of fractures (PCCF). Thirty-five children sustained a femur fracture, and 15 children had a fracture of the lower leg or tibia. The surgeons in charge applied an additional plaster cast in 7 of 15 children who suffered a lower leg fracture. The postoperative time interval until full weight bearing in the group of children who had suffered transverse or short oblique femur fractures was significantly shorter (median: 4.4 weeks; range: 0.1–9.1 weeks) than that in the group who had sustained more complex fracture patterns (median: 6.8 weeks; range: 2.9–13.9 weeks; P = 0.04). Similarly, transverse and short oblique lower leg and tibia fractures required less time until full weight bearing (median: 4.1 weeks; range 2.7–6.0 weeks) than complex lower leg fractures (median: 6.1 weeks; range: 1.3–12.9 weeks; P = 0.04). ESIN proved fairly effective in restoring full weight bearing in transverse or short oblique fractures of the lower extremities but was less effective in complex fractures. PMID:26986106

Slow Recovery of Weight Bearing After Stabilization of Long-Bone Fractures Using Elastic Stable Intramedullary Nails in Children.

PubMed

Lardelli, Patrizia; Frech-Dörfler, Martina; Holland-Cunz, Stefan; Mayr, Johannes

2016-03-01

Stabilization of diaphyseal long-bone fractures using elastic stable intramedullary nails (ESIN) in children promises early mobilization and rapid resumption of full weight bearing. We evaluated the duration of postoperative functional rehabilitation after ESIN, measured by the time from stabilization until first partial weight bearing, full weight bearing, and resumption of school sports. Fifty children with unstable, displaced fractures of the femur or lower leg treated with ESIN between 2002 and 2012 were included in this retrospective analysis. We classified fractures according to the pediatric comprehensive classification of fractures (PCCF). Thirty-five children sustained a femur fracture, and 15 children had a fracture of the lower leg or tibia. The surgeons in charge applied an additional plaster cast in 7 of 15 children who suffered a lower leg fracture. The postoperative time interval until full weight bearing in the group of children who had suffered transverse or short oblique femur fractures was significantly shorter (median: 4.4 weeks; range: 0.1-9.1 weeks) than that in the group who had sustained more complex fracture patterns (median: 6.8 weeks; range: 2.9-13.9 weeks; P = 0.04). Similarly, transverse and short oblique lower leg and tibia fractures required less time until full weight bearing (median: 4.1 weeks; range 2.7-6.0 weeks) than complex lower leg fractures (median: 6.1 weeks; range: 1.3-12.9 weeks; P = 0.04). ESIN proved fairly effective in restoring full weight bearing in transverse or short oblique fractures of the lower extremities but was less effective in complex fractures.

Treatment Approach for Infection of Healed Fractures After Internal Fixation.

PubMed

Lawrenz, Joshua M; Frangiamore, Salvatore J; Rane, Ajinkya A; Cantrell, William Alex; Vallier, Heather A

2017-11-01

To review the efficacy of a treatment approach for patients with infection and colonized implants after open reduction and internal fixation of fractures. Retrospective case series. Level one trauma center. Twenty patients were treated for wound infection with colonized implants after open reduction and internal fixation. Surgical debridement, removal of implants, and a short postoperative oral antibiotic course. The course of patients after surgical debridement and removal of implants, including culture results, antibiotic administration, and presence of recurrent clinical infection and radiographic union. Twenty patients had clinical presentations, including skin breakdown, serous drainage, purulent drainage and/or exposed implants, most commonly of the tibia (15 of 20). Mean time from index procedure to debridement with implant removal was 19.7 months. At the time of debridement and implant removal, 18 of 20 (90%) patients had a positive intraoperative culture (16 routine cultures and 2 broth cultures). The most common bacteria were Enterobacter cloacae (5/17) and methicillin-sensitive Staphylococcus aureus (4/17). All patients had soft tissue healing without signs of recurrent infection after mean follow up of 40 months after implant removal. Surgical debridement with implant removal plus a short oral antibiotic course is effective to resolve wound infection with a colonized implant in the setting of healed fracture after internal fixation. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bisphosphonate-ciprofloxacin bound to Skelite is a prototype for enhancing experimental local antibiotic delivery to injured bone.

PubMed

Buxton, T B; Walsh, D S; Harvey, S B; McPherson, J C; Hartmann, J F; Plowman, K M

2004-09-01

The risk of osteomyelitis after open bone fracture may be reduced by locally applied antibiotics. ENC-41-HP (E41), which comprises ciprofloxacin linked to a 'bone seeking' bisphosphonate, loaded on to carrier Skelite calcium phosphate granules (E41-Skelite) has favourable in vitro characteristics for application to wounded bone. This study assessed E41-Skelite in a rat model of acute tibial osteomyelitis. Mechanically induced tibial troughs were contaminated with approximately log10 4 colony forming units (c.f.u.) of Staphylococcus aureus (Cowan 1 strain) 'resistant' to E41 (minimum inhibitory concentration 8-16 microg/ml), lavaged and packed with Skelite alone, or with E41-Skelite slurry. Animals were killed at 24 h (n = 62), 72 h (n = 46) or 14 days (n = 12), and each tibia was assessed for S. aureus load (c.f.u./g tibia) and histological appearance (14 days only). At 24 and 72 h, the tibias of rats treated with E41-Skelite (n = 54) had a significantly lower mean (s.e.m.) load of S. aureus than animals that received Skelite alone (n = 54): log10 3.6(0.2) versus 6.4(0.1) c.f.u./g respectively at 24 h (P < 0.001, Mann-Whitney rank sum test) and log10 4.4(0.2) versus 6.6(0.1) c.f.u./g at 72 h (P < 0.001). At 14 days, E41-Skelite-treated tibias had fewer bacteria, no signs of osteomyelitis and histological signs of healing. E41-Skelite, a prototype granulated topical antibiotic delivery system, reduced the development of infection in experimental bone wounds. Copyright 2004 British Journal of Surgery Society Ltd.

Individual Trabecula Segmentation (ITS)-Based Morphological Analyses and Micro Finite Element Analysis of HR-pQCT Images Discriminate Postmenopausal Fragility Fractures Independent of DXA Measurements

PubMed Central

Liu, X. Sherry; Stein, Emily M.; Zhou, Bin; Zhang, Chiyuan A.; Nickolas, Thomas L.; Cohen, Adi; Thomas, Valerie; McMahon, Donald J.; Cosman, Felicia; Nieves, Jeri; Shane, Elizabeth; Guo, X. Edward

2011-01-01

Osteoporosis is typically diagnosed by dual energy x-ray absorptiometry (DXA) measurements of areal bone mineral density (aBMD). Emerging technologies, such as high-resolution peripheral quantitative computed tomography (HR-pQCT), may increase the diagnostic accuracy of DXA and enhance our mechanistic understanding of decreased bone strength in osteoporosis. Women with (n=68) and without (n=101) a history of postmenopausal fragility fracture had aBMD measured by DXA, trabecular plate and rod microarchitecture measured by HR-pQCT image-based individual trabeculae segmentation (ITS) analysis, and whole bone and trabecular bone stiffness by micro finite element analysis (μFEA) of HR-pQCT images at the radius and tibia. DXA T-scores were similar in women with and without fractures at the spine, hip and 1/3 radius, but lower in fracture subjects at the ultradistal radius. Trabecular microarchitecture of fracture subjects was characterized by preferential reductions in trabecular plate bone volume, number, and connectivity over rod trabecular parameters, loss of axially aligned trabeculae, and a more rod-like trabecular network. In addition, decreased thickness and size of trabecular plates were observed at the tibia. The differences between groups were greater at the radius than the tibia for plate number, rod bone volume fraction and number and plate-rod and rod-rod junction densities. Most differences between groups remained after adjustment for T-score by DXA. At a fixed bone volume fraction, trabecular plate volume, number and connectivity were directly associated with bone stiffness. In contrast, rod volume, number and connectivity were inversely associated with bone stiffness. In summary, HR-pQCT-based ITS and μFEA measurements discriminate fracture status in postmenopausal women independent of DXA measurements. Moreover, these results suggest that preferential loss of plate-like trabeculae contribute to lower trabecular bone and whole bone stiffness in women with fractures. We conclude that HR-pQCT-based ITS and μFEA measurements increase our understanding of the microstructural pathogenesis of fragility fracture in postmenopausal women. PMID:22072446

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

Prediction of bone strength at the distal tibia by HR-pQCT and DXA.

PubMed

Popp, Albrecht W; Windolf, Markus; Senn, Christoph; Tami, Andrea; Richards, R Geoff; Brianza, Stefano; Schiuma, Damiano

2012-01-01

Areal bone mineral density (aBMD) at the distal tibia, measured at the epiphysis (T-EPI) and diaphysis (T-DIA), is predictive for fracture risk. Structural bone parameters evaluated at the distal tibia by high resolution peripheral quantitative computed tomography (HR-pQCT) displayed differences between healthy and fracture patients. With its simple geometry, T-DIA may allow investigating the correlation between bone structural parameter and bone strength. Anatomical tibiae were examined ex vivo by DXA (aBMD) and HR-pQCT (volumetric BMD (vBMD) and bone microstructural parameters). Cortical thickness (CTh) and polar moment of inertia (pMOI) were derived from DXA measurements. Finally, an index combining material (BMD) and mechanical property (polar moment of inertia, pMOI) was defined and analyzed for correlation with torque at failure and stiffness values obtained by biomechanical testing. Areal BMD predicted the vBMD at T-EPI and T-DIA. A high correlation was found between aBMD and microstructural parameters at T-EPIas well as between aBMD and CTh at T-DIA. Finally, at T-DIA both indexes combining BMD and pMOI were strongly and comparably correlated with torque at failure and bone stiffness. Ex vivo, at the distal tibial diaphysis, a novel index combining BMD and pMOI, which can be calculated directly from a single DXA measurement, predicted bone strength and stiffness better than either parameter alone and with an order of magnitude comparable to that of HR-pQCT. Whether this index is suitable for better prediction of fracture risk in vivo deserves further investigation. Copyright © 2011 Elsevier Inc. All rights reserved.

Bone strength measured by peripheral quantitative computed tomography and the risk of nonvertebral fractures: the osteoporotic fractures in men (MrOS) study.

PubMed

Sheu, Yahtyng; Zmuda, Joseph M; Boudreau, Robert M; Petit, Moira A; Ensrud, Kristine E; Bauer, Douglas C; Gordon, Christopher L; Orwoll, Eric S; Cauley, Jane A

2011-01-01

Many fractures occur in individuals without osteoporosis defined by areal bone mineral density (aBMD). Inclusion of other aspects of skeletal strength may be useful in identifying at-risk subjects. We used surrogate measures of bone strength at the radius and tibia measured by peripheral quantitative computed tomography (pQCT) to evaluate their relationships with nonvertebral fracture risk. Femoral neck (FN) aBMD, measured by dual-energy X-ray absorptiometry (DXA), also was included. The study population consisted of 1143 white men aged 69+ years with pQCT measures at the radius and tibia from the Minneapolis and Pittsburgh centers of the Osteoporotic Fractures in Men (MrOS) study. Principal-components analysis and Cox proportional-hazards modeling were used to identify 21 of 58 pQCT variables with a major contribution to nonvertebral incident fractures. After a mean 2.9 years of follow-up, 39 fractures occurred. Men without incident fractures had significantly greater bone mineral content, cross-sectional area, and indices of bone strength than those with fractures by pQCT. Every SD decrease in the 18 of 21 pQCT parameters was significantly associated with increased fracture risk (hazard ration ranged from 1.4 to 2.2) independent of age, study site, body mass index (BMI), and FN aBMD. Using area under the receiver operation characteristics curve (AUC), the combination of FN aBMD and three radius strength parameters individually increased fracture prediction over FN aBMD alone (AUC increased from 0.73 to 0.80). Peripheral bone strength measures are associated with fracture risk and may improve our ability to identify older men at high risk of fracture. © 2011 American Society for Bone and Mineral Research.

Computational comparison of tibial diaphyseal fractures fixed with various degrees of prebending of titanium elastic nails and with and without end caps.

PubMed

Chen, Yen-Nien; Lee, Pei-Yuan; Chang, Chih-Han; Chang, Chih-Wei; Ho, Yi-Hung; Li, Chun-Ting; Peng, Yao-Te

2016-10-01

Elastic stable intramedullary nailing (ESIN) is a treatment strategy for the management of diaphyseal long-bone fractures in adolescents and children, but few studies have investigated the mechanical stability of tibial diaphyseal fractures treated with various degrees of prebending of the elastic nails. Therefore, the aim of this study was to compare the mechanical stability, including the gap deformation and nail dropping, of a tibia fracture with various fracture sites and fixed with various degrees of prebending of the elastic nails by the finite element method. Furthermore, the contribution of end caps to stability was taken into consideration in the simulation. A tibia model was developed with a transverse fracture at the proximal, middle and distal parts of the diaphysis, and fixed with three degrees of prebending of elastic nails, including those equal to, two times and three times the diameter of the intramedullary canal. The outer diameter of the nail used in the computation was 3.5mm, and the fractured tibia was fixed with two elastic double C-type nails. Furthermore, the proximal end of each nail was set to free or being tied to the surrounding bone by a constraint equation to simulate with or without using end caps. The results indicated that using end caps can prevent the fracture gap from collapsing by stopping the ends of the nails from dropping back in all prebending conditions and fracture patterns, and increasing the prebending of the nails to a degree three times the diameter of the canal reduced the gap shortening and the dropping distance of the nail end in those without using end caps under axial compression and bending. Insufficient prebending of the nails and not using end caps caused the gap to collapse and the nail to drop back at the entry point under loading. Using end caps or increasing the prebending of the nails to three times the diameter of the canal is suggested to stop the nail from dropping back and thus produce a more stable structure, with less gap deformation, in the management of a simulated tibial diapyhseal fracture by using titanium elastic nails with a double C-shape. Copyright © 2016 Elsevier Ltd. All rights reserved.

Pattern of Cortical Fracture following Corticotomy for Distraction Osteogenesis.

PubMed

Luvan, M; Kanthan, S R; Roshan, G; Saw, A

2015-11-01

Corticotomy is an essential procedure for deformity correction and there are many techniques described. However there is no proper classification of the fracture pattern resulting from corticotomies to enable any studies to be conducted. We performed a retrospective study of corticotomy fracture patterns in 44 patients (34 tibias and 10 femurs) performed for various indications. We identified four distinct fracture patterns, Type I through IV classification based on the fracture propagation following percutaneous corticotomy. Type I transverse fracture, Type II transverse fracture with a winglet, Type III presence of butterfly fragment and Type IV fracture propagation to a fixation point. No significant correlation was noted between the fracture pattern and the underlying pathology or region of corticotomy.

[A method for inducing standardized spiral fractures of the tibia in the animal experiment].

PubMed

Seibold, R; Schlegel, U; Cordey, J

1995-07-01

A method for the deliberate weakening of cortical bone has been developed on the basis of an already established technique for creating butterfly fractures. It enables one to create the same type of fracture, i.e., a spiral fracture, every time. The fracturing process is recorded as a force-strain curve. The results of the in vitro investigations form a basis for the preparation of experimental tasks aimed at demonstrating internal fixation techniques and their influence on the vascularity of the bone in simulated fractures. Animal protection law lays down that this fracture model must not fail in animal experiments.

Blast effect on the lower extremities and its mitigation: a computational study.

PubMed

Dong, Liqiang; Zhu, Feng; Jin, Xin; Suresh, Mahi; Jiang, Binhui; Sevagan, Gopinath; Cai, Yun; Li, Guangyao; Yang, King H

2013-12-01

A series of computational studies were performed to investigate the response of the lower extremities of mounted soldiers under landmine detonation. A numerical human body model newly developed at Wayne State University was used to simulate two types of experimental studies and the model predictions were validated against test data in terms of the tibia axial force as well as bone fracture pattern. Based on the validated model, the minimum axial force causing tibia facture was found. Then a series of parametric studies was conducted to determine the critical velocity (peak velocity of the floor plate) causing tibia fracture at different upper/lower leg angles. In addition, to limit the load transmission through the vehicular floor, two types of energy absorbing materials, namely IMPAXX(®) foam and aluminum alloy honeycomb, were selected for floor matting. Their performances in terms of blast effect mitigation were compared using the validated numerical model, and it has been found that honeycomb is a more efficient material for blast injury prevention under the loading conditions studied. © 2013 Elsevier Ltd. All rights reserved.

Tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail: a biomechanical analysis of the effect of nail length.

PubMed

Noonan, Timothy; Pinzur, Michael; Paxinos, Odysseas; Havey, Robert; Patwardhin, Avinash

2005-04-01

Fatigue fractures of the tibia have been observed at the level of the proximal end of the nail after successful tibiocalcaneal arthrodesis with a retrograde intramedullary device. To study the effect of nail length, five matched pairs of cadaver tibiae were instrumented with strain gauges and potted in methylmethacrylate from a level 3 cm proximal to the distal medial malleolus to simulate a successful tibiocalcaneal arthrodesis. A standard length (15 cm) ankle arthrodesis nail and an identical longer device terminating in the proximal tibial metaphysis were inserted in each paired tibia using appropriate technique. The strain of the posterior cortex of the tibia was recorded under bending moments of up to 50 Nm for each intact specimen after nail insertion and after proximal locking of the nail. The nails were then exchanged between the specimens of the same pairs and the experiment was repeated to insure uniformity. The standard length locked nail increased the principal strain of the posterior cortex of the tibia at the level of the proximal screw holes 5.3 times more than the locked long nail (353 and 67 microstrains), respectively. This stress concentration was not observed when the proximal extent of the nail terminated within the proximal tibial metaphysis. A successful tibiocalcaneal arthrodesis with a standard length locked intramedullary nail creates stress concentration around the proximal screw holes that may be responsible for the fractures observed clinically. This study supports the use of a "long" retrograde locked intramedullary nail for tibiocalcaneal arthrodesis in patients with systemic or localized osteopenia.

A Civilian/Military Trauma Institute: National Trauma Coordinating Center

DTIC Science & Technology

2012-10-01

the variation in practices for DVT screening, and there was another paper which talks about variation in practices about pain management for rib ...pelvic fractures , and long bone extremity fractures (femur or tibia). TBI was chosen as it is the most common cause of death and disability in...trauma patients, while hemorrhage is the second leading cause of death. Fractures were chosen as they represent a common injury in trauma patients. These

RECONSIDERATIONS REGARDING TIME OF FRACTURE HEALING IN PYCNODYSOSTOSIS

PubMed Central

Rabelo, Flávio Dorcilo; do Prado, Carlos Henrique Ribeiro; Rabelo, Flávio Leão; Martins, Letícia

2015-01-01

Objective: To discuss what has been described so far in the literature regarding the time taken for fracture consolidation in pycnodysostosis. Materials and Methods: Thirteen new cases were studied, as available from the medical records and radiographic examinations, thus encompassing a total of 44 fractures in patients evaluated between November 1970 and August 2004 at the Orthopedics Hospital, Goiânia. Field research, simultaneous clinical monitoring for new fractures in two patients and retrospective evaluation of medical records were undertaken. The purpose was to determine the total number of fractures in each patient and to determine which of these were viable for this study. The patient group was composed of three women and two men of mean age 51.4 years. The tibia was the bone most affected, followed by the femur. Fractures for which the follow-up was done at another clinic were excluded. Results: Out of the 12 fractures that were considered fully suitable for the study, nine occurred in femurs (six in the left femur and three in the right femur); one in the right tibia; one in the right clavicle; and one in the left ulna. Among these 12 fractures, eight developed pseudarthrosis after an average of 29.25 months; three consolidated well after an average of 5.83 months; and one evolved with delayed consolidation in just 2 months. Conclusion: In combination with genetic and micromorphological evaluations, further studies are awaited for reconfirmation of the diagnosis of such a rare clinical entity. PMID:27026972

Safety assessment characteristics of pedestrian legform impactors in vehicle-front impact tests.

PubMed

Matsui, Yasuhiro

2014-12-01

This study investigated the characteristics of safety assessment results of front-area vehicle impact tests carried out using the Transport Research Laboratory (TRL) legform impactor and a flexible legform impactor (FLEX legform impactor). Different types of vehicles (sedan, sport utility vehicle, high-roof K-car, and light cargo van) were examined. The impact locations in the study were the center of the bumper and an extremely stiff structure of the bumper (i.e., in front of the side member) of each tested vehicle. The measured injury criteria were normalized by injury assessment reference values of each legform impactor. The test results for center and side-member impacts indicated that there were no significant differences in ligament injury assessments derived from the normalized knee ligament injury measures between the TRL legform impactor and the FLEX legform impactor. Evaluations made using the TRL legform impactor and the FLEX legform impactor are thus similar in the vehicle safety investigation for knee ligament injury. Vehicle-center impact test results revealed that the tibia fracture assessments derived from the normalized tibia fracture measures did not significantly differ between the TRL legform impactor and the FLEX legform impactor. However, for an impact against an extremely stiff structure, there was a difference in the tibia fracture assessment between the FLEX legform impactor and the TRL legform impactor owing to their different sensor types. Copyright © 2014 Elsevier Ltd. All rights reserved.

First Reported Cases of Biomechanically Adaptive Bone Modeling in Non-Avian Dinosaurs.

PubMed

Cubo, Jorge; Woodward, Holly; Wolff, Ewan; Horner, John R

2015-01-01

Predator confrontation or predator evasion frequently produces bone fractures in potential prey in the wild. Although there are reports of healed bone injuries and pathologies in non-avian dinosaurs, no previously published instances of biomechanically adaptive bone modeling exist. Two tibiae from an ontogenetic sample of fifty specimens of the herbivorous dinosaur Maiasaura peeblesorum (Ornithopoda: Hadrosaurinae) exhibit exostoses. We show that these outgrowths are cases of biomechanically adaptive periosteal bone modeling resulting from overstrain on the tibia after a fibula fracture. Histological and biomechanical results are congruent with predictions derived from this hypothesis. Histologically, the outgrowths are constituted by radial fibrolamellar periosteal bone tissue formed at very high growth rates, as expected in a process of rapid strain equilibration response. These outgrowths show greater compactness at the periphery, where tensile and compressive biomechanical constraints are higher. Moreover, these outgrowths increase the maximum bending strength in the direction of the stresses derived from locomotion. They are located on the antero-lateral side of the tibia, as expected in a presumably bipedal one year old individual, and in the posterior position of the tibia, as expected in a presumably quadrupedal individual at least four years of age. These results reinforce myological evidence suggesting that Maiasaura underwent an ontogenetic shift from the primitive ornithischian bipedal condition when young to a derived quadrupedal posture when older.

First Reported Cases of Biomechanically Adaptive Bone Modeling in Non-Avian Dinosaurs

PubMed Central

Cubo, Jorge; Woodward, Holly; Wolff, Ewan; Horner, John R.

2015-01-01

Predator confrontation or predator evasion frequently produces bone fractures in potential prey in the wild. Although there are reports of healed bone injuries and pathologies in non-avian dinosaurs, no previously published instances of biomechanically adaptive bone modeling exist. Two tibiae from an ontogenetic sample of fifty specimens of the herbivorous dinosaur Maiasaura peeblesorum (Ornithopoda: Hadrosaurinae) exhibit exostoses. We show that these outgrowths are cases of biomechanically adaptive periosteal bone modeling resulting from overstrain on the tibia after a fibula fracture. Histological and biomechanical results are congruent with predictions derived from this hypothesis. Histologically, the outgrowths are constituted by radial fibrolamellar periosteal bone tissue formed at very high growth rates, as expected in a process of rapid strain equilibration response. These outgrowths show greater compactness at the periphery, where tensile and compressive biomechanical constraints are higher. Moreover, these outgrowths increase the maximum bending strength in the direction of the stresses derived from locomotion. They are located on the antero-lateral side of the tibia, as expected in a presumably bipedal one year old individual, and in the posterior position of the tibia, as expected in a presumably quadrupedal individual at least four years of age. These results reinforce myological evidence suggesting that Maiasaura underwent an ontogenetic shift from the primitive ornithischian bipedal condition when young to a derived quadrupedal posture when older. PMID:26153689

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.

Trampoline related injuries in children: risk factors and radiographic findings.

PubMed

Klimek, Peter Michael; Juen, David; Stranzinger, Enno; Wolf, Rainer; Slongo, Theddy

2013-05-01

Backyard trampolines are immensely popular among children, but are associated with an increase of trampoline-related injuries. The aim of this study was to evaluate radiographs of children with trampoline related injuries and to determine the risk factors. Between 2003 and 2009, 286 children under the age of 16 with backyard trampoline injuries were included in the study. The number of injuries increased from 13 patients in 2003 to 86 in 2009. The median age of the 286 patients was 7 years (range: 1-15 years). Totally 140 (49%) patients were males, and 146 (51%) females. Medical records and all available diagnostic imaging were reviewed. A questionnaire was sent to the parents to evaluate the circumstances of each injury, the type of trampoline, the protection equipment and the experience of the children using the trampoline. The study was approved by the Institutional Ethics Committee of the University Hospital of Bern. The questionnaires and radiographs of the 104 patients were available for evaluation. A fracture was sustained in 51 of the 104 patients. More than 75% of all patients sustaining injuries and in 90% of patients with fractures were jumping on the trampoline with other children at the time of the accident. The most common fractures were supracondylar humeral fractures (29%) and forearm fractures (25%). Fractures of the proximal tibia occurred especially in younger children between 2-5 years of age. Children younger than 5 years old are at risk for specific proximal tibia fractures ("Trampoline Fracture"). A child jumping simultaneously with other children has a higher risk of suffering from a fracture.

CERAMENT treatment of fracture defects (CERTiFy): protocol for a prospective, multicenter, randomized study investigating the use of CERAMENT™ BONE VOID FILLER in tibial plateau fractures

PubMed Central

2014-01-01

Background Bone graft substitutes are widely used for reconstruction of posttraumatic bone defects. However, their clinical significance in comparison to autologous bone grafting, the gold-standard in reconstruction of larger bone defects, still remains under debate. This prospective, randomized, controlled clinical study investigates the differences in pain, quality of life, and cost of care in the treatment of tibia plateau fractures-associated bone defects using either autologous bone grafting or bioresorbable hydroxyapatite/calcium sulphate cement (CERAMENT™|BONE VOID FILLER (CBVF)). Methods/Design CERTiFy (CERament™ Treatment of Fracture defects) is a prospective, multicenter, controlled, randomized trial. We plan to enroll 136 patients with fresh traumatic depression fractures of the proximal tibia (types AO 41-B2 and AO 41-B3) in 13 participating centers in Germany. Patients will be randomized to receive either autologous iliac crest bone graft or CBVF after reduction and osteosynthesis of the fracture to reconstruct the subchondral bone defect and prevent the subsidence of the articular surface. The primary outcome is the SF-12 Physical Component Summary at week 26. The co-primary endpoint is the pain level 26 weeks after surgery measured by a visual analog scale. The SF-12 Mental Component Summary after 26 weeks and costs of care will serve as key secondary endpoints. The study is designed to show non-inferiority of the CBVF treatment to the autologous iliac crest bone graft with respect to the physical component of quality of life. The pain level at 26 weeks after surgery is expected to be lower in the CERAMENT bone void filler treatment group. Discussion CERTiFy is the first randomized multicenter clinical trial designed to compare quality of life, pain, and cost of care in the use of the CBVF and the autologous iliac crest bone graft in the treatment of tibia plateau fractures. The results are expected to influence future treatment recommendations. Trial registration number ClinicalTrials.gov: NCT01828905 PMID:24606670

A New Measurement Technique of the Characteristics of Nutrient Artery Canals in Tibias Using Materialise's Interactive Medical Image Control System Software

PubMed Central

Li, Jiantao; Zhang, Hao; Yin, Peng; Su, Xiuyun; Zhao, Zhe; Zhou, Jianfeng; Li, Chen; Li, Zhirui; Zhang, Lihai; Tang, Peifu

2015-01-01

We established a novel measurement technique to evaluate the anatomic information of nutrient artery canals using Mimics (Materialise's Interactive Medical Image Control System) software, which will provide full knowledge of nutrient artery canals to assist in the diagnosis of longitudinal fractures of tibia and choosing an optimal therapy. Here we collected Digital Imaging and Communications in Medicine (DICOM) format of 199 patients hospitalized in our hospital. All three-dimensional models of tibia in Mimics were reconstructed. In 3-matic software, we marked five points in tibia which located at intercondylar eminence, tibia tuberosity, outer ostium, inner ostium, and bottom of medial malleolus. We then recorded Z-coordinates values of the five points and performed statistical analysis. Our results indicate that foramen was found to be absent in 9 (2.3%) tibias, and 379 (95.2%) tibias had single nutrient foramen. The double foramina was observed in 10 (2.5%) tibias. The mean of tibia length was 358 ± 22 mm. The mean foraminal index was 31.8%  ± 3%. The mean distance between tibial tuberosity and foramen (TFD) is 66 ± 12 mm. Foraminal index has significant positive correlation with TFD (r = 0.721, P < 0.01). Length of nutrient artery canals has significant negative correlation with TFD (r = −0.340, P < 0.01) and has significant negative correlation with foraminal index (r = −0.541, P < 0.01). PMID:26788498

[Repair and reconstruction for severe fracture and dislocation of ankle joint].

PubMed

Yin, Qingwei; Jiang, Yi; Xiao, Lianping; Li, Xiaodong; Fu, Jiaxin; Tian, Yonggang; Han, Liqiang; Liu, Zhi

2008-06-01

To summarize the technique and effect of the therapy for severe fracture and dislocation of ankle joint by operation. From March 2003 to February 2006, 76 cases were treated with primary open restoration and internal fixation for dislocated ankle joint fracture, with 47 males and 29 females, with the average age of 36.4 years (ranging from 18 years to 65 years). According to AO criterion, these fresh fractures were classified into 13 cases for type C3-1, 45 cases for type C3-2 and 18 cases for type C3-3. Based on the Gustilo-Anderson standard, 23 open fractures were classified into 17 cases for type II and 6 cases for type III A. The operation was delayed from 1 hours to 24 hours after the injury. All incisions healed at the first stage except 4 cases which delayed union because of simple infection by revision with ointment. A total of 72 cases were followed up, with the average time of 18.5 months (from 12 months to 35 months). The time of bone union was from 12 weeks to 24 weeks. The screws of fixation for lower tibia-fibula joint were found to be ruptured in 2 cases when further consultation was performed in the 16th and 20th week after the operation, respectively, and were broken within 1 year after the operation. These screws were taken out 12 weeks postoperative in 28 cases, while the whole internal fixations of the rest cases were taken out 1 year after the operation. The postoperative function of malleolus extended from 21.7 degrees to 26.8 degrees and flection from 38.5 degrees to 44.7 degrees. Assessed by the American Orthopaedic Foot and Ankle Society Clinical Rating Scales, 23 cases were excellent, 36 good, 13 fair, and the choiceness rate reached 81.94%. These procedures, together with reduction by twist after hospital, open and internal fixation in time, and parenchyma managed with internal fixation, are important to attain satisfactory effect for the treatment of severe fracture and dislocation of ankle joint.

Parametric analysis of occupant ankle and tibia injuries in frontal impact

PubMed Central

Mo, Fuhao; Jiang, Xiaoqing; Duan, Shuyong; Xiao, Zhi; Shi, Wei

2017-01-01

Objective Non-fatal tibia and ankle injuries without proper protection from the restraint system has gotten wide attention from researchers. This study aimed to investigate occupant tibia and ankle injuries under realistic frontal impact environment that is rarely considered in previous experimental and simulant studies. Methods An integrated occupant-vehicle model was established by coupling an isolated car cab model and a hybrid occupant model with a biofidelic pelvis-lower limb model, while its loading conditions were extracted from the realistic full-frontal impact test. A parametric study was implemented concerning instrument panel (IP) design and pedal intrusion/rotation parameters. Results The significant influences of the IP angle, pedal intrusion and pedal rotation on tibia axial force, tibia bending moment and ankle dorsiflexion angle are noted. By coupling their effects, a new evaluation index named CAIEI (Combined Ankle Injury Evaluation Index) is established to evaluate ankle injury (including tibia fractures in ankle region) risk and severity in robustness. Conclusions Overall results and analysis indicate that ankle dorsiflexion angle should be considered when judging the injury in lower limb under frontal impact. Meanwhile, the current index with coupling effects of tibia axial force, bending moment and ankle dorsiflexion angle is in a good correlation with the simulation injury outcomes. PMID:28910377

Plate Versus Intramedullary Nail Fixation of Anterior Tibial Stress Fractures: A Biomechanical Study.

PubMed

Markolf, Keith L; Cheung, Edward; Joshi, Nirav B; Boguszewski, Daniel V; Petrigliano, Frank A; McAllister, David R

2016-06-01

Anterior midtibial stress fractures are an important clinical problem for patients engaged in high-intensity military activities or athletic training activities. When nonoperative treatment has failed, intramedullary (IM) nail and plate fixation are 2 surgical options used to arrest the progression of a fatigue fracture and allow bone healing. A plate will be more effective than an IM nail in preventing the opening of a simulated anterior midtibial stress fracture from tibial bending. Controlled laboratory study. Fresh-frozen human tibias were loaded by applying a pure bending moment in the sagittal plane. Thin transverse saw cuts, 50% and 75% of the depth of the anterior tibial cortex, were created at the midtibia to simulate a fatigue fracture. An extensometer spanning the defect was used to measure the fracture opening displacement (FOD) before and after the application of IM nail and plate fixation constructs. IM nails were tested without locking screws, with a proximal screw only, and with proximal and distal screws. Plates were tested with unlocked bicortical screws (standard compression plate) and locked bicortical screws; both plate constructs were tested with the plate edge placed 1 mm from the anterior tibial crest (anterior location) and 5 mm posterior to the crest. For the 75% saw cut depth, the mean FOD values for all IM nail constructs were 13% to 17% less than those for the saw cut alone; the use of locking screws had no significant effect on the FOD. The mean FOD values for all plate constructs were significantly less than those for all IM nail constructs. The mean FOD values for all plates were 28% to 46% less than those for the saw cut alone. Anterior plate placement significantly decreased mean FOD values for both compression and locked plate constructs, but the mean percentage reductions for locked and unlocked plates were not significantly different from each other for either plate placement. The percentage FOD reductions for all plate constructs and the unlocked IM nail were significantly less with a 50% saw cut depth. Plate fixation was superior to IM nail fixation in limiting the opening of a simulated midtibial stress fracture, and anterior-posterior placement of the plate was an important variable for this construct. Results from these tests can help guide the selection of fixation hardware for patients requiring surgical treatment for a midtibial stress fracture. © 2016 The Author(s).

Complications and early results after operative fixation of 68 pilon fractures of the distal tibia.

PubMed

Lomax, Adam; Singh, Anjani; N Jane, Madeley; C Senthil, Kumar

2015-05-01

In this cohort study, we present comprehensive injury specific and surgical outcome data from one of the largest reported series of pilon fractures of the distal tibia treated in a UK tertiary referral centre. A series of 68 closed pilon fractures were retrospectively reviewed from case notes, plain radiographs and computed tomography imaging. Patient demographics, injury and fracture patterns, methods and timing of fixation and clinical and radiological outcomes were assessed over a mean follow-up period of 7.7 months (1.5-30). Overall, deep infection occurred in 1.6% with superficial infection and wound breakdown occurring in 6.3% of cases. Rates of nonunion and malunion were 7.8%. Radiological posttraumatic arthritis was present in 26.6%, which was symptomatic and requiring orthopaedic management in 9.4%. Further surgery for all causes occurred in 26.6% of cases. Fixation of these complex fractures in subspecialist units can achieve overall low rates of wound complications, with definitive fixation of selected fractures within 48 h of initial presentation achieving comparable results to those fixed in a delayed fashion. However, this injury continues to have a significant overall complication rate with a high chance of developing early posttraumatic arthritis and of requiring further surgery. © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Pattern of Cortical Fracture following Corticotomy for Distraction Osteogenesis

PubMed Central

Luvan, M; Roshan, G; Saw, A

2015-01-01

Corticotomy is an essential procedure for deformity correction and there are many techniques described. However there is no proper classification of the fracture pattern resulting from corticotomies to enable any studies to be conducted. We performed a retrospective study of corticotomy fracture patterns in 44 patients (34 tibias and 10 femurs) performed for various indications. We identified four distinct fracture patterns, Type I through IV classification based on the fracture propagation following percutaneous corticotomy. Type I transverse fracture, Type II transverse fracture with a winglet, Type III presence of butterfly fragment and Type IV fracture propagation to a fixation point. No significant correlation was noted between the fracture pattern and the underlying pathology or region of corticotomy. PMID:28611907

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.

Prognostic Factors for Predicting Outcomes After Intramedullary Nailing of the Tibia

PubMed Central

Schemitsch, Emil H.; Bhandari, Mohit; Guyatt, Gordon; Sanders, David W.; Swiontkowski, Marc; Tornetta, Paul; Walter, Stephen D.; Zdero, Rad; Goslings, J.C.; Teague, David; Jeray, Kyle; McKee, Michael D.; Schemitsch, Emil H.; Bhandari, Mohit; Guyatt, Gordon; Sanders, David W.; Swiontkowski, Marc; Tornetta, Paul; Walter, Stephen D.; Zdero, Rad; Goslings, J.C.; Teague, David; Jeray, Kyle; McKee, Michael D.

2012-01-01

Background: Prediction of negative postoperative outcomes after long-bone fracture treatment may help to optimize patient care. We recently completed the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT), a large, multicenter trial of reamed and unreamed intramedullary nailing of tibial shaft fractures in 1226 patients. Using the SPRINT data, we conducted an investigation of baseline and surgical factors to determine any associations with an increased risk of adverse events within one year of intramedullary nailing. Methods: Using multivariable logistic regression analysis, we investigated fifteen baseline and surgical factors for any associations with an increased risk of negative outcomes. Results: There was an increased risk of negative events in patients with a high-energy mechanism of injury (odds ratio [OR] = 1.57; 95% confidence interval [CI], 1.05 to 2.35), a stainless steel compared with a titanium nail (OR = 1.52; 95% CI, 1.10 to 2.13), a fracture gap (OR = 2.40; 95% CI, 1.47 to 3.94), and full weight-bearing status after surgery (OR = 1.63; 95% CI, 1.00 to 2.64). There was no increased risk with the use of nonsteroidal anti-inflammatory agents, late or early time to surgery, or smoking status. Open fractures had a higher risk of events among patients treated with reamed nailing (OR = 3.26; 95% CI, 2.01 to 5.28) but not in patients treated with unreamed nailing (OR = 1.50; 95% CI, 0.92 to 2.47). Patients with open fractures who had wound management either without any additional procedures or with delayed primary closure had a decreased risk of events compared with patients who required subsequent, more complex reconstruction (OR = 0.18 [95% CI, 0.09 to 0.35] and 0.29 [95% CI, 0.14 to 0.62], respectively). Conclusions: We identified several baseline fracture and surgical characteristics that may increase the risk of adverse events in patients with tibial shaft fractures. Surgeons should consider the predictors identified in our analysis to inform patients treated for tibial shaft fractures. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence. PMID:23032589

Effect of step width manipulation on tibial stress during running.

PubMed

Meardon, Stacey A; Derrick, Timothy R

2014-08-22

Narrow step width has been linked to variables associated with tibial stress fracture. The purpose of this study was to evaluate the effect of step width on bone stresses using a standardized model of the tibia. 15 runners ran at their preferred 5k running velocity in three running conditions, preferred step width (PSW) and PSW±5% of leg length. 10 successful trials of force and 3-D motion data were collected. A combination of inverse dynamics, musculoskeletal modeling and beam theory was used to estimate stresses applied to the tibia using subject-specific anthropometrics and motion data. The tibia was modeled as a hollow ellipse. Multivariate analysis revealed that tibial stresses at the distal 1/3 of the tibia differed with step width manipulation (p=0.002). Compression on the posterior and medial aspect of the tibia was inversely related to step width such that as step width increased, compression on the surface of tibia decreased (linear trend p=0.036 and 0.003). Similarly, tension on the anterior surface of the tibia decreased as step width increased (linear trend p=0.029). Widening step width linearly reduced shear stress at all 4 sites (p<0.001 for all). The data from this study suggests that stresses experienced by the tibia during running were influenced by step width when using a standardized model of the tibia. Wider step widths were generally associated with reduced loading of the tibia and may benefit runners at risk of or experiencing stress injury at the tibia, especially if they present with a crossover running style. Copyright © 2014 Elsevier Ltd. All rights reserved.

Interlocking intramedullary nailing in distal tibial fractures.

PubMed

Tyllianakis, M; Megas, P; Giannikas, D; Lambiris, E

2000-08-01

This retrospective study examined the results of non-pilon fractures of the distal part of the tibia treated with interlocking intramedullary nailing. Seventy-three patients with equal numbers of fractures treated surgically between 1990 and 1998 were reviewed. Mean patient age was 39.8 years, and follow-up averaged 34.2 months. The AO fracture classification system was used. Concomitant fractures of the lateral malleolus were fixed. All but three fractures achieved union within 4.2 months on average. Satisfactory or excellent results were obtained in 86.3% of patients. These results indicate interlocking intramedullary nailing is a reliable method of treatment for these fractures and is characterized by high rates of union and a low incidence of complications.

Fat embolism syndrome.

PubMed

Stein, Paul D; Yaekoub, Abdo Y; Matta, Fadi; Kleerekoper, Michael

2008-12-01

To assess the incidence and risk factors for fat embolism syndrome. Data from the National Hospital Discharge Survey (NHDS) were analyzed using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. From 1979 through 2005 among 928,324,000 patients discharged from short-stay hospitals in the United States, 41,000 (0.004%) had fat embolism syndrome. Among 21,538,000 patients with an isolated fracture of the femur (any site), tibia, fibula, pelvis, ribs, humerus, radius, or ulna, 25,000 (0.12%) developed fat embolism syndrome. Patients with multiple fractures of the femur (excluding neck) more often had fat embolism syndrome than those with isolated fractures (1.29% versus 0.54%). The incidence of fat embolism syndrome was lower with isolated fractures of the tibia or fibula (0.30%) and even lower with isolated fractures of the neck of the femur (0.06%). The incidence of fat embolism was too low to calculate with isolated fractures of the pelvis, ribs, humerus, radius, or ulna. Nonorthopedic conditions rarely, if ever, were accompanied by fat embolism syndrome. The fat embolism syndrome was more frequent in men (relative risk 5.71). Children, aged 0 to 9 years rarely had fat embolism syndrome. The fat embolism syndrome most commonly affected patients aged 10 to 39 years. The incidence of the fat embolism syndrome depends on the bone involved, whether fractures are isolated or multiple, the age of the patient and the gender. It rarely occurs as a result of medical conditions.

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

Radiographic Investigation of the Distal Extension of Fractures Into the Articular Surface of the Tibia (The RIDEFAST Study).

PubMed

Marchand, Lucas S; Rane, Ajinkya A; Working, Zachary M; Jacobson, Lance G; Kubiak, Erik N; Higgins, Thomas F; Rothberg, David L

2017-12-01

To determine whether radiographic measurements are predictive of involvement of the distal tibia articular surface in tibial shaft fractures. Retrospective review. Academic Level-I trauma hospital. Two-hundred seventeen patients with tibial shaft fractures distal to the isthmus (OTA/AO: 42-A1-3; 42-B1-3; 42-C1-3; and 43-A1-3). Analysis of anteroposterior (AP) and lateral radiographs. The following parameters were measured: (1) angle between the predominant fracture line and the plane of the tibial plafond (α-angle), (2) length of the shaft fracture, (3) distance from the most inferior extent of the shaft fracture to the tibial plafond (DTP), (4) width of the tibial plafond, (5) width of the tibial isthmus, (6) ratio of fracture length to DTP (FTP), and (7) fibular fracture distance. Distal intra-articular involvement (DIA). A total of 217 patients were identified, 56 (26%) with DIA. The FTP ratio as measured on both the AP (odds ratio: 8.20, confidence interval, 4.26-17.22, P < 0.0001) and lateral radiographs (10.00, 4.78-23.23, <0.0001) was the most effective screening measurement for DIA. AP and lateral FTP ratios of 0.224 and 0.255, respectively, achieved a negative predictive value of 100%, eliminating the need for computed tomography in 16%-23% of injuries. Involvement of the distal articular surface in patients with distal tibial shaft fractures is significantly associated with fracture geometry and pattern. The FTP ratio may be used as an effective screening tool to rule out of intra-articular involvement. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Morphologic and molecular alteration during tibia fracture healing in rat.

PubMed

Yu, M-D; Su, B-H; Zhang, X-X

2018-03-01

To monitor morphological feature and related osteogenic and bone metabolic change during healing of tibia fracture in a rat model. Tibia density and trabecular thickness were evaluated. Histopathology was examined by HE staining. Serous inflammatory factors IL-4, IL-6, TNF-α and metabolic biomarkers ALP, β-CTX, P1NP, were determined by ELISA. The expression of RUNX2, TGF-β1, VEGF-α, BMP-2, BMP-4, and BMP-7 in callus tissue were qualified by RT-PCR. Bone density decreased until week 4 and then increased post-operation. Trabeculae in callus were thickened over time with active osteogenesis. ELISA indicated the most severe inflammation at week 2, with the highest level of TNF-α, IL-6, and the lowest level of IL-4. After 4 weeks, the inflammation was alleviated accompanying with the decline of TNF-α and IL-6, while there was the elevation of IL-4. Bone metabolism showed active osteogenesis and resorption at week 6 with high P1NP and β-CTX. The expression of RUNX2, TGF-β1, VEGF-α, BMP-2, BMP-4, and BMP-7 increased progressively from week 1 to 6. The major lesions at week 2 in sham were tissue necrosis, periosteal reactive hyperplasia, inflammatory cell infiltration, capillary hyperplasia and slight fibro-blast cytopoiesis. At week 4, proliferation was greatly activated, fibrous callus shaped and chondrogenesis and some osteogenesis occurred at week 8. In rat model, bone density started to increase at week 6 after fracture, accompanied with trabeculae thickening, serous inflammatory factors decline, and peaked bone morphogenetic protein/growth factors, which indicated active osteogenesis was conforming to the classical phase of secondary fracture healing.

PHOSPHO1 is essential for mechanically competent mineralization and the avoidance of spontaneous fractures

PubMed Central

Huesa, Carmen; Yadav, Manisha C.; Finnilä, Mikko A.J.; Goodyear, Simon R.; Robins, Simon P.; Tanner, K. Elizabeth; Aspden, Richard M.; Millán, José Luis; Farquharson, Colin

2011-01-01

Phosphatases are essential for the mineralization of the extracellular matrix within the skeleton. Their precise identities and functions however remain unclear. PHOSPHO1 is a phosphoethanolamine/phosphocholine phosphatase involved in the generation of inorganic phosphate for bone mineralization. It is highly expressed at sites of mineralization in bone and cartilage. The bones of Phospho1−/− mice are hypomineralized, bowed and present with spontaneous greenstick fractures at birth. In this study we show that PHOSPHO1 is essential for mechanically competent mineralization that is able to withstand habitual load. Long bones from Phospho1−/− mice did not fracture during 3- point bending but deformed plastically. With dynamic loading nanoindentation the elastic modulus and hardness of Phospho1−/− tibiae were significantly lower than wild-type tibia. Raman microscopy revealed significantly lower mineral:matrix ratios and lower carbonate substitutions in Phospho1−/− tibia. The altered dihydroxylysinonorleucine/hydroxyllysinonorleucine and pyridoline/deoxypyridinoline collagen crosslink ratios indicated possible changes in lysyl hydroxylase-1 activity and/or bone mineralization status. The bone formation and resorption markers, N-terminal propeptide and C-terminal telopeptide of Type I collagen, were both increased in Phospho1−/− mice and this we associated with increased bone remodelling during fracture repair or an attempt to remodel a mechanically competent bone capable of withstanding physiological load. In summary these data indicate that Phospho1−/− bones are hypomineralized and, consequently, are softer and more flexible. An inability to withstand physiological loading may explain the deformations noted. We hypothesize that this phenotype is due to the reduced availability of inorganic phosphate to form hydroxyapatite during mineralization, creating an undermineralized yet active bone. PMID:21272676

Assessment of Severe Extremity Wound Bioburden at the Time of Definitive Wound Closure or Coverage: Correlation With Subsequent Postclosure Deep Wound Infection (Bioburden Study).

PubMed

Bosse, Michael J; Murray, Clinton K; Carlini, Anthony R; Firoozabadi, Reza; Manson, Theodore; Scharfstein, Daniel O; Wenke, Joseph C; Zadnik, Mary; Castillo, Renan C

2017-04-01

Infection remains the most common and significant complication after high-energy fractures. The Bioburden Study is a multicenter, prospective, observational cohort study of wound bacterial bioburden and antibiotic care in severe open lower extremity fractures. The aims of this study are to (1) characterize the contemporary extremity wound "bioburden" at the time of definitive wound closure; (2) determine the concordance between polymerase chain reaction results and hospital microbiology; (3) determine, among those who develop deep infections, the concordance between the pathogens at wound closure and at deep infection; and (4) compare the probability of deep infection between those who did and did not receive an appropriate course of antibiotics based on bioburden at the time of wound closure. To address these aims, sites collected tissue samples from severe lower extremity injuries at the time of wound closure and at first surgery for treatment of a deep infection, nonunion, flap failure, amputation, or other complications (because these surgeries may be due to undetected infection). Otherwise, if no further surgical treatment occurred, participants were followed for 12 months. The study was conducted at 38 US trauma centers and has enrolled 655 participants aged 18-64 years. This is the first large multi-institutional study evaluating the wound bioburden of severe open tibia fractures and correlating this bioburden with the risk of wound complications after definitive soft tissue closure.

Prior ankle fractures in postmenopausal women are associated with low areal bone mineral density and bone microstructure alterations.

PubMed

Biver, E; Durosier, C; Chevalley, T; Herrmann, F R; Ferrari, S; Rizzoli, R

2015-08-01

In a cross-sectional analysis in postmenopausal women, prior ankle fractures were associated with lower areal bone mineral density (BMD) and trabecular bone alterations compared to no fracture history. Compared to women with forearm fractures, microstructure alterations were of lower magnitude. These data suggest that ankle fractures are another manifestation of bone fragility. Whether ankle fractures represent fragility fractures associated with low areal bone mineral density (aBMD) and volumetric bone mineral density (vBMD) and/or bone microstructure alterations remains unclear, in contrast to the well-recognised association between forearm fractures and osteoporosis. The objective of this study was to investigate aBMD, vBMD and bone microstructure in postmenopausal women with prior ankle fracture in adulthood, compared with women without prior fracture or with women with prior forearm fractures, considered as typically of osteoporotic origin. In a cross-sectional analysis in the Geneva Retirees Cohort study, 63 women with ankle fracture and 59 with forearm fracture were compared to 433 women without fracture (mean age, 65 ± 1 years). aBMD was measured by dual-energy X-ray absorptiometry; distal radius and tibia vBMD and bone microstructure were measured by high-resolution peripheral quantitative computed tomography. Compared with women without fracture, those with ankle fractures had lower aBMD, radius vBMD (-7.9%), trabecular density (-10.7%), number (-7.3%) and thickness (-4.6%) and higher trabecular spacing (+14.5%) (P < 0.05 for all). Tibia trabecular variables were also altered. For 1 standard deviation decrease in total hip aBMD or radius trabecular density, odds ratios for ankle fractures were 2.2 and 1.6, respectively, vs 2.2 and 2.7 for forearm fracture, respectively (P ≤ 0.001 for all). Compared to women with forearm fractures, those with ankle fractures had similar spine and hip aBMD, but microstructure alterations of lower magnitude. Women with ankle fractures have lower aBMD and vBMD and trabecular bone alterations, suggesting that ankle fractures are another manifestation of bone fragility.

Effects of Roughly Focused Extracorporeal Shock Waves Therapy on the Expressions of Bone Morphogenetic Protein-2 and Osteoprotegerin in Osteoporotic Fracture in Rats

PubMed Central

Huang, Hai-Ming; Li, Xiao-Lin; Tu, Shu-Qiang; Chen, Xiao-Feng; Lu, Chang-Chun; Jiang, Liang-Hua

2016-01-01

Background: Roughly focused extracorporeal shock waves therapy (ESWT) is characterized by a wide focal area, a large therapy zone, easy positioning, and less pain during treatment. The purpose of this study was to investigate the effects of roughly focused ESWT on the expression of osteoprotegerin (OPG) and bone morphogenetic protein-2 (BMP-2) in osteoporotic fractures in rats. Methods: Seventy-two female Sprague-Dawley (SD) rats, 3 months old, were divided into sham-operated group (n = 6) and an ovariectomized (OVX) group (n = 66). Sixty OVX SD rats were used as a model of double proximal tibial osteotomy and inner fixation. The osteotomy site in the left tibia was treated with roughly focused ESWT once at an energy density of 0.26 mJ/mm2, 60 doses/min, and 2000 pact quantities. The contralateral right tibia was left untreated and served as a control. Expression of OPG and BMP-2 in the callus of the osteoporotic fracture area was assessed using immunohistochemistry, real-time polymerase chain reaction (PCR), and Western blotting analysis. Results: Bone mineral density (BMD) at the proximal tibia, femur, and L5 spine was significantly reduced after ovariectomy. BMD of proximal tibia was 12.9% less in the OVX group than that in the sham-operated group. Meanwhile, bilateral oophorectomy resulted in a lower trabecular bone volume fraction (BV/TV) in the proximal tibia of the sham-OVX animals. Three months after bilateral oophorectomy, BV/TV was 14.29% of baseline BV/TV in OVX legs versus 45.91% in the sham-OVX legs (P < 0.001). These data showed that the SD rats became a suitable model of osteoporosis, 3 months after they were OVX. Immunohistochemical analysis showed higher levels of BMP-2 and OPG expression in the treatment group than those in the control group. Compared with the contralateral controls, decreased expression of OPG and BMP-2 at 3 days after roughly focused ESWT, followed by a later increase at 7 days, was indicated by real-time PCR and Western blotting analysis. The OPG messenger RNA (mRNA) expression levels peaked at 6 weeks after the shock wave treatment, paired with a much earlier (at 4 weeks) increase of BMP-2, and declined close to normal at 8 weeks. Conclusions: Roughly focused ESWT may promote the expression of OPG and BMP-2 in the osteoporotic fracture area in rats. BMP-2 and OPG may act synergistically and may lead to a significant enhancement of bone formation and remodeling. PMID:27779163

Journal of Special Operations Medicine. Volume 10, Edition 2, Spring 2010

DTIC Science & Technology

2010-01-01

national (LN) male carried to the firebase clinic by his family in severe pain with swelling of his left thigh following a motor- Fracture Detection...tient. (Image 1a) Once the patient’s pain was controlled, the 18D used CR for comparison and con- firmation. (Image 1b) Case 2: Distal Fibular...swollen left leg. The 18D used US to confirm a suspected fracture. (Image 4a) Once the pain was con- trolled the 18D confirmed the fractured tibia with CR

Exchange nailing for nonunion of diaphyseal fractures of the tibia: our results and an analysis of the risk factors for failure.

PubMed

Tsang, S T J; Mills, L A; Frantzias, J; Baren, J P; Keating, J F; Simpson, A H R W

2016-04-01

The aim of this study was to identify risk factors for the failure of exchange nailing in nonunion of tibial diaphyseal fractures. A cohort of 102 tibial diaphyseal nonunions in 101 patients with a mean age of 36.9 years (15 to 74) were treated between January 1992 and December 2012 by exchange nailing. Of which 33 (32%) were initially open injuries. The median time from primary fixation to exchange nailing was 6.5 months (interquartile range (IQR) 4.3 to 9.8 months). The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify risk factors for failure to achieve union. Multiple causes for the primary nonunion were found for 28 (27%) tibiae, with infection present in 32 (31%). Six patients were lost to follow-up. Further surgical procedures were required in 35 (36%) nonunions. Other fixation modalities were required in five fractures. A single nail exchange procedure achieved union in 60/96 (63%) of all nonunions. Only 11 out of 31 infected nonunions (35.4%) healed after one exchange nail procedure. Up to five repeated exchange nailings, with or without bone grafting, ultimately achieved union in 89 (93%) fractures. The median time to union after exchange nailing was 8.7 months (IQR 5.7 to 14.0 months). Univariate analysis confirmed that an oligotrophic/atrophic pattern of nonunion (p = 0.002), a bone gap of 5 mm or more (p = 0.04) and infection (p < 0.001), were predictive for failure of exchange nailing Multiple regression analysis found that infection was the strongest predictor of failure (p < 0.001). Exchange nailing is an effective treatment for aseptic tibial diaphyseal nonunion. However, in the presence of severe infection with a highly resistant organism, or extensive sclerosis of the bone, other fixation modalities, such as Ilizarov treatment, should be considered. Exchange nailing is an effective treatment for aseptic tibial diaphyseal nonunion. ©2016 The British Editorial Society of Bone & Joint Surgery.

[Application of three-dimensional printing in the operation of distal tibia fracture involving epiphyseal plate injury for teenagers].

PubMed

Zhao, Jingxin; Ma, Yachang; Han, Dong; Jin, Yu

2017-10-01

To investigate the application value of three-dimensional (3-D) printing technology in the operation of distal tibia fracture involving epiphyseal plate injury for teenagers. The retrospective analysis was conducted on the clinical data of 16 cases of children patients with distal tibia fracture involving epiphyseal plate injury undergoing the operation by using of 3-D printing technology between January 2014 and December 2015. There were 12 males and 4 females with an age of 9-14 years (mean, 12.8 years). The causes of injury included traffic accident injury in 9 cases, heavy pound injury in 3 cases, and sport injury in 4 cases. The time from injury to operation was 3-92 hours (mean, 25.8 hours). According to Salter-Harris typing standard, the typing for epiphyseal injury was classified as type Ⅱ in 11 cases, type Ⅲ in 4 cases, and type Ⅳ in 1 case. The thin slice CT scan on the affected limb was performed before operation, and the Mimics14.0 medical software was applied for the design and the 1∶1 fracture model was printed by the 3-D printer; the stimulation of operative reduction was made in the fracture model, and bone plate, Kirschner wire, and hollow screw with the appropriate size were chosen, then the complete operative approach and method were designed and the internal fixator regimen was chosen, then the practical operation was performed based on the preoperative design regimen. The operation time was 40-68 minutes (mean, 59.1 minutes); the intraoperative blood loss was 5-102 mL (mean, 35 mL); the intraoperative fluoroscopy times was 2-6 times (mean, 2.8 times). All the patiens were followed up 12-24 months (mean, 15 months). The fracture of 15 cases reached anatomic reduction, and 1 cases had no anatomic reduction with the displaced end less than 1 mm. All the fractures reached bony union with the healing time of 2-4 months (mean, 2.6 months). There was no deep vein thrombosis, premature epiphyseal closure and oblique, or uneven ankle surface occurred, and there was no complication such as osteomyelitis, varus or valgus of ankle joint, joint stiffness, traumatic arthritis. Helfet scores of ankle function were measured at 12 months after operation, the results were excellent in 15 cases and good in 1 case. The angulation of introversion and extroversion for the affected limb was (6.56±2.48)°, and the growth length was (4.44±2.31) mm, and there was no significant difference ( t =0.086, P =0.932; t =0.392, P =0.697) when compared with the uninjured side [(6.50±1.51)°, (4.69±1.08) mm]. As the assistive technology, 3-D printing technology has a certain clinical application value in improving the effectiveness of distal tibia fracture involving epiphyseal plate injury.

Early Conversion of External Fixation to Interlocked Nailing in Open Fractures of Both Bone Leg Assisted with Vacuum Closure (VAC) - Final Outcome

PubMed Central

Raj, Manish; Kumar, Sunil; Singh, Pulkesh; Kumar, Dinesh; Singh, Jasveer; Deep, Akash

2016-01-01

Introduction Management of compound grade III fractures of both bone leg includes external stabilization for long period, followed by various soft tissue coverage procedures. Primary interlocking of tibia had been also done with variable results. External fixation for long time without any bone loss often leads to infected nonunion, loss of reduction, pin tract infection and failure of fixation, primary interlocking in compound grade III fractures had shown high medullary infection rate. We managed all cases of compound grade III A/B fractures with primary external fixation, simultaneous wound management using vacuum assisted closure (VAC) followed by early conversion to interlocking within 2 weeks of fixator application. Aim To determine the effectiveness of vacuum assisted closure (VAC) for the early conversion of external fixator to definitive interlocking in open fractures of the both bone leg. Materials and Methods In current study we selected 84 cases of compound grade IIIA/B diaphyseal fractures of both bone leg during period of May 2010 to September 2013. We managed these cases by immediate debridement and application of external fixation followed by repeated debridement, application of vacuum assisted closure (VAC) and conversion to interlocking within two weeks. Results Out of 84 cases union was achieved in 80(95%) of cases with definitive tibial interlocking. Excellent to good result were obtained in 77(91.8%) of cases and fair to poor result seen in rest of 7(8.2%) of cases according to modified Ketenjian’s criteria. 5 out of these 7 poor result group cases were from Compound Grade III B group to start with. Deep infection rate in our series were 7% i.e. total 6 cases and 4 out of these were from compound Grade III B group to start with. Conclusion Vacuum assisted closure (VAC) give a good help for rapid closure of the wound and help in early conversion to definitive intramedullary nailing. Reamed nail could well be used in compound grade IIIA/B fractures without increasing the risk of infection. It gives better stability to fracture site and lessen the risk of implant failure. PMID:27042541

Surgical treatment of refractory tibial stress fractures in elite dancers: a case series.

PubMed

Miyamoto, Ryan G; Dhotar, Herman S; Rose, Donald J; Egol, Kenneth

2009-06-01

Treatment of tibial stress fractures in elite dancers is centered on rest and activity modification. Surgical intervention in refractory cases has important implications affecting the dancers' careers. Refractory tibial stress fractures in dancers can be treated successfully with drilling and bone grafting or intramedullary nailing. Case series; Level of evidence, 4. Between 1992 and 2006, 1757 dancers were evaluated at a dance medicine clinic; 24 dancers (1.4%) had 31 tibial stress fractures. Of that subset, 7 (29.2%) elite dancers with 8 tibial stress fractures were treated operatively with either intramedullary nailing or drilling and bone grafting. Six of the patients were followed up closely until they were able to return to dance. One patient was available only for follow-up phone interview. Data concerning their preoperative treatment regimens, operative procedures, clinical union, radiographic union, and time until return to dance were recorded and analyzed. The mean age of the surgical patients at the time of stress fracture was 22.6 years. The mean duration of preoperative symptoms before surgical intervention was 25.8 months. Four of the dancers were male and 3 were female. All had failed nonoperative treatment regimens. Five patients (5 tibias) underwent drilling and bone grafting of the lesion, and 2 patients (3 tibias) with completed fractures or multiple refractory stress fractures underwent intramedullary nailing. Clinical union was achieved at a mean of 6 weeks and radiographic union at 5.1 months. Return to full dance activity was at an average of 6.5 months postoperatively. Surgical intervention for tibial stress fractures in dancers who have not responded to nonoperative management allowed for resolution of symptoms and return to dancing with minimal morbidity.

Assessment of the influence of Laser phototherapy on the bone repair process of complete fractures in tibiae of rabbits stabilized with semi-rigid internal fixation treated with or without MTA graft: a histological study

NASA Astrophysics Data System (ADS)

Soares, Luiz G. P.; Silva, Aline C. P.; Silva, Anna Paula L. T.; Neves, Bruno Luiz R. C.; Santos, Nicole R. S.; dos Santos, Jean N.; Pinheiro, Antonio L. B.

2016-03-01

Beside biomaterials, Laser phototherapy has shown positive effects as auxiliary therapy in bone repair process, especially when involving large bone losses. The aim of this histological study was to evaluate, by light microscopy, the influence of laser phototherapy on the repair of complete tibial fractures in rabbits treated or not with semi-rigid internal fixation and Mineral Trioxide Aggregate - MTA graft. Twelve Rabbits were randomly divided into four groups with three animals each. After general anesthesia, complete fractures were created in one tibia with a carborundum disk. All animals (groups I-IV) had the fracture stabilized with semi-rigid fixation (wire osteosynthesis - WO). Group I was routinely fixed with WO; groups II and IV fracture was filled by blood clot and MTA implant. In Groups III and IV fracture was filled by blood clot and further irradiated with laser (λ780 nm, 70 mW, CW, Φ = 0.04 cm2, 20.4 J/cm2, per session, t = 300s, 142.8 J/cm2 per treatment). The phototherapy protocol was applied immediately after the surgery and repeated each 48 hours during 15 days. Animal death occurred on the 30th postoperative day. After removal of the specimens, the samples were routinely processed, stained with HE and evaluated by light microscopy. Histologically, the group treated with MTA graft and irradiated with laser showed the fracture filled by a more organized and mature trabecular bone, when compared with all other groups. From the results of the present study, it may be concluded that the association of Laser phototherapy + MTA graft in fractures treated with WO improved bone repair when compared with fractures treated only with WO.

Fracture following lower limb lengthening in children: a series of 58 patients.

PubMed

Launay, F; Younsi, R; Pithioux, M; Chabrand, P; Bollini, G; Jouve, J-L

2013-02-01

Fracture is one of the main complications following external fixator removal used in cases of progressive lower limb lengthening; rates as high as 50% are found in the literature. The aim of this study was to determine the factors influencing this complication. One hundred and eleven cases of lower limb lengthening were performed in 58 patients (40 femurs and 71 tibias). The mean age at surgery was 10.1years old. Lengthening was performed in all cases with an external fixator alone, associated in 39.6% of cases with intramedullary nailing. The patients were divided into three groups according to disease etiology (congenital, achondroplasia and other). The fractures were classified according to the Simpson classification. Twenty fractures were recorded (18%). Sixteen fractures were found in patients with congenital disease, four with achondroplasia and none in the group of other etiologies. The fracture was more often in the femur (27.5%) than in the tibia (12.7%). The rate of fracture is influenced by different factors depending on the etiology of disease. In congenital diseases, the fracture rate is higher when there is lengthening of more than 15% of the initial length and a delay between surgery and the beginning of lengthening of less than 7days. In patients with achondroplasia, the influence of a relative percentage of lengthening is less important than in those with congenital disease. However, to avoid fractures, lengthening should not be started in children under the age of nine. Moreover, lengthening should begin at least 7days after the fixator has been placed. Retrospective. Level IV. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Myogenic progenitors contribute to open but not closed fracture repair.

PubMed

Liu, Renjing; Birke, Oliver; Morse, Alyson; Peacock, Lauren; Mikulec, Kathy; Little, David G; Schindeler, Aaron

2011-12-22

Bone repair is dependent on the presence of osteocompetent progenitors that are able to differentiate and generate new bone. Muscle is found in close association with orthopaedic injury, however its capacity to make a cellular contribution to bone repair remains ambiguous. We hypothesized that myogenic cells of the MyoD-lineage are able to contribute to bone repair. We employed a MyoD-Cre+:Z/AP+ conditional reporter mouse in which all cells of the MyoD-lineage are permanently labeled with a human alkaline phosphatase (hAP) reporter. We tracked the contribution of MyoD-lineage cells in mouse models of tibial bone healing. In the absence of musculoskeletal trauma, MyoD-expressing cells are limited to skeletal muscle and the presence of reporter-positive cells in non-muscle tissues is negligible. In a closed tibial fracture model, there was no significant contribution of hAP+ cells to the healing callus. In contrast, open tibial fractures featuring periosteal stripping and muscle fenestration had up to 50% of hAP+ cells detected in the open fracture callus. At early stages of repair, many hAP+ cells exhibited a chondrocyte morphology, with lesser numbers of osteoblast-like hAP+ cells present at the later stages. Serial sections stained for hAP and type II and type I collagen showed that MyoD-lineage cells were surrounded by cartilaginous or bony matrix, suggestive of a functional role in the repair process. To exclude the prospect that osteoprogenitors spontaneously express MyoD during bone repair, we created a metaphyseal drill hole defect in the tibia. No hAP+ staining was observed in this model suggesting that the expression of MyoD is not a normal event for endogenous osteoprogenitors. These data document for the first time that muscle cells can play a significant secondary role in bone repair and this knowledge may lead to important translational applications in orthopaedic surgery. Please see related article: http://www.biomedcentral.com/1741-7015/9/136.

Differentiating Stress Fracture From Periostitis.

PubMed

Martire, J R

1994-10-01

In brief Even in the age of high-technology MRI and CT, the triple-phase bone scan (TPBS) remains an exceptionally useful and accurate tool in evaluating athletic injuries. This is perhaps best seen in active people with overuse injuries of the tibia, femur, or humerus when plain films are negative but bone pain persists. Differentiating periostitis from stress fracture requires analyzing distinctive TPBS appearances and patterns.

Distal tibial fractures and non-unions treated with shortened intramedullary nail.

PubMed

Megas, P; Zouboulis, P; Papadopoulos, A X; Karageorgos, A; Lambiris, E

2003-01-01

We reviewed 18 patients, 14 with acute fractures and four with non-union of the distal tibia, treated between 1990 and 2001 with a shortened, reamed intramedullary nail. The mean follow-up was 38 (8-144) months. The fractures united at an average of 16 (12-18) weeks and the non-unions at 20 (12-30) weeks. Two patients required nail dynamization. No limb shortening nor material failures were seen. All patients returned to normal daily activities. Although technically demanding, intramedullary nailing for distal tibial fractures and non-unions with a shortened nail represents a safe and reliable method.

Comparison of cyclic and impact-based reference point indentation measurements in human cadaveric tibia.

PubMed

Karim, Lamya; Van Vliet, Miranda; Bouxsein, Mary L

2018-01-01

Although low bone mineral density (BMD) is strongly associated with increased fracture risk, up to 50% of those who suffer fractures are not detected as high-risk patients by BMD testing. Thus, new approaches may improve identification of those at increased risk for fracture by in vivo assessment of altered bone tissue properties, which may contribute to skeletal fragility. Recently developed reference point indentation (RPI) allows for assessment of cortical bone indentation properties in vivo using devices that apply cyclic loading or impact loading, but there is little information available to assist with interpretation of RPI measurements. Our goals were to use human cadaveric tibia to determine: 1) the associations between RPI variables, cortical bone density, and morphology; 2) the association between variables obtained from RPI systems using cyclic, slow loading versus a single impact load; and 3) age-related differences in RPI variables. We obtained 20 human tibia and femur pairs from female donors (53-97years), measured total hip BMD using dual-energy X-ray absorptiometry, assessed tibial cortical microarchitecture using high-resolution peripheral quantitative computed tomography (HR-pQCT), and assessed cortical bone indentation properties at the mid-tibial diaphysis using both the cyclic and impact-based RPI systems (Biodent and Osteoprobe, respectively, Active Life Scientific, Santa Barbara, CA). We found a few weak associations between RPI variables, BMD, and cortical geometry; a few weak associations between measurements obtained by the two RPI systems; and no age-related differences in RPI variables. Our findings indicate that in cadaveric tibia from older women RPI measurements are largely independent of age, femoral BMD, and cortical geometry. Furthermore, measurements from the cyclic and impact loading RPI devices are weakly related to each other, indicating that each device reflects different aspects of cortical bone indentation properties. Copyright © 2016. Published by Elsevier Inc.

A comparison of stereology, structural rigidity and a novel 3D failure surface analysis method in the assessment of torsional strength and stiffness in a mouse tibia fracture model.

PubMed

Wright, David A; Nam, Diane; Whyne, Cari M

2012-08-31

In attempting to develop non-invasive image based measures for the determination of the biomechanical integrity of healing fractures, traditional μCT based measurements have been limited. This study presents the development and evaluation of a tool for assessment of fracture callus mechanical properties through determination of the geometric characteristics of the fracture callus, specifically along the surface of failure identified during destructive mechanical testing. Fractures were created in tibias of ten male mice and subjected to μCT imaging and biomechanical torsion testing. Failure surface analysis, along with previously described image based measures was calculated using the μCT image data, and correlated with mechanical strength and stiffness. Three-dimensional measures along the surface of failure, specifically the surface area and torsional rigidity of bone, were shown to be significantly correlating with mechanical strength and stiffness. It was also shown that surface area of bone along the failure surface exhibits stronger correlations with both strength and stiffness than measures of average and minimum torsional rigidity of the entire callus. Failure surfaces observed in this study were generally oriented at 45° to the long axis of the bone, and were not contained exclusively within the callus. This work represents a proof of concept study, and shows the potential utility of failure surface analysis in the assessment of fracture callus stability. Copyright © 2012 Elsevier Ltd. All rights reserved.

Dynamic Stabilization of Simple Fractures With Active Plates Delivers Stronger Healing Than Conventional Compression Plating

PubMed Central

Tsai, Stanley; Bliven, Emily K.; von Rechenberg, Brigitte; Kindt, Philipp; Augat, Peter; Henschel, Julia; Fitzpatrick, Daniel C.; Madey, Steven M.

2017-01-01

Objectives: Active plates dynamize a fracture by elastic suspension of screw holes within the plate. We hypothesized that dynamic stabilization with active plates delivers stronger healing relative to standard compression plating. Methods: Twelve sheep were randomized to receive either a standard compression plate (CP) or an active plate (ACTIVE) for stabilization of an anatomically reduced tibial osteotomy. In the CP group, absolute stabilization was pursued by interfragmentary compression with 6 cortical screws. In the ACTIVE group, dynamic stabilization after bony apposition was achieved with 6 elastically suspended locking screws. Fracture healing was analyzed weekly on radiographs. After sacrifice 9 weeks postsurgery, the torsional strength of healed tibiae and contralateral tibiae was measured. Finally, computed tomography was used to assess fracture patterns and healing modes. Results: Healing in both groups included periosteal callus formation. ACTIVE specimens had almost 6 times more callus area by week 9 (P < 0.001) than CP specimens. ACTIVE specimens recovered on average 64% of their native strength by week 9, and were over twice as strong as CP specimens, which recovered 24% of their native strength (P = 0.008). Microcomputed tomography demonstrated that compression plating induced a combination of primary bone healing and gap healing. Active plating consistently stimulated biological bone healing by periosteal callus formation. Conclusions: Compared with compression plating, dynamic stabilization of simple fractures with active plates delivers significantly stronger healing. PMID:27861456

Outcome of limb reconstruction system in open tibial diaphyseal fractures.

PubMed

Ajmera, Anand; Verma, Ankit; Agrawal, Mukul; Jain, Saurabh; Mukherjee, Arunangshu

2015-01-01

Management of open tibial diaphyseal fractures with bone loss is a matter of debate. The treatment options range from external fixators, nailing, ring fixators or grafting with or without plastic reconstruction. All the procedures have their own set of complications, like acute docking problems, shortening, difficulty in soft tissue management, chronic infection, increased morbidity, multiple surgeries, longer hospital stay, mal union, nonunion and higher patient dissatisfaction. We evaluated the outcome of the limb reconstruction system (LRS) in the treatment of open fractures of tibial diaphysis with bone loss as a definative mode of treatment to achieve union, as well as limb lengthening, simultaneously. Thirty open fractures of tibial diaphysis with bone loss of at least 4 cm or more with a mean age 32.5 years were treated by using the LRS after debridement. Distraction osteogenesis at rate of 1 mm/day was done away from the fracture site to maintain the limb length. On the approximation of fracture ends, the dynamized LRS was left for further 15-20 weeks and patient was mobilized with weight bearing to achieve union. Functional assessment was done by Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria. Mean followup period was 15 months. The mean bone loss was 5.5 cm (range 4-9 cm). The mean duration of bone transport was 13 weeks (range 8-30 weeks) with a mean time for LRS in place was 44 weeks (range 24-51 weeks). The mean implant index was 56.4 days/cm. Mean union time was 52 weeks (range 31-60 weeks) with mean union index of 74.5 days/cm. Bony results as per the ASAMI scoring were excellent in 76% (19/25), good in 12% (3/25) and fair in 4% (1/25) with union in all except 2 patients, which showed poor results (8%) with only 2 patients having leg length discrepancy more than 2.5 cm. Functional results were excellent in 84% (21/25), good in 8% (2/25), fair in 8% (2/25). Pin tract infection was seen in 5 cases, out of which 4 being superficial, which healed to dressings and antibiotics. One patient had a deep infection which required frame removal. Limb reconstruction system proved to be an effective modality of treatment in cases of open fractures of the tibia with bone loss as definite modality of treatment for damage control as well as for achieving union and lengthening, simultaneously, with the advantage of early union with attainment of limb length, simple surgical technique, minimal invasive, high patient compliance, easy wound management, lesser hospitalization and the lower rate of complications like infection, deformity or shortening.

Role of the fibula in the stability of diaphyseal tibial fractures fixed by intramedullary nailing.

PubMed

Galbraith, John G; Daly, Charles J; Harty, James A; Dailey, Hannah L

2016-10-01

For tibial fractures, the decision to fix a concomitant fibular fracture is undertaken on a case-by-case basis. To aid in this clinical decision-making process, we investigated whether loss of integrity of the fibula significantly destabilises midshaft tibial fractures, whether fixation of the fibula restores stability to the tibia, and whether removal of the fibula and interosseous membrane for expediency in biomechanical testing significantly influences tibial interfragmentary mechanics. Tibia/fibula pairs were harvested from six cadaveric donors with the interosseous membrane intact. A tibial osteotomy fracture was fixed by reamed intramedullary (IM) nailing. Axial, torsion, bending, and shear tests were completed for four models of fibular involvement: intact fibula, osteotomy fracture, fibular plating, and resected fibula and interosseous membrane. Overall construct stiffness decreased slightly with fibular osteotomy compared to intact bone, but this change was not statistically significant. Under low loads, the influence of the fibula on construct stability was only statistically significant in torsion (large effect size). Fibular plating stiffened the construct slightly, but this change was not statistically significant compared to the fibular osteotomy case. Complete resection of the fibula and interosseous membrane significantly decreased construct torsional stiffness only (large effect size). These results suggest that fixation of the fibula may not contribute significantly to the stability of diaphyseal tibial fractures and should not be undertaken unless otherwise clinically indicated. For testing purposes, load-sharing through the interosseous membrane contributes significantly to overall construct mechanics, especially in torsion, and we recommend preservation of these structures when possible. Copyright © 2016 Elsevier Ltd. All rights reserved.

Central physeal arrests as a manifestation of hypervitaminosis A.

PubMed

Saltzman, Matthew D; King, Erik C

2007-01-01

Vitamin A is necessary for synthesis of visual pigments and required in appropriate amounts for membrane stability. Acute hypervitamin A intoxication can lead to increased intracranial pressure, vomiting, and lethargy. Chronic excessive intake of vitamin A can lead to pruritus, muscle and bone tenderness, and failure to thrive. Reported effects of hypervitamin A intoxication on bone include osteoporosis, fracture, cortical thickening, and metaphyseal irregularity. We are reporting on a case of central physeal arrest in the distal femur, proximal tibia, and distal tibia after excessive intake of vitamin A.

Vertebral deformities and fractures are associated with MRI and pQCT measures obtained at the distal tibia and radius of postmenopausal women

PubMed Central

Rajapakse, C. S.; Phillips, E. A.; Sun, W.; Wald, M. J.; Magland, J. F.; Snyder, P. J.; Wehrli, F. W.

2016-01-01

Summary We investigated the association of postmenopausal vertebral deformities and fractures with bone parameters derived from distal extremities using MRI and pQCT. Distal extremity measures showed variable degrees of association with vertebral deformities and fractures, highlighting the systemic nature of postmenopausal bone loss. Introduction Prevalent vertebral deformities and fractures are known to predict incident further fractures. However, the association of distal extremity measures and vertebral deformities in postmenopausal women has not been fully established. Methods This study involved 98 postmenopausal women (age range 60–88 years, mean 70 years) with DXA BMD T-scores at either the hip or spine in the range of −1.5 to −3.5. Wedge, biconcavity, and crush deformities were computed on the basis of spine MRI. Vertebral fractures were assessed using Eastell's criterion. Distal tibia and radius stiffness was computed using MRI-based finite element analysis. BMD at the distal extremities were obtained using pQCT. Results Several distal extremity MRI and pQCT measures showed negative association with vertebral deformity on the basis of single parameter correlation (r up to 0.67) and two-parameter regression (r up to 0.76) models involving MRI stiffness and pQCT BMD. Subjects who had at least one prevalent vertebral fracture showed decreased MRI stiffness (up to 17.9 %) and pQCT density (up to 34.2 %) at the distal extremities compared to the non-fracture group. DXA lumbar spine BMD T-score was not associated with vertebral deformities. Conclusions The association between vertebral deformities and distal extremity measures supports the notion of postmenopausal osteoporosis as a systemic phenomenon. PMID:24221453

Synchronous symmetrical atypical osteoid osteoma of tibia: a case report.

PubMed

Sreenivas, T; Menon, Jagdish; Nataraj, A R

2012-11-01

We report a case of synchronous symmetrical osteoid osteoma of tibia which was atypical in its appearance on imaging. Our patient was a 30-year-old woman presented with 2 years history of bilateral leg pain more on the right side. The pain was more during night and relieved on taking salicylates. Laboratory investigations were within normal limits. Radiographs and computed tomography revealed bilateral focal irregular cortical sclerosis with narrowing of medullary canal of mid tibia. The lesion on right side was excised enbloc followed by the lesion on left side 3 months later and histologically confirmed as osteoid osteoma. Initially, we thought it was stress fracture or subacute osteomyelitis but it was in fact histopathology which showed osteoid osteoma. Patient was completely asymptomatic postoperatively.

Leg lengthening - series (image)

MedlinePlus

... as Legg-Perthes disease Previous injuries or bone fractures that may stimulate excessive bone growth Abnormal spinal ... in the bone to be lengthened; usually the lower leg bone (tibia) or upper ... small steps, usually over the course of several months.

Finite Element Analysis of Absorbable Sheath to Prevent Stress Shielding of Tibial Interlocking Intramedullary Nail

NASA Astrophysics Data System (ADS)

Dong, Yansheng; Wang, Yongqing; Dong, Limin; Jia, Peng; Lu, Fengcheng

2017-07-01

The nail with absorbable sheath (AS nail) is designed to reduce the stress shielding effect of internal fixation with interlocking intramedullary nail. In order to verify its feasibility, two types of the finite element models of internal fixation of tibia with the AS nail and the common metal nail (CM nail) are established using the Softwares of Mimics, Geomagic, SolidWorks and ANSYS according to the CT scanning data of tibia. The result of the finite element analysis shows that the AS nail has great advantages compared with the CM nail in reducing the stress shielding effect in different periods of fracture healing. The conclusion is that the AS nail can realize the static fixation to the dynamic fixation from the early to the later automatically to shorten the time of fracture healing, which also provides a new technique to the interlocking intramedullary nail.

Papineau debridement, Ilizarov bone transport, and negative-pressure wound closure for septic bone defects of the tibia.

PubMed

Karargyris, Orestis; Polyzois, Vasilios D; Karabinas, Panayiotis; Mavrogenis, Andreas F; Pneumaticos, Spyros G

2014-08-01

Ilizarov pioneered bone transport using a circular external fixator. Papineau described a staged technique for the treatment for infected pseudarthrosis of the long bones. This article presents a single-stage Papineau technique and Ilizarov bone transport, and postoperative negative-pressure wound dressing changes for septic bone defects of the tibia. We studied the files of seven patients (mean age, 32 years) with septic bone defects of the tibia treated with a Papineau technique and Ilizarov bone transport in a single stage, followed by postoperative negative-pressure wound dressing changes. All patients had septic pseudarthrosis and skin necrosis of the tibia. The technique included a single-stage extensive surgical debridement of necrotic bone, open bone grafting with cancellous bone autograft and bone transport, and postoperative negative-pressure wound dressing changes for wound closure. The mean time from the initial injury was 6 months (range, 4-8 months). The mean follow-up was 14 months (range, 10-17 months). All patients experienced successful wound healing at a mean of 29 days. Six patients experienced successful bone regeneration and union at the docking side at a mean of 6 months. One patient experienced delayed union at the docking site, which was treated with autologous cancellous bone grafting. Two patients experienced pin track infection, which was successfully treated with antibiotics and pin site dressing changes. All patients were able to return to their work and previous levels of activity, except one patient who had a stiff ankle joint and had to change his job. No patient experienced recurrence of infection, or fracture of the regenerated or transported bone segment until the period of this study. The combined Papineau and Ilizarov bone transport technique with negative-pressure wound closure provides for successful eradication of the infection, reconstruction of the bone defect, and soft-tissue closure. A single-stage surgical treatment is feasible, without any complications.

Bone Geometry as a Predictor of Tissue Fragility and Stress Fracture Risk

DTIC Science & Technology

2006-10-01

WidthML/2) directions. Moment of inertia and section modulus were assessed because these geometric measures are related to the bending and...mandible: Thomas; 1963. Ferretti JL, Capozza RF, Mondelo N, Zanchetta JR. Interrelationships between densitometric, geometric , and mechanical...fractures. Am J Sports Med, 28:245-251, 2000. Miller GJ, Purkey WW, Jr. The geometric properties of paired human tibiae. J Biomech, 13:1-8, 1980

Major Extremity Trauma Research Consortium (METRC) 2011 Annual Report

DTIC Science & Technology

2011-01-01

military treatment centers (MTFs). METRC is designed to meet these needs. Anchored by a Data Coordinating Center at the Johns Hopkins Bloomberg...talus or crush injuries only). Excluded from the registry are hip fractures in patients 60 years or older and fractures to the wrist, hand, ankle ...OUTLET: Outcomes following severe distal tibia, ankle and/or foot trauma: comparison of limb salvage vs. transtibial amputation STATUS: Master protocol

Examining tissue composition, whole-bone morphology and mechanical behavior of GorabPrx1 mice tibiae: A mouse model of premature aging.

PubMed

Yang, Haisheng; Albiol, Laia; Chan, Wing-Lee; Wulsten, Dag; Seliger, Anne; Thelen, Michael; Thiele, Tobias; Spevak, Lyudmila; Boskey, Adele; Kornak, Uwe; Checa, Sara; Willie, Bettina M

2017-12-08

Gerodermia osteodysplastica (GO) is a segmental progeroid disorder caused by loss-of-function mutations in the GORAB gene, associated with early onset osteoporosis and bone fragility. A conditional mouse model of GO (Gorab Prx1 ) was generated in which the Gorab gene was deleted in long bones. We examined the biomechanical/functional relevance of the Gorab Prx1 mutants as a premature aging model by characterizing bone composition, tissue-level strains, and whole-bone morphology and mechanical properties of the tibia. MicroCT imaging showed that Gorab Prx1 tibiae had an increased anterior convex curvature and decreased cortical cross-sectional area, cortical thickness and moments of inertia, compared to littermate control (LC) tibiae. Fourier transform infrared (FTIR) imaging indicated a 34% decrease in mineral/matrix ratio and a 27% increase in acid phosphate content in the posterior metaphyseal cortex of the Gorab Prx1 tibiae (p < .05), suggesting delayed mineralization. In vivo strain gauge measurement and finite element analysis showed ∼two times higher tissue-level strains within the Gorab Prx1 tibiae relative to LC tibiae when subjected to axial compressive loads of the same magnitude. Three-point bending tests suggested that Gorab Prx1 tibiae were weaker and more brittle, as indicated by decreasing whole-bone strength (46%), stiffness (55%), work-to-fracture (61%) and post-yield displacement (47%). Many of these morphological and biomechanical characteristics of the Gorab Prx1 tibia recapitulated changes in other animal models of skeletal aging. Future studies are necessary to confirm how our observations might guide the way to a better understanding and treatment of GO. Copyright © 2017 Elsevier Ltd. All rights reserved.

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.

Targeted delivery of lovastatin and tocotrienol to fracture site promotes fracture healing in osteoporosis model: micro-computed tomography and biomechanical evaluation.

PubMed

Ibrahim, Nurul 'Izzah; Khamis, Mohd Fadhli; Mod Yunoh, Mohd Faridz; Abdullah, Shahrum; Mohamed, Norazlina; Shuid, Ahmad Nazrun

2014-01-01

Osteoporosis is becoming a major health problem that is associated with increased fracture risk. Previous studies have shown that osteoporosis could delay fracture healing. Although there are potential agents available to promote fracture healing of osteoporotic bone such as statins and tocotrienol, studies on direct delivery of these agents to the fracture site are limited. This study was designed to investigate the effects of two potential agents, lovastatin and tocotrienol using targeted drug delivery system on fracture healing of postmenopausal osteoporosis rats. The fracture healing was evaluated using micro CT and biomechanical parameters. Forty-eight Sprague-Dawley female rats were divided into 6 groups. The first group was sham-operated (SO), while the others were ovariectomized (OVx). After two months, the right tibiae of all rats were fractured at metaphysis region using pulsed ultrasound and were fixed with plates and screws. The SO and OVxC groups were given two single injections of lovastatin and tocotrienol carriers. The estrogen group (OVx+EST) was given daily oral gavages of Premarin (64.5 µg/kg). The Lovastatin treatment group (OVx+Lov) was given a single injection of 750 µg/kg lovastatin particles. The tocotrienol group (OVx+TT) was given a single injection of 60 mg/kg tocotrienol particles. The combination treatment group (OVx+Lov+TT) was given two single injections of 750 µg/kg lovastatin particles and 60 mg/kg tocotrienol particles. After 4 weeks of treatment, the fractured tibiae were dissected out for micro-CT and biomechanical assessments. The combined treatment group (OVx+Lov+TT) showed significantly higher callus volume and callus strength than the OVxC group (p<0.05). Both the OVx+Lov and OVx+TT groups showed significantly higher callus strength than the OVxC group (p<0.05), but not for callus volume. In conclusion, combined lovastatin and tocotrienol may promote better fracture healing of osteoporotic bone.

Fatigue Fractures

PubMed Central

Morris, James M.

1968-01-01

Fatigue (or stress) fracture of bone in military recruits has been recognized for many years. Most often it is a metatarsal bone that is involved but the tarsal bones, calcaneus, tibia, fibula, femur, and pelvis are occasionally affected. Reports of such fractures in the ribs, ulna and vertebral bodies may be found in the literature. In recent years, there has been increasing awareness of the occurrence of fatigue fractures in the civilian population. Weekend sportsmen, athletes in an early phase of training, and persons engaged in unaccustomed, repetitive, vigorous activity are potential victims of such a fracture. The signs and symptoms, roentgenographic findings, treatment and etiology of fatigue fractures are dealt with in this presentation. ImagesFigure 1.Figure 2.Figure 3.Figure 4.Figure 5.Figure 6. PMID:5652745

Interlocking Nailing Versus Plating in Tibial Shaft Fractures in Adults: A Comparative Study.

PubMed

Mukherjee, Sagnik; Arambam, Mahendra Singh; Waikhom, Sanjib; Santosha; Masatwar, Pranav Vitthal; Maske, Rohan Gautam

2017-04-01

Tibial diaphyseal fractures are the commonest long bone fractures in adults, most commonly managed by intramedullary interlocking nailing. However, several meta-analysis show that locking plate osteosynthesis is equally effective in managing tibial diaphyseal fractures and are associated with less number of complications. To compare the results of fixation of tibial fractures following plating and nailing in terms of union, patient satisfaction and complications. A hospital based non randomized clinical trial was performed from September 2013 to August 2016 where closed or open diaphyseal or metaphyseo- diaphyseal fractures of the tibia (closed or open Gustilo Anderson type 1 through 3B) were included. Simple sequential allocation was used for allotting the patients to two groups, one for interlocking nailing and other for plating. The patients were followed up for clinical, radiographic and functional results. Forty patients with 41 involved limbs completed follow up for one year. The duration of surgery and average blood loss during surgery was 75.45±3.03 minutes and 165.00±5.31 ml respectively in case of nailing and 85.05±2.54 minutes and184.29±5.33 ml respectively in case of plating and their difference was statistically significant. In our study union was achieved in less than 20 weeks in 29 (70.8%) of the patients and 25-30 weeks in nine (22%) cases. The average time of union in our study was 19.55±0.69 weeks in case of interlocking nailing and 20.38±1.39 weeks in case of plating and there was no statistically significant difference between the two. However, there is statistically significant difference in the functional score in between the two groups in terms of Lower Extremity Functional Score (LEFS). Delayed union in one case of nailing and two cases of plating, valgus malunion in one case of nailing and joint stiffness in two cases each of nailing and plating were the major complications observed. There was no difference between the two modalities in terms of fracture union. Complications were lesser but more serious in case of plating. Patient satisfaction was more with plating.

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.

Sagittal plane bending moments acting on the lower leg during running.

PubMed

Haris Phuah, Affendi; Schache, Anthony G; Crossley, Kay M; Wrigley, Tim V; Creaby, Mark W

2010-02-01

Sagittal bending moments acting on the lower leg during running may play a role in tibial stress fracture development. The purpose of this study was to evaluate these moments at nine equidistant points along the length of the lower leg (10% point-90% point) during running. Kinematic and ground reaction force data were collected for 20 male runners, who each performed 10 running trials. Inverse dynamics and musculoskeletal modelling techniques were used to estimate sagittal bending moments due to reaction forces and muscle contraction. The muscle moment was typically positive during stance, except at the most proximal location (10% point) on the lower leg. The reaction moment was predominantly negative throughout stance and greater in magnitude than the muscle moment. Hence, the net sagittal bending moment acting on the lower leg was principally negative (indicating tensile loads on the posterior tibia). Peak moments typically occurred around mid-stance, and were greater in magnitude at the distal, compared with proximal, lower leg. For example, the peak reaction moment at the most distal point was -9.61+ or - 2.07%Bw.Ht., and -2.73 + or - 1.18%Bw.Ht. at the most proximal point. These data suggest that tensile loads on the posterior tibia are likely to be higher toward the distal end of the bone. This finding may explain the higher incidence of stress fracture in the distal aspect of the tibia, observed by some authors. Stress fracture susceptibility will also be influenced by bone strength and this should also be accounted for in future studies. Copyright 2009 Elsevier B.V. All rights reserved.

Allograft-prosthesis composites after bone tumor resection at the proximal tibia.

PubMed

Biau, David Jean; Dumaine, Valérie; Babinet, Antoine; Tomeno, Bernard; Anract, Philippe

2007-03-01

The survival of irradiated allograft-prosthesis composites at the proximal tibia is mostly unknown. However, allograft-prosthesis composites have proved beneficial at other reconstruction sites. We presumed allograft-prosthesis composites at the proximal tibia would improve survival and facilitate reattachment of the extensor mechanism compared with that of conventional (megaprostheses) reconstructions. We retrospectively reviewed 26 patients who underwent resection of proximal tibia tumors followed by reconstruction with allo-graft-prosthesis composites. Patients received Guepar massive custom-made fully constrained prostheses. Allografts were sterilized with gamma radiation, and the stems were cemented into the allograft and host bone. The minimum followup was 6 months (median, 128 months; range, 6-195 months). Fourteen patients had one or more components removed. The median allograft-prosthesis composite survival was 102 months (95% confidence interval, 64.2-infinity). Of the 26 allografts, seven fractured, six showed signs of partial resorption, and six had infections develop. Seven allografts showed signs of fusion with the host bone. Six extensor mechanism reconstructions failed. Allograft-prosthesis composites sterilized by gamma radiation yielded poor results for proximal tibial reconstruction as complications and failures were common. We do not recommend irradiated allograft-prosthesis composites for proximal tibia reconstruction.

[Multiple long bone fractures in a child with pycnodysostosis. A case report].

PubMed

Rojas, Paula I; Niklitschek, Nathia E; Sepúlveda, Matías F

2016-06-01

Fractures are an important entity to consider in pediatric patients. There are certain diseases in which bones fracture with a minimal trauma. Pycnodysostosis is an autosomal recessive unusual type of cráneo metaphyseal dysplasia, that presents frequently as fracture in a pathological bone. A 9 year old caucasian female, diagnosed with pycnodysostosis, was admitted with a right femur fracture as a result of a low energy trauma. Radiographic studies showed bilateral femur fractures, proximal fracture and non-union in antecurvatum of the left tibia. Pycnodysostosis is a rare disease, generally diagnosed at an early age by growth restriction, frequent fractures or fractures with low energy trauma. Therapy alternatives are limited, and no permanent cure has been developed. If a patient has dysmorphic facial features and fractures in a pathological bone, it is important to suspect bone dysplasia, such as pycnodysostosis and its differential diagnoses. Sociedad Argentina de Pediatría.

Risk of injury to the sural nerve during posterolateral approach to the distal tibia: An ultrasound simulation study.

PubMed

Mizia, Ewa; Pękala, Przemysław A; Chomicki-Bindas, Piotr; Marchewka, Wojciech; Loukas, Marios; Zayachkowski, Alexander G; Tomaszewski, Krzysztof A

2018-05-08

Introduction When surgeons operate on the foot and ankle, the most common complication that may arise is injury of the cutaneous nerves. The sural nerve (SN) is potentially at risk of being injured when treating fractures involving the distal tibia using the posterolateral approach. The aim of this study was to evaluate how differences in length and position of the surgical treatment of fractures involving the distal tibia can affect the risk of SN injury. Materials and Methods The study involved 40 healthy volunteers (n=80 lower limbs). Ultrasound simulation of each potential surgical incision site was used to locate the SN and to assess the risk of injury. Results The study showed that the SN predominantly travels more posteriorly at levels more proximal from the tip of the lateral malleolus. At these more proximal points of the SN's course, it was proven that there was an overall increased incidence of iatrogenic injury to the SN in incisions made closer to the Achilles tendon. Based on these results, a quasi 3 dimensional figure was created showing the anatomical structures of this region to identify areas at high risk for SN injury. Conclusions By revealing how length and position of the surgical incision can influence the risk of SN injury, we hope to provide information to surgeons on the optimal technique to avoid iatrogenic SN injury while operating on the distal tibia via a posterolateral approach. This article is protected by copyright. All rights reserved. © 2018 Wiley Periodicals, Inc.

Compartment syndrome after tibial plateau fracture☆

PubMed Central

Pitta, Guilherme Benjamin Brandão; dos Santos, Thays Fernanda Avelino; dos Santos, Fernanda Thaysa Avelino; da Costa Filho, Edelson Moreira

2014-01-01

Fractures of the tibial plateau are relatively rare, representing around 1.2% of all fractures. The tibia, due to its subcutaneous location and poor muscle coverage, is exposed and suffers large numbers of traumas, not only fractures, but also crush injuries and severe bruising, among others, which at any given moment, could lead compartment syndrome in the patient. The case is reported of a 58-year-old patient who, following a tibial plateau fracture, presented compartment syndrome of the leg and was submitted to decompressive fasciotomy of the four right compartments. After osteosynthesis with internal fixation of the tibial plateau using an L-plate, the patient again developed compartment syndrome. PMID:26229779

Greater Polar Moment of Inertia at the Tibia in Athletes Who Develop Stress Fractures

PubMed Central

Weidauer, Lee A.; Binkley, Teresa; Vukovich, Matt; Specker, Bonny

2014-01-01

Background: Several previous investigations have determined potential risk factors for stress fractures in athletes and military personnel. Purpose: To determine factors associated with the development of stress fractures in female athletes. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 88 female athletes (cross-country, n = 29; soccer, n = 15; swimming, n = 9; track and field, n = 14; volleyball, n = 12; and basketball, n = 9) aged 18 to 24 years were recruited to participate in a longitudinal bone study and had their left distal tibia at the 4%, 20%, and 66% sites scanned by peripheral quantitative computed tomography (pQCT). Patients included 23 athletes who developed stress fractures during the following year (cases). Whole body, hip, and spine scans were obtained using dual-energy x-ray absorptiometry (DXA). Analysis of covariance was used to determine differences in bone parameters between cases and controls after adjusting for height, lower leg length, lean mass, fat mass, and sport. Results: No differences were observed between cases and controls in any of the DXA measurements. Cases had significantly greater unadjusted trabecular bone mineral content (BMC), greater polar moment of inertia (PMI) at the 20% site, and greater cortical BMC at the 66% site; however, after adjusting for covariates, the differences became nonsignificant. When analyses were repeated using all individuals who had ever had a stress fracture as cases (n = 31) and after controlling for covariates, periosteal circumference was greater in the cases than the controls (71.1 ± 0.7 vs 69.4 ± 0.5 mm, respectively; P = .04). Conclusion: A history of stress fractures is associated with larger bones. These findings are important because larger bones were previously reported to be protective against fractures and stress fractures, but study findings indicate that may not always be true. One explanation could be that individuals who sustain stress fractures have greater loading that results in greater periosteal circumference but also results in the development of stress fractures. PMID:26535343

Greater Polar Moment of Inertia at the Tibia in Athletes Who Develop Stress Fractures.

PubMed

Weidauer, Lee A; Binkley, Teresa; Vukovich, Matt; Specker, Bonny

2014-07-01

Several previous investigations have determined potential risk factors for stress fractures in athletes and military personnel. To determine factors associated with the development of stress fractures in female athletes. Case-control study; Level of evidence, 3. A total of 88 female athletes (cross-country, n = 29; soccer, n = 15; swimming, n = 9; track and field, n = 14; volleyball, n = 12; and basketball, n = 9) aged 18 to 24 years were recruited to participate in a longitudinal bone study and had their left distal tibia at the 4%, 20%, and 66% sites scanned by peripheral quantitative computed tomography (pQCT). Patients included 23 athletes who developed stress fractures during the following year (cases). Whole body, hip, and spine scans were obtained using dual-energy x-ray absorptiometry (DXA). Analysis of covariance was used to determine differences in bone parameters between cases and controls after adjusting for height, lower leg length, lean mass, fat mass, and sport. No differences were observed between cases and controls in any of the DXA measurements. Cases had significantly greater unadjusted trabecular bone mineral content (BMC), greater polar moment of inertia (PMI) at the 20% site, and greater cortical BMC at the 66% site; however, after adjusting for covariates, the differences became nonsignificant. When analyses were repeated using all individuals who had ever had a stress fracture as cases (n = 31) and after controlling for covariates, periosteal circumference was greater in the cases than the controls (71.1 ± 0.7 vs 69.4 ± 0.5 mm, respectively; P = .04). A history of stress fractures is associated with larger bones. These findings are important because larger bones were previously reported to be protective against fractures and stress fractures, but study findings indicate that may not always be true. One explanation could be that individuals who sustain stress fractures have greater loading that results in greater periosteal circumference but also results in the development of stress fractures.

Utility of cement injection to stabilize split-depression tibial plateau fracture by minimally invasive methods: A finite element analysis.

PubMed

Belaid, D; Vendeuvre, T; Bouchoucha, A; Brémand, F; Brèque, C; Rigoard, P; Germaneau, A

2018-05-08

Treatment for fractures of the tibial plateau is in most cases carried out by stable fixation in order to allow early mobilization. Minimally invasive technologies such as tibioplasty or stabilization by locking plate, bone augmentation and cement filling (CF) have recently been used to treat this type of fracture. The aim of this paper was to determine the mechanical behavior of the tibial plateau by numerically modeling and by quantifying the mechanical effects on the tibia mechanical properties from injury healing. A personalized Finite Element (FE) model of the tibial plateau from a clinical case has been developed to analyze stress distribution in the tibial plateau stabilized by balloon osteoplasty and to determine the influence of the cement injected. Stress analysis was performed for different stages after surgery. Just after surgery, the maximum von Mises stresses obtained for the fractured tibia treated with and without CF were 134.9 MPa and 289.9 MPa respectively on the plate. Stress distribution showed an increase of values in the trabecular bone in the treated model with locking plate and CF and stress reduction in the cortical bone in the model treated with locking plate only. The computed results of stresses or displacements of the fractured models show that the cement filling of the tibial depression fracture may increase implant stability, and decrease the loss of depression reduction, while the presence of the cement in the healed model renders the load distribution uniform. Copyright © 2018 Elsevier Ltd. All rights reserved.

PARACENTRAL ACUTE MIDDLE MACULOPATHY IN PURTSCHER RETINOPATHY.

PubMed

Rivera-De La Parra, David; Fromow-Guerra, Jans

2017-12-27

To describe paracentral acute middle maculopathy associated with Purtscher retinopathy, particularly in Purtscher flecken lesions as a retinal complication in a case secondary to fractures of long bones. Case report. A 16-year-old boy with bilateral paracentral scotomata presented with bilateral paracentral acute middle maculopathy as part of Purtscher retinopathy in both eyes as consequence of tibia and fibula fractures. Paracentral acute middle maculopathy is one of the optical coherence tomography findings in Purtscher retinopathy.

[A case of anterior tibial arteriovenous fistula after closed fracture of the leg].

PubMed

Touzard, R C

1975-01-01

This case permits one to emphasize the great rareness of arteriovenous fistula after closed fractures of the shaft of the tibia. Fistulas in this anterior tibial position are remarkably latent, cause no symptoms below the fistula nor symptoms of heart failure. Treatment by several ligatures, permitted this patient to return to work 15 days after operation without any further treatment. The patient no longer has any symptoms.

Bone geometry, volumetric bone mineral density, microarchitecture and estimated bone strength in Caucasian females with systemic lupus erythematosus. A cross-sectional study using HR-pQCT.

PubMed

Hansen, Stinus; Gudex, Claire; Åhrberg, Fabian; Brixen, Kim; Voss, Anne

2014-12-01

Patients with systemic lupus erythematosus (SLE) have an increased risk of fracture. We used high resolution peripheral quantitative computed tomography (HR-pQCT) to measure bone geometry, volumetric bone mineral density (vBMD), cortical and trabecular microarchitecture and estimated bone strength by finite element analysis (FEA) at the distal radius and tibia to assess bone characteristics beyond BMD that may contribute to the increased risk of fracture. Thirty-three Caucasian women with SLE (median age 48, range 21-64 years) and 99 controls (median age 45, range 21-64 years) were studied. Groups were comparable in radius regarding geometry and vBMD, but SLE patients had lower trabecular number (-7%, p < 0.05), higher trabecular separation (13%, p < 0.05) and lower FEA-estimated failure load compared to controls (-10%, p < 0.05). In tibia, SLE patients had lower total vBMD (-11%, p < 0.01), cortical area (-14%, p < 0.001) and cortical thickness (-16%, p < 0.001) and higher trabecular area (8%, p < 0.05). In subgroup analyses of the premenopausal participants (SLE n = 21, controls n = 63), SLE patients had significantly lower trabecular bone volume fraction [(BV/TV); -17%, p < 0.01], trabecular number (-9%, p < 0.01), trabecular thickness (-9%, p < 0.05) and higher trabecular separation (13%, p < 0.01) and trabecular network inhomogeneity (14%, p < 0.05) in radius along with lower BV/TV (-15%, p < 0.01) and higher trabecular separation (11%, p < 0.05) in tibia. FEA-estimated bone strength was lower in both radius (-11%, p < 0.01) and tibia (-10%, p < 0.05). In conclusion, Caucasian women with SLE compared to controls had fewer and more widely separated trabeculae and lower estimated bone strength in radius and lower total vBMD, cortical area and thickness in tibia.

Adaptations in tibial cortical thickness and total volumetric bone density in postmenopausal South Asian women with small bone size.

PubMed

Darling, Andrea L; Hakim, Ohood A; Horton, Khim; Gibbs, Michelle A; Cui, Liang; Berry, Jacqueline L; Lanham-New, Susan A; Hart, Kathryn H

2013-07-01

There is some evidence that South Asian women may have an increased risk of osteoporosis compared with Caucasian women, although whether South Asians are at increased risk of fracture is not clear. It is unknown whether older South Asian women differ from Caucasian women in bone geometry. This is the first study, to the authors' knowledge, to use peripheral Quantitative Computed Tomography (pQCT) to measure radial and tibial bone geometry in postmenopausal South Asian women. In comparison to Caucasian women, Asian women had smaller bone size at the 4% (-18% p<0.001) and 66% radius (-15% p=0.04) as well as increased total density at the 4% (+13% p=0.01) radius. For the tibia, they had a smaller bone size at the 4% (-16% p=0.005) and 14% (-38% p=0.002) sites. Also, Asians had increased cortical thickness (-17% p=0.04) at the 38% tibia, (in proportion to bone size (-30% p=0.003)). Furthermore, at the 4% and 14% tibia there were increased total densities (+12% to +29% p<0.01) and at the 14% tibia there was increased cortical density (+5% p=0.005) in Asians. These differences at the 14% and 38% (but not 4%) remained statistically significant after adjustment for Body Mass Index (BMI). These adaptations are similar to those seen previously in Chinese women. Asian women had reduced strength at the radius and tibia, evidenced by the 20-40% reduction in both polar Strength Strain Index (SSIp) and fracture load (under bending). Overall, the smaller bone size in South Asians is likely to be detrimental to bone strength, despite some adaptations in tibial cortical thickness and tibial and radial density which may partially compensate for this. Copyright © 2013 Elsevier Inc. All rights reserved.

Reconstruction of the lateral tibia plateau fracture with a third triangular support screw: A biomechanical study.

PubMed

Moran, Eduardo; Zderic, Ivan; Klos, Kajetan; Simons, Paul; Triana, Miguel; Richards, R Geoff; Gueorguiev, Boyko; Lenz, Mark

2017-10-01

Split fractures of the lateral tibia plateau in young patients with good bone quality are commonly treated using two minimally invasive percutaneous lag screws, followed by unloading of the knee joint. Improved stability could be achieved with the use of a third screw inserted either in the jail-technique fashion or with a triangular support screw configuration. The aim of this study was to investigate under cyclic loading the compliance and endurance of the triangular support fixation in comparison with the standard two lag-screw fixation and the jail technique. Lateral split fractures of type AO/OTA 41-B1 were created on 21 synthetic tibiae and subsequently fixed with one of the following three techniques for seven specimens: standard fixation by inserting two partially threaded 6.5 mm cannulated lag screws parallel to each other and orthogonal to the fracture plane; triangular support fixation-standard fixation with one additional support screw at the distal end of the fracture at 30° proximal inclination; and jail fixation-standard fixation with one additional orthogonal support screw inserted in the medial nonfractured part of the bone. Mechanical testing was performed under progressively increasing cyclic compression loading. Fragment displacement was registered via triggered radiographic imaging. Mean construct compliance was 3.847 × 10 -3  mm/N [standard deviation (SD) 0.784] for standard fixation, 3.838 × 10 -3  mm/N (SD 0.242) for triangular fixation, and 3.563 × 10 -3  mm/N (SD 0.383) for jail fixation, with no significant differences between the groups ( p  = 0.525). The mean numbers of cycles to 2 mm fragment dislocation, defined as a failure criterion, were 12,384 (SD 2267) for standard fixation, 17,708 (SD 2193) for triangular fixation, and 14,629 (SD 5194) for jail fixation. Triangular fixation revealed significantly longer endurance than the standard one ( p  = 0.047). Triangular support fixation enhanced interfragmentary stability at the ultimate stage of dynamic loading. However, the level of improvement seems to be limited and may not legitimate the intervention with an additional third screw.

Association of High-resolution Peripheral Quantitative Computed Tomography (HR-pQCT) bone microarchitectural parameters with previous clinical fracture in older men: The Osteoporotic Fractures in Men (MrOS) study.

PubMed

Fink, Howard A; Langsetmo, Lisa; Vo, Tien N; Orwoll, Eric S; Schousboe, John T; Ensrud, Kristine E

2018-05-08

High-resolution peripheral quantitative computed tomography (HR-pQCT) assesses both volumetric bone mineral density (vBMD) and trabecular and cortical microarchitecture. However, studies of the association of HR-pQCT parameters with fracture history have been small, predominantly limited to postmenopausal women, often performed limited adjustment for potential confounders including for BMD, and infrequently assessed strength or failure measures. We used data from the Osteoporotic Fractures in Men (MrOS) study, a prospective cohort study of community-dwelling men aged ≥65 years, to evaluate the association of distal radius, proximal (diaphyseal) tibia and distal tibia HR-pQCT parameters measured at the Year 14 (Y14) study visit with prior clinical fracture. The primary HR-pQCT exposure variables were finite element analysis estimated failure loads (EFL) for each skeletal site; secondary exposure variables were total vBMD, total bone area, trabecular vBMD, trabecular bone area, trabecular thickness, trabecular number, cortical vBMD, cortical bone area, cortical thickness, and cortical porosity. Clinical fractures were ascertained from questionnaires administered every 4 months between MrOS study baseline and the Y14 visit and centrally adjudicated by masked review of radiographic reports. We used multivariate-adjusted logistic regression to estimate the odds of prior clinical fracture per 1 SD decrement for each Y14 HR-pQCT parameter. Three hundred forty-four (19.2%) of the 1794 men with available HR-pQCT measures had a confirmed clinical fracture between baseline and Y14. After multivariable adjustment, including for total hip areal BMD, decreased HR-pQCT finite element analysis EFL for each site was associated with significantly greater odds of prior confirmed clinical fracture and major osteoporotic fracture. Among other HR-pQCT parameters, decreased cortical area appeared to have the strongest independent association with prior clinical fracture. Future studies should explore associations of HR-pQCT parameters with specific fracture types and risk of incident fractures and the impact of age and sex on these relationships. Published by Elsevier Inc.

Post-Traumatic Periprosthetic Tibial and Fibular Fracture After Total Ankle Arthroplasty: A Case Report.

PubMed

Brock, Amanda K; Tan, Eric W; Shafiq, Babar

Periprosthetic fractures after total ankle arthroplasty are uncommon, with most cases occurring intraoperatively. We describe a post-traumatic periprosthetic fracture of the distal tibia and fibula after total ankle arthroplasty that was treated with minimally invasive plate osteosynthesis. It is important for orthopedic surgeons not only to recognize the risk factors for postoperative periprosthetic total ankle arthroplasty fractures, but also to be familiar with the treatment options available to maximize function and minimize complications. The design of the tibial prosthesis and surgical techniques required to prepare the ankle joint for implantation are important areas of future research to limit the risk of periprosthetic fractures. Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

Complications of Elastic Stable Intramedullary Nailing for treating paediatric long bone fractures

PubMed Central

Nisar, Aamer; Bhosale, Abhijit; Madan, Sanjeev S.; Flowers, Mark J.; Fernandes, James A.; Jones, Stanley

2013-01-01

This study reports the complications observed in children with long bone fractures treated using Elastic Stable Intramedullary Nailing (ESIN). One hundred and sixty-four (n = 164) fractures in 160 patients under the age of 16 years formed the basis of our review. This included 108 boys and 52 girls with the median age of 11 years and median follow up of 7.5 months. The analysis included fractures of the radius/ulna, humerus, femur and tibia. All pathological fractures were excluded. In this series 54 patients (34%) had complications however majority of these were minor complications with irritation due to prominent nail ends being the commonest complication. No long-term sequelae were encountered in our patients. PMID:24403743

Bisphosphonates inhibit pain, bone loss, and inflammation in a rat tibia fracture model of complex regional pain syndrome

PubMed Central

Wang, Liping; Guo, Tian-Zhi; Wei, Tzuping; Li, Wen-wu; Shi, Xiaoyou; Clark, J David; Kingery, Wade S

2016-01-01

BACKGROUND Bisphosphonates are used to prevent the bone loss and fractures associated with osteoporosis, bone metastases, multiple myeloma, and osteogenis deformans. Distal limb fractures cause regional bone loss with cutaneous inflammation and pain in the injured limb that can develop into complex regional pain syndrome (CRPS). Clinical trials have reported that anti-resorptive bisphosphonates can prevent fracture-induced bone loss, inhibit serum inflammatory cytokine levels, and alleviate CRPS pain. Previously we observed that the inhibition of inflammatory cytokines or adaptive immune responses attenuated the development of pain behavior in a rat fracture model of CRPS and we hypothesized that bisphosphonates could prevent pain behavior, trabecular bone loss, post-fracture cutaneous cytokine up-regulation, and adaptive immune responses in this CRPS model. METHODS Rats underwent tibia fracture and cast immobilization for 4 weeks and were chronically administered either subcutaneously perfused alendronate or oral zoledronate. Behavioral measurements included hindpaw von Frey allodynia, unweighting, warmth, and edema. Bone microarchitecture was measured by uCT and bone cellular activity was evaluated by static and dynamic histomorphometry. Spinal cord Fos immunostaining was performed and skin cytokine (TNF, IL-1, IL-6) and nerve growth factor (NGF) levels were determined by EIA. Skin and sciatic nerve immunoglobulin levels were determined by EIA. RESULTS Tibia fracture rats developed hindpaw allodynia, unweighting, warmth, and edema, increased spinal Fos expression, trabecular bone loss in the lumbar vertebra and bilateral distal femurs as measured by uCT, increased trabecular bone resorption and osteoclast surface with decreased bone formation rates, increased cutaneous inflammatory cytokine and NGF expression and elevated immunocomplex deposition in skin and nerve. Alendronate (60 μg/kg/day s.c.) or zoledronate (3 mg/kg/day p.o.) treatment for 28 days, started at the time of fracture, completely inhibited the development of hindpaw allodynia and reduced hindpaw unweighting by 44 ± 13% and 58 ± 5%, respectively. Orally administered zoledronate (3 mg/kg/day for 21 days) treatment also completely reversed established allodynia and unweighting when started at 4-weeks post-fracture. Histomorphometric and uCT analysis demonstrated that both the 3 and 60 μg/kg/day alendronate treatments reversed trabecular bone loss (a 88 ± 25% and 188 ± 39% increase in the ipsilateral distal femur BV/TV, respectively) and blocked the increase in osteoclast numbers and erosion surface observed in bilateral distal femurs and in L5 vertebra of the fracture rats. Alendronate treatment inhibited fracture-induced increases in hindpaw inflammatory mediators, reducing post-fracture levels of TNF by 43 ± 9%, IL-1 by 60 ± 9%, IL-6 by 56 ± 14%, and NGF by 37 ± 14%, but had no effect on increased spinal cord Fos expression, or skin and sciatic nerve immunocomplex deposition. CONCLUSIONS Collectively, these results indicate that bisphosphonate therapy inhibits pain, osteoclast activation, trabecular bone loss, and cutaneous inflammation in the rat fracture model of CRPS, data supporting the hypothesis that bisphosphonate therapy can provide effective multimodal treatment for CRPS. PMID:27636578

[Clinical significance of MESS scoring system in the treatment of fractures of lower limb combined with vascular injuries].

PubMed

Zhou, Fei-Ya; Guo, Xiao-Shan; Gao, Wei-Yang; Chen, Xing-Long; Li, Zhi-Jie; Jiang, Liang-Fu

2010-06-01

To study the clinical significance of MESS scoring system in the treatment of fractures of lower limb combined with vascular injuries, and to evaluate its reliance. From March 2006 to March 2008, 28 patients with fractures of lower limb combined with vascular injuries were graded by MESS scoring system. There were 17 patients were male and 11 patients were female, ranging in age from 23 to 53 years, averaged 38 years. Seventeen patients had fractures at the superior segment of tibia and fibia, 7 patients had fractures at the inferior segment of femur, and other 4 patients had dislocation of knee joint. Among the patients, 18 patients had MESS scores more than 7.0 point, in which 13 patients were treated with one-stage amputation, 5 patients were treated with two-stage amputation; the other 10 patients had the MESS scores less than 7.0 point, and were treated with open reduction and internal fixation, in which 8 patients were treated with transplantation of great saphenous vein to repair blood vessles, and 2 patients were treated with vascular end to end anastomosis. Among the patients, including 18 patients whose MESS scores more than 7.0 point were treated with one-stage or two-stage amputation, and 10 patients whose MESS scores less than 7.0 point were treated with limb salvage operations, all the limbs survived. During the follow-up period (ranged from 0.5 to 1 year, the movement and sensory function of the limbs recovered well. MESS is a simple and reliable tool to determine the proper strategy for the patients suffering from vascular injuries with fractures.

Percutaneous external fixator pins with bactericidal micron-thin sol-gel films for the prevention of pin tract infection.

PubMed

Qu, Haibo; Knabe, Christine; Radin, Shula; Garino, Jonathan; Ducheyne, Paul

2015-09-01

Risk of infection is considerable in open fractures, especially when fracture fixation devices are used to stabilize the fractured bones. Overall deep infection rates of 16.2% have been reported. The infection rate is even greater, up to 32.2%, with external fixation of femoral fractures. The use of percutaneous implants for certain clinical applications, such as percutaneous implants for external fracture fixation, still represents a challenge today. Currently, bone infections are very difficult to treat. Very potent antibiotics are needed, which creates the risk of irreversible damage to other organs, when the antibiotics are administered systemically. As such, controlled, local release is being pursued, but no such treatments are in clinical use. Herein, the use of bactericidal micron-thin sol-gel films on metallic fracture fixation pins is reported. The data demonstrates that triclosan (2,4,4'-trichloro-2'-hydroxydiphenylether), an antimicrobial agent, can be successfully incorporated into micron-thin sol-gel films deposited on percutaneous pins. The sol-gel films continuously release triclosan in vitro for durations exceeding 8 weeks (longest measured time point). The bactericidal effect of the micron-thin sol-gel films follows from both in vitro and in vivo studies. Inserting percutaneous pins in distal rabbit tibiae, there were no signs of infection around implants coated with a micron-thin sol-gel/triclosan film. Healing had progressed normally, bone tissue growth was normal and there was no epithelial downgrowth. This result was in contrast with the results in rabbits that received control, uncoated percutaneous pins, in which abundant signs of infection and epithelial downgrowth were observed. Thus, well-adherent, micron-thin sol-gel films laden with a bactericidal molecule successfully prevented pin tract infection. Copyright © 2015 Elsevier Ltd. All rights reserved.

Women with previous fragility fractures can be classified based on bone microarchitecture and finite element analysis measured with HR-pQCT.

PubMed

Nishiyama, K K; Macdonald, H M; Hanley, D A; Boyd, S K

2013-05-01

High-resolution peripheral quantitative computed tomography (HR-pQCT) measurements of distal radius and tibia bone microarchitecture and finite element (FE) estimates of bone strength performed well at classifying postmenopausal women with and without previous fracture. The HR-pQCT measurements outperformed dual energy x-ray absorptiometry (DXA) at classifying forearm fractures and fractures at other skeletal sites. Areal bone mineral density (aBMD) is the primary measurement used to assess osteoporosis and fracture risk; however, it does not take into account bone microarchitecture, which also contributes to bone strength. Thus, our objective was to determine if bone microarchitecture measured with HR-pQCT and FE estimates of bone strength could classify women with and without low-trauma fractures. We used HR-pQCT to assess bone microarchitecture at the distal radius and tibia in 44 postmenopausal women with a history of low-trauma fracture and 88 age-matched controls from the Calgary cohort of the Canadian Multicentre Osteoporosis Study (CaMos) study. We estimated bone strength using FE analysis and simulated distal radius aBMD from the HR-pQCT scans. Femoral neck (FN) and lumbar spine (LS) aBMD were measured with DXA. We used support vector machines (SVM) and a tenfold cross-validation to classify the fracture cases and controls and to determine accuracy. The combination of HR-pQCT measures of microarchitecture and FE estimates of bone strength had the highest area under the receiver operating characteristic (ROC) curve of 0.82 when classifying forearm fractures compared to an area under the curve (AUC) of 0.71 from DXA-derived aBMD of the forearm and 0.63 from FN and spine DXA. For all fracture types, FE estimates of bone strength at the forearm alone resulted in an AUC of 0.69. Models based on HR-pQCT measurements of bone microarchitecture and estimates of bone strength performed better than DXA-derived aBMD at classifying women with and without prior fracture. In future, these models may improve prediction of individuals at risk of low-trauma fracture.

Biomechanical Assessment of Locked Plating for the Fixation of Patella Fractures.

PubMed

Wurm, Simone; Augat, Peter; Bühren, Volker

2015-09-01

To analyze the mechanical stability of locked plating in comparison with tension-band wiring for the fixation of fractures of the patella. Biomechanical tests were performed on artificial foam patella specimens comparing an angular stable plate and monocortical screws with tension-band wiring. Tests were performed under combined tension and bending until failure simulating physiological loading of the tibia during walking. Tension-band wiring failed at 66% of the failure load of plating (1052 N, P = 0.002) and had 5 times larger fracture gap displacements (P = 0.002). Based on the biomechanical advantages, locked plating of the patella may constitute a reasonable alternative in the treatment of patella fractures.

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

Nakata, Kouhei; Kawai, Nobuyuki; Sato, Morio, E-mail: morisato@mail.wakayama-med.ac.jp

Purpose: This study was designed to compare the strength among bone marrow nails created to treat long bone fractures using interventional procedures. Methods: Twelve resected intact tibiae of healthy swine were used. A circumferential bone fracture was made in nine tibiae and restored with the following created bone marrow nails: acrylic cement alone (ACA) (n = 3), acrylic-cement-filled bare metallic stent (AC-FBMS) (n = 3), and acrylic-cement-filled covered metallic (AC-FCMS) stent (n = 3). The remaining intact tibiae (n = 3) were used as controls. Results: A bone marrow nail was successfully achieved within 30 min in all swine. Themore » maximum injection volume of acrylic cement for creating ACA, AC-FBMS, and AC-FCMS was 1.7 {+-} 0.3, 3.2 {+-} 0.4, and 2.9 {+-} 0.4 mL, respectively. The thickness of bone marrow nail created in the ACA, AC-FBMS, and AC-FCMS groups was 3.6 {+-} 1.0, 10.3 {+-} 0.26, and 9.6 {+-} 0.32 mm, respectively (AC-FBMS group versus AC-FCMS group, p = 0.038), probably because of leakage of acrylic cement surrounding the interstices. The maximum bending power (kilonewton) and bending strength (newton/mm{sup 2}) in the normal long bone, ACA, AC-FBMS, and AC-FCMS groups were: 1.70 {+-} 0.25 and 79.2 {+-} 16.1; 0.21 {+-} 0.11 and 8.8 {+-} 2.8; 0.46 {+-} 0.06 and 18.2 {+-} 1.6; and 0.18 {+-} 0.04 and 7.8 {+-} 2.7, respectively. Conclusions: Although the maximum bending power and bending strength of AC-FBMS were not satisfactory, it was the most robust of the three marrow nails for restoring fractured long bone.« less

Biomechanical strength of the Peri-Loc proximal tibial plate: a comparison of all-locked versus hybrid locked/nonlocked screw configurations.

PubMed

Estes, Chris; Rhee, Peter; Shrader, M Wade; Csavina, Kristine; Jacofsky, Marc C; Jacofsky, David J

2008-01-01

The purpose of this study was to compare the biomechanical properties of a contoured locking plate instrumented with either an all-locked or hybrid locked/nonlocked screw construct in a proximal metaphyseal fracture of the tibia (AO 41-A3.2). A standardized proximal metaphyseal wedge osteotomy (AO 41-A3.2) was created in five pairs of cadaveric tibia. Each pair was randomly instrumented with either an all-locked or combination locked/nonlocked screw construct using a locked contoured periarticular plate (Peri-Loc periarticular locked plating system, Smith & Nephew, Memphis, TN). Vertical subsidence (irreversible deformation) and deflection (reversible deformation) in each pair were analyzed and compared. Load to failure, defined by complete fracture gap closure, was also determined. There was no statistically significant difference in vertical subsidence (P = 0.19) or deflection (P = 0.19) of the proximal tibia between the all-locked and combination locked/nonlocked screw construct with increasing levels of cyclical axial load from 200 to 1200 N. Failure occurred at a mean value of 2160 N in the locked group and 1760 N in the hybrid group (P = 0.19); the failure mode was plate bending in all specimens. The results indicate that the use of compression screws with locked screws in this particular construct allows a similar amount of irreversible and reversible deformation in response to an axial load when compared to an all-locked screw construct. This suggests that there is no statistically significant difference in the stability in fixation between the two methods, allowing the surgeon the freedom to choose the appropriate screw combination unique to each fracture.

[Advanced bone graft combined with locking compression plate for the treatment of middle and distal tibia nonunion].

PubMed

Zhao, Xue; Wang, Pan-feng; Zhang, Yun-tong; Zhang, Chun-cai; Xu, Shuo-gui; Zhang, Xin

2014-12-01

To explore methods of treating middle and distal tibia nonunion with the treatment of advanced bone graft combined with locking compression plate. From January 2011 to December 2012, 12 patients with middle and distal tibia nonunion were treated with advanced bone graft combined with locking compression plate. Among patients, there were 8 males and 4 females aged from 20 to 69 with an average of 47 years old. The time from first injuries to bone nonunion was from 9 months to 5 years, avergaed 19 months. Four cases were treated with external fixation, 6 cases were treated with plate fixation, 2 cases of 12 patients occurred broken of plate and nail. Eleven patients were non-infective bone nonunion and 1 patient was infective bone nonunion. Preoperative X-ray and CT showed all patients had sequestration and formation of ossified bone with different degrees. Operative time, blood loss, wound healing were observed, fracture healing time was evaluated by postoperative X-ray. Johner-Wruhs scoring standards was used to evaluate ankle joint function after operation at 10 months. Operative time ranged from 90 to 185 min with an average of (125.00±20.15) min; blood loss ranged from 225 to 750 ml with an average of (415.00±120.00) ml. All patients were followed up from 10 months to 2.5 years with an average of 1.5 years. Postoperative X-ray showed bone union was formed around fracture after operation at 4 months in all patients, 3 cases obtained bone healing within 6 months after operation, 9 cases obtained from 8 to 12 months. No infection, injury of nerve and vessles, and broken of plate and nail were ocurred. According to Johner-Wruhs scoring at 10 months after operation, 10 cases obtained excellent results, 1 good and 1 moderate. Advanced bone graft combined with locking compression plate, which can build fracture multi-point supporting based on full compression of bone nonunion to get effective fixation, is an effective method in treating middle and distal tibia nonunion.

Fracture reduction and primary ankle arthrodesis: a reliable approach for severely comminuted tibial pilon fracture.

PubMed

Beaman, Douglas N; Gellman, Richard

2014-12-01

Posttraumatic arthritis and prolonged recovery are typical after a severely comminuted tibial pilon fracture, and ankle arthrodesis is a common salvage procedure. However, few reports discuss the option of immediate arthrodesis, which may be a potentially viable approach to accelerate overall recovery in patients with severe fracture patterns. (1) How long does it take the fracture to heal and the arthrodesis to fuse when primary ankle arthrodesis is a component of initial fracture management? (2) How do these patients fare clinically in terms of modified American Orthopaedic Foot and Ankle Society (AOFAS) scores and activity levels after this treatment? (3) Does primary ankle arthrodesis heal in an acceptable position when anterior ankle arthrodesis plates are used? During a 2-year period, we performed open fracture reduction and internal fixation in 63 patients. Eleven patients (12 ankles) with severely comminuted high-energy tibial pilon fractures were retrospectively reviewed after surgical treatment with primary ankle arthrodesis and fracture reduction. Average patient age was 58 years, and minimum followup was 6 months (average, 14 months; range, 6-22 months). Anatomically designed anterior ankle arthrodesis plates were used in 10 ankles. Ring external fixation was used in nine ankles with concomitant tibia fracture or in instances requiring additional fixation. Clinical evaluation included chart review, interview, the AOFAS ankle-hindfoot score, and radiographic evaluation. All of the ankle arthrodeses healed at an average of 4.4 months (range, 3-5 months). One patient had a nonunion at the metaphyseal fracture, which healed with revision surgery. The average AOFAS ankle-hindfoot score was 83 with 88% having an excellent or good result. Radiographic and clinical analysis confirmed a plantigrade foot without malalignment. No patients required revision surgery for malunion. Primary ankle arthrodesis combined with fracture reduction for the severely comminuted tibial pilon fracture reliably healed and restored acceptable function in this highly selective patient group. Ring external fixation may be a useful adjunct to internal fixation, and this concept should be further studied. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Better Skeletal Microstructure Confers Greater Mechanical Advantages in Chinese-American Women Versus White Women

PubMed Central

Liu, X Sherry; Walker, Marcella D; McMahon, Donald J; Udesky, Julia; Liu, George; Bilezikian, John P; Guo, X Edward

2013-01-01

Despite lower areal bone mineral density (aBMD), Chinese-American women have fewer fractures than white women. We hypothesized that better skeletal microstructure in Chinese-American women in part could account for this paradox. Individual trabecula segmentation (ITS), a novel image-analysis technique, and micro–finite-element analysis (μFEA) were applied to high-resolution peripheral quantitative computed tomography (HR-pQCT) images to determine bone microarchitecture and strength in premenopausal Chinese-American and white women. Chinese-American women had 95% and 80% higher plate bone volume fraction at the distal radius and tibia, respectively, as well as 20% and 18% higher plate number density compared with white women (p < .001). With similar rodlike characteristics, the plate-to-rod ratio was twice as high in the Chinese-American than in white trabecular bone (p < .001). Plate-rod junction density, a parameter indicating trabecular network connections, was 37% and 29% greater at the distal radius and tibia, respectively, in Chinese-American women (p < .002). Moreover, the orientation of the trabecular bone network was more axially aligned in Chinese-American women because axial bone volume fraction was 51% and 32% higher at the distal radius and tibia, respectively, than in white women (p < .001). These striking differences in trabecular bone microstructure translated into 55% to 68% (distal radius, p < .001) and 29% to 43% (distal tibia, p < .01) greater trabecular bone strength, as assessed by Young’s moduli, in the Chinese-American versus the white group. The observation that Chinese-American women have a major microstructural advantage over white women may help to explain why their risk of fracture is lower despite their lower BMD. PMID:21351150

Injury tolerance criteria for short-duration axial impulse loading of the isolated tibia.

PubMed

Quenneville, Cheryl E; McLachlin, Stewart D; Greeley, Gillian S; Dunning, Cynthia E

2011-01-01

Impulse loading of the lower leg during events such as ejection seat landings or in-vehicle land mine blasts may result in devastating injuries. These impacts achieve higher forces over shorter durations than car crashes, from which experimental results have formed the current basis for protective measures of an axial force limit of 5.4 kN, as registered by an anthropomorphic test device (ATD). The hypotheses of this study were that the injury tolerance of the isolated tibia to short-duration axial loading is higher than that previously reported and that secondary parameters such as momentum or kinetic energy are significant for fracture tolerance, in addition to force. Seven pairs of cadaveric tibias were impacted using a pneumatic testing apparatus, replicating short-duration axial impulse events. One specimen from each pair was impacted with a light mass and the contralateral impacted with a heavy mass, to investigate the effects of momentum and kinetic energy, as well as force, on injury. Impacts were applied incrementally until failure. Force, kinetic energy, age, and height were shown to be significant factors in the probability of fracture. A 10% risk of injury corresponded to an impact force of 7.9 kN, with an average kinetic energy of 240 J. In comparison, this same impact level applied to an ATD would register a force of 16.2 kN because of the higher stiffness of the ATD. These results suggest that the current injury standard may be too conservative for the tibia during high-speed impacts such as in-vehicle land mine blasts and that factors in addition to force should be taken into consideration.

The uptake by the canine tibia of the bone-scanning agent 99mTc-MDP before and after an osteotomy.

PubMed

Hughes, S; Khan, R; Davies, R; Lavender, P

1978-11-01

The residue and extraction of technetium-labelled methylene diphosphonate (99mTc-MDP), a substance used in bone scanning, was examined in the canine tibia and found to be low. Examination of washout curves suggested that there were four compartments in cortical bone, a vascular, a perivascular, a bone fluid and a bone compartment. After an osteotomy in the canine tibia the residue of 99mTc-MDP increased. This was believed to be due to an increase in the blood supply to the bone and to an associated increase in new bone available for exchange. Bone scanning in a fracture is therefore a reflection of the vascular status of the bone being examined and of the uptake by bone. This is dependent on there being an adequate blood supply to the bone and an increased number of mineral-binding sites.

Solving cross-disciplinary problems by mathematical modelling

NASA Astrophysics Data System (ADS)

Panfilov, D. A.; Romanchikov, V. V.; Krupin, K. N.

2018-03-01

The article deals with the creation of a human tibia 3D model by means of “Autodesk Revit-2016” PC based on tomogram data. The model was imported into “Lira- SAPR2013 R4” software system. To assess the possibility of education and the nature of bone fracture (and their visualization), the Finite Element Analysis (FEA) method was used. The geometric parameters of the BBK model corresponded to the physical parameters of the individual. The compact plate different thickness is modeled by rigidity properties of the finite elements in accordance with the parameters on the roentgenogram. The BBK model included parameters of the outer compact plate and the spongy substance having a more developed structure of the epiphysic region. In the “Lira-SAPR2013 R4” software system, mathematical modeling of the traumatic effect was carried out and the analysis of the stress-strain state of the finite element model of the tibia was made to assess fracture conditions.

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

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.

Site Specific Effects of Zoledronic Acid during Tibial and Mandibular Fracture Repair

PubMed Central

Yu, Yan Yiu; Lieu, Shirley; Hu, Diane; Miclau, Theodore; Colnot, Céline

2012-01-01

Numerous factors can affect skeletal regeneration, including the extent of bone injury, mechanical loading, inflammation and exogenous molecules. Bisphosphonates are anticatabolic agents that have been widely used to treat a variety of metabolic bone diseases. Zoledronate (ZA), a nitrogen-containing bisphosphonate (N-BP), is the most potent bisphosphonate among the clinically approved bisphosphonates. Cases of bisphosphonate-induced osteonecrosis of the jaw have been reported in patients receiving long term N-BP treatment. Yet, osteonecrosis does not occur in long bones. The aim of this study was to compare the effects of zoledronate on long bone and cranial bone regeneration using a previously established model of non-stabilized tibial fractures and a new model of mandibular fracture repair. Contrary to tibial fractures, which heal mainly through endochondral ossification, mandibular fractures healed via endochondral and intramembranous ossification with a lesser degree of endochondral ossification compared to tibial fractures. In the tibia, ZA reduced callus and cartilage formation during the early stages of repair. In parallel, we found a delay in cartilage hypertrophy and a decrease in angiogenesis during the soft callus phase of repair. During later stages of repair, ZA delayed callus, cartilage and bone remodeling. In the mandible, ZA delayed callus, cartilage and bone remodeling in correlation with a decrease in osteoclast number during the soft and hard callus phases of repair. These results reveal a more profound impact of ZA on cartilage and bone remodeling in the mandible compared to the tibia. This may predispose mandible bone to adverse effects of ZA in disease conditions. These results also imply that therapeutic effects of ZA may need to be optimized using time and dose-specific treatments in cranial versus long bones. PMID:22359627

Bone Parameters in Anorexia Nervosa and Athletic Amenorrhea: Comparison of Two Hypothalamic Amenorrhea States.

PubMed

Kandemir, Nurgun; Slattery, Meghan; Ackerman, Kathryn E; Tulsiani, Shreya; Bose, Amita; Singhal, Vibha; Baskaran, Charumathi; Ebrahimi, Seda; Goldstein, Mark; Eddy, Kamryn; Klibanski, Anne; Misra, Madhusmita

2018-04-05

We have reported low bone mineral density (BMD), impaired bone structure, and increased fracture risk in anorexia nervosa (AN) and normal-weight, oligo-amenorrheic athletes (OA). However, data directly comparing compartment-specific bone parameters in AN, OA and controls are lacking. 426 females 14-21.9 years old were included; 231 AN, 94 OA and 101 normal-weight eumenorrheic controls. Dual energy x-ray absorptiometry was used to assess areal BMD (aBMD) of the whole body less head (WBLH), spine, and hip. High resolution peripheral quantitative CT was used to assess volumetric BMD (vBMD), bone geometry and structure at the non-weight bearing distal radius and weight-bearing distal tibia. AN had lower WBLH and hip aBMD Z-scores than OA and controls (p<0.0001). AN and OA had lower spine aBMD Z-scores than controls (p<0.01). At the radius, total and cortical vBMD, percent cortical area and thickness were lower in AN and OA vs. controls (p≤0.04); trabecular vBMD was lower in AN than controls. At the tibia, AN had lower measures for most parameters vs. OA and controls (p<0.05); OA had lower cortical vBMD than controls (p=0.002). AN and OA had higher fracture rates vs. controls. Stress fracture prevalence was highest in OA (p<0.0001); non-stress fracture prevalence was highest in AN (p<0.05). AN is deleterious to bone at all sites and both bone compartments. A high stress fracture rate in OA, who have comparable WBLH and hip aBMD measures to controls, indicates that BMD in these women may need to be even higher to avoid fractures.

Intramedullary nail fixation of non-traditional fractures: Clavicle, forearm, fibula.

PubMed

Dehghan, Niloofar; Schemitsch, Emil H

2017-06-01

Locked intramedullary fixation is a well-established technique for managing long-bone fractures. While intramedullary nail fixation of diaphyseal fractures in the femur, tibia, and humerus is well established, the same is not true for other fractures. Surgical fixations of clavicle, forearm and ankle are traditionally treated with plate and screw fixation. In some cases, fixation with an intramedullary device is possible, and may be advantageous. However, there is however a concern regarding a lack of rotational stability and fracture shortening. While new generation of locked intramedullary devices for fractures of clavicle, forearm and fibula are recently available, the outcomes are not as reliable as fixation with plates and screws. Further research in this area is warranted with high quality comparative studies, to investigate the outcomes and indication of these fractures treated with intramedullary nail devices compared to intramedullary nail fixation. Copyright © 2017 Elsevier Ltd. All rights reserved.

Proximal Tibia Medial Biplanar Retrotubercle Open Wedge Osteotomy for Varus Knees with Medial Gonarthrosis

PubMed Central

Türkmen, İsmail; Esenkaya, İrfan; Ünay, Koray; Türkmensoy, Fatih; Özkut, Afşar Timuçin

2014-01-01

Objectives: The purpose of this study is to evaluate the early results of proximal tibia medial biplanar retrotubercle open wedge osteotomy for varus gonarthrosis and compare the results with the literatüre. Methods: The results of proximal tibia medial biplanar retrotubercle open wedge osteotomy for 23 knees of 22 patients with medial gonarthrosis were evaluated clinically and radiologically. Results: Twenty of the patients were female and two were male. Mean age of the patients was 56.24; mean boy mass index was 31.95 and preoperative HSS (Hospital for Special Surgery) score was 68.7. Mean tibiofemoral axis was 186.39° and mean Insall-Salvatti index value was 1.04 preoperatively. Mean follow up period was 30.19 months. Mean HSS score was 86.48, femorotibial anatomic axis angle was 175° and Insall-Salvati index value 1.06 during the last follow-up. The improvement of the HSS score and the femorotibial anatomic axis angle was statistically significant. However, the change in Insall Salvati index values was statistically insignificant. Nonfatal pulmonary embolus in 1 patient, and deep vein thrombosis that occured one year after the procedure in 1 patient, rhabdomyolysis in 1 patient and loss of correction (relapse) in 1 patient were encountered as complications. Conclusion: Our results show that proximal tibia medial biplanar retrotubercle open wedge osteotomy improves the frontal and sagittal plane deformities without changing the patellar tendon length. Hence, possible patellofemoral problems are prevented and the clinical results are improved.

PTH 1-34 Ameliorates the Osteopenia and Delayed Healing of Stabilized Tibia Fracture in Mice with Achondroplasia Resulting from Gain-Of-Function Mutation of FGFR3

PubMed Central

Chen, Hangang; Sun, Xianding; Yin, Liangjun; Chen, Shuai; Zhu, Ying; Huang, Junlan; Jiang, Wanling; Chen, Bo; Zhang, Ruobin; Chen, Lin; Nie, Mao; Xie, Yangli; Deng, Zhongliang

2017-01-01

Bone fracture healing is processed through multiple stages including the cartilaginous callus formation and its transition to bony callus. FGFR3 negatively regulates chondrogenesis and enhances osteogenesis during skeleton development. We previously found in mice carrying gain-of-function mutation of FGFR3 that FGFR3 delays the healing of un-stabilized fracture that heals mainly through endochondral ossification. Since fracture is regularly treated in clinics with rigid fixation, and stabilized fracture is healed largely through intramembranous ossification, we asked whether FGFR3, a key regulator of osteogenesis, also affect the regeneration of stabilized fracture. We found that gain-of-function mutation of FGFR3 inhibits the initiation of chondrogenesis and the subsequent bone formation. We further studied whether PTH1-34 can improve the osteopenia and delayed healing of the stabilized tibia fracture in mice with achondroplasia. Fracture healing was evaluated by radiography, micro-CT, biomechanical tests, histology, and real-time polymerase chain reaction (RT-PCR) analysis. We found that PTH 1-34 can alleviate the decreased bone mass and compromised architecture in ACH mice. Histological analysis revealed that administration of PTH1-34 increased the size of both the total callus and cartilaginous callus at 14 days after the surgery in ACH mice. RT-PCR data suggested that systemic PTH1-34 accelerated the initiation of chondrogenesis and chondrocyte maturation (earlier and higher levels of expression of chondrogenesis related markers) and enhanced the osteogenic differentiation in the fracture callus in ACH mice. These results indicate that the PTH1-34 administration resulted in an enhanced callus formation during bone fracture healing in ACH mice, which is at least in part mediated by an increase of cartilaginous callus at early stage and the promotion of bone formation in bony callus. In summary, in this study we revealed that FGFR3 delays the regeneration of stabilized fracture by inhibiting both the chondrogenesis and osteogenesis, and PTH1-34 treatment can improve the dysregulated bone metabolism and delayed bone injury healing resulting from gain-of-function mutation of FGFR3. PMID:29104492

Alpha-7 nicotinic acetylcholine receptor agonist treatment reduces neuroinflammation, oxidative stress, and brain injury in mice with ischemic stroke and bone fracture.

PubMed

Han, Zhenying; Li, Li; Wang, Liang; Degos, Vincent; Maze, Mervyn; Su, Hua

2014-11-01

Bone fracture at the acute stage of stroke exacerbates stroke injury by increasing neuroinflammation. We hypothesize that activation of α-7 nicotinic acetylcholine receptor (α-7 nAchR) attenuates neuroinflammation and oxidative stress, and reduces brain injury in mice with bone fracture and stroke. Permanent middle cerebral artery occlusion (pMCAO) was performed in C57BL/6J mice followed by tibia fracture 1 day later. Mice were treated with 0.8 mg/kg PHA 568487 (PHA, α-7 nAchR-specific agonist), 6 mg/kg methyllycaconitine (α-7 nAchR antagonist), or saline 1 and 2 days after pMCAO. Behavior was tested 3 days after pMCAO. Neuronal injury, CD68(+) , M1 (pro-inflammatory) and M2 (anti-inflammatory) microglia/macrophages, phosphorylated p65 component of nuclear factor kappa b in microglia/macrophages, oxidative and anti-oxidant gene expression were quantified. Compared to saline-treated mice, PHA-treated mice performed better in behavioral tests, had fewer apoptotic neurons (NeuN(+) TUNEL(+) ), fewer CD68(+) and M1 macrophages, and more M2 macrophages. PHA increased anti-oxidant gene expression and decreased oxidative stress and phosphorylation of nuclear factor kappa b p65. Methyllycaconitine had the opposite effects. Our data indicate that α-7 nAchR agonist treatment reduces neuroinflammation and oxidative stress, which are associated with reduced brain injury in mice with ischemic stroke plus tibia fracture. Bone fracture at the acute stage of stroke exacerbates neuroinflammation, oxidative stress, and brain injury, and our study has shown that the α-7 nAchR agonist, PHA (PHA 568487), attenuates neuroinflammation, oxidative stress, and brain injury in mice with stroke and bone fracture. Hence, PHA could provide an opportunity to develop a new strategy to reduce brain injury in patients suffering from stroke and bone fracture. © 2014 International Society for Neurochemistry.

Radionuclide Imaging of Musculoskeletal Injuries in Athletes with Negative Radiographs.

PubMed

Nagle, C E; Freitas, J E

1987-06-01

In brief: Radionuclide bone scans can be useful in the diagnostic evaluation of musculoskeletal injuries in athletes. Bone scans can detect shinsplints, stress fractures, and muscle injuries before they are detectable on radiographs. Prognosis can be accurately assessed, allowing appropriate treatment to proceed without delay. The authors discuss the use of bone scans and identify musculoskeletal injuries that are associated with specific sports, such as stress fracture of the femur (soccer), tibia (running), scapula (gymnastics), and pars interarticularis (football or lacrosse).

Quantifying mechanical properties in a murine fracture healing system using inverse modeling: preliminary work

NASA Astrophysics Data System (ADS)

Miga, Michael I.; Weis, Jared A.; Granero-Molto, Froilan; Spagnoli, Anna

2010-03-01

Understanding bone remodeling and mechanical property characteristics is important for assessing treatments to accelerate healing or in developing diagnostics to evaluate successful return to function. The murine system whereby mid-diaphaseal tibia fractures are imparted on the subject and fracture healing is assessed at different time points and under different therapeutic conditions is a particularly useful model to study. In this work, a novel inverse geometric nonlinear elasticity modeling framework is proposed that can reconstruct multiple mechanical properties from uniaxial testing data. To test this framework, the Lame' constants were reconstructed within the context of a murine cohort (n=6) where there were no differences in treatment post tibia fracture except that half of the mice were allowed to heal 4 days longer (10 day, and 14 day healing time point, respectively). The properties reconstructed were a shear modulus of G=511.2 +/- 295.6 kPa, and 833.3+/- 352.3 kPa for the 10 day, and 14 day time points respectively. The second Lame' constant reconstructed at λ=1002.9 +/-42.9 kPa, and 14893.7 +/- 863.3 kPa for the 10 day, and 14 day time points respectively. An unpaired Student t-test was used to test for statistically significant differences among the groups. While the shear modulus did not meet our criteria for significance, the second Lame' constant did at a value p<0.0001. Traditional metrics that are commonly used within the bone fracture healing research community were not found to be statistically significant.

Trampoline related injuries in adults.

PubMed

Arora, Varun; Kimmel, Lara A; Yu, Kathy; Gabbe, Belinda J; Liew, Susan M; Kamali Moaveni, Afshin

2016-01-01

Trampoline-related injuries in adults are uncommon. Participation in trampolining is increasing following its admission as a sport in the Olympics and the opening of local recreational trampoline centres. The aim of this study was to assess the number and outcomes of adult trampoline-related orthopaedic injuries presenting to four trauma hospitals in Victoria. A cohort study was performed for the period 2007-2013. Adult patients registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) who had sustained a trampolining related injury were included in this study. Descriptive analyses were used to describe the patient population, the injuries sustained and their in-hospital and 6-month outcomes. There was an increase in trampolining injuries from 2007 (n=3) to 2012 (n=14) and 2013 (n=18). Overall, fifty patients with a median age of 25 (range 16-66) were identified. Thirty-five patients (70%) had lower limb injuries, 20 patients (40%) had spinal injuries and one patient had an upper limb injury. Thirty-nine patients (78%) required surgery. Fractures of the tibia (n=13), ankle fractures (n=12) and cervical spine injuries (n=7) were the most common injuries; all of which required surgery. Complications included death, spinal cord injuries, compartment syndrome and open fractures. At 6 months post injury, more than half (52%) of the patients had not achieved a good recovery, 32% had some form of persistent disability, 14% did not get back to work and overall physical health for the cohort was well below population norms for the SF-12. Adult trampoline-related injuries have increased in the last few years in this cohort identified through VOTOR. Lower limb and spinal injuries are most prevalent. Public awareness and education are important to reduce the risk for people participating in this activity. Copyright © 2015 Elsevier Ltd. All rights reserved.

Biomechanical assessment and clinical analysis of different intramedullary nailing systems for oblique fractures.

PubMed

Alierta, J A; Pérez, M A; Seral, B; García-Aznar, J M

2016-09-01

The aim of this study is to evaluate the fracture union or non-union for a specific patient that presented oblique fractures in tibia and fibula, using a mechanistic-based bone healing model. Normally, this kind of fractures can be treated through an intramedullary nail using two possible configurations that depends on the mechanical stabilisation: static and dynamic. Both cases are simulated under different fracture geometries in order to understand the effect of the mechanical stabilisation on the fracture healing outcome. The results of both simulations are in good agreement with previous clinical experience. From the results, it is demonstrated that the dynamization of the fracture improves healing in comparison with a static or rigid fixation of the fracture. This work shows the versatility and potential of a mechanistic-based bone healing model to predict the final outcome (union, non-union, delayed union) of realistic 3D fractures where even more than one bone is involved.

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.

Bone material strength is associated with areal BMD but not with prevalent fractures in older women.

PubMed

Rudäng, R; Zoulakis, M; Sundh, D; Brisby, H; Diez-Perez, A; Johansson, L; Mellström, D; Darelid, A; Lorentzon, M

2016-04-01

Reference point indentation is a novel method to assess bone material strength index (BMSi) in vivo. We found that BMSi at the mid-tibia was weakly associated with spine and hip areal bone mineral density but not with prevalent fracture in a population-based cohort of 211 older women. Reference point indentation is a novel method to assess BMSi in vivo. Lower BMSi has been observed in patients with prior fracture than in controls, but no association between BMSi and areal bone mineral density (aBMD) has been found. Population-based association studies and prospective studies with BMSi and fractures are lacking. We hypothesized that BMSi would be associated with prevalent fractures in older Swedish women. The aim was to investigate the associations between BMSi, aBMD, and prevalent fracture in older women. Two hundred eleven women, mean age 78.3 ± 1.1 years, were included in this cross-sectional, population-based study. BMSi was assessed using the OsteoProbe device at the mid-tibia. Areal BMD of the hip, spine, and non-dominant radius was measured using dual-energy X-ray absorptiometry (DXA). Fracture history was retrieved using questionnaires, and vertebral fractures were identified using vertebral fracture assessment (VFA) by DXA. One hundred ninety-eight previous fractures in 109 subjects were reported. A total of 106 women had a vertebral fracture, of which 58 women had moderate or severe fractures. An inverse correlation between BMSi and weight (r = -0.14, p = 0.04) was seen, and BMSi differed according to operator (ANOVA p < 0.01). Adjusting for weight and operator in a linear regression model, we found that BMSi was positively associated with aBMD of the total hip (β = 0.14, p = 0.04), non-dominant radius (β = 0.17, p = 0.02), and lumbar spine (L1-L4) (β = 0.14, p < 0.05). Using logistic regression, we could not find any association in crude or adjusted BMSi (for age, weight, height, walking speed, calcium intake, smoking, bisphosphonate and glucocorticoid use, and operator) with prevalent fractures. We conclude that BMSi is associated with aBMD but not with prevalent fracture in a population-based cohort of 211 older women.

Tension band plating of a nonunion anterior tibial stress fracture in an athlete.

PubMed

Merriman, Jarrad A; Villacis, Diego; Kephart, Curtis J; Rick Hatch, George F

2013-07-01

The authors present a rare technique of tension band plating of the anterior tibia in the setting of a nonunion stress fracture. Surgical management with an intramedullary nail is a viable and proven option for treating such injuries. However, in treating elite athletes, legitimate concerns exist regarding the surgical disruption of the extensor mechanism and the risk of anterior knee pain associated with intramedullary nail use. The described surgical technique demonstrates the use of tension band plating as an effective treatment of delayed union and nonunion anterior tibial stress fractures in athletes without the potential risks of intramedullary nail insertion. Copyright 2013, SLACK Incorporated.

Customized Knee Prosthesis in Treatment of Giant Cell Tumors of the Proximal Tibia: Application of 3-Dimensional Printing Technology in Surgical Design.

PubMed

Luo, Wenbin; Huang, Lanfeng; Liu, He; Qu, Wenrui; Zhao, Xin; Wang, Chenyu; Li, Chen; Yu, Tao; Han, Qing; Wang, Jincheng; Qin, Yanguo

2017-04-07

BACKGROUND We explored the application of 3-dimensional (3D) printing technology in treating giant cell tumors (GCT) of the proximal tibia. A tibia block was designed and produced through 3D printing technology. We expected that this 3D-printed block would fill the bone defect after en-bloc resection. Importantly, the block, combined with a standard knee joint prosthesis, provided attachments for collateral ligaments of the knee, which can maintain knee stability. MATERIAL AND METHODS A computed tomography (CT) scan was taken of both knee joints in 4 patients with GCT of the proximal tibia. We developed a novel technique - the real-size 3D-printed proximal tibia model - to design preoperative treatment plans. Hence, with the application of 3D printing technology, a customized proximal tibia block could be designed for each patient individually, which fixed the bone defect, combined with standard knee prosthesis. RESULTS In all 4 cases, the 3D-printed block fitted the bone defect precisely. The motion range of the affected knee was 90 degrees on average, and the soft tissue balance and stability of the knee were good. After an average 7-month follow-up, the MSTS score was 19 on average. No sign of prosthesis fracture, loosening, or other relevant complications were detected. CONCLUSIONS This technique can be used to treat GCT of the proximal tibia when it is hard to achieve soft tissue balance after tumor resection. 3D printing technology simplified the design and manufacturing progress of custom-made orthopedic medical instruments. This new surgical technique could be much more widely applied because of 3D printing technology.

Interlocking Nailing Versus Plating in Tibial Shaft Fractures in Adults: A Comparative Study

PubMed Central

Arambam, Mahendra Singh; Waikhom, Sanjib; Santosha; Masatwar, Pranav Vitthal; Maske, Rohan Gautam

2017-01-01

Introduction Tibial diaphyseal fractures are the commonest long bone fractures in adults, most commonly managed by intramedullary interlocking nailing. However, several meta-analysis show that locking plate osteosynthesis is equally effective in managing tibial diaphyseal fractures and are associated with less number of complications. Aim To compare the results of fixation of tibial fractures following plating and nailing in terms of union, patient satisfaction and complications. Materials and Methods A hospital based non randomized clinical trial was performed from September 2013 to August 2016 where closed or open diaphyseal or metaphyseo- diaphyseal fractures of the tibia (closed or open Gustilo Anderson type 1 through 3B) were included. Simple sequential allocation was used for allotting the patients to two groups, one for interlocking nailing and other for plating. The patients were followed up for clinical, radiographic and functional results. Results Forty patients with 41 involved limbs completed follow up for one year. The duration of surgery and average blood loss during surgery was 75.45±3.03 minutes and 165.00±5.31 ml respectively in case of nailing and 85.05±2.54 minutes and184.29±5.33 ml respectively in case of plating and their difference was statistically significant. In our study union was achieved in less than 20 weeks in 29 (70.8%) of the patients and 25-30 weeks in nine (22%) cases. The average time of union in our study was 19.55±0.69 weeks in case of interlocking nailing and 20.38±1.39 weeks in case of plating and there was no statistically significant difference between the two. However, there is statistically significant difference in the functional score in between the two groups in terms of Lower Extremity Functional Score (LEFS). Delayed union in one case of nailing and two cases of plating, valgus malunion in one case of nailing and joint stiffness in two cases each of nailing and plating were the major complications observed. Conclusion There was no difference between the two modalities in terms of fracture union. Complications were lesser but more serious in case of plating. Patient satisfaction was more with plating. PMID:28571220

Short-term effects of teriparatide versus placebo on bone biomarkers, structure, and fracture healing in women with lower-extremity stress fractures: A pilot study.

PubMed

Almirol, Ellen A; Chi, Lisa Y; Khurana, Bharti; Hurwitz, Shelley; Bluman, Eric M; Chiodo, Christopher; Matzkin, Elizabeth; Baima, Jennifer; LeBoff, Meryl S

2016-09-01

In this pilot, placebo-controlled study, we evaluated whether brief administration of teriparatide (TPTD) in premenopausal women with lower-extremity stress fractures would increase markers of bone formation in advance of bone resorption, improve bone structure, and hasten fracture healing according to magnetic resonance imaging (MRI). Premenopausal women with acute lower-extremity stress fractures were randomized to injection of TPTD 20-µg subcutaneous (s.c.) (n = 6) or placebo s.c. (n = 7) for 8 weeks. Biomarkers for bone formation N-terminal propeptide of type I procollagen (P1NP) and osteocalcin (OC) and resorption collagen type-1 cross-linked C-telopeptide (CTX) and collagen type 1 cross-linked N-telopeptide (NTX) were measured at baseline, 4 and 8 weeks. The area between the percent change of P1NP and CTX over study duration is defined as the anabolic window. To assess structural changes, peripheral quantitative computed topography (pQCT) was measured at baseline, 8 and 12 weeks at the unaffected tibia and distal radius. The MRI of the affected bone assessed stress fracture healing at baseline and 8 weeks. After 8 weeks of treatment, bone biomarkers P1NP and OC increased more in the TPTD- versus placebo-treated group (both p ≤ 0.01), resulting in a marked anabolic window (p ≤ 0.05). Results from pQCT demonstrated that TPTD-treated women showed a larger cortical area and thickness compared to placebo at the weight bearing tibial site, while placebo-treated women had a greater total tibia and cortical density. No changes at the radial sites were observed between groups. According to MRI, 83.3% of the TPTD- and 57.1% of the placebo-treated group had improved or healed stress fractures (p = 0.18). In this randomized, pilot study, brief administration of TPTD showed anabolic effects that TPTD may help hasten fracture healing in premenopausal women with lower-extremity stress fractures. Larger prospective studies are warranted to determine the effects of TPTD treatment on stress fracture healing in premenopausal women.

Evaluation of the effectiveness of toe board energy-absorbing material for foot, ankle, and lower leg injury reduction.

PubMed

Patalak, John P; Stitzel, Joel D

2018-02-17

Since 2000, numerous improvements have been made to the National Association for Stock Car Auto Racing, Incorporated (NASCAR®) driver restraint system, resulting in improved crash protection for motorsports drivers. Advancements have included seats, head and neck restraints (HNRs), seat belt restraint systems, driver helmets, and others. These enhancements have increased protection for drivers from severe crash loading. Extending protection to the driver's extremities remains challenging. Though the drivers' legs are well contained for lateral and vertical crashes, they remain largely unrestrained in frontal and frontal oblique crashes. Sled testing was conducted for the evaluation of an energy-absorbing (EA) toe board material to be used as a countermeasure for leg and foot injuries. Testing included baseline rigid toe boards, tests with EA material-covered toe boards, and pretest positioning of the 50th percentile male frontal Hybrid III anthropomorphic test device (ATD) lower extremities. ATD leg and foot instrumentation included foot acceleration and tibia forces and moments. The sled test data were evaluated using established injury criteria for tibial plateau fractures, leg shaft fractures, and calcaneus, talus, ankle, and midfoot fractures. A polyurethane EA foam was found to be effective in limiting axial tibia force and foot accelerations when subjected to frontal impacts using the NASCAR motorsport restraint system.

Use of external fixators for damage-control orthopaedics in natural disasters like the 2005 Pakistan earthquake.

PubMed

Awais, Syed; Saeed, Ayesha; Ch, Asad

2014-08-01

In the 2005 Pakistan earthquake, the great many injured with multiple fractures and open wounds provided a unique opportunity to practice damage-control orthopaedics. External fixators remain a time-tested tools for operating surgeons on such occasions. The locally manufactured, readily available Naseer-Awais (NA) external fixator filled such needs of this disaster with good outcome. This is a retrospective descriptive study of 19,700 patients that presented over seven months to the two centres established by the lead author (SMA) in Muzaffarabad and Mansehra just one night after the 2005 earthquake. A series of local and foreign orthopaedic surgeon teams operated in succession. The computerised patient data collection of 1,145 operations was retrospectively analysed. Of the 19,700 patients presenting to the SMA centres, 50% had limb injuries. Total fracture fixations were 1,145, of which 295 were external fixations: 185 were applied on the lower limb and 90 on upper limb, the majority were applied on tibia. External fixators are valuable damage-control tools in natural disasters and warfare injuries. The locally manufactured NA external fixator served the needs of the many limb injuries during the 2005 Pakistan earthquake.

Feline high-rise syndrome: 119 cases (1998-2001).

PubMed

Vnuk, D; Pirkić, B; Maticić, D; Radisić, B; Stejskal, M; Babić, T; Kreszinger, M; Lemo, N

2004-10-01

High-rise syndrome was diagnosed in 119 cats over a 4-year period. 59.6% of cats were younger than one year, and the average height of the fall was four stories. High-rise syndrome was more frequent during the warmer period of the year. 96.5% of the presented cats, survived after the fall. 46.2% of cats had fractured limbs; 38.5% of fractures were of the forelimb, 61.5% of the hindlimb. The tibia was fractured most often (36.4%), followed by the femur (23.6%). 78.6% of femoral fractures were distal. The mean age of patients with femoral fractures was 9.1 months, and with tibial fractures 29.2 months. Thoracic trauma was diagnosed in 33.6% of cats. Pneumothorax was diagnosed in 20% of cats, and pulmonary contusions in 13.4%. Falls from the seventh or higher stories, are associated with more severe injuries and with a higher incidence of thoracic trauma.

Bone geometry in young male and female football players: a peripheral quantitative computed tomography (pQCT) study.

PubMed

Lozano-Berges, Gabriel; Matute-Llorente, Ángel; Gómez-Bruton, Alejandro; González-Agüero, Alex; Vicente-Rodríguez, Germán; Casajús, José A

2018-05-08

The present study shows that football practice during growth may improve bone geometry in male and female football players. However, only females had better bone strength in comparison with controls. The aim of this study was to compare bone geometry in adolescent football players and controls. A total of 107 football players (71 males/36 females; mean age 12.7 ± 0.6/12.7 ± 0.6 years) and 42 controls (20 males/22 females; mean age 13.1 ± 1.4/12.7 ± 1.3 years) participated in this study. Total and trabecular volumetric bone mineral content (Tt.BMC/Tb.BMC), cross-sectional area (Tt.Ar/Tb.Ar), and bone strength index (BSI) were measured at 4% site of the non-dominant tibia by peripheral quantitative computed tomography (pQCT). Moreover, Tt.BMC, cortical BMC (Ct.BMC), Tt.Ar, cortical Ar (Ct.Ar), cortical thickness (Ct.Th), periosteal circumference (PC), endosteal circumference (EC), fracture load in X-axis, and polar strength strain index (SSIp) were measured at 38% site of the tibia. Multivariate analyses of covariance were used to compare bone pQCT variables between football players and controls using the tibia length and maturity offset as covariates. Female football players demonstrated 13.8-16.4% higher BSI, Ct.Th, fracture load in X-axis, and SSIp than controls (p < .0036). Males showed no significant differences in bone strength when compared to controls (p > .0036). In relation to bone mineral content and area, male football players showed 8.8% higher Tt.Ar and Tb.Ar at the 4% site of the tibia when compared to controls; whereas 13.8-15.8% higher Tt.BMC, Ct.BMC, and Ct.Ar at the 38% site of the tibia were found in female football players than controls (p < .0036). In this study, female adolescent football players presented better bone geometry and strength values than controls. In contrast, only bone geometry was higher in male football players than controls.

A Novel Shape Memory Plate Osteosynthesis for Noninvasive Modulation of Fixation Stiffness in a Rabbit Tibia Osteotomy Model

PubMed Central

Müller, Christian W.; Pfeifer, Ronny; Meier, Karen; Decker, Sebastian; Reifenrath, Janin; Gösling, Thomas; Wesling, Volker; Krettek, Christian; Krämer, Manuel

2015-01-01

Nickel-titanium shape memory alloy (NiTi-SMA) implants might allow modulating fracture healing, changing their stiffness through alteration of both elastic modulus and cross-sectional shape by employing the shape memory effect (SME). Hypotheses: a novel NiTi-SMA plate stabilizes tibia osteotomies in rabbits. After noninvasive electromagnetic induction heating the alloy exhibits the SME and the plate changes towards higher stiffness (inverse dynamization) resulting in increased fixation stiffness and equal or better bony healing. In 14 rabbits, 1.0 mm tibia osteotomies were fixed with our experimental plate. Animals were randomised for control or induction heating at three weeks postoperatively. Repetitive X-ray imaging and in vivo measurements of bending stiffness were performed. After sacrifice at 8 weeks, macroscopic evaluation, µCT, and post mortem bending tests of the tibiae were carried out. One death and one early implant dislocation occurred. Following electromagnetic induction heating, radiographic and macroscopic changes of the implant proved successful SME activation. All osteotomies healed. In the treatment group, bending stiffness increased over time. Differences between groups were not significant. In conclusion, we demonstrated successful healing of rabbit tibia osteotomies using our novel NiTi-SMA plate. We demonstrated shape-changing SME in-vivo through transcutaneous electromagnetic induction heating. Thus, future orthopaedic implants could be modified without additional surgery. PMID:26167493

Endochondral fracture healing with external fixation in the Sost knockout mouse results in earlier fibrocartilage callus removal and increased bone volume fraction and strength.

PubMed

Morse, A; Yu, N Y C; Peacock, L; Mikulec, K; Kramer, I; Kneissel, M; McDonald, M M; Little, D G

2015-02-01

Sclerostin deficiency, via genetic knockout or anti-Sclerostin antibody treatment, has been shown to cause increased bone volume, density and strength of calluses following endochondral bone healing. However, there is limited data on the effect of Sclerostin deficiency on the formative early stage of fibrocartilage (non-bony tissue) formation and removal. In this study we extensively investigate the early fibrocartilage callus. Closed tibial fractures were performed on Sost(-/-) mice and age-matched wild type (C57Bl/6J) controls and assessed at multiple early time points (7, 10 and 14days), as well as at 28days post-fracture after bony union. External fixation was utilized, avoiding internal pinning and minimizing differences in stability stiffness, a variable that has confounded previous research in this area. Normal endochondral ossification progressed in wild type and Sost(-/-) mice with equivalent volumes of fibrocartilage formed at early day 7 and day 10 time points, and bony union in both genotypes by day 28. There were no significant differences in rate of bony union; however there were significant increases in fibrocartilage removal from the Sost(-/-) fracture calluses at day 14 suggesting earlier progression of endochondral healing. Earlier bone formation was seen in Sost(-/-) calluses over wild type with greater bone volume at day 10 (221%, p<0.01). The resultant Sost(-/-) united bony calluses at day 28 had increased bone volume fraction compared to wild type calluses (24%, p<0.05), and the strength of the fractured Sost(-/-) tibiae was greater than that that of wild type fractured tibiae. In summary, bony union was not altered by Sclerostin deficiency in externally-fixed closed tibial fractures, but fibrocartilage removal was enhanced and the resultant united bony calluses had increased bone fraction and increased strength. Crown Copyright © 2014. Published by Elsevier Inc. All rights reserved.

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.

Sex differences and growth-related adaptations in bone microarchitecture, geometry, density and strength from childhood to early adulthood: a mixed longitudinal HR-pQCT study

PubMed Central

Gabel, Leigh; Macdonald, Heather M.; McKay, Heather A.

2016-01-01

Sex differences in bone strength and fracture risk are well-documented. However, we know little about bone strength accrual during growth and adaptations in bone microstructure, density and geometry that accompany gains in bone strength. Thus, our objectives are to 1) describe growth related adaptations in bone microarchitecture, geometry, density and strength at the distal tibia and radius in boys and girls; 2) compare differences in adaptations in bone microarchitecture, geometry, density and strength between boys and girls. We used HR-pQCT at the distal tibia (8% site) and radius (7% site) in 184 boys and 209 girls (9–20y at baseline). We aligned boys and girls on a common maturational landmark (age at peak height velocity; APHV) and fit a mixed effects model to these longitudinal data. Importantly, boys demonstrated 28–63% greater estimated bone strength across 12 years of longitudinal growth. Boys demonstrated 28–80% more porous cortices compared with girls at both sites across all biological ages, except at the radius at 9 years post-APHV. However, cortical density was similar between boys and girls at all ages at both sites, except at 9 years post-APHV at the tibia when girls’ values were 2% greater than boys’. Boys demonstrated 13–48% greater cortical and total bone area across growth. Load-to-strength ratio was 26–27% lower in boys at all ages, indicating lower risk of distal forearm fracture compared with girls. Contrary to previous HR-pQCT studies that did not align boys and girls at the same biological age, we did not observe sex differences in Ct.BMD. Boys’ superior bone size and strength compared with girls may confer them a protective advantage. However, boys’ consistently more porous cortices may contribute to boys’ higher fracture incidence during adolescence. Large prospective studies using HR-pQCT that target boys and girls who have sustained a fracture are needed to verify this. PMID:27556581

Ilizarov external fixation versus plate osteosynthesis in the management of extra-articular fractures of the distal tibia.

PubMed

Fadel, Mohamed; Ahmed, Mohamed Ali; Al-Dars, Ahmed Mounir; Maabed, Mustafa Ahmed; Shawki, Hashem

2015-03-01

The purpose of this study was to evaluate the outcome of Ilizarov external fixation (IE) versus dynamic compression plate (PO) in the management of extra-articular distal tibial fractures. Between 2010 and 2011, extra-articular distal tibial fractures in 40 consecutive patients met the inclusion criteria. They were classified according to AO classification fracture type A (A1, A2, and A3). In a randomized method, two equal groups were managed using either IE or PO. PO was performed using open reduction and internal fixation (ORIF) and DCP through anterolateral approach. IE was done using Ilizarov frame. For the PO group, non-weight bearing ambulation was permitted on the second postoperative day but partial weight bearing was permitted according to the progression in union criteria clinically and radiologically. For the IE group, weight bearing started as tolerated from the first postoperative day. Physiotherapy and pin-site care was performed by the patient themselves. Modified Mazur ankle score was applied to IE (excellent 10, good 10) and in PO (excellent 2, good 8, poor 6). Data were statically analysed using (Mann-Whitney test). The rate of healing in the IE group (average 130) was higher than the PO (average 196.5); plus, there were no cases of delayed union or nonunion in the IE group (p value 0.003). It was found that IE compared with PO provides provision of immediate weight bearing as tolerated following postoperative recovery, irrespective of radiological or clinical healing with no infection, deformity or non-union.

A rare combination of amniotic constriction band with osteogenesis imperfecta.

PubMed

Shah, Krupa Hitesh; Shah, Hitesh

2015-11-11

Amniotic constriction bands and osteogenesis imperfecta are disorders arising from a collagen defect. We report a rare association of amniotic bands with osteogenesis imperfecta in a child. The child was born with multiple amniotic bands involving the right leg, both hands and both feet. Multiple fractures of long bones of lower limbs occurred in childhood due to trivial trauma. Deformities of the femur and tibia due to malunion with osteopenia and blue sclerae were present. The patient was treated with z plasty of constriction band of the right tibia and bisphosphonate for osteogenesis imperfecta. This rare association of both collagen diseases may provide further insight for the pathogenesis of these diseases. 2015 BMJ Publishing Group Ltd.

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.

Effectiveness of various isometric exercises at improving bone strength in cortical regions prone to distal tibial stress fractures.

PubMed

Florio, C S

2018-06-01

A computational model was used to compare the local bone strengthening effectiveness of various isometric exercises that may reduce the likelihood of distal tibial stress fractures. The developed model predicts local endosteal and periosteal cortical accretion and resorption based on relative local and global measures of the tibial stress state and its surface variation. Using a multisegment 3-dimensional leg model, tibia shape adaptations due to 33 combinations of hip, knee, and ankle joint angles and the direction of a single or sequential series of generated isometric resultant forces were predicted. The maximum stress at a common fracture-prone region in each optimized geometry was compared under likely stress fracture-inducing midstance jogging conditions. No direct correlations were found between stress reductions over an initially uniform circular hollow cylindrical geometry under these critical design conditions and the exercise-based sets of active muscles, joint angles, or individual muscle force and local stress magnitudes. Additionally, typically favorable increases in cross-sectional geometric measures did not guarantee stress decreases at these locations. Instead, tibial stress distributions under the exercise conditions best predicted strengthening ability. Exercises producing larger anterior distal stresses created optimized tibia shapes that better resisted the high midstance jogging bending stresses. Bent leg configurations generating anteriorly directed or inferiorly directed resultant forces created favorable adaptations. None of the studied loads produced by a straight leg was significantly advantageous. These predictions and the insight gained can provide preliminary guidance in the screening and development of targeted bone strengthening techniques for those susceptible to distal tibial stress fractures. Copyright © 2018 John Wiley & Sons, Ltd.

Characteristics of bone fractures and usefulness of micro-computed tomography for fracture detection in rabbits: 210 cases (2007-2013).

PubMed

Sasai, Hiroshi; Fujita, Daisuke; Tagami, Yukari; Seto, Eiko; Denda, Yuki; Hamakita, Hideaki; Ichihashi, Tomonori; Okamura, Kensaku; Furuya, Masaru; Tani, Hiroyuki; Sasai, Kazumi; Yamate, Jyoji

2015-06-15

To characterize bone fractures and the usefulness of micro-CT for imaging fractures in pet rabbits. Retrospective case series. 210 client-owned rabbits with bone fractures. Medical records of rabbits evaluated for bone fractures from 2007 through 2013 were examined. Information was collected on signalment and nature of fractures, and radiographic and micro-CT images of fractures were reviewed. Almost half (n = 95 [47.7%]) of fractures were in rabbits < 3 years old. Accidental fall was the most common cause. Vertebral fracture was the most common type of fracture with a nonneoplastic cause (n = 46 [23.2%]) and was most common in the L4-L7 region. The tibia was the most common site for limb fracture among all fractures with a nonneoplastic cause (45 [22.7%]). Twelve (5.7%) fractures had a neoplastic cause, and 7 of these were associated with metastatic uterine adenocarcinoma. Females were significantly more likely to have a fracture caused by neoplasia than were males. Compared with radiography, micro-CT provided more detailed fracture information, particularly for complicated fractures or structures (eg, skull, pelvic, vertebral, and comminuted limb fractures). Findings were useful for understanding the nature of fractures in pet rabbits and supported the use of micro-CT versus radiography for fracture detection and evaluation.

Transitioning to an Intramedullary Lengthening and Compression Nail

PubMed Central

2017-01-01

Summary: The magnetic intramedullary lengthening nail is an innovative technology that allows for creative ways to treat difficult problems. The lengthening option has revolutionized femur fracture management with bone loss and malunion therapy. The compression version of this nail has provided a gradual method to compress nonunions and difficult fractures that may obviate the need for many current uses of external fixation. Three cases are presented in this manuscript demonstrating a new paradigm in the management of bone loss/shortening of the tibia and femur, and recalcitrant nonunions. PMID:28486284

Fat embolism syndrome in an adolescent before surgical treatment of an isolated closed tibial shaft fracture.

PubMed

Nawaf, Cayce B; Kelly, Derek M; Warner, William C; Beaty, James H; Rhodes, Leslie; Sawyer, Jeffrey R

2012-12-01

Fat embolism syndrome (FES) occurs most commonly in adults with high-energy trauma, especially fractures of the long-bones and pelvis. Because of unique age-related physiologic differences in the immature skeleton, as well as differences in fracture management in pediatric patients, FES is rare in children. To our knowledge, this is the first case report of FES occurring before surgical fixation of a closed tibial shaft fracture in an adolescent. A 16-year-old, 109 kg, Caucasian adolescent boy developed FES after closed diaphyseal fractures of the distal tibia and fibula, showing signs of respiratory distress and mental status changes. The FES resolved with supportive respiratory care and intramedullary nailing of the fracture was done without further respiratory compromise. FES is uncommon in children and adolescents. A high index of suspicion is required to make the diagnosis promptly and institute appropriate treatment. Intramedullary nailing of a long-bone fracture can be done safely and successfully after resolution of the FES.

Mechanical vibration testing of a tibia in vivo and finite element analysis of the shank resonant properties

NASA Astrophysics Data System (ADS)

Maslov, Leonid B.

2003-10-01

Recent clinical studies clearly indicate that the resonant frequencies can be used to assess the healing state of a fractured long bone. Although these studies clearly show a certain relation between the resonant frequencies and the stiffness of the bone, the nature of this relation has not yet studied very well. The attempt of considering the locomotion system of a human shank in complex is firstly presented in this paper. The finite element model of the soft and hard tissues composed of the human shank is developed and the vibration numerical analysis is performed. The values of the resonant frequencies for the isolated tibia and for the complex biomechanical system formed by tibia, fibula, achilles tendon and principal shank muscles are obtained during finite element analysis. The obtained result can be used as theoretical fundament to developing low-frequency resonant methods for testing and diagnostics of the physiological conditions of soft and hard tissue during medical treatment and rehabilitation time period after surgery operation.

A murine model of neurofibromatosis type 1 tibial pseudarthrosis featuring proliferative fibrous tissue and osteoclast-like cells.

PubMed

El-Hoss, Jad; Sullivan, Kate; Cheng, Tegan; Yu, Nicole Y C; Bobyn, Justin D; Peacock, Lauren; Mikulec, Kathy; Baldock, Paul; Alexander, Ian E; Schindeler, Aaron; Little, David G

2012-01-01

Neurofibromatosis type 1 (NF1) is a common genetic condition caused by mutations in the NF1 gene. Patients often suffer from tissue-specific lesions associated with local double-inactivation of NF1. In this study, we generated a novel fracture model to investigate the mechanism underlying congenital pseudarthrosis of the tibia (CPT) associated with NF1. We used a Cre-expressing adenovirus (AdCre) to inactivate Nf1 in vitro in cultured osteoprogenitors and osteoblasts, and in vivo in the fracture callus of Nf1(flox/flox) and Nf1(flox/-) mice. The effects of the presence of Nf1(null) cells were extensively examined. Cultured Nf1(null)-committed osteoprogenitors from neonatal calvaria failed to differentiate and express mature osteoblastic markers, even with recombinant bone morphogenetic protein-2 (rhBMP-2) treatment. Similarly, Nf1(null)-inducible osteoprogenitors obtained from Nf1 MyoDnull mouse muscle were also unresponsive to rhBMP-2. In both closed and open fracture models in Nf1(flox/flox) and Nf1(flox/-) mice, local AdCre injection significantly impaired bone healing, with fracture union being <50% that of wild type controls. No significant difference was seen between Nf1(flox/flox) and Nf1(flox/-) mice. Histological analyses showed invasion of the Nf1(null) fractures by fibrous and highly proliferative tissue. Mean amounts of fibrous tissue were increased upward of 10-fold in Nf1(null) fractures and bromodeoxyuridine (BrdU) staining in closed fractures showed increased numbers of proliferating cells. In Nf1(null) fractures, tartrate-resistant acid phosphatase-positive (TRAP+) cells were frequently observed within the fibrous tissue, not lining a bone surface. In summary, we report that local Nf1 deletion in a fracture callus is sufficient to impair bony union and recapitulate histological features of clinical CPT. Cell culture findings support the concept that Nf1 double inactivation impairs early osteoblastic differentiation. This model provides valuable insight into the pathobiology of the disease, and will be helpful for trialing therapeutic compounds. Copyright © 2012 American Society for Bone and Mineral Research.

Histopathological examination of bone debris from reaming of interlocking intra-medullary nail fixation of long bone fractures with concomitant head injury.

PubMed

Khallaf, Fathy G; Kehinde, Elijah O

2015-12-01

The aim of study was to test, for the presence of osteoblasts in the reaming debris of intramedullary nailing of femoral and tibial fracture in patients with and without severe head injury. Two groups of patients were studied. Group A (n = 32) had long bone fractures in addition to having head injuries. Group B (n = 35) had only long bone fractures. The fractures in the 2 groups of patients was treated by inter medullary nailing. Osteoblasts in the debris of the inter medullary nailing was compared between the 2 groups of patients. The results demonstrated that histopathological specimens from reaming debris of fractured femur and tibia in patients with head injury showed osteoblasts in (82.9%) and in (27.5%) of patients with isolated long bone fractures (p < 0.001). Healing indicators in diaphyseal fractures and concomitant head injury confirm fast and adequate healing in these patients and the presence of plenty of osteoblasts in their reaming debris may reflect a proof of accelerated fracture healing environment.

Primary Hyperparathyroidism is Associated with Abnormal Cortical and Trabecular Microstructure and Reduced Bone Stiffness in Postmenopausal Women

PubMed Central

Stein, Emily M; Silva, Barbara C; Boutroy, Stephanie; Zhou, Bin; Wang, Ji; Udesky, Julia; Zhang, Chiyuan; McMahon, Donald J; Romano, Megan; Dworakowski, Elzbieta; Costa, Aline G.; Cusano, Natalie; Irani, Dinaz; Cremers, Serge; Shane, Elizabeth; Guo, X Edward; Bilezikian, John P

2013-01-01

Typically, in the milder form of primary hyperparathyroidism (PHPT), seen in most countries now, bone density by DXA and detailed analyses of iliac crest bone biopsies by histomorphometry and µCT show detrimental effects in cortical bone, whereas the trabecular site (lumbar spine by DXA) and the trabecular compartment (by bone biopsy) appear to be relatively well preserved. Despite these findings, fracture risk at both vertebral and non-vertebral sites is increased in PHPT. Emerging technologies, such as high-resolution peripheral quantitative computed tomography (HRpQCT), may provide additional insight into microstructural features at sites such as the forearm and tibia that have heretofore not been easily accessible. Using HRpQCT, we determined cortical and trabecular microstructure at the radius and tibia in 51 postmenopausal women with PHPT and 120 controls. Individual trabecula segmentation (ITS) and micro finite element (µFE) analyses of the HRpQCT images were also performed to further understand how the abnormalities seen by HRpQCT might translate into effects on bone strength. Women with PHPT showed, at both sites, decreased volumetric densities at trabecular and cortical compartments, thinner cortices, and more widely spaced and heterogeneously distributed trabeculae. At the radius, trabeculae were thinner and fewer in PHPT. The radius was affected to a greater extent in the trabecular compartment than the tibia. ITS analyses revealed, at both sites, that plate-like trabeculae were depleted, with a resultant reduction in the plate/rod ratio. Microarchitectural abnormalities were evident by decreased plate-rod and plate-plate junctions at the radius and tibia, and rod-rod junctions at the radius. These trabecular and cortical abnormalities resulted in decreased whole bone stiffness and trabecular stiffness. These results provide evidence that in PHPT, microstructural abnormalities are pervasive and not limited to the cortical compartment. They may help to account for increased global fracture risk in PHPT. PMID:23225022

Effects of multi-deficiencies-diet on bone parameters of peripheral bone in ovariectomized mature rat.

PubMed

El Khassawna, Thaqif; Böcker, Wolfgang; Govindarajan, Parameswari; Schliefke, Nathalie; Hürter, Britta; Kampschulte, Marian; Schlewitz, Gudrun; Alt, Volker; Lips, Katrin Susanne; Faulenbach, Miriam; Möllmann, Henriette; Zahner, Daniel; Dürselen, Lutz; Ignatius, Anita; Bauer, Natali; Wenisch, Sabine; Langheinrich, Alexander Claus; Schnettler, Reinhard; Heiss, Christian

2013-01-01

Many postmenopausal women have vitamin D and calcium deficiency. Therefore, vitamin D and calcium supplementation is recommended for all patients with osteopenia and osteoporosis. We used an experimental rat model to test the hypothesis that induction of osteoporosis is more efficiently achieved in peripheral bone through combining ovariectomy with a unique multi-deficiencies diet (vitamin D depletion and deficient calcium, vitamin K and phosphorus). 14-week-old Sprague-Dawley rats served as controls to examine the initial bone status. 11 rats were bilaterally ovariectomized (OVX) and fed with multi-deficiencies diet. Three months later the treated group and the Sham group (n = 8) were euthanized. Bone biomechanical competence of the diaphyseal bone was examined on both, tibia and femur. Image analysis was performed on tibia via µCT, and on femur via histological analysis. Lower torsional stiffness indicated inferior mechanical competence of the tibia in 3 month OVX+Diet. Proximal metaphyseal region of the tibia showed a diminished bone tissue portion to total tissue in the µCT despite the increased total area as evaluated in both µCT and histology. Cortical bone showed higher porosity and smaller cross sectional thickness of the tibial diaphysis in the OVX+Diet rats. A lower ALP positive area and elevated serum level of RANKL exhibited the unbalanced cellular interaction in bone remodeling in the OVX+Diet rat after 3 month of treatment. Interestingly, more adipose tissue area in bone marrow indicated an effect of bone loss similar to that observed in osteoporotic patients. Nonetheless, the presence of osteoid and elevated serum level of PTH, BGP and Opn suggest the development of osteomalacia rather than an osteoporosis. As the treatment and fracture management of both osteoporotic and osteomalacia patients are clinically overlapping, this study provides a preclinical animal model to be utilized in local supplementation of minerals, drugs and growth factors in future fracture healing studies.

Effects of Multi-Deficiencies-Diet on Bone Parameters of Peripheral Bone in Ovariectomized Mature Rat

PubMed Central

El Khassawna, Thaqif; Böcker, Wolfgang; Govindarajan, Parameswari; Schliefke, Nathalie; Hürter, Britta; Kampschulte, Marian; Schlewitz, Gudrun; Alt, Volker; Lips, Katrin Susanne; Faulenbach, Miriam; Möllmann, Henriette; Zahner, Daniel; Dürselen, Lutz; Ignatius, Anita; Bauer, Natali; Wenisch, Sabine; Langheinrich, Alexander Claus; Schnettler, Reinhard; Heiss, Christian

2013-01-01

Many postmenopausal women have vitamin D and calcium deficiency. Therefore, vitamin D and calcium supplementation is recommended for all patients with osteopenia and osteoporosis. We used an experimental rat model to test the hypothesis that induction of osteoporosis is more efficiently achieved in peripheral bone through combining ovariectomy with a unique multi-deficiencies diet (vitamin D depletion and deficient calcium, vitamin K and phosphorus). 14-week-old Sprague-Dawley rats served as controls to examine the initial bone status. 11 rats were bilaterally ovariectomized (OVX) and fed with multi-deficiencies diet. Three months later the treated group and the Sham group (n = 8) were euthanized. Bone biomechanical competence of the diaphyseal bone was examined on both, tibia and femur. Image analysis was performed on tibia via µCT, and on femur via histological analysis. Lower torsional stiffness indicated inferior mechanical competence of the tibia in 3 month OVX+Diet. Proximal metaphyseal region of the tibia showed a diminished bone tissue portion to total tissue in the µCT despite the increased total area as evaluated in both µCT and histology. Cortical bone showed higher porosity and smaller cross sectional thickness of the tibial diaphysis in the OVX+Diet rats. A lower ALP positive area and elevated serum level of RANKL exhibited the unbalanced cellular interaction in bone remodeling in the OVX+Diet rat after 3 month of treatment. Interestingly, more adipose tissue area in bone marrow indicated an effect of bone loss similar to that observed in osteoporotic patients. Nonetheless, the presence of osteoid and elevated serum level of PTH, BGP and Opn suggest the development of osteomalacia rather than an osteoporosis. As the treatment and fracture management of both osteoporotic and osteomalacia patients are clinically overlapping, this study provides a preclinical animal model to be utilized in local supplementation of minerals, drugs and growth factors in future fracture healing studies. PMID:23977109

Experimental and finite element analysis of tibial stress fractures using a rabbit model.

PubMed

Franklyn, Melanie; Field, Bruce

2013-01-01

To determine if rabbit models can be used to quantify the mechanical behaviour involved in tibial stress fracture (TSF) development. Fresh rabbit tibiae were loaded under compression using a specifically-designed test apparatus. Weights were incrementally added up to a load of 30 kg and the mechanical behaviour of the tibia was analysed using tests for buckling, bone strain and hysteresis. Structural mechanics equations were subsequently employed to verify that the results were within the range of values predicted by theory. A finite element (FE) model was developed using cross-sectional computer tomography (CT) images scanned from one of the rabbit bones, and a static load of 6 kg (1.5 times the rabbit's body weight) was applied to represent running. The model was validated using the experimental strain gauge data, then geometric and elemental convergence tests were performed in order to find the minimum number of cross-sectional scans and elements respectively required for convergence. The analysis was then performed using both the model and the experimental results to investigate the mechanical behaviour of the rabbit tibia under compressive load and to examine crack initiation. The experimental tests showed that under a compressive load of up to 12 kg, the rabbit tibia demonstrates linear behaviour with little hysteresis. Up to 30 kg, the bone does not fail by elastic buckling; however, there are low levels of tensile stress which predominately occur at and adjacent to the anterior border of the tibial midshaft: this suggests that fatigue failure occurs in these regions, since bone under cyclic loading initially fails in tension. The FE model predictions were consistent with both mechanics theory and the strain gauge results. The model was highly sensitive to small changes in the position of the applied load due to the high slenderness ratio of the rabbit's tibia. The modelling technique used in the current study could have applications in the development of human FE models of bone, where, unlike rabbit tibia, the model would be relatively insensitive to very small changes in load position. However, the rabbit model itself is less beneficial as a tool to understand the mechanical behaviour of TSFs in humans due to the small size of the rabbit bone and the limitations of human-scale CT scanning equipment. The current modelling technique could be used to develop human FE models. However, the rabbit model itself has significant limitations in understanding human TSF mechanics.

Analysis of fracture healing in osteopenic bone caused by disuse: experimental study.

PubMed

Paiva, A G; Yanagihara, G R; Macedo, A P; Ramos, J; Issa, J P M; Shimano, A C

2016-03-01

Osteoporosis has become a serious global public health issue. Hence, osteoporotic fracture healing has been investigated in several previous studies because there is still controversy over the effect osteoporosis has on the healing process. The current study aimed to analyze two different periods of bone healing in normal and osteopenic rats. Sixty, 7-week-old female Wistar rats were randomly divided into four groups: unrestricted and immobilized for 2 weeks after osteotomy (OU2), suspended and immobilized for 2 weeks after osteotomy (OS2), unrestricted and immobilized for 6 weeks after osteotomy (OU6), and suspended and immobilized for 6 weeks after osteotomy (OS6). Osteotomy was performed in the middle third of the right tibia 21 days after tail suspension, when the osteopenic condition was already set. The fractured limb was then immobilized by orthosis. Tibias were collected 2 and 6 weeks after osteotomy, and were analyzed by bone densitometry, mechanical testing, and histomorphometry. Bone mineral density values from bony calluses were significantly lower in the 2-week post-osteotomy groups compared with the 6-week post-osteotomy groups (multivariate general linear model analysis, P<0.000). Similarly, the mechanical properties showed that animals had stronger bones 6 weeks after osteotomy compared with 2 weeks after osteotomy (multivariate general linear model analysis, P<0.000). Histomorphometry indicated gradual bone healing. Results showed that osteopenia did not influence the bone healing process, and that time was an independent determinant factor regardless of whether the fracture was osteopenic. This suggests that the body is able to compensate for the negative effects of suspension.

Lower extremity injury criteria for evaluating military vehicle occupant injury in underbelly blast events.

PubMed

McKay, Brian J; Bir, Cynthia A

2009-11-01

Anti-vehicular (AV) landmines and improvised explosive devices (IED) have accounted for more than half of the United States military hostile casualties and wounded in Operation Iraqi Freedom (OIF) (Department of Defense Personnel & Procurement Statistics, 2009). The lower extremity is the predominantly injured body region following an AV mine or IED blast accounting for 26 percent of all combat injuries in OIF (Owens et al., 2007). Detonations occurring under the vehicle transmit high amplitude and short duration axial loads onto the foot-ankle-tibia region of the occupant causing injuries to the lower leg. The current effort was initiated to develop lower extremity injury criteria for occupants involved in underbelly blast impacts. Eighteen lower extremity post mortem human specimens (PMHS) were instrumented with an implantable load cell and strain gages and impacted at one of three incrementally severe AV axial loading conditions. Twelve of the 18 PMHS specimens sustained fractures of the calcaneus, talus, fibula and/or tibia. The initiation of skeletal injury was precisely detected by strain gages and corresponded with local peak axial tibia force. Survival analysis identified peak axial tibia force and impactor velocity as the two best predictors of incapacitating injury. A tibia axial force of 5,931 N and impactor velocity of 10.8 m/s corresponds with a 50 percent risk of an incapacitating injury. The criteria may be utilized to predict the probability of lower extremity incapacitating injury in underbelly blast impacts.

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

Anterior tibial stress fractures treated with anterior tension band plating in high-performance athletes.

PubMed

Cruz, Alexandre Santa; de Hollanda, João Paris Buarque; Duarte, Aires; Hungria Neto, José Soares

2013-06-01

The non-surgical treatment of anterior tibial cortex stress fractures requires long periods of abstention from sports activities and often results in non-union. Many different surgical techniques have already been previously described to treat these fractures, but there is no consensus on the best treatment. We describe the outcome of treatment using anterior tibial tension band plating in three high-performance athletes (4 legs) with anterior tibial cortex stress fractures. Tibial osteosynthesis with a 3.5-mm locking compression plate in the anterolateral aspect of the tibia was performed in all patients diagnosed with anterior tibial stress fracture after September 2010 at Santa Casa Hospital. All of the fractures were consolidated within a period of 3 months after surgery, allowing for an early return to pre-injury levels of competitive sports activity. There were no infection, non-union, malunion or anterior knee pain complications. Anterior tibial tension band plating leads to prompt fracture consolidation and is a good alternative for the treatment of anterior tibial cortex stress fractures. Bone grafts were shown to be unnecessary.

Minimally invasive treatment of tibial pilon fractures through arthroscopy and external fixator-assisted reduction.

PubMed

Luo, Huasong; Chen, Liaobin; Liu, Kebin; Peng, Songming; Zhang, Jien; Yi, Yang

2016-01-01

The aim of this study was to evaluate the clinical outcome of tibial pilon fractures treated with arthroscopy and assisted reduction with an external fixator. Thirteen patients with tibial pilon fractures underwent assisted reduction for limited lower internal fixation with an external fixator under arthroscopic guidance. The weight-bearing time was decided on the basis of repeat radiography of the tibia 3 months after surgery. Postoperative ankle function was evaluated according to the Mazur scoring system. Healing of fractures was achieved in all cases, with no complications such as severe infection, skin necrosis, or an exposed plate. There were 9 excellent, 2 good, and 2 poor outcomes, scored according to the Mazur system. The acceptance rate was 85%. Arthroscopy and external fixator-assisted reduction for the minimally invasive treatment of tibial pilon fractures not only produced less trauma but also protected the soft tissues and blood supply surrounding the fractures. External fixation could indirectly provide reduction and effective operative space for arthroscopic implantation, especially for AO type B fractures and partial AO type C1 fractures.

Biomechanical comparison of straight and helical compression plates for fixation of transverse and oblique bone fractures: Modeling and experiments.

PubMed

Sezek, Sinan; Aksakal, Bunyamin; Gürger, Murat; Malkoc, Melih; Say, Y

2016-08-12

Total deformation and stability of straight and helical compression plates were studied by means of the finite element method (FEM) and in vitro biomechanical experiments. Fixations of transverse (TF) and oblique (45°) bone (OF) fractures have been analyzed on sheep tibias by designing the straight compression (SP) and Helical Compression Plate (HP) models. The effects of axial compression, bending and torsion loads on both plating systems were analyzed in terms of total displacements. Numerical models and experimental models suggested that under compression loadings, bone fracture gap closures for both fracture types were found to be in the favor of helical plate designs. The helical plate (HP) fixations provided maximum torsional resistance compared to the (SP) fixations. The fracture gap closure and stability of helical plate fixation for transverse fractures was determined to be higher than that found for the oblique fractures. The comparison of average compression stress, bending and torsion moments showed that the FEM and experimental results are in good agreement and such designs are likely to have a positive impact in future bone fracture fixation designs.

In vivo effect of shock-waves on the healing of fractured bone.

PubMed

Augat, P; Claes, L; Suger, G

1995-10-01

In a controlled animal experiment we attempted to clarify the question of whether there is a stimulating effect of extracorporeal shock-waves on the repair process of fractured long bones. As a fracture model we used an osteotomy in the diaphysis of the ovine tibia and an external fixation device. Shock-wave treatment at two levels of intensity and with four different numbers of applied shocks was performed with an electromagnetic acoustic source. Healing of the osteotomized bone was evaluated by biomechanical and radiological investigations on the whole bone as well as on bone sections from areas of the fracture gap and the periosteal fracture callus. We found a non-significant tendency to deterioration of the fracture healing with increasing shock-wave intensities. The study of treatment parameters led neither to significantly different biomechanical outcomes nor to altered radiological results in comparison to the untreated control group. RELEVANCE:--While we cannot comment upon the effectiveness of extracorporeal shock-waves in the delayed treatment of fractures or pseudarthrosis, our results suggest that shock-waves have no beneficial effect in acute fracture repair.

Closing wedge retrotubercular tibial osteotomy and TKA for posttraumatic osteoarthritis with angular deformity.

PubMed

Meehan, John P; Khadder, Mohammad A; Jamali, Amir A; Trauner, Kenneth B

2009-05-01

Posttraumatic osteoarthritis of the knee can be associated with angular deformities and alterations in the joint line as a result of the initial trauma and subsequent surgical procedures. These deformities can be characterized as extra-articular or intra-articular or can involve aspects of both. Conversion to total knee arthroplasty (TKA) may require either a staged or a simultaneous corrective osteotomy to restore the limb alignment and proper knee function. This article describes a closing wedge retrotubercular tibia osteotomy performed concurrently with TKA in an effort to correct an extra-articular varus deformity and to improve the patella tendon height in relation to the reconstructed joint line. A 57-year-old man previously treated for a Schatzker type 6 tibia plateau fracture presented with symptoms of arthritis pain and instability as a result of a varus thrust with weight bearing. Radiographs revealed posttraumatic osteoarthritis, a 35 degrees varus deformity, and patella infera. Maintaining the tibia tubercle continuity with the distal tibia allowed for correction of the varus deformity and improvement in the patella tendon height relative to the joint line. At 5-year follow-up, the patient had osteotomy healing, clinically neutral limb alignment, and improvement in joint line biomechanics with resolution of symptoms of pain and instability.

Fractography of human intact long bone by bending.

PubMed

Kimura, T; Ogawa, K; Kamiya, M

1977-05-27

Human intact tibiae were tested using the static bending method to learn about the relationship between the fracture surface and the failure mode. The bending test was applied to test pieces and to whole bones. The fracture surface was observed by scanning electron microscopy. The bone fracture is closely related to the architecture of the bone substance, especially to the direction of the Haversian canals and the lamellae. The failure mode and the sequence of the break line of the bone can be found out by the observation on the fracture surface. Hardly any crushing effects caused by the compressive force is seen. The mechanical properties of the fractured bone can be estimated to some extend by considering the direction of the break line and the failure mode. The strength calculated by the simple beam formula for elastic materials can not be obtained directly because of the plastic deformation of the bone. The results of the tensile test may be applied to the fracture using the static bending moment.

Predisposing factors and outcome of treatment of non-union of long-bone fractures in Ibadan, Nigeria.

PubMed

Ogunlade, S O; Omololu, A B; Alonge, T O; Diete, S T; Obawonyi, J E

2011-03-01

This study was done to find out factors that contribute to development of Non-union of long bone fractures in this environment and the outcome of operative intervention. This is a prospective hospital based study. All patients with Non-union of long bone fracture that presented in the hospital since January 1997 were recruited into the study. The data included causative factors, treatment given before presenting in the hospital, type of surgical procedure and result of treatment. The study was completed in December, 2005. 78 patients presented with 87 Non-union of long bones. A male, female ratio of 1.6:1 was encountered while 69.2 per cent of the patients were below the age 55years. Road Traffic Accident accounted for 68 fractures (78.2 per cent) while duration of injury before presentation varies from 6 months to 22 months. Atrophic non-union occurred in 60 cases (69.0 per cent) and hypertrophic non-union in 21 cases. Non-union of the femur occurred in 33 cases (37.9 per cent) humerus in 24 cases (27.6 per cent), tibia in 16 cases (18.4 per cent), radius and ulna in 14 cases (16.1 per cent). The initial treatments of the fresh fracture in the 78 patients with nonunion were by the traditional bonesetters in 51 patients (65.4 per cent) while the remaining fractures were treated by plaster of paris in hospital. Open reduction and internal fixation using plate and screws with bone grafting was the most common procedure for treating the non-union in most cases. Union was achieved in the entire patients following surgical intervention. Important factor that appears to contribute to non-union of long bone in this environment is soft tissue interposition between the fracture ends of the bone, which is found in all fractures with more than one diameter displacement. Another factor is interference with periosteal blood supply from disruption of soft tissue envelope as a result of high energy injuries which is also responsible for the displacements that were observed in these fractures. The treatment by traditional bone setters which entails daily massage of the fracture creating a macro movement at the fracture site is also an important contributing factor.

Fracture of the proximal tibia after revision total knee arthroplasty with an extensor mechanism allograft.

PubMed

Klein, Gregg R; Levine, Harlan B; Sporer, Scott M; Hartzband, Mark A

2013-02-01

Extensor mechanism reconstruction with an extensor mechanism allograft (EMA) remains one of the most reliable methods for treating the extensor mechanism deficient total knee arthroplasty. We report 3 patients who were treated with an EMA who sustained a proximal tibial shaft fracture. In all 3 cases, a short tibial component was present that ended close to the level of the distal extent of the bone block. When performing an EMA, it is important to recognize that the tibial bone block creates a stress riser and revision to a long-stemmed tibial component should be strongly considered to bypass this point to minimize the risk of fracture. Copyright © 2013 Elsevier Inc. All rights reserved.

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.

Transcutaneous monitoring of steroid-induced osteoporosis with Raman spectroscopy

NASA Astrophysics Data System (ADS)

Maher, Jason R.; Inzana, Jason; Takahata, Masahiko; Awad, Hani A.; Berger, Andrew J.

2012-01-01

Although glucocorticoids are among the most frequently prescribed anti-inflammatory agents used in the treatment of rheumatoid arthritis, extended exposure to this steroid hormone is the leading cause of iatrogenic osteoporosis. Recently, Raman spectroscopy has been utilized to exploit biochemical differences between osteoporotic and normal bones in order to predict fracture risk. In this presentation, we report the results of ongoing research in our laboratory towards the clinical translation of this technique. We will discuss strategies for the transcutaneous acquisition of spectra from the tibiae of mice that are of sufficient quality to generate accurate predictions of fracture risk.

A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.

PubMed

Guo, J J; Tang, N; Yang, H L; Tang, T S

2010-07-01

We compared the outcome of closed intramedullary nailing with minimally invasive plate osteosynthesis using a percutaneous locked compression plate in patients with a distal metaphyseal fracture in a prospective study. A total of 85 patients were randomised to operative stabilisation either by a closed intramedullary nail (44) or by minimally invasive osteosynthesis with a compression plate (41). Pre-operative variables included the patients' age and the side and pattern of the fracture. Peri-operative variables were the operating time and the radiation time. Postoperative variables were wound problems, the time to union of the fracture, the functional American Orthopaedic Foot and Ankle surgery score and removal of hardware. We found no significant difference in the pre-operative variables or in the time to union in the two groups. However, the mean radiation time and operating time were significantly longer in the locked compression plate group (3.0 vs 2.12 minutes, p < 0.001, and 97.9 vs 81.2 minutes, p < 0.001, respectively).After one year, all the fractures had united. Patients who had intramedullary nailing had a higher mean pain score (40 = no pain, 0 = severe pain), [corrected] but better function, alignment and total American Orthopaedic Foot and Ankle surgery scores, although the differences were not statistically significant (p = 0.234, p = 0.157, p = 0.897, p = 0.177 respectively). Three (6.8%) patients in the intramedullary nailing group and six (14.6%) in the locked compression plate group showed delayed wound healing, and 37 (84.1%) in the former group and 38 (92.7%) in the latter group expressed a wish to have the implant removed. We conclude that both closed intramedullary nailing and a percutaneous locked compression plate can be used safely to treat Orthopaedic Trauma Association type-43A distal metaphyseal fractures of the tibia. However, closed intramedullary nailing has the advantage of a shorter operating and radiation time and easier removal of the implant. We therefore prefer closed intramedullary nailing for patients with these fractures.

Acute versus chronic phase mechanisms in a rat model of CRPS.

PubMed

Wei, Tzuping; Guo, Tian-Zhi; Li, Wen-Wu; Kingery, Wade S; Clark, John David

2016-01-19

Tibia fracture followed by cast immobilization in rats evokes nociceptive, vascular, epidermal, and bone changes resembling complex regional pain syndrome (CRPS). In most cases, CRPS has three stages. Over time, this acute picture, allodynia, warmth, and edema observed at 4 weeks, gives way to a cold, dystrophic but still painful limb. In the acute phase (at 4 weeks post fracture), cutaneous immunological and NK1-receptor signaling mechanisms underlying CRPS have been discovered; however, the mechanisms responsible for the chronic phase are still unknown. The purpose of this study is to understand the mechanisms responsible for the chronic phases of CRPS (at 16 weeks post fracture) at both the peripheral and central levels. We used rat tibial fracture/cast immobilization model of CRPS to study molecular, vascular, and nociceptive changes at 4 and 16 weeks post fracture. Immunoassays and Western blotting were carried out to monitor changes in inflammatory response and NK1-receptor signaling in the skin and spinal cord. Skin temperature and thickness were measured to elucidate vascular changes, whereas von Frey testing and unweighting were carried out to study nociceptive changes. All data were analyzed by one-way analysis of variance (ANOVA) followed by Neuman-Keuls multiple comparison test to compare among all cohorts. In the acute phase (at 4 weeks post fracture), hindpaw allodynia, unweighting, warmth, edema, and/or epidermal thickening were observed among 90 % fracture rats, though by 16 weeks (chronic phase), only the nociceptive changes persisted. The expression of the neuropeptide signaling molecule substance P (SP), NK1 receptor, inflammatory mediators TNFα, IL-1β, and IL-6 and nerve growth factor (NGF) were elevated at 4 weeks in sciatic nerve and/or skin, returning to normal levels by 16 weeks post fracture. The systemic administration of a peripherally restricted IL-1 receptor antagonist (anakinra) or of anti-NGF inhibited nociceptive behaviors at 4 weeks but not 16 weeks. However, spinal levels of NK1 receptor, TNFα, IL-1β, and NGF were elevated at 4 and 16 weeks, and intrathecal injection of an NK1-receptor antagonist (LY303870), anakinra, or anti-NGF each reduced nociceptive behaviors at both 4 and 16 weeks. These results demonstrate that tibia fracture and immobilization cause peripheral changes in neuropeptide signaling and inflammatory mediator production acutely, but central spinal changes may be more important for the persistent nociceptive changes in this CRPS model.

Biomechanical analysis of four different fixations for the posterolateral shearing tibial plateau fracture.

PubMed

Zhang, Wei; Luo, Cong-Feng; Putnis, Sven; Sun, Hui; Zeng, Zhi-Min; Zeng, Bing-Fang

2012-03-01

The posterolateral shearing tibial plateau fracture is uncommon in the literature, however with the increased usage of computer tomography (CT), the incidence of these fractures is no longer as low as previously thought. Few studies have concentrated on this fracture, least of all using a biomechanical model. The purpose of this study was to compare and analyse the biomechanical characteristics of four different types of internal fixation to stabilise the posterolateral shearing tibial plateau fracture. Forty synthetic tibiae (Synbone, right) simulated the posterolateral shearing fracture models and these were randomly assigned into four groups; Group A was fixed with two anterolateral lag screws, Group B with an anteromedial Limited Contact Dynamic Compression Plate (LC-DCP), Group C with a lateral locking plate, and Group D with a posterolateral buttress plate. Vertical displacement of the posterolateral fragment was measured using three different strengths of axial loading force, and finally loaded until fixation failure. It was concluded that the posterolateral buttress plate is biomechanically the strongest fixation method for the posterolateral shearing tibial plateau fracture. Copyright © 2011 Elsevier B.V. All rights reserved.

Multiple fractures and impaired bone metabolism in Wolfram syndrome: a case report.

PubMed

Catalano, Antonino; Bellone, Federica; Cicala, Giuseppe; Giandalia, Annalisa; Morabito, Nunziata; Cucinotta, Domenico; Russo, Giuseppina Tiziana

2017-01-01

Wolfram Syndrome (WS) is a rare and lethal disease characterized by optic atrophy, diabetes mellitus, diabetes insipidus, and hearing loss. To date, osteoporotic related fractures have not been reported in affected patients. Here, we describe the case of a man affected by WS complicated by several bone fragility fractures. A 50-year-old Caucasian man was hospitalized because of tibia and fibula fractures. His clinical features included diabetes mellitus, diabetes insipidus, optic atrophy and deafness that were consistent with an unrecognized WS diagnosis, which was confirmed by the identification of a specific mutation in gene WFS1 encoding wolframin. Bone mineral density by phalangeal quantitative ultrasound demonstrated severe osteoporosis, with high serum levels of surrogate markers of bone turn-over. Previously unidentified rib fractures were also detected. To the best of our knowledge, this is the first report of osteoporotic related fractures in a patient affected by WS. Although no effective treatments are currently available to delay the progression of the disease, this case report suggests to evaluate fracture risk in the diagnostic work-up of WS.

[Periprosthetic knee fractures].

PubMed

Mittlmeier, T; Beck, M; Bosch, U; Wichelhaus, A

2016-01-01

The cumulative incidence of periprosthetic fractures around the knee is increasing further because of an extended indication for knee replacement, previous revision arthroplasty, rising life expectancy and comorbidities. The relevance of local parameters such as malalignment, osseous defects, neighbouring implants, aseptic loosening and low-grade infections may sometimes be hidden behind the manifestation of a traumatic fracture. A differentiated diagnostic approach before the treatment of a periprosthetic fracture is of paramount importance, while the physician in-charge should also have particular expertise in fracture treatment and in advanced techniques of revision endoprosthetics. The following work gives an overview of this topic. Valid classifications are available for categorising periprosthetic fractures of the femur, the tibia and the patella respectively, which are helpful for the selection of treatment. With the wide-ranging modern treatment portfolio bearing in mind the substantial rate of complications and the heterogeneous functional outcome, the adequate analysis of fracture aetiology and the corresponding transformation into an individualised treatment concept offer the chance of an acceptable functional restoration of the patient at early full weight-bearing and prolonged implant survival. The management of complications is crucial to the final outcome.

Significant bone microarchitecture impairment in premenopausal women with active celiac disease.

PubMed

Zanchetta, María Belén; Costa, Florencia; Longobardi, Vanesa; Longarini, Gabriela; Mazure, Roberto Martín; Moreno, María Laura; Vázquez, Horacio; Silveira, Fernando; Niveloni, Sonia; Smecuol, Edgardo; Temprano, María de la Paz; Hwang, Hui Jer; González, Andrea; Mauriño, Eduardo César; Bogado, Cesar; Zanchetta, Jose R; Bai, Julio César

2015-07-01

Patients with active celiac disease (CD) are more likely to have osteoporosis and increased risk of fractures. High-resolution peripheral quantitative computed tomography (HR-pQCT) permits three-dimensional exploration of bone microarchitectural characteristics measuring separately cortical and trabecular compartments, and giving a more profound insight into bone disease pathophysiology and fracture. We aimed to determine the volumetric and microarchitectural characteristics of peripheral bones-distal radius and tibia-in an adult premenopausal cohort with active CD assessed at diagnosis. We prospectively enrolled 31 consecutive premenopausal women with newly diagnosed CD (median age 29 years, range: 18-49) and 22 healthy women of similar age (median age 30 years, range 21-41) and body mass index. Compared with controls, peripheral bones of CD patients were significantly lower in terms of total volumetric density mg/cm(3) (mean ± SD: 274.7 ± 51.7 vs. 324.7 ± 45.8, p 0.0006 at the radius; 264.4 ± 48.7 vs. 307 ± 40.7, p 0.002 at the tibia), trabecular density mg/cm(3) (118.6 ± 31.5 vs. 161.9 ± 33.6, p<0.0001 at the radius; 127.9 ± 28.7 vs. 157.6 ± 15.6, p < 0.0001 at the tibia); bone volume/trabecular volume ratio % (9.9 ± 2.6 vs. 13.5 ± 2.8, p<0.0001 at the radius; 10.6 ± 2.4 vs. 13.1 ± 1.3, p < 0.0001 at the tibia); number of trabeculae 1/mm (1.69 ± 0.27 vs. 1.89 ± 0.26, p 0.009 at the radius; 1.53 ± 0.32 vs. 1.80 ± 0.26, p 0.002 at the tibia); and trabecular thickness mm (0.058 ± 0.010 vs. 0.071 ± 0.008, p < 0.0001 at the radius with no significant difference at the tibia). Cortical density was significantly lower in both regions (D comp mg/cm(3) 860 ± 57.2 vs. 893.9 ± 43, p 0.02; 902.7 ± 48.7 vs. 932.6 ± 32.6, p 0.01 in radius and tibia respectively). Although cortical thickness was lower in CD patients, it failed to show any significant inter-group difference (a-8% decay with p 0.11 in both bones). Patients with symptomatic CD (n = 22) had a greater bone microarchitectural deficit than those with subclinical CD. HR-pQCT was used to successfully identify significant deterioration in the microarchitecture of trabecular and cortical compartments of peripheral bones. Impairment was characterized by lower trabecular number and thickness-which increased trabecular network heterogeneity-and lower cortical density and thickness. In the prospective follow-up of this group of patients we expect to be able to assess whether bone microarchitecture recovers and to what extend after gluten-free diet. Copyright © 2015 Elsevier Inc. All rights reserved.

[Kirschner wire transfixation of unstable ankle fractures: indication, surgical technique and outcomes].

PubMed

Marvan, J; Džupa, V; Bartoška, R; Kachlík, D; Krbec, M; Báča, V

2015-01-01

PURPOSE OF THE STUDY The aim of the study was to assess treatment outcomes in patients undergoing K-wire transfixation of unstable ankle fractures and compare the results with those of patients in whom it was possible to perform primary one-stage osteosynthesis. MATERIAL AND METHODS Between 2009 and 2012, a total of 358 patients (191 women and 167 men) had surgery for unstable ankle fracture. At 1-year follow-up, their subjective feelings, objective findings and ankle radiographs were evaluated. The fractures were categorised according to the Weber classification. A patient group treated by one-stage osteosynthesis, a group with definitive transfixation and a group of patients in whom temporary transfixation was converted to definitive osteosynthesis were assessed and compared. RESULTS The group treated by one-stage osteosynthesis included 278 patients with an average age of 47 years; the group of 20 patients with definitive transfixation had an average age of 67 years, and the group of 60 patients who had temporary transfixation with subsequent conversion to internal osteosynthesis were 55 years on average. In the group with one-stage osteosynthesis, 223 (80%) ankle fractures on post-injury radiographs were associated with minor joint dislocations and 55 (20%) with major dislocations. On the other hand, the radiographs of the patients treated by temporary transfixation and delayed open reduction with internal fixation showed major dislocations in 38 (63%) and minor dislocations in the rest of the patients (37%); the difference between the two groups was statistically significant (p<0.001). Posterior malleolar fractures were most frequent in the group with temporary transfixation (60%) and least frequent in the group with primary osteosynthesis (44%); also this difference was statistically significant (p=0.032). At one-year follow-up, in the group with one-stage osteosynthesis, 220 patients (79%) had no radiographic signs of posttraumatic ankle osteoarthritis while, in the group with temporary transfixation, no radiographic evidence of ankle osteoarthritis was recorded in 25 (42%) patients. While tibiofibular synostosis was recorded in only few patients (9%) of the group with one-stage osteosynthesis, it showed a high occurrence in the group with temporary transfixation (35%). The patients with one-stage osteosynthesis (188/68%) had a higher proportion of excellent outcomes measured on the Olerund-Molander ankle scoring scale than the other two groups (temporary transfixation, 47%; definitive transfixation,10%); in both cases the difference was significant (p < 0.001 and p = 0.003, respectively). DISCUSSION In this study the morphological and clinical aspects of surgically treated ankle fractures were assessed. The patients with one-stage osteosynthesis were compared with those treated by temporary or definitive transfixation. The majority of patients undergoing temporary transfixation had a fractured posterior margin of the tibia and major ankle joint dislocation, which suggested serious injuries to bone and ligament structures. Generally, the use of only two K-wires inserted through the calcaneus and talus into the distal tibia is recommended. Patients with K-wire transfixation usually require a longer hospital stay because of the serious nature of their injuries. CONCLUSIONS The therapy of choice for unstable ankle fractures is one-stage osteosynthesis. Temporary transfixation is an effective method of primary management when an unstable fracture cannot be treated by definitive osteosynthesis at the early stage due to local or general health conditions of the patient. The temporary transfixation provides good alignment of the ankle joint necessary for successful healing of soft tissues. A higher occurrence of post-traumatic ankle osteoarthritis, ossification and distal tibiotalar synostosis found in the patients treated by temporary transfixation is more related to serious types of ankle fractures the patient had suffered than to the method itself. Key words: unstable ankle fracture, soft tissue condition, indications for transfixation, treatment outcome.

Distally based saphenous neurocutaneous perforator flap combined with vac therapy for soft tissue reconstruction and hardware salvage in the lower extremities.

PubMed

Wen, Gen; Wang, Chun-Yang; Chai, Yi-Min; Cheng, Liang; Chen, Ming; Yi-Min, L V

2013-11-01

The complex wound with the exposed hardware and infection is one of the common complications after the internal fixation of the tibia fracture. The salvage of hardware and reconstruction of soft tissue defect remain challenging. In this report, we presented our experience on the use of the distally based saphenous neurocutaneous perforator flap combined with vacuum-assisted closure (VAC) therapy for the coverage of the soft tissue defect and the exposed hardware in the lower extremity with fracture. Between January 2008 and July 2010, seven patients underwent the VAC therapy followed by transferring a reversed saphenous neurocutaneous perforator flap for reconstruction of the wound with exposed hardware around the distal tibia. The sizes of the flaps ranged from 6 × 3 cm to 15 × 6 cm. Six flaps survived completely. Partial necrosis occurred in one patient. There were no other complications of repair and donor sites. Bone healing was achieved in all patients. In conclusion, the reversed saphenous neurocutaneous perfortor flaps combined with the VAC therapy might be one of the options to cover the complex wound with exposed hardware in the lower extremities. © 2013 Wiley Periodicals, Inc.

Raman spectroscopy of bone metastasis

NASA Astrophysics Data System (ADS)

Esmonde-White, Karen A.; Sottnik, Joseph; Morris, Michael; Keller, Evan

2012-02-01

Raman spectroscopy of bone has been used to characterize chemical changes occurring in diseases such as osteoporosis, osteoarthritis and osteomyelitis. Metastasis of cancer into bone causes changes to bone quality that are similar to those observed in osteoporosis, such as decreased bone strength, but with an accelerated timeframe. In particular, osteolytic (bone degrading) lesions in bone metastasis have a marked effect on patient quality of life because of increased risk of fractures, pain, and hypercalcemia. We use Raman spectroscopy to examine bone from two different mouse models of osteolytic bone metastasis. Raman spectroscopy measures physicochemical information which cannot be obtained through standard biochemical and histological measurements. This study was reviewed and approved by the University of Michigan University Committee on the Care and Use of Animals. Two mouse models of prostate cancer bone metastasis, RM1 (n=3) and PC3-luc (n=4) were examined. Tibiae were injected with RM1 or PC3-luc cancer cells, while the contralateral tibiae received a placebo injection for use as controls. After 2 weeks of incubation, the mice were sacrificed and the tibiae were examined by Raman microspectroscopy (λ=785 nm). Spectroscopic markers corresponding to mineral stoichiometry, bone mineralization, and mineral crystallinity were compared in spectra from the cancerous and control tibiae. X-ray imaging of the tibia confirmed extensive osteolysis in the RM1 mice, with tumor invasion into adjoining soft tissue and moderate osteolysis in the PC3-luc mice. Raman spectroscopic markers indicate that osteolytic lesions are less mineralized than normal bone tissue, with an altered mineral stoichiometry and crystallinity.

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.

Characteristics on fractures of tibia and fibula in car impacts to pedestrians and bicyclists - influences of car bumper height and shape.

PubMed

Otte, D; Haasper, C

2007-01-01

This study deals with the analysis of lower leg fractures in pedestrians and bicyclists after collisions with passenger cars and examines to what extent the shape and location of the fractures in the lower leg changed, following alterations in the shape of bumpers. It can be assumed that that the bumpers changed in shape and effective impact height, not least due to the realization of the developments of vehicle safety tests as in the context of the European Union Directive 2003/102/EC on pedestrian protection. In addition, consumer protection tests, EuroNCAP, accomplished a change of the injury situation. All of these are mainly focused on pedestrian protection measurements but adopt the bicyclists also in their goal. For the study, traffic accidents from GIDAS (German in-Depth-Accident Study) were selected, which had been documented in the years 1995 to 2004 by scientific teams in Hannover and Dresden (Germany) and for which there is detailed information regarding injury patterns and collision speeds. The accident documentations can be regarded as representative and constitute a random sample with statistic weighing of the data. Altogether 143 cases of lower leg fractures (Tibia/ Fibula) with x-rays of pedestrians and 79 cases of bicyclists were differentiated according to new and old vehicles (year of manufacture before/after 1995). The bumper shapes were divided into classical types (protruding pronouncedly/ protruding integrated /integrated rounded). Besides the injuries to the lower leg, those to thighs and feet were also regarded, and the injury conditions involving the head and trunk were included in the kinematic analytics.

Injury pattern in lethal motorbikes-pedestrian collisions, in the area of Barcelona, Spain.

PubMed

Rebollo-Soria, M Carmen; Arregui-Dalmases, Carlos; Sánchez-Molina, David; Velázquez-Ameijide, Juan; Galtés, Ignasi

2016-10-01

There are several studies about M1 type vehicle-pedestrian collision injury pattern, and based on them, there has been several changes in automobiles for pedestrian protection. However, the lack of sufficient studies about injury pattern in motorbikes-pedestrian collisions leads to a lack of optimization design of these vehicles. The objective of this research is to study the injury pattern of pedestrians involved in collisions with motorized two-wheeled vehicles. A retrospective descriptive study of pedestrian's deaths after collisions with motorcycles in an urban area, like Barcelona was performed. The cases were collected from the Forensic Pathology Service database of the Institute of Legal Medicine of Catalonia. The selected cases were categorized as pedestrian-motorcycle collision, between January 1st, 2005 and December 31st, 2014. Data were collected from the autopsy, medical, and police report. The collected information was then analyzed using Microsoft Excel statistical functions. Traumatic Brain Injury is the main cause of death in pedestrian hit by motorized two-wheeled vehicles (62.85%). The most frequent injury was the subarachnoid hemorrhage, in 71.4% of cases, followed by cerebral contusions and skull base fractures (65.7%). By contrast, pelvic fractures and tibia fractures only appeared in 28.6%. The study characterizes the injury pattern of pedestrians involved in a collision with motorized two-wheeled vehicles in an urban area, like Barcelona, which has been found to be different from other vehicle-pedestrian collisions, with a higher incidence of brain injuries and minor frequency of lower extremities fractures in pelvis, tibia and fibula. Copyright © 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.

Distinct features of trampoline-related orthopedic injuries in children aged under 6 years.

PubMed

Choi, Eun Seok; Hong, Jin Heon; Sim, Jae Ang

2018-02-01

Concern has been growing about trampoline-related injuries among young children. Several published policy statements have repeatedly recommended that children younger than 6 years should not use trampolines. However, few studies have investigated the injuries caused by trampoline-related accidents among young children. This study aimed to identify the distinct features of trampoline-related orthopedic injuries in children younger than 6 years. We retrospectively reviewed the medical records of pediatric patients aged between 0 and 16 years who visited our regional emergency center due to trampoline-related orthopedic injuries between 2012 and 2015. Patients were divided into two groups: a preschool group (younger than 6 years) and a school group (older than 6 years). We compared the features of the injuries in the two groups. Among 208 patients, 108 (52%) were male and 100 (48%) were female. The mean age was 5.4 years. The preschool group accounted for 66%. There were no seasonal variations. Fractures were sustained in 96 patients (46%). The anatomical locations of injuries differed significantly between the two age groups. Proximal tibia fractures were more frequent in the preschool group than the school group (34% and 6%, respectively). Distal tibia fractures were more prevalent in the school group than the preschool group (44% vs. 13%, respectively). Surgical treatment was needed more frequently in the school group (p = 0.035, hazard ratio 2.52, 95% confidence interval: 1.03-6.17). Most of the injuries (82%) occurred at trampoline parks. The anatomical locations of trampoline-related orthopedic injuries differed significantly between age groups. Fractures were more common around the knee in younger children and the ankle in older children. Copyright © 2017 Elsevier Ltd. All rights reserved.

Extruded talus treated with reimplantation and primary tibiotalocalcaneal arthrodesis

PubMed Central

A’Court, J; Pillai, A

2017-01-01

Extruded talus is a rare serious result from a high-energy injury to a supinated and plantar flexed foot. Treatment remains controversial with a lack of congruent evidence for talar reimplantation. A 34-year-old woman was involved in a road traffic accident at 40 mph. Imaging revealed a left talus extruded anterolaterally with a talar neck fracture. Additional injuries included right acetabular fracture, transverse process fractures and rib fractures, which were treated conservatively. The talus was reimplanted and the talar neck fixed with a cortical screw. A hindfoot nail was used to fuse the calcaneus, talus and tibia. Follow-up at two years showed solid tibiotalocalcaneal fusion, with no evidence of avascular development, and the patient was fully weight bearing without pain. We believe this is the first published case of successful primary tibiotalocalcaneal fusion for extruded talus injuries. PMID:28349756

Bactericidal micron-thin sol-gel films prevent pin tract and periprosthetic infection.

PubMed

Qu, Haibo; Knabe, Christine; Burke, Megan; Radin, Shula; Garino, Jonathan; Schaer, Thomas; Ducheyne, Paul

2014-08-01

Orthopedic injuries constitute the majority of wounds sustained by U.S. soldiers in recent conflicts. The risk of infection is considerable with fracture fixation devices. In this pilot study, we examined the use of unique bactericidal micron-thin sol-gel films on fracture fixation devices and their ability to prevent and eradicate infections. External fixation was studied with micron-thin sol-gel coated percutaneous pins releasing triclosan and inserted medially into rabbit tibiae. A total of 11 rabbits received percutaneous pins that were either uncoated or sol-gel/triclosan coated. Internal fracture fixation was also studied using sol-gel coated intramedullary (IM) nails releasing vancomycin in the intramedullary tibiae. Six sheep received IM nails that were coated with a sol-gel film that either contained vancomycin or did not contain vancomycin. All animals were challenged with Staphylococcus aureus around the implant. Animals were euthanized at 1 month postoperative. Rabbits receiving triclosan/sol-gel coated percutaneous pins did not show signs of infection. Uncoated percutaneous pins had a significantly higher infection rate. In the sheep study, there were no radiographic signs of osteomyelitis with vancomycin/sol-gel coated IM nails, in contrast to the observations in the control cohort. Hence, the nanostructured sol-gel controlled release technology offers the promise of a reliable and continuous delivery system of bactericidals from orthopedic devices to prevent and treat infection. Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.

The role of internal fixation for long bone metastasis prior to impending fracture: an experimental model.

PubMed

Ibrahim, Mohammad; Terai, Hidetomi; Yamada, Kentaro; Suzuki, Akinobu; Toyoda, Hiromitsu; Nakamura, Hiroaki

2013-07-01

Patients with long bone metastasis have many therapeutic options, including surgery. However, the appropriate time for surgical intervention and the use of internal fixation prior to impending fracture remains controversial. The purpose of this study was to establish a long bone metastatic model with internal fixation, and to determine whether prophylactic internal fixation for long bone metastasis prior to impending fracture would affect bone destruction, tumor progression, and mortality. We implanted VX2 tumor cells into the tibiae of 45 rabbits divided equally into three groups: internal fixation, control, and sham groups. Rabbits were monitored by X-ray and computed tomography, and blood serum levels were examined every 2 weeks. Computed tomography data revealed significantly higher bone destruction in rabbit tibiae in the sham and control groups compared with those in the fixation group; there were volumetric bone losses of 0.2, 0.4, and 2.3% in the fixation, sham, and control groups, respectively, at 3 weeks, which increased to 1.2, 2.5, and 6.1% at 5 weeks. Rabbits in the fixation group showed significantly prolonged survival (64.5 ± 13.5 days) in comparison with rabbits in the sham group (50.3 ± 11.6 days) and control group (38.2 ± 4.9 days). Our results suggest that prophylactic internal fixation may hinder bone destruction and tumor progression, thus extending the survival period for patients with long bone metastasis.

Skeletal manifestations of hydatid disease in Serbia: demographic distribution, site involvement, radiological findings, and complications.

PubMed

Bracanovic, Djurdja; Djuric, Marija; Sopta, Jelena; Djonic, Danijela; Lujic, Nenad

2013-08-01

Although Serbia is recognized as an endemic country for echinococcosis, no information about precise incidence in humans has been available. The aim of this study was to investigate the skeletal manifestations of hydatid disease in Serbia. This retrospective study was conducted by reviewing the medical database of Institute for Pathology (Faculty of Medicine in Belgrade), a reference institution for bone pathology in Serbia. We reported a total of 41 patients with bone cystic echinococcosis (CE) during the study period. The mean age of 41 patients was 40.9±18.8 years. In 39% of patients, the fracture line was the only visible radiological sign, followed by cyst and tumefaction. The spine was the most commonly involved skeletal site (55.8%), followed by the femur (18.6%), pelvis (13.9%), humerus (7.0%), rib (2.3%), and tibia (2.3%). Pain was the symptom in 41.5% of patients, while some patients demonstrated complications such as paraplegia (22.0%), pathologic fracture (48.8%), and scoliosis (9.8%). The pathological fracture most frequently affected the spine (75.0%) followed by the femur (20.0%) and tibia (5.0%). However, 19.5% of patients didn't develop any complication or symptom. In this study, we showed that bone CE is not uncommon in Serbian population. As reported in the literature, therapy of bone CE is controversial and its results are poor. In order to improve the therapy outcome, early diagnosis, before symptoms and complications occur, can be contributive.

Skeletal Manifestations of Hydatid Disease in Serbia: Demographic Distribution, Site Involvement, Radiological Findings, and Complications

PubMed Central

Bracanovic, Djurdja; Sopta, Jelena; Djonic, Danijela; Lujic, Nenad

2013-01-01

Although Serbia is recognized as an endemic country for echinococcosis, no information about precise incidence in humans has been available. The aim of this study was to investigate the skeletal manifestations of hydatid disease in Serbia. This retrospective study was conducted by reviewing the medical database of Institute for Pathology (Faculty of Medicine in Belgrade), a reference institution for bone pathology in Serbia. We reported a total of 41 patients with bone cystic echinococcosis (CE) during the study period. The mean age of 41 patients was 40.9±18.8 years. In 39% of patients, the fracture line was the only visible radiological sign, followed by cyst and tumefaction. The spine was the most commonly involved skeletal site (55.8%), followed by the femur (18.6%), pelvis (13.9%), humerus (7.0%), rib (2.3%), and tibia (2.3%). Pain was the symptom in 41.5% of patients, while some patients demonstrated complications such as paraplegia (22.0%), pathologic fracture (48.8%), and scoliosis (9.8%). The pathological fracture most frequently affected the spine (75.0%) followed by the femur (20.0%) and tibia (5.0%). However, 19.5% of patients didn't develop any complication or symptom. In this study, we showed that bone CE is not uncommon in Serbian population. As reported in the literature, therapy of bone CE is controversial and its results are poor. In order to improve the therapy outcome, early diagnosis, before symptoms and complications occur, can be contributive. PMID:24039289

The Clinical and Economic Impact of Generic Locking Plate Utilization at a Level II Trauma Center.

PubMed

Mcphillamy, Austin; Gurnea, Taylor P; Moody, Alastair E; Kurnik, Christopher G; Lu, Minggen

2016-12-01

In today's climate of cost containment and fiscal responsibility, generic implant alternatives represent an interesting area of untapped resources. As patents have expired on many commonly used trauma implants, generic alternatives have recently become available from a variety of sources. The purpose of this study was to examine the clinical and economic impact of a cost containment program using high quality, generic orthopaedic locking plates. The implants available for study were anatomically precontoured plates for the clavicle, proximal humerus, distal radius, proximal tibia, distal tibia, and distal fibula. Retrospective review. Level II Trauma center. 828 adult patients with operatively managed clavicle, proximal humerus, distal radius, proximal tibia, tibial pilon, and ankle fractures. Operative treatment with conventional or generic implants. The 414 patients treated with generic implants were compared with 414 patients treated with conventional implants. There were no significant differences in age, sex, presence of diabetes, smoking history or fracture type between the generic and conventional groups. No difference in operative time, estimated blood loss or intraoperative complication rate was observed. No increase in postoperative infection rate, hardware failure, hardware loosening, malunion, nonunion or need for hardware removal was noted. Overall, our hospital realized a 56% reduction in implant costs, an average savings of $1197 per case, and a total savings of $458,080 for the study period. Use of generic orthopaedic implants has been successful at our institution, providing equivalent clinical outcomes while significantly reducing implant expenditures. Based on our data, the use of generic implants has the potential to markedly reduce operative costs as long as quality products are used. Therapeutic Level III.

Complex tibial fractures are associated with lower social classes and predict early exit from employment and worse patient-reported QOL: a prospective observational study of 46 complex tibial fractures treated with a ring fixator.

PubMed

Elsoe, Rasmus; Larsen, Peter; Petruskevicius, Juozas; Kold, Søren

2018-04-01

The long-term outcomes following complex fractures of the tibia are reported to carry a risk of knee pain, malalignment, articular injury and post-traumatic osteoarthritis. The main objective of this study was to account for the patient-reported quality of life (QOL) 12 months after ring fixator removal in patients with a complex tibial fracture. Secondary objectives included a review of the socio-economic characteristics of the patient group and the rate of return to work in the study period. A prospective follow-up study was conducted of 60 patients with complex fractures of the tibia treated with ring external fixation. Patient-reported outcomes, radiological outcomes and socio-economic status including employment status of the patients were obtained 12 months after frame removal. Forty-six patients completed the assessment 12 months after frame removal (77%). The mean age of the patient at the time of fracture was 54.6 years (range 31-86). There were 19 males and 27 females. At 12 months after frame removal, the mean EQ5D-5L index was 0.66 (CI 0.60-0.72). The mean EQ5D-5L VAS was 69 (CI 61-76). When this was compared to the established reference population from Denmark, the study population showed a significantly worse EQ5D-5L index. The majority of patients (87%) were in the lower social classes suggesting a higher degree of social deprivation in the study population. Twenty-seven per cent of patients who were employed prior to injury had returned to employment at approximately 19 months following fracture. The onset of post-traumatic osteoarthritis was present in the knee joint in 29% of patients following a proximal intra-articular fracture, whereas osteoarthritis was present at the ankle joint in 35% of patients following a distal intra-articular fracture 12 months after frame removal. This study indicates that at 12 months after frame removal there are poorer patient-reported QOL as when compared to reference populations. Furthermore, this study suggests that complex tibial fractures are associated with lower social classes and that only 27% of patients in this sample, who prior to injury were employed, had returned to employment at approximately 19 months after the injury.

Brain neuroplastic changes accompany anxiety and memory deficits in a model of complex regional pain syndrome.

PubMed

Tajerian, Maral; Leu, David; Zou, Yani; Sahbaie, Peyman; Li, Wenwu; Khan, Hamda; Hsu, Vivian; Kingery, Wade; Huang, Ting Ting; Becerra, Lino; Clark, J David

2014-10-01

Complex regional pain syndrome (CRPS) is a painful condition with approximately 50,000 annual new cases in the United States. It is a major cause of work-related disability, chronic pain after limb fractures, and persistent pain after extremity surgery. Additionally, CRPS patients often experience cognitive changes, anxiety, and depression. The supraspinal mechanisms linked to these CRPS-related comorbidities remain poorly understood. The authors used a previously characterized mouse model of tibia fracture/cast immobilization showing the principal stigmata of CRPS (n = 8 to 20 per group) observed in humans. The central hypothesis was that fracture/cast mice manifest changes in measures of thigmotaxis (indicative of anxiety) and working memory reflected in neuroplastic changes in amygdala, perirhinal cortex, and hippocampus. The authors demonstrate that nociceptive sensitization in these mice is accompanied by altered thigmotactic behaviors in the zero maze but not open field assay, and working memory dysfunction in novel object recognition and social memory but not in novel location recognition. Furthermore, the authors found evidence of structural changes and synaptic plasticity including changes in dendritic architecture and decreased levels of synaptophysin and brain-derived neurotrophic factor in specific brain regions. The study findings provide novel observations regarding behavioral changes and brain plasticity in a mouse model of CRPS. In addition to elucidating some of the supraspinal correlates of the syndrome, this work supports the potential use of therapeutic interventions that not only directly target sensory input and other peripheral mechanisms, but also attempt to ameliorate the broader pain experience by modifying its associated cognitive and emotional comorbidities.

Porosity, Mineralization, Tissue Type and Morphology Interactions at the Human Tibial Cortex

NASA Astrophysics Data System (ADS)

Hampson, Naomi A.

Prior research has shown a relationship between tibia robustness (ratio of cross-sectional area to bone length) and stress fracture risk, with less robust bones having a higher risk, which may indicate a compensatory increase in elastic modulus to increase bending strength. Previous studies of human tibiae have shown higher ash content in slender bones. In this study, the relationships between variations in volumetric porosity, ash content, tissue mineral density, secondary bone tissue, and cross sectional geometry, were investigated in order to better understand the tissue level adaptations that may occur in the establishment of cross-sectional properties. In this research, significant differences were found between porosity, ash content, and tissue type around the cortex between robust and slender bones, suggesting that there was a level of co-adaption occurring. Variation in porosity correlated with robustness, and explained large parts of the variation in tissue mineral density. The nonlinear relationship between porosity and ash content may support that slender bones compensate for poor geometry by increasing ash content through reduced remodeling, while robust individuals increase porosity to decrease mass, but only to a point. These results suggest that tissue level organization plays a compensatory role in the establishment of adult bone mass, and may contribute to differences in bone aging between different bone phenotypes. The results suggest that slender individuals have significantly less remodeled bone, however the proportion of remodeled bone was not uniform around the tibia. In the complex results of the study of 38% vs. 66% sites the distal site was subject to higher strains than the 66% site, indicating both local and global regulators may be affecting overall remodeling rates and need to be teased apart in future studies. This research has broad clinical implications on the diagnosis and treatment of fragility fractures. The relationships that were found between local variables and global geometry indicate that there was a fundamental difference between robust and slender bones, which affect the overall properties of the bone. This could allow for simple testing of bone geometry to predict an individual's fracture risk.

Exercise-Induced Changes in the Cortical Bone of Growing Mice Are Bone and Gender Specific

PubMed Central

Wallace, Joseph M.; Rajachar, Rupak M.; Allen, Matthew R.; Bloomfield, Susan A.; Robey, Pamela G.; Young, Marian F.; Kohn, David H.

2009-01-01

Fracture risk and mechanical competence of bone are functions of bone mass and tissue quality, which in turn are dependent on the bone’s mechanical environment. Male mice have a greater response to non weight-bearing exercise than females, resulting in larger, stronger bones compared with control animals. The aim of this study was to test the hypothesis that short-term weight-bearing running during growth (21 days starting at 8 weeks of age; 30 minutes/day; 12 meters/minute; 5° incline; 7 days/week) would similarly have a greater impact on cross sectional geometry and mechanical competence in the femora and tibiae of male mice versus females. Based on the orientation of the legs during running and the proximity of the tibia to the point of impact, this response was hypothesized to be greatest in the tibia. Exercise-related changes relative to controls were assayed by four-point bending tests, while volumetric bone mineral density and cross-sectional geometry were also assessed. The response to running was bone and gender-specific, with male tibiae demonstrating the greatest effects. In male tibiae, periosteal perimeter, endocortical perimeter, cortical area, medial-lateral width and bending moment of inertia increased versus control mice suggesting that while growth is occurring in these mice between 8 and 11 weeks of age, exercise accelerated this growth resulting in a greater increase in bone tissue over the 3 weeks of the study. Exercise increased tissue-level strain-to-failure and structural post-yield deformation in the male tibiae, but these post-yield benefits came at the expense of decreased yield deformation, structural and tissue-level yield strength and tissue-level ultimate strength. These results suggest that exercise superimposed upon growth accelerated growth-related increases in tibial cross-sectional dimensions. Exercise also influenced the quality of this forming bone, significantly impacting structural and tissue-level mechanical properties. PMID:17240210

Variation in tibial functionality and fracture susceptibility among healthy, young adults arises from the acquisition of biologically distinct sets of traits.

PubMed

Jepsen, Karl J; Evans, Rachel; Negus, Charles H; Gagnier, Joel J; Centi, Amanda; Erlich, Tomer; Hadid, Amir; Yanovich, Ran; Moran, Daniel S

2013-06-01

Physiological systems like bone respond to many genetic and environmental factors by adjusting traits in a highly coordinated, compensatory manner to establish organ-level function. To be mechanically functional, a bone should be sufficiently stiff and strong to support physiological loads. Factors impairing this process are expected to compromise strength and increase fracture risk. We tested the hypotheses that individuals with reduced stiffness relative to body size will show an increased risk of fracturing and that reduced strength arises from the acquisition of biologically distinct sets of traits (ie, different combinations of morphological and tissue-level mechanical properties). We assessed tibial functionality retrospectively for 336 young adult women and men engaged in military training, and calculated robustness (total area/bone length), cortical area (Ct.Ar), and tissue-mineral density (TMD). These three traits explained 69% to 72% of the variation in tibial stiffness (p < 0.0001). Having reduced stiffness relative to body size (body weight × bone length) was associated with odds ratios of 1.5 (95% confidence interval [CI], 0.5-4.3) and 7.0 (95% CI, 2.0-25.1) for women and men, respectively, for developing a stress fracture based on radiography and scintigraphy. K-means cluster analysis was used to segregate men and women into subgroups based on robustness, Ct.Ar, and TMD adjusted for body size. Stiffness varied 37% to 42% among the clusters (p < 0.0001, ANOVA). For men, 78% of stress fracture cases segregated to three clusters (p < 0.03, chi-square). Clusters showing reduced function exhibited either slender tibias with the expected Ct.Ar and TMD relative to body size and robustness (ie, well-adapted bones) or robust tibias with reduced residuals for Ct.Ar or TMD relative to body size and robustness (ie, poorly adapted bones). Thus, we show there are multiple biomechanical and thus biological pathways leading to reduced function and increased fracture risk. Our results have important implications for developing personalized preventative diagnostics and treatments. Copyright © 2013 American Society for Bone and Mineral Research.

Periarticular Fractures of the Knee in Polytrauma Patients

PubMed Central

Bertrand, M.L.; Andrés-Cano, P.; Pascual-López, F.J.

2015-01-01

Periarticular fractures around the knee are a challenge for the orthopaedic surgeon. When these fractures are presented in the context of a multiple trauma patient, they are even more difficult to manage because the treatment approach depends not only on the fracture itself, but also on the patient’s general condition. These fractures, caused by high-energy trauma, present complex fracture patterns with severe comminution and major loss of articular congruity, and are often associated with vascular and nerve complications, particularly in the proximal tibia, due to its anatomical features with poor myocutaneous coverage. They are almost always accompanied by soft tissue injury. The management of polytrauma patients requires a multidisciplinary team and accurate systemic stabilization of the patient before undertaking orthopaedic treatment. These fractures are usually addressed sequentially, either according to the general condition of the patient or to the local characteristics of the lesions. In recent decades, various fixation methods have been proposed, but there is still no consensus as to the ideal method for stabilizing these fractures. In this paper, we describe the general characteristics of these fractures, the stabilization methods traditionally used and those that have been developed in recent years, and discuss the treatment sequences proposed as most suitable for the management of these injuries. PMID:26312118

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.

Effect of Electromagnetic Wave on Bone Healing in Fixed and Unfixed Conditions.

PubMed

Onger, Mehmet Emin; Göçer, Hasan; Çirakli, Alper; Büyükceran, Ismail; Kiliç, Mesut; Kaplan, Süleyman

2016-09-01

Mobile phones have come into daily life and are now one of the most frequently used devices for communication. The aim of this study was to evaluate possible effect of electromagnetic wave (EMW) with and without fixation material on bone healing.Forty male rats were exposed to fracture on tibia bone and were randomly divided into 4 groups as E(+)K(+), E(+)K(-), E(-)K(+), and E(-)K(-) where E(+) means EMW exposure and K(+) means Kirschner wire fixation. At the end of study tibia samples were taken from all the groups for the quantitative evaluation of regeneration.Significant difference was found between Group E(+)K(+) and E(-)K(+) in terms of both new bone and capillary volume.Electromagnetic wave may be harmful for bone healing with fixation whereas it has no same effect on bone regeneration without fixation.

A surgical protocol of ankle arthrodesis with combined Ilizarov's distraction-compression osteogenesis and locked nailing for osteomyelitis around the ankle joint.

PubMed

Chen, Chuan-Mu; Su, Alvin W; Chiu, Fang-Yao; Chen, Tain-Hsiung

2010-09-01

Managing refractory osteomyelitis around the ankle joint has been challenging. Destruction of both the ankle and the subtalar joints was common in cases of open fracture. For those who already had multiple surgeries, it would be tough to salvage the limb. Our goal was to set up a staged surgical protocol aiming in treating the aforementioned clinical issue. Twelve male patients underwent our protocol since year 2000. All patients presented refractory osteomyelitis, ankle and subtalar joint destruction, and poor soft tissue condition. All cases had internal fixation for open fractures followed by multiple debridement surgery before. The mean age was 50.8 years (range, 37-71 years), and the median follow-up time was 61 months (range, 48-96 months). The surgical protocol consisted of radical debridement, distraction osteogenesis for segmental bone transport, and tibia lengthening to avoid leg length discrepancy followed by intramedullary nailing for tibio-talo-calcaneal arthrodesis. The external fixation period averaged 24.7 weeks (range, 12-36 weeks). The mean duration to solid union of the arthrodesis and the bridging callus was 18.3 weeks (range, 16-20 weeks). Mild surgical site infection occurred in four cases but all subsided after removal of the nail and oral antibiotics use. At latest follow-up, all patients were infection free and could walk with plantigrade feet. The mean American Orthopaedic Foot and Ankle Society hindfoot score rising from 21.5 points (range 20-24 points) preoperatively to 65.5 points (range, 60-72). This study has shown our staged surgical protocol may be effective in solving complicated osteomyelitis around the ankle, although salvaging the limb with successful ankle arthrodesis and minimized limb length inequality, yet improving the patients' ambulation level.

Open Fractures of the Hand: Review of Pathogenesis and Introduction of a New Classification System.

PubMed

Tulipan, Jacob E; Ilyas, Asif M

2018-02-01

Open fractures of the hand are a common and varied group of injuries. Although at increased risk for infection, open fractures of the hand are more resistant to infection than other open fractures. Numerous unique factors in the hand may play a role in the altered risk of postinjury infection. Current systems for the classification of open fractures fail to address the unique qualities of the hand. This article proposes a novel classification system for open fractures of the hand, taking into account the factors unique to the hand that affect its risk for developing infection after an open fracture. Copyright © 2017. Published by Elsevier Inc.

Evaluating Stiffness of Fibreglass and Thermoplastic Splint Materials and Inter-fragmentary Motion in a Canine Tibial Fracture Model.

PubMed

Wagoner, Amanda L; Allen, Matthew J; Zindl, Claudia; Litsky, Alan; Orsher, Robert; Ben-Amotz, Ron

2018-04-16

 Various materials are used to construct splints for mid-diaphyseal tibial fracture stabilization. The objective of this study was to compare construct stiffness and inter-fragmentary bone motion when fibreglass (FG) or thermoplastic (TP) splints are applied to either the lateral or cranial aspect of the tibia in a mid-diaphyseal fracture model.  A coaptation bandage was applied to eight cadaveric canine pelvic limbs, with a custom-formed splint made of either FG or TP material applied to either the lateral or cranial aspect of the osteotomized tibia. Four-point bending tests were performed to evaluate construct stiffness and inter-fragmentary motion in both frontal and sagittal planes.  For a given material, FG or TP, construct stiffness was not affected by splint location. Construct stiffness was significantly greater with cranial FG splints than with cranial TP splints ( p  < 0.05), but this difference was not significant when comparing splints applied laterally ( p  = 0.15). Inter-fragmentary motions in the sagittal and frontal planes were similar across splint types for cranial splints, but for lateral splints there was a 64% reduction in frontal plane motion when FG was used as the splint material ( p  = 0.03).  FG produces a stiffer construct, but the difference is not reflected in a reduction in inter-fragmentary motion. For lateral splints, FG splints are associated with reduced inter-fragmentary motion as compared with TP and may therefore have slight superiority for this application. Schattauer GmbH Stuttgart.

Multi-Elemental Profiling of Tibial and Maxillary Trabecular Bone in Ovariectomised Rats

PubMed Central

Han, Pingping; Lu, Shifeier; Zhou, Yinghong; Moromizato, Karine; Du, Zhibin; Friis, Thor; Xiao, Yin

2016-01-01

Atomic minerals are the smallest components of bone and the content of Ca, being the most abundant mineral in bone, correlates strongly with the risk of osteoporosis. Postmenopausal women have a far greater risk of suffering from OP due to low Ca concentrations in their bones and this is associated with low bone mass and higher bone fracture rates. However, bone strength is determined not only by Ca level, but also a number of metallic and non-metallic elements in bone. Thus, in this study, the difference of metallic and non-metallic elements in ovariectomy-induced osteoporosis tibial and maxillary trabecular bone was investigated in comparison with sham operated normal bone by laser ablation inductively-coupled plasma mass spectrometry using a rat model. The results demonstrated that the average concentrations of 25Mg, 28Si, 39K, 47Ti, 56Fe, 59Co, 77Se, 88Sr, 137Ba, and 208Pb were generally higher in tibia than those in maxilla. Compared with the sham group, Ovariectomy induced more significant changes of these elements in tibia than maxilla, indicating tibial trabecular bones are more sensitive to changes of circulating estrogen. In addition, the concentrations of 28Si, 77Se, 208Pb, and Ca/P ratios were higher in tibia and maxilla in ovariectomised rats than those in normal bone at all time-points. The present study indicates that ovariectomy could significantly impact the element distribution and concentrations between tibia and maxilla. PMID:27338361

Biomechanical study of prophylactic internal fixation of the radial osteocutaneous donor site using the sheep tibia model.

PubMed

Avery, C M E; Best, A; Patterson, P; Rolton, J; Ponter, A R S

2007-09-01

This study investigated the strengthening effect of different types of plate and position after osteotomy of the sheep tibia, which is a model for the radial osteocutaneous donor site. Fifty matched pairs of adult sheep tibias were tested in torsion and four-point bending. Firstly, the weakening effect of an osteotomy was compared with the intact bone. Then pairs of bones with an osteotomy were compared with and without reinforcement with different types of 3.5mm plate. The plate was placed in either the anterior (over the defect) or posterior (on the intact cortex) position. In torsion the mean strength of the intact bone was 45% greater than after osteotomy (P=0.02). The reinforced bone was on average 61% stronger than the unreinforced bone (P<0.001). In bending the mean strength of the intact bone was 188% greater than after osteotomy (P=0.02). The reinforced bone was on average 184% stronger then the unreinforced bone (P<0.001). The tibia was able to withstand much greater loads in bending. The dynamic compression plate was the strongest reinforcement in both torsion and bending. The position of the plate did not alter the strengthening effect in torsion but the posterior position resisted greater bending loads (P=0.01). This may not be relevant in clinical practice as the radius is likely to fracture first as a result of lower torsional forces.

[Balloon osteoplasty as reduction technique in the treatment of tibial head fractures].

PubMed

Freude, T; Kraus, T M; Sandmann, G H

2015-10-01

Tibial plateau fractures requiring surgery are severe injuries of the lower extremities. Depending on the fracture pattern, the age of the patient, the range of activity and the bone quality there is a broad variation in adequate treatment.  This article reports on an innovative treatment concept to address split depression fractures (Schatzker type II) and depression fractures (Schatzker type III) of the tibial head using the balloon osteoplasty technique for fracture reduction. Using the balloon technique achieves a precise and safe fracture reduction. This internal osteoplasty combines a minimal invasive percutaneous approach with a gently rise of the depressed area and the associated protection of the stratum regenerativum below the articular cartilage surface. This article lights up the surgical procedure using the balloon technique in tibia depression fractures. Using the balloon technique a precise and safe fracture reduction can be achieved. This internal osteoplasty combines a minimally invasive percutaneous approach with a gentle raising of the depressed area and the associated protection of the regenerative layer below the articular cartilage surface. Fracture reduction by use of a tamper results in high peak forces over small areas, whereas by using the balloon the forces are distributed over a larger area causing less secondary stress to the cartilage tissue. This less invasive approach might help to achieve a better long-term outcome with decreased secondary osteoarthritis due to the precise and chondroprotective reduction technique.

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.

Influence of 1800 MHz GSM-like electromagnetic radiation exposure on fracture healing.

PubMed

Aslan, Ahmet; Kırdemır, Vecihi; Kocak, Ahmet; Atay, Tolga; Baydar, Metin Lütfi; Özerdemoglu, Remzi Arif; Aydogan, Nevres Hürriyet

2014-02-01

In this study, we aimed to investigate whether 1800 MHz frequency electromagnetic radiation (EMR) has an effect on bone healing. A total of 30 Wistar albino rats were divided into two equal groups. Fractures were created in the right tibias of all rats; next, intramedullary fixations with K-wire were performed. A control group (Group I) was kept under the same experimental conditions except without EMR exposure. Rats in Group II were exposed to an 1800 MHz frequency EMR for 30 min a day for 5 days a week. Next, radiological, mechanical, and histological examinations were performed to evaluate tibial fracture healing. Radiological, histological and mechanical scores were not significantly different between groups (respectively, p = 0.114, p = 0.184 and p = 0.083), and all of these scores were lower than those of the controls. EMR at 1800 MHz frequency emitted from cellular phones has no effect on bone fracture healing. Copyright © 2014 IMSS. Published by Elsevier Inc. All rights reserved.

Influence of electric field exposure on bone growth and fracture repair in rats

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

McClanahan, B.J.; Phillips, R.D.

1983-01-01

Rats were exposed to a 60-Hz electric field at an unperturbed field strength of 100 kV/m to determine its affect on bone growth and fracture repair. Exposure of immature male and female rats for 20 h/day for 30 days did not alter growth rate, cortical bone area, or medullary cavity area of the tibia. In another experiment, midfibular osteotomies were performed and the juvenile rats were exposed at 100 kV/m for 14 days. Evaluation by resistance to deformation and breaking strength indicated that fracture repair was not as advanced in the exposed animals as in the sham-exposed animals. In anothermore » experiment measurements of resistance to deformation were made in adult rats at 16, 20 and 26 days after osteotmy. Fracture repair was slower in exposed compared to control animals at day 20 and, to a lesser extent, at day 16, but not at day 26. 28 references, 6 tables.« less

[A boy with a painful knee: bone tumour or stress fracture?].

PubMed

Robben, Bart J; Jutte, Paul C

2012-01-01

The symptoms of a stress fracture are almost identical to those of most bone tumours. Even with the use of various imaging techniques, it can be difficult to establish the correct diagnosis. Although a primary bone tumour requires early treatment to improve its prognosis, the discriminative factor in the diagnosis of a stress fracture is its clinical development over time. A 10-year-old boy was referred to our outpatient clinic on the suspicion of a primary bone tumour in his right tibia. A case was once described in this journal in which a stress fracture had eventually led to an amputation. The suspicion of primary bone tumour often marks the start of a long and intense diagnostic course. A stress fracture is the major diagnostic pitfall when there is a suspicion of such a tumour. If doubts persist after a diagnostic work-up by imaging, consultation with the Bone Tumour Committee is indicated. The patient can also be quickly referred to a centre specialised in treating bone tumours, as was the case in this article.

Fractures and Osteomalacia in a Patient Treated With Frequent Home Hemodialysis.

PubMed

Hanudel, Mark R; Froch, Larry; Gales, Barbara; Jüppner, Harald; Salusky, Isidro B

2017-09-01

Bone deformities and fractures are common consequences of renal osteodystrophy in the dialysis population. Persistent hypophosphatemia may be observed with more frequent home hemodialysis regimens, but the specific effects on the skeleton are unknown. We present a patient with end-stage renal disease treated with frequent home hemodialysis who developed severe bone pain and multiple fractures, including a hip fracture and a tibia-fibula fracture complicated by nonunion, rendering her nonambulatory and wheelchair bound for more than a year. A bone biopsy revealed severe osteomalacia, likely secondary to chronic hypophosphatemia and hypocalcemia. Treatment changes included the addition of phosphate to the dialysate, a higher dialysate calcium concentration, and increased calcitriol dose. Several months later, the patient no longer required a wheelchair and was able to ambulate without pain. Repeat bone biopsy revealed marked improvements in bone mineralization and turnover parameters. Also, with increased dialysate phosphate and calcium concentrations, as well as increased calcitriol, circulating fibroblast growth factor 23 levels increased. Copyright © 2017 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

Long-term results of various therapy concepts in severe pilon fractures.

PubMed

Koulouvaris, Panagiotis; Stafylas, Kosmas; Mitsionis, Gregory; Vekris, Marios; Mavrodontidis, Alexandros; Xenakis, Theodore

2007-07-01

Intra-articular fractures of the tibia plafond are among the most challenging of orthopaedic problems. This is a retrospective case-control study of surgically treated pilon fractures which was undertaken to compare the internal fixation with the two external fixation methods. This is a case-control study of 55 patients with 55 pilon fractures. There were 36 type C and 19 type B. Of these fractures, 24 were open and 31 closed. Three surgical protocols were used. In 20 patients, Group A, a half pin external fixator with ankle spanning was performed. The mean age of patients was 42.0 years (22.0-74.0), SD 14.1 and the mean follow-up was 77.7 months (38.0-132.0), SD 25.4. In 22 patients, Group B, a single ankle sparring ring hybrid external fixator under a small arthrotomy was performed. The mean age of patients was 48.4 years (28.0-76.0), SD 12.4 and mean follow-up was 67.9 months (36.0-132.0), SD 27.8. In 13 patients, Group C, a two-staged internal fixation was performed. The mean age was 45.6 years (30.0-66.0), SD 9.7 and the mean follow-up was 78.6 months (55.0-132.0), SD 25.4. We addressed the dissimilarity of the type of fracture in each group performing supplementary stratified analyses within each fracture type group. Group A had union in 6.9 months, group B in 5.6 months and group C in 5.1 months; P = 0.009. Six patients (Group A), two (Group B), and one (Group C) had limitation of ankle motion; P = 0.47. One patient from group C developed infection and the plate was removed. Four patients (Group A), one (Group B), and one (Group C) have developed posttraumatic arthritis (loss of joint space and pain); P = 0.25. Seven patients from Group A have reduced their activities; P = 0.004. In stratified statistical analysis by type of fracture, the associations noted for both fracture groups combined were also noted separately within each fracture group. In this long term follow-up study, the two-staged internal fixation and the hybrid fixation with small arthrotomy were equally efficacious in achieving bone union. Patients in external fixation with the ankle spanning had a significantly higher rate of delayed union. Also more patients in this group have reduced their activities.

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF).

PubMed

Audigé, Laurent; Slongo, Theddy; Lutz, Nicolas; Blumenthal, Andrea; Joeris, Alexander

2017-04-01

Background and purpose - The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF) describes the localization and morphology of fractures, and considers severity in 2 categories: (1) simple, and (2) multifragmentary. We evaluated simple and multifragmentary fractures in a large consecutive cohort of children diagnosed with long bone fractures in Switzerland. Patients and methods - Children and adolescents treated for fractures between 2009 and 2011 at 2 tertiary pediatric surgery hospitals were retrospectively included. Fractures were classified according to the AO PCCF. Severity classes were described according to fracture location, patient age and sex, BMI, and cause of trauma. Results - Of all trauma events, 3% (84 of 2,730) were diagnosed with a multifragmentary fracture. This proportion was age-related: 2% of multifragmentary fractures occurred in school-children and 7% occurred in adolescents. In patients diagnosed with a single fracture only, the highest percentage of multifragmentation occurred in the femur (12%, 15 of 123). In fractured paired radius/ulna bones, multifragmentation occurred in 2% (11 of 687); in fractured paired tibia/fibula bones, it occurred in 21% (24 of 115), particularly in schoolchildren (5 of 18) and adolescents (16 of 40). In a multivariable regression model, age, cause of injury, and bone were found to be relevant prognostic factors of multifragmentation (odds ratio (OR) > 2). Interpretation - Overall, multifragmentation in long bone fractures in children was rare and was mostly observed in adolescents. The femur was mostly affected in single fractures and the lower leg was mostly affected in paired-bone fractures. The clinical relevance of multifragmentation regarding growth and long-term functional recovery remains to be determined.

Risk Factors for Open Malleolar Fractures: An Analysis of the National Trauma Data Bank (2007 to 2011).

PubMed

Shibuya, Naohiro; Liu, George T; Davis, Matthew L; Grossman, Jordan P; Jupiter, Daniel C

2016-01-01

A limited number of studies have described the epidemiology of open fractures, and the epidemiology of open ankle fractures is not an exception. Therefore, the risk factors associated with open ankle fractures have not been extensively evaluated. The frequencies and proportions of open ankle fractures among all the recorded malleolar fractures in the US National Trauma Data Bank data set from January 2007 to December 2011 were analyzed. Clinically relevant variables captured in the data set were also used to evaluate the risk factors associated with open ankle fractures, adjusting for other covariates. The entire cohort was further subdivided into "lower" and "higher" energy trauma groups and the same analysis performed for each group separately. We found that a body mass index of >40 kg/m(2) and farm location were risk factors for open ankle fractures and impaired sensorium was protective against open ankle fractures. In the "lower energy" group, male gender, alcohol use, peripheral vascular disease, other injuries, and injury occurring at a farm location were risk factors for open fractures. In the "higher energy" group, female gender, work-related injury, and injury at a farm or industry location demonstrated statistically significantly associations with open fractures. Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.

Nontraumatic femur fracture in an oligomenorrheic athlete.

PubMed

Dugowson, C E; Drinkwater, B L; Clark, J M

1991-12-01

Exercise-associated amenorrhea is the cessation of menses in a woman following onset of training or an increase in training intensity. Its physiologic basis is characterized by consistently low levels of gonadotropin and ovarian hormones, but the underlying cause of this phenomenon is unknown. Although osteopenia has been described in amenorrheic women athletes, it has been primarily a laboratory diagnosis. Several recent studies have described a significantly lower bone mineral density (BMD) in the lumbar spine of amenorrheic athletes. Marcus et al. also reported an increased number of metatarsal and tibial stress fractures in a group of amenorrheic women. We report here the first case of a nontraumatic femur fracture in an amenorrheic athlete. A 32-yr-old white female, with four prior fibular stress fractures, suffered a left femoral shaft fracture during the 13th mile of a half-marathon. The fracture was successfully internally fixed. Biochemical studies showed no metabolic abnormality. Bone mineral density of the lumbar spine, femoral neck, tibia, and fibula were below the mean for both eumenorrheic and amenorrheic female athletes. Exercise-associated amenorrhea is a medical problem that may have serious implications for both competitive and high-intensity recreational female athletes.

Growth Kinematics of Opening-Mode Fractures

NASA Astrophysics Data System (ADS)

Eichhubl, P.; Alzayer, Y.; Laubach, S.; Fall, A.

2014-12-01

Fracture aperture is a primary control on flow in fractured reservoirs of low matrix permeability including unconventional oil and gas reservoirs and most geothermal systems. Guided by principles of linear elastic fracture mechanics, fracture aperture is generally assumed to be a linear function of fracture length and elastic material properties. Natural opening-mode fractures with significant preserved aperture are observed in core and outcrop indicative of fracture opening strain accommodated by permanent solution-precipitation creep. Fracture opening may thus be decoupled from length growth if the material effectively weakens after initial elastic fracture growth by either non-elastic deformation processes or changes in elastic properties. To investigate the kinematics of fracture length and aperture growth, we reconstructed the opening history of three opening-mode fractures that are bridged by crack-seal quartz cement in Travis Peak Sandstone of the SFOT-1 well, East Texas. Similar crack-seal cement bridges had been interpreted to form by repeated incremental fracture opening and subsequent precipitation of quartz cement. We imaged crack-seal cement textures for bridges sampled at varying distance from the tips using scanning electron microscope cathodoluminescence, and determined the number and thickness of crack-seal cement increments as a function of position along the fracture length and height. Observed trends in increment number and thickness are consistent with an initial stage of fast fracture propagation relative to aperture growth, followed by a stage of slow propagation and pronounced aperture growth. Consistent with fluid inclusion observations indicative of fracture opening and propagation occurring over 30-40 m.y., we interpret the second phase of pronounced aperture growth to result from fracture opening strain accommodated by solution-precipitation creep and concurrent slow, possibly subcritical, fracture propagation. Similar deformation mechanisms are envisioned to govern fracture growth over shorter timescales in reactive chemical subsurface environments including CO2 reservoirs, organic-rich shales, and geothermal systems.

Determination of Radiographic Healing: An Assessment of Consistency Using RUST and Modified RUST in Metadiaphyseal Fractures.

PubMed

Litrenta, Jody; Tornetta, Paul; Mehta, Samir; Jones, Clifford; OʼToole, Robert V; Bhandari, Mohit; Kottmeier, Stephen; Ostrum, Robert; Egol, Kenneth; Ricci, William; Schemitsch, Emil; Horwitz, Daniel

2015-11-01

To determine the reliability of the Radiographic Union Scale for Tibia (RUST) score and a new modified RUST score in quantifying healing and to define a value for radiographic union in a large series of metadiaphyseal fractures treated with plates or intramedullary nails. Healing was evaluated using 2 methods: (1) evaluation of interrater agreement in a series of radiographs and (2) analysis of prospectively gathered data from 2 previous large multicenter trials to define thresholds for radiographic union. Part 1: 12 orthopedic trauma surgeons evaluated a series of radiographs of 27 distal femur fractures treated with either plate or retrograde nail fixation at various stages of healing in random order using a modified RUST score. For each radiographic set, the reviewer indicated if the fracture was radiographically healed. Part 2: The radiographic results of 2 multicenter randomized trials comparing plate versus nail fixation of 81 distal femur and 46 proximal tibia fractures were reviewed. Orthopaedic surgeons at 24 trauma centers scored radiographs at 3, 6, and 12 months postoperatively using the modified RUST score above. Additionally, investigators indicated if the fracture was healed or not healed. The intraclass correlation coefficient (ICC) with 95% confidence intervals was determined for each cortex, the standard and modified RUST score, and the assignment of union for part 1 data. The RUST and modified RUST that defined "union" were determined for both parts of the study. ICC: The modified RUST score demonstrated slightly higher ICCs than the standard RUST (0.68 vs. 0.63). Nails had substantial agreement, whereas plates had moderate agreement using both modified and standard RUST (0.74 and 0.67 vs. 0.59 and 0.53). The average standard and modified RUST at union among all fractures was 8.5 and 11.4. Nails had higher standard and modified RUST scores than plates at union. The ICC for union was 0.53 (nails: 0.58; plates: 0.51), which indicates moderate agreement. However, the majority of reviewers assigned union for a standard RUST of 9 and a modified RUST of 11, and >90% considered a score of 10 on the RUST and 13 on the modified RUST united. The ICC for the modified RUST is slightly higher than the standard RUST in metadiaphyseal fractures and had substantial agreement. The ICC for the assessment of union was moderate agreement; however, definite union would be 10 and 13 with over 90% of reviewers assigning union. These are the first data-driven estimates of radiographic union for these scores.

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF).

PubMed

Joeris, Alexander; Lutz, Nicolas; Blumenthal, Andrea; Slongo, Theddy; Audigé, Laurent

2017-04-01

Background and purpose - To achieve a common understanding when dealing with long bone fractures in children, the AO Pediatric Comprehensive Classification of Long Bone Fractures (AO PCCF) was introduced in 2007. As part of its final validation, we present the most relevant fracture patterns in the lower extremities of a representative population of children classified according to the PCCF. Patients and methods - We included patients up to the age of 17 who were diagnosed with 1 or more long bone fractures between January 2009 and December 2011 at either of 2 tertiary care university hospitals in Switzerland. Patient charts were retrospectively reviewed. Results - More lower extremity fractures occurred in boys (62%, n = 341). Of 548 fractured long bones in the lower extremity, 25% involved the femur and 75% the lower leg. The older the patients, the more combined fractures of the tibia and fibula were sustained (adolescents: 50%, 61 of 123). Salter-Harris (SH) fracture patterns represented 66% of single epiphyseal fractures (83 of 126). Overall, 74 of the 83 SH patterns occurred in the distal epiphysis. Of all the metaphyseal fractures, 74 of 79 were classified as incomplete or complete. Complete oblique spiral fractures accounted for 57% of diaphyseal fractures (120 of 211). Of all fractures, 7% (40 of 548) were classified in the category "other", including 29 fractures that were identified as toddler's fractures. 5 combined lower leg fractures were reported in the proximal metaphysis, 40 in the diaphysis, 26 in the distal metaphysis, and 8 in the distal epiphysis. Interpretation - The PCCF allows classification of lower extremity fracture patterns in the clinical setting. Re-introduction of a specific code for toddler's fractures in the PCCF should be considered.

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF)

PubMed Central

Joeris, Alexander; Lutz, Nicolas; Blumenthal, Andrea; Slongo, Theddy; Audigé, Laurent

2017-01-01

Background and purpose To achieve a common understanding when dealing with long bone fractures in children, the AO Pediatric Comprehensive Classification of Long Bone Fractures (AO PCCF) was introduced in 2007. As part of its final validation, we present the most relevant fracture patterns in the lower extremities of a representative population of children classified according to the PCCF. Patients and methods We included patients up to the age of 17 who were diagnosed with 1 or more long bone fractures between January 2009 and December 2011 at either of 2 tertiary care university hospitals in Switzerland. Patient charts were retrospectively reviewed. Results More lower extremity fractures occurred in boys (62%, n = 341). Of 548 fractured long bones in the lower extremity, 25% involved the femur and 75% the lower leg. The older the patients, the more combined fractures of the tibia and fibula were sustained (adolescents: 50%, 61 of 123). Salter-Harris (SH) fracture patterns represented 66% of single epiphyseal fractures (83 of 126). Overall, 74 of the 83 SH patterns occurred in the distal epiphysis. Of all the metaphyseal fractures, 74 of 79 were classified as incomplete or complete. Complete oblique spiral fractures accounted for 57% of diaphyseal fractures (120 of 211). Of all fractures, 7% (40 of 548) were classified in the category "other", including 29 fractures that were identified as toddler’s fractures. 5 combined lower leg fractures were reported in the proximal metaphysis, 40 in the diaphysis, 26 in the distal metaphysis, and 8 in the distal epiphysis. Interpretation The PCCF allows classification of lower extremity fracture patterns in the clinical setting. Re-introduction of a specific code for toddler’s fractures in the PCCF should be considered. PMID:27882811

Case 24: Stress Fracture of the Tibia

DTIC Science & Technology

2008-03-01

extremity weight bearing bones. Most often this micro trauma is found in military recruits and athletes taking part in running activities. A...application of force most commonly related to running and jumping results in micro trauma to the cortical bone. The weight bearing bones of the lower...year old active duty U.S Army combat soldier deployed to Iraq. He had had progressive pain over his lower right leg that radiated to his knee joint

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.

The Outcomes of Nonelongating Intramedullary Fixation of the Lower Extremity for Pediatric Osteogenesis Imperfecta Patients: A Meta-analysis.

PubMed

Scollan, Joseph P; Jauregui, Julio J; Jacobsen, Christina M; Abzug, Joshua M

Osteogenesis imperfecta is usually due to autosomal dominant mutations in type I collagen, leading to an increase in fractures and bone deformities, especially in the long bones of the lower extremities. The use of nonelongating intramedullary rods is an established surgical intervention to address such deformities. The rate of surgical complications has been reported to be as high as 187%, with revision rates as high as 90%, although exact global rates are unknown. As such, we sought to determine the published rates of (1) bone-related complications (including both fracture and deformity), (2) rod migration, and (3) complications that require reoperation. Following the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines, 1295 studies were evaluated. After cross-referencing, and applying specific inclusion and exclusion criteria, a total of 7 studies were included in the final cohort. Data were extracted from the studies and analyzed. Random effect models determined the complication rates of intramedullary nonelongating rod procedures. A total of 359 primary nonelongating intramedullary rod procedures of tibiae and femurs, in patients with a mean age of 6 years (5.2 to 7.3 y), at a mean follow-up of 63 months (24 to 118 mo), were evaluated. 60% of the surgical procedures were on femurs, and 40% were on tibiae. The reoperation rate was 39.4%. The most common complication was rod migration, with a rate of 25.7%. The rate of bone-related complications was 19.5% including fractures (15.0%) and worsening bone deformity (4.3%). This is the first meta-analysis to identify the rates of complication and reoperation in lower limb intramedullary fixation for pediatric osteogenesis imperfecta patients. This study has shown that rod migration is the most common complication, followed by bone-related complications including fractures and deformity. Reoperations occur after nearly 40% of all procedures due to rod migration or bone-related complications. Level IV-retrospective meta-analysis.

Clinical, retrospective case-control study on the mechanics of obstacle in mouth opening and malocclusion in patients with maxillofacial fractures.

PubMed

Zhou, Hai-Hua; Lv, Kun; Yang, Rong-Tao; Li, Zhi; Yang, Xue-Wen; Li, Zu-Bing

2018-05-16

This study aims to identify and distinguish various factors that may influence the clinical symptoms (limited mouth opening and malocclusion) in patients with maxillofacial fractures. From January 2000 to December 2009, 963 patients with maxillofacial fractures were enrolled in this statistical study to aid in evaluating the association between various risk factors and clinical symptoms. Patients with fractured posterior mandibles tended to experience serious limitation in mouth opening. Patients who sustained coronoid fractures have the highest risk of serious limitation in mouth opening (OR = 9.849), followed by arch fractures, maxilla fractures, condylar fractures, zygomatic complex fractures and symphysis fractures. Meanwhile, the combined fracture of zygomatic arch and condylar process results in normal or mild mouth opening. High risks of sustaining malocclusion are preceded by the fracture of nasal bone (OR = 3.067), mandible, condylar neck/base, combined fracture of zygomatic arch and condylar process, mandibular body, bilateral condylar, dental trauma, mandibular ramus, symphysis, mandibular angle and mid-facial. Patients who experienced serious limitation in mouth opening are treated with surgery more frequently (OR = 2.118). No relationship exists between the treatment options and the patients with malocclusion.

Trabecular Bone Strength Predictions of HR-pQCT and Individual Trabeculae Segmentation (ITS)-Based Plate and Rod Finite Element Model Discriminate Postmenopausal Vertebral Fractures

PubMed Central

Liu, X. Sherry; Wang, Ji; Zhou, Bin; Stein, Emily; Shi, Xiutao; Adams, Mark; Shane, Elizabeth; Guo, X. Edward

2013-01-01

While high-resolution peripheral quantitative computed tomography (HR-pQCT) has advanced clinical assessment of trabecular bone microstructure, nonlinear microstructural finite element (μFE) prediction of yield strength by HR-pQCT voxel model is impractical for clinical use due to its prohibitively high computational costs. The goal of this study was to develop an efficient HR-pQCT-based plate and rod (PR) modeling technique to fill the unmet clinical need for fast bone strength estimation. By using individual trabecula segmentation (ITS) technique to segment the trabecular structure into individual plates and rods, a patient-specific PR model was implemented by modeling each trabecular plate with multiple shell elements and each rod with a beam element. To validate this modeling technique, predictions by HR-pQCT PR model were compared with those of the registered high resolution μCT voxel model of 19 trabecular sub-volumes from human cadaveric tibiae samples. Both Young’s modulus and yield strength of HR-pQCT PR models strongly correlated with those of μCT voxel models (r2=0.91 and 0.86). Notably, the HR-pQCT PR models achieved major reductions in element number (>40-fold) and CPU time (>1,200-fold). Then, we applied PR model μFE analysis to HR-pQCT images of 60 postmenopausal women with (n=30) and without (n=30) a history of vertebral fracture. HR-pQCT PR model revealed significantly lower Young’s modulus and yield strength at the radius and tibia in fracture subjects compared to controls. Moreover, these mechanical measurements remained significantly lower in fracture subjects at both sites after adjustment for aBMD T-score at the ultradistal radius or total hip. In conclusion, we validated a novel HR-pQCT PR model of human trabecular bone against μCT voxel models and demonstrated its ability to discriminate vertebral fracture status in postmenopausal women. This accurate nonlinear μFE prediction of HR-pQCT PR model, which requires only seconds of desktop computer time, has tremendous promise for clinical assessment of bone strength. PMID:23456922

Bone strength and muscle properties in postmenopausal women with and without a recent distal radius fracture.

PubMed

Crockett, K; Arnold, C M; Farthing, J P; Chilibeck, P D; Johnston, J D; Bath, B; Baxter-Jones, A D G; Kontulainen, S A

2015-10-01

Distal radius (wrist) fracture (DRF) in women over age 50 years is an early sign of bone fragility. Women with a recent DRF compared to women without DRF demonstrated lower bone strength, muscle density, and strength, but no difference in dual-energy x-ray absorptiometry (DXA) measures, suggesting DXA alone may not be a sufficient predictor for DRF risk. The objective of this study was to investigate differences in bone and muscle properties between women with and without a recent DRF. One hundred sixty-six postmenopausal women (50-78 years) were recruited. Participants were excluded if they had taken bone-altering medications in the past 6 months or had medical conditions that severely affected daily living or the upper extremity. Seventy-seven age-matched women with a fracture in the past 6-24 months (Fx, n = 32) and without fracture (NFx, n = 45) were measured for bone and muscle properties using the nondominant (NFx) or non-fractured limb (Fx). Peripheral quantitative computed tomography (pQCT) was used to estimate bone strength in compression (BSIc) at the distal radius and tibia, bone strength in torsion (SSIp) at the shaft sites, muscle density, and area at the forearm and lower leg. Areal bone mineral density at the ultradistal forearm, spine, and femoral neck was measured by DXA. Grip strength and the 30-s chair stand test were used as estimates of upper and lower extremity muscle strength. Limb-specific between-group differences were compared using multivariate analysis of variance (MANOVA). There was a significant group difference (p < 0.05) for the forearm and lower leg, with the Fx group demonstrating 16 and 19% lower BSIc, 3 and 6% lower muscle density, and 20 and 21% lower muscle strength at the upper and lower extremities, respectively. There were no differences between groups for DXA measures. Women with recent DRF had lower pQCT-derived estimated bone strength at the distal radius and tibia and lower muscle density and strength at both extremities.

Biomechanical comparison of straight DCP and helical plates for fixation of transverse and oblique bone fractures.

PubMed

Aksakal, Bunyamin; Gurger, Murat; Say, Yakup; Yilmaz, Erhan

2014-01-01

Biomechanical comparison of straight DCP and helical plates for fixation of transversal and oblique tibial bone fractures were analyzed and compared to each other by axial compression, bending and torsion tests. An in vitro osteosynthesis of transverse (TF) and oblique bone fracture (OF) fixations have been analysed on fresh sheep tibias by using the DCP and helical compression plates (HP). Statistically significant differences were found for both DCP and helical plate fixations under axial compression, bending and torsional loads. The strength of fixation systems was in favor of DC plating with exception of the TF-HP fixation group under compression loads and torsional moments. The transvers fracture (TF) stability was found to be higher than that found in oblique fracture (OF) fixed by helical plates (HP). However, under torsional testing, compared to conventional plating, the helical plate fixations provided a higher torsional resistance and strength. The maximum stiffness at axial compression loading and maximum torsional strength was achieved in torsional testing for the TF-HP fixations. From in vitro biomechanical analysis, fracture type and plate fixation system groups showed different responses under different loadings. Consequently, current biomechanical analyses may encourage the usage of helical HP fixations in near future during clinical practice for transverse bone fractures.

A prospective multi-center study of intramedullary nailing vs casting of stable tibial shaft fractures.

PubMed

Obremskey, William T; Cutrera, Norele; Kidd, Christopher M

2017-03-01

The purpose of this study was to determine optimal treatment of stable tibial shaft fractures using intramedullary nailing (IMN) or casting. We performed a multi-center prospective study cohort. Patients with stable tibia shaft fractures meeting Sarmiento's criteria (isolated closed fractures with less than 12 mm of shortening and 10° of angulation) were enrolled prospectively and treated with either a reamed IMN with static interlocking screws or closed reduction followed by long-leg casting. Both groups were weight bearing following surgery. Radiographs were taken until union, and range of motion of knee and ankle joints was assessed. Malalignment (>5°) and malunion (>10°) were determined. Functional outcome measures using short musculoskeletal assessment scores (SMFA) and a knee pain score were scheduled at 6 weeks, 3 months and 6 months. At 3 months, differences between the casting and IMN groups were noted in return to work (6/15 vs 3/17, P < 0.05); ankle dorsiflexion (7° vs 12°, P < 0.05); plantar flexion (28° vs 39°, P < 0.05); and SMFA domains of Dysfunction Index, Bother Index, daily activities, emotional status, and arm/hand function (P < 0.05). The SMFA mobility function demonstrated a significant trend (P = 0.065). At 6 months, malalignment was present in 3/15 in the casting group and in 1/17 in the IMN group (P = 0.02). Malunion was present in 1/15 in the cast group. One fracture in the casting group went on to nonunion and required late IMN placement at 7 months and eventually healed. There were no differences in ankle motion, SMFA scores, or return to work. There was no difference in knee pain between the groups as measured by VAS and Court-Brown pain scale at 6 months. Patients with stable tibia fractures treated with intramedullary nailing have improved clinical and functional outcomes at 3 months compared with those treated with casting, but there are no differences in any other outcome measure. Patients treated in a cast may have a higher incidence of malalignment or malunion. Level-II prognostic.

Characteristics on Fractures of Tibia and Fibula in Car Impacts to Pedestrians and Bicyclists – Influences of Car Bumper Height and Shape

PubMed Central

Otte, D.; Haasper, C.

2007-01-01

This study deals with the analysis of lower leg fractures in pedestrians and bicyclists after collisions with passenger cars and examines to what extent the shape and location of the factures in the lower leg changed, following alterations in the shape of bumpers. It can be assumed that that the bumpers changed in shape and effective impact height, not least due to the realization of the developments of vehicle safety tests as in the context of the European Union Directive 2003/102/EC on pedestrian protection. In addition, consumer protection tests, EuroNCAP, accomplished a change of the injury situation. All of these are mainly focused on pedestrian protection measurements but adopt the bicyclists also in their goal. For the study, traffic accidents from GIDAS (German in-Depth-Accident Study) were selected, which had been documented in the years 1995 to 2004 by scientific teams in Hannover and Dresden (Germany) and for which there is detailed information regarding injury patterns and collision speeds. The accident documentations can be regarded as representative and constitute a random sample with statistic weighing of the data. Altogether 143 cases of lower leg fractures (Tibia/Fibula) with x-rays of pedestrians and 79 cases of bicyclists were differentiated according to new and old vehicles (year of manufacture before/after 1995). The bumper shapes were divided into classical types (protruding pronouncedly/protruding integrated /integrated rounded). Besides the injuries to the lower leg, those to thighs and feet were also regarded, and the injury conditions involving the head and trunk were included in the kinematic analytics. PMID:18184485

Correlates of Trabecular and Cortical Volumetric Bone Mineral Density of the Radius and Tibia in Older Men: The Osteoporotic Fractures in Men Study

PubMed Central

Barbour, Kamil E; Zmuda, Joseph M; Strotmeyer, Elsa S; Horwitz, Mara J; Boudreau, Robert; Evans, Rhobert W; Ensrud, Kristine E; Petit, Moira A; Gordon, Christopher L; Cauley, Jane A

2010-01-01

Quantitative computed tomography (QCT) can estimate volumetric bone mineral density (vBMD) and distinguish trabecular from cortical bone. Few comprehensive studies have examined correlates of vBMD in older men. This study evaluated the impact of demographic, anthropometric, lifestyle, and medical factors on vBMD in 1172 men aged 69 to 97 years and enrolled in the Osteoporotic Fractures in Men Study (MrOS). Peripheral quantitative computed tomography (pQCT) was used to measure vBMD of the radius and tibia. The multivariable linear regression models explained up to 10% of the variance in trabecular vBMD and up to 9% of the variance in cortical vBMD. Age was not correlated with radial trabecular vBMD. Correlates associated with both cortical and trabecular vBMD were age (−), caffeine intake (−), total calcium intake (+), nontrauma fracture (−), and hypertension (+). Higher body weight was related to greater trabecular vBMD and lower cortical vBMD. Height (−), education (+), diabetes with thiazolidinedione (TZD) use (+), rheumatoid arthritis (+), using arms to stand from a chair (−), and antiandrogen use (−) were associated only with trabecular vBMD. Factors associated only with cortical vBMD included clinic site (−), androgen use (+), grip strength (+), past smoker (−), and time to complete five chair stands (−). Certain correlates of trabecular and cortical vBMD differed among older men. An ascertainment of potential risk factors associated with trabecular and cortical vBMD may lead to better understanding and preventive efforts for osteoporosis in men. © 2010 American Society for Bone and Mineral Research. PMID:20200975

Mandibular Reconstruction with Lateral Tibial Bone Graft: An Excellent Option for Oral and Maxillofacial Surgery.

PubMed

Miceli, Ana Lucia Carpi; Pereira, Livia Costa; Torres, Thiago da Silva; Calasans-Maia, Mônica Diuana; Louro, Rafael Seabra

2017-12-01

Autogenous bone grafts are the gold standard for reconstruction of atrophic jaws, pseudoarthroses, alveolar clefts, orthognathic surgery, mandibular discontinuity, and augmentation of sinus maxillary. Bone graft can be harvested from iliac bone, calvarium, tibial bone, rib, and intraoral bone. Proximal tibia is a common donor site with few reported problems compared with other sites. The aim of this study was to evaluate the use of proximal tibia as a donor area for maxillofacial reconstructions, focusing on quantifying the volume of cancellous graft harvested by a lateral approach and to assess the complications of this technique. In a retrospective study, we collected data from 31 patients, 18 women and 13 men (mean age: 36 years, range: 19-64), who were referred to the Department of Oral and Maxillofacial Surgery at the Servidores do Estado Federal Hospital. Patients were treated for sequelae of orthognathic surgery, jaw fracture, nonunion, malunion, pathology, and augmentation of bone volume to oral implant. The technique of choice was lateral access of proximal tibia metaphysis for graft removal from Gerdy tubercle under general anesthesia. The mean volume of bone harvested was 13.0 ± 3.7 mL (ranged: 8-23 mL). Only five patients (16%) had minor complications, which included superficial infection, pain, suture dehiscence, and unwanted scar. However, none of these complications decreases the result and resolved completely. We conclude that proximal tibia metaphysis for harvesting cancellous bone graft provides sufficient volume for procedures in oral and maxillofacial surgery with minimal postoperative morbidity.

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF)

PubMed Central

Audigé, Laurent; Slongo, Theddy; Lutz, Nicolas; Blumenthal, Andrea; Joeris, Alexander

2017-01-01

Background and purpose The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF) describes the localization and morphology of fractures, and considers severity in 2 categories: (1) simple, and (2) multifragmentary. We evaluated simple and multifragmentary fractures in a large consecutive cohort of children diagnosed with long bone fractures in Switzerland. Patients and methods Children and adolescents treated for fractures between 2009 and 2011 at 2 tertiary pediatric surgery hospitals were retrospectively included. Fractures were classified according to the AO PCCF. Severity classes were described according to fracture location, patient age and sex, BMI, and cause of trauma. Results Of all trauma events, 3% (84 of 2,730) were diagnosed with a multifragmentary fracture. This proportion was age-related: 2% of multifragmentary fractures occurred in school­children and 7% occurred in adolescents. In patients diagnosed with a single fracture only, the highest percentage of multifragmentation occurred in the femur (12%, 15 of 123). In fractured paired radius/ulna bones, multifragmentation occurred in 2% (11 of 687); in fractured paired tibia/fibula bones, it occurred in 21% (24 of 115), particularly in schoolchildren (5 of 18) and adolescents (16 of 40). In a multivariable regression model, age, cause of injury, and bone were found to be relevant prognostic factors of multifragmentation (odds ratio (OR) > 2). Interpretation Overall, multifragmentation in long bone fractures in children was rare and was mostly observed in adolescents. The femur was mostly affected in single fractures and the lower leg was mostly affected in paired-bone fractures. The clinical relevance of multifragmentation regarding growth and long-term functional recovery remains to be determined. PMID:27882814

Ballistic fractures: indirect fracture to bone.

PubMed

Dougherty, Paul J; Sherman, Don; Dau, Nathan; Bir, Cynthia

2011-11-01

Two mechanisms of injury, the temporary cavity and the sonic wave, have been proposed to produce indirect fractures as a projectile passes nearby in tissue. The purpose of this study is to evaluate the temporal relationship of pressure waves using strain gauge technology and high-speed video to elucidate whether the sonic wave, the temporary cavity, or both are responsible for the formation of indirect fractures. Twenty-eight fresh frozen cadaveric diaphyseal tibia (2) and femurs (26) were implanted into ordnance gelatin blocks. Shots were fired using 9- and 5.56-mm bullets traversing through the gelatin only, passing close to the edge of the bone, but not touching, to produce an indirect fracture. High-speed video of the impact event was collected at 20,000 frames/s. Acquisition of the strain data were synchronized with the video at 20,000 Hz. The exact time of fracture was determined by analyzing and comparing the strain gauge output and video. Twenty-eight shots were fired, 2 with 9-mm bullets and 26 with 5.56-mm bullets. Eight indirect fractures that occurred were of a simple (oblique or wedge) pattern. Comparison of the average distance of the projectile from the bone was 9.68 mm (range, 3-20 mm) for fractured specimens and 15.15 mm (range, 7-28 mm) for nonfractured specimens (Student's t test, p = 0.036). In this study, indirect fractures were produced after passage of the projectile. Thus, the temporary cavity, not the sonic wave, was responsible for the indirect fractures.

The Evaluation Of Therapeutic Efficacy and Safety Profile of Simvastatin Prodrug Micelles in a Closed Fracture Mouse Model

PubMed Central

Zhang, Yijia; Jia, Zhenshan; Yuan, Hongjiang; Dusad, Anand; Ren, Ke; Wei, Xin; Fehringer, Edward V.; Purdue, P. Edward; Daluiski, Aaron; Goldring, Steven R.; Wang, Dong

2016-01-01

Purpose To evaluate the therapeutic efficiency of a micellar prodrug formulation of simvastatin (SIM/SIM-mPEG) and explore its safety in a closed femoral fracture mouse model. Methods The amphiphilic macromolecular prodrug of simvastatin (SIM-mPEG) was synthesized and formulated together with free simvastatin into micelles. It was also labeled with a near infrared dye for in vivo imaging purpose. A closed femoral fracture mouse model was established using a three-point bending device. The mice with established closed femoral fracture were treated with SIM/SIM-mPEG micelle, using free simvastatin and saline as controls. The therapeutic efficacy of the micelles was evaluated using a high-resolution micro-CT. Serum biochemistry and histology analyses were performed to explore the potential toxicity of the micelle formulation. Results Near Infrared Fluorescence (NIRF) imaging confirmed the passive targeting of SIM/SIM-mPEG micelles to the bone lesion of the mice with closed femoral fracture. The micelle was found to promote fracture healing with an excellent safety profile. In addition, the accelerated healing of the femoral fracture also helped to prevent disuse-associated same-side tibia bone loss accompanying the femur fracture. Conclusion SIM/SIM-mPEG micelle was found to be an effective and safe treatment for closed femoral fracture repair in mice. The evidence obtained in this study suggests that it may have the potential to be translated into a novel therapy for clinical management of skeletal fractures and non-union. PMID:27164897

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.

[TRANSOSSEOUS OSTEOSYNTHESIS OF LOWER EXTREMITIES BONES FRACTURES AND QUALITY OF LIFE OF PATIENTS IN THE TREATMENT PERIOD].

PubMed

Dyusupov, A; Dyusupov, A; Manarbekov, E; Bukatov, A; Serikbaev, A

2018-02-01

The aim of the study is a comparative analysis of the quality of life in the treatment of fractures of the bones of the lower extremities of various localizations using transosseous and submerged osteosynthesis. We examined 397 patients with injuries of the lower segment of the lower extremity (patellar fractures - 81, multiple bones fractures of the tibia - 84 and fractures of the ankles, accompanied by a dislocation of the foot - 232). Patients were distributed in the subgroups depending on the treatment. The main group was performed using transosseous osteosynthesis, the comparison group - submerged osteosynthesis. The quality of life was examined using a general questionnaire SF-36 and specialized KOOS (with patella fractures) and FOAS (fractures of the bones of the lower leg and ankles). In patients with all localizations of fractures the quality of life was exceeded in the subgroups of the transosseous osteosynthesis group over the parameters of the comparison group. The most significant differences with the use of specialized questionnaires were revealed 6-9 months after trauma with a tendency to leveling to the end of the study (1 year). A more pronounced excess of the quality of life in the main group was seen in fractures of the shin bones. The study of the quality of life allows us to recommend the use of transosseous osteosynthesis for the treatment of lower segment of the lower limb bone fractures.

Postoperative hypoxemia due to fat embolism

PubMed Central

Bhalla, Tarun; Sawardekar, Amod; Klingele, Kevin; Tobias, Joseph D.

2011-01-01

Although the reported incidence of fat embolism syndrome (FES) is low (approximately 1%), it is likely that microscopic fat emboli are showered during manipulation of long bone fractures. Even though there continues to be debate regarding the etiology and proposed mechanism responsible for FES, significant systemic manifestations may occur. Treatment is generally symptomatic based on the clinical presentations. We report a 10-year-old girl who developed hypoxemia following treatment of a displaced Salter-Harris type II fracture of the distal tibia. The subsequent evaluation and hospital course pointed to fat embolism as the most likely etiology for the hypoxemia. We discuss the etiology for FES, review the proposed pathophysiological mechanisms responsible for its clinical manifestations, present currently accepted diagnostic criteria, and discuss its treatment. PMID:21957420

Ilizarov ring fixator for a difficult case of ankle syndesmosis disruption.

PubMed

Relwani, Jaikumar; Lahoti, Om; Orakwe, Sam

2002-01-01

Syndesmotic stabilization is recommended for tibiofibular diastasis, a Maisonneuve fracture, or syndesmotic instability after fixation of distal tibia-fibula fractures. In the case presented, a syndesmotic stabilization was performed with a screw inserted 2 cm above the tibiotalar joint Subsequent failure occurred due to the weight of the patient and a lack of compliance with the necessary nonweight bearing protocol. The Ilizarov frame was used to reduce and maintain a stable syndesmosis with a simple two-ring construct which allowed the patient to bear weight on the injured limb while his syndesmosis healed. This is not recommend as a routine method of treatment, but is presented as an extended indication of the Ilizarov frame for difficult cases.

The Effects of Targeted Deliveries of Lovastatin and Tocotrienol on Ossification-Related Gene Expressions in Fracture Healing in an Osteoporosis Rat Model

PubMed Central

Ibrahim, Nurul ‘Izzah; Mohamed, Norazlina; Soelaiman, Ima Nirwana; Shuid, Ahmad Nazrun

2015-01-01

Osteoporotic drugs are used to prevent fragility fractures, but their role in fracture healing still remains unknown. Thus, alternative agents with suitable mode of delivery are needed to promote fracture healing. This study was performed to investigate the effects of direct deliveries of lovastatin and tocotrienol to fracture sites on ossification-related gene expression in fracture healing in a postmenopausal osteoporosis model. Forty-eight Sprague Dawley female rats were divided into six groups. Group I comprised the sham-operated rats, while Groups II–VI were ovariectomized rats. After 8 weeks, the right tibiae of all rats were fractured and stabilized. Group I and Group II were given two single injections of lovastatin and tocotrienol carriers. Group III was given an estrogen preparation at 64.5 µg/kg daily via oral gavages. Group IV was injected with lovastatin particles (750 µg/kg), while Group V was injected with tocotrienol particles (60 mg/kg). Group VI received two single injections of 750 µg/kg lovastatin particles and 60 mg/kg tocotrienol particles. After 4 weeks, the gene expressions were measured. Group VI showed significantly higher gene expressions of osteocalcin, BMP-2, VEGF-α, and RUNX-2 compared to Group II. In conclusion, combined treatment of lovastatin and tocotrienol upregulated the expression of genes related to fracture healing. PMID:26501302

The Effects of Targeted Deliveries of Lovastatin and Tocotrienol on Ossification-Related Gene Expressions in Fracture Healing in an Osteoporosis Rat Model.

PubMed

Ibrahim, Nurul 'Izzah; Mohamed, Norazlina; Soelaiman, Ima Nirwana; Shuid, Ahmad Nazrun

2015-10-16

Osteoporotic drugs are used to prevent fragility fractures, but their role in fracture healing still remains unknown. Thus, alternative agents with suitable mode of delivery are needed to promote fracture healing. This study was performed to investigate the effects of direct deliveries of lovastatin and tocotrienol to fracture sites on ossification-related gene expression in fracture healing in a postmenopausal osteoporosis model. Forty-eight Sprague Dawley female rats were divided into six groups. Group I comprised the sham-operated rats, while Groups II-VI were ovariectomized rats. After 8 weeks, the right tibiae of all rats were fractured and stabilized. Group I and Group II were given two single injections of lovastatin and tocotrienol carriers. Group III was given an estrogen preparation at 64.5 µg/kg daily via oral gavages. Group IV was injected with lovastatin particles (750 µg/kg), while Group V was injected with tocotrienol particles (60 mg/kg). Group VI received two single injections of 750 µg/kg lovastatin particles and 60 mg/kg tocotrienol particles. After 4 weeks, the gene expressions were measured. Group VI showed significantly higher gene expressions of osteocalcin, BMP-2, VEGF-α, and RUNX-2 compared to Group II. In conclusion, combined treatment of lovastatin and tocotrienol upregulated the expression of genes related to fracture healing.

Allografts about the Knee in Young Patients with High-Grade Sarcoma.

PubMed

Brigman, Brian E; Hornicek, Francis J; Gebhardt, Mark C; Mankin, Henry J

2004-04-01

Reconstruction after resections for high-grade sarcomas about the knee in children and adolescents is a challenging problem because of the large soft tissue and skeletal defects, the effects of adjuvant therapy, and the potential for long-term use of the limb. One hundred sixteen patients, all 18 years or younger, with osteosarcoma or Ewing's sarcoma located between the middle femur and middle tibia, were treated with chemotherapy, resection, and allograft reconstruction. One hundred three patients with osteosarcoma and 13 patients with Ewing's sarcoma had 105 Stage II and 11 Stage III tumors. There were 72 osteoarticular grafts (39 femur, 33 tibia), 28 intercalary grafts (19 femur), seven allograft-prosthetic composites (all femur,) and nine allograft-arthrodeses (seven femur, two tibia). At latest followup, 49% of all of the allograft reconstructions were rated good or excellent, 14% were rated as fair, and 37% were failures. Sixteen percent had an infection develop. Twenty-seven percent of patients had a fracture, 34% had a nonunion, and 14 patients eventually required amputation. Reconstruction of large bone defects about the knee in young patients who are being treated with chemotherapy is difficult. Although complications significantly affect outcome, allografts are a viable option for reconstruction in children with high-grade sarcomas about the knee.

[Meta-analysis of risk factors of recurrence in patients with giant cell tumor on extremities].

PubMed

Li, Rongrui; Hu, Yongcheng

2014-12-23

To explore the risk factors of giant cell tumor on extremities for patients with postoperative recurrence. The literature reports published before June 2014 were searched in the electronic databases of CBM, CNKI, PUBNED, MEDLINE and EMBASE. Meta-analysis was performed by software Review Manager (Version 5.3). The odds ratios (OR) of gender, age, tumor site, Campanacci Classification, pathological fracture, selection of treatment and soft tissue invasion were analyzed with heterogeneity test. Publication bias were tested by funnel plot and fail-safe number.Sensitivity analysis was performed to assess the stability. A total of 15 case-control studies were identified. Age, location and type of surgery were associated with tumor recurrence. The combined OR (95%CI) was 1.83 (1.04-3.24) P = 0.04 for aged <20 years, 0.52(0.31-0.86) P = 0.01 for aged >40 years, 1.60 (1.06-2.42) P = 0.02 for distal radius, 0.35 (0.14-0.90) P = 0.03 for proximal humerus, 3.64 (1.88-7.04) P = 0.0001 for curettage,0.56 (0.35-0.91) P = 0.02 for curettage with PMMA, 1.79 (1.11-2.88) P = 0.02 for curettage with bone graft and adjuvant and 0.29 (0.12-0.66) P = 0.003 for resection respectively. There were not significant relationship between tumor recurrence and gender, tumor location (distal femur, proximal femur, distal tibia, proximal tibia), Jaffe staging, Campanacci classification,Enneking classification, pathological fracture, soft tissue invasion, extensive curettage, curettage with bone graft, curettage with polymethylmethacrylate and adjuvant (P > 0.05). Youth (aged <20 years), distal radius, curettage and curettage with bone graft and adjuvant are the risk factors for recurrence of giant cell tumor.However, advanced age (aged >40 years), proximal tibia, curettage with PMMA and resection appear to have lower risks for tumor recurrence.

Hypogonadal Men with Higher Body Mass Index have Higher Bone Density and Better Bone Quality but Reduced Muscle Density.

PubMed

Aguirre, Lina E; Colleluori, Georgia; Dorin, Richard; Robbins, David; Chen, Rui; Jiang, Bryan; Qualls, Clifford; Villareal, Dennis T; Armamento-Villareal, Reina

2017-12-01

Although hypogonadism is a risk factor for bone loss and fractures, the different etiopathophysiology and hormonal profile of classical and obesity-induced hypogonadism may lead to differences in musculoskeletal profile. This is a cross-sectional study of hypogonadal men between 40 and 74 years old. Our outcomes include: areal bone mineral density (aBMD) and body composition by dual-energy X-ray absorptiometry; volumetric BMD (vBMD) and soft tissue composition of the tibia by peripheral quantitative computed tomography. Fracture risk assessment tool (FRAX) scores were evaluated. Testosterone, estradiol, luteinizing hormone, follicle stimulating hormone, sex hormone-binding globulin, C-telopeptide, osteocalcin, and sclerostin were measured. We divided the population into subgroups of BMI: group 1: BMI < 30; group 2: BMI ≥30 to <35 and group 3: BMI ≥ 35 kg/m 2 . One-hundred five men were enrolled. Spine and hip aBMD, and total and trabecular vBMD at the 4% tibia significantly increased with increasing BMI. Cortical thickness (330.7 ± 53.2, 343.3 ± 35.4, and 358.7 ± 38.2 mm, p = 0.04; groups 1, 2 and 3, respectively) and cortical area (5.3 ± 0.7, 5.5 ± 0.6, and 5.7 ± 0.6 mm, p = 0.01; groups 1, 2 and 3, respectively) at 38% tibia increased with increasing BMI. While absolute lean mass increased with increasing BMI, % lean mass and muscle density (70.2 ± 5.0, 71.3 ± 6.4, and 67.1 ± 5.1 mg/cm 3 ; groups 1, 2 and 3, respectively) were lowest in group 3. Although severely obese hypogondal men have better BMD and bone quality, they have reduced muscle density, the significance of which remains to be determined.

Alterations of bone microstructure and strength in end-stage renal failure.

PubMed

Trombetti, A; Stoermann, C; Chevalley, T; Van Rietbergen, B; Herrmann, F R; Martin, P-Y; Rizzoli, R

2013-05-01

End-stage renal disease (ESRD) patients have a high risk of fractures. We evaluated bone microstructure and finite-element analysis-estimated strength and stiffness in patients with ESRD by high-resolution peripheral computed tomography. We observed an alteration of cortical and trabecular bone microstructure and of bone strength and stiffness in ESRD patients. Fragility fractures are common in ESRD patients on dialysis. Alterations of bone microstructure contribute to skeletal fragility, independently of areal bone mineral density. We compared microstructure and finite-element analysis estimates of strength and stiffness by high-resolution peripheral quantitative computed tomography (HR-pQCT) in 33 ESRD patients on dialysis (17 females and 16 males; mean age, 47.0 ± 12.6 years) and 33 age-matched healthy controls. Dialyzed women had lower radius and tibia cortical density with higher radius cortical porosity and lower tibia cortical thickness, compared to controls. Radius trabecular number was lower with higher heterogeneity of the trabecular network. Male patients displayed only a lower radius cortical density. Radius and tibia cortical thickness correlated negatively with bone-specific alkaline phosphatase (BALP). Microstructure did not correlate with parathyroid hormone (PTH) levels. Cortical porosity correlated positively with "Kidney Disease: Improving Global Outcomes" working group PTH level categories (r = 0.36, p < 0.04). BMI correlated positively with trabecular number (r = 0.4, p < 0.02) and negatively with trabecular spacing (r = -0.37, p < 0.03) and trabecular network heterogeneity (r = -0.4, p < 0.02). Biomechanics positively correlated with BMI and negatively with BALP. Cortical and trabecular bone microstructure and calculated bone strength are altered in ESRD patients, predominantly in women. Bone microstructure and biomechanical assessment by HR-pQCT may be of major clinical relevance in the evaluation of bone fragility in ESRD patients.

[Complex injuries associated with somnambulism].

PubMed

Sillesen, Nanna Hylleholt; Nielsen, Lisa Toft; Bonde, Christian

2010-12-13

Up to 3% of adults walk in their sleep and some perform complex behaviours. Treatment recommendations for sleepwalking are inconsistent. This case report describes a 64-year-old man who climbed out of a 2nd floor toilet window during somnambulism. He fell 6-8 meters and fractured the tibia, fibula, cervical columna, lumbal columna, calcaneus, costae and suffered a pneumothorax. Evidence to support sleepwalking treatment is lacking and besides benzodiazepines, prevention is the preferred treatment choice according to the literature.

Predictors of Postoperative Wound Necrosis Following Primary Wound Closure of Open Ankle Fractures.

PubMed

Ovaska, Mikko T; Madanat, Rami; Mäkinen, Tatu J

2016-04-01

Most open malleolar ankle fracture wounds can be closed primarily after meticulous debridement. However, the development of wound necrosis following operative treatment of open malleolar ankle fractures can have catastrophic consequences. The aim of this study was to identify risk factors predisposing to postoperative wound necrosis following primary wound closure of open malleolar ankle fractures. A total of 137 patients with open malleolar ankle fractures were identified. The open fracture wound was primarily closed in 110 of 137 (80%) patients, and postoperative wound necrosis occurred in 18 (16%) of these patients. These patients were compared to the open fracture patients without wound necrosis. Twenty possible risk factors for the development of wound necrosis were studied with logistic regression analysis. The variables that were independently associated with an increased risk for postoperative wound necrosis included ASA class ≥2, Gustilo grade III open injury, and the use of pulsatile lavage at index surgery. Our study showed that ASA class ≥2, Gustilo grade III open injury, and the use of pulsatile lavage at index surgery were the most important factors predisposing to postoperative wound necrosis following primary wound closure of open malleolar ankle fractures. The findings warrant a further study specifically comparing primary and delayed wound closure in patients with Gustilo grade III open malleolar ankle fractures and different ASA classes. Also, the role of pulsatile lavage should be re-evaluated. Level III, retrospective comparative series. © The Author(s) 2016.

Expected Time to Return to Athletic Participation After Stress Fracture in Division I Collegiate Athletes.

PubMed

Miller, Timothy L; Jamieson, Marissa; Everson, Sonsecharae; Siegel, Courtney

2017-12-01

Few studies have documented expected time to return to athletic participation after stress fractures in elite athletes. Time to return to athletic participation after stress fractures would vary by site and severity of stress fracture. Retrospective cohort study. Level 3. All stress fractures diagnosed in a single Division I collegiate men's and women's track and field/cross-country team were recorded over a 3-year period. Site and severity of injury were graded based on Kaeding-Miller classification system for stress fractures. Time to return to full unrestricted athletic participation was recorded for each athlete and correlated with patient sex and site and severity grade of injury. Fifty-seven stress fractures were diagnosed in 38 athletes (mean age, 20.48 years; range, 18-23 years). Ten athletes sustained recurrent or multiple stress fractures. Thirty-seven injuries occurred in women and 20 in men. Thirty-three stress fractures occurred in the tibia, 10 occurred in the second through fourth metatarsals, 3 occurred in the fifth metatarsal, 6 in the tarsal bones (2 navicular), 2 in the femur, and 5 in the pelvis. There were 31 grade II stress fractures, 11 grade III stress fractures, and 2 grade V stress fractures (in the same patient). Mean time to return to unrestricted sport participation was 12.9 ± 5.2 weeks (range, 6-27 weeks). No significant differences in time to return were noted based on injury location or whether stress fracture was grade II or III. The expected time to return to full unrestricted athletic participation after diagnosis of a stress fracture is 12 to 13 weeks for all injury sites. Athletes with grade V (nonunion) stress fractures may require more time to return to sport.

An Integrated Musculoskeletal-Finite-Element Model to Evaluate Effects of Load Carriage on the Tibia During Walking.

PubMed

Xu, Chun; Silder, Amy; Zhang, Ju; Hughes, Julie; Unnikrishnan, Ginu; Reifman, Jaques; Rakesh, Vineet

2016-10-01

Prior studies have assessed the effects of load carriage on the tibia. Here, we expand on these studies and investigate the effects of load carriage on joint reaction forces (JRFs) and the resulting spatiotemporal stress/strain distributions in the tibia. Using full-body motion and ground reaction forces from a female subject, we computed joint and muscle forces during walking for four load carriage conditions. We applied these forces as physiological loading conditions in a finite-element (FE) analysis to compute strain and stress. We derived material properties from computed tomography (CT) images of a sex-, age-, and body mass index-matched subject using a mesh morphing and mapping algorithm, and used them within the FE model. Compared to walking with no load, the knee JRFs were the most sensitive to load carriage, increasing by as much as 26.2% when carrying a 30% of body weight (BW) load (ankle: 16.4% and hip: 19.0%). Moreover, our model revealed disproportionate increases in internal JRFs with increases in load carriage, suggesting a coordinated adjustment in the musculature functions in the lower extremity. FE results reflected the complex effects of spatially varying material properties distribution and muscular engagement on tibial biomechanics during walking. We observed high stresses on the anterior crest and the medial surface of the tibia at pushoff, whereas high cumulative stress during one walking cycle was more prominent in the medioposterior aspect of the tibia. Our findings reinforce the need to include: (1) physiologically accurate loading conditions when modeling healthy subjects undergoing short-term exercise training and (2) the duration of stress exposure when evaluating stress-fracture injury risk. As a fundamental step toward understanding the instantaneous effect of external loading, our study presents a means to assess the relationship between load carriage and bone biomechanics.

Reproducibility of Direct Quantitative Measures of Cortical Bone Micro-architecture of the Distal Radius and Tibia by HR-pQCT

PubMed Central

Burghardt, Andrew J.; Buie, Helen R.; Laib, Andres; Majumdar, Sharmila; Boyd, Steven K.

2010-01-01

Quantitative cortical micro-architectural endpoints are important for understanding structure-function relations in the context of fracture risk and therapeutic efficacy. This technique study details new image-processing methods to automatically segment and directly quantify cortical density, geometry, and micro-architecture from HR-pQCT images of the distal radius and tibia. An automated segmentation technique was developed to identify the periosteal and endosteal margins of the distal radius and tibia, and detect intra-cortical pore space morphologically consistent with Haversian canals. The reproducibility of direct quantitative cortical bone indices based on this method was assessed in a pooled dataset of 56 subjects with two repeat acquisitions for each site. The in vivo precision error was characterized using root mean square coefficient of variation (RMSCV%) from which, the least significant change (LSC) was calculated. Bland-Altman plots were used to characterize bias in the precision estimates. The reproducibility of cortical density and cross-sectional area measures was high (RMSCV <1% and <1.5%, respectively) with good agreement between young and elder medians. The LSC for cortical porosity (Ct.Po) was somewhat smaller in the radius (0.58%) compared with the distal tibia (0.84%) and significantly different between young and elder medians in the distal tibia (LSC: 0.75% vs. 0.92%; p<0.001). The LSC for pore diameter and distribution (Po.Dm and Po.Dm.SD) ranged between 15 and 23μm. Bland-Altman analysis revealed moderate bias for integral measures of area and volume, but not density nor microarchitecture. This study indicates HR-pQCT measures of cortical bone density and architecture can be measured in vivo with high reproducibility and limited bias across a biologically relevant range of values. The results of this study provide informative data for the design of future clinical studies of bone quality. PMID:20561906

Major surgery in an osteosarcoma patient refusing blood transfusion: case report.

PubMed

Dhanoa, Amreeta; Singh, Vivek A; Shanmugam, Rukmanikanthan; Rajendram, Raja

2010-11-08

We describe an unusual case of osteosarcoma in a Jehovah's Witness patient who underwent chemotherapy and major surgery without the need for blood transfusion. This 16-year-old girl presented with osteosarcoma of the right proximal tibia requiring proximal tibia resection, followed by endoprosthesis replacement. She was successfully treated with neoadjuvant chemotherapy and surgery with the support of haematinics, granulocyte colony-stimulating factor, recombinant erythropoietin and intraoperative normovolaemic haemodilution. This case illustrates the importance of maintaining effective, open communication and exploring acceptable therapeutic alternative in the management of these patients, whilst still respecting their beliefs.

Factors associated with infection following open distal radius fractures.

PubMed

Glueck, Dane A; Charoglu, Constantine P; Lawton, Jeffrey N

2009-09-01

Open fractures are often classified according to a system described by Gustilo and Anderson. However, this system was applied to open long bone fractures, which may not predict the incidence of infection in open metaphyseal fractures of the upper extremity. Other studies have found that wound contamination and systemic illness were the best predictors of infections in open hand fractures. Our study assessed infection in open distal radius fractures and identifies factors that are associated with these infections. We hypothesize that contamination, rather than absolute wound size, is the best predictor of infection associated with open distal radius fractures. A review by CPT code yielded 42 patients with open distal radius fractures between 1997 and 2002 treated at a level one trauma center. Medical records and radiographic follow-up were reviewed to assess the time to irrigation and debridement, the number of debridements in initial treatment period, the method of operative stabilization, the Gustilo and Anderson type of fracture, the Swanson type of fracture, and description of wound contamination. Forty-two patients were followed up for an average of 15 months (range 4 to 68 months). Twenty-four fractures were classified as Gustilo and Anderson type I, ten were type II, and eight were type III, 30 were Swanson type I, and 12 were Swanson type II. Five of the 42 fractures were considered contaminated. Two were exposed to fecal contamination. The others were contaminated with tar, dirt/grass, and gravel, respectively. Three of 42 (7%) fractures developed infections. All three infected cases received a single irrigation and debridement. Two of five contaminated fractures (40%) developed a polymicrobial infection. Both were exposed to fecal contamination and, therefore, considered Swanson type II fractures. They were classified as Gustilo and Anderson type II and IIIB based solely upon the size of the wound. Both required multiple debridements and eventually wrist fusions. The third infection occurred in a Gustilo and Anderson type II and Swanson type I open fracture treated with one debridement and plate fixation. Hardware removal, debridement, and antibiotics resolved the infection. Three contaminated fractures that healed uneventfully received two debridements. Statistical analysis revealed a correlation with infection and contamination (p = 0.0331). The number of initial debridements played a role in infection, but was not statistically significant. No relationship between infection and time to initial irrigation and debridement, method of fixation, Gustilo and Anderson type, or Swanson type was found. We propose that open distal radius fractures behave differently than open long bone fractures. Infection developed in 7% of the distal radius fractures in our study and was significantly associated with wound contamination. We recommend that contamination be included as factor for prognosis in open distal radius fractures. Contaminated fractures should be treated with multiple debridements as part of the initial plan not based upon subsequent development of an infection.

Development of Raman spectral markers to assess metastatic bone in breast cancer

PubMed Central

Ding, Hao; Nyman, Jeffry S.; Sterling, Julie A.; Perrien, Daniel S.; Mahadevan-Jansen, Anita; Bi, Xiaohong

2014-01-01

Abstract. Bone is the most common site for breast cancer metastases. One of the major complications of bone metastasis is pathological bone fracture caused by chronic bone loss and degeneration. Current guidelines for the prediction of pathological fracture mainly rely on radiographs or computed tomography, which are limited in their ability to predict fracture risk. The present study explored the feasibility of using Raman spectroscopy to estimate pathological fracture risk by characterizing the alterations in the compositional properties of metastatic bones. Tibiae with evident bone destruction were investigated using Raman spectroscopy. The carbonation level calculated by the ratio of carbonate/phosphate ν1 significantly increased in the tumor-bearing bone at all the sampling regions at the proximal metaphysis and diaphysis, while tumor-induced elevation in mineralization and crystallinity was more pronounced in the metaphysis. Furthermore, the increased carbonation level is positively correlated to bone lesion size, indicating that this parameter could serve as a unique spectral marker for tumor progression and bone loss. With the promising advances in the development of spatially offset Raman spectroscopy for deep tissue measurement, this spectral marker can potentially be used for future noninvasive evaluation of metastatic bone and prediction of pathological fracture risk. PMID:24933683

Development of Raman spectral markers to assess metastatic bone in breast cancer

NASA Astrophysics Data System (ADS)

Ding, Hao; Nyman, Jeffry S.; Sterling, Julie A.; Perrien, Daniel S.; Mahadevan-Jansen, Anita; Bi, Xiaohong

2014-11-01

Bone is the most common site for breast cancer metastases. One of the major complications of bone metastasis is pathological bone fracture caused by chronic bone loss and degeneration. Current guidelines for the prediction of pathological fracture mainly rely on radiographs or computed tomography, which are limited in their ability to predict fracture risk. The present study explored the feasibility of using Raman spectroscopy to estimate pathological fracture risk by characterizing the alterations in the compositional properties of metastatic bones. Tibiae with evident bone destruction were investigated using Raman spectroscopy. The carbonation level calculated by the ratio of carbonate/phosphate ν1 significantly increased in the tumor-bearing bone at all the sampling regions at the proximal metaphysis and diaphysis, while tumor-induced elevation in mineralization and crystallinity was more pronounced in the metaphysis. Furthermore, the increased carbonation level is positively correlated to bone lesion size, indicating that this parameter could serve as a unique spectral marker for tumor progression and bone loss. With the promising advances in the development of spatially offset Raman spectroscopy for deep tissue measurement, this spectral marker can potentially be used for future noninvasive evaluation of metastatic bone and prediction of pathological fracture risk.

Hormonal and biochemical parameters and osteoporotic fractures in elderly men.

PubMed

Center, J R; Nguyen, T V; Sambrook, P N; Eisman, J A

2000-07-01

Low testosterone has been associated with hip fracture in men in some studies. However, data on other hormonal parameters and fracture outcome in men is minimal. This study examined the association between free testosterone (free T) estradiol (E2), sex hormone-binding globulin (SHBG), 25-hydroxyvitamin D [25(OH)D], parathyroid hormone (PTH), insulin-like growth factor I (IGF-I), and fracture in 437 elderly community-dwelling men. Age, height, weight, quadriceps strength, femoral neck bone mineral density (FN BMD), and fracture data (1989-1997) also were obtained. Fractures were classified as major (hip, pelvis, proximal tibia, multiple rib, vertebral, and proximal humerus) or minor (remaining distal upper and lower limb fractures). Fifty-four subjects had a fracture (24 major and 30 minor). There was no association between minor fractures and any hormonal parameter. Risk of major fracture was increased 2-fold for each SD increase in age, decrease in weight and height, and increase in SHBG, and risk of major fracture was increased 3-fold for each SD decrease in quadriceps strength, FN BMD, and 25(OH)D (univariate logistic regression). Independent predictors of major fracture were FN BMD, 2.7 (1.5-4.7; odds ratio [OR]) and 95% confidence interval [CI]); 25(OH)D, 2.8 (1.5-5.3); and SHBG, 1.7 (1.2-2.4). An abnormal value for three factors resulted in a 30-fold increase in risk but only affected 2% of the population. It is not immediately apparent how 25(OH)D and SHBG, largely independently of BMD, may contribute to fracture risk. They may be markers for biological age or health status not measured by methods that are more traditional and as such may be useful in identifying those at high risk of fracture.

Biomechanical analysis of posteromedial tibial plateau split fracture fixation.

PubMed

Zeng, Zhi-Min; Luo, Cong-Feng; Putnis, Sven; Zeng, Bing-Fang

2011-01-01

The purpose of this study was to compare the biomechanical strength of four different fixation methods for a posteromedial tibial plateau split fracture. Twenty-eight tibial plateau fractures were simulated using right-sided synthetic tibiae models. Each fracture model was randomly instrumented with one of the four following constructs, anteroposterior lag-screws, an anteromedial limited contact dynamic compression plate (LC-DCP), a lateral locking plate, or a posterior T-shaped buttress plate. Vertical subsidence of the posteromedial fragment was measured from 500 N to 1500 N during biomechanical testing, the maximum load to failure was also determined. It was found that the posterior T-shaped buttress plate allowed the least subsidence of the posteromedial fragment and produced the highest mean failure load than each of the other three constructs (P=0.00). There was no statistical significant difference between using lag screws or an anteromedial LC-DCP construct for the vertical subsidence at a 1500 N load and the load to failure (P>0.05). This study showed that a posterior-based buttress technique is biomechanically the most stable in-vitro fixation method for posteromedial split tibial plateau fractures, with AP screws and anteromedial-based LC-DCP are not as stable for this type of fracture. Copyright © 2010 Elsevier B.V. All rights reserved.

Interpretation and classification of bone scintigraphic findings in stress fractures.

PubMed

Zwas, S T; Elkanovitch, R; Frank, G

1987-04-01

A new system for classification of stress fractures identified by bone scintigraphy was developed and divided into four grades according to lesion dimension, bone extension, and tracer accumulation. The scintigraphic findings were evaluated for severity of lesions by extent of the visualized bone response, ranging from ill-defined cortical lesions with slightly increased activity (I) to well-defined intramedullary transcortical lesions with intensely increased activity (IV). Bone scintigraphies using [99mTc]MDP were obtained in 310 military recruits suspected of having stress fractures. In 235 patients, 391 stress fractures were diagnosed. Forty percent of the lesions were asymptomatic. Most of the lesions were in the tibiae (72%), and 87% of the patients had one or two lesions, while 13% had three to five lesions. Eighty-five percent of the lesions were classified as mild and showed early and more complete resolution on follow-up studies after treatment as compared to the severe grades. Furthermore, specific scintigraphic patterns have been introduced for distinguishing inflammatory shin-splints from stress fractures, allowing for their appropriate early treatment. Thus, early recognition of mild stress fracture scintigraphic patterns representing the beginning of pathologic bone response to stress enabled a prompt and effective treatment to prevent progression of lesions, protracted disability, and complications.

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.

Do bisphosphonates inhibit direct fracture healing?: A laboratory investigation using an animal model.

PubMed

Savaridas, T; Wallace, R J; Salter, D M; Simpson, A H R W

2013-09-01

Fracture repair occurs by two broad mechanisms: direct healing, and indirect healing with callus formation. The effects of bisphosphonates on fracture repair have been assessed only in models of indirect fracture healing. A rodent model of rigid compression plate fixation of a standardised tibial osteotomy was used. Ten skeletally mature Sprague-Dawley rats received daily subcutaneous injections of 1 µg/kg ibandronate (IBAN) and ten control rats received saline (control). Three weeks later a tibial osteotomy was rigidly fixed with compression plating. Six weeks later the animals were killed. Fracture repair was assessed with mechanical testing, radiographs and histology. The mean stress at failure in a four-point bending test was significantly lower in the IBAN group compared with controls (8.69 Nmm(-2) (sd 7.63) vs 24.65 Nmm(-2) (sd 6.15); p = 0.017). On contact radiographs of the extricated tibiae the mean bone density assessment at the osteotomy site was lower in the IBAN group than in controls (3.7 mmAl (sd 0.75) vs 4.6 mmAl (sd 0.57); p = 0.01). In addition, histological analysis revealed progression to fracture union in the controls but impaired fracture healing in the IBAN group, with predominantly cartilage-like and undifferentiated mesenchymal tissue (p = 0.007). Bisphosphonate treatment in a therapeutic dose, as used for risk reduction in fragility fractures, had an inhibitory effect on direct fracture healing. We propose that bisphosphonate therapy not be commenced until after the fracture has united if the fracture has been rigidly fixed and is undergoing direct osteonal healing.

Combat-related acetabular fractures: Outcomes of open versus closed injuries.

PubMed

Purcell, Richard L; Donohue, Michael A; Saxena, Sameer K; Gordon, Wade T; Lewandowski, Louis L

2018-02-01

Since the onset of the Global War on Terror close to 50,000 United States service members have been injured in combat, many of these injuries would have previously been fatal. Among these injuries, open acetabular fractures are at an increased number due to the high percentage of penetrating injuries such as high velocity gunshot wounds and blast injuries. These injuries lead to a greater degree of contamination, and more severe associated injuries. There is a significantly smaller proportion of the classic blunt trauma mechanism typically seen in civilian trauma. We performed a retrospective review of the Department of Defense Trauma Registry into which all US combat-injured patients are enrolled, as well as reviewed local patient medical records, and radiologic studies from March 2003 to April 2012. Eighty seven (87) acetabular fractures were identified with 32 classified as open fractures. Information regarding mechanism of injury, fracture pattern, transfusion requirements, Injury Severity Score (ISS), and presence of lower extremity amputations was analyzed. The mechanism of injury was an explosive device in 59% (n=19) of patients with an open acetabular fracture; the remaining 40% (n=13) were secondary to ballistic injury. In contrast, in the closed acetabular fracture cohort 38% (21/55) of fractures were due to explosive devices, and all remaining (n=34) were secondary to blunt trauma such as falls, motor vehicle collisions, or aircraft crashes. Patients with open acetabular fractures required a median of 17units of PRBC within the first 24h after injury. The mean ISS was 32 in the open group compared with 22 in the closed group (p=0.003). In the open fracture group nine patients (28%) sustained bilateral lower extremity amputations, and 10 patients (31%) ultimately underwent a hip disarticulation or hemi-pelvectomy as their final amputation level. Open acetabular fractures represent a significant challenge in the management of combat-related injuries. High ISS and massive transfusion requirements are common in these injuries. This is one of the largest series reported of open acetabular fractures. Open acetabular fractures require immediate damage control surgery and resuscitation as well as prolonged rehabilitation due to their severity. The dramatic number of open acetabular fractures (37%) in this review highlights the challenge in treatment of combat related acetabular fractures. Published by Elsevier Ltd.

Fracture healing with alendronate treatment in the Brtl/+ mouse model of osteogenesis imperfecta

PubMed Central

Meganck, J.A.; Begun, D.L.; McElderry, J.D.; Swick, A.; Kozloff, K.M.; Goldstein, S.A.; Morris, M.D.; Marini, J.C.; Caird, M.S.

2014-01-01

Osteogenesis imperfecta (OI) is a heritable bone dysplasia characterized by increased skeletal fragility. Patients are often treated with bisphosphonates to attempt to reduce fracture risk. However, bisphosphonates reside in the skeleton for many years and long-term administration may impact bone material quality. Acutely, there is concern about risk of non-union of fractures that occur near the time of bisphosphonate administration. This study investigated the effect of alendronate, a potent aminobisphosphonate, on fracture healing. Using the Brtl/+ murine model of type IV OI, tibial fractures were generated in 8-week-old mice that were untreated, treated with alendronate before fracture, or treated before and after fracture. After 2, 3, or 5 weeks of healing, tibiae were assessed using microcomputed tomography (μCT), torsion testing, quantitative histomorphometry, and Raman microspectroscopy. There were no morphologic, biomechanical or histomorphometric differences in callus between untreated mice and mice that received alendronate before fracture. Alendronate treatment before fracture did not cause a significant increase in cartilage retention in fracture callus. Both Brtl/+ and WT mice that received alendronate before and after fracture had increases in the callus volume, bone volume fraction and torque at failure after 5 weeks of healing. Raman microspectroscopy results did not show any effects of alendronate in wild-type mice, but calluses from Brtl/+ mice treated with alendronate during healing had a decreased mineral-to-matrix ratio, decreased crystallinity and an increased carbonate-to-phosphate ratio. Treatment with alendronate altered the dynamics of healing by preventing callus volume decreases later in the healing process. Fracture healing in Brtl/+ untreated animals was not significantly different from animals in which alendronate was halted at the time of fracture. PMID:23774443

Estimation of the Joint Patient Condition Occurrence Frequencies from Operation Iraqi Freedom and Operation Enduring Freedom. Volume I: Development of Methodology

DTIC Science & Technology

2011-03-28

CL CHEST 807.2 Closed Fracture of Sternum FRAC CL CHEST 808.8 Fracture of Pelvis Unspec, Closed FRAC CL PELVIS+UROGENITAL 810 Clavicle Fracture...of Pelvis Unspec, Open FRAC OP PELVIS+UROGENITAL 810.1 Clavicle Fracture, Open FRAC OP SHOULDER & UPPER ARM 810.12 Open Fracture of Shaft of Clavicle

Fracture Reactivation in Chemically Reactive Rock Systems

NASA Astrophysics Data System (ADS)

Eichhubl, P.; Hooker, J. N.

2013-12-01

Reactivation of existing fractures is a fundamental process of brittle failure that controls the nucleation of earthquake ruptures, propagation and linkage of hydraulic fractures in oil and gas production, and the evolution of fault and fracture networks and thus of fluid and heat transport in the upper crust. At depths below 2-3 km, and frequently shallower, brittle processes of fracture growth, linkage, and reactivation compete with chemical processes of fracture sealing by mineral precipitation, with precipitation rates similar to fracture opening rates. We recently found rates of fracture opening in tectonically quiescent settings of 10-20 μm/m.y., rates similar to euhedral quartz precipitation under these conditions. The tendency of existing partially or completely cemented fractures to reactivate will vary depending on strain rate, mineral precipitation kinetics, strength contrast between host rock and fracture cement, stress conditions, degree of fracture infill, and fracture network geometry. Natural fractures in quartzite of the Cambrian Eriboll Formation, NW Scotland, exhibit a complex history of fracture formation and reactivation, with reactivation involving both repeated crack-seal opening-mode failure and shear failure of fractures that formed in opening mode. Fractures are partially to completely sealed with crack-seal or euhedral quartz cement or quartz cement fragmented by shear reactivation. Degree of cementation controls the tendency of fractures for later shear reactivation, to interact elastically with adjacent open fractures, and their intersection behavior. Using kinematic, dynamic, and diagenetic criteria, we determine the sequence of opening-mode fracture formation and later shear reactivation. We find that sheared fracture systems of similar orientation display spatially varying sense of slip We attribute these inconsistent directions of shear reactivation to 1) a heterogeneous stress field in this highly fractured rock unit and 2) variations in the degree of fracture cement infill in fractures of same orientation, allowing fractures to reactivate at times when adjacent, more cemented fractures remain dormant. The observed interaction of chemical and mechanical fracture growth and sealing processes in this chemically reactive and heavily deformed rock unit results in a complex fracture network geometry not generally observed in less chemically reactive, shallower crustal environments.

Biomechanical Tolerance of Calcaneal Fractures

PubMed Central

Yoganandan, Narayan; Pintar, Frank A.; Gennarelli, Thomas A.; Seipel, Robert; Marks, Richard

1999-01-01

Biomechanical studies have been conducted in the past to understand the mechanisms of injury to the foot-ankle complex. However, statistically based tolerance criteria for calcaneal complex injuries are lacking. Consequently, this research was designed to derive a probability distribution that represents human calcaneal tolerance under impact loading such as those encountered in vehicular collisions. Information for deriving the distribution was obtained by experiments on unembalmed human cadaver lower extremities. Briefly, the protocol included the following. The knee joint was disarticulated such that the entire lower extremity distal to the knee joint remained intact. The proximal tibia was fixed in polymethylmethacrylate. The specimens were aligned and impact loading was applied using mini-sled pendulum equipment. The pendulum impactor dynamically loaded the plantar aspect of the foot once. Following the test, specimens were palpated and radiographs in multiple planes were obtained. Injuries were classified into no fracture, and extra-and intra-articular fractures of the calcaneus. There were 14 cases of no injury and 12 cases of calcaneal fracture. The fracture forces (mean: 7802 N) were significantly different (p<0.01) from the forces in the no injury (mean: 4144 N) group. The probability of calcaneal fracture determined using logistic regression indicated that a force of 6.2 kN corresponds to 50 percent probability of calcaneal fracture. The derived probability distribution is useful in the design of dummies and vehicular surfaces.

Comparison of Open and Closed Hand Fractures and the Effect of Urgent Operative Intervention.

PubMed

Minhas, Shobhit V; Catalano, Louis W

2018-06-13

To establish and compare the incidence of 30-day postoperative infection in surgically managed open and closed metacarpal and phalangeal fractures, and to determine whether open fractures treated urgently had a lower incidence of postoperative infection. We conducted a retrospective analysis of patient demographics, comorbidities, and 30-day infection rates of patients undergoing operative fixation of metacarpal, proximal, or middle phalanx fractures from 2008 to 2015 using the American College of Surgeons' National Surgical Quality Improvement Program database. A total of 3,506 patients were identified and patient variables and infection incidence were compared between open and closed injuries, as well as open injuries managed within 1 day of admission and those treated on an elective basis or treated more than 1 day after admission. Bivariate analysis was used to determine independent risk factors for postoperative infection. Although 34.2% of open hand fractures were taken urgently to the operating room, the diagnosis of open fractures along with nonurgent surgical treatment for open fractures was associated with a low incidence of postoperative infection. In addition, smoking was a risk factor for postoperative infection although anatomic location (phalanx vs metacarpal) was not. Patients undergoing surgery for metacarpal or proximal/middle phalangeal fractures are not at greater risk for infection based on the diagnosis of open fracture alone. In addition, patients with open fractures who are taken to the operating room more than 1 day from presentation did not have a higher incidence of infection. Smoking is associated with increased 30-day infection rates after surgery, and surgeons should identify these patients for preoperative risk stratification, counseling, and postoperative wound monitoring. Prognostic II. Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

A method of building of decision trees based on data from wearable device during a rehabilitation of patients with tibia fractures

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

Kupriyanov, M. S., E-mail: mikhail.kupriyanov@gmail.com; Shukeilo, E. Y., E-mail: eyshukeylo@gmail.com; Shichkina, J. A., E-mail: strange.y@mail.ru

2015-11-17

Nowadays technologies which are used in traumatology are a combination of mechanical, electronic, calculating and programming tools. Relevance of development of mobile applications for an expeditious data processing which are received from medical devices (in particular, wearable devices), and formulation of management decisions increases. Using of a mathematical method of building of decision trees for an assessment of a patient’s health condition using data from a wearable device considers in this article.

A method of building of decision trees based on data from wearable device during a rehabilitation of patients with tibia fractures

NASA Astrophysics Data System (ADS)

Kupriyanov, M. S.; Shukeilo, E. Y.; Shichkina, J. A.

2015-11-01

Nowadays technologies which are used in traumatology are a combination of mechanical, electronic, calculating and programming tools. Relevance of development of mobile applications for an expeditious data processing which are received from medical devices (in particular, wearable devices), and formulation of management decisions increases. Using of a mathematical method of building of decision trees for an assessment of a patient's health condition using data from a wearable device considers in this article.

Internal tibial torsion correction study. [measurements of strain for corrective rotation of stressed tibia

NASA Technical Reports Server (NTRS)

Cantu, J. M.; Madigan, C. M.

1974-01-01

A quantitative study of internal torsion in the entire tibial bone was performed by using strain gauges to measure the amount of deformation occuring at different locations. Comparison of strain measurements with physical dimensions of the bone produced the modulus of rigidity and its behavior under increased torque. Computerized analysis of the stress distribution shows that more strain occurs near the torqued ends of the bones where also most of the twisting and fracturing takes place.

Factorial correspondence analysis of fear-related behaviour traits in Japanese quail.

PubMed

Mignon-Grasteau, S; Roussot, O; Delaby, C; Faure, J M.; Mills, A; Leterrier, C; Guéméné, D; Constantin, P; Mills, M; Lepape, G; Beaumont, C

2003-02-28

Factorial correspondence analysis was performed on 341 quails from a F2 cross between two lines divergently selected on the duration of tonic immobility over 29 generations. Several fear- or stress-related traits were recorded, i.e. tonic immobility duration, number of inductions needed to induce tonic immobility, open-field behaviour (time spent walking, latency before first movement and number of defecations), asymmetry of tibia lengths and corticosterone concentration after restraint stress. Variables were categorised in classes and analysed by factorial correspondence analysis. The first axis was mostly described by open-field behaviour, and the second by tonic immobility traits (duration of tonic immobility and number of inductions), which showed that these behaviours were almost independent. No relationship was found between axes of the factorial correspondence analysis and corticosterone concentration or asymmetry of tibia lengths, showing that these variables reflected other characteristics of stress susceptibility than those described by tonic immobility and open-field behaviour. These results show that reaction to stress of quails is a multidimensional trait and cannot be summarised by one trait.

Fluid Lavage of Open Wounds (FLOW): A Multicenter, Blinded, Factorial Trial Comparing Alternative Irrigating Solutions and Pressures in Patients with Open Fractures

DTIC Science & Technology

2013-10-01

Multicenter, Blinded, Factorial Trial Comparing Alternative Irrigating Solutions and Pressures in Patients with Open Fractures PRINCIPAL...Solutions and Pressures in Patients with Open Fractures 5b. GRANT NUMBER W81XWH-12-1-0530 5c. PROGRAM ELEMENT NUMBER 6. AUTHOR(S) Kyle J. Jeray...important initial step in preventing infection in open fractures . However, there is little clinical evidence as to the best irrigation methods and additives

Recovery of mouth-opening after closed treatment of a fracture of the mandibular condyle: a longitudinal study.

PubMed

Niezen, E T; Stuive, I; Post, W J; Bos, R R M; Dijkstra, P U

2015-02-01

The aim of this retrospective study was to assess recovery of mouth opening after closed treatment of fractures of the mandibular condyle, and analyse which characteristics might influence recovery. We measured mouth opening in 142 patients (mean (SD) age 30 (14) years, 96 of whom were male) during follow-up at 3, 6, 13, 26, and 52 weeks after the injury. Fractures were assessed on radiographs. Data were analysed using a multilevel analysis. Half the fractures were of the low condylar neck (n=71). Thirty-seven patients had bilateral condylar fractures, 29 had dislocated fractures, and in 80 the fracture was displaced. One or more additional mandibular fractures were present in 68. During follow-up mean (SD) mouth opening increased to: 33.6 (9.6) at 3 weeks, 40.1 (10.0) at 6 weeks, 45.1 (9.6) at 13 weeks, 49.8 (9.5) at 26 weeks, and 52.6 (7.5) at 52 weeks. Older age, female sex, displaced fracture, bilateral fractures, additional mandibular fractures, and the interaction between follow-up time and additional mandibular fractures, were predictors of a less favourable recovery of mouth opening. Clinicians can use the results of this study to predict recovery of mouth opening after closed treatment of fractures of the mandibular condyle at first consultation. Copyright © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Chemical Signatures of and Precursors to Fractures Using Fluid Inclusion Stratigraphy

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

Lorie M. Dilley

Enhanced Geothermal Systems (EGS) are designed to recover heat from the subsurface by mechanically creating fractures in subsurface rocks. Open or recently closed fractures would be more susceptible to enhancing the permeability of the system. Identifying dense fracture areas as well as large open fractures from small fracture systems will assist in fracture stimulation site selection. Geothermal systems are constantly generating fractures (Moore, Morrow et al. 1987), and fluids and gases passing through rocks in these systems leave small fluid and gas samples trapped in healed microfractures. These fluid inclusions are faithful records of pore fluid chemistry. Fluid inclusions trappedmore » in minerals as the fractures heal are characteristic of the fluids that formed them, and this signature can be seen in fluid inclusion gas analysis. This report presents the results of the project to determine fracture locations by the chemical signatures from gas analysis of fluid inclusions. With this project we hope to test our assumptions that gas chemistry can distinguish if the fractures are open and bearing production fluids or represent prior active fractures and whether there are chemical signs of open fracture systems in the wall rock above the fracture. Fluid Inclusion Stratigraphy (FIS) is a method developed for the geothermal industry which applies the mass quantification of fluid inclusion gas data from drill cuttings and applying known gas ratios and compositions to determine depth profiles of fluid barriers in a modern geothermal system (Dilley, 2009; Dilley et al., 2005; Norman et al., 2005). Identifying key gas signatures associated with fractures for isolating geothermal fluid production is the latest advancement in the application of FIS to geothermal systems (Dilley and Norman, 2005; Dilley and Norman, 2007). Our hypothesis is that peaks in FIS data are related to location of fractures. Previous work (DOE Grant DE-FG36-06GO16057) has indicated differences in the chemical signature of fluid inclusions between open and closed fractures as well as differences in the chemical signature of open fractures between geothermal systems. Our hypothesis is that open fracture systems can be identified by their FIS chemical signature; that there are differences based on the mineral assemblages and geology of the system; and that there are chemical precursors in the wall rock above open, large fractures. Specific goals for this project are: (1) To build on the preliminary results which indicate that there are differences in the FIS signatures between open and closed fractures by identifying which chemical species indicate open fractures in both active geothermal systems and in hot, dry rock; (2) To evaluate the FIS signatures based on the geology of the fields; (3) To evaluate the FIS signatures based on the mineral assemblages in the fracture; and (4) To determine if there are specific chemical signatures in the wall rock above open, large fractures. This method promises to lower the cost of geothermal energy production in several ways. Knowledge of productive fractures in the boreholes will allow engineers to optimize well production. This information can aid in well testing decisions, well completion strategies, and in resource calculations. It will assist in determining the areas for future fracture enhancement. This will develop into one of the techniques in the 'tool bag' for creating and managing Enhanced Geothermal Systems.« less

Structural-Diagenetic Controls on Fracture Opening in Tight Gas Sandstone Reservoirs, Alberta Foothills

NASA Astrophysics Data System (ADS)

Ukar, Estibalitz; Eichhubl, Peter; Fall, Andras; Hooker, John

2013-04-01

In tight gas reservoirs, understanding the characteristics, orientation and distribution of natural open fractures, and how these relate to the structural and stratigraphic setting are important for exploration and production. Outcrops provide the opportunity to sample fracture characteristics that would otherwise be unknown due to the limitations of sampling by cores and well logs. However, fractures in exhumed outcrops may not be representative of fractures in the reservoir because of differences in burial and exhumation history. Appropriate outcrop analogs of producing reservoirs with comparable geologic history, structural setting, fracture networks, and diagenetic attributes are desirable but rare. The Jurassic to Lower Cretaceous Nikanassin Formation from the Alberta Foothills produces gas at commercial rates where it contains a network of open fractures. Fractures from outcrops have the same diagenetic attributes as those observed in cores <100 km away, thus offering an ideal opportunity to 1) evaluate the distribution and characteristics of opening mode fractures relative to fold cores, hinges and limbs, 2) compare the distribution and attributes of fractures in outcrop vs. core samples, 3) estimate the timing of fracture formation relative to the evolution of the fold-and-thrust belt, and 4) estimate the degradation of fracture porosity due to postkinematic cementation. Cathodoluminescence images of cemented fractures in both outcrop and core samples reveal several generations of quartz and ankerite cement that is synkinematic and postkinematic relative to fracture opening. Crack-seal textures in synkinematic quartz are ubiquitous, and well-developed cement bridges abundant. Fracture porosity may be preserved in fractures wider than ~100 microns. 1-D scanlines in outcrop and core samples indicate fractures are most abundant within small parasitic folds within larger, tight, mesoscopic folds. Fracture intensity is lower away from parasitic folds; intensity progressively decreases from the faulted cores of mesoscopic folds to their forelimbs, with lowest intensities within relatively undeformed backlimb strata. Fracture apertures locally increase adjacent to reverse faults without an overall increase in fracture frequency. Fluid inclusion analyses of crack-seal quartz cement indicate both aqueous and methane-rich inclusions are present. Homogenization temperatures of two-phase inclusions indicate synkinematic fracture cement precipitation and fracture opening under conditions at or near maximum burial of 190-210°C in core samples, and 120-160°C in outcrop samples. In comparison with the fracture evolution in other, less deformed tight-gas sandstone reservoirs such as the Piceance and East Texas basins where fracture opening is primarily controlled by gas generation, gas charge, and pore fluid pressure, these results suggest a strong control of regional tectonic processes on fracture generation. In conjunction with timing and rate of gas charge, rates of fracture cement growth, and stratigraphic-lithological controls, these processes determine the overall distribution of open fractures in these reservoirs.

Structural-Diagenetic Controls on Fracture Opening in Tight Gas Sandstone Reservoirs, Alberta Foothills

NASA Astrophysics Data System (ADS)

Ukar, E.; Eichhubl, P.; Fall, A.; Hooker, J. N.

2012-12-01

In tight gas reservoirs, understanding the characteristics, orientation and distribution of natural open fractures, and how these relate to the structural and stratigraphic setting are important for exploration and production. Outcrops provide the opportunity to sample fracture characteristics that would otherwise be unknown due to the limitations of sampling by cores and well logs. However, fractures in exhumed outcrops may not be representative of fractures in the reservoir because of differences in burial and exhumation history. Appropriate outcrop analogs of producing reservoirs with comparable geologic history, structural setting, fracture networks, and diagenetic attributes are desirable but rare. The Jurassic to Lower Cretaceous Nikanassin Formation from the Alberta Foothills produces gas at commercial rates where it contains a network of open fractures. Fractures from outcrops have the same diagenetic attributes as those observed in cores <100 km away, thus offering an ideal opportunity to 1) evaluate the distribution and characteristics of opening mode fractures relative to fold cores, hinges and limbs, 2) compare the distribution and attributes of fractures in outcrop vs. core samples, 3) estimate the timing of fracture formation relative to the evolution of the fold-and-thrust belt, and 4) estimate the degradation of fracture porosity due to postkinematic cementation. Cathodoluminescence images of cemented fractures in both outcrop and core samples reveal several generations of quartz and ankerite cement that is synkinematic and postkinematic relative to fracture opening. Crack-seal textures in synkinematic quartz are ubiquitous, and well-developed cement bridges abundant. Fracture porosity may be preserved in fractures wider than ~100 microns. 1-D scanlines in outcrop and core samples indicate fractures are most abundant within small parasitic folds within larger, tight, mesoscopic folds. Fracture intensity is lower away from parasitic folds; intensity progressively decreases from the faulted cores of mesoscopic folds to their forelimbs, with lowest intensities within relatively undeformed backlimb strata. Fracture apertures locally increase adjacent to reverse faults without an overall increase in fracture frequency. Fluid inclusion analyses of crack-seal quartz cement indicate both aqueous and methane-rich inclusions are present. Homogenization temperatures of two-phase inclusions indicate synkinematic fracture cement precipitation and fracture opening under conditions at or near maximum burial of 190-210°C in core samples, and 120-160°C in outcrop samples. In comparison with the fracture evolution in other, less deformed tight-gas sandstone reservoirs such as the Piceance and East Texas basins where fracture opening is primarily controlled by gas generation, gas charge, and pore fluid pressure, these results suggest a strong control of regional tectonic processes on fracture generation. In conjunction with timing and rate of gas charge, rates of fracture cement growth, and stratigraphic-lithological controls, these processes determine the overall distribution of open fractures in these reservoirs.

Regional variation of bone density, microarchitectural parameters, and elastic moduli in the ultradistal tibia of young black and white men and women.

PubMed

Unnikrishnan, Ginu; Xu, Chun; Popp, Kristin L; Hughes, Julie M; Yuan, Amy; Guerriere, Katelyn I; Caksa, Signe; Ackerman, Kathryn E; Bouxsein, Mary L; Reifman, Jaques

2018-07-01

Whole-bone analyses can obscure regional heterogeneities in bone characteristics. Quantifying these heterogeneities might improve our understanding of the etiology of injuries, such as lower-extremity stress fractures. Here, we performed regional analyses of high-resolution peripheral quantitative computed tomography images of the ultradistal tibia in young, healthy subjects (age range, 18 to 30 years). We quantified bone characteristics across four regional sectors of the tibia for the following datasets: white women (n = 50), black women (n = 51), white men (n = 50), black men (n = 34), and all subjects (n = 185). After controlling for potentially confounding variables, we observed statistically significant variations in most of the characteristics across sectors (p < 0.05). Most of the bone characteristics followed a similar trend for all datasets but with different magnitudes. Regardless of race or sex, the anterior sector had the lowest trabecular and total volumetric bone mineral density and highest trabecular separation (p < 0.001), while cortical thickness was lowest in the medial sector (p < 0.05). Accordingly, the anterior sector also had the lowest elastic modulus in the anterior-posterior and superior-inferior directions (p < 0.001). In all sectors, the mean anisotropy was ~3, suggesting cross-sector similarity in the ratios of loading in these directions. In addition, the bone characteristics from regional and whole-bone analyses differed in all datasets (p < 0.05). Our findings on the heterogeneous nature of bone microarchitecture in the ultradistal tibia may reflect an adaptation of the bone to habitual loading conditions. Published by Elsevier Inc.

The changing epidemiology of open fractures in vehicle occupants, pedestrians, motorcyclists and cyclists.

PubMed

Winkler, Dennis; Goudie, Stuart T; Court-Brown, Charles M

2018-02-01

To investigate the changing epidemiology of open fractures in vehicle occupants, pedestrians, motorcyclists and cyclists. Data on all non-spinal open fractures admitted to the Royal Infirmary of Edinburgh after a road traffic accident between 1988 and 2010 were collected and analysed to provide information about the changing epidemiology in different patient groups. Demographic information was collected on all patients with the severity of injury being analysed with the Injury Severity Score (ISS), Musculoskeletal Index (MSI) and the number of open fractures. The severity of the open fractures was analysed using the Gustilo classification. The 23-year study period was divided into four shorter periods and the results were compared. There were 696 patients treated in 23 years. Analysis showed that the incidence of RTA open fractures initially fell in both males and females and continued to fall in females during the 23 years. In males it levelled off about 2000. The age of the female patients also fell during the study period but it did not change in males. The only patient group to show an increased incidence of open fractures were cyclists. In vehicle occupants the incidence fell throughout the study period but it levelled off in pedestrians and motorcyclists. There was no difference in the severity of injury in any group during the study period. The most severe open fractures were those of the distal femur and femoral diaphysis although open tibial diaphyseal fractures were the most common fracture in all patient groups. Improved car design and road safety legislation has resulted in a reduction in the incidence of open fractures in vehicle occupants, pedestrians and motorcyclists. The most obvious group to have benefitted from this are older female pedestrians. The only group to show an increase in age during the study period were male motorcyclists. Copyright © 2017 Elsevier Ltd. All rights reserved.

Diagnostic accuracy of ultrasound in upper and lower extremity long bone fractures of emergency department trauma patients.

PubMed

Frouzan, Arash; Masoumi, Kambiz; Delirroyfard, Ali; Mazdaie, Behnaz; Bagherzadegan, Elnaz

2017-08-01

Long bone fractures are common injuries caused by trauma. Some studies have demonstrated that ultrasound has a high sensitivity and specificity in the diagnosis of upper and lower extremity long bone fractures. The aim of this study was to determine the accuracy of ultrasound compared with plain radiography in diagnosis of upper and lower extremity long bone fractures in traumatic patients. This cross-sectional study assessed 100 patients admitted to the emergency department of Imam Khomeini Hospital, Ahvaz, Iran with trauma to the upper and lower extremities, from September 2014 through October 2015. In all patients, first ultrasound and then standard plain radiography for the upper and lower limb was performed. Data were analyzed by SPSS version 21 to determine the specificity and sensitivity. The mean age of patients with upper and lower limb trauma were 31.43±12.32 years and 29.63±5.89 years, respectively. Radius fracture was the most frequent compared to other fractures (27%). Sensitivity, specificity, positive predicted value, and negative predicted value of ultrasound compared with plain radiography in the diagnosis of upper extremity long bones were 95.3%, 87.7%, 87.2% and 96.2%, respectively, and the highest accuracy was observed in left arm fractures (100%). Tibia and fibula fractures were the most frequent types compared to other fractures (89.2%). Sensitivity, specificity, PPV and NPV of ultrasound compared with plain radiography in the diagnosis of upper extremity long bone fractures were 98.6%, 83%, 65.4% and 87.1%, respectively, and the highest accuracy was observed in men, lower ages and femoral fractures. The results of this study showed that ultrasound compared with plain radiography has a high accuracy in the diagnosis of upper and lower extremity long bone fractures.

Soft-plastic brace for lower limb fractures in patients with spinal cord injury.

PubMed

Uehara, K; Akai, M; Kubo, T; Yamasaki, N; Okuma, Y; Tobimatsu, Y; Iwaya, T

2013-04-01

Retrospective study at a rehabilitation center. Patients with spinal cord injury, even if they are wheelchair users, sometimes suffer from fractures of the lower limb bones. As their bones are too weak to have surgery, and because a precise reduction is not required for restoration, such patients are often indicated for conservative treatment. This case series study investigated the use of a hinged, soft-plastic brace as a conservative approach to treating fractures of the lower extremities of patients with spinal cord injury. National Rehabilitation Center, Japan. Fifteen patients (male, n=10; female, n=5; average age, 52.7 years) with 19 fractures of the femur or the tibia who were treated with a newly-developed hinged, soft-plastic brace were studied. All of them used wheelchairs. We analyzed the time taken for fracture union and for wearing orthotics, degree of malalignment, femorotibial angle and side effects. The fractures in this series were caused by relatively low-energy impact. The average time taken for fracture union was 80.1 (37-189) days, and the average amount of time spent wearing orthotics was 77.9 (42-197) days. On final X-ray imaging, the average femorotibial angle was 176.9° (s.d. ±8.90), and 15° of misalignment in the sagittal plane occurred in one patient. A hinged, soft-plastic brace is a useful option as a conservative approach for treating fractures of the lower extremities in patients with spinal cord injury.

Does colostomy prevent infection in open blunt pelvic fractures? A systematic review.

PubMed

Lunsjo, Karl; Abu-Zidan, Fikri M

2006-05-01

Open pelvic fracture is a rare injury. Our aim in this study is to systematically review the literature to define when diverting colostomy is indicated to protect the patient from infection in open blunt pelvic fractures. Papers studying open pelvic fractures and the use of colostomy were retrieved through MEDLINE and PUBMED. The papers were critically appraised regarding their methodology and conclusions. Relevant information was combined. The level of evidence for the use of colostomy in open pelvic fractures is very low. All reports are retrospective and no statistical methods have been used to support conclusions drawn. We found no difference in the overall infectious complication rate between the colostomy and noncolostomy groups. There is an assumption that patients with perineal wounds would benefit from colostomy; however, rectal involvement in these injuries was not detailed. The role of colostomy in open blunt pelvic fractures is unresolved and randomized multicenter trials are needed.

Closed Versus Open Supracondylar Fractures of the Humerus in Children: A Comparison of Clinical and Radiographic Presentation and Results.

PubMed

Lewine, Eliza; Kim, Jaehon M; Miller, Patricia E; Waters, Peter M; Mahan, Susan T; Snyder, Brian; Hedequist, Daniel; Bae, Donald S

2018-02-01

The purpose of this investigation was to compare the presentation and postoperative results of children treated for open and closed, completely displaced type III supracondylar humerus fractures (SCFs). Thirty patients with open and 66 patients with closed, completely displaced type III SCFs were evaluated. Open fractures underwent irrigation and debridement, and all patients were treated by open or closed reduction and pin fixation. Medical records were reviewed to obtain demographic information as well as preoperative and postoperative clinical data regarding mechanism of injury, neurovascular status, associated injuries, postoperative range of motion, infections, and pain. Radiographs were evaluated to quantify displacement, Baumann's angle, humeral capitellar angle, position of the anterior humeral line, and adequacy of reduction. Outcomes were assessed using Flynn criteria. Mean clinical follow-up for the open and closed fracture groups was 8.9 and 5.7 months, respectively. Both groups were similar with respect to age, sex distribution, weight and body mass index, laterality of involvement, and mechanism of injury. At presentation, 35% of closed SCFs and 23% of open SCFs presented with abnormal neurovascular status. There was a higher prevalence of diminished/absent pulses or distal limb ischemia in patients with open injuries (27%) compared with closed fractures (18%). Conversely, severely displaced closed fractures were more commonly associated with nerve injury/palsy at presentation (35%) than those with open fractures (23%). Spontaneous nerve recovery was seen in 87% within 3 to 6 months. Postoperative loss of reduction and malunion were more common in the closed fracture group. However, 84% of patients achieved good-to-excellent results by Flynn criteria, with no appreciable difference based upon open versus closed fractures. With timely wound and fracture treatment, the clinical and radiographic results of children treated for open SCFs is similar to those with closed type III injuries, with little increased risk for infection, malunion, or neurovascular compromise. Level III.

Complex and open fractures: a straightforward approach to management in the cat.

PubMed

Corr, Sandra

2012-01-01

Cats often present with traumatic injuries of the limbs, including complex and open fractures, frequently as a result of road traffic accidents. On initial assessment, complex and open fractures may appear to require expertise beyond the experience of the general practitioner and, in some cases, referral to a specialist may be indicated or amputation should be considered. Many cases, however, can be managed using straightforward principles. This review describes a logical and practical approach to treating such injuries. It discusses general principles of fracture management, highlights the treatment of open fractures, and describes the use of external skeletal fixation for stabilisation of both open and complex fractures. Most fractures can be stabilised using equipment and expertise available in general practice if the basic principles of fracture fixation are understood and rigorously applied. Many textbooks and journal articles have been published on the management of fractures in companion animals, presenting case studies, case series and original biomechanical research. The simple strategy for managing complex injuries that is provided in this review is based on the published literature and the author's clinical experience.

Editorial: Spatial arrangement of faults and opening-mode fractures

NASA Astrophysics Data System (ADS)

Laubach, Stephen E.; Lamarche, Juliette; Gauthier, Bertand D. M.; Dunne, William M.

2018-03-01

This issue of the Journal of Structural Geology titled Spatial arrangement of faults and opening-mode fractures explores a fundamental characteristic of fault and fracture arrays. The pattern of fault and opening-mode fracture positions in space defines structural heterogeneity and anisotropy in a rock volume, governs how faults and fractures affect fluid flow, and impacts our understanding of the initiation, propagation and interactions during the formation of fracture patterns. This special issue highlights recent progress with respect to characterizing and understanding the spatial arrangements of fault and fracture patterns, providing examples over a wide range of scales and structural settings.

Quartz c-axis orientation patterns in fracture cement as a measure of fracture opening rate and a validation tool for fracture pattern models

DOE PAGES

Ukar, Estibalitz; Laubach, Stephen E.; Marrett, Randall

2016-03-09

Here, we evaluate a published model for crystal growth patterns in quartz cement in sandstone fractures by comparing crystal fracture-spanning predictions to quartz c-axis orientation distributions measured by electron backscatter diffraction (EBSD) of spanning quartz deposits. Samples from eight subvertical opening-mode fractures in four sandstone formations, the Jurassic– Cretaceous Nikanassin Formation, northwestern Alberta Foothills (Canada), Cretaceous Mesaverde Group (USA; Cozzette Sandstone Member of the Iles Formation), Piceance Basin, Colorado (USA), and upper Jurassic–lower Cretaceous Cotton Valley Group (Taylor sandstone) and overlying Travis Peak Formation, east Texas, have similar quartzose composition and grain size but contain fractures with different temperature historiesmore » and opening rates based on fluid inclusion assemblages and burial history. Spherical statistical analysis shows that, in agreement with model predictions, bridging crystals have a preferred orientation with c-axis orientations at a high angle to fracture walls. The second form of validation is for spanning potential that depends on the size of cut substrate grains. Using measured cut substrate grain sizes and c-axis orientations of spanning bridges, we calculated the required orientation for the smallest cut grain to span the maximum gap size and the required orientation of the crystal with the least spanning potential to form overgrowths that span across maximum measured gap sizes. We find that within a 10° error all spanning crystals conform to model predictions. Using crystals with the lowest spanning potential based on crystallographic orientation (c-axis parallel to fracture wall) and a temperature range for fracture opening measured from fluid inclusion assemblages, we calculate maximum fracture opening rates that allow crystals to span. These rates are comparable to those derived independently from fracture temperature histories based on burial history and multiple sequential fluid inclusion assemblages. Results support the R. Lander and S. Laubach model, which predicts that for quartz deposited synchronously with fracture opening, spanning potential, or likelihood of quartz deposits that are thick enough to span between fracture walls, depends on temperature history, fracture opening rate, size of opening increments, and size, mineralogy, and crystallographic orientation of substrates in the fracture wall (transected grains). Results suggest that EBSD maps, which can be more rapidly acquired than measurement of tens to hundreds of fluid inclusion assemblages, can provide a useful measure of relative opening rates within populations of quartz-filled fractures formed under sedimentary basin conditions. Such data are useful for evaluating fracture pattern development models.« less

Quartz c-axis orientation patterns in fracture cement as a measure of fracture opening rate and a validation tool for fracture pattern models

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

Ukar, Estibalitz; Laubach, Stephen E.; Marrett, Randall

Here, we evaluate a published model for crystal growth patterns in quartz cement in sandstone fractures by comparing crystal fracture-spanning predictions to quartz c-axis orientation distributions measured by electron backscatter diffraction (EBSD) of spanning quartz deposits. Samples from eight subvertical opening-mode fractures in four sandstone formations, the Jurassic– Cretaceous Nikanassin Formation, northwestern Alberta Foothills (Canada), Cretaceous Mesaverde Group (USA; Cozzette Sandstone Member of the Iles Formation), Piceance Basin, Colorado (USA), and upper Jurassic–lower Cretaceous Cotton Valley Group (Taylor sandstone) and overlying Travis Peak Formation, east Texas, have similar quartzose composition and grain size but contain fractures with different temperature historiesmore » and opening rates based on fluid inclusion assemblages and burial history. Spherical statistical analysis shows that, in agreement with model predictions, bridging crystals have a preferred orientation with c-axis orientations at a high angle to fracture walls. The second form of validation is for spanning potential that depends on the size of cut substrate grains. Using measured cut substrate grain sizes and c-axis orientations of spanning bridges, we calculated the required orientation for the smallest cut grain to span the maximum gap size and the required orientation of the crystal with the least spanning potential to form overgrowths that span across maximum measured gap sizes. We find that within a 10° error all spanning crystals conform to model predictions. Using crystals with the lowest spanning potential based on crystallographic orientation (c-axis parallel to fracture wall) and a temperature range for fracture opening measured from fluid inclusion assemblages, we calculate maximum fracture opening rates that allow crystals to span. These rates are comparable to those derived independently from fracture temperature histories based on burial history and multiple sequential fluid inclusion assemblages. Results support the R. Lander and S. Laubach model, which predicts that for quartz deposited synchronously with fracture opening, spanning potential, or likelihood of quartz deposits that are thick enough to span between fracture walls, depends on temperature history, fracture opening rate, size of opening increments, and size, mineralogy, and crystallographic orientation of substrates in the fracture wall (transected grains). Results suggest that EBSD maps, which can be more rapidly acquired than measurement of tens to hundreds of fluid inclusion assemblages, can provide a useful measure of relative opening rates within populations of quartz-filled fractures formed under sedimentary basin conditions. Such data are useful for evaluating fracture pattern development models.« less

Land-Surface Subsidence and Open Bedrock Fractures in the Tully Valley, Onondaga County, New York

USGS Publications Warehouse

Hackett, William R.; Gleason, Gayle C.; Kappel, William M.

2009-01-01

Open bedrock fractures were mapped in and near two brine field areas in Tully Valley, New York. More than 400 open fractures and closed joints were mapped for dimension, orientation, and distribution along the east and west valley walls adjacent to two former brine fields. The bedrock fractures are as much as 2 feet wide and over 50 feet deep, while linear depressions in the soil, which are 3 to 10 feet wide and 3 to 6 feet deep, indicate the presence of open bedrock fractures below the soil. The fractures are probably the result of solution mining of halite deposits about 1,200 feet below the land surface.

Role of Systemic and Local Antibiotics in the Treatment of Open Fractures.

PubMed

Carver, David C; Kuehn, Sean B; Weinlein, John C

2017-04-01

The orthopedic community has learned much about the treatment of open fractures from the tremendous work of Ramon Gustilo, Michael Patzakis, and others; however, open fractures continue to be very difficult challenges. Type III open fractures continue to be associated with high infection rates. Some combination of systemic and local antibiotics may be most appropriate in these high-grade open fractures. Further research is still necessary in determining optimal systemic antibiotic regimens as well as the role of local antibiotics. Any new discoveries related to novel systemic antibiotics or local antibiotic carriers will need to be evaluated related to cost. Copyright © 2016 Elsevier Inc. All rights reserved.

Hydrogen-rich saline prevents bone loss in diabetic rats induced by streptozotocin.

PubMed

Guo, Jialiang; Dong, Weichong; Jin, Lin; Wang, Pengcheng; Hou, Zhiyong; Zhang, Yingze

2017-10-01

As an antioxidant molecule, hydrogen has been received much more attention and reported to be used as the treatment strategy for various diseases. In this study, we hypothesize that systemic delivery of hydrogen saline water may improve the reservation of bone tissue in the tibias and femurs of osteoporotic rats caused by diabetes mellitus (DM), which is characterized by increased levels of oxidative stress and overproducing reactive oxygen species (ROS). The animals were divided into three groups of 12 animals and lavaged with normal saline (normal control and DM), or hydrogen saline water (DM + HRS). General status, blood glucose level, tibial and femoral mechanical strength, and micro-CT scans of the proximal tibia were recorded and analyzed. After 12 weeks, the glucose level was significantly decreased in the DM + HRS group compared with that of the DM group. Micro-CT scans showed that bone volume/total volume, connectivity density, trabecular thickness, and trabecular number were significantly increased compared with the DM group. Mechanical results of energy, stiffness and elastic modulus in the DM + HRS group were significantly higher than in the other groups for the tibia and femur. The results indicate that the systemic delivery of hydrogen saline water, which is safe and well tolerated, preserves bone volume and decreases fracture risks in streptozotocin-induced diabetic status rats, whose bone structure or inherent material properties of bone tissues are changed.

Comparison between the effects of platelet-rich plasma and bone marrow concentrate on defect consolidation in the rabbit tibia

PubMed Central

Batista, Marco Antonio; Leivas, Tomaz Puga; Rodrigues, Consuelo Junqueira; Arenas, Géssica Cantadori Funes; Belitardo, Donizeti Rodrigues; Guarniero, Roberto

2011-01-01

OBJECTIVE: To perform a comparative analysis of the effects of platelet-rich plasma and centrifuged bone marrow aspirate on the induction of bone healing in rabbits. METHOD: Twenty adult, male New Zealand rabbits were randomly separated into two equal groups, and surgery was performed to create a bone defect (a cortical orifice 3.3 mm in diameter) in the proximal metaphysis of each rabbit's right tibia. In the first group, platelet-rich plasma was implanted in combination with β-tricalcium phosphate (platelet-rich plasma group), and in the second group, centrifuged bone marrow in combination with β-tricalcium phosphate (centrifuged bone marrow group) was implanted. After a period of four weeks, the animals were euthanized, and the tibias were evaluated using digital radiography, computed tomography, and histomorphometry. RESULTS: Seven samples from each group were evaluated. The radiographic evaluation confirmed the absence of fractures in the postoperative limb and identified whether bone consolidation had occurred. The tomographic evaluation revealed a greater amount of consolidation and the formation of a greater cortical bone thickness in the platelet-rich plasma group. The histomorphometry revealed a greater bone density in the platelet-rich plasma group compared with the centrifuged bone marrow group. CONCLUSION: After four weeks, the platelet-rich plasma promoted a greater amount of bone consolidation than the bone marrow aspirate concentrate. PMID:22012052

Subacute reconstruction of lower leg and foot defects due to high velocity-high energy injuries caused by gunshots, missiles, and land mines.

PubMed

Celiköz, Bahattin; Sengezer, Mustafa; Işik, Selçuk; Türegün, Murat; Deveci, Mustafa; Duman, Haluk; Acikel, Cengiz; Nişanci, Mustafa; Oztürk, Serdar

2005-01-01

The present study reviews 215 male patients suffering high velocity-high energy injuries of the lower leg or foot caused by war weapons such as missiles, gunshots, and land mines. They were treated in the Department of Plastic and Reconstructive Surgery at Gulhane Military Medical Academy (Ankara, Turkey) between November 1993-January 2001. Severe soft-tissue defects requiring flap coverage and associated open bone fractures that were treated 7-21 days (mean, 9.6 days) after the injury were included in the study. Twenty-three of 226 extremities (10.2%) underwent primary below-knee amputation. The number of debridements prior to definitive treatment was between 1-3 (mean, 1.9). Gustilo type III open tibia fractures accompanied 104 of 126 soft-tissue defects of the lower leg. Sixty-four bone defects accompanied 83 soft-tissue defects of the feet. Eighteen local pedicled muscle flaps and 208 free muscle flaps (latissimus dorsi, rectus abdominis, and gracilis) were used in soft-tissue coverage of 209 defects. Overall, the free muscle flap success rate was 91.3%. Bone defects were restored with 106 bone grafts, 25 free fibula flaps, and 14 distraction osteogenesis procedures. Osseous and soft-tissue defects were reconstructed simultaneously at the first definitive treatment in 94% of cases. The mean follow-up after definitive treatment was 25 (range, 9-47) months. The average full weight-bearing times for lower leg and feet injuries were 8.4 months and 4 months, respectively. Early, aggressive, and serial debridement of osseous and soft tissue, early restoration of bone and soft-tissue defects at the same stage, intensive rehabilitation, and patient education were the key points in the management of high velocity-high energy injuries of the lower leg and foot. copyright 2005 Wiley-Liss, Inc.

The direct and indirect costs of long bone fractures in a working age US population.

PubMed

Bonafede, Machaon; Espindle, Derek; Bower, Anthony G

2013-01-01

Information regarding the burden of fractures is limited, especially among working age patients. The objective of this study was to evaluate the direct and indirect costs associated with long bone fractures in a working age population using real-world claims data. This was a claims-based retrospective analysis, comparing adult patients in the 6 months before and 6 months after a long bone fracture between 1/1/2001 and 12/31/2008 using the MarketScan Research Databases. Outcomes included direct medical costs and utilization, as well as work absenteeism and short term disability, which was available for a sub-set of the patients. Observed and adjusted incremental costs (i.e., the difference in costs before and after a fracture) were evaluated and reported in 2008 US$. A total of 208,094 patients with at least one fracture were included in the study. Six, mutually exclusive fracture cohorts were evaluated: tibia shaft (n = 49,839), radius (n = 97,585), hip (n = 11,585), femur (n = 6788), humerus (n = 29,884), and those with multiple long bone fractures (n = 12,413). Average unadjusted direct costs in the 6-months before a long bone fracture ranged from $3291 (radius) to $12,923 (hip). The average incremental direct cost increase in the 6-months following a fracture ranged from $5707 (radius) to $39,041 (multiple fractures). Incremental absenteeism costs ranged from $950 (radius) to $2600 (multiple fractures), while incremental short-term disability costs ranged from $2050 (radius) to $4600 (multiple fractures). The results of this study indicate that long bone fractures are costly, both in terms of direct medical costs and lost productivity. Workplace absences and short-term disability represent a significant component of the burden of long bone fractures. These results may not be generalizable to all patients with fractures in the US, and do not reflect the burden of undiagnosed or sub-clinical fractures.

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.

[Coral as support of traumatic articular compression. A prospective study of 23 cases involving the lower limb].

PubMed

de Peretti, F; Trojani, C; Cambas, P M; Loubière, R; Argenson, C

1996-01-01

Infection risk makes the management of a bone bank more and more difficult. On the other hand, realizing an autologous graft is not always without consequences. That is why we estimated the mechanical quality, the osteo-integration and the biocompatability of a coral graft. Between 1988 and 1992, two of us systematically used coral graft as "support" after lifting of some articular depression in fractures of inferior limb. Osteosynthesis was systematically associated. In this way, we operated 13 fractures of the lateral tibial plateau, 8 thalamic fractures of the calcaneus and 2 fractures of the inferior extremity of the tibia. Average follow-up is 20 months, with extremes of 68 and 12 months. Material ablation was realized 13 times and coral graft biopsy 4 times. Bone integration was estimated radiologically in 3 stages: stage 1: non union = "margin" around the coral, stage 2: possible integration = the coral is perfectly visible, but its borders grow indistinct, stage 3: certain integration = peripheral disparition of the coral weft, radiological interpenetration between coral and bone framework. We systematically searched for secondary displacements and complications. Mechanical conditions were respected, there was no secondary displacement. "Possible integration" (stage 2) was found in 8 cases at an average follow-up of 20 months. In 9 cases, we found "certain integration" (stage 3), at an average follow-up of 28 months. It is possible that a more important follow-up time would allow to find more integration cases. Biocompatibility is debatable under the operating conditions of the authors. We counted 5 aseptic serous flows which continued to be aseptic (1 tibial plateau, 1 inferior extremity of the tibia, 3 calcaneum). Three coral grafts were removed to obtain healing. When biocompatibility is satisfactory the integration is certain. The longer the follow-up time, the more stage 3 cases can be observed. Nevertheless, this integration runs out with time. We did not find any explication to aseptic serous flows. It may result from some impurities. On the other hand, use of the coralin hydroxyapatite does not seem to drive to allergic complications. In accordance with this study, we use the coral graft only in case of tibial plateau fracture. Our experience with coral graft in the other fields of bone surgery is not sufficient to express an opinion.

The effect of HIV on early wound healing in open fractures treated with internal and external fixation.

PubMed

Aird, J; Noor, S; Lavy, C; Rollinson, P

2011-05-01

There are 33 million people worldwide currently infected with human immunodeficiency virus (HIV). This complex disease affects many of the processes involved in wound and fracture healing, and there is little evidence available to guide the management of open fractures in these patients. Fears of acute and delayed infection often inhibit the use of fixation, which may be the most effective way of achieving union. This study compared fixation of open fractures in HIV-positive and -negative patients in South Africa, a country with very high rates of both HIV and high-energy trauma. A total of 133 patients (33 HIV-positive) with 135 open fractures fulfilled the inclusion criteria. This cohort is three times larger than in any similar previously published study. The results suggest that HIV is not a contraindication to internal or external fixation of open fractures in this population, as HIV is not a significant risk factor for acute wound/implant infection. However, subgroup analysis of grade I open fractures in patients with advanced HIV and a low CD4 count (< 350) showed an increased risk of infection; we suggest that grade I open fractures in patients with advanced HIV should be treated by early debridement followed by fixation at an appropriate time.

Anatomy, histology and elemental profile of long bones and ribs of the Asian elephant (Elephas maximus).

PubMed

Nganvongpanit, Korakot; Siengdee, Puntita; Buddhachat, Kittisak; Brown, Janine L; Klinhom, Sarisa; Pitakarnnop, Tanita; Angkawanish, Taweepoke; Thitaram, Chatchote

2017-09-01

This study evaluated the morphology and elemental composition of Asian elephant (Elephas maximus) bones (humerus, radius, ulna, femur, tibia, fibula and rib). Computerized tomography was used to image the intraosseous structure, compact bones were processed using histological techniques, and elemental profiling of compact bone was conducted using X-ray fluorescence. There was no clear evidence of an open marrow cavity in any of the bones; rather, dense trabecular bone was found in the bone interior. Compact bone contained double osteons in the radius, tibia and fibula. The osteon structure was comparatively large and similar in all bones, although the lacuna area was greater (P < 0.05) in the femur and ulna. Another finding was that nutrient foramina were clearly present in the humerus, ulna, femur, tibia and rib. Twenty elements were identified in elephant compact bone. Of these, ten differed significantly across the seven bones: Ca, Ti, V, Mn, Fe, Zr, Ag, Cd, Sn and Sb. Of particular interest was the finding of a significantly larger proportion of Fe in the humerus, radius, fibula and ribs, all bones without an open medullary cavity, which is traditionally associated with bone marrow for blood cell production. In conclusion, elephant bones present special characteristics, some of which may be important to hematopoiesis and bone strength for supporting a heavy body weight.

Clinical comparison between open plating and minimally invasive plate osteosynthesis for displaced proximal humeral fractures: A prospective randomized controlled trial.

PubMed

Sohn, Hoon-Sang; Jeon, Yoon Sang; Lee, JuHan; Shin, Sang-Jin

2017-06-01

Recently, minimally invasive plate osteosynthesis (MIPO) has been widely used for the treatment of proximal humeral fractures. However, there is concern about whether the MIPO in comminuted proximal humeral fractures is also comparable to open plating. The purpose of this study was to compare the clinical and radiographic outcomes of open plating and MIPO for acute displaced proximal humeral fractures. In this prospective, randomized controlled study, 107 patients who had an acute proximal humeral fracture were randomized to either the open plating or MIPO techniques. Forty-five patients treated with open plating and 45 with the MIPO technique who were followed up at least 1year were evaluated. Shoulder functional assessment, operating time, several radiographic parameters, and complications were evaluated at final follow-up. The mean follow-up period was 15.0 months in the open plating and 14.3 months in the MIPO technique. There were no statistically significant differences in functional assessment scores and radiographic parameters between the two groups. High complications rates were found in 4-part fracture in both surgical methods The average operation time in the MIPO group were significantly lower compared to the open plating group (p<0.05). This study showed MIPO in proximal humerus fractures had similar clinical and radiographic outcomes compared to the open plating. However, the MIPO technique in proximal humerus fracture provided significantly shorter operation time than the open plating. Copyright © 2017 Elsevier Ltd. All rights reserved.

Effects of long-term administration of carprofen on healing of a tibial osteotomy in dogs.

PubMed

Ochi, Hiroki; Hara, Yasushi; Asou, Yoshinori; Harada, Yasuji; Nezu, Yoshinori; Yogo, Takuya; Shinomiya, Kenichi; Tagawa, Masahiro

2011-05-01

To evaluate effects of long-term administration of carprofen on healing of a tibial osteotomy in dogs. 12 healthy female Beagles. A mid-diaphyseal transverse osteotomy (stabilized with an intramedullary pin) of the right tibia was performed in each dog. The carprofen group (n = 6 dogs) received carprofen (2.2 mg/kg, PO, q 12 h) for 120 days; the control group (6) received no treatment. Bone healing and change in callus area were assessed radiographically over time. Dogs were euthanized 120 days after surgery, and tibiae were evaluated biomechanically and histologically. The osteotomy line was not evident in the control group on radiographs obtained 120 days after surgery. In contrast, the osteotomy line was still evident in the carprofen group. Callus area was significantly less in the carprofen group, compared with the area in the control group, at 20, 30, and 60 days after surgery. At 120 days after surgery, stiffness, elastic modulus, and flexural rigidity in the carprofen group were significantly lower than corresponding values in the control group. Furthermore, histologic evaluation revealed that the cartilage area within the callus in the carprofen group was significantly greater than that in the control group. Long-term administration of carprofen appeared to inhibit bone healing in dogs that underwent tibial osteotomy. We recommend caution for carprofen administration when treating fractures that have delays in healing associated with a reduction in osteogenesis as well as fractures associated with diseases that predispose animals to delays of osseous repair.

[Diseases and overuse injuries of the lower extremities in long distance runners].

PubMed

Tschopp, M; Brunner, F

2017-06-01

Running is one of the most popular sports worldwide, with running events attracting hundreds of thousands of runners of all age groups. Running is an effective way to improve health but is also associated with a high risk of injuries. Up to 50% of regular runners report having more than one injury each year. Some injuries are caused by an accident but most are caused by overuse. The most frequent diagnoses are patellofemoral pain syndrome, tibial stress syndrome (shin splint), Achilles tendinopathy, iliotibial band friction syndrome (runner's knee), plantar fasciitis and stress fractures of the metatarsals and tibia. The knee is the most frequently injured joint in runners at all distances. Hamstring injuries are typically acute resulting in a sudden, sharp pain in the posterior thigh. Hip injuries are less common but it can be more difficult to make the correct diagnosis and treatment is more complex. Clinicians confronted by runners with shin pain must distinguish between stress fractures of the tibia, tibial stress syndrome (shin splints) and chronic exertional compartment syndrome. Foot and ankle injuries are the most common injuries reported by long distance and marathon runners. Excess body weight and the number of kilometers run per week are high risk factors for injuries. The roles of other factors, such as shoes, stretching and biomechanics are less clear. A detailed anamnesis and physical examination are important for the correct diagnosis or the necessity for further diagnostic imaging and subsequent therapy.

Transient gamma-secretase inhibition accelerates and enhances fracture repair likely via Notch signaling modulation

PubMed Central

Wang, Cuicui; Shen, Jie; Yukata, Kiminori; Inzana, Jason A.; O'Keefe, Regis J.; Awad, Hani A.; Hilton, Matthew J.

2014-01-01

Approximately 10% of skeletal fractures result in healing complications and non-union, while most fractures repair with appropriate stabilization and without pharmacologic intervention. It is the latter injuries that cannot be underestimated as the expenses associated with their treatment and subsequent lost productivity are predicted to increase to over $74 billion by 2015. During fracture repair, local mesenchymal stem/progenitor cells (MSCs) differentiate to form new cartilage and bone, reminiscent of events during skeletal development. We previously demonstrated that permanent loss of gamma-secretase activity and Notch signaling accelerates bone and cartilage formation from MSC progenitors during skeletal development, leading to pathologic acquisition of bone and depletion of bone marrow derived MSCs. Here, we investigated whether transient and systemic gamma-secretase and Notch inhibition is capable of accelerating and enhancing fracture repair by promoting controlled MSC differentiation near the fracture site. Our radiographic, microCT, histological, cell and molecular analyses reveal that single and intermittent gamma-secretase inhibitor (GSI) treatments significantly enhance cartilage and bone callus formation via the promotion of MSC differentiation, resulting in only a moderate reduction of local MSCs. Biomechanical testing further demonstrates that GSI treated fractures exhibit superior strength earlier in the healing process, with single dose GSI treated fractures exhibiting bone strength approaching that of un-fractured tibiae. These data further establish that transient inhibition of gamma-secretase activity and Notch signaling temporarily increases osteoclastogenesis and accelerates bone remodeling, which coupled with the effects on MSCs likely explains the accelerated and enhanced fracture repair. Therefore, we propose that the Notch pathway serves as an important therapeutic target during skeletal fracture repair. PMID:25527421

Current Concepts and Ongoing Research in the Prevention and Treatment of Open Fracture Infections

PubMed Central

Hannigan, Geoffrey D.; Pulos, Nicholas; Grice, Elizabeth A.; Mehta, Samir

2015-01-01

Significance: Open fractures are fractures in which the bone has violated the skin and soft tissue. Because of their severity, open fractures are associated with complications that can result in increased lengths of hospital stays, multiple operative interventions, and even amputation. One of the factors thought to influence the extent of these complications is exposure and contamination of the open fracture with environmental microorganisms, potentially those that are pathogenic in nature. Recent Advances: Current open fracture care aims to prevent infection by wound classification, prophylactic antibiotic administration, debridement and irrigation, and stable fracture fixation. Critical Issues: Despite these established treatment paradigms, infections and infection-related complications remain a significant clinical burden. To address this, improvements need to be made in our ability to detect bacterial infections, effectively remove wound contamination, eradicate infections, and treat and prevent biofilm formation associated with fracture fixation hardware. Future Directions: Current research is addressing these critical issues. While culture methods are of limited value, culture-independent molecular techniques are being developed to provide informative detection of bacterial contamination and infection. Other advanced contamination- and infection-detecting techniques are also being investigated. New hardware-coating methods are being developed to minimize the risk of biofilm formation in wounds, and immune stimulation techniques are being developed to prevent open fracture infections. PMID:25566415

In situ bone tissue engineering via ultrasound-mediated gene delivery to endogenous progenitor cells in mini-pigs.

PubMed

Bez, Maxim; Sheyn, Dmitriy; Tawackoli, Wafa; Avalos, Pablo; Shapiro, Galina; Giaconi, Joseph C; Da, Xiaoyu; David, Shiran Ben; Gavrity, Jayne; Awad, Hani A; Bae, Hyun W; Ley, Eric J; Kremen, Thomas J; Gazit, Zulma; Ferrara, Katherine W; Pelled, Gadi; Gazit, Dan

2017-05-17

More than 2 million bone-grafting procedures are performed each year using autografts or allografts. However, both options carry disadvantages, and there remains a clear medical need for the development of new therapies for massive bone loss and fracture nonunions. We hypothesized that localized ultrasound-mediated, microbubble-enhanced therapeutic gene delivery to endogenous stem cells would induce efficient bone regeneration and fracture repair. To test this hypothesis, we surgically created a critical-sized bone fracture in the tibiae of Yucatán mini-pigs, a clinically relevant large animal model. A collagen scaffold was implanted in the fracture to facilitate recruitment of endogenous mesenchymal stem/progenitor cells (MSCs) into the fracture site. Two weeks later, transcutaneous ultrasound-mediated reporter gene delivery successfully transfected 40% of cells at the fracture site, and flow cytometry showed that 80% of the transfected cells expressed MSC markers. Human bone morphogenetic protein-6 ( BMP - 6 ) plasmid DNA was delivered using ultrasound in the same animal model, leading to transient expression and secretion of BMP-6 localized to the fracture area. Micro-computed tomography and biomechanical analyses showed that ultrasound-mediated BMP-6 gene delivery led to complete radiographic and functional fracture healing in all animals 6 weeks after treatment, whereas nonunion was evident in control animals. Collectively, these findings demonstrate that ultrasound-mediated gene delivery to endogenous mesenchymal progenitor cells can effectively treat nonhealing bone fractures in large animals, thereby addressing a major orthopedic unmet need and offering new possibilities for clinical translation. Copyright © 2017, American Association for the Advancement of Science.

In situ bone tissue engineering via ultrasound-mediated gene delivery to endogenous progenitor cells in mini-pigs

PubMed Central

Bez, Maxim; Sheyn, Dmitriy; Tawackoli, Wafa; Avalos, Pablo; Shapiro, Galina; Giaconi, Joseph C.; Da, Xiaoyu; Ben David, Shiran; Gavrity, Jayne; Awad, Hani A.; Bae, Hyun W.; Ley, Eric J.; Kremen, Thomas J.; Gazit, Zulma; Ferrara, Katherine W.; Pelled, Gadi; Gazit, Dan

2017-01-01

More than 2 million bone-grafting procedures are performed each year using autografts or allografts. However, both options carry disadvantages, and there remains a clear medical need for the development of new therapies for massive bone loss and fracture nonunions. We hypothesized that localized ultrasound-mediated, microbubble-enhanced therapeutic gene delivery to endogenous stem cells would induce efficient bone regeneration and fracture repair. To test this hypothesis, we surgically created a critical-sized bone fracture in the tibiae of Yucatán mini-pigs, a clinically relevant large animal model. A collagen scaffold was implanted in the fracture to facilitate recruitment of endogenous mesenchymal stem/progenitor cells (MSCs) into the fracture site. Two weeks later, transcutaneous ultrasound-mediated reporter gene delivery successfully transfected 40% of cells at the fracture site, and flow cytometry showed that 80% of the transfected cells expressed MSC markers. Human bone morphogenetic protein-6 (BMP-6) plasmid DNA was delivered using ultrasound in the same animal model, leading to transient expression and secretion of BMP-6 localized to the fracture area. Micro–computed tomography and biomechanical analyses showed that ultrasound-mediated BMP-6 gene delivery led to complete radiographic and functional fracture healing in all animals 6 weeks after treatment, whereas nonunion was evident in control animals. Collectively, these findings demonstrate that ultrasound-mediated gene delivery to endogenous mesenchy-mal progenitor cells can effectively treat nonhealing bone fractures in large animals, thereby addressing a major orthopedic unmet need and offering new possibilities for clinical translation. PMID:28515335

Adolescence physical activity is associated with higher tibial pQCT bone values in adulthood after 28-years of follow-up--the Cardiovascular Risk in Young Finns Study.

PubMed

Tolonen, S; Sievänen, H; Mikkilä, V; Telama, R; Oikonen, M; Laaksonen, M; Viikari, J; Kähönen, M; Raitakari, O T

2015-06-01

High peak bone mass and strong bone phenotype are known to be partly explained by physical activity during growth but there are few prospective studies on this topic. In this 28-year follow-up of Cardiovascular Risk in Young Finns Study cohort, we assessed whether habitual childhood and adolescence physical activity or inactivity at the age of 3-18 years were associated with adult phenotype of weight-bearing tibia and the risk of low-energy fractures. Baseline physical activity and data on clinical, nutritional and lifestyle factors were assessed separately for females and males aged 3-6-years (N=395-421) and 9-18-years (N=923-965). At the age of 31-46-years, the prevalence of low-energy fractures was assessed with a questionnaire and several tibial traits were measured with pQCT (bone mineral content (BMC; mg), total and cortical cross-sectional areas (mm(2)), trabecular (for the distal site only) and cortical (for the shaft only) bone densities (mg/cm(3)), stress-strain index (SSI; mm(3), for the shaft only), bone strength index (BSI; mg(2)/cm(4), for the distal site only) and the cortical strength index (CSI, for the shaft only)). For the statistical analysis, each bone trait was categorized as below the cohort median or the median and above and the adjusted odds ratios (OR) were determined. In females, frequent physical activity at the age of 9-18-years was associated with higher adulthood values of BSI, total and cortical areas, BMC, CSI and SSI at the tibia independently of many health and lifestyle factors (ORs 0.33-0.53, P≤0.05; P-values for trend 0.002-0.05). Cortical density at the tibial shaft showed the opposite trend (P-value for trend 0.03). Similarly in males, frequent physical activity was associated with higher values of adult total and cortical areas and CSI at the tibia (ORs 0.48-0.53, P≤0.05; P-values for trend 0.01-0.02). However, there was no evidence that childhood or adolescence physical activity was associated with lower risk of low energy fractures during the follow-up. In conclusion, frequent habitual physical activity in adolescence seems to confer benefits on tibial bone size and geometry in adulthood. Copyright © 2015. Published by Elsevier Inc.

Upper extremity open fractures in hospitalized road traffic accident patients: adult versus pediatric cases.

PubMed

Rubin, Guy; Peleg, Kobi; Givon, Adi; Rozen, Nimrod

2017-10-24

Fractures in pediatrics show epidemiological characteristics which are different from fractures in adults. The objective of this study was to examine the injury profiles of open upper extremity fractures (UEFs) in all modes of injury related to road traffic accidents (RTAs) in adult and pediatric hospitalized patients. Data on 103,465 RTA patients between 1997 and 2013 whose records were entered in a centralized country trauma database were reviewed. Data on open UEFs related to mode of injury (car, motorcycle, bicycle, and pedestrian) was compared between adult (18+ years) and pediatric (0-17 years) RTA patients. Of 103,465 RTA cases, 17,263 (16.7%) had UEFs. Of 73,087 adults, 13,237 (18.1%) included UEFs and of 30,378 pediatric cases, 4026 (13.2%) included UEFs (p < 0.0001). Of 17,263 cases with UEFs, we reviewed 22,132 fractures with 2, 743 (12.4%) open fractures. Adults had a greater risk for open fractures (2221, 13%) than the pediatric cases (522, 10.3%) (p < 0.0001). Overall, of a total of 22,132 UEFs, most of the fractures were in the radius (22.8%), humerus (20.3%), clavicle (17.5%), and ulna (15.4%). The adult pedestrian group had a significantly higher risk for open UEFs than the pediatric group (11 vs 8%, p = 0.0012). This study demonstrates the difference between adult and pediatric open fractures in hospitalized RTAs. We showed that adults had a greater risk for open UEFs compared to children, and the adult pedestrian group particularly had a significantly higher risk for open UEFs than the pediatric group.

Histomorphometric Parameters of the Growth Plate and Trabecular Bone in Wild-Type and Trefoil Factor Family 3 (Tff3)-Deficient Mice Analyzed by Free and Open-Source Image Processing Software.

PubMed

Bijelić, Nikola; Belovari, Tatjana; Stolnik, Dunja; Lovrić, Ivana; Baus Lončar, Mirela

2017-08-01

Trefoil factor family 3 (Tff3) peptide is present during intrauterine endochondral ossification in mice, and its deficiency affects cancellous bone quality in secondary ossification centers of mouse tibiae. The aim of this study was to quantitatively analyze parameters describing the growth plate and primary ossification centers in tibiae of 1-month-old wild-type and Tff3 knock-out mice (n=5 per genotype) by using free and open-source software. Digital photographs of the growth plates and trabecular bone were processed by open-source computer programs GIMP and FIJI. Histomorphometric parameters were calculated using measurements made with FIJI. Tff3 knock-out mice had significantly smaller trabecular number and significantly larger trabecular separation. Trabecular bone volume, trabecular bone surface, and trabecular thickness showed no significant difference between the two groups. Although such histomorphological differences were found in the cancellous bone structure, no significant differences were found in the epiphyseal plate histomorphology. Tff3 peptide probably has an effect on the formation and quality of the cancellous bone in the primary ossification centers, but not through disrupting the epiphyseal plate morphology. This work emphasizes the benefits of using free and open-source programs for morphological studies in life sciences.