Isolated quadrilateral plate fracture with central hip dislocation after epileptic seizure in a postpartum patient: A case report.

Isolated quadrilateral plate fractures are extremely rare and their treatment is complex. The postpartum period and recent caesarean section additionally increase already significant risks of surgical treatment. Modified Stoppa approach and the use of infrapectineal plate represent the optimal surgical treatment method. One case of central hip dislocation and isolated quadrilateral plate fracture was reported during an epileptic seizure 1 day postpartum, which was treated with open reduction and internal fixation. A 25-year-old female patient had given birth via cesarean section. One day postpartum, she had multiple generalized tonic clonic seizures. Arteriovenous malformation was identified as the cause of seizures by MRI. The patient complained of left hip pain and inability to move the left leg which prompted clinical and radiological examination. A pelvic CT scan verified multifragmentary fracture of the quadrilateral plate without fracture of the acetabular columns. The central hip dislocation was verified. Due to the rarity of the fracture, the clinical decision-making process was difficult. The patient, being in the postpartum period, was also at a greater risk of infection. The patient was treated surgically, and osteosynthesis was performed with an infrapectineal plate for the acetabulum using the modified Stoppa approach. The initial incision was done through the same Pfannenstiel incision from caesarean section. The patient's postoperative recovery was good at 1 year follow-up.

OUTCOMES OF SURGICAL TREATMENT FOR DISPLACED BOTH-COLUMN ACETABULAR FRACTURES.

Complex both-column acetabulum fractures are severe injuries, often with associated injuries and complications with uncertain clinical and functional outcome. Modern traumatological protocols point to early surgical treatment, with anatomical reduction and stable internal fixation of fragments as a prerequisite for achieving a good treatment outcome. This retrospective-prospective multicenter cohort study was conducted during the 2014-2020 period and included 24 cases that met the input parameters, using the Letournel and Judet classification, and application of a combined surgical approach, a modified Stoppa and Kocher-Langenbeck approach. The results of treatment with complications, associated injuries and functional outcome are described. Fractures were caused by high kinetic energy trauma, and the cause was traffic accident in 17/24 (70.84%), fall from a height in 5/24 (20.83%) and crash injuries in 2/24 (8.33%) cases. The sample included 18 (75.00%) male and 6 (25.00%) female, with 10/24 (41.67%) right sided and 14/24 (58.33%) left sided fractures. Their mean age was 45.06 (range, 24-62) years. The mean follow-up time was 2.8 (range, 1-5) years. Postoperative complications were detected in 14/24 (58.33%) cases, including wound infection in 4/24 (16.67%), deep vein thrombosis in 2/24 (8.33%), heterotopic ossification in 2/24 (8.33%), hip osteoarthrosis in 3/24 (12.50%), avascular necrosis of femoral head in 2/24 (8.33%), total hip arthroplasty procedures in 3/24 (12.50%), abdominal complications in 2/24 (8.33%), urologic complications in 2/24 (8.33%), iatrogenic nerve lesion in 3/24 (12.50%), and fatal pulmonary embolism in 2/24 (8.33%) cases; there was no loss of reduction or non-union acetabular fracture. Associated injuries that we recorded as major trauma were presented in 13/24 (54.17%) study patients. The final functional results according to the Harris Hip Score (HHS) were excellent in 7/22 (31.82%), good in 10/22 (45.45%), moderate in 4/22 (18.18%) patients, and poor in 1/22 (4.55%) patient. The mean HHS was 84 (range 34-98). Complications and results have led us to a conclusion that primary injuries significantly affect the clinical and functional results. A good diagnostic procedure, assessment of the general condition and application of the trauma scoring system, surgical treatment that includes early hip reduction, open reduction internal fixation and physical rehabilitation are necessary.

The Importance of Primary Reconstruction in the Treatment of Blast Related Hand Injuries During Childhood.

INTRODUCTION: Blast injuries are common during wartime but are also related to various holiday festivals worldwide. Despite strict legislations, these devices still cause serious injuries leaving permanent disabilities. Children are affected in numerous cases with the hand being the most affected body region. The aim of our study was to profile the blast related hand injuries and to review treatment modalities that we used. METHODS: A retrospective study of patients treated for blast-devices related hand injuries between 2006 and 2015 was performed. RESULTS: 112 patient with blast related hand injuries were treated in our department during the 10-year period. Most of the patients were male. The dominant hand was injured in 83.9% of the patients. Associated injuries were observed in 14.3% of patients. 90 children were treated on an out-patient basis, mostly due to hand burns (86.7%) or uncomplicated blast injuries (13.3%). 22 children required hospitalization due to severe blast and crush injuries and amputations. Surgery was carried out as the urgent procedure and involved debridement with primary repair. In the case of amputations debridement and sufficient skin ensuring complete wound coverage was the procedure of choice. CONCLUSION: Blast related injuries of the hand during childhood are frequent and can cause different and complex defects. Besides prevention of these injuries, primary reconstruction of the affected hand is of outmost importance in preventing long-term consequences.

Fluoroscopic iliosacral screw placement made safe.

AIM: Unstable posterior pelvic ring injuries should be stabilised successfully by percutaneous iliosacral screwing. The intervention takes place under intraoperative fluoroscopic guidance. The inlet and outlet views are crucial and are performed by tilting the image intensifier. Safely interpreting fluoroscopic views can be challenging in certain clinical scenarios. We demonstrated on a series of patients howpreoperative CT scans can be used to anticipate the appropriate intraoperative inlet and outlet fluoroscopic views and positioning of the patient on the operating table, thereby avoiding possible operating table obstacles. MATERIALS AND METHODS: We analysed at random 30 pelvic CT scans from patients of different ages and both sexes, utilising the sagittal reconstructions. Inlet and outlet angle measurements were calculated on the scans to determine the appropriate intraoperative inlet and outlet views. RESULTS: The analysed CT scans showed an average inlet view of 22.3° (range 10.4°-39.8°) and an average outlet view of 42.3° (range 31.5°-53.1°). Sex and age had no influence on results. The calculated required free space under the operating table for unobstructed tilting of the C-arm was a minimum of 145cm. CONCLUSION: The significant anatomic variations of the posterior pelvic ring have been well documented in the literature. The angles required to obtain appropriate intraoperative inlet and outlet views are not perpendicular and differ greatly from traditional settings, which directed the beam 45° caudally and 45° cranially. The fluoroscopic beam would need to be angled differently in each patient to obtain ideal cardinal views that ultimately assist in safe iliosacral screw placement. To avoid collision of the C-arm with the operating table, it is essential to provide secure free space under the operating table of at least 145cm.

Complications of ESIN osteosynthesis--Experience in 270 patients.

BACKGROUND: Elastic stable intramedullary nailing (ESIN) osteosynthesis has been used in our department for the treatment of long-bone fractures in children and adolescents for more than 17 years. During this period we have shown that ESIN has several advantages compared with other methods of treatment. However, as with every other method, ESIN has its drawbacks and complications. These occur primarily if indication criteria are not respected or ESIN technique is inadequate. This paper presents the rate of complications that occurred with this method in our patients, and the means of prevention and treatment of these complications. PATIENTS AND METHODS: A total of 270 patients treated with ESIN osteosynthesis for fractures of long bones of the extremities completed treatment. The study was conducted at the Department of Child Surgery and Orthopaedics of the Clinical Hospital Centre in Rijeka. All the Nancy Nails used in the study were of the same quality, from one manufacturer and were applied using the standard ESIN technique. In 228 patients (84%), ESIN was the primary treatment, whereas in the remaining 42 patients (16%), ESIN was applied after an attempt at manual reposition and immobilisation of bone fragments. All patients had control radiography at least three times and postoperative monitoring was conducted for at least two years. RESULTS: A total of 35 of the 270 observed patients developed complications; some patients had several complications. There were 53 early intraoperational complications and 29 late postoperative complications. All complications resolved with appropriate therapy. The treatment was satisfactory in all patients except those with an elongation of the extremity (leg) of more than 1cm. CONCLUSION: Postoperative complications related to the ESIN method of osteosynthesis in the patients in this study were detected by radiological control examinations and long-term clinical monitoring. All the complications of ESIN were relatively easy to treat with current medical methods. The frequency of particular complications is significantly reduced if indication criteria for ESIN are respected and correct ESIN technique is used.

Nanobiotechnology and bone regeneration: a mini-review.

The purpose of this paper is to review current developments in bone tissue engineering, with special focus on the promising role of nanobiotechnology. This unique fusion between nanotechnology and biotechnology offers unprecedented possibilities in studying and modulating biological processes on a molecular and atomic scale. First we discuss the multiscale hierarchical structure of bone and its implication on the design of new scaffolds and delivery systems. Then we briefly present different types of nanostructured scaffolds, and finally we conclude with nanoparticle delivery systems and their potential use in promoting bone regeneration. This review is not meant to be exhaustive and comprehensive, but aims to highlight concepts and key advances in the field of nanobiotechnology and bone regeneration.

Incarcerated diaphragmatic hernia--differential diagnoses.

The incarceration of diaphragmatic hernia is very rare. We present a case of a four-year-old girl who developed the incarceration of left-sided diaphragmatic hernia, who, until then, was completely asymptomatic. This incarceration of the hernia represented a surgical emergency presenting as obstructive ileus and a severe respiratory distress which developed from what appeared to be full health. During a brief pre-operative examination a number of differential diagnoses were suggested. Along with the laboratory blood analysis (complete blood count and acid-base balance) a plain thoracic and abdominal radiography was done (babygram). After that, through an inserted nasal-gastric tube, barium meal of the upper gastrointestinal tract was done, showing abdominal organs in the left half of the thorax and a significant shift of the mediastinum to the right. With an urgent upper medial laparotomy we accessed the abdominal cavity and made the correct diagnosis. An opening was shown in the rear part of the left hemi-diaphragm with thickened and edematous edges, approx. 6 cm in diameter with incarcerated content. The incarcerated abdominal organs (stomach, transversal colon, small intestine and spleen) gradually moved into the abdominal cavity. The opening was closed with nonresorptive sutures (TiCron) size 2-0 with aprevious control and ventilated expansion of the well-developed left lung. In postoperative course the acid-base balance quickly recovered, as well as the general state of the patient and radiography showed a good expansion and lucency of the lung parenchyma and a return of the mediastinum into the middle part of the thorax.