Auto-Decompression - Preserved Neurological Function in Bilateral Cervical Facet Dislocations

Introduction Bilateral cervical facet dislocation (BCFD) is an uncommon injury with a high incidence of severe neurological impairment. We describe 4 cases of BCFD with preserved neurological function. Cases Case 1: A 78-year-old female who suffered two ground level falls (GLFs). Pre-operative American Spinal Injury Association (ASIA) Score was C5D. Imaging revealed a BCFD at C6/C7 and a C6 laminar fracture. Case 2: A 63-year-old male suffered a fall down 14 steps. Pre-operative ASIA score was E. Imaging demonstrated a BCFD at C7/T1, and a C6 laminar fracture. Case 3: A 46-year-old male collided with a tree while descending a hill on a bicycle. Pre-operative ASIA score was C6D. Imaging revealed a BCFD at C7/T1 and a C7 laminar fracture. Case 4: A 67-year-old male suffered a GLF while exiting a stationary car. Pre-operative ASIA score on admission was E. Imaging revealed a BCFD at C6/C7 with bilateral laminar fractures at C5 and C6. Outcome All cases underwent 2-stage surgical fixation. All cases maintained or had an improved ASIA score post-operatively. Conclusion In all cases, the presence of concurrent laminar fractures resulted in an auto-decompression of the spinal canal, preserving neurological function.

The Importance of Restoring Anatomy of the Proximal Interphalangeal Joint in Dorsal Fracture Dislocations.

The proximal interphalangeal joint (PIPJ) is a complex anatomical structure. In managing fracture dislocations about the PIPJ, the aim is to restore a congruent joint that allows for smooth gliding motion. Detailed knowledge of the anatomy and biomechanics of the PIPJ is necessary in managing these injuries with predictable success. The breadth of techniques previously described in the treatment of such injuries is testament to the difficulties faced in achieving optimal clinical and radiological outcomes. In this article we detail the anatomy and biomechanics of the PIPJ and summarize current literature and principles for the treatment of dorsal fracture dislocations.

Elbow Dislocation.

This article is a brief overview of the elbow dislocations focusing on updates in treatment and rehabilitation protocols. The fight between obtaining elbow stability without leading to long-term elbow stiffness has been a continued focus in field of sports medicine. This article highlights advances made to help treat the injuries appropriately and obtain optimal patient outcomes.

Carpal Fractures Other than Scaphoid in the Athlete.

Carpal fractures of bones other than the scaphoid occur at a much lower rate than scaphoid fractures. The close relationship between the carpus, intrinsic and extrinsic wrist ligaments, and wrist kinematics makes a thorough history, clinical examination, and interpretation of imaging for carpal malalignment essential. Carpal malalignment should be addressed with reduction and fixation. Nondisplaced fractures are often treated nonoperatively and displaced intraarticular fractures are almost always treatment operatively. The physician should keep in mind the athlete's specific goals and needs. Treatment must be individualized. Options for early return to play should be discussed when possible.

Management of Finger Joint Dislocation and Fracture-Dislocations in Athletes.

Although finger joint dislocations are generally thought of as benign by many athletes and assumed to be a sprain, these injuries represent a spectrum that includes disabling fracture-dislocations. Failure to recognize certain dislocations or fracture-dislocations may result in permanent deformity and loss of motion. Simple dislocations are frequently amenable to early return to play with protection; however, more complex injuries may require specialized splinting or surgery. Delay in diagnosis of unstable proximal interphalangeal fracture-dislocations may require reconstruction or fusion. Early diagnosis and appropriate treatment are essential to ensure optimal functional results.

The use of static progressive and serial static orthoses in the management of elbow contractures after complex fracture dislocation injuries: A pediatric case study.

INTRODUCTION: Contractures are the most common complication after traumatic injury to the elbow. Although evidence supporting the use of static progressive and serial static orthoses to help recover range of motion after these complex injuries is growing, there is currently a paucity of literature exploring its efficacy in pediatric populations. CASE DESCRIPTION: The following case study presents the results of the use of static progressive and serial static orthoses with a young patient who presented with both elbow extension and flexion contractures after a complex fracture dislocation injury. RESULTS: A noted and consistent improvement in both elbow extension and flexion can be observed after commencement of the static progressive and serial static orthoses. These results are consistent with the literature exploring the efficacy of these orthoses with adult populations with traumatic elbow injuries. DISCUSSION: Further studies evaluating the use of static progressive and serial static orthoses in the management of elbow contractures after traumatic injuries in pediatric populations is needed to establish best practices with this particular patient population.

A distraction technique using reduction multi-axial screws for open reduction of high-grade lumbar posterior dislocation:a case report and literature review.

BACKGROUND: L3 vertebral fractures with posterior dislocation are rare and usually secondary to high-energy trauma. To assess the outcome of a valuable distraction technique, using long-tail multiaxial pedicle screw which we have employed in reduction of L3 vertebral fracture with posterior dislocation, and emphasize the importance of preoperative blood vessel evaluation. CASE PRESENTATION: A 47-year-old patient fell from a height of 4 m and was paralyzed. Computed tomography scan revealed a three-column ligamentous injury with posterior fracture-dislocation of the L3 vertebral body. Computed tomography angiography showed that the third lumbar artery was ruptured without active bleeding. The patient underwent posterior approach with reduction, transpedicular fixation, and posterolateral fusion with autologous bone graft. Finally, Vertebral reduction and sagittal balance were achieved and patients recovered well after operation. CONCLUSION: Preoperative blood vessel evaluation is very important to avoid massive bleeding during the surgery, and the standard technique which can achieve good reduction is easy to understand, perform, and is reproducible.

Treatment of the displaced intracapsular fracture for the 'fitter' elderly patients: A randomised trial of total hip arthroplasty versus hemiarthroplasty for 105 patients.

Controversy exists for the optimum method of surgical treatment for the 'fitter' elderly patient with a displaced intracapsular fracture. 105 patients were randomised to treatment with either a cemented polished tapered stem hemiarthroplasty or a cemented total hip arthroplasty (THR) with a cemented acetabular cup. All patients were followed up for a minimum of one year using a blinded assessment of functional outcome. Those patients treated with a THR had a tendency to a longer hospital stay and increased medical (12 versus 62) and surgical complications (4 versus 2) in comparison to those treated by hemiarthroplasty. Mean operative times (842 versus 52 min) and operative blood loss (335mls versus 244mls) were increased for THR. Final outcome measures of residual pain and regain of function were similar for both methods of treatment. We recommend that caution should be exercised regarding the increased promotion of THR for intracapsular hip fractures until further studies are completed.

Functional and radiological outcomes of multiple dorsal carpometacarpal fracture dislocations treated with open reduction and internal fixation.

OBJECTIVES: This study aims to evaluate the clinical and radiological results of patients with multiple dorsal carpometacarpal (CMC) joint fracture dislocations treated with open reduction and internal fixation (ORIF). PATIENTS AND METHODS: We evaluated 14 patients (12 males, 2 females; mean age 35.1 years; range, 22 to 64 years) between January 2013 and December 2017. Our main outcome measurements were the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, loss of grip strength, limitation of range of motion (ROM), and Kellgren-Lawrence osteoarthritis classification identified with radiographs and computed tomography images. RESULTS: The mean QuickDASH scores at seventh week and third month were 73.57 (range, 65-90) and 29.11 (range, 25-42.5), respectively. The mean QuickDASH score at seventh, ninth, and 12th month, and final follow-up was 4.64 (range, 0-30) and the QuickDASH score at these follow-up points was not 0 for only three patients. The mean loss of grip strength was 32.14% and two patients (14.29%) had limitation of ROM in third proximal interphalangeal joint at final follow-up. Four patients had grade I, nine patients had grade II, and one patient had grade III osteoarthritis according to Kellgren-Lawrence classification at final follow-up. CONCLUSION: Although functional results demonstrated that multiple CMC joint fracture dislocations can be treated with ORIF, the high rate of osteoarthritis is a disadvantage.

Open reduction and internal fixation versus closed reduction and percutaneous fixation in the treatment of Bennett fractures: A systematic review.

PURPOSE: Open reduction and internal fixation (ORIF) of Bennett fractures is increasingly preferred over closed reduction and percutaneous fixation (CRIF) in an attempt to prevent the development of post-traumatic arthrosis. The aim of this systematic review was to determine whether the preference for ORIF is justified based on the available literature regarding functional outcome and complications after surgery. METHODS: A systematic review was performed in Medline, Embase, Cochrane CENTRAL, Web of science, and Google scholar. Duplicates were removed and title and abstract were screened after which full text articles were analysed. The reference lists of selected articles were screened for additional relevant studies. Study characteristics were recorded and methodological qualities were assessed after which data was extracted from the included articles. The Eaton-Littler score for post-traumatic arthrosis (primary outcome) on follow-up X-rays was used as primary outcome. Secondary outcomes were Grip strength, Pinch strength, persistent pain, fixation failure, functional impairment, infection and surgery time. RESULTS: Ten studies were included; three retrospective comparative studies and seven retrospective case series. Of the 215 patients in these studies, 138 had been treated using an open technique and 77 by a closed percutaneous technique. The pooled rate of post-traumatic arthrosis was 57.5% (26.6-85.5) in the ORIF group versus 26.1% (3.9-59.0) in the CRIF group. Mean surgical operation time was 71.9 min for ORIF and 30.2 min for percutaneous patients. Fixation failure was significantly more often seen in the ORIF patients, 8.2% (0.7-22.8) vs. 2.9% (0.8-9.1), Risk Ratio 1.132 (0.01-176.745); p = 0.048. Infection was only seen in 5 CRIF patients. Persistent pain was seen in 32.9% (0.6-83.1) in ORIF patients versus 22.3% (8.1-41.1) in the CRIF patients. The pooled means Grip strength was 48.3 kg (95% CI; 39.7-56.9) versus 43.4 kg (95% CI; 22.9-63.8) for ORIF and CRPF, respectively. Functional impairment was similar between the two groups, 1.4% (0.1-4.4) vs 1.8% (0.1-5.7) respectively. CONCLUSION: The analysed data do not confirm ORIF to prevent post-traumatic arthrosis, secondly more fixation failure and pain was seen in the ORIF group. The pooled data show percutaneous fixation to be preferable over ORIF in the surgical treatment of Bennett fractures.

Displaced distal radius fracture presenting with neuropraxia of the dorsal cutaneous branch of the ulnar nerve (DCBUN).

Nerve injuries, mostly to the median nerve, are common following distal radius fractures. Ulnar nerve injuries are rarely encountered, with only few case reports of motor or motor and sensory loss described in the literature. In this paper, we report two consecutive cases of young patients with a distal radius fracture and a pure sensory ulnar neuropathy. Both patients had a radially displaced fracture and presented with sensory loss and paresthesia in the distribution of the dorsal cutaneous branch of the ulnar nerve (DCBUN), which resolved after fracture reduction. We believe this clinical scenario is the result of traction or compressive neuropraxia of the DCBUN in the subcutaneous tissue around the ulnar styloid-a neurologic injury which had not yet been described for distal radius fractures.

Rare variants of Bosworth fracture-dislocation: Bosworth fracture-dislocation with medial malleolus adduction type fracture.

Bosworth ankle fracture-dislocation is rare, known to be an irreducible type of ankle injury, with a high incidence of complication. We present two cases of even rarer variants of Bosworth ankle fracture-dislocation. The first case is a type of supination external rotation adduction, and the second case is a type of supination external rotation adduction. These types have not been described before. In both of the cases we failed to achieve close reduction, and therefore proceeded with emergency surgeries, with open reduction and internal fixation. Both of the cases were performed with a postero-lateral approach to reduce the dislocations, and fix the fractures successfully. Unfortunately in one of the cases, acute compartment syndrome developed post-surgically. However, both cases showed good functional outcomes.

Repair and augmentation of the lateral collateral ligament complex using internal bracing in dislocations and fracture dislocations of the elbow restores stability and allows early rehabilitation.

PURPOSE: Most elbow dislocations can be treated conservatively, with surgery indicated in special circumstances. Surgical options, apart from fracture fixation, range from repair or reconstruction of the damaged ligaments to static external fixation, usually entailing either a long period of immobilization followed by carefully monitored initiation of movement or dynamic external fixation. In general, no consensus regarding surgical treatment has been reached. A new method of open ligament repair and augmentation of the lateral ulnar collateral ligament using a non-absorbable suture tape in cases of acute and subacute elbow instability following dislocations has been described here, which allows an early, brace-free initiation of the full range of motion. This is the first description of the technique of internal bracing of the lateral elbow with preliminary patient outcome parameters for acute treatment of posterolateral rotatory instability. METHODS: Seventeen patients (14 males and 3 females) with acute or subacute posterolateral elbow instability as a result of dislocation or fracture dislocation were treated in our centre (Sporthopaedicum, Straubing, Regensburg, Germany) from 2014 to 2015 with open LUCL re-fixation and non-absorbable suture tape augmentation. The elbows were actively mobilized immediately after the operation and a maximum bracing period of 3 days. RESULTS: At 10 month median follow-up, none of the patients showed clinically apparent signs of instability or suffered subluxation or re-dislocation. One patient required re-operation for heterotopic ossification. The median range of motion was from 10° (0-40) to 130° (90-50) and median Oxford, Mayo Elbow Performance score, Simple Elbow Value, and DASH Scores were 41(29-48), 100 (70-100), 83% (60-95), and 18.5 (1.6-66), respectively. All patients reported a complete return to pre-injury level of activity. CONCLUSION: Augmentation with a non-absorbable suture tape acting as an 'Internal Brace' following an elbow dislocation is a safe adjunct to primary ligament repair and may allow the early mobilization and recovery of elbow stability and range of motion. LEVEL OF EVIDENCE: IV.

A comparative study about the incidence of dislocation and peri-prosthetic fracture between dual mobility versus standard cups after primary total hip arthroplasty.

PURPOSE: Dislocation and peri-prosthetic fracture (PPF) are major reasons for revision THA (total hip arthroplasty). The main advantage of dual mobility (DM) cups is to minimize the incidence of dislocation compared to single mobility (SM) cups. We hypothesized that the use of DM would lead to an increased risk of PPF because of its greater stability. In contrast, standard cups would be at higher risk of dislocation. METHODS: A retrospective comparative study was performed in our institution including 126 revision THAs between January 2013 and December 2017. Collected data included gender, age, BMI, Parker score, ASA score, the etiology for primary THA, type of cup (SM or DM), cortical index, Noble index, and the stem fixation. RESULTS: Overall, 53 standard and 73 DM cups were included for study. In the dislocation group, 29 had standard cups (83%) and 6 had DM cups (17%). Dislocation was 12-fold higher in SM cups (p < 0.001). In the PPF group, 24 had standard cups (26%) and 67 had DM cups (74%). PFF was 12-fold higher for DM cups (p < 0.001). A higher Parker score and a higher cortical index had a protective effect on the risk of PPF (OR = 0.76 (p = 0.03), OR = 0.57 (p = 0.048)). CONCLUSION: The use of DM increased hip stability but led to a higher rate of PPF by load transfer on the femur. Further studies with larger cohort and follow-up are needed to confirm these findings and measure the incidence of these complications.

Use of Mother-Child Screws in the Treatment of Coronoid Fractures in Terrible Triad Injury of the Elbow.

PURPOSE OF THE STUDY This study aims to analyze the clinical and radiographic outcomes of a consecutive series of 18 patients with terrible triad injury. The coronoid fractures of these patients were repaired using Mother-Child screw (MCS). MATERIAL AND METHODS Twelve men and six women (mean age: 47.2 years) with terrible triad injury of the elbow were followed up for a mean of 17.6 months (range: 13-42 months). Surgical treatment consisted of open reduction and internal fixation of coronoid fractures with MCS, radial head fracture with MCS (Mason type II, n = 10), or mini-plate (Mason type III, n = 3). Furthermore, all underwent lateral collateral ligament repair (n = 9, 100%), and in cases of persistent instability, medial collateral ligament repair was performed (n = 3, 33%). RESULTS At last follow-up, average arc of ulnohumeral motion was 130° (range: 65° to 150°), average arc of forearm rotation was 148° (range: 100°-160°), mean Disabilities of the Arm, Shoulder and Hand (DASH) score was 7.1 (range: 0-28.5), and mean Mayo Elbow Performance Score (MEPS) was 92 (range: 70-100). According to the Mayo Elbow Performance Index (MEPI), 10 patients were excellent in, seven patients were good, and one patient was fair. All patients had a stable elbow. No secondary coronoid fragment dislocation or implant failures was reported. Fracture healing was observed in all patients. CONCLUSIONS This study shows that coronoid fracture treatment with MCS may be a new, effective and easy therapeutic option in terrible triad injury. Key words:terrible triad of the elbow, coronoid process, radial head, functional outcome.

A Novel Algorithmic Approach to Chronic Forearm Longitudinal Instability.

Essex-Lopresti Lesions are rare injuries that are often missed in the acute setting. Delayed intervention may lead to chronic wrist and elbow pain and overall poor outcomes. The literature currently supports treatments that involve shortening of the ulna to reduce the relative degree of ulnar impaction, followed by attempted reduction of the distal radioulnar joint. Although such techniques may help to temporarily reduce wrist pain secondary to ulnar impaction, they do not address the proximal migration of the radius and ipsilateral radial head dislocation at the elbow. Subsequent procedures are often needed to replace or resect the radial head. We present a novel approach to chronic Essex-Lopresti lesions resulting in anatomic restoration of forearm length with return of elbow and wrist flexion/extension as well as improved forearm pronation/supination.

Perilunate Injuries and Dislocations Etiology, Diagnosis, and Management.

Perilunate injuries most commonly occur in high energy trauma situations; however, they are rare and frequently missed. Familiarity with the complex bony and ligamentous anatomy is required to fully understand these complex injury patterns. Careful orthogonal imaging and evaluation is required to ensure timely diagnosis of a perilunate injury. Early recognition and management of acute perilunate injuries has been demonstrated to correlate with better patient outcomes. Delayed treatment of chronic injuries can result in post-traumatic osteoarthritis and carpal collapse requiring salvage interventions. Here, we review the anatomy, basic evaluation, and management of this frequently missed injury.

Posterior subdeltoid and external rotators preserving approach for reduction and fixation of displaced extra-articular fractures of the scapula.

BACKGROUND: Operative management of scapular body fractures, when indicated, typically involves extensive exposure through a posterior approach. We present our experience with a deltoid preserving approach that allows excellent exposure of the fracture lines for reduction and fixation while minimizing muscle detachment and overall tissue trauma. TECHNIQUE: Exposure of the scapula was obtained through a posterior incision. The posterior deltoid was exposed and retracted superiorly while the arm was abducted in accordance with Brodsky et al. The scapula was exposed in the interval between infraspinatus and teres minor. PATIENTS AND METHODS: Six patients were treated using this approach and were retrospectively reviewed. All were men with a mean age of 34 years (range 24-45 ± 6.7 years). The injuries involved two 14-A3.1 and four 14-A3.2 AO/OTA types of fractures. The mean follow-up after surgery was 28 months (range 21-36 ± 4.93 months). RESULTS: All fractures could be anatomically reduced and healed without compromise. The mean Constant score was 93.8 (range 91-97 ± 2.13), while range of motion and strength returned to levels equal to the uninjured shoulder. All patients returned to their previous level of activity. We did not observe atrophy of the posterior muscles or hardware complications, and none required hardware removal. CONCLUSION: The deltoid and external rotators preserving posterior approach permitted good visualization of the fractures while allowing reduction and fixation without extensive muscular dissection and provided excellent functional outcomes. We consider that it offers obvious advantages over more aggressive muscle detaching approaches. LEVEL OF EVIDENCE: Therapeutic study, IV.

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

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

Intramedullary elastic nailing of the displaced radial neck fractures in children.

OBJECTIVE: The aim of this study was to report the clinical and radiological results of 11 patients with Judet type 3 severely displaced radial neck fractures, who were treated with intramedullary elastic nail fixation with the help of percutaneous K-wire reduction maneuver (Métaizeau technique). METHODS: A total of 11 children (4 boys and 7 girls with a mean age of 7.7 (6-10) years) with Judet type 3 radial neck fractures were treated in our clinic between February 2013 and August 2015. The fractures were evaluated according to Judet classification system modified by Métaizeau. Reduction and fixation was performed within the first 24 h after injury in all patients. All fractures were treated by closed reduction using distal elastic intramedullary nail. Clinical evaluation was performed by measuring elbow range of motion (ROM) with goniometer, radiological evaluation by assessing fracture healing and functional evaluation by using Mayo Elbow Performance Score (MEPS). RESULTS: The mean MEPS score increased from 15 points preoperatively to 88 points postoperatively (range, 12-95 points). Radiological evaluation revealed that all fractures healed with excellent or good alignment. The mean flexion was 150° (range, 145-154°), extension 1° (range, 0-2°), supination 82° (range, 80-86°), and pronation 83° (range, 80-85°). CONCLUSION: Reduction and osteosynthesis of radial neck fractures by intramedullary nailing with the help of percutaneous K-wire manipulation appears to be a simple, safe and effective treatment method in children. LEVEL OF EVIDENCE: Level IV, Therapeutic study.