Stabilization of Comminuted Fractures of the Proximal Humerus with Intramedullary Nails and Angularly Stable Locking Plates-Functional Results before and during the SARS-COVID-19 Pandemics.

Background and Objectives: Intramedullary nailing (IMN) and angularly stable plating (ASP) are the most popular techniques for the stabilization of comminuted fractures of the proximal humerus, without either one being obviously superior. The aim of the study was to validate the functional outcomes of both stabilization techniques in the COVID-19 pandemic by comparing them with data obtained just before the pandemic, because the limitations of the COVID-19 pandemic are affecting several aspects of social and medical life-being afraid of the transmission of the infection, patients reduce their exposure to healthcare to absolutely essential emergencies. Moreover, working conditions in the operating theater have also become more restrictive. Materials and Methods: Investigations were performed on 112 adult patients with Neer's three- and four-fragment fractures stabilized with IMN (64) and ASP (48). Treatment effects were validated six months after surgery based on radiographs for evidence of bone union, humeral neck-shaft angle (NSA) and implant placement. Limb function was assessed with the QuickDash and Constant-Murley scores. Data obtained from patients treated in the COVID-19 pandemic were compared with those obtained before the pandemic. Results: The healing of all fractures was satisfactory, but complications developed in six cases. Three patients required secondary interventions due to inadequate repositioning: one after IMN and two after ASP. Additionally, one ASP was complicated by the secondary destabilization of a primarily properly stabilized major tubercle, and in two cases by conflict of the protruding implant with the acromion. ASP was noted to provide better functional results during the COVID-19 pandemic according to the Constant-Murley score (p = 0.0048; Student's t-test). No significant differences were observed in the pre-COVID-19 pandemic. Conclusions: Our results suggest that ASP is more beneficial for the stabilization of comminuted fractures of the proximal humerus during the COVID-19 pandemic.

THE RELATIONSHIP OF CLINICAL AND MORPHOLOGICAL DATA IN COMMINUTED FRACTURES OF THE LOWER JAW.

OBJECTIVE: The aim is to establish the relationship between some clinical, physiological and morphological parameters in patients with the consequences of an acute injury considering the features of pathological and reparative changes in the bone fragments of the lower jaw formed during a fracture using clinical and morphological methods. PATIENTS AND METHODS: Materials and methods: The material of the study was bone fragments of the lower jaw, removed during osteosynthesis operations in 20 patients with traumatic comminuted fractures. Also, the material of the study was the data obtained during the examination of the above patients. Morphological parameters characterizing the state of the fragments tissues removed during surgical treatment of fractures of the lower jaw and clinical parameters characterizing the patient's condition in cases of traumatic fractures of the lower jaw treatment were identified for frequency and correlation analysis. Different of frequency of individual indicators' gradations cases was determined by the χ-square test, correlations between parameters (correlations of pairs of parameters "clinic - morphology", "clinical and laboratory data - morphology") - by calculating the Pearson association coefficient. RESULTS: Results: The main pathological and reparative changes are determined in the bone fragments of the lower jaw after a traumatic fracture: osteomedullary ischemic necrosis (traumatic bone infarction), nonspecific productive inflammation, endosteal and periosteal bone regenerates. The severity and frequency of pathological and reparative changes in the bone fragments of the lower jaw vary, leading to various correlations between clinical and morphological indicators of the fragment tissues conditions. Reliable correlations were established between individual clinical and morphological indicators of the state of bone fragments corresponding to the values of the association coefficient in the range of 0.3-0.7, in particular: in the pair "age of the patient" - "endosteal regenerates" - the dependence is negative, of medium strength, significant (p<0.05); in the pair "age of the patient" - "periosteal regenerates" - the dependence is negative, of medium strength, significant (p<0.05); in the pair "fragment surface area" - "osteonecrosis" - the relationship is negative, weak, significant with the probability of error in assessing the value |ra| p<0.1; in the pair "locus of a fracture in the lower jaw" - "type of inflammation in the bone marrow" - the dependence is positive, of medium strength, highly reliable (p<0.01). CONCLUSION: Conclusions: A comprehensive clinical and morphological examination made it possible to calculate quantitative data that characterize the frequency parameters of the occur¬rence of certain pathological changes in the bone fragments of the lower jaw after a fracture and the features of individual clinical and morphological parameters conjugation in patients with the consequences of a mechanical jaw injury. The obtained data on the correlation dependences of the type "clinic - morphology" can be used to predict the severity of morphological parameters according to the known values of clinical parameters in patients with the consequences of mandibular fractures.

Efficacy of Intramedullary Nailing in the Treatment of Comminuted Proximal Humeral Fractures and Its Influence on Shoulder Joint Function Recovery.

In this paper, we have aimed to elucidate the therapeutic effect of intramedullary nailing (IMN) in treating comminuted proximal humeral fractures (CPHFs) and its influence on the recovery of shoulder joint function. For this purpose, 60 cases with CPHFs were selected, particularly from January 2020 to October 2021. In these cases, 28 cases were treated with a locking proximal humeral plate (LPHP) and assigned to the control (Con) group and the remaining 32 patients were treated with IMN and included in the research (Res) group. The therapeutic effect, surgical indicators, total complications, visual analogue scale (VAS) score, and postoperative shoulder joint function score were compared between the two arms. We observed that compared with the Con group, the effective rate in the Res group was higher while the operation time, intraoperative blood loss, and fracture healing time were shorter, the overall complication rate and VAS score were lower, and the postoperative shoulder joint function score was higher, all with statistical significance. The above results indicate that IMN is effective and safe in the treatment of CPHFs, which can validly reduce the discomfort of patients and facilitate the recovery of shoulder joint function.

Maxillofacial injury related to an exploding e-cigarette.

Electronic cigarettes (also known as e-cigarettes or electronic nicotine delivery systems) were invented in China in 2003 then introduced to the British market in 2007. They remain popular among the public and are deemed to be effective in reducing tobacco smoking (the UK being one of the first countries to embrace them in a harm reduction policy). However, reports in the media of e-cigarettes exploding are of concern, considering the potential functional and psychological impairment that lifelong disfigurement will cause, especially given their uptake among people of any age. We present a case of this rare, but dramatic, effect of e-cigarette use as a warning to the public.

Proximal Humerus Fracture Following Arthroscopic Biceps Tenodesis.

A 60-year-old woman with chronic atraumatic shoulder pain underwent arthroscopic biceps tenodesis. Upon presenting to the physical therapy clinic 7 days following surgery, she reported constant pain. Following the examination, the physical therapist reviewed the patient's postoperative radiographs and noted a comminuted but minimally displaced fracture of the right proximal humeral metaphysis. J Orthop Sports Phys Ther 2020;50(11):649. doi:10.2519/jospt.2020.9497.

Traumatic abdominal wall hernias: disruptions of the abdominal wall muscles associated to pelvic bone fractures illustrated by two case reports.

BACKGROUND: Blunt abdominal traumas are often associated with intra-abdominal injuries and pelvic fractures. Traumatic abdominal wall hernias due to disruption of the abdominal wall muscles may be overlooked. Delayed diagnosis can lead to hernia related complications. CASE PRESENTATION: We present two cases of high kinetic trauma with pelvic fractures and acute traumatic abdominal wall herniation. Both of these cases suffered from a delayed diagnosis and needed surgery to treat the symptomatic herniation. CONCLUSION: Clinical reassessment and appropriate medical imaging are mandatory in patients with high kinetic abdominal blunt traumas and associated pelvic fracture, in order to prevent delayed diagnosis and possible complications.

Proximal Cortical Breach After Retrograde Femoral Nailing for Femoral Shaft Fracture: A Case Report.

CASE: A case of a distal third femoral shaft fracture treated with retrograde nailing complicated by proximal cortical breach is presented. The proximal fracture was detected intraoperatively and treated with plating. CONCLUSION: Although rare, clinicians should be cognizant of the risk for proximal femur fractures secondary to retrograde femoral nailing in elderly patients.

Use of the Bridge Plate Technique for the Treatment of Hamatometacarpal Fracture-Dislocations.

Background: This study aimed to describe a novel surgical technique in which a bridge plate was used for the treatment of hamatometacarpal fracture-dislocations and to assess its radiologic and clinical outcomes. Methods: A retrospective review of 16 patients treated with the bridge plate technique for hamatometacarpal fracture-dislocations was performed between 2010 and 2015. Clinical and radiographic evaluations were performed at months 3, 6, and 12 postoperatively. Active wrist and metacarpophalangeal joint ranges of motion and Quick Disabilities of Arm, Shoulder, and Hand (DASH) scores were recorded for the injured hands. Grip strength data were collected for both the injured hands and the contralateral uninjured hands. Results: All patients included in our study were male (mean age 31 years). The average Quick DASH score was 24.3 ± 9.1 at 3 months, 12.3 ± 7.3 at 6 months, and 6.2 ± 6.6 at 12 months. All patients returned to their original jobs within 5 weeks of the procedure. Grip strength eventually recovered to 90% of that of the uninjured hand, and none of the patients complained of finger or wrist joint stiffness. Conclusions: The use of the bridge plate technique may be an effective alternative treatment for patients with comminuted hamatometacarpal fracture-dislocations.

Fatal and Nonfatal Rip Saw Injuries.

This paper deals with a fatal stab wound suffered by a 29-year-old man and nonfatal injuries of 35-year-old and 67-year-old saw operators. Rip saw is a machine that is specially designed for making a rip cut, a cut made parallel to the direction of the wood grain. Rip-saw-related injuries mostly occur when a person is struck by the cutting material, which usually involves splinters of irregular shape and diameter. When the splinter strikes the body diagonally, the injuries may include abrasions, lacerations, and cut wounds; in situations where the victim is struck directly, the most common injuries are oval- or star-shaped stab wounds with a varying width of abrasions around the wounds. Therefore, such injuries may come across as injuries produced by a knife-like instrument, which is an added difficulty in the interpretation of such injuries.

Hoffa fracture accompanied by dissection of the popliteal artery.

After a high-energy trauma, a 37-year-old motorcyclist presented to the emergency ward with a Hoffa fracture of the lateral femoral condyle of the right knee. Following admission, the patient developed a pale, cold and pulseless right foot. CT angiography scan showed a 5 cm dissection of the popliteal artery. Emergency arterial reconstruction was performed and the Hoffa fracture was repaired in a second stage. To our knowledge, this is the first report of a patient with a Hoffa fracture accompanied by a popliteal artery dissection.

Radial Nerve Sensory Branch Anatomical Variant: A Case Report and Literature Review.

CASE: Two patients sustained comminuted extra-articular distal humerus fractures. One patient was neurovascularly intact preoperatively. The other patient had a complete radial motor palsy with preserved sensation. Intraoperatively, both exhibited anatomic variants of the radial sensory nerve of the arm that pierced the triceps rather than branching from the distal third of the radial nerve proper, as is traditionally reported. CONCLUSIONS: Although rare, variations in the radial nerve may exist about the distal humerus. Surgeons should be aware of these variations to avoid iatrogenic injury.

Acute burst fracture in Kummell's disease with acute onset neurological deficit: a case report on role of spinal stability and technical notes on "pivot ligamentotaxis".

BACKGROUND: Kummell's Disease has insidious progression. Neurological deficit is usually slow in onset and progression and only few cases of acute neurological deficit have been reported. We came across a case of Kummell's disease which progressed to burst fracture, developed neurological deficit within two weeks. We managed patient with "pivot ligamentotaxis" and Polymethylmethacrylate augmented, posterior compressed, short segment percutaneous pedicle screw fixation. CASE PRESENTATION: Eighty-three years old woman following fall was on conservative management at another hospital. She had no neurological deficit. A week later her back pain aggravated and two weeks later developed bilateral buttock pain, bilateral lower limb weakness and diminished sensation in the sacral area. Radiological investigations (X-rays, Magnetic resonance imaging and Computed tomography) showed L1 vertebral body fracture with vacuum cleft and fracture fragment retropulsed into the spinal canal. A diagnosis of Kummell's disease with burst fracture of L1 vertebra & neurological deficit was made. Patient was managed with Polymethylmethacrylate augmented, posterior compressed, short segment percutaneous pedicle screw fixation. The reduction of the retropulsed fragment was achieved by virtue of "Pivot ligamentotaxis". The patient got relieved of the symptoms (Preoperative VAS 8 and postoperative VAS 3) and was allowed brace assisted ambulation on first postoperative day. CONCLUSION: This study reports acute occurrence of the burst fracture in unstable vertebra inflicted by Kummell's disease and role of spinal stability in recovery. We achieved closed reduction of the fracture fragments and relief of the cord compression by posterior compression with "pivot ligamentotaxis".

Fracturas Mandibulares Conminutadas por Impacto de Proyectil Balístico: Propuesta de Tratamiento Inicial Mediante Método de Fijación Alternativo / Mandibular Fractures Comminuted by Ballistic Projectile Impact: Initial Treatment Proposal Using Alternative Fixation Method

RESUMEN: El trauma maxilofacial por arma de fuego representa un desafío terapéutico principalmente debido a la gran conminución de tejidos que genera. Específicamente, en casos de fracturas mandibulares conminutadas, las modalidades de tratamientos incluye la reducción cerrada, fijación con tutor externo, fijación interna con alambres y reducción abierta y fijación interna utilizando placas y tornillos. El objetivo del presente trabajo es describir un tratamiento inicial con un método de fijación para fracturas mandibulares conminutadas como dispositivo alternativo al tutor externo clásicamente utilizado. Se desarrolla una revisión de la literatura actual acerca del tratamiento inicial o de urgencia de fracturas mandibulares conminutadas por impacto de proyectil balístico, haciendo énfasis en las indicaciones de cada modalidad de tratamiento y sus respectivas ventajas y desventajas. Luego se describe detalladamente el proceso de confección de un método de fijación alternativo junto con la exposición de casos clínicos donde fue utilizado como alternativa de tratamiento. La reducción y fijación obtenida por el dispositivo presentado logra resultados satisfactorios, sin encontrarse diferencias significativas a los elementos de fijación clásicos. Tanto el uso de placas de reconstrucción como el de tutor externo constituyen alternativas válidas para el tratamiento de fracturas mandibulares conminutadas. El dispositivo descrito y utilizado en los pacientes es una alternativa eficiente, de fácil confección y bajo costo económico demostrando buenos resultados en relación a la consolidación de fracturas conminutadas. Se debe conocer las indicaciones para la aplicación de cada modalidad de tratamiento.

ABSTRACT: Ballistic maxillofacial trauma represents a challenge for surgeons because of the important comminution process it presents. Specifically, in cases of mandibular comminuted fractures, the different treatment modalities include closed reduction, external fixation and internal fixation. The purpose of this case series is to describe an initial treatment modality, with a fixation method for comminuted mandibular fractures as an alternative for the classic external fixator. We conducted a literature review about the initial treatment for ballistic comminuted mandibular fractures, emphasizing indications of each treatment modality and their respective advantages and disadvantages. Next, we described the preparation process of an alternative fixation method along with a case series, where it was used as a therapeutical alternative. The reduction as well the fixation achieved by the external fixator, showed satisfactory results without significant differences noted with traditional fixation methods. Both, reconstruction plates and external fixators, are valid alternatives for treating comminuted mandibular fractures. The method described and used in these patients is and efficient alternative, easy to make and at a low cost, with good results in relation to fracture consolidation. We propose that every treatment modality and its indications should be evaluated in order to treat each case adequately.

Custom-Made Cement-Linked Distal Femoral Replacement for Interprosthetic Femur Fractures: Five-Year Follow-Up.

Interprosthetic femur fractures between total hip and total knee replacements are challenging injuries with rising incidence. Stability of the either implants, quality, and quantity of remaining bone as well as patients' comorbidities play an important role in operative management. Open reduction and internal fixation, advanced revision arthroplasty techniques, and megaprostheses are available options. In more complex cases, custom-made implants maybe necessary to achieve immediate weight-bearing and restore function.

Fatal Transorbital Intracranial Penetrating Injury Due to a Bicycle Brake Handle.

Transorbital intracranial injuries are uncommon and mostly accidental in nature. These injuries are usually associated with high mortality. The key to preventing this mortality involves an early diagnosis of intracranial injuries and immediate and appropriate management. Any delay can pose a serious risk to the patient's life. A case of a 55-year-old man who had experienced an accidental self-fall while riding a bicycle is presented. Initially, he was treated at a primary health center. He was referred to the tertiary care institute due to unavailability of ancillary investigation at the primary health center. He was declared dead on arrival at the casualty in the tertiary institute. On autopsy, it was observed that the injury above the right side of the upper eyelid was penetrating the right side roof of the orbit and the right cerebral cortex and brainstem. The highlighting feature of the case is that, despite the fatal penetrating brain injury, the eyeball did not sustain any major injury.

Central dislocation of femoral head without involvement of acetabular anterior and posterior columns.

Objective This study was performed to explore the treatment of central dislocation of the femoral head without involvement of the acetabular columns. Methods Preoperatively, a three-dimensionally printed model of the patient's pelvis was manufactured according to the patient's computed tomography data. An all-locking anatomical plate was designed based on the mirror of the ipsilesional semi-pelvis. The fracture was reduced using reduction forceps and femoral traction via the lateral rectus approach. The customized plate was used as a template for reduction of the quadrilateral plate fracture. Results Reduction and fixation of this patient's fracture was achieved with a customized all-locking anatomical plate with a propeller shape via the lateral rectus approach. Conclusions This report describes an isolated quadrilateral plate fracture with central dislocation of the femoral head without involvement of the columns, which is a rare injury that has not yet been classified. It was effectively treated using a customized all-locking anatomical plate with propeller shape via the lateral rectus approach.

Autopsy Features of Fatal Donkey Attack.

Lethal donkey attacks have very rarely been described. The case of a 65-year-old man who was found deceased on a country road with 2 domestic donkeys nearby is, therefore, reported. Examination of the body revealed contusions and lacerations of the face and scalp, a comminuted fracture of the left maxilla, comminuted fracturing of the right radius and ulna and of the left anterior superior iliac spine, a flail chest, and pulmonary contusions. In addition, there were bite marks on the left thigh, right buttock, right axilla/upper arm, and left cheek which corresponded to the dental arcades of the donkeys. Death had resulted from blunt chest trauma due to an attack by 1 or 2 donkeys. Deaths and serious injuries are much more commonly caused by horses; however, this case shows that even domesticated donkeys may also rarely be capable of inflicting significant trauma and so should be approached with circumspection.

Surgical Stabilization of Rib Fractures in a 6-Year-Old Child After Blunt Trauma.

When identified, rib fractures in children are associated with high-energy trauma, nonaccidental trauma, or both. Traditionally, the optimal management of rib fractures in children is supportive care. In this case report, we present a 6-year-old boy who underwent surgical rib fixation for multiple displaced and comminuted rib fractures after being stepped on by a horse.