RESUMO
Lumbar facet fractures are rarely reported and have been linked to sports and spine surgery. We describe the case of a 77-year-old patient who sustained an injury from multiple landmine blasts during the Vietnam War. He had low back pain since that time, which was initially managed conservatively. However, the pain progressed over decades to severe neurogenic claudication that greatly restricted his quality of life. Neuroimaging revealed the presence of bone fragments impinging on the spinal canal at the L5/6 level (transitional anatomy) that resulted from a comminuted fracture of the lumbar facet at the inferior articular process. We performed an L5/6 decompressive laminectomy, with removal of these fragments, and posterior instrumented fusion, with substantial improvement in symptoms. This case illustrates a unique mechanism of lumbar facet fracture and the biomechanic origination, natural history, and optimal treatment of this entity. We expand on the spectrum of lumbosacral injuries associated with the combat blast injury that have only increased in prevalence in recent conflicts.
Assuntos
Fraturas Cominutivas , Fusão Vertebral , Espondilolistese , Masculino , Humanos , Idoso , Espondilolistese/complicações , Espondilolistese/cirurgia , Constrição Patológica/complicações , Fraturas Cominutivas/complicações , Qualidade de Vida , Região Lombossacral , Vértebras Lombares/cirurgia , Fusão Vertebral/métodosRESUMO
RATIONALE: Incidence of lunate fractures is very low, less than 1% of all fractures. Lunate fractures generally come from high-energy injuries, often combined with other wrist fractures. Simple lunate fractures can be fixed with screws or Kirschner wires. However, Comminuted lunate fractures are difficult to reduce and fixe by conventional methods. PATIENT CONCERNS: Here we report a 42-year-old male construction worker who was crushed by an excavator bucket and presented with comminuted lunate fracture combined with distal radius fracture and scaphoid fracture. DIAGNOSES: Comminuted lunate fracture, distal radius fracture, and scaphoid fracture. INTERVENTIONS: The posterior approach was used to reconstruct the radial lunate bone with polymethylmethacrylate cement, and cannulated screws were used to fix the scaphoid and distal radius fractures. OUTCOMES: At the 3rd month after surgery, the movement of the right wrist joint improved. At the sixth month after surgery, the patient returned to the building site and began working at the same intensity as before the injury. LESSONS: Although the incidence of comminuted lunate fractures is very low, they occur sometimes. For comminuted lunate fractures, early identification and intervention can preserve most of the function of the wrist joint.
Assuntos
Fraturas Ósseas , Fraturas Cominutivas , Traumatismos da Mão , Osso Semilunar , Fraturas do Rádio , Osso Escafoide , Fraturas do Punho , Traumatismos do Punho , Masculino , Humanos , Adulto , Fraturas Ósseas/cirurgia , Osso Semilunar/diagnóstico por imagem , Osso Semilunar/cirurgia , Osso Semilunar/lesões , Osso Escafoide/cirurgia , Osso Escafoide/lesões , Traumatismos do Punho/complicações , Traumatismos do Punho/cirurgia , Fraturas Cominutivas/complicações , Fraturas Cominutivas/cirurgia , Rádio (Anatomia)/lesões , Fraturas do Rádio/complicações , Fraturas do Rádio/cirurgia , Fixação Interna de FraturasRESUMO
CASE: An 18-year-old male polytrauma patient sustained a high-energy posterior fracture dislocation of his left elbow associated with a comminuted and irreparable O'Driscoll type 2 subtype 3 anteromedial facet coronoid fracture. He underwent early coronoid reconstruction using ipsilateral olecranon osteoarticular autograft with incorporation of the sublime tubercle attachment of the medial collateral ligament and repair of the lateral ulnar collateral ligament. A 3-year follow-up revealed a functional, painless, congruent, and stable elbow. CONCLUSION: Early reconstruction of a highly comminuted coronoid fracture may be a useful salvage option for the polytrauma patient, thereby avoiding complications associated with late reconstruction of posttraumatic elbow instability.
Assuntos
Articulação do Cotovelo , Fraturas Ósseas , Fraturas Cominutivas , Luxações Articulares , Instabilidade Articular , Traumatismo Múltiplo , Olécrano , Fraturas da Ulna , Masculino , Humanos , Adolescente , Articulação do Cotovelo/cirurgia , Olécrano/cirurgia , Fraturas da Ulna/cirurgia , Fraturas da Ulna/complicações , Autoenxertos , Instabilidade Articular/cirurgia , Fraturas Ósseas/complicações , Fraturas Cominutivas/cirurgia , Fraturas Cominutivas/complicações , Luxações Articulares/diagnóstico por imagem , Luxações Articulares/cirurgia , Luxações Articulares/complicações , Traumatismo Múltiplo/cirurgia , Traumatismo Múltiplo/complicaçõesRESUMO
Among zygomaticomaxillary complex (ZMC) fractures presenting to a tertiary urban academic center, the authors hypothesized the presence of both clinical and radiographic predictors of operative management. The investigators conducted a retrospective cohort study of 1,914 patients with facial fractures managed at an academic medical center in New York City between 2008 and 2017. The predictor variables were based on both clinical data and features of pertinent imaging studies, and the outcome variable was an operative intervention. Descriptive and bivariate statistics were computed and the p-value was set at 0.05. In total, 196 patients sustained ZMC fractures (5.0%) and 121 (61.7%) ZMC fractures were treated surgically. All patients who presented with globe injury, blindness, retrobulbar injury, restricted gaze, or enophthalmos and a concurrent ZMC fracture were managed surgically. The most common surgical approach was the gingivobuccal corridor (31.9% of all approaches), and there were no significant immediate postoperative complications. Younger patients (38.9 ± 18 years vs. 56.1 ± 23.5 years, p < 0.0001) and patients with greater than or equal to 4 mm of orbital floor displacement were more likely to receive surgical treatment than observation (82 vs. 56%, p = 0.045), as were patients with comminuted orbital floor fractures (52 vs. 26%, p = 0.011). In this cohort, patients more likely to undergo surgical reduction were young patients with ophthalmologic symptoms on presentation and at least 4 mm displacement of the orbital floor. Low kinetic energy ZMC fractures may warrant surgical management as often as high-energy ZMC fractures. While orbital floor comminution has been shown to be a predictor for operative reduction, in this study we also demonstrated a difference in the rate of reduction based on the severity of orbital floor displacement. This may have significant implications in both the triage and selection of patients most suitable for operative repair.
Assuntos
Fraturas Cominutivas , Fraturas Maxilares , Fraturas Orbitárias , Fraturas Cranianas , Fraturas Zigomáticas , Humanos , Estudos Retrospectivos , Fraturas Zigomáticas/cirurgia , Fraturas Maxilares/cirurgia , Fraturas Orbitárias/complicações , Fraturas Cominutivas/complicaçõesRESUMO
OBJECTIVES: To determine the incidence of patients with isolated pubic rami fractures on computed tomography scans who have dynamic instability secondary to occult lateral compression pelvic ring injuries. DESIGN: Retrospective comparison study. SETTING: Urban level 1 trauma center. PATIENTS/PARTICIPANTS: This study included geriatric patients with isolated pubic rami fractures and inability to mobilize secondary to pain. INTERVENTION: Lateral stress radiographs of pelvis to evaluate for ≥1 cm dynamic instability. MAIN OUTCOME MEASUREMENTS: Physical therapy clearance, hospital length of stay, and discharge location. RESULTS: A total of 19 patients were identified over 12 months. Patients were predominantly geriatric (median age: 75 years, interquartile range: 67 to 90), woman (11/19), with unilateral (17/19) comminuted distal rami fractures (12/19) sustained in ground-level falls (12/19). Dynamic instability was identified in 42% of patients (8/19). Magnetic resonance imaging, obtained in 6 of these patients, demonstrated occult posterior ring fractures in all cases. Patients with dynamic instability were more likely to have comminuted distal rami fractures (Nakatani type 1b) and a longer hospital length of stay. There was also a trend for these patients to be unable to clear physical therapy by discharge (63% (5/8) versus 36% (4/11)). The 90-day mortality rate of the cohort was 16% (3/19). CONCLUSIONS: Patients presenting with seemingly isolated pubic rami fractures on radiographs and computed tomography scans who are unable to mobilize may have occult lateral compression injuries with dynamic instability. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Fraturas Ósseas , Fraturas Cominutivas , Ossos Pélvicos , Fraturas da Coluna Vertebral , Feminino , Humanos , Idoso , Ossos Pélvicos/diagnóstico por imagem , Ossos Pélvicos/lesões , Estudos Retrospectivos , Fraturas Ósseas/complicações , Fraturas Ósseas/diagnóstico por imagem , Fraturas Ósseas/cirurgia , Fraturas da Coluna Vertebral/complicações , Pelve/lesões , Fraturas Cominutivas/complicaçõesAssuntos
Fraturas Cominutivas , Trombose , Fraturas da Tíbia , Fraturas Cominutivas/complicações , Fraturas Cominutivas/diagnóstico por imagem , Humanos , Artéria Poplítea/diagnóstico por imagem , Trombose/etiologia , Tíbia/diagnóstico por imagem , Fraturas da Tíbia/complicações , Fraturas da Tíbia/diagnóstico por imagemRESUMO
OBJECTIVES: To determine whether displacement on lateral stress radiographs (LSRs) in patients with minimally displaced lateral compression type 1 pelvic ring injuries is associated with any demographic and/or injury characteristics. DESIGN: Retrospective comparative cohort. SETTING: Urban level 1 trauma center. PATIENTS/PARTICIPANTS: Ninety-three consecutive patients with minimally displaced lateral compression type 1 injuries. INTERVENTION: Displacement of pelvic ring injury on LSR (≥10 mm vs. <10 mm). MAIN OUTCOME MEASUREMENTS: Demographic and injury characteristics (mechanism of injury, Nakatani rami classification, rami comminution, Denis zone, complete/incomplete sacral fracture, sacral comminution). RESULTS: 65.6% of patients (n = 61) had ≥10 mm of displacement on LSR. On univariate analysis, displacement was associated with increased age [median difference 11: confidence interval (CI), 2-23], female sex [proportional difference (PD): 25.1%, CI, 3.9%-44.4%], Nakatani classification (type I PD: 27.9%, type II PD: -19.5%), and rami comminution (PD: 55.6%, CI, 35.4%-71.3%). On multivariate analysis, displacement was only associated with rami comminution (odds ratio: 16.48, CI, 4.67-58.17). Displacement was not associated with energy of injury mechanism, sacral fracture Denis zone, complete sacral fracture, sacral comminution, or bilateral rami fractures. CONCLUSIONS: Although rami comminution was the only variable found to be independently associated with displacement ≥10 mm on LSR, no single variable perfectly predicted displacement. Future studies are needed to determine whether displacement on stress radiographs should change the management of these injuries. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Fraturas Ósseas , Fraturas Cominutivas , Ossos Pélvicos , Fraturas da Coluna Vertebral , Feminino , Fraturas Ósseas/complicações , Fraturas Cominutivas/complicações , Humanos , Ossos Pélvicos/lesões , Estudos Retrospectivos , Sacro/diagnóstico por imagem , Sacro/lesões , Fraturas da Coluna Vertebral/complicaçõesRESUMO
OBJECTIVES: To characterize the location and frequency of the fracture lines and comminution zones of both-column fractures using fracture mapping. METHODS: Both-column fractures were retrospectively reviewed in 4 Level 1 trauma centers. Mimics software was used to reconstruct the both-column fractures and simulate the fracture reduction. Then, the fracture lines and the intra-articular and extra-articular comminution zones were drawn on a 3-dimensional innominate bone template. The distribution of fracture lines and fracture fragments were also mapped on the two-dimensional template of the acetabulum. All the included patients were divided into low-variety group and high-variety group according to the anterior column fracture line above or below the anterior superior spine. The anatomical characteristics of the posterior wall fragment were also analyzed in these 2 groups. RESULTS: Seventy-eight patients with both-column fracture were included. The T type or inverted Y type main fracture lines divided the innominate bone into low-variety (n = 11) and high-variety (n = 67) both-column fractures. The extra-articular comminution zones are usually distributed between the posterior iliac fragment and anterior column fragment. High-variety type both-column fractures are usually combined with high and sharp posterior wall fragments, whereas low-variety type both-column fractures are usually accompanied by low and flat posterior wall fragments. The comminution zones in the acetabulum are mostly concentrated in the anterior and inferior parts of the acetabulum. CONCLUSIONS: The innominate bone is divided into 3 major parts in the both-column fracture, and the fracture center is located at the proximal of the acetabular dome. The both-column fractures are divided into low-variety and high-variety patterns. The location of the anterior column fracture determined the characteristics of the posterior wall fragment.
Assuntos
Fraturas Ósseas , Fraturas Cominutivas , Fraturas do Quadril , Ossos Pélvicos , Fraturas da Coluna Vertebral , Acetábulo/diagnóstico por imagem , Acetábulo/lesões , Fixação Interna de Fraturas/métodos , Fraturas Ósseas/complicações , Fraturas Ósseas/diagnóstico por imagem , Fraturas Ósseas/cirurgia , Fraturas Cominutivas/complicações , Fraturas Cominutivas/diagnóstico por imagem , Fraturas Cominutivas/cirurgia , Fraturas do Quadril/complicações , Humanos , Ossos Pélvicos/lesões , Estudos Retrospectivos , Fraturas da Coluna Vertebral/complicaçõesRESUMO
INTRODUCTION: Operative treatment of tibial pilon fracture is challenging. There is a lack of consensus and only one clinical study on the optimal location of distal tibial plating for fixation of pilon fractures based on varus or valgus fracture patterns. We hypothesize that complications rates, specifically mechanical complications, are not influenced by the location of the tibial plating in the fixation of pilon fractures with respect to varus or valgus fracture patterns. MATERIALS AND METHODS: Sixty-nine patients who had single plating for tibial pilon from 2007 to 2017 were recruited. They were divided into two groups, transverse fibular fracture (varus fracture pattern) and comminuted fibular fracture (valgus fracture pattern). Our primary outcome measure was any mechanical complications as a result of the location of plating (medial vs lateral) on varus or valgus fracture patterns. RESULTS: There were 38 (55.1%) patients with varus fracture pattern and 31 (44.9%) patients with valgus fracture pattern tibial pilon fractures. In the varus fracture pattern group, mechanical complications were not significantly different between the two plating locations (27.3 vs 33.3%, p > 0.05). Notably, there were more fibula fixations performed in patients with medial plating (74.1 vs 45.5%, p = 0.092) when compared those with lateral plating in the varus fracture pattern group. There were also no statistically significant differences found although 10 (40%) out of 25 patients had mechanical complications in the medial plating group compared to 1 (16.7%) out of 6 patients with lateral plating (p = 0.383) in the valgus fracture pattern group. CONCLUSION: There were no differences in mechanical complications for medial vs lateral plating in tibial pilon fracture based on varus or valgus deforming forces. As much as we should consider the fracture patterns and deforming forces when deciding on plating location, other factors such as careful soft tissue management and fragment-specific fixation should be prioritized.
Assuntos
Fraturas do Tornozelo , Fraturas Cominutivas , Fraturas da Tíbia , Fraturas do Tornozelo/cirurgia , Fixação Interna de Fraturas/métodos , Fraturas Cominutivas/complicações , Fraturas Cominutivas/cirurgia , Humanos , Estudos Retrospectivos , Tíbia , Fraturas da Tíbia/complicações , Fraturas da Tíbia/cirurgia , Resultado do TratamentoRESUMO
CASE: A 41-year-old woman sustained a distal radius fracture with concomitant median nerve transection. The wound was consistent with an inside-to-outside mechanism with noted metaphyseal bone loss at the level of the median nerve injury. The median nerve was not amenable to primary repair, and given concern for inability to define the zone of the injury, the patient underwent delayed reconstruction of the nerve. CONCLUSION: A review of the literature highlights the rare incidence of this combined injury that can be undetected or misdiagnosed as an acute carpal tunnel syndrome or stretch injury to the median nerve.
Assuntos
Síndrome do Túnel Carpal , Fraturas Cominutivas , Fraturas do Rádio , Adulto , Síndrome do Túnel Carpal/cirurgia , Feminino , Fixação Interna de Fraturas/efeitos adversos , Fraturas Cominutivas/complicações , Fraturas Cominutivas/diagnóstico por imagem , Fraturas Cominutivas/cirurgia , Humanos , Nervo Mediano/lesões , Nervo Mediano/cirurgia , Fraturas do Rádio/complicações , Fraturas do Rádio/diagnóstico por imagem , Fraturas do Rádio/cirurgiaRESUMO
Background: Although postoperative outcomes of olecranon fractures are relatively favorable, postoperative stiffness of the elbow joint occurs occasionally. We aimed to identify negative prognostic factors for unfavorable outcomes following olecranon fractures. Methods: We retrospectively reviewed the records of 100 patients with olecranon fractures and collected data on the conducted procedures, age, fracture condition, postoperative reduced position, and postoperative active range of motion (AROM) of the elbow joint. The primary outcome was the regaining of an AROM of > 130° flexion and < -30° extension of the elbow joint at the final follow-up. We performed multivariate logistic regression analysis to identify the negative prognostic factors. Results: The mean follow-up period was 11 months. All patients regained an average AROM of 121 degrees. Eighty-one patients regained a favorable AROM of the elbow joint. On univariate logistic regression analysis, diabetes mellitus (OR, 8.2; 95%CI, 1.6-41.7), comminution of the fractured site (OR, 23.1; 95% CI, 13.2-165.0), and utilization of the tension band wiring (TBW) technique (OR, 7.5; 95% CI, 1.16-48.2) were significant factors in aggravating the final result of elbow AROM. On multivariate analysis, patients with diabetes mellitus (OR, 10.9; 95% CI, 2.83-41.9), comminuted fractures (OR, 11.4; 95% CI, 2.61-50.2), or undergoing the tension band wiring technique (TBW) (OR, 5.5; 95% CI, 1.35-50.2) showed reduced postoperative AROM of the elbow joint; postoperative malreduction of the articular surface was not a negative prognostic factor. Seven of 51 patients treated with TBW underwent revision surgery because of non-union or postoperative displacement. Conclusions: TBW for olecranon fractures is a simple and cost-effective procedure; however, negative effects could develop when regaining sufficient postoperative AROM of the elbow joint. Therefore, rigid fixation without reoperation may lead to a favorable outcome. Postoperative malreduction does not always worsen the postoperative AROM of the elbow joint, at least not in the early postoperative period.
Assuntos
Fraturas Ósseas/cirurgia , Olécrano/lesões , Olécrano/cirurgia , Redução Aberta , Amplitude de Movimento Articular , Fios Ortopédicos/efeitos adversos , Complicações do Diabetes , Feminino , Fraturas Cominutivas/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Reoperação/estatística & dados numéricos , Estudos RetrospectivosRESUMO
As the brachial plexus traverses the costoclavicular space, it is susceptible to compression by pathologies affecting the clavicle. Clavicle nonunions with hypertrophic callus may cause a delayed onset of brachial plexus palsy. We present a rare case of a floating shoulder injury causing medial and posterior cord brachial plexus palsy two months after initial injury. After the diagnosis was established, the patient was treated successfully with expeditious brachial plexus decompression, callus excision, and rigid osteosynthesis, with healing of the clavicle nonunion and scapular fracture, and recovery of sensory and motor deficits.
Assuntos
Neuropatias do Plexo Braquial/etiologia , Clavícula/lesões , Fraturas Cominutivas/complicações , Fraturas não Consolidadas/complicações , Escápula/lesões , Acidentes de Trânsito , Idoso , Placas Ósseas , Neuropatias do Plexo Braquial/cirurgia , Clavícula/cirurgia , Descompressão Cirúrgica , Fixação Interna de Fraturas , Fraturas Cominutivas/cirurgia , Fraturas não Consolidadas/cirurgia , Humanos , Masculino , Escápula/cirurgiaRESUMO
Background: This study aimed to evaluate the clinical and radiological outcomes following an arthroscopic-assisted reduction and volar plating (AR-VP) surgery through pronator quadratus (PQ) preservation for treating intra-articular distal radius fractures (IA-DRFs) and to assess prognostic factors that affect functional outcomes. Methods: Between March 2014 and February 2017, 54 patients who had intra-articular DRF and underwent AR-VP through the PQ preservation technique and completed 1-year follow-up were enrolled. Patients were divided into the satisfactory group (excellent and good results) and an unsatisfactory group (fair and poor results) based on the modified Mayo Wrist Scoring System (MMWS) scored at 1-year follow-up to determinate prognostic factors that affected clinical outcomes. Patients' demographics, clinical outcome measures (VAS, DASH, PRWE, etc.), and pre-and post-operative radiographic parameters were analyzed. Results: The outcomes according to MMWS were 10 excellent, 22 good, 14 fair, and 8 poor. A univariate analysis showed a significant difference between the groups (p < .05) for all radiographic parameters, sex, and the presence of an intra-articular comminution. In the multivariate analysis, female gender, presence of an intra-articular comminution, and difference of palmar articular tilt compared to uninjured wrist (> 20.1°) at trauma were considered as significant poor prognostic factors of functional outcome. Conclusions: AR-VP surgery through PQ preservation for intra-articular DRFs has reliable clinical and radiological outcomes. However, female gender, presence of an intra-articular comminution, and difference of palmar articular tilt compared to the uninjured wrist (> 20.1°) at initial injury were considered poor prognostic factors for AR-VP through PQ preservation for intra-articular DRF.
Assuntos
Artroscopia , Placas Ósseas , Fixação Interna de Fraturas/métodos , Fixação de Fratura/métodos , Fraturas Intra-Articulares/cirurgia , Fraturas do Rádio/cirurgia , Adolescente , Adulto , Idoso , Feminino , Seguimentos , Fraturas Cominutivas/complicações , Fraturas Cominutivas/cirurgia , Humanos , Fraturas Intra-Articulares/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Medidas de Resultados Relatados pelo Paciente , Prognóstico , Radiografia , Fraturas do Rádio/diagnóstico por imagem , Fatores Sexuais , Adulto JovemRESUMO
CASE: An open obturator dislocation with associated pelvic ring injury and perineal wound underwent fixation and aggressive debridement. Despite this, the patient proceeded to infection requiring additional debridements and prolonged intravenous antibiotics. At 18 months postinjury, the patient developed avascular necrosis and significant heterotopic ossification; however, she was able to ambulate. CONCLUSIONS: Open obturator dislocations of the hip require a multidisciplinary team. Despite prompt antibiotic therapy and aggressive debridement, patients are at high risk of infection because of the microbial environment in this region. Open obturator hip dislocations are at significant risk of avascular necrosis despite timely reduction.
Assuntos
Fixação Intramedular de Fraturas , Fraturas Cominutivas/cirurgia , Luxação do Quadril/cirurgia , Ossos Pélvicos/lesões , Períneo/lesões , Acidentes de Trânsito , Adolescente , Feminino , Necrose da Cabeça do Fêmur/etiologia , Fraturas Cominutivas/complicações , Fraturas Cominutivas/diagnóstico por imagem , Luxação do Quadril/complicações , Luxação do Quadril/diagnóstico por imagem , Humanos , Osteomielite/etiologia , ReoperaçãoRESUMO
CASE: A 33-year-old man presented with acute abdominal and left hip pain after being struck by a motor vehicle. Radiographs revealed a comminuted left subtrochanteric femoral fracture. Computed tomography demonstrated a large pelvic hematoma and a radiopaque mass in the abdomen. Laparoscopy revealed the mass to be a large bone fragment lying within the greater omentum. The bone fragment, which seemed to be a femoral fracture fragment, was removed, and the fracture was repaired with a short cephalomedullary nail. CONCLUSION: Rarely, subtrochanteric fracture fragments can penetrate the pelvis or abdomen because of high-energy trauma. Recognizing this possibility is important to assure a correct diagnosis and subsequent treatment.
Assuntos
Dor Abdominal/etiologia , Fraturas Cominutivas/complicações , Fraturas do Quadril/complicações , Dor Abdominal/diagnóstico por imagem , Adulto , Fraturas Cominutivas/diagnóstico por imagem , Fraturas do Quadril/diagnóstico por imagem , Humanos , Masculino , Tomografia Computadorizada por Raios XRESUMO
The combination of tendon and ligament ruptures with fracture of the talus is very rare. We demonstrate our experience in the acceptable management of a 34-year-old male referred with a closed comminuted fracture of the talar body after falling 7 meters. During the surgery, complete rupture of the peroneus brevis tendon, partial rupture of the peroneus longus tendon, and an avulsed superficial deltoid ligament from medial malleolus were found. Twelve months after open reduction and internal fixation of the talar body fracture and repair of the peroneal tendons and superficial deltoid ligament, the patient was satisfied, without any talar dome collapse, sclerosis, or arthritic changes. It is recommended to take care of possible tendon or ligament ruptures during fixation of talar fractures in cases of high-energy trauma.
Assuntos
Traumatismos do Tornozelo/complicações , Fraturas Fechadas/complicações , Fraturas Cominutivas/complicações , Tálus/lesões , Traumatismos dos Tendões/complicações , Adulto , Traumatismos do Tornozelo/diagnóstico , Traumatismos do Tornozelo/cirurgia , Fixação de Fratura , Fraturas Fechadas/diagnóstico , Fraturas Fechadas/cirurgia , Fraturas Cominutivas/diagnóstico , Fraturas Cominutivas/cirurgia , Humanos , Masculino , Ruptura , Traumatismos dos Tendões/diagnóstico , Traumatismos dos Tendões/cirurgiaRESUMO
BACKGROUND: Shear humeral capitellum fracture (CF) treatment can be complicated by comminution of the distal lateral humeral column (LHC). Although treatment with a 3.5 mm posterolateral distal humerus plate with support (PDHPWS) has been proposed, its indications have not yet been outlined. The purpose of this study was to describe a classification system for this fracture pattern and provide a therapeutic algorithm to avoid complications associated with PDHPWS fixation. METHODS: Thirty-four patients who underwent surgical treatment for CF with LHC comminution were enrolled. The humeral capitellum angle (α angle) measured on the sagittal view of computed tomography reconstructions corresponded to the height of the LHC fracture line; based on this height, the severity of LHC injury was categorized as subtype L (low fracture line, 60° < α < 90°), subtype M (moderate fracture line, 45° < α < 60°) or subtype H (high fracture line, α < 45°). The therapeutic algorithm was countersunk compression screws for subtype L, lateral buttressing combined with/without an anterior antiglide mini-fragment plate for subtype M and a dorsolateral anatomical locking plate for subtype H. At the end of the follow-up period, the treatment outcome was evaluated by radiography and an assessment of the range of motion. A functional assessment was carried out using the Mayo Elbow Performance Score (MEPS) and Disabilities of the Arm, Shoulder and Hand (DASH) score. RESULTS: The mean age of patients in this cohort was 49.6 ± 14.6 years, and the mean follow-up duration was 48.9 ± 34.6 months. There were 10 cases classified as subtype L, with a mean α angle of 80.6 ± 8.8°. The mean α angle for the 13 cases classified as subtype M was 52.1 ± 4.6° and that for the 11 cases classified as subtype H was 24.1 ± 22.4°. All fractures healed uneventfully, and implant removal was required in 8 cases (one subtype M and seven subtype H). The average MEPS in the three subgroups was 84.5 (subtype L), 87.3 (subtype M) and 78.2 (subtype H), while the average DASH score was 13.9 (subtype L), 11.6 (subtype M) and 21.5 (subtype H). Compared with the other subtypes, subtype H showed the smallest improvement in mean elbow function (112.7° in flexion, 13.6° in extension, 66.4° in pronation and 71.4° in supination). No cases of heterotopic ossification or avascular necrosis of the capitellum developed in any group. CONCLUSION: By analyzing the fracture morphology, a substantial portion of CFs with mild to moderate LHC comminution could be successfully managed by a simpler and less aggressive method with fewer complications than PDHPWS. LEVELS OF EVIDENCE: Level IV; Case Series; Treatment Study.
Assuntos
Articulação do Cotovelo/cirurgia , Fixação Interna de Fraturas/métodos , Fraturas Cominutivas/complicações , Fraturas do Úmero/classificação , Fraturas do Úmero/cirurgia , Adulto , Idoso , Algoritmos , Avaliação da Deficiência , Articulação do Cotovelo/diagnóstico por imagem , Feminino , Fraturas Cominutivas/cirurgia , Humanos , Fraturas do Úmero/diagnóstico por imagem , Úmero/cirurgia , Masculino , Pessoa de Meia-Idade , Radiografia , Amplitude de Movimento Articular/fisiologia , Estudos Retrospectivos , Índice de Gravidade de Doença , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
INTRODUCTION: Surgical management of thoracolumbar burst fractures is controversial. While the goals of surgical treatment are well accepted (i.e., fracture reduction and stabilization, neural elements decompression, and segmental angular deformity correction), the choice of the best surgical approach (i.e., posterior vs. anterior vs. combined approach) remains controversial. Several studies have debated the advantages of each surgical approach but there is no definitive evidence available to date, particularly in young adult patients. The aim of this study was to assess whether posterior approach alone can be a valid surgical treatment for patient under the age of 40 affected by thoracolumbar burst fractures and incomplete neurological deficits. MATERIAL AND METHODS: A total of 10 consecutive patients affected by thoracolumbar burst fractures associated with incomplete neurological deficits treated at our institution from January 2015 to February 2017 were included in our study. All patients were under the age of 40 at the time of injury and underwent decompression and stabilization using the posterior surgical approach alone. Demographics, clinical, and radiographic parameters were recorded preoperatively, postoperatively and at the latest available follow-up. The minimum follow-up was set at 2 years post-operatively. RESULTS: The mean operative time was 303.6 min (range, 138-486). Average blood loss was 756 mL (range, 440-2100). Nine out of ten patients returned to a normal neurological status after surgery while 1 patient showed some improvement but did not recover completely. Segmental kyphotic deformity improved from a mean of 21.8° before surgery to 14.8° at the time of the last follow-up. The anterior and posterior wall height of the fractured vertebra was restored with an average of 4 mm. The Visual Analogue Scale score reported an improvement from the mean preoperative value of 7.92 to 1.24 at the last follow-up; 8 out of 10 patients resumed physical activity while all of them returned to work. CONCLUSIONS: A single posterior surgical approach is an acceptable option in terms of clinical, radiological and functional outcomes at 2 years follow-up in patients under the age of 40 presenting with a thoracolumbar burst fracture and neurological deficit.
Assuntos
Fraturas Cominutivas/cirurgia , Fraturas por Compressão/cirurgia , Vértebras Lombares/lesões , Vértebras Torácicas/lesões , Adulto , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Descompressão Cirúrgica/métodos , Feminino , Seguimentos , Fixação Interna de Fraturas/métodos , Fraturas Cominutivas/complicações , Fraturas Cominutivas/diagnóstico por imagem , Fraturas por Compressão/complicações , Fraturas por Compressão/diagnóstico por imagem , Humanos , Cifose/diagnóstico por imagem , Cifose/cirurgia , Vértebras Lombares/patologia , Masculino , Doenças do Sistema Nervoso/diagnóstico , Doenças do Sistema Nervoso/epidemiologia , Doenças do Sistema Nervoso/etiologia , Duração da Cirurgia , Avaliação de Resultados em Cuidados de Saúde , Radiografia/métodos , Estudos Retrospectivos , Fraturas da Coluna Vertebral/diagnóstico por imagem , Fraturas da Coluna Vertebral/cirurgia , Fusão Vertebral/métodos , Vértebras Torácicas/patologia , Escala Visual AnalógicaRESUMO
BACKGROUND: Posttraumatic arthritis of tibiotalar joints after AO/OTA type C3 pilon fractures, especially in young patients with a significant osteochondral defect in the tibial plafond joint surface, is a challenging situation. We report a joint-preserving technique using autologous osteochondral graft in combination with ankle distraction and supramalleolar osteotomy (SMOT), if necessary, to improve its outcome. METHODS: Seventeen patients with an average age of 32.1 years with Takakura grade 1 to 3A posttraumatic arthritis of the tibiotalar joint after AO/OTA type C3 pilon fractures received osteochondral autograft transplantation, ankle distraction, and SMOT, when supramalleolar malalignment was present, between February 2010 and November 2015. The visual analog scale (VAS), Short-Form 36 (SF-36) score, American Orthopaedic Foot & Ankle Society (AOFAS) score, and ankle range of motion were used for outcome analysis. Radiographic assessment of any SMOT and the apparent joint space was performed. Fourteen patients were followed for an average of 18 months. RESULTS: The VAS, SF-36, and AOFAS scores as well as the ankle range of motion all improved significantly at the last follow-up after the surgery (P < .01). No deep surgical site infection, donor site complication, nonunion, osteochondral block loosening, or resorption was noted. No secondary arthrodesis was needed at the end of follow-up. CONCLUSION: Autologous osteochondral graft transplantation in combination with ankle distraction and SMOT was a promising joint-preserving technique for early posttraumatic arthritis of tibiotalar joint after severe pilon fractures in young patients. LEVEL OF EVIDENCE: Level IV, case series.