Melone's concept revisited in comminuted distal radius fractures: the three-dimensional CT mapping.

BACKGROUND: There is no consensus in the literature about the ideal classification of the distal radius fracture for the clinical practice. The traditional Melone classification system divides the distal radius into four basic components, the shaft, radial styloid, dorsal medial fragment, and volar medial fragment. The aim of this study was to identify fracture lines in comminuted distal radius fractures using three-dimensional mapping of computed tomography (CT) images to test the hypothesis that fracture fragments can be divided according to the Melone classification. METHODS: Fifty-nine consecutive OTA/AO 23C3 fractures presented at the hospital between January 2018 and October 2019 were retrospectively reviewed. The fracture lines were characterized in the axial, sagittal, and coronal CT planes. After reducing the fractures in a three-dimensional (3D) model, the fracture lines were plotted from the CT images and were then superimposed on one another and oriented to fit a standard template. The area of articular surfaces was measured and compared to quantify the differences between the radial bone fragments. RESULTS: Thirty-five cases (59.3%) in this study fit the Melone classification and 24 cases (40.7%) did not. On the radiocarpal surface, there was a greater concentration of fracture lines in the dorsal area of the radius than in the volar area. On the distal radioulnar joint (DRUJ), the fracture lines were focused around two specific concentrated regions. For the articular surface area, the mean area of the radial styloid, volar medial fragment, and dorsal medial fragment was 141.13 ± 90.16 mm2, 147.79 ± 75.94 mm2, and 79.05 ± 70.73 mm2, respectively. There was a significant difference in articular surface area for the Melone fragments (P = 0.002). CONCLUSIONS: The Melone classification system is not suitable for characterizing all C3 fractures. The findings of this study confirm that the dorsal medial fragments are relatively comminuted and small. Extra care should be given to these small fragments when reducing the fracture.

Primary cemented bipolar radial head prostheses for acute elbow injuries with comminuted radial head fractures: mid-term results of 37 patients.

BACKGROUND: Radial head arthroplasty represents a widely accepted treatment for elbow injuries with non-reconstructible radial head fractures. The aim of this retrospective multicenter study was to assess mid-term results of patients with clearly defined elbow injuries including type III fractures of the radial head according to Mason's classification type III after primary arthroplasty using a cemented bipolar design. MATERIALS AND METHODS: In 45 cases a primary cemented bipolar arthroplasty of the radial head was implanted for elbow injuries combined with an acute Mason type III radial head fracture. In all patients associated fractures were detected with preoperative CT scans and ligamentous injuries were evaluated and both were addressed intraoperatively based on a standardized algorithm. Patients with associated injuries other than coronoid fractures and collateral ligament tears were excluded from this study to obtain a more homogenous sample. Clinical and radiological assessment was performed on thirty-seven patients at an average of 5.6 years postoperatively. RESULTS: DASH Score, functional rating index of Broberg and Morrey, Mayo Elbow Performance Score, and Mayo Modified Wrist Score confirmed good-to-excellent results in most of the patients. Compared to the unaffected arm range of motion and grip strength were slightly reduced. No elbow instability or loosening of the prosthesis, and minor degenerative changes were detected in a few cases. CONCLUSION: Primary cemented bipolar arthroplasty for type III fractures according to Mason's classification in an elbow injury pattern only including associated coronoid fractures and/or ligamentous tears resulted in good-to-excellent mid-term results. These results suggest that primary bipolar radial head arthroplasty combined with distinct treatment of all associated injuries provides good functional outcomes concerning range of motion, elbow stability, and strength in this cohort. However, the associated injuries may influence clinical and radiological outcome and need to be detected, classified, and treated carefully.

Excellent results and low complication rate for anatomic polyaxial locking plates in comminuted proximal ulna fractures.

BACKGROUND: Comminuted fractures of the proximal ulna remain a great challenge in orthopedic surgery. The purpose of this study was to report the outcomes of comminuted proximal ulna fractures treated with a new construct type-anatomically preformed polyaxial locking compression plates. METHODS: Between 2013 and 2016, 46 patients with isolated comminuted fractures were treated with a 2.7-/3.5-mm VA-LCP Olecranon Plate (Synthes, Umkirch, Germany). Of these, 44 were available for an assessment after a mean follow-up period of 2.5 years (range, 12-50 months). We evaluated range of motion, time to recovery, revision rate, and indications, as well as functional scores. Radiographs were analyzed. RESULTS: The study included 8 Mayo IB, 29 Mayo IIB, and 7 Mayo IIIB fractures. All fractures showed bony union, and only 2 revision surgical procedures were performed because of a new trauma. No other complications occurred. Mean range of motion was 139° (range, 105°-150°), and the mean pain level was less than 1 on a visual analog scale. Regarding elbow function, we found a mean Mayo Elbow Performance Score of 98; a mean Oxford Elbow Score of 44; and a mean Disabilities of the Arm, Shoulder and Hand score of 6. Of the plates, 41% were removed after an average time of 16 months, whereby a significant improvement in extension deficit was detected (P < .01). Ninety-five percent of all patients returned to their pretrauma sports level. CONCLUSION: The 2.7-/3.5-mm VA-LCP Olecranon Plate represents an effective option with excellent fracture reduction, sufficient stability for early postoperative functional rehabilitation, and a minimum of complications.

Intraobserver and interobserver reliability of recategorized Neer classification in differentiating 2-part surgical neck fractures from multi-fragmented proximal humeral fractures in 116 patients.

BACKGROUND: Optimal fracture classification should be simple and reproducible and should guide treatment. For proximal humeral fractures, the Neer classification is commonly used. However, intraobserver and interobserver reliability of the Neer classification has been shown to be poor. In clinical practice, it is essential to differentiate 2-part surgical neck fractures from multi-fragmented fractures. Thus, the aim of this study was to evaluate whether surgeons can differentiate 2-part surgical neck fractures from multi-fragmented fractures using plain radiographs and/or computed tomography (CT). METHODS: Three experienced upper limb specialists and trauma surgeons (B.O.S., A.P.L., and V.L.) independently reviewed and classified blinded plain radiographs and CT scans of 116 patients as showing 2-part surgical neck fractures or multi-fragmented fractures. Each imaging modality was reviewed and classified separately by each surgeon, after which each surgeon reviewed both modalities at the same time. This process was repeated by all surgeons after 24 weeks. Intraobserver and interobserver analyses were conducted using Cohen and Fleiss κ values, respectively. RESULTS: The κ coefficient for interobserver reliability showed substantial correlation (0.61-0.73) and was as follows: 0.73 for radiographs alone, 0.61 for CT scans alone, and 0.72 for radiographs and CT scans viewed together. After 24 weeks, the process was repeated and intraobserver reliability was calculated.The κ coefficient for intraobserver reliability showed substantial correlation (0.62-0.75) and was as follows: 0.62 for radiographs alone, 0.64 for CT scans alone, and 0.75 for radiographs and CT scans viewed together. CONCLUSION: Clinicians were able to differentiate 2-part surgical neck fractures from multi-fragmented fractures based on plain radiographs reliably.

Intraobserver and interobserver agreement in the classification and treatment of proximal humeral fractures.

BACKGROUND: There is controversy surrounding the reliability of radiographic measurements and existing classifications for proximal humeral fractures. METHODS: Ten orthopedists, divided into 2 groups by length of experience, evaluated radiographs in 3 views from 40 proximal humeral fractures. We evaluated 11 radiographic criteria (including the Neer and pathomorphologic classifications, head-shaft angle, displacement of the humeral shaft, and lesser and greater tuberosities) and treatment indication. We also analyzed the criteria that most influenced the choice of treatment. RESULTS: Interobserver reliability was substantial for the presence of fracture of the greater tuberosity (κ = 0.749) and medial metaphyseal comminution (κ = 0.627) and moderate for the pathomorphologic classification (κ = 0.504), displacement of the greater tuberosity (κ = 0.422), and treatment decision (κ = 0.565). Intraobserver reliability was substantial for treatment indication (κ = 0.620) and presence of displacement of the fracture of the greater tuberosity (κ = 0.627 and 0.611) and moderate for the Neer (κ = 0.490) and pathomorphologic (κ = 0.607) classifications. The results were influenced by the observer's experience. The surgical indication was influenced by the pathomorphologic classification in 50% of the evaluators (odds ratio, 4.85; range, 3.30-8.65). CONCLUSION: The pathomorphologic classification has higher reliability than the Neer classification and was the factor that most influenced the surgical decision. The determination of the presence of fracture and displacement of the greater tuberosity and medial metaphyseal comminution is reliable with the use of simple radiographs, and the results were influenced by the observer's experience.

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF).

Background and purpose - The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF) describes the localization and morphology of fractures, and considers severity in 2 categories: (1) simple, and (2) multifragmentary. We evaluated simple and multifragmentary fractures in a large consecutive cohort of children diagnosed with long bone fractures in Switzerland. Patients and methods - Children and adolescents treated for fractures between 2009 and 2011 at 2 tertiary pediatric surgery hospitals were retrospectively included. Fractures were classified according to the AO PCCF. Severity classes were described according to fracture location, patient age and sex, BMI, and cause of trauma. Results - Of all trauma events, 3% (84 of 2,730) were diagnosed with a multifragmentary fracture. This proportion was age-related: 2% of multifragmentary fractures occurred in school-children and 7% occurred in adolescents. In patients diagnosed with a single fracture only, the highest percentage of multifragmentation occurred in the femur (12%, 15 of 123). In fractured paired radius/ulna bones, multifragmentation occurred in 2% (11 of 687); in fractured paired tibia/fibula bones, it occurred in 21% (24 of 115), particularly in schoolchildren (5 of 18) and adolescents (16 of 40). In a multivariable regression model, age, cause of injury, and bone were found to be relevant prognostic factors of multifragmentation (odds ratio (OR) > 2). Interpretation - Overall, multifragmentation in long bone fractures in children was rare and was mostly observed in adolescents. The femur was mostly affected in single fractures and the lower leg was mostly affected in paired-bone fractures. The clinical relevance of multifragmentation regarding growth and long-term functional recovery remains to be determined.

Comparison of Autogenous and Alloplastic Cranioplasty Materials Following Impact Testing.

Alloplastic materials are often used when significant defects exist. Benefits include no donor site morbidity, relative ease of use, limitless supply, and predictable durability. Depending on the type of alloplast, limitations include a persistent risk of extrusion and infection. Of particular interest in relation to cranioplasties is the ability of the material to provide neuroprotection. The integrity and neuroprotective properties of autologous bone flaps, polymethylmethacrylate (PMMA), and high-density porous polyethylene (PP) were evaluated following impact testing. Three groups of New Zealand white rabbits (N = 4) underwent a cranioplasty with either a bone flap, PMMA, or PP. In the control group (N = 4), the animals had no cranioplasty. At the end of the eighth week, an impact was delivered to the center of each cranioplasty. At necropsy each cranium and brain was evaluated grossly and histologically. There was a statistical significant difference among groups for the severity of the hemorrhage (P = 0.022) and the grade of cranioplasty disruption (P = 0.0045). Autologous bone was found to be the weakest of the materials tested. In this group severe injury resulted at much lower energy levels than was observed in the control, PMMA, or PP groups. Both PMMA and PP were resistant to fracture and disruption. PMMA provided the greatest neuroprotection, followed by PP. Autologous bone provided the least protection with cranioplasty disruption and severe brain injury occurring in every patient. Brain injury patterns correlated with the degree of cranioplasty disruption regardless of the cranioplasty material. Regardless of the energy of impact, lack of dislodgement generally resulted in no obvious brain injury.

A Method of Open Reduction of an Irreducible Hawkins Type III Fracture of the Talar Neck.

Hawkins type III fracture talar neck may sometimes be a nightmare for surgeons to reduce, even intraoperatively. It is difficult to reduce as the talar body is locked into its dislocated posteromedial position out of both the ankle and subtalar joint. Maneuvers of reduction have been described both in dorsiflexion and plantarflexion of ankle, but these are complicated and not tissue friendly. Further, various methods of grasping and pushing the dislocated talar body by use of joysticks and distractors have been advocated. To accomplish this intraoperatively, we present a convenient and utilitarian method using only 2 smooth 1.5-mm Kirschner wires and a JESS distractor clamp. Two key concepts to keep in mind while reducing such fracture dislocations are also highlighted. This was done in a 22-year-old male with 7-day-old Hawkins type III fracture of the left talar neck and a right Pilon fracture with good results at 2 year follow-up.

Zygomatic arch fracture: a new classification and treatment algorithm with epidemiologic analysis.

Determining the optimal method for zygoma fracture reduction is a common challenge. Numerous methods for treating zygomatic arch fractures have been suggested. However, a substantial gap exists between suggested treatment strategies and real-world practice. A general consensus of classification and treatment guidelines for zygomatic arch reduction has not yet been established. We reviewed our cases and propose a new classification of zygomatic arch fracture and a treatment algorithm for successful reduction based on the injury vectors.

Progressive kyphotic deformity in comminuted burst fractures treated non-operatively: the Achilles tendon of the Thoracolumbar Injury Classification and Severity Score (TLICS).

INTRODUCTION: The Thoracolumbar Injury Classification and Severity (TLICS) scale has been considered one of the best available grading systems for evaluating thoracolumbar fractures, especially due to the fact that, differently from previous classifications, it can be used as a practical algorithm to orient the clinical decision-making between conservative and surgical management. CASE REPORT: The authors describe a case of a 54-year-old patient presenting with low-back pain after having struck her back on the handrail. The neurological exam was unremarkable. The CT-scan of the lumbar spine demonstrated a L1 comminuted burst fracture. The MRI demonstrated no evidence of posterior ligamentous complex injury. According to the TLICS classification (total score of 2) the patient was managed conservatively with a thoracolumbar brace. Although at the 1-month follow-up the X-rays demonstrated no major changes and the pain had clinically improved, the patient was lost to follow-up. After 12 months the patient presented back to the emergency department with complaints of increased back pain. The repeat CT-scan demonstrated a remarkable worsening of the vertebral body fracture, with a major kyphotic deformity. The patient was submitted to a staged anterior-posterior procedure consisting in posterior decompression of the T12-L2 levels, a T10-L4 pedicle screw fixation and, finally, a lateral transpsoas approach for L1 corpectomy and reconstruction with an expandable interbody cage and plate fixation. At the 6-months follow-up, the patient presented another episode of back pain and a new L4 endplate fracture was identified. After 2 months of failed conservative treatment, the patient was treated with percutaneous kyphoplasty. At the 12-months follow-up after the initial surgical procedure, the patient was pain free and with stable radiographs. CONCLUSIONS: In this Grand Rounds presentation, the authors perform a comprehensive discussion about the historical developments in the classification systems for thoracolumbar fractures with special emphasis in the new TLICS system. Although such score presents several advantages in relation to other grading systems, patients with comminuted burst fractures deserve special attention, even if initially classified as non-operative according to the TLICS algorithm. In such cases, if a decision of conservative management is taken, a close follow-up is recommended due to the high likelihood of long-term kyphotic deformity.

Sequelae of underdiagnosed foot compartment syndrome after calcaneal fractures.

The calcaneus is the most frequently fractured tarsal bone. Compartment syndrome (CS) complicates fractures and other injuries and is most commonly described in association with the lower leg. The long-term sequelae of CS of the foot can include toe clawing, permanent loss of function, persistent pain, muscle atrophy, contracture, painful warts, weakness, and sensory disturbances. The incidence and clinical significance of untreated CS after calcaneal fractures were questioned. All compliant patients treated by us for a calcaneus fracture underwent a physical examination and medical interview: 47 (49 fractures) were included in the final cohort (36 males, 11 females, mean age 49 ± 14.5 years, mean follow-up 23 ± 16 months). Missed CS sequelae were diagnosed by the presence of claw toes and plantar sensory deficits. The functional outcome and pain at rest and during activity were scored. Five patients (10%) had missed CS, and their functional score was significantly lower than for those without CS (52 ± 21.5 versus 77.4 ± 22 for no CS, p < .05). All missed CS cases were diagnosed in patients with a Sanders type 3 or 4 fracture. Intra-articular fracture was a significant factor associated with developing CS sequelae (p = .045). Untreated CS can cause muscle and nerve injury and contribute to a poor functional outcome. Because CS is more likely to develop after highly comminuted intra-articular fractures, these patients warrant close monitoring for CS development. Early detection and treatment might result in fewer late disabling sequelae of this injury.

[Osteoporotic fractures of the proximal humerus]. / Osteoporotische Frakturen am proximalen Humerus.

Fractures of the proximal humerus are typical osteoporotic fractures of the elderly with an increasing incidence. Computed tomography (CT) with 3D reconstruction plays a more and more decisive role in the diagnostics because of an improved understanding of fractures in 3D images. The resulting correct fracture classification has significance for the decision of the best therapy procedure. Currently an extended version of the Codman classification with its four and more fragments is used to give additive information about varus or valgus dislocation, impression or distraction. The comparison of conservative and operative treatment showed no predominance of one of the procedures, therefore both strategies are justified. An operative treatment is recommended in complex fractures. Thus, early functional mobilization, early self-dependence and return to the activities of daily living are possible. Intramedullary nailing is advised in 2-part fractures, in dislocated multipart fractures locking plating or a primary reverse shoulder arthroplasty with refixation of the tuberosities in patients over 75 years. However, the improved plate and nail systems with polyaxiality, calcar screws, modern plate and nails designs as well as the possibility of arthroscopy-assisted nail implantation or plate removal combined with arthroscopic arthrolysis are innovative.

Newly defined fracture pattern specific to Mason III radial head fractures: fracture description, management and outcomes using screw fixation.

BACKGROUND: Radial head fractures are the most common type of elbow fracture and are universally classified under the Mason classification system. Mason type III fractures are comminuted and are the most difficult to treat, generally requiring plating if possible, or more commonly arthroplasty or excision, which gives a variable outcome. We hypothesized that a new and specific fracture pattern of the radial head (Mason III) can be treated successfully with screw fixation. METHODS: Six patients presented to the senior surgeon's clinic with this unusual Mason III fracture pattern. In these patients, the fracture was acute, requiring an open reduction and internal fixation with the use of three headless compression screws. Average follow-up time was 21 months. Using serial X-rays and the Broberg-Morrey elbow score, the six acute fractures were evaluated radiologically and functionally. RESULTS: All six patients had good to excellent results using the Broberg-Morrey scoring system. All patients showed radiological and clinical union within 3 months of injury. No patient required revision surgery or excision at a later date. DISCUSSION: We have recognized a specific type of comminuted and displaced Mason III radial head fracture that has not previously been described in the literature. This type of fracture is amenable to open reduction internal fixation with buried compression screws giving a good to excellent outcome, while avoiding the common consequences seen with a radial head excision, arthroplasty or plate fixation.

Staged posterior tibial plating for the treatment of Orthopaedic Trauma Association 43C2 and 43C3 tibial pilon fractures.

OBJECTIVE: Obtaining an accurate reduction of the posterior malleolar fragment in high-energy pilon fractures can be difficult through standard anterior or medial incisions, resulting in a less than optimal articular reduction. The purpose of this study was to report on our results using a direct approach with posterior malleolar plating in combination with staged anterior fixation in high-energy pilon fractures. DESIGN: Prospective clinical cohort. SETTING: A Level I trauma and tertiary referral center. PATIENTS/PARTICIPANTS: From January 1, 2005, to December 31, 2008, 19 Orthopaedic Trauma Association 43C pilon fractures (16 C3 and 3 C2) with a separate, displaced, posterior malleolar fragment were treated by the authors. Nine patients were treated with posterior plating of the tibia (PL) through a posterolateral approach followed by a staged direct anterior approach. Ten patients with similar fracture patterns were treated using standard anterior or anteromedial incisions (A) with indirect reduction of the posterior fragment. All 19 patients were available for follow-up at an average of 40 months (range, 28-54 months). INTERVENTION: All patients were treated with open reduction and internal fixation for their pilon fractures. MAIN OUTCOME MEASUREMENTS: Quality of reduction was assessed using postoperative plain radiographs and computed tomography. Serial radiographs were taken during the postoperative course to assess the progression of healing and the development of joint arthrosis. Clinical follow-up included physical examination and evaluation of the ankle using the American Orthopaedic Foot and Ankle Society Ankle & Hindfoot score, Maryland Foot Score as well as noting all complications. RESULTS: There were no differences in injury pattern or time to surgery between groups. Of the 10 patients who were in the A group, 4 (40%) had more than 2 mm of joint incongruity at the posterior articular fracture edge as compared with no patients in the PL group as measured on postoperative computed tomography scans. At latest follow-up, 7 (70%) patients in the A group had radiographic evidence of joint space narrowing compared with 3 (33%) in the PL group. Ankle range of motion for the A group was 35.8° versus 34.2° for the PL group (nonsignificant). There were 2 delayed wound healing complications in the A group with one deep infection in the PL group. Two patients in the A group required arthrodesis procedures resulting from posttraumatic arthrosis compared with none in the PL group. No significant difference was seen in postoperative complications across both groups. The average Maryland Foot Score and American Orthopaedic Foot and Ankle Society/Ankle & Hindfoot score for the PL group was 86.4/85.2 compared with 69.4/76.4 for the A group. CONCLUSIONS: The addition of a posterior lateral approach offers direct visualization for reduction of the posterior distal fragment of the tibial pilon. Although the joint surface itself cannot be visualized, this reduction allows the anterior components to be secured to a stable posterior fragment at a later date. This technique improved our ability to subsequently obtain an anatomic articular reduction based on computed tomography scans and preservation of the tibiotalar joint space at a minimum 1-year follow-up. Furthermore, it correlated with an improvement in clinical outcomes with increases in Maryland Foot Score and Ankle & Hindfoot score for the posterior plating group. Although promising, continued follow-up will be needed to determine the long-term outcome using this technique for treating tibial pilon fractures.

Loss of correction in unstable comminuted distal radius fractures with external fixation and bone grafting--a long term followup study.

Over the years, management of complex distal radius fractures by closed means has often failed leading to late collapse. We have chosen the principle of ligamentotaxis using external fixation and bone grafting in this study to prevent late complications. Eighty one patients with complex distal radius fractures belonging to Type IV A, IV B, IV C of Universal classification were treated with an AO external fixator between 1995 and 2001. Mean age group was 38. 47 years with longest follow up of 7 years. Bone grafting was done primarily in 20 patients and early grafting (within 3 weeks) in 5 patients. Statistically significant differences were observed between the two groups(with or without bone grafting) with respect to postoperative values of (radial length, radial tilt and volar tilt). Results were assessed based on Sarmientos criteria. 56 patients had excellent results, 9 had good results and 16 had poor results. Late collapse with decreased radial length was observed in 18 patients who did not undergo bone grafting. Mean grip strength was 63 percent. Osteoarthritic changes were noted in 20 patients. We conclude that accurate anatomic reduction is necessary for achieving good to excellent functional and cosmetic results. Bone grafting is the mainstay of treatment in comminuted distal radius fractures along with fracture stabilisation.

Medial fracture line significance in calcaneus fracture.

In Sanders' classification of calcaneus fractures, the medial fracture line (subtype C) is close to the tarsal canal, which contains an artery for the talus and calcaneus. We hypothesized that because of this brittle vascular localization, patients with C line fracture patterns might describe radiologic subtalar arthritis more often and have more complaints. The purpose of the present study was to compare the results of C line fracture patterns with other types of calcaneus fractures. A total of 25 surgically treated feet were involved. Regarding Sanders' classification, group 1 included fractures involving the C line (11 feet), and group 2 included fractures not involving the C line (14 feet). Patient age at admission, trauma date, and interval until surgery were obtained from the patients' medical records. The Bohler angles were determined from the radiographs. At the last follow-up visit, the radiologist graded subtalar arthritis using computed tomography. For clinical follow-up, the American Orthopaedic Foot and Ankle Society and Maryland scores were assessed. No significant differences were found in mean age, follow-up period, delay to surgery, or postoperative Bohler angle between the 2 groups. The mean preoperative Bohler angle was significantly low for group 1. Although not significantly different, the mean American Orthopaedic Foot and Ankle Society and Maryland scores were lower for group 1 (81.9 and 84.3) than group 2 (87.8 and 92.0), and the median subtalar arthritis grade was greater for group 1 (score 2) than for group 2 (score 1.5). The worse results with C line fracture patterns despite satisfactory reduction might result from sinus tarsi artery damage. Angiographic investigations could clarify this theory in the future. Consequently, surgeons must inform and should hesitate to operate on patients with these highly comminuted C line calcaneus fractures.

A new approach to the treatment of nasal bone fracture: radiologic classification of nasal bone fractures and its clinical application.

PURPOSE: A radiologic examination is required in the treatment of nasal bone fracture to determine the fracture condition. Thus, there is an increasing need for radiologic classification of nasal bone fractures that can be applied to clinical practice. MATERIALS AND METHODS: Computed tomography was performed in 125 patients with nasal bone fractures to determine which axial view best showed the entire nasal view. The obtained axial view was then used as a reference for classification. The length from the top to the base of the nasal bone was divided into upper, middle, and lower levels, after which the fracture location was determined. If the fracture spanned the boundaries of these levels, it was classified as the total level. Subsequently, the fracture was subclassified based on the fracture direction and pattern and the concurrent fracture. RESULTS: Radiologic examination of patients with nasal bone fracture showed that nasal bone fracture was frequently found at the total, middle, upper, and lower levels, in that order. Nasal bone fractures at the upper level showed lower frequencies of complication and reoperation than the fractures at the other levels, whereas nasal bone fractures at the total level showed the highest frequencies of complication and reoperation. CONCLUSION: Radiologic classification can be useful for preoperative and postoperative evaluations of nasal bone fractures and can be helpful in understanding such fractures because it can efficiently predict the prognosis of a fracture.

[Reliability of load-sharing classification in indications for anterior vertebral body replacement in thoracolumbar spine fractures]. / Spolehlivost "load-sharing" klasifikace v indikaci prední náhrady obratlového tela u zlomenin torakolumbální pátere.

INTRODUCTION: So far, the Load-Sharing Classification (LSC) has been the commonest method employed to identify indication for anterior replacement of vertebral bodies in thoracolumbar spine fractures. The aim of this study was to verify reliability of the LSC method in indications for anterior replacement surgery. METHODS: Fractures were examined using x-ray, CT and MRI methods. The prospective study included only patients with type A3 comminuted fractures (AO classification) of the thoracolumbar vertebrae (Th11-L2), with MRI confirmed grade 3 or 4 intervertebral disc injuries (according to Oner) and with no concomitant nerve injuries. All fractures were treated using isolated posterior transpedicular (TP) fixation. 18 months after the procedure, angulation of the regional kyphosis, screw rupturing, Visual Analogue Scale (VAS) scores at rest and under loading, Pain Scale (PS) scores and Work Scale (WS) scores were assessed. The study group included 42 patients aged 27-72 years (the mean age was 51.55 y.o.a.), 28 subjects were males and 14 females. Using the LSC classification system, the study group was divided into two subgroups, one including patients with LSC up to grade 6 - Group A (18 subjects) and the other one including patients with LSC 7 to 9 - Group B (24 subjects). RESULTS: Statistical assessment of clinical (PS, WS, VAS at rest and VAS after loading) and radiological findings (the degree of kyphotic changes) at month 18 identified no statistically significant correlations between the two subgroups. TP fixation failures (srews rupturing) occured only in Group A in two subjects. DISCUSSION: Based on the LSC, Group B was expected to have inferior outcomes, however, this was not the case in our study group. Therefore, it can be concluded that LSC is not a reliable predictor of the final clinical and radiological findings in the type A3 fractures with grade 3 or 4 TH-L intervertebral disc injuries. The defined LSC 6- point threshold for indications for anterior vertebral body and disc replacements is arguable. CONCLUSION: The authors do not consider the LSC method sufficiently reliable for determining indications for anterior replacements.

Intracapsular condylar fracture of the mandible: our classification and open treatment experience.

PURPOSE: We studied the classification of intracapsular condylar fracture (ICF) of the mandible based on coronal computed tomography (CT) scans and present our open treatment experience at the temporomandibular joint (TMJ) division of Shanghai's Ninth People's Hospital (Shanghai, China). MATERIALS AND METHODS: From 1999 to 2008, 229 patients with 312 ICFs were treated in our division. Among them, 195 patients (269 joints) had CT scans for classification. We modified the classification of Neff et al, adding a new fracture type according to our experience: type A, fracture line through lateral third of condylar head with reduction of ramus height; type B, fracture line through middle third of condylar head; type C, fracture line through medial third of condylar head; and type M, comminuted fracture of condylar head. There was no ramus height reduction in fracture types B and C. Our treatment protocol is open reduction for a fracture in which the superolaterally dislocated ramus stump is out of the glenoid fossa or any type of fracture with displaced or dislocated fragments that may cause TMJ dysfunction later. RESULT: Among the 269 joints, 116 had type A fractures (43.1%), 81 had type B fractures (30.1%), 11 had type C fractures (4.1%), and 58 had type M fractures (21.6%); 3 joints (1.1%) had fractures that were not displaced. Of the joints, 173 had open reduction-internal fixation; postoperative CT scans showed that 95.6% of these had absolute anatomic or nearly anatomic reduction. In all of them normal mouth opening and occlusion were restored. No or little deviation was found during mouth opening. Complications were pain in the joint (n = 1), crepitations (n = 2), and facial nerve (temporal branch) paralysis (n = 1). Two patients had the plate removed because of these complications. CONCLUSION: Our new classification based on CT scans can better guide clinical treatment. Open reduction for ICF can restore the anatomic position for both the condyle and TMJ soft tissues with few complications, which can yield better functional and radiologic results.

[Hawkins type III fracture: dislocation of the talus and fracture of the medial malleolus treated by distraction external fixation]. / Hawkins-Typ-III-Fraktur : Dislokation des Talus und Fraktur des Malleolus medialis behandelt durch distrahierende externe Fixation.

These injuries are extremely rare and severe. The literature describes only individual cases of such injuries. We report a case of a displaced fracture of the talar neck with a complete posterior dislocation and rotation of the body of the talus (Hawkins type III) associated with medial malleolus fracture, treated with the method of urgent open reduction and internal fixation of the talar neck and medial malleolus as well as with the method of distraction external fixation.A 26-year-old male was injured after a fall from a height of over 8 m and was admitted as an emergency to the University Orthopedic and Traumatology Clinic in Nis. Surgery was performed within 4 h postinjury. He was mobilized with crutches with non-weight bearing. The external fixator was removed 10 weeks postsurgery, when physical therapy was initiated. The follow-up was 3 years. There were neither early nor late postoperative complications. Three years postinjury, movements in the ankle joint were satisfactory (plantar flexion 35 degrees , dorsal flexion up to 10 degrees , moderately limited movements in the subtalar joint). There were no signs of avascular necrosis; the patient walked normally and went back to physical work 2 years postinjury. Urgent open reduction and internal fixation of the Hawkins type III fracture with dislocation of the talus and distraction external fixation can play an important role in the prevention of avascular necrosis of the talus and other complications which follow this injury.