Do multiple fractures affect risk of fixation failure after surgical treatment of midshaft clavicle fracture? A retrospective cohort study.

BACKGROUND: Surgical treatment of midshaft clavicle fractures is associated with quick recovery and low risk of non-union. However, fixation failure may occur in case of severe comminution fractures. Moreover, clinical outcomes may be affected when clavicle fractures occur in combination with other injuries, particularly those involving the lower extremities, as the use of crutches or walkers may hinder the process of rehabilitation by adding strain on the acromioclavicular (AC) joint, resulting in possible fixation failure. This study aims to identify risk factors for fixation failure of midshaft clavicle fractures and elucidate the role of combined fractures in treatment outcomes. METHODS: This study included patients diagnosed with midshaft clavicle fractures who underwent initial surgery between January 2012 and November 2021 at a designated regional trauma center hospital. Retrospective evaluation of fixation failure was carried out in 352 patients with midshaft clavicle fractures using standard clinical evaluation protocols and conventional radiographs. The prevalence of fixation failure and the effects of several demographic variables on the risk of fixation failure and non-union were examined. Multivariate logistic regression analysis was carried out to identify independent risk factors for fixation failure. RESULTS: Fixation failure occurred in 40 patients (11.4%). Multivariate analysis identified comminution [odds ratio (OR) 3.532, p value = 0.003, 95% confidence interval (CI) 1.55-8.05)] and fewer number of screws (OR 0.223, p value = 0.022, 95% CI 0.06-0.80) as risk factors for fixation failure. Surgical techniques using wire cerclage reduced the chances of fixation failure in comminuted fractures (OR 0.63, p value = 0.033, 95% CI 0.05-0.80). Combined fractures that required rehabilitation using walkers or crutches increased the risk of non-union (OR 19.043, p value = 0.032, 95% CI 1.28-282.46). CONCLUSIONS: Additional fixation of comminuted fractures using cerclage can reduce the risk of treatment failure, while multiple fractures or rehabilitation for ambulation increases the risk of the same. LEVEL OF EVIDENCE: III.

Surgical stabilization of severe chest wall injury following cardiopulmonary resuscitation.

BACKGROUND: Cardiopulmonary resuscitation (CPR) contributes to significant chest wall injury similar to blunt trauma. With benefits realized for surgical stabilization of rib fractures (SSRFs) for flail injuries and severely displaced fractures following trauma, SSRF for chest wall injury following CPR could be advantageous, provided good functional and neurologic outlook. Experience is limited. We present a review of patients treated with SSRF at our institution following CPR. METHODS: A retrospective analysis of patients undergoing SSRF following CPR was performed between 2019 and 2020. Perioperative inpatient data were collected with outpatient follow-up as able. RESULTS: Five patients underwent SSRF over the course of the 2-year interval. All patients required invasive ventilation preoperatively or had impending respiratory. Mean age was 59 ± 12 years, with all patients being male. Inciting events for cardiac arrest included respiratory, ventricular tachycardia, ventricular fibrillation, pulseless electrical activity, and anaphylaxis. Time to operation was 6.6 ± 3 days. Four patients demonstrated anterior flail injury pattern with or without sternal fracture, with one patient having multiple severely displaced fractures. Surgical stabilization of rib fracture was performed appropriately to restore chest wall stability. Mean intensive care unit length of stay was 9.8 ± 6.4 days and overall hospital length of stay 24.6 ± 13.2 days. Median postoperative ventilation was 2 days (range, 1-15 days) with two patients developing pneumonia and one requiring tracheostomy. There were no mortalities at 30 days. One patient expired in hospice after a prolonged hospitalization. Disposition destination was variable. No hardware complications were noted on outpatient follow-up, and all surviving patients were home. CONCLUSION: Chest wall injuries are incurred frequently following CPR. Surgical stabilization of these injuries can be considered to promote ventilator liberation and rehabilitation. Careful patient selection is paramount, with surgery offered to those with reversible causes of arrest and good functional and neurologic outcome. Experience is early, with further investigation needed. LEVEL OF EVIDENCE: Therapeutic, Level V.

The Association of Zygomaticomaxillary Complex Fractures with Naso-Orbitoethmoid Fractures in Pediatric Populations.

BACKGROUND: Naso-orbitoethmoid fractures associated with ipsilateral zygomaticomaxillary complex fractures are more challenging injuries than zygomaticomaxillary complex fractures alone. However, there is a paucity of information on this complex fracture pattern in the pediatric population. This study investigated the cause, treatment, and outcomes of combined zygomaticomaxillary complex and naso-orbitoethmoid fractures versus isolated zygomaticomaxillary complex fractures in pediatric patients. METHODS: This was a 25-year retrospective cohort study of pediatric patients who presented to a single institution with zygomaticomaxillary complex fractures. Baseline patient demographics and clinical information, and concomitant injuries, treatment/operative management, and postoperative complications/deformities were recorded and compared between patients with combined zygomaticomaxillary complex and naso-orbitoethmoid fractures and patients with isolated zygomaticomaxillary complex fractures. RESULTS: Forty-nine patients were identified to have had zygomaticomaxillary complex fractures in the authors' 25-year study period, of whom 46 had adequate clinical documentation and follow-up. Seventeen patients had combined zygomaticomaxillary complex-naso-orbitoethmoid fractures, of whom six had panfacial fractures. Both patient groups (zygomaticomaxillary complex only and combined zygomaticomaxillary complex-naso-orbitoethmoid fractures) were similar in terms of demographics. However, a significantly greater proportion of combined fracture patients experienced postoperative complications compared to isolated zygomaticomaxillary complex fracture patients, even after excluding those with panfacial fractures (87.5 percent versus 35.3 percent; p < 0.001). Enophthalmos (37.5 percent) and midface growth restriction (37.5 percent) were the two most common complications/deformities in all combined fracture patients. CONCLUSIONS: High-impact trauma can lead to zygomaticomaxillary complex fractures with associated naso-orbitoethmoid fractures in children. This injury pattern was found to cause significantly greater postoperative morbidity than isolated zygomaticomaxillary complex fractures alone. Thus, pediatric patients presenting with this complex facial fracture pattern should be closely monitored. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

A patient with severe polytrauma with massive pulmonary contusion and hemorrhage successfully treated with multiple treatment modalities: a case report.

BACKGROUND: The mortality rate is very high for patients with severe multiple trauma with massive pulmonary contusion containing intrapulmonary hemorrhage. Multiple treatment modalities are needed not only for a prevention of cardiac arrest and quick hemostasis against multiple injuries, but also for recovery of oxygenation to save the patient's life. CASE PRESENTATION: A 48-year-old Japanese woman fell down stairs that had a height of approximately 4 m. An X-ray showed pneumothorax, pulmonary contusion in her right lung, and an unstable pelvic fracture. A chest drain was inserted and preperitoneal pelvic packing was performed to control bleeding, performing resuscitative endovascular balloon occlusion of the aorta. A computed tomography scan revealed massive lung contusion in the lower lobe of her right lung, pelvic fractures, and multiple fractures and hematoma in other areas. An emergency thoracotomy was performed, and then we performed wide wedge resection of the injured lung, clamping proximal to suture lines with two Satinsky blood vessel clamps. The vessel clamps were left in the right thoracic cavity. The other hemorrhagic areas were embolized by transcatheter arterial embolization. However, since her respiratory functions deteriorated in the intensive care unit, veno-venous extracorporeal membrane oxygenation was used for lung assist. Planned reoperation under veno-venous extracorporeal membrane oxygenation was performed on day 2. Since her respiratory condition improved gradually, the veno-venous extracorporeal membrane oxygenation circuit was withdrawn on day 7. She was transferred to the psychiatric ward of our hospital on day 75. CONCLUSION: Utilizing multiple treatment modalities such as resuscitative endovascular balloon occlusion of the aorta, damage control surgery, transcatheter arterial embolization, and veno-venous extracorporeal membrane oxygenation with appropriate timing saves a patient with severe polytrauma with massive pulmonary contusion including intrapulmonary hemorrhage.

Conservative Treatment or Surgical Treatment: A Case Report and Literature Review of Multiple Fractures of the Lower Extremities in a Child with Insensitivity to Pain.

Congenital pain insensitivity is a rare genetic disease and its clinical manifestations are many. In orthopaedics, common complications of this disease include painless fracture and Charcot's arthropathy. We followed up a case of multiple fractures of the lower extremity in two years, during which time he came to the clinic for five painless fractures of the lower extremity in a total of six parts. A mutation was found on the NTKRI gene (chr1:156813923(hg19), NM_001007792.1: c.1221938C > T). We have developed a combination of surgery and conservative treatments for his condition, focusing on the mental state of the child and considering comprehensive treatment to be the best option for this type of patient. Occult fractures caused by pain insensitivity are often treated only as fractures, however their complications require routine examination and cleaning, suitable protective shoes, splint fixation, stretching, guided exercise planning, and early treatment of injuries. Due to the risk of fracture in the future, it is important that parents pay attention to the behavior and psychology of the child, such as not letting the child participate in exercise with a risk of injury, protective measures while playing, engaging in psychological counseling, and inducing interest in mental activity. These interventions will play a very important role in preventing the recurrence of fracture.

Analysis of the advantages of 3D printing in the surgical treatment of multiple rib fractures: 5 cases report.

BACKGROUND: Rib fractures account for a fairly high proportion of chest injuries, ranging from 55 to 80%. The most common mechanisms of injury include: traffic accident, extrusion and falls from significant heights. Besides, the surgical treatment of multiple rib fractures has been accepted by more and more medical professionals. We reported 5 clinical cases of patients with multiple rib fractures undergoing open reduction and internal fixation using 3D printing technology. CASE PRESENTATION: Retrospective analysis of 5 clinical cases of multiple rib fractures from January 2017 to August 2018 in our hospital. A preoperative CT thin slice scan was used to reconstruct the 3D model according to the scanning results, and 3D printing technology was adopted to prepare the rib model. Preoperative reconstruction of the rib's normal shape and lock plate for the shaped ribs was created according to reconstructed model. For multiple fractures especially patients with severely deformed rib shape, it is suggested to intraoperative shape directly to the metal bone plate fixed on the ribs on both ends of the fracture line, in order to establish a basic support frame. The other various fracture section can be fixed on the lock plate respectively. Postoperative chest radiographs of the 5 patients showed that the internal fixations were in good and natural shape. The thoracic contour was well formed and symmetrically with the contralateral side. CONCLUSION: Making the rib model and the pre-shaped titanium alloy rib locking plate using 3D printing technology, provided a more minimally invasive and precisely individualized treatment for some rib fracture operations.

Long-term follow-up after rib fixation for flail chest and multiple rib fractures.

PURPOSE: Rib fixation for flail chest has been shown to improve in-hospital outcome, but little is known about treatment for multiple rib fractures and long-term outcome is scarce. The aim of this study was to describe the safety, long-term quality of life, and implant-related irritation after rib fixation for flail chest and multiple rib fractures. METHODS: All adult patients with blunt thoracic trauma who underwent rib fixation for flail chest or multiple rib fractures between January 2010 and December 2016 in our level 1 trauma facility were retrospectively included. In-hospital characteristics and implant removal were obtained via medical records and long-term quality of life was assessed over the telephone. RESULTS: Of the 864 patients admitted with ≥ 3 rib fractures, 166 (19%) underwent rib fixation; 66 flail chest patients and 99 multiple rib fracture patients with an ISS of 24 (IQR 18-34) and 21 (IQR 16-29), respectively. Overall, the most common complication was pneumonia (n = 58, 35%). Six (9%) patients with a flail chest and three (3%) with multiple rib fractures died, only one because of injuries related to the thorax. On average at 3.9 years, follow-up was obtained from 103 patients (62%); 40 with flail chest and 63 with multiple rib fractures reported an EQ-5D index of 0.85 (IQR 0.62-1) and 0.79 (0.62-0.91), respectively. Forty-eight (48%) patients had implant-related irritation and nine (9%) had implant removal. CONCLUSIONS: We show that rib fixation is a safe procedure and that patients reported a relative good quality of life. Patients should be counseled that after rib fixation approximately half of the patients will experience implant-related irritation and about one in ten patients requires implant material removal.

[Acute exacerbation of chronic CLL with multiple pathological fractures : A rarity]. / Akute Exazerbation einer chronischen CLL mit multiplen pathologischen Frakturen : Eine Seltenheit.

Chronic lymphatic leukaemia (CLL) is one of the most common leukaemic diseases in middle Europe. Pathological fractures are rare findings in patients with CLL. The diagnosis of CLL is in most cases an incidental finding as it often stays asymptomatic for years. This article presents an interesting case of a 65-year-old male patient with known asymptomatic CLL for 5 years and fractures of the proximal femur and proximal radius after trauma. During the hospital stay the patient suffered multiple pathological fractures with histological findings of bony infiltration of the CLL and an acute phase, which was treated by combination chemotherapy.

Traumatic Lateral Spondyloptosis: Case Series.

OBJECTIVE: To apprise readers about this rare but severest form of traumatic spine injury and its surgical management. BACKGROUND: Complete fracture dislocation and subluxation (>100%) of 1 vertebral body in the coronal or sagittal plane with respect to the adjacent vertebra is defined as spondyloptosis. In coronal spondyloptosis the subluxated vertebral bodies lie beside each other, and the condition is lateraloptosis. Patients with lateraloptosis present unique surgical challenges because reduction and achieving realignment of spinal column require meticulous planning and execution. METHODS: A retrospective analysis of patients admitted with lateraloptosis over a 4-year period (2013-2016) was done. Lateraloptosis was defined on computed tomography as complete subluxation of the spinal column with more than 50% of adjacent vertebral bodies lying directly lateral to each other. RESULTS: Five men, ranging from 18 to 50 years (mean, 35.2 years) old were included in the study. Three patients had thoracic spine lateraloptosis, and in 2 the injury was at the thoracolumbar junction. All patients underwent single-stage posterior surgical reduction and fixation. Intraoperatively, cord transection was seen in 3 patients, and dural tear with cerebrospinal fluid leak was seen in 1 patient. The mean follow-up period was 14 months (range, 1-36 months), during which 1 patient died of complications arising from bedsores. All patients remained at American Spinal Injury Association grade A neurologically. CONCLUSION: Lateraloptosis is difficult to treat, and the aim of surgery is to stabilize the spine. Rehabilitation remains the most crucial factor, but the scarcity of proper rehabilitation centers results in high mortality and morbidity.

Distal radius nonunion after epiphyseal plate fracture in a 15 years old young rider.

BACKGROUND AND AIM OF THE WORK: Radius and ulna fractures are the most common long bone fractures in children and adolescents. The majority of these injuries involve the distal metaphyseal portion of the radius associated or not to physeal plate injuries. Because of the high remodelling potential of the distal radius in growing children most injuries heal without complication after closed reduction and immobilization in a long arm cast. Nonunions of closed distal radius fracture are an extremely rare occurrence especially in paediatric population. Methods: In this report, we describe a rare case of distal radius fracture nonunion in a 15-years old male rider treated conservatively with cast immobilization. Eight months later he underwent surgical closed reduction and fixation with kirschner wire and cannulated screw. Results: Follow-up at 2 years showed satisfying radiological and functional outcomes. The patient ultimately returned to ride 3 months following surgery. Conclusions: Nonunion is rarely seen in distal radius fractures in healthy children and adolescents, and there are few studies in the literature. Treatment of the nonunion must be individualized and the results are not entirely predictable.

A Rare Case of Infantile Myofibromatosis Presenting to the Emergency Department as Undiagnosed Long Bone Fractures.

Infantile myofibromatosis is a disorder of mesenchymal tumors that usually presents within the first 2 years of life. Most patients initially present because of the presence of visible or palpable subcutaneous tumors. We report a case of a fussy 5-week-old infant who presented to an emergency department with bilateral femur fractures initially thought to be due to nonaccidental trauma or a metabolic bone disorder. She was ultimately diagnosed after admission with infantile myofibromatosis after taking an extensive family history and after further laboratory and radiologic evaluation. There are no previously published cases of undiagnosed infantile myofibromatosis presenting to the emergency department, especially with multiple long bone fractures.

Solitary Frontal Sinus Fractures Compared to Multiple Facial Fractures, Energy Impact Dependency.

Frontal sinus fractures account for 2% to 15% of maxillofacial injuries. Up to 66% to 87% of the patients with frontal sinus fractures experience associated facial fractures. The majority of classifications used today categorize frontal sinus fractures depending on the integrity of the anterior table, posterior table, and the nasofrontal outflow. A retrospective study was performed, which included 24 patients diagnosed with frontal sinus fractures. Treatment in all patients consisted of open reduction and bone fixation. We analyzed population variables, injury etiology, fracture site, associated craniofacial injuries, surgical technique employed, handling of the nasofrontal duct, and postoperative complications. The most frequent etiology was falling accidents. Fifty-eight percent of the fractures involved both the anterior and posterior tables. Sixty-six percent experienced associated facial fractures. Fifty percent of frontal sinus fractures were treated by open reduction internal fixation as the only treatment, 33.3% underwent sinus obliteration, and 16.6% were treated with cranialization. Frontal sinus fractures resulting from high-energy impact exhibited additional facial bone fractures in 100% of the cases, whereas fractures following low-energy impact showed involvement of additional facial fractures in only 27% of the cases. In this report, we suggest a modification to the anteroposterior classification of frontal sinus fractures. In addition to the involvement of the anterior and posterior walls and the degree of dislocation, high and low energy impact can direct us to the involvement of additional facial fractures and influence the surgical strategy.

Multiple pseudofractures due to Fanconi's syndrome associated with Wilson's disease.

We report a 40-year-old man who presented with multiple bone pseudofractures after about 20 years from the onset of Wilson's disease (WD). At age 36, he first noticed pain in his left shoulder. At age 39, he had multiple chest pain. On neurologic examinations, dysarthria and dysphagia due to pseudobulbar palsy, rigidity and tremor on right upper lim were observed. WD was confirmed because of low levels of plasma cupper and ceruloplasmin in addition to ATP7B gene mutation. The chest X-ray revealed multiple fractures of the several ribs. We diagnosed osteomalacia due to Fanconi's syndrome because of hypophosphatemia and the impairment of renal tubules for WD. After administration of vitamin D, there happened no new bone pseudofractures. Although bone pseudofractures accompanied by Wilson's disease generally happen in childhood, we should be aware of this symptom even in adulthood.

Styloid Process Fracture Associated With Maxillofacial Trauma: Incidence, Distribution, and Management.

PURPOSE: Fracture of the styloid process of the temporal bone has been infrequently reported. The present study evaluated the incidence, causes, distribution, and management of styloid process fracture in association with other maxillofacial fractures. MATERIALS AND METHODS: A prospective evaluation of patients with maxillofacial trauma over a period of 1 year was carried out and patients' characteristics, mode and distribution of injury, and length of styloid process were recorded. Patients were divided into 5 groups based on the site of maxillofacial fracture and into 2 groups based on styloid process length to evaluate their association with styloid process fracture. The authors' unit protocol was carried out for management of styloid process fracture. RESULTS: Of 84 patients with maxillofacial trauma, 27 patients (14 men, 13 women; mean age, 25.7 ± 8.92 yr) had styloid process fracture. The most common cause of injury was road traffic accidents. Mandibular and multiple facial fractures accounted for most concomitant styloid process fractures. The mean length of the styloid process in patients with fracture was 2.46 ± 0.89 cm and no relevant association was present between the length and fracture of the styloid process. All patients responded well to initial conservative management. CONCLUSION: Styloid process fractures are relatively common injuries in developing countries and a meticulous examination is essential for prompt diagnosis and adequate care.

[Infantile acquired brain injury, a personal experience. Demands from the socio-familial point of view]. / Daño cerebral sobrevenido infantil, una experiencia personal. Reclamaciones desde el punto de vista sociofamiliar.

We report on the experience of a family in which the youngest child has acquired brain injury and the struggle undertaken by the family to improve the neurorehabilitation resources in the public health service. The article outlines the main demands, from the socio-familial point of view, as regards the improvement of neurological rehabilitation and the resources needed to deliver it.

TITLE: Daño cerebral sobrevenido infantil, una experiencia personal. Reclamaciones desde el punto de vista sociofamiliar.Se describe la experiencia de una familia en la que el hijo menor tiene daño cerebral sobrevenido y la lucha emprendida por la familia para mejorar los recursos neurorrehabilitadores de la sanidad publica. Se recogen las principales reclamaciones, desde el punto de vista sociofamiliar, en cuanto a la mejora en la atencion neurorrehabilitadora y los recursos necesarios.

A rare case of multiple phosphaturic mesenchymal tumors along a tendon sheath inducing osteomalacia.

BACKGROUND: Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome characterized by renal phosphate wasting, hypophosphatemia, reduction of 1,25-dihydroxyl vitamin D, and bone calcification disorders. Tumors associated with TIO are typically phosphaturic mesenchymal tumors that are bone and soft tissue origin and often present as a solitary tumor. The high production of fibroblast growth factor 23 (FGF23) by the tumor is believed to be the causative factor responsible for the impaired renal tubular phosphate reabsorption, hypophosphatemia and osteomalacia. Complete removal of the tumors by surgery is the most effective procedure for treatment. Identification of the tumors by advanced imaging techniques is difficult because TIO is small and exist within bone and soft tissue. However, systemic venous sampling has been frequently reported to be useful for diagnosing TIO patients. CASE PRESENTATION: We experienced a case of 39-year-old male with diffuse bone pain and multiple fragility fractures caused by multiple FGF23-secreting tumors found in the hallux. Laboratory testing showed hypophosphatemia due to renal phosphate wasting and high levels of serum FGF23. Contrast-enhanced MRI showed three soft tissue tumors and an intraosseous tumor located in the right hallux. Systemic venous sampling of FGF23 revealed an elevation in the right common iliac vein and external iliac vein, which suggested that the tumors in the right hallux were responsible for overproduction of FGF23. Thereafter, these tumors were surgically removed and subjected to histopathological examinations. The three soft tissue tumors were diagnosed as phosphaturic mesenchymal tumors, which are known to be responsible for TIO. The fourth tumor had no tumor structure and was consisting of hyaline cartilage and bone tissue. Immediately after surgery, we noted a sharply decrease in serum level of FGF23, associated with an improved hypophosphatemia and a gradual relief of systematic pain that disappeared within two months of surgery. CONCLUSION: The authors reported an unusual case of osteomalacia induced by multiple phosphaturic mesenchymal tumors located in the hallux. Definition of tumors localization by systemic venous sampling led to successful treatment and cure this patient. The presence of osteochondral tissues in the intraosseous tumor might be developed from undifferentiated mesenchymal cells due to high level of FGF23 produced by phosphaturic mesenchymal tumors.

Less invasive lumbopelvic fixation technique using a percutaneous pedicle screw system for unstable pelvic ring fracture in a patient with severe multiple traumas.

Pelvic ring fractures are defined as life-threatening injuries that can be treated surgically with external or internal fixation. The authors report on an 81-year-old woman with an unstable pelvic fracture accompanying multiple traumas that was successfully treated with a less invasive procedure. The patient was injured in a traffic accident and sustained a total of 20 fractures, including pelvic ring, bilateral rib, and lumbar transverse processes fractures, and multiple fractures of both upper and lower extremities. The pelvic ring fracture was unstable with fractures of the bilateral sacrum with right sacroiliac disruption, right superior and inferior pubic rami, left superior pubic ramus, and ischium. During emergency surgery, bilateral external fixation was applied to the iliac crest to stabilize the pelvic ring. Second and third surgeries were performed 11 and 18 days after the first emergency surgery, respectively, to treat the multiple fractures. At the third surgery, the pelvic ring fracture was stabilized surgically using a less invasive posterior fixation technique. In this technique, 2 iliac screws were inserted on each side following an 8-cm midline posterior incision from the S-1 to S-3 spinous process, with the subcutaneous tissue detached from the fascia of the paraspinal muscles. The S-2 spinous process was removed and 2 rods were connected to bilateral iliac screws to stabilize the bilateral ilium in a switchback fashion. A crosslink device was applied to connect the 2 rods at the base of the S-2 spinous process. Following pelvic fixation, percutaneous pedicle screws were inserted into L-4 and L-5 vertebral bodies on both sides, and connected to the cranial rod connecting the bilateral iliac screws, thus completing the lumbopelvic fixation. The postoperative course was favorable with no postoperative complications. At the 10-month follow-up, bone union had been achieved at the superior ramus of the pubis, the patient did not complain of pain, and her activities of daily life returned to preinjury status. Unstable pelvic ring fractures need to be sufficiently stabilized for good surgical outcome. However, to avoid postoperative complications, a less invasive treatment is preferred, particularly in cases with poor general condition. This procedure is less invasive and provides sufficient stabilization to the unstable pelvic ring fracture, and thus is the ideal surgical procedure for such cases.

Noncontiguous double-level unstable spinal injuries.

PURPOSE: Noncontiguous double-level unstable spinal injuries (NDUSI) are uncommon and have not been well described. In this study, we aimed to better understand the patterns of NDUSI, in order to recommend proper diagnostic and treatment methods, as well as to raise awareness among traumatologists about the possibility of these uncommon injuries. METHODS: A total of 710 consecutive patients with spine fractures were treated for >9 years since 2007 at a single regional trauma center. Of them, 18 patients with NDUSI were reviewed retrospectively. RESULTS: The incidence of NDUSI was 2.5 % of all spine fractures. In 17 of 18 patients (94.7 %), NDUSI was caused by a high-energy trauma. Nine patients (50.0 %) exhibited complete neurological deficit. Spinal cord injury occurred in the cranial injured region in all American Spinal Injury Association grade A cases. In one case, a second fracture was overlooked at the initial examination. CONCLUSION: NDUSI are common in cases of high-energy trauma and should be taken into consideration at the initial examination. A second fracture may be easily overlooked because of the high frequency of concomitant severe spinal cord injury in the cranial injured region and/or loss of consciousness due to associated injuries. To avoid overlooking injuries, full spine computed tomography is useful at the initial examination. Operative reduction and internal fixation with instrumentation through a posterior approach is recommendable for cases of NDUSI. In elderly patients, a very rapid stabilizing surgery should be planned before aspiration pneumonia occurs or the pulmonary condition worsens.