Pediatric Maisonneuve: case report of a rare pattern of injury.

A 12-year-old boy presented to our emergency department complaining of pain and functional limitation on his right ankle after an indirect trauma. Plain radiographs were taken identifying a type II epiphysiolysis of the distal tibia and a proximal fibula fracture. An open reduction and internal fixation was performed without transyndesmal fixation. Maisonneuve fractures are an uncommon injury in the pediatric population. This fracture pattern has not been described by the Dias-Tachdjian classification. It is important to bear in mind that, based on the need for osteosynthesis for the epiphysiolysis, the treatment of these fractures in children usually differs from that in the adults as no transyndesmal screw fixation is required.

[Cost-analysis of treating patients with multiple injuries in a reference hospital in Spain]. / Análisis del coste del tratamiento del paciente politraumatizado en un hospital de referencia en España.

INTRODUCTION: The aim of this study is to analyse the costs of the treatment of a group of patients with severe injuries. The distribution of the costs between the different departments involved in the management of these patients is also investigated. MATERIAL AND METHOD: The data from patients who suffered severe injuries, and recorded in the Traumasur data base, were prospectively gathered to be used in the study. The data from a total of 131 patients treated in the year 2008 were collected. Data obtained from the hospital finance office were also used, providing the overall cost as well as the separate costs of each of the departments involved in the treatment. RESULTS: The injury severity score (ISS) and the new injury severity score (NISS) mean values were 31.8 and 39.4, respectively. The mortality rate was 17.5%. The overall costs of the patients was 3,791,879.3 €, with a mean cost per patient of 28,945 €. The mean percentage of the overall costs of the treatment incurred by the ICU and the ward was 62% and 12.7%, respectively. The cost of the ICU admission increased up to 68.4% in patients with an ISS>40. Although the patients who died had more serious injuries, they had a lower cost in all areas. CONCLUSION: Patients with multiple injuries represent a significant health cost, with the greater percentage being due to the hospital stay, particularly that in ICU. Other cost areas involve a lower percentage of the cost.

Comparison between external fixators and fixed-angle volar-locking plates in the treatment of distal radius fractures.

Distal radius fractures are a common disorder in industrialized nations associated with osteoporosis, with a reported incidence of two fractures per thousand patients per year. We performed a retrospective study comparing two sets of 40 patients, with fracture of the distal radius treated with Penning external fixator, compared to 40 patients treated with fixed-angle volar-locking plate (Plate Depuy ® DVR), with the objective of finding differences between both treatment methods in anatomical values, functional outcomes and complication rates. All fractures were classified according to the AO classification. Postero-anterior and lateral radiographs of the wrist were taken after fracture, after surgery and at 6 months after surgery. We also assessed functional outcome. Minimum follow up was of 10 months. We compared complications between both groups. In the group of patients treated with fixed-angle volar-locked plate, radiological results are found to be closer to the anatomical references. Final outcomes revealed similar functional scores between both groups. The complications rate was statistically higher in the group of patients who underwent external fixation. In the fixed-angle volar-locked plate group, most of complications were related to patient discomfort due to the volar-locking plate.

Damage control orthopaedics in severe polytrauma with femur fracture.

OBJECTIVE: To evaluate the rate of systemic complications and mortality in severe polytrauma patients with associated femur fracture treated by early external fixation of femur. PATIENTS AND METHODOLOGY: We made a retrospective cohort study with forty-one adult multitrauma patients (New Injury Severity Score ≥ 19) with femur fracture treated by external fixation following Damage Control Orthopaedic surgery. The mortality rates, TRISS analysis, incidence of ARDS and MOF were analysed. RESULTS: The mean NISS was 41.2 and the mean age 32.7. 50% of patients were in shock on admission. All patients were treated in the first 12 hours with external fixation. 30% of patients developed ARDS and six patients had MOF. Five patients treated by external fixation died. Difference between predicted mortality by TRISS and actual mortality showed a reduction of 15.9% (0.71 predicted survival versus 0.88 real survival). CONCLUSIONS: An aggressive and early Damage Control approach to treat femur fractures in severe polytrauma patients led to low mortality rate comparing to the predicted mortality by TRISS.

Distal tibial fracture below a total knee arthroplasty: retrograde intramedullary nailing as an alternative method of treatment: a case report.

An 85-year-old woman with a history of insulin-dependent diabetes mellitus, hypertension, and chronic venous insufficiency with underlying venous stasis who sustained a fall in her house presented to the emergency room with a displaced distal diaphyseal tibial fracture and a stable total knee arthroplasty. At her third day of admission, an intramedullary nail was inserted in a retrograde fashion through the calcaneus and talus into her tibial shaft to stabilize the fracture; there were no postoperative complications. Three years after surgery, the patient remains pain-free, the fracture had united, and her functional status is the same as it was before the fracture. There are different options for solving these types of fractures. Nonoperative, external fixation, conventional or locking plates and antegrade and retrograde intramedullary nailing could be used; however, they should be weighed against the particular issues of the patient involved. We think that a retrograde nailing technique through the calcaneotalotibial axis could be an alternative method for these types of fractures in a fragile patient with important comorbidities with few complications and good functional outcome.

A polytrauma patient with an unusual posterior fracture-dislocation of the femoral head: a case report.

We report a case of a 27-year-old man who was involved in a high-speed car accident. He sustained multiple organ damage including multiple brain petechiae suggesting diffuse axonal damage, aortic dissection, retroperitoneal haematoma and a fracture-dislocation of the right hip with a femoral head fracture and an ipsilateral intertrochanteric fracture. Due to the general condition of the patient, physiological stabilisation was prioritized, and at 2 weeks the fracture-dislocation of the hip was treated with a proximal femoral nail for the intertrochanteric fracture and Herbert screws for the femoral head fracture. Postoperatively, two episodes of recurrent hip dislocation occurred, and this was stabilized eventually with a Steinman pin inserted across the hip joint and taken out 1 month later. Weight-bearing was allowed according to clinical and radiographical assessments. Heterotopic ossification developed around the hip joint, but without evidence of AVN or osteoarthritis. At 18-months follow-up, the fractures had healed and the patient had a Harris Hip score of 79.1. Anatomical reduction and stable fixation of fracture-dislocations of the hip are important for achieving an acceptable result.

Medial complex elbow dislocation: an unusual pattern of injury.

A 47-year-old man sustained a medial complex dislocation of the right elbow. After initial evaluation, closed reduction was performed. On examination under general anesthesia, the elbow was unstable under varus and valgus stress. Computed tomography scan showed a medial epicondyle and a coronoid fracture. Both medial and lateral approaches were used to fix the epicondylar fragment, the coronoid fragment, and the complex damage to the soft tissues. Immobilization in a cast for 1 week followed by early motion in a dynamic orthosis resulted in a good outcome. Follow up at 2 years showed a range of motion of 110 degrees of flexion-extension and 170 degrees of pronation-supination. Radiographs showed no significant arthritis or heterotopic ossifications.

Removal of a broken intramedullary femoral nail with an unusual pattern of breakage: a case report.

To the best of our knowledge, only 3 cases, including the present case, have been reported with a three part broken pattern. However, this is the first case associated with a distal locking screw broken. We report the case of a 31-year-old patient who sustained an open femoral shaft fracture . The fracture was stabilized with a Kuntcher femoral nail. After 7 months of the initial surgery he presented with a three part broken intramedullary nail and the distal locking screw broken. We used a combined technique for the removal of the nail through the nonunion fracture site; we used a pull out technique for the middle fragment and a curved thin hook for the distal fragment. Then we applied bone allograft and stabilized with a cannulated intramedullary femoral nail (Synthes, Oberdorf, Switzerland). After 2 years of follow up the nonunion was consolidated and the patient presented a good clinical outcome. This is of particular interest because it is a unique case and the association with a broken distal locking screw is reported for the first time in this study. A combination of methods through the nonunion site approach and an alternative instrumental is a good method for the removal of a hollow femoral intramedullary nail with this unusual pattern of breakage.

Early results with the new internal fixator systems LCP and LISS: a prospective study.

The Locking Compression Plate (LCP) and the Less Invasive Stabilisation System (LISS) are new implants with angular stability developed by the AO/ASIF. They offer an alternative for internal fixation in complex intra-articular fractures and high-energy diaphyseal fractures of the long bones. The new system was used in a prospective study to treat 113 patients (76 women, 37 men; average age: 53.1 years) with 122 injuries (multifragment shaft fractures or complex intra-articular, delayed/ non-union, malunion) from October 2002. Of these, 13 affected the humerus, 20 the radius, 2 the ulna, 21 the femur, 42 the tibia, 10 the fibula, 2 the acetabulum and 12 the calcaneus. Because of severe concomitant injuries, 18 fractures were first treated with an external fixator and definitively stabilised more than two weeks after the injury. Thirty-one patients were operated on after failure of other implants and non-union. Clinical and radiographic findings as well as complications were followed prospectively over a mean period of 20 months (range: 13 to 30). One patient was lost to follow-up. A total of 112 patients underwent a standardised follow-up examination. The outcome correlated with the severity of the fracture, anatomic reduction, adequate positioning of the plate and concomitant injuries. Despite the large number of open and comminuted fractures, no serious complications such as deep infections, vascular lesions, deep venous thrombosis or non-unions were noted. We found the new internal fixator system to be a safe and reliable procedure. It offers numerous fixation possibilities and has proven its value in complex fracture situations and in revision operations. A good knowledge of biomechanics is essential as well as precise preoperative planning.

Non-monomelic synchronous primary multicentric chondrosarcoma: a case report.

We report a patient with simultaneous presentation of two histologically grade 2 conventional chondrosarcomas non-derived from pre-existing cartilaginous lesions, in the absence of pulmonary or visceral involvement. One tumour was located at the right proximal femur and the other one at the right scapula. There was no evidence of local recurrence or pulmonary or visceral involvement three years and a half after total scapulectomy and resection of the proximal third of the femur. To the best of our knowledge, this is the first report of a patient with two non-monomelic synchronous chondrosarcomas arising in two previously normal bones of the skeleton. Such cases are often difficult to differentiate from metastatic disease.