Proximal Femoral Fractures and Anticoagulation Therapy - When Is Surgery Safe?

Patients presenting with proximal femur fractures are at high risk of developing DVT and pulmonary embolism. Many of these patients suffer from additional anticoagulant treatment. Patients on anticoagulation treatment are complex to manage, especially regarding timing of surgery due to implemented quality control recommendations. The present review analyses the present data timing of surgery and perioperative surgical considerations on anticoagulation treatment in this patients group.

Standard Approaches to the Acetabulum Part 3: Intrapelvic Approach.

Introduction The intrapelvic approach was originally described by Hirvensalo et al. from Finland in the early 90ies (8) and a further comparable description was published shortly thereafter by Cole et al. (5). Since then, various modifications have been described. Whereas the ilioinguinal approach was used until then to treat acetabular fractures with relevant anterior column involvement from an extrapelvic view, the intrapelvic approach was developed to address the often accompanied central hip dislocation in these fracture types with relevant fractures of the quadrilateral surface. With this approach a complete different view to the antero-medial acetabular pathology was possible. The view from more medial allows a better direct access to joint structures "below" the pelvic brim in the true pelvis (intrapelvic) in contrast to the extrapelvic access with the ilioinguibnal approach. Meanwhile, the surgical technique has been described in detail and some modifications and tricks have been published (5, 8, 10, 13, 19). The intrapelvic approach offers several advantages compared to the ilioinguinal approach: • lower invasiveness without substantial muscle detachment, • direct view of the superior pubic rami from superior and medial, the inferior anterior column and the quadrilateral surface up to the posterior border of the posterior column at the greater sciatic notch, • reduction and fixation of the anterior column and the quadrilateral surface under direct visualization, • reduction of antero-superior marginal impactions under direct visualization, • low risk of heterotopic ossification, • low risk of lesions to the lateral cutaneous femoral nerve. The aim of the third part of "standard approaches of the acetabulum" is to report on the special topics indication, positioning, exposure, incision, dissection, the anatomical basis of osteosynthesis and present results using the via the intrapelvic approach.

Standard Approaches to the Acetabulum Part 2: Ilioinguinal Approach.

The ilioinguinal approach is one of the standard approaches in the treatment of displaced acetabular fractures used during the last decades (9). The meta-analysis of Giannoudis et al. showed that 21.9% of acetabular fractures were historically treated using this approach (3). One of the disadvantages of this study was, that studies focussing especially on posterior wall stabilization and studies dealing with more complex fracture types treated by extended approaches were integrated. Thus, these fracture types were overrepresented. Re-analysis excluding these data lead to an increase of the rate of anterior approaches to 25.9%. More recent data (years 2005-2007) from the German multicenter study showed that presently in almost 45% of the cases the single ilioinguinal approach was used and only 38% of patients were stabilized via the KocherLangenbeck approach (11). Historically, the Smith-Peterson approach (15, 17) and the iliofemoral approach were used to treat acetabular fractures. In the 60ies, based on the work by Letournel and Judet, the ilioinguinal approach was developed for acetabular fracture fixation (9). It is an extrapelvic approach resulting in an indirect reconstruction concept of the acetabulum without direct visualization of the articular acetabulum. The ilioinguinal approach was the standard anterior approach during the last 30-40 years. An important advantage is the reduced soft tissue detachment of periarticular muscles with only a small risk of developing heterotopic bone formation. The aim of the second part of "Standard approaches to the acetabulum" is to report on the special topics indication, positioning, exposure, incision, dissection, the anatomical basis of osteosynthesis and present results using ilioinguinal approach.

Frequency of successful intra-articular puncture of finger joints: influence of puncture position and physician experience.

OBJECTIVE: Physicians and specialists routinely perform IA punctures and injections on patients with joint injuries, chronic arthritis and arthrosis to release joint effusion or to inject drugs. The purpose of this study was to investigate the frequencies of intra- and peri-articular cannula positioning during this procedure. METHODS: A total of 300 cadaveric finger joints were injected with a methyl blue-containing solution and subsequently dissected to distinguish intra- from peri-articular injections. To assess the influence of puncture position on successful injection, half of the joints were injected dorsally and the other half dorso-radially. To assess the importance of practical experience for a positive outcome, half of the injections were performed by an inexperienced resident and half by a skilled specialist. RESULTS: The overall frequency of occurrence of peri-articular injections was much higher than expected (overall: 23%, specialist: 15%, resident: 32%) The failure rate was significantly higher than the average with the joints of the little finger and the DIP joints of each phalanx. CONCLUSIONS: Even skilled specialists cannot guarantee to insert the cannula into the joint in every case. Unintended peri-articular drug injection moreover may affect the surrounding ligaments or tendons, leading to serious complications. Correct positioning of the needle in the joint may be facilitated by fluoroscopy in doubtful cases.

The influence of lateral and anterior angulation of the proximal ulna on the treatment of a Monteggia fracture: an anatomical cadaver study.

We have investigated the anatomy of the proximal part of the ulna to assess its influence on the use of plates in the management of fractures at this site. We examined 54 specimens from cadavers. The mean varus angulation in the proximal third was 17.5 degrees (11 degrees to 23 degrees ) and the mean anterior deviation 4.5 degrees (1 degrees to 14 degrees ). These variations must be considered when applying plates to the dorsal surface of the ulna for Monteggia-type fractures. A pre-operative radiograph of the contralateral elbow may also be of value.

Wrist arthrography after acute trauma to the distal radius: diagnostic accuracy, technique, and sources of diagnostic errors.

RATIONALE AND OBJECTIVES: The objective of this investigation was to determine the diagnostic accuracy of wrist arthrography in the detection of interosseous ligament disruptions and of triangular fibrocartilage complex (TFCC) lesions in patients after acute wrist trauma and to define the sources of diagnostic error of wrist arthrography after recent trauma. METHODS: Twenty-two patients with radial fractures after acute wrist trauma underwent arthrography and arthroscopy of the wrist. Arthrography was performed in a standardized manner by two- or three-compartment injection technique. Subsequently wrist arthroscopy was performed within the same session. Image analysis included the evaluation of interosseous carpal ligaments, the TFCC, and the osseous structures. RESULTS: In 22 patients, 11 injuries of the intrinsic ligaments and the TFCC were diagnosed by arthroscopy, of which 9 had been diagnosed correctly with arthrography before surgery. One scaphoid fracture previously missed on conventional radiographs also could be diagnosed by arthrography. CONCLUSION: Arthrography of the posttraumatic wrist is a valuable tool in the diagnostic evaluation of interosseous carpal ligaments and the TFCC.

Denervation of the radiocarpal joint. A follow-up study in 22 patients.

Denervation surgery has been a mainstay of our management of chronic pain in the wrist. If there is useful movement at the wrist we prefer denervation to arthrodesis. We have reviewed 22 patients at a mean of 50 months after such denervation surgery at the wrist. This was the only treatment in 16 patients; the other six also had other treatments. Pain was reduced in 16 patients, and 17 were satisfied or improved. None of the patients wished to have a supplementary arthrodesis. We stress the importance of preoperative blockade tests and of a very detailed knowledge of the local anatomy.

The anatomy of the joint as a risk factor for Lisfranc dislocation and fracture-dislocation. An anatomical and radiological case control study.

he anatomy of the mortise of the Lisfranc joint between the medial and lateral cuneiforms was studied in detail, with particular reference to features which may predispose to injury. In 33 consecutive patients with Lisfranc injuries we measured, from conventional radiographs, the medial depth of the mortise (A), the lateral depth (B) and the length of the second metatarsal (C). MRI was used to confirm the diagnosis. We calculated the mean depth of the mortise (A+B)/2, and the variables of the lever arm as follows: C/A, C/B and C/mean depth. The data were compared with those obtained in 84 cadaver feet with no previous injury of the Lisfranc joint complex. Statistical analysis used Student's two-sample t-test at the 5% error level and forward stepwise logistic regression. The mean medial depth of the mortise was found to be significantly less in patients with Lisfranc injuries than in the control group. Stepwise logistic regression identified only this depth as a significant risk factor for Lisfranc injuries. The odds of being in the injury group is 0.52 (approximately half) that of being a control if the medial depth of the mortise is increased by 1 mm, after adjusting for the other variables in the model. Our findings show that the mortise in patients with injuries to the Lisfranc joint is shallower than in the control group and the shallower it is the greater is the risk of injury.

Primary ulnar head prosthesis for the treatment of an irreparable ulnar head fracture dislocation.

We report the case of an irreparable fracture - dislocation of the ulnar head with a concomitant fracture of the radius (Galeazzi lesion), treated by implantation of a Herbert Ulnar Head Prosthesis((R)). A stable distal radio-ulnar joint was achieved by careful dissection of a posterior soft tissue flap and accurate reduction of the radius.

[Ultrasound identification and size determination of the palmaris longus tendon]. / Sonographische Identifikation und Grössenbestimmung der Palmaris-longus-Sehne.

Since the palmaris longus tendon is subject to a wide range of anatomical variations (in 10% of the cases, aplasia is observed), the identification and determination of its length and thickness is of importance for the pre-operative planning of ligament reconstructive surgery. Thirty healthy volunteers aged between 6 and 50 years were examined using high-resolution 10-12 MHz US probes. We determined the length and thickness of the tendon, and its relationship to the median nerve in the distal region of the forearm. Thanks to the dynamic nature of the examination and the typical tendinous echo structure, the palmaris longus tendon was accurately identified by US in both children and adults. Ultrasonography is highly suitable for the identification of the palmaris longus tendon and aids the pre-operative planning of ligament reconstructions.

[Ultrasound anatomy of the sciatic nerve of the thigh]. / Die Sonoanatomie des Nervus ischiadicus am Oberschenkel.

Ultrasound examinations of the sciatic nerve were performed using high-resolution transducers (7.5, 10 to 20 MHz) both in anatomical specimens and in healthy volunteers. The ultrasonographic anatomy (sono-anatomy) of the nerve, its course along the thigh and its echogenicity in comparison with muscles, tendons and adipose tissue were investigated in 10 isolated muscle/nerve preparations. In addition, the influence of the angle of the applied transducer on the various different tissues was evaluated. In the clinical part of the study, the sciatic nerve was identified ultrasonographically in both thighs of 50 sex-matched healthy volunteers aged between 2 and 76 years. The normal sciatic nerve presents as a tubular echogenic structure with parallel linear internal echoes in the longitudinal section, and as a punctiform moderately echoic structure in cross-section, with the perineurium producing bright boundary echoes. Varying the insonating angle of the transducer reduced echogenicity, but to a smaller degree than in muscles and tendons. Unequivocal identified of the sciatic nerve from the level of the gluteal fold to its bifurcation in the distal thigh was possible in all but one case. We conclude that the course of the sciatic nerve along the thigh can be reliably identified and imaged with high-resolution ultrasound.

[The distal radius and surrounding soft tissues--ultrasound anatomy and ultrasound pathology in the adult and child]. / Der distale Radius und seine umgebenden Weichteile--Sonoanatomie und Sonopathologie beim Erwachsenen und beim Kind.

BACKGROUND: The aim of the study was to evaluate the ultrasonographic anatomy of the distal forearm (i.e. distal radius and surrounding soft tissue) and the typical changes occurring during growth, in adults and children. MATERIAL AND METHODS: The ultrasonographic anatomy was evaluated in 10 healthy adults aged between 20 and 60 years, and 20 healthy children aged between 2 and 18 years. Particular attention was paid to dynamic examination comparing both limbs, and isolated investigations of functional tendon. RESULTS: An anatomical description of the tissues of the distal forearm was possible at all ages. During growth, secondary ossification centres and the transitional osteochondral region of the growth plate need particular consideration. DISCUSSION AND CONCLUSION: Both in children and adults, ultrasonography can provide valuable information in the evaluation of acute trauma, follow-up of fractures and osteosynthesis, suspected osteomyelitis and chronic disorders. In children, special attention must be paid to the development of the epiphyseal region, as reflected by ossification centre, growth plate and articular cartilage.

[Ultrasound imaging of foreign bodies--an experimental study]. / Sonograpische Darstellung von Fremdkörpern--eine experimentelle Studie.

In an experimental study, the US pattern of foreign materials such as are often found in wounds, was investigated. The exploration was carried out with the aid of high-resolution, mechanical US probes (10-12 MHz) used to examine foreign bodies placed in a gelatine bath and in the shoulder of a pig. The study showed that all foreign bodies that measured at least 1-2 mm in diameter were reliably detected. The intensity of the interface echoes was identical with all the materials employed, irrespective of the nature of the surface. However, the artefacts caused by the foreign bodies used revealed considerable differences. Complete acoustic shadow, acoustic attenuation, reverberation echoes and even "comet-tail" artefacts were observed. In clinical practice, familiarity with the artefacts that may be expected during sonographic exploration and localization of foreign bodies in wounds would seem to make good sense.

[Value of ultrasound in diagnosis of post-traumatic heterotopic ossifications]. / Stellenwert der Sonographie in der Diagnostik posttraumatischer heterotoper Ossifikationen.

Heterotopic ossification is a non-neoplastic deposit of bone within soft tissue (myositis ossificans). The most common localized form is post-traumatic myositis ossificans. The ultrasonographic appearance of heterotopic ossification is characterized by highly echogenic areas with attenuation or complete disappearance of the acoustic signal distal to these areas. The size and extent of para-articular ossifications can also be evaluated, and the choice of the surgical approach is facilitated and damage to soft tissue minimized by the ultrasonographic examination.

[Value of ultrasound of the support and locomotor system--with special reference to radiation exposure and cost reduction]. / Stellenwert der Sonographie am Stütz- und Bewegungsapparat--unter besonderer Berücksichtigung von Strahlenbelastung und Kostenreduktion.

In recent years, ultrasonic assessment of the locomotory system has become established both as a screening method in patients with chronic disorders and for evaluating acute injuries. Thanks to technical improvements to the equipment (use of high-frequency probes up to 20 MHz), ever smaller structures can be visualized. Ultrasonography can be carried out immediately following the clinical- and possibly radiological-assessment, by one and the same investigator, and requires little extra time. A bilateral examination in particular permits good evaluation of the extent of an injury and, with appropriate experience and good-quality equipment, an accurate assessment of the anatomical topography. Ultrasonography should now be used as the primary imaging method in the diagnosis of injuries to the following parts of the locomotory system, thus helping to minimize the number of expensive, and more invasive, diagnostic procedures: muscles and tendons, peri-articular soft tissue (in particular shoulder, knee and elbow joints), detection of intra-articular effusions, collections of fluid and, where applicable, ultrasonically guided puncture. In numerous other problems, too (postoperative complications, foreign bodies, fractures, osteomyelitis, soft tissue inflammation, etc.), ultrasound can deliver the first information. In this way, expensive diagnostic techniques can be reserved for special cases only, thus reducing costs. Furthermore, used as an adjunctive method, ultrasonography can reduce the number of diagnostic and follow-up X-rays in the case of injuries to the AC joint, shoulder dislocations, Hill-Sachs lesions, fractures in children, and for the detection of foreign bodies, again reducing radiation exposure and overall costs.

[Ultrasound fracture diagnosis--an experimental study]. / Die sonographische Frakturdiagnostik--eine experimentelle Studie.

Thanks to the increasing use of ultrasonography in the diagnostic evaluation of the musculoskeletal system, and the development of high-resolution ultrasonic transducers with ever better image quality, as well as the greater general trend towards non-invasive techniques, the use of ultrasonography in the diagnosis and follow-up of fractures would appear to make good sense. The aim of the present experimental study was, therefore, to identify the typical acoustic pattern of fractures and areas of bone impression and defects, while taking account of possible sources of error due to artefacts. Experiments were carried out on cadaver bones immersed in a water bath, using 7.5 and 10 MHz linear transducers. Depending on its size, the bony defect is represented by an interruption of the cortical echo, or a dorsal band of echoes limited to the fracture zone. Of interest is the fact that fractures and bony defects are not represented as such when the transducer is directed parallel to the line of the fracture or the impression area. Particular attention needs to be paid to the numerous artefacts occurring at the margins of the fracture. In summary, it may be noted that using resolution transducers under standardised experimental examination conditions, cortical interruptions of not less than 1 mm can be identified.

[Ultrasound imaging of osteosynthesis materials in traumatology--an experimental study]. / Sonographische Darstellung von Osteosynthesematerial in der Traumatologie--eine experimentelle Studie.

The aim of the present study was to establish the typical ultrasound (US) patterns of metal implants used for internal fracture fixation, and consequently to use US for the identification and localisation of such implants. We investigated both the visualization of the implants in term of size and shape, material (titanium, steel, biodegradable screws) and surface structures, and possible changes in the echo pattern in relationship to surrounding structures (muscles, body fluid), proximity to bone, and changes in the angle of insonation. For this purpose ultrasonography was performed on artificial and isolated cadaver bones in a water bath, as well as on cadaver limbs following prior implantation of screws, plates, K-wires and cerclage wires. We found that, from a certain size upwards, metal implants can be easily localised on the basis of typical artefacts (resonance artefact, comet-tail artefact). US is thus most suitable for localisation of metal implants. The spatial and anatomical relationship to bony structures, joints, tendons, muscles and blood vessels can be determined with a high degree of accuracy.

Screw fixation of medial malleolar fractures: a cadaveric biomechanical study challenging the current AO philosophy.

The AO Foundation advocates the use of partially threaded lag screws in the fixation of fractures of the medial malleolus. However, their threads often bypass the radiodense physeal scar of the distal tibia, possibly failing to obtain more secure purchase and better compression of the fracture. We therefore hypothesised that the partially threaded screws commonly used to fix a medial malleolar fracture often provide suboptimal compression as a result of bypassing the physeal scar, and proposed that better compression of the fracture may be achieved with shorter partially threaded screws or fully threaded screws whose threads engage the physeal scar. We analysed compression at the fracture site in human cadaver medial malleoli treated with either 30 mm or 45 mm long partially threaded screws or 45 mm fully threaded screws. The median compression at the fracture site achieved with 30 mm partially threaded screws (0.95 kg/cm(2) (interquartile range (IQR) 0.8 to 1.2) and 45 mm fully threaded screws (1.0 kg/cm(2) (IQR 0.7 to 2.8)) was significantly higher than that achieved with 45 mm partially threaded screws (0.6 kg/cm(2) (IQR 0.2 to 0.9)) (p = 0.04 and p < 0.001, respectively). The fully threaded screws and the 30mm partially threaded screws were seen to engage the physeal scar under an image intensifier in each case. The results support the use of 30 mm partially threaded or 45 mm fully threaded screws that engage the physeal scar rather than longer partially threaded screws that do not. A 45 mm fully threaded screw may in practice offer additional benefit over 30 mm partially threaded screws in increasing the thread count in the denser paraphyseal region.

Is sparing the pronator quadratus muscle possible in volar plating of the distal radius?

We measured the length of the distal radius that can be exposed by mobilizing the distal edge of pronator quadratus (PQ) without detaching its radial attachment. Measurements were made in 20 cadaveric upper limbs from the distal margin of the radius in line with the scaphoid and lunate fossae to the distal margin of the PQ, before and after mobilization of the muscle from its distal attachment. The mean distance from the distal edge of the PQ to the scaphoid fossa was 13.1 mm and to the lunate fossa was 10.7 mm. This increased to a mean of 26.2 mm for the scaphoid and a mean of 23.8 mm for the lunate fossa following mobilization of PQ. Subperiosteal retrograde release of the PQ from its distal margin will allow for the placement of a volar plate and insertion of locking peri-articular screws in the great majority of volar locking plate systems on the market.