Late Periprosthetic Femoral Stress Fracture Associated with Extra-articular Deformity in a Patient with Fibrous Dysplasia: A Case Report.

CASE: In the setting of a total hip arthroplasty performed in a patient with a proximal femoral deformity, atraumatic periprosthetic femoral stress fracture may arise as a complication. We report a rare case of a late periprosthetic femoral stress fracture around a cemented stem in a patient with a history of fibrous dysplasia of the proximal femur. After a 10-year uneventful period, the patient complained about a subtle, subacute pain in his left thigh induced by exercise but not with daily axial load. Diagnosis of a nondisplaced, incomplete (i.e., only compromising the lateral femoral cortex) periprosthetic femoral stress fracture was made with plain radiographs, blood work, and bone scintigraphy. Surgical treatment consisted of a minimally invasive plate osteosynthesis bridging the femoral deformity plus percutaneous osteoperiosteal decortication. At 5-year follow-up, the patient was asymptomatic with full return to physical activity, with radiographs evidencing callus formation. CONCLUSION: Stress fractures around well-fixed femoral stems, while infrequent, should be addressed in patients with a history of severe proximal femur deformity experiencing atraumatic thigh pain.

El acortamiento del radio como factor limitante para la reducción cerrada en fracturas de antebrazo pediátrico / Radius shortening as a limiting factor for closed reduction in pediatric forearm fractures

IntroducciónLas fracturas diafisarias de antebrazo (FDA) en pacientes esqueléticamente inmaduros son lesiones comunes que representan el 30% de las fracturas de la extremidad superior en este grupo etario. Existen casos con lesiones inestables o reducciones inaceptables, en los cuales está indicada la resolución quirúrgica mediante la reducción y estabilización con clavos endomedulares elásticos (CEE) por vía percutánea. Una de las ventajas que ofrece este sistema es evitar un abordaje del foco de fractura, pudiendo realizar la reducción de forma cerrada en la gran mayoría de estas. Sin embargo, no siempre es posible lograr una aceptable reducción cerrada y entonces es necesaria la apertura del foco de fractura. El objetivo de este estudio fue determinar si existen factores preoperatorios para predecir la dificultad de efectuar una reducción cerrada en estos pacientes.MétodosSe realizó un estudio retrospectivo de pacientes esqueléticamente inmaduros con FDA agudas, tratados con CEE por el mismo cirujano pediátrico. La variable de resultado primaria se definió como la necesidad de llevar a cabo una reducción abierta; considerado como un abordaje quirúrgico directo en el sitio de fractura. Se analizaron las características demográficas de los pacientes incluidos y las radiográficas de la fractura.ResultadosEncontramos que la mediana del porcentaje del acortamiento del radio preoperatorio en los grupos de reducción cerrada y reducción abierta fue del 1 y 5%, respectivamente; resultando en una diferencia estadísticamente significativa (p = 0,04).ConclusiónEl acortamiento del radio en las radiografías preoperatorias permite predecir un aumento del riesgo de requerir una reducción abierta de la fractura (39% de asociación); por lo cual, esta variable debe ser considerada por el traumatólogo general como un factor pronóstico para definir la derivación de estos pacientes.(AU)

IntroductionDiaphyseal forearm fractures in skeletally immature patients are common injuries that account for 30% of upper extremity fractures in this age group. There are cases with unstable injuries or unacceptable reductions, in which surgical resolution by reduction and stabilisation with percutaneous elastic endomedullary nailing is indicated. One of the advantages of this system is that it avoids an approach to the fracture site, allowing closed reduction in the vast majority of fractures. However, it is not always possible to achieve an acceptable closed reduction and opening of the fracture site is necessary. The aim of this study was to determine whether there are preoperative factors to predict the difficulty of performing closed reduction in these patients.MethodsA retrospective study of skeletally immature patients with acute diaphyseal forearm fractures treated with elastic endomedullary nailing by the same paediatric surgeon was performed. The primary outcome variable was defined as the need for open reduction; considered as a direct surgical approach to the fracture site. Demographic characteristics of the included patients and radiographic characteristics of the fracture were analysed.ResultsWe found that the median percentage of preoperative radial shortening in the closed reduction and open reduction groups was 1 and 5%, respectively; resulting in a statistically significant difference (p = 0.04).ConclusionRadial shortening on preoperative radiographs predicts an increased risk of requiring an open reduction of the fracture (39% association); thus we understand that this variable should be considered by the general traumatologist as a prognostic factor in defining the referral of these patients.(AU)

Radius shortening as a limiting factor for closed reduction in pediatric forearm fractures / El acortamiento del radio como factor limitante para la reducción cerrada en fracturas de antebrazo pediátrico

IntroductionDiaphyseal forearm fractures in skeletally immature patients are common injuries that account for 30% of upper extremity fractures in this age group. There are cases with unstable injuries or unacceptable reductions, in which surgical resolution by reduction and stabilisation with percutaneous elastic endomedullary nailing is indicated. One of the advantages of this system is that it avoids an approach to the fracture site, allowing closed reduction in the vast majority of fractures. However, it is not always possible to achieve an acceptable closed reduction and opening of the fracture site is necessary. The aim of this study was to determine whether there are preoperative factors to predict the difficulty of performing closed reduction in these patients.MethodsA retrospective study of skeletally immature patients with acute diaphyseal forearm fractures treated with elastic endomedullary nailing by the same paediatric surgeon was performed. The primary outcome variable was defined as the need for open reduction; considered as a direct surgical approach to the fracture site. Demographic characteristics of the included patients and radiographic characteristics of the fracture were analysed.ResultsWe found that the median percentage of preoperative radial shortening in the closed reduction and open reduction groups was 1 and 5%, respectively; resulting in a statistically significant difference (p = 0.04).ConclusionRadial shortening on preoperative radiographs predicts an increased risk of requiring an open reduction of the fracture (39% association); thus we understand that this variable should be considered by the general traumatologist as a prognostic factor in defining the referral of these patients.(AU)

IntroducciónLas fracturas diafisarias de antebrazo (FDA) en pacientes esqueléticamente inmaduros son lesiones comunes que representan el 30% de las fracturas de la extremidad superior en este grupo etario. Existen casos con lesiones inestables o reducciones inaceptables, en los cuales está indicada la resolución quirúrgica mediante la reducción y estabilización con clavos endomedulares elásticos (CEE) por vía percutánea. Una de las ventajas que ofrece este sistema es evitar un abordaje del foco de fractura, pudiendo realizar la reducción de forma cerrada en la gran mayoría de estas. Sin embargo, no siempre es posible lograr una aceptable reducción cerrada y entonces es necesaria la apertura del foco de fractura. El objetivo de este estudio fue determinar si existen factores preoperatorios para predecir la dificultad de efectuar una reducción cerrada en estos pacientes.MétodosSe realizó un estudio retrospectivo de pacientes esqueléticamente inmaduros con FDA agudas, tratados con CEE por el mismo cirujano pediátrico. La variable de resultado primaria se definió como la necesidad de llevar a cabo una reducción abierta; considerado como un abordaje quirúrgico directo en el sitio de fractura. Se analizaron las características demográficas de los pacientes incluidos y las radiográficas de la fractura.ResultadosEncontramos que la mediana del porcentaje del acortamiento del radio preoperatorio en los grupos de reducción cerrada y reducción abierta fue del 1 y 5%, respectivamente; resultando en una diferencia estadísticamente significativa (p = 0,04).ConclusiónEl acortamiento del radio en las radiografías preoperatorias permite predecir un aumento del riesgo de requerir una reducción abierta de la fractura (39% de asociación); por lo cual, esta variable debe ser considerada por el traumatólogo general como un factor pronóstico para definir la derivación de estos pacientes.(AU)

Radius shortening as a limiting factor for closed reduction in pediatric forearm fractures. / El acortamiento del radio como factor limitante para la reducción cerrada en fracturas de antebrazo pediátrico.

INTRODUCTION: Diaphyseal forearm fractures in skeletally immature patients are common injuries that account for 30% of upper extremity fractures in this age group. There are cases with unstable injuries or unacceptable reductions, in which surgical resolution by reduction and stabilisation with percutaneous elastic endomedullary nailing is indicated. One of the advantages of this system is that it avoids an approach to the fracture site, allowing closed reduction in the vast majority of fractures. However, it is not always possible to achieve an acceptable closed reduction and opening of the fracture site is necessary. The aim of this study was to determine whether there are preoperative factors to predict the difficulty of performing closed reduction in these patients. METHODS: A retrospective study of skeletally immature patients with acute diaphyseal forearm fractures treated with elastic endomedullary nailing by the same paediatric surgeon was performed. The primary outcome variable was defined as the need for open reduction; considered as a direct surgical approach to the fracture site. Demographic characteristics of the included patients and radiographic characteristics of the fracture were analysed. RESULTS: We found that the median percentage of preoperative radial shortening in the closed reduction and open reduction groups was 1 and 5%, respectively; resulting in a statistically significant difference (p = 0.04). CONCLUSION: Radial shortening on preoperative radiographs predicts an increased risk of requiring an open reduction of the fracture (39% association); thus we understand that this variable should be considered by the general traumatologist as a prognostic factor in defining the referral of these patients.

Uso de la matriz dérmica acelular para el tratamiento de zonas críticas en defectos de cobertura. Serie de casos / The role of dermal regeneration templates in severe soft tissue defects. Management of "critical zones". Case series

Introducción: El objetivo de esta serie de casos es describir los resultados y las complicaciones de pacientes con heridas gra-ves con defecto de cobertura en zonas críticas tratadas con una matriz dérmica acelular. materiales y métodos: Se realizó una revisión retrospectiva de los pacientes con déficit de cobertura en zonas críticas tratados con matriz dérmica acelular en nuestro centro. Definimos como zona crítica al déficit de cobertura que no pueda ser tratado solo con injerto de piel. Evaluamos variables preoperatorias, intraoperatorias y posoperatorias. Resultados: Los diagnósticos iniciales fueron tumor (3 pacientes), trauma agu-do (3 pacientes) y secuela de síndrome compartimental (2 pacientes). El defecto de cobertura estaba localizado en la pierna (3 casos), en la mano (2 casos), en el muslo (1 caso), en el antebrazo (1 caso) y en el pie (1 caso). La zona crítica se caracterizó por exposición tendinosa con pérdida de peritenon (5 casos), exposición ósea y pérdida de periostio (1 caso), exposición de injerto de nervio (1 caso) y exposición de osteosíntesis (1 caso). Se registraron tres complicaciones. Dos pacientes requirieron una nueva colocación de matriz y, en otro paciente, se realizó un colgajo neurocutáneo de safeno interno por fracaso de la cobertura con membrana. Conclusiones: Los sustitutos dérmicos se caracterizan por su fácil uso y versatilidad. Esta técnica otorga protección en situaciones de exposición ósea, además de proveer un plano de deslizamiento en caso de exposición tendinosa. El uso de matriz dérmica permite, además, ahorrar el empleo de colgajos. Nivel de Evidencia: IV

Introduction: The aim of this study is to report outcomes and complications in a series of patients suffering soft tissue defects in critical areas treated using an acellular dermal matrix. Materials and Method: A retrospective review of patients with soft tissue coverage deficits in critical areas treated with acellular dermal matrix in our center over a five-year period was conducted. The preoperative variables analyzed were: age, sex, comorbidities, number of previous surgeries, size and characteristics of the critical area and cause of the coverage defect. The intraoperative variables analyzed were: size of the dermal substitute used, surgical time and complications. The postoperative variables were: incorporation of the dermal substitute, time elapsed until the placement of the skin graft, and postoperative complications. Results: The initial diagnoses were tumor (3 patients), acute trauma (3 patients) and sequelae of compartment syndrome (2 patients). The soft tissue defect was located in the leg (3 cases), in the hand (2 cases), in the thigh (1 case), in the forearm (1 case) and in the foot (1 case). In 5 cases the critical zone was characterized by tendon exposure with loss of peritenon; in one case bone exposure and loss of periosteum; in one case exposure of nerve graft and in one case exposure of osteosynthesis material. Three complications were recorded. Conclusion: Dermal substitutes are characterized by their versatility. This technique can provide protection in situations of bone exposure, in addition to providing a gliding plane in case of tendon exposure. In situations of failure or impossibility of performing a biological reconstruction, dermal substitutes havea role within reconstructive options. Level of Evidence: IV

Soporte circunferencial posterior en fracturas de platillo tibial / Posterior circumferential support in tibial plateau fractures

Las técnicas quirúrgicas que más se utilizan en la actualidad para fracturas de platillo tibial no contemplan correctamente la conminución ósea multiplanar ni la presencia de fragmentos óseos posteriores. Nos hemos enfrentado con esta problemática al tratar a un paciente con fractura de platillo tibial tipo Schatzker VI, en la cual se suplementó la osteosíntesis habitualmente utilizada con una placa horizontal circunferencial posterior. Se logró la consolidación ósea y los resultados funcionales a corto plazo fueron buenos. Del análisis de la bibliografía citada, se concluye en que se han desarrollado varias técnicas de contención posterior de los platillos tibiales, y la osteosíntesis circunferencial es una técnica por considerar. Nivel de Evidencia: IV

Surgical techniques commonly used today for tibial plateau fractures do not properly contemplate multiplanar bone comminution nor the presence of posterior bone fragments. We have faced this problem when treating a patient with a Schatzker VI type fracture, in which the commonly used osteosynthesis was supplemented with a posterior horizontal circumferential plate. Bone consolidation and good results were achieved in the short term in the case we present. From the analysis of the cited literature, we concluded that several techniques for containing posterior tibial plateau bone comminution have been developed. Among them, circumferential osteosynthesis is a technique to take into account. Level of Evidence: IV

Luxación periastragalina medial pura: reporte de casos y revisión bibliográfica / Pure medial subtalar dislocation: case report and literature review

Las luxaciones subastragalinas (periastragalinas) sin fractura asociada son un cuadro poco frecuente. Representan solo el 1% de las luxaciones en el ser humano. Presentamos tres casos de luxaciones mediales puras en pacientes que sufrieron un traumatismo de alta energía. En todos los casos, el tratamiento consistió en la reducción cerrada bajo anestesia y posterior inmovilización; la evolución fue satisfactoria. Las luxaciones subastragalinas requieren de un diagnóstico temprano y una rápida resolución. Con estos casos se quiere demostrar la importancia de la sospecha diagnóstica y el beneficio de un tratamiento precoz y acertado. Nivel de evidencia: IV

Isolated subtalar dislocations without associated fracture are a rare entity. They represent only 1% of dislocations in humans. We present a series of 3 cases of pure medial dislocations in patients who suffered high-energy trauma. In all cases, the treatment was closed reduction under anesthesia and subsequent immobilization; all with good results. Subtalar dislocations require early diagnosis and rapid resolution. The aim of this presentation is to demonstrate the importance of diagnostic suspicion and the benefit of early treatment for successful outcome. Level of evidence: IV

Fasciitis and Streptococcal Toxic-shock Syndrome: The Importance of Early Diagnosis and Surgical Management.

INTRODUCTION: Fasciitis of the limb and toxic-shock syndrome due to Streptococcus Pyogenes infection is considered a surgical emergency. This condition may occur in previously healthy patients. It is a life-threatening condition with high morbidity rates when treatment is delayed due to poor diagnosis and non-surgical intervention. CASE REPORT: 17-year-old male patient sustained a minor ankle trauma while skating. Initials findings were a 1cm wound in relation with his left lateral malleolus and moderate swelling. About 6 h later, the patient was admitted at the emergency room with disproportionate limb pain, increased swelling, persistent fever, paleness, tachycardia, and hypotension. The patient was intubated due to his unstable hemodynamic condition and underwent fasciotomy of the limb. A vacuum-assisted closure device was used. After the first surgical procedure, patient's condition radically improved. He was extubated with good clinical prognosis. He underwent several surgical procedures in a 3-weeks lapse until the wound finally healed. CONCLUSION: Streptococcal toxic-shock syndrome and limb fasciitis have no specific early signs or symptoms. It seems that clinical dissociation (disproportionate pain together with a minor wound) should become an alarm sign to trauma surgeons. It is important to contemplate this serious condition as differential diagnosis in every patient undergoing trauma with torpid evolution. Aggressive surgical management is the gold standard treatment and should not be delayed.