A system of predictive scores to evaluate the risk of multilevel noncontiguous spinal fractures in patients with traumatic cervical spine injury.

PURPOSE: To develop a predictive scoring system to identify traumatic cervical spine injury patients at a high risk of having multilevel noncontiguous spinal fractures. METHODS: This 12-year retrospective observational cohort study included 588 traumatic cervical spine-injured patients. Patients were categorized into two groups: patients with multilevel noncontiguous spinal fractures and patients without this remote injury. Potential risk factors were examined using multivariable analysis to derive a predictive risk score from independent predictors. Results are presented as odds ratio with a 95% confidence interval (95% CI). The accuracy of the calculated predicted score was demonstrated by the area under the receiver operating characteristic curve (AuROC). RESULTS: The incidence of noncontiguous fracture among the patients was 17% (100 of 588). The independent risk factors associated with multilevel noncontiguous spinal fractures were motor weakness, intracranial injury, intrathoracic injury, and intraabdominal injury. The AuROC of the prediction score was 0.74 (95% CI 0.69, 0.80). The patients were classified into three groups, low-risk group (score< 1), moderate-risk group (score 1-2.5), and high-risk group (score≥ 3), based on the predicted risk of multilevel noncontiguous spinal fractures. CONCLUSIONS: This tool can potentially help preventing the missed diagnosis of cervical spine injuries with multilevel noncontiguous spinal fractures. CT scans or MRI of the entire spine to investigate remote multilevel noncontiguous spinal fractures may have a role in cervical spine-injured patients who have at least one of the independent risk factors and are strongly suggested for patients with scores in the high-risk group.

Acute traumatic lateral atlantoaxial dislocation associated with locked atlas lateral mass and odontoid process fracture: A clinical case study and literature review.

Background: Traumatic atlantoaxial dislocation combined with locked atlas lateral mass and odontoid process fracture is a complex injury and is extremely rare. We describe the surgical technique by presenting a clinical case study in managing a traumatic lateral atlantoaxial dislocation combined with a locked atlas lateral mass and a type II odontoid fracture (Grauer type IIB). Case description: This is a clinical case study of a 38-year-old female patient who presented with severe neck pain without neurological deficit following a traffic accident. Computed tomography showed a type IIB odontoid fracture and a lateral C1-C2 dislocation with a laterally locked left lateral mass at the C1-C2 level. Emergency management included protecting the cervical spine and applying gradually increasing skull traction. The locked lateral mass and laterally-dislocated C1-C2 facet joints were partially reduced. An intraoperative joint reduction operation with leverage technique was then performed. Posterior C1-C2 fixation (a modified Harms-Goel technique) and fusion with iliac bone graft were then executed. Outcome: Postoperatively, neck pain improved significantly. The atlantoaxial joint was successfully reduced and stabilized. Solid bony fusion was confirmed by a radiographic study at the 1-year follow-up. Conclusions: Based on a review of current literature, traumatic lateral atlantoaxial dislocation combined with a locked atlas lateral mass and type IIB odontoid fracture is rarely seen. It is an extremely unstable injury. Our proposed leverage technique used in conjunction with a modified Harms-Goel technique is an effective alternative treatment. This approach can assist surgeons in the management of these difficult cases.

Ipsilateral anterior hip dislocation and posterior knee subluxation: a case report.

Hip or knee dislocations are two orthopedic emergencies. Concomitant hip and knee dislocations are extremely rare. The authors report a case of ipsilateral anterior hip and posterior knee dislocations. Firstly, closed reduction of the knee and spanning external fixation was performed and then the hip was closely reduced under general anesthesia.

Less invasive plate osteosynthesis in humeral shaft fractures.

OBJECTIVE: Stable internal fixation of the humeral shaft by less invasive percutaneous plate insertion using two separate (proximal and distal) incisions, indirect reduction by closed manipulation and fixation to preserve the soft tissue and blood supply at the fracture zone. Early mobilization of the shoulder and elbow to ensure a good functional outcome. INDICATIONS: Humeral shaft fractures (classified according to AO classification as: 12-A, B, C). Humeral shaft fractures extending to the proximal or distal shaft, small or deformed medullary canal or open growth plate. CONTRAINDICATIONS: Humeral shaft fractures with primary radial nerve palsy. Proximal humeral shaft fractures extending to the humeral head. Distal humeral fractures extending to the elbow joint. SURGICAL TECHNIQUE: Two incisions proximal and distal to the fracture zone are used. A 3-cm proximal incision lies between the lateral border of the proximal part of the biceps and the medial border of the deltoid. Distally, a 3-cm incision is made along the lateral border of the biceps. The interval between biceps and brachialis is identified. The biceps is retracted medially to expose the musculocutaneous nerve. The brachialis muscle has dual innervation, the medial half being innervated by the musculocutaneous nerve and the lateral half by the radial nerve. The brachialis is split longitudinally at its midline. The musculocutaneous nerve is retracted along with the medial half of the brachialis, while the lateral half of the brachialis serves as a cushion to protect the radial nerve. A deep subbrachial tunnel is created from the distal to the proximal incision. The selected plate is tied with a suture to a hole at the tip of the tunneling instrument for pulling the plate back along the prepared track. The plate is aligned in the correct position on the anterior surface of the humerus. Traction is applied and the fracture reduced to restore alignment by image intensifier, followed by plate fixation with at least two bicortical locking screws or three bicortical conventional screws in each fragment. RESULTS: Between January 2003 and January 2006, 23 patients were operated on using the less invasive plate osteosynthesis technique. The minimum follow-up period of 12 months was completed in 20 patients. The mean healing time was 14.6 weeks, defined as three of four cortices having stable bridging callus. In one patient with delayed union, healing was observed after 28 weeks. Functional outcomes were evaluated using the Constant Score and the Hospital for Special Surgery (HSS) Score. 19 patients had good to excellent elbow function with a mean HSS Score of 93.5 points. All patients achieved satisfactory shoulder function with a mean Constant Score of 85.8 points compared to 90.6 on the healthy side. Complications observed were one paresthesia of lateral cutaneous nerve of forearm (no radial nerve injury) and one loosening of the LCP (Locking Compression Plate) screws due to technical error.

Treatment of femoral fracture through the sliding screw portal following fixation of the femoral neck fracture.

The authors report a case of secondary femoral fracture through the sliding hip screw portal following fixation of the femoral neck fracture. The femoral neck and subtrochanteric fracture was successfully treated by superimposing a trochanteric stabilization plate (TSP) onto the regular sliding hip screw.

Pseudoaneurysm of profunda femoris artery following internal fixation of intertrochanteric fracture: two cases report.

The authors report two cases of an uncommon but preventable complication after fixation of intertrochanteric hip fracture, the pseudoaneurysm of the profunda femoris artery. Both cases in the present study presented as proximal thigh mass, and soft tissue sarcoma was suspicious in one case. The diagnosis was confirmed by angiographic study and the feeding vessels were successfully occluded during angiography. Proper placement of the retractors, using a shorter drill or drill guard, accurate screw length and a shorter side-plate DHS were recommended to prevent this problem.