Factors Associated With Infection in Patients With Combined Pelvic Ring and Bladder Injuries.

OBJECTIVES: To identify the infection rate in patients with combined pelvic ring and bladder injuries. Secondary aims included identifying treatment and injury factors associated with infection. DESIGN: Retrospective review. SETTING: Single Level I Tertiary Academic Center. PATIENTS SELECTION CRITERIA: All patients over a 12-year period with combined pelvic ring and bladder injuries were evaluated. Exclusion criteria were nonoperative management of the pelvic ring, isolated posterior fixation, and follow-up <90 days. OUTCOME MEASURE AND COMPARISONS: Primary outcome measured was deep infection of the anterior pelvis requiring surgical irrigation and debridement. RESULTS: In total, 106 patients with anterior stabilization of the pelvis in the setting of a bladder injury were included. Seven patients (6.6%) developed a deep infection and required surgical debridement within 90 days. Patients undergoing open reduction and internal fixation with plating of the anterior pelvis and acute concomitant bladder repair had an infection rate of 2.2% (1/43). Patients undergoing closed reduction and anterior fixation with either external fixation or percutaneous rami screw after bladder repair had an infection rate of 17.6% (3/17). There was a higher infection rate among patients with combined intraperitoneal (IP) and extraperitoneal (EP) bladder injuries (23%) when compared with those with isolated EP (3.8%) or IP (9.1%) bladder injuries (P = 0.029). CONCLUSIONS: Acute open reduction and internal fixation of the anterior pelvis in patients with combined pelvic ring and bladder injuries has a low infection rate. Patients with combined IP and EP bladder injuries are at increased risk of infection compared with those with isolated IP and EP injuries. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Proximal tibia fracture dislocations: Management and outcomes of a severe and under-recognized injury.

INTRODUCTION: Proximal tibia fracture dislocations (PTFDs) are a subset of plateau fractures with little in the literature since description by Hohl (1967) and classification by Moore (1981). We sought to evaluate reliability in diagnosis of fracture-dislocations by traumatologists and to compare their outcomes with bicondylar tibial plateau fractures (BTPFs). METHODS: This was a retrospective cohort study at 14 level 1 trauma centers throughout North America. In all, 4771 proximal tibia fractures were reviewed by all sites and 278 possible PTFDs were identified using the Moore classification. These were reviewed by an adjudication board of three traumatologists to obtain consensus. Outcomes included inter-rater reliability of PTFD diagnosis, wound complications, malunion, range of motion (ROM), and knee pain limiting function. These were compared to BTPF data from a previous study. RESULTS: Of 278 submitted cases, 187 were deemed PTFDs representing 4% of all proximal tibia fractures reviewed and 67% of those submitted. Inter-rater agreement by the adjudication board was good (83%). Sixty-one PTFDs (33%) were unicondylar. Eleven (6%) had ligamentous repair and 72 (39%) had meniscal repair. Two required vascular repair. Infection was more common among PTFDs than BTPFs (14% vs 9%, p = 0.038). Malunion occurred in 25% of PTFDs. ROM was worse among PTFDs, although likely not clinically significant. Knee pain limited function at final follow-up in 24% of both cohorts. CONCLUSIONS: PTFDs represent 4% of proximal tibia fractures. They are often unicondylar and may go unrecognized. Malunion is common, and PTFD outcomes may be worse than bicondylar fractures.

Idiopathic Transverse Myelitis Mimicking an Intramedullary Spinal Cord Tumor.

The differential diagnoses for spinal cord lesions include spinal tumors and inflammatory processes. The distinction between these pathologies can be difficult if solely based on imaging. We report for the first time to our knowledge a case of idiopathic transverse myelitis (ITM) mimicking a discrete cervical spinal lesion in a 66-year-old man who presented with gait instability and neck pain. The patient's symptoms failed to resolve after an initial course of steroid therapy. Surgical biopsy confirmed the diagnosis of ITM. Subsequent treatment with dexamethasone resulted in complete resolution of the symptoms as well as the intramedullary enhancement. ITM is most common in the cervical and thoracic spine, spanning 3-4 spinal segments. It usually occupies more than 50% of the cross-sectional area of the spinal cord and tends to be central, uniform, and symmetric. It exhibits patchy and peripheral contrast enhancement. These criteria are useful guidelines that help distinguish ITM from neoplastic spinal lesions. A decision to perform biopsy must take into consideration the patient's clinical symptoms, the rate of progression of neurological deficits, and the imaging characteristics of the lesion. Surgical biopsy for questionable lesions should be reserved for patients with progressive neurological deficits refractory to empirical medical therapy.