Heroin-induced osteoporosis presented with bilateral femoral neck insufficiency fractures in a male adult: a case report.

BACKGROUND: Osteoporosis has been associated with several disorders; however, there have been only a limited number of reports on heroin-induced osteoporosis. We report a rare case presented with bilateral femoral neck insufficiency fractures without trauma history, caused by heroin-induced osteoporosis. We collect sufficient clinical data and further shed light on the potential mechanism of how heroin affects bone formation and decreases bone density. CASE PRESENTATION: A 55-year-old male patient with normal body mass index (BMI) suffered from bilateral hips pain gradually without trauma history. He had intravenous heroin addiction for more than 30 years. Radiography revealed bilateral femoral neck insufficiency fractures. Laboratory tests showed elevated alkaline phosphatase levels (365 U/L) and decreased inorganic phosphate (1.7 mg/dL), calcium (8.3 mg/dL), 25-(OH)D3 (20.3 ng/ml) and testosterone levels (2.12 ng/ml). Magnetic resonance imaging (MRI) revealed increased signals on STIR images over the sacral ala and bilateral proximal femur, and multiple band-like lesions at the vertebrae of the thoracic and lumbar spine. Bone densitometry revealed osteoporosis with a T score of minus 4.0. The screen for urine morphine was positive (> 1000 ng/ml). Through assessment of the patient, the diagnosis was insufficiency fractures of bilateral femoral neck caused by opioid-induced osteoporosis. After hemiarthroplasty, regular medication with vitamin D3 and calcium, and detoxification treatment, and the patient recovered well after 6 months of follow-up. CONCLUSION: The aim of this report is to highlight the laboratory and radiology findings in a case of osteoporosis caused by opioid addiction and discuss the potential pathway by which osteoporosis is induced by opioids. When an unusual osteoporosis presents with insufficiency fractures, heroin-induced osteoporosis should be considered.

"Fragment Width Ratio" as a Predictor of Nonunion for Femoral Shaft Fracture With Third Fragments.

Previous studies have reported that large fracture fragment with displacement might cause nonunion of femoral shaft fractures. We therefore intended to delineate significant risk factors for developing a nonunion predisposed by a major fracture fragment. We analyzed 61 patients who were operated on using interlocking nails for femoral shaft fractures from 2009 to 2018. We classified patients with modified Radiographic Union Scale for Tibia fractures scores of less than 11 or needing reoperations by 1 year postoperatively as nonunion. We thereafter measured parameters of the displaced fracture fragment and fracture site to identify the significant difference between the union and non-union groups. We also applied the receiver operating characteristic curve to demonstrate a threshold value for the fragment width (FW) ratio. Among 61 patients with complete follow-up, no significant difference was found regarding length, displacement, and angulation of fragments between patients with and without union. Except for higher mean FW (P=.03) and the FW ratio (P=.01) in patients with nonunion, the logistic regression analysis demonstrated that FW ratio significantly affected union (P=.018; odds ratio, 0.21; 95% CI, 0.001-0.522). Although a fracture fragment greater than 4 cm with displacement greater than 2 cm was reported to significantly cause nonunions, our study showed that an FW ratio greater than 0.55 instead of fragment size or displacement was predictive for the occurrence of nonunion adjoining to the fracture site. Fixation of the third fracture fragment should not be ignored for preventing a nonunion. More attention should be paid to achieve a better fixation for a major fracture fragment with an FW ratio greater than 0.55 to avoid the development of non-union following the use of interlocking nail for femoral shaft fracture. [Orthopedics. 2023;46(3):169-174.].

Functional outcomes following fixation of a marginal distal radius fracture with two commonly used volar locking plates: a retrospective cohort study.

INTRODUCTION: The volar locking plate has been widely used for unstable distal radius fractures to provide early recovery of wrist function. Volar plate prominence to the watershed line has been reported to be related to flexor tendon irritation, and avoid implant prominence in this area was suggested. On the other hand, marginal distal radius fracture patterns required the plate to cross the watershed line, making conflict over plate positioning on marginal distal radius fractures. This study compared functional outcomes in patients with marginal distal radius fractures treated with two different implants. MATERIALS AND METHODS: A retrospective study was conducted, all patients who received a Synthes 2.4 mm LCP or an Acumed Acu-Loc VLP between January 2015 and December 2018 were reviewed. The marginal distal radius fracture pattern was the most distal horizontal fracture line within 10 mm of the lunate fossa's joint line. The primary outcomes including patient-reported pain scores, range of motion, and grip strength were assessed. Secondary outcomes included patient-based subjective satisfaction scores of the injured wrist and hand function. The Mayo Wrist Score and the requirement for a secondary procedure related to hardware complications were also recorded. RESULTS: Forty-two patients met our inclusion criteria. Twenty-one patients were treated with the Synthes 2.4 mm LCP, and 21 patients with the Acumed Acu-Loc VLP. The primary outcome revealed that post-operative range of motion (P = 0.016) and grip strengths (P = 0.014) were significantly improved in the Acu-Loc VLP group. The MAYO wrist score in the Acu-Loc VLP group was also significantly better (P = 0.006). CONCLUSIONS: Despite advances in implant designs, flexor tendon irritation or rupture is still a complication following distal radius's volar plating. We believe the Acumed Acu-Loc VLP design provided better functional outcomes than the Synthes 2.4 mm LCP if appropriately and carefully placed into its designed-for position. This positioning results in promising patient satisfaction when treating marginal distal radius fractures.

Concomitant Acromioclavicular and Coracoclavicular Ligament Reconstruction with a Duo-Figure-8 Autogenic Graft Wrapping Technique for Treating Chronic Acromioclavicular Separation.

BACKGROUD: Coracoacromial ligament transfer is the traditional procedure for treating chronic acromioclavicular separation, but it is significantly inferior to ligament reconstruction according to biomechanical and clinical studies. However, ligament reconstruction carries the risk of complications of graft loosening and peri-tunnel fractures. Currently, there is no ligament reconstruction procedure optimal for preventing such complications. The purpose of this study was to describe and retrospectively analyze the clinical and radiological outcomes of a "duo-figure-8" autogenic graft wrapping technique, which was used to concomitantly reconstruct the acromioclavicular and coracoclavicular ligaments. METHODS: Preoperative, immediate postoperative, and final follow-up oputcomes were evaluated in 10 enrolled patients. Radiographic outcomes were indicated by the bilateral difference of the coracoclavicular distance (CCD) and overlapping length of the acromioclavicular joint (OLac). Quality of reduction was classified into 4 grades according to bilateral CCD difference into overreduction (< 0 mm), anatomic reduction (0-4 mm), partial loss of reduction (4-8 mm), and recurrent dislocation (> 8 mm). Clinical outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) and Constant scores. RESULTS: The mean side-to-side differences for CCD were 11.9 mm (preoperative), -0.1 mm (immediate postoperative), and 3.4 mm (final follow-up); those for OLac were 9.4 mm (preoperative) and 2.7 mm (final follow-up). CCD and OLac outcomes significantly improved at final follow-up (p < 0.05). At the immediate postoperative stage, 6 and 4 patients had overreduction and anatomic reduction, respectively. At final follow-up, 7 and 3 patients had anatomic reduction and partial loss of reduction, respectively. The magnitude of improvement of ASES scores for patients with anatomic reduction and partial loss of reduction (p = 0.20) was 18.1 and 20.0, respectively. The magnitude of improvement of Constant scores in patients with anatomic reduction and partial loss of reduction (p = 0.25) was 19.9 and 22.3, respectively. CONCLUSIONS: The technique yielded acceptable functional outcomes in patients with anatomic reduction or partial loss of reduction. The "duo-figure-8" wrapping method-a single autogenic tendon graft passing beneath the coracoid process with a tendon-knot fixation over the distal clavicle and looping around the acromion intramedullary-did not increase the risk of peri-tunnel fractures over the clavicle, coracoid process, or acromion.

Peri-implant Fractures Following Hook Plate Fixation for Unstable Distal Clavicle Fractures.

Clavicle hook plate is a common implant for treating distal clavicle fracture. Although high bone union rate and good functional outcome have been reported, so have several complications, such as osteolysis and fracture of the acromion, loss reduction, hook impingement, and rotator cuff tear. Peri-implant fracture over the medial side of the hook plate is a rare complication. Sporadic cases have been reported, and most of them have had no history of trauma. Between June 2015 and August 2018, 7 patients treated for distal clavicle fracture with a 3.5-mm locking compression hook plate with no history of trauma experienced peri-implant fracture of the medial clavicle. This complication occurred at a mean of 29 days. The incidence rate was 9.8%. Peri-implant fracture following hook plate fixation for distal clavicle fracture was not rare. Small hook angle, prolonged retention of the implant, an eccentric medial screw, high plate screw density, and small clavicle diameter may be risk factors for peri-implant fracture. Regarding treatment, 2 patients chose fracture revision with a distal clavicle locking plate and 5 patients chose conservative treatment. All patients achieved bone union at fracture sites. Surgical and conservative management of peri-implant fracture can achieve good functional outcome. [Orthopedics. 2020;43(5);e359-e363.].

Residual foreign body in the foot causing chronic osteomyelitis mimicking a pseudotumor: A case report.

Osteomyelitis from a retained foreign body should be included in the differential diagnosis of any osteolytic lesion of the foot. We report here a case of a 59-year-old man who presented with swelling over the dorsolateral aspect of the right foot. Plain x-ray showed an osteolytic lesion that mimicked a pseudotumor. Magnetic resonance imaging (MRI) showed multilocular fluid collection over the right cuboid with a hypointense lesion over the plantar fascia. The patient underwent surgery and a rubber fragment (1 cm × 0.8 cm) was removed from his foot that had been present for two years following a stabbing injury. The patient fully recovered without complication or disability.

Popliteal artery occlusion concomitant with a tibial plateau fracture and posterior cruciate ligament avulsion fracture.

In acute trauma, posterior cruciate ligament (PCL) injury may occur concomitantly with a bony fracture and be easily overlooked. A popliteal artery injury associated with a tibial plateau fracture and PCL avulsion fracture is rare. Missed or delayed diagnosis of this condition leads to a high amputation rate. Therefore, close attention is required with this type of injury. The limb can be saved though early detection and immediate reconstruction of the injured artery, followed by fasciotomy. We report here a rare case of popliteal artery occlusion proximal to the surgical zone, which was diagnosed after fixation of a medial tibial plateau fracture and posterior cruciate avulsion injury. In dashboard injuries without knee dislocation, the arterial intima may be injured and become vulnerable, even with an initial ankle brachial index greater than 0.9. This can cause concomitant occlusion of the popliteal artery due to iatrogenic retraction during surgery. Therefore, a neurovascular examination should be repeated to prevent delayed-onset thrombosis. To the best of our knowledge, this is the first case of popliteal artery injury concomitant with a tibial plateau fracture and PCL avulsion owing to initial dashboard injury-related arterial intima injury, which can present with a normal ankle brachial index.

Anatomic three-dimensional model-assisted surgical planning for treatment of pediatric hip dislocation due to osteomyelitis.

Management of pediatric septic coxarthritis and osteomyelitis of the femur is challenging, and the sequelae of multiplanar hip joint deformity with instability are difficult to reconstruct. The inadequacy of a suitable device for fixing small bones during pediatric osteotomy is a hindrance to the correction of subluxated hip joints and deformed femurs in children. Two-dimensional axial images and three-dimensional (3D) virtual models representing the patient's individual anatomy are usually reserved for more complex cases of limb deformity. 3D printing technology can be used for preoperative planning of complex pediatric orthopedic surgery. However, there is a paucity of literature reports regarding the application of 3D-printed bone models for pediatric post-osteomyelitis deformity. We herein present a case of a 4-year-old boy who underwent treatment for post-osteomyelitis deformity. We performed corrective surgery with Pemberton osteotomy of the right hip, multilevel varus derotation osteotomy of the right femur, and immobilization with a hip spica cast. A 3D-printed bone model of this patient was used to simulate the surgery, determine the proper osteotomy sites, and choose the appropriate implant for the osteotomized bone. A satisfactory clinical outcome was achieved.

Postanesthesia alternation of lower limb contractures in children with spastic cerebral palsy.

The aim of this study was to clarify the effects of general anesthesia (GA) on joint range of motion (ROM) in children with spastic cerebral palsy (SCP). Eighty-four SCP cases (mean age 8.4 years) admitted for first corrective surgery were retrospectively reviewed. Lower limb ROM were measured 1 day before operation and immediately after GA. Contracture of hip, knee, and ankle joints decreased significantly after GA, with + 11.1° (39.5%) for the hip abduction angle, -3.7° (18.0%) for the Thomas test, -15.0° (19.1%) for the popliteal angle, + 6.6° (39.8%) and 7.0° (109%) for ankle dorsiflexion with knee flexion and extension, respectively (all P < 0.001). These changes were correlated positively to pre-GA contracture and body weight, negatively to age, but independent of preoperative functional level, geographic classification of SCP, or modified Ashworth scale. On the basis of these findings, routine post-GA reassessments of joint ROM before corrective surgeries were recommended for pediatric SCP cases.

Open reduction and internal fixation of ankle fracture using wide-awake local anaesthesia no tourniquet technique.

INTRODUCTION: Ankle fractures frequently occur and must be treated with open reduction for long-term stability. The existing anaesthesia methods include general anaesthesia, spinal and epidural anaesthesia, peripheral nerve block and local anaesthesia with IV sedation. However, each method has its inherent risks and potential costs, and the use of a tourniquet is inevitable. Therefore, the wide-awake local anaesthesia no tourniquet (WALANT) technique provides an alternative method for equivalent haemostasis and pain control without the use of a tourniquet. PATIENTS AND METHODS: We prospectively enrolled 13 consecutive patients (9 males and 4 females) who presented ankle fractures and required ORIF from January 2017 to December 2017. The fracture types of the 13 patients included lateral malleolar fracture (three patients), bimalleolar fracture (two patients), bimalleolar equivalent fracture (three patients), medial malleolar fracture (two patients) and trimalleolar fracture (three patients; articular surface involvement <25%). We used a solution of 1% lidocaine mixed with 1:40,000 epinephrine for WALANT. RESULTS: All patients underwent surgery if they exhibited an initial numerical pain rating scale (NPRS) score of 0 without using a tourniquet. Only two patients required an additional 5 ml of local anaesthesia due to NPRS score elevation during the surgery; no dose exceeded the safe limit of 7 mg/kg. No local complications occurred, and no shifts to other anaesthesia methods were required due to the failure of WALANT. CONCLUSIONS: WALANT simplified surgical preparations and provided a safe and reliable method for ankle fracture management. Because the use of a tourniquet was not required, reduced postsurgical pain was observed. Moreover, the use of local anaesthesia resulted in more satisfied patients and facilitated easier recovery.

Comparison of Wide-Awake Local Anesthesia No Tourniquet With General Anesthesia With Tourniquet for Volar Plating of Distal Radius Fracture.

Wide-awake local anesthesia no tourniquet (WALANT) is used for various hand surgeries, but there are no reports of its use for distal radius fractures. The authors compared perioperative variables and clinical outcomes for volar plating for distal radius fractures with WALANT vs general anesthesia with tourniquet. This retrospective study included 47 patients who presented with distal radius fractures between January 2015 and February 2017. Twenty-one underwent surgical volar plating with WALANT, and 26 underwent surgical volar plating with general anesthesia with tourniquet. Patients were followed for 12 months. The 2 groups were compared regarding perioperative parameters and clinical outcomes, including perioperative field pain evaluated by visual analog scale score on postoperative day 1, range of motion 12 months postoperatively, and Mayo wrist score. The WALANT group had a lower mean visual analog scale score and a shorter mean hospitalization (both P<.001), but greater mean blood loss (P<.001). No significant differences were found regarding operative time (P=.214) or time to union (P=.180). At 12-month follow-up, no significant differences were found regarding wrist extension (P=.721), wrist flexion (P=.119), or Mayo wrist score (P=.223). Although both techniques permitted volar plating for distal radius fractures, WALANT allowed immediate intervention and led to less postoperative pain and shorter hospitalization. Although control of blood loss was worse with WALANT, blood loss was limited to a mean of 22.62 mL and did not interfere with the surgical field. [Orthopedics. 2019; 42(1):e93-e98.].

WALANT for distal radius fracture: open reduction with plating fixation via wide-awake local anesthesia with no tourniquet.

BACKGROUND: The wide-awake local anesthesia no tourniquet (WALANT) technique is applied during various hand surgeries. We investigated the perioperative variables and clinical outcomes of open reduction and internal fixation (ORIF) for distal radius fractures under WALANT. METHODS: From January 2015 to January 2017, 60 patients with distal radius fractures were treated, and 24 patients (40% of all) were treated with either a volar or a dorsal plate via WALANT procedure. Of these 24 patients, 21 radius fractures were fixed with a volar plate, and the other 3 were fixed with a dorsal plate. Radiographs; range of motions; visual analog scale (VAS); quick disabilities of the arm, shoulder, and hand (Quick DASH) questionnaire; and time to union were evaluated. RESULTS: One of the 24 patients could not tolerate the WALANT procedure and was reported as a failed attempt at WALANT. In the cohort, 23 patients successfully received distal radius ORIF under WALANT procedure. The average age is 60.9 (range, 20-88) years. The average operation time was 64.3 (range, 45-85) minutes, the average blood loss was 18.9 (range, 5-30) ml, and the average of duration of hospitalization is 1.8 (range, 1-6) days. The average postoperative day one VAS was 1.6 (range, 1-3). The average time of union was 20.7 (range, 15-32) weeks. The mean follow-up period was 15.1 (range, 12-24) months. Functional 1-year postoperative outcomes revealed an average Quick DASH score of 7.60 (range, 4.5-13.6) and an average wrist flexion and extension of 69.6° (range, 55-80°) and 57.4° (range, 45-70°). There was no wound infection, neurovascular injury, or other major complication noted. CONCLUSIONS: WALANT for distal radius fracture ORIF is a method to control blood loss by the effects of local anesthesia mixed with hemostatic agents. Without a tourniquet, the procedure prevents discomfort caused by tourniquet pain. Without sedation, patients could perform the active range of motion of the injured wrist to check if there is impingement of implants. It eliminates the need of numerous preoperative examinations, postoperative anesthesia recovery room care, and side effects of the sedation. However, patients who are not amenable to the awake procedure are contraindications.

Comparing morbidities of bone graft harvesting from the anterior iliac crest and proximal tibia: a retrospective study.

BACKGROUND: The anterior iliac crest (AIC) and proximal tibia (PT) are common donor sites for autologous bone graft harvesting. We compared pain levels at these harvest sites on 1 day, 5 days, 2 weeks, 4 weeks, and 8 weeks post-harvest. METHODS: We retrospectively reviewed 18 patients undergoing autologous bone grafting surgery at a level I trauma center between June 2013 and October 2014. Ten grafts were harvested from the AIC group and eight from the PT group. A standard visual analog scale (VAS) was used to rate pain at the harvest sites on postoperative day (POD) 1, 5, 14, 28, and 56 and at the recipient site on POD 1. RESULTS: There were no statistically significant differences between both groups in age (p = 0.474), gender (p = 1.00), incidence of harvest site morbidity (p = 1.00), and average VAS at the recipient site on POD 1 (p = 0.471). VAS at the harvest site on POD 1, 5, and 14 confirmed statistically that pain was more severe in the AIC group than in the PT group (p < 0.001). However, no significant difference was observed on POD 28 and 56 between both groups. Pain was significantly less on POD 1 in the PT group at the harvest site than at the recipient site (p < 0.001). CONCLUSIONS: The PT is a suitable harvest site, producing statistically less pain for at least two postoperative weeks than the AIC. Besides, patients report less postoperative pain at the PT harvest site than at the recipient site.

Strategies for obstacle crossing in older adults with high and low risk of falling.

[Purpose] Tripping is a frequent cause of falls among aging adults. Appropriate limb movements while negotiating obstacles are critical to trip avoidance. The aim of our study was to investigate the mechanics of obstacle crossing in older adults at low or high risk of falling. [Subjects and Methods] Twenty community-dwelling adults aged ≥55 years, were evaluated with the Tinetti Balance and Gait scale and classified as being at high or low risk of falling. Between-group comparisons of kinematics were evaluated for obstacle heights of 10%, 20%, and 30% of leg length. [Results] The high-risk group demonstrated greater toe-obstacle clearance of the leading leg. Increasing obstacle height led to increased maximal toe-obstacle clearance, toe-obstacle distance, and shortened swing phase of the leading limb. Adaptation of clearance height was greater for the trailing leg. Individuals at high risk of falling demonstrated less symmetry between the leading and trailing legs and a narrower step width, features that increase the likelihood of tripping. [Conclusion] Kinematic parameters of obstacle clearance, including the symmetry index described in our study, could provide clinicians with a quick screening tool to identify patients at risk of falling and to evaluate outcomes of training programs.

Removal of forearm plate leads to a high risk of refracture: decision regarding implant removal after fixation of the forearm and analysis of risk factors of refracture.

INTRODUCTION: Plate fixation is the gold standard for the treatment of forearm fractures at present, and whether or not to remove the implant after bone union remains controversial. This study demonstrated some cases of refracture in adult forearm fractures after bone union and discussed the risk factors for decision-making regarding implant removal. METHODS: We reviewed patients with forearm diaphyseal fractures (including the radius, ulna, or both bones) who received open reduction and internal fixation (ORIF) from January 2008 to May 2011 in our institute. Fracture type was classified according to the AO/OTA system. All patients were fixed with a 3.5-mm dynamic compression plate. The patients were divided into two main groups: group A received implant removal after bone union, and group B retained the implant. RESULTS: There were 122 patients (170 bones) included in this study (40 females and 82 males). In group A, 7/51 patients (8/62 bones; 12.9 %) had refracture. As classified by the AO/OTA classification, one patient was classified as type A1, one patient as type A2, two patients as type A3, and three patients as type B3. All patients suffered refracture without high-energy trauma. In group B, the refracture rate was 2.77 %, and all were caused by high-energy trauma. Patients with refracture had a shorter time interval between ORIF and implant removal. The possible risk factors of refracture in this study included a wedge bone defect on plain film, implant removal performed after less than 18 months, and AO/OTA type B fracture. CONCLUSION: The incidence of refracture was significantly lower in the group that retained the implant. Routine implant removal after bone union in adult forearm fractures is not recommended due to the higher refracture rate.

Impact of foot progression angle on the distribution of plantar pressure in normal children.

BACKGROUND: Plantar pressure distribution during walking is affected by several gait factors, most especially the foot progression angle which has been studied in children with neuromuscular diseases. However, this relationship in normal children has only been reported in limited studies. The purpose of this study is to clarify the correlation between foot progression angle and plantar pressure distribution in normal children, as well as the impacts of age and sex on this correlation. METHODS: This study retrospectively reviewed dynamic pedobarographic data that were included in the gait laboratory database of our institution. In total, 77 normally developed children aged 5-16 years who were treated between 2004 and 2009 were included. Each child's footprint was divided into 5 segments: lateral forefoot, medial forefoot, lateral midfoot, medial midfoot, and heel. The percentages of impulse exerted at the medial foot, forefoot, midfoot, and heel were calculated. FINDINGS: The average foot progression angle was 5.03° toe-out. Most of the total impulse was exerted on the forefoot (52.0%). Toe-out gait was positively correlated with high medial (r = 0.274; P < 0.001) and forefoot impulses (r = 0.158; P = 0.012) but negatively correlated with midfoot impulse (r = -0.273; P<0.001). The moderating effects of age and sex on these correlations were insignificant. INTERPRETATION: Foot progression angle demonstrates significant impact on the distribution of foot pressure, regardless of age or sex. Foot progression angle should be taken into consideration when conducting pedobarographic examinations and balancing plantar pressure as part of the treatment of various foot pathologies.

Traumatic Separation of the Distal Ulnar Physis in Children: A New Classification for Displaced Volar-Flexion Injuries.

OBJECTIVES: To propose a new fracture classification according to the direction of epiphysis displacement and to compare clinical findings and surgical outcomes between these subtypes. DESIGN: Retrospective study. SETTING: A tertiary referral hospital. PATIENTS: Twelve adolescents (mean age, 13.4 ± 1.3 years) who experienced separation of the distal ulnar physis were identified from the pediatric trauma database. INTERVENTION: Closed reduction was attempted for all injuries. If a satisfactory alignment could not be achieved, an open reduction was performed. MAIN OUTCOME MEASUREMENTS: The clinical outcome was evaluated with Mikic's criteria (union, alignment, length, distal radioulnar joint subluxation, limitations of elbow/wrist function, and degree of supination/pronation). The impacts of fracture patterns and locations of wrist abrasions on treatment decisions and clinical outcomes were tested with Fisher exact tests (unadjusted) and logistic regression analyses (adjusted for age and gender) with the bootstrap method. Five orthopedic surgeons used the new classification, and the reproducibility was tested with multirater kappa. RESULTS: The injury patterns included 6 dorsally-tilted distal ulnas (type 1) and 6 volarly-tilted distal ulnas [type 2-A (n = 1), type 2-B (n = 3), and type 2-C (n = 2)]. All type 1 fractures were successfully treated with closed reduction. Five of 6 cases with type 2 injuries failed closed reduction because of entrapment of the extensor carpi ulnaris tendon in the fracture site. Eleven of the patients' outcomes were excellent. One patient with a type 2-C injury experienced ulnar growth arrest. The multirater kappa for the new classification equals to 0.94, and P < 0.001. CONCLUSIONS: A majority of volar-flexion injuries require surgery to reduce the entrapped soft tissue. This new classification is easy to understand with a good interrater reproducibility. It is useful in identifying the injury mechanism and correlated with the likelihood of open reduction. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison of dynamic and locked compression plates for treating midshaft clavicle fractures.

The purpose of this study was to compare the parameters of perioperative course and cost-effectiveness for patients with midshaft clavicle fractures treated by dynamic compression plates or locked compression plates.This retrospective, case-controlled study involved 54 patients with midshaft clavicle fractures who received dynamic compression plates (n=21) or locked compression plates (n=33) between January 2002 and December 2008. Indications for surgery included displacement or shortening >2 cm, comminuted fractures, and skin tenting. Patients with previous malunion, nonunion, multiple injuries of the shoulder girdle, or open fractures were excluded. Preoperative demographics showed no statistically significant differences between the 2 groups. Eighteen patients with dynamic compression plates and 28 patients with locked compression plates with postoperative follow-up >1 year were included for comparison. Statistical analyses for operative time, blood loss, complication rate, hospital stay, and union rate demonstrated no statistically significant difference between the 2 groups. The only statistically significant difference was a higher rate of plate removal requests in the dynamic compression plate group. Considering medical expenditure, locked compression plates cost 6 times more than dynamic compression plates in the authors' institution (US $600 vs $100, respectively).Other than more plate removal requests in the dynamic compression plate group and greater expense in the locked compression plate group, dynamic compression plates and locked compression plates achieved satisfactory operative outcomes in treating midshaft clavicle fractures, with no statistically significant difference between perioperative course and eventual fracture union observed between the 2 groups.

Aberrant femoral torsion presenting with frog-leg squatting mimicking gluteal muscle contracture.

BACKGROUND: Patients with frog-leg squatting have restricted internal rotation and adduction of the affected hips during sitting or squatting. In the surgical literature, the cause generally has been presumed to arise from and be pathognomonic for gluteal muscle contracture. However, we have encountered patients with frog-leg squatting but without gluteal muscle contracture. QUESTIONS/PURPOSES: We therefore raised the following questions: What are the imaging features of patients with frog-leg squatting? Do conditions other than gluteal muscle contracture manifest frog-leg squatting? PATIENTS AND METHODS: We retrospectively reviewed the MR images of 67 patients presenting with frog-leg squatting from April 1998 to July 2010. There were four females and 63 males; their mean age was 22.2 years (range, 4-50 years). During MRI readout, we observed aberrant axes of some femoral necks and obtained additional CT to measure femoral torsion angles in 59 of the 67 patients. RESULTS: MR images of 27 (40%) patients had signs of gluteal muscle contracture. Twenty-two (33%) patients (40 femora) had aberrant femoral torsion, including diminished anteversion (range, 6°-0°; average, 3.9°) in 11 femora of eight patients and femoral retroversion (range, < 0° to -31°, average, -7.5°) in 29 femora of 17 patients. The remaining 18 (27%) patients did not have gluteal muscle contracture or aberrant femoral torsion. The observation of aberrant femoral torsion was not anticipated before imaging studies. CONCLUSIONS: In addition to gluteal muscle contracture, aberrant femoral torsion can be a cause of frog-leg squatting. LEVEL OF EVIDENCE: Level II, diagnostic study. See the guidelines for Authors for a complete description of levels of evidence.

Rhabdomyolysis as a postoperative complication of multilevel soft-tissue surgery in a child with cerebral palsy.

Rhabdomyolysis is a potentially life-threatening syndrome if unrecognized. The most common causes are trauma, excessive muscle activity, alcohol abuse, and toxic substances. Rhabdomyolysis as a postoperative complication in children with cerebral palsy who have received multilevel soft-tissue surgery has not been reported in the literature. The purposes of this study are to present the case of a 12-year-old boy with spastic quadriplegic cerebral palsy who developed rhabdomyolysis after soft-tissue release and to review the literature. The patient was treated with adequate sedation and hydration, and discharged in a stable condition 11 days after surgery. His serum creatine kinase level had returned to within the normal range by the 17th postoperative day. At the 6-month follow-up, there were no systemic sequelae. The prompt recognition of rhabdomyolysis depends on a high level of suspicion. Routine checks of urine color after surgery is mandatory. For patients with high muscle tone, monitoring of muscle enzymes is recommended. Adequate sedation, pain control and hydration may prevent the progression of this life-threatening condition.