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BACKGROUND: Weil's osteotomy (WO) and distal metatarsal metaphyseal osteotomy (DMMO) are considered to be the gold standard of managing metatarsalgia. Stiffness and floating toe are the main disadvantages of the WO, whereas delayed union or malunion and prolonged swelling are the main complications of the DMMO. The purpose of this study is to compare these two methods, in terms of outcome and complications, through a metaanalysis of the literature. MATERIALS AND METHODS: Pubmed, Google Scholar and Mendeley databases were searched for studies comparing directly the outcome of DMMO and Weil's osteotomy, with a minimum follow up of six months. The random effects model was used for the metaanalysis. The quality of studies was assessed using the MINORS criteria. RESULTS: Four studies were eligible for the analysis including 211 patients in total. The mean difference of the postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score and the visual analogue scale (VAS) among the two techniques was - 1,04 (C.I.: -3,50 - 1,43) and - 0,39 (CI: -0,83 - 0,08) respectively. The risk difference regarding postoperative stiffness, swelling and residual metatarsalgia was - 0,09 (95% C.I.: -0,23 - 0,06), - 0,17 (95% C.I.: -0,62 - 0,29) and - 0,06 (95% C.I.: -0,20 - 0,08) respectively. CONCLUSION: Based on the existing literature, Weil's osteotomy and DMMO are equally safe and effective for the treatment of metatarsalgia. More studies of better quality are required, in order to extract safer and absolute conclusions regarding this topic.
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Lipomas are the most common soft-tissue tumors in the human body, but their location in the hand is rare. Symptomatic hand lipomas, due to nerve compression, are even rarer. We present a case of median nerve neuropathy as a result of a giant palm lipoma, located on the thenar and hypothenar areas of the hand. The patient had typical symptoms of carpal tunnel syndrome, along with compromised thumb motion. Intraoperatively, the recurrent motor branch of the median nerve was sitting on the lipoma under a great tension. This particular location of the motor branch of the median nerve in relation to the lipoma makes this case unique. The tumor was excised protecting the neurovascular structures, and a few weeks later the patient regained full thumb motion, grip strength, and resolution of dysesthesia.
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Bizarre parosteal osteochondromatous proliferation (BPOP), or Nora's lesion, is an unusual, benign, bony lesion often found in the tubular small bones of the hand and foot. In general, two characteristic radiological signs are used to diagnose the lesion, namely, (1) the absence of corticomedullar continuity and (2) BPOP developed from the parosteal surface of bones with an intact underlying cortex. Here, we present an atypical case of Nora's lesion of the proximal phalanx of the index finger, in which BPOP was diagnosed only histologically, with preoperative imaging examinations (X-ray and MRI) suggesting another lesion (enchondroma). Therefore, imaging (X-ray and MRI) alone may be inadequate to achieve the correct diagnosis of the lesion because many cartilaginous neoplasms may surround a broad range of lesions that mimic BPOP. Only histopathological evidence can confirm the correct diagnosis of the lesion.
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Abstract Lipomas are the most common soft-tissue tumors in the human body, but their location in the hand is rare. Symptomatic hand lipomas, due to nerve compression, are even rarer. We present a case of median nerve neuropathy as a result of a giant palm lipoma, located on the thenar and hypothenar areas of the hand. The patient had typical symptoms of carpal tunnel syndrome, along with compromised thumb motion. Intraoperatively, the recurrent motor branch of the median nerve was sitting on the lipoma under a great tension. This particular location of the motor branch of the median nerve in relation to the lipoma makes this case unique. The tumor was excised protecting the neurovascular structures, and a few weeks later the patient regained full thumb motion, grip strength, and resolution of dysesthesia.
Resumo Os lipomas são os tumores de partes moles mais comuns no corpo humano, mas sua localização na mão é rara. Os lipomas de mão que causam sintomas por compressão do nervo são ainda mais raros. Apresentamos um caso de neuropatia do nervo mediano decorrente de um lipoma palmar gigante, localizado nas regiões tenar e hipotenar da mão. A paciente apresentava sintomas típicos de síndrome do túnel do carpo, além de comprometimento dos movimentos do polegar. Durante a cirurgia, o ramo motor recorrente do nervo mediano repousava sobre o lipoma sob grande tensão. Esta localização particular do ramo motor do nervo mediano em relação ao lipoma torna este caso único. O tumor foi extirpado, protegendo as estruturas neurovasculares e, poucas semanas depois, a paciente havia recuperado totalmente os movimentos do polegar e força de preensão, além de apresentar resolução da disestesia.
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Humanos , Femenino , Persona de Mediana Edad , Neoplasias de los Tejidos Blandos/terapia , Síndrome del Túnel Carpiano , Neuropatía Mediana , Mano/cirugía , LipomaRESUMEN
Partial quadriceps tendon ruptures are rare and they are usually managed non-operatively, provided that the extensor mechanism is intact. In case the extension mechanism is compromised, a more aggressive treatment is required, which includes surgical repair of the tendon. We present an extremely rare case of a 42-year-old male lifter who sustained a quadriceps tendon delamination tear, after lifting weights. Careful clinical examination revealed a compromised extension mechanism of the knee. Proper imaging confirmed the diagnosis of partial but significant rupture of the undersurface of the quadriceps tendon, which was treated operatively (standard tendon repair with the Krakow technique and three transosseous tunnels) with a very good outcome.
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Pure dislocation of the ankle is an extremely rare injury accounting for only 0.065% of all ankle injuries and 0.46% of all ankle dislocations. The mechanism of the injury generally consists of high-energy trauma which is associated with a combination of plantar flexion and inversion or eversion of the foot. We present a case of a 22-year-old male patient who sustained a closed pure ankle dislocation after a fall from a small height. He was treated conservatively with closed reduction and circumferential cast immobilization for six weeks, followed by a functional rehabilitation program. The patient presented to the emergency department with an acutely painful and deformed right ankle after falling from a height of 1 m (stairs). Radiographs showed a posteromedial ankle dislocation without fracture. Urgent closed reduction of the dislocation was performed and a posterior below-knee back slab was applied to immobilize the ankle. Dorsalis pedis and posterior tibial arteries were intact. Check X-rays confirmed proper reduction of the ankle joint. Post reduction computed tomography (CT) scan did not show any associated fractures. Magnetic resonance imaging (MRI) revealed a multiligamentous ankle injury and a small osteochondral lesion of the anteromedial talar dome. The back slab was changed to a below-knee circular cast two weeks later, as soon as the soft tissue swelling subsided. The cast was removed at the six-week follow-up and physiotherapy was initiated in order to gain functional rehabilitation and improve the range of motion. At the final follow-up (12 months), the ankle range of motion (ROM) was the same as the pre-injury status and the patient was able to return to his work. Pure ankle dislocation is a rare injury. A satisfactory outcome can be expected, provided that the appropriate conservative treatment followed by a strict rehabilitation protocol is applied.
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Purpose: To investigate the outcome of capitellum and trochlea fractures through a systematic review of the contemporary literature. The effect on the outcome, of the posterolateral column comminution and the surgical approach used for fixation, was also evaluated. Methods: PUBMED, SCOPUS and MENDELEY databases were searched for capitellum and trochlea fractures and a systematic review was conducted according to PRISMA guidelines. The minimum one year clinical outcome and the flexion extension arc of these fractures, as well as the risk of developing degenerative arthritis were evaluated. The studies included to the meta - analysis were assessed based on the Newcastle Ottawa score. A fixed effect model was performed to compare the outcome and range of motion among Dubberley type A and type B fractures as well as between the extended lateral approach and the posterior transolecranon approach which were performed for Dubberley type B fractures. Furthermore the relative risk of degenerative arthritis (DA) among type A and type B fractures was also estimated. Chi square test was used to test heterogenity among studies. Results: Ten nonrandomized case series were eligible to our inclusion criteria, including 76 patients in total. The fixed overall Mayo Elbow Performance Score (MEPS) and the Range of Motion (ROM) of the Dubberley type A fractures was 86 (95% C.I.: 85,1-86,9) and 124 0 (95% C.I.: 122 0-124 0) respectively. The fixed overall MEPS and ROM of the Dubberley type B fractures was 84 (95%C.I.: 79,9-88,1) and 122 0 (95% C.I.: 120 0-123 0) respectively. Significant heterogenity was found though between studies regarding MEPS of type B fractures. The fixed overall MEPS and ROM for fractures treated with an extended lateral approach was 89,4 (95% C.I.: 85,36-93,44) and 123 0 (120 0-126 0) respectively. The fixed overall MEPS and ROM for fractures treated with a posterior transolecranon approach was 68,75 (95% C.I.: 67,89-69,6) and 122 0 (114 0-130 0) respectively. The degenerative arthritis relative risk (RR) of type B compared to type A fractures was 3,91 (95% C.I.: 0,84-18,13). Conclusion: There is no statistically significant difference among type A and type B fractures, in terms of outcome and ROM. The posterior transolecranon approach leads to a lower MEPS as opposed to the extended lateral approach. High quality studies comparing directly the outcome of type A and type B fractures are required, in order for safe conclusions to be extracted.
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Introduction: Neglected distal humerus fractures are rare injuries, which the orthopaedic surgeon will not deal many times in his career. We present a case of a young patient with such an injury, who was treated with a corrective osteotomy and fixation, resulting in a very good outcome. This case report highlights the importance of surgical intervention for distal humerus fracture malunion. A narrative review of the literature regarding this topic is presented as well. Case Report. A 42-year-old female patient presented to our department nine weeks after a displaced distal humerus fracture, which was treated conservatively in another institution. Ulnar nerve neuropathy, pain, and severe stiffness of the elbow were her main symptoms. Open correction of the deformity, anatomical reduction of the articular surface, and realignment of the metaphyseal level of the fracture were performed. Six months postoperation, a painless flexion-extension arc of 110° and a normal rotation of the forearm was achieved. Conclusion: Distal humerus fracture malunion is a challenge. The operation needed for this purpose is much more demanding, and postsurgical complications are more likely to occur as opposed to the treatment of acute fractures. If a proper surgery is performed though, a good clinical outcome can be expected.
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PURPOSE: To investigate the incidence and the outcome of post-traumatic and iatrogenic sciatic nerve palsy (SNP) associated with fractures of the acetabulum. The results of sciatic nerve grafting for treatment were also investigated. METHODS: PUBMED, SCOPUS and COCHRANE databases were searched for longitudinal observational studies reporting sciatic nerve palsy related to acetabular fractures in adult patients over the last 20 years. Data regarding patients demographics, type of acetabular fracture, rate of post traumatic and iatrogenic sciatic nerve palsies as well as recovery rate are reported. Studies were assessed for their quality. Random effects meta-analyses were carried out to pool overall proportions of SNP incidence and complete recovery. Variations in SNP incidence by main study characteristics were assessed by subgroup analysis and meta-regression. A narrative review of sciatic nerve grafting was also conducted. RESULTS: Twenty studies reporting 44 post-operative and 18 iatrogenic SNPs in 651 patients were reviewed. The pooled incidence of posttraumatic SNP was 5.1% (95% CI 2.7-8.2%). The pooled incidence of iatrogenic SNP was 1.4% (95% CI 0.3-2.9%). Complete recovery of post-traumatic and iatrogenic SNP occurred in 64.7% (95% CI 41.7-85.4%) and 74.1% (95% CI 31.5-100%), respectively. CONCLUSION: A favorable outcome of both post-traumatic and iatrogenic SNP related to acetabular fractures has been found. Due to the poor results of sciatic nerve grafting, a "wait and see" approach may be the best option, in cases of a contused but anatomically intact sciatic nerve.
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Fracturas Óseas , Fracturas de Cadera , Neuropatía Ciática , Fracturas de la Columna Vertebral , Acetábulo/lesiones , Acetábulo/cirugía , Adulto , Fijación Interna de Fracturas/efectos adversos , Fijación Interna de Fracturas/métodos , Fracturas Óseas/complicaciones , Fracturas Óseas/epidemiología , Fracturas Óseas/cirugía , Fracturas de Cadera/cirugía , Humanos , Enfermedad Iatrogénica , Incidencia , Estudios Retrospectivos , Nervio Ciático/lesiones , Neuropatía Ciática/epidemiología , Neuropatía Ciática/etiología , Fracturas de la Columna Vertebral/complicaciones , Resultado del TratamientoRESUMEN
Peripheral arterial pseudoaneurysm is an uncommon complication after open reduction and internal fixation of bone fractures. Here, we describe a rare case of a 72-year-old man who developed a delayed pseudoaneurysm of the anterior interosseous artery after open reduction and internal fixation of an isolated ulnar fracture (nightstick fracture). He presented with a painful forearm mass and anterior interosseous nerve (AIN) neuropathy. Though rare, the appearance of AIN neuropathy is a potential complication of forearm fractures' fixation that should be diagnosed early and managed with a prompt and appropriate treatment.
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PURPOSE: Metatarsal fractures are relatively common injuries that they might lead to significant disability and chronic pain if suboptimally treated. Operative treatment is reserved for the displaced fractures. The primary aim of the herein study is to present the union time and rate, as well as the functional outcome of the surgically treated isolated lesser metatarsal shaft and neck fractures. The secondary aim is to present the related complications of each fixation method. METHODS: The electronic databases of Pubmed, Scopus, Embase and Cochrane libraries were searched from January 1990 to December 2020. PRISMA guidelines were used for data collection. We retrieved five articles including in total 154 patients, which were compatible to our inclusion criteria and they were used for this systematic review. RESULTS: A total of 75 patients were treated with percutaneous antegrade pinning resulting in AOFAS score: 96.4 ± 4.8 and time to heal 7.4 ± 1 weeks, 34 patients underwent ante/retrograde pinning resulting in AOFAS score: 95.2 ± 4.75 and time to heal 6.5 ± 1 weeks, and 45 patients underwent open reduction and internal fixation with plate and screws resulting in a time to union 10.9 ± 0.5 weeks. CONCLUSION: Our results demonstrate that K wire intramedullary nailing regardless of the specific technique (antegrade, retrograde, ante/retrograde) is associated with better outcomes compared to open reduction and internal fixation as it permits faster weight bearing and quicker rehabilitation. K-wire fixation is related to statistically significant shorter time for the fracture to heal, by approximately three weeks compared to open reduction and internal fixation. Future research should focus on studies directly comparing the different intramedullary K-wiring techniques and also K-wiring versus plate fixation.
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Fijación Intramedular de Fracturas , Fracturas Óseas , Huesos Metatarsianos , Hilos Ortopédicos , Fijación Intramedular de Fracturas/efectos adversos , Fracturas Óseas/cirugía , Humanos , Huesos Metatarsianos/cirugía , Resultado del TratamientoRESUMEN
OBJECTIVE: The aim of this systematic review was to present the outcome of Lisfranc joint injuries treated with closed reduction and screw percutaneous fixation. METHODS: We searched in Pubmed and Google Scholar Databases for articles regarding screw percutaneous fixation of Lisfranc injuries. Seven studies in total were found to be compatible to our search, according to PRISMA guidelines. Four of those met the criteria of the review and they were included in the meta-analysis. A total number of 106 patients were separated into five groups according to the type of injury and the mean AOFAS score of each group was calculated. Cases in which percutaneous fixation was converted to open treatment due to poor reduction were not included in the study. In addition we compared the outcome score between types of injury according to Myerson classification as well as between purely ligamentous and osseoligamentous injuries. The characteristics of all seven selected studies, such as kind of screw used for fixation, post operative protocol, complications and outcome are mentioned as well. RESULTS: Average AOFAS score was 86,2 for type A, 87,54 for type B, and 85 for type C injuries respectively. In pure dislocation group the average AOFAS score was 86,43 and in fracture dislocation group was 87,36. Good to excellent outcome can be expected in patients with different types of injury according to Myerson classification following percutaneous fixation of lisfranc joint injury. Patients with type B injury or a fracture dislocation injury might have better outcome, although this difference was not found to be statistically significant. CONCLUSION: Percutaneous fixation of tarsometatarsal joint injuries is a relatively simple and safe method of treatment, leading to a good functional outcome, especially for Myerson type B as well as for fracture dislocation type of injuries, provided that an anatomical reduction has been achieved. LEVEL OF EVIDENCE: Level III, Therapeutic Study.
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Tornillos Óseos , Fractura-Luxación/cirugía , Fijación Interna de Fracturas/métodos , Fracturas Óseas/cirugía , Huesos Metatarsianos/cirugía , Articulaciones Tarsianas/lesiones , Fractura-Luxación/diagnóstico , Fracturas Óseas/diagnóstico , Humanos , Huesos Metatarsianos/lesiones , Radiografía , Articulaciones Tarsianas/diagnóstico por imagen , Articulaciones Tarsianas/cirugíaRESUMEN
Ulnar nerve injury as a result of closed forearm fractures in children is a rare but disastrous complication, affecting significantly the function of the upper extremity. The management of these injuries is still controversial in the literature. This is a review of small case series and case reports, in which an algorithm of treatment is proposed. A brief description of a relative case, which was treated successfully in our department, is presented as well. This case motivated the authors to perform this study.
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Hand compartment syndrome is a rare condition which can result from crush injuries, fractures, burns, intravenous fluid extravasation, etc. Failing to recognize and treat it early leads to significant functional deficits of the hand. Few cases of iatrogenic hand compartment syndrome have been described in the literature so far. We present a case of a hand intravenous (IV) contrast medium extravasation injury in a 72-year-old female patient, during a CT scan. As soon as the swelling of the hand was noticed, elevation of the limb was suggested and ice was applied. Few hours later though the patient developed compartment syndrome of the hand with paresthesias and severe pain with passive movement of the fingers. Left hand emergent fasciotomies were performed leading to a good functional outcome.
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INTRODUCTION: Sciatic nerve radiculopathy can present as a result of intraspinal or extraspinal causes. Intraspinal disorders can be disk hernia, spinal trauma, tumors, or infection, whereas extraspinal cause representsa disorder outside the lumbar spine. A gluteal artery (GA)false aneurysm can potentially compress the sciatic nerve and causes radiculopathy, with subsequent motor and sensory deficits. This condition can result mainly from trauma or infection, but it can also be iatrogenic. CASE REPORT: We report a case of an 85-year-old male with a left sciatic nerve palsy as a result of a superior GA pseudoaneurysm post bone marrow biopsy (BMP). A short review of the literature regarding this topic is presented as well. Only a small number of similar cases are reported in the literature. CONCLUSION: This case report emphasizes on the high suspicion index that the clinician should have managing a patient who suffers from sciatic nerve palsy with a history of a previous procedure around the pelvis' area, such as BMP.
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Fractures of the proximal epiphysis of the tibia are rare, representing 0.5 to 3.0% of all epiphyseal injuries. These injuries can damage the popliteal vessels and their bifurcation, affecting the blood supply of the lower limb, as well as the nerves below the knee. Epiphyseal growth arrest is also a potential complication, leading to various angular deformities. We present a case of a 13-year-old male athlete with a posteriorly displaced Salter-Harris type II fracture of the proximal epiphysis of the left tibia who was treated conservatively with closed reduction and cast immobilization.