Partial articular fractures of the radial head: How to understand them using computed tomography.

BACKGROUND: The optimal treatment for different types of displaced partial articular radial head fractures is still debatable. Fractures involving the articulating portion of the radial head can be defined also as bi-articular and are often underestimated. Moreover, the complete loss of periosteal contact between fracture fragments is a marker of instability. Available classifications do not emphasize these aspects. The purpose of the present study is to describe two assessment methods to identify fractures involving the articulating portion of the radial head and complete loss of periosteal contact with the help of 2D-3D CT scan. The second purpose is to propose a classification of the displaced partial articular radial head fractures basing on these two assessment methods. HYPOTHESIS: We hypothesize that the proposed classification is reliable. PATIENTS AND METHODS: By observing the position of the bicipital tuberosity with respect to the ulna in reference to the coronal plane in the 3D-CT scan and by observing the location of the fracture fragment in the 2D axial scan, it is possible to understand if a displaced partial articular fracture involves the articulating portion of the radial head. Also, it is possible to understand the presence or absence of a complete loss of periosteal contact between the two fracture fragments by observing the coronal and sagittal 2D-CT scans. We identified 20 displaced partial articular radial head fractures on a series of 149 patients with radial head fractures. Following the above-described assessment methods, these 20 fractures were classified in three subgroups. Also, seven evaluators were asked to use these assessment methods to classify these 20 fractures in the three subgroups, in order to evaluate inter- and intra-observer agreement. RESULTS: Eight fractures involved the non-articulating portion of the radial head with complete loss of periosteal contact, eight involved the non-articulating portion of the radial head without complete loss of periosteal contact, and four involved the articulating portion of the radial head with or without complete loss of periosteal contact. The kappa for intra-observer reliability ranged from 0.46 to 0.84. The average kappa for inter-observer reliability was 0.570 (range: 0.526 to 0.676). The Kendall's coefficient for inter-observer concordance was 0.673. DISCUSSION: Prognostically, displaced partial fractures of the articulating portion of the radial head could differ from the other types, regardless of whether or not there is a complete loss of periosteal contact. Underestimating this fracture pattern can lead to poor results due to risk of forearm rotation blockage. Moreover, underestimating complete loss of periosteal contact in displaced partial fractures of the non-articulating portion of the radial head could lead to poor results. The described evaluation methods have moderate reliability, but can represent, along with other described methods, a good starting point to better understand and treat these insidious fractures. LEVEL OF EVIDENCE: III; retrospective study.

Tibial tubercle avulsion fracture during sport activities in adolescent: a case report.

BACKGROUND AND AIM OF WORK: Tibial tubercle avulsion fractures (TTAF) are uncommon condition in children and adolescents. These lesions may be misdiagnosed and consequently not properly treated. Reduction and fixation is indicated if displacement is higher than 2mm or if the extensor apparatus is damaged. Authors present a case of a TTAF associated with a complete lateral patellar retinaculum lesion in a 13-year-old male adolescent non-professional basketball player. METHODS: Surgery consisted of reduction and fixation with 2 half threaded cancellous and washers; TTA was then basted and reinforced with a non absorbable suture according to Krachow technique and finally the patellar lateral retinaculum through a direct repair with absorbable material. RESULTS: Clinical evaluation after 3 years showed bone healing, a complete resolution of pain, complete range of motion, good strength and complete functionality of the operated limb. CONCLUSIONS: Misdiagnosis or delayed treatment of TTAF can often result in nonunion, functional impairment, and persistent pain. For these reasons, authors believe that a stable and quick fixation associated to specialized rehabilitation are crucial for recovery. (www.actabiomedica.it).

Open fracture-dislocation of the knee associated with nonunion of the medial femoral condyle and chronic tendon patellar rupture.

BACKGROUND AND AIM OF WORK: The incidence of coronal fractures of the femoral condyle, Hoffa fractures, ranges from 8.7% to 13% of all fractures of the distal femur and are often observed in polytraumas. Hoffa fractures may be misdiagnosed and consequently not properly treated. Reduction and synthesis of this type of fracture should be achieved to avoid complications such as nonunion, pain, functional impairment. The authors present a case of a 5 year old nonunion of a Hoffa fracture of the medial condyle with chronic patellar tendon rupture.   Methods: Revision surgery consisted of reduction and fixation of the Hoffa fracture with screws associated with bone grafting from the iliac crest. Distalization of the patella by Z-plasty and reconstruction of the patellar tendon with Achille's allograft were also performed.   Results: Clinical evaluation after 10 months following the end of the treatment showed a complete resolution of pain, almost complete range of motion, good strength and almost complete functionality of the operated limb.   Conclusions Mistakes in the diagnosis or treatment of Hoffa fracture can often result nonunion, functional impairment, and persistent pain. To avoid these, the senior authors of this text believe that the correct treatment of acute Hoffa fracture and its potential associated injuries are crucial, according to the concept of early damage control and later synthesis with soft tissue reconstruction.

The orthopaedic and traumatology scenario during Covid-19 outbreak in Italy: chronicles of a silent war.

BACKGROUND: From February 21, the day of hospitalisation in ICU of the first diagnosed case of Covid-19, the social situation and the hospitals' organisation throughout Italy dramatically changed. METHODS: The CIO (Club Italiano dell'Osteosintesi) is an Italian society devoted to the study of traumatology that counts members spread in public and private hospitals throughout the country. Fifteen members of the CIO, Chairmen of 15 Orthopaedic and Trauma Units of level 1 or 2 trauma centres in Italy, have been involved in the study. They were asked to record data about surgical, outpatients clinics and ER activity from the 23rd of February to the 4th of April 2020. The data collected were compared with the data of the same timeframe of the previous year (2019). RESULTS: Comparing with last year, overall outpatient activity reduced up to 75%, overall Emergency Room (ER) trauma consultations up to 71%, elective surgical activity reduced up to 100% within two weeks and trauma surgery excluding femoral neck fractures up to 50%. The surgical treatment of femoral neck fractures showed a stable reduction from 15 to 20% without a significant variation during the timeframe. CONCLUSIONS: Covid-19 outbreak showed a tremendous impact on all orthopaedic trauma activities throughout the country except for the surgical treatment of femoral neck fractures, which, although reduced, did not change in percentage within the analysed timeframe.

Medial epicondyle avulsion after elbow dislocation in an adolescent non-professional soccer player treated with a cannulated screw: a case report.

BACKGROUND AND AIM OF THE WORK: Medial epicondyle fractures of the humerus account for 11-20% of all elbow injuries in children and in 30-55% of cases they are associated with an elbow dislocation. Undisplaced fractures are usually treated conservatively but literature is controversial regarding the treatment of displaced fractures (≥5mm) in paediatric fractures. In recent years, there is an emerging consensus that such patients may benefit more from open reduction and internal fixation. Authors report a case of a 15 years old nonprofessional soccer player who suffered of an elbow dislocation with an intra-articular fragment derived from avulsion of the medial epicondyle. METHODS: Clinical and instrumental evaluation confirmed elbow dislocation with an intra-articular fragment derived of the medial epicondyle. After the reduction an open reduction and internal fixation with cannulated screw was performed. RESULTS: Clinical evaluation after 90 days showed resolution of pain and almost complete ROM and complete recovery of strength and of functionality of the operated limb. Furthermore, x-rays demonstrated consolidation of the fracture. CONCLUSIONS: this case confirms that a precise evaluation of the fracture and its displacement is at the base of satisfactory outcomes. If fracture is displaced≥5mm and patient is near skeletal maturity open reduction and fixation is indicated.

Rectus femoris myotendinous lesion treated with PRP: a case report.

BACKGROUND AND AIM OF WORK: Musculoskeletal injuries are the most common cause of severe, chronic pain and physical disability for the majority of all sport-related injuries. Platelet-rich plasma is being used more frequently to promote healing of muscle injuries. We report a case of 39 years old non professional soccer player who came to our attention for a quadriceps muscle pain onset after kicking the ball during a match. METHODS: Clinical and instrumental evaluation revealed a myotendinous junction rupture of the rectus femoris with retraction of 1.5 cm from the anterior inferior iliac spine. We decided to treat the patient with PRP ultrasound guided injections and a specific rehabilitation protocol. RESULTS: Clinical evaluation 45 days following the end of the treatment showed the resolution of the pain and the full recovery of strength and range of motion. Muscle healing was documented by magnetic resonance imaging. CONCLUSIONS: Even if the role of PRP in muscle injury is not still clear, the result observed confirms that it could be used in the treatment of muscle lesions.