Case report of a delayed iatrogenic Pipkin type III femoral head fracture-dislocation.

RATIONALE: Pipkin III femoral head fracture dislocation (FHFD) is rarely observed in clinical practice, and its outcome is alarming. A considerable proportion of Pipkin III fractures result from repeated or forceful closed reduction of an irreducible FHFD. Pipkin type III fractures pose a therapeutic challenge. Most patients underwent total hip arthroplasty. PATIENT CONCERNS: A 34-year-old man experienced high-energy trauma to the left hip from a terrible traffic accident. Radiography and computed tomography (CT) at the local hospital revealed a left posterior FHFD. Emergency close reduction of the hip was performed.48 hours later, the patient was transferred to our institution. New radiography and CT examinations demonstrated an iatrogenic femoral neck fracture (FNF) associated with FHFD. In addition, a right talar fracture was observed. DIAGNOSIS: Pipkin III fracture combined with contralateral talar fracture. INTERVENTIONS: Considering his Pipkin fracture classification (Pipkin Type-III) and the time to surgery after his injury (>48 hours), the patient underwent left total hip arthroplasty uneventfully, followed by below-ankle plaster cast immobilization for his right ankle. OUTCOMES: At the 6-month follow-up, the patient was able to walk pain-free, and plain radiographs were satisfactory, with no evidence of heterotopic ossification or osteonecrosis of the talus. LESSONS: Before emergency closed reduction, early recognition of the unique characteristics of an irreducible FHFD is essential to avoid iatrogenic femoral neck fracture.

The effect of the angle between fracture line and Kirschner wires on stability in supracondylar humerus fractures treated with Kirschner wire fixation: A finite element analysis.

OBJECTIVES: This study aims to investigate the effects of the angles created by the Kirschner wires (K-wires), which are applied in the percutaneous fixation of supracondylar humerus fractures with cross K-wire, with the fracture line on fracture stabilization. PATIENTS AND METHODS: The study was conducted on distal humerus fracture models. Medial and lateral K-wires were placed in the fracture models. The angle between the fracture line and the K-wire inserted from medial was represented by alpha (α), while the angle between the fracture line and the K-wires inserted from lateral was represented by beta (ß). A combination of various angles (30°, 45°, and 60°) was used in each model, where no two models had the same combination of α and ß, resulting in nine different wire configurations. The simulation program was used to simulate the effects of forces, which were applied on rotation, flexion and extension directions, on these models. We measured and compared the stress on the wires and the displacement of fractures under different force configurations. RESULTS: When the force was applied in the counterclockwise direction, the stresses were 58 megapascal (MPa) on medial K-wire, 24 MPa on lower lateral K-wire, and 45 MPa on upper lateral K-wire in (45°, 45°) wire configuration. When the force was applied in the clockwise direction, the stresses were 57 MPa on medial K-wire, 23 MPa on lower lateral K-wire, and 45 MPa on upper lateral K-wire in (45°, 45°) wire configuration. In all models, the increased α and ß angles were translated into the decreased stress on K-wires at the fracture level and decreased displacement under rotational deforming forces. Despite having generally lower fracture displacement, the increased α and ß angles led to variable changes in the stress on K-wires against flexion and extension forces. CONCLUSION: In supracondylar humerus fractures, increasing the insertion angle of both medial and lateral K-wires augments stabilization and reduces displacement, particularly against rotational deforming forces.

The addition of an anti-rotation screw to the dynamic hip screw.

The aim of this study is to assess if there is a difference in outcomes between a dynamic hip screw with or without an anti-rotation screw in the treatment of hip fractures. All patients with an intracapsular hip fracture who underwent dynamic hip screw osteosynthesis between January 2010 and December 2013 in three Dutch hospitals were reviewed. Minimal follow-up was one year. The study included a total of 364 patients. 24 patients were lost to follow-up and excluded. 297 (87.4%) were in the dynamic hip screw group and 43 (12.6%) in the dynamic hip with anti-rotation screw group. Direct comparison of patient characteristics of the two groups showed significant differences in age, sex, Garden classification and Pauwels classification. Patients operated with a dynamic hip screw and anti-rotation screw are significantly younger and their fractures are significantly more dislocated and steeper. To draw conclusions about differences in outcome, a randomised clinical trial should be performed.

A treatment strategy to avoid iatrogenic Pipkin type III femoral head fracture-dislocations.

INTRODUCTION: Reduction is urgently required in cases of traumatic hip dislocation to decrease the risk of avascular necrosis of the femoral head. However, successful reduction may not always be feasible for hip dislocations associated with femoral head fractures. This irreducibility may provoke further incidental fractures of the femoral neck with resultant Pipkin type III injuries. The purpose of this study was to describe an appropriate treatment strategy for irreducible femoral head fracture-dislocations. MATERIALS AND METHODS: We treated nine patients with irreducible hip dislocations with femoral head fractures (eight Pipkin type II and one type IV) for which reduction failed in the emergency room or operating theater. All of these cases required operative management. RESULTS: Five of the nine patients experienced femoral neck fractures after closed reduction were attempted. These five cases underwent joint replacement at the time of injury or after developing avascular necrosis of the femoral head. Analysis of radiographs and computed tomography (CT) scans revealed that the fractured femoral head was perched on the sharp angle of the posterior wall of the acetabulum in the irreducible hips. After recognizing the irreducibility, the other four cases underwent immediate open reduction without further attempts at closed reduction, which saved the natural hip joint without neck fracture or avascular necrosis. CONCLUSIONS: Repeated or forceful closed reduction of irreducible femoral head fracture-dislocation injuries may result in iatrogenic femoral neck fractures with Pipkin type III injuries. Before attempting reduction, careful examination of plain radiographs and CT images may be helpful for determining the safest treatment strategy.

Displaced humeral shaft fractures in children and adolescents: results and adverse effects in patients treated by elastic stable intramedullary nailing.

PURPOSE: The objectives of this study were to retrospectively investigate the clinical and radiological outcome of humeral shaft fractures treated by ESIN in children <16 years old and to evaluate the functional outcome of these injuries using the short version of the Disabilities of the Arm, Shoulder and Hand Outcome questionnaire (Quick DASH(®)). METHODS: We retrospectively evaluated children with fractures of the humeral shaft, surgically treated by ESIN. All the patients were regularly followed clinically and radiographically for at least 1 year after their index surgery. After hardware removal, the patients were asked to answer the short version of the Disabilities of the Arm, Shoulder and Hand Outcome questionnaire (Quick DASH). RESULTS: Thirty-eight patients met the inclusion criteria. Mean age at the time of trauma was 11.1 years. Mean follow-up was 30 months. All fractures healed, but three patients had a residual valgus of >10°, two a residual varum of >10°, four a residual recurvatum deformity of >10°, and one a residual procurvatum deformity of >10°. Four complications were observed. Functional outcome was nevertheless good in all the patients, with a mean Quick DASH(®) score of 3. CONCLUSION: The study shows good clinical and functional outcomes in children and adolescents with closed isolated fractures of the humeral shaft surgically treated by ESIN, even with ensuing mild residual frontal and sagittal plane deformity. However, conservative treatment has also been advocated in the scientific literature for this type of injuries, and surgical treatment should not be considered as the only option for the management of humeral shaft fractures in older children and adolescents.