Radiographic Evaluation of Carpal Mechanics and the Scapholunate Angle in a Clenched Fist with Dynamic Computed Tomography Imaging.

Purpose: The long-term consequences of injuries to the scapholunate joint can severely limit hand function, and the potential for posttraumatic deformity makes early recognition of these injuries important. The purpose of this study was to evaluate the motion of the scapholunate joint in normal wrists through the radial and ulnar deviation using novel dynamic computed tomography (CT) imaging. Methods: Fifteen participants consented to have their uninjured wrists scanned. A protocol was designed to ensure adequate time, yet limited exposure, for volunteers. Participants began with the hand in a relaxed fist position and then proceeded to clench the hand in a full fist and relax. Once relaxed again, the wrist was maximally ulnarly deviated and then maximally radially deviated in a fluid motion. Dynamic CT imaging was captured throughout the range of motion. Results: The scapholunate angle was measured on dynamic wrist images. The mean range of the scapholunate angle that the wrists moved through was 37.2°-45.9°, and the mean midpoint angle was 41.2° ± 0.4°. All wrists had small, measurable differences in the scapholunate angle when moving from the maximum ulnar deviation to the maximal radial deviation. The average maximum angle change through the range is 11.7°, whereas the average minimum angle change was 0.9°. Conclusions: In this study, scapholunate angle calculations using dynamic wrist CT scans were within the range of accepted normal for the angle in uninjured wrists. With the increased focus on dynamic imaging for wrist motion, it may be possible to derive a standardized protocol for mapping the carpal motion that is clinically applicable and reproducible. Type of study/level of evidence: Diagnostic IV.

Morbidity and mortality following pelvic ramus fractures in an older Atlantic Canadian cohort

Background: Pelvic ramus fractures in older patients are associated with substantial morbidity and mortality. There is a paucity of literature on fractures of the pelvis in this age group. The purpose of this study was to report mortality rates following such injuries. In addition, we aimed to describe and quantify the important resultant morbidity in this vulnerable population. Methods: We performed a retrospective chart review of all low-energy pelvic ramus fractures in patients more than age 60 years that occurred between January 2000 and December 2005. Data on survival, hospital length of stay, ambulatory status and place of residence were recorded. For comparison, we calculated the mortality rate for a surrogate age- and sex-matched group using Statistics Canada survival data for use as an uninjured control group. Results: We identified 43 patients (32 women [74%]; mean age 79.4 yr) with isolated low-energy pelvic ramus fractures over the study period. The 1- and 5-year mortality rates were 16.3% (95% confidence interval [CI] 7.8%­30.3%) and 58.1% (95% CI 43.3%­71.6%), respectively, both significantly higher than the point estimates for the control group (6.6% and 31.3%, respectively). Following injury, 14/39 patients (36%) permanently required increased ambulatory aids, and 8 (20%) required a permanent increase in everyday level of care. Conclusion: The results suggest that there may be increased mortality and morbidity following low-energy pattern pelvic ramus fractures in an older population compared to age- and sex-matched uninjured control subjects.

Contexte: Les fractures du bassin chez les personnes âgées sont associées à une morbidité et une mortalité substantielles. La littérature sur les fractures du bassin dans ce groupe d'âge est peu abondante. Le but de cette étude était donc de faire état des taux de mortalité suite à de telles blessures. Nous avons aussi voulu décrire et quantifier l'importante morbidité qui en résulte chez cette population vulnérable. Méhodes: Nous avons effectué une revue rétrospective de tous les cas de fractures du bassin consécutives à un traumatisme de faible énergie chez des patients de plus de 60 ans survenues entre janvier 2000 et décembre 2005. Les données de survie, la durée de l'hospitalisation, le statut ambulatoire et le lieu de résidence ont été notées. À des fins de comparaison, nous avons calculé le taux de mortalité pour un groupe témoin indemme assorti selon l'âge et le sexe en nous servant des données de survie de Statistique Canada. Résultats: Nous avons recensé 43 patients (32 femmes [74 %]; âge moyen 79,4 ans) porteurs de fractures du bassin isolées consécutives à un traumatisme de faible énergie pour la période de l'étude. Les taux de mortalité à 1 an et à 5 ans ont été de 16,3 % (intervalle confiance [IC] de 95 % 7,8 %­30,3 %) et 58,1 % (IC de 95 % 43,3 %­71,6 %), respectivement, tous deux significativement plus élevés que les estimations ponctuelles pour le groupe témoin (6,6 % et 31,3 %, respectivement). Après le traumatisme, 14 patients sur 39 (36 %) ont eu besoin de façon permanente et croissante de dispositifs d'aide à la marche et 8 (20 %) ont eu besoin de façon permanente d'un niveau de soins quotidiens accru. Conclusion: Les résultats donnent à penser que la mortalité et la morbidité pourraient être plus marquées après une fracture de la hanche consécutive à un traumatisme de faible énergie chez la population âgée, comparativement à des témoins assortis selon l'âge et le sexe.

Dynamic CT Scan of the Normal Scapholunate Joint in a Clenched Fist and Radial and Ulnar Deviation.

BACKGROUND: Injuries to the scapholunate can have severe long-term effects on the wrist. Early detection of these injuries can help identify pathology. The purpose of this study was to evaluate the motions of the scapholunate joint in normal wrists in a clenched fist and through radial and ulnar deviation using novel dynamic computed tomography (CT) imaging. METHODS: Fifteen participants below 40 years of age consented to have their wrist scanned. Eight participants were randomized to have the right wrist scanned and 7 the left wrist. Volunteers were positioned at the back of the gantry with the wrist placed on the table, palmar side down. Participants began with the hand in a relaxed fist position and then proceeded through an established range of motion protocol. Dynamic CT imaging was captured throughout the range of motion. RESULTS: The movement in the healthy scapholunate joint through a clenched fist and radial and ulnar deviation is minimal. The averages were 1.19, 1.01, and 0.95 mm, representing the middle, dorsal, and volar measurements, respectively. CONCLUSIONS: This novel dynamic CT scan of the wrist is a user-friendly way of measuring of the scapholunate distance, which is minimal in the normal wrist below 40 years of age.

Use of large osteochondral allografts in reconstruction of traumatic uncontained distal femoral defects.

UNLABELLED: Large osteoarticular injuries with subchondral bone loss involving the knee in young active patients often result in significant morbidity and loss of normal joint function. A review of the current literature reveals that multiple surgical management options are currently employed, however there is no consensus on standard of care. Osteochondral allografting provides an attractive alternative treatment option for the repair of large articular defects of the knee. METHODS: In this article we present the case of a young male who suffered traumatic intraarticular bone loss secondary to a grade IIIA distal femoral fracture and subsequently underwent reconstruction of his medial femoral condyle using a fresh-frozen osteochondral allograft. RESULTS: We present the radiographic and functional outcome of this patient at two years post-operative. The range of motion of the knee was 0-130° and the patient's post-operative functional outcome was evaluated using the Knee injury and Osteoarthritis Outcome Score (KOOS), which was 76%. CONCLUSIONS: While further research is required, the results of our case study concur with the current body of literature supporting the use of fresh-frozen osteochondral allograft as a reconstructive option for treating large traumatic intraarticular lesions involving the distal femur.

Does early fixation of posterior wall acetabular fractures lead to increased blood loss?

OBJECTIVE: Controversy exists regarding the ideal timing of acetabular fracture surgery. Surgery within the first 24 hours might put patients at risk for increased blood loss; however, early treatment might facilitate fracture reduction and patient mobilization. The purpose of this study was to determine whether early surgery for posterior wall acetabular fractures results in higher intraoperative blood loss. DESIGN: Retrospective review. SETTING: Level I academic trauma center. METHODS: A 1-year retrospective review of 49 consecutive posterior wall acetabular fractures from a single Level I trauma center. Outcome variables were analyzed with t tests, Pearson correlation coefficient, and multiple linear regression analysis. INTERVENTION: Surgery for posterior wall acetabular fractures. MAIN OUTCOME MEASURES: Estimated blood loss (EBL), preoperative and postoperative hematocrit levels, and intraoperative and postoperative blood product requirements as a function of the timing of surgery. RESULTS: No difference in EBL was shown between the fractures fixed within 24 hours of injury (mean = 644 mL) and those fixed later (573 mL, P = 0.50). No difference was observed when analyzing timing of surgery as a continuous variable (P = 0.45) or other outcome variables. A post hoc power analysis demonstrated that our sample could detect a difference in EBL of 166 mL. CONCLUSIONS: Our study suggests that posterior wall fractures might be a subset of acetabular fractures that can be treated immediately without increased risk of excessive blood loss. It should be emphasized that our findings should not be applied to other more complex types of fractures of the acetabulum. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Surgeon variability in the treatment of pelvic ring injuries.

Pelvic ring injuries are associated with the potential for long-term disability and high mortality rates. No well-established, definitive treatment algorithms have been presented in the literature. We evaluated agreement among surgeons in selecting treatment of pelvic ring injuries and investigated the relationship between type of injury and treatment plan. We conducted a prospective agreement analysis of pelvic ring injury images at a level I regional trauma center. Eighty-nine isolated pelvic ring disruptions were selected; they were the only injuries present on the images and were thought to comprise a variety of pelvic fracture types from a database of 1600 pelvic fractures. Sets of injury images were randomly ordered and distributed to 5 orthopedic trauma surgeons blinded to patient name, attending surgeon, date of injury, and eventual treatment. Surgeons reviewed images, independently selected preferred treatments, and classified injuries with the Young-Burgess and Tile systems. Eight weeks later, images were again randomly ordered and distributed to the same 5 orthopedic surgeons, who again independently selected preferred treatments and classified injuries. Kappa analyses of agreement among surgeons and within each surgeon over time were conducted. Analysis among surgeons' treatment plans based on radiographic assessment alone revealed a mean kappa value of 0.47, indicating moderate level of agreement. Analysis of data collected 8 weeks later yielded a mean kappa value of 0.56, representing moderate agreement within each surgeon over time. Young-Burgess and Tile classifications yielded consistent treatment plans for certain fracture types and varied plans for other types. Our results question the usefulness of the 2 classification systems for predicting treatment decisions.

Classification of pelvic fractures: analysis of inter- and intraobserver variability using the Young-Burgess and Tile classification systems.

Classification systems for pelvic ring injuries have been developed to assist in understanding the anatomy of the injury, predicting prognosis, and helping define treatment. Despite the frequent clinical use of the Young-Burgess and Tile classification systems, to our knowledge little work has been conducted to validate either system. We assessed the degree of inter- and intraobserver variability when using both the Young-Burgess and Tile classification systems and thereby assessed their validity for clinical use. Eighty-nine isolated pelvic ring disruptions were selected. Sets of injury images were randomly ordered and distributed to 5 orthopedic trauma surgeons blinded to the patients' names, attending surgeons, dates of injury, and eventual treatments. The surgeons were asked to independently classify each pelvic ring disruption based on the Young-Burgess and Tile classifications. Eight weeks later, the same images were randomly ordered and redistributed to the same 5 surgeons, who were again asked to classify the pelvic injuries. A kappa analysis was conducted to analyze agreement among surgeons. A moderate degree of agreement was shown among orthopedic trauma surgeons when using both the Young-Burgess and Tile classification systems. Intraobserver agreement was found to be substantial for the Young-Burgess classification and moderate for the Tile classification. The degree of inter- and intraobserver variability may limit the usefulness of the 2 classification systems, both clinically and for research purposes.