Technical Trick: The Trochanteric Hook Plate in Treatment of B1 Periprosthetic Femur Fractures.

Vancouver B1 periprosthetic fractures undergoing operative fixation remain difficult to treat due to a short proximal segment that offers limited options for fixation. The trochanteric hook plate addresses this issue by maximizing proximal purchase and utilizing the entire lateral surface area of the greater trochanter. A surgical technique that prioritizes proximal fixation and adheres to basic principles resulted in all fractures healing in a small case series. (Journal of Surgical Orthopaedic Advances 29(4):199-201, 2020).

Is the Midterm Progress of Pediatric and Adolescent Talus Fractures Stratified by Age?

The outcomes of pediatric talus fractures have been minimally reported in published studies. The purpose of the present retrospective study was to determine the clinical and radiographic outcomes after talus fractures in pediatric and adolescent patients and to define the differences among the different age groups in this population. A total of 52 children and adolescents (54 fractures) with 24 type 1 (44.44%), 13 type 2 (24.07%), 8 type 3 (14.81%), and 9 type 4 (16.67%) Marti-Weber fractures were considered. Of the 52 patients, 19 (35.19%; 21 talus fractures) with follow-up data available for >12 months were included in the final study population. Of the 21 fractures, 9 (42.86 %) were type 1, 4 (19.05%) were type 2, 1 (4.76%) was type 3, and 7 (33.33%) were type 4. The mean patient age was 14.7 (range 4 to 18) years. The patients were divided into 3 age groups: group 1, age ≤11.9 years; group 2, age 12.0 to 15.8 years; and group 3, age 16.1 to 18.0 years. Of the 21 fractures, 3 (14.29%) were treated nonoperatively and 18 (85.71%) operatively. The overall mean follow-up duration was 40.3 (range 14 to 95) months. The outcomes of interest included fracture nonunion, talar avascular necrosis, ankle range of motion, pain, arthrosis, and arthrodesis. After treatment, the mean ankle range of motion was 20° (range 0° to 35°) of dorsiflexion and 40° (range 0° to 45°) of plantarflexion. Complications included persistent pain in 10 fractures (47.62%), 3 cases of nonunion (14.29%), 3 cases of avascular necrosis (14.29%; of which, 1 [4.76%] required ankle and subtalar fusion), and arthrosis developing in ≥1 surrounding joint in 12 fractures (57.14%). Of the 12 fractures in group 3, 9 (75.00%) developed arthrosis and 2 (16.67%) subsequently required arthrodesis. Our observations suggest that the incidence of displaced talus fractures, as well as complications, increases with patient age.

Calcaneus Fractures: A Possible Musculoskeletal Emergency.

BACKGROUND: Calcaneal fractures are commonly seen and treated in the emergency department. There are subsets of calcaneal fractures that pose a high risk to the adjacent soft tissue of the heel and can result in full-thickness tissue necrosis. OBJECTIVE: To identify which calcaneal fractures need to be managed within hours and triaged to the orthopedic team and which can be temporized in a neutral or plantarflexed ankle splint and seen in an outpatient setting. DISCUSSION: Tongue-type calcaneal fractures and tuberosity fractures must be triaged appropriately within the first few hours of presentation to prevent skin compromise. This requires the emergency physician to understand the radiographic morphology of the fracture as well as the clinical signs of skin compromise. Communication with the orthopedic surgery service is essential and splinting in a specific manner is important to stabilize the soft tissue envelope. CONCLUSION: Recognizing the calcaneal injury pattern and implementing the correct treatment strategy is paramount to having successful patient outcomes. A delay or error in treatment can turn a closed fracture into an open fracture.

Ball and Socket Ankle: Mechanism and Computational Evidence of Concept.

The ball and socket ankle joint is a morphologically abnormal joint characterized by rounding of the articular surface of the talus. Other than anecdotal observation, little evidence has been presented to describe the development of this deformity. The purpose of the present study was to review ankle and subtalar joint mechanics and to kinematically examine the functional combination of these joints as a mechanism of the ball and socket ankle deformity. We reviewed functional representations of the ankle joint, subtalar joint, and ball and socket ankle deformity. A computational study of joint kinematics was then performed using a 3-dimensional model derived from a computed tomography scan of a ball and socket deformity. The joint kinematics were captured by creating a "virtual map" of the combined kinematics of the ankle and subtalar joints in the respective models. The ball and socket ankle deformity produces functionally similar kinematics to a combination of the ankle and subtalar joints. The findings of the present study support the notion that a possible cause of the ball and socket deformity is bony adaptation that compensates for a functional deficit of the ankle and subtalar joints.

The anterior head of deltoid in relation to anterior clavicle plating: how much are we releasing?

Middle to distal-third clavicular shaft fractures are commonly treated with precontoured anterior plating. Some surgeons use mini-fragment plate fixation and position these plates on the anterior clavicle. Recent studies demonstrated the advantages of anterior clavicle plating, including a possible biomechanical advantage with cantilever bending forces and less subsequent implant removal. The insertion and positioning of anteriorly based clavicle plates requires the release of a portion of the anterior deltoid origin from the lateral clavicle. The purpose of this study is to evaluate the anatomy of the deltoid in relation to the clavicle and to determine the percentage of the deltoid origin released to place modern anterior precontoured plates. Methods: Six right and 4 left cadaver shoulders were dissected, each from separate cadaveric specimens (6 male and 4 female). All measurements were made with digital calipers. The length of the clavicle was measured from the acromioclavicular joint to the sternoclavicular joint. The length of deltoid origin on the lateral clavicle was measured from the acromioclavicular joint to the most medial attachment of the deltoid on the clavicle. Percentage of clavicle with deltoid origin was subsequently calculated. Results: The average length of the cadaveric clavicles was 164.4 mm with a range from 134.3 to 178.1 mm. The average amount of deltoid origin on the clavicle was 58.7 mm with a range from 43.4 to 69 mm. On average 35.5% of the clavicle had deltoid origin, with a range from 30.2% to 38.8%. Conclusion: On average, 35.5% of the clavicular osseous anatomy contains deltoid origin. This should be taken into consideration when performing anterior plating for clavicle fractures. With a significant portion of deltoid origin elevated, surgeons may consider altering postoperative protocols until some interval healing has occurred to this anterior head of the deltoid.

Contributions of Pubic Rami Fracture Morphology and Fixation to Pelvic Ring Stability in Type 1 Lateral Compression Injuries: A Biomechanical Cadaveric Study.

BACKGROUND: Treatment of lateral compression type 1 (LC-1) injuries has historically been nonoperative with immediate weight-bearing. However, management of these injuries remains controversial, with reports of displacement at follow-up for nonoperatively managed LC-1 fractures. The goal of our study was to determine the effect of superior pubic ramus fracture morphology and fixation construct on pelvic stability. METHODS: Ten fresh-frozen cadaveric were transected into hemi-pelvises. Incomplete Denis type 1 sacral fractures were made. Hemi-pelvises were randomized to receive a transverse-type or oblique-type superior pubic ramus fracture with the contralateral hemi-pelvis receiving the opposing morphology. A lateral load to 135N was applied with an Instron materials testing machine and lateral displacement of the hemi-pelvis was recorded. Deflection and stiffness were calculated. Statistical analysis was conducted using a t test assuming unequal variances with an alpha = 0.05. RESULTS: Oblique-type superior pubic ramus fractures allowed more deflection compared with transverse-type fractures in the absence of fixation (P = 0.018). The posterior-only and combined anterior and posterior fixation configurations on average reduced deflection more than no fixation or anterior fixation only. In all fixation configuration cases, the average deflection for transverse-type fractures was less than that of the oblique-type fractures. CONCLUSIONS: Our findings suggest that displacement of LC-1 pelvic injuries may be related to pubic rami fracture morphology. When looking at initial injury imaging, oblique-type pubic rami fractures may suggest an increased potential for displacement over time. In such cases, we recommend an examination under anesthesia to evaluate for underlying instability and consideration for fixation. LEVEL OF EVIDENCE: Therapeutic Level V.

Setting Yourself Up for Success: Retrograde Intramedullary Nailing in Periprosthetic Fractures About Total Knee Arthroplasty.

Treatment of periprosthetic fractures above total knee arthroplasty remains challenging because of assessment of implant stability and the short segment of often osteoporotic bone available for distal fixation. Fractures with significant medial comminution should undergo retrograde intramedullary nailing or dual-implant fixation, as isolated lateral locked plating is not indicated. There are a multitude of objective and subjective factors incorporated into the decision to proceed with retrograde nailing including assessment of the patient's functional status, fracture morphology, implant stability, and compatibility of the prosthesis with retrograde nailing. Here, we review the steps to success in using retrograde intramedullary nailing in the treatment of specific periprosthetic fractures about total knee arthroplasty.

Treatment of Young Femoral Neck Fractures.

Femoral neck fractures in the physiologically young patient are challenging injuries to manage. A tenuous blood supply and the intrasynovial nature of the fracture create a challenging biological environment. To make matters worse, the biomechanics are equally problematic. Frequently, these fractures in younger populations are high Pauwel angle fractures that see considerable force, especially shear. These factors combine to make nonunion and avascular necrosis all too common. In the current study, we will highlight the challenges inherent to managing these injuries and will discuss techniques and implants that may help mitigate some of these challenges.

Open Hip Dislocation Through the Scrotum without Osseous Injury: A Case Report.

CASE: A 36-year-old bicyclist sustained an open anterior hip dislocation through the scrotum after being struck by 2 motor vehicles. There was no osseous injury present. The hip was irreducible by closed means and required open reduction via a Smith-Petersen approach. Postoperatively, the patient did not develop osteonecrosis of the femoral head but did have signs of mild osteoarthritis and heterotopic ossification. CONCLUSION: Open anterior hip dislocation into the scrotum is an exceedingly rare injury. Closed reduction can be attempted, but open intervention is often required. A Smith-Petersen approach allows visualization for reduction and does not violate the vascularity to the femoral head.

Management of a Combined Femoral Head and Neck Fracture: A Case Report.

CASE: A 19-year-old woman sustained a traumatic hip injury with dislocation and fractures of the femoral head and neck. A modified Gibson approach with trochanteric flip osteotomy was performed. We describe the management technique used to reduce and stabilize the femoral head and neck fractures during surgical hip dislocation. The stabilization of the femoral head to the femoral neck was performed primarily in a retrograde manner. CONCLUSION: Retrograde fixation of combined femoral head and neck fractures can be safely performed during surgical hip dislocation with satisfactory results.