Reporte de caso de una niña de 9 años de edad con una fractura acetabular fisaria desplazada tratada quirúrgicamente: 5 años de seguimiento / Case report of an acetabular displaced physeal fracture in a 9-year-old girl treated surgically: follow-up of 5 years / Relato de caso de uma menina de 9 anos com fractura de acetábulo desviada tratada cirurgicamente: seguimento de 5 anos

Las fracturas acetabulares con compromiso del cartílago trirradiado (CTR) en pacientes pediátricos son muy poco frecuentes, difíciles de diagnosticar y complejas de tratar; pudiendo dejar graves secuelas. Generalmente son producto de accidentes de tránsito de alta energía cinética. Debido a su baja prevalencia no hay grandes series en la bibliografía y por ende tampoco existe un consenso terapéutico. Realizamos una puesta a punto del tema a propósito de un atípico caso de una niña de 9 años con una fractura del acetábulo con compromiso del CTR, producido por un traumatismo de baja energía cinética. Registramos su diagnóstico y tratamiento quirúrgico, evaluamos su resultado clínico - radiológico y funcional mediante el Hip Harris Score (HHS) al final de su seguimiento de 5 años.

Acetabular fractures with compromise of the triradiate cartilage (TRC) in pediatric patients are very rare, difficult to diagnose and complex to treat, also can leave serious consequences. They are generally product of high energy kinematics. Due to its low prevalence, there are no large series in the literature and therefore there is no therapeutic consensus. We carried out a recapitulation of the subject regarding an atypical case of a 9-year-old girl with an acetabulum fracture with compromise of the TRC, produced by a low kinetic energy trauma. We recorded the diagnosis and surgical treatment, and also, we evaluated the clinical-radiological and functional results through the Hip Harris Score (HHS) at the end of their 5-year follow-up.

As fraturas acetabulares com compromisso da cartilagem trirradiada (TRC) em pacientes pediátricos são muito poco frecuentes, de difícil diagnóstico e complexas de tratar; e podem deixar sérias consequências. Geralmente são o produto de acidentes de trânsito de alta energia cinética. Devido à sua baixa prevalência, não há grandes séries na literatura e, portanto, não há consenso terapêutico. Realizamos uma atualização do tema referente a um caso atípico de uma menina de 9 anos com fratura de acetábulo com comprometimento do CTR, produzida por um trauma de baixa energia cinética. Registramos seu diagnóstico e tratamento cirúrgico, avaliamos seus resultados clínico-radiológicos e funcionais por meio do Hip Harris Score (HHS) ao final de seu seguimento de 5 anos.

Reparación de fractura aislada del mango del martillo con cemento ionomérico vidrioso autocurado / Repair of a malleus handle fracture using glass ionomer luting cement

Resumen La fractura aislada del mango del martillo es una entidad clínica poco habitual, pero frecuentemente subdiagnosticada. Lo fundamental es la sospecha clínica. El diagnóstico se confirma con la otoscopia neumática o la otomicroscopia con maniobra de Valsalva, en la cual se observa una movilidad anormal del mango del martillo. El rasgo de fractura se puede demostrar con tomografía computada de alta resolución o cone beam. Existen diferentes opciones de tratamiento como interposición de cartílago o uso de prótesis de reemplazo osicular así como cemento óseo. El cemento ionomérico vidrioso autocurado, muy utilizado en odontología, se ha usado en distintas cirugías otológicas con buenos resultados y biocompatibilidad. A nuestro saber no se ha usado en esta patología por lo que presentamos esta serie de tres casos en los cuales se ha usado esta novedosa técnica con buenos resultados clínicos.

Abstract Isolated fracture of the manubrium of the malleus is a rare clinical entity. Clinical suspicion is paramount. The usual clinical presentation is acute otalgia followed by tinnitus and fluctuating hearing loss after a brisk introduction and withdrawal of a finger into the external auditory canal. On physical examination, the eardrum looks normal on otoscopy. Only in pneumatic otoscopy or otomicroscopy with Valsalva an abnormal motility of the manubrium could bee seen. High-resolution computed tomography (CT) or cone beam CT is able to show the fracture line. Several treatment options have been proposed, such as interposition of bone or cartilage between the manubrium and the incus, total or partial ossicular replacement prosthesis; and the use of bone cement. Glass ionomer luting cement, with wide use in dentistry, has been used in several otological procedures with good biocompatibility and results, however, to our best knowledge, it has not been used to repair this type of fractures, so we present this novel material in three cases.

Fractura esternal: descripción de tratamiento quirúrgico / Sternal fracture: surgical management description

Resumen Objetivo: Describir características demográficas y tratamiento quirúrgico realizado a pacientes con fractura de esternón (FE) en los últimos 5 años. Materiales y Método: Estudio descriptivo retrospectivo de pacientes operados por fractura esternal entre enero de 2015 y enero de 2020. Se analizaron edad, sexo, antecedentes mórbidos, hemodinamia de ingreso, mecanismo causal, características de lesión esternal, lesiones asociadas, indicación quirúrgica y complicaciones. Resultados: Durante el período ingresaron a nuestro hospital 9 pacientes (7 hombres) de 21 a 91 años. Todos fueron operados. La mayoría ingresó con hemodinamia estable. El mecanismo fue siempre traumático. Las indicaciones quirúrgicas fueron: dolor intratable, alteración de la mecánica ventilatoria, tórax volante, deformidad y ayuda en la rehabilitación de un trauma raquimedular. Discusión: La FE es una patología infrecuente, siendo aún más escasa su resolución quirúrgica reportada a nivel mundial. Conclusiones: Presentamos el primer reporte de una serie de casos de FE operada en Chile. La osteosíntesis esternal permite el manejo de la FE con buenos resultados funcionales con baja tasa de morbilidad. Los resultados obtenidos son comparables a los observados en la literatura internacional.

Aim: To describe demographic characteristics and surgical treatment carried out on patients with a sternal fracture (SF) in the last 5 years. Materials and Method: Retrospective descriptive study of patients operated on for SF between January 2015 and January 2020. We analyzed age, sex, morbid history, hemodynamics on admission, causal mechanism and characteristics of sternal injury, associated injuries, surgical indication and complications. Results: During the period, 9 patients were admitted to our hospital (7 men) from 21 to 91 years old. All were operated. Most were admitted with stable hemodynamics. The mechanism was always traumatic. The surgical indications were: intractable pain, alteration of ventilatory mechanics, flail chest, deformity and aid in the rehabilitation of spinal cord trauma. Discussion: SF is an infrequent pathology, its surgical resolution reported worldwide being even scarce. Conclusions: We present the first report of a series of cases of SF operated in Chile. Sternal osteosynthesis allows the management of EF with good functional results with a low morbidity rate. The results obtained are comparable to those observed in the international literature.

Computed tomography with low-dose radiation versus standard-dose radiation for diagnosing fractures: systematic review and meta-analysis

BACKGROUND: Computed tomography (CT) accounts for 13% of all radiological examinations in the United States and 40-70% of the radiation that patients receive. Even with the advent of magnetic resonance imaging (MRI), CT continues to be the gold standard for diagnosing bone fractures. There is uncertainty as to whether CT with a low radiation dose has a fracture detection rate similar to that of standard-dose CT. OBJECTIVE: To determine the detection rate of low-dose radiation CT and standard-dose radiation CT for fractures, in patients with suspected fractures. DESIGN AND SETTING: Systematic review of comparative studies on diagnostic accuracy within the evidence-based health program at a federal university in São Paulo (SP), Brazil. METHODS: We searched the electronic databases Cochrane Library, MEDLINE, EMBASE and LILACS up to June 29, 2020, for studies evaluating the detection rates of low-dose CT and standard-dose CT for diagnosing bone fractures. The Research Triangle Institute (RTI) item bank tool was used for methodological quality evaluation. RESULTS: The fracture detection rate according to the number of bones evaluated, using CT with low-dose radiation was 20.3%, while with standard-dose radiation it was 19.2%, and the difference between the methods was not significant. The fracture detection rate according to the number of patients, using CT with low-dose radiation was 56.0%, while with standard-dose radiation it was 58.7%, and this difference between the methods was not significant, either. CONCLUSION: CT with low-dose radiation presented detection rates similar to those of CT with standard-dose radiation, regardless of the bones evaluated. REGISTRATION NUMBER: CRD42019148491 at the PROSPERO database.

Epifisiolisis distal del fémur en un recién nacido / Distal epiphysiolysis of the femur in a newborn

La separación por fractura de la epífisis del fémur distal es una lesión relativamente poco frecuente en los recién nacidos, pero se ha documentado como una complicación del parto distócico. La mayoría de los casos ocurren a nivel distal del húmero y, de manera excepcional, afectan al fémur. La epifisiolisis distal del fémur casi no está descrita en la literatura. Se localizan normalmente en el tercio superior del fémur por un movimiento de torsión de este en los partos en posición podálica e incluso en cesáreas distócicas. El diagnóstico diferencial al inicio de la exploración suele ser con artritis séptica del recién nacido. A partir de un paciente de 3 días de vida que se presenta a su control posterior al alta con tumefacción en una de sus rodillas, se plantea este difícil e infrecuente diagnóstic

Fracture separation of the epiphysis from the distal femur is a relatively rare lesion in newborns, but it has been documented as a difficult complication of labor. Most of the cases occur at the distal humeral level and exceptionally affect the femur. Epiphysiolysis of the distal femur is practically not described. They are normally located in the upper third of the femur due to a twisting movement of the femur in breech deliveries and even in difficult caesarean sections. The differential diagnosis at the beginning of the examination is usually with septic arthritis of the newborn. This difficult and infrequent diagnosis arises from a 3-day-old baby who presents for his post-discharge check-up with swelling in one of his knees.

Current opinions on the mechanism, classification, imaging diagnosis and treatment of post-traumatic osteomyelitis / 中华创伤杂志(英文版)

Post-traumatic osteomyelitis (PTO) is a worldwide problem in the field of orthopaedic trauma. So far, there is no ideal treatment or consensus-based gold standard for its management. This paper reviews the representative literature focusing on PTO, mainly from the following four aspects: (1) the pathophysiological mechanism of PTO and the interaction mechanism between bacteria and the body, including fracture stress, different components of internal fixation devices, immune response, occurrence and development mechanisms of inflammation in PTO, as well as the occurrence and development mechanisms of PTO in skeletal system; (2) clinical classification, mainly the etiological classification, histological classification, anatomical classification and the newly proposed new classifications (a brief analysis of their scope and limitations); (3) imaging diagnosis, including non-invasive examination and invasive examination (this paper discusses their advantages and disadvantages respectively, and briefly compares the sensitivity and effectiveness of the current examinations); and (4) strategies, including antibiotic administration, surgical choices and other treatment programs. Based on the above-mentioned four aspects, we try to put forward some noteworthy sections, in order to make the existing opinions more specific.

Tratamiento quirúrgico de las fractura de pared posterior de acetábulo: resultados a corto y mediano plazo / Surgical treatment in acetabular posterior wall fractures: short and medium-term results

OBJETIVO: Evaluar los resultados radiológicos a corto y mediano plazo de pacientes operados de fractura de pared posterior de acetábulo, describir la morfología de la fractura, presencia de lesiones asociadas y la necesidad de artroplastia total de cadera (ATC) durante la evolución. MATERIAL Y MÉTODOS: Estudio retrospectivo-descriptivo de una serie consecutiva de 40 pacientes operados entre julio de 2012 y julio de 2017 por fractura de pared posterior de acetábulo. Treinta y siete hombres y tres mujeres con una edad promedio de 41 años fueron operados (mediana de seguimiento 17,7 meses). Se registró el mecanismo del accidente y presencia de lesiones asociadas. Se registraron el número de fragmentos que presentaba la fractura, presencia de impactación marginal, compromiso de la cabeza femoral, presencia de fragmentos intra-articulares y complicaciones postoperatorias. Para el análisis estadístico se utilizó el test de Wilcoxon. RESULTADOS: Todos los casos fueron secundarios a un accidente de alta energía. Un 70% de los pacientes presentó luxación posterior. La mayoría de los pacientes presentó una fractura entre 2 y 5 fragmentos (70%), 47,5% de los pacientes presentó impactación marginal, 37,5% compromiso de la cabeza femoral en zona de carga, 30% fragmentos intra-articulares. La complicación que más frecuente se observó fue la artrosis post-traumática la cual se presentó en un 22,5%. Cinco pacientes (12,5%) requirieron ATC. CONCLUSIÓN: Aunque se categorizan dentro de los patrones simples, las fracturas de pared posterior son lesiones complejas. La tomografía axial computada preoperatoria es esencial para determinar lesiones intra-articulares dada su alta frecuencia y también permite realizar un buen plan preoperatorio.

OBJECTIVE: Evaluate radiologic results in short and medium-term in surgically treated patients with acetabular posterior wall fracture. Describe fracture morphology, the presence of associated lesions and the necessity of total hip arthroplasty (THA) during the evolution. MATERIALS AND METHODS: A retrospective-descriptive study design of 40 patients treated during July 2012 and July 2017 for acetabular posterior wall fracture. 37 men and 3 women, 41 years old mean age. The mean follow-up was 17.7 months. Accident mechanism and presence of associated lesions were registered, as well as the number of fragments of the fracture, the presence of marginal impaction, femoral head compromise, intra-articular fragments and postoperatory complications. Wilcoxon test was used for the statistical analysis. RESULTS: Every case resulted due to a high energy accident. 70% of patients had posterior luxation of the hip. 70% of patients presented 2 to 5 fragments. 47.5% of patients presented marginal impaction, 37.5% compromised femoral head and 30% intra-articular fragments. The most frequent complication was post-traumatic arthrosis, which appeared in 22.5% of patients. Five patients required THA. CONCLUSION: Though it is categorized as simple fracture pattern, posterior wall fractures are complex. Preoperatory CT scan is essential to determine intra-articular lesions due to its high frequency and permits to plan an adequate intervention.

Ex-vivo evaluation of the three-column concept in canine thoracolumbar fractures / [Avaliação em ex-vivo do conceito dos três compartimentos em fraturas toracolombares da coluna]

Traumatic events such as a motor vehicle accident or falling from heights are very common in veterinary medicine and often lead to vertebral fracture-luxation with concomitant spinal cord injuries, mostly in the thoracolumbar spine. The purpose of this cadaveric biomechanical study was to determine the feasibility of the three-column concept in canine thoracolumbar segments with induced fractures. Eighteen Functional Spinal Units (FSU) of the thoracolumbar segments (T12-L2) were collected from 18 medium-sized adult dog cadavers and were subjected to flexion-extension and lateral bending tests so that range of motion (ROM) was recorded with a goniometer. Fractures were induced by compressive loads applied by a universal testing machine (EMIC®). After this, specimens were screened using computed tomography (CT) and the fractures were graded as affecting one, two or three columns, and divided into groups A, B, and C, respectively. Post-fracture range of motion (ROM) was compared with the previous results. Groups B and C (with fractures in two or three columns) had instability in the two axes evaluated (P<0.05). The outcomes of this study support the applicability of the three-column theory to thoracolumbar spines of dogs, as the FSUs that suffered fractures in two or more columns showed axial instability.(AU)

Eventos traumáticos, como acidentes automobilísticos ou quedas, são muito comuns na medicina veterinária e, frequentemente, levam a fraturas ou luxações vertebrais, associadas a lesões medulares concomitantes, mais frequentemente na coluna toracolombar. O propósito deste estudo biomecânico em cadáveres foi determinar a viabilidade da teoria dos três compartimentos em fraturas induzidas em segmentos toracolombares de cães. Dezoito unidades espinhais funcionais (UEF) de segmentos toracolombares (T12-L2) foram coletadas de 18 cadáveres de cães adultos de médio porte e submetidas a testes de flexão-extensão e curvamento lateral, de modo que a amplitude de movimento (ADM) foi registrada com um goniômetro. Fraturas foram induzidas por meio de cargas compressivas aplicadas por uma máquina universal de ensaios (EMIC®). As amostras foram submetidas à tomografia computadorizada (TC), e as fraturas foram classificadas como afetando um, dois ou três compartimentos e divididas nos grupos A, B e C, respectivamente. A ADM pós-fratura foi comparada com os resultados prévios. Os grupos B e C (com fraturas em dois ou três compartimentos) apresentaram instabilidade nos dois eixos avaliados (P<0,05). Os resultados deste estudo corroboram a aplicabilidade da teoria dos três compartimentos para segmentos de coluna toracolombar em cães, uma vez que as UEF que sofreram as fraturas em dois ou mais compartimentos apresentaram instabilidade axial.(AU)

Intermittent vibrations accelerate fracture healing in sheep

Abstract Purpose: To investigate the effect of intermittent vibration at different intervals on bone fracture healing and optimize the vibration interval. Methods: Ninety sheep were randomized to receive no treatment (the control group), incision only (the sham control group), internal fixation with or without metatarsal fracture (the internal fixation group), and continuous vibration in addition to internal fixation of metatarsal fracture, or intermittent vibration at 1, 2, 3, 5, 7 and 17-day interval in addition to internal fixation of metatarsal fracture (the vibration group). Vibration was done at frequency F=35 Hz, acceleration a=0.25g, 15 min each time 2 weeks after bone fracture. Bone healing was evaluated by micro-CT scan, bone microstructure and mechanical compression of finite element simulation. Results: Intermittent vibration at 7-day interval significantly improved bone fracture healing grade. However, no significant changes on microstructure parameters and mechanical properties were observed among sheep receiving vibration at different intervals. Conclusions: Clinical healing effects should be the top concern. Quantitative analyses of bone microstructure and of finite element mechanics on the process of fracture healing need to be further investigated.

Fractura de miembro inferior de alta energía asociada a lesión multiligamentaria de rodilla / Multiligament knee injuries with high energy limb fractures

Introducción: La lesión multiligamentaria de la rodilla en pacientes con fracturas del miembro inferior ipsilateral es una entidad poco frecuente y que suele pasar desapercibida en la etapa aguda. El objetivo de este trabajo es analizar una serie de pacientes con fractura de miembro inferior asociado a lesión multiligamentaria de rodilla. Materiales y método: Se realizó una búsqueda retrospectiva de enero 2010 a diciembre 2016, de aquellos pacientes atendidos en nuestro centro con fractura de miembro inferior asociada a inestabilidad multidireccional de la rodilla ipsilateral. Se evaluó el patrón de fractura, la lesión ligamentaria asociada, si presentaba Resonancia Magnética (RM) inicial que pesquisara el diagnóstico de dicha lesión, y la decisión del momento del tratamiento quirúrgico. Se realizó una valoración del dolor con la Escala Visual Analógica (EVA) y funcional con escala de Lysholm y Tegner a todos aquellos pacientes con más de 12 meses de evolución postoperatoria. Resultado: Se encontraron 6 pacientes con un promedio de edad de 26 años. Cinco pacientes presentaban resonancia magnética al momento del trauma. El intervalo de tiempo promedio entre la resolución de la fractura y la reparación ligamentaria fue de 4 días. El promedio de las escalas evaluadas fue: EVA 0.2, Tegner 4 y Lysholm 87. Conclusión: En pacientes con fractura de miembro inferior de alta energía el compromiso ligamentario no debe subestimarse. Consideramos que la realización de una RM durante la atención inicial del paciente optimiza los tiempos en el diagnóstico y tratamiento de dichas lesiones y conlleva a mejores resultados funcionales al final del tratamiento. Tipo de studio: Serie de casos. Estudio retrospectivo. Nivel de evidencia: IV.

Introduction: Multiligament knee injuries in patients with ipsiletaral inferior limb fractures is a rare entity that can be easily missed. The objective of this work was to analyze a series of patients with multiligament lesion associated with inferior limb fracture. Material and method: A retrospective search was carried out from January 2010 to December 2016 of patients admitted in our hospital with diagnosis of inferior limb fracture associated to multidirectional knee instability. We evaluated the fracture pattern, ligament knee injury, if an initial Magnetic Resonance Imaging (MRI) was performed and the surgical timing. We evaluated pain with Visual Analogue Scale (VAS) and functional outcomes using Tegner and IKDC scores. We included patients with more than one-year postoperative. Results: Six patients were evaluated with an average age of 26 years-old. Five patients presented initial MRI, before the first surgery was performed. The average time between fracture osteosynthesis and ligament reconstruction was 4 days. VAS, Tegner and IKDC mean results were 0.2, 4 and 87 respectively. Conclusion: In patients with high-energy lower limb fractures, ligament compromise must be suspected. We consider that MRI should be performed during the first examination to optimize the diagnosis and treatment of possible associated ligament injuries and to obtain better functional outcomes. Type of study: Retrospective cases serie. Level of evidence: IV.

Three-dimensional architecture of intraosseous vascular anatomy of the hamate: a micro-computed tomography study / 北京大学学报(医学版)

OBJECTIVE@#To obtain three-dimensional intraosseous artery of the hamate and to provide the vascular anatomy basis of hamate fracture fixation.@*METHODS@#PbO (lead monoxide, Sinopharm Chemical Reagent Beijing Co. Ltd) was ground into particles less than 40 μm and suspended in turpentine oil (Chemical Reagent Beijing Co. Ltd) at ratios of 1 g : 1.5 mL, 1 g : 1 mL and 1 g : 0.5 mL. Three specimens were investigated. Brachial arteries were cannulated and perfused with lead-based contrast agent. Hamates were harvested and scanned using micro-computed tomography (microCT). The acquisition protocols were as follows: CT scan setup: total rotation [Degrees], 360; rotation steps, 360; X-ray detector setup: transaxial, 2048; axial, 2048; exposure time, 1 500 ms, Binning, 1; system magnification: high-med. X-ray tube setup: 80 kV, 500 mA current. The down-sampling factor used in the reconstruction was 2. The effective voxel size of the final image was 27.30 μm. The three-dimensional model of the hamate was generated and the distribution and pattern of vessels were evaluated.@*RESULTS@#There were abundant extraosseous vessels around the hamate. They were mainly running in the tendons and ligaments around the hamate. Four vascular zones were identified on the hamate surface. They were on the palmar platform of the hamate body, on the dorsal side, on the ulnar side and on the tip of hamulus, namely. There were anastomoses among 4 vascular zones. We did not observe any vessels penetrating through the articular cartilage. The extraosseous vessels of the vascular zones gave a number of intraosseous branches into the hamate. The hamate body received intraosseous blood supply from the dorsal, palmar and ulnar while the hamulus from the palmar, ulnar and hamulus tip. There were some intraosseous branches anastomosing with each other.@*CONCLUSION@#The extraosseous and intraosseous vessels of the hamate were more than what used to be considered. The hamate body and hamulus received blood supply from multiple directions and arteries anastomosed extensively both outside and inside the hamate, making it possible that the intraosseous perfusion survived after fracture. It is likely that the nonunion after the hamate fracture is not caused by the vascular damage but the malalignment of the fragments.

Fractura de clavícula distal con cortical superior indemne: cirugía mínimamente invasiva / Distal clavicle fracture with intact upper cortex: minimally invasive surgery

INTRODUCCIÓN Las fracturas de clavícula distal desplazadas son manejadas generalmente de manera quirúrgica dada la alta probabilidad de no-unión con el tratamiento ortopédico. El propósito de este trabajo es evaluar el uso del sistema de fijación con doble botón cortical para la reducción y estabilización de la fractura de clavícula distal que presenten indemnidad de la cortical superior. MÉTODOS: Estudio retrospectivo observacional clínico-imagenológico de pacientes con fractura desplazada de clavícula distal operados con técnica mínimamente invasiva mediante reducción con sistema de fijación con doble botón cortical. Se describe como criterio radiológico de "Cortical Superior Indemne (CSI)" la presencia del rasgo de fractura a 1cm o más, hacia distal desde el tubérculo conoide, identificándose ese criterio como característica necesaria para la indicación del tratamiento propuesto. Se describen las complicaciones post-operatorias, progresión radiológica y resultados funcionales. RESULTADOS: 21 pacientes fueron tratados con esa técnica con un seguimiento promedio de 23,4 meses. No hubo casos de no unión, infección o herida dehiscente y ningún paciente requirió el retiro del dispositivo. Se encontró un Simple Shoulder Test (SST) promedio de 79,4 (66 - 91,7) y QuickDASH de 11 (6,8 - 15,9). El 87,5% de las fracturas desplazadas de clavícula distal tenían indemnidad de la cortical superior. CONCLUSIÓN: La técnica mínimamente invasiva para la reducción y fijación de la fractura de clavícula distal desplazada con botones corticales es una alternativa simple, reproducible, con pocas complicaciones y excelentes resultados funcionales.

BACKGROUND: Displaced distal clavicle fractures are commonly managed through surgery due to a high probability of nonunion with conservative treatments. The purpose of this study is to evaluate the use of Flip-buttons as a minimally invasive method for fixing and stabilizing displaced distal clavicle fractures when the upper cortical it́s intact. METHODS: A retrospective observational study of radiological and clinical results of patients with displaced distal clavicle fracture that were treated with the Flip-button technique. The indication for using this surgical method was based on the radiological criteria of "Intact Upper Cortical (IUC)" described by the authors as the presence of the fracture 1cm or more, distally to de conoid tubercle. Post-operative complications, radiologic and functional progress were recorded. RESULTS: 21 patients were treated with this technique, all with complete bony union. No patients presented infection or wound dehiscence and implant removal was not necessary in any case. The mean follow-up was of 23,4 months. The mean score in Simple Shoulder Test (SST) was 79,4 (66 - 91,7) and a mean QuickDASH of 11 (6,8 - 15,9). 87,5% of all the displaced distal clavicle fractures had IUC. CONCLUSION: The minimally invasive technique for the reduction and fixation of the displaced distal clavicle fracture with cortical buttons is a simple and reproducible alternative, with few complications and excellent functional results.

Evaluación radiológica de los elementos de osteosíntesis en el miembro superior / Radiological evaluation of bone synthesis in the upper limb

El tratamiento de las fracturas óseas del miembro superior puede realizarse por métodos cerrados o abiertos. Los cerrados se basan en el principio de inmovilización y/o tracción con materiales externos, mientras que los abiertos utilizan elementos quirúrgicos de fijación interna o externa. Los rayos X(Rx) constituyen la primera y mejor metodología para la evaluación posquirúrgica de estos elementos. El conocimiento básico de los materiales utilizados es necesario para conseguir una buena evaluación e informe médico.

The treatment of bone fractures of the upper limb can be performed by closed or open methods. Closed methods are based on the principle of immobilisation and / or traction with external materials. Instead, open surgical methods use elements of internal or external fixation. The x-ray is the first method of choice in the post-operative evaluation of these elements. A basic knowledge of the materials used is necessary to make a good assessment and medical report.

Effects of local alendronate administration on bone defect healing. Histomorphometric and radiological evaluation in a rabbit model

Abstract Purpose: To performed a histomorphometric and radiological study to evaluate the effects of alendronate sodium administered locally in mandibular bone defects created in rabbits. Methods: Two circular defects 5 mm in diameter were created bilaterally in the mandibular corpus of 20 New Zealand rabbits (i.e., four defects per animal). Each defect received one of four treatments: no treatment (EC group), alendronate irrigation (AL group), autogenous bone grafting (AG group), or alendronate irrigation with autogenous bone grafting (AL+AG group). Histomorphometric and radiological assessments were conducted at 4 and 8 weeks after surgery. Results: Between-group comparisons of the new bone area, the value of the AL+AG group was significantly lower thanthe remaining three groups at 4 weeks postoperatively. In all groups, the new bone area was significantly larger at 8 weeks than at 4 weeks. The residual graft area at 4 and 8 weeks was significantly higher in the AL+AG group than in the AG group, although it was significantly smaller at 8 weeks than at 4 weeks in both these groups. Conclusion: The use of alendronate sodium in conjunction with autogenous bone grafting improves the osteoconductive properties of the graft, enhances graft retention in the defect, and improves ossification.

Are diaphyseal clavicular fractures still treated traditionally in a non-surgical way? / Fraturas da diáfise da clavícula ainda são tratadas tradicionalmente, de forma não cirúrgica?

ABSTRACT OBJECTIVE: To evaluate the decision of orthopedics surgeons regarding which cases they would indicate surgery or non-surgical treatment. METHODS: 20 images of radiographs with fracture in the middle third of the collar bone (AO/OTA 15-B) in anteroposterior view were analyzed, and divided into four groups: group 1 - fracture type AO/OTA 15-B1 without displacement; group 2 - fracture type AO/OTA 15-B1 with displacement; group 3 - fracture type AO/OTA 15-B2; group 4 - fracture type AO/OTA 15-B3. The evaluator was requested to indicate the choice of treatment, surgical or non-surgical. RESULTS: There was no strong correlation between the amount of surgical indications and the working experience or age of the medical evaluator. It was observed that the average of surgical indications in the total sample was 52%. When indications were studied in different areas of Brazil, there was no significant difference among them. No pattern for the Brazilian regions studied was observed in the case analysis. Even within a group (cases of the same complexity), no specific pattern of surgical indication was observed. CONCLUSION: No association between surgical indication and the length of professional experience was found. The Southern and Southeastern regions were those that most recommended surgeries in groups 2, 3, and 4. In no region the same level of surgical indication for cases of the same complexity rate was kept.

RESUMO OBJETIVO: Avaliar a decisão de cirurgiões ortopédicos sobre em que casos indicariam a cirurgia ou tratariam não cirurgicamente. MÉTODOS: Foram analisadas 20 imagens de radiografias com fratura do terço médio da clavícula (AO/OTA 15-B) em incidência anteroposterior, que foram divididas em quatro grupos: 1 - fratura do tipo AO/OTA 15-B1 sem desvio; 2 - fratura do tipo AO/OTA 15-B1 com desvio; 3 - fratura do tipo AO/OTA 15-B2; 4 - fratura do tipo AO/OTA 15-B3. Ao avaliador, foi solicitado que indicasse o tipo de tratamento: cirúrgico ou não cirúrgico. RESULTADOS: Não houve correlação forte entre a quantidade de indicações cirúrgicas e o tempo de atuação do médico avaliador ou sua idade. Verificou-se que a média de indicação de cirurgias no total da amostra foi de 52%. Quando estudadas as indicações por diferentes regiões do Brasil, não houve diferença significativa. Não foi verificado qualquer padrão para as regiões brasileiras na análise por caso. Mesmo dentro de um grupo (casos de mesma complexidade), não foi verificado um padrão específico de indicação cirúrgica. CONCLUSÃO: Não foi verificada associação entre a indicação cirúrgica e o tempo de atuação do profissional. As regiões Sul e Sudeste são as que mais recomendam a cirurgia dos grupos 2, 3 e 4. Verificou-se que em nenhuma região foi mantido o mesmo nível de indicação de cirurgias para casos do mesmo grau de complexidade.

Frecuencia de diagnóstico de lesiones óseas en luxación glenohumeral anterior / Frecuency of diagnosis of bone lesions in cases of anterior glenohumeral dislocation

Resumen: Antecedentes: Las luxaciones de hombro son motivo común de consulta en las salas de emergencia; presentan un alto índice de recurrencia (hasta 96%) a causa de las lesiones óseas asociadas. El objetivo de este estudio fue identificar un subregistro de lesiones identificadas en radiografía inicial comparada con radiografía postreducción. Material y métodos: Se evaluaron las radiografías de 46 pacientes con sospecha de luxación glenohumeral anterior para diagnóstico e identificación de lesiones óseas iniciales; posteriormente, se realizó reducción y se analizó la serie ósea radiográfica postreducción (AP, Stryker y West Point) para evidenciar lesiones óseas subdiagnosticadas inicialmente. Resultados: Se identificó lesión ósea en 26.1% de los individuos en la radiografía AP en un primer momento; de las personas que no mostraron fractura prerreducción, en 67.6% se encontró lesión ósea en las series radiográficas postreducción. Conclusiones: Se encontró un subdiagnóstico de 67.6% de las lesiones evidentes en la serie ósea postreducción en comparación con la radiografía AP inicial.

Abstract: Background: Shoulder dislocation is a common reason for admission in the emergency room. Its recurrence rate may be as high as 96% due to the associated bone lesions. The purpose of this study is to identify the underreporting of lesions comparing those identified in the initial X-ray with those identified in the post-reduction X-ray. Material and methods: X-rays of 46 patients with suspected anterior glenohumeral dislocation were assessed for diagnostic purposes and to identify the initial bone lesions. After patients had undergone reduction, post-reduction serial bone X-rays (AP, Stryker, Westpoint) were taken and analyzed looking for bone lesions that were initially missed. Results: Bone lesions were identified in 26.1% of the patients based on the initial AP X-rays. In 67.6% of the patients without a pre-reduction fracture a bone lesion was found in the post-reduction serial X-rays. Conclusions: The underreporting rate of bone lesions was 67.6% comparing the initial AP X-rays with the post-reduction serial bone X-rays.

Análisis imagenológico del calcáneo aplicada a la fijación interna de fracturas a través del abordaje del seno del tarso / Imaging of the Calcaneus applied to the internal fixation of fractures by a sinus tarsi approach

Resumen: Objetivo: La técnica a través del abordaje del seno del tarso (AST), se ha convertido en una opción cada vez más popular para el tratamiento de las fracturas de calcáneo. A pesar de los buenos resultados reportados, las complicaciones relacionadas con la fijación interna no han sido analizadas aún. A través de mediciones en tomografías computadas con reconstrucción 3D (TC) hemos planteado el objetivo de realizar una descripción del calcáneo aplicada al uso de osteosíntesis en fracturas de dicho hueso. Métodos: Se obtuvieron, retrospectivamente, 24 estudios de TC de 22 pacientes consecutivos que presentaban calcáneos sanos sin antecedente de cirugía ni fractura, 18 hombres y cuatro mujeres, 14 derechos y 10 izquierdos. La edad promedio fue de 45.8 (rango: 19-79) años. Se realizaron mediciones del ancho y largo de tornillos que se necesitarían para fijar una fractura de calcáneo con un montaje predefinido. Resultados: Los resultados están enfocados en mediciones obtenidas de imágenes de TC, las cuales ayudarían al cirujano a un correcto posicionamiento, angulación y largo de los tornillos necesarios para la fijación interna de fracturas de calcáneo. Conclusión: Este estudio describe una serie de mediciones del calcáneo que resultan de utilidad para la fijación interna de fracturas de calcáneo a través del AST. Su propósito es minimizar las complicaciones derivadas del uso de osteosíntesis en estas fracturas.

Abstract: Objective: The mini-invasive technique, through a sinus tarsi approach (STA), has become an increasingly popular choice for the treatment of calcaneal fractures. However, despite the good results reported, the complications related with internal fixation have not yet been analyzed. Using 3D reconstruction CT scans, we proposed doing biometric description of the calcaneus with the purpose of performing osteosynthesis as treatment for calcaneal fractures. Methods: A total of 24 CT scans were retrospectively obtained from 22 consecutive patients with healthy calcanei and no history of surgery or fracture. They included 18 males and 4 females; 14 right and 10 left calcanei. Mean age was 45.8 (range 19-79). The width and length of the screws needed to fix a calcaneal fracture with a predefined montage were measured. Results: The results focus on biometric measurements obtained from CT scans that may help surgeons achieve proper positioning, angulation and length of the screws needed for the internal fixation of calcaneal fractures. Conclusion: This study describes a series of biometric calcaneal measurements that are useful for the internal fixation of calcaneal fractures using a sinus tarsi approach. The purpose is to minimize the complications resulting from osteosynthesis to treat these fractures.

Modified Stoppa Approach for Surgical Treatment of Acetabular Fracture

BACKGROUND: We analyzed the extent of the comminution in the acetabular weight-bearing area, the clinical and radiographic results, and the complications after a minimum 2-year follow-up of the modified Stoppa approach for the treatment of acetabular fractures, and we attempted to evaluate the efficacy of the operative technique. METHODS: All of the 22 patients, who needed the anterior approach for the treatment of acetabular fractures at our hospital from November 2007 to November 2010, were subjected to surgery via the modified Stoppa approach. Fracture pattern, operative time, blood loss during the operation, quality of reduction, number of bony fragments in the acetabular weight-bearing area, and postoperative complications were assessed by retrospectively analyzing the medical records and the radiographic examinations. The results after the operation were analyzed based on the criteria of Matta. RESULTS: The clinical results were excellent in 3 cases, good in 13 cases, and poor in 4 cases, while the radiographic results were excellent in 5 cases, good in 13 cases, and poor in 2 cases. Although the quality of reduction and the clinical results according to the extent of comminution were statistically significant (p = 0.03 and p = 0.04, respectively), the radiographic results were not statistically significant (p = 0.74). CONCLUSIONS: It can be concluded that the modified Stoppa approach could be used as an alternative to the classic ilioinguinal approach. In addition, comminution of the acetabular fracture was an important factor causing non-anatomic reduction and finally unsatisfactory clinical results.

Intraoperative Three-Dimensional Imaging in Calcaneal Fracture Treatment

BACKGROUND: To compare the effectiveness of intraoperative three-dimensional (3D) image and conventional two-dimensional (2D) fluoroscopic images, which are used in the treatment of acute calcaneal fractures. METHODS: We retrospectively analyzed 40 patients who suffered calcaneal fracture and underwent surgery at Inje University Busan Paik Hospital. The patients were divided into two groups. Only 2D fluoroscopy was used to evaluate 20 patients of group 1. On the other hand, 3D fluoroscopy was performed on the remaining 20 patients of group 2; 3D fluoroscopy was performed on these patients after they were extensively evaluated by 2D fluoroscopy during surgery. We reviewed the radiographic and clinical outcomes of these patients, whose average follow-up period was 42.6 months. RESULTS: In group 2, 3D fluoroscopy detected four cases (20%) of articular incongruence and screw misplacement. All these complicated cases were corrected during surgery. At the final follow-up session, the mean American Orthopedic Foot and Ankle Society (AOFAS) hind foot score was 78.3 (range, 65 to 95) in group 1 and 82.3 (range, 68 to 95) in group 2. CONCLUSIONS: Intraoperative 3D imaging of calcaneal fractures is considered to be useful in evaluating the congruence of joints and the placement of implants.