Fracture-Related Complication: Fat Embolism Syndrome

Fat embolization is a common occurrence after trauma or during orthopedic procedures involving intramedullary manipulation. Although uncommon, fat embolism syndrome (FES) with respiratory failure, neurologic dysfunction, and petechial rash can be fatal to patients. Two theories are proposed for the manifestation of FES: in the mechanical theory, FES occurs when fat tissue in the bone marrow enters the bloodstream and mechanically blocks it; the biochemical theory proposes that FES occurs due to an inflammatory reaction caused by free fatty acids. There are currently no clear diagnostic criteria for FES, and symptoms and signs are typically nonspecific. For the treatment of FES, conservative and supportive management is performed for the specific symptoms, and close monitoring of the respiratory and neurologic systems is required in high-risk groups. Early fracture fixation of long bones helps prevent and reduce the severity of fat embolism.

Comparison of Locking Plate Osteosynthesis versus Coracoclavicular Stabilization for Neer Type IIB Lateral Clavicle Fractures

Background@#The best option for the treatment of Neer type IIB lateral clavicle fractures remains controversial. The aim of this study was to compare outcomes and complications between pre-contoured locking plate osteosynthesis (PLPO) and coracoclavicular stabilization (CCS) using a TightRope for the treatment of type IIB fractures. @*Methods@#Forty-six consecutive type IIB fractures were treated with PLPO (17 cases) or CCS (29 cases). The mean follow-up period was 33.7 months (range, 12–144 months). Radiographic outcomes were evaluated using serial plain radiographs. Clinical outcomes were evaluated using the University of California, Los Angeles (UCLA) score, the American Shoulder and Elbow Surgeons (ASES) score, and subjective shoulder value (SSV). @*Results@#Of the 46 cases, complete bony union within 6 months after surgery was achieved in 42 cases (91.3%). The union rate was 100% (17/17) in the PLPO group and 86.2% (25/29) in the CCS group, showing a statistically significant difference (p = 0.043). No significant differences in terms of UCLA score (32.8 vs. 32.1), ASES score (93.2 vs. 90.8), or SSV (89.1% vs. 90.3%) were observed between the PLPO and CCS groups. The complication rates were 17.6% (3/17; 2 cases of screw breakage and 1 case of stiffness) in the PLPO group and 37.9% (11/29; 4 cases of nonunion, 3 cases of stiffness, 2 cases of skin irritation, 1 case of superficial infection, and 1 case of coracoid button migration) in the CCS group, showing no statistically significant difference (p > 0.05). Four cases with nonunion after CCS did not require reoperation because they had good to excellent clinical outcomes without radiographic progression. @*Conclusions@#Although a higher nonunion rate was observed in the CCS group compared with the PLPO group, satisfactory clinical outcomes were obtained for both groups. Both techniques can be regarded as useful options for the treatment of Neer type IIB lateral clavicle fractures.

Alternative management of intractable chylous ascites following robot-assisted pancreaticoduodenectomy of Viscum album sclerotherapy: a case report

A patient showed signs of fever and Hemovac insertion site discharge 8 days after surgery and was admitted. Abdominal paracentesis found milky ascites with triglyceride levels of the peritoneal fluid as high as 1,603 g/mL. Diagnosed as chylous ascites, symptomatic therapy such as empirical antibodies and diuretics was administered with paracentesis before being discharged. The ascites volume increased again, and the patient was re-admitted. The patient was treated with orlistat, octreotide, total parenteral nutrition administration, ascites drainage, and diuretics. Ascites levels increased further and intraperitoneal Viscum was administered. Clear ascites was observed, and the patient was discharged. We reported a case where conventional treatment for chylous ascites that occurred after pancreaticoduodenectomy was shown to be ineffective while Viscum extracted from mistletoe was able to manage chylous ascites.

Clinical Outcomes and Radiologic Characteristics of Insufficiency Femoral Neck Fracture in Elderly Patients

Purpose@#In elderly patients, femoral neck insufficiency fractures that occur without a history of trauma are difficult to diagnose and treat, so it is emphasized that early suspicion of fractures and additional diagnostic tests are conducted. @*Materials and Methods@#Between December 2010 to December 2019, 12 femoral neck insufficiency fractures (group 1) were evaluated by comparing them with 50 traumatic femoral neck fractures of a similar age. Along with demographic data, neck cortical thickness, shaft cortical thickness, head diameter, neck width, trochanter width, shaft width, neck-shaft angle, hip axis length, femoral neck index on the simple radiographic image were compared. @*Results@#Seven of the 12 cases were non-displaced fractures, and it took an average of 19.2 days to diagnose the fracture after the symptoms occurred. The height was smaller than the control group at 149.1 cm in group 1 and 157.2 cm in group 2 (p<0.001). The cortical thickness of the medial femoral neck showed significant differences between the two groups: 3.16 mm in group 1 and 4.11 mm in group 2 (p=0.004). There was no statistical difference in the other measurements. @*Conclusion@#Femoral neck insufficiency fracture often has a delayed diagnosis because of the characteristics of the fracture. The cortical thickness of the medial femoral neck in simple radiographic images can help suspect femoral insufficiency fractures in elderly patients when considered with detailed medical history taking and a physical examination.

Characteristics of Elbow Dislocation in Patients with Preexisting Cubitus Varus

Background@#The aim of this study was to investigate the clinical presentations, patterns of soft-tissue injuries, and outcomes of treatment of elbow dislocations in patients with preexisting cubitus varus. @*Methods@#Four cases of elbow dislocation in patients with preexisting cubitus varus, which were treated at 3 residency training hospitals, were retrospectively reviewed. Soft-tissue injury patterns were investigated using magnetic resonance imaging (MRI).Clinical outcomes were assessed at an average of 50.8 months (range, 34–82 months) after treatment using the Mayo Elbow Performance Score (MEPS) and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. @*Results@#The mean patient age was 49.5 years (range, 33–57 years). All patients had a posteromedial elbow dislocation, which was an indirect injury caused by a fall onto an outstretched hand. One patient had failed closed reduction; 3 others had redislocation or gross instability after closed reduction. Significant tears of the lateral collateral ligament complex and common extensor group were shown in MRI. All patients had surgical treatment including lateral complex repair only (n = 2), repair of both sides’ complexes (n = 1), and corrective osteotomy with lateral complex repair (n = 1). At the final follow-up, the mean MEPS was 92.5 ± 8.7 and the mean QuickDASH score was 4.5 ± 6.4. @*Conclusions@#Elbow dislocation in patients with preexisting cubitus varus may present as posteromedial dislocation with acute instability. Surgical treatment of this injury led to acceptable clinical outcomes.

Stratification of Nuclear Homogeneous Patterns on HEp-2 Cells Based on Neutrophil Nuclear Staining / 전남의대학술지

Antinuclear antibody (ANA) testing is used to diagnose systemic autoimmune rheumatic disease (SARD). Nuclear homogeneous patterns on ANA-HEp-2 cells can result from anti-double-stranded DNA (dsDNA), anti-nucleosome, anti-histone, anti-Scl-70, or anti-dense fine speckles 70 (DFS70) antibodies (Abs). This study aimed to find a way to discriminate DFS70 Abs from others by way of assessing neutrophil nuclear staining on anti-neutrophil cytoplasmic antibody (ANCA) testing. Nuclear staining on ANCAneutrophils was assessed to stratify nuclear homogeneous patterns on ANA-HEp-2 cells. Enrolled subjects included (1) young individuals with a dense fine speckled pattern on ANA testing (young non-SARD group, n=71) and patients with (2) systemic lupus erythematosus (SLE group, n=35); (3) rheumatoid arthritis possibly with histone, nucleosome Abs, and others (RA group, n=51); and (4) diffuse systemic sclerosis with Scl-70 Abs (diffuse SSc group, n=19). Negative rates (95% confidence interval) of neutrophil nuclear staining were 97.2% (90.2%-99.7%) in the young non-SARD group, 2.9% (0.1%-14.9%) in the SLE group, 3.9% (0.5%-13.5%) in the RA group, and 47.4% (24.5%-71.1%) in the diffuse SSc group. The negative rate of the young non-SARD group was significantly higher than those of the other groups (all p<0.05). In conclusion, this study suggests that the assessment of nuclear staining on ANCA-neutrophils can help to stratify nuclear homogeneous patterns on ANA-HEp-2 cells and thus to determine whether the ANA pattern is attributed to DFS70 Abs, which can be found in healthy individuals, especially in young individuals.

Decision-Making and Principle of Management in Periprosthetic Femoral Fracture after Total Hip Arthroplasty / 대한정형외과학회잡지

Periprosthetic femoral fractures remain as one of the most challenging complications following total hip arthroplasty. A thorough clinical and radiographic evaluation, precise classification, and understanding of modern management principles are essential to obtain optimal results for these fractures. The Vancouver classification system is a simple, effective, and reproducible method for the planning treatments of these injuries. The fractures associated with a stable femoral stem can be treated effectively with osteosynthesis, but periprosthetic femoral fractures associated with a loose stem require revision arthroplasty. This paper describes the principle of the treatment of patients with periprosthetic femoral fractures and how to assess the stability of the femoral stem.

The Characteristics of Nonmotorized and Electric Kickboard Injury: Retrospective Analysis from a Single Tertiary Institution / 대한스포츠의학회지

Purpose@#Recently, there has been an increasing number of kickboard injuries at our orthopedic clinic and emergency room. Therefore, this study is to identify the incidence and characteristics of nonmotorized and electric kickboard injuries with emergency room surveillance. @*Methods@#Between August 2018 and January 2021, patients who visited the emergency room of a tertiary hospital with nonmotorized and electric kickboard injuries were included. The incidence, severity, and characteristics were analyzed. @*Results@#There were a total of 204 patients who visited our emergency room during the study period. There were 139 nonmotorized kickboard injuries with 115 minor, 11 moderate, and 13 severe injuries. Fifty-six electric kickboard injuries were 47 minor, one moderate, and eight severe injuries. The incidence of injury depended on-site and was as follows: face and head (63.7%), upper extremity, lower extremity, abdomen and chest, and spine. @*Conclusion@#Face and head injuries were the most common injuries in body part, while minor trauma was the most common diagnosis. With the increasing incidence of kickboard injuries, we should be more mindful that protective equipment and safety rules may be necessary.

Short- to mid-term outcomes of radial head replacement for complex radial head fractures

Background@#The purpose of the current study was to investigate short- to mid-term outcomes and complications following radial head replacement (RHR) for complex radial head fractures and to identify factors associated with clinical outcomes. @*Methods@#Twenty-four patients with complex radial head fractures were treated by RHR. The mean age of the patients was 49.8 years (range, 19–73 years). Clinical and radiographic outcomes were evaluated for a mean follow-up period of 58.9 months (range, 27–163 months) using the visual analog scale (VAS) score for pain, the Mayo elbow performance score (MEPS), the quick disabilities of the arm, shoulder and hand (Quick-DASH) score, and serial plain radiographs. Complications were also evaluated. @*Results@#At the final follow-up, the mean VAS score, MEPS, and Quick-DASH score were 0.6±1.1, 88.7±11.5, and 19.4±7.8, respectively. The mean range of motion was 132.7o of flexion, 4.7o of extension, 76.2o of pronation, and 77.5o of supination. Periprosthetic lucency was observed in six patients (25%). Heterotopic ossification was observed in four patients (16.7%). Arthritic change of the elbow joint developed in seven patients (29.2%). Capitellar wear was found in five patients (20.8%). Arthritic change of the elbow joint was significantly correlated with MEPS (P=0.047). Four cases of complications (16.6%) were observed, including two cases of major complications (one stiffness with heterotopic ossification and progressive ulnar neuropathy and one stiffness) and two cases of minor complications (two transient ulnar neuropathy). @*Conclusions@#RHR for the treatment of complex radial head fractures yielded satisfactory short- to mid-term clinical outcomes, though radiographic complications were relatively high.

Short- to mid-term outcomes of radial head replacement for complex radial head fractures

Background@#The purpose of the current study was to investigate short- to mid-term outcomes and complications following radial head replacement (RHR) for complex radial head fractures and to identify factors associated with clinical outcomes. @*Methods@#Twenty-four patients with complex radial head fractures were treated by RHR. The mean age of the patients was 49.8 years (range, 19–73 years). Clinical and radiographic outcomes were evaluated for a mean follow-up period of 58.9 months (range, 27–163 months) using the visual analog scale (VAS) score for pain, the Mayo elbow performance score (MEPS), the quick disabilities of the arm, shoulder and hand (Quick-DASH) score, and serial plain radiographs. Complications were also evaluated. @*Results@#At the final follow-up, the mean VAS score, MEPS, and Quick-DASH score were 0.6±1.1, 88.7±11.5, and 19.4±7.8, respectively. The mean range of motion was 132.7o of flexion, 4.7o of extension, 76.2o of pronation, and 77.5o of supination. Periprosthetic lucency was observed in six patients (25%). Heterotopic ossification was observed in four patients (16.7%). Arthritic change of the elbow joint developed in seven patients (29.2%). Capitellar wear was found in five patients (20.8%). Arthritic change of the elbow joint was significantly correlated with MEPS (P=0.047). Four cases of complications (16.6%) were observed, including two cases of major complications (one stiffness with heterotopic ossification and progressive ulnar neuropathy and one stiffness) and two cases of minor complications (two transient ulnar neuropathy). @*Conclusions@#RHR for the treatment of complex radial head fractures yielded satisfactory short- to mid-term clinical outcomes, though radiographic complications were relatively high.

Current Concepts for Classification and Treatment of Distal Clavicle Fractures

Distal clavicle fractures are less common than mid-shaft fractures in adults and there is no consensus on the best classification system or the ideal treatment approach considering that high nonunion rates have been reported. Although there are numerous treatment options for distal clavicle fractures, a gold standard treatment has not yet been established. Each surgical technique has its pros and cons. In this review article, we provide an overview of classification systems and treatment methods for distal clavicle fractures.

Primary Total Elbow Replacement for Treatment of Complex Distal Humerus Fracture: Outcomes of Short-term Follow-up

Background@#High complication rate after open reduction and internal fixation can lead to use of primary total elbow replacement (TER) in treatment of complex distal humerus fractures in elderly patients. The purpose of this study was to investigate the short-term outcomes and complications after primary TER in patients with complex distal humerus fracture. @*Methods@#Nine patients with acute complex distal humerus fracture were treated by primary TER using the semiconstrained Coonrad-Morrey prosthesis. The mean age of patients was 72.7 years (range, 63–85 years). Clinical and radiographic outcomes were evaluated over a mean follow-up of 29.0 months (range, 12–65 months) using visual analog scale (VAS) score for pain; Mayo elbow performance score (MEPS); Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score; and serial plain radiographs. Complications were also evaluated. @*Results@#At the final follow-up, mean VAS, MEPS, and Quick-DASH scores were 1.2, 80.5, and 20, respectively. The mean range of motion was 127.7o of flexion, 13.8o of extension, 73.3o of pronation, and 74.4o of supination. There was no evidence of bushing wear or high-grade implant loosening on serial plain radiographs. Three complications (33.3%) comprising two periprosthetic fractures and one ulnar neuropathy were observed. @*Conclusions@#Primary TER for treatment of complex distal humerus fractures in elderly patients yielded satisfactory short-term outcomes. However, surgeons should consider the high complication rate after primary TER.

Total Ankylosis by Heterotopic Ossification in an Adolescent Anterior Trans-olecranon Fracture Dislocation: A Case Report

The incidence of heterotopic ossification in adolescents appears to be lower than in adults. There exist very few reports of heterotopic ossification with total bony ankylosis in child or adolescent populations. We describe a case of total bony ankylosis of the elbow secondary to heterotopic ossification, in a 14-year-old female. Total ankylosis of the elbow at 45 degrees of flexion was noted 6 months post-surgery, and complete surgical excision of the heterotopic mass was performed. After an additional one-time dose of radiation therapy and nonsteroidal anti-inflammatory drug medication, full range of motion was obtained without any recurrence or other complications, up to the last follow-up of 30 months.

Management and Outcome of Patients with Acetabular Fractures: Associated Injuries and Prognostic Factors

PURPOSE@#The aim of this study was to determine which factors contribute to the surgical treatment outcomes of acetabular fractures. Simultaneously, we aim to report on the treatment results after our hospital was designated as the focused training center for trauma.@*METHODS@#We conducted a retrospective review of all patients who experienced acetabular fractures from January 1, 2014 to May 1, 2017 and visited our hospital. Patients who had associated pelvic ring fractures or were lost to the one-year follow-up were excluded; a total of 37 fractures were evaluated. We evaluated the clinical results using the scoring system of Merle d'Aubigné (MDA) and grade of Brooker for heterotopic ossification.@*RESULTS@#Thirty-seven patients (31 men and 6 women) were identified. The mean injury severity score (ISS) was 8.7, with 32.4% of patients having a score >15. The average blood transfusion in the first 24 hours was 0.54 pints. Falling was the most common injury mechanism (32.4%). Chest injury was the most common associated injury (16.2%), followed by head injury (13.5%). The posterior wall and both column fracture were the most common (37.8%) fracture patterns. Excellent and good clinical grades of MDA included 28 patients (75.6%) and fair and poor grades included nine (24.3%), respectively. Four patients were diagnosed with a post-operative infection (10.8%); one out of four patients who had co-morbidity died (2.7%), and another patient underwent a replacement surgery (2.7%). Multivariate analysis showed that age and operation time were associated with MDA. In addition, operation time and ISS were significant co-factors of the Brooker grade.@*CONCLUSIONS@#Korea University Guro Hospital showed similar treatment results of acetabular fractures compared to other publications. The age and operation time were co-factors of the clinical outcome of this fracture. Additionally, increased operation time and injury severity score were suggested to increase the Brooker grade.

Analysis of Risk Factors for Infection in Orthopedic Trauma Patients

PURPOSE@#We perform an analysis of infection risk factors for fracture patients and confirm that the risk factors reported in previous studies increase the risk of actual infection among fractured patients. In addition, injury severity score (ISS) which is used as an evaluation tool for morbidity of trauma patients, confirms whether there is a relationship with infection after orthopedic fracture surgery.@*METHODS@#We retrospectively reviewed 1,818 patients who underwent fixation surgery at orthopedic trauma team, focused trauma center from January 1, 2015 to December 31, 2017. Thirty-five patients were infected after fracture surgery. We analyzed age, sex, open fracture criteria based on Gustilo-Aderson classification 3b, anatomical location (upper extremity or lower extremity) of fracture, diabetes, smoking, ISS.@*RESULTS@#Of 1,818 patients, 35 (1.9%) were diagnosed with postoperative infection. Of the 35 infected patients, nine (25.7%) were female and five (14.0%) were upper extremity fractures. Three (8.6%) were diagnosed with diabetes and eight (22.8%) were smokers. Thirteen (37.1%) had ISS less than nine points and six (17.1%) had ISS 15 points or more. Of 1,818 patients, 80 had open fractures. Surgical site infection were diagnosed in 12 (15.0%) of 80. And nine of 12 were checked with Gustilo-Aderson classification 3b or more. Linear logistic regression analysis was performed using statistical analysis program Stata 15 (Stata Corporation, College Station, TX, USA). In addition, independent variables were logistic regression analyzed individually after Propensity scores matching. In all statistical analyzes, only open fracture was identified as a risk factor.@*CONCLUSIONS@#The risk factors for infection in fracture patients were found to be significantly influenced by open fracture rather than the underlying disease or anatomical feature of the patient. In the case of ISS, it is considered that there is a limitation. It is necessary to develop a new scoring system that can appropriately approach the morbidity of fracture trauma patients.

Minimally Invasive Stabilization with Percutaneous Screws Fixation of APC-3 Pelvic Ring Injury

Pelvic fractures are associated with life-threatening injuries and high rates of morbidity and mortality. Management of internal blood loss associated with unstable pelvic ring injuries is paramount during the initial period. The reconstruction of the pelvic ring is of importance because it is a major contributor to the stability of the pelvic ring. We report the case of a 25-year-old man who had an unstable pelvic ring fracture combined with rupture of an obturator artery and had a successful and satisfactory treatment using minimally invasive surgery with percutaneous antegrade screw fixation.

Total Ankylosis by Heterotopic Ossification in an Adolescent Anterior Trans-olecranon Fracture Dislocation: A Case Report

The incidence of heterotopic ossification in adolescents appears to be lower than in adults. There exist very few reports of heterotopic ossification with total bony ankylosis in child or adolescent populations. We describe a case of total bony ankylosis of the elbow secondary to heterotopic ossification, in a 14-year-old female. Total ankylosis of the elbow at 45 degrees of flexion was noted 6 months post-surgery, and complete surgical excision of the heterotopic mass was performed. After an additional one-time dose of radiation therapy and nonsteroidal anti-inflammatory drug medication, full range of motion was obtained without any recurrence or other complications, up to the last follow-up of 30 months.

Clinical Features and Characteristics of Greater Tuberosity Fractures with or without Shoulder Dislocation

PURPOSE: The purpose of this study was to compare the characteristics and clinical features of greater tuberosity fractures with or without a shoulder dislocation. MATERIALS AND METHODS: A total of 108 cases of greater tuberosity fractures (56 cases with shoulder dislocation, 52 cases without shoulder dislocation) were reviewed retrospectively. Age, sex, side, injury mechanism, fracture displacement, fracture morphology, number of fracture fragments, main fragment size, treatment, and combined injuries were investigated. RESULTS: The age, sex, side, injury mechanism, treatment, and combined injuries were similar in both groups (p>0.05). A statistically significant difference in fracture displacement, fracture morphology, number of fracture fragment, and main fragment size was observed between the two groups (p < 0.05). CONCLUSION: In greater tuberosity fractures with a shoulder dislocation, the prevalence of fracture displacement was high and the depression type of fractures occurred frequently. In addition, the number and size of the fracture fragment increased. Therefore, an understanding of these fracture patterns will be helpful for deciding treatment and prognosis.

Surgical Treatment of Ipsilateral Multi-Level Femoral Fracture Treated Using Antegrade Intramedullary Nail

Ipsilateral fractures of proximal femur with shaft and condylar region are very rare. Current concept of management is based on fixation of each fracture as independent entity using separate fixation modalities for proximal and distal parts of femur. However, we considered that antegrade femoral nailing with cephalomedullary screw fixation is a good option for ipsilateral multi-level femoral fractures. Here, we present an experience of satisfactory treatment for ipsilateral femoral neck fracture, subtrochanteric fracture, comminuted shaft fracture with supracondylar fracture following road traffic accident.

Compartment Syndrome of the Upper Extremity Induced by Extravasation of Contrast Media after Computed Tomography: A Case Report

The incidence of contrast media extravasation has been increasing gradually. Most contrast media extravasations only can cause pain, swelling and erythema. However, in more severe cases, skin necrosis, ulceration, or compartment syndrome may occur, often necessitating a surgery. Early diagnosis and treatment should be established on the spot in order to avoid such a severe damage. We present a case of 42-year-old woman with a compartment syndrome in the right upper extremity caused by extravasation of computed tomography contrast media.