Physiologic widening of the medial clear space: What's normal?

BACKGROUND: Literature has validated the use of stress radiographs for evaluation of ankle stability. However, to our knowledge no study has reported the amount of physiological widening that occurs with manual external rotation stress test in uninjured ankles. The purpose of this study was to assess the amount of medial clear space widening that occurs with a manual external rotation stress test in uninjured ankles. METHODS: A cohort of adult patients undergoing operative fixation of unstable ankle fractures were prospectively enrolled to have their contralateral ankle undergo manual external rotation stress examination. Fluoroscopic images of the unaffected ankle were performed in the OR. A non-stressed mortise view and manual external rotation stress view were obtained with a standardized marker to correct for magnification differences. The images were de-identified, presented in a randomized order and reviewers who were blinded. Each reviewer measured the medial clear space. RESULTS: Thirty fluoroscopic images on fifteen patients were obtained. The mean medial clear space on the non-stressed mortise view was 3.1 mm (SD-0.69; Range 1.9 to 4.2, 95% CI [2.75, 3.45]) versus a mean of 3.2 mm (SD-0.71; Range 2.0 to 4.7, 95% CI [2.94, 3.66]) in the stressed mortise view group. Inter-rater reliability was excellent between all observers for medial clear space (ICC-0.88; CI [0.78, 0.94]). CONCLUSIONS: Our results support the previous literature and allow us to advocate for ankle fractures with >5 mm medial clear space after external rotational stress to be considered unstable. Additionally, ankles with a medial clear space between 4 and 5 mm, instability should be considered only if lateral shift is > 2 mm on stress examination. Our data shows that no physiologically healthy ankles widened beyond these established cut-offs before or after the manual external rotation stress.

Plantar Medial Avulsion Fragment Associated With Tongue-Type Calcaneus Fractures.

BACKGROUND: The plantar fascia attaches to the tuberosity of the calcaneus, which produces a distinct plantar medial avulsion (PMA) fracture fragment in certain calcaneal fractures. We hypothesized that tongue-type fractures, as described by the Essex-Lopresti classification, were more likely to be associated with this PMA fracture than joint depression fractures. METHODS: A retrospective chart review was performed at 2 distinct Level I trauma centers to identify patients sustaining calcaneal fractures. Radiographs were then reviewed to determine the Essex-Lopresti classification, OTA classification, and presence of a PMA fracture. RESULTS: The review yielded 271 total patients with 121 (44.6%) tongue-type (TT), 110 (40.6%) joint depression (JD), and 40 (14.8%) fractures not classifiable by the Essex-Lopresti classification. In the TT group, 73.6% of the patients had the PMA fracture whereas only 8.2% of JD and 15.0% of nonclassifiable fractures demonstrated a PMA fragment ( P < .001). CONCLUSION: Plantar medial avulsion fractures occurred in 38.4% of the calcaneal fractures reviewed with a significantly greater proportion occurring in TT (73.6%) as opposed to JD (8.2%). Given the plantar fascia attachment to the PMA fragment, there may be clinical significance to identifying this fracture and changing treatment management; however, this requires further investigation. LEVEL OF EVIDENCE: Level III, comparative study.

The role of computed tomography scans in diaphyseal femur fractures following gunshot injuries: A survey of orthopaedic traumatologists.

The objective of this study was to analyze if the addition of CT changed the management of femoral shaft fractures caused by gunshot wounds when compared to those managed with plain radiography alone. METHODS: A multiple-choice, single-answer electronic survey was created to compare utility of advanced imaging when treating femur fractures resulting from gunshot injury. A total of ten femoral shaft fracture cause by gunshot injuries were selected for an online survey to be administered to orthopeaedic traumatologists. The survey compared the use the of fixation device and surgical planning before and after the CT scan. RESULTS: A total of 99 surveys were initiated, of which 82 were completed. For proximal shaft fractures, 37% of experts reported that a CT scan should be ordered based on the radiograph alone, prior to reviewing the CT. After reviewing the CT, 5% of experts reported that they would have performed a "major" change, and 10% reported that they would have performed a "minor" change. 4% of surveyors would have changed their decision regarding ordering a CT. For distal femoral shaft fractures, 42% of experts selected that a CT scan would have been ordered prior to reviewing the CT. After reviewing the CT, 2% would have performed a "major" change, and 8% would have performed a "minor" change in management. 5% of surveyors would have changed their decision regarding ordering a CT. CONCLUSION: Our study demonstrated that CT scans are relatively unlikely to cause major changes in fracture management of gunshot-induced fractures of femoral shaft.

Fractures of the Calcaneus.

Calcaneal fractures are potentially devastating injuries. To effectively manage calcaneal fractures, surgeons must understand the anatomy of the calcaneus as well as the surgical techniques necessary to restore normal biomechanics of the foot. Surgeons also must understand calcaneal fracture patterns and classifications; initial management techniques, surgical indications and rationale, temporizing management techniques, surgical approaches, definitive management techniques, and postoperative management for calcaneal fractures; as well as outcomes and common complications of calcaneal fractures.

The Antibiotic Nail in the Treatment of Long Bone Infection: Technique and Results.

Antibiotic cement nails provide a useful and relatively simple technique to treat intramedullary osteomyelitis of the long bones. These devices provide stability as well as local, targeted antibiotics, which are both critical aspects of osteomyelitis management. Additionally, the use of a threaded core is a critical component of successful cement nail assembly. With adherence to the simple principles outlined in this review, surgeons can expect reliably good results using these drug-delivery implants.

Evaluation of Intra-articular Fracture Extension After Gunshot Wounds to the Lower Extremity: Plain Radiographs Versus Computer Tomography.

OBJECTIVE: This study was to compare the use of computer tomography with plain radiographs for the evaluation of intra-articular extension of long bone fractures in the lower extremity after low-energy gunshot wounds. DESIGN: Retrospective chart and radiographic review. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Data were collected from a single institution from 2000 to 2014. Inclusion criteria consisted of patients greater than 17 years of age, low-velocity gunshot injuries causing fracture of the femur or tibia, plain radiographs with adequate films, and computed tomography (CT) imaging of the fracture. This consisted of 133 patients with 140 fractures. INTERVENTION: Intra-articular fracture extension was evaluated on initial plain radiographs and CTs. MAIN OUTCOME MEASURES: Comparison of "gold standard" CT with all reviewers' evaluation of plain radiographs. RESULTS: There were 140 total fractures; 108 were femoral fractures and 32 were tibial fractures. By comparing plain radiographs with the gold standard CT, the reviewers demonstrated correct diagnosis in 85% of intra-articular fractures and 96% of non-intra-articular fractures. In addition, the reviewers accurately diagnosed 70.8% of intra-articular extensions in the diaphysis and 70.5% in the metaphysis. The sensitivity and specificity for plain radiographs were 85.3% and 96.0%, respectively, for all locations. Metaphyseal and diaphyseal fractures demonstrated the poorest sensitivity at 80.7% and 82.1%, respectively. CONCLUSIONS: Low-energy gunshot wounds with fractures in the diaphyseal of the distal femur and all metaphyseal fractures warrant CT evaluation to better examine for intra-articular fracture extension. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Role of Computed Tomography in Surgical Planning for Trimalleolar Fracture. A Survey of OTA Members.

OBJECTIVE: Does the additional information provided by computed tomography (CT) alter surgeons' treatment plans for trimalleolar ankle fracture? DESIGN: Prospective. SETTING: Electronic survey. PATIENTS/PARTICIPANTS: Members of the OTA. INTERVENTION: Compare management of trimalleolar ankle fracture before and after CT. MAIN OUTCOME MEASUREMENTS: Compare types of fixation used, indication for fixation, and approach need for fixation before and after CT. RESULTS: Overall, OTA members' operative technique changed in 430 of the 1710 (25.1%) cases after review of the CT images. Of the 430 observations in which the operative technique was altered, the surgeon had initially stated that they would not have requested a CT in 51.2% incidences. When analyzing if CT affected whether or not operative fixation was indicated, a total of 16.3% responses changed. Surgeons were significantly more likely to change from no fixation to fixation (11.5%) than vice versa (4.8%) after reviewing CT imaging. A total of 17.8% of responses changed operative approach after reviewing the CT; 11.7% changed to open reduction internal fixation, whereas 6.1% changed away from open reduction internal fixation. CONCLUSION: A consensus on the ideal treatment of trimalleolar fractures remains elusive, evidenced by a high variation in treatment preference, both before and after CT review. Our results demonstrate with the additional information delineated on CT, a surgeons' operative plan, technique, and approach often change. With greater than 25% of respondents changing their treatment strategy after seeing CT imaging, radiographs alone limited surgeon understanding of fracture pattern. Because of difficulty understanding the posterior fracture fragment, we recommend preoperative CT on all trimalleolar fractures. LEVEL OF EVIDENCE: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Associated Injuries in Skeletally Immature Children with Pelvic Fractures.

BACKGROUND: Pediatric pelvic fractures are rare injuries resulting from high-energy mechanisms that warrant an extensive work-up for associated injuries. OBJECTIVES: We performed a retrospective study to review concomitant injuries in children who suffered a pelvic fracture and have an open triradiate cartilage. METHODS: Using a database, pediatric pelvic fractures presenting to the authors' institution were extracted. Radiographs and computed tomography scans were reviewed, ensuring that triradiate cartilages were not fused and the pelvic injuries were classified using the Modified Torode Classification. Epidemiologic data extracted included Glasgow Coma Scale (GCS), Injury Severity Score (ISS), and Abbreviated Injury Score (AIS). RESULTS: Sixty patients met the inclusion criteria, and their average age was 8.3 years (range 2-14 years). There were no mortalities. The most common mechanism of injury was a vehicle striking a pedestrian. There were no significant correlations between GCS, ISS, and AIS. All 60 children (100%) suffered extremity injuries. Nineteen patients required surgical orthopedic intervention, and 6 required operative stabilization of the pelvis. Patients who were struck by a motor vehicle were more likely to have multiple pelvic fractures (p < 0.05). Patients with multiple pelvic fractures were more likely to require orthopaedic surgical intervention and require a blood transfusion (p < 0.05). Patients who had type III-B or IV fractures were more likely to require a transfusion than patients with III-A fracture (p < 0.05). CONCLUSIONS: Patients sustaining fractures to an immature pelvis are likely to have additional injuries, which may be fatal or disabling if not diagnosed in a timely manner.

Inadvertent Reduction of Symphyseal Diastasis During Computed Tomography.

OBJECTIVE: To determine the quantifiable difference in pubic symphysis diastasis when comparing computed tomography (CT) and pelvic radiographs in individuals with anterior pelvic ring injuries. DESIGN: Retrospective chart and radiographic review. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Between 2002 and 2013, all individuals requiring internal fixation of the anterior pelvic ring were reviewed. Of the 163 patients, 72 met the inclusion criteria. Patients with a symphysis dislocation were included if the pelvic radiograph and CT were performed without a pelvic binder, and imaging was adequate for required measurements. INTERVENTION: Symphyseal diastasis was measured on the initial pelvic radiograph, the CT scout, and axial views. MAIN OUTCOME MEASUREMENTS: Comparison of measured symphyseal diastasis on CT and pelvic radiographs. RESULTS: Seventy-two patients met the inclusion criteria. Ninety-seven percent (70/72) had a reduction of their symphysis diastasis in the CT with an average reduction of 6.6 mm (Range, -2.6 to 35.5 mm). The average diastasis on radiograph was 26.3 mm compared with 19.7 mm on CT scout (P < 0.001). Fourteen patients (19.2%) had a reduction from greater than 25 mm to less than 25 mm-a traditional cutoff for operative intervention. CONCLUSIONS: The anteroposterior pelvis radiograph remains an important part of the workup for trauma patients. Reliance on CT alone may underestimate the true degree of pelvic displacement. Failure to obtain pelvic radiographs in the acute setting limits the information in which the medical team can base both immediate and definitive decisions about pelvic ring injuries. LEVEL OF EVIDENCE: Diagnostic level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of treadmill and overground walking on function and attitudes in older adults.

PURPOSE: The purpose of this study was to determine whether treadmill walking, as a mode of physical activity for older adults, was comparable with overground walking when considering 1) spatiotemporal gait characteristics (walking velocity, stride length, and stride rate) at a preferred velocity and a prescribed intensity typical of many exercise prescriptions (i.e., RPE of 13); and 2) the effects on physical function (short physical performance battery (SPPB), lateral mobility, 400-m walk) and participants' attitude towards training and level of enjoyment. METHODS: Gait characteristics were measured at each participant's preferred and RPE 13 velocity during treadmill and overground walking (N=23, 74+/-4 yr). Participants were then randomized to either a treadmill or overground progressive intensity and duration walking program of 18 sessions. RESULTS: Both the preferred and RPE 13 walking velocities were significantly slower on the treadmill compared with overground (t(22)=-10.87, P<0.001 and t(22)=-8.54, P<0.001, respectively), as a result of significantly shorter stride lengths and slower stride rates. After training, there were no differences between the groups for RPE 13 velocity, SPPB or lateral mobility. However, following the intervention, the overground group completed the 400-m walk faster (F(1,15)=6.06, P<0.05), had a more favorable attitude towards training, and expressed a more favorable level of enjoyment about the training program than the treadmill group (F(1,16)=7.5; P<0.05). CONCLUSION: An overground walking program appears to offer some advantages over a treadmill walking program in older adults. Using RPE alone to regulate intensity may reduce the benefits of a treadmill walking program in older adults.