A Maisonneuve Fracture in an Active Duty Sailor: A Case Report.

Maisonneuve fractures are relatively well known in the sports medicine, and orthopedic communities, however, can be commonly missed among primary care providers. The following case outlines an active duty 35-yr-old female patient who presented with acute pain on the left ankle and lower leg after she misjudged a step. The injury is a combination of high fibular and medial malleolar fractures with a disruption of the tibiofibular syndesmosis ligaments. This is a result of extreme external rotation and pronation of a fixed foot. The proper diagnosis is reliant on ankle and tibiofibular films, to include orthogonal views. This case serves as a reminder to always examine joints above and below the injury site, obtain orthogonal views of a fracture, as well as the unstable nature of syndesmosis injuries. This fracture is commonly a sports-related injury; thus, it is particularly important for military providers to be aware of Maisonneuve fractures and the common pitfalls in diagnosis and treatment.

The Efficacy of a Single-Incision Versus Two-Incision Four-Compartment Fasciotomy of the Leg: A Cadaveric Model.

OBJECTIVES: Replicating an established cadaveric model, this study investigates the efficacy of single-incision and 2-incision fasciotomies to satisfactorily decompress all 4 compartments of the leg. We hypothesized that both techniques would adequately release each compartment and that a compartment syndrome could not be recreated in the deep posterior compartment after releases by either technique. METHODS: Acute compartment syndrome was simulated in 8-paired, fresh-frozen human cadaver legs by infusing normal saline into all 4 compartments. Subsequent 4-compartment fasciotomies were performed on each pair using both techniques. After fascial release, the deep posterior compartment was reinfused in an attempt to recreate an acute compartment syndrome. Statistical analysis was performed using the Student t-test with significance set at a P value less than 0.05. RESULTS: Sustainable pressures greater than 60 mm Hg were established in all 4 compartments of each specimen. Postfasciotomy pressures were all reduced to less than 30 mm Hg using both single-incision and 2-incision techniques. There were no statistically significant differences in postrelease pressures between the 2 techniques in any compartment. The average postrelease pressure in the deep posterior compartment was 4.6 mm Hg (range 0-10 mm Hg) with the single-incision technique and 5.6 mm Hg (range 1-10 mm Hg) with the 2-incision technique (P = 0.44). After complete fasciotomies, it was not possible to recreate the elevated pressures of acute compartment syndrome in the deep posterior compartment of any specimen. CONCLUSIONS: A single-incision, 4-compartment fasciotomy is as effective as a 2-incision technique for release of acute compartment syndrome in this cadaveric model.

Variability of acetabular coverage between supine and weightbearing pelvic radiographs.

BACKGROUND: Radiographic measures of acetabular coverage are essential screening tools used to characterize bony structure contributing to femoroacetabular impingement (FAI). Small changes in pelvic tilt result in altered radiographic measures of acetabular coverage. Positional changes in pelvic tilt are known to occur between the supine and weightbearing positions. It is unclear whether alteration of pelvic tilt between these positions is clinically sufficient to influence measures of acetabular coverage. PURPOSE/HYPOTHESIS: To determine whether, and to what degree, imaging position (supine vs weightbearing) is capable of altering several measures of acetabular orientation: pubic symphysis to sacrococcygeal distance (PSSC), angle of Sharp (SA), Tönnis angle (TA), percentage of acetabular crossover (CO), and lateral center-edge angle of Wiberg (LCEA). The hypothesis was that imaging position would significantly alter all measures of acetabular orientation. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A total of 50 consecutive symptomatic hips referred to a single provider for FAI were evaluated with standardized supine and weightbearing anteroposterior pelvic radiographs. Two independent reviewers blinded to patient positioning reviewed each radiograph at 2 separate time points. Mean measurements in each position were compared by use of paired Student t tests, and a Bonferroni-adjusted significance level of P = .01 was used to represent significance. RESULTS: Statistically significant differences between the supine and weightbearing radiographs were identified for PSSC and all measures of acetabular coverage (P < .003). The mean PSSC decreased between the supine and weightbearing positions by an average of 13.4 mm (P < .001), thereby resulting in decreased mean LCEA, TA, SA, and CO of 1.2°, 1.3°, 0.8°, and 6.3%, respectively (P < .002). The change in positional pelvic tilt was not uniformly predictable and accounted for large measurement changes in some individuals. PSSC also demonstrated considerable inter- and intrasubject variability but averaged 55.8 mm supine and 44.9 mm weightbearing for females and 37.0 mm supine and 20.6 mm weightbearing for males. CONCLUSION: In this study of nonarthritic adult patients with hip pain, the data indicate that positional changes are capable of significantly altering pelvic tilt and radiographic measures of acetabular coverage. It appears that the weightbearing position typically, but not universally, correlates with additional posterior pelvic tilt and decreased measures of acetabular coverage. Individual positional variability can contribute to large-magnitude changes in radiographic acetabular measures.

The effect of pelvic tilt on radiographic markers of acetabular coverage.

BACKGROUND: Radiographic indices of acetabular coverage are crucial to objectively characterize femoroacetabular impingement and plan bony decompression. It is established that changes in pelvic inclination result in alterations of acetabular crossover; however, it is unclear what influence this has on other measures of acetabular anatomy. HYPOTHESIS: The objective of the present study was to determine if, and to what degree, a variation in pelvic tilt alters 4 measures of acetabular anatomy: the angle of Sharp, Tönnis angle, percentage of acetabular crossover, and lateral center edge angle (LCEA). The hypothesis was that pelvic tilt would significantly alter all measures of acetabular coverage. STUDY DESIGN: Descriptive laboratory study. METHODS: Fluoroscopic images of 8 adult hemipelvises were obtained at 7 positions of rotation in the sagittal plane to investigate the change of each measurement in response to pelvic orientation. Two reviewers obtained measurements from each image at 2 separate time points. RESULTS: Each increment of pelvic inclination resulted in increased measures of acetabular coverage for all measurements, whereas each increment of decreased pelvic inclination resulted in decreased measures of acetabular coverage for all measurements. Significant differences in the measured LCEA, acetabular crossover, and Tönnis angle were identified at each increment of tilt as compared with neutral radiographs. No significant differences could be identified for the angle of Sharp. CONCLUSION: Pelvic tilt significantly alters the measures of LCEA, crossover, and Tönnis angle in this cadaveric study. Pelvic inclination results in increased measures of acetabular coverage, whereas decreasing inclination decreases each measure. CLINICAL RELEVANCE: Given the known individual and positional pelvic tilt variability, standing anteroposterior pelvic radiographs may provide a more physiological representation of acetabular coverage in the young adult population.