Complications and technical pitfalls of titanium elastic nail fixation for midclavicular fractures.

Intramedullary titanium elastic nails have been reported to fix displaced midclavicular fractures with excellent functional outcomes and minor complications. This study reports and analyzes the complications and technical pitfalls associated with titanium elastic nail fixation of displaced midclavicular fractures and describes how to prevent these problems. The authors operated on 27 patients (17 men, 10 women; mean age, 45.8 years; range, 16.5-66.9 years) with marked displaced midclavicular fractures using intramedullary titanium elastic nail fixation. The mean Constant score and Disability of the Arm, Shoulder, and Hand score were 93.58 (range, 66.5-100) and 6.22 (range, 0-35), respectively. The mean length difference compared with the contralateral clavicle was a shortening of 0.3 cm (range, -1.5 to 1 cm). Eight patients (30%) had different levels of difficulty at the medial entry point. Clavicular length shortening of more than 1 cm occurred in 5 patients (19%), and all of these patients experienced medial nail tip prominence/protrusion. One patient had 1-cm lengthening of the injured clavicle caused by distraction of the fracture site during titanium elastic nail insertion. Iatrogenic perforation of the posterolateral cortex occurred in 3 patients. Initial misplaced nail insertion occurred in 1 woman who underwent revision with the mini-open method. In 2 patients it was impossible to remove the full nail under general anesthesia. In conclusion, high patient satisfaction and functional outcomes were achieved after titanium elastic nail fixation of displaced midclavicular fractures. However, some complications and technical pitfalls must be considered before titanium elastic nails are used to fix displaced midclavicular fractures.

Successful teriparatide treatment of atypical fracture after long-term use of alendronate without surgical procedure in a postmenopausal woman: a case report.

OBJECTIVE: Bisphosphonates are used as first-line therapy for postmenopausal osteoporosis owing to their potent inhibition of bone resorption. Long-term use of bisphosphonates may lead to low-energy femoral subtrochanteric or shaft fractures in a very few patients. The aim of this study was to describe the clinical course of a patient treated with alendronate for 3 years who developed an atypical femoral fracture and to hypothesize the beneficial effects of teriparatide on the healing of the patient's atypical femoral fracture. METHODS: A 63-year-old Asian woman had a lumbar osteoporotic fracture and received 70 mg of alendronate for 3 years. Pain and soreness in the thigh presented initially and exacerbated thereafter. X-ray revealed a right femoral diaphysis stress fracture. She then received teriparatide for the treatment of osteoporosis and the femoral atypical fracture. RESULTS: Pain and tenderness improved remarkably after teriparatide treatment for 1 month, and these symptoms disappeared after teriparatide treatment for 9 months. The patient also received raloxifen as further therapy, and the fracture line had completely disappeared by 15 months after treatment. CONCLUSIONS: Even though a previous study has reported that teriparatide healed stress fractures in a rat model and even with the time course of fracture healing in our patient, we are still not certain that teriparatide played a primary role in the positive response to therapy. Vitamin D therapy, calcium, and alendronate discontinuation may have played secondary roles. This case report may serve to introduce a direction for future research into the pharmacological treatment of atypical femoral fractures. Surgical treatment of incomplete atypical femoral fractures may be a safer method.

Minimally invasive fixation of displaced midclavicular fractures with titanium elastic nails.

OBJECTIVES: Clavicular fractures account for 2.6% of all fractures, and more than 80% involve the middle third of the clavicle. Plate fixation has been the most common method of fixation reported but has been associated with complications such as infection, wound breakdown, nonunion, implant failures, poor cosmetic outcome, and local skin numbness. We report on a series of cases receiving minimally invasive insertion of titanium elastic nails (TEN) to fix the displaced midclavicular fractures. DESIGN: Prospective, clinical study. SETTING: Regional referral center. PATIENTS/PARTICIPANTS: From November 2006 to October 2007, we operated on 23 patients (16 men) with displaced (no cortical contact between the proximal and distal fragments radiographically and/or greater than 2 cm of shortening) midclavicular fractures fixed with TEN. The mean age of the patients was 41.57 years. INTERVENTION: All patients with displaced midclavicular fractures were treated with TEN. The nails were inserted from the medial entry point on the sternal end and passed through the fracture site under fluoroscopy monitoring. MAIN OUTCOME MEASUREMENTS: Complications, clavicular shortening after TEN fixation, Constant shoulder score, and Disability of the Arm, Shoulder, and Hand score for functional outcome measurement. RESULTS: Closed reduction was successful in 16 patients, and seven patients needed open reduction. There was no nonunion, infection, nail breakage, or refracture after nail removal in our series. The mean operative wound length was 2.2 cm, and mean clavicular length shortening was 0.32 cm. Iatrogenic perforation of the lateral cortex occurred in two patients, and nail misplacement occurred in one patient requiring revision. All patients followed up greater than 12 months. The mean Disability of the Arm, Shoulder, and Hand score was 6 (range, 0-35; standard deviation, 10.47) and mean Constant score was 96 (range, 78-100; standard deviation, 6.34). CONCLUSIONS: Minimally invasive fixation with TEN is a safe method and can be performed with minor complications. This method of fixation of displaced midclaviclular fractures should result in a good cosmetic appearance and satisfactory stabilization of displaced midclavicular fractures without comminution.

Anterior approach for posteromedial tibial plateau fractures.

Fractures of the posteromedial tibial plateau are rare and their treatment is not well established. Between January 2004 and December 2008, eight patients with fractures of the posteromedial tibia plateau were identified. All patients were treated with fracture reduction using an anterior approach. After a mean follow-up of 21 months, the average range of knee motion was 0-123 degrees of flexion. Seven patients had been injured in motor-scooter accidents, in which the protective front plate of the scooter had hit the knee while it was in the 90 degrees -flexion position. At the final follow-up, 87.5% (7/8) patients had satisfactory reductions of the articular surface, and all patients had acceptable alignments. There were no neural or vascular injuries following surgery, and no superficial or deep infections. The average Hospital for Special Surgery Knee Score was 89. In conclusion, fracture reduction using the anterior approach is associated with fewer complications than the posterior approach, and good functional recovery can be expected.

Treatment of the Posterolateral Tibial Plateau Fractures using the Anterior Surgical Approach.

BACKGROUND: Fracture of the posterolateral tibial plateau is relatively uncommon. While surgical treatment by the posterior approach is theoretically ideal, this approach is associated with numerous complications. We describe a series of fractures of the posterolateral tibial plateau treated by the anterior surgical approach. METHODS: Fifteen patients with posterolateral tibial plateau fractures were included in this study. All patients were treated operatively using the anterior approach. The quality of fracture reduction was evaluated and functional results were estimated by the Hospital for Special Surgery knee scoring system. RESULTS: The most common cause of fracture was a motor scooter accident (86%, 13 of 15 patients), which may have resulted in the protective front plate of the scooter hitting the knee in the flexion position, causing an axial compression and valgus force, resulting in the fracture of the posterolateral tibial plateau. The average knee motion after surgery was 0-124° of flexion and 14 out of 15 patients (93%) experienced satisfactory articular reduction. There were no postoperative neural or vascular injuries and no wound complications. The average Hospital for Special Surgery knee score was 92 (range, 74-98). CONCLUSIONS: In our series, with careful preoperative planning, the anterior approach for the surgical treatment of posterolateral tibial plateau fractures had no complications and was associated with satisfactory outcomes.

Acute dislocation of the proximal tibiofibular joint.

The patient was a 19-year-old female who reported an acute onset of lateral left knee pain while participating in a 3-legged race. The patient reported to the emergency department immediately following the injury. Observation revealed prominence along the lateral aspect of the knee. The patient was unable to bear weight on her left lower extremity and her symptoms were exacerbated with extension of the knee. Although the initial radiographs of the left knee and lower leg showed no apparent fracture, a widening of the interosseous space between the tibia and the fibula and an altered position of the fibular head were noted on the anterior to posterior radiographic view. On the lateral radiographic view there was anterior displacement of the left fibula compared to the right. These radiographic findings suggested an anterolateral dislocation of the fibular head, the diagnosis of which was confirmed upon the completion of axial computed tomography. Successful closed reduction was achieved and the patient was treated with a period of protected weight bearing on crutches, progressing to full weight bearing over 6 weeks. At 1 year following the injury, the patient was participating in all regular activities of daily living without pain or instability. Early detection and immediate reduction of an acute dislocation of the proximal tibiofibular joint are important to prevent long-term disability.

Infection after surgical reconstruction of a clavicle fracture using a reconstruction plate: a report of seven cases.

Mid-shaft clavicle fractures have traditionally been treated conservatively, although this has been associated with non-union and unsatisfactory shoulder function. The preferred approach is plate fixation, with a reconstruction plate for open reduction and internal fixation. Infection is a potential complication after such surgery, with rates of 0.4-7.8% reported in the literature. In our cases, an infection rate of 4.9% (7 of 142 patients) was noted; five of the seven patients suffered from acute postoperative infection within 1 month of surgery. The average time to presentation with an infection was 28 (23-32) days, with signs and symptoms of wound dehiscence in one patient and sinus discharge in four patients. Two patients suffered from subacute infections, with durations of 72 and 103 days, presenting with local heat and radiographic findings of screw loosening. Six of the cases healed with primary bony union after intensive debridement and early removal of the implants.

Death from colonic disease in epidermolysis bullosa dystrophica.

BACKGROUND: Squamous cell carcinomas and renal failure were reported the causes of death in patients with recessive dystrophic epidermolysis bullosa (RDEB). Death from colonic disease in epidermolysis bullosa (EB) is never reported. CASE PRESENTATION: We demonstrate a male patient with RDEB. He suffered megacolon due to fecal impaction and died from sigmoid colon perforation with peritonitis at age 35 years. CONCLUSION: Constipation is a common clinical feature of RDEB, but fetal complications of chronic constipation are rarely reported. To the author's best knowledge, it has not been reported or recognized in the English literature previously. The aggressive assessment of constipation with fecal impaction is recommended in patients with RDEB.

Corrosive injury from arterial injection of hydrochloric acid.

This report presents a case of hydrochloric acid injection in the inguinal area in a suicide attempt, resulting in total occlusion of the external iliac artery, requiring disarticulation of the hip. To the authors' best knowledge, it has not been previously reported in the English medical literature. The accelerated destructive activity of these irritant chemicals and deep tissue damages are emphasized. Early and aggressive debridement with copious saline irrigation and circumspect monitoring are recommended.