Lisfranc injury: A review and simplified treatment algorithm.

BACKGROUND: Lisfranc injuries encompass large spectrum of injuries varying from low energy to high energy complex fracture dislocations. Whilst multiple complex classification systems exist; these do little to aid and direct the clinical management of patients. Therefore, this study aims to provide a simplified treatment algorithm allowing clinicians to standardise care of Lisfranc injuries. METHODS: A comprehensive literature search was performed, and abstracts were reviewed to identify relevant literature. RESULTS: Delay in diagnosis has a negative impact on outcome. If a Lisfranc injury is suspected and plain radiographs are inconclusive; computed tomography and if necessary magnetic resonance imaging are indicated if there is still an index of suspicion. In the absence of joint dislocation/subluxation management will be determined by stability which can be best assessed by weightbearing radiographs. If stable, injuries can be treated conservatively in a non-weight bearing cast for 6 weeks followed by a period of graduated weight bearing. Evidence is mounting that with regard to unstable purely ligamentous Lisfranc injuries primary arthrodesis (PA) has: better functional outcomes, increased cost effectiveness and reduced rates of return to theatre. With regard to bony unstable Lisfranc injuries more research is required before a single treatment modality - PA or open reduction internal fixation can be advocated, due to the lack of randomized control trials and limited patient follow-up periods in existing studies. CONCLUSION: A simplified treatment algorithm excluding the requirement for complex classifications is suggested. This may help with the diagnosis and management of these injuries. It is our believe that this algorithm will aid health professionals to standardize care for these injuries. Further prospective research trials are required to assess outcomes of different modalities of operative management, particularly with regards to open reduction and internal fixation versus primary arthrodesis for bony Lisfranc injuries. LEVEL OF EVIDENCE: Level 5.

Galeazzi Injuries.

Fractures of the radial shaft associated with disruption of the distal radioulnar joint (DRUJ) are termed Galeazzi fractures. These fractures are unstable injuries requiring open reduction and internal fixation of the fracture to achieve optimal outcomes. DRUJ stability should be carefully assessed intraoperatively and addressed accordingly.

Elbow Fracture-Dislocations: Determining Treatment Strategies.

Elbow dislocations represent common injuries. A quarter of these injuries involve at least 1 fracture. The sequel of elbow fracture-dislocations can be fraught with complications, including recurrent instability, posttraumatic arthritis, elbow contracture, and poor functional results. The 3 main patterns of injury are valgus posterolateral rotatory instability, varus posteromedial rotatory instability, and transolecranon fracture-dislocation. This article discusses each pattern individually, including the anatomy, the typical injury pattern, and treatment strategies. It also discusses common complications that can occur.

Low-Energy Lisfranc Injuries: When to Fix and When to Fuse.

Lisfranc injuries can be devastating to the athlete and nonathlete. In the athletic population, minor loss of midfoot stability compromises the high level of function demanded of the lower extremity. The most critical aspect of treatment is identifying the injury and severity of the ligamentous/articular damage. Not all athletes are able to return to their previous level of function. With appropriate treatment, a Lisfranc injury does not mandate the cessation of an athletic career. We focus on the diagnosis and an algorithmic approach to treatment in the athlete discussion the controversy of open reduction and internal fixation versus arthrodesis.

Fracture-dislocation of the thoracolumbar spine without neurological deficit: a report of two cases and literature review.

INTRODUCTION: We report two cases of fracture-dislocation of the thoracolumbar spine without neurological deficit and outline the putative mechanisms responsible for the escape of neural tissues from injurious forces and the surgical management strategies for this type of injury. We also review similar cases described in the literature. CASE REPORTS: A 24-year-old female with post-traumatic fracture dislocation at the T10-T11 level without neurological deficit, along with a right femoral shaft fracture, was managed with laminectomy of T10-T11 levels with bilateral facetectomy and transpedicular screws and with an intramedullary interlocking nail for the femur fracture. Another 26-year-old female (post-traumatic fracture dislocation at the T12 - L1 level treated by open reduction and pedicle screw instrumentation elsewhere) presented with implant failure and re-dislocation which was managed with laminectomy of T12- L1 levels, facetectomy and discectomy, and deformity correction, followed by 9 mm × 25 mm bullet cage insertion and fixation using transpedicular screws. Neurological function was preserved postoperatively. Both individuals returned to household activity 6 months postoperatively. DISCUSSION: Fracture-dislocations of the thoracolumbar spine without neurological deficit have been infrequently reported. The mechanism responsible for the preservation of normal neurological function; is either posterior element fractures leading to free-floating laminae or a fracture-separation of the vertebral arch, in which pedicle fractures allow the posterior elements to remain nearly aligned, with preservation of the spinal canal integrity and maintenance of normal spinal cord function. These fracture-dislocations need to be managed carefully to achieve a good outcome.

Medial Epicondyle Fractures: Current Practices and Preferences Between SLAOTI Members (Sociedad Latinoamericana de Ortopedia y Traumatología Infantil).

BACKGROUND: Medial epicondyle fractures represent up to 20% of elbow fractures in children and adolescents. There is a growing body of literature to support surgical fixation for displaced fractures. However, controversy regarding imaging modality for displacement measurement and surgical indications remain controversial. The purpose of this survey was to gauge Latin American surgeons' practices and preferences for the evaluation and treatment of medial epicondyle fractures. METHODS: A web-based survey containing 19 questions was distributed to active members of SLAOTI (Sociedad Latinoamericana de Ortopedia y Traumatología Infantil) in November 2018. The survey elicited information regarding surgeon demographics, evaluation methods, the factors involved in the decision to perform surgery, and their experience in cases of symptomatic nonunion. Categorical variables were summarized using frequencies and proportions. Analysis of associations between surgeon demographics and treatment preferences were carried out. RESULTS: A total of 193 out of 354 completed questionnaires were returned (54% response rate). In total, 74% of the participants (142/193) favored radiographs for the evaluation of the fracture displacement, and 25.4% (49/193) added a computed tomography scan for a more detailed evaluation. The majority of respondents (48.2%) would consider a 5 mm displacement as the cutoff for surgical treatment, 21.8% 2 mm, 20.7% 10 mm, and 9.3% 15 mm. There were no differences between the experience of the participants, academic versus private setting, or training regarding surgical/nonsurgical management. CONCLUSIONS: There are significant differences in opinions between SLAOTI members as to the optimal management of medial epicondyle fractures. Implications of disagreement in evaluation and treatment support the need for multicenter prospective studies to develop evidence-based guidelines for the management of this fracture. LEVEL OF EVIDENCE: Level V-expert opinion. Cross-sectional electronic survey.

Carpal Fractures Other than Scaphoid in the Athlete.

Carpal fractures of bones other than the scaphoid occur at a much lower rate than scaphoid fractures. The close relationship between the carpus, intrinsic and extrinsic wrist ligaments, and wrist kinematics makes a thorough history, clinical examination, and interpretation of imaging for carpal malalignment essential. Carpal malalignment should be addressed with reduction and fixation. Nondisplaced fractures are often treated nonoperatively and displaced intraarticular fractures are almost always treatment operatively. The physician should keep in mind the athlete's specific goals and needs. Treatment must be individualized. Options for early return to play should be discussed when possible.

Management of Finger Joint Dislocation and Fracture-Dislocations in Athletes.

Although finger joint dislocations are generally thought of as benign by many athletes and assumed to be a sprain, these injuries represent a spectrum that includes disabling fracture-dislocations. Failure to recognize certain dislocations or fracture-dislocations may result in permanent deformity and loss of motion. Simple dislocations are frequently amenable to early return to play with protection; however, more complex injuries may require specialized splinting or surgery. Delay in diagnosis of unstable proximal interphalangeal fracture-dislocations may require reconstruction or fusion. Early diagnosis and appropriate treatment are essential to ensure optimal functional results.

Bilateral posterior fracture dislocation of the shoulders : review of case reports and treatment.

Bilateral Posterior Fracture Dislocation (BPFD) of the shoulder is an uncommon but not rare presentation. We describe etiology, diagnostics, treatments and outcome and give a historic review and with a current approach of this pathology. We reviewed 55 cases (110 shoulders), mostly men (49/55), with a mean age of 49.2 years, mean follow up 21.9 months, mean delay until diagnose of 12.7 days (0-112 days), with a seizure as the cause in 80.0% . Other causes are electrocution, trauma or other. If the mechanism is not clear an epileptic insult should be considered the cause until proven otherwise. Closed reduction or mini open reduction is common in the more dated literature, but gives a overall good outcome. Arthroplasty is the prefered method in the more recent literature. Autografts from the shoulder treated with arthroplasty can be used to reconstruct the articular surface of the contralateral shoulder. High index of suspicion is important and a CT is most important diagnostic tool.

The addition of an anti-rotation screw to the dynamic hip screw.

The aim of this study is to assess if there is a difference in outcomes between a dynamic hip screw with or without an anti-rotation screw in the treatment of hip fractures. All patients with an intracapsular hip fracture who underwent dynamic hip screw osteosynthesis between January 2010 and December 2013 in three Dutch hospitals were reviewed. Minimal follow-up was one year. The study included a total of 364 patients. 24 patients were lost to follow-up and excluded. 297 (87.4%) were in the dynamic hip screw group and 43 (12.6%) in the dynamic hip with anti-rotation screw group. Direct comparison of patient characteristics of the two groups showed significant differences in age, sex, Garden classification and Pauwels classification. Patients operated with a dynamic hip screw and anti-rotation screw are significantly younger and their fractures are significantly more dislocated and steeper. To draw conclusions about differences in outcome, a randomised clinical trial should be performed.

Entrapment of the extensor pollicis longus tendon in a pediatric Smith fracture: A case report.

RATIONALE: Most pediatric distal radius fractures are effectively treated nonoperatively; however, operative intervention is indicated in patients with open and highly unstable fractures, in those with concomitant neurovascular injuries and in patients whom soft tissue interposition between fracture fragments precludes anatomical reduction. Notably, soft tissue interposition between fracture fragments is diagnostically challenging. Surgeons must be mindful of this rare complication for early detection and prompt treatment. PATIENT CONCERNS: A 14-year-old boy presented to the emergency department with left wrist pain after falling from a bicycle. Plain radiography and computed tomography revealed a displaced Smith fracture, which was irreducible by closed reduction, necessitating open reduction and volar plate fixation. The patient reported inability to extend his thumb at his 6-week postoperative follow-up visit. DIAGNOSIS: Ultrasonography showed extensor pollicis longus (EPL) tendon entrapment near the fracture site. INTERVENTIONS: A second operation was performed 10 weeks after the first surgery, and intraoperative exploration revealed EPL tendon entrapment. The EPL tendon was torn to shreds; therefore, extensor indicis proprius tendon transfer was performed for EPL tendon reconstruction. OUTCOMES: The patient's thumb motion was completely restored after the second operation. LESSENS: EPL tendon entrapment in a pediatric Smith fracture is rare. Signs of EPL tendon entrapment include inability to perform active thumb extension, dorsal wrist pain radiating along the course of the EPL tendon, which is exacerbated by thumb flexion, a tenodesis effect elicited on thumb examination, and difficulty in anatomical fracture reduction. Surgical exploration of the EPL tendon is warranted in patients presenting with any of these signs following attempted reduction of a Smith fracture.

Hip arthroscopy-assisted reduction and fixation for femoral head fracture dislocations: Clinical and radiographic short-term results of seven cases.

PURPOSE: Femoral head fracture dislocations are serious articular fractures that are associated with soft tissue injuries and are challenging to treat. Arthroscopic surgery may be a way to treat fracture reduction and fixation, thereby avoiding the need for extensive arthrotomy. METHODS: We followed up a consecutive series of seven patients with femoral head fracture dislocation via a scope-assisted percutaneous headless screw fixation between 2016 and 2017. The clinical and radiological results were assessed. RESULTS: The locations of the fracture were all involving infra-foveal area. The mean follow-up duration was 18 (range 12-24) months. The mean Harris hip score was 90.8 (range 88-93) at the latest follow-up. None of the patients showed early osteoarthritis, heterotopic ossification, or avascular necrosis. The average maximal displacement of the fracture site was improved from preoperative 6.79 mm (range 4.21-12.32) to postoperative 2.76 mm (range 0.97-3.97). Concomitant intra-articular hip lesions secondary to traumatic hip dislocation can also be treated. CONCLUSION: Managing the infra-foveal fracture of the femoral head using arthroscopic reduction and fixation with headless screws can be a safe and minimally invasive option. More patients and longer follow-up are needed for a definite conclusion.

A comparison of bone union and complication rates between locking and non-locking plates in distal fibular fracture: Retrospective study of 106 cases.

BACKGROUND: Ankle fractures represents the third most frequent fracture in elderly patients. There is a current tendency to fix long bones fractures with locking plates. However, we rarely find published accounts about the use of locking plates in distal fibula fractures, except for biomechanical ones, studying human cadaveric fibula. OBJECTIVES: The main objective was to compare radiographic bone union rates at 6 and 12 weeks of follow up, then wound complications and hardware removal rates, and construct cost. STUDY DESIGN & METHODS: We retrospectively analyzed 105 patients who underwent surgery with locking plates or non-locking plates over a two-year period, out of which 42 patients were treated with non-locking plates (VIVES™ - StrykerⓇ) and 63 with locking plates (VariAx™ - StrykerⓇ,). We analyzed bone union on anterior posterior and lateral X-rays of the ankle. We collected data of wound complications and hardware removal from patient records. Multiple linear regression techniques were performed after identifying dependent variables. RESULTS: There was no significant difference between non-locking and locking plates in the radiographic bone union rate of distal fibula, respectively at 6 and 12 post-operative weeks (85.71% vs. 81%; p = 0.525 and 97.62% vs. 96.83%; p = 1). No significant difference was found in the wound complication rate between the two groups (11.9% vs. 11.12%; p = 0.9). No significant differences were found in the hardware removal rate, either with or without operative site's infection (respectively: 30.95% vs. 39.68%; p = 0.361 and 21.42% vs. 38.09%; p = 0.071). Cost efficiency is in the favor of non-locking plates. CONCLUSION: Non-locking constructs are as effective as locking constructs in the treatment of displaced distal fibula fractures at a substantially lower cost. High-quality randomized controlled trials are needed in the future to verify the finding of this study.

Hidden blood loss after hip hemiarthroplasty using the superPATH approach: A retrospective study.

OBJECTIVE: The purpose of this study was to compare perioperative hidden blood loss after hip hemiarthroplasty via the SuperPATH approach and the conventional posterior approach (the Moore approach). PATIENTS AND METHODS: From January 2015 to January 2017, 130 patients (80.7 ±â€¯6.0 years) with displaced femoral neck fracture (Garden type III or IV) undergoing hip hemiarthroplasty were included in this study. As a non-randomisation study, Fifty-two patients (SuperPATH group) were operated using the SuperPATH approach, and 78 patients (Moore group) were operated with the conventional posterior approach (Moore approach). The demographic and relevant clinical information of the patients were collected. According to the combination formulas of Nadler, Gross and Sehat, the hidden blood loss (HBL) of each patient was calculated. Student's t-test for independent samples was used to compare the normally distributed variables and the Mann-Whitney U test was used to compare variables not following a normal distribution. RESULTS: The visible blood loss (VBL) in the SuperPATH group was 123.7 ±â€¯47.5 ml, the hidden blood loss (HBL) was 1084.1 ±â€¯816.8 ml and the HBL% was 82.7 ±â€¯16.5%. In the Moore group, the VBL was 303.6 ±â€¯139.6 ml, the HBL was 700.2 ±â€¯563.8 ml and the HBL% was 61.5 ±â€¯23.8%. The patients in the SuperPATH group had more HBL and HBL% (P < 0.05). However, no significant difference was observed of total blood loss (TBL) between the two groups (P = 0.125). CONCLUSIONS: HBL should not be ignored in patients who underwent hip hemiarthroplasty for displaced femoral neck fractures, as it is a significant portion of TBL. Compared with the conventional approach, the SuperPATH approach had a greater amount of HBL. A better understanding of HBL after hip hemiarthroplasty may help surgeons improve clinical assessment and ensure patient safety.

Percutaneous fixation of Lisfranc joint injuries: A systematic review of the literature.

OBJECTIVE: The aim of this systematic review was to present the outcome of Lisfranc joint injuries treated with closed reduction and screw percutaneous fixation. METHODS: We searched in Pubmed and Google Scholar Databases for articles regarding screw percutaneous fixation of Lisfranc injuries. Seven studies in total were found to be compatible to our search, according to PRISMA guidelines. Four of those met the criteria of the review and they were included in the meta-analysis. A total number of 106 patients were separated into five groups according to the type of injury and the mean AOFAS score of each group was calculated. Cases in which percutaneous fixation was converted to open treatment due to poor reduction were not included in the study. In addition we compared the outcome score between types of injury according to Myerson classification as well as between purely ligamentous and osseoligamentous injuries. The characteristics of all seven selected studies, such as kind of screw used for fixation, post operative protocol, complications and outcome are mentioned as well. RESULTS: Average AOFAS score was 86,2 for type A, 87,54 for type B, and 85 for type C injuries respectively. In pure dislocation group the average AOFAS score was 86,43 and in fracture dislocation group was 87,36. Good to excellent outcome can be expected in patients with different types of injury according to Myerson classification following percutaneous fixation of lisfranc joint injury. Patients with type B injury or a fracture dislocation injury might have better outcome, although this difference was not found to be statistically significant. CONCLUSION: Percutaneous fixation of tarsometatarsal joint injuries is a relatively simple and safe method of treatment, leading to a good functional outcome, especially for Myerson type B as well as for fracture dislocation type of injuries, provided that an anatomical reduction has been achieved. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Negative prognostic factors in surgical treatment for trimalleolar fractures.

PURPOSE: Trimalleolar fractures are a common injury of the ankle that require surgical treatment to obtain an anatomic reduction of both malleoli and stabilization of the syndesmosis. This study aims to report the outcomes of surgical treatment for trimalleolar fractures, identifying the risk factors determining a worse result. MATERIALS AND METHODS: Between January 2013 and December 2016, 48 patients with trimalleolar fracture treated with open reduction and internal fixation were retrospectively analyzed. The mean age was 44.69 years, and average body mass index (BMI) was 29.04. According to the Danis-Weber classification, 30 (62.5%) fractures were type B and 18 (37.5%) were type C. Clinical and radiographic evaluations at 3, 6, and 12 months were assessed. The functional results of Visual Analogue Staircases and Olerud-Molander (O&M) ankle score were reported. RESULTS: No significant difference was found among the size of the PM in patients with and without ankle dislocation (p = 0.364). Therefore, there is no correlation between the size of the posterior fragment and the ankle dislocation and the size of the posterior malleolus and syndesmosis stability (p = 0.328). Age over 61 years, BMI > 40, ASA > 1, type C fracture, and fracture dislocation were considered as negative prognostic fractures. CONCLUSIONS: Surgical treatment for trimalleolar fractures needs accurate preoperative planning. Age over 61 years, BMI > 40, ASA > 1, type C fracture, and fracture dislocation were considered as negative prognostic fractures.

Displaced distal radius fracture presenting with neuropraxia of the dorsal cutaneous branch of the ulnar nerve (DCBUN).

Nerve injuries, mostly to the median nerve, are common following distal radius fractures. Ulnar nerve injuries are rarely encountered, with only few case reports of motor or motor and sensory loss described in the literature. In this paper, we report two consecutive cases of young patients with a distal radius fracture and a pure sensory ulnar neuropathy. Both patients had a radially displaced fracture and presented with sensory loss and paresthesia in the distribution of the dorsal cutaneous branch of the ulnar nerve (DCBUN), which resolved after fracture reduction. We believe this clinical scenario is the result of traction or compressive neuropraxia of the DCBUN in the subcutaneous tissue around the ulnar styloid-a neurologic injury which had not yet been described for distal radius fractures.

Bone fractures from generalized convulsive seizures and status epilepticus-A systematic review.

OBJECTIVE: We present a systematic review of the literature regarding types and anatomic distribution of fractures in association with generalized convulsive status epilepticus (GCSE) and convulsive seizures in adult patients accompanied by an illustrative case of a patient with GCSE and diffuse postictal pain from underlying bone fractures. METHODS: The library search engines PubMed and EMBASE were screened systematically using predefined search terms. All identified articles written in English were screened for eligibility by two reviewers. The preferred reporting items for systematic reviews and meta-analyses guidelines were followed. RESULTS: The screening of 3145 articles revealed 39 articles meeting the inclusion criteria. Among all fractures, bilateral posterior fracture-dislocations of the shoulders were reported most frequently (33%), followed by thoracic and lumbar vertebral compression fractures (29%), skull and jaw fractures (8%), and bilateral femoral neck fractures (6%). Risk factors for seizure-related fractures are seizure severity, duration of epilepsy, the use of antiseizure drugs known to decrease bone density, and a family history of fractures. Based on these findings, a three-step screening procedure is proposed to uncover fractures in the postictal state. All studies were retrospective without standardized screening methods for seizure-associated fractures resulting in a very low level of evidence and a high risk of bias. SIGNIFICANCE: Posterior fracture-dislocations of the shoulders, thoracic and lumbar vertebral compression, fractures of the skull and jaw, and bilateral femoral neck fractures are most frequently reported. Preventive measures including bone densitometry, calcium/vitamin D supplementation, and bisphosphonate therapy should be reinforced in epilepsy patients at risk of osteoporosis. As long as the effect of standardized screening of fractures is not investigated, it is too early to integrate such a screening into treatment guidelines. In the meantime, clinicians are urged to heighten awareness regarding seizure-associated fractures, especially in patients with postictal pain, as symptoms can be unspecific and misinterpretation may impede rehabilitation.

Unstable Dorsal Fracture-Dislocations of the Proximal Interphalangeal Joint: Volar Plate Fixation with or without Bone Graft.

BACKGROUND: To evaluate the treatment of severe dorsal fracture dislocation (DFD) injuries of the proximal interphalangeal joint (PIPJ) by open reduction, bone grafting and fixation with mini-hook plates. METHODS: Fourteen patients with extensive dorsal fracture dislocation of the PIPJ were operatively treated to reconstruct the fractured middle phalanx volar lip using a fabricated hook plate in conjunction with elevation and bone grafting of depressed articular fragments where present. RESULTS: Restoration of PIPJ articular anatomy and congruence by hook plate fixation permitted full-range mobilization of the joint during fracture healing, with an average arc of motion of 81° and an average loss of extension of 12.9° at a minimum of 6 months follow up. Hook plate treatment of PIPJ fracture dislocation restores articular anatomy and joint congruence at a single sitting and permits post-operative mobilization without the need for extension block splinting. CONCLUSIONS: Our results demonstrate a good range of motion following treatment, however hardware removal and tenolysis was necessary in 36% of cases.

Surgical revision of radial head fractures: a multicenter retrospective analysis of 466 cases.

BACKGROUND: Radial head fractures lead to persisting disability in a considerable number of cases. This study aimed to investigate their most common revision causes and procedures. METHODS: This multicenter retrospective study reviewed the cases of 466 adult patients who had undergone surgical revision after operative or nonoperative treatment of a radial head fracture. The initial diagnosis was a Mason type I fracture in 13.0%, Mason type II fracture in 14.6%, Mason type III fracture in 22.8%, Mason type IV fracture in 20.9%, terrible-triad injury in 12.8%, Monteggia-like lesion in 13.1%, and Essex-Lopresti lesion in 2.0%. Initial treatment was nonoperative in 30.2%, open reduction and internal fixation (ORIF) in 44.9%, radial head arthroplasty in 16.6%, radial head resection in 3.7%, sole treatment of concomitant injuries in 2.6%, and fragment excision in 2.0%. Up to 3 revision causes and procedures were recorded per case. RESULTS: The most common complications were stiffness (67.4%), instability (36.5%), painful osteoarthritis (29.2%), ORIF related (14.8%), nonunion or necrosis (9.2%), radial head arthroplasty related (7.5%), ulnar neuropathy (6.0%), and infection (2.6%). Revision procedures frequently included arthrolysis (42.1%), arthroplasty (24.9%), implant removal (23.6%), ligament repair or reconstruction (23.0%), débridement (14.2%), repeated ORIF (8.2%), and/or radial head resection (7.7%). Mason type I or II fractures were primarily revised because of stiffness and painful osteoarthritis. Complications after Mason type III fractures were predominantly ORIF related. Fracture-dislocations showed a wide range of complications, with instability and stiffness comprising the most common causes of revision. CONCLUSIONS: The complications of radial head fractures are characteristic to their classification. Knowledge of these findings might guide surgeons in treating these injuries and may help counsel patients accordingly.