Osteochondral Fracture of Posterior Aspect of Lateral Femoral Condyle After Lateral Patella Dislocation: A Case Report.

CASE: A healthy 15-year-old girl presented with osteochondral fracture at the posterior aspect of the lateral femoral condyle (LFC) associated with a right patellar dislocation after a noncontact injury. The patient remained asymptomatic 18 months after the arthroscopically assisted reduction and internal fixation of the osteochondral fracture using bioabsorbable pins and was able to eventually resume her usual activities of daily living. CONCLUSIONS: This is the first report of an osteochondral fracture at the posterior aspect of the LFC after an acute patellar dislocation, successfully treated with arthroscopically assisted reduction and internal fixation using bioabsorbable pins. This rare injury and unique mechanism of injury have been discussed.

Cough-induced costal cartilage fracture.

We present two cases of atraumatic costal cartilage fracture secondary to violent coughing. Although costal cartilage fractures due to trauma and bony rib fractures due to violent coughing have been described, to our knowledge there have been no prior reported cases of cough-induced costal cartilage fracture. It is important for radiologists to consider costal cartilage fractures, which are often more subtle than osseous injuries, in patients with chest pain, and understand that they may not always be preceded by direct trauma. Identifying this injury is clinically important and will prevent patients from undergoing unnecessary examinations to rule out a cardiac cause of chest pain or a pulmonary embolism.

Histopathological Effects of Bone Cement on Cartilage Tissue.

INTRODUCTION: Glass ionomer bone cement is frequently applied with cartilage grafts in otology, even as a single unit. OBJECTIVE: This experimental study was performed to investigate the histopathological effects of bone cement on cartilage tissue. METHODS: The study was conducted between January 2018 and April 2018 and used 12 New Zealand White rabbits. The right ears of the rabbits constituted the study group, while the left ears were the controls. Ketac Cem Radiopaque (3 M Germany) was used as glass ionomer cement. Tissue samples from the rabbits were subjected to histopathological analysis to compare acute and chronic inflammation, foreign body reaction, angiogenesis, collagenesis, fibrosis, necrosis, cartilage fracture, osseous metaplasia, and loss of chondrocyte nuclei between the groups. RESULTS: The rates of cartilage fracture (P = 0.044), foreign body reaction (P < 0.001), acute inflammation (P = 0.009), chronic inflammation (P = 0.002), and angiogenesis (P = 0.003) were significantly higher in the study group compared with the controls. The study group showed some degree of necrosis; no necrosis was observed in the control group, but the difference was not statistically significant (P = 0.101). There were no significant differences in fibrosis, collagenesis, osseous metaplasia, or loss of chondrocyte nuclei between the groups. CONCLUSIONS: This study showed that application of bone cement can cause acute and chronic inflammation, foreign body reactions, angiogenesis, and cartilage fractures. Further studies are needed to determine the long-term effects of bone cement on cartilage.

A Fatal Mediastinitis Due to a Neck Trauma from an Undeclared Assault.

History of neck trauma should be promptly investigated in patients with severe infections of the chest as mediastinitis. We present a forensic case of a death due to a mediastinitis in a patient with an undetected fracture of the superior horn of the thyroid cartilage that was exclusively revealed at autopsy examination. Histological analyses of the neck tissues showed signs of pharyngeal mucosal microperforation caused by the fracture and surrounded by an inflammatory reaction. The fracture was caused by a not declared manual strangulation attempt, happened several days before medical evaluations. We share our experience to emphasize the importance of revealing the etiologies of fatal infections of the mediastinum both for clinical and forensic purposes.

Incidence and Imaging Findings of Costal Cartilage Fractures in Patients with Blunt Chest Trauma: A Retrospective Review of 1461 Consecutive Whole-Body CT Examinations for Trauma.

Purpose To assess the incidence of costal cartilage (CC) fractures in whole-body computed tomographic (CT) examinations for blunt trauma and to evaluate distribution of CC fractures, concomitant injuries, mechanism of injury, accuracy of reporting, and the effect on 30-day mortality. Materials and Methods Institutional review board approval was obtained for this retrospective study. All whole-body CT examinations for blunt trauma over 36 months were reviewed retrospectively and chest trauma CT studies were evaluated by a second reader. Of 1461 patients who underwent a whole-body CT examination, 39% (574 of 1461) had signs of thoracic injuries (men, 74.0% [425 of 574]; mean age, 46.6 years; women, 26.0% [149 of 574]; mean age, 48.9 years). χ2 and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Interobserver agreement was calculated by using Cohen kappa values. Results A total of 114 patients (men, 86.8% [99 of 114]; mean age, 48.6 years; women, 13.2% [15 of 114]; mean age, 45.1 years) had 221 CC fractures. The incidence was 7.8% (114 of 1461) in all whole-body CT examinations and 19.9% (114 of 574) in patients with thoracic trauma. Cartilage of rib 7 (21.3%, 47 of 221) was most commonly injured. Bilateral multiple consecutive rib fractures occurred in 36% (41 of 114) versus 14% (64 of 460) in other patients with chest trauma (OR, 3.48; 95% CI: 2.18, 5.53; P < .0001). Hepatic injuries were more common in patients with chest trauma with CC fractures (13%, 15 of 114) versus patients with chest trauma without CC fractures (4%, 18 of 460) (OR, 3.72; 95% CI: 1.81, 7.64; P = .0001), as well as aortic injuries (n = 4 vs n = 0; P = .0015; OR, unavailable). Kappa value for interobserver agreement in detecting CC fractures was 0.65 (substantial agreement). CC fractures were documented in 39.5% (45 of 114) of primary reports. The 30-day mortality of patients with CC fractures was 7.02% (eight of 114) versus 4.78% (22 of 460) of other patients with chest trauma (OR, 1.50; 95% CI: 0.65, 3.47; P = .3371). Conclusion CC fractures are common in high-energy blunt chest trauma and often occur with multiple consecutive rib fractures. Aortic and hepatic injuries were more common in patients with CC fractures than in patients without CC fractures. © RSNA, 2017.

Osteochondral Fractures of the Knee in Skeletally Immature Patients: Short-Term Results of Operative Fixation using Omnitech Screws.

PURPOSE OF THE STUDY: Retrospective case series looking at the use of Omnitech compression screws for the management of osteochondral fractures in skeletally immature patients. MATERIAL AND METHODS: Nine patients with a mean age of 14 were included in the study with a mean follow up of 26 months. RESULTS: The average KOOS, IKDC and Tegner Lysholm Scores were 86.7, 90.34 and 96.1 respectively. CONCLUSION: The use of Omnitech screws in the acute setting for skeletally immature patients shows excellent short-term outcomes.

Plantar talar head contusions and osteochondral fractures: associated findings on ankle MRI and proposed mechanism of injury.

OBJECTIVE: To evaluate the significance of plantar talar head injury (PTHI) in predicting osseous and soft tissue injuries on ankle MRI. MATERIALS AND METHODS: The IRB approved this HIPAA-compliant retrospective study. The study group consisted of 41 ankle MRIs with PTHI that occurred at our institution over a 5 ½ year period. Eighty MRIs with bone injuries in other locations matched for age, time interval since injury, and gender formed a control group. Injuries to the following structures were recorded: medial malleolus, lateral malleolus/distal fibula, posterior malleolus, talus, calcaneus, navicular, cuboid, lateral, medial and syndesmotic ligaments, spring ligament complex, and extensor digitorum brevis (EDB) muscle. Twenty separate logistic regressions determined which injuries PTHI predicted, using the Holm procedure to control for family-wise alpha at 0.05. RESULTS: PTHI strongly predicted the occurrence of injuries involving the anterior process of the calcaneus [24 % of cases, odds ratio (OR) 12.66], plantar components of the spring ligament (27 %, OR 9.43), calcaneal origin of the EDB and attachment of the dorsolateral calcaneocuboid ligament (22 %, OR 7.22), cuboid (51 %, OR 6.58), EDB (27 %, OR 5.49), anteromedial talus (66 %, OR 4.78), and posteromedial talus (49 %, OR 4.48). PTHI strongly predicted lack of occurrence of syndesmotic ligament injury (OR 19.6). The PTHI group had a high incidence of lateral ligamentous injury (78 %), but not significantly different from the control group (53 %). CONCLUSIONS: PTHI is strongly associated with injury involving the transverse tarsal joint complex. We hypothesize it results from talo-cuboid and/or talo-calcaneal impaction from a supination injury of the foot and ankle.

Healing potential of the cartilage correlates with location on the femoral head: a basic research using a rabbit model.

PURPOSE: The purpose of this study is to investigate whether healing potential of the femoral cartilage differs according to the site of injury in a rabbit, and whether poor potential of the cartilage repair correlates with the injured site which is not in contact with acetabulum. Furthermore, the efficacy of intraarticular injection of hyaluronic acid into the hip for the cartilage with lower healing potential was evaluated. METHODS: Male Japanese white rabbits were used in this study. Via the posterolateral approach, the articular capsule was incised and a 4 × 4 mm chondral defect was made at the load-bearing area (group A) or at head-neck junction (group B), and intraarticular injection of hyaluronic acid was performed to the group B model (group C). RESULTS: In group A, histological evaluation at 8 weeks revealed that the chondral defect was filled with cartilaginous tissue. However, in group B, the chondral defect was not filled with any tissue and subchondral bone was exposed. In group C, the defect was filled with synovial-like tissue, and smooth surface was reacquired macroscopically. According to the ICRS score, significant differences were detected between group A and group B, group A and group C, and group B and group C. There were no differences in the radiographic findings among the 3 groups. CONCLUSIONS: The cartilage at head-neck junction of the femoral head had poorer healing potential than that at load-bearing area. Administration of HA could be promising for preventing progression of cartilage degeneration even at head-neck junction.

Adolescent patellar osteochondral fracture following patellar dislocation.

PURPOSE: Patellar dislocations in adolescents may cause osteochondral fractures of the patella. The aim of this study was to review the outcomes of adolescent patients who underwent surgical intervention for patellar osteochondral fracture following patellar dislocation. METHODS: Nine patients who underwent surgery for osteochondral fracture of the patella following dislocation were identified retrospectively. Following arthroscopic examination, if the fragment was large enough to support fixation, headless screws or bioabsorbable pins were used. Otherwise, the loose body was excised, and the donor site was managed with a microfracture. Postoperatively, patients were assessed using the International Knee Documentation Committee (IKDC) and Knee injury and Osteoarthritis Outcome Score (KOOS) outcome measures. RESULTS: The average age of the patients was 14.6 with average follow-up 30.2 months. Four of the nine patients underwent fixation, while five patients underwent removal of loose body with microfracture. The average defect size in the nonfixation group was 1.2 cm(2) compared with 3.2 cm(2) in the fixation group. The IKDC scores for fixation and nonfixation groups were 63.9 (SD = 18) and 76.1 (SD = 11.7), respectively. The KOOS subscale scores for symptoms, function in sports and recreation, and knee-related quality of life were higher for the nonfixation group when compared to the fixation group. CONCLUSIONS: This is the first known series examining surgical outcomes of osteochondral fractures of the patella following patellar dislocations in the adolescent population. While patients without fixation were less symptomatic in this series, this may be attributable to more severe injuries in patients undergoing fracture fixation. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Timing in hip arthroscopy: does surgical timing change clinical results?

PURPOSE: To our knowledge, there is no report in the orthopaedic literature that correlates the duration of hip pain with the results of hip arthroscopic surgery. The aim of this study was to compare the modified Harris Hip Score (mHHS) with patient satisfaction in a prospective study over a two year period. METHODS: We present a prospective single-surgeon series of 525 consecutive patients undergoing hip arthroscopy for a labral tear, femoroacetabular impingement (FAI), or a chondral lesion. Modified HHS was recorded for all patients at the time of surgery and at six weeks, six months and one, two and three years after hip arthroscopy. At the time of surgery, patients were divided into three groups based on duration of preoperative symptoms: group A, under 6 months; group B, six months to three years; group C, over three years. RESULTS: Mean age was 39 years. There were significantly better outcomes for patients who underwent surgery within six months of symptom onset compared with those who waited longer. Patients who had symptoms for over 3 years by the time of surgery had a significantly poorer result than those with a shorter symptom duration and a higher chance of requiring revision surgery. CONCLUSIONS: We recommend that patients with a diagnosis of labral tear, FAI or a chondral lesion should undergo hip arthroscopic surgery within six months of symptom onset. Patients with persistent symptoms for over three years should be made aware of the poorer outcome after hip arthroscopy.

[Acute osteochondral lesions after patella dislocation]. / Akute osteochondrale Läsionen nach Patellaluxation.

Acute osteochondral lesions of the knee are injuries often caused by patella dislocations. In cases of negative standard x-rays magnetic resonance imaging (MRI) scans should be used to exclude these injuries, as even large fragments can escape visualization with x-rays. These lesions are strong indications for surgical intervention especially if refixation is considered. The intra-articular defect is visualized using arthroscopy and the dislocated fragment is retrieved entirely. Inspection of the fragment is performed ex situ to determine whether or not refixation should be performed. The refixation technique to be used for lesions in the femoro-patellar joint depends on fragment size and defect site. Current biodegradable implants have demonstrated good clinical results without the need for implant removal. The rehabilitation protocol should be individualized to the patient, size and site of the defect.

Osteochondrosis and osteochondral fragments in Standardbred trotters: prevalence and relationships.

REASONS FOR PERFORMING STUDY: Developmental orthopaedic diseases (DOD) such as osteochondrosis (OC)/osteochondrosis dissecans (OCD), palmar/plantar osteochondral fragments (POF), ununited palmar/plantar eminences (UPE) and dorsoproximal first phalanx fragments are well recognised in the horse. Aetiopathogeneses are controversial and molecular genetic screening of DNA has recently been employed for their elucidation. Precise phenotypic definition and knowledge of breed-specific prevalence and interrelations are essential for the interpretation of following genomic studies in Standardbred trotters. OBJECTIVES: To assess the prevalence, trend of development and interrelation of DOD in tarsocrural, metacarpophalangeal (MCP) and metatarsophalangeal (MTP) joints in Standardbred trotters. METHODS: The tarsocrural and MCP/MTP joints of 464 Norwegian Standardbred yearlings were radiographed and the prevalence and interrelation of osteochondral lesions calculated. RESULTS: Osteochondral lesions were diagnosed in 50.7% of the horses. The prevalence of tarsocrural OC/OCD at the distal intermediate ridge of the tibia (DIT) and the lateral trochlear ridge of the talus (LTT) was 19.3%. The prevalence of OC/OCD in MCP joints was 3.6%, whereas those of POF and UPE in MCP/MTP joints were 23.1 and 3.9%, respectively. Interrelation was evident for 1) most equivalent lesions in joint homologues, 2) OCD DIT and OCD LTT and 3) POF and UPE. Lesions in hock and fetlock joints were generally not significantly associated. CONCLUSIONS: The prevalence of tarsocrural OC/OCD in Norwegian Standardbreds is apparently increasing, whereas that of other articular DOD appears stable. Association analyses verify bilateralism for most equivalent lesions and suggest aetiological resemblance also between other lesions. The absence of a significant association between tarsocrural OCD and POF implies that the lesions must be considered statistically different disorders. POTENTIAL RELEVANCE: The prevalence results emphasise that DOD should be considered in Standardbred breeding regimens (e.g. by sire selection subsequent to progeny testing). Also, improved phenotypic definitions will help elucidate the true causal genes in following genomic studies.

Oesophageal balloon tracheoplasty in early tracheal stenosis following percutaneous tracheostomy.

Percutaneous tracheostomy is an efficient technique used in intensive care units. Although a safe procedure, serious early and late complications can occur. A rare complication is suprastomal stenosis following inadvertent tracheal cartilage fracture resulting in stenosis. Management is complicated, often requiring specialised equipment. While surgical treatment techniques are evolving, none are universally applicable. We report a case of early tracheal stenosis following percutaneous tracheostomy, treated successfully using a novel technique of oesophageal balloon tracheoplasty. To our knowledge, this is the first reported case of immediate post percutaneous tracheostomy suprastomal stenosis treated with balloon tracheoplasty using an oesophageal balloon catheter which is readily available in most endoscopy units.

Causes of laryngeal cartilage and hyoid bone fractures found at postmortem.

The principal aims of this retrospective study were to assess the prevalence and causes of laryngo-hyoid fractures found in coroners' adult postmortem examinations over a five-year period. In 78 of 1930 cases (4%), there was a fracture of the larynx (thyroid or cricoid cartilage) or hyoid bone. The thyroid cartilage alone was fractured in 38 cases; the hyoid bone alone was fractured in 19 cases; the larynx and hyoid bone were both fractured in 21 cases, including one which involved the cricoid cartilage. There was no evidence of surface injury to the neck in 14.1% of cases. The majority (44/78; 56.4%) involved classical manual or ligature 'pressure to the neck', i.e. hanging (32) or strangulation (12) but a significant minority (35.9%) involved other circumstances: road/rail traffic collision (12; 15.4%); falls (6; 7.7%); assaults involving blunt force trauma to the head and neck (4; 5.1%); incised wounds (3; 3.8%); gunshot wounds (2; 2.6%); and explosion (1; 1.3%). The circumstances of death and cause of fracture(s) were 'unascertained' in four cases (5.1%). Postmortem artefact accounted for two cases (2.6%).

Fracture patterns of the nasal septum.

OBJECTIVE: To evaluate fracture patterns of the nasal septum. STUDY DESIGN: Cross-sectional cadaveric study. SETTING: Synthes research laboratories, Philadelphia, PA. SUBJECTS AND METHODS: Eighteen cadavers were divided into three groups. Group A was subjected to low-level force administered to the nasal tip. Group B underwent moderate-level force and group C high-level force. Cadavers subsequently underwent dissection of the nose and nasal septum. RESULTS: Fracture patterns were apparent and related to the force applied. Fracture patterns were classified into three types depending on the location and extent. Group A was the most variable. Three cadavers were classified as type 1, two as type 2, and one as type 3. The average amount of force required to produce a fracture in this group was 100 N. Group B cadavers all developed type 3 fractures. Group C cadavers primarily developed type 3 fractures except for one that developed a type 1. Fractures were further classified in regard to the septum being displaced off the nasal spine. CONCLUSION: Based on our observation, we conclude that fracture patterns of the nasal septum do exist and appear to be related to the amount of force sustained.

Surgical management of articular cartilage defects in the knee.

The treatment of isolated cartilage lesions of the knee is based on several underlying principles, including a predictable reduction in the patient's symptoms, improvements in function and joint congruence, and prevention of progressive damage. Surgical options for cartilage restoration are described as palliative treatments, such as débridement and lavage; reparative, such as marrow stimulation techniques; or restorative, such as osteochondral grafting and autologous chondrocyte implantation. The choice of an appropriate treatment should be made on an individual basis, with consideration for the patient's specific goals (such as pain reduction or functional improvement), physical demand level, prior treatment history, lesion size and location, and a systematic evaluation of the knee that considers comorbidities, including alignment, meniscal status, and ligament integrity. It is important for the physician to be familiar with the indications, surgical techniques, and clinical outcomes of the available treatment options for chondral defects of the knee.

Airway injury during emergency transcutaneous airway access: a comparison at cricothyroid and tracheal sites.

BACKGROUND: Oxygenation via the cricothyroid membrane (CTM) may be required in emergencies, but inadvertent tracheal cannulation may occur. In this study, we compared airway injury between the tracheal and CTM sites using different techniques for airway access. METHODS: Anesthesiologists performed 4 airway access techniques on excised porcine tracheas. The techniques were 1) wire-guided (WGT), 2) trocar (TT), 3) needle cannula (NCT), and 4) surgical-scalpel with endotracheal tube (ST). Participants performed each technique at both the CTM and tracheal sites. Specimens were assessed for injury. RESULTS: Injury was observed in 8 of 40 and 27 of 40 specimens at the CTM and tracheal sites, respectively (P < 0.001). Injury was more frequent at the tracheal site compared with the CTM in both the TT and ST groups (P = 0.02) but not for the NCT and WGT. The rank order for any injury at the tracheal site was ST (9 of 10) = TT (9 of 10) > WGT (6 of 10) > NCT (3 of 10) (P = 0.02, highest versus lowest), whereas there was no difference in injury at the CTM. The rank order for posterior injury at the tracheal site was TT (9 of 10) = ST (9 of 10) > WGT (5 of 10) > NCT (2 of 10) (P = 0.005, highest versus lowest). The rank order for penetrating injury at the tracheal site was ST (6 of 10) = TT (6 of 10) > WGT (2 of 10) > NCT (1 of 10) (P = 0.057, highest versus lowest). There was no difference in the incidence of lateral, superficial, or perforating injuries among sites and techniques. Fractures were more common at the tracheal site (15 of 40 vs 0 of 40, P < 0.001) and differed by technique. The rank order of fracture incidence at the tracheal site was ST (6 of 10) > WGT (5 of 10) > TT (4 of 10) > NCT (0 of 10) (P = 0.011, highest to lowest). Compression of >50% was seen in 10 of 40 vs 28 of 40 (P < 0.001) specimens at the CTM and tracheal sites, respectively. The rank order of compression of >50% of airway lumen for both sites was TT > ST > WGT > NCT (P = 0.03, P < 0.001, CTM and tracheal sites, respectively, highest versus lowest). CONCLUSION: Airway injury and luminal compression were more common at the tracheal site than at the CTM. The ST and TT were associated with the highest incidence of injury. This has implications for emergency airway access in cases in which it may be difficult to accurately identify the CTM.