Alessandra Maresca

Critical review of pelvic fractures associated with external iliac artery lesion: A series of six cases

INTRODUCTION Bleeding associated with pelvic fracture mostly comes from the pre-sacral and lumbar venous plexus, or directly from the fracture site. Bleeding as a consequence of arterial lesion is less common (15-20%), and that resulting from lesion of the external iliac artery (EIA) is extremely rare. The mortality rate associated with iliac artery injury ranges from 38% to 72%. Total body CT-scan with contrast medium, angiography or packing can be performed when there is arterial injury. In some cases, embolisation can stop bleeding; however, when there is involvement of the aorta, common iliac artery or EIA, immediate surgery is mandatory. The aim of this study was to report our experience of pelvic fractures associated with EIA lesion. MATERIALS AND METHODS Six patients with pelvic fracture and associated rupture of the EIA have been observed at our unit from 2004 to 2009. According to Tile classification there were three cases of type C and two cases of type B fracture. One case was a two-column acetabular fracture. Angiography was performed in all cases. RESULTS Three patients died on the day of trauma: two after angiography, and one after surgery of vascular repair. Three patients survived: two underwent a hemipelvectomy, and one underwent hip disarticulation. DISCUSSION Haemodynamic instability in patients with pelvic ring fracture is usually because of venous bleeding from the pre-sacral and lumbar plexus, or from the fracture site. Arterial injury is present in around 20% of cases. EIA lesions require immediate surgical treatment to restore blood flow. Depending on the type of injury, vascular surgery can be associated with pelvic fracture stabilisation. CONCLUSIONS Pelvic ring fracture associated with an EIA lesion is extremely rare, with few cases reported in the literature. Angiography is used for diagnosis, and immediate surgical treatment is required to restore blood flow. Associated injuries and open fracture can lead to fatal complications or amputation. Rates of mortality and severe disability are extremely high.

Asymmetrical bilateral traumatic fracture dislocation of the hip: a report of two cases

We report on two cases of simultaneous asymmetrical bilateral hip dislocation. Both patients were involved in car accidents. The first case is a 23-year-old man who had a bilateral hip dislocation, anterior on the right side and posterior on the left associated with bilateral femoral head fracture. The second case presented the same dislocations of the hips associated with acetabular fracture on the right side. Closed reduction of the hips was performed in both cases. In the first case the femoral head fragments was subsequently removed. In the second case internal fixation of the acetabular fracture was postponed.

Methods to avoid gamma nail complications

Femoral neck fractures are progressively increasing, due to higher survival rates, particularly among the female population. The gamma nail was created to treat intertrochanteric fracture types 31-A1, 31-A2 and 31-A3 and in some cases basicervical fractures of type 31-B2-1. Complications can be classified as intraoperative and postoperative. The intraoperative might be related to the nail’s introduction site, lag and distal locking screw positions. Postoperative complications depend mostly on an incorrect surgical technique, which can lead to an inaccurate nail position and consequent implant failure. We rarely observe failures caused by severe bone osteoporosis.

Multifocal humeral fractures

INTRODUCTION Multifocal humeral fractures are extremely rare. These may affect the neck and the shaft, the shaft alone, or the diaphysis and the distal humerus. There is no classification of these fractures in the literature. MATERIALS AND METHODS From 2004 to 2010, 717 patients with humeral fracture were treated surgically at our department. Thirty-five patients presented with an associated fracture of the proximal and diaphyseal humerus: synthesis was performed with plate and screws in 34 patients, and the remaining patient had an open fracture that was treated with an external fixator. RESULTS Mean follow-up was 3 years and 3 months. A classification is proposed in which type A fractures are those affecting the proximal and the humeral shaft, type B the diaphysis alone, and type C the diaphysis in association with the distal humerus. Type A fractures are then divided into three subgroups: A-I, undisplaced fracture of the proximal humerus and displaced shaft fracture; A-II: displaced fracture of the proximal and humeral shaft; and A-III: multifragmentary fracture affecting the proximal humerus and extending to the diaphysis. DISCUSSION Multifocal humeral fractures are very rare and little described in the literature, both for classification and treatment. The AO classification describes bifocal fracture of the humeral diaphysis, type B and C. The classification suggested in this article mainly concerns fractures involving the proximal and humeral shaft. CONCLUSIONS A simple classification of multifocal fractures is suggested to help the surgeon choose the most suitable type of synthesis for surgical treatment.

Intra-articular fragments in acetabular fracture-dislocation.

Acetabular fractures are often associated with dislocation of the femoral head. When the dislocation is reduced, > or = 1 fragments may remain inside the joint, especially in posterior dislocation. In this kind of dislocation, the fracture of the posterior wall of the acetabulum may be comminuted. The fragments attached to the joint capsule or free may remain between the femoral head and the acetabulum. During reduction, these fragments are dragged inside the joint. The presence of the fragments in the hip joint may prevent complete reduction of the dislocation. Surgery should be performed early to reduce the risk of aseptic necrosis of the femoral head. Sometimes the fragments derive from a fracture of the femoral head without involving the posterior wall. Fragments are difficult to detect by conventional radiography; therefore, computed tomography scans are always indicated in fracture-dislocations pre- and postoperatively to check that all intra-articular fragments have been removed and the fracture has been reduced. We observed 373 cases of acetabular fracture between January 1, 1997 and December 31, 2007. One hundred twenty-seven cases presented a dislocation: 5 anterior, 13 central, and 109 posterior. In 45 cases, after reduction of the dislocation, 2 anterior and 43 posterior intra-articular fragments were observed. Removing a loose body inside the joint is always necessary because movement causes damage of the cartilage and therefore an early arthritis. The strategy to remove and the approach differs according to the kind of dislocation observed.

Le fratture laterali del femore prossimale: tecnica MIPO

An increase in the elderly population has resulted in a higher incidence of peritrochanteric fractures of the femur. The goal in the treatment of these fractures is to achieve a stable fixation, which allows for early patient mobilization. The Gamma 3 nail represents a minimally invasive surgical procedure. The minimally invasive technique results in greater respect for tissues, less blood loss and then a quick recovery.

Come affrontare e prevenire le complicanze e gli insuccessi nelle fratture laterali del collo del femore trattate con l’inchiodamento endomidollare

Complications of treatment with intramedullary nail of lateral femoral fractures can be divided in intraoperative and postoperative. Intraoperative complications are usually related to poor fracture reduction, to the target device, to inadequate X-ray control and to incorrect nail introduction. Postoperative complications are usually related to synthesis malpositioning, to poor fracture reduction, to lateral fractures engaging the femoral neck and generating an unstable fracture, to bone stock loss in low proximal femoral fractures and to fracture non-union.