Daniel T. Altman

Clinical spectrum of acute compartment syndrome of the thigh and its relation to associated injuries.

The reason for the described clinical variability of acute compartment syndrome of the thigh, with high morbidity and mortality in some patients and an uncomplicated clinical course in others, is not known. To better define the clinical spectrum and factors determining the clinical course of this rare clinical entity, we did a retrospective multicenter study of 28 patients with 29 thigh compartment syndromes. The leading cause of acute thigh compartment syndrome was blunt trauma from motor vehicle accidents (46%) or contusion (39%). Pain with passive motion was present in all patients who were conscious, followed by paresthesia (60%), and paralysis (42%). The anterior compartment was involved most frequently with mean compartment pressure of 58 ± 3 mm Hg. Myonecrosis, sepsis, and need for skin grafting were observed more frequently in patients with ipsilateral femur fracture. Only 7% of patients with isolated thigh compartment syndromes had short-term complications compared with 57% of patients with ipsilateral femur fractures. The incidence of complications correlated with the time to fasciotomy. Mortality was limited to patients with high injury severity scores. The clinical spectrum of thigh compartment syndrome is comparable with that of other compartment syndromes and its clinical course is determined by its associated injuries.

Functional Outcome After Acute Compartment Syndrome of the Thigh

BACKGROUND Acute compartment syndrome of the thigh is an uncommon condition that is associated with a high rate of morbidity. Because of its rarity, limited information is available on the long-term functional outcome for patients with this condition and the factors that affect the clinical result. METHODS Eighteen patients with acute compartment syndrome of the thigh were evaluated at an average of sixty-two months after treatment. Functional outcome was evaluated by means of physical examination, isokinetic thigh-muscle testing, and validated functional outcome scores. RESULTS Long-term functional deficits were present in eight patients, and only five patients had full recovery of thigh-muscle strength. The persistent dysfunction was reflected in worse overall functional outcome scores. High injury severity scores, ipsilateral femoral fracture, prolonged intervals to decompression, the presence of myonecrosis at the time of fasciotomy, and an age of more than thirty years were associated with increased long-term functional deficits, persistent thigh-muscle weakness, and worse functional outcome scores. CONCLUSIONS Acute compartment syndrome of the thigh is often associated with considerable long-term morbidity. Several factors can affect the functional outcome, and knowledge of these factors can help in the development of a more effective clinical management strategy to reduce long-term morbidity.

Defining the relationship between rotator cuff injury and proximal humerus fractures.

The purpose of our study was to correlate radiographic characteristics with rotator cuff tendon injury on magnetic resonance imaging after fractures of the proximal humerus. We prospectively obtained magnetic resonance imaging on 30 patients with proximal humerus fractures after classifying each fracture radiographically using Neer and AO systems and determining the displacement of the greater tuberosity. Twelve patients (40.0%) had either complete ruptures or avulsions of at least one of the rotator cuff muscles. No abnormality was identified in the rotator cuff musculature in nine patients (29%). Severity of injury to the rotator cuff tendons increased substantially with respect to increasing AO and Neer classes and 5 mm or greater displacement of the greater tuberosity fragment. Additional study is needed to determine the exact role of rotator cuff tendon injury in the ultimate function attained by patients with proximal humerus fractures.Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

CT-Guided Iliosacral Screw Placement: Technique and Clinical Experience

OBJECTIVE The purpose of this study was to describe the technique of and experience in using CT guidance for percutaneous iliosacral screw placement in patients with unstable pelvic fractures. CONCLUSION CT-guided iliosacral screw placement is a safe and accurate procedure that can be performed by radiologists in a radiology suite.

Anterior and posterior fusion for children with tuberculosis of the spine.

The authors reviewed the use of chemotherapy and anterior/posterior spinal fusion without instrumentation to treat children with extensive spinal tuberculosis and kyphosis. Six children underwent anterior and posterior spinal fusion. All of the patients were followed until after maturity, except for 1 child who died of pulmonary tuberculosis 4 months after surgery and thus was excluded from the study. Preoperative kyphotic deformity averaged 100 ° (range, 75 °-130 °). The average age at the time of surgery was 7.5 years (range, 4.7-10 years). Spinal involvement extended from 2 to 10 vertebral bodies (average, 7.6) and was limited to the thoracic region from T-2 to T-12. Preoperative, postoperative, and followup anterior/posterior and lateral standing radiographs were obtained. The kyphotic angle was measured from the lateral view. The surgical correction of preoperative kyphosis averaged 28.6 ° (range, 20 °-45 °). One patient underwent repeat anterior fusion at 9 months for graft failure. At the time of followup, all grafts had fused and all patients were without pain. The average duration of followup was 12.8 years (range, 9.5-14.5 years). Complications secondary to chronic chemotherapy occurred in 2 children. Longterm followup revealed solid fusion, improvement of the kyphotic deformity, and good functional outcome in all 5 patients.

Cervical spine clearance in the traumatically injured patient: is multidetector CT scanning sufficient alone? Clinical article.

OBJECT Clearance of the cervical spine in patients who have sustained trauma remains a contentious issue. Clinical examination alone is sufficient in neurologically intact patients without neck pain. Patients with neck pain or those with altered mental status or a depressed level of consciousness require further radiographic evaluation. However, no consensus exists as to the appropriate imaging modality. Some advocate multidetector CT (MDCT) scanning alone, but this has been criticized because MDCT is not sensitive in detecting ligamentous injuries that can often only be identified on MRI. METHODS Patients were identified retrospectively from a prospectively maintained database at a Level I trauma center. All patients admitted between January 2004 and June 2011 who had a cervical MDCT scan interpreted by a board-certified radiologist as being without evidence of acute traumatic injury and who also had a cervical MRI study obtained during the same hospital admission were included. Data collected included patient demographics, mechanism of injury, Glasgow Coma Scale score at the time of MRI, the indication for and findings on MRI, and the number, type, and indication for cervical spine procedures. RESULTS A total of 1004 patients were reviewed, of whom 614 were male, with an overall mean age of 47 years. The indication for MRI was neck pain in 662 patients, altered mental status in 467, and neurological signs or symptoms in 157. The MRI studies were interpreted as normal in 645 patients, evidencing ligamentous injury alone in 125, and showing nonspecific degenerative changes in the remaining patients. Of the 125 patients with ligamentous injuries, 66 (52.8%) had documentation of clearance (29 clinical, 37 with flexion-extension radiographs). Another 32 patients were presumed to be self-cleared, bringing the follow-up rate to 82% (98 of 119). Five patients died prior to clearance, and 1 patient was transferred to another facility prior to clearance. Based on these data, the 95% confidence interval for the assertion that clinically irrelevant ligamentous injury in the face of normal MDCT is 97%-100%. No patient with ligamentous injury on MRI was documented to require a surgical procedure or halo orthosis for instability. Thirty-nine patients ultimately underwent cervical surgical procedures (29 anterior and 10 posterior; 5 delayed) for central cord syndrome (21), quadriparesis (9), or discogenic radicular pain (9). None had an unstable spine. CONCLUSIONS In this study population, MRI did not add any additional information beyond MDCT in identifying unstable cervical spine injuries. Magnetic resonance imaging frequently detected ligamentous injuries, none of which were found to be unstable at the time of detection, during the course of admission, or on follow-up. Magnetic resonance imaging provided beneficial clinical information and guided surgical procedures in patients with neurological deficits or radicular pain. An MDCT study with sagittal and coronal reconstructions negative for acute injury in patients without an abnormal motor examination may be sufficient alone for clearance.

Symptomatic hypertrophic pubic ramus nonunion treated with a retrograde medullary screw.

Pubic ramus fracture nonunion is an unusual problem. Percutaneous retrograde superior pubic ramus medullary screw fixation was successfully used in two patients with prolonged symptomatic nonunions of the superior pubic ramus.

Results of a Computed Tomography Protocol Evaluating Distal Third Tibial Shaft Fractures to Assess Noncontiguous Malleolar Fractures

BACKGROUND Intra-articular tibia fractures are reported to occur in 1% to 25% of tibia diaphyseal fractures. The objective of this study was to create a standard protocol to evaluate noncontiguous malleolar fractures associated with distal third tibial diaphyseal fractures using computed tomography (CT). METHODS Sixty-six patients with 67 distal third tibia fractures were treated at a level one trauma center from December 2005 to November 2007. These patients were then evaluated using a CT protocol to assess the ankle joint. There were 45 men and 21 women with average age of 44 years (range 18-69 years). All films were independently examined by two orthopedic traumatologists and one musculoskeletal radiologist. RESULTS Twenty-nine of 67 (43%) distal third tibial shaft fractures had associated intra-articular fractures determined by CT scan. There were 23 posterior malleolus fractures, 3 anterolateral fragments, and 3 medial malleolus fractures. Twenty-seven of 29 fractures (93%) were associated with spiral type fracture patterns (p = 0.001). Seventeen of 29 (59%) intra-articular fractures required operative fixation. Seventy-six percent were noncontiguous fractures. The radiologist detected 20 of 29 (69%) intra-articular fractures using high-resolution monitors, and the orthopedic surgeons averaged 13 of 29 (45%) using initial injury radiographs in the emergency department. CONCLUSION Plain radiographs are often insufficient for detecting posterior malleolus fractures in conjunction with ipsilateral distal third diaphyseal tibia fractures. Using a preoperative CT protocol for tibial shaft fractures can significantly improve the ability to diagnose associated intra-articular fractures that may not be evident on plain radiographs. Knowledge of these associated intra-articular fractures may prompt fracture stabilization and can prevent displacement during intramedullary nailing of tibia shaft fractures.

Retrograde nailing of femur fractures in patients with myelopathy and who are nonambulatory

The authors studied 10 consecutive patients with closed femoral shaft or supracondylar fractures who were nonambulatory and who were treated by reamed retrograde intramedullary nailing via an intercondylar notch approach. The study consisted of five women and five men with an average age of 60.7 years (range, 40-89 years). Six patients had spinal cord lesions, one had a brain injury, one had cerebral palsy, one had multiple sclerosis, and one had progressive myelopathy. Three fractures were supracondylar, and seven fractures involved the mid-distal diaphysis. The average time of surgery was 110 minutes (range, 70-225 minutes) with an average estimated blood loss of 288 mL (range, 150-400 mL). There were two postoperative deaths (at 15 days and 2 months, respectively) after the procedure that were attributable to pneumonia. The remaining eight patients were observed for an average of 13 months (range, 6-20 months) after surgery. All fractures healed as evaluated radiographically. Retrograde intramedullary nailing is a simple, safe, and effective alternative to nonoperative treatment for femoral shaft or supracondylar fractures in patients who are nonambulatory. Stabilization by this method allows fracture healing and rapid return of patients to their previous level of function. There were no nonunions, malunions, significant shortening, implant failure, or wound infections.

Femoral bone strains during antegrade nailing: A comparison of two entry points with identical nails using finite element analysis

BACKGROUND Antegrade femoral nailing has become the standard treatment for diaphyseal femoral shaft fractures. Concerns linger that improper location of the nail entry point may lead to iatrogenic fracture and further complications. This study used finite element analysis to compare the strain magnitude and distribution resulting from each of two entry points in the proximal femur during antegrade nailing. METHODS A finite element model was created from a CT scan of a 37 year old male femur and of a standard antegrade nail. Using implicit time-stepping, the nail was inserted through piriformis and trochanteric entry points and strain was computed at 9 anatomic locations. FINDINGS The strain levels were higher overall when inserting a nail through the trochanteric starting point. The highest strain occurred immediately medial and lateral to the trochanteric entry point. The posterior greater trochanter also showed very high strain levels during nail insertion. All strain values for nail insertion through the piriformis entry point were less than 2000 μm/m. INTERPRETATION The trochanteric entry will have a much greater potential of iatrogenic fracture of the proximal femur during insertion of a nail. Strains with this entry point exceed the yield level of bone and the repeated loading with the progression of the nail could cause fissures or fractures. Caution should be taken during insertion of an antegrade nail when utilizing a lateral trochanteric starting point secondary to an increased risk of trochanteric fracture and lateral cortex fracture.