David Limb

Radial nerve palsy associated with fractures of the shaft of the humerus A SYSTEMATIC REVIEW

The management of radial nerve palsy associated with fractures of the shaft of the humerus has been disputed for several decades. This study has systematically reviewed the published evidence and developed an algorithm to guide management. We searched web-based databases for studies published in the past 40 years and identified further pages through manual searches of the bibliography in papers identified electronically. Of 391 papers identified initially, encompassing a total of 1045 patients with radial nerve palsy, 35 papers met all our criteria for eligibility. Meticulous extraction of the data was carried out according to a preset protocol. The overall prevalence of radial nerve palsy after fracture of the shaft of the humerus in 21 papers was 11.8% (532 palsies in 4517 fractures). Fractures of the middle and middle-distal parts of the shaft had a significantly higher association with radial nerve palsy than those in other parts. Transverse and spiral fractures were more likely to be associated with radial nerve palsy than oblique and comminuted patterns of fracture (p < 0.001). The overall rate of recovery was 88.1% (921 of 1045), with spontaneous recovery reaching 70.7% (411 of 581) in patients treated conservatively. There was no significant difference in the final results when comparing groups which were initially managed expectantly with those explored early, suggesting that the initial expectant treatment did not affect the extent of nerve recovery adversely and would avoid many unnecessary operations. A treatment algorithm for the management of radial nerve palsy associated with fracture of the shaft of the humerus is recommended by the authors.

DOES ‘CANAL CLEARANCE’ AFFECT NEUROLOGICAL OUTCOME AFTER THORACOLUMBAR BURST FRACTURES?

Surgical decompression of the spinal canal is presently accepted worldwide as the method of treatment for thoracolumbar burst fractures with neurological deficit in the belief that neurological recovery may be produced or enhanced. Our clinical and laboratory experience, however, indicates that the paralysis occurs at the moment of injury and is not related to the position of the fragments of the fracture on subsequent imaging. Since the preoperative geometry of the fracture may be of no relevance, our hypothesis, backed by more than two decades of operative experience, is that alteration of the canal by surgical clearance does not affect the neurological outcome. We have reviewed the existing world literature in an attempt to find evidence-based justification for the variety of surgical procedures used in the management of these fractures. We retrieved 275 publications on the management of burst fractures of which 60 met minimal inclusion criteria and were analysed more closely. Only three papers were prospective studies; the remainder were retrospective descriptive analyses. None of the 60 articles included control groups. The design of nine studies was sufficiently similar to allow pooling of their results, which failed to establish a significant advantage of surgical over non-surgical treatment as regards neurological improvement. Significant complications were reported in 75% of papers, including neurological deterioration. Surgical treatment for burst fracture in the belief that neurological improvement can be achieved is not justified, although surgery may still occasionally be indicated for structural reasons. This information should not be withheld from the patients.

A Dynamic Study of Thoracolumbar Burst Fractures

BACKGROUNDnThe degree of canal stenosis following a thoracolumbar burst fracture is sometimes used as an indication for decompressive surgery. This study was performed to test the hypothesis that the final resting positions of the bone fragments seen on computed tomography imaging are not representative of the dynamic canal occlusion and associated neurological damage that occurs during the fracture event.nnnMETHODSnA drop-weight method was used to create burst fractures in bovine spinal segments devoid of a spinal cord. During impact, dynamic measurements were made with use of transducers to measure pressure in a synthetic spinal cord material, and a high-speed video camera filmed the inside of the spinal canal. A corresponding finite element model was created to determine the effect of the spinal cord on the dynamics of the bone fragment.nnnRESULTSnThe high-speed video clearly showed the fragments of bone being projected from the vertebral body into the spinal canal before being recoiled, by the action of the posterior longitudinal ligament and intervertebral disc attachments, to their final resting position. The pressure measurements in the synthetic spinal cord showed a peak in canal pressure during impact. There was poor concordance between the extent of postimpact occlusion of the canal as seen on the computed tomography images and the maximum amount of occlusion that occurred at the moment of impact. The finite element model showed that the presence of the cord would reduce the maximum dynamic level of canal occlusion at high fragment velocities. The cord would also provide an additional mechanism by which the fragment would be recoiled back toward the vertebral body.nnnCONCLUSIONSnA burst fracture is a dynamic event, with the maximum canal occlusion and maximum cord compression occurring at the moment of impact. These transient occurrences are poorly related to the final level of occlusion as demonstrated on computed tomography scans.

Measurement of canal occlusion during the thoracolumbar burst fracture process

Post-injury CT scans are often used following burst fracture trauma as an indication for decompressive surgery. Literature suggests, however, that there is little correlation between the observed fragment position and the level of neurological injury or recovery. Several studies have aimed to establish the processes that occur during the fracture using indirect methods such as pressure measurements and pre/post impact CT scans. The purpose of this study was to develop a direct method of measuring spinal canal occlusion during a simulated burst fracture by using a high-speed video technique. The fractures were produced by dropping a mass from a measured height onto three-vertebra bovine specimens in a custom-built rig. The specimens were constrained to deform only in the impact direction such that pure compression fractures were generated. The spinal cord was removed prior to testing and the video system set up to film the inside of the spinal canal during the impact. A second camera was used to film the outside of the specimen to observe possible buckling during impact. The video images were analysed to determine how the cross-sectional area of the spinal canal changed during the event. The images clearly showed a fragment of bone being projected from the vertebral body into the spinal canal and recoiling to the final resting position. To validate the results, CT scans were taken pre- and post-impact and the percentage canal occlusion was calculated. There was good agreement between the final canal occlusion measured from the video images and the CT scans.

Evaluation of the mechanical and architectural properties of glenoid bone

Successful glenoid fixation in shoulder arthroplasty is partly dependent on the properties of the underlying bone. Therefore, mapping of the glenoid surface and locating the bone with the highest quality, in terms of mechanical properties and morphology, is a key requirement in ensuring effective fixation. To this end, an investigation was undertaken to study the relationship between indentation behavior and the quality of the glenoid bone. Nineteen embalmed glenoids were obtained from human cadavers (mean age at death, 82 years). Each specimen was tested using a cylindrical indentor at 11 predetermined points to investigate load-displacement behavior. Microcomputed tomography analysis was performed to ascertain the bone volume (BV)/total volume (TV) fraction of the trabecular bone and the subchondral thickness. Statistical analysis showed that both strength and modulus varied with indentation position. Significant relationships were found between either strength or modulus and BV/TV or subchondral thickness, although the explained variance was relatively low.

Spontaneous isolated rupture of popliteus tendon presenting as locked knee: case study and literature review

Traumatic isolated rupture of the popliteus tendon has been described as a rare cause of haemarthrosis of the knee. There has been only one reported case of spontaneous rupture of the popliteus tendon in the English literature before. We present the case of a 70-year-old lady who had spontaneous rupture of the popliteus tendon without history of significant trauma. She presented with a painful locked knee without any features of instability. The diagnosis was made on arthroscopy of the knee and she made a complete recovery after partial excision of the torn tendon. Our literature review looks at treatment options in relation to best functional outcome.RésuméLa rupture traumatique isolée du tendon poplité a été décrite comme une cause rare d’hémarthrose du genou. Il n’y a eu qu’un seul cas de rupture spontanée de tendon poplité rapporté jusqu’à présent dans la littérature anglo-saxonne. Nous présentons le cas d’une femme de 70 ans qui a eu une rupture spontanée du tendon poplité sans histoire traumatique évidente. Elle s’est présentée avec un genou douloureux bloqué sans aucun signe d’instabilité. Le diagnostic a été fait par arthroscopie du genou et elle récupéra complètement après excision partielle du tendon déchiré. Notre revue de la littérature a été orientée sur la recherche des options thérapeutiques qui ont permis d’obtenir le meilleur résultat fonctionnel