Hobie Summers

A reliable method for intraoperative evaluation of syndesmotic reduction.

Objectives: To determine the accuracy of a technique for intraoperative assessment of syndesmotic reduction in ankle fractures. Design: Prospective, case series. Setting: University hospital. Patients/Participants: Eighteen consecutive patients with suspected syndesmotic injuries were enrolled between 2007 and 2009. The diagnosis of syndesmotic injury was based on static ankle radiographs. The study group consisted of 12 male and 6 female patients with an average age of 32 years (range 19–56 years). Intervention: All patients had mortise and talar dome lateral fluoroscopic images obtained of the uninjured ankle in the operating room. The injured ankle underwent operative reduction and provisional fixation using the uninjured ankle radiographs as a template for comparison. An intraoperative computed tomography (CT) scan was obtained to verify the syndesmotic reduction before syndesmotic fixation. If the reduction was not anatomic, the reduction was revised using fluoroscopy and the CT repeated. Main Outcome Measurements: Accuracy of syndesmotic reduction performed using fluoroscopy and confirmed by intraoperative CT scan. Results: Using the technique described, intraoperative CT confirmed anatomic reduction initially in 17 of the 18 fractures. The 1 case where CT did change the course of treatment, revision of fibular fracture reduction resulted in an anatomic reduction of the syndesmosis on repeat CT. Conclusions: Accurate evaluation of the syndesmotic reduction can be determined intraoperatively using comparison mortise and talar dome lateral fluoroscopic images. Direct visualization of the syndesmosis or CT may not be necessary to achieve an accurate reduction in these injuries.

Does screw configuration affect subtrochanteric fracture after femoral neck fixation

A subtrochanteric femur fracture after cannulated screw fixation of a femoral neck fracture is a devastating complication. We hypothesized that an apex-distal screw orientation would tolerate higher loads to subtrochanteric fracture. Human cadaveric femora were instrumented with three cannulated screws in either an apex-distal or an apex-proximal configuration. Specimens were loaded along the mechanical axis to failure creating a subtrochanteric femur fracture. Ultimate load to failure and the effect of bone density on load to failure were compared between groups. There was a greater load to failure in the apex-distal group compared with the apex-proximal group. The mean force to fracture in the apex-distal group (11,330 N; standard deviation = 3151 N) was greater than the mean force to fracture in the apex-proximal group (7795 N; standard deviation = 3194 N). Previous investigations have shown improved femoral neck fixation with an apex-distal configuration, but none has examined the relationship between screw orientation and subtrochanteric fractures. Our observations support the use of an apex-distal configuration for cannulated screw fixation of femoral neck fractures.

Pediatric calcaneal fractures

Although operative treatment of displaced, intra-articular fractures of the calcaneus in adults is generally accepted as standard practice, operative treatment for the same fractures in the skeletally immature remains controversial, potentially because the outcome for fracture types (intra- vs. extra-articular) and severity (displaced vs. nondisplaced) have been confounded in studies of children. We review herein the results of 21 displaced, intra-articular fractures in 18 skeletally immature patients, who were treated with open reduction and internal fixation using a standard surgical approach and protocol developed for adults. The average pre-operative Böhlers angle on the injured side was −5° (range: −35 – +35) compared to 31° (range: +22 – +47) on the uninjured side, indicating substantial displacement. There were no post-operative infections or wound healing problems, and all but one patient was followed to union (average follow-up: 1.5 years; range: 0.30–4.3 years). Maintenance of reduction was confirmed on follow-up radiographs with an average Böhlers angle of 31° (range: +22 – +49). We demonstrate that results for operative fixation of displaced, intra-articular calcaneal fractures in the skeletally immature are comparable to those in adults when the treatment protocol is the same.

Irreducible Ankle Fracture-Dislocation Due to Tibialis Anterior Subluxation: A Case Report

Irreducible ankle fracture-dislocations are rare. Several cases of irreducible ankle fracture-dislocation have been reported in published studies secondary to the tibialis posterior tendon, deltoid ligament, or extensor digitorum longus tendon blocking the reduction. We report a case of irreducible ankle fracture-dislocation resulting from posteromedial subluxation of the tibialis anterior tendon around a medial malleolar fracture fragment. Ultimately, the ankle required open reduction of the incarcerated tendon to reduce the joint and proceed with internal fixation of the associated fracture. The patients postoperative course was uncomplicated, and the tibialis anterior tendon was functioning at 10 months postoperatively, after which he did not return for follow-up examinations. To our knowledge, this is the first reported case of the tibialis anterior tendon blocking closed reduction of an ankle fracture-dislocation.

Percutaneous Stabilization of Traumatic Peroneal Tendon Dislocation

Level of Evidence: V, Expert Opinion

Advanced Imaging Lacks Clinical Utility in Treating Geriatric Pelvic Ring Injuries Caused by Low-Energy Trauma

Objectives: Is advanced imaging necessary in the evaluation of pelvic fractures caused by low-energy trauma in elderly patients? Design: Retrospective review. Setting: Single institution, Level 1 Trauma Center. Patients: Age ≥60 years old treated for low-energy traumatic pelvic ring injuries. Intervention: None. Main Outcomes: Posterior pelvic ring injuries diagnosed on advanced imaging, radiographic displacement, admission status, hospital length of stay, change in weight-bearing status recommendations, and whether operative treatment was pursued. Results: Eighty-seven patients met the inclusion criteria, of which 42 had advanced imaging to evaluate the posterior pelvic ring (10 magnetic resonance imaging, 32 computed tomography). More posterior pelvic ring injuries were identified with advanced imaging compared with radiographs alone (P < 0.001). There was no statistically significant difference in rate of admission (P = 0.5) or hospital length of stay (P = 0.31) between patients with radiographs alone compared with patients evaluated with radiographs plus advanced imaging. The rate of displacement >1 cm at presentation and 6-week follow-up was unaffected by the presence of a posterior injury diagnosed on advanced imaging. Treatment for all 87 patients remained weight-bearing as tolerated with assist device irrespective of advanced imaging findings, and no patient underwent surgical intervention by 12-week follow-up. Conclusions: Despite frequent identification of posterior pelvic ring injuries in patients evaluated with advanced imaging, admission status, length of hospital stay, radiographic displacement, and treatment recommendations were unaffected by these findings. The use of advanced imaging in elderly patients with low-energy traumatic pelvic ring fractures may not be necessary. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Practicality of exchanging transparent 3D CT for radiography for pelvic fractures

OBJECTIVE We assess the utility of transparent 3D reconstructed CT images for evaluation of traumatic pelvic bony injuries compared to traditional radiographs. METHODS Radiographs and 3D reconstructed CT were anonymized and randomized before review by 4 board certified physicians using a standardized questionnaire and compared to a gold-standard axial CT by a fifth board certified physician. RESULTS 49 patients were included. We found significant agreement (K=[0.5-0.92], p<0.001) and comparable accuracy (K=[0.36-0.38], p<0.02) and ghost images of radiographs and transparent 3D reconstructed CT without a difference in confidence (p=0.38). CONCLUSION Transparent 3D reconstructed CT images may be sufficient for pelvic trauma injury without the use of radiographs.

Evaluation of Common Fractures of the Hip in the Elderly

Hip fractures in the geriatric population are a common injury encountered in the emergency department. The recommendations for preoperative medical workup and management of these patients have recently been evaluated. Although medical therapies have been designed in an attempt to decrease the rate of these fractures, attempts to medically manage osteoporosis has created a new “atypical” fracture pattern that must be recognized and managed appropriately. The current recommendations for preoperative medical evaluation and management of patients with hip fractures will be reviewed. In addition, the epidemic of new fractures created by long-term bisphosphonate use will be described, and the current recommendations for the management of these fractures detailed.