Jinshe Pan

A occult and regular combination injury: the posterior malleolar fracture associated with spiral tibial shaft fracture.

PURPOSE It is known that tibial diaphyseal fractures are often associated with the posterior malleolar fracture (PMF). There are a few studies on tibial shaft fractures with respect to posterior malleolus fracture. However, we found that the incidence of PMF was higher than the previously reported. METHODS A total of 288 tibial shaft fractures were studied to analyze posterior malleolar in the Third Hospital of Hebei Medical University between January 2005 and June 2007. From June 2007, computed tomography (CT) scan or magnetic resonance imaging (MRI) was routinely performed in the ankle region, whereas the distal third spiral tibial fracture was found in the primary plain X-ray films. RESULTS The PMF was found in 28 cases (9.7% of 288 cases). Only nine cases were observed preoperatively in plain X-ray films, four cases were detected intraoperatively, and 15 cases were not detected at all during the treatment. In the retrospective study, three PMF of 34 tibial shaft spiral fractures was detected in plain films, 23 PMFs detected by CT, and 4 PMFs detected by MRI. In four cases, there was no PMFs. CONCLUSION Spiral fractures of the distal tibia commonly have an associated occult posterior malleolus fracture. Even the careful radiographic examination of the ankle joint, that is mandatory before surgery, may not detect this injury. CT scan or MRI may be a compensative method to detect these injuries. CT scan should be routinely performed in clinical practice.

The anterior dislocation of the sacroiliac joint: a report of four cases and review of the literature and treatment algorism

Pelvic fractures are an uncommon injury in pediatric trauma patients, but the morbidity and mortality associated with these injuries can be profound. Of the posterior pelvic ring disruptions, the posterior dislocation of sacroiliac joint, which is the traditional dislocation of the sacroiliac joint, occurs in most incidences of pediatric trauma patients. There are few reports, however, on the “anterior” dislocation of sacroiliac joint, in which the ilium dislocates anterior to the sacrum and often combines with symphyseal diastasis and fractures of pubic rami and ilia. The distinct fracture-dislocation of sacroiliac joint is a subtype of completed posterior pelvic fracture. Literature review contains little information about such type of dislocation. We present four cases of pediatric trauma patients with the “anterior” dislocation of sacroiliac joint. After a thorough literature review of existing classification of pelvic fractures, we name it as the anterior dislocation of sacroiliac joint.

The application of the axial view projection of the S1 pedicel for sacroiliac screw.

BACKGROUND The objective of this study was to position the iliosacral screws speedily, easily, and safely, we sought to delineate readily reproducible radiographic anatomic clues of the pedicel of S1 for the iliosacral screw placement. METHODS We used eight normal adult pelvic specimens lying on the operation table in the prone position. First, the C-arm fluoroscope unit is positioned for the lateral view of the body of S1. We gradually changed the angle of the C-arm to ventral and cephalad. When a clear oval track image appears, we fix the angle of the C-arm. With the assistance of the C-arm projection, the starting point for the guide pin is centered on the oval track, and the orientation is adjusted. When the projection of the guide pin became a point inside of the oval track, the guide pin is inserted using battery-powered equipment. The accuracy and angle of pin placement is assessed using computed tomography scans in all cases. RESULTS In all the pelves, the oval track has been successfully found, and the guide pins are accurately inserted using the sacral pedicel axial view. In the angular orientations by the computed tomography scan, the transverse plane inclination to the ventral of the guide pin is approximately 38.3 degrees +/- 1.9 degrees, and the frontal plane inclination to the cephalad is approximately 29.6 degrees +/- 2.0 degrees. CONCLUSION The sacral pedicel axial view projection is a optimal radiographic technique for percutaneous placement of iliosacral screws in clinical practice. We can get the limpid axial view of pedicel of S1 to applicate this project method, which provides a speedier method with less radiation exposure for percutaneous placement of iliosacral screws.

The role of the calcar femorale in stress distribution in the proximal femur

Objective:  To investigate the role of the calcar femorale in stress distribution in the proximal femur.

An irreducible variant of femoral neck fracture: a minimally traumatic reduction technique.

We present 25 cases of irreducible variant femoral neck fractures that require surgical management after routine manipulative manoeuvre attempts have failed. In our study, an irreducible variant of femoral neck fractures is defined as a reduction that cannot be achieved after multiple attempts at closed reduction. This was evident radiographically, as seen in displaced–impacted femoral neck fractures when the proximal femur compacts and rotates along with the distal part, and anatomical reduction cannot be achieved with manipulative manoeuvres. Another rare situation also included is when the proximal fragment disconnects from the femur and dislocates as a ‘floating’ component, consequently resulting in failure of alignment of the distal fragment to the proximal femur.Here, we describe a technique, applied as a minimally traumatic procedure to achieve anatomic reduction in such cases. With the patient placed in supine position on the fracture table under general anaesthesia, the injury site is exposed and the procedure performed under intra-operative radiographic control. Location of the femoral artery is done first by palpation. The insertion site of the K-wires or Steinman pins on the proximal thigh is 1.5–3 cm lateral to the femoral artery. The K-wires or Steinmanpins are inserted vertically into the middle 1/2–2/3 of the femoral head and more than 1 cm inferior to the sub-chondral bone of the femoral head to a depth of approximately, 1/2 diameter of the femoral head. The pins are then used as a joystick to control the movement of the proximal femur. With the help of the K-wires, surgeons can manually control the movement of the proximal femur and ensure anatomic reduction with the distal fragment using routine-closed reduction. Three cannulated screws are used to stabilise the fracture after anatomic reduction is achieved and maintained in a stable position. All cases were treated with this minimally invasive procedure and internal fixation, 25 fractures united,uneventfully, whilst two of them developed femoral head necrosis at 10 months and 4.5 years postoperatively, respectively.

Superior gluteal artery injury presenting as delayed onset shock.

Injury to the superior gluteal artery (SGA) is usually associated with acetabular fractures or posterior pelvic ring injuries. The diagnosis is suspected in cases of initial hemodynamic instability which is refractory to resuscitation. The initial presentation is often dramatic and is caused by direct injury to the artery at the time of traumatic impact. In these cases, patient management at most trauma centers follows a pre-arranged algorithm which decreases the likelihood of a missed diagnosis. Delayed arterial bleeding, however, is rare and potentially catastrophic since most algorithms are not designed to detect these infrequent occurrences. We present two such cases due to initial blunt buttock trauma combined with an anterior pelvic ring fracture and a L2 spine fracture which resulted in delayed massive bleeding from the SGA. Delayed arterial bleeding should be considered in late onset shock associated with pelvic or lumbar vertebrae body fractures or direct buttock injury. If active bleeding is suspected, urgent arteriography with embolization is the treatment of choice.

Irreducible lateral knee dislocation with incarceration of the lateral femoral condyle in the posterolateral capsuloligamentary structures: a case report and literature review

Knee dislocations are relatively rare 1 , often associated with neurovascular injury, and usually amenable to closed reduction 2 . The irreducible knee dislocation is an even rarer occurrence 3 , 4 . Irreducibility of a knee dislocation is usually due to the medial femoral condyle being buttonholed through the gap formed by medial capsuloligamentary structures. We have treated a rare irreducible dislocation of the left knee in which the neurovascular status was intact. MRI revealed entrapment of the posterolateral capsuloligamentary structures in the intercondylar notch. Emergency operation was performed to reduce the dislocation and reconstruct the injured ligaments. We have described the case in order to present the characteristics of this dislocation and guidelines for its diagnosis and treatment.

Axial view of acetabular anterior column: a new X-ray projection of percutaneous screw placement

IntroductionTo search for a new radiographic view/projection of the acetabular anterior column to provide a safe guide for percutaneous screw placement for acetabular fractures.Materials and methodsEight pelvic specimens taken from normal adult cadavers were positioned in a supine position on the operating table. First, the ipsilateral ilium-oblique view of the observed side was obtained on C-arm fluoroscopy by tilting the C-arm approximately 35° toward the contralateral hip joint. Then, the tilting angle of the C-arm was changed gradually until an oval track image (acetabular anterior column axial view) appeared. The oval shadow was clear only in one position as the angle of the C-arm was changed toward the caudal side of the operating table. A guide pin was put on the skin of the cadaver, and the location and tilting direction of the guide pin were adjusted under C-arm fluoroscopy until the pin’s shadow became a point in the center of the oval track. Then, the guide pin was inserted into the bone using a battery-powered drill. The degree of inclination of the guide pin in the cadaver in the frontal and sagittal planes was measured using computed tomography (CT).ResultsAxial views of the anterior column were found successfully in all of the pelvic specimens, and the guide pins were inserted accurately into the acetabular anterior column under C-arm fluoroscopic guidance. On the CT-reconstructed image, the average degree of angle between the guide pin and the sagittal plane was 33.6° (range 29.6°–36.5°). The average angle between the guide pin and the transverse plane was 59.1° (range 56.4°–63.2°).ConclusionThis axial view of the acetabular anterior column is a novel X-ray projection which provides an optimal method for guiding percutaneous insertion of anterior column screws for acetabular fractures.

The application of closed reduction internal fixation and iliac bone block grafting in the treatment of acute displaced femoral neck fractures.

Objective This study aimed to evaluate the preliminary clinical and radiographic outcomes of acute displaced femoral neck fracture treated by closed reduction and internal fixation (CRIF) with free iliac bone block grafting with comparison to a routine protocol of CRIF without bone grafting. Methods From December 2008 to February 2010, 220 adult patients with acute displaced femoral neck fractures were enrolled in this study. In study group, there were 124 patients (57 males, 67 females) with a mean age of 44.8 years (range, 20-64 years). There were 70 transcervical fractures and 54 subcapital fractures. The patients were treated by CRIF and free iliac bone block grafting. The control group consisted of 96 adult patients (46 males, 50 females) with a mean age of 46.3 years (range, 23-64 years). There were 61 transcervical fractures and 35 subcapital fractures. The patients in control group were treated by CRIF without bone grafting. Results In study group, 112 patients were followed up for an average of 27.4 months (range, 24-34 months). All fractures healed within 5 months. However, 10 patients presented AVN of the femoral heads. The mean Harris score was 88.6 (range, 41-100). In control group, 68 patients were followed up for an average of 31.2 months (range, 24-42 months). The rates of AVN of the femoral head and fracture nonunion in control group were 26.5% (18/68) and 16.2% (11/68), respectively, significantly higher than those in study group (both P<0.05). The mean Harris score in control group was 83.8 (41–100), significantly lower than that in study group (P<0.05). Conclusion Acute displaced femoral neck fractures can be treated by CRIF and free iliac bone block grafting in a minimally invasive manner. This technique can guarantee uneventful fracture healing and significantly reduce the rate of femoral head osteonecrosis.

Unusual Combination of Posterior Femoral Head Dislocation With Anterior and Posterior Wall Fractures in the Ipsilateral Acetabulum

Although hip dislocation combined with acetabular fracture is not an uncommon injury, anterior acetabular wall fractures rarely occur in patients who have posterior fracture-dislocations of the hip. This article presents a unique case of anterior and posterior wall fractures of the ipsilateral acetabulum in a patient who sustained traumatic posterior hip dislocation that resulted from a high-speed motor vehicle accident. The initial imaging evaluation, which did not include the obturator oblique view, revealed no concomitant anterior acetabular wall fracture. Repeated manipulative reductions were unsuccessful in reducing the displaced hip joint. Pelvic computed tomography (CT) scans revealed the initially missed anterior acetabular wall fracture fragments incarcerated in the left hip joint in addition to the hip dislocation and the posterior acetabular wall fracture. The incarcerated bone fragments lay between the anterior wall and the femoral head, and between the posterior wall and the femoral head, which appeared to derive from both anterior and posterior acetabular walls, respectively. Open reduction and internal fixation was performed to manage the posterior dislocation and associated acetabular fractures. Intraoperatively, the major anterior wall fragment was used to reconstruct the defected posterior wall. This case highlights the necessity of suspicion and pre- and postoperative monitoring of the obturator oblique view and CT scans to detect the potentially existing anterior acetabular wall fracture. Early surgical intervention is important to guarantee satisfactory outcomes of such complex fracture-dislocation injuries.