Mitchell Bernstein

Sprengel deformity: pathogenesis and management.

&NA; Sprengel deformity (ie, congenital elevation of the scapula) is a rare clinical entity. However, it is the most common congenital anomaly of the shoulder. Sprengel deformity is caused by abnormal descent of the scapula during embryonic development. Sprengel deformity is associated with cosmetic deformity and decreased shoulder function. Diagnostic confusion with limited scoliosis can be dangerous to the patient because it may delay proper treatment of other abnormalities that may be present with even mild cases. Sprengel deformity is commonly linked to a variety of conditions, including Klippel‐Feil syndrome, scoliosis, and rib anomalies. Nonsurgical management can be considered for mild cases. Surgical management is typically warranted for more severe cases, with the goal of improving cosmesis and function. Surgical techniques are centered on resection of the protruding portion of the scapula and inferior translation of the scapula. Recent long‐term studies indicate that patients treated surgically maintain improved shoulder function and appearance.

Management of Posttraumatic Radioulnar Synostosis

&NA; Posttraumatic radioulnar synostosis is a rare complication following fracture of the forearm and elbow. Risk factors for synostosis are related to the initial injury and surgical management of the fracture. Typically, patients present with complete loss of active and passive forearm pronation and supination. Evidence of bridging heterotopic bone between the radius and ulna can be seen on plain radiographs. Although nonsurgical management is sufficient in some cases, surgical excision is typically required. The timing of surgical intervention remains controversial. However, early resection between 6 and 12 months after the initial injury can be performed safely in patients with radiographic evidence of bony maturation. Surgical management consists of complete resection of the synostosis with optional interposition of biologic or synthetic materials to restore forearm rotation. A low recurrence rate can be achieved following primary radioulnar synostosis excision without the need for routine adjuvant prophylaxis.

Primary perivascular epithelioid cell neoplasm (PEComa) of bone: Report of two cases and review of the literature

Primary perivascular epithelioid cell neoplasms (PEComas) of bone are rare mesenchymal tumors. Histologically, they are composed predominantly of perivascular epithelioid cells and have the capacity to metastasize. PEComas have been reported within intra-abdominal and intra-pelvic organs. To the best of our knowledge, only seven primary PEComas of bone have been described in the English literature. We present two cases of PEComa of bone, one arising from the distal fibula and one from the acetabulum. Both were treated by surgical excision and one also received adjuvant chemotherapy.

Ankle Distraction Arthroplasty: Indications, Technique, and Outcomes.

Ankle distraction is an alternative to ankle arthrodesis or total ankle arthroplasty in younger patients with arthritis. Ankle distraction involves the use of external fixation to mechanically unload the ankle joint, which allows for stable, congruent range of motion in the setting of decreased mechanical loading, potentially promoting cartilage repair. Adjunct surgical procedures are frequently done to address lower-extremity malalignment, ankle equinus contractures, and impinging tibiotalar osteophytes. Patients can bear full weight during the treatment course. The distraction frame frequently uses a hinge, and patients are encouraged to do daily range-of-motion exercises. Although the initial goal of the procedure is to delay arthrodesis, many patients achieve lasting clinical benefits, obviating the need for total ankle arthroplasty or fusion. Complications associated with external fixation are common, and patients should be counseled that clinical improvements occur slowly and often are not achieved until at least 1 year after frame removal.

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.

Total hip arthroplasty and femoral nail lengthening for hip dysplasia and limb-length discrepancy

The application of distraction osteogenesis through the use of magnet-operated, remote-controlled intramedullary lengthening continues to provide new opportunities for accurate limb equalization. While limb-length discrepancy and deformity can be addressed by total hip arthroplasty alone, the magnitude of correction is limited by the soft-tissue envelope and complications such as sciatic nerve palsy. This 3-patient case series presents the combination of staged ipsilateral total hip arthroplasty and retrograde intramedullary femoral nail lengthening for the correction of both deformity and limb-length discrepancy. Our results report leg-length equalization, independent ambulation without assistive devices, and excellent bone and functional outcomes without complications, demonstrating that this combined technique can be used to achieve targeted lengthening and deformity correction.

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.

Bifocal Tibial Transport with the TSF

This is a case of a 24-year-old male with a type IIIB right tibial fracture after an injury sustained after a motor vehicle collision. He had a 6 cm bone defect in the diaphysis and soft tissue invagination into the defect. He was treated with application of a Taylor Spatial Frame (TSF), bone transport, and elevation of the flap and docking site grafting. 1 Brief Clinical History An otherwise healthy 24-year-old male suffered an open type IIIB tibial fracture after a motor vehicle collision. He was initially treated with a spanning “trauma”monolateral external fixator. His soft tissue lesion was treated with skin grafting. He had a 6 cm distal diaphyseal bone defect that had not been yet treated. He presented to our service 6months into treatment for management of the bone defect and invagination of the soft tissue. He had not been ambulating on his extremity and developed knee, ankle, and toe contractures. His bone quality demonstrated early signs of disuse osteopenia. 2 Preoperative Clinical Photos and Radiographs