Multiligament knee injuries with associated tibial plateau fractures: A report of two cases

The management of a combination of fracture and multiligament knee injury (MKI) in traumatic knee injury remains controversial, and there are evolving treatment recommendations. Currently, there are no studies focusing on older adult patients with MKI’s in combination with tibia fractures. As a result, there is no well-established treatment algorithm for older adult patients with these complex injuries. We report two cases of MKI’s with concomitant fractures in patients fifty years of age or older. Both patients were treated surgically for their associated tibial plateau fractures, but were managed with conservative treatment of the multiligamentous knee injuries. We also provide a review of the literature and guidelines for older adult patients with these types of complex traumatic injuries. Early to mid term acceptable outcomes were achieved for both patients through surgical fixation of the tibial plateau fracture and conservative treatment of the ligament injuries. We propose a comprehensive treatment algorithm for management of these complex injuries.     

Femoral vessel injuries; high mortality and low morbidity injuries

Femoral vessel injuries are amongst the most common vascular injuries admited in busy trauma centers. The evolution of violence and the increase in penetrating trauma from the urban battlefields of city streets has raised the incidence of femoral vessel injuries, which account for approximately 70% of all peripheral vascular injuries. Despite the relatively low mortality associated with these injuries, there is a high level of technical complexity required for the performance of these repairs. Similarly, they incur low mortality but are associated with significantly high morbidity. Prompt diagnosis and treatment are the keys to successful outcomes with the main goals of managing ischemia time, restoring limb perfusion, accomplishing limb salvage and instituting rehabilitation as soon as possible.     

Lisfranc- und Chopart-Luxationsfrakturen

Injuries of the Chopart and Lisfranc joint lines are severe injuries of the foot which can cause severe alteration of the entire foot function. Even today these injuries are frequently missed because they often occur in patients with multiple traumatic injuries, but low energy trauma to the foot might also lead to difficulties in diagnosis due to a heterogeneous clinical appearance. Therefore an important aspect is the exact radiological diagnostics especially even if there is a minimal clinical suspicion. Standard plain x-rays in three planes and a CT examination are essential. The goal of the treatment is an anatomical reconstruction of the joints and the treatment of concomitant ligamentous injuries, which can only be achieved with open reduction and adequate osteosynthesis or temporary arthrodesis. Using an appropriate and consistent therapy a satisfactory outcome for the patient can be achieved even with serious injuries.     

Management of intra-articular metacarpal base fractures of the second through fifth metacarpals

Intra-articular fractures of the second through fifth metacarpal bases are uncommon injuries but can result in serious morbidity if improperly managed. These injuries usually occur because of forced flexion of the wrist with simultaneous extension of the arm, as occurs with a punch or a fall. As there are few large series of reports for these injuries, there is no consensus in the current literature on the most appropriate treatment for them. Whereas some authors have reported successful results after closed reduction, many recommend open reduction with internal fixation to ensure the integrity of the tendinous insertions of the extensor carpi radialis longus, extensor carpi radialis brevis, and extensor carpi ulnaris. This article reviews the case reports and case series extant in the literature concerning intra-articular fractures of the bases of the second through fifth metacarpals, and it provides important diagnostic and management considerations for these injuries.     

Sportverletzungen – Möglichkeiten und Grenzen der konservativen Therapie

Germans have an above average participation in sports in a European comparison and sustain approximately 2 million sports-related injuries per year. Professional athletes sustain injuries much more often than amateur athletes. The most common injuries in sports are muscular injuries, especially injuries of the ischiocrural muscles. Treatment of these injuries is the domain of conservative treatment using a variety of methods. The most common treatment modalities are presented and analyzed with respect to their evidence base. Despite extensive use of the measures recommended for conservative management, especially in professional sports, not all treatment modalities are evidence-based and potentially associated with significant risks. In addition, there are limits to conservative treatment, which justify surgical treatment of muscle injuries. Apart from impending compartment syndromes, which must be treated only by surgery, the indications for surgery in muscle injuries should be reserved for difficult cases and after careful consideration. Even initial attempts at conservative treatment have demonstrated good results after protracted care. Particular examples exist within professional soccer at the Champions League level, demonstrating that conservative management of grade III ruptures of the hamstring close to the attachment point enables a return to competition.     

Aktuelle Aspekte und neue Techniken bei Schultereckgelenksprengung

With 12% of all injuries concerning the shoulder, acromioclavicular (AC) joint dislocations are a common injury especially in young and active patients. The Rockwood classification is widely accepted, which differentiates between six types depending on the degree of injury and the vertical dislocation. Because the classification does not adequately address the horizontal instability, its benefits are questionable and there is currently no consensus. For this reason, the classification and the therapy of these injuries are increasingly becoming the subject of scientific investigations. Whereas conservative treatment for type I and II injuries and operative treatment for type IV–VI injuries are widely accepted, there is still no agreement in treating type III lesions. The goal of this review article is to present the current evidence for the diagnostics, different classifications and therapeutic possibilities.     

Costs of hand emergencies

In France at the present time, there is no comprehensive registry of hand injuries. Three types of occurrences; motor vehicle accidents, work accidents, and accidents incident to activities of daily living, are covered by different types of insurance. It is the individual insurance companies, payers of the indemnification, who maintain registries of these accidents. Statistics on work accidents are very detailed and consistent, but they are oriented toward risk management. The aggregate cost of traumatic injuries to the hand is not known. Only large financial institutions are equipped to determine appropriate preventive measures and to establish premium rates based on loss experience. In 2001, hand injuries accounted for 27% of work accidents causing loss of work of at least 1 day. About 29.8% of these work accidents caused permanent partial impairment. About 17.7% of total days lost and 18.2% of the total costs of permanent impairment were due to hand injuries. In the system of compensation for work accidents, there is a major difference in the cost according to the severity of the impairment. If the permanent impairment is equal to or less than 9%, a lump sum payment is made, but if the permanent impairment is over 9%, the worker receives regular payments for the rest of his life. In 2000, the average cost of a work injury with partial permanent impairment of over 9% was [symbol: see text] 85,405, while the average cost of a lump sum settlement was only [symbol: see text] 1479, a ratio of 57 to 1. The compensation costs represent 80% of the cost of work accidents, while the cost of treatment, including all providers and institutions, makes up only 20% of the cost. Compensation for sequelae of accidents in the course of daily life is new for the insurance companies, although these accidents are frequent and often cause significant repercussions in the professional lives of victims because of the loss of hand function. Provision of optimal treatment for these traumatic injuries from the very first moment is the best strategy for the third party payers. Better results of treatment not only reduce the costs of compensation for permanent partial impairment, but also greatly diminish the psychological impact on the injured worker. In the future, the management of the costs of these work injuries will become a priority. Pressure from consumers, which is growing, will favor this trend through the intermediary of private insurance companies.     

Trauma to the medial ray of the foot: A classification of patterns of injury and their management

AimsFractures and dislocations of the midfoot are relatively uncommon but can be life changing injuries. Within the literature, there has been scant specific reference to the identification and management of medial ray injuries in midfoot trauma. Moreover, it is appreciated that these injuries are associated with poor outcomes. We aim to clearly define these injury characteristics and demonstrate fixation techniques.Patients and methodsA retrospective review of the case notes and imaging was conducted for operatively treated midfoot injuries between January 2013 and January 2018.Results161 patients were identified, 31 of these with imaging and operative diagnosis suggestive of medial ray injury. Studying these 31 injuries revealed five patterns of injury.ConclusionWhen treating midfoot trauma, it is important to fully understand the injury pattern as this dictates the principles and techniques of fixation. Identification and knowledge of these five injury patterns will aid surgeons in future management of these injuries and may improve treatment outcomes.     

Indications for operative fixation of distal radius fractures - a review of the evidence

Operative fixation of distal radius fractures is one of the most commonly performed orthopedic procedures. However, there remains little consensus on the indications for operative versus nonoperative treatment of these injuries. The American Academy of Orthopaedic Surgeons has recently published clinical practice guidelines to help guide management of these injuries. The purpose of this paper is to review the biomechanical and clinical retrospective and prospective data pertinent to the indications for operative management of distal radius fractures. Conflicting data exists as to the optimal management of these injuries, especially in patients over the age of 55. Although there is some evidence to support operative fixation of distal radius fractures, better longterm, prospective, randomized studies with validated patient outcome measures are needed to definitively establish the optimal method of treatment for these injuries.     

Platelet enriched plasma for acute muscle injury

Hamstring muscle strains are among the most common injuries in sport, but despite increasing research into the epidemiology, aetiology and management the rates of both injury and re-injury remain high. Typically, hamstring injury management is conservative, but recently the use of autologous platelet enriched plasma (PEP), has been proposed as a treatment tool which may optimise muscle regeneration and enhance clinical outcomes. Unfortunately however, there remains little scientific evidence for the clinical use of these techniques in muscle injuries. This report outlines the current clinical evidence for the use of PEP in muscle injuries. A case report of a patient with a grade II semi-membranosus muscle strain, injected with PEP while concurrently using platelet inhibitors will illustrate the clinical, radiological and theoretical challenges of this new technique. Further clinical research into the clinical utility of PEP in muscle injury is required and it is incumbent on Sports Physicians and researchers to address this research deficit, if PEP is to live up to its high public profile.     

Injuries as a result of treatment of tibial fractures in children: Claims for compensation submitted to the Patient Insurance Center in Finland

Background and purpose Tibial fractures comprise 10% of all fractures in children. To our knowledge there have been no previous reports of treatment injuries in these fractures. We analyzed compensation claims concerning treatment of these fractures in Finland. We used this information to determine preventable causes of treatment injuries.Material and methods In Finland, the Patient Insurance Center (PIC) provides financial compensation for patients who have sustained an injury in connection with medical treatment or operation. We retrospectively analyzed all claims for compensation arising from treatment of tibial fractures in children that had been received by the PIC between 1997 and 2004. The mode of treatment, complications, and permanent sequelae were assessed. We also estimated the number of avoidable treatment injuries.Results and interpretation The PIC received 50 claims for compensation during the 8-year study period. The claims were based on the following issues: pain, incorrect diagnosis and treatment, permanent disability, extra treatment expenses, inappropriate behavior of the medical personnel, and loss of income of the parents. 35/50 claims had received compensation, of which 32 were related to the treatment and 3 to infections. The treatment injuries that had led to compensation comprised a delay in diagnosis and treatment in 15 patients, inappropriate casting in 9, inappropriate operative treatment in 5, and other causes in 3 patients. An unsatisfactory standard of treatment and missed diagnosis were the most common reasons for compensation. In restrospect, all but 1 of the 35 injuries that had led to compensation were considered to be avoidable.     

A military perspective to articular cartilage defects

Articular cartilage injuries present a challenge in terms of definitive treatment in the United States military population. Active duty soldiers' physical demands are unlike the general population in that a military career requires soldiers to maintain a physical activity level similar to that of an athletic population. Current treatment options for the chondral defect include microfracture, osteochondral transplantation, and autologous chondrocyte implantation. These treatment modalities carry specific advantages and disadvantages and must be considered when evaluating and treating patients with chondral injuries. It is unclear which procedure is the best first-line treatment for these injuries, but newer studies are beginning to evaluate these procedures over time and in high demand populations. The purpose of this article is to review current treatment options as they relate to return to full activity of the young "combat athlete." Results of each treatment option from published data will be compared and reviewed throughout this article.     

Acute injuries of the distal radioulnar joint

Distal radioulnar joint injuries can occur in isolation or in association with distal radius fractures, Galeazzi fractures, Essex-Lopresti injuries, and both-bone forearm fractures. The authors have classified DRUJ/TFCC injuries into stable, partially unstable (subluxation), and unstable (dislocation) patterns based on the injured structures and clinical findings. Clinical findings and plain radiographs are usually sufficient to diagnose the lesion, but axial CT scans are pathognomonic. Diagnostic arthroscopy is the next test of choice to visualize stable and partially unstable lesions. Stable injuries of the DRUJ/TFCC unresponsive to conservative measures require arthroscopic debridement of the TFCC tear, along with ulnar shortening if there is ulnar-positive variance. Partially unstable injuries, on the other hand, are treated with direct arthroscopic or open repair of the TFCC tear, once again, along with ulnar shortening if ulnar-positive variance is present. Unstable injuries include simple and complex DRUJ dislocations. A simple DRUJ dislocation is easily reducible but may be stable or unstable. In complex dislocation, reduction is not possible because there is soft tissue interposition or a significant tear. After the associated injury is dealt with, treatment for complex injuries requires exploration of the DRUJ, extraction of the interposed tissue, repair of the soft tissues, and open reduction and internal fixation of the ulnar styloid fracture (if present and displaced). The early recognition and appropriate treatment of an acute DRUJ injury are critical to avoid progression to a chronic DRUJ disorder, the treatment of which is much more difficult and much less satisfying.     

距骨软骨损伤的诊疗进展

距骨软骨损伤的诊断可依据患者的症状、病史、MRI检查、详细的体格检查及关节镜检查,治疗上包括保守治疗和手术治疗,保守治疗风险较小,对于轻度损伤效果好;手术治疗包括清创、骨髓刺激术、内固定术以及软骨移植、自体软骨细胞移植、关节腔内注射生物附加物、超声波及电磁刺激技术、组织工程技术等。目前临床最常使用的方法是清创骨髓刺激术、软骨移植及自体软骨细胞移植术。清创、骨髓刺激术在关节镜下微创进行,操作简单、费用低、手术效果好、患者术后疼痛轻,但其术后形成的是纤维软骨,对于小范围损伤成功率较高,一旦失败将造成更大范围的缺损。软骨移植术可以Ⅰ期完成手术,达到透明软骨恢复,但是供区存在不同程度的病理性变化。软骨细胞移植术能解决初次治疗失败后遗留的较大骨软骨缺损,不影响供区,可达到透明软骨修复。但其治疗时间长,必须分期手术及治疗费用较高。各种治疗方法近期治疗效果满意,但远期疗效仍值得商榷。对于自体软骨细胞移植术及新兴的组织工程学治疗技术,仍具有广阔的科研前景。     

The impact of the 21st century on rugby injuries

STUDY DESIGN: This is a review article concerning rugby injuries resulting in tetraplegia between the years of 1965 and 2000. It is based on a review of worldwide literature. OBJECTIVES: The objective is to evaluate research that has taken place in the last 10 years. SETTING: The author first became interested in this problem in 1965 when there were few papers on the subject. Understanding of these injuries has changed decade by decade and the number of spinal injuries has increased dramatically. For the first three decades the author was actively engaged in gathering material particularly at the National Spinal Injuries Centre. During the last 10 years there has been a greater understanding in the mechanism of these injuries. METHODS: The following subjects were reviewed in the literature: (1). mechanism of injury; (2). the diameter of the spinal canal; (3). arthritis; (4). treatment; (5). fitness and (6). medico-legal aspects. RESULTS: These injuries are no longer regarded as an Act of God or bad luck but mechanisms of injury have been clearly defined. CONCLUSION: To prevent these injuries occurring there is a need for: (1). better statistics; (2). enforcement of the laws; (3). improved standards of refereeing; (4). higher standards of fitness and training in particular to de-power the set scrum; (5). study of the cervical spine to look for abnormalities which would predispose the player to tetraplegia; (6). the use of MRI and CT scans to monitor the spinal cord anatomy; (7). the importance of pathology and the status of the cervical spine; (8). the awareness of the dangers to the cord of congenital and acquired abnormalities that could prejudice spinal cord function and (9). the awareness of the necessity for comprehensive insurance.     

Trattamento ottimale delle lesioni degli arti superiori nel polifratturato

In the last decades there has been an increase in the rate of high-energy traumas. They lead to multiple traumatic injuries, affecting different organs and body systems. The approach to these multi-trauma patients is complex and requires the cooperation of a multi-disciplinary team of experts working together. Orthopaedic treatment is generally considered after vital parameters have been stabilized, but should not be excessively postponed to avoid complications at the time of surgery. Upper limb injuries are frequent but often misdiagnosed and not adequately treated. The authors describe the current treatment of the most frequent injuries of shoulder, elbow, wrist and hand in polytrauma patients.     

Hepatic trauma: contemporary management

In the introduction, I posed several questions that were issues/controversies. The answers will probably be interpreted as equally controversial. I do not believe there is strong evidence that the incidence of liver injuries has increased. Diagnostic modalities have contributed to this seeming increase, as well as population increases and the concentration of severe liver injuries in trauma centers, now present in 35 states. I believe there are more blunt injuries now, relative to penetrating injuries. The peak of penetrating injuries occurred in the 1970s and 1980s and lasted almost 2 decades. I believe some authors are overly enthusiastic for nonoperative management. I am particularly critical of authors who do not include all components of the surgical armamentarium into their treatment of severe liver injuries. I also believe that the complications following nonoperative management are currently unacceptable, as documented in the references. I have shared with you the strategies for operative management, but there are equally good or better strategies in the surgical literature.     

Soft Tissue Management in Open Fractures of the Lower Leg: The Role of Vacuum Therapy

Abstract   The management of severe open fractures of the lower leg continues to challenge the treating surgeon. Major difficulties include high infection rates as well as adequate temporary soft tissue coverage. In the past, these injuries were commonly associated with loss of the extremity. Today, vacuum therapy provides not only safe temporary wound coverage but also conditioning of the soft tissues until definitive wound closure. Amongst other advantages, bacterial clearance and increased formation of granulation tissue are attributed to vacuum therapy, making it an extremely attractive tool in the field of wound healing. However, despite its clinical significance, which is underlined by a constantly increasing range of indications, there is a substantial lack of basic research and well-designed studies documenting the superiority of vacuum therapy compared to alternative wound dressings. Vacuum therapy has been approved as an adjunct in the treatment of severe open fractures of the lower leg, complementing repeated surgical debridement and soft tissue coverage by microvascular flaps, which are still crucial in the treatment of these limb-threatening injuries. Vacuum therapy has in general proven useful in the management of soft tissue injuries and, since it is generally well tolerated and has low complication rates, it is fast becoming the gold standard for temporary wound coverage in the treatment of severe open fractures of the lower leg.     

Editorial Commentary: Should Proximal Hamstring Surgery Make You Nervous?

In recent times, there has been an increased awareness of high-grade proximal hamstring injuries, many of which are now being managed surgically. Yet, surgical treatment of these injuries is challenging and carries potential risks of serious neurologic complications. Indeed, it is likely that postoperative neurologic complications are under-recognized. As such, knowledge of the intimate anatomic relation of the pudendal nerve and other neural structures around the proximal hamstring is essential and should provide a road map for safer and more successful surgery.     

Nonunion of a sacral fracture refractory to bone grafting: internal fixation and osteogenic protein-1 (BMP-7) application

Nonunion of a sacral fracture is a serious clinical condition: chronic pain, sitting discomfort, limp, neurological implications, and inability to work are frequent findings. Surgical treatment of these injuries often turns out to be technically difficult also for the expert pelvic surgeon and not infrequently provides poor radiographic and clinical results. The gold standard treatment at present is open excision, reaming of the nonunion site and internal fixation, performed by a multi-stage approach; as an adjunct, autologous cancellous bone grafting is usually performed in most severe cases. We report a case of a sacral nonunion in which traditional techniques failed, successfully treated by osteogenic protein-1 (BMP-7) application. The employment of BMPs demonstrated successful results in various types of fracture, but there is limited experience about their use in pelvic ring injuries: Further studies are necessary to better know the possible complications and to define their actual potential.