Use of the Patellar-Pubic Percussion Test in the Diagnosis and Management of a Patient with a Non-Displaced Hip Fracture

Abstract

This case report describes the diagnosis and subsequent medical and physical therapy management of a 68-year-old patient with an undiagnosed non-displaced hip fracture. Initial plain film radiographs and a computed tomography (CT) scan of the involved hip were both interpreted as negative. One of the findings on the physical examination included a positive patellar-pubic percussion test (PPPT). This finding in a female patient of this age raised the suspicion of an occult hip fracture and she was referred back to her primary care physician. Repeat radiographs revealed a non-displaced hip fracture and the patient was treated surgically. The PPPT is an easy-to-implement clinical examination tool that may be extremely useful in physical therapy practice to guide the decision-making process for patients with suspected hip fractures. The utilization of the PPPT by the treating physical therapist for the patient in this case report contributed to a timely diagnosis, potentially preventing the disabling sequelae associated with a displaced femoral fracture.     

Pantomography vs Mandibular Series for the Detection of Mandibular Fractures

OBJECTIVE: The two primary radiographic techniques used for the evaluation of mandible injury are a pantomographic series (PS) and the standard four-view mandibular series (MS). Despite a tenuous foundation, there is apparent bias in favor of PS compared with MS. Many emergency departments do not have ready access to the specialized equipment necessary to perform a pantomographic study. The hypothesis of this study was that a high-quality standard MS is as sensitive and specific as a PS in the detection of mandibular fractures. METHODS: This was a prospective, blinded study of 54 patients presenting with acute mandibular injury comparing MS and PS. The study design used two board-certified emergency physicians and a single staff radiologist who read a series of MS and PS films in a randomized fashion without access to clinical information or identifying patient data. The absolute number of fractures present was determined by a neuroradiologist with access to both MS and PS simultaneously as well as pertinent clinical information. RESULTS: Thirty patients had 47 mandibular fractures. The sensitivity for fracture detection for each physician was 0.85, 0.77, and 0.89 with MS and 0.79, 0.74, and 0.83 with PS (p > or = 0.51, p > or = 1.00, and p > or = 0.51, respectively, McNemar's binomial test). The specificity for fracture detection for each physician was 0.88, 0.92, and 0.96 for MS and 0.96, 1.00, and 0.92 for PS (p > 0.625, p > 0.50, and p = 1.00, respectively, McNemar's binomial test). CONCLUSIONS: A standard mandibular series is as sensitive and specific as pantomography in the detection of mandibular fractures.     

透视导航下经皮螺钉置入内固定髋臼骨折18例

背景:移位的髋臼骨折常需要切开复位内固定手术治疗.广泛的手术暴露可以产生许多并发症.经皮螺钉置入内固定髋臼骨折可以减少这些并发症.计算机辅助透视导航技术可以提高螺钉固定的精确度以及减少X射线透视的时间.目的:评估在透视导航指引下经皮螺钉置入内固定髋臼骨折的临床应用结果.方法:使用C臂透视导航设备对伴有20个髋臼损伤的18例患者行导航下髋臼骨折经皮螺钉置入内固定.采集图像后在导航下按照损伤部位分为髋臼前柱骨折和髋臼后柱骨折,分别采用不同的空心螺钉固定.置入后第2天开始进行静力性肌肉收缩以及限制性主动和被动关节活动,4周后开始部分负重锻炼.观察螺钉置入时间,验证螺钉位置偏差,观察螺钉生物相容性及置入后不良反应,随访时进行d'Aubigne and Postel评分.结果与结论:放置空心螺钉30枚.置入中每枚空心螺钉放置平均时间为24.1 min,X射线图像采集平均27.6 s.将导航下图像与真实C臂机射片进行对照,螺钉置入后验证位置平均偏差为1.5 mm,平均偏差角度为2.25°.置入后1例患者出现股神经损伤症状,2个月后恢复,该神经症状与髋臼骨折使用有限切开复位有关,与螺钉置入固定无关.置入后无感染及内固定失败.d'Aubigne and Postel评分优13例,良4例,一般1例,优良率94%.结果证实,对于无移位或移位后能够闭合复位或有限切开复位的髋臼骨折透视导航下经皮螺钉置入内固定技术能够成为一种安全有效的骨折固定方法.     

Occipital condyle fracture in a victim of a motor vehicle collision

Occipital condyle fractures are rarely reported in the Emergency Medicine literature. It is unclear whether these fractures are rare or under-diagnosed. Occipital condyle fractures are associated with high-energy blunt trauma with significant cranial-cervical torque or axial loading. We report a case of a female patient with an occipital condyle fracture. The patient only complained of shoulder pain, but was found to have high cervical spine tenderness, after a moderate-speed front-end motor vehicle collision. Initial cervical spine radiographs were non-diagnostic. Computed tomography of the cervical spine demonstrated a non-displaced occipital condyle fracture. Conservative management with a semi-rigid cervical collar was successful in treating this patient's fracture. A review of the literature covers the diagnosis, radiographic findings, and management of this fracture.     

Nondisplaced pubic ramus fracture associated with exsanguination and death

We present a case of an elderly man who sustained non-displaced fractures through the right superior and inferior pubic rami after a fall from standing and had a tragic outcome. While minimally displaced pubic ramus fractures are typically stable and require only symptomatic treatment, there have been reports, such as this one, of low-energy pubic rami fractures resulting in massive hemorrhage. Despite aggressive resuscitation and embolization of the right obturator artery, our patient ultimately died during his hospitalization. This report highlights the need to maintain a high index of suspicion for intrapelvic bleeds even in patients with nondisplaced pubic rami fractures. Rapid recognition and treatment of intrapelvic bleeds can be lifesaving.     

Evaluation of 238 consecutive patients with the extended data set of the Standardised Audit for Hip Fractures in Europe (SAHFE)

PURPOSE: The aim of this paper is to introduce the extended data set inquiries of the Standardised Audit of Hip Fractures in Europe (SAHFE) and to report our experiences of its use. METHOD: The extended SAHFE data set was applied to 238 consecutive patients (mean age 78.4 (50 - 102) years, 52 males, 186 females) aged over 50 years with non-pathological fractures of the hip. The extended data set contains 95 questions concerning the patient's abilities prior fall and at follow-up, detailed background factors, concomitant diseases, additional details of the injury, treatment, fracture type and reduction and complications. RESULTS: Thirty-nine percent of the fractures occurred at home and 38% in a hospital. Thirteen percent of the cervical fractures were non-displaced (Garden 1 & 2) and half of the trochanteric fractures intertrochanteric two-part fractures (A11 - A13). The mean Garden alignment index evaluated from antero-posterior roentgenograms changed from the preoperative 144 degrees to the postoperative 168 degrees and that from lateral projections from 144 degrees to 171 degrees , respectively. Most of the patients (89%) had associated diseases, especially cardiovascular conditions. The patients' functioning was significantly impaired at four months compared with the preoperative situation according to the ADL score. The need for social support and assistance had increased, respectively. A total of 63% of the surgeries were delayed for more than 24 hours. Low molecular weight heparin was given to every patient for thromboembolic prophylaxis and 92% received antibiotic prophylaxis. Urinary tract (21%) and chest infections (7%) were the most common complications. The deep infection rate was 2.5%. CONCLUSION: The extended SAHFE data set is useful and makes it possible to study in more detail the background and outcome factors of hip fractures in a standardized manner.     

Ultrasound evaluation of elbow fractures in children

Purpose

Elbow fractures are a common pathology in any pediatric emergency unit. X-ray of the elbow is the standard diagnostic procedure. Previous studies have shown that fractures can also be visualized by ultrasound (US). The aim of our study was to evaluate the diagnostic accuracy of US in comparison to X-rays in diagnosing pediatric elbow fractures.

Methods

Sixty-seven patients aged 1–13 years with clinically suspected elbow fracture were first examined by US followed by standard two-plane radiographs. US examination was done with a 12-MHz linear probe from seven longitudinal positions across the distal humerus and additionally from longitudinal positions across the radial head and olecranon. The sonographic and radiological findings were compared in a contingency table, and sensitivity, specificity, and positive and negative predictive values of the US diagnostic procedure were calculated.

Results

With X-ray, we found 48 patients with an elbow fracture and 19 patients with no fracture. With US, we found 46 patients with an elbow fracture and 21 patients with no fracture. In comparison to X-ray diagnosis, we calculated for US diagnosis a sensitivity of 97.9 %, a specificity of 95 %, a negative predictive value of 95 %, and a positive predictive value of 97.9 %.

Conclusion

Typical elbow fractures in children could also be visualized by US. A positive fat pad sign, in particular, serves as a strong indicator for elbow joint fractures and can be identified very sensitively by US. We confirm US as a valuable primary screening tool for elbow injuries in children. In the absence of US signs of fracture and in sonographically confirmed non-displaced fractures, standard X-rays are dispensable, thereby minimizing the X-ray burden in children without loss of diagnostic safety.     

Traitement des fractures récentes du scaphoïde carpien

Scaphoid fractures are common but present unique challenges because of the particular geometry of the bone and the tenuous vascular pattern of the scaphoid. Delays in diagnosis and inadequate treatment for acute scaphoid fractures may lead to non-unions that can progress to carpal collapse and degenerative arthritis of the wrist. Improvements in diagnosis, surgical treatment and implant materials have encouraged a trend toward early internal fixation even for non-displaced scaphoid fractures that could potentially be treated non-operatively. In our experience wrist arthroscopy is a useful tool in the management of these fractures not only for assessing the quality of reduction but also for visualizing osteochondral and ligamentous injuries associated with intra-articular fractures.     

Volume slicing of cone-beam computed tomography images for navigation of percutaneous scaphoid fixation

Purpose  

Percutaneous scaphoid fixation (PSF) is growing in popularity as a treatment option for non-displaced fractures. Success of this procedure demands high-precision screw placement, which can be difficult to achieve with standard 2D imaging. This study aimed to develop and test a system for computer-assisted navigation using volume slicing of 3D cone-beam computed tomography (CBCT).     

双下肢悬吊牵引治疗新生儿股骨干骨折的护理

目的：探讨新生儿股骨干骨折采用双下肢悬吊牵引法治疗的护理方法。方法：回顾性分析我院2001年1月～2006年1月收治的18例股骨干骨折新生儿采用双下肢悬吊牵引法治疗的护理记录及临床资料,总结股骨干骨折新生儿的护理要点。结果：18例股骨干骨折新生儿中,3例出现牵引处皮肤小水疱,3例合并新生儿病理性黄疸。经积极的治疗和精心的护理,5例X线拍片提示对位、对线好,达到临床愈合出院,13例分别于出院后继续小夹板或支具固定,X线片随访3～6个月,发现小儿双下肢活动自如,长度一致,无成角畸形。结论：双下肢悬吊牵引法是治疗新生儿股骨干骨折的常用方法,新生儿股骨干骨折的修复是一个漫长的过程,医院的治疗护理和家庭的延续护理是两个不可缺少的重要环节。     

Evaluation of 238 consecutive patients with the extended data set of the Standardised Audit for Hip Fractures in Europe (SAHFE)

Purpose: The aim of this paper is to introduce the extended data set inquiries of the Standardised Audit of Hip Fractures in Europe (SAHFE) and to report our experiences of its use.

Method: The extended SAHFE data set was applied to 238 consecutive patients (mean age 78.4 (50 - 102) years, 52 males, 186 females) aged over 50 years with non-pathological fractures of the hip. The extended data set contains 95 questions concerning the patient's abilities prior fall and at follow-up, detailed background factors, concomitant diseases, additional details of the injury, treatment, fracture type and reduction and complications.

Results: Thirty-nine percent of the fractures occurred at home and 38% in a hospital. Thirteen percent of the cervical fractures were non-displaced (Garden 1 & 2) and half of the trochanteric fractures intertrochanteric two-part fractures (A11 - A13). The mean Garden alignment index evaluated from antero-posterior roentgenograms changed from the preoperative 144° to the postoperative 168° and that from lateral projections from 144° to 171°, respectively. Most of the patients (89%) had associated diseases, especially cardiovascular conditions. The patients' functioning was significantly impaired at four months compared with the preoperative situation according to the ADL score. The need for social support and assistance had increased, respectively. A total of 63% of the surgeries were delayed for more than 24 hours. Low molecular weight heparin was given to every patient for thromboembolic prophylaxis and 92% received antibiotic prophylaxis. Urinary tract (21%) and chest infections (7%) were the most common complications. The deep infection rate was 2.5%.

Conclusion: The extended SAHFE data set is useful and makes it possible to study in more detail the background and outcome factors of hip fractures in a standardized manner.     

Evaluation of 238 consecutive patients with the extended data set of the Standardised Audit for Hip Fractures in Europe (SAHFE)

Purpose: The aim of this paper is to introduce the extended data set inquiries of the Standardised Audit of Hip Fractures in Europe (SAHFE) and to report our experiences of its use.

Method: The extended SAHFE data set was applied to 238 consecutive patients (mean age 78.4 (50?–?102) years, 52 males, 186 females) aged over 50 years with non-pathological fractures of the hip. The extended data set contains 95 questions concerning the patient's abilities prior fall and at follow-up, detailed background factors, concomitant diseases, additional details of the injury, treatment, fracture type and reduction and complications.

Results: Thirty-nine percent of the fractures occurred at home and 38% in a hospital. Thirteen percent of the cervical fractures were non-displaced (Garden 1 & 2) and half of the trochanteric fractures intertrochanteric two-part fractures (A11?–?A13). The mean Garden alignment index evaluated from antero-posterior roentgenograms changed from the preoperative 144° to the postoperative 168° and that from lateral projections from 144° to 171°, respectively. Most of the patients (89%) had associated diseases, especially cardiovascular conditions. The patients' functioning was significantly impaired at four months compared with the preoperative situation according to the ADL score. The need for social support and assistance had increased, respectively. A total of 63% of the surgeries were delayed for more than 24 hours. Low molecular weight heparin was given to every patient for thromboembolic prophylaxis and 92% received antibiotic prophylaxis. Urinary tract (21%) and chest infections (7%) were the most common complications. The deep infection rate was 2.5%.

Conclusion: The extended SAHFE data set is useful and makes it possible to study in more detail the background and outcome factors of hip fractures in a standardized manner.     

经皮空心钉固定治疗小儿股骨颈骨折的疗效观察

目的:观察C型臂引导下闭合复位空心钉固定治疗小儿股骨颈骨折的疗效.方法:回顾性分析本院2000年1月～2003年12月股骨颈骨折11例的临床资料.对3例骨折移位不明显者采用原位1枚空心钉固定;对8例明显移位成角者采用2枚空心钉固定3例,采用1枚空心钉 克氏针固定5例.结果:全部病例骨折处愈合良好,无1例发生股骨头髓板早闭及髋内翻,仅1例股骨头轻度坏死.结论:空心钉固定治疗小儿股骨颈骨折疗效好,操作方法简单,损伤小,并发症少,建议推广应用.     

Validation of a new surgical procedure for percutaneous scaphoid fixation using intra-operative ultrasound

A new technique for percutaneous fixation of non-displaced scaphoid fractures is described. The technique used pre-operative planning from computed tomography images, registration to intra-operatively acquired three-dimensional ultrasound images, and intra-operative guidance using an optical tracking system. Two stand-alone software applications were developed. The first one was used to determine the surgical plan pre-operatively and the second one was used to guide the surgeon during screw insertion. Laboratory validation of the technique included measurements of the inter-operator and intra-operator variability in the outcome of scaphoid fixation using the proposed procedure, and also included comparison of the performance of this procedure with the conventional percutaneous fixation technique using fluoroscopy. The results showed that the tight accuracy requirements of percutaneous scaphoid fixation were met and that the consistency was superior to the conventional technique.     

Digital radiography in the diagnosis of Toddler's fracture

BACKGROUND: The objective of this study was to evaluate the accuracy of digital imaging in the diagnosis of toddler's fractures. METHODS: Medical records for a 9.4-year period were reviewed to locate children whose initial radiographs were interpreted as normal by a pediatric radiologist and whose subsequent bone scans or follow-up radiographs showed toddler's fractures. Radiographs from these children (ie, positive controls) and from children without toddler's fractures (ie, negative controls) were digitized to create a film bank that was reviewed by a panel of 14 physicians with various medical backgrounds. Medical records were reviewed for demographic information, findings on history and physical examination, and radiographic and laboratory tests. RESULTS: Pediatric radiology physicians correctly diagnosed 73.2 +/- 5.4% of the digitized images, as compared with pediatric emergency physicians, 66.7 +/- 6.5% and residents/fellows, 57.1 +/- 6.9%. CONCLUSION: Digitized images may be helpful in evaluating limping children with suspected toddler's fractures, possibly eliminating the need for further diagnostic studies.     

Potential use of HMG-CoA reductase inhibitors for osteoporosis

OBJECTIVE: To review the current clinical data describing the effects of hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors in bone formation and reduction of fracture incidence and their potential use for osteoporosis. DATA SOURCES: English-language articles and abstracts were identified from a MEDLINE database search (1966-May 2001) that used the key words osteoporosis, HMG-CoA reductase inhibitors, and treatment. STUDY SELECTION AND DATA EXTRACTION: All the articles identified from the data sources were evaluated, and all information deemed relevant was included in this review. DATA SYNTHESIS: In the past, there has been considerable emphasis placed in the detection, prevention, and treatment of osteoporosis. New drug therapies have been introduced in the market aimed at decreasing bone loss and increasing bone formation, with the ultimate goal of decreasing fractures. Currently, there are a variety of agents available for the treatment of osteoporosis. A limited number of case-control studies have suggested that HMG-CoA reductase inhibitors (statins) may have the potential to reduce the risk of fractures by increasing bone formation, although other studies have failed to show a benefit in fracture reduction. The potential benefit of this therapy is still undetermined because of a lack of randomized, controlled, clinical trials and conflicting data. CONCLUSIONS: At this time, there are limited data on the role of statins in the treatment of osteoporosis. Practitioners must be cautious when using these agents over other proven conventional therapies. Randomized, controlled, clinical trials are needed to accurately determine the role of these agents in the treatment of osteoporosis.     

病灶清除植骨合克氏针内固定对儿童肱骨近端病理性骨折疗效观察

目的:探讨病灶清除植骨联合克氏针内固定治疗儿童肱骨近端病理性骨折临床疗效。方法:回顾性分析2015年1月~2017年1月收治的行病灶清除植骨联合克氏针内固定治疗的22例肱骨近端病理性骨折患儿临床资料。观察术后并发症、影像学检查结果、骨折愈合时间及临床疗效。结果:21例患儿骨折愈合良好,平均9周骨折愈合,无骨折延迟愈合或不愈合及针道感染等发生;1例因术后过早、过度负重活动导致克氏针松动及骨折断端成角,再次手术后行Samfiento支具固定,术后12周骨折愈合;按照Conmanl-Murley评分法评定疗效,优19例,良2例,可1例,优良率为95.5%。结论:病灶清除植骨联合克氏针内固定治疗儿童肱骨近端病理性骨折具有创伤小、对骨折愈合影响小、避免二次切开取内固定等优点。     

The complexity of seat belt injuries including spinal injury in the pediatric population: a case report of a 6-year-old boy and the literature review.

We present, along with a literature review, the case report of a 6-year-old boy, involved in a high-speed motor vehicle accident, who sustained a seat belt injury of the lumbar spine. We discuss the clinical presentation of thoracolumbar fractures in children, the sensitivity of clinical examination and radiographic evaluation and the associated abdominal injuries that are commonly present with seat belt spinal injuries. Computerized tomography is limited in the detection of soft tissue spinal fractures because these fractures occur in the plain of the section. Plain lateral x-rays of the lumbar spine and computerized tomographic three-dimensional reconstruction images can be helpful but they cannot evaluate the extent of the soft tissue injury. The magnetic resonance imaging scan is the best diagnostic tool to provide the diagnosis.     

螺旋CT三维重建在儿童肱骨远端骨骺损伤中的应用

目的探讨螺旋CT三维重建在儿童肱骨远端骨骺损伤中的诊断价值。方法收集20例小儿肱骨远端骨骺损伤的X线片与螺旋CT三维重建图像进行对比分析。结果 20例中肱骨外髁骨骺骨折11例,肱骨远端全骺分离2例,肱骨内上髁骨骺分离7例。X线平片与CT三维重建诊断结果相符的8例,X线平片发现了骨折但CT三维重建检查发现更多骨折的4例,X线平片怀疑有骨折但通过CT三维重建确定诊断的5例,通过CT三维重建检查更正X线平片诊断的3例。结论与X线平片相比,螺旋CT三维重建对儿童肱骨远端骨骺损伤的诊断更具优势,临床效果满意。     

骨折类型与老年髋部骨折术后疗效分析

目的探讨老年髋部骨折类型对术后疗效的影响。方法 2007年4月至2008年11月收治老年髋部骨折患者121例。入组后根据X线表现将髋部骨折分为非移位型股骨颈骨折、移位型股骨颈骨折、稳定型股骨转子间骨折和非稳定型股骨转子间骨折四种。详细记录患者并存症、手术细节、术后并发症等。观察四组患者住院期间、术后6个月、12个月四种骨折患者的死亡率以及功能恢复情况。结果符合入选标准93例,其中不稳定型股骨转子间骨折22例,稳定型股骨转子间骨折30例,移位型股骨颈骨折19例,非移位型股骨颈骨折22例。四组患者年龄、并存症等一般情况差异无统计学意义。住院期间、术后6个月移位型股骨颈骨折患者死亡率较其他三组高,但差异无统计学意义;而术后12个月不稳定型股骨转子间骨折患者死亡率较其他三组明显升高。此外出院时移位型股骨颈骨折患者ADL评分较其他三组明显升高;术后6个月、12个月四组患者ADL评分差异无统计学意义。结论排除自身差异后,髋部骨折类型对术后疗效具有一定影响。早期(住院期间、术后6个月)移位型股骨颈骨折死亡率较其他三种类型骨折高,晚期(术后12个月)不稳定型股骨转子间骨折死亡率较其他三种类型髋部骨折高。骨折类型对术后功能恢复...