Stress fractures: aetiology and management principles

Stress fractures are common injuries that may present to general practice, emergency departments or orthopaedic clinics. An understanding of how bone remodels, which has evolved since Wolff's original theory almost 130 years ago, aids treatment of stress fractures. Further research into the forces bones can withstand and the mechanisms of failure have helped prevention of these injuries. The aetiology is believed to be multifactorial. Various risk factors contribute at varying levels in individuals with stress injuries. Stress fractures can occur in weight-bearing bones as well as non-weight-bearing bones and the injuries are often specific to certain activities. In order to diagnose and treat these injuries, it is important for the clinician to understand the changes occurring at a microscopic level and the many contributory risk factors. These risk factors can be elucidated by a focused history and examination and supplemented with blood tests and radiological investigations. This information can aid the clinician in staging the injury and allow tailored treatment. This increases the chance of optimal recovery.     

面中份骨折并发眼损伤的诊治

目的探讨面中份骨折并发眼损伤的原因，讨论眼损伤的诊治方法。方法收集武汉大学口腔医院1998年1月2003年12月间住院治疗的面中份骨折患者的临床资料，对96例面中份骨折及并发的眼损伤进行分类。探讨眼损伤的原因和治疗效果。结果96例面中份骨折患者中，16例并发眼损伤，早期行开放复位固定术并针对病因治疗后均取得良好疗效。结论对面中份骨折的患者，应注意眼损伤的检查，行开放复位固定术时应同时将眶周移位的软组织复位，修复骨组织缺损。     

Intraoperative arthroscopy of the TMJ during surgical management of condylar head fractures: A preliminary report

Purpose

The purpose of this preliminary study was to evaluate intraarticular soft tissues of the temporomandibular joint (TMJ) using intraoperative arthroscopy during open reduction and internal fixation (ORIF) of condylar head fractures (CHF).

Prognosis of permanent teeth in the line of mandibular fractures

Abstract A total of 45 mandibular fracture patients with 54 teeth in the fracture line were evaluated retrospectively. One tooth in the fracture line was lost in the accident, 6 were extracted later and 47 could be saved (87%). At the follow-up examination 38% of the teeth were diagnosed to have pulp necrosis, which was found more frequently in the older patients and in cases in which the time elapsing between the injury and the follow-up was longer. Pulp necrosis was also more frequent in cases in which the fracture line ran through the apex or dislocation of the fracture parts existed after the injury.     

Anterior open bite: aetiology and management

Anterior open bite has a multi-factorial aetiology comprising: genetically inherited skeletal pattern, soft tissue effect and digit-sucking habits. To formulate an appropriate treatment plan, accurate diagnosis is essential. Simple open bites may sometimes resolve completely during the transition from mixed to permanent dentition, if the digit-sucking habit is broken. More significant open bites, however, sometimes extending right back to the terminal molars, rarely resolve spontaneously and will often require complex orthodontic treatment, involving active molar intrusion or even major orthognathic surgery. Unfortunately, surgery has associated risks attached, including pain, swelling, bruising, altered nerve sensation and, occasionally, permanent anaesthesia, as well as involving significant costs, as with any major surgical procedure under general anaesthesia. The introduction of Temporary Anchorage Devices (TADs) has expanded the possibilities of orthodontic treatment, beyond traditional limitations of tooth movement. Molar intrusion can be successfully carried out without the need for major surgical intervention, thus avoiding all the attendant risks and disadvantages. This paper provides an overview of anterior open bite and uses an illustrative case where open bite was successfully treated with a combination of fixed appliance therapy and TADs. Clinical Relevance: Anterior open bite is commonly seen in general practice. A knowledge of the possible aetiological factors and their potential management should be understood by general dental practitioners. The increased popularity of TADS allows a new and less invasive approach to management of these cases.     

Bicycle helmets are protective against facial injuries,including facial fractures: a meta-analysis

Cycling is a popular activity. However there are risks associated with cycling, including facial injury. Helmets are often worn to prevent head injury. Evidence for their protection against facial injury is limited. This meta-analysis investigated the effect of bicycle helmets on the incidence of facial injury. The PubMed/MEDLINE, Google Scholar, and Cochrane Library databases were searched. Studies included were observational and involved adult participants. Paediatric studies, studies on helmet legislation, and those combining facial injuries with other injury types were excluded. The studies were evaluated by two reviewers. Risk of bias was assessed using the RevMan bias assessment tool. Odds ratios (OR) were extracted for facial injuries and facial fractures. Two meta-analyses were performed using these categories. Nine of the 102 studies identified were included. Helmets were protective against facial injury (OR 0.69, 95% confidence interval 0.63–0.75, P < 0.0001). Five studies reported facial fracture rates; helmets were protective against these also (OR 0.79 95% confidence interval 0.70–0.90, P = 0.0003). There are no randomized controlled trials on this topic and the number of studies available is small. Bicycle helmets offer protection against facial injuries and this should be considered by cyclists when deciding whether or not to use one.     

Complications related to midfacial fractures: operative versus non-surgical treatment

The treatment of midfacial fractures depends on the dislocation of the fracture and patient-related limitations. Surgical treatment risks iatrogenic complications. In 740 patients with midfacial fractures, the age, sex, fracture type, concomitant injuries, cause of accident and the decision to use operative or non-surgical treatment were recorded. Follow-up was performed 6 and 12 months after the injury. In 41% the fractures were isolated; they were multiple in 59%. Initially, hypaesthesia of the infraorbital nerve was present in 10% of the single and 16% of the multiple fracture patients. Surgical treatment was performed in 57% of the single and in 75% of the multiple fracture patients. Women underwent surgical treatment considerably less frequently than men. After 6 and 12 months, significantly more complications were present in the surgically treated cohort. Nerve disturbances and ‘meteorosensitivity’ were most prominent. These results, together with previous findings, indicate that there is a need for prospective clinical investigations that fulfil the criteria of evidence-based medicine to generate guidelines for decision making in trauma surgery. In the meantime, the decision to use surgical treatment for midfacial fractures has to be made carefully.     

Acute midfoot injuries and their management

Acute injuries of the midfoot are uncommon and can be challenging to diagnose and manage. These injuries are frequently overlooked, as the initial plain radiographs, can be difficult to interpret or are misleading. As the consequences of a missed midfoot injury can be devastating for the patient and are so difficult to treat, all orthopaedic surgeons should be highly suspicious when managing patients with midfoot trauma. This article summarizes the current literature about the midfoot injuries and focuses in their management. Non-displaced fractures and stable injuries can be treated conservatively with immobilization for 4–6 weeks. Displaced fractures, unstable or high-energy complex injuries should be treated surgically. Extra care should be given to maintain the length of the medial and lateral columns, in order to avoid long-term deformity and disability. In general the achievement of anatomic reduction and stable fixation of these injuries leads to good functional long term outcomes.     

成人髁突骨折保守治疗与手术治疗的系统评价

目的：评价保守治疗或手术治疗成人髁突骨折的疗效。方法：运用循证医学方法，选用开口度、咬合关系2个结局变量，利用SPSS11．0软件包中R×C列联表的妒检验对不同骨折部位治疗方法的选择是否相同进行假设检验。综合评价国内外已公开发表的关于成人髁突骨折经保守治疗或手术治疗的疗效研究。总样本361例，手术例数共246例，非手术例数115例。其中，高位骨折手术例数49例，非手术例数71例；中位骨折手术例数70例，非手术例数19例；低位骨折手术例数127例；非手术例数25例。结果：（1）高位骨折，手术组开口度恢复情况好于非手术组；中位骨折，手术组开口度恢复情况与非手术组相同；对于低位骨折，手术组开口度恢复情况与非手术组亦相同。（2）高位骨折，手术组咬合关系恢复率高于非手术组：中位骨折，手术组咬合关系恢复情况与非手术组相同：低位骨折．手术组咬合关系恢复情况与非手术组相同。结论：髁突高位骨折经手术治疗后，开15度及咬合关系均优于非手术治疗：中位骨折及低位骨折经手术治疗与非手术治疗后，开口度及咬合关系无显著差异。     

Recurrent mandibular fractures: a retrospective study over 17 years on aetiology,demographics, fracture patterns,and management

Recurrent fractures of the mandible are rare, however in Darwin, Australia, their occurrence is relatively frequent. This retrospective study identified 127 patients with 148 recurrent mandibular fractures treated at Royal Darwin Hospital between 2000 and 2017. Age, sex, ethnicity, marital status, aetiology, risk factors, anatomical location of the fractures, fracture patterns, and management of the fractures were analysed. The majority of patients were male (85.8%) (P < 0.001); 62.8% were unmarried (P < 0.001) and 72.4% were indigenous (P < 0.001). Alcohol was involved in 79.1% of cases (P < 0.001) and assault was the most common mechanism of injury (84.5%) (P < 0.001). The angle of the mandible was the most common site (P < 0.001), and recurrent fractures were more likely to occur at sites different to a previous fracture fixation site (P < 0.001). Smoking, alcohol abuse, and diabetes were strongly associated with recurrent fractures (all P < 0.001). Most patients were managed with open reduction internal fixation. In conclusion, recurrent fractures of the mandible frequently involved the angle of the mandible and occurred at different sites. Their incidence was more common among the unmarried, male, and indigenous population, and smoking, alcohol abuse, and diabetes were found to be significant risk factors.     

Influence of age on the management of blow-out fractures of the orbital floor

This study concerns 50 patients with blow-out fractures of the orbital floor, including 15 children, and was designed to evaluate the influence of age on clinical presentation and postoperative results. Fourteen of the 15 children were found to have a trap-door fracture. This type of fracture was not found in adults, who usually present with a large "open-door" fracture. In trap-door fractures, orbital tissues are liable to become trapped and even strangulated. It is therefore suggested that young patients with severely restricted eyeball motility, an unequivocal positive forced duction test, and findings indicating blow-out fracture of the orbital floor on CT, should undergo operative treatment as soon as possible after injury. A "wait and see" policy, keeping the patient under observation, seems to be appropriate for blow-out fractures in adults. Surgical treatment is recommended only in those adult patients who demonstrate impairment of vertical eyeball motility within the mainfield of view after the haemorrhage and oedema have resolved and in whom change in motility is no longer seen and Hertel measurements have stabilized.     

Algorithms for the management of frontal sinus fractures: A retrospective study

The aim of this study was to evaluate the long-term results and to evaluate the validity of the treatment algorithm that can be safely applied in dfrontal sinus fractures. All patients were evaluated in terms of late-term contour deformity and further craniometric analysis for measurement of maximum amount of displacement, fracture surface area (mm²) and the maximum angulation of the fracture (degree) were done. 125 patients (101 male, 24 female) with frontal sinus fractures with an average age of 22.4 years (range,17–66 years) were reviewed. All patients with isolated anterior table fractures without displacement were followed up on conservative basis. 33 patients with anterior table fractures with displacement and 39 patients with anterior and posterior table fractures were also followed on conservative basis without surgical intervention. The cut-off value of the maximum amount of displacement was confirmed to be 4.5 mm in prediction of late-term contour deformities (p < 0.001). The maximum amount of displacement was decreased by an average of 1.8 mm at late-term. Apart from the standard protocols, within the limitations of the study it seems that isolated anterior table fractures with a maximum amount of displacement of less than 4.5 mm can be treated conservatively without leading to contour deformities. CSF leakage in the acute setting might not always require cranialization and this may spontaneously resolve within 10 days. Cranialization should be considered whenever CSF leakage lasts longer than 10 days.     

Multiple fractures of primary molars caused by injuries to the chin: report of two cases

Abstract – Two cases of multiple fractures of the primary molars caused by injuries to the chin are presented. Clinical and radiographic examinations revealed a vertical fracture line in the maxillary and mandibular primary molars. Pulpotomy or pulpectomy treatment was performed on the affected teeth, which were then restored with preformed stainless steel crowns.     

Inferior alveolar and mental nerve injuries associated with open reduction and internal fixation of mandibular fractures: A Seven Year retrospective study

PurposeTo document adverse neurosensory changes in the inferior alveolar nerve (IAN) and mental nerve (MN) after surgical mandibular fracture treatment and to identify risk factors associated with these changes.Materials and methodsA retrospective study of patients surgically treated for mandibular fractures. The primary study variable was the postoperative change in IAN/MN neurosensory examination after fracture fixation. Risk factors were categorized as demographic, anatomic, experience of the operator, fracture displacement and number of miniplates placed at each fracture site. Appropriate statistics were computed.Results209 patients with 293 fractures were analysed. One hundred twenty fractures (41%) were located between the lingula and mental foramen, and 173 fractures (59%) were located distal to the mental foramen. Two hundred seventeen (41%) were displaced by 5 mm or more. In 38 fractures (13%), the IAN/MN neurosensory status worsened after treatment. In a multivariate model, fracture displacement, operator inexperience and two plate fixation were associated with a statistically significant risk (P ≤ 0.05) for postoperative deterioration of IAN/MN sensation.ConclusionFixation with two miniplates, fracture displacement of 5 mm or more and operator inexperience were associated with an increased risk for deterioration of the IAN/MN neurosensory status after treatment of mandibular fractures.     

Paediatric supracondylar fractures: an overview of current management and guide to open approaches

Supracondylar fractures of the humerus are common fractures in children. Closed reduction and percutaneous pinning is the primary method of management, though 2–12% of these fractures require open reduction. There is no conclusive evidence to dictate the best surgical approach to the fracture. This paper aims to review supracondylar fractures of the humerus and discusses the early and late associated complications. The treatment options are then examined, with a focus on the preferred surgical approach to open reduction. If an orthopaedic surgeon is going to learn only one approach for reduction of these challenging fractures, then we recommend becoming familiar with the anterior approach. This is the approach one would need to use in most open fractures and in those where exploration of the brachial artery is indicated. It gives access to the neurovascular structures, to the fracture site and also to the soft tissues that are likely to block reduction. The cosmetic and functional outcomes are reported to be good.     

The effect of treatment timing on the management of facial fractures: a systematic review

The ideal timing for treatment of facial fractures has not been well established. The objective of this systematic review was to examine the effects of treatment delay on outcome in the management of facial fractures. The PubMed database was used to search for relevant English-language articles published between 1979 and 2013. Cross-referencing identified additional studies. There were no selection restrictions for study type. The first author, using pre-defined data fields, extracted information independently. Studies were assessed by study type, evidence level, sample size, data collected, outcome variables, control of confounding variables, and findings. Thirty studies were identified. Inconsistency was identified with data collected, outcome variables, and findings. Of the 30 studies identified, 28 were case series, thereby providing a low level of evidence overall. The majority of case series were retrospective and sample sizes were predominantly small. Control of confounding variables was poor. Eighteen studies found no statistically significant relationship between treatment delay and treatment outcome. Nine studies found a statistically significant relationship between treatment delay and worse treatment outcomes. There were three studies with conflicting results. With the current body of evidence, definitive conclusions cannot be drawn on the timing of treatment for facial fractures.