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.     

跖跗关节损伤的疗效分析

[目的]分析1984～2004年间对跖跗关节损伤采用非手术治疗和手术治疗的效果.[方法]回顾性研究20年对13名跖跗关节损伤病人采取闭合复位治疗(3例)和开放复位内固定治疗(10例)的结果.平均随访6.9年(从6个月～20年).将治疗结果按照疼痛、功能、步态、畸形和X线片形态等进行评定,分为好、中、差.[结果]全部的病人均获得解剖复位.在随访取出内固定物和拆除管型石膏的病人中没有发现再脱位,未见纵弓塌陷.13例均获得较好的结果.[结论]跖跗关节损伤获得成功疗效的关键是早期准确的诊断,及时的解剖复位和稳定的固定.稳定的,无移位的损伤可以通过管型石膏制动,保护下承重治疗.不稳定的骨折脱位需要开放复位内固定治疗.     

Le fratture della caviglia e del piede in età evolutiva

Foot and ankle fractures represent 12% of all paediatric fractures. Physeal growth makes the paediatric patient’s bone different compared to that adults in term of diagnosis, treatment and complications. The diagnosis is based on clinical examination and conventional X-ray; CT scans are the gold standard for complex lesions. The most frequent complication of physeals injuries is the early closure of the growth plate with possible angular deformities and leg length discrepancy. Most injuries may be treated conservatively. Surgical treatment is necessary when anatomical reduction cannot be achieved.

     

Trauma of the liver and hepatic pedicle

Traumatic injuries of the liver and hepatic pedicle secondary to blunt abdominal trauma are unusual and often associated with injuries of other abdominal and/or thoracic organs. These lead the patient to an emergency operation for hemorrhagic shock. The diagnosis of trauma severity and hepatic pedicle involvement is made intraoperatively. Often only one anatomical structure of the hepatic pedicle is involved, whereas involvement of two or all three anatomical structures is rare and associated with a bad prognosis. The management of these injuries still remain one of the most challenging scenario in trauma surgery. The overall experience is not significant. Clear treatment guidelines or management algorithms have not yet been established, in part due to the complexity, severity and variability of these injuries and to the lack of large series with these rare events. Three cases of associated liver and hepatic pedicle injuries treated in our unit are reported.     

Arthroskopisch assistierte Frakturversorgung am oberen Sprunggelenk

Acute ankle fractures are one of the most common fractures in adults with an incidence of 0.1–0.2?% per year. Operative treatment by open reduction and internal fixation (ORIF) is the standard method of treatment for unstable or dislocated fractures. The main goal of the operation is the anatomical realignment of the joint and restoration of ankle stability; nevertheless, anatomical reduction does not automatically lead to favorable clinical results. According to several studies the mid-term and in particular the long-term outcome following operative treatment is often poor with residual symptoms including chronic pain, stiffness, recurrent swelling and ankle instability. There is growing evidence that this poor outcome might be related to occult intra-articular injuries involving cartilage and soft tissues. In recent studies the frequency of fracture-related osteochondral lesions was reported to be approximately 64?%. By physical examination, standard radiography or even computed tomography (CT), these intra-articular pathologies cannot be reliably diagnosed; therefore, many authors emphasize the value of ankle arthroscopy in acute fracture treatment as it has become a safe and effective diagnostic and therapeutic procedure. Arthroscopically assisted open reduction and internal fixation (AORIF) allows control of the reduction as well examination of all intra-articular structures. If necessary, intra-articular pathologies can be addressed by removing ruptured ligaments and loose bodies, performing chondroplasty or microfracturing. So far there is no evidence that supplementary ankle arthroscopy increases the complication rate. On the other hand, the positive effect of AORIF has also not been clearly documented; nevertheless, there are clear indications that arthroscopically assisted fracture treatment is beneficial, especially in complex fractures.     

External femorotibial transfixation in femoral fracture with joint involvement in a child

Long bone fractures combined with joint injuries run a high risk of destabilising the articulations. Remaining joints incongruence can lead to early arthosis especially in cases of severe injuries or not achieved anatomical reduction. A number of osteosynthesis methods are available for anatomical repair of the articular facet. This report presents a seven years old boy with an open comminuted fracture of the distal femur and consecutive joint instability, treated with a Transfixation (Orthofix) of the knee joint. The functional results suggest this method as an alternative treatment.     

Classification, staging, urgency and indications in pelvic injuries

For primary evaluation, classification and indication of pelvic ring injuries the exact knowledge of the injury mechanism and the clinical and radiological signs is mandatory. Clear injury definitions are proved for prognostical reasons and for the timing of the specific treatment. The simple classification of stable A-type injuries, rotational B-type injuries and translationally stable C-type injuries is the basis for further treatment. Whereas A-type fractures normally need no surgical stabilization, except in severely displaced fractures or possible organ injuries due to fracture fragments, in B-type injuries solely stabilization of the anterior pelvic ring provides sufficient stability for early ambulation with partial weight bearing. In C-type injuries a combined posterior and anterior stabilization is required for anatomical reduction and early ambulation. With this concept the pelvic girdle can be reconstructed anatomically in the majority of cases.     

Fracture dislocations of the carpometacarpal joints of the fingers

ObjectiveFracture dislocations of the multiple carpometacarpal joints [CMCJ] of the fingers are uncommon injuries that can significantly compromise hand function and durability if managed sub-optimally. These injuries are at risk of being missed as they are commonly a part of major high energy trauma with associated more obvious and immediately threatening injuries getting all the attention. The clinical and radiological parameters which could help a surgeon to detect and analyse these injuries well are discussed. The management of these injuries with emphasis on the pattern of K-wire fixation is presented.MethodA review of multiple CMCJ dislocations at our institution found 39 hands in 38 patients (one case with bilateral injury) over a seven-year period (January 2010 to January 2017). The pattern of injury noted in these cases was assessed and categorized. Our preferred management plan for these injuries is discussed.ResultsThe patterns of dislocations noted in a total of 39 cases were-dorsal (25), dorsal radial (6), volar (1), volar radial (5) and divergent (2). The dorsal dislocations were the commonest (25/39) and additional 6/39 were radial-dorsal, only six displaced in a volar direction. Divergent dislocation was seen in only two cases.ConclusionThe pattern of dislocations noted in 39 cases in our institute (Ganga Hospital- A tertiary level trauma center) is presented to provide an overview of the spectrum of the injuries which a surgeon could face. Early surgery is recommended and should be aimed to restore perfect anatomical alignment of the skeleton. Surgeon should have a low threshold for open reduction in case of gross swelling or inability to get an anatomical closed reduction. The method of K-wire fixation presented herein has resulted in good outcome in our practice; wherein we fix the dislocated CMCJ by inserting K-wires from the radial and ulnar borders of the hand and avoiding wires in the central part of the hand. This prevents extensor tendons tethering by the K-wires. The fixation achieved by multiple K-wires passed in this manner provides enough stability to allow for early active mobilisation of the fingers. The need for careful assessment to detect associated nerve injury and compartment syndrome; and post-operative strict hand elevation and prevention of stiffness of the MCP joints has been emphasized.The CMCJ dislocations have innumerable patterns possible; however, the management principles remain the same. In spite of the gross distortion of the anatomy seen in these injuries, anatomical reduction and adequate stabilization to allow early mobilization generally results in satisfactory outcomes.     

Verletzungen der Fußwurzel, Luxationen und Frakturen im Lisfranc-Gelenk

Lisfranc injuries are rare, accounting for under 1% of all fractures. In 90% of cases the dislocation is combined with a fracture, while in the remaining 10% the ligaments only are affected. The injury can present in various ways. Isolated complex foot trauma is not difficult to diagnose, but in more than 20% of all Lisfranc luxations the diagnosis is missed. This is because when confronted with a multiply traumatised patient physicians concentrate on any life-threatening injuries and not on the foot, but the diagnosis of Lisfranc injury is very often missed even after low-energy trauma because the presentation is occult. In addition to the history, knowledge of the condition of the soft tissues and skill in the interpretation of X-rays and also of the results of computer tomography are necessary. The treatment of choice is open reduction and internal fixation with Kirschner wires ore single screws. Concomitant compartment syndrome is present in up to 60% of cases. Good functional results can be achieved by timely diagnosis, early internal fixation with anatomical reduction and consistent management of soft tissue.     

Ewing sarcoma of the mandible mimicking an odontogenic abscess – a case report

Injuries resulting from the use of angle grinders are numerous. The most common sites injured are the head and face. The high speed disc of angle grinders does not respect anatomical boundaries or structures and thus the injuries produced can be disfiguring, permanently disabling or even fatal. However, aesthetically pleasing results can be achieved with thorough debridement, resection of wound edges and careful layered functional closure after reduction and fixation of facial bone injuries. A series of penetrating facial wounds associated with angle grinder use are presented and the management and prevention of these injuries discussed.     

Arthroscopic treatment of shoulder fractures

Therapeutic options for shoulder joint fractures include conservative treatment or surgery, but indications for either treatment remain vague. Arthroscopic treatment of glenoid fractures and greater tuberosity fractures represents an alternative and allows anatomical reduction and reliable fixation with decreased soft tissue trauma. With this minimally invasive technique, large muscular dissections are avoided and postoperative recovery is shortened. This technique also allows a complete joint inspection and a more accurate diagnosis for associated injuries than conventional imaging methods. Arthroscopy is a useful diagnostic tool that may avoid underestimation of these associated injuries (labrum, rotator cuff tendons, cartilage) and is also helpful for treating these lesions in the same time. However, arthroscopic treatment of shoulder fractures needs a leaming curve depending on surgeon's experience in shoulder arthroscopy. At present, indications for arthroscopic treatment of shoulder fractures are limited to anterior or posterior glenoid rim fractures and some greater tuberosity fractures. This selection is best made using preoperative computed tomography and especially 2D reconstruction.     

Design distaler volarer Radiusplatten

The operative treatment of unstable distal radius fractures primarily aims for the anatomical reduction of the joint while addressing accompanying injuries. Anatomical reduction, stable fixation and early functional movement of the joint are the three cornerstones of modern treatment concepts of distal radius fractures. Distal radius volar locking plates play a major role in the treatment and rehabilitation of the most commonly occurring fracture in humans. This article outlines the different principles in the current design of available distal radius volar locking plates. The biomechanical aspects, anatomical findings and clinical evaluation that have influenced current design features and trends in new developments of the latest plates are emphasized. This is an ongoing process that is supported through the investigation and feedback of clinical science.     

Primary fusion versus open reduction internal fixation for purely ligamentous lisfranc injuries: A Prospective comparative study and analysis of factors affecting the outcomes

BackgroundThe studies evaluating the outcomes of treatment of purely ligamentous unstable Lisfranc injuries are scarce. This study aimed at comparing outcomes of primary tarso-metatarsal joints fusion versus open reduction and internal fixation in treatment of such condition and determining the possible factors that may alter the outcomes.MethodsThis study comprised 30 patients; 16 in fusion group and 14 in ORIF group. One column was operated on in 2 patients, two columns in 21, and three columns in 7. The mean follow-up period was 36 months.ResultsThere was no statistically significant difference between both groups regarding patients or injury characteristics. The mean AOFAS and FFI-Rs scores were 88.9 and 22.7 in the fusion group, compared to 61.7 and 34.5 in the ORIF group (P = .03,.04 respectively). At final follow-up all patients in the primary arthrodesis group were maintaining an anatomical reduction versus 71.5% in the ORIF group. Sixteen patients (53%) reported prominent hardware troubles that required removal. Five patients in ORIF group developed osteoarthritis, and four of them underwent secondary fusion. There was significantly higher incidence of posttraumatic osteoarthritis in patients with non-anatomical reduction and complete injuries. Better mean AOFAS and FFI-Rs scores occurred with non-smokers and with anatomical reduction.ConclusionBased on this limited case series, purely ligamentous Lisfranc injuries were found to have better outcomes when managed with a primary fusion as compared to ORIF.Achieving and maintaining anatomical reduction was the most important factor that is significantly attributed to improved outcomes. Possible arthritic changes and additional surgeries apart from implant removal could be avoided by primary fusion.Level of evidencelevel I- prospective comparative case study.     

Acute femoral "peel-off" tears of the posterior cruciate ligament: technique for arthroscopic anatomical repair

Management of posterior cruciate ligament injuries remains a topic of discussion among treating physicians. Injury severity, anatomical location, and presence of concomitant associated knee injuries are important factors that may be used to guide treatment strategies. Various subtypes of posterior cruciate ligament injury have been identified. Each has unique properties that affect treatment design. Among these subtypes is the acute femoral "peel-off" tear, which represents a distinct pattern of injury that consistently has demonstrated a favorable capacity for healing with repair rather than reconstruction. In this article, we present an arthroscopic anatomical repair technique that has been used with success at our institution. It is important to properly identify such injuries in a timely manner so that appropriate treatment is initiated and the patient may be spared a lengthier and more technically complex reconstruction procedure.     

移位髋臼骨折合并不稳定型骨盆后环损伤的临床特征及复位顺序

目的 探讨移位髋臼骨折(displaced acetabular fracture,DAF)合并不稳定型骨盆后环损伤(posterior pelvic injury,PPI)的临床特征及复位顺序.方法 1997年3月至2007年3月,资料完整的DAF合并PPI患者39例,合并同侧PPI 25例、对侧9例、双侧5例.根据AO/OTA分型方法,髋臼A型骨折9例,B型25例,C型5例;骨盆后环B型损伤31例,C型8例.DAF与PPI同期切开复位内固定33例,分期手术3例,另3例PPI行非手术治疗.术中首先复位DAF 10例,首先复位PPI 18例,DAF与PPI同时复位11例.结果 术后随访12～120个月,平均33.7个月.根据Matta的评价标准,DAF解剖复位27例、复位满意4例、不满意8例.根据Meats的评价标准,PPI解剖复位24例、复位满意8例、不满意7例.其中因PPI移位而影响DAF满意复位者7例.DAF术后Matta功能评分为4～18分,平均14.7分.PPI术后Majeed疗效评分为51～100分,平均87.8分.以两个损伤部位的最低评分作为总体治疗结果,优25例、良3例、可2例、差9例.结论 在处理累及髋臼双柱的DAF合并PPI时,PPI的准确复位是DAF获得满意复位的解剖基础,DAF的损伤类型及其复位质量是决定远期疗效的主要因素.     

Hoffa's fracture with ipsilateral fibular fracture in a 16-year-old girl:An approach to a rare injury

Hoffa''s fracture is an uncommon fracture of the femoral condyle with coronal orientation of the fracture line. The mechanism of injury in pediatric Hoffa''s fracture is road traffic accident, sports injury, and trivial injury. Clinical examination and proper imaging is important for diagnosis of pediatric Hoffa''s fracture because of high chances of missing these injuries which can lead to nonunion and malunion at the fracture site. Open reduction and anatomical reduction of intraarticular fragment is the gold standard treatment of these fractures. We present a rare case of Hoffa''s fracture in a 16-year-old girl with associated ipsilateral fibular fracture.     

Dislocations of the carpal bones. Diagnosis and therapy

Dislocations of the carpal bones are rare. Because of the difficult radiological anatomy of the carpus, the diagnosis of such injuries is often missed. The treatment of a primary diagnosed luxation is easy, and an anatomical position of the carpal bones can be achieved by closed reduction. The functional result is good. In contrast the treatment of delayed diagnosed dislocations is very problematic, and the outcome of the mainly operative therapy is unsatisfactory on the whole. The radiological findings on dislocations of the carpal bones are discussed in principle. The indication of non-operative and operative treatment is outlined.     

Principles in the management of a mangled hand

Mangling hand injuries are high energy complex conditions that are challenging to manage. They require careful planning and meticulous execution of treatment. A clear set of anatomical and functional goals at the outset guides the planning. The first surgery is crucial to ensure good vascularity to the salvaged tissue, prevent infection and achieve bony stabilization. Re-look surgery and definitive reconstruction can then follow. Post-operative therapy is an important component of treatment. Despite best efforts, outcomes are variable in these devastating injuries. Secondary procedures and provision of prostheses will do much to improve the patient''s body image and limb function. This article provides a set of principles that will guide the assessment and treatment of such injuries.KEY WORDS: Amputation, hand fractures, hand surgery, mangled hand, mutilating hand     

Editorial Commentary: Early Surgery and Restricted Rehabilitation Are Recommended for High-Grade Acromioclavicular Joint Dislocation

Despite acromioclavicular (AC) joint injuries being common, there are still controversies about the treatment; nonoperative versus surgical, who to operate, when to operate, which technique to use, and which rehabilitation protocol to use. Orthopaedic surgeons are often faced with these patients fearing not regaining normal function and to some degree acceptable cosmetic outcomes. Despite increasing interest in surgical management of type 3 AC joint injuries, surgical management has not been demonstrated to yield superior functional outcomes compared with nonoperative treatment. Interestingly, studies have demonstrated that good outcomes are achieved with most surgical techniques even though they are all associated with loss of initial reduction. This brings into question whether surgery is necessary in the early phase and how we can mitigate the effects of gravity to maintain reduction. Studies that can aid surgeons in patient selection for treatment protocols (nonoperative versus surgical) and timing of surgery are needed. We recommend early surgery, and restricted rehabilitation, for high-grade acromioclavicular joint dislocation.