Fraktursonografie im Kindesalter

X-rays are the standard imaging procedure for the diagnosis of pediatric long bone fractures. Recent studies show that ultrasound (US) imaging is also qualified to diagnose pediatric long bones fractures. Thus, the diagnosis and decision-making for the treatment of metaphyseal forearm fractures in children can be performed by solely using US. The sonographic fat pad sign has been proven to be a useful primary screening tool for pediatric elbow injuries. If there is a negative fat pad sign, a fracture is unlikely and taking additional radiographs is dispensable at this time. If there is a positive fat pad sign, a fracture is likely and radiographs should be taken. US is also useful to exclude subcapital humeral fractures and to estimate fracture displacement. If a fracture of the subcapital humerus is present, additional radiographs are necessary to avoid overlooking of pathologic fractures. For reliable sonographic fracture diagnosis in childhood, a detailed history und exact clinical examination are required.     

Pediatric spinal injuries– current concepts

Spinal injuries in children contribute to the highest mortality and morbidity among all pediatric injuries. Fortunately, these injuries are a rare clinical entity but pose a difficulty in diagnosis due to challenges in neurological evaluation of a child and varied radiological presentation. Anatomical and biomechanical aspects of developing musculoskeletal system, relative plasticity of the pediatric spine make children vulnerable to spine injuries. Though motor vehicle collisions are common, children also suffer non-accidental trauma, falls and sports injuries. More chances of cervical spine involvement, higher susceptibility of spinal cord to tensile forces and associated multisystem injuries result in devastating consequences in children compared to adults. Injuries like SCIWORA, vertebral apophyseal injuries, birth-related spinal cord injuries are more specific injuries in pediatric age group. A vigilant clinical, neurological and radiological evaluation is mandatory in all children with suspected spinal injuries. Normal radiological features like ossification centers, pseudosubluxation and physiological vertebral wedging should be carefully noted as they could be misinterpreted as injuries. While CT scans help in better understanding of the fracture pattern, Magnetic Resonance Imaging in children is beneficial especially in detecting SCIWORA and other soft tissue injuries. Management principles of these pediatric spinal injuries are similar to adults. Literature evidences support conservative management in injuries like SCIWORA, unless there is an ongoing spinal cord compression. As in adults, the role of high dose methylprednisolone is still controversial in pediatric spinal cord injuries. Stable spinal injuries can be managed conservatively using orthosis or halo. Instrumentation by both anterior and posterior techniques has been described, but it is challenging due to smaller anatomy and poor implant purchase. In addition to pedicle screw instrumentation, wiring techniques are very beneficial especially in younger children.     

Sonoanatomie der kindlichen Gelenke

The radiological work-up of joint injuries in young children can be very tedious due to the absent ossification of secondary ossification centers, which cannot be seen directly on plain X-ray images in this age group. Cartilaginous joint structures therefore cannot be distinguished from joint gaps using X-ray images in young children. High-resolution ultrasound scanning probes facilitate ultrasound studies of cartilaginous joint structures and growth plates in young children, thus providing a new and rewarding option for imaging of traumatic alterations of growing joints, especially in children whose secondary ossification centers have not yet undergone calcification processes. The use of ultrasound for evaluation of joint injuries avoids the shortcomings of ionizing radiation, contralateral joints can be examined for comparison, and functional dynamic studies can be obtained easily.     

Elastic nailing of tibia shaft fractures in young children up to 10 years of age

IntroductionAlthough tibia shaft fractures in children usually have satisfactory results after closed reduction and casting, there are several surgical indications, including associated fractures and soft tissue injuries such as open fractures. Titanium elastic nails (TENs) are often used for pediatric tibia fractures, and have the advantage of preserving the open physis. However, complications such as delayed union or nonunion are not uncommon in older children or open fractures. In the present study, we evaluated children up to 10 years of age with closed or open tibial shaft fractures treated with elastic nailing technique.MethodsA total of 16 tibia shaft fractures treated by elastic nailing from 2001 to 2013 were reviewed. The mean patient age at operation was 7 years (range: 5–10 years). Thirteen of 16 cases were open fractures (grade I: 4, grade II: 6, grade IIIA: 3 cases); the other cases had associated fractures that necessitated operative treatments. Closed, antegrade intramedullary nailing was used to insert two nails through the proximal tibial metaphysis. All patients were followed up for at least one year after the injury. Outcomes were evaluated using modified Flynn's criteria, including union, alignment, leg length discrepancies, and complications.ResultsAll fractures achieved union a mean of 16.1 weeks after surgery (range: 11–26 weeks). No patient reported knee pain or experienced any loss of knee or ankle motion. There was a case of superficial infection in a patient with grade III open fracture. Three patients reported soft tissue discomfort due to prominent TEN tips at the proximal insertion site, which required cutting the tip before union or removing the nail after union. At the last follow-up, there were no angular or rotational deformities over 10° in either the sagittal or coronal planes. With the exception of one case with an overgrowth of 15 mm, no patient showed shortening or overgrowth exceeding 10 mm. Among final outcomes, 15 were excellent and 1 was satisfactory.SummaryEven with open fractures or soft tissue injuries, elastic nailing can achieve satisfactory results in young children, with minimal complications of delayed bone healing, or infection.     

Minimally invasive plate osteosynthesis using posterolateral approach for distal tibial and tibial shaft fractures

ObjectiveThe objective of the study was to evaluate the effectiveness of the posterolateral minimally invasive plate osteosynthesis (MIPO) method for managing distal tibial or tibial shaft fractures with severe anterior and medial soft tissue injuries.Materials and methodsFive consecutive patients with three distal tibial and two tibial shaft fractures (three open fractures) at a level-1 trauma and tertiary referral center were retrospectively reviewed. All patients were definitively treated and followed to bone union. Main outcome was measured by American Orthopaedic Foot and Ankle Society (AOFAS) ankle–hindfoot score, complications, and bone union on radiographs.ResultsThe average follow-up period was 15.8 months (range, 12–24 months). The average AOFAS score was 88.2 (range, 81–90). There were no complications, such as incision breakdown, deep infection, or impingement of the flexor hallucis longus tendon. Bone union was achieved in all cases.ConclusionsPosterolateral MIPO is a feasible option when treating these fractures, especially in cases with severe anterior and medial soft tissue injuries.     

Pediatric sternal fractures from a Level 1 trauma center

Background/purposeSternal fractures are rare in children. The purpose of this series is to document traumatic findings in pediatric patients with sternal fractures at a Level 1 trauma center.Study designWe reviewed the charts of patients with radiologically confirmed sternal fractures from a trauma database at a pediatric Level 1 trauma center between January 1, 2000 and December 31, 2015. We report mechanisms of injury, associated injuries, complications, and outcomes associated with sternal fractures.ResultsOver the 16-year period, 19/25,781 (0.07%) admitted patients had radiologically confirmed sternal fractures. 15/19 (78.9%) patients were male. The median age was 14 years, with interquartile range 10–16 years. 7/19, (36.8%) were sustained owing to motor vehicle accidents. Associated injuries included substernal hematoma (n = 6), pulmonary contusion (n = 4), vertebral injury (n = 2), rib fracture (n = 4), intraabdominal injury (n = 3), pneumothorax (n = 3), long bone injury (n = 3) traumatic brain injury (n = 2), hemothorax (n = 2), pneumomediastinum (n = 2) and cardiac contusion (n = 1).ConclusionsIn this series, pediatric sternal fractures were caused by high velocity mechanisms and had significant comorbidity. While patients with isolated sternal fractures may be candidates for emergency department discharge, a thorough evaluation should be performed in children with sternal fractures to identify concurrent injuries.Level of evidenceLevel IV.     

Disorders of the immature carpus

Carpal disorders in children are often associated with developmental abnormalities of structures surrounding the wrist. In addition, carpal ossification throughout childhood has unique influences on pediatric carpal injury. Because the immature carpus is composed of unossified cartilage, carpal abnormalities in young children are frequently undetectable on plain radiographs. Clinical suspicion of an abnormality may elicit further imaging with MRI, which can provide detailed information about cartilaginous structures.     

Clinical and financial impacts of flexible intramedullary nailing in pediatric diaphyseal forearm fractures: A case–control study

Purpose:Flexible intramedullary nailing is regularly applied for pediatric displaced unstable forearm fractures. When compared to closed reduction and casting (orthopedic treatment), flexible intramedullary nailing decreases malalignment, shortens immobilization time, and should decrease follow-up controls. Comparing flexible intramedullary nailing and orthopedic treatment in the clinical, radiological, and financial managements of these fractures was performed.Methods:Retrospective 5 years study of pediatric cases in two pediatric orthopedic university departments. Treatment method, post-operative course, and radiological follow-up were reviewed. Number of radiographs, follow-up controls, type and duration of immobilization, final bone angulation, and reported complications were compared. Extensive financial analysis was completed.Results:Of 73 girls and 168 boys included in the study, 150 were treated by flexible intramedullary nailing and 91 by orthopedic treatment. No difference was noted with regard to total number of radiographs (7.3 vs 7.2, respectively). Total number of follow-ups was 6.4 and 5.5, respectively. Malalignment occurred in two flexible intramedullary nailing and sixteen orthopedic treatments. The least expensive cost was ambulatory orthopedic treatment.Conclusion:Flexible intramedullary nailing treated children had similar numbers of radiographs or follow-up consultation, but less malunion when compared to orthopedic treatment. Orthopedic management was systematically cheaper than flexible intramedullary nailing. Unless post-operative management guidelines decreasing the number of radiographs and follow-ups are implemented, flexible intramedullary nailing will remain a costly procedure when compared to conventional orthopedic treatment.Level of evidence:level III case–control retrospective study.     

MRI Detection of Forearm Soft Tissue Injuries with Radial Head Fractures

Background

This study aims to evaluate the incidence of forearm soft tissue abnormalities associated with radial head fracture severity based on the Mason classification system.

Methods

Eighteen patients (age 18–45 years) were prospectively evaluated with elbow radiographs and magnetic resonance imaging (MRI) following longitudinal forearm trauma. MRI was performed within 10 days of the initial injury. Radiographs and MR images were evaluated in a blinded fashion by two musculoskeletal radiologists.

Results

Thirteen of 18 patients presented with Mason type I radial head fractures. In all patients with Mason type I fractures, the interosseous membrane (IOM) was intact. Two patients had Mason type II fractures with associated partial and compete tearing of the IOM and three patients had Mason type III fractures with complete tearing of the IOM. Edema was noted in the pronator quadratus in six of 13 type I injuries and seen in all type II and III injuries. No structural forearm soft tissue abnormalities were present in patients with Mason type I injuries. The presence of edema within the pronator quadratus correlated with distal forearm pain.

Conclusions

The severity of radial head fracture correlates with longitudinal forearm injury evidenced by the presence of IOM tearing. The findings suggest patients with Mason type II or III fractures of the radial head should undergo further evaluation of the forearm for associated soft tissue injuries. Edema within the pronator quadratus was present following forearm trauma regardless of the severity of fracture and was related to symptomatic forearm pain.     

Sonographic differentiation of stable and unstable lateral condyle fractures of the humerus in children

Fractures of the lateral humeral condyle in children may cause difficulties in diagnosis and treatment. The fracture line involves the cartilaginous trochlea, which cannot be visualized on conventional radiographs. Therefore, a differentiation is not possible between the conservatively treated stable and the surgically treated unstable fracture, which involves the joint surface but is not dislocated primarily. We performed high-resolution ultrasonography in six children (age, 4-9 years) with a lateral condyle fracture of the humerus and uncertain joint involvement. Ultrasonography was able to visualize the fracture line through the joint surface in two children. Additional three-dimensional information could be gained that helped to plan further surgical procedures. The sonographic findings were confirmed intraoperatively and by magnetic resonance imaging in one child. In the remaining four children, ultrasonography was able to rule out joint involvement, thus classifying the fracture as stable. Conservative treatment was started, and the sonographic findings were confirmed by radiographs 4 days after the trauma to rule out secondary displacement. High-resolution ultrasonography is able to diagnose fracture involvement of the joint forming cartilaginous trochlea humeri in children, thus making further invasive or costly investigations such as magnetic resonance imaging unnecessary.     

The utility of the pelvic radiograph in the assessment of pediatric pelvic fractures

BACKGROUND: Computed tomographic (CT) scanning is sensitive in detecting pelvic fractures in the pediatric patient. Pelvic fractures in the pediatric population rarely require emergent intervention, thus providing time to obtain the optimal imaging study. The objective of this study was to compare pelvic radiographs and abdominal pelvic CT scans of all pediatric trauma patients with pelvic injury to determine the role of pelvic imaging in the immediate trauma resuscitation. METHODS: A retrospective review was performed of pediatric patients (age < 18 years) with a pelvic fracture identified from the registry of a Level I pediatric trauma center for the period 1993 to 2001. Patients with a documented pelvic injury and both a pelvic CT scan and pelvic radiograph available for review were extracted for analysis. For this study, all films were re-reviewed by an attending pediatric radiologist, and the abnormalities were categorized by the area of injury. The data were comparatively analyzed according to the area of injury and the soft tissue findings. RESULTS: For the 8-year period, 130 pediatric patients with a pelvic fracture were identified, including 103 patients with both a pelvic CT scan and radiographs. Of the 151 fractures identified by pelvic CT scan, 81 were also identified by the pelvic radiograph (54%). There were 38 soft tissue hematomas noted by pelvic CT scan and only 2 identified by the pelvic radiograph. The greatest discrepancy was noted in comparison of the sacral region (16 abnormal pelvic CT scans vs. 3 abnormal radiographs); the least discrepancy was noted in the evaluation of the hip (6 abnormal pelvic CT scans vs. 5 abnormal radiographs). CONCLUSION: The pelvic radiograph lacked the sensitivity of the pelvic CT scan for detecting pelvic fractures in all anatomic areas evaluated. Pelvic CT scan also offers additional information regarding soft tissue injury not available on most pelvic radiographs. In the trauma patient that will undergo abdominopelvic CT scanning as part of the trauma evaluation, a pelvic radiograph may be superfluous. Screening pelvic radiography should be reserved for the rare unstable patient or the patient in whom an abdominopelvic CT scan is not otherwise indicated.     

Pediatric Lisfranc variants and equivalent injuries: A review

IntroductionPediatric Lisfranc injuries are rare and a limited number of series or case reports have been published. Diagnosis can be easily missed and long-term outcome is not sufficiently presented. The primary aim of this paper is to review the literature about pediatric Lisfranc variants and equivalent injuries. This article also provides a review on Lisfranc joint anatomy, pediatric Lisfranc injuries, and stress or acute fractures involving the first and central (second to third) metatarsal (MT) bases, in an effort to detect potential pediatric Lisfranc variants and equivalent injuries, which were not accurately diagnosed.MethodsThe bibliographic survey to identify pediatric Lisfranc variants and equivalent injuries was conducted in the PubMed and Scopus databases, with no time limit. Four terms were used for searching in all possible combinations: Pediatric/children, Lisfranc/tarsometatarsal, variant/equivalent, injury/fracture. The only inclusion criterion was the age of the patients, which had to be less than 12 years. Reports on adolescents or adults were excluded.ResultsThe research indicated that there was only one study mentioning the pediatric Lisfranc equivalent injury, while there were no cases recorded as pediatric Lisfranc variants. The literature review regarding the final clinical outcome of both pediatric Lisfranc injuries and fractures, either stress or acute, involving the central MT base, indicated that early degenerative changes often occur, and may be responsible for chronic pain and activity limitation, even after mild and subtle low energy injuries.Discussion/ConclusionsThis review suggests that stress fractures involving the central MT base could be considered as a variant of the Lisfranc injury in children. Care should be taken to exclude occult fractures or ligamentous injuries to the medial and central Lisfranc joint complex in the presence of fractures involving the base or proximal portion of the first MT, including injuries to the physeal plate, to rule out the pediatric Lisfranc equivalent injury.     

Prevalence and clinical significance of occult fractures in children with radiograph-negative acute ankle injury: A meta-analysis

Background and purpose

Plain radiographs may fail to reveal an ankle fracture in children because of developmental and anatomical characteristics. In this systematic review and meta- analysis, we estimated the prevalence of occult fractures in children with acute ankle injuries and clinical suspicion of fracture, and assessed the diagnostic accuracy of ultrasound (US) in the detection of occult fractures.

Methods

We searched the literature and included studies reporting the prevalence of occult fractures in children with acute ankle injuries and clinical suspicion of fracture. Proportion meta-analysis was performed to calculate the pooled prevalence of occult fractures. For each individual study exploring the US diagnostic accuracy, we calculated US operating characteristics.

Results

9 studies (involving 187 patients) using magnetic resonance imaging (MRI) (n = 5) or late radiographs (n = 4) as reference standard were included, 2 of which also assessed the diagnostic accuracy of US. Out of the 187 children, 41 were found to have an occult fracture. The pooled prevalence of occult fractures was 24% (95% CI: 18–31). The operating characteristics for detection of occult ankle fractures by US ranged in positive likelihood ratio (LR) from 9 to 20, and in negative LR from 0.04 to 0.08.

Interpretation

A substantial proportion of fractures may be overlooked on plain radiographs in children with acute ankle injuries and clinical suspicion of fracture. US appears to be a promising method for detection of ankle fractures in such children when plain radiographs are negative.Acute ankle injuries (AAI) are common in patients of all ages and may constitute up to 12% of emergency department (ED) visits (Cockshott et al. 1983). They involve about 25% of all injuries of the musculoskeletal system (Pijnenburg et al. 2000). It has been estimated that approximately 1ankle injury per 10,000 people occurs every day (Vasukutty et al. 2011).Of primary concern is whether patients with AAI have fractures. When there is clinical suspicion of fracture, clinicians have traditionally relied on the use of plain radiographs to exclude ankle fractures. However, interpretation of conventional radiographic imaging of childhood injuries is challenging, due to the developmental and anatomical characteristics of children (Marsh and Daigneault 2000). In children, plain radiographs may fail to reveal a fracture; accurate diagnosis can be complicated by endochondral ossification, additional areas of ossification, and open epiphyseal plates (Endele et al. 2012). This gives a risk of over- treatment of children without fracture and under-treatment of those with fracture, with medical (Ogden 1987), financial (Kan et al. 2009), and psychosocial (Loder et al. 1995) consequences.Using different imaging methods such as late radiographs (Simanovsky et al. 2005, 2009, Sankar et al. 2008, Kan et al. 2009) or magnetic resonance imaging (MRI) (Stuart et al. 1998, Launay et al. 2008, Boutis et al. 2010, Endele et al. 2012, Gufler et al. 2013) as reference standard, numerous studies have looked for the presence of occult fractures in children with radiograph-negative AAI and clinical suspicion of fracture. Some authors have also assessed the accuracy of ultrasound (US) in the detection of occult ankle fractures, comparing it with late radiographs as reference standard (Simanovsky et al. 2005, 2009). To date, however, no systematic reviews or meta-analyses on this topic have appeared. We therefore undertook a systematic review and—where appropriate—a meta-analysis of the relevant literature to estimate the prevalence of occult fractures in children with AAI. The main questions addressed in this review were: “what is the prevalence and what is the clinical significance of occult fractures in children with radiograph-negative AAI and clinical suspicion of fracture?” We also wanted to assess the diagnostic accuracy of US in detection of occult fractures in such children.     

Ultrasound imaging in musculoskeletal injuries-What the Orthopaedic surgeon needs to know

Patients with musculoskeletal complaints have either been ignored or advised investigations far beyond their means or comfort. Focusing attention only on spine and head restricted the evaluation in cases of trauma and were followed up only if the injuries were life threatening. In the same vein, the extremities often got overlooked or at best were evaluated only by plain radiographs. Soft tissue injuries were therefore often missed and not only raised the morbidity in the patient but also dissatisfaction towards the treating physician. Recent exponential improvement in medical ultrasound technology has revolutionised the field of musculoskeletal imaging. Cutting-edge technology using state-of-the-art machines and high-frequency transducers have placed it in a stronger position as compared to in the past in many aspects of musculoskeletal imaging. Also, with better techniques and understanding of the modality, under given set of circumstances MSK ultrasound has far reaching results allowing for detailed evaluation of soft tissues including nerves, ligaments and tendons.     

Radionuclide Assessment of Heterotopic Ossification in Spinal Cord Injury Patients

ABSTRACT

Whole body ^99m Tc-pyrophosphate bone scans were obtained and correlated with skeletal radiographs for detection of heterotopic ossification in 135 spinal injury patients. There were 40 patients with recent injury (less than 6 months) and 95 with injury of over 6 months duration. Heterotopic new bone was detected on the bone scan in 33.7% of 95 patients with spinal cord injuries of more than 6 months duration and 30% of 40 patients with injuries of less than 6 months. The radionuclide scan was found to be useful in detection of heterotopic ossification at its early stage and in its differentiation from other complications in spinal cord injury patients.     

MRI shows a high incidence of carpal fractures in children with posttraumatic radial-sided wrist tenderness

Background and purpose — The epidemiology and optimal diagnostics of wrist injuries in children are not knotwn. We describe fractures revealed by magnetic resonance imaging (MRI) in a prospective population of children and adolescents with posttraumatic radial-sided wrist tenderness, and compare the diagnostic value of radiographs and computed tomography (CT) with that of MRI.

Patients and methods — From 2004 to 2007, patients less than 18 years of age who presented at our emergency department were included in the study. 90 wrists in 89 patients underwent clinical, radiographic, and low-field MRI investigation. If plain radiographs or MRI revealed a scaphoid fracture, a supplementary CT scan was performed. Sensitivity and specificity of radiographs and CT for diagnosis of scaphoid fractures was calculated using MRI as the reference standard.

Results — 74 fractures were diagnosed in 61 of 90 wrists using MRI; 48 wrists had a scaphoid fracture, 8 had a distal radius fracture, 7 had a capitate fracture, and 3 had a triquetrum fracture. The most common combination of fractures was scaphoid and capitate. The sensitivity of radiographs for visualization of scaphoid fractures was 54% and the specificity was 100%. The sensitivity for other fractures was <50%. The sensitivity of CT for visualization of scaphoid fractures was 96% and it was between 33% and 100% for other fractures.

Interpretation — MRI showed a high incidence of fractures in children and adolescents with posttraumatic radial wrist tenderness, and it led to the diagnosis of more fractures than plain radiographs and CT. A scaphoid fracture was the most common carpal injury, followed by fracture of the capitate.     

Histological and radiographic evaluation of three common tendon transfer techniques in an un-ossified bone porcine model: implications for early anterior tibialis tendon transfers in children with clubfeet

PurposeTo compare the histological healing and radiographic effects of tendons transferred to ossified or unossified bone using different tendon fixation techniquesMethodsNine new-born piglets underwent bilateral tendon transfers to either the ossified boney calcaneal body or unossified apophysis. The tendons were fixed using metallic suture anchors, sutures alone or a bone tunnel. At six weeks of age, calcanei were harvested, radiologically imaged and then prepared for histology. A semi-quantitative aggregated scoring system with values ranging from 0 (poor) to 15 (excellent), was used to grade healing at the surgical enthesis and the apophyseal ossification was graded by five independent reviewers in triplicate using a modified (1 to 4) validated scoring system.ResultsHistologically, the cartilaginous transfers utilizing the tunnel and suture techniques also demonstrated the best average aggregated scores of entheses healing rivalling that measured in transfers using the classic bone tunnel technique (clinical benchmark), whereas suture anchor fixation demonstrated the worst healing in both the ossified and unossified samples. All three transfer techniques caused at least minor alterations in apophyseal ossification, with the most significant changes observed in the metallic suture anchor cohort. The tunnel and suture techniques demonstrated similar and more mild abnormalities in ossification.ConclusionTendon transfers to unossified bone heal histologically as well as transfers classically performed through tunnels in bone. Suture fixation or tunnel techniques appear radiographically and histologically superior to suture anchors in our newborn porcine model.Level of evidence      

Osteochondral fracture of the patella without soft tissue injury and with no dislocation: A case report

IntroductionOsteochondral fracture of the patella is a fairly common pathology, but almost always associated with a spectrum of soft tissue injuries including anterior cruciate ligament (ACL) rupture. We present a rare case of an osteochondral fracture of the patella in the absence of ligament or soft tissue injuries and with no dislocation of the patella in a pediatric patient.Presentation of caseAn 11-year-old male presented to the orthopedic clinic on crutches following a football injury. The patient had pain in his left knee with flexion deformity. Plain film radiography of the left knee was taken, and an osteochondral fracture of the patella was suspected. Further imaging studies were conducted including computed tomography (CT) and magnetic resonance imaging (MRI) which revealed an isolated osteochondral fracture of the patella with no other associated injuries. Open reduction and internal fixation of the displaced fragment was successfully preformed with favorable outcomes. During follow-up, almost full range of motion was regained, and plain film radiography revealed healed fracture with a normal appearance of the patella.DiscussionTraumatic osteochondral fracture of the patella is a common injury and most of these injuries are commonly accompanied by an acute dislocation of the patella or soft tissue injuries such as rupture of the anterior cruciate ligament (ACL) and almost half of all patellar dislocations incidence are associated with osteochondral fractures of the patella. This case had an isolated osteochondral fracture of patella.ConclusionAs demonstrated in this case, osteochondral fractures are common among younger population and patients need to be thoroughly evaluated. Advanced Imaging such as MRI and CT are essential to exclude soft tissue injuries. Although management is highly variable, the importance of open reduction and early fixation should be emphasized for optimal outcomes.     

Richtungsweisende Diagnostik der posttraumatischen Gonarthrose

Diagnostic imaging is performed as indicated by the patient's clinical history and the clinical examination.The imaging technique selected is tailored to the findings, and the standard technique is still conventional radiography. Other diagnostic imaging techniques are often advisable in addition: for example, magnetic resonance imaging is of increasing importance for the assessment of lesions fo the soft tissues (such as ligaments) and of cartilaginous pathology.However, in specific situations computed tomography (e.g. in the case of joint fractures) and conventional long-axis radiographs are indispensable even today.     

Reasons for failure of surgical treatment in 25 tibial plateau fractures

BackgroundThe management of tibial plateau fracture is challenging. Restoration of articular congruity and early range of motion should be the primary goal. Proper and adequate preoperative planning is essential for a good outcome.PurposeThe study was a retrospective analysis of failed surgical treatment of tibial plateau fractures.MethodsTwenty-five patients with tibial plateau fractures were referred to our hospital after having undergone surgery elsewhere. Because of functional disability, the patients received revision surgery with concomitant treatment of associated soft tissue injuries. The average age at operation was 43.5 years (range, 27–71 years). The average interval between the first treatment and the secondary operation was 10.4 months (range, 6–24 months). From the radiographs and operative findings, we analyzed the factors that cause failure of the index surgical treatments for tibial plateau fractures.ResultsSchatzker classification identified five type II, one type III, four type IV, seven type V, and eight type VI fractures. Among these 25 cases, nonunion was found in seven (28%) patients and malunion in 18 patients (72%). The causes of failed surgeries included inadequate fixation (76%), malreduction (84%), and bone defect (100%). In addition, there were associated soft tissue injuries in nine patients (36%).ConclusionsThe main elements of the surgical management of tibial plateau fractures are anatomical reduction, firm fixation, and bone grafting. Inadequate fixation, malreduction, and bone defects can lead to the failure of surgical treatment. The key to successful surgical treatment is a well-designed surgical scheme tailored on the specific fracture type and soft tissue condition; this can prevent serious complications and resultant malpractice suits.