Triquetral Fractures Overview

Purpose of ReviewThe triquetrum is the second most commonly fractured carpal bone, comprising 15–18% of all carpal bone fractures. This review summarizes the current knowledge of triquetral fractures, including the anatomy and pathophysiology, evaluation and diagnosis, treatment and management, post-treatment outcomes, and complications.Recent FindingsTriquetral fractures are frequently caused by impaction of the ulnar wrist after a fall on an outstretched hand or by avulsion of attached ligaments. There are three main types of triquetral fractures: dorsal cortical fractures, triquetral body fractures, and volar cortical fractures. Dorsal cortical fractures are the most common and are usually benign, while volar cortical fractures are the least common and can be problematic. Nonsurgical management is indicated for most triquetral fractures, which usually results in good outcomes. Surgical treatment is indicated for fractures with significant displacement or evidence of instability. Complications of triquetral fractures include non-union, triangular fibrocartilage complex injury, and pisotriquetral arthritis.SummaryWhile less common than scaphoid fractures, triquetral fractures should remain in the differential diagnosis for patients with ulnar-sided wrist pain after falling on an outstretched hand. Most triquetral fractures can be treated with immobilization, though they should be thoroughly evaluated due to their potential to result in instability, loss of motion, and arthrosis. Further research is needed to determine the best method of surgical treatment.     

Design and biomechanical study of slide-poking external fixator for hip fracture

BackgroundFemoral head collapse and coxa vara lead to internal fixator failure in elderly patients with hip fracture. External fixator application is an optimal choice; however, the existing methods have many disadvantages.MethodsType 31-A1.3 hip fracture models were developed in nine pairs of 1-year-old fresh bovine corpse femur specimens. Each left femur specimen was fixed by a dynamic hip screw (control group), and each right femur specimen was fixed by the slide-poking external fixator (experimental group). Vertical loading and torsion tests were then performed in both groups.ResultsIn the vertical loading experiment, a 1000-N load was implemented. The mean vertical downward displacement of the femoral head in the experimental and control groups was 1.49322 ± 0.116280 and 2.13656 ± 0.166374 mm, respectively. In the torsion experiment, when the torsion was increased to 10.0 Nm, the mean torsion angle in the experimental and control groups was 7.9733° ± 1.65704° and 15.4889° ± 0.73228°, respectively. The slide-poking external fixator was significantly more resistant to compression and rotation than the dynamic hip screw.ConclusionThe slide-poking external fixator for hip fractures that was designed and developed in this study can provide sufficient stability to resist compression and rotation in hip fractures.     

Biomechanical evaluation of the reconstruction of the calcar femorale in femoral neck fractures: a comparative finite element analysis

ObjectiveFemoral neck fractures are common. We evaluated the biomechanical performance of an internal fixation method based on traditional three cannulated screws (3CS) inserted from below the fracture in the direction of the calcar femorale in the treatment of Pauwels III femoral neck fracture.MethodsWe constructed and evaluated a three-dimensional model of a Pauwels III femoral neck fracture with four models of internal fixation (3CS, and 150°, 155°, and 160° nailing angles) for reconstruction of the calcar femorale, by finite element analysis (FEA).ResultsThe peak stress values at the fracture ends in the 3CS, 150°, 155°, and 160° nailing angle models were 30.052 MPa, 33.382 MPa, 34.012 MPa, and 29.858 MPa; peak stress values for internal fixed stress were 315.121 MPa, 228.819 MPa, 198.173 MPa, and 208.798 MPa; and the maximum displacement of the femoral head was 13.190 mm, 13.183 mm, 12.443 mm, and 12.896 mm, respectively.ConclusionFEA showed that the new nailing methods and the 160° nailing angle for reconstruction of the calcar femorale showed better performance in resisting shearing force for Pauwels III femoral neck fracture, with better mechanical properties, than those with the other three models. These findings can provide a clinical reference.     

Multilevel percutaneous vertebroplasty with the Spine Jack® system in a patient with Cushing disease

BackgroundPercutaneous vertebroplasty (PV) is a minimally invasive procedure that requires the injection of cement into a fractured vertebral body. Spine Jack® is a vertebroplasty system with an intracorporal implant designed to restore the height of the vertebral body in osteoporotic vertebral fractures. There are no reported cases of PV with Spine Jack® system as treatment for multilevel compression fractures in patients with vertebral osteoporosis due to Cushing disease.Case presentationA 55‐year‐old man with lumbago, impaired deambulation 6 weeks prior to presentation, with Oswestry score of 72% and a visual analogue scale (VAS) score of 9 points. Imaging studies showed osteoporotic fractures at T5, T8, T11, T12, and L1‐L5 vertebrae secondary to Cushing disease. PV was performed with a Spine Jack® intracorporal implant device, in three sessions, and multiple levels were operated at each intervention. Post‐operative course demonstrated improvement of pain, height, correction of the kyphotic angle and Oswestry score, without any neurological deficits despite having nine vertebral fractures.ConclusionPercutaneous vertebroplasty with the Spine Jack® system is a safe and effective procedure to treat multilevel vertebral fractures due to Cushing disease, improving the quality of life and allowing the patient to remain pain‐free while avoiding major surgery.     

Sonographic diagnosis of a radiographically occult displaced fracture of a costal cartilage

We report the case of a 22‐year‐old athlete who sustained a blunt thoracic trauma to the right chest causing a costal cartilage fracture. Plain radiographs revealed no abnormalities while sonographic (US) examination performed a week later because of persistent pain led to the diagnosis of a displaced fracture of the right tenth costal cartilage. A follow‐up US examination confirmed the healing of the fracture and allowed the patient to return to competitive sport activity. We recommend the use of US in patients with persisting pain after thoracic trauma with negative plain radiographs of the ribs to rule out radiographically occult costal cartilage fractures. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45 :605–607, 2017     

Role of US in evaluating breast implant integrity

Purpose

To assess the diagnostic accuracy and inter-observer variability of ultrasound (US) in recognizing signs of intra or extra-capsular rupture of silicone breast implants by using the magnetic resonance imaging (MRI) findings as the reference standard.

Methods

150 patients for a total of 300 implants underwent breast US and subsequently MR examination searching for signs of intra or extra-capsular rupture. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy were calculated for breast US having MRI findings as the reference standard. Cohen’s kappa statistics was used in order to assess inter-observer agreement for US.

Results

170/300 (57 %) implant ruptures were detected at US (intra-capsular n = 110, extra-capsular n = 60). By comparing US findings with MR results, overall sensitivity, specificity, accuracy, PPV, and NPV of 79, 63, 70, 65, and 77 %, respectively, were found for breast US. In case of intra-capsular rupture, sensitivity, specificity, accuracy, PPV, and NPV of 63, 63, 63, 45, and 77 %, respectively, were obtained; 100 % values were found for extra-capsular rupture US diagnosis.

Conclusion

US can be used as the first examination in patients with breast implants. US intra-capsular rupture detection requires further evaluation by MRI; in case of extra-capsular rupture US diagnosis, surgical implant removal could be proposed without further investigations.     

Liquid nitrogen for cryotherapy treatment for osteosarcoma of the middle femur: A case report

BackgroundOsteosarcoma is the most common primary malignant bone tumor in children and adolescents. Cryotherapy liquid nitrogen has been used an adjuvant treatment for tumors for some decades.Case presentationA 23‐year‐old male patient was admitted to our hospital, mainly due to progressive pain in his left thigh, and confirmed osteosarcoma by local biopsy. A total length of 28 cm tumor bone was completely resected at the region of above and below lesion 3 cm under the guidance of MRI. After removed part of the tumor tissue, tumor bone was dealt with liquid nitrogen for 20 minutes. Finally, the bone was fixed with intramedullary needles for reconstruction. Three months after surgery, the X‐ray examination showed poor bone growth at both distal sides of osteotomy and disuse degeneration of knee joint. The patient was performed an incision on the lateral side of the distal left thigh to secure the locking plate, and followed up every 3 months. Two years after operation, there was no sign of local recurrence.ConclusionLiquid nitrogen for cryotherapy may be a feasible local therapy for large lesion of osteosarcoma in middle femur.     

Imperforate hymen causing congenital hydrometrocolpos

A 3-day-old girl in good health was referred to our department for the evaluation of an abdominal mass detected at birth. Prenatal ultrasound (US) examinations had shown no anomaly. US examination revealed the presence of a hypoechoic and corpusculated cystic formation of about 8 × 5 × 4 cm located in the mid region of the abdomen. The uterus was not visible and the kidneys were normal with no sign of hydronephrosis. The ovaries were normal. Physical examination confirmed US findings revealing the presence of a curved membrane which covered the vaginal opening. Based on these findings, the patient was diagnosed to have hydrometrocolpos. Hymenectomy was performed and about 100 ml of milky fluid was subsequently removed by aspiration. The patient presented no other congenital anomalies and US follow-up showed a normal structure of the uterus.     

Minimally invasive treatment of forearm double fracture in adult using Acumed forearm intramedullary nail: A case report

BACKGROUNDCurrently, open reduction internal fixation is the conventional surgical method for treatment of double ulna and radius fracture. However, open reduction is associated with a high risk of complications. This case of forearm double fracture involved a patient treated using an Acumed intramedullary nail. The patient experienced good follow-up outcomes. The Acumed forearm intramedullary nail enables early functional exercise and hastens healing of the fracture. Few studies have reported on the use of this approach for the treatment of fractures.CASE SUMMARYA 23-year-old male patient was admitted to hospital after 5 h of pain, swelling, and limited activity of left forearm caused by a careless fall. Physical examination showed stable basic vital signs, swelling of the left forearm, and severe pain when pressing on the injured part of the forearm. Further, friction was felt at the broken end of the bone; the skin was not punctured. Movement of the left hand was normal, and the left radial artery pulse was normal. Three-dimensional computed tomography examination showed an ulna fracture of the left forearm and comminuted fracture of the radius. The fracture was located in the upper third of the radius, with significant displacement on the fracture side. Clinical diagnosis further confirmed the left radius comminuted fracture and ulna fracture. After analyzing the fracture pattern, age, and other patient characteristics, we chose an Acumed nail for treatment and achieved good follow-up outcomes.CONCLUSIONAcumed forearm intramedullary nail for fixation of ulna and radius fracture reduced complication risk and resulted in good follow-up outcomes.     

The Diagnostic Accuracy of Ultrasonography for the Diagnosis of Rib Fractures in Patients Presenting to Emergency Department With Blunt Chest Trauma

BackgroundRib fractures are the most common complications of blunt chest trauma (BCT). Computed tomography (CT) is the modality of choice for BCT, but with several disadvantages. Ultrasonography (US) is an inexpensive, readily available, and relatively harmless imaging alternative. However, a direct comparison of the sonographic evaluation of the rib as a whole with CT as a reference has not been performed to date.ObjectiveThis study aimed to compare the diagnostic accuracy of US with CT for the detection of rib fractures in patients who presented to emergency department (ED) with BCT.MethodsWe included a convenience sample of adult patients who presented to the ED with thoracic pain after BCT in the last 24 h in this prospective, observational, diagnostic accuracy study. The diagnostic utility of US performed by an emergency physician was compared with thorax CT.ResultsThe final study population included 145 patients. The diagnostic accuracy of US was 80% with a sensitivity of 91.2% and specificity of 72.7% for the detection of any rib fracture (positive likelihood ratio 3.4 and negative likelihood ratio 0.12). If we considered each rib separately, the sensitivity of US decreased to 76.7% and specificity increased to 82.7% (81.3% accuracy).ConclusionsA negative US of the site of the highest tenderness and neighboring ribs in a patient with BCT who presented to the ED with lateralizing pain decreases the possibility of a rib fracture significantly. However, a positive US performs poorly to specify the exact location and number of the fractured ribs.     

Changes and significance of plasma fibrinogen gamma‐chain concentration in preeclampsia patients

ObjectiveTo investigate the plasma fibrinogen gamma‐chain concentration in preeclampsia patients and explore its value in preeclampsia prediction and auxiliary diagnosis.MethodsFollow‐up of pregnant women who regularly attended perinatal care at two hospitals in China was performed, and clinical data and plasma samples were collected at each examination until delivery. The gamma‐chain concentration was detected by Western blotting, and Quantity One Software was used for gamma‐chain grayscale value measurements.ResultsForty‐two patients with preeclampsia and 42 control patients completed the follow‐up. In the control group, the gamma‐chain concentration at 32 weeks of gestation was higher than that at 20 weeks of gestation, but the difference was not statistically significant (p > 0.05). In the experimental group, the gamma‐chain concentration at preeclampsia diagnosis was significantly higher than that at 20 weeks of gestation (p < 0.05). Compared with the control group, the gamma‐chain concentration was higher at 20 weeks of gestation in the experimental group, but the difference was not statistically significant. However, at 32 weeks of gestation and at the time of diagnosis, the gamma‐chain concentration in the experimental group was significantly higher than that in the control group (p < 0.05). At 32 weeks of gestation and at the time of diagnosis, the AUCs from ROC curve analysis of plasma fibrinogen gamma‐chain concentrations were 0.64 and 0.71, respectively.ConclusionPlasma fibrinogen synthesis and degradation were disrupted in preeclampsia patients before and after diagnosis, and gamma‐chain concentration was significantly increased. Plasma fibrinogen gamma chain may be of some value in preeclampsia prediction and auxiliary diagnosis.     

Benefit of lag screw placement by a single- or two-screw nailing system in elderly patients with AO/OTA 31-A2 trochanteric fractures

ObjectiveTo retrospectively analyze the clinical outcomes of two intramedullary fixation devices, the INTERTAN nail and Gamma3 nail, for treatment of AO/OTA 31-A2 trochanteric fractures in elderly patients.MethodsIn total, 165 elderly patients underwent treatment for AO/OTA 31-A2 trochanteric fractures in our hospital from June 2017 to June 2018 (INTERTAN group, n = 79; Gamma3 group, n = 86). All patients underwent radiological and clinical investigations and were followed up for an average of 12 months. Age, sex, fracture type, surgical time, intraoperative blood loss, fracture healing time, and complications were compared between the two groups.ResultsThe surgical time was significantly shorter and the intraoperative blood loss volume was significantly lower in the Gamma3 than INTERTAN group (58.2 ± 2.5 vs. 81.7 ± 14.2 minutes and 170 ± 29 vs. 220 ± 16 mL, respectively). However, there were no significant differences in the reduction quality, hospital stay, fracture healing time, Harris hip score, postoperative complications, or 1-year postoperative mortality.ConclusionBoth INTERTAN and Gamma3 nails may be effective for surgical treatment of AO/OTA 31-A2 trochanteric fractures in elderly patients. However, the Gamma3 nail was superior to the INTERTAN nail in terms of surgical time and intraoperative blood loss.     

The evaluation of the sensitivity and specificity of wrist examination findings for predicting fractures

Background

The aim of this study was to evaluate the sensitivity and specificity of physical examination findings and functional tests in adult acute wrist trauma patients who presented to the emergency department (ED) and to create a reliable and practical clinical decision rule for determining the necessity of radiography in wrist trauma.

Point of care ultrasound (POCUS) telemedicine project in rural Nicaragua and its impact on patient management

Background

Point of care ultrasound (POCUS) is a useful diagnostic tool in medicine. POCUS provides an easy and reproducible method of diagnosis where conventional radiologic studies are unavailable. Telemedicine is also a great means of communication between educators and students throughout the world.

Hypothesis

Implementing POCUS with didactics and hands-on training, using portable ultrasound devices followed by telecommunication training, will impact the differential diagnosis and patient management in a rural community outside the United States.

Materials and methods

This is an observational prospective study implementing POCUS in Las Salinas, a small village in rural western Nicaragua. Ultrasound was used to confirm a diagnosis based on clinical exam, or uncover a new, previously unknown diagnosis. The primary endpoint was a change in patient management. International sonographic instructors conducted didactic and practical training of local practitioners in POCUS, subsequently followed by remote guidance and telecommunication for 3 months.

Results

A total of 132 patients underwent ultrasound examination. The most common presentation was for a prenatal exam (23.5 %), followed by abdominal pain (17 %). Of the 132 patients, 69 (52 %) were found to have a new diagnosis. Excluding pregnancy, 67 patients of 101 (66 %) were found to have a new diagnosis. A change in management occurred in a total of 64 (48 %) patients, and 62 (61 %) after excluding pregnancy.

Conclusion

Implementing POCUS in rural Nicaragua led to a change in management in about half of the patients examined. With the appropriate training of clinicians, POCUS combined with telemedicine can positively impact patient care.     

Can strain US-elastography with strain ratio (SRE) improve the diagnostic accuracy in the assessment of breast lesions? Preliminary results

PurposeTo assess the diagnostic value of strain ratio elastography (SRE), a semiquantitative elastosonographic method based on the displacement of the tissue from an external source (manual compression with the transducer), as compared and in combination with conventional ultrasound for the differentiation of breast lesions.MethodsOne hundred and eighty-two patients with breast lesions consecutively underwent B-mode, color Doppler US, and strain US-elastography. Each lesion was classified according to the BI-RADS lexicon by evaluating the size, the B-mode, and color Doppler features and then evaluated by SRE. Histology proven by biopsy was used as the gold standard and the patients with malignant lesions subsequently underwent operations. The diagnostic performance of each method was assessed with 2 × 2 contingency tables and ROC curve analysis. To maximize the SRE sensitivity and specificity, the SRE cut-off value was calculated using the Youden test.ResultsHistological examination revealed 66 benign and 116 malignant breast lesions. The conventional ultrasound showed sensitivity and specificity for the differentiation of benign and malignant lesions of 86.2% and 75.8%, respectively. Similar results were found for strain US-elastography with a cut-off of 2.49, with sensitivity and specificity of 89.7% and 72.7%, respectively. The association of conventional ultrasound with the SRE value increased the sensitivity (98.3%) but decreased the specificity compared with conventional US alone (63.6%).ConclusionStrain US-elastography can be associated with BI-RADS US examination. According to our preliminary results, it helped increase the sensitivity although it decreased the specificity. However, further multicenter studies on a larger population are warranted.     

普通X线在腕关节损伤诊断中的价值分析

目的:分析普通X线在腕关节损伤诊断中的价值分析。方法:在我院自2018年11月-2019年11月随机选取300例患者进行研究。300例患者分别采用普通X线与64排螺旋CT扫描进行诊断,对比两种方法对患者腕关节的骨折、脱位的显示情况,并且对比两种诊断的准确性。结果:在本次检查中,DR检查总共发现195例骨折现象,25例脱位现象,骨折现象大多发生与尺桡骨远端以及舟状骨处。采用螺旋CT对患者腕关节进行扫描检查,共发现195例骨折患者,105例脱位患者,其中多发性骨折90例。DR检查中,多发性骨折漏诊4例,(P>0.05);诊断比较,其中DR 172例多发性骨折患者,螺旋CT 176例多发性骨折患者,DR诊断中,多发性骨折漏诊4例,(P>0.05)。结论:X线在腕关节损伤诊断中具有良好的应用价值,同时对患者的诊断较为准确,为临床治疗提供了可靠的诊断依据,值得广泛推广使用。     

Renal artery aneurysm mimicking a solid parenchymal lesion

A 40-year-old woman was referred to our department for further investigation of a renal mass identified at an ultrasound (US) examination carried out in a private clinic because of abdominal pain. The mass was oval and hypoechoic, measured about 20 mm in diameter and was located near the left renal sinus; color Doppler showed peripheral blood flow. US examination carried out in our department using different equipment confirmed the presence of the mass but revealed intralesional blood flow suggesting aneurysm. This diagnosis was confirmed at subsequent computed tomography (CT) scanning and magnetic resonance imaging (MRI). The patient refused to undergo surgery and she is currently being monitored and has suffered no sequelae.     

Snapping wrist due to bony prominence and tenosynovitis of the first extensor compartment: A case report

BACKGROUNDA snapping wrist is a rare symptom that results from the sudden impingement of one anatomic structure against another, subsequently causing a sudden movement only during wrist movement.CASE SUMMARYA 30-year-old woman with a history of right wrist contusion reported right wrist snapping after overuse. The snapping became symptomatic after moving heavy objects. The pain persisted even when she received 1 mo of conservative treatment. Physical examination showed painful wrist snapping during wrist radioulnar motion and thumb abduction-adduction. Radiography demonstrated bone overgrowth over the radial styloid process. Sonography disclosed a tendon jumping over a bony prominence in the first compartment during wrist motion. Magnetic resonance imaging revealed no anomalous tendon nor tumorlike lesion. Under the wide-awake local anesthesia no tourniquet (WALANT) technique, the lesion was identified in the first extensor compartment. The patient received stepwise extensor retinaculum release, synovectomy, and bone spur removal. By 6^th week, the patient was completely free of pain and unable to snap her wrist. She started working 7 wk after the surgery. One year after the surgery, the wrist snap was not recurrent.CONCLUSIONCareful physical examination and dynamic sonography may confirm the diagnosis of a snapping wrist. With the WALANT technique, the lesion could be identified under direct vision, and we could take stepwise interventions according to intraoperative presentations.     

Ultrasound-assisted triage of ankle trauma can decrease the need for radiographic imaging

BackgroundAn ankle sprain is a common injury, and patients are usually examined with plain radiographs to rule out a fracture despite the fact that only a small minority actually have one.PurposeTo investigate if ultrasound (US)-guided triage can decrease the need for radiographic imaging in patients with ankle trauma.HypothesisOrthopedic surgeons can use point-of-care US with limited training to triage ankle trauma that requires standard radiographs.MethodsSeven junior orthopedic surgeons underwent a 30-minute standardized training session using a basic US musculoskeletal examination designed to exclude ankle fractures.One-hundred twenty-two patients with ankle trauma were included at the emergency department and underwent clinical investigation, including examination according to the Ottawa ankle rules as well as US and standard ankle radiographs. In this study group, radiographs identified 23 significant fractures. Ultrasound-guided triage could not exclude a fracture in 37 patients. All of the 23 fractures seen on radiographs were among the 37 patients where US could not rule out a fracture. Ottawa ankle rules managed to exclude the need for radiographs in 28 of the 122 patients, whereas 85 who underwent the US-guided triage could have avoided a radiograph. Avulsion fractures at the tip of the fibula were not considered significant.ConclusionThis study demonstrates that with limited standardized training a junior, an orthopedic surgeon is able to use US-guided triage during the primary examination at the emergency department to exclude at least significant ankle fractures. This practice could decrease the need for radiographic imaging, avoiding a mandatory radiographic investigation in many patients with ankle trauma. It would also make it possible to treat many patients with ankle trauma more rapidly and to reduce costs and radiation exposure.