Rare shear-type fracture of the talar head in a thirteen-year-old child — Is this a transitional fracture: A case report and review of the literature

BACKGROUNDTalar fractures are exceedingly rare in childhood. There are very few studies on the clinical aspects, the long-term outcomes and the appropriate treatment of these fractures in pediatric patients. The mechanism of trauma consists of the application of a sudden dorsiflexion force on a fully plantar-flexed foot. Traumatic mechanism, symptoms and imaging of injuries of the talar head are similar to transitional fractures that are normally described at the distal epiphysis of the tibia: the so-called transitional fracture is defined as an epiphyseal injury when the growth plate has already started to close.CASE SUMMARYA thirteen-year-old girl reported a high-energy trauma to her right foot, due to falling from her horse. X-rays at the Emergency Department were negative. Because of persistent pain, the patient was assessed by an orthopedic surgeon after two weeks and computed tomography scans revealed a misdiagnosed displaced shear-type fracture of the talar head. Hence, surgical open reduction and fixation with two headless screws was performed. The girl was assessed regularly, and plain films at follow-up revealed complete healing of the fracture. Within six months after surgery, the patient returned to pre-injury sport activities reporting no complications.CONCLUSIONInjuries of the talar head in childhood should be considered as transitional fractures. Open reduction with internal fixation aims to reduce malalignment and osteoarthritis. Computed tomography scans are recommended in these cases.     

Does an ulnar styloid fracture interfere with the results of a distal radius fracture?

Background  

The ulnar styloid is a supportive structure for the capsular ligament complex of the distal radioulnar joint. The relation between fractures of the ulna and distal radius is not clear, especially in regard to whether ulnar fractures predict worse outcomes for distal radius fractures. The objective of this study was to analyze the influence of ulnar styloid fractures in patients with reducible and unstable distal radius fractures.     

Chronic myeloid leukemia in pregnancy: an absolute contraindication to neuraxial anesthesia?

Chronic myeloid leukemia is rare in pregnancy with an estimated incidence of 1:75 000. It is a genetic myeloproliferative disorder marked by increased and unregulated growth of myeloid cells in the bone marrow. The terminal phase of chronic myeloid leukemia may develop into a blast crisis, defined as >30% myeloblasts in the circulation. A blast crisis resembles an acute leukemia and is associated with rapid clinical deterioration and short survival. Targeted gene therapy with tyrosine kinase inhibitors is effective in treatment but when these agents are discontinued, as in pregnancy, the patient may relapse and blast cells may enter the circulation. Theoretically, a central nervous system blast crisis may be induced by inadvertent intrathecal seeding of circulating blast cells, and is associated with a high mortality rate and a median life expectancy of three months. We describe the anesthetic management of a patient with chronic myeloid leukemia and blast cells in the circulation who required cesarean delivery. After considering the potential anesthetic risks and benefits, general anesthesia was chosen. Although an iatrogenic central nervous system blast crisis is extremely rare, the high morbidity and mortality associated with such an event should be considered when formulating an anesthetic plan.     

Traumatic hyoid bone fracture �C a case report and review of the literature

Objective:

To present a case of traumatic hyoid bone fracture and a review of the literature

Rationale:

Traumatic hyoid bone fractures are rare, however with the increasing popularity of martial arts the incidence of traumatic hyoid bone fracture may increase in prevalence.

Clinical Features:

A thirteen year old taekwondo athlete collapsed after receiving a kick to the anterior neck. Following first aid emergency care the athlete reported pain with speaking and swallowing and was suffering from dyspnea. Ecchymosis and tenderness were noted over the hyoid bone.

Intervention and Outcome:

Lateral radiographs revealed fracture of the hyoid. Patient was sent home with analgesics and instructed to rest. The athlete was cleared for sport at 4 weeks post injury.

Conclusion:

Ensuring airway integrity and screening for signs of laryngeal laceration are essential in the management of suspected hyoid bone fractures. Observation for 48–72 hours is highly recommended.     

Does failure to visualize the ureter distal to an impacted calculus constitute an impediment to successful lithotripsy?

BACKGROUND: A severe degree of ureteral obstruction is viewed as a predictor of poor outcome in shockwave lithotripsy (SWL). Impacted stones are often considered a contraindication to in-situ SWL. PATIENTS AND METHODS: Impaction in our study was defined as failure to visualize the ureter distal to the calculus with proximal hold-up of contrast for as long as 3 hours on an intravenous urogram (IVU). We evaluated 30 patients with impacted ureteral calculi, who were compared with a second unimpacted group matched for stone size and stone location. The calculi were reorganized into < or =10-mm and >10-mm groups. The results were compared in terms of clearance rates, number of shockwaves, number of sessions, and number of days between the start of SWL and clearance. RESULTS: Between January 1998 and December 2001, 30 impacted stones were treated with lithotripsy. Complete clearance rates in the impacted as well as the non-impacted group were 76.7%. There was no statistical difference in the number of shockwaves, sessions, or time to clearance. The results were poorer in lower-ureteral than upper-ureteral calculi, but this difference did not reach statistical significance. However, the differences between the < or =10-mm and >10-mm stones were statistically significant. CONCLUSION: Impaction on an IVU does not affect the results of lithotripsy.     

Distal forearm fracture in the adult: is ORIF of the radius and closed reduction of the ulna a treatment option in distal forearm fracture?

INTRODUCTION: Distal forearm fractures in younger adults are rare injuries resulting from high energy trauma. Treatment options vary from cast fixation, external fixator, percutaneus pinning and open reduction and internal fixation. METHOD: We retrospectively reviewed 13 patients aged 18-59 from 1996 to 2005 with a distal unstable forearm fracture. All were treated with open reduction and internal fixation of the radius. The ulna was stabilized either by an open reduction and internal fixation or by a closed reduction with or without pin fixation and cast fixation in all cases. At follow-up, we evaluated the radiologic results in terms of forearm fracture retention and functional outcome according to the wrist score by Krimmer. RESULT: Radial inclination amounted to 24 degrees at the injured side when compared to 27 degrees at the non-injured side, palmar tilt was 3 degrees versus 7 degrees and ulna variance was -2 versus -1 mm. According to the modified wrist score by Krimmer, seven excellent, two good and four fair results were achieved. The range of motion of the injured wrist joint was 149 degrees of rotation, in the sagittal plane 106 degrees , frontal plane 61 degrees and on the non-injured side rotation was 171 degrees , and movement in the sagittal plane was 146 degrees and 79 degrees in the frontal plane. Decreased forearm rotation (107 degrees vs. 162 degrees ) and decreased range of motion in the sagittal plane (77 degrees vs. 114 degrees ) were measured in patient following open reduction and internal fixation of radius and ulna compared to the outcome in patients with open reduction and internal fixation of the radius and closed reduction of the ulna. Grip strength of the injured side averaged 350 N versus 440 N which is 76% of that of the opposite side. All patients stated no pain at rest and some experienced slight pain at work. Three patients had an excellent performance at daily activities, nine patients presented problems with certain activities, and one patient showed severe limitations. CONCLUSIONS: Open reduction and internal fixation of the radius is the keystone in treating distal forearm fracture. In case of stable retention of the ulnar head after closed reduction, cast fixation with or without percutaneus pin fixation is a sufficient method to treat unstable distal forearm fractures. In patients with remaining instability of the distal ulna fracture, ORIF is indicated.     

Is there a role of preservation of the spleen in distal pancreatectomy?

BACKGROUND: The spleen may be preserved during distal pancreatectomy (DP) for benign disease. The aim of this retrospective study was to compare the postoperative course of DP with or without splenectomy. STUDY DESIGN: From June 1992 to June 1997, 40 adult patients without chronic pancreatitis underwent elective DP for benign lesions. Fifteen underwent spleen-preserving DP (Conservative Group) and 25 DP with splenectomy (Splenectomy Group). In spleen-preserving DP, we attempted to preserve the splenic artery and vein. RESULTS: Spleen-preserving DP was successfully performed in all 15 cases. Patient groups were comparable for clinical features, indication for DP, and surgical procedure. There were no postoperative deaths. The overall incidence of pancreatic fistula was 23%, but was significantly higher in the Conservative Group (40%) than in the Splenectomy Group (12%; p < 0.05). Subphrenic abscesses were more frequently observed in the Conservative Group than in the Splenectomy Group (p < 0.05). The mean duration of postoperative hospital stay was 19 days (range 6 to 46 days) in the Conservative Group and 12.5 days (range 7 to 45 days) in the Splenectomy Group (p < 0.05). At the end of mean followup of 30 months (range 8 to 40 months), no severe postsplenectomy sepsis was observed in the Splenectomy Group. CONCLUSIONS: In our experience, DP with splenectomy has a lower morbidity rate and we consider it to be the best procedure for benign pancreatic disease.     

Revascularisation by ingrowth of a free flap: Fact or fiction?

Revascularisation of a critically ischaemic extremity by means of a free flap occurs through the development of vascular connections at the free flap-surrounding tissue interface. Three clinical cases are presented showing that in the particular situation of free tissue reconstruction of an ischaemic limb, vascular connections develop which are able at least partially to supply the free flap after occlusion of its arterial pedicle. One other case demonstrates similar vascular connections by angiography © 1997 Wiley-Liss, Inc. MICROSURGERY 17:417–422 1996     

Is delayed reconstruction using the latissimus dorsi free flap a worthy option in the management of open IIIB tibial fractures?

Early reconstruction of severe open fractures, performed within 7 days of the injury, has a better outcome than closure after 7 days. However, the uncertain demarcation of damaged tissue often results in delayed reconstruction. In this article, we report our surgical outcomes of delayed reconstruction using latissimus dorsi free flap with internal fixation. Twenty‐three patients with Gustilo type IIIB open tibial fractures Between March 2009 and May 2012 were included in this study. There were 16 cases of distal 1/3 fracture of the tibia, 4 of midshaft fracture, 1 of proximal 1/3 fracture, and 2 of segmental fracture. Serial debridement with application of negative pressure wound therapy (NPWT) was performed before the final operation. All patients underwent internal fixation of the bone and reconstruction of soft tissue defect using latissimus dorsi free flap. The number of serial debridements, excluding those performed during emergency and finial operation, ranged from 1 to 5 (mean 2.69) times. Mean time from injury to final operation was 10.65 (range, 7–22) days. All flaps survived without complications. Three cases (13%) were infected, and three cases required further bone graft surgery to facilitate bone union (13%). Bone union was achieved after a mean 6.3 (range, 3–12) months. Mean follow‐up period was 16.34 (range, 12–26) months. During follow‐up, all patients were able to ambulate without use of an aid. In cases of severe open fracture, treatment should emphasize soft tissue coverage rather than rushing to achieve definitive fixation in the setting of poor surrounding tissues. When delayed reconstruction is inevitable, radical debridement is performed first, then NPWT is used as bridging therapy, and free flap could be considered for definite soft tissues coverage. © 2015 Wiley Periodicals, Inc. Microsurgery 36:453–459, 2016.     

Volkmann’s contracture of the forearm due to an insect bite: a case report and review of the literature

Compartment syndrome affecting the upper limb is reported rarely in the literature and is usually limited to single case reports. Upper limb compartment syndrome secondary to envenomation is rare, especially in the UK. Worldwide, it has been reported resulting from snake and insect bites, mostly from snakes from the Viperidae family, and from insects such as bees and wasps. Reports from the UK are limited to one case of an adder bite.We present a case of a previously fit and well adult who developed an ischaemic contracture of the forearm after an insect bite. Surgical exploration revealed segmental necrosis and contracture of the superficial and deep flexors of the fingers, requiring fasciotomy and tendon-lengthening procedures. This is the first report of a compartment syndrome, or a late ischaemic contracture from an insect bite in the UK. Owing to the rarity of compartment syndrome of the upper limb secondary to envenomation, a delay in diagnosis and treatment can lead to irreversible changes in the muscular compartments of the forearm.     

Is the presence of surgically treatable coronary artery disease a contraindication to liver transplantation?

Advanced coronary artery disease has been traditionally considered an absolute contraindication to orthotopic liver transplantation where chronic liver failure significantly increases the surgical risk for coronary artery bypass grafting. Performing a simultaneous coronary artery bypass grafting and liver transplant is a theoretically attractive strategy in liver transplant candidates with coronary artery disease in need of revascularization. In the present article, we report a successful simultaneous coronary artery bypass grafting and orthotopic liver transplant with 1-yr post-operative follow-up and we discuss the rationale for this approach. In selected cases, the presence of advanced coronary artery disease should not be considered an absolute contraindication to liver transplantation.     

To fix or not to fix? The role of fibular fixation in distal shaft fractures of the leg

Background

The role of stabilisation of the fibula in distal two-bone fractures of the leg is controversial. Some studies indicate the need for fibular stabilisation in 43 AO fractures, but few studies consider the role of the fibula in 42 AO fractures. The aim of the current paper is to explain the role of stabilisation of the fibula in 42 AO fractures, correlating the rates of healing and non-union between patients with and without fibula fixation.

Materials and methods

A total of 60 patients with 42 AO (distal) shaft fracture of the tibia with associated fracture of the fibula were selected. Patients were divided into two groups according to whether or not the fibula was fixed: Group I (n = 26) comprised patients who had their fibula fixed while Group II (n = 34) comprised patients who did not. The fibular fracture was classified according to the AO and related to the level of the tibial fracture. Other parameters examined were the union rate of the two groups correlated to the fracture pattern and position of the fibular fracture; the demographic data, such as age and gender; the presence of an open fracture, and the type of tibial fixation device used (nail or plate).

Results

None of the parameters considered (open injury, AO classification, device used and level of the fibular fracture relative to the tibial) were shown to have an influence on the development of a non-union.

Conclusion

This study showed a higher non-union rate when the fracture of the tibia and fibula were at the same level, the tibia was fixed with a bridging plate and the fibula left untouched. For this reason, we recommend fibular fixation in all 42 distal fractures when both fractures lie on the same plane and the tibial fracture is relatively stabilised.     

Is a fracture of the transverse process of L5 a predictor of pelvic fracture instability?

In the management of a pelvic fracture prompt recognition of an unstable fracture pattern is important in reducing mortality and morbidity. It is believed that a fracture of the transverse process of L5 is a predictor of pelvic fracture instability. However, there is little evidence in the literature to support this view. The aim of this study was to determine whether a fracture of the transverse process of L5 is a reliable predictor of pelvic fracture instability. We reviewed our hospital trauma database and identified 80 patients who sustained a pelvic fracture between 2006 and 2010. There were 32 women and 48 men with a mean age of 40 years (10 to 96). Most patients were injured in a road traffic accident or as a result of a fall from a height. A total of 41 patients (51%) had associated injuries. The pelvic fractures were categorised according to the Burgess and Young classification. There were 45 stable and 35 unstable fractures. An associated fracture of the transverse process of L5 was present in 17 patients; 14 (40%) of whom had an unstable fracture pattern. The odds ratio for an unstable fracture of the pelvis in the presence of a fracture of the transverse process of L5 was 9.3 and the relative risk was 2.5. A fracture of the transverse process of L5 in the presence of a pelvic fracture is associated with an increased risk of instability of the pelvic fracture. Its presence should alert the attending staff to this possibility.     

A rare combination injury of type III Monteggia fracture dislocation and ipsilateral epiphyseal fracture of distal radius in children. Is there a probability of missing the Monteggia component?

Combined type III Monteggia fracture dislocation and ipsilateral distal radial epiphyseal fracture is a very rare injury. Because of difficulty in performing the proper clinical evaluation of a child in an acute injury state, one of the components of this combined injury may be missed. We report a tenyear-old male child with this kind of injury where the Monteggia lesion was initially missed at the emergency department. Later we found the combined epiphyseal fracture of distal radius and Monteggia lesion in the ipsilateral side of the same limb which was managed by closed reduction and K-wire fixation. Bony union as well as wrist and elbow motion was complete 3 months after surgical intervention.     

Is there a role for total ankle replacement in polio patients?: A case report and review of the literature

Although poliomyelitis is almost eradicated, as orthopaedic surgeons we occasionally encounter residual deformities in patients who suffered the disease in the past. An equino-varus deformity of the foot is the commonest deformity seen.In this report we present a 53 years old lady who had poliomyelitis as a child and presented with a painful, degenerate ankle and 12 degrees of varus deformity. CT confirmed advanced degenerative changes. The management options included realignment and fusion, supramalleolar ostoetomy or total ankle replacement. In view of the satisfactory active range of motion and advanced OA confirmed by CT scan we considered the option of total ankle replacement. To our knowledge this has never been reported before.At two and half years follow up the patient showed satisfactory functional results (AOFAS score 88/100) and high satisfaction. Plain radiographs revealed a well aligned joint with no evidence of loosening or osteolysis.     

Small colorectal cystic metastases to the liver: still a diagnostic dilemma? A report of a case and a review of the literature

Background

Although cystic colorectal metastases are rare (1.8%), they are still a crucial challenge for the surgeon especially in terms of detection and differential diagnosis. Since prognosis after resection is very good (40% 5-year survival), early diagnosis is essential.

Case report

A 55-year-old man was admitted to our hospital with a suspected diagnosis of multiple small liver metastases. He had previously undergone left sided-cholectomy followed by chemotherapy for colonic carcinoma. Computed tomography (CT) revealed multiple small (<15?mm) intrahepatic biliary cysts, suspected for cystic colorectal liver metastases.

Conclusion

The diagnosis of cystic colorectal liver metastases is quite difficult and it is mostly based on the last-generation magnetic resonance (MR). In spite of this, we must often rely on histological results for a definitive diagnosis.     

Management of heel ulcers in insensate foot by using free prefabricated radial fascial flap — a new flap

Heel ulcers are common in insensate foot. The management of such ulcers require tissue not only to resurface the skin defect, which is small in most of the cases; but also well vascularised tissue to fill the cavity which results after excision of the ulcer. We have described a new flap prefabricated radial fascial flap, by which both aims are achieved easily.