Accuracy of radiographs in assessment of displacement in lateral humeral condyle fractures

Purpose

Determining the magnitude of displacement in pediatric lateral humeral condyle fractures can be difficult. The purpose of this study was to (1) assess the effect of forearm rotation on true fracture displacement using a cadaver model and to (2) determine the accuracy of radiographic measurements of the fracture gap.

Methods

A non-displaced fracture was created in three human cadaveric arms. The specimens were mounted on a custom apparatus allowing forearm rotation with the humerus fixed. First, the effect of pure rotation on fracture displacement was simulated by rotating the forearm from supination to pronation about the central axis of the forearm, to isolate the effects of muscle pull. Then, the clinical condition of obtaining a lateral oblique radiograph was simulated by rotating the forearm about the medial aspect of the forearm. Fracture displacements were measured using a motion-capture system (true-displacement) and clinical radiographs (apparent-displacement).

Results

During pure rotation of the forearm, there were no significant differences in fracture displacement between supination and pronation, with changes in displacement of <1.0 mm. During rotation about the medial aspect of the forearm, there was a significant difference in true displacements between supination and pronation at the posterior edge (p < 0.05).

Conclusion

Overall, true fracture displacement measurements were larger than apparent radiographic displacement measurements, with differences from 1.6 to 6.0 mm, suggesting that the current clinical methods may not be sensitive enough to detect a displacement of 2.0 mm, especially when positioning the upper extremity for an internal oblique lateral radiograph.     

Isolated fractures of the greater trochanter with occult intertrochanteric extension

Introduction

Isolated fractures of the greater trochanter (GT) are relatively rare. The diagnosis can be done on routine radiographs, but it is difficult to fully define the geographic extent of these injuries. This study examined the pattern and extent of an injury shown by magnetic resonance imaging (MRI) and radionuclide bone scan (RBS) in patients whose plain radiographs revealed fractures limited to the GT.

Materials and methods

Between July 2004 and October 2008, 25 patients who displayed an isolated GT fracture on plain radiograph examination were examined by both MRI and RBS due to a suspicion of an extension into the intertrochanteric (ITC) region. The patients were then divided into two groups. Group A patients had an isolated fracture of GT, and group B patients had an occult fracture of ITC.

Results

All 25 cases were caused by a low-energy injury and plain radiographs showed non-displaced or minimally displaced isolated GT fractures. For 22 of the 25 patients, the result agreed with MRI and RBS. However, three patients had focal increased uptake at the GT region only according to RBS and an extension of signal intensity into the ITC region according to MRI. Group A and B comprised 5 and 20 patients, respectively. Of the group B patients, 8 had fractures with MRI evidence of complete extension across the ITC region and 12 had incomplete extension. Eleven of the 12 incomplete types showed an extension more than half way to the medial cortex. Fifteen group B patients underwent an internal fixation using a two-hole dynamic hip screw.

Conclusion

Patients with an isolated fracture of GT can have a broader fracture extending into the ITC region than that diagnosed by standard radiographs. We recommend that all patients presenting with an isolated GT fracture on the plain radiographs should undergo MRI examination.     

Displaced proximal humeral fractures: operative versus non-operative treatment—a 2-year extension of a randomized controlled trial

Background

Surgical treatment for displaced proximal humeral fractures is widely used. However, there are very few randomized controlled studies comparing surgical treatment to conservative treatment, and the evidence is debated. The aim of this study was to describe patients with displaced proximal humeral fractures in a 2-years extension of a randomized controlled trial, their functional outcome and quality of life.

Materials and methods

Patients from a single-center randomized controlled study of fifty patients aged 60 or above with displaced proximal humeral fracture (AO/OTA group B2 or C2) were randomized to surgical or conservative treatment. Surgery was performed with an angular stable implant. The main outcome was Constant score at 2-year follow-up. Secondary outcomes were an ASES self-assessment form, the 15D quality of life assessment and radiographs at 2 years.

Results

A marked improvement of shoulder function and health-related quality of life for both surgically and conservatively treated patients occurs between 6 and 12 months. Almost no change was observed between 1 and 2 year. There were no significant differences between the two treatments at 2-year follow-up.

Conclusions

In this randomized controlled trial, surgical treatment proved no better results than conservative treatment for patients with displaced proximal humeral fracture at 2-year follow-up.     

Percutaneous screw fixation of acetabular fractures with 2D fluoroscopy-based computerized navigation

Introduction

The treatment of displaced acetabular fractures with formal open reduction and internal fixation has gained general acceptance. However, extensile exposure can lead to complications. Two-dimensional fluoroscopy-based computerized navigation for placement of percutaneous screw across non-displaced acetabular fractures has attracted interest by making use of stored patient-specific imaging data to provide real-time guidance in multiple image planes during implant placement. The purpose of the present study was to document early treatment results and complications associated with this new technique and evaluate its clinical application to displaced acetabular fractures amenable to closed or limited open reduction.

Materials and methods

Eighteen adult patients with 12 non-displaced and 8 displaced acetabular fractures were treated with percutaneous screw fixation under the guidance of a fluoroscopy-based navigation system. There were 14 men and four women with a mean age of 42.1 years (range 19–54 years). According to the AO and Orthopaedic Trauma Association Classification, there were nine 62-A3, five 62-B1, three 62-B2, and three 62-B3. The mean follow-up was 21 months (range 12–28 months). The mean time from injury to surgery was 4 days (range 2–7 days).

Results

A total of 30 acetabular screws were inserted, including 21 anterior column screws and 9 posterior column screws. The average operation time was 24.6 min (range 16–47 min) from the image acquisition to wound closure. The average fluoroscopic time was 28.4 s (range 11–58 s). Compared to the final position of the screw, the average deviated distance of wire tip was 2.5 mm (range 1.1–3.6 mm) and the average trajectory difference was 2.45° (range 1.5°–4.6°). Maximal gap displacement averaged 10 mm (range 2–22 mm) preoperatively and 3 mm (range 0–5 mm) postoperatively; while maximal step displacement averaged 4 mm (range 1–10 mm) preoperatively and 2 mm (range 0–4 mm) postoperatively. One patient sustained a transient femoral nerve palsy and resolved 2 months after the operation. No superficial or deep infection occurred. Using the rating system of D’Aubigne and Postel, 13 patients had excellent results, 4 patients had good results, and 1 patient had a fair result.

Conclusion

Percutaneous screw fixation of acetabular fractures with 2D fluoroscopy-based navigation could be applied not only to non-displaced fractures but also to displaced fractures amenable to closed or limited open reduction.     

Subsequent displacement of initially nondisplaced and minimally displaced fractures of the lateral humeral condyle in children

BACKGROUND: Although conservative treatment is a well-established method for treating nondisplaced and minimally displaced (< or =2 mm) fractures of the lateral humeral condyle in children, there is still great uncertainty concerning the rate and time course of subsequent displacement. Therefore, the appropriate frequency of radiographic follow-up remains unclear. The aim of the study was to determine the rate of subsequent displacement after conservative treatment of nondisplaced and minimally displaced fractures of the lateral humeral condyle in children. METHODS: A retrospective analysis of 51 consecutive patients with nondisplaced and minimally displaced fractures of the lateral humeral condyle was performed. RESULTS: Five fractures (9.8%) displaced within 5 days while immobilized and were safely detected by a follow-up radiograph within 1 week after trauma. Additional follow-up radiographs between the first and third weeks did not show relevant alterations in the fracture gap. Mean time of cast immobilization was 22 days, with a range of 17 to 34 days. No pseudarthrosis occurred. CONCLUSION: Fractures with less than or equal to 2 mm of displacement can probably be primarily treated safely by cast immobilization. Anteroposterior and lateral radiographs out of plaster between the fourth and sixth days are necessary to diagnose subsequent displacement of unstable fractures, whereas further "late" displacement did not occur.     

Impact of ulnar styloid fractures in nonoperatively treated distal radius fractures

Purpose

The effect of an ulnar styloid fracture (USF) on the stability of nonoperatively treated distal radius fractures (DRF) is unknown. The aim of this study was to evaluate the influence of USFs on the dislocation of DRFs treated by closed reduction.

Methods

Standardized radiographs of 100 nonoperatively treated DRFs were evaluated. DRFs with a USF were compared to DRFs without a USF with respect to dorsal tilt, radial inclination, and ulnar variance.

Results

We evaluated the radiographs of 100 DRFs in 99 consecutive patients, of whom 84 were women. An accompanying USF was present in 58 wrists, of which 49 were displaced. On the trauma radiograph, the USF group showed significantly more overall dislocation. After closed reduction, fracture position improved, and no significant differences in dislocation were observed between groups. After a mean of 42 days, radial inclination significantly decreased if a USF was present. When USF displacement was taken into account, significantly more ulnar variance occurred in the displaced USF group on the trauma and follow-up radiograph compared to the nondisplaced USF group and no-USF group.

Conclusions

The results of this study show that presence of a dislocated USF in patients with a DRF is associated with a worse position directly after trauma, and with recurrence of radial shortening after adequate reduction. These results warrant early radiologic follow-up in patients with reduced combined DRFs and USFs in order to evaluate the redislocation of the distal radius. Early detection of redislocation in these combined fractures may induce early surgical intervention.     

Locking versus non-locking neutralization plates for treatment of lateral malleolar fractures: a randomized controlled trial

Purpose

The reduction of periosteal compression through the use of a locking plate may minimize disturbances of bone blood supply and may improve the rate of bone union. A single-centre, assessor blinded randomized controlled trial was conducted to compare the clinical effectiveness of a locking plate and a non-locking plate.

Methods

A total of 52 patients with AO/OTA 44B lateral malleolar fractures were included in this study. All patients underwent surgical fixation using a lag screw and neutralization plate. An identical treatment protocol was used in all patients, with exception of plate selection. The rate of radiographic bone union, defined as the complete disappearance of fracture lines confirmed through anteroposterior, lateral, and internal oblique views was compared at three, six, and 12 months following surgery. In addition, the Medical Outcomes 36-Item Short-Form Health Survey (SF-36) score, the time required for resolution of tenderness at the fracture site and the complication rate were evaluated.

Results

Twenty-three patients were randomly assigned to undergo fixation using a locking plate, and 29 patients were assigned to undergo fixation using a non-locking plate. Intention-to-treat analysis showed no difference in the radiographic bone union rate of fibula, SF-36 score, the time for resolution of tenderness at the fracture site and complication rates.

Conclusion

No differences were observed in patients with AO/OTA 44B lateral malleolar fractures undergoing fixation with a locking versus non-locking neutralization plate.     

Superior clavicle plate with lateral extension for displaced lateral clavicle fractures: a prospective study

Background

Until now there have been no prospective studies describing the results of using the superior clavicle plate with lateral extension in patients with displaced lateral clavicle fractures (Neer type 2). The purpose of this study was to evaluate the results of applying this plate for this specific type of fracture.

Materials and methods

In this prospective study, seven patients (mean age 43, M:F; 6:1) with a fresh displaced lateral clavicle fracture were evaluated with a mean follow-up of 10 months. Analysis included functional and subjective outcome, time until union, time until return to work, and complications.

Results

All patients achieved clinical and radiological union within 6–12 weeks. Full range of motion as well as a return to work was achieved in most cases within 2 weeks. The mean Constant score was 98 (range 90–100), the DASH score was 3.6 (range 0–11.4), and the Shoulder Rating Questionnaire score was 97 (range 96–100). No major complications were encountered. Three patients required plate removal: two because of a prominent and subcutaneous plate and one because of an intra-articular screw.

Conclusions

In this study, use of the superior clavicle plate with lateral extension yielded excellent results in the treatment of this difficult fracture. In particular, patients acquired full range of motion within 2 weeks, reflecting the stability of the osteosynthesis achieved with this implant.     

The effect of minimally displaced posterior malleolar fractures on decision making in minimally displaced lateral malleolus fractures

Purpose

Despite the high incidence of cases of minimally displaced lateral or posterior malleolus ankle fractures, treatment guidelines are still an issue of controversy. The purpose of this study was to delineate treatment preferences among orthopaedic surgeons in these fractures with and without concomitant posterior malleolus fractures. We hypothesized that concomitant minimally displaced fractures of the posterior malleolus can shift treatment preference towards operative intervention.

Methods

A questionnaire-based study was conducted among orthopaedic surgeons attending the 2012 European Federation of National Associations of Orthopaedics and Traumatology Conference (EFORT) in Berlin, Germany. Treatment preferences were reported for minimally displaced lateral malleolus fractures seen on radiographs and were then compared with treatment preferences when computed tomography (CT) was added revealing a concomitant minimally displaced posterolateral fracture of the posterior malleolus.

Results

The cohort comprised 177 surgeons from all six continents. When radiographs showing a minimally displaced lateral malleolus fracture were presented, nonoperative management was indicated by 35 % (62) of participants, whereas 65 % (115) preferred operative intervention. After CT views were added showing an accompanying minimally displaced posterolateral posterior malleolus fracture, 79 % (140) suggested operative intervention and only 21 % (37) advocated nonoperative management (p = 0.03).

Conclusions

Most surgeons prefer open reduction with internal fixation for minimally displaced lateral malleolar fractures. The presence of concomitant posterior malleolus fractures in these cases shifts treatment preference further towards open reduction with internal fixation. Because the posterior malleolus fragment might not be well delineated on standard ankle radiographs, a high index of suspicion is warranted, and the use of CT should be considered in these cases.     

Surgical treatment of lateral Hoffa fracture with a locking plate through the lateral approach

Objectives

The goal of this study is to determine the efficacy of the surgical treatment of lateral Hoffa fracture with a locking plate and cannulated or lag screws through the lateral approach.

Materials and methods

A total of 12 isolated lateral Hoffa fractures were identified during the study period (February 2005 to February 2010). All fractures were treated by open reduction through the lateral approach. Internal fixation was performed with a contoured locking plate and cannulated or lag screws introduced from the non-weight-bearing area of the cartilage surface of the lateral femoral condyle. Radiological and functional outcome analysis was performed using Knee Society scores.

Results

Bony union of Hoffa fracture was achieved in all patients. The articular surface of lateral femoral condyle was anatomically reduced. There was no loss of reduction and fixation. Functional outcome of knee measurements showed a continuous significant improvement over the follow-up period.

Conclusion

Fixation with a locking plate and cannulated or lag screws for lateral Hoffa fracture seemed to be effective and reliable. The lateral approach had advantages for reduction and fixation of lateral Hoffa fracture during operation.     

Internal oblique radiographs for diagnosis of nondisplaced or minimally displaced lateral condylar fractures of the humerus in children

BACKGROUND: Several radiographic criteria based on only standard anteroposterior and lateral radiographs have been suggested for predicting the stability of lateral condylar fractures of the humerus in children. Despite adherence to these guidelines, further displacement often occurs after the initial diagnosis and stability assessment. The purpose of this study was to define the usefulness of an internal oblique radiograph in the assessment of these fractures. METHODS: We prospectively studied fifty-four lateral humeral condylar fractures in fifty-four children seen between March 2002 and December 2004 to determine the efficacy of internal oblique radiographs in gauging the amount of displacement and the fracture pattern. Plain anteroposterior, lateral, internal oblique, and external oblique radiographs were initially made for all fifty-four patients, and three-dimensional computed tomography scans were performed for seven patients. RESULTS: A large percentage (70%) of the fractures were seen to have different amounts of displacement on the anteroposterior and internal oblique radiographs, and a large percentage (75%) were seen to have different fracture patterns, according to the criteria suggested by Finnbogason et al., on the two views. The internal oblique radiograph was more accurate for demonstrating the fracture gap (thirty cases were seen to have more displacement on that view) and for demonstrating the fracture pattern (twenty cases were seen to have more instability on the internal oblique view). We also confirmed the direction of the fracture line and the location of the fragment more accurately with three-dimensional computed tomography. CONCLUSIONS: It is not optimal to evaluate the amount of displacement and the stability of a lateral condylar fracture of the humerus in children on the basis of just anteroposterior and lateral elbow radiographs. Classifications should be based on the greatest displacement seen on at least three radiographic views, especially the internal oblique view.     

Adherence to a femoral neck fracture treatment guideline

Purpose

In 2007 the Dutch Surgical Society published a clinical practice guideline for the treatment of hip fracture patients, based on the best available international evidence at that time. We investigated to what extent treatment of femoral neck fracture patients in the Netherlands corresponded with these guidelines, and determined differences in patient characteristics between the treatment groups.

Methods

All femoral neck fracture patients treated in 14 hospitals between February 2008 and August 2009 were included. Patient characteristics, X-rays, and treatment data were collected retrospectively.

Results

From a total of 1,250 patients 59 % had been treated with arthroplasty, 39 % with internal fixation, and 2 % with a non-operative treatment. While 74 % of the treatment choices complied with the guideline, 12 % did not. In 14 % adherence could not be determined from the available data. Arthroplasty was preferred over internal fixation in elderly patients with severe comorbidity, pre-fracture osteoporosis and a displaced fracture, who were ambulatory with aids pre-fracture (odds ratio, OR 2.2–58.1). Sliding hip screws were preferred over cancellous screws in displaced fractures (OR 1.9).

Conclusions

Overall guideline adherence was good. Most deviations concerned treatment of elderly patients with a displaced fracture and implant use in internal fixation. Additional data on these issues, preferably at a higher scientific level of evidence, is needed in order to improve the guideline and to reinforce a more uniform treatment of these patients.     

Primary total hip arthroplasty versus internal fixation in displaced fracture of femoral neck in sexa- and septuagenarians

Background

The optimal treatment of femoral neck fracture in the elderly patient is still under debate. In patients aged 60–80 years, the decision between internal fixation and arthroplasty remains controversial. The primary aim of the present study is to evaluate the functional outcome of patients aged 60–80 years with femoral neck fracture treated with total hip arthroplasty or closed reduction and internal fixation. The secondary aim is to evaluate the incidence of nonunion and avascular necrosis in femoral neck fracture in different age groups.

Materials and Methods

We studied 100 patients affected by displaced fracture of the femoral neck from May 2007 through June 2010. There were 60 men and 40 women with mean age of 66 years. Fifty patients were treated with closed reduction and internal fixation with cannulated screws (group A), and the other 50 patients with total hip arthroplasty (group B). Mean surgical time, blood loss, duration of hospital stay, Harris hip score, complications, and need for reoperation were recorded.

Results

Harris hip score was significantly higher in group B at 3-, 6-, 12-, and 18-month follow-up evaluation. The overall complication rate was 28 % in group A and 32 % in group B, which was not statistically significant. A statistically significant difference was found regarding patients who required reoperation in group A (20 %) compared with group B (no one). The average Harris hip score in the internal fixation group was 90.6 and in the total hip arthroplasty group was 93.7, which was statistically significant (p < 0.05). Our study showed an increased risk for intracapsular hip fracture developing nonunion with older age.

Conclusions

Primary total hip arthroplasty compared with internal fixation appears to be a reasonably safe method of treating displaced fracture of femoral neck in elderly patients. We also concluded that outcome regarding hip function is generally better after total hip arthroplasty compared with internal fixation.

Level of evidence

Level II-Prospective cohort study.     

Reduced head–neck offset in nontraumatic osteonecrosis of the femoral head

Introduction

Risk factors for nontraumatic osteonecrosis of the femoral head have in common that they trigger intravascular coagulation and thus lead to devascularization of the femoral head. In part of the patients, however, no risk factors seem to be evident. Mechanical reasons contributing to nontraumatic osteonecrosis have not been discussed so far. We hypothesized that recurrent traumatization of the vessels supplying the femoral head by a cam-type mechanism as in femoroacetabular impingement could add to intravascular coagulation. We, therefore, asked whether structural abnormalities at the femoral head–neck junction indicative of such a mechanism could be observed in radiographs of patients with osteonecrosis of the femoral head.

Materials and methods

The preoperative anteroposterior and lateral radiographs of 77 patients who underwent surgery because of osteonecrosis of the femoral head were retrospectively screened for a reduced head–neck offset by measuring the α-angle. For comparison, the α-angle was measured on anteroposterior and lateral radiographs of 339 control subjects without evident underlying hip pathology.

Results

The mean α-angle was 62.8° (SD 18.7°) for anteroposterior and 67.6° (SD 13.2°) for lateral radiographs in patients with nontraumatic osteonecrosis of the femoral head, whereas in control subjects, the mean α-angle was 47.2° (SD 9.6°) (p < 0.0001) and 47.6° (SD 10.3°) (p < 0.0001), respectively.

Conclusions

A reduced head–neck offset in patients with nontraumatic osteonecrosis of the femoral head may act as a mechanical (co-)factor in developing osteonecrosis of the femoral head.     

Radiographic evaluation of ventral instability in lumbar spondylolisthesis: do we need extension radiographs in routine exams?

Purpose

To determine the usefulness of acquiring extension radiographs for the evaluation of the degree of spondylolisthesis.

Methods

Routine radiographs of the lumbar spine were retrospectively evaluated in 87 patients (mean-age 63, range 32–86) by two independent radiologists. All patients received radiographs in standing neutral, flexion and extension position. Vertebral body depth, sagittal translational displacement and lordosis angle were measured and slip percentage (SP) was calculated on standing neutral, flexion and extension radiographs. Statistical analysis was performed with a two-sided t test. Inter- and intraobserver reliability was assessed using the kappa-coefficient.

Results

There was no statistically significant SP-difference between neutral standing and extension images. Ventral instability was diagnosed in 25–34 % (cut-off >8 % SP-difference) for neutral versus flexion comparison. The detection rate of flexion–extension radiographs representing the extremes of motion was lower with 15–22 %. Inter- and intraobserver reliability was good to excellent.

Conclusion

Slip percentage in routine standing extension radiography ultimately does not differ from that obtained in a static neutral standing view. Extension radiography may therefore be omitted in a routine work-up of ventral instability in lumbar spondylolisthesis.     

Minimally displaced clavicle fracture after high-energy injury: Are they likely to displace?

Background

Nondisplaced or minimally displaced clavicle fractures are often considered to be benign injuries. These fractures in the trauma patient population, however, may deserve closer follow-up than their low-energy counterparts. We sought to determine the initial assessment performed on these patients and the rate of subsequent fracture displacement in patients sustaining high-energy trauma when a supine chest radiograph on initial trauma survey revealed a well-aligned clavicle fracture.

Methods

We retrospectively reviewed the cases of trauma alert patients who sustained a midshaft clavicle fracture (AO/OTA type 15-B) with less than 100% displacement treated at a single level 1 trauma centre between 2005 and 2010. We compared fracture displacement on initial supine chest radiographs and follow-up radiographs. Orthopedic consultation and the type of imaging studies obtained were also recorded.

Results

Ninety-five patients with clavicle fractures met the inclusion criteria. On follow-up, 57 (60.0%) had displacement of 100% or more of the shaft width. Most patients (63.2%) in our study had an orthopedic consultation during their hospital admission, and 27.4% had clavicle radiographs taken on the day of admission.

Conclusion

Clavicle fractures in patients with a high-energy mechanism of injury are prone to fracture displacement, even when initial supine chest radiographs show nondisplacement. We recommend clavicle films as part of the initial evaluation for all patients with clavicle fractures and early follow-up within the first 2 weeks of injury.     

Minimally invasive percutaneous plate osteosynthesis for ankle fractures: a prospective observational cohort study

Background

The gold standard for the surgical management of ankle fractures is through open reduction and internal fixation. The rate of wound problems has been reported to be as high as 18 %, especially in patients with poor vascular supply or in diabetics. Minimally invasive percutaneous plate osteosynthesis (MIPPO) has been described as a potential solution for these patients.

Patients and methods

This is a prospective observational cohort study. From October 2009 to February 2010, and following ethical approval of our research, adult patients admitted at our level I trauma center with a closed lateral malleolar displaced unstable fracture (Lauge-Hansen supination-external rotation) with or without a medial-sided injury and patients with an undisplaced fracture associated with medial clear space opening on external rotation stress radiographs were recruited and managed using MIPPO technique. All patients were followed up for a minimum of 12 months post-surgery (12–20 with a mean of 16.5 months). Trauma mechanism, comorbidities, classifications, trauma-surgery interval, image intensifier duration, surgery duration, complications, and function American Orthopaedic Foot and Ankle Society (AOFAS) were analyzed.

Results

Thirty-two patients were recruited of which 20 fulfilled the inclusion criteria (16 females, 4 males) and were available for follow-up. Ten fractures (50 %) were classified as 44-B1, 7 fractures (35 %) as 44-B2, and 3 fractures (15 %) as 44-B3 according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification (100 % were supination-external rotation injuries). At 8 weeks post-surgery, all fractures had healed. The duration of surgery ranged between 15 and 73 min (average 32.8) from skin incision to closure. There were 2 complications (1 malunion and 1 skin necrosis requiring implant removal). At 12-month follow-up, AOFAS average was 88.3 (72–100 standard deviation of 6.8 points).

Conclusion

MIPPO technique proved to be a viable option for lateral malleolar fracture treatment with a low complication rate and high functional outcome at 1 year. It is particularly useful in patients with a high risk of wound complication.     

Early MRI diagnostics for suspected scaphoid fractures subsequent to initial plain radiography

Aim

In the United Kingdom, diagnostic management of patients presenting to emergency department with a scaphoid injury varies. Follow-up plain radiographs, after an initial inconclusive X-ray, are common practice. We optimised the diagnostic pathway for these patients by focusing on the most appropriate diagnostic modality and on minimising the time to follow-up diagnostics.

Materials and methods

A baseline audit in the period 2008–2009 involving a total of 184 patients was conducted, and after the introduction of new local guidelines for scaphoid injury diagnostics, a follow-up audit involving 79 patients was undertaken in 2010–2012.

Results

In the original audit, 130 patients had only scaphoid radiographs, of which 23 underwent initial and follow-up X-rays, and 107 initial-only radiographs. Of those 23, just one single patient (4 %) displayed a scaphoid fracture. Others underwent three imaging procedures: initial radiographs, follow-up radiographs and either bone scan (41 patients) or MRI (13 patients). A further 6/41 (15 %) and 4/13 (31 %) fractures were detected by bone scan and MRI, respectively. In the re-audit, when MRI replaced follow-up X-rays and bone scans, 7 out of 77 (9 %) patients were diagnosed with scaphoid fracture. Time from initial plain radiograph to follow-up MRI was reduced from an original mean of 36 to 14 days during the re-audit period.

Conclusion

The introduction of early MRI enhances scaphoid injury diagnostics and accelerates patient management. We therefore endorse the introduction of this approach on a wider scale through an update of the clinical guidelines for scaphoid injuries.     

Fracture of the talar neck associated with a compression fracture of the calcaneocuboid joint in a 5-year-old child: a case report

Objective

The objectives of this present case study are to report a rare combination of a displaced talar neck fracture with a compression fracture of the calcaneocuboid joint in a 5-year-old child and to describe its radiological features, surgical treatment and clinical outcome.

Case summary

A 5-year-old male boy was injured in a car accident in which his left foot underwent one of the tires. On arrival at the hospital, a displaced talar neck fracture associated both with a cuboid fracture and compression of the articular surface of the cuboid at the calcaneocuboid join was identified. Fractures were fixed surgically. Leg was protected with a below-knee plaster split immobilization and non-weight-bearing for 5 weeks. After that period, the patient initiated a rehabilitation protocol with active and passive motion exercises.

Discussion

Fractures and fracture dislocations at the mid-tarsal joint have an important impact on the global foot function because malunion can result in post-traumatic arthritis and three-dimensional deformities of the foot. If a cuboid compression fracture is not reduced properly, it can result in the shortening of the lateral column with the development of an abduction, pronation and flat foot deformity. A talar neck fracture, if unreduced, can result in medial column displacement and rotational dislocation of the talar head, leading to a subluxation in the talonavicular joint with severe restriction of foot function. With early surgical treatment and open reduction and internal fixation, our patient recovered from the accident without having symptoms of pain, avascular necrosis, postoperative foot deformities or neurovascular deficits.

Conclusions

The combination of a displaced talar neck fracture with a compression fracture of the calcaneocuboid joint in children usually requires correct diagnoses and early treatment with anatomic reduction and internal fixation to prevent severe post-traumatic deformities.

Level of evidence

V.