CT fluoroscopically guided percutaneous placement of transiliosacral rod for sacral insufficiency fracture: case report and technique

Treatment of sacral insufficiency fractures (SIFs) has traditionally been conservative, but several patients have been treated with percutaneous sacroplasty. Unfortunately, in the setting of severe, bilateral SIFs, cement may not withstand shear forces present at the lumbosacral junction, and surgical hardware may not provide adequate fixation in osteoporotic, cancellous bone of the sacrum, leading to eventual pseudarthrosis. Thus, we propose a novel technique in which guidance with CT fluoroscopy allows placement of a transiliosacral bar in conjunction with sacroplasty.     

Percutaneous vertebroplasty: indications, contraindications, technique, and complications

Percutaneous vertebroplasty is emerging as one of the most promising new interventional procedures for relieving (or reducing) painful vertebra, with the injection of surgical polymethylmethacrylate or cement into vertebral bodies. This imaged-guided technique, originally used to treat vertebral hemangioma, has recently been extended to the treatment of metastases, osteoporotic compression fractures, and vertebral myeloma. It is increasingly being accepted as a main treatment of choice in the management of resistant back pain due to vertebral compression fractures, especially in the elderly individual who is not a candidate for surgery. In this article, we review indications, contraindications, technique, and complications of percutaneous vertebroplasty.     

Added Value of Dedicated Spine CT to Detect Fracture in Patients with CT Chest,Abdomen, and Pelvis in the Trauma Setting

PurposeFractures of the thoracolumbar spine account for up to 90% of spinal fractures, and are associated with significant disability. The advantage of acquiring dedicated spine CT imaging in addition to visceral CT studies of the chest, abdomen and pelvis for detection of spinal fractures has not been definitively established. This retrospective study seeks to determine the contribution of dedicated spine CT in the acute clinical setting.MethodsPatients who were diagnosed with fractures of the thoracic or lumbar spine at our institution between January 1, 2010 and June 30, 2014 were identified. Additional inclusion criteria included having a CT of the chest and/or abdomen and pelvis followed by a dedicated thoracic or lumbar spine CT within 30 days. Reports were reviewed for accuracy of fracture detection, and missed fractures were retrospectively analyzed on images for detectability.ResultsA total of 102 patients met our inclusion criteria for a total of 312 fractures. Of the 312 fractures, 31 (10%) were missed on the initial visceral CT in 18 of the 102 patients. In all but two cases, at least one fracture was identified on the visceral spine CT. There were no cases in which the newly identified fractures changed patient management.ConclusionAll fractures requiring surgical intervention were identified on the visceral CT. A dedicated spine CT does detect additional spine fractures but does not clearly alter patient management.     

肋骨骨折诊治现状

肋骨骨折是胸部外伤中的常见疾病,但对肋骨骨折患者的手术治疗策略尚未达成共识。胸部x线及CT扫描是肋骨骨折诊断的基本手段。肋骨骨折可选择非手术治疗或内固定手术治疗。本文针对内固定手术的指征、方法、器械进行综述。针对患者合体化情况选择合适治疗方案,可以获得良好疗效。     

Dermatomyositis and calcific myonecrosis in the leg: ultrasound as an aid in management

Calcific myonecrosis, often reported in the setting of prior trauma or compartment syndrome, has traditionally been treated with surgical debridement; however, these cases are often complicated by poor wound closure and poor healing. Serial percutaneous aspirations, instead, have been proposed as an alternative treatment option. This is the first report, to our knowledge, of the use of ultrasound guidance in the aspiration of calcific myonecrosis as an aid in management.     

Operative treatment for fifthmetatarsal base fractures

Successful surgical treatment of proximal fifth metatarsal fractures depends on an understanding of different fracturepatterns and their potential for healing. Simple auvlsion fractures of the tuberosity heal uneventfully with symptomatic treatment. Certain transverse fractures of the metaphyseal-diaphyseal region have a higher incidence of delayed union and nonunion. These fractures heal more predictably and quickly with early surgical intervention. Use of a intramedullary screw or corticocancellous bone graft has been proven successful in accomplishing union in displaced intra-articular fractures, delayed unions, and nonunions. Acute Jones fractures and Torg type I fractures may heal with closed methods, but surgical intervention increases the rate of union, speeds recovery time, and is indicated in athletes or other physically competative persons. Complications may be lessened by strict adherence to surgical technique and the use of appropriate implants.     

跟骨骨折外固定技术的发展

20世纪以来,足踝外科领域对于跟骨骨折的处理逐渐成熟,但是内固定技术一直存在内植物占位以及切口皮肤感染等问题。外固定技术为上述问题提供了解决方案,使用外固定处理开放性跟骨骨折以及软组织条件差的闭合性跟骨骨折具有诸多优势。临床上应用外固定技术对跟骨骨折的治疗早已开展,然而外固定治疗跟骨骨折的相关文献却很少。本文就跟骨骨折应用外固定技术治疗的历史及方法作一综述,理清其优劣,便于临床医师选择及制定手术方案、治疗策略。     

Displaced femoral neck stress fractures in Royal Marine recruits--management and results of operative treatment

Femoral neck stress fractures (FNSF) represent 3.5%-8% of stress fractures in military recruits; potentially resulting in medical discharge and/or complications. The incidence of displaced FNSF in the British Army has been reported as 1.8 in 10,000 recruits. We aimed to review the incidence and outcome of displaced FNSF in Royal Marine recruits. Retrospective review identified 6 recruits who sustained a displaced FNSF from 2001 to 2011 representing an incidence of 9.3 in 10,000 recruits. All were treated urgently by internal fixation. There were no cases of avascular necrosis, no surgical complications and no further procedures required. All united with a mean time to union of 11 months. 50% had a union time greater than 1 year. These fractures are slow to unite but with urgent surgical intervention and stable fixation 100% union was achieved. Awareness of this guides the management and rehabilitation whilst avoiding the risks of unnecessary secondary surgical interventions.     

Utility of roof arc measurements in acetabular fractures

For patients with acetabular fractures, the extent to which a fracture involves the weight-bearing dome has been estimated with the “roof arc” measurement obtained on radiographs and computed tomographic (CT) studies. We present the method for measuring the roof arc on radiographs and estimating this arc on CT scans. We also studied the utility of these roof arc measurements for predicting surgical vs. conservative management. Thirty-five patients with transverse or T-shaped acetabular fractures were reviewed. Roof arc measurements were performed on radiographs and CT scans. The clinical record for each patient was reviewed to determine whether the patient had been treated conservatively or surgically. Patients treated operatively for their acetabular fractures had a smaller roof arc measurement, as measured on radiographs, when compared to those patients treated nonoperatively. CT estimation of the roof arc measurement also was different between the two groups. We conclude that roof arc measurements are useful to further characterize patients with acetabular fractures.     

Small fragment wounds: biophysics, pathophysiology and principles of management

Military surgical doctrine has traditionally taught that all ballistic wounds should be formally managed by surgical intervention. There is now, however, both experimental and clinical evidence supporting the nonoperative treatment of selected small fragment wounds. Low energy-transfer wounds affecting the soft tissues, without neuro-vascular compromise and with stable fracture patterns, may be suitable for early antibiotic treatment. The management of ballistic wounds to the gastrointestinal tract requires surgical intervention but, advances in the treatment of these wounds, especially those involving the colon, may allow more effective treatment with a reduced morbidity.     

Basic,Balanced Diet Meets Requirements of Athletes

Abstract

Fractures of the proximal humerus occur frequently, and are primarily insufficiency fractures that occur in the elderly. Thorough clinical evaluation is essential in identifying associated neurovascular injury, which warrants emergent surgical referral. Good quality radiographs remain a necessary diagnostic tool in the evaluation of proximal humerus injuries. An appreciation of the relevant anatomy and predictable patterns of deformation aid in understanding the basic classification of proximal humerus fractures. Most of these fractures are minimally displaced and can be treated nonoperatively with acceptable clinical outcomes. Familiarity with the basic surgical treatment modalities is helpful to physicians involved in the pre- and postoperative management. Significantly displaced proximal humerus fractures are typically treated with surgical reduction and internal fixation. Complex fractures in the elderly and fracture dislocations are indications for humeral head prosthetic replacement. Proximal humerus fractures are strongly associated with decreased bone mineral density and future fracture risk, and should prompt a referral for medical management of osteoporosis.     

Spinal trauma: therapy--options and outcomes

The management of patients with spinal trauma is based on the following goals: (1) the preservation of life; (2) preserving and maximising the neurological function; and (3) providing a stable, painless vertebral column. There have been advances in both non operative as well operative modalities of treatment of patients with spinal injuries. These advances have led to renewed interest in the management of a spinally injured patient. However, despite these advances controversies exist regarding the classification of these fractures, the use of pharmacological intervention, the timing of surgical intervention and indeed the use of surgical intervention itself in the management of these fractures. Most of these controversies surround the treatment of thoracic and lumbar fractures. The purpose of this article is to provide an over view of the therapy options available in the treatment of these fractures. The article shall also look at some of the controversies surrounding the management of these fractures.     

髋臼骨折手术入路选择策略

髋臼骨折的损伤机制为股骨头撞击髋臼导致的髋臼骨性结构破坏,手术日的是重建髋关节的头臼匹配关系并维持稳定.由于髋关节的特殊解剖结构,股骨头的遮挡使其前后面不能相互照应,因此手术入路的选择关系到手术区域显露、骨折复位质量、固定效果,直接影响手术疗效;合理的手术入路选择在手术时间、术中出 血、手术创伤及手术并发症等方面均有较...     

Percutaneous osteoplasty with use of a cement-filled catheter for a pathologic fracture of the humerus

Percutaneous osteoplasty has been used for pathologic fractures of long bones as an adjunct to orthopedic surgery. The present report describes a case of percutaneous osteoplasty with a cement-filled catheter and cement augmentation as the principal therapy to unite a painful pathologic fracture of the humerus. After the procedure, the patient experienced immediate pain relief and improved limb mobility. Percutaneous osteoplasty with this method holds promise as a treatment for pathologic fractures of the humerus that are not amenable to surgical repair.     

LCP、锁钉及多针固定中老年肱骨外科颈骨折的对比研究

目的探讨锁定加压钢板(LCP)、带锁髓内钉和多枚克氏针应用在中老年肱骨外科颈复杂性骨折治疗中的临床疗效。方法对本院2002年10月—2007年3月手术治疗并获得1年随访的肱骨外科颈骨折58例,年龄39～65岁,NeerⅡ型骨折33例,Ⅲ～Ⅳ型骨折25例,按手术方式不同分为:LCP组36例,带锁髓内钉治疗组(A组)11例,多枚克氏针治疗组(B组)11例,各组均采用手法复位。术后就术中出血量、切口总长度、伤口延迟愈合率、8周骨折愈合率、术后肩关节外展活动度方面,将LCP组分别与A组、B组进行统计学分析,肩关节功能按Constant-Murley绝对值标准评分。结果LCP组和A组比较切口总长度、伤口延迟愈合率、8周骨折愈合率无统计学意义(P>0.05),两组术中出血量、肩关节最大外展度数有统计学意义(P<0.05)。LCP组和B组比较术中出血量、伤口延迟愈合率无统计学意义(P>0.05),两组切口总长度、8周骨折愈合率、肩关节最大外展度数有统计学意义(P<0.05)。肩关节功能Constant-Murley绝对值评分结果:治疗Ⅱ型骨折LCP组优良率90.9%,Ⅲ～Ⅳ型骨折LCP组优良率85.7%。A组优良率45.5%,B组优良率36.4%。结论治疗中老年肱骨外科颈复杂性骨折首选应用锁定加压钢板技术固定,其临床疗效优于带锁髓内钉和多枚克氏针固定技术。     

Anatomic, clinical, surgical, and radiographic correlation of the zygomatic complex fracture.

Understanding the mechanisms by which clinical signs and symptoms are produced is a prerequisite to the correct appreciation of radiographic features. Radiographs of facial trauma are no different in this respect. This paper describes the specific clinical findings associated with each displaced bony fragment of the zygomatic complex fracture. Limitation of jaw movement and flattening of the cheek are produced by depressed fractures of the temporal process or zygomatic arch; unilateral epistaxis is a result of fractures of the zygomatic process of the maxilla or the floor of the orbit; paresthesia or anesthesia of the cheek results from fractures of the infraorbital process or orbital floor; unequal pupil heights is associated with fracture of the frontal process; and decreased extraocular muscle function with diplopia is caused by fractures of the orbital process, frontal process, or orbital floor. The clinical and radiographic findings are correlated with surgical management.     

Nonunion of a first rib fracture in a gymnast

Isolated fracture of the first rib is uncommon, but has been reported to occur in sports such as basketball, baseball, and dancing. It has not been reported to occur in gymnasts. Usually, these fractures heal with an adequate period of rest. Rarely do first rib fractures become nonunions. They have been felt to be asymptomatic and are usually found incidentally on routine chest roentgenograms. Symptomatic nonunion of a first rib fracture has not been reported previously. Our patient did not respond to nonoperative treatment and required surgical intervention to alleviate her symptoms. We agree that most fractures of this type heal without complications. However, if a persistently symptomatic nonunion ensues, we suggest transaxillary resection of 90% or more of the first rib.     

Comparison between standard radiography and spiral CT with 3D reconstruction in the evaluation, classification and management of tibial plateau fractures

The aim of this study was to compare the diagnostic efficiency of plain film and spiral CT examinations with 3D reconstructions of 42 tibial plateau fractures and to assess the accuracy of these two techniques in the pre-operative surgical plan in 22 cases. Forty-two tibial plateau fractures were examined with plain film (anteroposterior, lateral, two obliques) and spiral CT with surface-shaded-display 3D reconstructions. The Swiss AO-ASIF classification system of bone fracture from Müller was used. In 22 cases the surgical plans and the sequence of reconstruction of the fragments were prospectively determined with both techniques, successively, and then correlated with the surgical reports and post-operative plain film. The fractures were underestimated with plain film in 18 of 42 cases (43 %). Due to the spiral CT 3D reconstructions, and precise pre-operative information, the surgical plans based on plain film were modified and adjusted in 13 cases among 22 (59 %). Spiral CT 3D reconstructions give a better and more accurate demonstration of the tibial plateau fracture and allows a more precise pre-operative surgical plan. Received: 10 August 1999; Revised: 7 December 1999; Accepted: 27 December 1999     

改良Stoppa入路治疗骨盆髋臼骨折进展研究

骨盆、髋臼解剖结构复杂,手术治疗骨盆、髋臼骨折存在很大难度。髂腹股沟入路是手术治疗骨盆、髋臼骨折的标准前侧入路。由于其手术操作复杂,对术者手术技术要求非常高。同时,该入路不能直视四边体,骨折复位、固定困难。术后易出现复位不良、螺钉进入关节、大出血、下肢血栓、感染等严重并发症。改良Stoppa入路的出现,使骨盆、髋臼的手术入路得以简化。同时,该入路能够直视四边体,方便复位、固定。基于以上优点,改良Stoppa入路被广泛应用。近年,部分学者对改良Stoppa入路进行了进一步改良,使手术创伤进一步减小,术野显露更加充分,骨折复位、固定更加方便。本文即对改良Stoppa入路治疗骨盆髋臼骨折的进展进行综述。     

Endovascular treatment of cranial dural arteriovenous fistulae: a single-centre, 14-year experience and the impact of Onyx on local practise

Introduction  

Dural arteriovenous fistulae (DAVFs) are a potentially dangerous group of intracranial arteriovenous shunts with significant morbidity and mortality. Treatment has traditionally included transvenous and/or transarterial embolisation, which may be followed by surgical ligation. This study assesses the impact of Onyx on treatment.