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.     

Cyclic supraventricular tachycardia in the parturient: to treat or not to treat?

Cardiac arrhythmias are more common in pregnant women than in non-pregnant women. In the asymptomatic pregnant patient with a stable fetus, watchful waiting might be the best strategy. Herein, we describe the first reported case of a pregnant patient who developed cyclic supraventricular tachycardia during labor. No treatment was prescribed, with a good maternal and fetal outcome.     

Dislocation fracture of the pisiform in a 14-year-old—a rare injury to the hand

Isolated dislocation or dislocation fracture of the pisiform are rare injuries with only few cases reported in the literature. Injuries to the pisiform occur more often in combination with other carpal injuries as the sturdiness and stability of its ligamentous attachments protect it from dislocating following a minor trauma. The most cases of dislocation or fracture occur following a direct trauma to the palmar and ulnar aspects of the wrist. Predominantly young male patients present with this problem. We present a case of a 14-year-old female who suffered from a dislocation fracture after falling from her bicycle on her outstretched hand. After confirming the diagnosis of pisiform dislocation fracture and reviewing the literature, we performed pisectomy with rerouting of the flexor carpi ulnaris tendon by suturing it to the ligamentous attachments. These rare injuries to the wrist are demanding in diagnostics and treatment and could be neglected in acute period. However, with a correct diagnosis and appropriate treatment, an excellent clinical outcome can be achieved.Level of Evidence: Level V, diagnostic study     

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.     

Hormonal stimulation of spermatogenesis: a new way to treat the infertile male with non-obstructive azoospermia?

International Urology and Nephrology -     

The impact of the Major Trauma Network: will trauma units continue to treat complex foot and ankle injuries?

IntroductionApril 1st 2012 saw the introduction of National Trauma Networks in England. The aim to optimise the management of major trauma. Patients with an ISS ≥ 16 would be transferred to the regional Major Trauma Centre (level 1). Our premise was that trauma units (level 2) would no longer manage complex foot and ankle injuries thereby obviating the need for a foot and ankle specialist service.MethodsRetrospective analysis of the epidemiology of foot and ankle injuries, using the Gloucestershire trauma database, from a trauma unit with a population of 750,000. Rates of open fractures, complex foot and ankle injuries and requirement for stabilisation with external fixation were reviewed before and after the introduction of the regional Trauma Network. Secondly, using the Trauma Audit & Research Network (TARN) database, all foot and ankle injuries triaged to the regional Major Trauma Centre (MTC) were reviewed.ResultsIncidence of open foot and ankle injuries was 2.9 per 100,000 per year. There were 5.1% open injuries before the network and 3.2% after (p > 0.05). Frequency of complex foot and ankle injuries was 4.2% before and 7.5% after the network commenced, showing no significant change. There was no statistically significant change in the numbers of patients with complex foot and ankle injuries treated by application of external fixators. Analysis of TARN data revealed that only 18% of patients with foot and ankle injuries taken to the MTC had an ISS ≥ 16. The majority of these patients were identified as requiring plastic surgical intervention for open fractures (69%) or were polytrauma patients (43%). Only 4.5% of patients had isolated, closed foot and ankle injuries.ConclusionWe found that at the trauma unit there was no decrease in the numbers of complex foot and ankle injuries, open fractures, or the applications of external fixators, following the introduction of the Trauma Network. These patients will continue to attend trauma units as they usually have an ISS < 16. Our findings suggest that there is still a need for foot and ankle specialists at trauma units, in order to manage patients with complex foot and ankle injuries.     

Neuromodulation of the superior hypogastric plexus: a new option to treat bladder atonia secondary to radical pelvic surgery?

Background

The aim of this study is to report on the impact of neuromodulation to the superior hypogastric plexus in patients with bladder atonia secondary to pelvic surgery.

Methods

In 4 consecutive patients with bladder atonia secondary to pelvic surgery, we performed a laparoscopic implantation of a neurostimulator—LION procedure—to the entire superior hypogastric plexus.

Results

Of the 4 reported patients, 3 are able to partially void or empty their bladder.

Conclusions

If the presented results could be obtained in further patients and maintained in long-term follow-up, the LION procedure to the superior hypogastric plexus could change the management of bladder function in patients with bladder atonia.     

Is it feasible to treat unstable hangman’s fracture via the primary standard anterior retropharyngeal approach?

Purpose

The goal of this study was to evaluate the results and feasibility of primary anterior cervical discectomy and fusion (ACDF) with plating for unstable traumatic spondylolisthesis of the axis, the so-called hangman’s fracture, via the standard anterior retropharyngeal approach.

Methods

The clinical and radiological records of 17 patients (14 males and 3 females, mean age: 51 years, range 17–73 years) with unstable hangman’s fracture who were treated between January 1996 and June 2012 were reviewed retrospectively. ACDF with plating at C2–3 level was performed in all patients (type II fracture: 12 patients, type IIA fracture: 3 patients and type III fracture: 2 patients, based on the Levine and Edwards classification). Combined morbidity, complications, neurological improvement and fusion rate were assessed.

Results

Seventeen patients underwent fusion surgery via the standard anterior retropharyngeal approach. Four patients required an additional posterior arthrodesis to augment the anterior procedure. Patients wore a Philadelphia collar for 4–6 weeks and fusion at C2–3 was achieved in all patients. Two cases of complications were observed during treatment, comprising of one case of non-union and one case of transient dysphagia that resolved after 3 months. However, none of the patients experienced worsening of the neurological function post-operatively. There were no cases of permanent nerve injury or infection.

Conclusions

Treatment of the hangman’s fracture is dependent on the stability of the injury. Although the treatment for unstable hangman’s fracture is still controversial, we carefully suggest that primary ACDF with plating via the standard anterior retropharyngeal approach may be a feasible treatment option. It provides immediate stability and allows for early ambulation while promoting a stable bone union with minimal morbidity.     

Inhibition of tubule-cell proliferation to prevent cyst formation: a new avenue to treat ADPKD?

Tubule-cell hyperproliferation precedes cyst development in autosomal dominant polycystic kidney disease (ADPKD). Parker et al. report that insulin-like growth factor-1 stimulates ADPKD cell proliferation by activating Ras and Raf; inhibition of Ras or Raf abolished this effect. Inhibiting tubule-cell proliferation could halt cyst formation and prolong survival of functional tubules, offering a new treatment for ADPKD patients.     

Use of Teriparatide to improve fracture healing: What is the evidence?

Teriparatide is a recombinant form of the biologically active component of Parathyroid hormone. It has been shown to increase bone mass and prevent fractures in osteoporotic bone. It is licensed by the Food and Drug Administration for the treatment of Osteoporosis. Over the last decade, a growing body of evidence has accumulated suggesting a role for Teriparatide in the management of fractures. Studies in both normal and delayed healing models have shown improvement in callus volume and mineralisation, bone mineral content, rate of successful union and strength at fracture sites. However most of these results have been derived from animal studies. The majority of this research on humans has comprised low level evidence, with few randomised controlled trials, many case reports and case series. Nevertheless, the results from these studies seem to support research from animal models. This has led to a growing number of clinicians using Teriparatide “off license” to treat fractures and non-unions in their patients. This review presents a critical appraisal of the current evidence supporting the use of Teriparatide for fracture healing, delayed unions and non unions and in the setting of osteoporotic fractures, the studies producing this evidence and their transferability to human beings.     

A complex fracture of the hyoid bone and the larynx after a bicycle accident – Case report and review of literature

Introduction and importanceReports about laryngeal trauma and fractures of the hyoid bone are rare in the literature. Most cases are forensic cases and the results of postmortem analysis. Traumatic larynx and hyoid bone fractures represent a rare but important differential diagnosis of the common symptom hoarseness.Case presentationA 60-year-old female patient presented with unclear dysphonia and globus sensation following intubation for a surgical treatment for a lower leg fracture after a bicycle accident two months ago. Endoscopy and the computed tomography (CT) of the neck revealed a fixed and immobile fractured piece of the larynx, a hyoid bone fracture and a pseudarthrosis between the greater horn of the hyoid bone and the upper edge of the thyroid cartilage. The hyoid bone fracture led to a distortion of the supraglottis. After surgical removal of the fractured part of the hyoid bone and the pseudarthrosis separation, the supraglottis appeared symmetrical again. Four weeks after surgery the patient was symptom-free.Clinical discussionThough combined hyoid bone and larynx fractures after traumatic injuries are rare, they represent an important differential diagnosis in trauma patients with dysphagia or dysphonia. The clinical symptoms can vary and occur immediately or within a latent period taking weeks or months until the proper diagnosis. Depending on the symptoms, surgical management can be effective.ConclusionAn isolated partial resection of the hyoid bone with separation of the pseudarthrosis is a reasonable therapeutic option and can lead to completely resolving symptom. Preoperatively, a CT provides further valuable information.