Biomechanical analysis of peri‑implant fractures in short versus long cephalomedullary implants following pertrochanteric fracture consolidation

IntroductionPertrochanteric femur fracture fixation with use of cephalomedullary nails (CMN) has become increasingly popular in recent past. Known complications after fracture consolidation include peri‑implant fractures following the use of both short and long nails, with fracture lines around the tip of the nail or through the interlocking screw holes, resulting in secondary midshaft or supracondylar femur fractures, respectively. Limited research exists to help the surgeon decide on the use of short versus long nails, while both have their benefits. The aim of this biomechanical study is to investigate in direct comparison one of the newest generations short and long CMNs in a human anatomical model, in terms of construct stability and generation of secondary fracture pattern following pertrochanteric fracture consolidation.MethodsEight intact human anatomical femur pairs were assigned to two groups of eight specimens each for nailing using short or long CMNs. Each specimen was first biomechanically preloaded at 1 Hz over 2000 cycles in superimposed synchronous axial compression to 1800 N and internal rotation to 11.5 Nm. Following, internal rotation to failure was applied over an arc of 90° within one second under 700 N axial load. Torsional stiffness as well as torque at failure, angle at failure, and energy to failure were evaluated. Fracture patterns were analyzed.ResultsOutcomes in the study groups with short and long nails were 9.7 ± 2.4 Nm/° and 10.2 ± 2.9 Nm/° for torsional stiffness, 119.8 ± 37.2 Nm and 128±46.7 Nm for torque at failure, 13.5 ± 3.5° and 13.4 ± 2.6° for angle at failure, and 887.5 ± 416.9 Nm° and 928.3 ± 461.0 Nm° for energy to failure, respectively, with no significant differences between them, p ≥ 0.17. Fractures through the distal locking screw holes occurred in 5 and 6 femora instrumented with short and long nails, respectively. Fractures through the lateral entry site of the head element were detected in 3 specimens within each group. For short nails, fractures through the distal shaft region, not interfacing with the implant, were detected in 3 specimens.ConclusionFrom a biomechanical perspective, the risk of secondary peri‑implant fracture after intramedullary fixation of pertrochanteric fractures is similar when using short or long CMN. Moreover, for both nail versions the fracture pattern does not unexceptionally involve the distal locking screw hole.     

Outcomes for late presenting lateral condyle fractures of the humerus in children: A case series

BackgroundFractures of lateral condyle of humerus are very common in children. While the management of acute displaced and rotated lateral condyle fracture of humerus with early open reduction and internal fixation yields good results, the results of late treatment are less clear. We conducted this study to analyse the results of operative treatment of late presenting fractures and see if it is dependent on the patient's age, fracture type, or the time until treatment.Materials & methodsA retrospective study of 40 patients with a symptomatic lateral condyle fracture beyond 3 weeks, who underwent open reduction and internal fixation between January 2002 and December 2011, was conducted. Fractures were described as per Jakob's classification. Patients radiographs were evaluated, and clinical evaluation was done with Mayo elbow scoring and Dhillon scoring system as well as range of motion.ResultsThirty-nine fractures united with average time of 7.8 weeks except one who had previous surgery done for the fracture and developed avascular necrosis. The average Mayo score was 93 and average Dhillon score was 7.6. The average improvement in the arc of motion was 40.32° (77.3–117.6°). Younger age and shorter time to operation had a statistically significant but weak effect on outcomes.ConclusionsFunctional outcomes of fractures managed surgically revealed good results, even in the fractures presenting more than 12 weeks after injury. Families with children presenting late should be offered ORIF to improve function and decrease symptoms.     

How to choose the suitable FNS specification in young patients with femoral neck fracture: A finite element analysis

BackgroundConsensus regarding the optimal approach for the treatment of femoral neck fractures remains lacking. A new internal fixation femoral neck system (FNS) was developed and used in clinical practice. We aimed to investigate the biomechanical outcomes of different types of FNS in the treatment of unstable femoral neck fractures.MethodIn this study, we constructed three different types of unstable femoral neck fractures of Pauwels classification with angles of 50°, 60°, and 70°. We set up four test groups, namely, the one-hole plated FNS group, two-hole plated FNS group, inverted cannulated screw group and triangle cannulated screw group. Under 2100 N axial loads, displacements and the von Mises stress of the femur and internal fixation components were measured for each fracture group.ResultsWhen the Pauwels angle was 50°or 60°, the one-hole locking plated FNS was as superior as the two-hole plated FNS in terms of femur and internal fixation displacement, and the inverted cannulated screw had slightly better stability than the triangular cannulated screw. However, when the angle increases to 70°, the two-hole locking plate has the minimum displacement, followed by the triangular cannulated screw and inverted cannulated screw, which is the worst displacement for the single-hole locking plate. Regardless of the angle, the two sets of FNS have higher internal fixation stress than the two sets of cannulated screws, which is approximately 1.6-3.0 times that of the cannulated screw group.ConclusionFrom the perspective of biomechanics, we suggest that when the angle of the fracture line is less than 60°, both single-hole locking plated or double-hole locking plated FNS can be used to treat unstable femoral neck fractures. However, when the angle of the fracture line is greater than 70°, we recommend using a double-hole locking plated FNS. This result needs further verification in further clinical studies.     

Pediatric elbow measurement parameters: Evaluation of the six angles in inter- and intra-observer reliability

BackgroundSeveral radiographic measurements of the humerus can be used to evaluate the treatment outcome of supracondylar fractures in children. Because of the cartilaginous nature of the immature elbow, interpretation of radiographs around this area is sometimes challenging and can be unreliable. This study was conducted to determine the inter-observer and intra-observer reliability of the six commonly used radiographic measurements of the distal humerus.MethodThe Baumann angle, humero-ulna angle, metaphyseal-diaphyseal angle, radial epiphyseal angle, shaft-condylar angle and lateral capitellohumeral angle of the humerus were measured by two observers on the radiographs of uninjured elbows from 58 children. The values between each measurement were compared and correlated using a Pearson coefficient of correlation to determine the inter-observer and intra-observer reliability.ResultsAll of the radiographic parameters showed excellent intra-observer reliability with the correlation coefficient values of the Baumann angle, humero-ulna angle, metaphyseal-diaphyseal angle, radial epiphyseal angle, shaft-condylar angle, lateral capitellohumeral angle as 0.945, 0.95, 0.909, 0.888, 0.961 and 0.975 (p < 0.001), respectively. The inter-observer reliability of the Baumann and humero-ulna angles were also found to be highly correlated at r = 0.843 (p < 0.001) and 0.878 (p < 0.001), respectively. The metaphyseal-diaphyseal angle had poor reliability with r = 0.136 (p = 0.291) while the radial epiphyseal angle, shaft-condylar angle, and lateral capitellohumeral angle demonstrated good reliability with r = 0.675 (p < 0.001), 0.747 (p < 0.001), and 0.686 (p < 0.001), respectively.ConclusionThe Baumann angle and humero-ulna angle measurements of distal humerus showed excellent inter- and intra-observer reliability. Both parameters represent repeatable and reliable methods for determining the outcome of supracondylar humeral fractures in pediatric population.     

The accuracy and precision of computer assisted surgery in the assessment of frontal plane deviations of the lower extremity: a femoral fracture model

Objectives  Mechanical axis deviation of the lower extremity as a result of malreduction or malunion of fractures plays an important role in the development of arthritis. Therefore it is crucial to restore the limb alignment as accurate as possible. The purpose of this study was to evaluate the accuracy and precision of navigation in assessing isolated frontal plane (varus/valgus) deviations of the lower limb in a simulated fracture model of the femur. Materials and methods  Three fracture models with ten specimens in each were created in femoral synthetic composite bones to simulate a subtrochanteric (AO/OTA 31-A1), mid-diaphyseal (AO/OTA 32-A3), and supracondylar (AO/OTA 33-A1) femur fracture. Each specimen was mounted on a custom holding device and registered with the navigation system. Eight custom-made aluminum wedges of varying angles (5°–26°) were used to create varus/valgus angulations at the fracture site. After wedge placement, the frontal plane deformity was recorded and registered by the navigation system. The means and standard deviations for each navigated wedge angle were calculated and compared to the actual wedge angle using a one sample t test. A single factor ANOVA test was subsequently performed to see if the differences between the navigated mean angles in each fracture group were statistically significant. The level of significance was defined as P < 0.05. Results  None of the navigated mean angles were found to be significantly different from the actual wedge angles (P = 0.05–1.00). More specifically, the differences between the navigated mean angles and the actual wedge angles ranged from 0° to 0.7°. Furthermore, the differences between the navigated mean angles in each angle group were found to be statistically insignificant (P = 0.53–0.99). Conclusion  The high accuracy and precision of navigation systems in determining frontal plane deformities of long bones can make them an invaluable tool for the exact reduction and realignment of lower extremity fractures.     

A lateral fracture step-off of 2mm increases intra-articular pressure following tibial plateau fracture

IntroductionThe aim of this study was to evaluate the effects of increasing posttraumatic step-offs after lateral tibial plateau fracture reduction on the intra-articular pressure.Materials and MethodsIn eight fresh-frozen human cadaveric knees with intact menisci, a standardized sagittal osteotomy of the lateral tibial condyle was performed as an OTA/AO type 41-B1 fracture-model. The fragment was fixed by a customized sled including an angular stable tibia plate to evaluate step-offs from 0 mm to 8 mm in 1mm increments. In a servo-hydraulic testing machine, an axial force was applied to the tibial plateau in 0° (700N), 15° (700N), 30° (700N), 60° (350N), and 90 ° (350N) of flexion while the joint pressure was recorded by two pressure sensors.ResultsA 1mm step-off did not result in an increased joint pressure. At 60° of flexion a 2mm step-off increased the lateral joint pressure by 61.84kPa (P = 0.0027). In 30° of flexion, a 3mm step raised the lateral joint pressure by 66.80kPa (p = 0.0017), whereas in 0°, 15° and 90° of flexion, a 4mm step increased the pressure by >50kPa (P < 0.05). Concomitant medial joint pressure increments were lower than those in the lateral plateau. A significant increase of 19-24kPa in the medial joint pressure was detected in 90° of flexion with a 1mm lateral step (P = 0.0075), in 15° and 60° of flexion with a 2mm step (P < 0.05), in 0° of flexion with a 4mm step (P = 0.0215) and in 30° of flexion with a 7mm step (P = 0.0487).ConclusionLateral fracture step-offs of 2mm or larger should be reduced intraoperatively to avoid large increases in lateral joint pressure.     

The posterior intrafocal pin improves sagittal alignment in Gartland type III paediatric supracondylar humeral fractures

IntroductionClosed reduction and percutaneous Kirschner wire fixation are widely recommended for displaced supracondylar humeral fractures. However, the optimal K-wire configuration is still controversial. The purpose of this study was to compare the results of crossed pinning with or without a posterior intrafocal pin in Gartland type III supracondylar humeral fractures.Patients and methodsWe retrospectively reviewed 93 children who underwent crossed pinning for Gartland type III supracondylar humeral fractures between January 2009 and December 2013. One surgeon preferentially added one posterior intrafocal pin onto the crossed pins in 35 children, and the other surgeons used standard crossed pinning technique in 58 children. Results were assessed by range of elbow motion and radiographic measures including the Baumann angle, the lateral humerocapitellar angle and the position of the anterior humeral line (AHL).ResultsThe demographic data were comparable between the 2 groups. Children treated with the additional posterior intrafocal pin had greater range of elbow motion (138.7° vs. 133.6°, p = 0.01) and had a greater lateral humerocapitellar angle (44.9° vs. 37.8°, p = 0.01) measured 3 months postoperatively. The percentage of AHL position in the posterior third was significantly higher in children with the posterior intrafocal pin immediately after fixation (odds ratio [OR]: 6.26) and 3 months later (OR: 2.84). The percentage of AHL position in the anterior third was also significantly lower in children with the posterior intrafocal pin 3 months postoperatively (OR: 0.29). No pin site infection or nerve injury was associated with the additional posterior pin.ConclusionsAdding one posterior intrafocal pin to crossed pinning can facilitate fracture reduction and enhance fixation stability. Better sagittal alignment and elbow motion support this safe and effective technique in treating type III humeral supracondylar fractures.     

选择性胫骨外髁U形截骨入路治疗胫骨外侧平台塌陷粉碎骨折

目的:探讨选择性胫骨外髁"U "形截骨入路治疗胫骨外侧平台塌陷粉碎骨折的方法和临床疗效。方法:自2014年1月至2019年10月,采用选择性胫骨外髁" U"形截骨入路对15例胫骨外侧平台塌陷粉碎骨折患者进行手术治疗,其中男9例,女6例;年龄25~70(38.5±7.7)岁。按照胫骨平台外侧髁骨折ABC分型,A型2例,B型6例,BC型4例,C型3例;合并内侧平台骨折5例;左膝8例,右膝7例。伤后至就诊时间1~14(3.4±1.2) d。所有患者CT提示胫骨外侧平台塌陷>2 mm,粉碎骨块>2块,胫骨外侧髁皮质完整。术后12个月采用Rasmussen骨折复位解剖学评分评价骨折复位情况,并采用Rasmussen功能评分评价膝关节功能。结果:15例患者选择性"U "形截骨一次成功,手术时间55~110(85.6±20.0) min,外侧平台手术时间20~60(30.5±10.5) min。所有患者获随访,时间12~24(14.6±2.5)个月。骨折愈合时间12~24(13.6±3.6)周。术后12个月膝关节Rasmussen骨折复位解剖学评分14~18(17.5±0.3)分,其中优13例,良2例。膝关节Rasmussen功能评分13~30(26.8±2.5)分;其中优12例,良1例,可2例。2例外侧平台高度分别丢失2 mm和4 mm,1例膝关节5°外翻畸形,1例关节僵硬(10°~100°)。未发生腓总神经损伤、腘血管损伤,术后无感染、内固定失效等严重并发症。结论:采用选择性胫骨外髁" U"形截骨入路治疗胫骨外侧平台塌陷粉碎性骨折,具有手术切口简单、骨折显露直接、复位固定准确、手术时间短,并发症少等优点,是一种有效、可靠的方法。     

Effect of deferred treatment of supracondylar humeral fractures

PurposeTiming of surgery remains a controversial topic in the treatment of the supracondylar humeral fracture. In our institution, patients are not brought to theatre after midnight, except in the ‘life or limb’ situation. We hypothesised that time to surgery has no significant influence on complication rate with supracondylar fracture of the humerus.MethodsA retrospective review was performed of all patients who required operative intervention for supracondylar fractures of humerus between 2004 and 2006. Patients' charts were assessed for demographic details, fracture type, time to theatre and complications. Statistical comparisons were performed between different fracture grades.ResultsWe identified 124 supracondylar fractures of humerus that required operative intervention between 2004 and 2006. Fractures were mainly treated with operative manipulation with medial and lateral crossed K-wire fixation. Gartland III and flexion type fractures had a significantly shorter time to surgery than Gartland II (p < 0.05). There was no significant difference in complication rate between fractures operated after midnight or deferred until the morning (p = 0.68). Most common complications identified were ulnar nerve palsy and AIN palsy.ConclusionsWe have found no difference in complication rates when treatment of supracondylar fractures is delayed. Supracondylar fractures which are not grossly displaced, have no neurovascular deficit or risk of skin compromise, can be safely deferred without an increased risk of complication. Operative treatment of supracondylar fractures can be delayed until the next morning, except in the ‘life or limb’ situation.     

Functional outcome of supracondylar humerus fracture in children with the use of pin configuration as per Bahk classification

IntroductionA variety of fracture patterns are seen in supracondylar humerus fractures in children and these are well described by Bahk et al. Currently followed treatment protocol doesn’t recognize these common fracture patterns and pin placement is done at the discretion of the treating surgeon. The aim of the study is to evaluate the usefulness of Bahk classification system in deciding the pin configuration for the specific fracture patterns and thereby assess the functional outcome in the management of supracondylar fractures in children.MethodThe study was done on 100 children of 2–12 years of age from February 2019 to January 2020. After closed reduction under general anesthesia, fractures were classified and pin configuration was decided according to Bahk classification. In the follow-up, patients were assessed for clinicoradiological outcomes based on Modified Flynn’s criteria, Baumann angle, and anterior humeral line.ResultsIn our study Typical transverse and low sagittal fracture were the most common fracture patterns. In the final follow up as per Flynn’s criteria, 93% of the patients showed excellent results. Mean Baumann’s angle was not significantly different from the uninjured side and anterior humeral line passed through anterior or middle third of the capitulum in 95% patients.ConclusionUsing pin configuration suitable to fracture pattern as per Bahk classification improves functional outcome in supracondylar humerus fractures in children and minimizes complications.     

Inter-and intra-rater reliability of vertebral fracture classifications in the Swedish fracture register

AIM To investigate the inter-and intra-rater reliability of the vertebral fracture classifications used in the Swedish fracture register.METHODS Radiological images of consecutive patients with cervical spine fractures(n = 50)were classified by 5 raters with different experience levels at two occasions. An identical process was performed with thoracolumbar fractures(n = 50). Cohen's kappa was used to calculate the inter-and intra-rater reliability.RESULTS The mean kappa coefficient for inter-rater reliability ranged between 0.54 and0.79 for the cervical fracture classifications, between 0.51 and 0.72 for the thoracolumbar classifications(overall and for different sub classifications), and between 0.65 and 0.77 for the presence or absence of signs of ankylosing disorder in the fracture area. The mean kappa coefficient for intra-rater reliability ranged between 0.58 and 0.80 for the cervical fracture classifications, between 0.46 and0.68 for the thoracolumbar fracture classifications(overall and for different sub classifications) and between 0.79 and 0.81 for the presence or absence of signs of ankylosing disorder in the fracture area.CONCLUSION The classifications used in the Swedish fracture register for vertebral fractures have an acceptable inter-and intra-rater reliability with a moderate strength of agreement.     

Changes in radiological parameters during reduction of femoral neck fractures: A radiographic evaluation of cadavers

ObjectiveTo investigate changes in the Garden index and other radiological parameters during reduction of femoral neck fractures.MethodsTen healthy, human femoral specimens were obtained. A 2.0 mm diameter Kirschner wire was implanted in the centre of the femoral head. A perpendicular osteotomy was made in the middle of the femoral neck. The distal osteotomy surface was used as the angle of rotation (pronation and supination up to 90° at 10° intervals). Anterior-posterior and lateral view radiographs were taken at different angles. The Garden index and other relevant data were analysed using the picture archiving and communication system. Changes in the area of the femoral head fovea at different rotation angles were measured.ResultsThere were no significant differences in the Garden index between 0–30° of pronation and supination (p > .05). For angles of 40–90°, there were statistically significant differences in the Garden index (p < .05). The area of femoral head fovea decreased with increasing pronation angle, and increased with increasing supination angle.ConclusionsThe Garden index does not change significantly if the angle of fracture rotation is 0–30° (in either pronation or supination) during femoral neck fracture reduction. Therefore, it is impossible to judge the rotation of fracture in this range of angles. The Garden index can detect the rotation of fracture for rotation angles of 40–90° (in either pronation or supination). Changes in the area of the femoral head fovea can help determine the rotation of femoral neck fractures.Level of EvidenceLevel V.     

双切口克氏针及外侧可吸收张力带内固定治疗儿童肱骨髁上骨折

目的：探讨双侧克氏针结合外侧可吸收张力带内固定治疗儿童肱骨髁上骨折的临床疗效。方法：2006年至2010年采用双侧切口切开,交叉克氏针并可吸收张力带内固定治疗82例儿童肱骨髁上骨折,男53例,女29例;年龄5～12岁,平均7岁。根据骨折临床愈合后肘关节屈伸功能及肘部提携角结果,按Flynn评定标准综合评定疗效。结果：82例均获随访,时间0.5年,肘关节屈伸活动受限（2.8±3.7）°,提携角（12.7±2.2）°。依据疗效评定标准,优80例,良2例。结论：采用双侧切口交叉克氏针并可吸收张力带内固定治疗儿童肱骨髁上骨折,能早期进行肘关节功能锻炼,具有创伤小、固定牢固、恢复快的特点,是目前手术治疗儿童肱骨髁上骨折较理想的方法。     

Acetabular morphological variation in Asian patients with femoral neck fracture: A three-dimensional CT-based study

AimsThe acetabular morphology varies greatly among individuals, and hypoplasia is more common in Asia than in Europe. Dislocation after bipolar hip arthroplasty (BHA) for femoral neck fracture occurs at a constant rate, and is affected by the acetabular morphology. This study aimed to clarify individual differences in the acetabula of Asian patients with displaced femoral neck fractures.Patients and methodsFifty patients with displaced femoral neck fractures were assessed (50 fractured hips, 50 non-fractured hips). On CT corrected by the anterior pelvic plane, the 100 hips were assessed regarding acetabular coverage (six parameters), acetabular depth (two parameters), and acetabular opening angle (four parameters). Additional parameters related to the fracture and sex were examined. The percentile of each parameter was shown for all hips.ResultsThere was no patient with hip dysplasia defined as superior acetabular sector angle (SASA) less than 110° Compared with men, women had a significantly smaller anterior acetabular sector angle (AASA) (p = 0.016), and significantly larger acetabular inclination angle (p = 0.006) and acetabular index angle (p = 0.034). In the group with a normal SASA, seven hips (7.3%) had an anterior wall defect (AASA<50°) and five hips (5.2%) had a posterior wall defect (posterior acetabular sector angle<90°).ConclusionOlder adults with femoral neck fractures can have anterior wall and posterior wall defects, even if their SASA is normal. Hidden acetabular dysplasia may be related to post-BHA dislocation. So, our results suggest that is important to accurately evaluate the acetabulum of patients with femoral neck fracture before surgery.     

3D modelling of tibial plateau fractures: Variability in fracture location and characteristics across Schatzker fracture types

IntroductionNumerous classifications have been developed to assess tibial plateau fractures (TPF). Of these, the Schatzker system is the most widely reported in the literature yet this system is limited in its characterisation of morphological fracture features underlying the fracture location. The purpose of this study was to compare 3D morphological features of TPFs across different Schatzker types.MethodsThis study retrospectively analysed preoperative TPF imaging data to reconstruct 3D models of the fractures. Ninety-one fractures (29 female, 62 male) were analysed and classified using Schatzker. Fracture location across Schatzker types was compared based on division of the articular surface into six ‘zones’. Additionally, morphological characteristics of the fractures were compared based on fracture type, including; the number, volume and shape of the fragments.ResultsSchatzker II, IV and VI fractures were most common, making up 41%, 16% and 20%, respectively. Type II fractures commonly involved both the lateral and central aspect of the tibial plateau, similarly, type IV fractures incorporated the lateral condyle in most cases. Considering the morphological metrics, statistically significant differences were observed between Schatzker types for the number of; total, articular, cortical and volumetrically significant (all P < 0.001) fragments along with the volume of both primary (P < 0.001) and secondary (P = 0.02) fragments.DiscussionAssessment of underlying fracture characteristics in addition to fracture location can serve to provide greater detail relating to fracture morphology, which has the potential to assist with both surgical decision making and assessment of postoperative outcomes. Incorporating this information as part of a hierarchical or multifactorial framework for classifying fractures may help distinguish subtle differences between fracture types that are classifiable using the most current systems.     

Addition of 3D-CT evaluation to radiographic images and effect on diagnostic reliability of current 2018 AO/OTA classification of femoral trochanteric fractures

IntroductionThe AO/OTA classification for diagnosing femoral trochanteric fractures (31A fractures) was revised in 2018. No studies have investigated whether the addition of CT to radiographic diagnosis improves the inter-rater reliability of classifying 31A fractures with the current AO/OTA criteria. The study aimed to test the hypothesis that the addition of three-dimensional CT (3D-CT) to radiographic diagnosis would improve diagnostic reliability.MethodsA retrospective review was conducted to assess the diagnostic reliability of classification of 31A fractures with current AO/OTA criteria. Radiographs and 3D-CT images from 89 cases were assessed. Major fracture types (A1, A2, and A3) and subgroups were diagnosed by nine orthopedic surgeons who were classified into three groups (high-, intermediate-, and low-experience) according to their clinical experience. Anterior–posterior and lateral radiographs were provided to diagnose fracture type (first assessment). After a 6-week interval, radiographs and 3D-CT images of all cases were evaluated by each rater (second assessment). Fleiss's Kappa was used to determine inter-rater reliability.ResultsIn the first assessment, the Kappa value indicated fair inter-rater reliability in all groups (high-experience group: κ = 0.296, 95% confidence interval [CI] 0.239–0.352; intermediate-experience group: κ = 0.367, 95% CI 0.305–0.428; low-experience group: κ = 0.304, 95% CI 0.246–0.362). With the addition of 3D-CT (second assessment), reliability improved from fair to moderate in the high- and intermediate-experience groups (κ = 0.483, 95% CI 0.428–0.539 and κ = 0.409, 95% CI 0.352–0.466, respectively). By contrast, reliability remained fair in the low-experience group (κ = 0.322, 95% CI 0.322–0.431). The inter-rater reliability of diagnosing subgroup fracture types improved for A2.3 and A3.1 in all three groups and for A3.2 and A3.3 in the intermediate- and low-experience groups.ConclusionThe current AO/OTA classification revised in 2018 provided fair reliability in diagnosing femoral trochanteric fractures in all three surgeon groups. The addition of 3D-CT to radiographic image evaluation improved reliability in high- and middle-expertise groups. The addition of 3D-CT to radiographic evaluation often improved the diagnostic reliability for unstable fractures, although there was some variation among fracture subgroups.     

Elbow fractures in children: An epidemiological analysis of 589 cases

The radiographs of 589 elbow fractures in children under the age of 16 years were reviewed. The most common fractures were: supracondylar fracture of the humerus - 55 per cent, fracture of the radial neck - 14 per cent, and fracture of the lateral humeral condyle -12 per cent. One fifth of all fractures of the olecranon were associated with another elbow fracture; most often a fracture of the medial epicondyle. The average annual incidence of elbow fractures in the age group studied was 12 per 10.000 (10.0 - 14.7) without a significant change of the incidence between 1950 and 1979. Supracondylar and lateral condylar fracture of the humerus and fracture of the olecranon occurred more often in boys. Fractures of the lateral humeral condyle were more often caused by higher energy levels than the other fracture groups.     

A radiographic zone-based approach to predict meniscus injury in lateral tibial plateau fracture

ObjectivesThere is limited data regarding meniscal injury and it's association to fracture location and articular impaction/displacement (AID) in tibial plateau fractures. The purpose of this study was to predict lateral meniscal injury in tibial plateau fractures, based on location and extent of AID as visualized on pre op CT images.DesignRetrospective review study.SettingLevel I academic trauma center.PatientsWe retrospectively reviewed lateral tibia plateau fracture patients that were treated operatively using CPT codes 27535 and 27536. Two hundred patients were identified. Inclusion criteria were lateral tibia plateau fracture, age of 18 years or older, and documented direct examination of lateral meniscus integrity intraoperatively. Seventy patients met inclusion criteria.InterventionThe injured lateral tibial plateau was divided into four quadrants on pre-operative CT and maximum AID was measured. The zone of fracture was defined as the location of largest AID (Image-1). All patients had an arthrotomy at the time of surgery to evaluate the integrity of the meniscus. Intra operative data regarding meniscal integrity and preoperative CT data were analyzed. Logistic regression was used to estimate what effect zone and amount of AID had on predicting the meniscal injury. Receiver operating characteristic (ROC) analysis was performed to determine cut off points for high sensitivity/specificity.Main outcome measurementsAmount and area of depression in the lateral tibial plateau as relates to meniscal injury.ResultsMean age was (45.1 ± 12.9) years. Twelve had Schatzker type I and 58 had type II fractures. Twenty-two patients had meniscus injury (MI) and forty-eight patients did not have a meniscus injury (NMI). Mean AID for MI was 12.48 mm ± 7.17 mm and 6.4 mm ± 4.3 mm for NMI (p<0.01). In MI group, largest AID was in Posterolateral (PL) zone(17.58 mm ± 8.9 mm) followed by Anteromedial (AM) zone (13.3 mm ± 7.2 mm) and Anterolateral (AL) zone (9.4 mm ± 5.8 mm). In NMI group largest AID was in AL zone (8.52 mm ± 2.6 mm) followed by AM zone (8.04 mm ± 5.4 mm) and PL zone (7.75 mm ± 2.35 mm). Patients with PL zone involvement had a lower meniscus tear rate compare to other zones. Logistic regression revealed that for every 1 mm increase in AID there is a 21% increase chance of meniscus tear (p<0.01). Comparison of the zones indicated that for the same AID, AL and AM zone fractures have 7.3 and 5.6 times increase risk of meniscus tear, respectively, as compared to PL zone (p<0.05). ROC analysis revealed that AID of 4.3 mm as a cut off point provides 100% sensitivity for diagnosis of meniscus tear.ConclusionWith 1 mm increase in AID there is a 21% increase in chance of meniscal tear. With the same AID, AL and AM zone fractures have a significantly higher chance of having a meniscal tear. AID of 4.3 mm provides 100% sensitivity to predict meniscal tear in lateral tibia plateau fracture. These values are useful in predicting pre op meniscal tear without MRI.     

Elbow fractures in children. An epidemiological analysis of 589 cases

The radiographs of 589 elbow fractures in children under the age of 16 years were reviewed. The most common fractures were: supracondylar fracture of the humerus -55 per cent, fracture of the radial neck -14 per cent, and fracture of the lateral humeral condyle -12 per cent. One fifth of all fractures of the olecranon were associated with another elbow fracture; most often a fracture of the medial epicondyle. The average annual incidence of elbow fractures in the age group studied was 12 per 10.000 (10.0-14.7) without a significant change of the incidence between 1950 and 1979. Supracondylar and lateral condylar fracture of the humerus and fracture of the olecranon occurred more often in boys. Fractures of the lateral humeral condyle were more often caused by higher energy levels than the other fracture groups.