The Hyperplantarflexion Ankle Fracture Variant

Various patterns of ankle fractures that are not accounted for by common classification systems have been the subject of case reports. The first difficulty with these variant patterns is recognizing all associated pathology, followed by the successful application of stable fixation. The purpose of this study was to describe the common morphologic features and ligamentous injuries of a unique variant fracture pattern, as well as the surgical treatment technique and the short-term functional and radiographic outcomes. Of 121 consecutive unstable ankle fractures over a 2-year period, 7 patients were found to have a similar constellation of injuries around the ankle. A vertical shear fracture of the posteromedial tibial rim was the main feature. Six of the 7 also had a fracture of the posterior malleolus. On magnetic resonance imaging, the deltoid and posterior tibiofibular ligaments were intact in all cases. Fractures were treated with open anatomic reduction of the posteromedial and posterior fragments with antiglide plate fixation. All fractures healed at 2 months without loss of reduction, fixation failure, or surgical complications. The average American Academy of Orthopaedic Surgeons lower extremity score was 79 at an average of 8 months' follow-up. The common radiographic and morphologic features associated with this posteromedial fracture indicate that it likely occurs through a common mechanism that involves hyperplantarflexion. The characteristics of this fracture pattern have not been fully described previously, but this ankle fracture variant may occur in up to 6% of cases. Unstable ankle fractures should be evaluated carefully for evidence of posteromedial involvement so appropriate treatment may proceed.     

Capitellum Fracture Fragment Excision: a Case Series

Background

Fractures of the capitellum are rare injuries, and few studies have reported the results of fragment excision.

Questions/Purposes

The purpose of this study was to determine range of motion and short-term clinical outcomes for patients treated with capitellum excision.

Methods

A retrospective review was performed to identify all patients with an isolated capitellum fracture who underwent excision as definitive treatment at our institutions. Mechanism of injury, associated elbow injuries, type of capitellum fracture, complications, and postoperative outcomes including final elbow range of motion (ROM), elbow instability, and Disabilities of the Arm, Shoulder and Hand (DASH) score were recorded.

Results

Four patients met the inclusion and exclusion criteria of this study. All patients were female with an average age of 69 years (range 42–85). Based on the Bryan and Morrey classification system, three (75%) fractures were classified as type I and one (25%) fracture as type III. The average clinical follow-up was 11 months. Final examination demonstrated a mean elbow range of motion from 14° (range 0–30) of extension to 143° (range 130–160) of flexion. All patients had full forearm rotation, and there was no clinical evidence of elbow instability. The average DASH score was 18.3 (12.5–24.2) at final follow-up.

Conclusion

Excision of the capitellum, much like excision of the radial head, results in acceptable short-term outcome scores and elbow range of motion in patients with fractures that are not amenable to open reduction and internal fixation.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-015-9452-x) contains supplementary material, which is available to authorized users.     

The Axillary View Typically Does Not Contribute to Decision Making in Care for Proximal Humeral Fractures

Background

Convention dictates that an axillary view be obtained when evaluating proximal humerus fractures (PHF). However, the axillary view is frequently omitted because of pain and technical considerations. Furthermore, its diagnostic utility is unclear in this setting.

Questions/Purposes

The purpose of this study was to (1) determine the rate of obtaining an adequate axillary X-ray and complete shoulder series at a level I trauma center, (2) understand the cost of ordering and attempting an axillary radiograph, and (3) determine if axillary radiographs influence the management of PHF.

Patients and Methods

PHF treated between 2009 and 2011 that were ordered for an AP, scapular Y, and axillary view was identified. The types of radiographs actually obtained were recorded. The cost of obtaining three views and a single view of the shoulder with X-ray was determined. Lastly, three surgeons reviewed 42 PHF, both with and without an axillary view (AV), and treatment recommendations were compared.

Results

30% of PHF in this series had an adequate axillary view, and 14% received a complete trauma series. No factors could be identified that were associated with successfully obtaining an axillary view. Reviewers demonstrated substantial intraobserver reliability (κ = 0.759–0.808) regarding treatment recommendations for PHF with and without the axillary view. The addition of the AV had minimal influence on treatment recommendations.

Conclusion

Considering that the axillary view for PHF is painful, labor-intensive, costly, and does not appear to provide additional diagnostic value, orthopedic surgeons can consider foregoing the use of the axillary view when evaluating and treating PHF, particularly if other advanced imaging is utilized.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-015-9445-9) contains supplementary material, which is available to authorized users.     

Complete exposure of the articular surface for fixation of patellar fractures

Anterior tension band fixation constructs are among the mainstay of treatment of patella fractures and lead to reliable results with simple transverse fracture patterns. However, comminuted fractures of the patella require much more extensive articular reconstruction than interdigitating two large fragments to achieve a good result. In this report, we describe a technique for exposure, reduction, and stabilization of patella fractures that allows for direct visual reduction of the articular surface. Subsequent devices are applied directly to the bony surfaces of the patella without soft-tissue interposition, which distinguishes it from traditional approaches. This technique may be used to ensure articular surface congruity in simple transverse fractures and may be particularly useful in comminuted fractures when patellar excision would otherwise be considered.     

Conjugal transfer vaccinia

Two cases of conjugal contact transfer vaccinia are described. Each patient had intimate contact after their respective partners, active-duty military personnel, received the smallpox vaccination.