Acute Traumatic Fractures Research Articles

Update on Talar Fracture Patterns: A Large Level I Trauma Center Study

Prior studies of talar fracture patterns are dated and based on radiography only. The purpose of our study was to describe talar fracture patterns and associated injuries in a modern large level 1 trauma center setting using both radiography and CT. The radiolog and clinical data of patients with acute talar fractures diagnosed over an 18-month period were retrospectively reviewed. Data analysis included descriptive statistics for injury mechanisms and associated injuries. Over the study period, a total of 132 talar fractures were detected in 122 patients. The most common talar fracture location was the body (61%). The most common body fractures were dome compression (26%), lateral process (24%), and posterior tubercle (21%). Of the 132 fractures, 62% were comminuted and 21 (16%) were vertical neck fractures compatible with the Hawkins-Canale classification. Both radiography and CT were used in 91% of cases, with CT providing additional information in 112 (93%) cases. By use of CT as the reference standard, the sensitivity of radiography for detecting talar fractures was 74%. The most common fracture missed by radiography was talar dome compression (31% not seen on radiography) Talar fractures were associated with adjacent joint subluxation or dislocation in more than 66% of the cases and adjacent fracture in more than 72% of the cases. In our study, the most common site of talar fracture was the body. Current classification systems do not apply to most talar fractures. Talar fracture patterns cannot be characterized with radiography alone. CT is a critical tool for the detection and characterization of talar fractures. There is a high incidence of adjacent fracture and dislocation with acute traumatic talar fractures.

Intramedullary nailing without interlocking screws for femoral and tibial shaft fractures

Intramedullary fixation is the treatment of choice for diaphyseal fractures of the femur and tibia. Locking the implant can sometimes be cumbersome and time consuming. In our institution, fractures with axial and rotational stability are treated with intramedullary nailing without interlocking. All consecutive patients presented in the University Medical Center Utrecht from October 2003 to August 2009 with acute traumatic diaphyseal fractures of the tibia or femur that were considered axial and rotational stable were included. They underwent internal fixation using intramedullary nails without interlocking. Patient records were evaluated for duration of surgery, perioperative complications, consolidation time and re-operations. Twenty-nine long bone fractures were treated in 27 patients: 20 men and 7 women, with an average age of 28.9 years (range 15.6-54.4). There were 12 femoral fractures and 17 tibial fractures. Sixteen fractures were closed and 13 were open (10 Gustilo 1, 3 Gustilo 2). The mean operating time was 43 min (range 18-68 min) for tibial fractures and 55 min (range 47-150 min) for femoral fractures. Postoperative complications occurred in six patients. Two patients (three fractures) were lost to follow-up. Healing occurred in 25 of the 26 remaining fractures (96 %) without additional interventions. One tibia was secondarily converted to a standard locked nail because of axial and rotational instability. All patients returned to their pre-injury level of activity. The use of intramedullary nailing without interlocking is associated with minimal complications in selected fractures. The advantages include a short operating time and the simplicity of its application.

MRI study of post-traumatic incompetence of posterior ligamentous complex: importance of the supraspinous ligament. Prospective study of 74 traumatic fractures

Posterior ligamentous complex (PLC) components have an orderly sequence of rupture. However, it is still unclear how many structures have to be damaged to consider it disrupted. We aim to establish imaging criteria, which can define the complex as competent or incompetent. Prospective study of 74 consecutive vertebral acute traumatic fractures, using X-rays and MRI scan (FS-T2-w/STIR sequences). We analyzed the association between MRI signal (intact, edema, disruption) of each PLC component-facet capsules (FC), interspinous ligaments (ISL), supraspinous ligaments (SSL) and ligamentum flavum (LF)-and the variables: AO/TLICS classification, treatment, surgical findings, interspinous diastasis index (IDI), local kyphosis (LVK) and ISS (TLICS) score. χ2 test and U Mann-Whitney were used for statistics. MR images of ISL edema correlated surgically with intact ligaments or laxity, and were associated with 87.5% of facet distraction, LVK: 11.6º, IDI: 1.2. Images of ISL, SSL or LF disruptions showed in all cases ruptures under surgical examination. Images of SSL disruption associated with LVK: 14.5º, IDI: 1.8. Images of ISL disruption associated with SSL/LF rupture, LVK: 16º, and IDI: 2; while LF disruption showed LVK: 18º, IDI: 1.9. When comparing "competent PLC" (images of facet distraction and ISL edema) with "incompetent PLC" (images of SSL disruption ± ISL or LF disruption) the latest showed more severe scores in every variable (p < 0.001), except neurologic status. Following PLC rupture sequence, ISL edema with facet distraction seems not to be enough to define a posterior tension band incompetence. It is the further step of SSL rupture what gives the key to PLC incompetence.

Sequential Damage Assessment of the Different Components of the Posterior Ligamentous Complex After Magnetic Resonance Imaging Interpretation

Prospective cohort study. To study whether there is a sequential pattern in the posterior ligamentous complex (PLC) rupture caused by deforming traumatic forces by analyzing magnetic resonance (MR) images in a consecutive prospective cohort of patients with traumatic vertebral fracture. PLC plays an important role in vertebral stability. However, the sequence in which the different components of the PLC tear, in the face of traumatic forces, has not been yet described. Prospective study of 74 consecutive vertebral acute traumatic fractures analyzed using radiography and magnetic resonance imaging (MRI) (FS-T2-w/short-tau inversion-recovery [STIR] sequences). Fracture morphology was classified according to the AO classification. Integrity of each PLC component-facet capsules, interspinous ligament (ISL), supraspinous ligament (SSL), and ligamentum flavum (LF)-was assessed and classified as intact, edema, or disruption. ISL edema was further subdivided depending on the extension (>50%/<50%). We analyzed the association between MRI signal and the AO progressive scale of morphological damage. AO type A1/A2 fractures associated with only facet distraction. A3 fractures showed additional ISL edema, usually less than 50%, with neither SSL nor LF disruption. Type B1 fractures associated with facet distraction, ISL edema or disruption, and low rate of SSL/LF disruptions; B2 fractures increased SS/LF disruption rates. Type C fractures associated with facet fracture or dislocation and ISL, SSL, or LF complete rupture. We found high association (P < 0.001) between AO progressive scale and MRI signal. MRI analysis showed that posterior distraction forces begin in the facets and extend throughout the ISL, starting at its posterosuperior margin (finally disinserting the SSL superiorly) and traveling diagonally toward anteroinferior border, finally tearing the LF. MR images correlated with AO progressive scale of morphological damage, which showed a progressive orderly rupture sequence among the different PLC components as traumatic forces increased.

Radiological Outcome of Short Segment Posterior Stabilisation and Fusion in Thoracolumbar Spine Acute Fracture

The optimal management of thoracolumbar spine fractures remains a matter of controversy. The current literature implies that the use of short-segment pedicle screw fixation may be inappropriate because of its high reported failure rate. The purpose of this study is to report the short-term results of thoracolumbar burst and compression fractures treated with short-segment pedicle instrumentation. From 2002 to 2007, 19 patients with thoracolumbar acute traumatic fractures were instrumented with posterior short-segment pedicle screws. The patients' case notes, operation records, preoperative and postoperative radiographs (sagittal index, anterior body compression and regional kyphosis), computed tomography scans, neurological findings (Frankel functional classification), and follow-up records up to 18 months were reviewed. A statistically significant difference was found between the patients' preoperative, postoperative and follow-up sagittal index, anterior body compression and regional kyphosis measurement. One case resulted in screw pedicle screw pullout and subsequently, kyphotic deformity. The patient underwent revision surgery to long-segment posterior instrumentation and fusion. None of the patients showed an increase in neurological deficit. In conclusion, the short-term follow-up results suggest a favourable outcome for short-segment instrumentation. Load shearing classification is essential for the selection of patient for short-segment instrumentation. However, the long-term follow-up evaluation will be needed to verify our findings.

Posterior approach for thoracolumbar corpectomies with expandable cage placement and circumferential arthrodesis: a multicenter case series of 67 patients

The purpose of this multicenter trial was to investigate the outcome and durability of a single-stage thoracolumbar corpectomy using expandable cages via a posterior approach. The authors conducted a retrospective chart review of 67 consecutive patients who underwent single-stage thoracolumbar corpectomies with circumferential reconstruction for pathological, traumatic, and osteomyelitic pathologies. Circumferential reconstruction was accomplished using expandable cages along with posterior instrumentation and fusion. Correction of the sagittal deformity, the American Spinal Injury Association score, and complications were recorded. Single-stage thoracolumbar corpectomies resulted in an average sagittal deformity correction of 6.2° at a mean follow-period of 20.5 months. At the last follow-up, a fusion rate of 68% was observed for traumatic and osteomyelitic fractures. Approximately one-half of the patients remained neurologically stable. Improvement in neurological function occurred in 23 patients (38%), whereas 7 patients (11%) suffered from a decrease in lower-extremity motor function. The deterioration in neurological function was due to progression of metastatic disease in 5 patients. Five constructs (7%) failed-3 of which had been placed for traumatic fractures, 1 for a pathological fracture, and 1 for an osteomyelitic fracture. Other complications included epidural hematomas in 3 patients and pleural effusions in 2. Single-stage posterior corpectomy and circumferential reconstruction were performed at multiple centers with a consistent outcome over a wide range of pathologies. Correction of the sagittal deformity was sustained, and the neurological outcome was good in the majority of patients; however, 18% of acute traumatic fractures required revision of the construct.

Therapieempfehlungen zur Versorgung von Verletzungen der Brust- und Lendenwirbelsäule

This paper gives recommendations for treatment of thoracolumbar and lumbar spine injuries. The recommendations are based on the experience of the involved spine surgeons, who are part of a study group of the "Deutsche Gesellschaft für Unfallchirurgie" and a review of the current literature. Basics of diagnostic, conservative, and operative therapy are demonstrated. Fractures are evaluated by using morphologic criteria like destruction of the vertebral body, fragment dislocation, narrowing of the spinal canal, and deviation from the individual physiologic profile. Deviations from the individual sagittal profile are described by using the monosegmental or bisegmental end plate angle. The recommendations are developed for acute traumatic fractures in patients without severe osteoporotic disease.

Minimally Invasive Surgery for Traumatic Spinal Pathologies

Prospective registry. The objective of this study was to examine patient outcomes using a mini-open, lateral approach for the treatment of traumatic thoracic and lumbar fractures. The high-quality published studies that examine treatment methods for acute traumatic thoracic and lumbar fractures are few and a few that are present contain insufficient samples to make broad conclusions. Despite this, we know that conventional surgical techniques often include large, morbid exposures. More recent advancements in less invasive surgical techniques have greatly decreased the associated morbidities of conventional approaches, namely, thoracotomy. A total of 52 patients were treated at 1 of 2 institutions for traumatic thoracic or lumbar fractures with a mini-open lateral approach for corpectomy. Patients were prospectively followed for clinical outcomes, with treatment and in-hospital complications collected retrospectively. The majority of patients (94.2%) presented with traumatic burst fractures with instability and neurologic deficit. Patients were treated with mini-open, lateral corpectomies from T7 to L4, the majority at T12 and L1, and were followed 2 years after surgery. Supplemental internal fixation was used in all patients: 75% anterolateral plating and 46.1% transpedicular fixation (11 [21.2%] patients with combined). Median operative time, estimated blood loss, and hospital stay were 128 minutes, 300 mL, and 4 days, respectively. Complications were observed in 13.5% of patients and no reoperations occurred. Neurologic status, assessed using American Spinal Injury Association categorization, improved significantly postoperatively, with 73% of patients either completely neurologically intact or with only slight residual deficits (American Spinal Injury Association E or D). No patient experienced neurologic deterioration. Expandable wide-footprint titanium cages were used in 34.6% of patients, which resisted radiographic subsidence seen in some patients treated with expandable cylindrical titanium cages. The mini-open lateral approach for thoracic and lumbar corpectomy was shown to be safe and effective in this series while avoiding many of the associated morbidities of thoracotomies for anterior column reconstruction and open posterior approaches.

Vertebroplasty in the management of traumatic burst fractures: A case series

This study aimed to assess the role of percutaneous vertebroplasty (VP) in the management of acute traumatic burst fractures. We describe three cases where percutaneous VP was carried out for traumatic non-osteoporotic burst vertebral fractures. For clinical symptoms and the effect of the VP procedure to be assessed, all patients completed a visual analogue scale and a mobility score before the procedure and at day 1 and 3 months post procedure. Improvements in both pain and mobility scores immediately post procedure were seen in all patients, and these results persisted at 3-month follow up. Percutaneous VP provided a successful, minimally invasive treatment of these patients' traumatic fractures while avoiding major surgical procedures and associated surgical morbidity and complications.

Comparison of kyphoplasty with use of a calcium phosphate cement and non-operative therapy in patients with traumatic non-osteoporotic vertebral fractures

One of the current standard treatment options for younger patients with stable traumatic vertebral fractures is conservative treatment using braces. Kyphoplasty as a minimally invasive procedure has been shown to be effective in stabilizing vertebral body fractures, resulting in immediate pain relief and improved physical function. The purpose of this prospective study was to clarify whether patients with acute traumatic vertebral fractures benefit more from kyphoplasty or from conservative treatment with a brace. A prospective study was undertaken in two centers. Forty patients with acute painful traumatic vertebral body fractures type A1-A3 (AO-classification) after adequate trauma, without osteoporosis, suitable for kyphoplasty or therapy by brace were included into the study. Follow-up was 12 months. Patients of the kyphoplasty group showed an immediate beneficial and significant effect postoperatively, and better outcomes 1 and 3 months after operation compared to the conservatively treated group in pain feeling, mobility and vertebral body height. After 12 months the difference between both groups was not significant excepting the vertebral body height. Kyphoplasty provides early and lasting reduction of pain and improvement of daily activity. However, there are clinically asymptomatic cement leakages in up to 45% of which we do not know the consequences in long term. Every patient with traumatic vertebral body fracture treated by kyphoplasty has to be informed about that. Long-time results are outstanding and our findings require confirmation by randomized controlled trials.

Reconstruction of Acute Traumatic Tibial Fractures with the Ilizarov Method

Background: Since the first application of external fixators in 1853, the indications, popularity, and designs have changed continuously. A variety of reliable pin fixators are now available with different clinical and mechanical properties1. They are easy to apply and have become quite handy in centers where poly trauma is regularly managed2. A comparatively recent innovation, the Ilizarov circular external fixator3 has the advantage of stability and rigidity and is widely used in Russia, Europe and America in the management of complicated fractures of upper and lower limbs. Recently introduced in Nigeria, the circular frame is yet to enjoy adequate popularity, due to unavailability and lack of trained manpower in its use7. At Hopeville Specialist Hospital, we adopted the Ilizarov device and techniques as a primary treatment method for complicated fractures. This study aims to review the results of treatment and evaluate the utility of the Ilizarov techniques in our practice. Method: A retrospective study of 35 fractures of the tibia in 33 patients, treated in our hospital between January 2000 and March 2006. Results: There were 23 males (69.7%) and 10 females (30.3%). Average age was 35.3 years. 27(77.1%) fractures were open and 8 (22.9%) were closed. According to Gustilo et al8, open fractures were two Type I, thirteen Type II and twelve Type III. Two (5.7%) were bicondylar plateau fractures with extensive shaft extension, twenty-four (68.6%) fractures in the midshaft, five (14.3%) fractures at the distal third and four (11.4%) were pilon type of fractures. There were seven segmental diaphyseal fractures. To date, thirty-three fractures are healed. The average time for application of the apparatus to fracture healing was 4.3 months. One fracture required autogenous bone graft for union. One patient is undergoing callus transportation for bone replacement. The most common complication was pin tract infection seen in nine (25.7%) patients. Conclusion: We treated 35 tibial fractures in 33 patients using Ilizarov techniques as primary treatment method. Thirty-three fractures have healed. The results are promising and our experience confirms the utility of the technique in our practice. We conclude that the Ilizarov technique is an effective device for the treatment of long bone fractures with a high rate of union and a relatively low complication rate. We recommend it to any surgeon involved in the treatment of fractures. We suggest a \" Centre for Ilizarov Techniques\" be established in Nigeria for training of doctors. Keywords: Ilizarov apparatus, acute fracture care. Nigeria Journal of Orthopaedics and Trauma Vol. 7 (2) 2008: pp. 66-69

Vertebroplasty and kyphoplasty: friends or foes?

This paper aims to compare vertebroplasty and kyphoplasty by illustrating the two techniques, analysing the results and discussing the indications in relation to the type of fracture. Vertebroplasty was performed on 805 vertebral bodies in 485 patients affected by osteoporosis (310), metastasis (160) and vertebral haemangioma (15). The approach was unipedicular in 365 patients and bipedicular in 120 patients. Biopsies were obtained in patients with no known primary cancer (75). Kyphoplasty was performed in 39 patients with Magerl type A1 and A3 fractures within 3 months from the trauma. A bipedicular approach was used in all cases. Outcomes were assessed on the basis of the visual analogue scale and the Oswestry Disability Index. In patients treated with vertebroplasty, success rates at 24-72 h were 90% for osteoporotic fractures, 100% for vertebral haemangiomas and 77% for metastatic fractures. Extravertebral vascular or discal leakage of cement occurred in 39 patients, but only two of them reported radicular pain due to epidural involvement. Osteoporotic patients developed new vertebral fractures at adjacent levels in 25 cases and at distal levels in 19 cases. In patients treated with kyphoplasty, pain relief was achieved within one month after treatment in 90% of cases. None of the patients wore orthotic braces after treatment, and no vertebral collapse was observed. Vertebroplasty and kyphoplasty are both useful in the management of vertebral pain. In light of our experience, vertebroplasty is better indicated for vertebral fractures due to osteoporosis, haemangioma or metastasis on account of its simplicity and minimal invasiveness. Kyphoplasty is suggested in acute traumatic fractures of type A1 and A3 according to Magerl, as it allows recovery of vertebral stability and a better distribution of the cement.

Percutaneous augmentation of the superior pubic ramus with polymethyl methacrylate: treatment of acute traumatic and chronic insufficiency fractures

The injection of polymethylmethacrylate (PMMA) is a minimally invasive image-guided procedure that is typically used to treat vertebral body fractures due to osteoporosis or neoplastic involvement. The injection of PMMA into various other locations including the sacrum, acetabulum, pedicles, femur and tibia has been reported previously, and these procedures have, overall, been highly effective at alleviating pain and discomfort. Although the injection of PMMA into the vertebral body is a very common procedure that has been performed for over 2 decades for the percutaneous treatment of vertebral body fractures, the percutaneous injection of PMMA has not been reported in the English literature as treatment for superior pubic ramus fractures. We report the percutaneous treatment of an acute superior pubic ramus fracture and of a chronic insufficiency fracture of the superior pubic ramus using a parasymphyseal approach to access the region of injury.

Prospective study of standalone balloon kyphoplasty with calcium phosphate cement augmentation in traumatic fractures

Prospective consecutive series cases study to investigate the clinical and radiological results of standalone balloon kyphoplasty and cement augmentation with calcium phosphate in traumatic fractures. Independent observer evaluation of radiological and computer tomography results, visual analogue scale (VAS), Roland-Morris score and complications with acute traumatic compression fractures type A, treated with a standalone balloon kyphoplasty and cement augmentation with calcium phosphate (Calcibon); follow-up time at a mean of 30 months (24-37 months). From August 2002 to August 2003, consecutive patients with traumatic compression fractures (Magerl type A) without neurological deficit underwent standalone kyphoplasty with Calcibon. We report here the pre-, post-operative and the follow-up results, applying the VAS (0-10) for pain rating, the Roland-Morris (0-24) disability score, CT-scan examination, detailed radiographic evaluation of vertebral body (VB) deformity and segmental kyphosis measurement. The pre-operative X-ray measurements, VAS and the 7 days Roland-Morris scores are compared with the post-operative and the 30 months follow-up findings. Twenty-eight patients with 33 treated fracture levels were included in this study. The mean initial vertebral deformity (VB kyphosis) was 17 degrees, corrected to a post-operative of 6 degrees. We noted a loss of correction at the follow-up in comparison to the post-operative standing X-ray at 24 h of 3 degrees vertebral deformity and 3 degrees segmental kyphosis. The VAS score demonstrates a decrease over time from a mean of 8.7-3.1 at 7 days and to 0.8 at the last follow-up. The Roland-Morris disability score demonstrates a similar improvement. We noticed no major complications related to the procedure. The mean cement resorption after 1 year was 20.3% (0.3-35.3%) and is related to the individual biological resorption process and is not predictable. All patients with vertebral fractures as sole medical problem were discharged within 48 h. All active patients returned to the same work within 3 months with the same working ability as before the accident. Standalone balloon kyphoplasty is a potential alternative mini-invasive technique to reduce the fractures. However, due to the intrinsic characteristic of calcium phosphate cement (Calcibon) we recommend the application of this biological cement for standalone reduction and stabilisation only in fractures type A1 and A3.1 in young patient. In case of higher destruction levels of the VB, we propose the utilisation of Calcibon associated with posterior instrumentation. Having regard to the pointed out indications, our preliminary results demonstrate a new possibility to treat this kind of fractures, allowing a rapid handling of pain, early discharge and return to normal activities.

Assessment of Two Thoracolumbar Fracture Classification Systems as Used by Multiple Surgeons

The reproducibility and repeatability of modern systems for classification of thoracolumbar injuries have not been sufficiently studied. We assessed the interobserver and intraobserver reproducibility of the AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification and compared it with that of the Denis classification. Our purpose was to determine whether the newer, AO system had better reproducibility than the older, Denis classification. Anteroposterior and lateral radiographs and computerized tomography scans (axial images and sagittal reconstructions) of thirty-one acute traumatic fractures of the thoracolumbar spine were presented to nineteen observers, all trained spine surgeons, who classified the fractures according to both the AO and the Denis classification systems. Three months later, the images of the thirty-one fractures were scrambled into a different order, and the observers repeated the classification. The Cohen kappa (kappa) test was used to determine interobserver and intraobserver agreement, which was measured with regard to the three basic classifications in the AO system (types A, B, and C) as well as the nine subtypes of that system. We also measured the agreement with regard to the four basic types in the Denis classification (compression, burst, seat-belt, and fracture-dislocation) and with regard to the sixteen subtypes of that system. The AO classification was fairly reproducible, with an average kappa of 0.475 (range, 0.389 to 0.598) for the agreement regarding the assignment of the three types and an average kappa of 0.537 for the agreement regarding the nine subtypes. The average kappa for the agreement regarding the assignment of the four Denis fracture types was 0.606 (range, 0.395 to 0.702), and it was 0.173 for agreement regarding the sixteen subtypes. The intraobserver agreement (repeatability) was 82% and 79% for the AO and Denis types, respectively, and 67% and 56%, for the AO and Denis subtypes, respectively. Both the Denis and the AO system for the classification of spine fractures had only moderate reliability and repeatability. The tendency for well-trained spine surgeons to classify the same fracture differently on repeat testing is a matter of some concern.

ASSESSMENT OF TWO THORACOLUMBAR FRACTURE CLASSIFICATION SYSTEMS AS USED BY MULTIPLE SURGEONS

Background: The reproducibility and repeatability of modern systems for classification of thoracolumbar injuries have not been sufficiently studied. We assessed the interobserver and intraobserver reproducibility of the AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification and compared it with that of the Denis classification. Our purpose was to determine whether the newer, AO system had better reproducibility than the older, Denis classification. Methods: Anteroposterior and lateral radiographs and computerized tomography scans (axial images and sagittal reconstructions) of thirty-one acute traumatic fractures of the thoracolumbar spine were presented to nineteen observers, all trained spine surgeons, who classified the fractures according to both the AO and the Denis classification systems. Three months later, the images of the thirty-one fractures were scrambled into a different order, and the observers repeated the classification. The Cohen kappa (κ) test was used to determine interobserver and intraobserver agreement, which was measured with regard to the three basic classifications in the AO system (types A, B, and C) as well as the nine subtypes of that system. We also measured the agreement with regard to the four basic types in the Denis classification (compression, burst, seat-belt, and fracture-dislocation) and with regard to the sixteen subtypes of that system. Results: The AO classification was fairly reproducible, with an average kappa of 0.475 (range, 0.389 to 0.598) for the agreement regarding the assignment of the three types and an average kappa of 0.537 for the agreement regarding the nine subtypes. The average kappa for the agreement regarding the assignment of the four Denis fracture types was 0.606 (range, 0.395 to 0.702), and it was 0.173 for agreement regarding the sixteen subtypes. The intraobserver agreement (repeatability) was 82% and 79% for the AO and Denis types, respectively, and 67% and 56%, for the AO and Denis subtypes, respectively. Conclusions: Both the Denis and the AO system for the classification of spine fractures had only moderate reliability and repeatability. The tendency for well-trained spine surgeons to classify the same fracture differently on repeat testing is a matter of some concern.

Pedicle fracture of the axis: report of two cases and a review of literature

Clinical and neuroradiological features of two cases with unilateral pedicle fractures of C2 were presented and the literature of this rare traumatic fracture was reviewed. Both 37- and 57-year-old woman had traffic accident and were admitted in our institute. Both patients were neurologically free except for neck pain. Plain X-ray of cervical spine did not show abnormal findings. Computerized tomography (CT) with bone window showed the location and extension of the traumatic fracture in C2 pedicle. The fracture was located in the portion between the lateral border of the odontoid process and pars interarticularis. Fractures of the C2 pedicle are rarely seen in acute traumatic fractures. They can be overlooked because there is confusion in the describing of anatomical location of C2 pedicle in some medical literature. For proper diagnosis of pedicle fracture of the axis, understanding of the anatomy of C2 and CT findings with bone window are important.

Single shot fast spin echo diffusion-weighted MR imaging of the spine: Is it useful in differentiating malignant metastatic tumor infiltration from benign fracture edema?

Purpose This study aims to evaluate the usefulness of single shot fast spin echo diffusion-weighted MR imaging (DWSSFSE) in differentiating malignant metastatic tumor infiltration of vertebral bone marrow from benign vertebral fracture edema. Materials and methods Forty-six consecutive patients with 59 acute osteoporotic or traumatic vertebral fractures (mean age=59) and 31 patients with 98 vertebral metastasis including 20 pathologic fractures (mean age=53) were included in this study. Diffusion-weighted MR images were obtained by single-shot fast spin echo technique with diffusion gradient ( b=500 s/mm 2, TR/TE: 5002/99) by using a 1.5 T MR scanner (Signa MR/i; GE Medical Systems, Milwaukee, WI, USA). T1- and T2-weighted images and short inversion time inversion-recovery (STIR) images were available in all 157 lesions, while contrast-enhanced images were available in 98 metastatic lesions. We evaluated signal intensity patterns on DWSSFSE in 157 lesions, which showed low signal intensity on T1-weighted images in both benign fractures and metastasis. The lesions on DWSSFSE were categorized as low, intermediate, and high signal intensity relative to presumed normal vertebra by concordant inspection of two experienced musculoskeletal radiologists. Results In benign fractures, DWSSFSE images showed low signal intensity in 56 vertebrae (95%) in 43 patients (93%) and intermediate signal intensity in only 3 vertebrae (5%) in 3 patients (7%). On the other hand, metastases most commonly had low signal intensity in 57 vertebrae (58%) in 25 patients (80%), intermediate signal intensity in 35 vertebrae (36%) in 16 patients (52%), and high signal intensity in 6 vertebrae (6%) in 3 patients (10%). Thus, intermediate and high signal intensities are far more common than benign fractures. Such differences in signal intensity were statistically significant (chi-square test, P<.05). High or intermediate signal intensity on DWSSFSE was highly specific for the diagnosis of metastatic tumor infiltration of the spine (sensitivity: 42%; specificity: 95%; true positive rate: 93%; false negative rate: 52%). Conclusions DWSSFSE of the spine may be useful in differentiating metastatic tumor infiltration of vertebral bone marrow from benign fracture edema.

Diagnostic value of three-dimensional reconstruction in CT of traumatic spinal fractures

Evaluation of the diagnostic value of three-dimensional CT-reconstruction in the pre-operative evaluation of traumatic fractures of the spine, compared with axial slices and two-dimensional reconstruction. The CT image data of 65 patients with 85 different acute traumatic spine fractures (C 2 through L 5) were collected in a period of 42 months. Retrospectively performed 2D- and 3D-reconstructions were analyzed independently by three CT-experienced readers using the Magerl classification and the readings compared with intraoperative findings or the final diagnoses. The fractures were classified according to the AO-classification as 56 compression, 16 distraction and 13 rotation fractures. Axial slices alone incorrectly classified 2 (1.2 %) of 168 (56 fractures x 3 readers) type A fractures. The CT classification was incorrect in 17 (35.4 %) of 48 (16 fractures x 3 readers) type B fractures and in 31 (79.5 %) of 39 (13 fractures x 3 readers) type C fractures. The 2D-reconstruction increased the percentage of incorrect diagnoses to 13 (7.7 %) type A, to 26 (54.2 %) type B and to 27 (69.2 %) type C fractures. The 3D-mode incorrectly classified 2 of 168 type A fractures (1.2 %), 6 of 48 type B fractures (12.5 %), and 1 of 39 type C fractures (2.6 %). The axial mode was superior to the 2D-reconstructions in type A and type B fractures, but inferior in type C fractures. The percentage of correctly classified type B fractures was significantly higher (p < 0.05) with 3D-reconstruction than with the 2D-mode. In type C fractures, this percentage was significantly higher (p < 0.001) with the 3D-mode than with axial slices or 2D-reconstruction. The interactive monitor analysis of the 3D-reconstructions with additional virtual cutting by the reader improved the analysis, especially the evaluation of the spinal canal. The 3D-reconstruction in traumatic spine fractures significantly improves the diagnostic outcome, especially the visualization and classification of rotation fractures. Its disadvantages are a slight increase in artifacts and impaired visualization of small details. Interactive monitor analysis and post-processing of the 3D-mode proved to be advantageous.

Short tau inversion recovery and three-point Dixon water-fat separation sequences in acute traumatic bone fractures at open 0.35 tesla MRI.

Fat suppression can be used to improve the diagnostic confidence in traumatic bone fractures of the extremities. We compared a three-point Dixon "sandwich" water-fat separation (WFS) sequence, resulting in a water-only and a fat-only image set after one excitation, with the STIR sequence on an open 0.35 T superconductive MR system. T1-weighted, STIR (2000/40 [TR/TE]), and WFS (2000/36 [TR/TE]) MR images were prospectively obtained in 27 patients with 40 radiologically diagnosed fractures immediately after first-line treatment. Signal-to-noise (S/N) ratio, contrast-to-noise (C/N) ratio, and bone marrow edema volumes were measured together with qualitative parameters (four-point scale). WFS was significantly superior to STIR in all quantitative parameters (better S/N ratio, P<0.001; better C/N ratio, P<0.001; larger marrow edema, P <0.023; Wilcoxon signed rank test). Visibility of bone marrow edema, visibility of fracture line, and preservation of anatomical details were better with the WFS sequence ( P<0.001, P<0.001, P<0.001, respectively; ANOVA). Fat saturation was rated more homogeneous, however, with the STIR sequence (not significant; P<0.101). On the basis of qualitative and quantitative assessments, the three-point Dixon "sandwich" water-fat separation sequence was consistently superior to the STIR sequence in the delineation of traumatic fractures.