Base Fractures Research Articles

Imaging characteristics and treatment strategies for carotid artery occlusion caused by skull base fracture.

The internal carotid artery occlusion caused by head and neck trauma, also known as traumatic intracranial artery occlusion, is relatively rare clinically. Traumatic skull base fracture is a common complication of traumatic brain injury. Traumatic skull base fracture is one of the causes of traumatic internal carotid artery occlusion. If not detected early and treated in time, the prognosis of patients is poor. This editorial makes a relevant analysis of this disease.

Predicting Progressive Hemorrhagic Injury Following Traumatic Brain Injury by the Evaluation of D-Dimer/Fibrinogen Ratio

Abstract Background Prognosis of traumatic brain injury (TBI) significantly depends on the incidence of progressive hemorrhagic injury (PHI). The present study was conducted to assess whether D-dimer/fibrinogen ratio can predict PHI among the patients with TBI. Materials and Methods A total of 150 patients were included in this retrospective study; among them 72 had PHI and 78 did not have PHI. Demographic, clinical, radiological, and laboratory parameters including plasma D-dimer and plasma fibrinogen levels and subsequently D-dimer/fibrinogen ratio were evaluated. Independent t-test, Mann–Whitney U test, chi-square test, Fisher's exact test, and multivariate logistic regression were used for statistical analysis. Results Age, injury time, first computed tomography time, Glasgow Coma Scale scores, unreactive pupils, abnormal cisterns, midline shift above 5 mm, skull base fracture, epidural hematoma, subdural hematoma, intraventricular hemorrhage, cerebral hematoma, brain contusion, plasma D-dimer concentration, plasma fibrinogen concentration, and D-dimer/fibrinogen ratio vary significantly between PHI and non-PHI groups (p < 0.05). Multivariate logistic regression showed that the Glasgow Coma Scale score (odds ratio [OR], 0.531; 95% confidence interval [CI], 0.436–0.648; p = 0.004) and D-dimer/fibrinogen ratio (OR, 3.784; 95% CI, 2.086–6.867; p = 0.027) were the two independent predictors for PHI. Conclusion D-dimer/fibrinogen ratio is a useful parameter in predicting the incidence of PHI among the patients with TBI.

Stress-strain state of dental immediate prosthesis and associated tissue under the influence of external force

Purpose: to analyze the stress-strain state (SSS) of a removable plate immediate denture with a printed dentition made of polymethyl methacrylate (PMMA) and a polyethylene terephthalate (PET) base under multifactor loading conditions based on the principles of mathematical modeling. Materials and methods: For mathematical modeling of SSS, Comsol Multiphysics 5.6 software (Comsol Inc., USA) was used, which provided numerical data for analytical interpretation. We considered a flat 2D model consisting of a printed monolithic dentition and a PMMA bonding layer, a PET base, the mucous membrane of the prosthetic field and jaw bone tissue. Results: The fields of von Mises stresses (VM) and deformations under the influence of normal, oblique and tangential loads (up to 500 N), the localization of their maximum values and the average value inside the prosthetic structure, mucous membrane and bone tissue were determined. The maximum values of VM in the mucous membrane are compared with the pain threshold based on known literature data on algesiometry of the oral mucosa. An assessment was made of the critical length of microcracks (CLM) according to Griffiths, which lead to the formation of a main crack followed by brittle fracture of the structure base. Using the phase field method, the probability of crack formation in the considered model of an orthopedic structure under the influence of static loads of various magnitudes and directions was calculated. Conclusions: Using the method of mathematical modeling of SSS, it was shown that failures when using immediate dentures with printed teeth made of PMMA and a PET base can be caused by the effect of overloading the areas of the base and caused by the deformation process inside the prosthetic structure. The maximum stress in the prosthetic elements was 79.7 MPa and deformation – 0.47 mm. The pain threshold of the oral mucosa is higher than the highest stress value in the prosthetic bed according to Mises (0.002 MPa) for normal load of 500 N. The SSS heterogeneity coefficient of the removable plate immediate prosthesis model is 8.6. The critical length of a microcrack according to Griffiths is lcrit = 1.9...2.7 µm. Using the Comsol Multiphysics phase field method, it was established that the probability of the formation of a large crack in the base of the prosthesis was 6·10–3 %, 0.36 %,0.73 % for a normal, inclined and shear load of 500 N, which is a sufficient value for the operation of removable laminar dentures with printed teeth from PMMA and a PET base during the warranty period.

Non-operative treatment of metacarpal fractures and patient-reported outcomes: a multicentre snapshot study

Abstract Purpose This study aimed to investigate practice variation in non-operative treatment methods and immobilisation duration for metacarpal fractures, and to evaluate patient-reported outcomes. Methods Conducted in 12 Dutch hospitals over three months in 2020, this study included adult patients with non-operatively treated solitary metacarpal fractures. Fractures were classified into intra-articular base, extra-articular base, shaft, neck, and intra-articular head fractures. The treatment methods (functional treatment allowing digit mobilisation or immobilisation) and immobilisation duration were assessed. Patient-reported outcomes were evaluated using the Michigan Hand Outcomes Questionnaire (MHQ) at three months post-trauma. Results Of 389 included patients, shaft fractures were most common (n = 150, 39%), with 93% immobilised, followed by fifth metacarpal neck fractures (n = 93, 24%), with 75% immobilised. Immobilisation rates for fifth metacarpal neck fractures varied between hospitals, ranging from 29% (95% CI 0.10–0.58) to 100% (95% CI 0.78–1.00). The median immobilisation duration for all fractures was 23 days (IQR: 20–28), and hospital setting was independently associated with this duration. Patients with metacarpal shaft fractures immobilised for less than 21 days had higher MHQ scores compared to those immobilised for 21 days or more (median (IQR) 83 (76–100) versus 71 (57–89), p = 0.026). Conclusions The results showed practice variation in the treatment of metacarpal fractures, especially in the treatment of fifth MC neck fractures, with some hospitals following the Dutch guideline that advocates functional treatment while others did not. There are suggestions that prolonged immobilisation of metacarpal shaft fractures may lead to a worse MHQ score. These findings underscore the need for adherence to treatment protocols and emphasize functional treatment to potentially improve patient outcomes and cost-effectiveness.

Analysis of moderate and severe traumatic brain injury associated with skull base fracture: a local tertiary center experience

BackgroundTraumatic brain injury (TBI) is a major medical and social concern in developing countries. TBI-related morbidity and mortality statistics in Egypt are lacking and do not reflect the actual magnitude of the problem.ObjectivesTo overview the incidence of moderate and severe head trauma in a heavily populated developing country and document the outcome of moderate and severe TBI associated with skull base fracture (SBF).MethodologyData of patients admitted to our center with moderate and severe TBI associated with skull base fracture (SBF) were reviewed in the period between January 2019 and March 2023.ResultsThe most common type of trauma was road traffic accidents in 54.2% of the patients; 91.2% had Single SBF (middle cranial fossa fracture was predominant 58.5%). 25.5% had an initial GCS of ≤ 8. Periorbital ecchymosis was the most common presenting sign in 36.3%. The most frequent complication (37.3%) was pneumocephalus. The presence of skull base fracture inversely affected the Glasgow outcome scale extended GOSE (P = 0.001, r = 0.674). Higher initial GCS scores were positively correlated with good GOSE (GOSE) (P = 0.001, r =− 0.222).ConclusionsRTA represents a significant cause for moderate and severe TBI in young male population. SBF is associated with poor outcome in moderate and severe TBI. Higher initial GCS score was positively correlated with good GOSE. It is important to have an overview of different types of TBI in Egypt.

Operative versus non-operative treatment of ulnar styloid process base fractures: a systematic review and meta-analysis.

Ulnar styloid process (USP) fractures are present in 40-65% of all distal radius fractures (DRFs). USP base fractures can be associated with distal radioulnar joint (DRUJ) instability and ulnar sided wrist pain and are treated by conservative management and surgical fixation, without consensus. This systematic review and meta-analysis compares operative to non-operative treatment of concomitant ulnar styloid base fractures in patients with distal radius fractures. PubMed/Medline/Embase/CENTRAL databases were searched identifying RCTs and comparative observational studies. Effect estimates were extracted and pooled using random effect models to account for heterogeneity across studies. Results were presented as (standardized) mean differences (SMD or MD) or odds ratios (OR) and corresponding 95% confidence intervals (95%CI). Two RCTs (161 patients) and three observational studies (175 patients) were included. Tension band wiring was used for surgically treated USP fractures. Results were comparable across the different study designs and hence pooled across studies. Non-surgically treated patients had better wrist function at 6months (SMD 0.57, 95%CI 0.30; 0.90, I2 = 0%). After 12months there was no observed difference (MD 2.31, 95%CI -2.57; 7.19, I2 = 91%). Fewer patients had USP non-unions in the operative group (OR 0.08, 95%CI 0.04; 0.18, I2 = 0%). More patients suffered complications in the operative group (OR 14.3; 95%CI 1.08; 188, I2 = 89%). Routinely fixating USP base fractures as standard of care is not indicated. Surgery may be considered in selective cases (e.g. persistent DRUJ instability during ballottement test after fixation of the radius).

Traumatic encephalocele in the nasal cavity after 6 years of trauma: a case report

BackgroundEncephalocele refers to protrusion of the meninges and brain tissue through a skull bone defect. It results from congenital, traumatic, neoplastic, or spontaneous reasons. Traumatic encephalocele occurs because of the posttraumatic fracture of the skull bone or iatrogenic causes. The manifestations vary a lot, such as rhinorrhea, seizures, headaches, and focal neurological deficits.Case presentationA 20-year-old Syrian male presented to our department with the complaint of clear cerebrospinal fluid drainage from his right nostril, which started 6 years ago after a head trauma, moderate headache, and episodes of tonic–clonic seizures without any response to medical treatment. Then, 2 months ago, the patient had meningoencephalitis, so he was admitted to the intensive care unit and treated for a month until he was cured. The patient underwent radiological investigations, which showed that he had a base fracture with an encephalocele in the nasal cavity. The brain tissues with the meninges herniated through the skull base fracture with a significant expansion of the subarachnoid spaces in the right hemisphere. He was advised to undergo surgical repair at that time, but he refused the surgery. During this visit, surgery was indicated. The surgery was done by a specialist who returned the herniated brain tissues to their normal location, repaired the meninges, and reconstructed the skull base with bone cement and bio-glue. The patient’s recovery after the surgery was uneventful.ConclusionTraumatic encephalocele is a rare and unexpected complication of trauma, but we should keep it in mind when the patient comes with head trauma because of its life-threatening consequences. This complication can happen after years of trauma if the patient refuses treatment, therefore, we must educate patients about the dangerous results of neglecting cerebrospinal fluid leakage and skull fractures.

Effect of patient age on fifth metatarsal fracture pattern, management, and outcomes

Patients with 5th metatarsal (MT) fractures encompass a broad age distribution. This study evaluated the impact of age on the differences in clinical outcomes and management of these fractures. This was a retrospective cohort study of patients presenting to a single large, urban, academic hospital system with a 5th MT fracture over a 10-year period. Patients were stratified into groups of younger than 65 years old and equal to or greater than 65 years old. Initial and successive radiographs were reviewed, and fractures were categorized as Zone 1, Zone 2, Zone 3, Shaft, Neck, or Head fractures. 2,461 patients with 5th MT fractures were evaluated. Patients who did not follow up after initial evaluation in the emergency department or urgent care were excluded. Among 2,020 patients with mean follow-up of 1.03 years who met inclusion criteria, 76.2% were younger than 65 years and 23.8% were greater than or equal to 65 years. There was a significant difference in fracture type between groups as older patients were more likely to sustain metatarsal neck fractures but less likely to sustain Zone 1 base fractures (p < 0.05). There was no difference in time to clinical healing (p = 0.108) or time to radiographic union (p = 0.367) for all fractures between age groups. In conclusion, older patients sustain different 5th metatarsal fracture patterns compared to younger patients. However, despite the differences in age, there was no evidence for any difference in clinical and radiographic outcomes between groups.

Early Treatment of Cerebrospinal Fluid Leakage After Traumatic Injury Using Pedicled Autologous Fascia Flap.

This study aims to investigate the efficacy of early intervention in cerebrospinal fluid leakage following traumatic brain injury through the utilization of pedicled autologous fascia flaps. A retrospective case series, spanning from May 2021 to May 2022, analyzed 8 traumatic brain injury cases with concomitant cerebrospinal fluid leakage. Each patient underwent simultaneous brain surgery and transcranial repair of the cerebrospinal fluid leak, employing a pedicled autologous fascia flap. Clinical and imaging data were comprehensively recorded throughout the entire duration of the cases, and patient follow-ups were conducted through outpatient visits and telephone consultations. The study comprised 8 enrolled patients, consisting of 7 males and 1 female, all of whom sustained injuries from traffic accidents. The mean age ranged from 17 to 55 years. Among the patients, three presented with acute epidural hematoma, three with simple concave fractures, and 2 with concave fractures accompanied by brain contusion. Frontal sinus fractures were observed in all cases. All surgical interventions were successful, with no instances of cerebrospinal fluid leakage postoperatively. In addition, none of the patients developed intracranial infections. At the conclusion of the follow-up period, recurrent cerebrospinal fluid leakage was not observed in any of the patients. In cases where surgical intervention is necessary for cerebrospinal fluid leakage resulting from anterior cranial base fractures, the application of pedicled autologous fascia flaps in the acute stage proves effective in repairing leaks at the anterior cranial base. This approach may contribute to a reduction in the incidence of intracranial infections, ultimately yielding satisfactory patient recovery.

Traumatic Brain Injury in Admitted Patients with Ocular Trauma

To characterize the epidemiology of simultaneous traumatic brain injury (TBI) and ocular trauma. In this retrospective, observational study, de-identified data from patients admitted with ocular trauma and TBI was extracted from the National Trauma Data Bank (2008-2014) using International Classification of Diseases 9th Revision, Clinical Modification diagnostic codes and E-codes relating to injury circumstances. Mechanisms, types of ocular and head injuries, intention, and demographic distribution were determined. Association of variables was calculated with Student’s t and chi-squared tests and logistic regression analysis. Of 316,485 patients admitted with ocular trauma, 184,124 (58.2%) also had TBI. The mean (standard deviation [SD]) age was 41.8 (23) years. Most were males (69.8%). Race/ethnicity distribution was 68.5% white, 13.3% black, and 11.4% Hispanic patients. The mean (SD) Glasgow Coma Score (GCS) was 12.4 (4.4) and Injury Severity Score (ISS) was 17 (10.6). Frequent injuries were orbital fractures (49.3%) and eye/adnexa contusions (38.3%). Common mechanisms were falls (27.7%) and motor vehicle-occupant (22.6%). Firearm-related trauma (5.2%) had the greatest odds of very severe injury (ISS >24) (odds ratio [OR]: 4.29; p<0.001) and severe TBI (GCS <8) (OR: 5.38; p<0.001). Assault injuries were associated with the greatest odds of mild TBI (OR: 1.36; p<0.001) and self-inflicted injuries with severe TBI (OR: 8.06; p<0.001). Eye/adnexal contusions were most associated with mild TBI (OR: 1.25; p<0.001). Optic nerve/visual pathway injuries had greater odds of severe TBI (OR: 2.91; p<0.001) and mortality (OR: 2.27; p<0.001) than other injuries. Of associated head injuries, the odds of severe TBI were greatest with skull base fractures (OR: 4.07; p<0.001) and mortality with intracerebral hemorrhages (OR: 4.28; p<0.001). Mortality occurred in 5.9% of patients. TBI occurred in nearly two-thirds of ocular trauma admissions. The mortality rate was low with implications for challenging rehabilitation and long-term disability in survivors.

Impacts of Downed Dead Wood Poplar Trees on Forest Regeneration in the Semi-Arid Region of Northern China

In the past few decades, due to rising temperatures and changes in precipitation, the degree of drought in semi-arid areas has increased, leading to a large number of tree deaths and threatening the natural forests distributed in the semi-arid areas of North China. This article takes the forest ecosystem of Saihanwula Nature Reserve in the southern section of Greater Khingan Mountains in China’s semi-arid region as a research area and studies the distribution of downed dead wood and its impact on forest renewal in the area. We used the sample plot survey method, investigated the number of downed dead wood, decay class, dumping direction, existence form, and the number of regenerated seedlings in the sample plot, and calculated the density of regenerated seedlings in different plots. The renewal density is 4050 ± 824, 2950 ± 265, plants/ha, and 2625 ± 237 plants/ha, respectively, in the sample plots for Later-death plot, Mid-death plot, and Early-death plot. The average storage of downed dead wood in Saihanwula Nature Reserve is 58.51 ± 16.56 m3/ha. The distribution densities of downed dead wood are 50 ± 21, 806 ± 198, 189 ± 76, and 22 ± 5 plants/ha for decay classes II, III, IV, and V respectively. The main form of downed dead wood in the research area is “trunk base fracture”, accounting for 68.78% of the total number of downed dead wood. A large number of downed dead wood had serious negative effects, such as crushing and injuring the regeneration seedlings and other plants under the forest at the moment of dumping and for a long time after dumping. The crushed and injured rate is 5.3~7.8%, with downed dead wood accumulated in the forest from the early stage of downed dead wood. It had negative effects on the regeneration of seeds, seedlings, and young trees, such as obstructing and hiding the light from the soil surface and inhibiting the regeneration and growth of seedlings. However, after the trees were dumped, large gaps appeared in the forest, increasing the sunlight area on the soil surface. In the later stage of tree death, moderately high decayed downed dead wood changed the soil structure in terms of soil softness, water holding capacity, and nutrient content, thus promoting the growth of seedlings and young trees. Reasonably utilizing the relationship between downed dead wood and forest renewal can effectively promote the healthy development of forests.

Arthroscopic reduction and hollow screw internal fixation for Eyres Type IIIA scapular coracoid fracture: a case report

BackgroundA coracoid process fracture combined with an acromioclavicular (AC) joint dislocation is an uncommon injury that typically causes significant pain and limits shoulder movement. Open reduction and internal fixation have been the traditional treatment approach. However, arthroscopic techniques are emerging as a promising alternative for managing these injuries.Case representationA 35-year-old woman presented with right shoulder pain following an accidental fall. Imaging studies revealed a coracoid process fracture along with an AC joint dislocation. The fracture was classified as an Eyres Type IIIA, which warranted surgical intervention. Our team performed arthroscopic coracoid fracture reduction and internal fixation surgery, as well as AC joint dislocation repair using Kirschner wires. Six months after surgery, the patient demonstrated a satisfactory functional outcome with complete bone healing.ConclusionThis case report highlights the potential of arthroscopic reduction and fixation as a novel treatment option for fractures of the coracoid base.

Comparative study of short-term effectiveness of three surgical methods for ulnar styloid base fracture complicated with triangular fibrocartilage complex injury

To compare the short-term effectiveness of arthroscopic suture of triangular fibrocartilage complex (TFCC), arthroscopic suture of TFCC combined with open reduction and internal fixation, and simple open reduction and internal fixation in the treatment of distal radius fractures combined with ulnar styloid base fractures and TFCC injury. A clinical data of 97 patients with distal radius fractures combined with ulnar styloid base fracture and TFCC injury, who were admitted between September 2019 and September 2022 and met the selective criteria, was retrospectively analyzed. After reduction and internal fixation of distal radius fractures, 37 cases underwent arthroscopic suture of TFCC (TFCC group), 31 cases underwent arthroscopic suture of TFCC combined with open reduction and internal fixation of ulnar styloid base fractures (combination group), and 29 cases underwent simple open reduction and internal fixation of ulnar styloid base fractures (internal fixation group). There was no significant difference in baseline data between groups ( P>0.05), such as gender, age, injury side, time from injury to operation, and preoperative radius height, palm inclination, ulnar deviation, grip strength, wrist range of motion (ROM) in rotation, ulnar-radial deviation, and flexion-extension. The differences (change value) in radius height, metacarpal inclination angle, ulnar deviation angle, grip strength, and wrist ROM in rotation, ulnar-radial deviation, and flexion-extension between preoperative and 12 months after operation in 3 groups were compared. The effectiveness was evaluated according to the modified Gartland-Werley score at 12 months after operation. All incisions healed by first intention. All patients were followed up 12-18 months (mean, 14 months). X-ray films showed that there were 4 patients with non-union of ulnar styloid base fracture in TFCC group, and the remaining patients had fracture healing at 3 months after operation. The radius height, palm inclination, and ulnar deviation of 3 groups at 12 months after operation were significantly better than those before operation ( P<0.05); however, the differences in the change values of the above indexes between groups was not significant ( P>0.05). At 12 months after operation, the change values of wrist ROM in rotation, ulnar-radial deviation, and flexion-extension in the TFCC group and the combination group were significantly greater than those in the internal fixation group ( P<0.05), and there was no significant difference between the TFCC group and the combination group ( P>0.05). The change values of grip strength was significantly greater in the combination group than in the internal fixation group ( P<0.05); there was no significant difference between the other groups ( P>0.05). The excellent and good rates according to the modified Gartland-Werley score were 91.89% (34/37), 93.54% (29/31), and 72.41% (21/29) in the TFCC group, the combination group, and the internal fixation group, respectively. The excellent and good rates of the TFCC group and the combination group were significantly higher than that of the internal fixation group ( P<0.05); there was no significant difference between the TFCC group and the combination group ( P>0.05). For ulnar styloid base fractures with TFCC injury, compared with simple open reduction and internal fixation, arthroscopic suture of TFCC or suture TFCC combined with internal fixation treatment are both beneficial for wrist function recovery, and their short-term effectiveness are similar. Therefore, arthroscopic suture of TFCC may be a better choice.

Pediatric Facial Fractures: A Multi-Institutional Level 1 Trauma Center Analysis of Incidence, Interventions, and Outcomes

Study Design Retrospective chart review. Objective The management of pediatric facial fractures presents distinctive considerations compared to adults. This study aims to provide a unique perspective on the correlations between the mechanism of injury, types of facial fractures, and fracture interventions and management utilized in 2 North Carolina Level 1 Trauma Centers to determine the optimal management options for this patient population. Methods An IRB-approved retrospective chart review was performed of pediatric facial trauma patients ages &lt;18 years old between January 2020 and December 2022 at Atrium Health Wake Forest Baptist Medical Center and Atrium Health Charlotte Medical Center. Data on patient demographics, mechanism of injury, facial fractures, interventions, and outcomes were collected. Results Of 2,977 pediatric facial trauma patients, 582 patients sustained at least 1 facial fracture at the time of injury. Adolescents were significantly less likely to be transferred from outside institutions and to be admitted for further care ( P = 0.002). Adolescents experienced higher levels of residual symptoms following initial discharge ( P = 0.001) and were less likely to have a symptom resolution within 1 year ( P &lt; 0.0001). Neonates and infants were significantly more likely to receive conservative interventions and to sustain calvarium and skull base fractures ( P &lt; 0.0001). Conclusions This study identifies differences in pediatric age groups related to transfers, admittance, fracture type, management, and outcomes. Our data suggests adolescent patients may experience a higher incidence of residual symptoms with lower levels of symptom resolution within 1 year. Further investigation into these differences may elicit optimized methods of fracture management in pediatric age groups and allow for effective, individualized care with improved long-term outcomes.

Open vs. closed reduction with pinning for displaced Rockwood and Wilkins' type C thumb metacarpal base fractures in children.

The treatment of severely displaced Rockwood and Wilkins' type C (RWC) thumb metacarpal basal fractures remains controversial in children. This retrospective study aimed to compare the efficacy of two treatment methods, open vs. closed reduction with pinning of such injuries. This study included 30 patients with open physes, 14 boys and 16 girls, who all received either closed or open reduction treatment. The primary outcomes of interest included healing time, complications, and functional results, which were evaluated using the improved Mayo score standard. The minimum follow-up period was 24 months, with a mean of 30.3 months (range 24.0-45.0 months). Statistical significant was defined as P < 0.05. All fractures were healed within 7 weeks after surgery, regardless of which surgical approach was used. However, the recovery time was markedly faster in the closed group, with a mean of 4.2 weeks, than in the open group, with a mean of 4.7 weeks (P < 0.05). The operation time for closed group, taking 20 min in average, was also shorter than that for open group (P < 0.05). The total incidence of mild complications was lower for patients in the closed group than for patients in the open group (6.3% vs. 21.4%, P < 0.05). No major complications were observed in either group. In the closed group, a total of 15 patients exhibited excellent outcomes, while only one patient demonstrated good outcomes. On the other hand, in the open group, 12 patients experienced excellent outcomes, whereas two patients had good outcomes. There were no instances of osteomyelitis, refractures or nonunion, avascular necrosis (AVN), or premature physeal closure in either group. The data from the open group and closed group procedures for severely shifted RWC fractures in children indicate comparable prognoses and complication rates between the two groups. Obviously closed reduction, in particular, offers several advantages over open procedure, including shorter surgical duration, fewer K-wires required, and no need for open incisions. Consequently, closed reduction is the preferred method for treating such RWC fractures.

In Vitro Biomechanical Study of Femoral Neck Fracture Fixation with Two or Three Cannulated Screws in Dogs.

To evaluate the in vitro mechanical properties of basilar fractures of the femoral neck stabilized with two or three titanium-cannulated screws in dogs. Ex vivo study. Cadaveric canine femur (n = 21). The bones were divided as follows: Group 1: control (no osteotomy); Group 2: osteotomy and stabilization with two cannulated screws; and Group 3: osteotomy and stabilization with three cannulated screws. All groups were tested with destructive axial compression with load applied to the femoral head. The stiffness, load, and displacement were evaluated at the failure of Group 1, and the yield load and displacement of Groups 2 and 3. The placement of the three cannulated screws was more demanding than two cannulated screws because of the risk of cortical perforation, especially in the trochanteric fossa area. The smaller the width of the femoral neck, the higher the risk of cortical bone wall perforation. The intact control bones were stiffer (674 N/mm) than both the two-screw repair (90 N/mm) and three-screw repair (120 N/mm) groups (p < 0.05). The failure load was greatest for Group 1 (2692 N). The yield loads for Groups 3 and 2 were 586 and 303 N, respectively. There was no difference between groups for displacement. In vitro cadaveric models of femoral neck basilar fractures repaired with three cannulated screws were significantly stronger than two cannulated screws, but the clinical efficacy must be evaluated by comparing them in vitro with noncannulated stainless steel screws.

Pediatric Foot: Development, Variants, and Related Pathology.

Pediatric foot development throughout childhood and adolescence can present a diagnostic dilemma for radiologists because imaging appearances may be confused with pathology. Understanding pediatric foot development and anatomical variants, such as accessory ossification centers, is essential to interpret musculoskeletal imaging in children correctly, particularly because many of these variants are incidental but others can be symptomatic. We first briefly review foot embryology. After describing common accessory ossification centers of the foot, we explain the different patterns of foot maturation with attention to irregular ossification and bone marrow development. Common pediatric foot variants and pathology are described, such as tarsal coalitions and fifth metatarsal base fractures. We also discuss pediatric foot alignment and various childhood foot alignment deformities.

Anterior Versus Lateral Skull Base Fractures: Differences in Hospital Course and Need for Surgery

Background: Skull base fracture management depends on location, severity, and can range from observation to surgical intervention. A comparison between the different locations of skull base fractures, namely anterior versus lateral, with regards to hospital length of stay (LOS), need for intensive care, and surgery has not been studied. Methods: Patients with skull base fractures between 2012 and 2019 were reviewed. Demographics and inpatient events were collected. Multivariate logistic and linear regressions evaluated the association between fracture location, multiple traumas, loss of consciousness, and mechanism of injury with hospital course and sequalae. Results: There were 134 patients (74.6% male) with skull base fractures (67 anterior and 67 lateral), with an average age of 44.2 years. The mechanism of injury was more likely to be MVCs in anterior fractures and falls in lateral fractures (MVC: 56.7% vs 34.3%; falls: 28.4% vs 44.8%, P = .03). Patients with anterior fractures were more likely to undergo any surgery ( P &lt; .002), and surgeries for facial fractures ( P &lt; .005), but less likely to need ICU care ( P = .01). When admitted, patients with anterior skull base fractures had longer ICU stays ( P = .03). They were also more likely to experience vision difficulties whereas patients with lateral fractures were more likely to experience hearing loss ( P = .02). Conclusion: Patients with lateral skull base fractures are more likely to require an ICU admission compared to anterior fractures, but anterior fractures are more likely to need surgery and have longer ICU stays when admitted. A better understanding of the expected hospital course for patients based on skull base fracture location can improve care-coordination, hospital resource management and patient counseling.

Neurotrauma and Cerebrospinal Fluid in Homer's Poems

AbstractHomer's Iliad, from the 8th century BC, remains the oldest record of Greek medicine and a unique source of surgical history. The Odyssey, also authored by Homer, narrates several medically significant events. Among the 148 war traumas described in the Iliad, over a quarter occurred in the craniocervical region. Studies on the Odyssey report at least 11 craniocervical traumas, 9 of which prove fatal. Is there any indication of the presence of cerebrospinal fluid (CSF) in the cases described by Homer, considering its last mention was 800 years prior in the Egyptian surgical papyrus of Edwin Smith? A passage in the Iliad suggests that the “tears” Homer mentions in the eyes of Eumelos, resulting from trauma, might be due to CSF oculorrhea secondary to a skull base fracture. In Odyssey Book IX, when the Cyclops strikes the heads of two sailors, and fluid and cranial contents emerge, it can be inferred that the poet was aware of fluid in the head (CSF), as there is no mention of blood. It is proposed that 800 years after the writing of the Edwin Smith papyrus, Homer probably provides the second human observation of CSF associated with traumatic situations involving direct head blows.

Non-operative management of metacarpal II-IV fractures: A retrospective study from a tertiary hand unit

Metacarpal fractures produce significant hand disability, and non-operative management of these fractures can produce satisfactory functional outcomes with few complications. However, most studies assessing non-operative outcomes of metacarpal fractures revolves around metacarpals I and V, which possess different anatomy. Therefore, further investigation into outcomes after non-operative treatment of metacarpals II-IV is required to inform management decisions and allow modification of the rehabilitation protocols to specific fracture patterns. All records for 76 non-operative patients presenting with fractures of metacarpals II-IV to our tertiary centre in the year 2019 were retrospectively reviewed. Patients were treated with thermoplastic splinting or fibreglass casting with a rehabilitative exercise programme. Range of motion (ROM) of the Metacarpophalangeal (MCPJ), Proximal Interphalangeal (PIPJ), and Distal Interphalangeal joints (DIPJ), return to work time, and complications were assessed at 12 weeks post-treatment. Mean return to work time was 5.4 weeks, and patients did not report any serious adverse events; the main complication reported was tenderness on palpation (20%). The MCPJ exhibited the poorest ROM (9° flexion reduction relative to the healthy hand). Metacarpal II fractures were associated with significantly worse MCPJ flexion than metacarpal III (p=0.022) and metacarpal IV (p=0.049) fractures. Fractures of the metacarpal base were associated with superior MCPJ flexion (p=0.004) but longer return to work time (p=0.042) than head fractures. Spiral fractures were associated with shorter return to work time (p=0.043) and superior ROM results (p=0.041). In conclusion, outcomes of the non-operative treatment of metacarpal II-IV fractures are highly dependent on the location and pattern of the fracture, and this should be considered during clinical decision making.