Base Fractures Research Articles

Prognostic factors and clinical nomogram for in-hospital mortality in traumatic brain injury

BackgroundTraumatic brain injury (TBI) is a major cause of death and functional disability in the general population. The nomogram is a clinical prediction tool that has been researched for a wide range of medical conditions. The purpose of this study was to identify prognostic factors associated with in-hospital mortality. The secondary objective was to develop a clinical nomogram for TBI patients' in-hospital mortality based on prognostic factors. MethodsA retrospective cohort study was conducted to analyze 14,075 TBI patients who were admitted to a tertiary hospital in southern Thailand. The total dataset was divided into the training and validation datasets. Several clinical characteristics and imaging findings were analyzed for in-hospital mortality in both univariate and multivariable analyses using the training dataset. Based on binary logistic regression, the nomogram was developed and internally validated using the final predictive model. Therefore, the predictive performances of the nomogram were estimated by the validation dataset. ResultsPrognostic factors associated with in-hospital mortality comprised age, hypotension, antiplatelet, Glasgow coma scale score, pupillary light reflex, basilar skull fracture, acute subdural hematoma, subarachnoid hemorrhage, midline shift, and basal cistern obliteration that were used for building nomogram. The predictive performance of the nomogram was estimated by the training dataset; the area under the receiver operating characteristic curve (AUC) was 0.981. In addition, the AUCs of bootstrapping and cross-validation methods were 0.980 and 0.981, respectively. For the temporal validation with an unseen dataset, the sensitivity, specificity, accuracy, and AUC of the nomogram were 0.90, 0.88, 0.88, and 0.89, respectively. ConclusionA nomogram developed from prognostic factors had excellent performance; thus, the tool had the potential to serve as a screening tool for prognostication in TBI patients. Furthermore, future research should involve geographic validation to examine the predictive performances of the clinical prediction tool.

Severe Traumatic Brain Injury Induced Coagulopathy in Pediatric: An Important Lesson with Literature Review

Children with coagulopathy had a greater mortality rate after moderate to severe traumatic brain injury (TBI). The purpose of the current study was to examine the most recent relevant literature in relation to the therapy of TIC in pediatric isolated severe TBI patients. A 5 years old boy presented to emergency department with decrease of consciousness after hit by a motorcycle. He was referred from the district hospital without proper stabilization within 3 hours after the injury. From the blood examination, hemoglobin level was 8.1 g/dl, base deficit -9.9mEq/L with PTT and aPTT no coagulation suggesting coagulopathy. Emergency non-contrast head computed tomography was performed and showed anterior skull base fracture with discontinuity in left squamous suture suggesting a diastases fracture with an air hypodensity lesion in left frontal area suggesting a pneumocephalus. There was also a hyperdense lesion with crescent shape in frontal and interhemispheric region suggesting subdural hematoma. Delayed operation for almost 6 hours was advocated due to transfusion of whole blood and fresh frozen plasma to correct coagulopathy. The operation was successful, the patient was survived but upon 2 years follow up, the patient still wasn’t able to perform normal daily activity. Localized injury at the brain manifesting in systemic coagulopathy requires special care. Several steps need to be evaluated before surgery but it should not delay the attempt of controlling the source of coagulopathy by it means lesion in the brain. Our case demonstrates the important of recognizing and managing coagulopathy in severe traumatic brain injury.

Suggestions for Introducing Some New Terms in Pelvic and Acetabular Surgery

Background. The rapid advancement of modern surgical methods for treating pelvic bone fractures has underscored the necessity for developing a new terminological framework. This is because the classical anatomical terminology of the pelvis no longer aligns with the demands of the therapeutic process and scientific research in this field. The traditional set of anatomical names and landmarks falls short in providing detailed descriptions of all intricacies of injuries when employing contemporary surgical techniques. The existing terminology system needs to catch up with the level of contemporary pelvic surgery, enabling a comprehensive and understandable characterization of existing pathology and the treatment being administered for all medical professionals.
 Purpose of the study was to create names for certain parts of the pelvic bones and their areas that currently lack specific designations and to propose the developed terms for professional discussion.
 Methods. A retrospective analysis was conducted on X-rays and computer tomography scans of patients with pelvic bone injuries, performed from 2020 to 2022. A list of potential new anatomical terms was compiled through a literature review.
 Results. In several cases, we encountered a deficiency of terms in diagnosing pelvic injuries and describing surgical procedures. New terms were developed to denote areas of the pelvis and their injuries, including the pubic bone base, vertical fractures of the pubic bone base, longitudinal fractures of the pubic bone base, incomplete rupture of the pubic symphysis, the base of the ilium, longitudinal fracture of the iliac base, fracture-subluxation and fracture-dislocation of the iliac base, calcar of the iliac bone, calcar spike, and the bone corridor.
 Conclusions. The incorporation of new anatomical terms into clinical practice will help enhance the precision of diagnosis and surgical planning in pelvic fractures. Standardizing the terminology will promote uniformity in approaches and knowledge sharing among specialists, ultimately improving the quality of surgical care for patients with pelvic injuries.

MENGUNGKAP PERISTIWA KEMATIAN KRIMINAL KASUS PEMBEKAPAN PERSPEKTIF MEDIKOLEGAL

Death is a definite thing in life that can be identified clinically in a person through observing the changes that occur in the corpse's body. The mechanism of death can be unnatural. In this case, wounds were found in the mouth, a form of mechanical smothering. Smothering can cause death, so it is an important reason to discuss and aims to reveal unnatural injuries and what events occurred. The examination method uses the principles of evidence based medicine. On external examination, bruises were found on the inner lips, both eyes (racoon eyes), left cheek, upper jaw, lower jaw, abrasions on the lips with teeth prints, and cheeks and several other bodies injuries. The lips, the tips of both fingers and the tips of the toes were bluish in color and bleeding spots were found on both inner eyelids. The conclusion of the external examination of the corpse showed that the wounds were unnatural and there were signs of strong pressure on the mouth and nose area which could cause suffocation and there were signs of cranial base trauma. These wounds were caused by blunt trauma Key words: Asphyxia, Cranial Base Fracture, smothering

Evaluation of Prosthetic Complications with Metal-Acrylic Resin Implant-Fixed Complete Dentures: A Medium- and Long-Term Retrospective Analysis with Up to 13 Years of Follow-up

To present prosthetic complications observed in the medium and long term in patients treated with metal-acrylic resin implant-supported fixed complete dentures (MAIFCDs). A total of 87 patients who were treated with MAIFCDs were included. Acrylic resin (denture teeth and base) fracture, screw loosening (prosthetic or abutment), screw (prosthetic or abutment), and framework fracture were analyzed for descriptive statistics. Product-limit survival estimates were used for the cumulative no-complication rate (CNCR) of prostheses. All results were assessed using α = .05. The average observation time was 42.9 months (range: 19 to 153). Of 597 implants, 8 mandibular (44.4%) and 10 maxillary implants (55.6%) failed. In total, 29 patients (33.3%) experienced no complications in an average of 7 years, and 58 patients (66.6%) experienced at least one complication. The average time for the first complication to occur was 23 months (range: 1 to 97 months). The average number of complications was 5.9/patient. Acrylic resin complications were the most frequent, followed by screw loosening, screw fracture, and framework fracture. Of those patients with complications, 9 (16%) had maxillary MAIFCDs with an average of 4 complications. In total, 28 patients (48%) had only mandibular MAIFCDs with an average of 5 complications, and 21 patients (36%) had both arches treated with MAIFCDs with an average of 9 complications. Mandibular MAIFCDPs in women had a higher CNCR compared to maxillary MAIFCDs of both women and men and when both arches of women were treated with MAIFCDs (P < .05). The CNCR of MAIFCDs differed depending on the arch treated and sex. Mandibular MAIFCDs in women had a lower complication rate than MAIFCDs in other arch-sex pairs. Acrylic resin related complications were commonly observed as well as prosthetic screw loosening.

Arthroscopic-Assisted Treatment of Bennett Fractures: A Potentially Advantageous Operative Procedure?

Articular fractures of the base of the first metacarpal (Bennett fractures) have been studied for years to determine the best method of reduction and fixation. This study aims to show the application of the percutaneous reduction and internal fixation technique with cannulated screws and arthroscopic assistance in articular fractures of the base of the first metacarpal. Descriptive cohort study in a series of 30 patients, the first cohort in our country and the largest series published so far, in which 8 patients presented with type 2A fracture and 19 patients with type 2B of the Torres-Becerra classification underwent the mentioned technique under direct vision and control of the articular reduction by arthroscopy evaluating the intraoperative characteristics of the articular surface, stability of de reduction and fixation. Assessment of functional and rehabilitation results with a minimum postoperative follow-up of 6 to 12 months. The senior author has used this technique with consistent clinical outcomes to improve reduction and fixation of intra-articular base fractures of first metacarpal bone (Bennett), reducing the articular step-off and gapping permitting an early rehabilitation progress with satisfactory functional results. We can suggest that this surgical method for the treatment of Bennett fractures may offer multiple advantages: adequate debridement of the trapeziometacarpal joint, direct visualization of the articular surface during reduction, achieving greater precision in fixation with minimum morbidity, imperceptible incisions and scars, shorter surgical time, and fewer associated complications.

How good is good enough? Lessons learned from review of outcomes of 50 patients following extraoral open reduction and internal fixation of condylar neck and base fractures at a regional major trauma centre

The management of mandibular fractures is routine owing to their frequency, particularly those of the mandibular condyle, which are invariably common. Notwithstanding disparities in the literature, the international consensus towards which fractures of the mandibular condyle benefit from open surgical intervention is almost universally accepted. Closed reduction or non-operative management may be utilised in certain circumstances. Whilst outcome research has addressed complications with respect to operative side effects, outcomes related to the quality of bone repair and the setting in which this is delivered have not been universally addressed. The aim of this study was to determine the predictability of translating an indicated operative treatment plan into an acceptable functional result. We evaluated the outcomes of 59 extracapsular condylar fractures in 50 patients who were treated by extraoral open reduction and internal fixation (ORIF) between March 2021 and August 2022. We reviewed demographic data, surgical approach, and plating strategy, and critically evaluated the clinical and radiological outcomes. Whilst we found that the quality of reduction was not universally perfect, the majority were within tolerance, which we set according to the Strasbourg Osteosynthesis Research Group (SORG) definition for minimal displacement (<2 mm overlap and 10° angulation). The cohort had good functional occlusion and minimal long-term postoperative complications. Two patients required re-operation for non-union, and we discuss causality in these cases. In conclusion, we found that ORIF of condylar neck and base fractures is predictable in real-time surgical practice with respect to functional outcome. However, if imperfectly reduced, there is a small risk of non-union.

Rehabilitation of a patient with single complete tooth supported overdenture against the unmodified natural dentition using functionally generated path technique – A Case Report

Meyer’s proposed chew-in technique also called functionally generated path (FGP) technique, is indicated for the restoration of an edentulous arch that is opposed by natural teeth as it does seem to provide the most accurate method of recording occlusal patterns, also help to minimize the effects of negative factors, and to overcome the deficiencies of articulators. As stated by Rudd and Morrow, this technique is especially suitable for tooth-supported complete dentures, due to inherent stability of tooth-supported record bases helps in recording jaw relationships accurately. Whenever a single complete denture is opposed by natural dentition, problems observed are abrasion of the artificial acrylic resin teeth and frequent fractures of resin denture base due to occlusal stresses. Hence this case report describes the single complete tooth supported overdenture with a metal-based denture and metal occlusal surfaces against unmodified natural dentition which has shown to achieve a good denture stability with occlusal harmony, and patient satisfaction.

Abstract 162: Indirect Carotid Cavernous Fistula with Oculomotor Nerve Palsy Secondary to Trauma

Introduction Intriguing and uncommon, we present a fascinating case of carotid‐cavernous fistula (CCF) following ocular trauma. Delving into medical nuances and outcomes, this reported case offers valuable insights for clinicians and researchers in the field of ophthalmology and interventional Neurology. Methods An elderly patient presented to the emergency department with diplopia and left eyelid ptosis two weeks after left ocular trauma. The patient had exotropia and hypotropia with restricted movement in all directions but mostly during adduction and infraduction which led to the diagnosis of oculomotor nerve palsy. Computer Tomography (CT) head was obtained which showed mild left proptosis with the prominence of the optic nerve sheath complex, CT angiography revealed asymmetric prominence of the left ophthalmic veins and enlarged left cavernous sinus with outward convex borders. CT face and mandible with IV contrast did not show any bony deformity. The patient underwent cerebral angiography that showed an indirect type 4 cavernous‐carotid fistula. Results A precise incidence of CCF fistula has not been reported so far in the literature but it is estimated to be present in 0.2 % of patients presenting with traumatic brain injury with an increased incidence of 4 % with basilar skull fractures. They can occur spontaneously or following closed skull injury, skull base fractures, or iatrogenically after craniotomies, endoscopic transsphenoidal or sinus surgery, and endovascular procedures. They can be classified based on angiographic arterial architecture (direct or indirect), hemodynamics (high flow or low flow), and etiology (spontaneous or traumatic). Type A are direct fistulas, whereas types B, C, and D are indirect fistulas. Direct CCFs often present with pulsatile exophthalmos, orbital bruit, chemosis, diplopia, ocular redness, orbital pain, swelling, swishing or buzzing sounds, headache, or vision loss. Indirect low‐flow CCFs may be asymptomatic and insidious in onset and mostly present with chemosis and conjunctival injection. Conclusion Indirect carotid‐cavernous fistula rarely occurs secondary to a head trauma without any bony deformity and it's even rare to have an oculomotor nerve palsy on presentation, it should be considered as an etiology when evaluating patients for ocular nerve palsies.

Curative effect of external fixation combined with kirschner wire versus hollow screw in the treatment of first metacarpal bone base fracture

PurposeThis study was conducted aimed at comparing the curative effect of external fixation combined with Kirschner wire fixation versus hollow screw fixation in the treatment of first metacarpal bone base fracture.MethodsThe current retrospective study included a total of 80 patients diagnosed with first metacarpal bone base fracture who were admitted in Wuxi 9th People’s Hospital Affiliated to Soochow University between October 2017 and October 2020. The patients enrolled were equally divided into the combined group (40 cases, receiving external fixation combined with Kirschner wire fixation), and the control group (40 cases, receiving hollow screw fixation). Perioperative indices were collected and compared between the two groups. Pain scores before operation and three months, six months, and one year after operation were compared. Additionally, we compared the finger function in the last follow-up visit ( the follow-up period was 1 year) and rate of complications.ResultsOperation time, amount of bleeding, length of incision, length of hospital stay, and fracture healing time did not differ between the two groups (all P > 0.05). Pain score was comparable between the two groups before operation (P = 0.704). Despite lower results showing at 3, 6, and 12 months after operation in both groups, the pain score did not significantly differ in any time point between the two groups (all P > 0.05). Additionally, no significant differences were observed in finger function and rate of complications at the last follow-up between the two groups (both P > 0.05).ConclusionExternal fixation combined with Kirschner wire fixation and hollow screw fixation exhibited similar curative effect in treating first metacarpal bone base fracture, indicating both surgery methods may be considered as the preferred approach.

Facial Palsy Treatment After Cranial Base Fracture : A Systematic Review

Facial nerve paralysis is a common event in cases of cranial base trauma. Especially facial nerve paralysis due to trauma or fracture of the temporal bone accounts for around 7-10% of cases. Analysis of studies related to the management of facial nerve paralysis due to skull base fractures still needs to be studied. The aim of this paper is to examine in more depth the management of facial nerve paralysis due to traumatic skull base fractures. This research analyzes studies through the PubMed, Google Scholar, and Proquest databases. After searching, 729 articles were found. Seven articles were found that were suitable and discussed the management of facial nerve paralysis due to cranial base trauma. Based on the results of the investigation, it was found that the management carried out was based on the severity scale of facial paralysis where medical or surgical treatment could be carried out according to the required indications.

Epidemiology and treatment of traumatic facial nerve palsy following skull base fractures : Results from the IBM MarketScan commercial database (2006-2019)

Epidemiology and treatment of traumatic facial nerve palsy following skull base fractures : Results from the IBM MarketScan commercial database (2006-2019)

Anatomical position of the mandibular condyle after open versus closed treatment of unilateral fractures: A three-dimensional analysis

This study aimed to compare open and closed treatment for unilateral mandibular condyle neck and base fractures by final three-dimensional (3D) condylar position at 6 months follow-up. 3D position was associated with mandibular functioning and pain. A total of 21 patients received open (n = 11) or closed (n = 10) treatment. 3D positions were assessed on cone-beam computed tomography scans. Volume differences, root mean square, translations, and rotations were obtained related to the pursued anatomical position and compared between treatment groups by the Mann-Whitney U test. The 3D position parameters were associated with the maximum interincisal opening (MIO), mixing ability test (MAT), Mandibular Function Impairment Questionnaire (MFIQ), and pain based on Spearman correlation coefficients (rs). Translation in the medial-lateral direction was smaller after open treatment (P = 0.014). 3D position was not associated with the MAT; however, worse position was associated with a smaller MIO. A larger pitch rotation was associated with a worse MFIQ (rs = 0.499, P = 0.025). Volume reduction of the affected condyle was associated with more pain (rs = −0.503, P = 0.020). In conclusion, after unilateral condylar fractures, worse 3D position is associated with a smaller mouth opening and worse patient-reported outcomes. This is independent of the chosen treatment, despite a better anatomical reduction after open treatment.

Concomitant high-risk pulmonary embolism and subdural hematoma: endo-vascular system thrombolysis as a possible solution to a difficult challenge

Acute pulmonary embolism (PE) is a challenging and potentially fatal cardiovascular disorder. In high-risk patients, percutaneous catheter embolectomy may be considered when thrombolysis is contraindicated or has failed. We hereby discuss the case of a 60-year-old man who was found unconscious on the ground with signs of head trauma and respiratory failure. He was found to have a massive pulmonary embolism and multiple basilar skull fractures associated with slight subdural and subarachnoid hemorrhages. His acute treatment required a multidisciplinary discussion and approach. EkoSonic™ Endovascular System (EKOS) thrombolysis was successfully performed. The patient required intensive care unit (ICU) monitoring and treatment for 31 days. Upon discharge, henoxaparin 4000 UI twice per day was prescribed as anticoagulant, without any evidence of pulmonary hypertension or severe neurological sequelae.

Variations in the Management of Zone 2 5th Metatarsal Fractures Based on Physician Specialty

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: There is a wide variation in the management of acute “Zone 2” 5th metatarsal (MT) base fractures. The purpose of this study was to quantify these differences and evaluate the effect of treating physician specialty. Methods: This was a retrospective cohort study of patients with acute Zone 2 5th MT fractures who presented to a single large, urban, academic medical center between December 2012 and April 2022. Zone 2 was defined as the region of the 5th MT base bordered by the 4th and 5th MT articulation on the oblique radiographic view. Logistic regression was used to evaluate the odds of undergoing operative treatment based on provider specialty. Results: A total of 633 patients presented with Zone 2 fractures during the study period. 40.6% of patients initially presented to the ED, 36.3% to an urgent care (UC) center, and 23.1% directly to the office. Ultimately, 57.2% of patients were treated by orthopedic surgeons, 39.6% by podiatrists, and 3.2% by primary care physicians. For patients treated nonoperatively, the management plan significantly differed by treating specialty. Compared to podiatrists, patients treated by orthopedic surgeons were more likely to be treated in a hard sole shoe (30.8% versus 7.6%, p&lt; 0.001) and less likely to be treated using a CAM boot (57.3% versus 76.3%, p&lt; 0.001). Similarly, patients treated by orthopedic surgeons were more likely to be made WBAT compared to patients treated by podiatrists (71.8% versus 42.0%, p&lt; 0.001). Conclusion: Overall, 2.5% of patients with Zone 2 metatarsal fractures were treated operatively. 0.5% of patients treated by orthopedic surgeons underwent surgery compared to 6.1% of patients treated by podiatrists (p=0.001). Furthermore, when controlling for age, sex, and time between injury and initial presentation to the office, the likelihood of undergoing operative treatment was still significantly greater when being treated by a podiatrist (OR=16.5, p=0.009). There is considerable heterogeneity among the treatment strategies for Zone 2 proximal 5th MT fractures. Compared to podiatrists, orthopedic surgeons are less likely to treat patients operatively and more likely to allow early weight bearing.

Operative Treatment of Jones Fractures (OTA Type 87,5.2A) is not Associated with Earlier Clinical or Radiographic Healing

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: The purpose of this study was to compare the time to radiographic and clinical healing between patients with metadiaphyseal metatarsal fractures (True Jones) treated operatively and those treated nonoperatively. Methods: This was a retrospective cohort study of patients presenting to a single large, urban, academic hospital center with Jones fractures between December 2012 and April 2022. Jones fractures were defined as 5th metatarsal base fractures occurring in the proximal metadiaphyseal region, just distal to the articulation of the 4th and 5th metatarsals on the oblique radiographic view (Zone 3). Information regarding patient demographics, injury mechanism, clinical presentation, management, and time to healing was collected. A fracture was defined as clinically healed when the patient had returned to their baseline ambulatory status without pain and there was an absence of tenderness to palpation on physical examination. Radiographic healing was defined as the presence of complete osseous consolidation. A total of 2,466 patients presented with 5th metatarsal fractures during the study period. Results: Among all 5th metatarsal fractures, 170 patients (6.9%) were classified as “true Jones” fractures. The mean age of patients presenting with Jones fractures was 46.1 +/- 18.6 years, and 65.8% were female. 19.9% were treated operatively (92.9% with screw fixation and 7.1% with ORIF), and 80.1% were treated nonoperatively. 95.9% of patients with Jones fractures went on to heal with no difference in time to radiographic healing (p = 0.296) or clinical healing between both groups (p = 0.228). Furthermore, there was no difference between groups with respect to the proportion of patients who developed delayed radiographic union with incomplete osseous healing at 6 months post-injury (9.3% in the nonoperative group versus 10.7% in the operative group, p = 0.098). Conclusion: Contrary to popular opinion, operative treatment of true Jones fractures was not associated with faster or more reliable radiographic union or time to clinical healing compared to patients treated nonoperatively. The overall rate of nonunion in true Jones fractures was found to be lower than previously described, and there was no evidence of any difference in nonunion rate with operative treatment compared to nonoperative management.

Normal Variation of the Lisfranc Joint: Tridimensional Analysis using Weight-Bearing Computed Tomography Imaging

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Untreated Lisfranc injuries can lead to chronic pain, midfoot arthritis, and functional disability 1,2,5. Approximately 20% of Lisfranc injuries are misdiagnosed or completely missed on initial evaluation, which can be attributed to a lack of parameters of what is within normal limits for subjects without injury in the Lisfranc complex3,4. The purpose of this study is to identify anatomic variations of unidimensional, bidimensional, and tridimensional (1D, 2D, 3D) measurements of the Lisfranc complex of normal individuals using weight-bearing computed tomography (WBCT) imaging. Our hypothesis is that there is some variation among individuals with a difference between right and left of the same individual of less than 10%. Methods: A total of 191 subjects with bilateral WBCT scans of the foot were collected from three tertiary medical centers from 2019-2022. Exclusion criteria included: history of Lisfranc injury, first to fourth metatarsal base fractures, Charcot arthropathy, midfoot arthritis, cuneiform fractures, and forefoot surgery proximal to the metatarsal neck region. The following Lisfranc joint measurements were collected6 bilaterally: joint volume (3D), area of the joint on a consistent axial slice (2D), and distance between the second metatarsal and medial cuneiform (1D). Foot alignment was assessed using lateral talar-first metatarsal angle (Meary’s Angle). Patient demographics (age, sex, weight, height, BMI) were also collected. Descriptive statistics were calculated for quantitative variables. Percent difference was used to assess volume, area, and distance variation between sides.7 Correlation between demographic data and Lisfranc measurements was assessed using Pearson Correlation tests. A T-test was used for categorical variables. A p-value &lt; 0.05 was considered statistically significant. Results: The cohort included 61% female and 39% male with an average age of 45.2±17.3 years. The mean volume, area, and distance measurements of the Lisfranc joint for both left and right sides are shown in Figure 1. Overall, the mean percent difference between left and right sides were 11.9%, 14.9% and 13.9% for volume, area and diastasis, respectively (Figure 1). No association was found between age, BMI, or weight and the volume, area or distance measurements. A correlation (r=0.48, p= &lt; 0.001) was found between height and left Lisfranc joint volume, but no other measurements. Significant difference between sex in volume (p &lt; 0.001) and area (p &lt; 0.001) measurements were found. Foot alignment did not have a correlation with a variation of the Lisfranc complex measurements. Conclusion: This study provides an objective characterizing of the anatomic variations of the Lisfranc joint amongst healthy individuals. Differences in the measurements and the large standard deviation in absolute measurements of volume, area, and distance suggests that percent difference with the contralateral side may be a better metric to use to diagnose Lisfranc instability. Our results showed that the difference between bilateral sides in a patient is less than 15% for volume, area, and diastasis. The results of this study can set the foundation for future studies to determine the cut-off value for the diagnosis of Lisfranc instability using WBCT imaging.

The Accuracy of 3D Measurements in Weightbearing Computed Tomography to Diagnose Lisfranc Instability

Category: Midfoot/Forefoot; Other Introduction/Purpose: Up to one-third of Lisfranc injuries are missed on initial evaluation, resulting in significant morbidity. Prompt diagnosis of Lisfranc injuries is, therefore, critical in optimizing outcomes, and yet there remains a lack of consensus on diagnostic criteria to identify Lisfranc instability using anatomic measurements. Prior studies have underscored the utility of weight-bearing computed tomography (WBCT) in diagnosing Lisfranc instability, which allows for bilateral three-dimensional (3D) evaluation under physiologic load. The aim of this study was to quantify appropriate cutoff values using 3D anatomic measurements of Lisfranc instability under physiologic load and as compared to the uninjured extremity. Methods: A total of 234 adult patients with bilateral WBCT scans of the foot were included: 43 patients with Lisfranc instability &amp; 191 patients without a history of midfoot injuries. Lisfranc instability was confirmed intraoperatively or by clinical evaluation by the surgeon. Patients with prior midfoot surgery, Charcot arthropathy, severe midfoot arthropathy, or significantly displaced fracture of the cuneiforms or 1st, 2nd, or 3rd metatarsal bases were excluded. Lisfranc joint measurements were conducted bilaterally, including C1-M2 diastasis, C1-M2 area and 3D WBCT volume. Patient demographics were collected. Descriptive statistics were calculated for quantitative variables. Percent difference as compared to the contralateral side was calculated for volume, area, and diastasis. Mann Whitney U tests were utilized to determine differences in measurements between patients in the Lisfranc cohort and patients in the uninjured cohort (p-value &lt; 0.05). Diagnostic cutoffs for Lisfranc instability were determined with minimum distance to the corner analysis on ROC curves. Results: The distribution of patients with Lisfranc instability was 58% female with an average age of 38.5±17.6 years. Of the Lisfranc injuries, 36% were purely ligamentous, 18% demonstrated an avulsion injury, and 43% involved a metatarsal base fracture. In the Lisfranc cohort, the median percent difference between injured and uninjured feet was 28.2% (IQR: 20.9%) for volume, 36.3% (IQR: 31.1%) for C1-M2 area, and 40.0% (IQR: 23.3%) for C1-M2 diastasis. Mann-Whitney testing was significant for percent difference between left and right feet for Lisfranc patients versus patients with an uninjured midfoot (p &lt; 0.001). The area under the curve and associated diagnostic cutoffs for Lisfranc instability, were 0.81 and 18% for volume, 0.84 and 20% for area, and 0.91 and 28% for diastasis (Figure 1). Conclusion: Diastasis (1D), area (2D), and volume (3D) measurements are effective measurements to diagnose Lisfranc instability on WBCT. With current diagnostic algorithms, however, 1D measurements afford superior diagnostic sensitivity as compared to 2D and 3D measurements when using WBCT, suggesting Lisfranc instability may be best appreciated in the axial plane. Additional studies are necessary to expand the sample population to assess for corroboration with the current results, especially for subtle Lisfranc instability.

Zone 2 5th Metatarsal Fractures Treated Nonoperatively Have Similar Time to Healing to Those Treated Operatively

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: The purpose of this study was to quantify the time to clinical and radiographic healing in Zone 2 proximal 5th metatarsal (MT) fractures and to compare these outcomes to those of Zone 2 fractures treated operatively. Methods: A retrospective cohort study of all Zone 2 metatarsal fractures seen at a single large, urban, academic medical center between December 2012 and April 2022 was performed. Zone 2 injuries were defined as fractures entering the proximal 4-5 MT articulation on the oblique radiographic view. Clinical healing was characterized by the return to baseline ambulatory function without discomfort and a lack of tenderness on physical examination. Radiographic healing was defined as complete osseous consolidation. A total of 374 patients with Zone 2 proximal 5th MT fractures were included in the analysis. The mean age of patients was 53.8 +/- 16.6 years, and 74.3% were female. Results: 93.3% of patients with Zone 2 metatarsal fractures were treated nonoperatively. In the nonoperative group, 6.6% experienced delayed bony union with incomplete radiographic healing after 6 months, compared to 16.0% of the operative group (p = 0.095). However, by 1 year post-injury, 98.9% of patients who underwent nonoperative management and 96.0% of operative patients demonstrated radiographic union. Two patients failed nonoperative management and underwent operative fixation for symptomatic nonunions. There was no difference in time to radiographic healing between patients treated nonoperatively and those treated operatively (4.4 +/- 2.8 months vs 5.4 +/- 4.7 months, p = 0.413). Similarly, there was no difference in time to clinical healing between both groups (2.3 +/- 1.9 months vs 2.6 +/- 3.8 months, p = 0.723). Conclusion: Zone 2 5th metatarsal base fractures, which are often incorrectly referred to as Jones fractures despite being proximal to the fractures originally characterized by Jones, can be successfully treated with nonoperative management. There is no evidence that operative treatment leads to significantly faster clinical or radiographic healing for patients.

A comparative study on the clinical efficacy of microplate trans-carpometacarpal joint fixation and non-trans-carpometacarpal joint fixation in treating fractures with dislocation or subluxation of the base of the fourth and fifth metacarpal bones

BackgroundThis study aimed to compare the clinical efficacy of microplate trans-carpometacarpal joint fixation and non-trans-carpometacarpal joint fixation in treating fractures and dislocation or subluxation of the base of the fourth and fifth metacarpal bones.MethodFrom 2015 to 2021, 100 cases of metacarpal basal fractures with dislocation or subluxation were randomly divided into the trans-carpometacarpal joint fixation group (group A) and non-trans-carpometacarpal joint fixation group (group B). Group A (n = 50) comprised 44 males and 6 females, with an average age of 28.8 ± 6.1 y and an Orthopedic Trauma Association (OTA) fracture classification of type B1 (n = 29) or C1 (n = 21). Group B (n = 50) comprised 45 males and 5 females, with an average age of 28.9 ± 5.7 y and an OTA fracture classification of type B1 (n = 28) or C1 (n = 22). All patients were complicated with dislocation or subluxation. The surgery time, fracture healing time, postoperative handgrip strength, and total active motion (TAM) scores of the ring and little fingers were recorded and compared between the two groups. The clinical efficacy of patients was evaluated using scoring methods such as DASH (disabilities of the arm, shoulder and hand), visual analogue scale (VAS), and Mayo at 3, 6, and 12 months after surgery.ResultsThere was no significant difference in the general indexes, surgery time, or fracture healing time between the two groups (P > 0.05). There were no significant differences in handgrip strength and TAM scores of the ring and little fingers between the two groups at 3 and 12 months postoperatively (P > 0.05), but there were significant differences in these indexes 6 months postoperatively (P < 0.05). There were no significant differences in the DASH, VAS, and Mayo scores at 3 and 12 months postoperatively (P > 0.05), but there were significant differences between the two groups in the DASH and Mayo scores (P < 0.05) but not the VAS score (P > 0.05) 6 months postoperatively.ConclusionIn the treatment of fourth and fifth metacarpal basal fractures with dislocation or subluxation, both microplate transarticular fixation and non-transarticular fixation could achieve fracture fixation and healing, and each method had advantages and disadvantages. The clinically appropriate fixation method should be selected according to the experience of the surgeon and the degree and type of fracture and dislocation.