Bony Injuries Research Articles

Risk Factors for Cage Subsidence After Transforaminal Lumbar Interbody Fusion: A Systematic Review and Meta-Analysis.

A systematic review and meta-analysis. Cage subsidence (CS) is a common complication following transforaminal lumbar interbody fusion (TLIF) surgery. This study aimed to identify and analyze risk factors associated with CS following TLIF. A comprehensive search was conducted across PubMed, Scopus, Embase, and Google Scholar for studies published up to March 31, 2024. Pooled odds ratios (OR), standardized mean differences (SMD), and 95% CI were calculated for each identified risk factor. Interstudy heterogeneity was evaluated using the I² statistic, and either a random-effects or fixed-effects model was applied as appropriate. Publication bias was assessed through funnel plots. Nine studies, comprising data on 1403 patients who had undergone TLIF, were included in the final analysis. Significant risk factors for CS included age (SMD=0.27; 95% CI: 0.12-0.41) and bony endplate injury (OR=7.52; 95% CI: 2.08-27.17). However, no significant associations were found with other potential risk factors, such as cage height, body mass index (BMI), bone mineral density, smoking status, diabetes, sex, center point ratio (CPR), disc height (preprocedure and postprocedure), or surgery location. This meta-analysis identified older age and injury to the bony endplate as significant risk factors for CS after TLIF. These findings may help inform clinical decision-making and guide risk stratification in patients considering TLIF.

International Perspectives on the Management of Acute Mallet Finger Injuries: A Cross-Sectional Survey.

Background: Mallet fingers are common injuries with management often being guided by presence of fracture, joint subluxation, chronicity and patient requirements and surgeon preferences. The purpose of this study was to understand current trends of management of mallet finger injuries. Methods: This study surveyed an international group of English-speaking hand surgeons (n = 244) with different types of mallet finger injury patterns to assess current trends and identify any regional variations in practice. Results: Nonoperative management with extension splinting was the preferred treatment for soft tissue (93%) and congruent bony (87%) mallet finger injuries amongst surgeons from all regions. Similarly, most surgeons (76%) preferred operative treatment for incongruent bony injuries. The management of subtle joint subluxation was contentious with 36% recommending splinting and the rest opting for closed reduction and wiring or open reduction. Conclusions: While there is no consensus on treatment, surgeons seem to prefer nonoperative treatment for most soft tissue mallet injuries. Surgeon preference seems to dictate the management of bony mallet injuries especially with incongruent joints. Prospective randomised studies would be beneficial in providing evidence-based guidelines for management of this common injury. Level of Evidence: Level V (Therapeutic).

Selective Conservatism in the Management of Spinal Stab Wounds Remains Applicable-A Critical Review of 169 Patients Managed at a Major Trauma Center in South Africa.

Spinal stab wounds (SW) are relatively uncommon and can be both morbid and fatal. The exact role of surgery remains somewhat unclear. This study reviews our institutional experience of spinal SW management and examines the clinical outcome of these patients in a developing world setting. A retrospective study was conducted over a 10-year study period from December 2012-December 2022 at a major trauma center in South Africa. All patients who sustained spinal SW were included. One hundred sixty-nine patients with spinal SW were included (male: 87%, mean age: 28years, median Injury Severity Score [ISS]: 9). AIS classifications: E (51%), C (18%), A (14%), D (12%), B (4%). Nearly all patients (95%) underwent CT scan and 81% had an MRI. 72% had bony injury and 60% had spinal cord injury. Five percent of all patients underwent surgical intervention. Overall, 5% of patients required intensive care unit (ICU) admission and 9% had one or more complications. Common complications were hospital acquired pneumonia and pressure sores. The overall in hospital mortality rate was 1% (2/169). Of the 167 patients who survived to hospital discharge, 88% were discharged to spinal rehabilitation centers and the remaining patients were discharged home. Our study supports a conservative management in select SW patients, especially in the absence of progressive neurological deficits or spinal instability. Non-operative management aligns well with resource-constrained public healthcare facilities in our environment. Further research should aim to develop context-specific guidelines to refine surgical decision-making and improve outcomes across varied healthcare settings.

Unique Treatment of Ventricular Tachycardia Storm in a Patient With Cervical Spine and Chest Wall Injuries.

Ventricular tachycardia storm (VTS/ES) is defined as the occurrence of three or more episodes of sustained ventricular tachycardia within a twenty-four-hour period, with or without a defibrillator. It has not been reported de novo in trauma patients. The literature indicates blunt cardiac injury as a potential etiology of ventricular dysrhythmia. We present a patient with a history of atrial fibrillation and a cardiac resynchronization device with defibrillator who presented neurologically intact with cervical vertebral, internal, and bony thoracic injuries following a ground level fall. Within 24hours, the patient developed VTS/ES that was ultimately resolved with a stellate ganglion block. This is the first report of a trauma patient with suspected blunt cardiac injury undergoing a stellate ganglion block following the onset of VTS/ES. Blunt cardiac injury is worth consideration as an etiology in post-trauma patients with ventricular tachycardia storm, particularly when no other source is identified. Stellate ganglion block, which can be performed at bedside with appropriate specialist availability, can be considered among treatment options in trauma patients.

Craniocervical Junction and Upper Cervical Spine Fractures: Historical Systems and Advancements with the AO Spine Classification.

Study DesignSystematic Review.ObjectivesTo describe existing craniocervical junction and upper cervical spine classification systems and their integration into a unified rational hierarchical system of the AO Spine Upper Cervical Injury Classification System (UCIC).MethodsA systematic review of MEDLINE, EMBASE and Cochrane Databases was performed in keeping with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.Results859 articles were identified which yielded 10 established classification systems for injuries of the occipital condyles, craniocervical junction as well as atlas and axis. All systems were either non-hierarchical, conferred minimal clinical significance or failed to consider neurological status of patients. For example, the Traynelis classification simply relies upon describing the direction of displacement which has dubious clinical significance. Similarly, the Jefferson description of atlas fractures simply grades injuries by fracture line pattern. The AO Spine UCIC system synthesizes each published historical scheme into a rational graded method by which clinicians can assess the severity of injuries to this region. The three grades of injury range from type A being generally stable bony injuries, type B constituting potentially unstable (osseoligamentous) injuries and type C representing grossly unstable translational injuries.ConclusionThe AO Spine UCIC System is a validated methodoogy of integrating historical landmark grading systems and evolving this into a structured means of grading severity of injuries to guide timely clinical management. The implementation of this universal system will enable clinicians to consistently assess craniocervical junction injuries and implement appropriate managemen strategies. Future studies will examine outcomes after operative or non-operative management with progression to a standardized quantified algorithm.

Association of Anterolateral Ligament, Kaplan Fibers, and Condylar Strap Injuries with Posterior Cruciate Ligament, Medial Collateral Ligament, Lateral Collateral Ligament, Meniscal, and Bony Injuries in Patients with High-Grade Anterior Cruciate Ligament Injury: A 3-T Magnetic Resonance Imaging Study

Association of Anterolateral Ligament, Kaplan Fibers, and Condylar Strap Injuries with Posterior Cruciate Ligament, Medial Collateral Ligament, Lateral Collateral Ligament, Meniscal, and Bony Injuries in Patients with High-Grade Anterior Cruciate Ligament Injury: A 3-T Magnetic Resonance Imaging Study

P.123 Decoding the brachial plexus : from fundamentals to advances - anatomy, imaging and pathologies

Background: The brachial plexus provides motor and somatosensory innervation to the upper limb and upper chest. Evaluation of brachial plexus disease is based on history, physical examination etc but imaging plays an important role for lesion localization, characterization and its classification. Effective reporting of imaging findings requires that neuroradiologist should be familiar with the brachial plexus anatomy, relevant landmarks, the spectrum and categories of brachial plexopathies. All above objectives will be discussed in this oral presentation. Methods: Normal brachial plexus anatomy is assumed for five anatomic landmarks: neural foramen, interscalene triangle, lateral border of the first rib, medial border of the coracoid process, and lateral border of the pectoralis minor corresponding to level of roots, trunks, divisions, cords and terminal branches. Conventional radiography has role in evaluating bony injuries. CT has limited role. MR used for comprehensive evaluation of the brachial plexus. Causes of brachial plexopathy are divided into traumatic and nontraumatic with specific features of each. Results: Imaging of brachial plexus is important part of treatment planning and rehabilitation of brachial plexopathies. Confident reporting can be done by knowing basics and injury patterns. Conclusions: Neuroradiologist should have sound knowledge of brachial plexus imaging in order to better contribute to pateint care.

Cone beam CT in the imaging of musculoskeletal trauma: a scoping review.

Cone beam computed tomography (CBCT) is an emerging technology in musculoskeletal (MSK) imaging. The objective of this scoping review was to provide an overview of the research surrounding CBCT utility in bony injury assessment as an alternative to other imaging modalities and investigate any gaps in the current evidence base. MEDLINE, CINAHL, and PubMed were searched up to January 2025 for articles including CBCT studies on human participants following trauma. An online literature review tool was used to manage and streamline the review process. The search yielded 23 studies. The image quality and diagnostic accuracy of CBCT were high overall, and a number of studies confirmed the radiation dose to be lower than multislice CT. Studies examined CBCT for extremity trauma, with half the studies focused solely on the wrist. The utility appears greatest in the identification of radiographically occult fractures. Limited cost-effectiveness analysis has been undertaken. Overall, the literature suggests CBCT can be an effective tool in the diagnosis of bony injuries with greater sensitivity than radiography at a lower radiation dose than multi-slice computed tomography. However, evaluation of wider patient and economic impacts of adopting CBCT in MSK trauma pathways is recommended.

Scintigraphy for the diagnosis of primary unrecognised fractures in multiple trauma patients - a prospective, blinded, monocentric study

IntroductionAfter structured (S3 guideline, ATLS®) acute care of multiple trauma patients in trauma centers, post-acute missed injuries continue to occur with incidence rates ranging from 1.3 to 39% as described in literature. The aim of the tertiary survey was the reduction of these rates. However, high numbers of missed injuries continue to be reported. The aim of this prospective, single-center, blinded clinical diagnostic study was to determine whether the standardised use of 3-phase whole-body skeletal scintigraphy in severely injured patients can reduce the number of missed injuries compared with the established standard procedure for polytrauma diagnosis.Methods26 patients aged 18 years or older (median 53.5 years, 4 female, 22 male) with an ISS ≥ 9 were evaluated by an orthopaedic and trauma surgeon using skeletal scintigraphy after completion of standardised trauma room diagnostics and tertiary survey, a median of 7 days after trauma. All clinical and diagnostic examinations were then analysed and a final consensus was reached on the bony injuries. An evaluation of each procedure against the consensus was performed for the whole body and five body regions.ResultsSkeletal scintigraphy was clearly superior to the established method (sensitivity 98.8% vs. 75.4%). Of the 60 additional bony injuries identified, 25 were treated without therapeutic consequences. Twenty-nine were treated conservatively without additional immobilisation and five with additional immobilisation. One unnecessary immobilisation was ended and no surgical treatment was required.ConclusionThree-phase whole-body skeletal scintigraphy is a low-risk, highly sensitive tool for reducing the incidence of missed injuries. A more liberal indication for skeletal scintigraphy should be given for injuries of increasing severity and in persons with impaired consciousness or paralysis, to avoid sequelae of missed injuries.Clinical trial registrationThe study was registered at the German Clinical Trails Register (DRKS) with the identifier DRKS00029402.

Bony injuries in a Late Triassic forerunner of mammals from Brazil.

Traversodontidae is a clade of non-mammaliaform cynodonts within the Cynognathia lineage, representing the most successful herbivorous/omnivorous group of the Triassic period. Here, we describe bony injuries in the ribs of a ~ 228-million-year-old traversodontid from Brazil. The specimen, assigned to Exaeretodon riograndensis, was discovered in Upper Triassic strata of the Santa Maria Supersequence, Paraná Basin. Macroscopic analysis, supported by micro-computed tomography, revealed the presence of bony calluses in the ribs, indicative of a transverse traumatic fracture, likely caused by a fall or an interaction (either intra- or interspecific) during the individual's lifetime. Such trauma would have likely hindered its locomotion, impacting foraging efficiency and predator evasion. However, this species was possibly gregarious, which may have helped mitigate the injury's impact on survival through group behavior. This finding represents a rare documented case of paleopathology in non-mammaliaform cynodonts, contributing to discussions on their behavior and paleoecology during the Triassic.

Traumatic Vertebral Artery Injury: Diagnosis, Natural History, and Key Considerations for Management.

Vertebral artery injury (VAI) is a known complication of blunt cervical spine trauma with a potential risk of stroke. Factors including cervical bony injury, spinal cord injury, and overall trauma severity have been linked to an increased risk of VAI. Despite its prevalence, there is little consensus on various aspects of this pathology, including its initial screening, diagnostic approaches, and therapeutic strategies. A recent systematic review and meta-analysis from our group highlighted the dynamic nature of vertebral artery occlusion, revealing the underrecognized recanalization rates and potential stroke risks associated with delayed recanalization. While anticoagulant and/or antiplatelet therapy (ACAP) remains the cornerstone of VAI management, treatment is often complicated by co-existing injuries, such as intracranial hemorrhage or cervical trauma, which may preclude or delay ACAP usage or necessitate surgical intervention. This comprehensive narrative review synthesizes the latest evidence on VAI and associated ischemic sequelae, with the goal of elucidating its pathophysiology and natural history, summarizing current data on screening and diagnosis, and exploring key considerations for medical and endovascular management.

ACR Appropriateness Criteria® Acute Shoulder Pain: 2024 Update.

ACR Appropriateness Criteria® Acute Shoulder Pain: 2024 Update.

Wrist and Forearm Fractures from Ballistic Injuries.

Wrist and Forearm Fractures from Ballistic Injuries.

Bony Mallet Finger: A Comparative Review of Approaches in Pediatric vs. Adult Populations

Background: Bony mallet finger injuries result from distal phalanx fracture, often involving avulsion fractures of the distal phalanx. Optimal management remains debated, particularly between pediatric and adult populations. Objective: This review compares surgical and conservative treatments for acute bony mallet finger fractures, focusing on healing times, functional recovery, and complications. Methods: A systematic search of PubMed, Scopus, and Cochrane Library (2014–2024) identified studies evaluating treatment strategies in adults and children. Outcomes assessed included healing time, clinical recovery, and complication rates. Results: Conservative treatment, was preferred in adults, leading to healing times of 6–8 weeks but with a higher incidence of deformities. Surgery, useful in pediatric cases, provided faster recovery and superior functional outcomes. The Ishiguro method in children showed improved extension recovery with shorter immobilization. Surgery in adults led to quicker functional recovery but had higher complication rates. Pediatric surgical cases had a slightly higher risk of growth disturbances, though overall better functional outcomes. Conclusions: Pediatric patients had superior long-term outcomes regardless of treatment modality. While conservative treatment in adults resulted in prolonged recovery and more deformities, surgery carried a higher complication risk. Both groups showed a favorable prognosis, warranting further research to refine treatment strategies.

Demographics, radiographic characteristics, treatment, and classification of pediatric thumb bony Ulnar Collateral Ligament (UCL) injuries

Background: Pediatric thumb ulnar collateral ligament (UCL) injuries usually have osseous involvement presenting as a Salter-Harris III avulsion fracture from the base of the proximal phalanx. There is limited guidance about when surgical or non-surgical treatment is more appropriate. Methods: Patients with thumb bony UCL injuries who presented to a large pediatric hospital between 2007 and 2017 were retrospectively identified. Demographics, fracture pattern, treatment, clinical course, and outcomes were collected. Radiographic measurements included size and displacement of fracture fragment as a percentage of the proximal phalanx base articular surface. A classification system was developed incorporating clinical stability of the metacarpophalangeal joint and quantity of displacement. Results: Sixty-five patients were included (47 males and 18 females). The mean age at time of injury was 14.8 SD 1.9 yrs old. 46 (71%) injuries occurred during sporting activities. 50 (77%) patients underwent nonsurgical management with immobilization, and 15 (23%) patients were treated surgically with open reduction internal fixation. For patients treated surgically, the mean fragment size was 28.2% SD 6.8% of the articular surface compared to 14.3% SD 12.5% of those treated non-surgically (P<0.0001). The mean fracture displacement for surgically treated patients was 32.7% SD 19.0% compared to 11.4% SD 7.3% of those treated non-surgically (P<0.0001). Overall, 100% of patients reported they were able to return to their previous level of activity. Conclusion: Many pediatric thumb bony UCL injuries can be treated non-surgically. A classification system based upon joint stability and fracture displacement may help guide appropriate management of these injuries.

Clinico-Epidemiological Study of Lateral Ankle Sprains in Patients Attending a Tertiary Care Centre in Nepal

Lateral ankle sprains are the most common injuries among the general population and athletes. The rate of recurrence of these injuries and their progression to chronic ankle instability is common. The study was performed to study the clino-epidemiological aspects of lateral ankle sprains in a tertiary care setting. This type of study has not been studied to date in our patient cohort and the results of the study can help to draw important guidelines in diagnosis and treatment of these injuries. All skeletally mature patients of both sexes with lateral ankle sprains were taken into the study. Relevant history, clinical examination, areas of tenderness, and anterior drawer test in plantar flexion and neutral were performed. A radiographic evaluation of the patient was performed to rule out bony injury. The total number of patients was 86. These injuries were seen in 46.5% of overweight or obese patients. The most common mechanism of injury is twisting injury in 52 patients (60.5%), followed by road traffic accidents and sports injuries, with 10 patients (11.6%) in each. Most of the ankle sprains were grade I injuries (72 patients, 83.7%), while 12 (14.0%) were grade II, and 2 (2.3%) were grade III injuries. This study has provided a comprehensive clinical and epidemiological overview of lateral ankle sprains in tertiary care setting in Nepal. It has highlighted the need for patient education regarding ankle sprains.

What is the Role of Point of Care Ultrasound for Suspected Pulled Elbow in Children?

Objective: Our objective was to evaluate and appraise the existing evidence on the use of point of care ultrasound (POCUS) for pulled elbow, including its positive findings and their reliability. Methods: We searched PubMed, Medline, EMBASE, CINAHL and Google Scholar for prospective and retrospective studies evaluating POCUS use for suspected pulled elbow. We identified positive sonographic findings along with their sensitivity and specificity relating to this diagnosis. Results: We included 13 studies that reviewed ultrasonographic findings in suspected pulled elbow. These studies discussed a range of sonographic findings between them, including radio- capitellar distance, ‘J-sign’/ ‘Hook sign’, fat pad sign and partial eclipse sign. The studies were of mixed quality and were susceptible to bias. Conclusions: Children presenting with suspected pulled elbow who have evidence of hook sign (or J-sign) and an absence of elbow effusion on POCUS can be diagnosed with pulled elbow and safely undergo reduction. POCUS can be used following reduction to demonstrate resolution of these signs and confirm its success. Elbow injuries with effusion are likely to have bony injury, meaning that X-ray is required. Additional prospective study of children presenting with elbow injury would be required to accurately determine the effectiveness of POCUS in the diagnosis of pulled elbow.

Near-Hanging Injuries: Perspective for the Trauma and Emergency Surgeon.

Introduction: Near-hanging injuries are a significant cause of morbidity and mortality worldwide. These injuries result in complex clinical presentations due to the combination of mechanical asphyxia and potential neck and cervical spine trauma. The primary objectives of this narrative review include assessing the incidence, sex distribution, pathophysiology, prognostic indicators, neurologic outcomes, and treatment strategies.Methods: Review performed using Medline in English from 1946 to 2023. Excluded: articles of accidental, sex-related, auto-asphyxiation, cancer-related, and pediatric near-hanging, review articles, and case reports.Results: 53 articles were first reviewed; 30 articles encompassing 4712 patients had complete demographic and neck injuries data. Sixteen articles reported the presence and absence of ligature markings in 1778 patients. Ligature markings were present in 1103 (73.5%). Median Age: 33 (29-38) 75.7% male distribution. Suicide attempt: 97.3%. Neck vascular injuries, aerodigestive, and neck bony injuries occurred in 83 (1.8%), 123 (2.6%), and 125 (2.7%), respectively. Cardiac arrest: 1195 (25.3%) and GCS<9-2125 (45%) were the major contributors to the mortality: 26.9%. Glasgow Outcome Score>3 or by a Cerebral Performance Category score of 1-2 was documented in 35.2% of patients. Hyperbaric oxygen treatment, hypothermia treatment, and targeted temperature management did not appear to be useful from the standpoint of survival in patients who suffered a cardiac arrest.Conclusions: Near-hanging as an attempt to suicide is more frequent in young male patients. The incidence of associated neck injuries is low; mortality is likely to occur in patients with cardiac arrest with an associated neurologic injury. There is insufficient evidence to support the use of hyperbaric oxygen treatment, hypothermia treatment, and targeted temperature management in patients who have suffered a cardiac arrest and severe neurologic injury after near-hanging.

Management of anterior shoulder instability in the contact athlete: a narrative review.

Anterior shoulder instability (ASI) is a common occurrence in the athletic population with specific management challenges in contact athletes due to the high activity demand and repetitive trauma during sport. This study aims to provide a narrative review of the current literature on ASI in contact athletes, with an emphasis on pathophysiology, mechanisms of injury, clinical presentation, diagnostic strategies, treatment options, including in-season management, and outcomes. A narrative review of the current literature on ASI in contact athletes was conducted, including key studies on the management and outcomes of conservative and surgical interventions. ASI typically occurs from abduction and external rotation forces. Diagnosis relies on clinical assessment and imaging (magnetic resonance imaging or computed tomography), to evaluate soft tissue and bony injuries. Non-operative management is associated with high recurrence rates in contact athletes. Surgical options include arthroscopic Bankart repair (ABR) with or without remplissage, open Bankart repair (OBR), or bone block procedure such as Latarjet procedure or distal tibia allograft. All of which have been shown to decrease risk of recurrence and have a high rate of return to sport. The choice of procedure depends on the extent of soft tissue and bony involvement and the athlete's individual demands. ABR with glenoid bone loss >13.5% have high recurrence rates, therefore, additional procedures such as remplissage or bone block procedures should be considered. ASI in the contact athlete is a common and challenging injury to manage. Surgical intervention provides superior outcomes in terms of stability and recurrence prevention compared to non-operative management of ASI in the contact athlete. Patient-specific considerations including level of sport, patient goals, and timing of season are considerations for treatment. Labral injury with <13.5% of glenoid bone loss and on-track Hill-Sachs lesion ABR is recommended, labral injury with 13.5-20% of glenoid bone loss with off-track Hill-Sachs lesion ABR with remplissage or OBR with capsule shift is recommended, and if >20% then bone block procedure is recommended.

The ability of the Knee Osteoarthritis Outcome Score to detect changes over time is limited in patients with patellar instability due to substantial ceiling effect

PurposeThe purpose of the current study was to evaluate important aspects of interpretability (floor and ceiling effects) for the Knee injury and Osteoarthritis Outcome Score (KOOS) in patients with patellar instability. Secondarily, the study aims to provide minimal important clinical difference (MICD) values for all subscales in this patient category.MethodsPatients undergoing patella stabilising surgery with an individualised approach based on anatomic deviation were prospectively included if (1) ≥13 years of age at the time of surgery, (2) fluent in Norwegian and (3) able to understand and complete the questionnaires. Patients were excluded if they had concomitant bony and/or knee ligament injuries. KOOS was completed before and 6 months after surgery. Interpretability of the KOOS was evaluated according to recommendations from COnsensus‐based Standards for the selection of health Measurement INstruments. A floor or ceiling effect is considered to be present if the number of patients that had a score in the lower (0–10) or upper (90–100) end of the scale exceeded 15%. This was identified with a distribution‐based approach with standard deviation (SD) of the change score between pre‐ and postoperative scores using the following equation: MICD = 0.5 × SD.ResultsA substantial ceiling effect was present in the KOOS subscales pain and activities of daily living (ADL) measured prior to surgery, and in all, except the quality of life subscale, 6 months after surgery. KOOS ADL demonstrated the highest number of patients, 46% preoperatively and 72% postoperatively with a ceiling effect. In addition, 32% of patients had the best possible score on the pain subscale 6 months after surgery. The only subscale that displayed a floor effect was the preoperative KOOS Sport/Rec. The MICD for the different subscales ranged from 7.6 to 12.4.ConclusionThe substantial ceiling effect in the current implies that the KOOS is not suited to evaluate the long‐term effect of treatment in patients with patellar instability.Level of EvidenceLevel II.