C2 Fractures Research Articles

Simultaneous Traumatic Fractures of the Atlas and Axis: Presentation, Management, and Outcomes from a Series of 103 Consecutive Patients.

Simultaneous fractures of C1 and C2 are increasingly common, but contemporary series are limited in their evaluation. All patients with traumatic fractures of both C1 and C2 admitted to an academic trauma center from 2012 to 2022 were retrospectively analyzed. Multivariable regression was used to identify characteristics relevant to management and outcomes. 103 patients were identified, most of whom (52.4%) were age ≥80 years, suffered ground-level falls (80.6%), and had minor associated injuries (median Injury Severity Score 1), but had a 28.2% 1-year mortality rate. Landells Type 1 fractures were the most common C1 fracture (50.5%), and dens fractures were the most common C2 fracture (74.8%). Most patients did not undergo MRI, but ligamentous injury was seen in 54.8% of those who did. Fourteen patients (13.6%) had surgery upfront, and 7 (6.8%) had surgery after a trial of nonoperative management. Selection for upfront surgery was associated with neurologic deficits (p=0.010) and age (p=0.026). Dens fracture patients tended to have C2 as their lower instrumented vertebra (p=0.0902), and hangman's fracture patients tended to have C3 as theirs (p=0.0714). Upfront surgery decreased the odds of bony nonunion (p=0.0281). 91.7% of patients with bony nonunion with flexion-extension films had fibrous nonunion. Simultaneous atlantoaxial fractures commonly occur in elderly patients after ground level falls with minor associated injuries. Surgical selection is driven by neurologic deficits and age, and C2 fracture type may influence procedure choice. Surgery decreases the odds of bony nonunion, and fibrous nonunion is common in its absence.

Management of Type III Occipital Condyle Fractures

Background/Objectives: Occipital condyle fractures (OCFs) can be seen in around 4–19% of patients who suffer from cervical spine trauma. Anderson and Montesano system type III OCFs, which are avulsion fractures, are potentially unstable and operative. This study evaluates the management of type III OCFs at our institution over a 22-year period. Methods: This retrospective study reviewed all cases of type III OCFs at our institution from July 2001 to March 2023, identified via imaging reports. Using the in-house radiology imaging informatics system “Doris” (Dig Our Radiology Information System), reports containing the terms subluxation, avulsion, unstable, or type 3/III with occipital condyle, occipital condylar, occipital fx, or occipital fracture were collected. We also searched for Montesano type III/3 fracture. Electronic medical records were used to collect clinical and demographic data. Patients evaluated by the neurosurgical team with at least 1 month of follow-up were included in the analysis. Results: A total of 563 patients were identified with type III OCFs. A total of 56 patients met the inclusion criteria. The majority (91%, 51/56) were treated conservatively with cervical orthosis. A small subset (8.9%, 5/56) underwent occipito-cervical fusion. Three had concomitant unstable C1 fractures, while the other two had significant coronal deformity associated with their type III OCF. Conclusions: At our institution, type III OCFs are predominantly managed with cervical orthosis. Only those with an associated malalignment of the occipito-cervical joint underwent fusion. These findings suggest that most type III OCFs can be treated conservatively with orthosis once stability is confirmed with an upright radiograph.

Outcomes of Treatment of Intra-Articular Distal Radius Fractures with Volar Locked Plates in Patients Above 50 Years

Objective: Outcomes of the treatment of intra-articular distal radius fractures seen in patients above 50 years with volar locked plates were evaluated.  Study design: Twenty Eight patients (8 female and 20 male) treated in our clinic with volar locked plates because of intra-articular distal radius fractures were evaluated after a 17-month (range 8-30 months) follow-up. Mean age of the patients was 45.2 (range 50-64) years. Fractures were classified according to Frykman and AO classifications. According to the Frykman classification, 2 patients had type 3 (7%), 1 patient had type 4 (5.5%), 14 patients had type 7 (50%) and 11 patients had type 8 (37.5%) fractures. According to the AO classification, 6 patients had B2 (23.5%), 4 patients had C1 (14%), 11 patients had C2 (37.5%) and 7 patients had C3 (25%) fractures. All patients were evaluated clinically and radiologically. Clinical outcomes of the patients were evaluated using Gartland and Werley’s evaluation scores and DASH-T scores. Radiologic outcomes were evaluated according to the radiologic evaluation criteria modified by Steward et al.  Results: According to the evaluation scores of Gartland and Werley, 20 patients yielded excellent (72%), 5 patients good (18%) and 3 patients moderate (10%) results. Mean DASH-T score of the patients was 34 (range 31 to 40).  Conclusions: Treatment of intra-articular distal radius fractures seen above 50 years of age with volar locked plates is an efficient and safe method. Use of volar locked plates reduces the complication risk of reduction loss and need for grafts in osteoporotic fractures.

Comparison of the stability of dual INFIX and INFIX combined with sacroiliac screw fixation for C1 type pelvic fractures

To evaluate the biomechanical stability of dual anterior subcutaneous internal fixation (INFIX) in pelvic C1 fractures by finite element analysis, and to compare it with INFIX combined with sacroiliac screws to determine whether it is sufficient to replace the combined fixation of anterior and posterior rings. The pelvic CT data of a 43-year-old female volunteer were imported into the computer and the normal pelvic model and pelvic C1 fractures model were constructed using Mimics, Workbench and other software. The latter was fixed with dual INFIX and INFIX combined with sacroiliac screws, respectively. First, the effectiveness of the normal pelvic model in anatomical landmarks, stress conduction and displacement distribution was verified. Then, a vertical downward load of 500 N was applied to the two internal fixation models to simulate the standing and sitting positions of the human body, and the displacement of the anterior and posterior ring fractures ends, the stress of the internal fixation and the stress of the nail channel in the bone were collected. The model passed the validity verification. The maximum displacement of the anterior and posterior ring fractures in the standing dual INFIX group were 0.861 mm and 4.128 mm, respectively, which were both smaller than the 0.152 mm and 0.293 mm in the combined fixation group. The displacement of the posterior ring fractures in the sitting dual INFIX group was 3.757 mm, which was larger than the 0.560 mm in the combined fixation group, while the maximum displacement of the anterior ring fractures was 0.221 mm, which was not much different from the 0.194 mm in the combined fixation group. The maximum stress of internal fixation in the standing dual INFIX group was greater than that in the combined fixation group, while the opposite was true in the sitting position. The maximum stress of each internal fixation was lower than the yield strength of titanium alloy 790 MPa. The maximum stress of the nail channel in the standing and sitting daul INFIX groups was lower than that in the combined fixation group, and the stress of all nail channels was lower than the strength limit of bone 290 to 540 MPa. The stability of dual INFIX fixation in anterior and posterior ring fractures is generally inferior to that of INFIX combined with sacroiliac screw fixation. Although simple dual INFIX fixation can share part of the load for the posterior ring, the posterior ring will still have a large displacement, so the fixation of the posterior ring is very important. In addition, the fixation strength and stability of dual INFIX in the anterior ring are better than INFIX. When INFIX cannot provide sufficient strength to stabilize the anterior ring fractures, dual INFIX will be a good choice.

Experimental study of fractures of the posterior pelvic ring C1.1 using LC-II screws and internal fixation by plate

IntroductionTo compare the biomechanical outcomes of C1.1 posterior pelvic ring fractures treated with different numbers of LC-II screws and plate internal fixation.Materials and methodsNine adult preserved pelvic specimens were used. After being measured by bone densitometry, the specimens were randomly divided into 3 groups of 3 pelvic specimens each. The C1.1 pelvic fractures were generated by iliac osteotomies and anterior pelvic ring osteotomies. The fractures were fixed and randomly divided into three groups: (1) one LC-II screw, (2) two LC-II screws, and (3) two reconstruction plates. The anterior pelvic rings were all fixed with pubic branch screws. A biomechanical testing machine loaded all specimens vertically, recording the displacement and ultimate load of the specimens to quantify the stiffness.ResultsWhen loads up to 1000 N were applied, the displacement of the iliac bone was close between the one LC-II screw and the two LC-II screw group specimens; (P > 0.05); when loads such as 1000 N, 1200 N and 1400 N were applied, there was no significant difference in displacement between the plate fixation group and the two LC-II screw fixation group (P > 0.05), both of which were superior to the one LC-II screw fixation group (P < 0.05). There was no significant difference in compressive stiffness between the two LC-II screw fixation groups and the plate fixation group (P > 0.05), and both were superior to the one LC-II screw fixation group (P < 0.05) the ultimate load of both the two LC-II screws and the steel plate is greater than that of one LC-II screw (1.74 times the ultimate load of one LC-II screw for the two LC-II screws and 1.83 times the ultimate load of one LC-II screw for the steel plate).ConclusionFor posterior pelvic ring fractures of type C1.1, placement of two LC-II screws provides comparable posterior pelvic ring stability compared to reconstructed plates. At loads below 1000 N, one LC-II screw fixation and two LC-II screws were comparable in restoring posterior pelvic ring stability.

Differences in Cervical Spine Fractures in Patients Younger or Older Than 65 Years of Age: Implications for the Canadian C-Spine Rule.

There has been a distinction made in the 2001 Canadian C-Spine Rule regarding patients 65 and older and younger than 65 years of age as far as indications for cervical spine CT scanning. We sought to determine if there are differences in the symptoms, mechanisms of injury, fracture locations, and types that are still relevant in 2024. The institutional review board approved this retrospective study of cervical spine CT emergency department results from 2 hospitals in our health system after reviewing 5 years of data in patients experiencing trauma. In addition to the primary variable of age (younger than 65 years and 65 years and older), we looked at injury mechanism, fracture types, sites, symptoms, and operative or medical treatments. Because the demographics of our home site is different from most towns in the United States, we provide race/ethnicity data. Of 21,986 cervical spine CTs, 190/9455 (2.0%) participants 65 years of age and older and 199/12,531 (1.6%) participants younger than 65 years of age had fractures (total, 389/21,986, 1.8%). There were more cases of falls from standing (106, 55.8%) and falls from a height (46, 4.2%) in those 65 years and older and this mechanism was associated with a higher risk of C1 and C2 fractures (52, 27.4%; and 78, 41.1%, respectively). Among the C1 fractures, anterior and posterior arch fractures predominated (37, 19.5%). For C2 fractures, types 2 and 3 odontoid fractures (39, 20.5%; and 12, 6.3%) were more common in the older cohort. Motor vehicle collisions were more common in the younger cohort (89, 44.7%), and they were associated with more C5-C7 fractures (47, 23.6%; 60, 30.2%; and 66, 33.2%, respectively) including the facets (49, 24.6%), spinous processes (31, 15.6%), and transverse processes (52, 26.1%). Overall, the rates of instability, surgical intervention, and asymptomatic fractures were similar in the 2 age groups. Cervical spine fractures appear in about 1.8% of the CT scans performed in a busy emergency department environment. Fractures in the elderly occur more commonly due to falls, are located at C1 and C2, and may involve ligamentous injuries. Younger patients incur trauma more commonly due to motor vehicle collisions, and they are more likely to affect the posterior elements, especially C5-C7. The differences in trends for fractures in the 65 years of age and older and younger than 65 years of age groups have persisted since the Canadian C-Spine Rule 1996-1998 data were collected.

Halo Vest Immobilization: Is It Still a Valid Treatment for Atlantoaxial Fractures?

IntroductionAtlanto-axial injuries pose a significant threat to morbidity and mortality. This retrospective study aims to analyze clinical and radiological results, failure rates, and complications in a series of patients treated with a halo vest, validating the effectiveness of this device through long-term follow-up. Materials and methodsThis study reviewed adult patients with acute upper cervical spine injuries treated with halo vest immobilization from 1994 to 2022. Fracture types were classified based on Computed Tomography (CT) characteristics. Clinical and radiological follow-ups were performed at the end of treatment and at 3 months after the removal of the system. ResultsMost treated patients were males (70%) with a mean age of 38 years. Car accidents were the primary cause of injury (63%). Among 161 patients, 134 had a C2 fracture, 20 had a C1 fracture, 5 had a C1-C2 rotational dislocation, and 2 had other unclassified combined C1/C2 fractures. Patients without additional injuries or neurological deficits had significantly shorter hospitalization (8 vs. 16 days and 12 vs. 22 days, respectively) compared to those with additional injuries (p value<.00001) or neurological deficits (p value=0.00164). At the 6-month follow-up, radiological and clinical outcomes were available for 147 patients. X-rays in 139 cases showed fracture fusion (94.6%). Clinical follow-up revealed normal or slightly reduced range of motion in 144 cases (98%). Pain was absent or episodic in all the patients except one. In 131 cases (89%), an excellent or good clinical result was achieved. Complications did not impact treatment. ConclusionsBased on our results, the halo vest is a valid treatment for atlanto-axial injuries in selected patients. This includes young and middle-aged individuals (up to 65 years old) with C1 and/or C2 fractures. Halo vest treatment is associated with minor complications and yields a high percentage of excellent/good clinical results.

C1-ring оsteosynthesis as a functionally preserving operation for unstable atlas fractures

Objective. To analyze the dynamics of pain syndrome, quality of life and functional status of patients with unstable atlas fractures after C1-ring osteosynthesis.Material and Methods. Study design: observational retrospective case series study (n = 15). The intensity of pain syndrome was assessed using the VAS scale before surgery, 3 days, and 3 and 6 months after surgery. The quality of life was assessed using the Neck Disability Index (NDI) before surgery, and 3 and 6 months after surgery. Functional status, as well as cervical spine range of motion (head turn left/right, flexion/extension) was assessed 3 and 6 months after surgery. The integrity of the atlas bone ring and the degree of fusion after fixation were assessed using axial CT scans; and the lateral mass separation was assessed using frontal CT scans. The criterion for transverse ligament injury was a separation of lateral masses of more than 8.1 mm. Results. All patients had C1 fractures type 3B according to Gehweiler, out of them 7 patients (46.7 %) had traumatic injury to the atlas transverse ligament according to Dickman type 1, and 8 patients (53.3 according to Dickman type 2. The average age of patients was 40 years (12; 71), the male/female ratio was 2/1. In 7 patients (46.7 %), the cause of injury was diving, in 6 (40.0 %) it was a traffic accident, and in 2 (13.3 %) – a fall from a standing height. Observation of patients revealed a positive dynamics in the form of statistically significant regression of pain according to VAS before and 6 months after surgery from 6.8 (6.0; 8.0) to 1.0 (1.0; 0.0) points (Z = -3.434; p = 0.001). A positive trend was also noted in the form of a decrease in NDI scores and an improvement in the quality of life after 3 (Z = -3.411; p = 0.001) and 6 months after surgery (Z = -3.410; p = 0.001). The range of motion (turn left/right, flexion/extension) increased statistically significantly by the 6th month after C1-ring osteosynthesis, and its indicators were close to physiological ones. Postoperative CT scans showed positive dynamics in the form of statistically significant regression of the lateral mass separation from 10.4 mm (8.9; 11.4) to 2.2 mm (1.8; 2.6); Z = -3.408; p = 0.001. Complete fusion of the atlas fracture was observed after 12.5 months (8.5; 16.5).Conclusion. Isolated posterior osteosynthesis of the atlas ring for Gehweiler type 3B injury using a repositioning compression maneuver under distraction conditions is physiologically justified. It is a reliable method of stabilization, ensures the restoration of congruence and the entire range of motion in the atlanto-occipital and atlantoaxial joints and stability of the occipital-atlantoaxial complex. This operation contributes to a considerable and long-term reduction in the intensity of pain syndrome and a significant improvement in the quality of life.

Comparison of surgical and conservative therapy in older patients with distal radius fracture: a prospective randomized clinic al trial

IntroductionThe distal radius fracture is considered the most common fracture in humans. For fractures classified as Arbeitsgemeinschaft für Osteosynthese (AO) 23-C1 + C2, there is no consensus on treatment in older patients due to inconsistent study results. The aim of this study was to compare conservative and surgical treatment in relation to wrist function and satisfaction in patients older than 65 years.MethodsIn this prospective randomized clinical trial, patients aged older than 65 years who suffered an isolated AO-classified C1 or C2 distal radius fracture were randomized to surgical treatment using palmar plate osteosynthesis or conservative treatment. Patient-rated wrist evaluation (PRWE) score and disabilities of arm, shoulder, and hand (DASH) was assessed 3, 6 and 12 months post-interventionally. Satisfaction, range of motion (ROM) and pain scores were evaluated at 6 weeks and 3, 6 and 12 months post-interventionally.ResultsA total of 80 patients with a mean age of 77.3 years (± 6.1 years) in the conservative group and 72.5 years (± 5.3 years) in the surgery group were included. Both the PRWE score, and the DASH score showed a statistically significant difference between the two groups after 3 months, 6 months and 12 months (p < 0.001). Patients in the surgical cohort showed a statistically significant higher satisfaction at the 6-week, 6-month and 12-month follow-up (p < 0.001 6 weeks + 12 months; p = 0.004 6 months).ConclusionIn this prospective randomized study, surgical treatment proved to be superior to conservative treatment in terms of the primary outcome variable PRWE score. Satisfaction was significantly better in the surgical group.

Rotation Preserving Fixation for the Treatment of C1 Burst Fracture Combined With Type II Odontoid Fracture: 2 Case Reports and Literature Review.

This study aimed to evaluate the clinical feasibility and effectiveness of a monoaxial screw-rod system and anterior screw fixation for C1 and type II odontoid fractures. We conducted a retrospective review of 2 consecutive patients with acute C1 and Anderson-D'Alonzo type II odontoid fractures. Both patients underwent treatment using a posterior monoaxial screw-rod system and anterior screw fixation. We reviewed their clinical records, including the visual analog pain scale and Neck Disability Index scores, as well as pre- and postoperative radiographs. Additionally, pre- and postoperative computed tomography images were used to classify the fracture types and assess the C1 to C2 reduction, rotation, and instability. Both patients presented with type II C1 and type II B odontoid fractures, combined with Dickman type II transverse atlantal ligament injuries. All surgical procedures were successfully performed without complications such as vertebral artery injury, neurological deficit, esophageal injury, or wound infection. Both patients achieved almost complete bone healing of the fractures, and C1 to C2 rotation was well preserved (32° and 49°) without atlantoaxial instability after follow-ups of 21 and 25 months, respectively. A monoaxial screw-rod system and anterior screw fixation could be promising surgical strategies for C1 fractures combined with type II odontoid fractures, even in cases involving transverse atlantal ligament injuries. The preservation of C1 to C2 rotation without atlantoaxial instability was observed after fixation. However, extensive case-finding and long-term follow-up are needed to understand the effectiveness of this treatment. In order to preserve the C1-C2 rotation, a monoaxial screw-rod system and anterior screw fixation may be more suitable for patients with C1 fractures combined with type II odontoid fractures.

Postmortem CT and autopsy findings in an elevator-related death: a case report

AbstractElevator-related fatalities and injuries are rarely discussed. Falls have been identified as the first cause of mortality in the majority of these accidents. Evidence suggests that many elevator accidents may be attributed to inadequate equipment maintenance or malfunctions of the devices. This study examines a case involving an elevator maintenance worker found within an elevator shaft, using postmortem computed tomography (PMCT) along with a full autopsy. The autopsy revealed that the cause of death was severe polytrauma resulting from dragging, compression, and crushing mechanisms, which resulted in a dislocated skull and multiple thoraco-abdominal injuries, including exposed organs and viscera. Detailed examination identified a cranio-encephalic crush, leading to a significant alteration in the physiognomy of the facial structures. Additionally, PMCT revealed complex spinal fractures, such as a Jefferson fracture and a complete Chance fracture at the D6 vertebra, accompanied by spinal deviation proximal to the fracture site. Autopsy findings corroborated these PMCT results. A multidisciplinary approach, including PMCT, is proposed as a strategic method for the comprehensive reconstruction of such accidents, facilitating the collection of extensive data.

Assessing the Impact of Undiagnosed C1‒C2 Rotatory Subluxation in the Conservative Treatment of Odontoid Fractures

The presence of clear high-grade rotatory subluxation, in addition to an odontoid fracture, is a definite indication for surgery. However, the presence of a more subtle subluxation-Grades 1, 2, or 3-can often be overlooked, and as a result, prognostic associations with C2 fractures are rare. In light of this, we assessed the failure rate of conservative management in patients with both an odontoid fracture and a concurrent C1‒C2 rotatory subluxation. Retrospective, cohort (nested case‒control) study of patients with odontoid C2 fractures with or without C1‒C2 joint rotatory subluxation was performed. Patients were classified according to the type of odontoid fracture (Alonzo classification) and the presence of C1-C2 subluxation (Feldings classification). The number of patients who were initially treated with collars and then underwent surgery due to conservative treatment failure was analyzed. We performed logistic regression analysis to determine the odds ratio (OR) and generate a ROC curve of the association between the degree of subluxation and failure of conservative treatment. 115 patients with C2 fractures that were treated conservatively with or without C1‒C2 rotatory subluxation. Of all 115 , 29 (25%) experienced treatment failure and required surgery. A statistically significant correlation was found between treatment failure and the presence of rotatory subluxation ,(odds ratio 10), compared with patients without C1-C2 subluxation. In our series, C2 Alonzo fractures with a C1‒C2 rotatory subluxation had a 10-fold increased risk of secondary displacement and subsequent need for surgery. Further research on this association could improve the management of these conditions.

Diagnosis and Treatment of Cervical Spine Fractures in Children

Background. Cervical spine injuries in children are relatively uncommon and account for approximately 1.5% of trauma admissions. The aim of our study was to determine the incidence and patterns of pediatric cervical spine fractures in a single Trauma Center over the last decade.Material and methods. The hospital’s medical database was queried for data from the period between January 2014 and December 2023. An initial search revealed that 511 patients had been hospitalized with neck injuries in that time frame. Among these records, we identified 24 patients with a fracture of the cervical spine. The inclusion criteria were: (1) age under 18 yo, (2) fracture of the cervical spine (3) follow-up of at least 6 months. A thorough analysis was performed, including injury mechanism, diagnosis, medical procedures and final outcome., A Neck Disability Index (NDI) was assessed for all patients at the six months’ follow-up visit to evaluate treatment outcomes.Results. The study group consisted of 14 boys and 10 girls aged 4.6 to 18 years (average age 14.2). We diagnosed one case of an isolated C1 fracture, six C2 fractures, two C4 fractures, two C5 fractures, two C7 fractures, and nine cases of multiple spinal fractures. Additionally, we diagnosed two cases of cervical spine dislocation: one of right-sided rotational dislocation of C6/C7 and one of complete dislocation of C2/C3. Eight patients were treated surgically by open reduction combined with anterior plate fixation. Four patients were treated using a halo vest. Eleven patients were treated conservatively: six using a Minerva orthosis, four with a cervical-thoracic orthosis, and one with a rigid cervical collar. The highest NDI values were encountered in the group of patients with concomitant intracerebral injury, where the mean value was 18.6/45 (12-26/45). The mean NDI score for the remaining patients was 4/45 (0 - 9/45).Conclusions. 1. The incidence of cervical spine fractures in children is low. 2. Most cervical spine injuries in children are treated conservatively with good outcomes. 3. Both conservative and surgical treatment of cervical spine fractures in children produces good results 4. Computed Tomography remains the gold standard for diagnosing cervical spine fractures in children. 5. The halo-vest in pediatric patients suffering from C2 fractures was well tolerated and provided good outcomes. 6. Surgical treatment of lower cervical fractures by open reduction with anterior fusion is efficient in terms of fusion status and patient satisfaction. 7. Prospective, randomized, multicenter studies are required to assess the epidemiology, methodology, and treatment effects of cervical spine fractures in children.

Far Cortical Locking Versus Standard Constructs for Locked Plate Fixation in the Treatment of Acute, Displaced Fractures of the Distal Femur

Background: Fixation of distal femoral fractures remains a challenge, and nonunions are common with standard constructs. Far cortical locking (FCL) constructs have been purported to lead to improved fracture-healing as compared with that achieved with traditional locking bridge plates. We sought to test this hypothesis in a comparative effectiveness clinical trial. Methods: This randomized trial was performed across 16 centers and included adult patients with an AO/OTA type 33A or 33C distal femoral fracture that was suitable for bridging fixation. We excluded patients with periprosthetic fractures. Participants were randomly assigned to either FCL fixation or standard locking plate fixation. The primary outcome was a hierarchical composite of radiographic and clinical fracture-healing at 3 months after fixation. We estimated between-group differences with use of the win ratio approach. Secondary outcomes included radiographic healing, clinical fracture-healing, complications, reoperations, and health-related quality of life (Short Form-36 Health Survey Version 2 [SF-36] Physical Component Summary and Mental Component Summary scores) at 3, 6, and 12 months after fixation. Results: We randomly assigned 193 patients to treatment with either FCL screws (96 patients) or standard screws (97 patients). The study population had a mean age of 63.4 years, consisted predominantly of women (68%), and was well-balanced between AO/OTA 33A and 33C fractures. Based on 4,355 pairwise comparisons, the calculated win ratio was 1.18 (95% confidence interval [CI], 0.77 to 1.79; p = 0.45), indicating that patients assigned to FCL screws had better outcomes in 51% of the comparisons. Radiographic healing did not differ significantly between the groups (odds ratio, 1.36; 95% CI, 0.69 to 2.72; p = 0.38), nor did Function IndeX for Trauma (FIX-IT) scores (p = 0.41). There were no significant differences between the groups in terms of SF-36 Physical Component Summary scores at 3 months or in the change in scores at 12 months after fixation. Conclusions: In this multicenter randomized trial of adult patients with an AO/OTA type 33A or 33C distal femoral fracture, similar clinical and radiographic healing outcomes were observed in the FCL and standard fixation groups. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The establishment of a novel upper cervical complex fracture classification system

BACKGROUND CONTEXTUpper cervical complex fractures are associated with high rates of neurological damage and mortality. The Dickman's classification is widely used in the diagnosis of upper cervical complex fractures. However, it falls short of covering the full spectrum of complex fractures. This limitation hinders effective diagnosis and treatment of these injuries. PURPOSETo address the diagnostic gap in upper cervical complex fractures, the study introduces a novel classification system for these injuries, assessing its reliability and usability. STUDY DESIGNProposal of a new classification system for upper cervical complex fractures. PATIENT SAMPLEThe study comprised the clinical data of 242 patients with upper cervical complex fractures, including 32 patients treated at our hospital, along with an additional 210 cases from the literature. OUTCOME MEASURESThe inter-observer and intra-observer reliability (kappa coefficient, κ) of this classification system were investigated by 3 spine surgeons. The 3 researchers independently re-evaluated the upper cervical complex fracture classification system 3 months later. METHODSThe proposed classification categorizes upper cervical complex fractures into 3 main types: Type I combines odontoid and Hangman's fractures into 2 subtypes; Type II merges C1 with odontoid/Hangman's fractures into 3 subtypes; and Type III encompasses a combination of C1, odontoid, and Hangman's fractures, divided into 2 subtypes. Meanwhile, a questionnaire was administered in 15 assessors to evaluate the system's ease of use and clinical applicability. RESULTSA total of 45 cases (18.6%) unclassifiable by Dickman's classification were successfully categorized using our system. The mean κ value of inter-observer reliability was 0.783, indicating substantial reliability. The mean κ value of intra-observer reliability was 0.862, indicating almost perfect reliability. Meanwhile, thirteen assessors (87.7%) stated that the classification system is easy to remember, easy to apply, and they expressed intentions to apply it in clinical practice in the future. CONCLUSIONSThis system not only offers high confidence and reproducibility but also serves as a precise guide for clinicians in formulating treatment plans. Future prospective applications are warranted to further evaluate this classification system.

Osteosynthesis by locking plate for proximal tibial fractures

IntroductionTreatment of proximal tibial fractures is known to be difficult. We report our own experience of the treatment of these fractures and evaluate our results. The hypothesis was that the clinical and radiological results were good. Material and MethodFrom January 2004 to October 2008, fourteen AO-type 41A2–3 and C1 fractures have been treated with a LCP locking plate (8 women and 6 men, average age 60.42). Plating was performed either with an open approach or a minimal invasive approach. Clinical and radiological follow-up was carried out looking for range of motion of the knee joint and autonomy level. ResultsMean follow-up was 32.63 months (12–70). Range of motion was maintained with a mean arch of 117.5° Autonomy was maintained in all cases. Professional, domestic and sports activities were unchanged. No infection or general complication occurred. Bone fusion was obtained in all cases after an average of 13.28 weeks. 6° of valgus deformation, already seen immediately postoperatively was observed once. Secondary displacement was observed in 6 cases, with an average of 2.83° Discussion-conclusionWe report good radiological results, with only one initial malalignment. The hypothesis was confirmed. However, X-ray analysis at consolidation shows 6 secondary displacements, without any satisfactory explanation. Though the clinical consequences of these malunions are minimal. Osteosynthesis with plate, in the sight of this study, yields good clinical results. Radiological evolution concerning the evolution of bone axes puts the emphasis on careful operative technique and adequate time to weight bearing. Level of evidenceretrospective study, IV

Percutaneous treatment of type C distal radius fractures using dual-external fixator

BackgroundThis study aimed to introduce a potential alternative percutaneous treatment for AO types C1, C2, and C3 distal radius fractures using dual-external fixator (a no-bridging cemented-pin frame and a conventional wrist-bridging external fixator). Materials and methodsFrom January 2018 to January 2021, 52 patients (52 distal radius fractures) were treated with dual-external fixator. For comparison, 61 patients (61 distal radius fractures) were treated with a plate and screw system. Wrist function was assessed using the Mayo Wrist Score. Patient satisfaction was assessed using the Short Assessment of Patient Satisfaction. A P < 0.05 was considered statistically significant. ResultsFracture healing was achieved in all patients. At the final follow-up of 29 months (range, 24–34 months) vs 36 months (range, 26–39 months) (P > 0.05), the patients treated with dual-external fixator and a plate and screw system achieved mean ulnar deviations of 31° vs 29° (P < 0.05), mean Mayo Wrist Scores of 91.12 ± 5.98 vs 88.12 ± 7.54 (P < 0.05), and mean patient satisfaction scores of 23.42 ± 2.47 vs 23.04 ± 2.32 (P > 0.05). ConclusionsAO types C1, C2, and C3 distal radius fractures can be treated successfully using dual-external fixator. The technique is a potential alternative in addition to the conventional treatments. Level of evidenceLevel IIa.

Computed Tomographic Scan for Head Injury Patients: Any Justification for Adapting Routine Cranio-Cervical Examination Irrespective of Clinical Severity?

This study aimed to assess the prevalence of concomitant cervical spine and head injury at our University Teaching Hospital in Nigeria and attempted to justify examining patients' head and cervical spine using computed tomography (CT) scan at presentation irrespective of the head injury severity by clinical assessment using Glasgow Coma Scale (GCS). All eligible patients, 1-80 years of age who presented with head injuries in the accident and emergency (A&E) unit during the study period, were included if they satisfied the inclusion criteria. Post-resuscitation GCS was assessed clinically, and head and cervical spine injury (CSI) were observed radiologically on cranio-cervical CT scan for all patients. The presence of cervical spine fractures, subluxation or dislocation was considered a confirmation of CSI. There were 143 patients with head injuries studied; 90.2% of them were males. The mean age of the patients was 28.87 ± 15.93 years. The most common cause of injury was road traffic accidents in 110 (76.90%). The prevalence of CSI was 11.2%. Majority of the patients with CSI in this study (56.25%) had a mild head injury, 25% had a moderate head injury, and 18.75% had a severe head injury. The lower cervical spine was the most frequently injured segment in this study, involving 10 patients. Multi-level cervical vertebral body fractures of C3 to C6 were the most common form of CSI in this segment. The prevalence of concomitant cervical spine and head injury was significant in this study. This was confirmed among study subjects with a clinical diagnosis of mild-to-moderate head injury as compared with moderate-to-severe head injury. Therefore, all patients who sustained a head injury irrespective of severity are required to have a complete and rapid evaluation of the cervical spine.

Spontaneous resolution of traumatic cervical epidural hematoma: illustrative case.

Cervical epidural hematomas are rare and can arise for many reasons. Patients typically present with pain and/or symptoms of spinal cord compression. Prompt surgical decompression is typically pursued when deficits are present in an effort to improve long-term neurological outcomes. However, the authors report the case of a patient with a traumatic dorsal cervical epidural hematoma with spontaneous resolution within 16 hours. A 49-year-old male with a history of C5-6 anterior cervical fusion 3 years prior presented with neck pain after blunt force trauma. The exam revealed only tenderness in the cervical spine. Initial computed tomography revealed fractures of C1 and C4. Urgent magnetic resonance imaging (MRI) demonstrated a dorsal cervical epidural hematoma causing compression of the spinal cord from the occiput to C5. An operation was scheduled for the following morning; however, after he reported new symptoms, repeat MRI was performed, which confirmed no evidence of a cervical epidural hematoma. This case demonstrates that a traumatic cervical epidural hematoma can resolve spontaneously within a short time frame. Close monitoring of these patients is vital, and it is important to reimage patients if new signs and/or symptoms arise to potentially change the timing and/or nature of the proposed surgery. https://thejns.org/doi/10.3171/CASE24167.

In-hospital outcomes following surgery versus conservative therapy in elderly patients with C2 fractures: a propensity score-matched analysis.

Second cervical vertebrae (C2) fractures are a common traumatic spinal injury in the elderly population. Surgical fusion and nonoperative bracing are two primary treatments for cervical instability, but the former is often withheld in the elderly due to concerns for poor postoperative outcomes arising from patient frailty. This study sought to evaluate the in-hospital differences in mortality, outcomes, and discharge disposition in elderly patients with C2 fractures undergoing surgical intervention compared with conservative therapy. The National Trauma Data Bank was queried from 2017 to 2019 for all patients aged ≥ 65 years with C2 fractures undergoing either surgical stabilization or conservative therapy. Propensity score matching was performed using k-nearest neighbors with replacement based on patient demographics, comorbidities, insurance type, injury severity, and fracture type. Group differences were compared using Student t-tests and Pearson's chi-square tests with Benjamini-Hochberg multiple comparisons correction. Subgroup analyses were performed in the 65-74, 75-79, and 80+ year age subgroups. Six thousand forty-nine patients were identified, of whom 2156 underwent surgery and 3893 received conservative treatment. Following matching, the surgery group had significantly lower mortality rates (5.52% vs 9.6%, p < 0.001), a longer mean hospital length of stay (LOS; 12.64 vs 7.49 days p < 0.001), and slightly higher rates of several complications (< 3% difference), as well as lower rates of discharge home (14.56% vs 23.52%, p < 0.001) and to hospice (1.07% vs 2.09%, p = 0.02) and a higher rate of discharge to intermediate care (68.83% vs 48.28%, p < 0.001). Similar trends in mortality and LOS were noted in all 3 subgroups. In elderly patients with C2 fractures, surgical stabilization confers a small survival advantage with a slightly higher in-hospital complication rate compared to conservative therapy. The increased rate of discharge to rehabilitation may represent better long-term prognosis following surgery. The increased risk of short-term complications is present but relatively small, thus surgery should not be withheld in patients with good long-term prognosis.