Concomitant Soft Tissue Injuries Research Articles

Prevalence and Predictors of Concomitant Meniscal and Ligamentous Injuries Associated With ACL Surgery: An Analysis of 20 Years of ACL Reconstruction at a Tertiary Care Children’s Hospital

Background: There is an increasing rate of procedures being performed for concomitant injuries during anterior cruciate ligament (ACL) surgery. Few studies have examined risk factors for these associated injuries in young patients. Hypothesis: There are patient-related factors predictive of concomitant knee pathology that differ between age-based cohorts. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Natural language processing was used to extract clinical variables from available notes of patients undergoing ACL surgery between 2000 and 2020 at a single institution (5174 ACL surgeries; mean age, 17 ± 4 years; 53.1% female; accuracy, >98%). Patients were stratified to pediatric (5-13 years), adolescent (14-19 years), and young adult (20-35 years) cohorts. Logistic regression was used to determine predictors of concomitant injury to the menisci, medial collateral ligament (MCL), posterolateral corner (PLC), and posterior cruciate ligament (PCL). Results: Between 2000 and 2020, 54% of pediatric, 71% of adolescent, and 70% of adult patients had ≥1 concomitant soft tissue injury. In children and adolescents, increased age was consistently predictive of sustaining a concomitant injury (P < .02). Female children had increased odds of concomitant medial meniscal injury, while female adults had decreased odds (P≤ .046). Adolescent and adult female patients had decreased odds of concomitant lateral meniscal injury (P≤ .027). Female children had increased odds of injury to the MCL (P = .015), whereas female children and adolescents had decreased odds of PCL injury (P≤ .044). Adolescents undergoing revision ACL surgery had increased odds of meniscal injury (P≤ .001) and decreased odds of concomitant MCL injury (P = .028). Increased body mass index (BMI) was associated with increased odds of concomitant medial meniscal injury in all cohorts (P≤ .041), lateral meniscal injury in adults (P = .045), and PLC injury in children (P = .016). Contact injuries were associated with increased odds of MCL injury in adolescents (P = .017) and PLC injury in adolescents and adults (P < .014). Conclusion: These findings support the hypothesis, as there were multiple factors that significantly affected the risk of concomitant injuries that differed between cohorts. Increased age, BMI, and contact injury history were generally associated with increased odds of sustaining a concomitant injury, whereas female sex and revision ACL surgery had mixed effects. Further studies are essential to investigate the sex-based differences in risk for concomitant injuries and to develop tailored treatment plans that minimize the risk of secondary ACL injury.

Hoffa fractures are associated with concomitant soft tissue injures and a high postoperative complication rate

IntroductionHoffa fractures are a rare and often overlooked entity. The main goal of surgical treatment is to restore the articular surface and maintain knee function. However, current clinical data indicate heterogeneous outcomes. The aim of this multicenter study was to obtain a representative data set of patients with isolated Hoffa fractures with special emphasis on concomitant soft tissue injuries, diagnostic algorithms, treatment strategies and functional outcomes.Materials and methodsParticipating Level I trauma centres were asked to review their internal database for isolated Hoffa fractures treated surgically between 2010 and 2020. Demographics, mechanism of injury, diagnostic and therapeutic algorithm, Letenneur classification, concomitant soft tissue injuries, and postoperative knee function and complications were analysed.ResultsA total of 56 patients from six participating trauma centres were included. The median age at injury was 45 years (15–94) with a median follow-up of 19 months (2–108). The most common mechanism of injury was high-energy trauma, with unicondylar lateral Letenneur type I and II fractures being the most common. Surgical treatment was independent of the type of fracture and included isolated screw fixation, combined plate and screw fixation and isolated plate osteosynthesis. Isolated screw fixation resulted in significantly better range of motion (ROM) values (p = 0.032), but the highest number of postoperative complications (n = 14/20, n.s.) compared to the other fixation techniques. The highest number of fixation failures requiring revision was observed in the plate and screw fixation group (n = 3/8, p = 0.008). Osteochondral flake fractures (n = 12/43, 27%) and lateral meniscus injuries (n = 5/49, 10%) were commonly seen in Hoffa fractures.ConclusionsTreatment of Hoffa fractures with screw fixation resulted in significantly better functional outcomes, probably due to less comminuted fractures. Concomitant cartilage, meniscal and ligamentous injuries are common and warrant preoperative recognition and management.

Poster 326: Concomitant Meniscal and Ligamentous Injuries Associated with Pediatric and Adolescent ACL Tears: Data from the Boston Children’s Hospital ACL Registry

Objectives: There has been a well-documented increase in pediatric and adolescent ACL injuries and surgery in recent years, especially in athletes. ACL tears are infrequently isolated injuries, as there are known associated concomitant injuries. However, the risk factors for and incidence of these different associated injuries are poorly characterized, particularly in this high-risk population. Therefore, the purpose of this study was to use a large database of pediatric and adolescent ACL surgeries to examine the incidence of common concomitant soft tissue injuries and their associated risk factors in this sub- population. Methods: Following institutional review board approval, a natural language processing (NLP) pipeline was developed to identify ACL surgery cases from the electronic health records of patient evaluated at Boston Children’s Hospital Orthopedics and Sports Medicine clinics between 2000-2020 (from &gt;23 million notes). Following training and validation, the model achieved median accuracy of 98%, median sensitivity 97% and median specificity of 98% in identifying ACL surgery cases and extracting variables from clinical visits and operative notes. Stepwise logistic regression was performed to evaluate the associations between sex, age, body mass index (BMI), injury mechanism (contact vs. non-contact injury), and history of prior ipsilateral ACL injury with presence of concomitant injuries to the meniscus (lateral, medial, or both), medial collateral ligament (MCL), posterior cruciate ligament (PCL) and posterolateral corner (PLC), which was defined as any grade 2 or 3 fibular/lateral collateral ligament, popliteofibular ligament, or popliteus tendon injury. Adjusted odds ratios (aOR) and corresponding 95% confidence interval (95%CI) were calculated and considered significant at P&lt;.05. Results: The model identified 5,648 ACL surgeries from 4,992 unique patients of any age (age: 17.0 ± 4.0; 53% females), of which 4,727 surgeries (4,221 unique patients, age: 15.9 ± 2.2; 55% females) were performed in children and adolescents (&lt;20 years old). Of these cases in the study population, 2,895 (61%) demonstrated at least one concomitant soft-tissue injury. These concomitant injuries included 1,715 (36%) medial meniscus injuries, 1,632 (35%) lateral meniscus injuries, 1,274 (27%) MCL injuries, 312 (7%) PCL injuries, and 445 (9%) PLC injuries. For meniscal injury, higher BMI (aOR=1.03 [95%CI: 1.01, 1.04]) and older age (aOR=1.12 [95%CI: 1.09, 1.15]) were associated with increased rate of concomitant medial meniscus injuries (P&lt;.001). Similarly, higher BMI (aOR=1.02 [95%CI: 1.00, 1.03]), older age (aOR=1.09 [95%CI: 1.06, 1.12]), and history of prior ipsilateral ACL injury (aOR=1.39 [95%CI: 1.10, 1.76]) were associated with increased rate of concomitant lateral meniscus injury, while female sex (aOR=0.79 [95%CI: 0.70, 0.90]) was associated with decreased rate of concomitant lateral meniscus injuries (P&lt;.01). Female sex (aOR=1.31 [95%CI: 1.14, 1.51]), older age (aOR=1.17 [95%CI: 1.14, 1.21]), and contact injury (aOR=1.59 [95%CI: 1.36, 1.85]) were associated with increased rate of concomitant MCL injury. History of prior ipsilateral ACL injury (aOR=0.68 [95%CI: 0.52, 0.89]) was associated with decreased rate of concomitant MCL injury (P&lt;.01). Older age (aOR=1.06 [95%CI: 1.01, 1.12]) was associated with increased rate of concomitant PCL injury, while female sex (aOR=0.63 [95%CI: 0.49, 0.79]) was associated with decreased rate of concomitant PCL injury (P&lt;.03). Finally, older age (aOR=1.21 [95%CI: 1.15, 1.27]) and contact injury (aOR=1.37 [95%CI: 1.10, 1.69]) were associated with increased rate of concomitant PLC injury, whereas history of prior ipsilateral ACL injury (aOR=0.46 [95%CI: 0.27, 0.78]) was associated with decreased rate of concomitant PLC injury (P&lt;.01). Conclusions: The current largescale single-site study of well over 4,000 surgical cases suggests that the majority (61%) of pediatric and adolescent ACL injuries are accompanied with one or more injuries to major soft tissue structures within the knee, with injuries to the medial and lateral menisci being the most prevalent. Notably, this rate is higher than what was previously reported in the pediatric literature, adding additional concerns and complexities to the clinical care of pediatric and adolescent patients with ACL tears. Higher BMI, older age, and a contact injury mechanism showed consistent adverse effects, in terms of concomitant soft tissue injury risk. History of prior ipsilateral ACL injury and female sex had some positive and some negative prognostic value, in terms of soft tissue risk, though to a varying degree. Specifically, older age and higher BMI were associated with increased rates of concomitant meniscal injury, which is in line with current literature. Patient with contact injuries were more likely to have injury to the collateral ligaments. The sex-related differences in injury patterns, as well as the potentially protective effect of prior ipsilateral ACL injury on collateral ligaments suggest potentially lower energy injury mechanisms being associated with ACL graft tear, compared with native ACL ligament tear. Given the implications of concomitant soft tissue injuries on overall prognosis and arthritis risk in this young, active sub-population, these data underscore the importance of future studies investigating prevention strategies and awareness and the vigilance ACL surgeons must apply to the detection and thoughtful treatment of these common additional injuries.

Relationship between Time to Surgical Debridement and Rate of Wound Infection in Open Tibia Fracture in a Tertiary Care Hospital

Background: The most frequent open long bone injury requiring immediate surgical intervention is an open tibial fracture. Within 6 hours of the injury, emergent surgical debridement of an open tibia fracture is advised by current guidelines. Recently, the 6-hour rule became challenged and delaying in debridement of an open fracture may be unethical. Methods: This cross-sectional study was carried out to assess the relationship between time of surgical debridement and rate of infection after open fracture tibia at National Institute of Traumatology and Orthopedic Rehabilitation (NITOR) on 608 patients with open fracture tibia (all Gustilo types) within 24 hours of injury from January 2018 to October 2019. Results: The mean age of the 608 patients was 36.2±15.5 years. The foremost mechanism of injury was road traffic accident (72.0%) and among the associated injuries, concomitant soft tissue injury (32.5%) was prevalent. Gustilo III was predominant injury (72.1%) and infection rates among the Gustilo subtype II was predominant (31.3%). After debridement 73 (12.0%) patients were contamination free. A significant association was found in the contamination rate between surveillance culture and post-debridement culture (p=0.000). Positive correlation found between debridement done ≥6 hours and infection present in 3rd culture from ward (r=0.237). Conclusion: The study insights that injury characteristics, infection pattern and infection rate of open fracture tibia. Delay in debridement has a significant relationship with wound infection, with more virulent multidrug resistance phenotypes.

Epidemiology of Traumatic Peripheral Vascular Injury in Patients Presenting at Tertiary Care Center of Nepal

Introduction:Traumaticperipheralvascularinjuryremainsasignificantcauseofmorbidityandmortalityamongthegeneralpopula- tion. Majority of peripheral arterial injury are caused by a blunt trauma with a concomitant soft tissue injury and fractures requiring multidisciplinaryapproach.Despitemajoreffortsinestablishingprotocolsandguidelines,optimalstrategiesoftraumaticperipheral vascular injury are still under investigation and may vary depending upon the local setup and expertise available. The aim of this study was to identify the epidemiological profile of traumatic peripheral vascular injury presenting at tertiary care center of Nepal. Method: This is a retrospective study of patients who underwent vascular surgery in College of Medical Sciences Bharat- pur, from December 2018 and July 2021. Ethical approval was taken from the Institutional Review Committee of College of Medical Sciences (Registration Number 2020-081). Data for the study was retrieved from Emergency records, oper- ation records and medical record department of the hospital. A total of 63 cases of all age and sex were included in the study. Only patients having traumatic peripheral arterial injury and undergoing surgical intervention were included in the study. Patient data was initially tabulated using Microsoft Excel and analysis was done in SPSS software version 22.0. Result:Traumatic peripheral arterial injury was most commonly seen in 21-30 years (36.5%) age group with male preponderance (88.9%).Sharpinjurymechanismaccountedfor(42.9%),followedbyroadtrafficaccidents(41.3%).Upperlimbarterialinjurywasseenin 61.9% of patients and radial artery was the most common to be injured (34.9%). Associated tendon injury was seen in 63.5%, whereas nerveinjurywasseenin20.6%.Complicationswereseenin47.6%patientsandwoundinfectionwasthemostcommonailment(12.7%). Conclusion:Traumatic peripheral vascular injury has a male preponderance with road traffic incidents being the major mechanism of injury in Nepal. These injuries have a high rate of complications.

Biplanar Proximal Tibial Opening-Wedge Osteotomy for a Chronic PCL Tear With Medial Compartment Arthritis

Background: Chronic posterior cruciate ligament (PCL) insufficiency leads to instability of the knee, resulting in increased loading of the medial and patellofemoral compartments. Chronic PCL insufficiency progressively damages the menisci and chondral surfaces and can accentuate and worsen varus malalignment. Biplanar proximal tibial opening-wedge osteotomy (BPTO) is a treatment option for chronic PCL tears with medial compartment arthritis which concurrently treats sagittal (flat slope) and varus coronal alignment. Indications: Opening-wedge BPTO is indicated in active patients who present with varus malalignment and flat slope with concomitant degenerative medial compartment osteoarthritis and PCL insufficiency. In general, BPTO is contraindicated in patients with a significantly elevated body mass index (BMI), smokers, or in those who have advanced tricompartmental osteoarthritis. Technique Description: Preoperative long-leg radiographs are essential to preoperative evaluation. Ideal coronal alignment following correction would have the mechanical axis pass through the apex of the lateral tibial eminence to properly off-load the medial compartment. Magnetic resonance imaging (MRI) studies are also useful for determining the presence and extent of concomitant soft tissue and chondral injury, especially in the lateral compartment. This video demonstrates the senior author’s preferred technique for a biplanar proximal tibial opening (PTO) with concomitant chondroplasty and partial medial meniscectomy (PMM). The senior author’s preferred order of operations is also displayed and involves first performing an arthroscopy, then proceeding with the open portions of the case, including the medial approach and subsequent osteotomy. Results: Past studies have supported PTO as a reliable treatment option for varus malalignment. Bode et al reported a 5-year survival rate of 96% of patients with an overall complication rate of 8.6%. The authors also reported that Lysholm scores were also significantly improved at 60-month follow-up compared with preoperative scores. Discussion: This is a technique for the correction of a varus malalignment with concomitant flat slope and PCL insufficiency with biplanar open-wedge PTO. This operation corrects the mechanical axis and sagittal slope of the knee and restores proper load distribution across the tibiofemoral articulation. In conclusion, a biplanar open-wedge PTO is a useful alternative to joint arthroplasty for active patients with a chronic PCL tear, medial compartment arthritis, and varus malalignment. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Periarticular distal radius fractures and complex ligamentous injury: The role of arthroscopic evaluation

PurposeDistal radius fractures are associated with a high incidence of concomitant soft tissue injuries, including lesions of the triangular fibrocartilage complex and intercarpal ligaments. While advanced imaging has allowed for greater identification of such tears, discerning which lesions pose a functional consequence remains a challenge for the hand surgeon. A review and guideline for arthroscopic evaluation of suspected combined injuries is presented. ResultsArthroscopic evaluation of distal radius fractures provides several unique advantages in such instances. Articular reduction can be performed via direct visualization with improvement in step-off and gapping. Furthermore, ligamentous injuries and carpal alignment can be directly assessed and treated. ConclusionsSubtle features of combined ligamentous trauma may be overlooked in the presence of more obvious fracture patterns. Wrist arthroscopy allows not only for a gold-standard method of evaluating of these soft tissue injuries, but also a means of treatment.

Role of Multidetector Computed Tomography in the Evaluation of Maxillofacial Trauma.

Maxillofacial fractures are among the commonest injuries occurring in trauma patients. Multislice computed tomography (CT) is a widely used radiological investigation that accurately reveals the number, location, and extent of the fractures as well as concomitant soft tissue injuries and has been found to be superior in the diagnosis of maxillofacial fractures owing to high sensitivity and specificity. This study was performed to assess the efficacy of axial, coronal, sagittal, and three-dimensional (3D) reformatted images in the detection of fractures in maxillofacial trauma. This was a cross-sectional descriptive study conducted on 49 adult patients with maxillofacial injuries undergoing multislice CT using a multidetector SiemensSOMATOM Emotion eco 16 slice CT scanner (Siemens AG, Munich, Germany). CT protocol consisted of non-contrast axial 16-slice helical series beam collimation ~ 3 mm, pitch ~ 0.8 - 1, tube current ~ 270 mAs, voltage ~ 130 kV, Total exposure time ~ 18 seconds, total radiation ~ 200 mGy. Along with the axial, coronal and sagittal images were reconstructed with 0.5 mm increment. 3D volume-rendering images were also obtained. 3D images were compared with axial images, coronal and sagittal plane images. The maximum number of cases was in the age group of 21-30 years with the male: female ratio being 5.12:1. The most common cause of injury was road traffic accidents (RTA). Mandible fractures were found to be the most common (20 patients, 40.8%) followed by fractures of nasal bone (18 patients, 36.7%). The incidence of frontal bone fractures was found to be the least(six patients, 12.24%). Our study found that 3D images are superior to axial in assessing the extent and degree of displacement of maxillofacial fractures in general. The maxillary sinus was found to be the most commonly fractured sinus (19 patients, 38.7%). Sphenoid sinus fractures were the least common (seen in two patients, 4.08%). CT findings correlated with the operative findings in most types of fractures. Multidetector CT with multiplanar and 3D reformation is highly accurate in the identification of fractures and assessing the extent and degree of displacement of fractures; hence, it is the imaging modality of choice in maxillofacial trauma.3D images are much better for the detection of maxillofacial fracturescompared to axial, coronal, or sagittal views, especially in maxilla and mandibular bone fractures. It is also found to be betterat providing information on thepatterns of the fracture lines and the displacement of the fracture fragments. Another added advantage of multidetector CT is that it is a non-invasive technique with good accuracy and a short scan time.

A CLINICORADIOLOGICAL STUDY TO EVALUATE CONCOMITANT INJURIES IN ANTERIOR CRUCIATE LIGAMENT INJURED PATIENTS

Introduction: The anterior cruciate ligament (ACL) is a major stabilizer of the knee and so it is constantly injured . Purpose of this study was to evaluate concomitant injuries associated with ACL tear with respect to age, sex and duration since injury. This is a Materials and Methods: hospital based cross-sectional study conducted in 70 ACL injured patients of age group 19-50 years. Clinical tests to detect ACL and other soft tissue injuries of knee joint were carried out and positive ndings are further evaluated and conrmed with MRI. 64.29% cases of ACL Results: injury were associated with other concomitant soft tissue injuries. The most common concomitant injury was medial meniscus tear which was associated with 45.71% cases and second commonest was lateral meniscus injury accounting for 37.14% cases. The prevelance of medial meniscus injury increases with increasing duration since trauma and this association was found to be statistically signicant . Concomitant injuries were more frequent in patients who presented late after trauma and in older age groups and these associations were found to be statistically signicant. Conclusion: The high prevalence of concomitant injuries to the ACL found in this study points to the necessity for further investigation of injury to adjacent soft tissues in ACL injured patients so that more appropriate therapeutic practices can be implemented before and after the surgery

Management of tibial plateau fractures with special reference to column classification

Objective of the paper is to evaluate the outcome of the management of tibial plateau fractures with reference to Luo’s three column classification concept. The selection of surgical approach and appropriate fixation construct was dictated by the number of distinct articular fragments on CT scans and the concomitant soft tissue injury. The primary outcome measure was to evaluate the relationship between the number of column involved and fixation construct on secondary loss of reduction at healing. Secondary loss of reduction was defined as a change of alignment of ≥ 5 degrees into either varus or valgus at union. The secondary outcome measures were delayed union, non-union, peri-implant fracture and infection rates. Functional outcome were evaluated using Knee Society Score. Forty-six patients were available for final follow up. Immediate postoperative mal-alignment was noted in 5 patients. For our primary outcome measure, we have one patient with secondary loss of reduction at final follow-up in double plating group. Secondary outcome measures showed non-union in 1 (2.17%), delayed union in 3 (6.52%), superficial infection in 3 (6.52%) and deep infection in 1 patient (2.17%). No peri-implant fracture was seen. The mean time for bone healing and full-weight bearing walk was 14.5 weeks. The mean range of motion of the affected knees was 2.39 to 131.27 at final follow-up of 12 months. In sight of the findings of our study along with existing literature Luo’s three column classification is an ideal classification in managing tibial plateau fractures as it dictates the appropriate fixation construct based on the number articular fragments. However it does not take into account the integrity of soft tissues, which is almost universal association with high velocity complex tibial plateau fractures. Hence, repercussions of use of fixation construct with multiple plates will unfold in future with long follow-up comparative studies addressing the bony as well as soft tissue complications.

Risk factors for major amputation after arterial vascular trauma of the lower extremity.

Arterial vascular trauma bears a great risk of poor functional outcome or limb loss. The aim of this study was to analyze amputation rates of patients after vascular trauma and to perform a predictor analysis for the risk of major amputation. In a single-center retrospective analysis of 119 extremities treated for arterial vascular injury between 1990 and 2018 amputation rates and factors associated with limb loss were assessed. All patients were treated for traumatic vascular injuries; iatrogenic injuries were not included in the study. During the study period, a total of 119 legs in 118 patients were treated after arterial vascular trauma. The in-hospital major amputation rate was 16.8% and the mortality rate was 2.5%. In the predictors analysis, vascular re-operation (amputation rate 53.8% vs 12%, odds ratio = 8.56), a Rutherford category ⩾IIb (25.4% vs 4.2%, odds ratio = 6.43), work-related or traffic accidents (28.2% vs 0%, odds ratio = 4.86), concomitant soft tissue or bone injuries (26.7% vs 7.3%, odds ratio = 4.64), polytrauma (33.3% vs 12%, odds ratio = 3.68), and blunt trauma (18.9% vs 0% for penetrating trauma, odds ratio = 1.64) were found to be associated with amputation. Lower extremity arterial vascular trauma was associated with a significant major amputation rate. Several predictors for limb loss were identified, which could aid in identifying patients at risk and adapting their treatment.

The role of arthroscopy in the diagnosis of concomitant soft tissue injuries in scaphoid fractures and the effect of concomitant soft tissue injuries and fracture comminution on outcomes: A case-control study.

Objectives This study aims to evaluate the role of arthroscopy in the diagnosis of concomitant injuries, to investigate the relationship between comminution and concomitant injuries, and to analyze the effect of concomitant injuries on functional outcomes in acute and subacute scaphoid fracture.Patients and methods Between January 2011 and September 2018. A total of 32 acute scaphoid fracture patients (29 males, 3 females; mean age: 30±12 years; range, 18 to 65 years) were retrospectively analyzed. None of them had an obvious ligament injury in the radiological assessment. Functional outcomes were compared between concomitant and non-concomitant injuries and between comminuted and non-comminuted injuries. The percentage of range of motion (ROM), grip, and pinch strength were recorded according to the contralateral extremity to detect the restriction rate. The Mayo Wrist Score (MWS), the Turkish version of the Quick Disability of the Arm, Shoulder, and Hand (Q-DASH) and Patient-Rated Wrist Evaluation (PRWE) questionnaires were used to evaluate the functional results. Subjective pain was assessed using the Visual Analog Scale (VAS). The relationship between concomitant injuries and comminution was investigated.Results There were 13 patients with comminuted fractures. Concomitant injuries were diagnosed in 17 patients. The presence of concomitant injuries was higher in comminuted fractures than in non-comminuted fractures. There was no significant difference between the groups in ROMs. The final follow-up Q-DASH, PRWE, MWS, and VAS scores and the pinch strength of non-comminuted fractures were found to be statistically better than those of comminuted fractures. There were statistically worse Q-DASH, PRWE, MWS, and VAS scores in patients with concomitant injuries.Conclusion Arthroscopic scaphoid fracture surgery allows the diagnosis and treatment of concomitant lesions. The functional outcomes of concomitant lesions and comminuted fractures seem to be worse than those of others, while the ROM is comparable.

Retrospective Cohort Study of Frequency and Patterns of Orbital Injuries on Whole-Body CT with Maxillofacial Multi-Slice CT

Background: High-impact trauma frequently leads to injuries of the orbit, but literature focusing on the viscerocranium rather than the neurocranium is underrepresented. Methods: Retrospective cohort study (2006–2014) at an urban level 1 trauma center assessing the frequency and typical patterns of orbital injuries on whole-body computed tomography (WBCT) with maxillofacial multi-slice CT (MSCT) after severe trauma. (1) Screening of consecutive WBCT cases for dedicated maxillofacial MSCT. (2) Examination by two independent experts’ radiologists for (peri-/)orbital injuries. (3) Case review for trauma mechanisms. Results: 1061 WBCT were included revealing 250 (23.6%) patients with orbital injuries. Less than one-quarter (23.3%) of patients showed osseous and 9.5% showed soft tissue injuries. Combined osseous and soft tissue lesions were present in 39.2% of orbital injuries, isolated soft tissue injuries were rare. Single- or two-wall fractures of the orbit were prevalent, and the orbital floor was affected in 67% of fractures. Dislocated extraocular muscles (44.6%), deformation of the ocular globe (23.8%), and elongation of the optic nerve (12.9%) were the most frequently soft tissue findings. Vascular trauma was suspected in 15.8% of patients. Conclusions: Orbital trauma was confirmed in 23.6% of cases with suspected facial injuries after severe trauma. Concomitant soft tissue injuries should be excluded explicitly in cases with orbital fractures to prevent loss of vision or ocular motility.

Screw Fixation of Pediatric Tibial Tubercle Fractures.

Tibial tubercle fractures are rare injuries that account for <1% of physeal fractures. These fractures are thought to be increasing in frequency, particularly in young, adolescent males who participate in basketball and other sports with repeated running and jumping. The tibial apophysis becomes mechanically vulnerable as the proximal tibial physis closes from posteromedial to anterolateral, enabling the quadriceps to overpower the chondroepiphysis and avulse the proximal tibial epiphysis from the tibial metaphysis. Position the patient supine with the leg on a bump or bone foam. Perform a longitudinal incision centered over the fracture site (i.e., the tibial tubercle); a medial parapatellar incision may be utilized if an intra-articular component is present. Develop medial and lateral soft-tissue flaps to expose the fracture. Evaluate the soft-tissue stripping and capsule. Debride any hematoma, fracture fragments, and soft tissue from the fracture site with use of irrigation and a curet. Use a towel clip, bone clamp, and/or ballpoint pusher to reduce the fragment. Place 2 to 3 parallel guide pins from anterior to posterior, capturing fracture fragments within the epiphysis and apophysis under fluoroscopic guidance. Carefully place a guidewire in the distal fragment to avoid splitting the fragment, which is often small. An arthrotomy or arthroscopy is utilized to assess intra-articular reduction if necessary. Assess and measure pin lengths and placement with use of fluoroscopy. Place screws sequentially to avoid rotation of the fragment and take care to avoid splitting the fragment when placing distal screws. Repair any patellar, capsular, retinacular, or meniscal damage. A suture anchor may be utilized to repair the patellar tendon if necessary. The skin is closed in a layered fashion. Apply a cylinder cast or hinged knee braced locked in extension. Nonoperative treatment in a long-leg cast in extension may be considered for nondisplaced fractures or fractures that are stably reduced with <2 mm of displacement and acceptable alignment in the cast following reduction. Operative treatment is indicated for fractures with ≥2 mm of displacement, intra-articular extension with an incongruent joint, and for patients who will not tolerate being non-weightbearing in a cast. Closed reduction is generally attempted for fractures without intra-articular extension. If closed reduction is successful, fixation may be performed with Kirschner wires and/or percutaneous screws. Open reduction is often necessary and has been reported to be performed in as many as 98% of surgical cases for tubercle fractures2. This approach allows access to intra-articular displacement and the ability to obtain a stable, anatomic reduction while addressing concomitant soft-tissue injury, if present. The expectation following successful reduction and screw fixation of tibial tubercle fractures is that these young patients will be able to regain their motion and strength, and ultimately return to preinjury activity levels. A consecutive series of 86 patients with surgically treated tibial tubercle fractures found that all patients demonstrated full radiographic healing at the time of the latest follow-up (range, 3 to 34 months), return to full activities between 10 and 42 weeks, return of good to excellent range of motion in 89% of patients, and a 10% to 20% complication rate, including partial physeal arrest, decreased range of motion, quadriceps contracture, and painful implants. Additionally, a systematic review of 23 articles with 336 surgically treated tibial tubercle fractures found 98% of patients return to preinjury activity and knee range of motion with a 28% complication rate (most commonly due to painful implants). Place the fluoroscopic image view across the room from the surgeon for ease of viewing.Use computed tomography or magnetic resonance imaging if the fracture has intra-articular extension.Use 4.5 or 6.5-mm cannulated, partially threaded screws.Carefully monitor for compartment syndrome.Place screws by hand, sequentially.

Fabrication and in vitro evaluation of 3D composite scaffold based on collagen/hyaluronic acid sponge and electrospun polycaprolactone nanofibers for peripheral nerve regeneration.

Replacement of peripheral nerve autografts with tissue engineered nerve grafts will potentially resolve the lack of nerve tissue especially in patients with severe concomitant soft tissue injuries. This study attempted to fabricate a tissue engineered nerve graft composed of electrospun PCL conduit filled with collagen-hyaluronic acid (COL-HA) sponge with different COL-HA weight ratios including 100:0, 98:2, 95:5 and 90:10. The effect of HA addition on the sponge porosity, mechanical properties, water absorption and degradation rate was assessed. A good cohesion between the electrospun PCL nanofibers and COL-HA sponges were seen in all sponges with different HA contents. Mechanical properties of PCL nanofibrous layer were similar to the rat sciatic nerve; the ultimate tensile strength was 2.23 ± 0.35 MPa at the elongation of 35%. Additionally, Schwann cell proliferation and morphology on three dimensional (3D) composite scaffold were evaluated by using MTT and SEM assays, respectively. Rising the HA content resulted in higher water absorption as well as greater pore size and porosity, while a decrease in Schwann cell proliferation compared to pure collagen sponge, although reduction in cell proliferation was not statistically significant. The lower Schwann cell proliferation on the COL-HA was attributed to the greater degradation rate and pore size of the COL-HA sponges. Also, dorsal root ganglion assay showed that the engineered 3D construct significantly increases axon growth. Taken together, these results suggest that the fabricated 3D composite scaffold provide a permissive environment for Schwann cells proliferation and maturation and can encourage axon growth.

Surgical and Nonsurgical Pediatric Hand Fractures: A Cohort Study.

This retrospective cohort study reports on hand fractures in a large pediatric population and identifies the characteristics and patterns of fractures that required surgical correction. A χ2 analysis was done to evaluate the association between individual fracture variables and surgery. The STROBE checklist was applied. One thousand one-hundred seventy-three hand fractures were reviewed. Peak age was 16 years for boys and 14 years for girls. Most fractures were closed (96.0%) and nonrotated (91.3%), and had no concomitant soft tissue injury (72.7%). More than half (56.3%) were nonepiphyseal plate fractures; yet as a single diagnosis, Salter-Harris II fractures were most common (30.2%). The following variables were significantly associated with surgery: open fractures, rotational deformity, distal phalangeal fracture location, multiple fractures, oblique pattern, comminution, displacement >2 mm, intra-articular involvement, and angulation >15°. Most fractures required only immobilization and early range of motion (64.3%). Closed reduction was required in 22.7%. Minor surgery by the primary provider was performed in 3.2% of fractures. Surgery by a hand surgeon was performed in 9.8%. The most common patterns requiring surgery were proximal or middle phalanx head or neck fractures (38.2%) and metacarpal midshaft fractures (20.9%). The most common operation was open reduction internal fixation (52.2%). Pediatric hand fractures are common, but 90.2% do not require surgery and, as such, primary providers play a key role in management. Certain fracture variables and patterns are more likely to lead to surgery.

Occult scaphoid fractures: current evidence and diagnostic algorithm

Scaphoid fractures are frequent but are overlooked in 20-40% of cases on initial radiographs. In so-called occult scaphoid fractures, i.e. clinical scaphoid fractures with negative X‑ray diagnostics, the hand of the patient is often empirically immobilized with acast and the X‑ray diagnostics repeated 10days later. Based on the current literature the authors propose adiagnostic algorithm that incorporates various patient characteristics and socioeconomic aspects and suggests a possible follow-up treatment. For high-demand and manually working patients, timely advanced diagnostic imaging may be medically and socioeconomically meaningful. Pensioners and patients with low manual demands, however, can be treated according to the traditional algorithm. Additional use of computed tomography (CT) or magnetic resonance imaging (MRI) diagnostics with or without intra-articular contrast agent might be helpful if concomitant soft tissue injuries are suspected.

Tibial spine avulsion fractures: treatment update.

The purpose of this review is to summarize and clarify the current framework for treating tibial spine avulsion fractures (TSAFs). We will discuss how these fractures are classified both on plain radiographs and MRI as well as report the incidence of concomitant soft tissue injury, an important consideration that guides treatment. We will also compare guidelines for nonsurgical versus surgical treatment and summarize frequently used surgical techniques. Finally, we will review outcomes following treatment, including common complications. Although TSAFs only constitute 2-5% of all pediatric knee injuries, the incidence is increasing. A recently developed MRI-based system for evaluating TSAFs is another tool that aids in the treatment of these injuries. TSAFs can be classified using plain radiographs as well as MRI. Type I fractures are usually treated with immobilization whereas type II fractures typically undergo an initial attempt at closed reduction followed by arthroscopic or open reduction and fixation if needed. Type III fractures are indicated directly for arthroscopic surgery and both suture and screw fixation produce good clinical outcomes. All-epiphyseal or transphyseal approaches can minimize the risk of physeal injury in skeletally immature patients. Common complications following TSAF injury and treatment are residual laxity, knee stiffness, and nonunion or malunion.

Tendon healing in the context of complex fractures.

Tendons connect muscle to bone and play an integral role in bone and joint alignment and loading. Tendons act as pulleys that provide anchorage of muscle forces for joint motion and stability, as well as for fracture reduction and realignment. Patients that experience complex fractures also have concomitant soft tissue injuries, such as tendon damage or rupture. Tendon injuries that occur at the time of bone fracture have long-term ramifications on musculoskeletal health, yet these injuries are often disregarded in clinical treatment and diagnosis for patients with bone fractures as well as in basic science approaches for understanding bone repair processes. Delayed assessment of soft tissue injuries during evaluation of trauma can lead to chronic pain, dysfunction, and delayed bone healing even following successful fracture repair, highlighting the importance of identifying and treating damaged tendons early. Treatment strategies for bone repair, such as mechanical stabilization and biological therapeutics, can impact tendon healing and function. Because poor tendon healing following complex fracture can significantly impact the function of tendon during bone fracture healing, a need exists to understand the healing process of complex fractures more broadly, beyond the healing of bone. In this review, we explored the mechanical and biological interaction of bone and tendon in the context of complex fracture, as well as the relevance and potential ramifications of tendon damage following bone fracture, which has particular impact on patients that experience complex fractures, such as from combat, automobile accidents, and other trauma.

Using External Fixation in distal tibial fractures- good principle, debatable application- Case presentation

Abstract Distal tibial fractures usually result from high-energy trauma, affecting young, active people, producing long-term disability and numerous complications. Their treatment is difficult, especially in type C fractures, which affect both the articular surface and the metaphysis, are quite frequent comminuted fractures, and are accompanied by soft tissue injuries. In these situations, External Fixation (EF) is used as a temporary bridging method, either for treating concomitant soft tissue injuries (in open fractures) or for achieving and maintaining reduction in order to prevent blisters or compartment syndrome, possibly resulting from severe displacement, bleeding or oedema. It must be however underlined that EF is rarely a definitive method for these fractures, especially when the ankle is splinted, and it must be followed by definitive Internal Fixation (IF) - the so-called “sequential method”, otherwise restoration of a normal ankle anatomy and function is improbable, resulting in ankle stiffness or even osteoarthritis. This paper presents a case in which this principle was only partially applied, thus requiring corrective surgery followed by a long-term recovery period.