Coronal Fracture Research Articles

In Brief: The Lichtman Classification for Kienböck Disease.

In Brief: The Lichtman Classification for Kienböck Disease.

Articular coronal fracture angle of posteromedial tibial plateau fragments: A computed tomography fracture mapping study

ObjectivesThe purpose of this study is to analyze posteromedial fragment morphology using two-dimensional computed tomography fracture mapping and to compare posteromedial fragment morphology in various Schatzker type tibial plateau fractures. Materials & methodsOne hundred twenty-seven consecutive AO/OTA B- and C-type tibial plateau fractures were retrospectively analyzed using 2DCT fracture mapping. The posteromedial articular fracture angle and articular surface areas of all fractures with posteromedial fragments were calculated. Based on biomechanical studies, posteromedial fragments with coronal fracture angles >68° were considered amenable for anterolateral stabilization with standardized plating. Kruskall-Wallis non-parametric test was used for statistical comparison of morphological features of posteromedial fragments between the various Schatzker types. ResultsForty-seven out of 127 tibial plateau fractures included a posteromedial fragment. The mean posteromedial articular fracture angle was 44° (range: 2°-90o, standard deviation: 23°). Forty fragments (85%) had a fracture angle of <68°, increasing the risk for insufficient stabilization with standardized anterolateral plating. The mean articular surface area was 34% of the entire tibial plateau (range: 7%–53%, SD: 12%). There were no significant differences in posteromedial fragment morphology between Schatzker type IV, V, and VI fractures. Discussion and conclusionPosteromedial fragments commonly occur not only in Schatzker type V and VI, but also in Schatzker type IV tibial plateau fractures. Eighty-five percent of tibial plateau fractures with a posteromedial fragment may benefit from non-standard customized lateral plating, or may require an additional medial or posterior surgical approach for fracture-specific fixation to optimize screw purchase and biomechanical stability.

Clinical experience with management of Hoffa fractures using headless compression screw and headed screw

Purposeto analyze the radiological and functional outcomes of patients after surgical treatment of coronal plane fractures of femoral condyle using headless compression screw and cannulated cancellous (CC) screws (headed screws). Material and methodIn this prospective study 30 cases were included, out of which 15 were treated with headed screws and other 15 were treated with headless screws. Active knee mobilization exercises were started from the third postoperative day. Initially, patients were kept non-weight bearing; partial weight bearing was started at 10 weeks and progressed to full weight bearing as tolerated. Follow-up visits conducted at 2, 4 and 12 weeks, thereafter at 6 and 12 months. The long term final results were rated using Neer's rating system. ResultsResults were graded as excellent (score > 85), Satisfactory (score 71–85), Unsatisfactory (score 56–70), and Failure (score < 55). In CC screw group the outcome was good in 10 cases (66.66%) and poor in 5 cases (33.33%) whereas in headless group outcome was good in 13 cases (86.66%) and poor in 2 (13.33%) Conclusionfixation of Hoffa fracture with headless compression screw in comparison to CC screw (Headed Screw) have no significant difference in terms of functional outcome like range of motion but complications and implant failure is significantly higher in cases fixed with CC screw than in headless screw. So we conclude that overall outcome is better in study group fixed with headless compression screw as compared to cases fixed with CC Screw.

Dorsolateral Biplane Closing Radial Osteotomy and Lunate Fixation for Stage IIIC Kienböck Disease: A New Surgical Approach.

The treatment of advanced-stage Kienböck disease (KD) remains highly controversial. Particularly important is stage IIIC KD, which includes patients with a lunate coronal fracture. The purpose of this paper was to describe a new approach to KD in patients with Lichtman stage IIIC KD, and our results using it. The procedure combines a dorsolateral biplane closing radial osteotomy and lunate fixation. A total of 11 patients from January 2002 through December 2016 with documented KD who underwent this technique were included. The patients were assessed before surgery, then postoperatively at 1 and 10 days, 3 and 6 weeks, 3 and 6 months, and annually. Wrist range of motion, grip and pinch strength, the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, a Modified Mayo Wrist Score (MMWS), 10-point visual analog scale, radiologic measurements, and data related to consolidation were collected. All statistical analyses were performed using the statistical software package SPSS. Some degree of pain relief, improvements in the QuickDASH score, MMWS score, grip strength, and the degrees of flexion and extension were observed, the results being statistically significant (P<0.05). After surgery, the values for radial and sagittal tilt were statistically different than those measured before surgery. Carpal collapse was not evident either before or after surgery. In conclusion, combining a dorsolateral radial osteotomy and a lunate compression screw may expand the options for patients with Lichtman stage IIIC KD. Our experience indicates that it is a viable option in challenging clinical scenarios.

Fixation of the Fractured Lunate in Kienböck Disease.

To describe an uncommon subset of fractured lunates in Kienböck disease that is salvageable by internal fixation. We performed a retrospective review for patients with Kienböck disease treated by internal fixation. Demographic data, objective and radiographic measurements, patient-reported outcome measures (Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation) and pain (visual analog scale) scores were collected. Of the 7 patients treated, 5 were available for review. At an average follow-up of 7.1 years (range, 1.5-15 years), all patients had activity-related wrist pain but were pain-free at rest. Radiographic assessment showed union in all lunates and a normal radioscaphoid angle and Stahl index. The modified carpal height ratio was reduced in 4 patients and normal in one. There was no observed narrowing or irregularity of the radiocarpal or midcarpal joints. Patient-reported outcome measures in 2 patients were unsatisfactory. Computed tomography of the lunate in Kienböck disease is an important investigative tool. A coronal split fracture of these lunates can be salvageable by internal fixation. Revascularization of the lunate can be performed when the fragment is of sufficient size. Therapeutic V.

Algorithmic treatment of Busch-Hoffa distal femur fractures: A technical note based on a modified Letenneur classification

Treatment of distal femur fractures in the coronal plane can be challenging. Depending on fracture line orientation, topography and associated comminution, decision-making regarding approach and fixation is not straightforward and can result in complications. Therefore, treatment of coronal plane distal femur fractures (Busch-Hoffa fractures) should be approached in a systematic manner, leading to efficient planning and operative execution. Here, we offer a proposed treatment algorithm, guiding treatment, approach and fixation based on the modified Letenneur classification of coronal plane distal femur fractures.

MANAGEMENT OF COMPLICATED CROWN FRACTURE BY REATTACHMENT WITH SUPER BOND: A CASE SERIES

Coronal fracture of teeth is a prevalent form of dental trauma. Mainly it affects anterior teeth due to accidental injury, but sometimes posterior teeth may also get affected. The immediate restoration of the original fractured segment not only offers an alternative treatment in the emergency but also restores patient

Research progress of posteromedial rotatory instability of the elbow

To summarize the research progress in posteromedial rotatory instability (PMRI) of the elbow joint. The recent researches about the management of PMRI of the elbow joint from the aspects of pathological anatomy, biomechanics, diagnosis, and therapy were analyzed and summarized. The most important factors related to PMRI of the elbow joint are lateral collateral ligament complex (LCLC) lesion, posterior bundle of the medial collateral ligament complex (MCLC) lesion, and anteromedial coronoid fracture. Clinical physical examination include varus and valgus stress test of the elbow joint. X-ray examination, computed tomography, particularly three-dimensional reconstruction, are particularly useful to diagnose the fracture. Also MRI, arthroscopy, and dynamic ultrasound can assistantly evaluate the affiliated injury of the parenchyma. It is important to repair and reconstruct LCLC and MCLC and fix coronoid process fracture for recovering stability of the elbow joint. There are such ways to repair ligament injury as in situ repairation and functional reconstruction, which include direct suturation, borehole repairation, wire anchor repairation, and transplantation repairation etc. The methods for fixation of coronal fracture include screw fixation, plate fixation, unabsorbable suture fixation, and arthroscopy technology. It is crucial that recovering the stability of the elbow joint and early functional exercise for the treatment of PMRI. Individual treatment is favorable to protect soft tissue, reduce surgical complications, and improve the functional recovery and the quality of life.

Management of isolated coronal shear fractures of the humeral capitellum with Herbert screw fixation through anterolateral approach

BackgroundDue to the intraarticular and complex nature of the coronal shear fracture of the humeral capitellum and its rarity, it has been difficult to formulate a universally accepted method of surgical management. The purpose of this study is to retrospectively evaluate the clinical outcomes of 15 patients with isolated coronal shear fractures of the capitellum treated by Herbert screw fixation through anterolateral approach, and to address the safety and tips for this surgical procedure.MethodsThis retrospective study included 15 isolated coronal shear fractures of the capitellum without posterior involvement, which were classified according to the Dubberley classification as 11 type 1A fractures and 4 type 3A fractures. All fractures were treated with Herbert screws fixation via the anterolateral approach. Clinical and radiographic evaluation was performed regularly, with a mean follow-up of 29 months.ResultsThe mean operative time was 81 min. There were no wound healing problems or infection. One incomplete posterior interosseous nerve injury occurred, which recovered soon without residual compromise. All fractures healed well. At the final follow-up, the average range of motion was 134°in flexion-extension and 172°in supination-pronation. There was no significant difference between the affected and the unaffected elbows with regard to motion in flexion-extension or flexion-extension. The average Mayo Elbow Performance Index Score was 93 with 11 excellent and 4 good. No evidence of avascular necrosis, posttraumatic osteoarthritis, or heterotrophic ossification was found.ConclusionOpen reduction and internal fixation using Herbert screws through a anterolateral approach is a reliable and effective treatment for coronal shear fractures of capitellum, and able to achieve stable fixation and restoration of a functional range of motion.

Fracture-pattern-related therapy concepts in distal humeral fractures.

Around one third of humeral fractures and 2–6% of all fractures occur to the distal part of the humerus. There is a bimodal distribution differentiating between young male patients with high-energy and elderly female patients with low-energy trauma related to osteoporosis. The AO classification and Dubberley subclassification are used in daily routine. Most fractures are diagnosed on radiographs. For further evaluation, three-dimensional computed tomography is recommended, especially for comminuted or complex fractures. Owing to the long immobilization and resultant poor functional outcome, conservative treatment is followed for inoperable patients. The operative approach and osteosynthesis depend on the fracture pattern. In A1 avulsion fractures, open reduction and screw fixation are recommended. In A2/A3 fractures, a triceps-sparing approach following a 90° double-plate construction (radial dorsal/ulnar lateral) with locking plates is favored. Partial articular B1/B2 fractures are exposed via a medial or lateral approach using unilateral locking plates to stabilize the medial/lateral column. Coronal shear fractures (B3) are classified after Dubberley and are treated via an extended Kocher approach and headless compression screws in anteroposterior direction. If there is a further posterior comminution or a lateral column fragment, stabilization is needed for the lateral/medial column with a precontoured locking plate. In solely articular fracture patterns, a dorsal approach with either a 90° or 180° double-plate construction is advised. If a reconstruction is not possible owing to fracture complexity or bone quality, total elbow arthroplasty is a viable option. However, lifelong limitation in weight-bearing up to 5 kg, limited longevity, and the potential for complicated revision surgery should be considered.

The Impact of Computed Tomography on Decision Making in Tibial Plateau Fractures.

Schatzker introduced one of the most used classification systems for tibial plateau fractures, based on plain radiographs. Computed tomography brought to attention the importance of coronal plane-oriented fractures. The goal of our study was to determine if the addition of computed tomography would affect the decision making of surgeons who usually use the Schatzker classification to assess tibial plateau fractures. Image studies of 70 patients who sustained tibial plateau fractures were uploaded to a dedicated homepage. Every patient was linked to a folder which contained two radiographic projections (anteroposterior and lateral), three interactive videos of computed tomography (axial, sagittal, and coronal), and eight pictures depicting tridimensional reconstructions of the tibial plateau. Ten attending orthopaedic surgeons, who were blinded to the cases, were granted access to the homepage and assessed each set of images in two different rounds, separated to each other by an interval of 2 weeks. Each case was evaluated in three steps, where surgeons had access, respectively to radiographs, two-dimensional videos of computed tomography, and three-dimensional reconstruction images. After every step, surgeons were asked to present how would they classify the case using the Schatzker system and which surgical approaches would be appropriate. We evaluated the inter- and intraobserver reliability of the Schatzker classification using the Kappa concordance coefficient, as well as the impact of computed tomography in the decision making regarding the surgical approach for each case, by using the chi-square test and likelihood ratio. The interobserver concordance kappa coefficients after each assessment step were, respectively, 0.58, 0.62, and 0.64. For the intraobserver analysis, the coefficients were, respectively, 0.76, 0.75, and 0.78. Computed tomography changed the surgical approach selection for the types II, V, and VI of Schatzker (p < 0.01). The addition of computed tomography scans to plain radiographs improved the interobserver reliability of Schatzker classification. Computed tomography had a statistically significant impact in the selection of surgical approaches for the lateral tibial plateau.

Bicondylar Tibial Plateau Fractures: A Critical Analysis Review.

* Bicondylar tibial plateau fractures represent a broad category of complex, high-energy injuries associated with a high surgical complication rate.* Computed tomography and magnetic resonance imaging aid in diagnosis, classification, and surgical planning and should be considered during the initial evaluation or after provisional stabilization is performed as part of staged treatment.* No one classification system has superior descriptive traits or reliability. Simply classifying the fracture as unicondylar (partial articular) or bicondylar (complete articular) is the most reliable approach.* Malalignment, especially in the coronal plane, and instability predict poor outcomes and should direct surgical intervention. Articular displacement is less predictive.* Dual plating is the most stable type of fixation biomechanically but is associated with soft-tissue complications.* Single lateral locked plating is an alternative fixation type for bicondylar fractures without a large posteromedial coronal fracture line.* Hybrid external fixators are another means of fixation that avoid large exposures and associated soft-tissue disruption.* No one fixation strategy is superior in all cases. Patient and injury characteristics should be evaluated on a case-by-case basis to optimally direct the treatment of these complex injuries.

Retrospective analysis of open reduction and internal fixation of coronal plane fractures of the capitellum and trochlea using the anterolateral approach.

Introduction: Coronal plane distal humeral injuries are relatively rare. Numerous classification systems have been proposed as the complexity of these fractures has been realized. We in the present series of ten patients describe the surgical technique of Open Reduction and Internal Fixation of Coronal plane fractures of the distal humerus with headless compression screws performed using the anterolateral approach.Material and method: It was a retrospective study, the data collected from March 2010 to 2015 was analysed and the final outcome was assessed using the DASH score. Out of a total of 13 patients with distal humerus coronal plane fractures, 10 patients were available for follow up. The X-rays and CT scans were reviewed and the fractures were classified according to Dubberley and Bryan and Morrey classification. Radiographic were evaluated for presence of union or nonunion, avascular necrosis, joint line step-off (none/1-mm/>1-mm), hardware failure and instability.Results: The average age was 41 years. The average DASH score in our study was around 24. The time to union ranged between 8–12 weeks with the average time being around 10 weeks. One patient had post traumatic Arthritis radiologically classified as Broberg and Morrey Type 2 and one patient had Heterotrophic ossification Brooker Grade 1.Conclusion: Open reduction and internal fixation of coronal shear fractures of capitellum and trochlea using headless screw compression via the antero-lateral approach is a reliable treatment modality and results in stable fixation with restoration of a functional arc of motion.Level of evidence: IV

Lečenje subluksacijske povrede istovremeno sa prelomom krunice - prikaz slučaja

Traumatic dental injuries are not only a serious public health problem, but they are also the most common injuries among children according to the epidemiological data. Subluxation is defined as the loosening of a tooth without displacement. Coronal fractures are the most common injuries. Considering the treatment options, which are suitable for the concomitant occurrence of these two traumatic injuries, there are only limited number of studies in the literature. In the concomitant occurrence of these two trauma types, like in other traumatic injuries, if the treatment is not implemented timely, long-term problems may develop. The objective of this case report was to describe the therapeutic approach to the subluxation concomitant with a coronal fracture.

Induced post-traumatic apexification: 20 year follow-up and morphological study after new fracture

Apexification is an endodontic technique used in immature necrotic teeth, the primary goal of which is to induce a calcified barrier in roots with open apices and to promote the continuation of apical root development. A 7-year-old patient with a coronal fracture in a maxillary central incisor was treated with an apexification technique using calcium hydroxide. The apical closure was obtained after one year, then a permanent root canal filling was performed. The tooth was monitored for a period of 20 years, up to when a trauma caused its extraction. The newly formed root was analyzed macroscopically, histologically and through scanning electron microscopy. A morphologically normal root was observed, with a large apex and accessory foramina, showing a combination of tissue structures similar to secondary and tertiary dentine, close to amorphous mineralized areas. Despite the final evolution of the case, calcium hydroxide apexification is a good therapy in order to treat pulp necrosis in an immature tooth, leading to complete development of the root and allowing the tooth to be kept in the mouth.

Endocrown in premolar using lithium disilicate-reinforced ceramic: a case report

Este caso clínico descreve a restauração de um dente tratado endodonticamente com uma endocoroa em cerâmica de dissilicato de lítio fabricada pelo sistema CAD/CAM. O caso é de uma paciente do sexo feminino, 48 anos, que apresentava fratura coronária de um dente tratado endodonticamente. Uma restauração com endocoroa em dissilicato de lítio fabricada pelo sistema CAD/CAM foi indicada. As coroas foram avaliadas usando um sistema de avaliação de qualidade da Associação Dental da Califórnia e exame de acompanhamento. Uma endocoroa cerâmica em dissilicato fabricada por CAD/CAM foi uma alternativa de tratamento restaurador confiável para um pré-molar tratado endodonticamente. O preparo minimamente invasivo para endocoroa que preserva o máximo de estrutura dentária é considerado padrão ouro para restaurações dentárias. Ainda, tal alternativa restauradora é mais conservadora em comparação à coroa total com retentor intrarradicular e apresenta apropriado desempenho mecânico e longevidade com um menor custo e rapidez no preparo.

Hoffa Fragments in the Geriatric Distal Femur Fracture: Myth or Reality?

Background:Previous research reported the frequency of coronal plane (Hoffa) fractures in high-energy supracondylar femur fractures in a relatively young population. It is the purpose of this study to identify the frequency of coronal plane fractures seen in elderly patients.Methods:All patients over the age of 18 years treated for supracondylar femur fractures at 2 level I trauma centers were reviewed over a 4-year period. The patients were stratified (≥60 years and <60 years) and compared to determine differences in injury characteristics and fracture patterns with special attention to the prevalence of coronal plane fractures.Results:One hundred ten patients were identified with supracondylar femur fractures (12 Orthopaedic Trauma Association [OTA] 33A; 2 OTA 33B; 96 OTA 33C). Thirty-two of the 96 intercondylar fractures were in patients >60 years of age. The elderly group included a higher percentage of females (81% vs 36%, P = .0001) and was more likely to sustain their injury due to a fall (59% vs 19%, P = .0001). Coronal plane fractures were visualized on computed tomography scans in 56 (58%) of the 96 33C femur fractures. Forty-four percent of elderly patients sustained a coronal plane fracture compared with 66% of the younger cohort (P = .04). The percentage of open fractures (30% elderly vs 46%) was not significantly different between the 2 groups (P = .17).Conclusions:The occurrence rate of 44% in this study was higher than expected and is the first to provide this information in the elderly patients on this fracture. It is important that a high index of suspicion be maintained for the Hoffa fracture in all distal femur fractures, regardless of age or mechanism of injury.

Surgically treated Hoffa Fractures with poor long-term functional results

IntroductionHoffa fractures are rare injuries and usually involve the lateral condyle. There are few published studies of large series of isolated coronal plane fractures of the femoral condyle. The aim of the study to determine the long-term functional outcomes and complications in surgically treated Hoffa fractures. Patients and methodsA retrospective review was made of 13 consecutive patients who were treated surgically for an isolated coronal plane fracture of the distal femur posterior condyle. The patients were evaluated with physical examination, PA and lateral radiographs and CT at the final follow-up examination. Functional outcome was evaluated with the OXFORD knee scoring system and Knee Society Score (KSS). Pain at rest and in activity was assessed using a Visual Analog Scale (VAS). ResultsThe patients comprised 11 males and 2 females with an average age at surgery of 27.5 years. The mean follow-up period was 93 months (range, 62–134 months). Mean time to fracture healing was 10 weeks (range, 8–12 weeks). The mean ROM was determined as 110°, mean KSS 78,4 and mean Oxford knee score 38,2. The mean KSS was 66,5 for medial Hoffa fracture patients and it was 83,8 for lateral Hoffa fracture patients. The mean Oxford knee score was 33,2 for medial Hoffa fracture patients and it was 40,4 for lateral Hoffa fracture patients. The mean VAS at rest and in activity was 1,1 and 2,9, respectively. Osteoarthritis was seen in 7 (54%) patients and avascular necrosis in 2 (15.4%). Varus instability was determined in 1 patient and valgus instability in 1 patient. ConclusionHoffa fractures may easily be overlooked if the radiological examination is not made carefully. Screw fixation was seen to provide enough biomechanical stability until the fracture healed. Arthrosis is a frequent long-term complication which worsens the functional results. Medial Hoffa fractures tend to have worse functional results than lateral Hoffa fractures. Level of evidence: Therapeutic Level IV retrospective case series.

The Correlation Between Vertical Laminar Fractures and the Severity of Associated Burst Fractures.

Patients with laminar fractures have a higher chance of experiencing severe trauma and neurologic deficit. In previous studies, laminar fractures were divided into different types based on the axial plane of computed tomographic scans. No report described the morphology of vertical laminar fractures in the coronal plane. Furthermore, the correlation between a specific type of laminar fracture and the extent of severity of thoracolumbar (TL) burst fractures has rarely been mentioned. A retrospective evaluation of 341 patients with TL burst fractures with or without laminar fractures were divided into 6 groups based on the morphology observed across reconstructed coronal and axial computed tomographic planes. The Thoracolumbar Injury Classification and Severity Score (TLICS), Load Sharing Classification (LSC), and American Spinal Injury Association (ASIA) impairment scale were evaluated for each patient. Intergroup comparisons were also performed for all metrics. The TLICS, LSC, and ASIA impairment scale were determined for each laminar fracture group. Statistical differences were found in most intergroup comparisons across all metrics. Significantly higher injury scores were observed in the groups with a more severe coronal and axial laminar fracture, and the injury severity in the coronal scan played a more decisive role. The morphology of vertical laminar fractures as observed across multiple image planes was more complex and accurate than an analysis based solely on the axial plane. Different morphologies indicated differences in the severity of associated TL burst fractures. The laminar fracture in the coronal plane was associated with the severity of spinal injury.

Extensile lateral approachによる上腕骨遠位端coronal shearfractureの治療経験

Extensile lateral approachによる上腕骨遠位端coronal shearfractureの治療経験