Distal Shaft Research Articles

Metabolic abnormalities underlying nonunion in the adult fracture patient

Introduction: The objective of this study is to comprehensively evaluate fracture type, category of nonunion, and metabolic profile to identify metabolic causes that may impact fracture union. Methods: A retrospective chart review of patients diagnosed with nonunion after fracture fixation was performed. Patient demographics, fracture characteristics, and metabolic profiles were assessed. Results: Data was collected from 94 patients with nonunion, with a mean age of 54.7 years, 50% men, 47.3% obese, and 60.8% current/former smokers. The most common nonunited bone was the femur (48%), tibia (22%), humerus (15%), ulna (5%), clavicle (3%), and fibula (2%). The distal femur, femoral shaft, and tibial shaft made up 50% of the nonunion. The intra-articular fracture was diagnosed in 13% and open injuries in 27%. The most common metabolic abnormalities were low hemoglobin (62.3%), elevated neutrophil percentage (61.9%), elevated erythrocyte sedimentation rate in women (51.8%), low testosterone (46.9%), and hypovitaminosis D (44.3%). Conclusion: The prevalence of metabolic abnormalities was documented across all nonunion types, suggesting this is not unique to atrophic nonunion. Given the high morbidity and cost of nonunion, and low cost of vitamin supplementation, future prospective studies are warranted to identify effective prevention and treatment.

Assessment and Validation of Anterior Humeral Line for Diagnosing Supracondylar Humerus Fractures in the Pediatric Population.

Pediatric supracondylar humerus fractures are commonly evaluated using the anterior humeral line (AHL) on a lateral radiograph. Rotational variations in radiographic projection are common due to child discomfort and could lead to changes in management based on where the AHL intersects the capitellum. The purpose of this study was to establish whether rotational variations in elbow rotation leads to significant changes in AHL position and whether drawing the AHL based on the distal humerus versus shaft is more tolerant to rotation. Fifty children with nonoperative supracondylar humerus fractures were identified with sub optimally positioned injury and well positioned follow-up lateral radiographs. The proportion of the bone anterior to the intersection of the AHL and the capitellum was measured using the humeral shaft versus distal humerus to guide position of the AHL. This process was repeated on ten pediatric humerus dry cadaveric specimens which were imaged in 5-degree rotational increments along the axis of the humeral shaft from -20 to +20 degrees. AHL position correlated poorly when measured on rotated lateral radiographs of clinical patients versus non-rotated lateral radiographs when using the distal humerus as a guide (intraclass correlation coefficient 0.14), compared with when using the humeral shaft as a guide (intraclass correlation coefficient 0.81). When assessing the pediatric humerus dry cadavers between the 2 techniques, there was greater statistically significant variation in rotated positions compared with the neutral position in the distal humerus AHL measurement approach compared with the humeral shaft AHL measurement approach, with the mean AHL within the central third of the capitellum for more rotational positions when using the shaft compared with the distal humerus. With rotated lateral elbow radiographs in supracondylar humerus fractures, utilizing the humeral shaft provides more consistent AHL measurements than utilizing the distal humerus, and thus drawing the line starting at the shaft of the humerus is recommended for surgical decision making.

Management of Humeral Fracture in a Dog at Klinik Bersama Dokter Hewan Jungle Bekasi

A humeral fracture is a discontinuity of the humeral bone due to an injury or illness. A three-year-old black mongrel female dog weighing 12.5 kg was brought to the Jungle Veterinary Clinic in Bekasi City, Indonesia, due to lameness and swelling in the left front limb. The radiological examination indicated an oblique fracture of the distal diaphysis of the left humerus. Haematological and biochemistry tests indicated neutrophilia, leukocytosis, and decreased erythrocyte, haemoglobin, hematocrit, MCV and MCH levels, while the levels of globulin and ALP were elevated. An orthopaedic surgery was performed using cerclage wires in conjunction with the intramedullary pin approach to immobilize the fracture. Post-surgery medical treatments were oral Amoxicillin 20 mg/kg, tramadol 5 mg/kg, meloxicam 0.1 mg/kg, Curcuma™ ½ tablet, Sangobion™ ½ tablet, and Kalmicetin™ ointment for topical wound dressing twice a day. The surgical wound healed and front leg function improved seven days after surgery

Comparison of Outcomes of Long Versus Short Cephalomedullary Nails for the Fixation of Intertrochanteric Femur Fractures: A Systematic Review and Meta-analysis of 14,547 Patients.

Intertrochanteric Femur Fractures (IFF) fixation could be done with short or long Cephalomedullary Nails (CMNs). Nevertheless, despite several studies in the literature, there has been a continued lack of consensus on which design of CMN is better than the other. Hence, the current review aimed to evaluate the evidence about short versus long CMNs for the fixation of IFF. PRISMA guidelines were followed, and the protocol for the study was registered to PROSPERO. Four databases, Medline/PubMed, Embase, Scopus, and Cochrane Library, were searched. A total of 31 studies with 6 randomized trials (RCTs) and 25 non-randomized studies were included. Demographic data, follow-up period, and primary and secondary outcomes were extracted and evaluated from each of the included studies; statistical analysis was done by Review Manager Software version 5.4.1. Fourteen thousand five hundred forty-seven patients were included in this review. Long CMNs showed statistically significant lower rates of ipsilateral shaft femur refracture (OR 1.60, 95% CI 1.14, 2.24, p = 0.007); however, the difference was not statistically significant between the two groups for mortality at 30days and within 1year. Statistically significant shorter duration of surgery (MD-17.83 (95% CI -22.03, -13.63, p < 0.05), less intra-operative blood loss (MD -62.65, 95% CI -97.13 to -28.17, p = < 0.05), and lower blood transfusion rates (OR 0.71, 95% CI 0.62, 0.83, p < 0.05) for short CMNs; no statistically significant difference for the length of hospital stay, implant-related complications, overall complications, re-operation rates, fluoroscopy time, and functional outcome between two groups of CMNs was seen. With shorter operative time, lesser intra-operative blood loss, and lower postoperative transfusion rates for short CMNs, they have certain benefits over longer CMNs. However, more distal shaft femur fractures were seen in the shorter versionof nail, which should be considered before offering these nails to a patient; careful and individualized postoperative weight-bearing protocol could minimize the same. The online version contains supplementary material available at 10.1007/s43465-023-00915-5.

Imaging of Parosteal Lipoma: A Case Report

Parosteal lipoma is an extremely rare benign tumor, accounting for 0.3% of all lipoma. They are often located in the lower limbs, contiguous to the periosteum, and associated with osseous changes. We present a case of a parosteal lipoma appearing in the distal femur with a bony excrescence in a 57-year-old female patient, presenting with a painless soft tissue mass that had been progressing for 10 years. Imaging showed a juxta cortical adipose mass, located in the mid and distal left femoral diaphysis, with adjacent cortical thickening, and osseous excrescences.

(152) A Case of Penile Neoplasm Masquerading as Acute Peyronie's Disease

Abstract Introduction Painful erections with curvature is pathognomonic for acute Peyronie’s Disease (PD). While resolution of pain and stabilization of curvature define the transition from acute to stable PD, there is high variability in the time from symptom onset to resolution. Thus, when to image and consider alternative diagnoses is poorly defined. We present a case of persistent distal penile pain and curvature with erections, initially diagnosed as acute PD, but subsequently found to be epithelioid hemangioendothelioma (EHE), a rare vascular neoplasm on the spectrum between a hemangioma and an angiosarcoma, with high probability of local recurrence and ability to metastasize. Objective To raise awareness that painful penile erections with curvature may not necessarily represent acute PD and foster discussion of when imaging, testing and alternative diagnoses should be considered. Methods Case report of a 51-year-old male seeking a third opinion for painful penile nodule with curvature of approximately four years duration. Results A 51-year-old male presented to our clinic complaining of an extremely painful penile nodule with curvature. He initially presented to another urologist with similar symptoms approximately 4 years previously and was diagnosed with acute PD. He had no prior history of penile trauma, erectile dysfunction, Dupuytren’s contractures or family history of PD. He was started on vitamin E, L-arginine and pentoxyphylline. He sought a second opinion about three years later when his symptoms remained unchanged and, again, was diagnosed with acute PD and told to return when his pain had resolved. His symptoms persisted and approximately 1 year later presented to our clinic for evaluation. Physical examination demonstrated a 1 cm tender nodule between the corpora cavernosa at the distal shaft. Pharmacologic erection demonstrated a 30-degree upward curvature at this site. Given the duration of his symptoms, ultrasound was obtained. A 1.4 cm circumscribed lesion with internal vascularity was identified; however, MRI identified dorsal angulation of the shaft in this area but did not visualize a mass. Due to extreme pain, the patient desired excision of the mass. Intraoperatively, a well circumscribed lesion with a vascular pedicle was identified between the corpora and the neurovascular bundle. The mass was easily excised without evidence of invasion of surrounding tissues. Final pathology demonstrated an epithelioid hemangioendothelioma with question of a positive margin. The case was discussed at a Multidisciplinary Tumor Board and given the sparsity of literature on the tumor, particularly in the penis, it was felt that excision of surrounding tissues to ensure negative margins would be best. The patient returned to the OR two weeks after his initial surgery and the surrounding corpora were excised. Final pathology demonstrated no evidence of residual malignancy. PET/CT was negative for metastatic disease. Conclusions While current guidelines indicate that penile angulation may rarely be due to other causes, including tumors, there are no recommendations on when alternative diagnoses should be investigated and imaging obtained. We present a case report of epithelioid hemangioendothelioma masquerading as acute PD that was identified due to abnormal duration of symptoms. Disclosure No

(532) An Innovative Combination of Penile Corporeal Girth Enhancement and Erection Restoration

Abstract Introduction It has been controversial in penile venous surgery for erection restoration and penile enhancement across three centuries thus far. Objective Based on the De Novo penile fibro-vascular assembly, we report an anatomy-physiology-based combination of a physiological penile corporeal diameter expansion and erection restoration surgery in recent decades. Methods From 2012 to 2022, intractable impotence and subjective micropenis prompted 23 men to seek penile venous stripping (PVS) and factual penile enhancement (TPE). All patients received dual cavernosography demonstrating penile venous anatomy and veno-occlusive dysfunction. PVS entailed the venous stripping of one deep dorsal vein and two cavernosal veins after every emissary's vein was double ligated 0.3 cm apart closest to the outer tunica with a 6-0 nylon suture. In addition, the para-arterial veins were just segmentally ligated. In TPE, a longitudinal incision was performed bilaterally over 3 and 9 O'clock positions along the pendulous penis. Every tunic defect was then water-tight sutures with a 7x3 cm rectangle venous stripe as an inner tunica bilaterally, subsequently covered with a piece of 7x3 venous wall, fascia tense lata, or a controlled tissue integration material sheet for surrogating the outer layer bilaterally. On penile girth and glans penis, the diameter was measured preoperatively and postoperatively in six months when a cavernosography was conducted, if available. Radio-opacity was used to compare the femoral cortex and the penile crus on preoperative and postoperative cavernosography. Additionally, the abridged 5-item version of the International Index of Erectile Function (IIEF-5) score system and the erection hardness scale (EHS) was used to confirm improvement preoperatively and postoperative follow-up yearly either by telephone or INTERNET. Results The average follow-up period was 5.3±0.8 years. The operation time was 7.2±1.8 hours. The material of outer patches was fascia tense lata (n=3), Surgifrom (n=6), penile vein (n=8), internal spermatic vein (n=3), and cephalic vein (n=3). The radiopacity was unexceptionally enhanced postoperatively. It was a significant difference between the preoperative and postoperative IIEF-5scores (9.7±2.8 vs. 20.8±2.3; P&amp;lt;0.01). The EHS improved at least one scale. The diameter of the glans and distal penile shaft is increased from 2.78±0.33 cm and 3.41±0.41 cm (n=18) to 2.98±0.32 cm and 3.49±0.31 cm, respectively. Although the satisfaction rate is only 70.0% (16/23), the intracorporeal retention and erection quality improvement were unexceptional. Conclusions This novel combination strategy of factorial penile enhancement and erection restoration is feasible. However, it requires a more significant sample size and longer-term follow; the surgery technology is conspicuously challenging. Disclosure No

(123) Novel Low Intensity Shockwave Therapy Sham Delivery Method (Zero Energy) Assessed Objectively by Grayscale and Doppler Ultrasound Results

Abstract Introduction Most ED LiSWT studies use the IIEF as a primary outcome. While clinically relevant, the IIEF does not directly assess erectile tissue structure. To establish a more objective parameter, we investigated the estimation of hypoechoic area in grayscale ultrasound images of erectile tissue as an objective primary outcome for clinical trials assessing the efficacy of LiSWT. During erection, grayscale imaging of the penis demonstrates corpora cavernosa (CC) that is homogenous in healthy men and heterogeneous to varying degrees in men with ED. A critical aspect of using grayscale ultrasound is to determine that sham treatment reliably results in no significant improvement in erectile tissue structure. Other studies have used sham probes with cotton wadding or non-penetrable gel pads to dampen delivery of shockwave energy flux density, however a small amount of energy may still be delivered. We report a novel sham-controlled methodology in LiSWT RCT for ED. Objective To evaluate erectile tissue heterogeneity as an endpoint in LiSWT sham-controlled trials using grayscale analysis of percent hypoechoic regions in CC after sham delivery of zero energy flux density. Methods A single-blind, sham-controlled, randomized prospective study was performed in men with ED naïve to any kind of acoustic wave therapy. Those meeting inclusion/exclusion completed baseline assessments and were randomized to active or sham within each treatment arm. This interim sub-analysis only examined the sham group (n = 7). For each treatment, the shockwave device was already on in the exam room. When the subject was ready a curtain was suspended above his mid-section blocking the device, and noise cancelling headphones provided. When the probe was placed on the penis, a high-quality recording of shockwave sounds was activated for sham treatment. Twenty weeks after zero energy sham treatment, grayscale and DUS imaging using a 15.4 MHz probe under pharmacologic erection 3-4/4 hardness was performed before unblinding. Grayscale percent hypoechoic regions within the CC were assessed by computer-assisted histometry using Image J. (Fig 1) The IIEF was also administered to all patients at baseline and week 20. Grayscale data were analyzed by two-way repeated measures ANOVA. IIEF-EF scores and bloodflow values (PSV and EDV) were compared using the Wilcoxon matched-pairs signed rank test. Results Compared to baseline, there were no significant changes (p&amp;gt;0.7; see figure) at week 20 in hypoechoic area in the proximal, middle, and distal erect penile shaft. (Fig 2) Furthermore, there were no significant changes in PSV (p&amp;gt;0.15), EDV (p&amp;gt;0.2), or IIEF-EF (p&amp;gt;0.6) from baseline to week 20. Conclusions Using computer-assisted histometry to determine hypoechoic area in grayscale ultrasound images to assess penile erectile tissue heterogeneity, we demonstrated that a novel sham treatment protocol that ensures zero energy delivery does not change erectile tissue integrity. The lack of improvement in PSV, EDV, and IIEF-EF further support our findings with grayscale ultrasound. Future studies will assess the appropriateness of grayscale ultrasound image analysis as a primary endpoint in LiSWT clinical trials. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: TRT, Cynosure.

Species of Dactylogyridae (Monogenoidea, Polyonchoinea) from the gills of haemulid and lutjanid fishes (Perciformes) from the Pacific coast of Mexico.

Examination of the gill lamellae of the Panama grunt Rhencus panamensis (Steindachner) (Haemulidae), golden snapper Lutjanus inermis (Peters), and yellow snapper Lutjanus argentiventris (Peters) (Lutjanidae) (Perciformes) from the coast of the Guerrero State (eastern Tropical Pacific) of Mexico revealed 5 species of Monogenoidea: Euryhaliotrema disparum n. sp. on R. panamensis; Haliotrematoides uagroi n. sp. on L. inermis; and E. anecorhizion Kritsky & Mendoza-Franco, 2012, E. fastigatum (Zhukov, 1976) Kritsky & Boeger, 2002, and E. paracanthi (Zhukov, 1976) Kritsky & Boeger, 2002 on L. argentiventris. Specimens found on R. panamensis were assigned within Euryhaliotrema as a new species possessing the atypical morphology of the male copulatory organ (i.e., a coiled tube with clockwise rings). Haliotrematoides uagroi n. sp. differs from Haliotrematoides striatohamus (Zhukov, 1981) Mendoza-Franco, Reyes-Lizama & Gonzalez-Solis, 2009 from Haemulon spp. (Haemulidae) from the Caribbean Sea (Mexico) in having inner blades on the distal shafts of the ventral and dorsal anchors. The present paper represents the first finding of a species of Euryhaliotrema (E. disparum n. sp.) on a species of Rhencus and the second species on a haemulid host, and H. uagroi n. sp. as the first monogenoidean species described on L. inermis. Euryhaliotrema anecorhizion, E. fastigatum, and E. paracanthi on L. argentiventris in the Pacific coast of Mexico represent new geographical records.

Erişkin distal humerus kompleks kırıklarında ideal cerrahi tedavi seçeneği var mı?

Objective: The aim of this study is to define the ideal surgical treatment option for distal humerus fractures by comparing different surgical techniques.&#x0D; &#x0D; Material and methods: Seventy-one patients with distal humerus diaphysis fractures who were treated between 2015 and 2020 were retrospectively investigated,. The patients were operated on with the posterior approach of open reduction and plate-screw osteosynthesis (Group A), plated with the minimal invasive technique (Group B), operated on using the lateral approach (Group C) and treated with an external fixator (Group D). Age, gender, mechanism of fracture, fracture type and AO class, applied surgical method, additional injuries, duration of operation, amount of bleeding, amount of fluoroscopy used, length of hospital stay, radiological angular values, union time, complications, and clinical examination findings of the patients were examined retrospectively and the differences between the mentioned surgical methods were investigated.&#x0D; &#x0D; Results: Blood loss was significantly less in Groups C and D (p

Possibility of Avoiding Anesthesia in the Reduction of Greenstick and Angulated Forearm and Distal-End Radius Fractures in Children: A Comparative Study.

Introduction Greenstick and angulated forearm bone fractures are the most common fractures in children and invariably require closed reduction under anesthesia. However, pediatric anesthesia is somewhat risky and not always available in developing countries like India. Therefore, this study aimed to evaluate the standard (quality) of closed reduction without anesthesia in children and to determine satisfaction among parents. Materials and methods The present study included 163 children with closedangulated fractures of the distal radius andfracture shafts of both forearm bones, who were treated by closed reduction. One hundred and thirteen were treated without any anesthesia (study group) on an outpatient department (OPD) basis, whereas50 children of similar age and fracture type underwent reduction with anesthesia (control group). After reduction by both methods check X-ray was done to evaluate the quality of the reduction. Results The average age of the 113 children in the present study was 9.5 years (range: 3.5-16.2 years), of which 82 children had radius or ulna fractures, and 31 had isolated distal radius fractures. In 96.8% of children, ≤10° of residual angulation was achieved. Furthermore, 11 children (12.4%) used paracetamol or ibuprofen for pain control in the study group. Moreover, 97.3% of parents stated that they would like their children to be treated without anesthesia if any fracture occurred again. Conclusions Closed reduction of greenstick angulated forearm and distal-end radius fracture in children in the OPD without anesthesia achieved satisfactory reduction and high parent satisfaction while reducing the risks of pediatric anesthesia and its associated complications.

Evaluation of Fixation of Fracture Shaft of Radius Ulna without Tourniquet

Background: Plate fixation is the mainstay of care for distal forearm shaft fractures in adults. By and large, volar or dorsal plating is used for radial shaft fractures. The radius's lateral surface offers an equal and constantly curved region for inserting a plate. The radial bow may be readily evaluated and restored after surgery. A prospective investigation was performed to examine the result of lateral plating of radius shaft fractures. Objective: In this study our main goal is to evaluate the treatment outcome of fixation of fracture shaft of radius ulna. Method: The research was conducted at tertiary medical hospital and district general hospital, Dinajpur included 100 patients. Several of them had broken both of their forearm bones, while others had broken only the radial shaft. Within 36 hours of damage, all patients were fixed with a 3.5 mm restricted contact dynamic compression plate or locking compression plate on the lateral surface of the radius. Typical procedure was used to repair the ulna. Results: During the study, majority were belong to 32-40 years age group, 36%. Followed by 20% were belong to 41-50 years age group, 11% belong to 20-31 years age group. In addition to that, 80% were male. 75% had fractured both of their forearm bones. Followed by 70% had closed fractured type, 35% had motor vehicle accident and lastly 85% had middle third radial shaft. Union was assessed by gradual disappearance of the fracture line and/or development of bridging callus at the fracture site. After getting treatment, 89% patients had excellent results, 8% had satisfactory and 1% had unsatisfactory result. There was 1% failure (nonunion). Conclusion: As compared to conventional methods, radial lateral plating holds promise as a viable option. Longitudinal studies with larger patient groups and study criteria are needed to confirm the potential advantages and validate our results.

A new method for sex estimation based on femoral cross-sectional geometry measurements and its validation using recent and ancient populations.

Estimating sex is a fundamental task in biological and forensic anthropology. This study aimed to develop new methods for sex estimation based on femoral cross-sectional geometry (CSG) variables and to test their applicability in recent and ancient assemblages. The sample was divided into a study group (living individuals, N = 124) for creating sex prediction equations and two test groups: living individuals (N = 31) and prehistoric individuals (N = 34). The prehistoric sample was divided into three subgroups according to subsistence strategy (hunter-gatherers, early farmers that also hunted, and farmers and herders). Femoral CSG variables (size, strength, and shape) were measured from CT images using dedicated software. Discriminant functions for sex estimation were calculated for various bone completeness scenarios and validated using the test groups. Size and strength parameters were sexually dimorphic, while shape was not. Discriminant functions for sex estimation produced success rates in the living sample between 83.9 and 93.5%; the distal shaft yielded the highest results. Success rates were lower among the prehistoric test sample, with better results (83.3%) for the mid-Holocene population (farmers and herders) than for earlier groups (e.g., hunter-gatherers; < 60%). These results were compared with those obtained using other methods for sex estimation based on various skeletal elements. This study provides new, reliable, and simple methods with high success rates for sex estimation based on femoral CSG variables obtained automatically from CT images. Discriminant functions were created for various conditions of femoral completeness. However, these functions should be used carefully in past populations from different settings.

Epidemiology of 936 Humeral Shaft Fractures in a Large Finnish Trauma Center.

Humeral shaft fractures are relatively common injuries and are classified according to location and fracture morphology. Epidemiological studies improve understanding of injury patterns and lay foundations for future research. There are only a few published larger epidemiological studies on humeral shaft fractures. We retrospectively analyzed the medical records of adult patients having sustained a humeral shaft fracture treated in the Helsinki University Hospital between 2006 and 2016. We recorded patient and fracture characteristics, timing and mechanism of injury, associated injuries, and one-year mortality. We identified 914 patients (489 females, median age 61.4 years; 425 males, median age 50.4 years) with 936 fractures. Over 60% of these fractures were sustained from simple falls. The patient age distribution was bimodal, with highest fracture rates in elderly females and young males. We divided the fractures into typical traumatic, periprosthetic, and pathological fractures. Of the 872 typical traumatic fractures, 3.0% were open. In addition, there were 24 (2.6%) periprosthetic and 40 (4.3%) pathological fractures. An associated injury was found in 24% of patients, with primary radial nerve palsy being the most common (10%). Primary radial nerve palsies were more common in distal shaft fractures and high energy injuries. The one-year mortality was 9.2%. In this study, the most common injury mechanism was a simple fall. The most common associated injury was a primary radial nerve palsy. The observed bimodal fracture distribution is consistent with previous literature.

Lateral Approach for Distal Articular Fractures of Humerus in Canines-A Review of 4 Cases

Background: Humeral condylar fractures have fracture lines that extend through the joint surface and through one or both epicondyles or epicondylar crests, or into the distal shaft. Addressing the distal articular Humeral fractures in dogs through lateral approach by using positional transcondylar screws. Methods: A total of four cases of dogs with different age groups, breeds and sex with fore limb lameness caused due to trauma were included in the study. Clinical and standard radiological examination of all revealed intercondylar fractures with reduced range of motion where the fracture of the condyle extending from the articular surface. After preoperative evaluation all the animals were subjected to surgical reduction by lateral approach under general anaesthesia using positional transcondylar screws (n=2) with or without K-wires in cross fashion (n=2). This approach avoided the necessity of olecranon osteotomy and triceps tenotomy with their associated complications. Result: Excellent limb utility was obtained during postoperative period by clinical and radiographical grading system. To conclude, the use of fully threaded cortical screws was found effective for surgical management of distal humeral condylar fractures in dogs via lateral exposure.

E029 Erdheim-Chester disease: a rare multisystem disorder

Abstract Background/Aims Erdheim-Chester disease is a rare non-Langerhans cell histiocytosis with multiorgan involvement. Otherwise known as polyostotic sclerosing histiocytosis it is characterised by proliferation and infiltration of lipid laden macrophages into bone marrow. Extraskeletal involvement is commonly seen involving heart, CNS, skin, lung, kidney, and retroperitoneum resulting in a variety of presenting features. Methods Case: 75-year-old male referred to rheumatology connective tissue disease clinic by respiratory team with dyspnoea and unintentional weight loss of 20kg in one year. CT had shown pleural effusions and interstitial markings in mid zones felt to be due to cardiac failure. PMH - IHD, CABG. Mildly elevated dsDNA of 10. He denied cough, sputum or haemoptysis. No mouth ulceration, alopecia, sicca symptoms, Raynaud's, rashes, fevers, myalgia, or joint swelling. No family history of rheumatic disease. On examination reduced air entry to lung bases, no synovitis, no nail bed changes, no lymphadenopathy. Results Further investigations showed persistent mildly elevated dsDNA, crithidia negative, negative ANA on HEp2, Hb 136, WCC 13.8, PLT 329, complement levels normal, Igs normal, IgG4 normal, NTproBNP raised 3196, ESR 27, CRP 28. Further CT CAP - bilateral pleural effusions, thickened enhancement of pleura bilaterally without focal mass, increased interstitial markings lung mid zones, significant thick pericardial enhancement and pericardial effusion, thickening around distal oesophagus and a rind of inflammatory thickening around distal thoracic aorta. Transthoracic echocardiogram - small pericardial effusion without haemodynamic compromise, normal left and right ventricular function. NM whole body - marked increased uptake in diametaphyseal regions of tibial bones and distal aspect of femora. MRI femurs - significant symmetrical abnormality in distal femoral shaft and metaphyseal region of both femora, endosteitis with extensive linear and patchy reduction T1 signal intensity and increase in STIR intensity within medullary cavity of distal femur. CT guided biopsy of distal femur identified foamy histiocytic infiltration with fibrosis. BRAF mutation testing of plasma showed strong positive result confirming molecular diagnosis of Erdheim-Chester disease. Cardiac MRI had been requested and MRI of brain was normal. He was treated initially with 40mg prednisolone, weaned to 15mg, and weekly PEG interferon with improvement in dyspnoea and weight loss. However, he deteriorated slowly over the next year and died of cardiac failure. Conclusion Histiocytic disorders such as Erdheim-Chester disease do rarely present to rheumatology given multisystem involvement and diagnostic uncertainty. This patient had skeletal, cardiac, lung, and gastrointestinal involvement resulting in his dyspnoea and weight loss. Initial treatment involves corticosteroid and interferon. Approximately 50% of patients have BRAF mutation and may respond to vemurafenib therapy. Our patient unfortunately deteriorated prior to being considered for this treatment. Prognosis is poor with a 3-year survival of 50%. Disclosure G. Starritt: None. D. McCormick: None.

Treatment outcomes of applying external fixator on distal radius fractures: a randomized clinical trial to compare between two directions of force exertion in parallel to radius shaft and perpendicular to the distal radius articular surface

BackgroundExternal fixation has been one of the conventional managements of unstable distal radius fracture. The main aim of this paper is to compare two methods of applying distractive force along the radius shaft versus perpendicular to the distal radius articular surface.DesignSixty patients with unstable distal radius fracture were included in present clinical trial and randomized in two groups, using block randomization method. In group A (first arm), distraction force was exerted parallel to the radius shaft. In group B (second arm), the external fixator was adjusted based on radial and palmar tilt of the mean population healthy wrist so that distraction was exerted perpendicular to the wrist articular surface.MethodsRadiological and clinical parameters were evaluated in both groups of patients pre-operatively, immediately after surgery, and 6 weeks post-operatively. We also followed up patients clinically at 12 weeks after surgery. Patient-Rated Wrist Evaluation (PRWE), Mayo wrist score, and Quick Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires were used in order to assess patients’ clinical and functional states.ResultsThe method used in group B resulted in better improvement of palmar tilt both immediately (P = 0.007) and at 6 weeks follow up (P = 0.013) post-operatively in comparison with patients in group A. Radius height and radial inclination were also better restored when using the proposed modified method (P = 0.001 and < 0.001, respectively). There was no difference in any of clinical results (range of motion, grip strength, PRWE, Mayo, and DASH scores) between two groups of study, 12 weeks after surgery.ConclusionApplying distractive force perpendicular to the distal radius articular surface seems to improve some radiological outcomes, probably due to better reduction maintenance, when compared with the technique of applying distraction force along distal radius shaft axis.Level of EvidenceLevel I (clinical trial study).Trial registrationThis study is registered at Iranian Registry of Clinical Trials (IRCT) with approval code of IRCT20200313046759N1.

Comprehensive multidisciplinary phenotyping of patients with hypospadias. A pilot study

Hypospadias is an abnormal formation of the urethra, ventral skin, and corporal bodies. Location of the urethral meatus has historically been the phenotypic landmark that defines hypospadias. Nonetheless, classifications following location of the urethral meatus fail to consistently predict outcomes and have no correlation with the genotype. Description of the urethral plate is very subjective and difficult to reproduce. We hypothesize that the use of digital pixel cluster analysis and correlation to histological analysis can provide a novel method to describe the phenotype of patients with hypospadias. A standardized hypospadias phenotyping protocol was developed. 1. Digital images of the anomaly, 2. Anthropometric assessment of penile dimensions (penile length, urethral plate length and width, glans width, ventral curvature), 3. Classification using the GMS score, 4. Tissue sampling (foreskin, glans, urethral plate, periurethral ventral skin) and H&E analysis by a blinded pathologist. A k-means colorimetric pixel cluster analysis was performed following the same anatomical landmark distribution as the histology samples. Analysis was performed using MATLAB v R2021b 9.11.0.1769968. A total of 24 patients prospectively enrolled with a standard protocol. Mean age at surgery was 16.25 months Urethral meatus was distal shaft in 7 patients, 8 coronal, 4 glanular, 3 midshaft, 2 penoscrotal. Average GMS score was 7.14 (±1.58). Average glans size was 15.71mm (±2.33) and urethral plate width 5.57mm (±2.06). Eleven patients underwent Thiersch-Duplay repair, 7 TIP, 5 MAGPI, and 1 a first stage preputial flap. Mean follow-up was 14.25 months (±3.7 months). Two (8.3%) postoperative complications (1 urethrocutaneous fistula and 1 ventral skin wound dehiscence) were reported in the study period. Eleven (52.3%) patients with histological analysis had an abnormal pathology report. Of those, 6 (54%) had reported abnormal lymphocyte infiltration interpreted as chronic inflammation at the urethral plate. The second most common finding was hyperkeratosis visualized in the urethral plate in 4 (36.3%) and one with reported fibrosis in the urethral plate. K-means pixel analysis demonstrated a k1 mean of 64.2 for reported urethral plate inflammation vs 53.1 for non-reported urethral plate inflammation (p=0.002) CONCLUSIONS: Current phenotyping of hypospadias using only anthropometric variables can be expanded including histological and pixel analysis correlation. Pixel clustering has a potential for a priori prediction of urethral plate quality beyond the current subjective assessment. A larger cohort will allow identification of possible predictive associations that might impact intraoperative decision-making and surgical outcomes.

A RETROSPECTIVE AUDIT INVESTIGATING THE MDT CARE PROVIDED FOR FRAGILITY NON-HIP FEMORAL FRACTURES WITHIN A MAJOR TRAUMA CENTRE

There has been extensive research into neck of femur fractures in the elderly. Fragility non-hip femoral fractures share many of the same challenges [1]. Surgical management is complex, patients are frail and mortality rates have been reported as high as 38% [2]. Despite this, relatively little data is available evaluating the level of MDT care provided to non-hip femoral fractures.This audit aimed to evaluate the standard of MDT care provided for patients with non-hip femoral fractures according to the NHFD key performance indicators. The following fractures were included in the dataset: distal femoral, femoral shaft and peri-prosthetic femoral. Patients under 65 were excluded. Data was retrospectively collected using post-operative and medical documentation. Performance was assessed according to five key performance indicators:Did orthogeriatrics review the patient within 72-hours?Was surgery performed within 36-hours?Was the patient weight bearing post-operatively?Was a confusion assessment completed?Was the patient discharged home?38 patients met the inclusion criteria. 84% of patients were seen by orthogeriatrics within 72 hours of admission. 32% of patients were operated on within 36-hours of admission, with time to theatre exceeding 36-hours in 92% of peri-prosthetic fractures. 37% of patients were not advised to full weight bear post operatively. 84% of patients received a confusion assessment whilst 61% of patients were discharged to their prior place of living.Our results suggest that non-hip femoral fractures do not receive the same standard of MDT care as neck of femur fractures. Greater prioritisation of resources should be given to this patient subset so that care is equivalent to hip-fracture patients. Time to surgery is a particular area for improvement, particularly in peri-prosthetic fractures, a trend that is mirrored nationally. Greater emphasis should be placed on encouraging full-weight bearing post-operatively to prevent post-surgical complications.

Satisfactory Results Can Be Obtained by Closed Percutaneous Pinning and Intramedullary Nailing in Distal Tibial Joint-Related Tibia Diaphysis Fractures

Amaç: Amacımız, distal tibia eklem hattına uzanan tibia diyafiz kırıklarında intramedüller çivilemenin sonuçlarının araştırılması ve minimal invaziv plak osteosentez yöntemi ile karşılaştırılmasıdır. &#x0D; Gereç ve Yöntem: Kliniğimizde tibia distal eklem hattına uzanan ancak eklemde impaksiyon izlenmeyen tibia diyafiz kırığı nedeni ile 2019 – 2021 yılları arasında tedavi ve takibi yapılan tüm hastalar retrospektif olarak araştırıldı. Tüm hastaların yaş, cinsiyet ve taraf gibi demografik verileri, yaralanma mekanizmaları, tibia diyafiz ve pilon kırık tipleri, klinik ağrı skorları, radyolojik kaynamaları ve komplikasyonları değerlendirildi. &#x0D; Bulgular: Çalışmaya dahil edilen 27 hastadan 15 hasta (%55,56) intramedüller çivileme ile tedavi edilirken, 12 hastada (%44,44) minimal invaziv plak osteosentez kullanılmıştır. İMÇ uygulanan grubun ortanca yaşı 62 (Aralık: 34-67 yaş) iken, MİPO uygulanan grupta ortanca yaşı 51 (Aralık: 33-52) olduğu ve aralarında anlamlı fark olduğu görüldü (p=0,038). Yaralanma mekanizmaları açısından gruplar arasında anlamlı fark tespit edildi (p=0,023). Taraf, cinsiyet, kırık tipi ve ağrı skorları açısından iki grup arasında fark görülmedi (p&gt;0,050). Hastaların tamamında radyolojik tam iyileşme elde edildi. Dört hastada (%14,81) yara yerinde yumuşak doku ilişkili komplikasyonlar tespit edildi. Komplikasyon gelişen hastaların tamamının MİPO grubunda olduğu görüldü ve gruplar arasında komplikasyon gelişimi açısından anlamlı fark tespit edildi (p=0,028). &#x0D; Sonuç: Distal tibia eklem hattına uzanan tibia diyafiz kırıklarında, eklemde impaksiyon eşlik etmiyor ise, perkütan kanüllü vidalar ile eklemde mutlak stabilitenin elde edilmesini takiben uygulanan intramedüller çivileme ile tatminkar klinik ve radyolojik sonuçlar ve düşük komplikasyon oranları elde edilebilir.