Head Fractures Research Articles

Posterior fracture dislocation of the proximal humerus

Posterior dislocation fractures of the humerus occur as impression fractures of the humeral head (reverse Hill–Sachs fracture) and posteriorly dislocated proximal humeral (PH) fractures with a subcapital component. This study evaluated fracture patterns, current treatment, and revision rates. Data of patients who underwent surgical treatment for PH dislocation fractures in two level-I trauma centers between 2010 and 2018 were retrospectively reviewed. We identified 41 shoulders in 37 patients (n = 12 female, n = 25 male; average age 52 [25–91] years) with open surgical treatment of PH posterior dislocation fractures. In 14 patients, the cause was convulsive seizure or electrical accident, in 23 patients, a fall or high-energy trauma. There were 22 shoulders with impression fractures without a subcapital aspect; 19 shoulders had a posteriorly dislocated subcapital fracture. All patients were treated surgically via a deltopectoral approach. Five of the impression type fractures were treated prosthetically; the other 17 impression type fractures had humeral head-preserving reconstruction. The 19 cases of subcapital dislocation fractures were treated with open reduction and internal fixation with a PHILOS plate (n = 13) or with a prosthesis (n = 6). Within a mean follow-up period of 4.3 (1–9) years, the overall revision rate was 15% (6/41). Four patients underwent elective arthroscopic capsulotomy and implant removal. Two patients required revision surgery due to loss of reduction or humeral head necrosis. Impression type fractures were slightly more common than posteriorly dislocated PH fractures with a subcapital fracture component. In 73% of cases (n = 30), humeral head-preserving reconstruction was performed. The overall mid-term revision rate was 15% with a low-rate of secondary conversion to total shoulder arthroplasty (3%). Longer term functional outcomes of the patients are needed to better evaluate the treatment concept.

Proximal radius fracture morphology following axial force impact: a biomechanical evaluation of fracture patterns

BackgroundThe most common location for articular fractures of the radial head is often reported to be the anterior lateral aspect of the radial head with the arm in neutral position. However, these findings mainly base on clinical observations rather than precise biomechanical measurements. The purpose of this study was to evaluate the formation of proximal radius fractures, the association between axial forces and fracture morphology, energy to failure and bone stiffness in a biomechanical in-vitro setup.Methods18 fresh-frozen cadaveric radii performed axial load compression with 10 mm/min loading until bone failure. Energy to failure and bone stiffness were recorded. Proximal radial head fracture morphology and affection of the anterolateral quadrant were optically analyzed.ResultsAll radii survived a compression load of 500 N. The mean compressive forces that lead to failure were 2,56 kN (range 1,30 – 7,32). The mean stiffness was 3,5 kN/mm (range 2,0 – 4,9). 11 radial neck fractures and 7 radial neck and radial head multifragment fractures were documented. The anterolateral quadrant was involved in 78% of tested radii.ConclusionThe anterolateral quadrant of the radial head (in neutral position of the forearm) is confirmed to be the most common location for articular radial head fractures in a biomechanical setting. In case of a fall on the outstretched arm radial neck fractures should be securely ruled out due to prior occurrence to radial neck and head fractures.

Comparison of compression screws used for mandible head fracture treatment\u2014experimental study

ObjectivesCompression screws that can fix a fracture of the condylar head of the mandible are available. Although typical titanium lag screws are generally used, a series of headless screws have been designed for this purpose. The “headless” advantage derived from the complete submergence of the screw in the bone after fixation is the lack of irritation of the lateral ligament of the temporo-mandibular joint by the screw head. The aim of this study is to compare the compression force of typically used lag screws with that of newly developed headless compression screws.Materials and methodsThis study tested five types of screws with a 14-mm length: 10 2.0-mm lag screws and 40 headless screws (four groups of equal size: 1.5-mm H screws, 1.8-mm H screws, 2.0-mm H screws, and 1.8-mm W screws). Two cuboid blocks of standardized polyurethane foam were fixed by one screw. The maximal compression force (F in N) and torque at maximal compression force (T in Ncm) were tested according to the guidelines of the American Society for Testing and Materials (ASTM F1839-08).ResultsThe test results were as follows: 2.0-mm lag screw: F = 211.5 ± 20.7 and T = 21.1 ± 1.6; 1.5-mm H screw: F = 47.2 ± 5.6 and T = 18.2 ± 1.1; 1.8-mm H screw: F = 95.5 ± 9.8 and T = 18.2 ± 1.1; 2.0-mm H screw: F = 145.1 ± 18.4 and T = 25.5 ± 1.5; and 1.8-mm W screw: F = 180.5 ± 8.7 and T = 26.4 ± 2.8. Each type of screw significantly differed from one another as far as compression forces (F) were considered (p < 0.05): the best is the lag screw contrary to the thinnest H screw which is the worst one. For all tested screws, the compression force depended on the torque (S curve relationship was revealed, p < 0.05) and screw diameter (a larger diameter yielded greater compression, p < 0.05).ConclusionsThe 8-mm headless screws featured only a small loss of compression ability compared to the titanium lag screws.Clinical relevanceHeadless screws are mechanically attractive fixation materials for condylar head fracture treatment.

Effectiveness of regional clinical pathways on postoperative length of stay for hip fracture patients: A retrospective observational study using the Japanese Diagnosis Procedure Combination database

BackgroundRegional clinical pathways, a new type of clinical pathway, are practiced with the aim of standardizing and optimizing medical care by cooperation among multiple medical institutions in a region. However, current evaluation of the effectiveness of regional clinical pathways for hip fracture, a major health problem requiring hospitalization for orthopedic surgery, is insufficient. This study aimed to determine the association between regional clinical pathways and postoperative hospital length of stay (LOS) among hip fracture patients. In particular, we focused on the variation in postoperative LOS of hip fracture patients among hospitals and the contribution of regional clinical pathways to this variation. MethodsUsing data from the Diagnosis Procedure Combination (DPC) database in Japan from April 2011 to March 2013, patients who were diagnosed with “fracture of head and neck of femur” (ICD10 code S72.0) or “pertrochanteric fracture” (S72.1) and received “bipolar hip arthroplasty” or “open reduction and internal fixation” were extracted. A total of 110,133 patients were included. Associations between regional clinical pathways and postoperative LOS were analyzed using cross-sectional analysis with multilevel regression models. ResultsHospitals that implemented a regional clinical pathway showed a significant reduction (13 days) in the postoperative LOS of hip fracture patients. We found a 16% inter-hospital variation in postoperative LOS, which might be explained by hospital-level implementation of regional clinical pathways. Application of regional clinical pathways at the patient level resulted in a 4-day decrease in postoperative LOS. ConclusionsImplementation of regional clinical pathways for hip fracture patients at the hospital level was associated with reduced postoperative LOS, regardless of whether or not pathways were implemented at the patient level. This suggests that regional clinical pathways are effective for patient care management in hospitals.

Falls from a balcony while intoxicated: a new injury trend among young adults?

BackgroundUnintentional falls from heights, including balconies, result in life threatening traumatic injury. Alcohol, when combined with environmental factors and poor judgement, can potentially lead to fatal outcomes. One trauma center’s registry identified a group of young adults falling from balconies and we investigated the role of alcohol.MethodsHospital trauma service admissions from 2010 through 2017 were reviewed for unintentional falls from heights. Suicide attempts and unintentional falls off ladders or roofs were excluded. Data were obtained from trauma registry and medical record review, as well as social work service interviews.ResultsFalls from heights comprised 4.8% of injuries treated at our trauma center during the eight-year study period with 98.5% admitted. Of patients admitted because of falls, 10.3% (55/532) were from a balcony. The majority of this group of patients was male and 19–29 years old (67%). Of patients with a blood alcohol concentration (BAC) determination, 62% had a positive BAC upon hospital admission with an average of 0.20 g/dL among those 34 patients. No gender differences were evident for alcohol use. Seven of the eight patients under the legal drinking age of 21 years were a subgroup with high alcohol use as compared with patients 21 years and older (p = 0.099). Ninety-four percent of falls occurred at residential locations such as dormitories or apartment complexes, often during a social event. Backward falls off railings and attempts to jump to adjoining balconies were common. Head, thorax/abdomen, and extremity fractures were common, with an average injury severity score (ISS) of 16. Average length of hospital stay was 8 days. Most patients (67%) were discharged home after hospital stay, but 21% were transferred to inpatient rehabilitation or skilled nursing facilities. There were two deaths.ConclusionsFalls from balconies among young adults occur in our area yet the true frequency of these events remain unknown. Occurrence was most common among underage drinkers. Generalization is difficult with this small sample, yet high risk behaviors and environmental factors were evident. It is imperative that educational programs focus on this population with collaborative prevention efforts focused on the dangers of, and increased risk of injury associated with the balcony environment.

Reverse vascularized bone graft of the lateral distal humerus for non-union of the radial neck fracture: anatomical study and case report

A few treatment options for radial neck non-union have been reported, including radial head excision, radial head replacement, and internal fixation with a bone graft. We describe a new treatment for radial neck non-union using a reverse vascularized bone graft of the lateral distal humerus. In the anatomical study, the posterior radial collateral artery (PRCA) was dissected in eight fresh-frozen cadaver arms. The number of branches from the PRCA to the humerus was determined, and the distances from these branches to the lateral epicondyle of the humerus were measured. We then used this information to create a reverse vascularizedhumeral bone graft, which was used to treat non-union of a radial neck fracture in a 73-year-old female. There were two to four PRCA branches (mean: 3.3) entering the bone. The distance from the branches to the lateral epicondyle of the humerus ranged from 2.5 to 10.8 cm. The mean distances from the most proximal and distal PRCA branches to the lateral epicondyle of the humerus were 7.6 cm and 3.4 cm, respectively. The case of non-union of a radial neck fracture was successfully treated with a reverse vascularized humeral bone graft. There were no major complications, and radiographs showed bony union at 8 weeks postoperatively. This procedure may become a new option for the treatment of non-union of fractures of the radial head and neck, as it enables preservation of the radial head, which is an important structure in the elbow and proximal radioulnar joints.

Comparison of Reverse Shoulder Arthroplasty and Hemiarthroplasty for Proximal Humeral Fractures: What about Functional Outcome? Reverse versus Hemiarthroplasty in Shoulder Fractures

Purpose: Shoulder replacement becomes more indicated in complex fractures of the humeral head. Indications depend on some factors especially age and fracture’s pattern. The aim of our study is to compare the functional results of both reverse shoulder arthroplasty (RSA) and hemi-arthroplasty (HA) in complex proximal humerus fractures. Materials and Methods: Fifty-two shoulder arthroplasties (20 reverse shoulder arthroplasties, 38 hemiarthroplasties), were reviewed retrospectively, between January 2010, and December, 2015. Preoperative, operative, and postoperative evaluations were achieved based on medical observations. At last follow-up, functional outcomes were established according Constant-Murley Score and American Shoulder and Elbow Surgeons (ASES) score. Complications rates were well-defined and compared between the study groups. Results: The mean of follow-up was 41.5 months. Comparing the study groups, reverse shoulder arthrosplasties were significantly older (mean age: 76.3 versus 66). These fractures occur more in women (70% versus 57%). At last follow-up, functional outcomes were better in reverse shoulder arthroplasty group (Constant-Murley Score 76 versus 59; ASES score 56 versus 41). The mean anterior elevation and external rotation were better in reverse shoulder arthroplasty respectively (110°versus 88°; 28° versus 19°). Revision was more required in hemiarthroplasty group than reverse shoulder arthroplasty group. Conclusion: Reverse shoulder arthroplasty seems to improve functional outcome at intermediate and long-term of follow-up of proximal complex humeral fractures on comparison to hemiarthroplasty.

Bilateral Concomitant Radial Head and Capitellar Fractures: A Case Report

Concomitant bilateral radial head and capitellar fractures is a rarely mentioned entity. We present a case of a 36-year-old male presenting for fall on both outstretched hands, resulting in bilateral elbow pain and limited ROM. Imaging showed concomitant bilateral radial head and capitellar fractures. The right elbow underwent capitellar fixation with countersunk Herbert screws and excision of the displaced radial head fragment. Conservative treatment was chosen for the left side. Post-op follow-up showed good bone healing with return to normal ROM bilaterally. Elbow fractures are complicated to treat, but good understanding of the treatment methods can nonetheless result in satisfactory results when applied properly.

Research progress in treatment of comminuted radial head fractures

Radial head fracture accounts for one third of the elbow joint fracture. At present, for fractures without obvious displacement, non operative treatment can achieve good results. In the case of complicated comminuted fracture of the radial head, open reduction with internal fixation and the radial head replacement have their own advantages and disadvantages. There is no exact reference for the selection of surgical procedures, and the best treatment regimen remains controversial. No matter which method is adopted, it is necessary to repair accompanied injuries. Meanwhile, postoperative standard rehabilitation exercise is also essential for the recovery of elbow function. The typing of radial head comminuted fracture and the status quo of its treatment is reviewed in this paper, so as to provide reference for better clinical treatment. Key words: Radius fractures; Fracture fixation, internal; Arthroplasty, replacement

Blunt trauma to the antecubital fossa causing brachial artery injury and minor fractures around the elbow joint, an easily missed diagnosis with potential devastating consequences: a case report

BackgroundBlunt trauma causing brachial artery injury in a young patient is very rare. Cases of brachial artery injury may be associated with closed elbow dislocation or instability. Elbow dislocation may not be evident clinically and radiologically on initial presentation.Case presentationThis is a case of a 37-year-old, right-hand dominant, Malay man who fell approximately 6 meters from a rambutan tree and his left arm hit the tree trunk on his way down. He was an active tobacco smoker with a 20 pack year smoking history. On clinical examination, Doppler signals over his radial and ulnar arteries were poor. He proceeded with emergency computed tomography angiogram of his left upper limb which showed non-opacification of contrast at the distal left brachial artery just before the bifurcation of the left brachial artery at his left elbow joint. Radiographs and computed tomography scan also showed undisplaced fracture of left lateral epicondyle and radial head with no evidence of elbow dislocation. He subsequently underwent left brachial to brachial artery bypass which was done using reversed saphenous vein graft and recovered well. His fractures were treated using 90 degree long posterior splint for 2 weeks and he was then allowed early range of motion of the left elbow. This patient developed left elbow dislocation 6 weeks postoperatively. Closed manipulative reduction of his left elbow resulted in incomplete reduction. The functional outcome of his left elbow was limited with a range of motion of left elbow of 0–45 degrees. However, he was not keen for surgery to stabilize his elbow joint during his last follow-up 6 months post injury.ConclusionsThis is an uncommon case of brachial artery injury in a civilian caused by blunt trauma associated with occult elbow instability/dislocation and minor fractures around the elbow joint. The treatment of brachial artery injury with clinical evidence of distal ischemia is surgical revascularization. The possibility of elbow instability and dislocation need to be considered in all cases of brachial artery injury because early radiographs and computed tomography scans may be normal. Short-term posterior splint immobilization is not sufficient to prevent recurrent dislocations.

Isolated Avulsion Fracture of the Medial Head of the Gastrocnemius Muscle in a Young Boy

Isolated Avulsion Fracture of the Medial Head of the Gastrocnemius Muscle in a Young Boy

Classification proposal for fractures of the processus condylaris mandibulae

ObjectiveThe current classification of mandibular condyle fractures as basal, low neck, and high neck as reported by Loukota et al. (Br J Oral Maxillofac Surg 43:72–73, 2005) and Neff et al. (Craniomaxillofac Trauma Reconstr 7:S44–S58, 2014) has a weakness. Nearly no high-neck fractures are reported (they are typically classified as type C head fractures) contrary to basal condylar fractures, which are overestimated (nearly all low-neck fractures are classified as basal). The aim of this study is to present a modified AO/SORG classification of mandibular condyle fractures.Material and methodsA new arrangement of the reference lines is proposed because the fracture lines are mainly oblique in this region. The proposed classification was validated using a series of 84 cases that were treated surgically.ResultsThe diagnoses using the proposed new classification system significantly differed from those based on the old system (p < 0.005). All basal fractures in the new classification system were also classified as basal in the old system. The same was true for type C head fractures. The differences were found for low-neck fractures (4 of 84 diagnoses differed between the old and new classifications, i.e., they were previously classified as basal fractures) and high-neck fractures (3 of 84 fractures were diagnosed as low-neck fractures or type C head fractures using the old classification).ConclusionThe epidemiology of the condyle injury should be based on a classification, which reveals types of fractures which are represented by factually and frequently observed cases. That is why a relatively common AO/SORG classification can be modified for the benefit of assessing incidences of high-neck and low-neck fractures.Clinical relevanceConsidering that the treatment of the high-neck fractures is much technically complicated than the low-neck ones, this will have an influence on the management of trauma to the area.

Massive wear in a CoCrMo head following the fracture of an alumina head.

The catastrophic fracture of an alumina femoral head is, fortunately, an increasingly rare event. The improvements made in the quality of modern ceramics, together with greater care in the manufacture of femoral stem cones and higher levels of expertise of the surgeons implanting the head itself, have significantly reduced this risk. A statistical analysis by Piconi (1) evaluates the percentage of breakage in modern ceramic heads at less than 0.02% (1 fracture every 5000 implants). We can therefore say that today the use of ceramic heads is highly reliable, but in certain cases, due mostly to negligence or technical errors, the fracture of the head is still possible. In these cases the problem we are facing is how to proceed in the revision of the implant, as simply replacing the head may lead to a further and more severe failure of the implant. (Hip International 2002; 1: 37-42).

НАШ ОПЫТ ЛЕЧЕНИЯ СИНОВИАЛЬНОГО ХОНДРОМАТОЗА ПЛЕЧЕВОГО СУСТАВА

Incidence rate of primary synovial chondromatosis of the shoulder joint makes 15–28 %. It is a rare benign lesion of&#x0D; synovial membrane of the joint featured by multiple foci of cartilaginous metaplasia in tissues of the membrane. Dif-&#x0D; ferential diagnostics should be conducted with the diseases, accompanied by formation of intra-articular loose bodies&#x0D; (secondary chondromatosis) at osteochondritis dissecans, osteochondral fracture of the humeral head, and tuberculous&#x0D; rheumatism. But the critical role belongs to histopathology report and molecular genetic analysis. Synovial chondroma-&#x0D; tosis most frequently afflicts one of the major joints (knee, hip, elbow, or shoulder). The pathology develops mainly in&#x0D; young men. Published descriptions of the development of this shoulder joint lesion are very sparse. Diagnostics becomes&#x0D; possible only on the grounds of histological examination of cartilage flaps removed from the joint. Present treatment&#x0D; of synovial chondromatosis includes removal of intra-articular cartilage bodies, either with open surgery or by arthro-&#x0D; scopic approach. The authors of the article present the clinical example of diagnostics and surgical treatment of the&#x0D; patient with primary synovial chondromatosis. The disease, aged more than 4 years, was accompanied with limited&#x0D; movements in the shoulder joint. Postoperative check-up examination established restored volume of movements and&#x0D; no pain syndrome in the joint. The patient came back to everyday routine and amateur sport. Therefore, adequate&#x0D; volume of surgical intervention excludes the recurrence of the disease in early and remote postoperative period. The&#x0D; patient is able to work and participate in routine physical activity.

Bone Radiographic Changes in Slaughter Buffalos with Low Body Condition Index

Background: The largest buffalo herd in Brazil is located on the Island of Marajó, in the State of Pará, northern Brazil. The pastures of the Island of Marajó consist of low quality graminaceous plants, which are generally poor in protein and mineral content. Unbalanced diets associated with low quality pastures are responsible for latent, sub-clinical diseases and metabolic disorders in bovines which affect bone health, especially in periods such as pregnancy and lactation. The purpose of this study was to point out and to describe the radiographic bone changes of buffalos with low body index bred in extensive system and intended for slaughter on the Island of Marajó, Brazil.Materials, Methods &amp; Results: Radiographic examinations of anatomical pieces were obtained from 34 animals of buffalo species, with no distinction of gender, age, or breed. The animals were selected among those that were in the stockyard waiting for slaughtering for the obtainment of the anatomical pieces. For this selection, low physical condition was considered, which mainly included individuals with body condition indexes (ICC) of 1 and 2, on a scale of 1 to 5. From this selection, 98 anatomical pieces were obtained, which included: 28 sets of ribs, 20 femurs, 26 metacarpus, 7 mandibles, 3 radius and ulnas, 4 sets of vertebrae, 4 sets of metacarpus and phalanges, 1 tarsus and 1 set of tarsus and metatarsus. All the pieces were separated, identified, packed in plastic bag and forwarded to the radiographic study. At least one radiographic projection was obtained of each anatomical piece. These were identified, manually processed and stored for subsequent assessment. A single observer, in order to identify and to describe the bone radiographic changes, subjectively performed the radiographic assessment.Discussion: Bone changes were remarkable and in animals of this study, reinforcing the nutritional aspect as being of great importance for the perfect mineral homeostasis and for the osteoarticular system maintenance. Consistent radiographic findings with osteopenia are most often related to nutritional disorders that affect bone metabolism, mainly involving the homeostasis of calcium (Ca) and phosphorus (P). The nutritional hyperparathyroidism, more commonly reported in dogs, cats and exotic animals is a common example of these affections, in which the bone radiopacity reduction is the most evident radiographic aspect. Copper (Cu) deficiency has been correlated with osteochondrosis, epiphyseal fracture of the femoral head and degenerative arthropathy of the hip joint, and erosion of the articular cartilage in a deer (Cervu selaphus). Degenerative arthropathy through radiographs was also found in this study. From the bone radiographic analysis, it is concluded that the osteodystrophic diseases of buffalos raised in pasture system on the Island of Marajó, Pará, Brazil, present a variety of pathological conditions and the most commonly found were: osteoporosis characterized at the radiographic examination for the bone decreased radiopacity, change in bone trabeculae (medullary expansion) and cortical thinning, followed by pathological fractures with high incidence in the ribs. The low body condition, the underdevelopment and cachexia states of the animals in this study indicate the lack of an appropriate prophylactic conduct and a proper feed management. Therefore, the low reserves of P and Cu in the organism may have contributed to the osteoporotic process and, possibly, also to the protein-energy deficit, leading to secondary bone changes and causing a lack of productivity in the herd.

Open stent graft repair with upper-half Sternotomy for blunt thoracic aortic injury: a case report

BackgroundThoracic endovascular aortic repair is now widely applied to the treatment of blunt aortic injury. However, its long-term outcomes remain unclear. Endoleakage and migration might occur in the long term, especially when younger patients undergo endovascular aortic repair. In open stent grafting, the proximal end of the open stent graft is directly sutured to the native aorta, which may reduce the risk of endoleakage and migration. We applied open stent grafting to the treatment of blunt aortic injury in the subacute phase and herein report the patient’s clinical course.Case PresentationA 20-year-old man with a developmental disorder collided with a steel tower while skiing. He was transferred to our hospital by helicopter. X-ray examination and computed tomography revealed fractures of left humeral head and femoral neck and aortic isthmus dissection. We did not perform an acute-phase operation because of the presence of multiple trauma and instead performed open stent grafting with an upper-half sternotomy 42 days after the injury. He recovered uneventfully without psychological problems other than his preexisting developmental disorder. No endoleakage or aneurysm was observed during an 18-month follow-up period.ConclusionsOpen stent grafting might be an alternative to open surgery and thoracic endovascular aortic repair for blunt chest trauma, although intensive follow-up is needed.

Cementless total hip replacement with femoral calcar reconstruction for unstable intertrochanteric fractures combined with femoral head necrosis

Objective To explore the feasibility and therapeutic effects of total hip replacement (THR) for intertrochanteric fractures combined with late necrosis of the femoral head. Methods From June 2010 to October 2015, 8 patients underwent THR for intertrochanteric fractures combined with necrosis of the femoral head. They were 6 males and 2 females, with an average age of 53.5 years (from 45 to 67 years). According to the Evans-Jensen classification, 2 fractures were type ⅠB, 5 type ⅡA and one type ⅡB. All the 8 fractures were complicated with late femoral head necrosis, 5 cases of which were ischemic. According to the Ficat classification, the ischemic necrosis was type Ⅲ in one and type Ⅳ in 5 cases. In the other 3 cases, the necrosis secondary to the hip osteoarthrosis was type Ⅲ according to the Tonnis classification. The necrotic femoral head was removed after osteotomy of the femoral neck via the posterolateral approach; after reduction of the femoral calcar, the intertrochanteric fracture was reduced and fixated in a press-fit manner through antegrade implantation of a biological stem prosthesis. Functional assessment of the affected hip was carried out at the final follow-up using Harris scoring. Results The 8 patients were followed up for an average of 25.5 months (from 12 to 45 months). After operation, biological press-fit and initial stability of the femoral stem were achieved in all the patients. The X-ray films showed bone ingrowth fixation in all the 8 hips at 3 months postoperatively. The Harris hip scores at the final follow-up averaged 92.3(from 89 to 98). The pa-tients showed fine subjective satisfaction. Follow-ups revealed no infection, prosthetic failure, osteolysis, dislocation or articular instability. Conclusion In treatment of intertrochanteric fractures combined with necrosis of the femoral head, THR can lead to fixation and reduction of the intertrochanteric fracture and re-placement of the necrotic femoral head at one stage, promoting functional recovery of the affected hip. Key words: Hip fractures; Arthroplasty, replacement, hip; Femoral head necrosis

Quantification and Further Refinements of Dorsal Metacarpal Artery Perforator Flap for Reconstruction of Wounds of Fingers upto Distal Interphalangeal Joints.

To assess the outcome of dorsal metacarpal artery perforator flap for coverage of finger defects extending upto distal interphalangeal joint (DIPJ). Case series. Jinnah Burn and Reconstructive Surgery Centre, Lahore, from March 2015 to May 2017. Our study was carried out in two parts. 1st part of study was to measure average flap length in our population. Five hundred cases were enrolled to measure flap length, from pivot point of the flap to the distal border of extensor retinaculum. This length was traced to fingers to determine its coverage area. This was followed by clinical study in 35 cases. All patients with wounds over dorsal surface of fingers upto distal interphalangeal joint and volar surface of fingers upto mid of middle phalanx, single or multiple finger defects with exposed tendon joints or bones were included in the study. Patients with history of trauma to the dorsum of hand, metacarpal head or neck fracture and patients with history of diabetes or peripheral vascular disease were excluded. Flap length decreased from radial to ulnar side of hand. Average length of flap based on the second metacarpal artery was 7cm while of the third was 6.6 cm and the fourth was 6.1 cm. This flap length covered upto mid of middle phalanx in border digits while upto PIPJ in central digits. This data was confirmed in 35 patients in which 36 flaps were raised to cover finger defects. Thirty-four flaps survived completely while tip necrosis was seen in 2 cases. The dorsal metacarpal artery perforator flap is a thin, pliable flap, which has minimal donor-site morbidity. It can reliably cover soft tissue defects of dorsum of fingers upto mid of middle phalanx in border digits and upto PIPJ in central digits.

Hip arthroscopy enables classification and treatment of precollapse subchondral insufficiency fracture of the femoral head associated intra-articular pathology

PurposeThe purposes of this study were to investigate (1) the clinical, radiographic and arthroscopic presentation of patients with subchondral insufficiency fracture of the femoral head (SIFFH) and (2) the outcomes following arthroscopic treatment with internal fixation using hydroxyapatite poly-lactate acid (HA/PLLA) threaded pins and concomitant arthroscopic treatment of associated findings.MethodsNine patients (median age 49.0 years, range 43–65, five female and four male patients) with SIFFH who underwent arthroscopic treatment with labral repair, capsular closure and internal fixation of SIFFH using HA/PLLA pins were retrospectively reviewed. Inclusion criteria were adult patients with precollapse SIFFH with minimum 1-year follow-up (median follow-up 30.0 months, range 12–56).ResultsAcetabular labral tears were observed in all patients. The median BMI was 24.3 kg/m2 (range 20.1–31.8). Clinical presentations and radiographic measurements demonstrated mixed type FAI in six patients, borderline developmental dysplasia in two patients and pincer type FAI in one patient. The median MHHS significantly improved from preoperatively (67.1, range 36.3–78.0) to post-operatively (96.8, range 82.5–100; p = 0.001). The median NAHS significantly improved from preoperatively (34.0, range 17–63) to post-operatively (78.0 range 61–80; p = 0.001).ConclusionSIFFH is associated with bony deformities and labral tears. Precollapse SIFFH can be treated with bioabsorbable pin stabilization of unstable lesions and treatment of associated intra-capsular pathology in those with stable lesions as determined by a new arthroscopic classification system with promising early outcomes.Level of EvidenceIV.

Advantages of Modular Radial Head Prosthesis Use in Highly Comminuted Fractures

This article aims to evaluate the results and outcomes of patients with highly comminuted radial head fractures, Mason III / IV type, treated surgically by arthroplasty with a cemented modular radial head prosthesis. A fracture of the radial head with a high degree of comminution left untreated can lead to complex functional impairment in which both elbow flexion and extension and also the pronation / supination of the forearm are limited, all of which will affect their daily activities. Management of radial head fractures should be based on both injury-specific factors and patient factors. Injury-specific factors include fracture size, displacement, rotation block, and associated injuries. Patient factors include age, associated injuries, bone quality, and activity level. Six patients underwent surgery for highly comminuted radial head fractures. All participants were followed up to 36 months postsurgery. A final review was carried out at 12-36 months after surgery when clinical, functional and imagistic assessment was performed. Functional results were very good; stability and ROM data obtained were within normal limits. Surgical treatment using modular radial head prosthesis offered excellent results, the elbow mobility being in the normal range and patients requiring a short period of recovery to achieve these parameters.