Iatrogenic Fracture Research Articles

Closed reduction of glenohumeral dislocations with associated tuberosity fracture in the emergency department is safe

AimA fracture of the tuberosity is associated with 16% of glenohumeral dislocations. Extension of the fracture into the humeral neck can occur during closed manipulation, leading some to suggest that all such injures should be managed under general anaesthesia in the operating theatre. The purpose of this study was to establish the safety of reduction of glenohumeral dislocations with tuberosity fractures in the emergency department (ED). Patients and methodsWe reviewed 188 consecutive glenohumeral dislocations with associated tuberosity fractures identified from a prospective orthopaedic trauma database. Patient demographics, injury details, emergency department management and complications were recorded. The method of reduction, sedation, grade of clinician and outcome were documented. ResultsThe mean age was 61 years (range 18–96 years) with 79 males and 109 females. The majority of injuries (146, 78%) occurred after a fall from standing height. Closed reduction under sedation in the ED was successful in 162 (86%) cases. Of the remainder, 22 (11%) failed closed reduction under sedation and subsequently went to theatre and 6 (3%) were deemed not suitable for ED manipulation. At presentation 35 (19%) patients had a nerve injury, of which 29 (90%) resolved spontaneously. Two iatrogenic fractures occurred during close manipulation, one in the ED and the other in the operating theatre. Therefore, the risk of iatrogenic propagation of the fracture into the proximal humerus neck was 0.5% if the reduction was performed in the ED, and 1% over-all. More than two attempted reductions predicted a failed ED reduction (P = 0.001). ConclusionClosed reduction of glenohumeral dislocations with associated tuberosity fractures in the ED is safe, with a rate of iatrogenic fracture of 1%. These injuries should be managed by those with appropriate experience only after two adequate radiographic views. In cases where there is ambiguity over the integrity of the humeral neck, reduction should be delayed until multiplanar CT imaging has been obtained.

Treatment of Chronic Anterior Shoulder Dislocation by Coracoid Osteotomy with or without Bristow–Latarjet Procedure

ObjectiveTo investigate the clinical efficacy and outcomes of the coracoid osteotomy with or without Bristow–Latarjet procedures in the treatment of chronic anterior shoulder dislocation (CASD).MethodsBetween January 2013 and January 2019, 20 shoulders of 18 patients who were diagnosed with chronic anterior dislocation and underwent open reduction in our trauma center were retrospectively studied. Open coracoid osteotomy with Bristow–Latarjet procedures were performed on 16 shoulders and open coracoid osteotomy without Bristow–Latarjet procedures were performed on four shoulders. Open coracoid osteotomy with or without Bristow–Latarjet procedures were chosen on the basis of the stability of the shoulder after reduction. Outcomes were assessed preoperatively and postoperatively with the visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, the University of California Los Angeles (UCLA) shoulder rating scale, and the range of motion (ROM) for shoulder activity.ResultsThere were three males and 15 females with an average age of 60.94 ± 2.69 years. The time between dislocation and treatment ranged from 21 to 240 days with an average of 73.3 ± 14.4 days. All patients were available for a mean follow‐up of 15.2 ± 4.3 months. No procedure‐related death or incision‐related superficial or deep tissue infection was identified in all cases. No iatrogenic neurovascular injuries or fractures were found in this study. At the time of 12 months follow‐up, the range of motion and the shoulder functional evaluation (VAS [P < 0.001], ASES [P < 0.001], and UCLA score [P < 0.001]) in patients who underwent Bristow–Latarjet procedures were significantly improved. Subluxation after surgical procedure was found and confirmed in one patient and this patient refused to undergo revision surgery. According to the Samilson and Prieto classification system, 16 shoulders were assessed as grade 0, three shoulders were grade 1, one shoulder was grade 2.ConclusionsCoracoid osteotomy with or without Bristow–Latarjet procedure yielded an acceptable clinical result in this study. This method has the advantages of enlarging the exposure of surgical field, assisting reduction of shoulder, and convenient conversion to Bristow–Latarjet procedure. It is an efficient and reliable method for treatment of chronic anterior shoulder dislocation.A 69‐year‐old woman diagnosed with right chronic anterior shoulder dislocation with large Hill–Sachs lesion. The latarjet procedure with remplissage technique was applied for this patient.

Late mandibular fracture after attempted third molar surgery: case report

Removal of lower third molar corresponds to one of the most common procedures in oral surgery. The extraction can result in several intraoperative or postoperative complications, especially when fully impacted molars are involved. This case report describes a mandibular angle fracture following removal of a fully impacted lower third molar of a 41 years old male patient. The fracture occurred 3 days after the attempt to extract the tooth 38 by a dentist surgeon. Several factors influencing the possibility of fracture including gender, age, dental position, and angulation were reviewed and associated with the injury. A fracture line in the angular region of the jaw was observed in radiological and tomographic analysis, both essential to perform the diagnosis. Open reduction internal fixation treatment approach was realized to ensure the best patient’s recovery. We conclude that the difficult to maintain a soft diet and the complete dentition factor could have been determinant to cause the fracture.Descriptors: Mandibular Fractures; Fracture Fixation; Molar, Third.ReferencesAl-Belasy FA, Tozoglu S, Ertas U. Mastication and late mandibular fracture after surgery of impacted third molars associated with no gross pathology. J Oral Maxillofac Surg. 2009; 67(4):856-61.daBodner L, Brennan PA, McLeod NM. Characteristics of iatrogenic mandibular fractures associated with tooth removal: review and analysis of 189 cases. Br J Oral Maxillofac Surg. 2011;49(7):567-72.Bouloux GF, Steed MB, Perciaccante VJ. Complications of third molar surgery. Oral Maxillofac Surg Clin North Am. 2007; 19(1):117-28.Joshi A, Goel M, Thorat A. Identifying the risk factors causing iatrogenic mandibular fractures associated with exodontia: a systemic meta-analysis of 200 cases from 1953 to 2015. Oral Maxillofac Surg. 2016;20(4):391-96.Libersa P, Roze D, Cachart T, Libersa JC. Immediate and late mandibular fractures after third molar removal. J Oral Maxillofac Surg. 2002;60(2):163-66.Perry PA, Goldberg MH. Late mandibular fracture after third molar surgery: a survey of Connecticut oral and maxillofacial surgeons. J Oral Maxillofac Surg. 2000;58(8):858-61.Pires WR, Bonardi JP, Faverani LP, Momesso GAC, Muñoz XMJP, Silva AFM et al. Late mandibular fracture occurring in the postoperative period after third molar removal: systematic review and analysis of 124 cases. Int J Oral Maxillofac Surg. 2017;46(1):46-53.Krimmel M, Reinert S. Mandibular fracture after third molar removal. J Oral Maxillofac Surg. 2000;58(10):1110-12.Wagner KW, Otten JE, Schoen R, Schmelzeisen R. Pathological mandibular fractures following third molar removal. Int J Oral Maxillofac Surg. 2005;34(7):722-26.Ethunandan M, Shanahan D, Patel M. Iatrogenic mandibular fractures following removal of impacted third molars: an analysis of 130 cases. Br Dent J. 2012;212(4):179-84.Ellis E 3rd. Management of fractures through the angle of the mandible. Oral Maxillofac Surg Clin North Am. 2009;21(2):163-74.Pell GJ, Gregory GT. Report on a ten year study of a tooth division technique for removal of impacted teeth. Am J Orthodont Surg. 1942; 28:660-71.Antoun JS, Lee KH. Sports-related maxillofacial fractures over an 11-year period. J Oral Maxillofac Surg. 2008;66(3):504-8.Chrcanovic BR, Custódio AL. Considerations of mandibular angle fractures during and after surgery for removal of third molars: a review of the literature. Oral Maxillofac Surg. 2010; 14(2):71-80. Iizuka T, Tanner S, Berthold H. Mandibular fractures following third molar extraction. A retrospective clinical and radiological study. Int J Oral Maxillofac Surg. 1997;26(5):338-43.Woldenberg Y, Gatot I, Bodner L. Iatrogenic mandibular fracture associated with third molar removal. Can it be prevented?. Med Oral Patol Oral Cir Bucal. 2007;12(1):E70-2.Miyaura K, Matsuka Y, Morita M, Yamashita A, Watanabe T. Comparison of biting forces in different age and sex groups: a study of biting efficiency with mobile and non-mobile teeth. J Oral Rehabil. 1999;26(3):223-27.Bezerra TP, Studart-Soares EC, Pita-Neto IC, Costa FW, Batista SH. Do third molars weaken the mandibular angle?. Med Oral Patol Oral Cir Bucal. 2011;16(5):e657-63.Grau-Manclús V, Gargallo-Albiol J, Almendros-Marqués N, Gay-Escoda C. Mandibular fractures related to the surgical extraction of impacted lower third molars: a report of 11 cases. J Oral Maxillofac Surg. 2011;69(5):1286-90.

A hybrid treatment modality of a subtrochanteric femoral fracture in a patient with osteoporosis due to a renal Fanconi syndrome: a case report.

A 24-year-old male with an idiopathic renal Fanconi syndrome presented to our ER after a low-energetic fall. Conventional imaging revealed a right subtrochanteric femoral fracture, severely decreased bone quality and cannulated collum femoris screws on the contralateral side. Regular plate-screw osteosynthesis or cephalomedullary implantation was deemed insufficient, due to a high iatrogenic and periprosthetic fracture probability. The decision was made to perform a plate-screw osteosynthesis combined with an intramedullary polymer bone enhancement (IlluminOss), to minimize this risk. No complications occurred perioperatively. The patient was able to walk independently two months postoperatively. This case shows that use of polymer implant as an enhancement of osteosynthesis in repair of fractures in the Fanconi syndrome is a safe and possible useful treatment method.

Notes on…

Matthew Oxford is one of only a handful of veterinary dentists in the UK and established the New Forest Veterinary Dental Service in 2011 to provide a service for referral veterinary dental and oral surgery procedures for other veterinary practices. He has written this short article to offer a pragmatic approach to the extraction of root fragments and, especially in the case of iatrogenic root fractures, this approach is useful to mitigate some of the stress of the procedure.

Results of proximal femoral nail in intertrochanteric fracture of femur

Introduction: Intertrochanteric Femur fractures comprise approximately half of all hip fracture caused by low energy mechanism. These hip fractures occur in characteristic population with risk factors including increasing age, female gender, osteoporosis, a history of fall and gait abnormality. In spite of great advances made in the field of trauma in last 50 years management of this fracture has always remained subject of debate. There are several internal fixation options for managing these fractures that generally fall into two categories: some form of intramedullary fixation or some form of plating. Proximal Femoral Nailing is load bearing device with rotational stability and also short lever arm in addition to indirect fracture reduction. Materials & Methods: In this age group, we have done a prospective study in 70 patients of proximal femur fractures of femur operated with proximal femoral nailing at our institute with follow up of 5 – 24 months. All patients between above 31 years of age with proximal femur fractures of femur admitted in tertiary center in government setup - meeting the inclusion and the exclusion criteria during the study period were the subjects for the study. Patient were regularly followed up radiologically. Final outcome is measured with Harris Hip Score. Results: In the present study, 70 cases of intertrochanteric fractures treated operatively with proximal femoral nail (PFN), and the results were analyzed. In this series, low velocity injury (Domestic fall) was the cause of fracture in the majority (70%), especially in the elderly female patients. Boyd & Griffin type 2 was the commonest type (42%) following fall while walking, etc. The operations were completed within 2 hours in 98% of the patients. For PFN minimum duration was 40 minutes and maximum duration was 150 minutes and mean duration was 80 minutes. On final follow up one patient had iatrogenic basicervical fracture, one patient had outward migration of screw, two patient had backout of derotation screw, 10 patient had varus collapse, five patient had abductor weakness on followup. On 6 month follow up thirty patient had separated lesser trochanter with union of fracture but there was no limitation of movement & any residual deformity. The functional result according to Harris Hip Score was found to be excellent in 51.42%, good in 31.42%, fair in 10% and poor in 7.14% of patients. Conclusion: Intertrochanteric fractures commonly occur in elderly persons, usually following minor trauma whereas in young patients a major trauma is needed to cause this fracture. Proximal femoral nail offer less invasive option for fixation of intertrochanteric hip fractures. Unstable fractures can be fixed faster and with lesser soft tissue dissection. On basis of our study we have concluded that PFN should always be considered for management of intertrochanteric fractures in young as well as elderly patients who have multiple pre-existing illness.

Distal interlocking for short trochanteric nails: static, dynamic or no locking? Review of the literature and decision algorithm.

Pertrochanteric hip fractures are among the most common and the use of short cephalomedullary nails as the treatment of choice is increasing.A systematic review regarding distal locking options for short cephalomedullary nails was undertaken using Medline/PubMed®, Embase® and Cochrane Library® in order to evaluate current indications, associated complications and to provide treatment recommendations.The results seem to support the use of distal static locking for unstable fractures, dynamic locking for length stable/rotational unstable fractures and no locking for stable fractures.Complications associated with distal locking include iatrogenic fractures, thigh pain, delayed union and nonunion, implant failure, screw loosening and breaking, drill bit breaking, soft tissue irritation, femoral artery branch injury, intramuscular haematoma and compartment syndrome. It is also associated with longer operative time and radiation exposure.In unlocked constructs, dorsomedial comminution and nail/medullary canal mismatch contribute to peri-implant fractures. Anterior cortical impingement is associated with cut-out and nonunion.Most studies comparing distally locked and unlocked nails report a short follow-up.Distal locking mode should be based on the fracture’s stability.Cite this article: EFORT Open Rev 2020;5:421-429. DOI: 10.1302/2058-5241.5.190045

Management of the bone loss by metaphyseal sleeves in primary and revision knee arthroplasty: clinical experience and outcome after forty three cases.

Management of metaphyseal bone loss in complex primary and revision TKA is a challenge for surgeons. Out of various types of bony defects, large metaphyseal bone loss (AORI types IIB and III) requires special augments in the form of cones or sleeves. The aim of this study is to assess the reliability of metaphyseal sleeves, in dealing with massive bone defects to provide stability for immediate weight bearing and also to check short to mid-term survivorship of metaphyseal sleeves in Asian population by assessing various parameters and complications. This is a retrospective study that includes 36 patients (43 knees), operated from 2011 to 2019. Patients with AORI type IIB (large metaphyseal bone defect) and AORI type III (metaphyseal defect with compromised collateral ligaments) were included. We included both the primary and revision knee arthroplasties in our study. Our interest in this study was to look for incidence of intra-operative iatrogenic fracture on the one hand, and post-operative complications in the form of peri-prosthetic joint infection and aseptic loosening on the other hand. Knee Society Score (KSS) was used to assess improvement in patient's clinical outcome. SPSS version 23 was used to process data. The average age of patients in our study was 59.4 (SD 9.78) years. Male to female ratio was 21:15. The average follow-up was 5.42 (SD 2.24) years with the longest follow up of nineyears. Metaphyseal sleeves were used in 12 primary TKA and 31 revision TKA. During surgery, iatrogenic fracture of tibial condyle was encountered in three patients (6.9%), all were managed without any intervention and union was achieved in all cases. There was not a single case with aseptic loosening as per radiological criteria in our study. Peri-prosthetic joint infection (PJI) was encountered in a single case (2.3%). Pre-op Knee Society Score (KSS) was 36.21 (SD 7.43) where as it improved to 92.00 (SD 5.66),sixmonths after surgery. Also the range of flexion was increased from 76.83o (SD 14.07o) to 122.91o (SD 4.84o). In our study, metaphyseal sleeves showed excellent short to mid-term survivorship in AORI types IIB and III boneloss in Asian population. These results are comparable to various studies conducted on North American and European population. Metaphyseal sleeve is a reliable tool in the armamentarium ofthe arthroplasty surgeon. It is user friendly implant and provides immediate stability to allow full weight-bearing mobilization.

The Strange Case of a Broken Periodontal Instrument Tip

This case report describes a rare case of a broken periodontal probe tip and its removal. A male patient presented himself in June 2019 due to a painful tooth in the upper left quadrant. The patient elected treatment in the dental school’s student course. In October 2019, in preparation for full-mouth rehabilitation, a complete diagnostic status was performed, including radiographs. In this context, a metal-dense fragment was identified in the apical region of the (missing) tooth 45. It was diagnosed as the broken tip of a periodontal probe (type AE P OWB). Since a PCP-12 probe is generally used in-house, iatrogenic damage during the initial examination or student course could be excluded a priori. The patient was not able to remember any treatment that could be associated with the instrument’s breaking. Since the probe fragment was palpable and a translocation could not be precluded, the patient agreed to its removal under local anesthesia, after a cone-beam CT. This article describes and discusses this particular case, with special emphasis on iatrogenic instrument fractures and their removal.

Iatrogenic biological fracture of the cervical spine during gradual halo traction for kyphotic deformity correction: case report

BackgroundSevere kyphotic deformities carry high risk for neurological injuries as osteotomies are often required for correction. Surgeons often utilize a staged approach for dealing with these conditions starting with a period of halo traction to stretch tight soft tissues and partially correct the deformity, followed by surgery. Halo traction is a relatively safe procedure and complications are uncommon. We report a unique case of iatrogenic fracture of the cervical spine during gradual halo traction for deformity correction of a severe cervical kyphosis.Case presentationAn 80-year-old female with previous cervical spine tuberculosis infection and C5-C6 anterior spinal fusion developed severe cervical kyphosis of 64° from C2-C6 and neck pain requiring deformity correction surgery. Gradual increase in traction weight was applied, aiming for a maximum traction weight of 45 pounds or half body weight. During the 1st stage halo-gravity traction, sudden neck pain and a loud cracking sound was witnessed during increase of the traction weight to 14 pounds. Imaging revealed a fracture through the C4 and reduction in kyphosis deformity to 11° from C2-C6. There was no neurological deficit. No further traction was applied and the patient underwent an in-situ occipital to T3 fusion without osteotomies. At 3-year follow-up, the patient was symptom-free and radiographs showed solid fusion and maintenance of alignment.ConclusionsIatrogenic fracture may occur with halo traction. Elderly patients with osteoporotic and diseased bone should be closely monitored during the treatment. A fracture without complications was a fortunate complication as the patient was able to avoid any high-risk osteotomies for deformity correction.Level of evidenceIV

Iatrogenic humeral anatomic neck fracture after intraosseous vascular access

Intraosseous infusion has become a key tool in the resuscitation of critically ill or injured patients, both in pre-hospital settings and in emergency departments. Intraosseous access is obtained through the percutaneous placement of a needle into the medullary space of a bone, thereby allowing access into the systemic venous circulation via the medullary space, which is essential to treat patients in shock, cardiac arrest, airway compromise, or major trauma. This becomes critically important when obtaining conventional intravenous access is difficult or impossible. Few cases of iatrogenic fracture have been reported for intraosseous access in the tibia and no case to-date has been reported of iatrogenic fracture secondary to humeral access. We report a case of a 55-year-old patient being resuscitated emergently with proximal humeral intraosseous infusion for cardiac and respiratory arrest secondary to status epilepticus. After successful resuscitation and removal of the intraosseous cannula, the patient noted new-onset shoulder pain. The patient was ultimately diagnosed with an iatrogenic fracture of the anatomic neck of the humerus through the intraosseous needle tract when the appropriate history was obtained in conjunction with cross-sectional imaging. As the use of intraosseous access expands, such fractures may well be seen more frequently. Intraosseous access is limited to the period of resuscitation and the cannula is often not present at the time of imaging. It is important for radiologists to recognize the findings related to intraosseous access as well as this complication with its characteristic locations and morphology.

Classifications in Brief: The Dorr Classification of Femoral Bone.

Classifications in Brief: The Dorr Classification of Femoral Bone.

Application of a Fork Plate for Greater Trochanter Osteosynthesis in Total Hip Arthroplasty.

The aim of the study was to assess the effectiveness of using an original technique of greater trochanter fragment fixation during total hip replacement.Materials and MethodsSince 2013, this construction has been implanted in 175 patients in the clinic of the Russian Scientific Research Institute of Traumatology and Orthopedics named after R.R. Vreden. By the present time, 50 patients have been examined in order to assess the effectiveness of this construction. They were divided into three groups depending on the cause of greater trochanter fixation by the original plate: osteotomy according to T. Paavilainen, periprosthetic Vancouver type AG fractures, false joints of the greater trochanter. The degree of consolidation of the greater trochanter fragment with the femoral bone metadiaphysis was assessed using the roentgenometric technique according to M. Hamadouche’s recommendations. The functional result of the hip was evaluated according to the Oxford Hip Score scale.ResultsThe nonunion rate in the presented groups was 8.3% in fragment fixation after osteotomy according to T. Paavilainen, 25% after fragment fixation in periprosthetic Vancouver type AG fracture, and 11.1% in fixation of the greater trochanter fragment when treating a false joint of the given localization.ConclusionPreliminary results of the greater trochanter fixation using the original fork plate during total hip replacement showed sufficient effectiveness not only in osteotomies of the greater trochanter, periprosthetic iatrogenic and pathological Vancouver type AG fractures but also in case of false joints of this localization developed due to the failure of the previous fixation.

Iatrogenic fracture of lingual plate of bone and Displacement of Mandibular Third Molar into Submandibular Tissue Space. A Case Report.

Abstract: displacement of impacted third molar tooth or fragment during surgical extraction to adjacent tissue spaces such as submandibular or pterygomandibular is not a common complication. Retrieval of displaced tooth or fragment is complicated by difficult visibility, accessibility and instrumentation. Patient and methods: Referred male patient with displaced decapitated lower third molar tooth into submandibular tissue space. The displaced tooth was retrieved intra orally by raising lingual flap, using local anesthesia nerve block. The tooth was removed safely without complications and wound healing was normal. Conclusion: wisdom tooth removal must be done by an expert surgeon with adequate clinical and radiological assessment to avoid inadvertent complications. In case of iatrogenic displacement of the tooth or fragment into tissue space, computed tomography (CT) is a proper tool to estimate its exact location. Introduction: Surgical removal of impacted wisdom teeth is common surgical procedure with minimum complications of about 1% of cases which include bleeding, pain, swelling, infection and nerve parenthesis (lingual, inferior alveolar) either temporary or permanent. 1-4 Displacement of wisdom tooth or fragment into tissue space (submandibular or pterygomandibular) is uncommon complication in practice and in literature.5, 6 Iatrogenic displacement of wisdom occur due to lack of experience, improper preoperative clinical and radiographic estimation, improper treatment plan and uncontrolled application of force specially by elevators.7 This case report showing iatrogenic displacement of decapitated lower left wisdom retrieved surgically by intraoral lingual flap approach under local anesthesia.

Direct Anterior Approach Versus Posterolateral Approach for Hemiarthroplasty in the Treatment of Displaced Femoral Neck Fractures in Geriatric Patients.

BackgroundIn the present study, we aimed to evaluate early clinical and biochemical outcomes of direct anterior approach (DAA) versus posterolateral approach (PLA) for hemiarthroplasty in the treatment of displaced femoral neck fractures in geriatric patients.Material/MethodsBetween September 2012 and September 2017, a total of 110 patients who underwent hemiarthroplasty for displaced femoral neck fractures were retrospectively analyzed. The patients were divided into 2 groups according to the surgical technique PLA (Group 1, n=54) and DAA (Group 2, n=56). Clinical and biochemical results were compared.ResultsThere was no significant difference in the demographic characteristics of the patients, fixation type, and follow-up (P>0.05). However, there was a significant difference in the duration of surgery, amount of blood transfusion, change from baseline in postoperative hemoglobin levels, amount of intraoperative gauze dressing, amount of drainage fluid from the surgical wound, postoperative VAS scores, incision length, length of hospital stay, and Barthel Index scores in favor of DAA group (P<0.05). There was no significant difference in the degree of mobilization (P>0.05). None of the patients had postoperative complications in Group 1, while 3 patients in Group 2 developed a lateral femoral cutaneous nerve lesion and one patient had a missed iatrogenic fracture of the greater trochanter.ConclusionsOur study results suggest that early clinical and biochemical outcomes are better in DAA than PLA with early return to daily living activities in patients undergoing hemiarthroplasty for displaced femoral neck fractures.

Does using different entrance points for intramedullary nails affect clinical outcomes for femoral shaft fractures? A retrospective clinical comparative study

OBJECTIVE:We examined the clinical and radiological outcomes of femoral shaft fractures treated with two different intramedullary nail designs using either greater trochanteric or trochanteric fossa entrance.METHODS:The medical records of patients undergoing operations for a shaft fracture either with a nail with trochanteric entrance or trochanteric fossa entrance were retrospectively reviewed. Inclusion criteria were: having the necessary medical records including radiographic images and follow-up data, at least 12 months of follow-up, skeletal maturity (≥16 years of age) not having osteoporosis (≤60 years of age). Exclusion criteria were: pathological fractures, fragility fractures, fractures that extend to hip or knee joint capsule, lack of enough medical data, less than 12 months of follow up, and patients yet to reach skeletal maturity.RESULTS:A total of 65 patients (67 femur fractures) were treated with intramedullary nails using a trochanteric fossa entrance (TFE) and 21 patients (23 femur fractures) were treated with nails using a greater trochanteric entrance (GTE). No statistically significant differences were evident between groups in terms of union time, blood loss, need for implant removal, implant failure, or revision operation. However, the duration of postoperative hospitalization was significantly shorter in the GTE nail group and the need for open reduction of the fracture was less common in these patients. Although there were no significant differences between groups in terms of complications and union among isthmal and infra-isthmal fractures, malreduction and iatrogenic fractures were more common with the use of GTE nails for treatment of supra-isthmal fractures.CONCLUSION:Use of intramedullary nails via both GTE and TFE were safe and efficient for the treatment of isthmal and infra-isthmal fractures. However, varus malalignments associated with iatrogenic fractures were more common with trochanteric entrance nails. Together, our results show that the use of nails via TFE may represent a safer option for surgical treatment of supra-isthmal fractures.

Is Full-Length Intramedullary Nail Necessary for Atypical Subtrochanteric Femoral Fracture Associated with Bisphosphonate?

BackgroundAmerican Society for Bone and Mineral Research recommend the use of intramedullary reconstruction of full length-nail for atypical subtrochanteric femoral fracture (ASFF). However, there is no study on the incidence of the ipsilateral femoral fracture after index operation of ASFF, and full-length nail has disadvantage as iatrogenic fracture and leg length discrepancy (LLD). The aim of this study was to investigate the incidence of ipsilateral secondary fracture after using partial-length nail, and to compare the outcomes on surgery of ASFF between partial length-nails and full length-nails.MethodsForty-five consecutive fractures with ASFFs which had undergone intramedullary fixation using cephalomedullary nail between 2011 and 2018 were enrolled. The 45 cases were grouped based on nail length into the partial-length nail group (n=26) and the full-length nail group (n=19). Ipsilateral secondary fracture, time to union, intra-operative iatrogenic fracture, metal failure, LLD, operative duration, and post-operative 24-hr blood loss were investigated.ResultsThere was no ipsilateral secondary fracture after index operation. There were no statistically significant differences between the partial-length nail and full-length nail groups in the time to union, LLD, and post-operative 24-hr blood loss (P=0.427, 0.478, and 0.228, respectively). Operative duration showed statistically significant difference between 2 groups (P=0.034). Metal failure were occurred in 1 (3%) case of the partial-length nail group and 2 (10%) cases of the full-length nail group. Iatrogenic fractures during nail insertion occurred in 2 (7%) cases of the partial-length-nail group and 3 cases (15%) of the full-length nail group.ConclusionsAlthough large scale studies are required, our study indicate that full-length nails are not usually required for the treatment of ASFF.

Evaluation of residual bone mass of the mandibular third molar and the risk of mandibular fracture.

A quantification of the residual bone mass of the mandible (B/A) was utilized in this study to examine the correlation between mandibular fracture and residual bone mass. To improve the clinical utilization rate and reduce the incidence of iatrogenic mandibular fractures, the B/A ratio calculation should be simplified. Data were collected from the Yanbian University Hospital on 175 cases of mandibular fracture with third molar (M3), 67 normal cases without fractures and 20 cases of impacted teeth extraction. Twenty cases of iatrogenic mandibular fracture were collected, and the case records and panoramic radiographs of the patients were recorded. The average B/A ratio of mandibular angle fracture group was 0.61±0.10.The value of B/A was found to be statistically significant in terms of whether M3 emerged from alveolar bone (P = 0.001), location (horizontal P < 0.001, vertical P < 0.001), the degree of impaction (P < 0.001), the number of roots (P < 0.001), the difference in impaction (P < 0.001), and the fracture type (P = 0.002). The average B/A ratio of normal group was 0.62±0.10. In the statistical results of the B/A value of normal patients, M3 involving alveolar bone (P < 0.001), position classification (P < 0.05), degree of impaction (P < 0.001) and presence or absence of a root (P < 0.05) were statistically significant. The average B/A ratio of iatrogenic mandibular angle fracture group was 0.28±0.08. The average B/A ratio of the extraction group for impacted teeth was 0.62 ± 0.09. There is a high risk of mandibular angle fracture when the (B/A) value of the residual bone height (B) in the mandibular M3 area compared to the mandibular bone height (A) in the M3 area is less than 0.4.

Removal of Elastic Stable Intramedullary Nail

Introduction: Removal of the elastic stable intramedullary nail (ESIN) after the union is routinely performed in the pediatric population. However, ESIN removal can be lengthy and difficult due to the strong bonding between nail and bone. Technique: We preferred keeping the nail tip tangentially flush (&lt;5mm) to the bone to avoid skin irritation. In our technique, after incision and subcutaneous dissection, the nail tip is identified and exposed using a 6-mm osteotome, and a trough is created around it sufficient enough to pass the hollow mill over it. In cases with buried nail tip, a rectangular cortical window may be required. The nail tip is then gently bent at 90° using the hollow mill as the lever taking care not to cause an iatrogenic fracture. The nail tip is held at the bent from sideways with a plier and the nail is removed by rotatory backward motion or reverse impaction using a mallet in cases of strong bonding between nail and bone. Using this technique, ESIN removal was successful in all 28 cases using the previous incision. Of these cases, 10 were forearm (36%), 8 were tibia (28%), 7 were femur (25%) and 3 were humerus (11%). 6 cases (21%) were considered difficult due to increased thickness of the nails, deeper location of the nail tip, and increased bone growth around the tip of nails. Conclusion: Our technique is simple, innovative, and can be easily reproduced by all Orthopaedic Surgeons. The use of this technique is recommended for all ESIN removals. Keywords: Diaphyseal fractures; Elastic stable intramedullary nail; Hardware removal; Paediatric long bone.

Treatment of anterior glenohumeral dislocations with manual reduction of WU medical school

To investigate the technique, mechanism and clinical efficacy of manual reduction of WU medical school in the treatment of anterior glenohumeral dislocations. From January 2016 to December 2017, 181 patients with anterior glenohumeral dislocations were treated with our manual reduction, including 71 males and 110 females, ranging in age from 19 to 94 years old, with a mean age of(61.1±16.3) years old; 68 cases of subglenoid type, 93 cases of subcoracoid type and 20 cases of subclavian type. Constant score was used to evaluate limb function while the external fixation was removed. One hundred and fifty-seven patients achieved reduction at the first attempt and 23 patients achieved at the second time. There was no vascular damage, nerve damage or iatrogenic fracture accmpanied. The Constant score ranged from 75 to 100, with a mean score of 92.1±4.3. One hundred and sixty-eight patients were followed up, and the duration ranged from 12 to 24 months, with an average of (16.1±3.2) months, no recurrent dislocation occurred during the follow up period. The manual reduction of WU medical school in the treatment of anterior glenohumeral dislocations has high success rate and low complication rate, which is scientific, safe, standardized, easy to learn and worth promoting.