Posterior Angulation Research Articles

Plate fixation with autogenous bone grafting for longstanding humeral shaft nonunion: A retrospective study of 6 cases.

Longstanding humeral shaft nonunion is uncommon because humeral shaft fractures often respond well to conservative and surgical treatments. However, when it occurs, the treatment of longstanding humeral shaft nonunion is challenging. This study is a retrospective analysis of the clinical and radiographic findings in a consecutive series of patients with longstanding humeral shaft nonunions who underwent locking compression plate (LCP) fixation and autogenous iliac crest bone grafting.Six patients were surgically treated at Xi’an Hong Hui Hospital for longstanding humeral shaft nonunions between February 2011 and June 2015. Four patients were of synovial pseudarthrosis, 1 was atrophic, and 1 was hypertrophic. Follow-up was for at least 12 months after intervention. Standardized treatment included a thorough debridement, LCP and screw fixation, and autogenous iliac crest bone grafting. In 3 patients, a single plate was applied, and in the other 3 patients, double plates were used. The main outcome measurements were shoulder and elbow function (Constant and Murley scale, and Mayo elbow performance index [MEPI]) and the visual analog scale (VAS) for pain. In addition, all complications were documented.Our series included 6 male patients with an average age of 56.3 years and an average nonunion duration of 19.5 years. All patients had previously undergone at least 1 operation. At a mean of 26 months follow-up, all fractures had achieved solid union and none of the implants had evidence of loosening or breakage. Postoperative alignment was within 10° of anatomic in 4 patients, 1 patient had 23° of valgus angulation, and 1 patient had a posterior angulation of 12°. Mean humeral shortening was 2.8 cm. The mean Constant and Murley joint function score was 88.3 points, the mean MEPI was 96.7 points, and the mean VAS was 0.7. All patients reported significant improvement in shoulder and elbow function, and each patient was able to resume work and was satisfied with the treatment.Plate fixation combined with autogenous iliac crest bone grafting is an excellent option for the treatment of longstanding humeral shaft nonunion.

A prospective RCT comparing the outcome of above-knee and below-knee pop cast application for isolated tibial shaft fractures in children

Purpose: Above-Knee Cast has been standard treatment for treating tibial fractures in children. We conducted this study to evaluate the time of union, complication and cost of treatment between above- Knee and Below-Knee Cast groups in children with isolated tibial shaft fractures. Study Design: Sixty children of age 6 months-15 years were randomized into Above-Knee and Below-Knee Cast group, who were followed and compared; till 6 months from January 2012 to March 2013. 10 children (6 torus, 2 undisplaced, 2 displaced fractures) lost to follow up at 6 months and were analyzed with missing value data analysis at 6 months. Results: All fracture united (8.30±2.69 weeks in Above-Knee Cast, 7.70±2.54 weeks in Below-Knee Cast). The pre-reduction parameters were varus (2-8o), valgus (4-8o), anterior angulation (4-9o), Posterior angulation (2-10o), Internal Rotation (3-6o), External rotation (3-6o), shortening (6.46 mm). At 6 months, above parameters were 2.83o±0.85, 3.20o±0.44, 2.83o±1.32, 2.67o±0.84, 3.40o±0.54, 2.83o±0.75, 2.67±1.15mm respectively in Above-Knee group and 2.60o±0.84, 2.50o±0.52, 3.00o±1.00, 2.93o±1.32, 3.00o±1.41, 2.33o±0.57, 2.00±0.00mm respectively in Below-Knee group. Reinforcement requirement of plaster was higher in Below-Knee cast (p=0.014). There were no refractures, residual complications. Conclusions and clinical relevance: Below-Knee cast is as effective as Above-Knee Cast for treatment of Isolated tibial shaft fractures in child with superior ROM at knee and low cost (p

Factors Affecting Posterior Angulation in Retrograde Intramedullary Nailing for Distal Femoral Fractures

Factors Affecting Posterior Angulation in Retrograde Intramedullary Nailing for Distal Femoral Fractures

Congenital Posteromedial Bowing of the Tibia: A Single Center Experience

Summary Congenital posteromedial bowing of the tibia (CPMBT) is a rare congenital anomaly of the lower limbs. The aim of the present study was to analyze our experience in the treatment of CPMBT. A retrospective study of patients treated for CPMBT in the period January 2000 – June 2016 was performed. In the observed period, six patients were treated (five girls and one boy), with predominance of the right tibia involvement (5:1). The initial treatment included a series of corrective casts (4-9) applied in all patients, followed by removable splints and physiotherapy. Four children with residual angulation of tibia after walking age were prescribed ankle-foot orthosis (AFO) as a prevention of pathological fractures. Both posterior and medial angulation correct over time. Mean initial shortening was 11 mm. At the last follow-up visit, mean shortening was 23.33mm. Three patients had lower limb shortening of more than 2 cm. In two of them, with shortening of 27 mm and 35 mm, Ilizarov lengthening was performed. In one girl, we performed lengthening over titanium elastic nails. In the other girl, after lengthening, circular frame was exchanged with a locking plate to reduce fixator wearing time. There were no major complications of treatment. Patients were followed up for 2-12 years (mean 6.83 years). None of them reached skeletal maturity yet. Primary manifestation of CPMBT – angulation of tibia and fibula as well as calcaneovalgus deformity usually correct spontaneously or with conservative measures. However, limb length inequality, as a consequence of CPMBT, progresses with growth and may require surgical correction in some children. Therefore, all children with CPMBT should be followed up until skeletal maturity.

Mesiodistal dental movement toward remodeled edentulous alveolar ridge: Digital model assessment.

The aims of this study were to compare the changes in posterior dental inclination and angulation, and the posterior tooth crown sizes and alveolar ridge thicknesses consequent to the orthodontic procedures of closing and opening of mandibular first molar edentulous spaces. The sample comprised 16 patients (4 men, 12 women) with an initial mean age of 34.17years and unilateral or bilateral absence of mandibular permanent first molars. The space closure group (SCG) comprised 12 hemiarches with a mandibular first molar edentulous space varying from 2 to 7mm, orthodontically treated with space closure. The space opening group (SOG) comprised 14 quadrants with a mandibular first molar edentulous space varying from 7.1 to 12mm, orthodontically treated with space reopening for prosthetic replacement. Digital dental models were obtained before treatment and after space closure or opening, and posterior tooth angulation and inclination, cervico-occlusal crown height, and alveolar ridge thickness were evaluated. Interphase and intergroup comparisons were performed with dependent t tests and t tests, respectively (P<0.05). Mandibular secondmolar uprighting and changes in buccolingual inclination of the posterior teeth were similar in the groups. The second molar cervico-occlusal crown height increased in the SCG and decreased in the SOG. The alveolar ridge thickness increased in the SCG and remained stable in the SOG. The only significant intergroup differences were that the secondmolar cervico-occlusal crown height and the alveolar ridge thickness increased in the SCG, and decreased and remained stable in the SOG.

Posterior teeth angulation in non-extraction and extraction treatment of anterior open-bite patients

BackgoundThis study cephalometrically evaluated the posterior teeth angulation changes of anterior open-bite non-extraction and extraction treatment in the permanent dentition, with anterior vertical elastics.MethodsThe sample consisted of initial and final lateral headfilms of 60 patients divided into 2 groups: Group 1 consisted of 30 patients treated with non-extraction with an initial mean age of 15.26 years and treated with fixed appliances for a mean period of 2.46 years. Group 2 consisted of 30 patients treated with extractions, with an initial mean age of 14.03 years, and treated with fixed appliances for a mean period of 2.49 years. Within-group treatment changes were evaluated with paired t tests. Results were considered statistically significant at P < 0.05.ResultsThe mandibular posterior teeth were significantly uprighted in both groups with both treatment protocols.ConclusionsCorrection of anterior open bite with either non-extraction or extractions with continuous archwires and vertical anterior elastics uprights the mandibular posterior teeth.

Three-dimensional Planning and Reconstruction of the Mandible in Children with Craniofacial Microsomia Type III Using Costochondral Grafts.

Background:In craniofacial microsomia (CFM) Type III patients, autogenous costochondral grafts (CCG) are conventionally used for the reconstruction of the ramus and condyle. The aim of this study was to describe the use of CCG in children with CFM in terms of outcomes, growth patterns, and complications.Materials and Methods:This is a retrospective study of nine, aged 4–12 years, patients with CFM Type III, who underwent reconstruction of the mandibular ramus condyle unit by CCG. Seven patients had right-sided CFM and two had left-sided CFM. The rationale for this choice was to utilize the potential growth of the CCG, providing length to the ramus, and the joint by acting as a growth center; to control the repositioning of the chin center; and to improve child compliance by undergoing only one operation. The surgical treatment plan was determined preoperatively, based on measurements of mandibular vertical and horizontal deficiency and analysis of the mandibular posterior and anterior angulation. The mandibular planes and axis were defined by a three-dimensional simulation software program to perform a “mock surgery”, by creating a prototype model. Clinical follow-up included measurements of the maximal opening, observation of the facial symmetry, and recording of complications, such as reankylosis.Results:There were no serious postoperative complications, infections, or graft rejections. Successful postoperative occlusal cants were noted and measured in five patients and acceptable results were obtained in three patients. In one case, the CCG underwent distraction osteogenesis to improve the facial symmetry. In one patient, the graft continued to grow and the chin started to deviate into the opposite side. Measuring and calculating the ratio of the ramus height on the panoramic X-ray revealed a good relation between the healthy contralateral and the reconstructed ipsilateral ramus. Postoperative mean mouth opening was 34.3 mm, with minimal midline deviation of 2.6 mm in occlusion. Mean follow-up was 51.7 months. The mean postoperative occlusal cant analysis for eight patients was 3.66°.Conclusion:CCG is useful in treating CFM Type III. The growth potential of the CCG makes it the ideal choice for children. The advantages of this graft are its biological compatibility, workability, functional adaptability, and minimal additional detriment to the patient. The use of a stereolithographic model preoperatively improved intraoperative precision by clearly displaying detailed anatomy of the patient undergoing craniofacial surgery. The surgeon can plan the length of the CCG before surgery and use the printed template while harvesting without waiting for the exact measurements to be provided by the facial surgical team.

Posterior tooth angulations in patients with anterior open bite and normal occlusion.

The aim of this study was to compare the posterior tooth angulations in patients with open-bite malocclusion and normal occlusion. Lateral cephalometric headfilms of 45 untreated open-bite subjects were compared with the lateral headfilms of 45 subjects with normal occlusion in the permanent dentition. The groups were matched for age and sex distribution and compared with t tests. The maxillary and mandibular premolars were more mesially angulated in relation to the bisected occlusal plane, and the first and secondmolars were significantly more distally angulated in the open-bite group in relation to the palatal and mandibular planes. The maxillary and mandibular premolars were more mesially angulated in relation to the bisected occlusal plane and therefore do not compensate for the divergence of the palatal and mandibular planes as the molars do.

A New Dicynodont (Therapsida: Anomodontia) from the Permian of Southern Brazil and Its Implications for Bidentalian Origins.

Dicynodonts were a highly successful group of herbivorous therapsids that inhabited terrestrial ecosystems from the Middle Permian through the end of the Triassic periods. Permian dicynodonts are extremely abundant in African deposits, but are comparatively poorly known from the other regions of Gondwana. Here we describe a new South American dicynodont, Rastodon procurvidens gen. et sp. nov., from the Boqueirão farm site of the Rio do Rasto Formation, Paraná Basin, Guadalupian/Lopingian of Brazil. Diagnostic features of R. procurvidens include uniquely anteriorly-curved maxillary tusks, well-developed ridges extending from the crista oesophagea anteriorly along the pterygoid rami, strong posterior angulation of the posterior pterygoid rami, and a bulbous, well-developed retroarticular process of the articular. Phylogenetic analysis indicates that R. procurvidens is the earliest and most basal member of Bidentalia, a cosmopolitan clade that includes Permian and Triassic dicynodonts whose dentition is usually reduced to a pair of maxillary tusks.

Effect of Off-Axis Fluoroscopy Imaging on Two-Dimensional Kinematics in the Lumbar Spine: A Dynamic In Vitro Validation Study.

Spine intersegmental motion parameters and the resultant regional patterns may be useful for biomechanical classification of low back pain (LBP) as well as assessing the appropriate intervention strategy. Because of its availability and reasonable cost, two-dimensional (2D) fluoroscopy has great potential as a diagnostic and evaluative tool. However, the technique of quantifying intervertebral motion in the lumbar spine must be validated, and the sensitivity assessed. The purpose of this investigation was to (1) compare synchronous fluoroscopic and optoelectronic measures of intervertebral rotations during dynamic flexion-extension movements in vitro and (2) assess the effect of C-arm rotation to simulate off-axis patient alignment on intervertebral kinematics measures. Six cadaveric lumbar-sacrum specimens were dissected, and active marker optoelectronic sensors were rigidly attached to the bodies of L2-S1. Fluoroscopic sequences and optoelectronic kinematic data (0.15-mm linear, 0.17-0.20 deg rotational, accuracy) were obtained simultaneously. After images were obtained in a true sagittal plane, the image receptor was rotated in 5 deg increments (posterior oblique angulations) from 5 deg to 15 deg. Quantitative motion analysis (qma) software was used to determine the intersegmental rotations from the fluoroscopic images. The mean absolute rotation differences between optoelectronic values and dynamic fluoroscopic values were less than 0.5 deg for all the motion segments at each off-axis fluoroscopic rotation and were not significantly different (P > 0.05) for any of the off-axis rotations of the fluoroscope. Small misalignments of the lumbar spine relative to the fluoroscope did not introduce measurement variation in relative segmental rotations greater than that observed when the spine and fluoroscope were perpendicular to each other, suggesting that fluoroscopic measures of relative segmental rotation during flexion-extension are likely robust, even when patient alignment is not perfect.

A study of correlation between posterior palatal seal width and soft palatal angulation with palatal contour.

Context:The spatial relationship of posterior palatal seal (PPS) width and vibrating lines varies among individuals. Such variability could be related to contour of the palate.Aims:The study was carried out to evaluate the relationship between PPS width of the patient intra-orally and cephalometric tracing of the same patient. Second part of the study was formulated to determine whether the anterior and posterior vibrating lines can be distinguished as two separate lines by different observers.Materials and Methods:A lateral cephalogram was made to trace the hard and soft palatal contour, and the angle of the palatal contour was measured with the v-ceph program. Correlation analysis was conducted to examine the relationship between the distance from anterior to posterior vibrating lines and the angle of the palatal contour at the junction of the hard and soft palate.Statistical Analysis Used:The data were analyzed using the Karl Pearson Correlation test.Results:Correlation of the angle of the palatal contour to PPS width, showed perfectly positive value; whereas, correlation of angle between anterior nasal spine-posterior nasal spine (ANS-PNS) and PNS-Uvula (U) to PPS width showed partially positive value.Conclusion:The correlation of angle between hard tissue and soft tissue to PPS width, and the angle between ANS-PNS and PNS-U to PPS width, increases with an increase in PPS width.

Clinical Characteristics of Posterior Staphylomas in Myopic Eyes With Axial Length Shorter Than 26.5 Millimeters

To describe the features of posterior staphylomas in myopic eyes with an axial length shorter than 26.5mm causing visual loss in old age. Retrospective, observational case series. After reviewing cases of staphyloma, we isolated 16 eyes from 10 patients with an axial length <26.5mm for further analysis. These patients had all undergone fundus photography and spectral-domain optical coherence tomography (SDOCT) and some had undergone 3-dimensional magnetic resonance imaging (3D-MRI). The mean age of the patients was 70.0 ± 6.3 years (mean ± standard deviation; range 59-81). The mean axial length of the eyes with a posterior staphyloma was 25.14 ± 0.77mm and the mean refractive error of the affected eyes was-4.28 ± 2.65 diopters. The median visual acuity was 20/60. All eyes presented with diffuse chorioretinal atrophy, which resembles pathologic myopic maculopathy. Fuchs spots previously were detected in 3 eyes (19%) and lacquer cracks in 2 (12%). SDOCT imaging of the macula showed decreased choroidal thickness in all eyes. A macular retinoschisis was detected in 5 eyes (31%), decreased ellipsoid zone reflectivity in 4 (25%), foveal retinal detachment in 2 (12%), a dome-shaped macula in 1 (6%), a choroidal neovascularization-related subretinal scar in 3 (19%), and loss of ellipsoid zone and outer nuclear layer in 3 (19%). The 3D-MRI scans from 8 eyes showed posterior staphylomas, lateral angulation, or protrusion in all eyes. No eye featured a tilted disc syndrome. Posterior staphylomas in myopic eyes with an axial length shorter than 26.5mm exhibit features resembling pathologic myopic maculopathy. This type of staphyloma might cause visual impairment in elderly patients and can be considered atypical forms ofpathologic myopia in old age.

Posterior odontoid process angulation in pediatric Chiari I malformation: an MRI morphometric external validation study.

OBJECT Osseous anomalies of the craniocervical junction are hypothesized to precipitate the hindbrain herniation observed in Chiari I malformation (CM-I). Previous work by Tubbs et al. showed that posterior angulation of the odontoid process is more prevalent in children with CM-I than in healthy controls. The present study is an external validation of that report. The goals of our study were 3-fold: 1) to externally validate the results of Tubbs et al. in a different patient population; 2) to compare how morphometric parameters vary with age, sex, and symptomatology; and 3) to develop a correlative model for tonsillar ectopia in CM-I based on these measurements. METHODS The authors performed a retrospective review of 119 patients who underwent posterior fossa decompression with duraplasty at the Monroe Carell Jr. Children's Hospital at Vanderbilt University; 78 of these patients had imaging available for review. Demographic and clinical variables were collected. A neuroradiologist retrospectively evaluated preoperative MRI examinations in these 78 patients and recorded the following measurements: McRae line length; obex displacement length; odontoid process parameters (height, angle of retroflexion, and angle of retroversion); perpendicular distance to the basion-C2 line (pB-C2 line); length of cerebellar tonsillar ectopia; caudal extent of the cerebellar tonsils; and presence, location, and size of syringomyelia. Odontoid retroflexion grade was classified as Grade 0, > 90°; Grade I,85°-89°; Grade II, 80°-84°; and Grade III, < 80°. Age groups were defined as 0-6 years, 7-12 years, and 13-17 years at the time of surgery. Univariate and multivariate linear regression analyses, Kruskal-Wallis 1-way ANOVA, and Fisher's exact test were performed to assess the relationship between age, sex, and symptomatology with these craniometric variables. RESULTS The prevalence of posterior odontoid angulation was 81%, which is almost identical to that in the previous report (84%). With increasing age, the odontoid height (p < 0.001) and pB-C2 length (p < 0.001) increased, while the odontoid process became more posteriorly inclined (p = 0.010). The pB-C2 line was significantly longer in girls (p = 0.006). These measurements did not significantly correlate with symptomatology. Length of tonsillar ectopia in pediatric CM-I correlated with an enlarged foramen magnum (p = 0.023), increasing obex displacement (p = 0.020), and increasing odontoid retroflexion (p < 0.001). CONCLUSIONS Anomalous bony development of the craniocervical junction is a consistent feature of CM-I in children. The authors found that the population at their center was characterized by posterior angulation of the odontoid process in 81% of cases, similar to findings by Tubbs et al. (84%). The odontoid process appeared to lengthen and become more posteriorly inclined with age. Increased tonsillar ectopia was associated with more posterior odontoid angulation, a widened foramen magnum, and an inferiorly displaced obex.

Displacement pattern of the anterior segment using antero-posterior lingual retractor combined with a palatal plate.

ObjectiveTo evaluate and compare the effects of two appliances on the en masse retraction of the anterior teeth anchored by temporary skeletal anchorage devices (TSADs).MethodsThe sample comprised 46 nongrowing hyperdivergent adult patients who planned to undergo upper first premolar extraction using lingual retractors. They were divided into three groups, based on the lingual appliance used: the C-lingual retractor (CLR) group (group 1, n = 16) and two antero-posterior lingual retractor (APLR) groups (n = 30, groups 2 and 3). The APLR group was divided by the posterior tube angulation; posterior tube parallel to the occlusal plane (group 2, n = 15) and distally tipped tube (group 3, n = 15). A retrospective clinical investigation of the skeletal, dental, and soft tissue relationships was performed using lateral cephalometric radiographs obtained pretreatment and post en masse retraction of the anterior teeth.ResultsAll groups achieved significant incisor and canine retraction. The upper posterior teeth did not drift significantly during the retraction period. The APLR group had less angulation change in the anterior dentition, compared to the CLR group. By changing the tube angulation in the APLR, the intrusive force significantly increased in the distally tipped tube of group 3 patients and remarkably reduced the occlusal plane angle.ConclusionsCompared to the CLR, the APLR provides better anterior torque control and canine tipping while achieving bodily translation. Furthermore, changing the tube angulation will affect the amount of incisor intrusion, even in patients with similar palatal vault depth, without the need for additional TSADs.

The accuracy of locating the cricothyroid membrane by palpation - an intergender study.

BackgroundThe cricothyroid membrane (CTM) is the recommended site of access to the airway during cricothyrotomy to provide emergency oxygenation. We sought to compare the ability of physicians to correctly identify the CTM in male and female patients.MethodsIn a prospective observational study, anaesthetists were asked to locate the CTM by palpation which was then identified using ultrasound and the distance between the actual and estimated margin of the CTM was measured. Participants assessed the ease of CTM palpation using a visual analog scale. In a second series, the angulation of the posterior junction of the thyroid laminae was measured using ultrasound.Results23 anaesthetists and 44 subjects participated. A total of 36 assessments were carried out in each gender. Incorrect identification of the CTM was more common in females (29/36 vs. 11/36, P < 0.001) and the distance from the CTM in the vertical plane was greater (11.0 [6.5–20.0] vs. 0.0 [0.0–10.0] mm, P < 0.001). In females distance from the CTM correlated positively with neck circumference (P = 0.005) and BMI (P = 0.00005) and negatively with subject height (P = 0.01). Posterior thyroid cartilage angulation was greater in females (118.6 ± 9.4° vs. 95.9 ± 12.9°, P = 0.02) and was lower in patients with correctly identified CTMs (100.0 ± 14.9° vs. 115.6 ± 15.9°, P = 0.02). VRS palpation correlated with decreased posterior thyroid cartilage angulation (P = 0.04).ConclusionsCTM localisation is more difficult in female subjects irrespective of body habitus. It may be prudent to localize this structure by additional means (e.g. ultrasound) in advance of any airway manoeuvres or to modify the cricothyrotomy technique in the event that it is necessary in an emergency.

Reduction techniques in treatment of coronal femoral intertrochanteric fractures with proximal femoral nail antirotation

Objective To explore the reduction techniques in the treatment of coronal femoral intertrochanteric fractures with proximal femoral nail antirotation (PFNA).Methods A retrospective study was performed of the 45 patients with unstable coronal femoral intertrochanteric fracture who had been treated with reduction and osteosynthesis at our department from March 2008 to August 2012.Of them,22 cases received closed reduction,including 5 males and 17 females with a mean age of 81.1 ± 13.6 years; 23 cases received limited open reduction with Kirschner wire prying or forceps clamping,including 7 males and 16 females with a mean age of 78.6 ± 12.3 years.All the patients were fixated with PFNA.The 2 groups were compared in terms of operation time,blood loss,hospital stay,time of fracture healing,complications and Harris hip score at the last follow-up.Results Of this series,42 patients were followed up (21 in each group) for 12 to 40 months (average,19.6 months).The open reduction group had significantly greater blood loss (365.6 ± 89.1 mL),significantly longer operation time (64.5 ± 14.2 min) and a significantly lower rate of complications (0) than the closed reduction group (221.3 ± 105.0 mL,53.6 ± 6.5 min and 23.8％ respectively) (P ＜ 0.05).However,there were no significant differences between the 2 groups regarding hospital stay,time of fracture healing or Harris hip score at the last follow-up (P ＞ 0.05).Conclusions As it is difficult to perform closed reduction for coronal intertrochanteric fractures,limited open reduction may be preferable in most of the cases because it can improve reduction and decrease incidence of postoperative complications by effectively correcting displacements caused by varus and anterior or posterior angulation. Key words: Hip fractures; Fracture fixation, intramedullary; Bone nails

Significant Association Between Snapping Scapula Syndrome and Anterior Angulation of the Superomedial Scapular Angle

Objectives:Significant Association Between Snapping Scapula Syndrome and Anterior Angulation of the Superomedial Scapular Angle.Methods:In this Institutional Review Board approved study, bony morphologies of the scapula were evaluated on the MRIs of 28 patients (28 scapulae) with SSS and 20 patients (22 scapulae) with non-SSS pathologies. Patients with SSS were identified from a prospective surgical registry that had undergone a preoperative shoulder MRI along with scapular bursectomy and/or superomedial angle resection. The non-SSS patients underwent shoulder MRIs for other reasons that subsequently allowed for evaluation of the scapula. The medial scapula corpus angle (MSCA), was measured on axial STIR or PD FSE sequences cranial to the spine of the scapula (Figure 1). Scapula length angled towards rib cage was documented. Scapulae were categorized as straight, s-shaped or concave. Two blinded observers, one radiologist and one orthopedic surgeon, reviewed all MRIs. MSCAs were measured using Stryker OfficePACS Power 4.1 Express Edition (Kalamazoo, MI). Positive MSCAs were defined as anterior scapular angulation towards the thorax in the axial plane whereas negative MSCAs were defined as posterior scapular angulation away from the thorax in the axial plane.Results:Axial scapula corpus configurations were identified: 31 scapulae were of the straight type, 14 were s-shaped and 5 were concave. All five concave scapulae had surgically confirmed SSS. The measurement of MSCA had excellent inter-observer agreement of 0.81 [95% CI, 0.68 to 0.89] and a fair to good intra-observer agreement of 0.68 [95% CI, 0.50 to 0.80]. There were significant differences in the mean MSCAs between those with SSS (14.4° ± 19.3°) and those with other pathologies (-3.3° ± 15.3°; p = 0.001). After excluding all concave scapulae (n = 5), the differences in the mean MSCAs between the SSS and non-SSS groups were significant (MSCA for SSS: 15.3° ± 17.5° MSCA for non-SSS: -3.3° ± 15.3°; p < 0.0001). Twenty of 28 (71.4%) scapulae with a positive MSCA had SSS, whereas only 3 of 17 (25%) scapulae with a negative MSCA had SSS (see Figure 1). The mean length of the medial scapula border angled to towards the rib cage was 14.4 mm (± 4.6 mm).Conclusion:Anterior angulation of the superomedial angle in the axial plane had an association with SSS. Those patients with a concave-shaped scapula and a positive MSCA may be at risk for SSS. This information may have clinical relevance in the treatment of SSS patients since there are no guidelines on the amount of scapular resection may or may not be needed. The MSCA may prove helpful in determining the location and amount of scapula resection needed to reduce SSS symptoms in patients.

Technical tips: Dualplate fixation technique for comminuted proximal humerus fractures

The authors report dualplate fixation technique for providing stable fixation in comminuted proximal humerus fractures. This technique has been used for proximal humerus fractures with metaphyseal comminution and provides excellent anatomical reduction and neck shaft angle (NSA).The recently locking plate is clinically more widely used due to its small size, low rigidity, high elasticity, and biomechanical properties such as fixed initial angle and rotational stability. However, in severely comminuted complex type proximal metaphyseal humerus fractures, the use of locking plate alone does not provide stable fixation, leading to complications such as varus collapse, anterior–posterior angulation, screw cutout, nonunion, malunion, and metal failure.Therefore, a more robust and enhanced fixation method, the dual plating technique using the locking compression plate (Proximal Humeral Internal Locking System and Variable Angle Locking Compression Plate) was developed.

The intellectual disabilities evaluation and advice system (IDEAS): Outcome of the first 55 cases

IDEAS (intellectual disabilities evaluation and advice system) provides the opportunity for physicians who are sending samples for the Greenwood Genetic Center (GGC) 92-gene X-linked intellectual disability (XLID) (formerly X-linked mental retardation) panel to have their male patient's clinical features reviewed by an experienced panel of six Clinical Geneticists. They were asked to obtain parental consent, complete a one-page information form, and provide A-P and lateral photographs. The panel members independently reviewed the material and forwarded comments about clinical features, possible diagnoses, and/or further testing for the patient. We present the results of the first 55 patients evaluated. In only a single case did all panelists agree on a non-XLID diagnosis, later proven by genetic testing. The XLID gene panel diagnosed an additional five (9%) cases, but in only two cases did one panelist suggest the correct gene, which was one of four they suggested. This paper examines the possible reasons for the low rate of clinical diagnosis and suggests that, while the data received were often incomplete, the most important reasons for lack of diagnoses were the source of referral and selection of patients for review. We did note that there were a number of instances where we disagreed with the submitted information as to whether the individual was dysmorphic and with the stated presence of certain physical signs, most often downslanted palpebrae and posterior ear angulation. These differences in assessment of clinical signs and the general lack of completeness and detail provided in the standard data sheet, including that regarding the extended family history, lead us to raise concerns regarding the feasibility of establishing high quality central clinical databases designed to aid in the interpretation of exomic/genomic variants.

Assessment of the severity of femoral neck fractures with CT scan

Objective To develop a quantitative assessment of the severity of femoral neck fractures with CT scan.Methods The preoperative X-ray and CT data were reviewed of 229 patients with femoral neck fracture who had been treated in our department from December 2008 to April 2012.Posterior fracture fragment,posterior angulation,longitudinal maximum displacement,location of fracture line,and difference in neck-shaft angle were measured in the 3-D reconstruction images of CT scans.The severity of the fracture was categorized as slight,(score ≤5,grade Ⅰ),moderate (score 6 to 8,grade Ⅱ) and severe (score ≥9,grade Ⅲ) according to the measurements of the above 5 indexes.A comminuted fracture was categorized into grade Ⅲ.Results Posterior comminutions were found in 35 cases (15.3％),but not in the other 194 ones (84.7 ％).No posterior angulation was observed in 27 cases (11.8％).Posterior angulation ≤30° was found in 44 cases (19.2％),that from 30° to 60° in 115 cases (50.2％),and that ≥60° in 43 cases (18.8％).Twenty patients(8.7％) had no displacement.Fracture displacement ≤ 10 mm was observed in 96 cases (41.9％),that from 10 to 20 mm in 96 cases (41.9％),and that ≥20mmin 17 cases (7.4％).The facture line was located below the head in 131 cases (57.2％),at the head-neck in 88 cases (38.4％),and across the neck in 9 cases (3.9％).The difference in neck-shaft angle was 0° in 12 cases (5.2％),≤ 10° in 105 cases (43.4％),10° to 20° in 84 cases (35.3％) and ≥20° in 28 cases (17.6％).In the 229 cases,our severity scores were related to Garden classification in the following manners:all Garden Ⅰ cases belonged to grade Ⅰ; Garden Ⅱcases contained grade Ⅰ in 15 cases (45.5％) and grade Ⅱ in 18 cases (54.5％);Garden Ⅲ cases included grade Ⅰ in 6 cases (3.1％),grade Ⅱ in 123 cases (64.7％) and Grade Ⅲ in 61 cases (32.2％); all Garden Ⅳ cases were Grade Ⅲ.Conclusion In assessment of the severity of femoral neck fractures,CT scans can be more accurate,objective and reliable,and can be quantified as well. Key words: Femur; Fracture, bone; Tomography, spiral computed