Proximal Fracture Line Research Articles

Fracture pattern analysis of fractures to the diaphysis of the fifth metatarsal

BackgroundFractures to the fifth's metatarsal (MT-V) diaphysis are common. These are inconsistently referred to as diaphyseal-, shaft-, or Dancer's fractures. A comprehensive analysis of the MT-V fracture morphology is missing. The aim was to qualitatively and quantitatively analyze fracture patterns of MT-V diaphyseal fractures. HypothesisFractures to the shaft of the fifth metatarsal feature specific fracture morphologies. Materials and methodsRetrospective, radiologic database study. Included were all acute, isolated MT-V shaft fractures (including the proximal [Lawrence and Botte (L&B) III] and distal meta-diaphysis). Demographics and fracture characteristics were assessed. Each proximal fracture line was drawn, scaled, and a qualitative and quantitative fracture line analysis was conducted. The quantitative fracture line analysis aimed at identifying dens clusters with arbitrary shape using the DBSCAN algorithm. Data are presented as mean±standard deviation. ResultsOut of 704 eligible MT-V fractures, 156 met the inclusion criteria. Patient's mean age was 46±19 years and 94% suffered a low energy trauma. Qualitative and quantitative fracture line analysis revealed three distinct fracture patterns. The proximal (30%) and distal (5%) meta-diaphyseal clusters showed a predominant transverse fracture pattern. The vast majority of diaphyseal fractures (56%) were spiral/oblique fractures, progressing from the proximal lateral meta-diaphyseal region in an oblique course at 61±9° to the medial distal diaphyseal cortex. Seven percent of diaphyseal fractures showed a transverse fracture pattern. DiscussionBased on a qualitative and quantitative analysis of all MT-V shaft fractures, three distinct fracture clusters were identified with homogeneous fracture patterns. MT-V shaft fractures should therefore be classified as proximal meta-diaphyseal (L&B Type III), diaphyseal (oblique or transverse) and distal meta-diaphyseal. Level of proofIV; retrospective database study.

The Case Files

The Case Files

MFC Bone Graft for Scaphoid Nonunion, Osteonecrosis, and Failed Prior Surgery: Three Strikes But Not Necessarily Out: Commentary on an article by Nicholas Pulos, MD, et al.: "Free Vascularized Medial Femoral Condyle Bone Graft After Failed Scaphoid Nonunion Surgery".

Commentary Patients with a nonunion of the scaphoid with a proximal fracture line, osteonecrosis of the proximal pole, and a previously unsuccessful attempt at achieving surgical union present the orthopaedic surgeon with a difficult clinical decision. Some surgeons might advocate nonoperative treatment, with the expectation that a salvage procedure (scaphoid excision and 4-corner fusion, proximal row carpectomy, total wrist arthrodesis, or total wrist arthroplasty) might eventually be required to relieve pain and maintain motion. Others might recommend repeat open reduction and internal fixation using either vascularized or nonvascularized local bone, whereas those who are experienced with microsurgical techniques might attempt, on the basis of the data presented in this article, a vascularized medial femoral condyle (MFC) bone graft in order to achieve union and restore vascularity (and therefore mitigate against eventual collapse) of the proximal pole. The authors give us an honest appraisal and have made an important iterative contribution to the care of young patients with this challenging clinical problem. They acknowledged an almost 20% rate of additional surgery (apart from scheduled surgery for the removal of Kirschner wires) and also reported a 1-in-6 rate of persistent nonunion. Even though these results are a reason for reflection and discussion, this surgical procedure is an attempt to restore preinjury anatomy, which is, in my opinion, a worthy goal for these young, physically active patients. Whether the main issue is carpal collapse and humpback deformity in an SNAC (scaphoid nonunion advanced collapse) wrist following scaphoid fracture with proximal pole osteonecrosis (and an initial attempt at achieving surgical union), or pain and tenderness over the proximal pole due to fragmentation and collapse as well as the development of osteoarthritis between the distal scaphoid pole and the radial styloid, remains open to discussion. Also, this article did not address specifically whether the goal of restoration of scaphoid length by means of an MFC graft is directly related to the restoration of carpal alignment. It would seem so; however, this point is really only academic since proximal pole fractures and nonunions do not routinely lead to arthrosis between the proximal pole of the scaphoid and the distal radial articular surface as is seen in chronic SLAC (scapholunate advanced collapse) wrists. Although 1 patient had a subsequent radial styloid excision, the distal pole was not excised, presumably because of the condition of either the proximal pole or the scapholunate ligament, or both. Several caveats outlined in the article bear repetition. First, patients frequently lost wrist motion following this procedure, and this was manifested by several patients’ inability to return to push-up exercises. This is not an unimportant point, especially in patients with specific functional requirements related to their employment. Second, there were some sports-related difficulties as well as persistent discomfort that compromised the outcomes. My mention of this is not meant to denigrate the procedure or the results, but rather to encourage the surgeon to set realistic expectations—i.e., of results that are either similar to or slightly better than those achievable with salvage procedures in terms of pain relief, motion, and strength with (hopefully) longer-term durability. The cases presented in this article are seen infrequently, and the patients often expect a full return to sports and vocational activities. Preoperative counseling and the setting of achievable goals are to be stressed. The surgical results in this retrospective study suggest that, in the infrequent situation where a young patient presents with “3 strikes” (nonunion, osteonecrosis, and prior unsuccessful surgery), he/she might not necessarily be “out.”

Can Jones fracture be treated conservatively?

Category: Midfoot/Forefoot Introduction/Purpose: Operative management is the treatment of choice for Jones fracture. Situations are fought where operative management may not be possible or may not be accepted. Such situations being more common in developing countries, clinicians are forced to undertake conservative management. Pertain to this, many questions are still unanswered. Can conservative management succeed? If so, what should be the protocol? What all could be the possible complications? And how to overcome them? To answer all these questions, we undertook a study to evaluate results of conservative management of Jones fracture. The purpose of this study was also to suggest conservative management guidelines. Methods: Retrospective analysis of 32 conservatively treated Jones fracture cases over period of two years was done with average follow up of nine months. Only cases included were those between the ages of 20 to 50 years, not willing for operative management. Cases in the same age group, willing for surgery and cases lost to follow up were excluded. Conservative management comprised of full length below knee non weight bearing plaster cast in eversion and dorsiflexion for four weeks followed by short length below knee weight bearing plaster cast in neutral position of ankle and subtalar joint. Radiological evaluations were done at the end of 4, 8, 14, 20 and 26 weeks. Results of serial clinical and radiological assessments were analysed. Results: Thirty out of 32 cases went on to sound clinical as well as radiological union. With respect to average time to union, two major group of cases could be segregated. First group (20 cases) had a proximal fracture line nearer to zone 1 and took 11 weeks to unite. Second group (12 cases) had a distal fracture line nearer to zone 3 and took 18 weeks to unite. Both the nonunion cases were from this group. Clinical union preceded radiological union by average of 2 to 3 weeks. Conclusion: Jones fracture could be successfully treated conservatively even in young and active population provided specific protocol is followed. Initial full length below knee plaster in dorsiflexion and eversion neutralized deforming forces of peronei and plantar fascia while next short below knee walking plaster cast helped to regain muscle tone, increased perfusion and simulated walking leading to union. Fractures nearer the tuberosity had a faster union in comparison to distal fractures nearer the shaft. In view of short follow up with small numbers of present study, a multicentric prospective study comparing results of surgical versus conservative treatment is deemed.

A modified Matti-Russe technique of grafting scaphoid non-unions.

In treatment of scaphoid non-union bone healing requires beside vital tissue and stability, enduring compression and a good interface between the graft and scaphoid fragments. While fixation techniques show a good primary stability, they reduce sintering and thus compression of fragments in the long term. Therefore, a modified technique optimising the cancellous interface between graft and scaphoid but still providing enough stability without fixating implants should be evaluated. A corticocancellous bone graft from iliac crest was shaped ellipsoid and was implanted in a modified Matti-Russe press fit-technique. Thereby the cancellous side contacts the scaphoid fragments. In a retrospective design, we reviewed 52 patients with documented non-unions of the scaphoid. The average length of follow-up was 8.6 months. Range-of-motion, pain and grip-strength was measured and compared with contralateral wrist. Radiological assessment included beside X-rays CT scans. Results were further measured by DASH score and Mayo wrist score. The average postoperative pain was 0.9 based on NRS-Score. The mean range-of-motion was satisfactory with a dorsal-palmar arch of 115.3°, radial-ulnar: 48.2° and pro-supination: 171.3°. Mayo Wrist Score showed with 91.2 out of 100 an excellent result. The analysis of DASH score revealed a mild subjective constriction (9.2/100). Regarding roentgenographic findings complete union was confirmed in 44 of the 52 patients (84.6%). Patients with non-union were significantly older than patients with union (p < 0.05). Grip-strength on average was equal to that of the uninjured hand although in failure cases a slightly reduced grip-strength was seen. The modified technique of Matti-Russe provided a good contact of the cancellous part of the bone graft to the scaphoid in grafting a scaphoid pseudarthrosis with a high healing rate. However, since age, previous failed surgery and a proximal fracture line are the most important handicaps for bone healing in this study, for patients at risk gadolinium-enhanced MRI scan could be helpful to estimate vascularisation preoperatively. In cases of poor vitality, vascularised bone grafting should be considered.

Logistic regression analysis of risk factors for femoral head osteonecrosis after healed intertrochanteric fractures.

To evaluate the potential risk factors of the development of femoral head osteonecrosis after healed intertrochanteric fractures. We retrospectively reviewed all patients who were operated upon with closed reduction and internal fixation for intertrochanteric fractures by our medical group from December 1993 to December 2012. Patients with healed fractures were identified. Age, gender, comorbidities favouring osteonecrosis, causes of injuries, fracture patterns, the location of the primary fracture line, time from injury to surgery, fixation methods, and the development of femur head osteonecrosis of these patients were summarised. Univariate and multivariate logistic regression analysis were performed to evaluate the correlation between potential risk factors and the development of femoral head osteonecrosis. A total of 916 patients with healed intertrochanteric fractures were identified. Femoral head osteonecrosis was found in 8 cases (0.87%). According to the results of univariate logistic regression, a more proximal fracture line, fixation with dynamic hip screws and age were found to be statistically significant factors. The results of multivariate logistic regression analysis indicated that the statistically significant predictors of femoral head osteonecrosis were younger age (odds ratio [OR] = 17.103; 95% confidence interval [CI], 1.988-147.111), a more proximal fracture line (OR = 31.439; 95% CI, 3.700-267.119) and applying dynamic hip screw as the internal fixation (OR = 11.114; 95% CI, 2.064-59.854). Regular follow-up is commended in young patients with a proximal fracture line who underwent closed reduction and internal fixation with dynamic hip screw, even though the bone had healed.

Suprapatellar approach to tibial medullary nailing with electromagnetic field-guided distal locking

Closed tibial shaft fractures are the domain of intramedullary nailing. With the introduction of new nail designs and technologies, even small, dislocated distal fragments can be anatomically aligned and safely fixed. Unsolved or to a lesser degree controlled are the problems of distal locking in the freehand technique, which can still be difficult and can lead to a significant radiation exposure, and how to control very short proximal tibial fragments in metaphyseal tibial fractures or tibial segmental fractures, where the proximal fracture line also runs through the metaphysis.By using a suprapatellar approach, i.e. a skin incision proximal to the patella with an entry point into the tibial bone from within the knee at the same site as for a standard infrapatellar approach, and then nailing the tibia in a semi-extended position, i.e. the knee is only flexed 10-20°, the intraoperative dislocation of a short proximal fragment can be avoided. The main indications for semi-extended tibial nailing are a short diaphyseal fragment in an isolated tibial shaft fracture, a segmental fracture where the proximal fracture line is metaphyseal and in patients where infrapatellar soft tissues are compromised.The use of the electromagnetic guidance system SureShot® generates reliable and reproducible results, reduces the operating time and is independent from radiation for distal locking.

Location of civilian ballistic femoral fracture indicates likelihood of arterial injury

BackgroundWe evaluated whether the location of a ballistic femoral fracture helps predict the presence of arterial injury. We hypothesized that fractures located in the distal third of the femur are associated with a higher rate of arterial injury. MethodsWe conducted a retrospective review of electronic medical records at our level I trauma centre and found 133 consecutive patients with femoral fractures from civilian gunshots from 2002 to 2007, 14 of whom sustained arterial injury. Fracture extent was measured with computerized viewing software and recorded with a standard technique, calculating proximal, distal, and central locations of the fracture as a function of overall length of the bone. Analyses were conducted with Student's t, Chi-squared, and Fisher's exact tests. ResultsThe location of any fracture line in the distal third of the femur was associated with increased risk of arterial injury (P<0.05). The odds ratio for the presence of arterial injury when the proximal fracture line was in the distal third of the femur was 5.63 (95% confidence interval, 1.7–18.6; P<0.05) and when the distal fracture line was in the distal third of the femur was 6.72 (95% confidence interval, 1.78–25.44; P<0.05). ConclusionsA fracture line in the distal third of the femur after ballistic injury is six times more likely to be associated with arterial injury and warrants careful evaluation. Our data show that fracture location can help alert clinicians to possible arterial injury after ballistic femoral fracture.

Surgical treatment of displaced fractures of the greater tuberosity of the humerus

Objective To discuss the techniques and efficacy of surgical treatment of displaced fractures of the humeral greater tuberosity. Methods We reviewed the 20 patients who had been treated and followed up for displaced fractures of the humeral greater tuberosity in our institute between June 2006 and June 2011.They were 11 men and 9 women,aged from 30 to 69 years(average,49.6 years).The time intervals from injury to surgery ranged from one to 122 days (average,8.2 days).(Open surgery was performed for 17 patients,arthroscopy for 2 and open surgery plus arthroscopy for one.In open surgery the deltopectoral approach was adopted for 7 patients and the trans-deltoid approach for 10.Of the 7 fixation methods adopted,the cannulated screws were the most frequently used (in 11 cases).The functional outcomes of the injured shoulders were evaluated by the University of California at Los Angeles (UCLA) shoulder rating system.Results The patients obtained a mean follow-up of 13.6 months (range,6 to 51 months).The fractures all united 6 weeks postoperatively.By the UCLA system,the 7 patients in whom the deltopectoral approach was adopted scored an average of 28.4 points,the 10 patients in whom the trans-deltoid approach was adopted scored an average of 30.4 points,the 2 patients undergoing arthroscopy scored an average of 34.5 points,and the one undergoing open surgery plus arthroscopy scored 34 points.Ten cases were rated as excellent,3 as good and 7 as poor,with a good to excellent rate of 65.0％. Conclusions Open reduction and internal fixation is the mainstay treatment of displaced fractures of the greater tuberosity of the humerus.The trans-deltoid approach may be the most frequently used.The methods of internal fixation varied depending on the characteristics of the fracture.The arthroscopic indications for fractures of greatertuberosity are moderate fragments,proximal fracture line,little displacement and little comminution. Key words: Shoulder fractures; Humeral fractures; Surgical procedure; operative; Pain,postoperative

Intramedullary Fixation of Fibular Fractures Associated With Pilon Fractures

The purpose of this study was to determine the ability of intramedullary fibular fixation to maintain reduction until healing and to determine the overall complication rate in high-energy pilon fractures associated with fibular fractures. Retrospective study. Level I university trauma center. From 2000 to 2007, 972 pilon fractures were treated at our institution, 38 of which were treated with an intramedullary device for the associated fibular fracture. Two patients had acute amputations and two died; 1-year follow-up was obtained in 27 of the remaining patients. Average length of follow-up was 21 months. A retrospective chart and radiograph review was conducted of all patients for data extraction. Fibular fixation type and length, fibular healing, and complications. Average patient age was 36 years (range, 18-59 years). Four of the fibular fractures were segmental. All fractures had at least 50% of the cortex intact to prevent shortening. The average height of the fibular fractures from the distal tip was 6.9 cm (range, 1.3-22.2 cm). In 20 patients, a 3.5-mm fully threaded cortical screw was used for stabilization, and in the remaining seven, a 2.5-mm wire was used. The intramedullary implant extended 8.5 cm above the most proximal fracture line on average (range, 1.6-29.8 cm). Fibular alignment was within 3 degrees of anatomic in all cases after initial fixation. At final follow-up, fibular alignment had not changed more than 1 degrees in any case. No complications related to the fibular incision occurred, and all fibula fractures healed within 3 months. In axially and rotationally stable fibular fracture patterns associated with pilon fractures, intramedullary fibular stabilization was effective in maintaining fibular alignment. This technique led to reliable fracture healing in appropriately selected fractures and may be particularly advantageous in patients with compromised lateral and posterolateral soft tissues.

Falhas na utilização de poliacetal e poliamida em forma de haste intramedular bloqueada para imobilização de fratura femural induzida em bovinos jovens

Apesar da expressiva evolução da ortopedia veterinária nos últimos anos, as fraturas de ossos longos em grandes animais são constante desafio para o médico-veterinário. O presente estudo é parte da proposta de desenvolvimento de um sistema de haste intramedular polimérica, de baixo custo e fácil aplicação, para uso em bovinos jovens e neonatos. Os objetivos foram avaliar, in vivo, hastes de poliacetal e poliamida para imobilização de fraturas femorais em bovinos jovens. Cinco bezerros machos foram submetidos à anestesia geral e tiveram os fêmures esquerdos fraturados e, em seguida, imobilizados, utilizando-se uma haste cilíndrica de poliacetal ou poliamida inserida no canal intramedular e bloqueada por quatro parafusos corticais de aço inoxidável, inseridos na diáfise em seu sentido lateral-medial e igualmente distribuídos distal e proximal à linha de fratura. Durante um período de 60 dias pós-cirúrgico, os animais foram avaliados por meio de exames clínicos e radiográficos. Houve fratura em quatro das cinco hastes de poliacetal implantadas pela primeira vez e em duas das quatro hastes de poliamida que foram implantadas após a quebra das de poliacetal. Todas as falhas ocorrerem nas primeiras duas semanas de imobilização. Não foram verificados quaisquer sinais de rejeição aos materiais usados. Os resultados demonstram que as hastes de poliacetal e poliamida não apresentaram resistência suficiente para, de acordo com o modelo proposto, promover imobilização precoce de fraturas de fêmur em bovinos jovens.

Bone Transport Osteogenesis for Reconstruction of a Bone Defect in the Tibiotarsus of a Yellow-naped Amazon Parrot (Amazona ochrocephala auropalliata)

A yellow-naped Amazon parrot (Amazona ochrocephala auropalliata) was presented 5 months after a traumatic fracture of its left tibiotarsus. Fixation of the simple, closed, mid-diaphyseal fracture was originally with an intramedullary pin and external coaptation with a modified Robert-Jones bandage. During the subsequent 5 months, the bone became osteopenic, and the middle third of the tibiotarsus exhibited probable avascular necrosis. After various fixation attempts failed, the parrot was fitted with a ring fixator device, and bone transport osteogenesis was attempted. Within 7 weeks, the left tibiotarsus had regrown to full length, but the docking site at the proximal fracture line had not healed. After 2 more surgeries to debride bone ends to stimulate healing, the leg in this parrot became functional. This is the first reported clinical use of bone transport osteogenesis in a pet bird. Materials and techniques were applied successfully to this parrot, which suggests that bone transport osteogenesis deserves further study for the repair of large bone defects in birds.

Avascular necrosis of the femoral head after intertrochanteric fractures.

To determine factors that may influence the appearance of avascular necrosis after intertrochanteric fractures. Retrospective. University hospital. Twelve patients between the ages of fifty-nine and eighty-eight who had developed avascular necrosis of the femoral head after treatment of an intertrochanteric femur fracture at our institution between 1976 and 1995. Fractures were classified according to Kyle and Gustilo. There were three Type I, two Type II, six Type III, and one Type IV fractures. Risk factors for osteonecrosis, fracture pattern, surgical influence, location of the nail within the femoral head, and valgus malalignment. All fractures healed. Five patients had risk factors for osteonecrosis. Intertrochanteric fractures with a proximal fracture line appeared in five patients. The nail tip was situated in every quadrant of the femoral head. Valgus malalignment occurred in three cases. Avascular necrosis of the femoral head is an uncommon complication after intertrochanteric fractures. The pathogenesis is unknown, but in patients developing pain who have had intertrochanteric fractures, osteonecrosis should be included in the differential diagnosis, especially in cases with risk factors for osteonecrosis or a proximal intertrochanteric fracture line that perhaps disrupts the vascular anastomotic ring at the base of the femoral neck.

Avascular necrosis of the femoral head after intertrochanteric fractures.

To determine factors that may influence the appearance of avascular necrosis after intertrochanteric fractures. Retrospective. University hospital. Twelve patients between the ages of fifty-nine and eighty-eight who had developed avascular necrosis of the femoral head after treatment of an intertrochanteric femur fracture at our institution between 1976 and 1995. Fractures were classified according to Kyle and Gustilo. There were three Type I, two Type II, six Type III, and one Type IV fractures. Risk factors for osteonecrosis, fracture pattern, surgical influence, location of the nail within the femoral head, and valgus malalignment. All fractures healed. Five patients had risk factors for osteonecrosis. Intertrochanteric fractures with a proximal fracture line appeared in five patients. The nail tip was situated in every quadrant of the femoral head. Valgus malalignment occurred in three cases. Avascular necrosis of the femoral head is an uncommon complication after intertrochanteric fractures. The pathogenesis is unknown, but in patients developing pain who have had intertrochanteric fractures, osteonecrosis should be included in the differential diagnosis, especially in cases with risk factors for osteonecrosis or a proximal intertrochanteric fracture line that perhaps disrupts the vascular anastomotic ring at the base of the femoral neck.

The Use of Sonography for Evaluation of the Integrity and Healing Process of the Tibiofibular Interosseous Membrane in Ankle Fractures

This study evaluates the value of sonography in the diagnosis of the rupture and healing process of the interosseous membrane in Weber type B and C ankle fractures. In 90 such fractures a rupture of the interosseous membrane was intraoperatively observed in 35 cases (38.8%). All Weber type C fractures showed a rupture of the interosseous membrane, whereas only 23% of the Weber type B fractures were associated with a rupture of the interosseous membrane (p < 0.001). In the vast majority of the cases (77%), particularly in all Weber type B fractures (p < 0.01), the rupture of the interosseous membrane extended above the proximal fracture line of the fibula. By means of sonography, in the acute posttrauma period a rupture of the interosseous membrane was found in 37.4% of the cases. Thus, in our series the results of sonography and the operative findings coincided in 88.6% of the cases concerning location, type, and extent. Sonography was performed by three unbiased observers, and the results were compared with the intraoperative findings. Thus, the sensitivity of the sonography in the diagnosis of the rupture of the interosseous membrane was 88.8%, the diagnostic value of the method 92.2%, and specificity 94.5%. The sonographic findings of the healing process of the interosseous membrane were in absolute (100%) agreement with the intraoperative observations at the time of removal of the osteosynthesis material. Complete healing occurred within 3-5 months after trauma in 70% of the cases of ruptured interosseous membrane.(ABSTRACT TRUNCATED AT 250 WORDS)

Lumbosacral Lesions Associated with Pelvic Ring Injuries

In pelvic ring injuries, an anterior lesion is usually combined with a lesion of the posterior ring segment. A fracture of the sacrum is the most common type of posterior lesion. Its severity ranges from a stable minimal compression fracture of the ala of the sacrum to a displaced fracture with complete loss of stability. The fracture line commonly involves the first and second sacral foramina, exiting the bone distally through its free border and proximally just lateral to the articular process of S1. This study shows that in a number of cases the proximal fracture line passes through or medial to the articular process of S1. Consequently, displacement of the involved hemipelvis causes no damage to the lumbosacral junction if the fracture line passes lateral to the articular process of S1. However, any displacement of the mobile hemipelvis must injure the lumbosacral junction with the latter fracture pattern if the fracture line passes through or medial to the articular process of S1. We found an injury of the lumbosacral junction in 6% of all of our pelvic ring injuries and in 38% of those with an unstable vertical sacral fracture. One kind of these lesions, the locked dislocation of the L5/S1 joint, was shown to inhibit reduction of a displaced sacral fracture. Furthermore, these lesions may be responsible for some of the lumbosacral pain frequently persisting after pelvic ring injuries.