Rare Fracture Research Articles

Perinatal Femoral Fracture: A Ten-Year Observational Case Series Study.

Background: perinatal femoral fractures (PFF) are relative rare birth-related fractures. Among treatment options, Bryant traction reported satisfactory outcomes in PFF of children under 3 years of age. The aim of this study is to assess the risk factors, diagnosis, management, and outcome in the 10-year multicentric experiences of all newborns treated for PFF in Catania city hospitals. Methods: 15,628 children, hospitalized in four neonatal units, were retrospectively reviewed. The following data were collected: gender, birth weight, gestational age, presentation, mode delivery, and fracture type according to AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF). In each case, diagnosis was achieved after the clinical examination and X-Ray exam. Each patient underwent Bryant’s skin traction of the affected limb, and was clinically followed for at least two years. Results: eight newborns were included in the study (five males). The average birth weight was 2.656 kg with a gestational age of 37.5 weeks; 4 cases were preterm birth; 5 patients had a cephalic presentation. According to the AO PCCF classification, three fractures were ranked 32-D/4.1 and five were 32-D/5.1. The entire cohort had an excellent outcome. Conclusions: prematurity, low birth weight, and caesarean section could be PFF risk factors. Bryant’s skin traction is an effective option to achieve an excellent outcome.

Motion preserving management of unstable traumatic clivus fracture extending through bilateral occipital condyles

We describe non-operative management a rare traumatic clival fracture extending through the bilateral occipital condyles. Clinical History: A 26-year-old female who was involved in a high-speed motor vehicle crash presented to an outside facility with difficulty speaking. Subsequent CT of the cervical spine demonstrated a fracture of the clivus with extension through the bilateral occipital condyles. She was then transferred to our hospital for further management where complete trauma survey noted multiple other injuries including traumatic subarachnoid hemorrhage, spinal epidural hematoma, bilateral pneumothoraces, liver laceration, bilateral upper extremity injuries, and lumbosacral fractures. Additional spinal imaging was negative for any associated vascular or spinal cord injury. Given her young age, there was a strong interest to preserve craniocervical motion and the decision was made to treat her with non-operatively with halo placement. After 18 weeks of rigid fixation, follow up imaging demonstrated completely healed fractures and at twenty-one weeks post fixation she demonstrated preserved motion of the craniocervical junction. This is a review of the literature and case report regarding this rare entity and its management.

Surgical outcomes of traumatic C2 body fractures: a retrospective analysis.

C2 vertebral body fractures are relatively rare fractures with no defined management protocol and outcomes. The aim of the study was to evaluate the clinical and radiological outcomes of C2 body fractures. The study was conducted at the Department of Neurosurgery, Nizam's Iinstitute of Medical Sciences, Hyderabad, India, following clearance from the Institutional Ethical Committee. The data of all patients with traumatic C2 body fracture who were managed at our Department between January 2008 and January 2019 were retrieved from the database. Functional status of the patients was assessed by Neck Disability Index while pain was assessed by VAS at follow-up after at least 6 months. Fusion and regional kyphotic angles (O-C2 and C2-C7) were assessed for radiological outcome. There were a total of 16 patients with isolated C2 body fractures in the defined time period. The male (N.=11): female (N.=5) distribution was 2.2:1. Ten patients had road traffic accidents while the remaining 6 had history of fall from height. Only 3 patients presented with neurological deficits. Benzel type 3 fracture pattern distribution was the most common fracture pattern (type 1=1, type 2=5, type 3=9). Of these, 10 were operated and 6 were managed conservatively. The VAS and NDI values improved significantly in all at follow-up when compared to values at presentation (P=0.001). Time to return to work was significantly shorter in those treated with surgical intervention (mean: 2.9±0.87) (P=0.001). Fusion was achieved in all the patients in both groups. Mean O-C2 angle at follow-up was 21.13±10.1. Mean O-C2 angle was significantly decreased in non-surgical group at follow-up (P=0.039) but no significant reduction was observed in surgical group. The management of C2 body fractures needs to be individualized, reserving surgical management for fractures requiring fragment retrival or restitution of alignment if facets were fractured.

The Traumatic Vacuum Phenomenon at the Anterior Portion of the Spine: A Clue to Extensive Spinal Fracture

A sixty-seven-year-old man complained back pain after falling from a ladder. On arrival, he had no neurological deficits in either leg. Emergency truncal computed tomography (CT) demonstrated multiple rib fractures with lung contusion and air density at the anterior portion of the 12th thoracic spine with fracture of the spinous process. Magnetic resonance imaging demonstrated an area of high intensity at the anterior portion of the 10 and 11th thoracic spine with the posterior portion of the 11 and 12th thoracic spine, suggesting extensive unstable lower thoracic fracture. The present case suggested that air density at the anterior portion of the spine on the CT might be an important clue that suggests the existence of rare extensive thoracic spinal fracture.

Geological Controls on High Production of Tight Sandstone Gas in Linxing Block, Eastern Ordos Basin, China

AbstractTight sandstone gas in the Linxing Block, eastern Ordos Basin, has been successfully exploited. The high performance is mainly a result of the special geological conditions. The key geological controls for high production have been discussed on the basis of seismic data, field observation, sample features, mercury porosimetry, mechanical properties, and basin modeling. Firstly, the coal measures have good gas generation potential, not only because of the existence of coalbeds and organic‐rich shales, but also because coal laminae and microbial mats in the shales significantly increase their total organic carbon (TOC) contents. Secondly, except for the uplifted zone of the Zijinshan complex and the eastern fault zone, rare large faults develop in the Carboniferous–Permian sequence, ensuing the sealing capacity of cap rock. Small fractures generally concentrated in the sandstones rather than the mudstones. Thirdly, gas accumulation in the Linxing Block was controlled by the tectonic, burial and thermal histories. Gas accumulation in the Linxing Block started in the Late Triassic, followed by three short pauses of thermal maturation caused by relatively small uplifts; the maximum hydrocarbon generation period is the Early Cetaceous as a combined result of regional and magmatic thermal metamorphisms. Field profiles show abundant fractures in sandstone beds but rare fractures in mudstone beds. Mechanical properties, determined by lithostratigraphy, confine the fractures in the sandstones, increasing the permeability of sandstone reservoirs and retaining the sealing capacity of the mudstone cap rocks. The modern ground stress conditions favor the opening of predominant natural fractures in the NNW–SSE and N–S directions. These conclusions are useful for exploring the potential tight sandstone gas field.

Mini-Plate and Screw Fixation Technique for Comminuted Flexor Digitorum Profundus Avulsion Fracture

Avulsion fracture of flexor digitorum profundus (FDP) tendon is relatively rare fracture at the distal phalangeal base than avulsion fracture of terminal extensor tendon. Terminal extensor avulsion fracture, known as bony mallet finger, could be successfully treated by closed reduction and pinning, such as extension block technique. However, most of FDP avulsion fracture, known as Jersey’s finger, needed open reduction, because of the proximal migration of fracture fragment and difficulty of pin fixation. Up to date, most of FDP avulsion fractures were treated by open reduction and fixation by pull-out suture or suture anchor technique. We report a case of comminuted FDP avulsion fracture, successfully treated by open reduction and mini-plate and screw fixation technique.

The Epidemiology of Metatarsal Fractures Among Older Females With Bisphosphonate Exposure

Bisphosphonates (BP) are used to treat osteoporosis, although rare atypical femur fractures have occurred with long-term exposure, especially among Asians. Metatarsal fractures have also been reported with atypical femur fracture. We examined the epidemiology of metatarsal fractures among 48,390 females aged ≥50 years who initiated oral BP and were followed for a median 7.7 years, including 68 females who experienced an atypical femur fracture. Incident metatarsal fractures after BP initiation were identified by clinical diagnoses and validated by record review. The association of BP, clinical risk factors, race/ethnicity, and metatarsal fracture was examined by using Cox proportional hazard analyses. Among 1123 females with incident metatarsal fracture, 61.0% had an isolated fifth metatarsal fracture. The incidence of metatarsal fracture was 312 per 100,000 person-years of follow-up and was substantially lower for Asians. The adjusted relative rate for metatarsal fractures was 0.5 (95% confidence interval 0.4 to 0.6) for Asians compared with whites. Younger age, prior fracture, other risk factors, and current BP were associated with an increased relative rate of metatarsal fracture, but BP duration was not. Females with atypical femur fracture were not more likely to experience metatarsal fracture (2.9% versus 2.3%, p = .7), but only 68 females had an atypical fracture and stress fracture of the metatarsals was not examined. Except for age, the demographic profile for metatarsal fracture after initiating BP was similar to that for osteoporotic fracture, with Asians at a much lower risk. Although metatarsal fractures were not associated with BP duration or atypical femur fracture, the subset of metatarsal stress fractures was not specifically examined.

Segmental tibial fracture with physeal and diaphyseal fracture causing popliteal artery and common peroneal nerve injury in a 12-year-old child: A rare case with a unique injury mechanism

Proximal tibial physeal injuries with neurovascular injuries are rare. Here, we report the case of a 12-year-old boy with a rare fracture pattern that is segmental tibia fracture with physeal and diaphyseal fracture with popliteal artery and common peroneal nerve injury, which has never been reported earlier to the best of our knowledge. We also discuss the possible mechanism of injury and also describe the surgical decision-making and highlight the importance of prompt identification and early management of such patients for a good clinical outcome.

Does ORIF of rare scapular spine fractures sustained after reverse shoulder arthroplasty benefit elderly patients? A case-series appraisal

PurposeScapular spine fractures sustained after reverse shoulder arthroplasty (RSA) are debilitating for elderly patients with osteoporosis. We examined the 1-year postoperative outcomes of open reduction and internal fixation (ORIF) in a small case-series, and hypothesised that patients undergoing surgical treatment for post-RSA scapular spine fractures would improve in function and pain. MethodsFive consecutive RSA patients within our shoulder arthroplasty register who sustained a scapular spine fracture underwent ORIF using a double plating technique. Standard radiographs and clinical/patient-rated assessments of Constant–Murley (CS), Shoulder Pain And Disability Index (SPADI), Subjective Shoulder Value (SSV) and visual analogue scale (VAS) pain were made up to 12months post-ORIF. Patients were also asked to rate their satisfaction since the surgery. Post-ORIF complications were documented. All post-RSA data were used as a baseline measure for comparison with post-fracture outcomes. ResultsMean CS, SPADI and SSV scores as well as pain were similar to pre-fracture scores. All patients improved in function and pain, and would undergo the same procedure again. Individual cases of iatrogenic pneumothorax and screw loosening were reported. ConclusionsORIF is a viable option with adequate improvements in function and pain for elderly patients with debilitating scapular spine fractures after RSA.

Clinical and Radiographic Outcomes After Surgical Treatment of Proximal Humeral Fractures with Head-Split Component.

Head-split fractures are a subgroup of proximal humeral fractures in which the fracture line affects the articular surface. Limited data are available regarding outcomes and risk factors for failure following surgical treatment of this rare fracture type. Of 45 patients with head-split fractures identified, a total of 30 (67%) were included in this retrospective study, with a mean follow-up of 49 ± 18 months (range, 12 to 83 months). Of those 30, 24 were treated with open reduction and internal fixation (ORIF), 4 with reverse total shoulder arthroplasty (RTSA), and 2 with hemiarthroplasty. Subjective Shoulder Value, Simple Shoulder Test, Constant score, and biplanar radiographs were assessed. Fracture pattern, quality of reduction, eventual complications, revision procedures, and clinical failure (adjusted Constant score < 40) were analyzed, and risk factors for failure were calculated. The overall complication rate was 83% (ORIF: 21 of 24 [88%]; RTSA: 3 of 4 [75%]; and hemiarthroplasty: 1 of 2 [50%]). The most common complications following ORIF were humeral head osteonecrosis (42%), malunion of the lesser tuberosity (33%), and screw protrusion (29%), whereas all complications following RTSA were related to tuberosity problems. Revision was performed in 7 of 24 (29%) of initial ORIF patients, and no revisions were performed in RTSA or hemiarthroplasty patients. Four patients (17%) who underwent primary ORIF underwent conversion to RTSA, and 3 patients (12.5%) had screw removal due to penetration. The overall clinical failure rate was 50% (ORIF: 12 of 24 [50%]; RTSA: 1 of 4 [25%]; and hemiarthroplasty: 2 of 2 [100%]). No significant association was found between preoperative factors and clinical failure. ORIF and primary RTSA showed higher average clinical outcome scores than primary hemiarthroplasty and secondary RTSA. In general, patients who required revision had worse Subjective Shoulder Value (p = 0.014), Simple Shoulder Test (p = 0.028), and adjusted Constant scores (p = 0.069). Head-split fractures of the humerus treated with ORIF showed high complication and revision rates. RTSA resulted in comparable clinical outcomes and complication rates; however, the complications associated with RTSA were mostly related to tuberosity problems, which in this small series did not require revision. Therefore, RTSA may be the most predictable treatment option for head-split fractures in elderly patients. Therapeutic Level IV. See Instructions for Authors for a complete list of levels of evidence.

Bilateral Tibial Tubercle Avulsion Fractures in Children - Clinical Results of a Rare Fracture.

Tibial tubercle avulsion fractures are rare, they represent less than 1% of all physeal fractures. Compared to monolateral tibial tubercle avulsion fractures, bilateral occurrence is even rarer. The purpose of this study is to report about the so far largest group of bilateral avulsion fractures and to compare them to unilateral fractures as well as to current literature. All patients who suffered from bilateral tibial tubercle fractures between January 2009 and March 2019 were included. All medical records and radiographs were reviewed and a clinical follow-up was performed. The examined criteria were age, gender, mechanism of injury, classification, risk factors, complications, management and outcomes. Clinical outcome was measured using the well established Tegner activity scale and Lysholm-Gillquist score. The same criteria were analyzed in a literature review of bilateral tibial tubercle fractures to compare our results to available literature. We found four children with bilateral tibial tubercle avulsion fractures. All patients were male with a mean age of 14.5 ± 0.7 years (13 - 15). Mean follow-up examination was 13.6 ± 6.5 months (8 - 29) after surgery. The avulsions occurred during jumping activities in all cases. All children could no longer stand or move because of sudden pain in the knee. We found type IV fractures in three cases, type III fractures in four cases and one type V fracture according to the Ogden classification. All children were treated by open or closed reduction and stabilization with screws or K-wires. Follow-up showed complete fracture healing without complications in all patients. There were no changes in Tegner activity scale and Lysholm-Gillquist Score and knee function comparable to prior to the accident was achieved in all cases. Good clinical results without restrictions regarding function of the knee joint can be achieved by direct operative treatment of bilateral tibial avulsion fractures. A reduction in sporting activity has not to be expected. There were no differences between bilateral or unilateral tibial tubercle avulsion fractures.

Short-oblique lumbar spine fracture in ankylosing spondylitis patient

Ankylosing spondylitis (AS) is a chronic inflammatory joint disease that mainly causes fusion of the intervertebral discs and facet joints by involving the axial skeleton that typically leads to kyphotic bamboo spine. Demineralization of vertebral bodies in AS raises the risk of spinal fracture even after a simple trauma. During the progression of the disease, the spine becomes more prone to injury, even after minor trauma. Patients with AS have a higher fracture risk during their lifetime by four times compared to the normal population. A 61-year-old male, a known case of AS, came to the emergency room complaining of back pain. His neurological examination was normal, and the images showed transverse/oblique fracture involving L2 vertebral body associated with small retropulsed fragments and bone debris. Posterior spinal fixation and fusion with a bone graft from T10 to S1 was decided to stabilize the fracture. On the 2nd postoperative day, the radiograph showed good alignment and fixation. One-year follow up showed a normal neurological exam with a stable and fused spine. In this case, we present a rare lumbar spine fracture orientation in a patient with AS, with a good outcome with 1-year follow-up. Up to our knowledge, this is the first report to presenting a short-oblique fracture in a patient with AS disease.

Rare atlas fracture detected using postmortem computed tomography: A case report

We report the autopsy of a traffic accident victim with a rare atlas fracture. The deceased was 52-year-old man found dead on the road because of a traffic accident. We performed a postmortem computed tomography and an autopsy on the body. The sagittal reformation image of postmortem computed tomography showed a vertically separated anterior arch of atlas, suggesting a “horizontal fracture.” Therefore, we assumed that cervical hyperextension may have been one of the forces that affected him during the accident. Minor spinal cord injury was also noted. In this case, postmortem computed tomography played an important role in detecting the spinal cord injury, considering the mechanism of the traffic accident, and supported the autopsy.

Atypical Femur Fractures: Review of Epidemiology, Relationship to Bisphosphonates, Prevention, and Clinical Management.

Bisphosphonates (BPs) are highly effective in treating osteoporosis and reducing hip, vertebral, and other fractures by as much as 50% to 70%. However, since 2006, atypical femur fractures (AFFs) emerged as potential side effects of BPs and other treatments. These fractures have unusual radiologic features and occur with little trauma. Public concern has led to a >50% decrease in BP usage. AFFs are rare: for each AFF, >1200 fractures, including 135 hip fractures, are prevented. Case definition criteria were updated by the American Society of Bone and Mineral Research in 2014. Many epidemiologic studies have been reported, and although methodologically challenging, generally support a BP-AFF association. However, the magnitude of the association between BPs and AFFs is uncertain: estimates of relative risk for AFFs among BP users vs nonusers range from 1 to 65 with a meta-analysis estimate of 1.7. Although mechanistic studies have proposed several hypotheses explaining how BPs might decrease bone strength, AFF pathogenesis remains uncertain and cannot explain the paradox of efficacy of reduction of common fractures while increasing risk for rare fractures at one site. There are several consistent risk factors, including Asian race (in North America), femoral bowing, and glucocorticoid use, whereas others remain unclear. Consensus is emerging about strategies to prevent AFFs in BP users (including drug holidays after 5 years' use in some patients). In conclusion, AFFs can be devastating, but even under the most pessimistic assumptions, the benefit/risk ratio is highly positive for BPs, particularly during 3 to 5 years of use. As understanding of AFFs increases, it is becoming increasingly possible to maximize BP benefits while minimizing AFF risk.

A Rare Knee Fracture with Underestimated Severity.

Author(s): Takeda, Shinsuke; Iwatsuki, Katsuyuki; Tabuchi, Akihiko; Kubo, Sadahiro; Teranishi, Satoshi; Hirata, Hitoshi | Abstract: n/a

Stress fracture of the thoracic spine in a male rugby player: a case report

This case reports a stress fracture of the thoracic spine in a professional rugby player. This is a rare anatomical location for this type of injury in this population and has not previously been described. Physicians should be aware that performance of rugby specific movements may lead to rare stress fractures in certain anatomic locations.

Stress fracture of the thoracic spine in a male rugby player: a case report

This case reports a stress fracture of the thoracic spine in a professional rugby player. This is a rare anatomical location for this type of injury in this population and has not previously been described. Physicians should be aware that performance of rugby specific movements may lead to rare stress fractures in certain anatomic locations.

Infected Seymour-Type Fracture

Extra-articular, transverse, distal phalangeal fractures that involve the physis, are termed Seymour fractures. They are frequently associated with an avulsion of the nail and a laceration of the nail bed. For this type of fractures, sur-gical intervention is needed to explore the fracture site for soft tissue interposition. Its failure may result in several complications. The authors report an adult Seymour-type fracture, which developed an infection due to interposition of the germinal matrix of the nail complex on the fracture site. The purposes of this article are to demonstrate that this rare fracture can also occur in adults, highlight the importance of treating this injury with the basic principles of open fracture treatment, and evidence one of its complications if not well treated.

Surgically Relevant Patterns in Triplane Fractures: A Mapping Study.

Triplane ankle fractures are complex transitional fractures that often necessitate surgical treatment. Axial fracture lines determine optimal screw trajectories for fixation. The purpose of our study was to identify fracture patterns in triplane fractures by illustrating fracture lines in the axial plane of the distal tibial metaphysis and epiphysis. We retrospectively reviewed records of children presenting with ankle fractures at 1 center from January 2007 through June 2017. Thirty-three cases of triplane fractures with available computed tomographic (CT) scans were identified. Fractures in the axial plane of the metaphysis were identified 10 mm proximal to the physis, and fractures in the epiphysis were identified midway between the physis and distal tibial articular surface. Fracture lines were drawn and were superimposed on unfractured bone templates to generate fracture maps, and heat maps were then created to show areas of high and low fracture densities. In the metaphysis, the most common fracture pattern was medial-lateral lines in the posterior metaphysis. This metaphyseal pattern was consistent across 2, 3, 4, and 5-part fractures. There were clear zones of rare fracture involvement in the anterior and anterolateral metaphysis. In the epiphysis, anterior-to-posterior fracture lines were common in the anterior epiphysis. All cases had an epiphyseal fracture exit through the anterior epiphysis. Fracture extension into the posteromedial epiphysis was a feature of all fracture classes. Fracture mapping of triplane fractures suggests consistent axial fracture patterns in the metaphysis and epiphysis with additional class-dependent fractures in the epiphysis. This study provides visual guidelines to assist surgeons in understanding the axial fracture patterns of individual triplane fractures for surgical planning.

Injuries of Children and Young People in Sports: Stress Fractures and Fracture of the Sleeve Sleeve

Introduction: With the dramatic increase in the competitive sports of children and young people, overuse injuries have become more important in the pediatric population. Among these, the most frequent injuries in young athletes are stress fractures. The absence of evident traumatic history and the subtle radiographic changes can cause a diagnostic difficulty and delay the treatment. Fracture of the patella sleeve is a rare fracture only occurs in children. The diagnosis is difficult, both clinically and radiologically. High patella and hemarthrosis are important signs to diagnose this fracture. Presentation of 2 clinical cases of injuries in children and young people in sports: stress fractures and fracture of the patella sleeve. Methods: Retrospective descriptive method with reports of clinical cases based on patients’ electronic clinical processes. Results: We present a case of a child, a 13-year-old soccer practitioner who had mentioned well localized pain in the anterior aspect of the right leg with 5 days of evolution and analgesic gait and no history of trauma. The radiographs and CT showed a juxtaposed cortical lesion with apparent contact with the cortical bone without associated periosteal reaction. NMR confirmed stress fracture of the proximal tibial shaft. It was treated conservatively with immobilization with plaster and discharge. We present the case of an 11-year-old boy who suffered a fracture of the patella sleeve. In the imaging study, a fragment of bone with a displacement from the lower pole of the patella was visible. An open fracture reduction was performed. During the surgery confirmed avulsion fracture of a small osteochondral fragment, configuration of a sleeve-like fracture. The amount of cartilage was small, so it was decided to reinsert the 2 anchorages for patellar tendon. After fracture healing and rehabilitation, both returned to sports activity without sequelae or functional limitations. Discussion/Conclusion: A knowledge of the fracture of the patella sleeve, together with its clinical and radiological features, is important to avoid misdiagnosis and treatment delay. Care should be taken not to disturb the proximal tibial process. Although relatively uncommon in the pediatric age, the incidence of fractures described stress have been increasing in this age group. A high degree of suspicion is required to make the diagnosis and avoid too invasive treatment. REFERENCES Ray JM, Hendrix J. Incidence, mechanism of injury, and treatment of fractures of the patella in children. J Trauma 1992;32:464–7. Bates DG, Hresko MT, Jaramillo D. Patellar sleeve fracture: demonstration with MR imaging. Radiology 1994;193:825–7. Wu CD, Huang SC, Liu TK. Sleeve fracture of the patella in children. A report of five cases. Am J Sports Med 1991;19:525– 8. Houghton GR, Ackroyd CE. Sleeve fractures of the patella in children: a report of three cases. J Bone Joint Surg Br 1979;61:165–8. Shands PA, McQueen DA. Demonstration of avulsion fracture of the inferior pole of the patella by magnetic resonance imaging. A case report. J Bone Joint Surg Am 1995;77:1721–3. Dai LY, Zhang WM. Fractures of the patella in children. Knee Surg Sports Traumatol Arthrosc 1999;7:243–5. Fredericson M, Bergman G, Hoffman KL, et al. Tibial stress reaction in runners: correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med 1995; 23: 472-81. Hunter-Griffin LY. Clinics in sports medicine: overuse injuries. Philadelphia (PA): W.B. Saunders, 1987. Jackson DW, Bailey D. Shin splints in the young athlete: a non-specific diagnosis. Phys Sports Med 1975; 3: 45-51.