Reduction Maneuvers Research Articles

Abstract No. 359 - Management of high hepatopulmonary shunt fractions in patients undergoing radioembolization

Purpose Consensus guidelines dictate that patients with high hepatopulmonary shunt fractions should not undergo Y-90 radioembolization (RE), or should have administered activity reduced 20-40% to decrease the risk of radiation pneumonitis. We reviewed our experience of managing and treating patients with high shunt fractions. Materials and Methods We retrospectively reviewed 247 patients treated from 2004-11. We calculated pulmonary radiation dose based on technetium macroaggregated albumin (TcMAA) scintigraphy, and reviewed dose calculations and reductions as well as adjunctive prophylactic techniques utilized to reduce lung exposure during the delivery of RE microspheres. Results A total of 50/247 patients (20%) had shunt fractions > 10%. Glass microspheres were used to treat 20 and resin to treat 30 patients. 18 patients were treated with recommended dose reduction only. 4 patients with high shunt fractions (25-44%) were treated prior to RE with bland embolization and/or sclerosis, and repeat TcMAA scintigraphy demonstrated median shunt reduction of 34% (range 0 - 51%). 15 patients (including these 4) were treated using various prophylactic techniques such as hepatic vein balloon occlusion, variceal embolization, and bland arterial embolization before or during RE delivery, and 10/15 received full dose without reduction. An additional 17 patients received no dose reduction or adjuvant maneuvers because the calculated lung dose was well below 30 Gy. Of the 50 patients, only 7 would have received calculated lung exposures > 30 Gy without dose adjustment. Calculated median expected lung dose for the prophylactic treatment group was 16 Gy (range 8-68 Gy). In follow up, 1 heavily pretreated patient developed radiation pneumonitis requiring corticosteroid therapy (shunt 28%, lung exposure 16 Gy). Conclusion Standard recommendations for RE dose reductions for high hepatopulmonary shunt fractions are not mathematically justifiable, may compromise therapeutic efficacy in the liver, and are most often avoidable without substantial increase in risk. Shunting high enough to exceed the 30 Gy pulmonary threshold can be reduced by adjunctive techniques.

Outcomes of anterior lumbar interbody fusion in low-grade isthmic spondylolisthesis in adults: A continuous series of 65 cases with an average follow-up of 6.6 years

Surgical treatment of isthmic spondylolisthesis continues to be controversial. The fusion procedure can either be instrumented using a posterior and/or anterior approach or non-instrumented. The role of associated decompression, reduction of the slippage, disc height restoration and lordosis restoration has not definitely been established. The goal of this study was to evaluate the efficacy of anterior approach for interbody fusion (ALIF) without any reduction maneuver. Sixty-five patients with isthmic spondylolisthesis were operated on, using an ALIF. The average patient age was 40 years. The preoperative maximum walking time was 20 minutes. Ten patients had radiculopathy. The average preoperative Beaujon Hospital disability index was 9/20. Standard static and dynamic X-rays were evaluated in all patients; a CT scan was performed in 33 patients 1 year after the surgery. The olisthetic vertebra had slipped by an average of 12 mm. Thirty-five of the spondylolisthesis cases had abnormal vertebral motion. At an average follow-up of 6.6 years, lumbar pain and radicular pain had been reduced by 4.6 and 5 points on the visual analogue scale, respectively. Twenty-seven patients could walk for an unlimited amount of time. Three patients still had radiculopathy. The Beaujon Hospital disability index had improved by an average of 7.3 points. The fusion rate was 91%. The slippage had decreased by 30%, despite no specific reduction maneuvers at the time of surgery. The disc height had increased by 177%. On the sagittal plane, lordosis had improved by 5°, without any changes in the pelvic parameters. In situ ALIF provides results that are comparable to those obtained with other techniques. This study confirms the essential role of fusion in achieving good functional results, given that hypermobility of the olisthetic level contributes to the symptoms generation. Level IV. Retrospective study.

Percutaneous treatment of high-risk patients with intra-articular calcaneus fractures: A case series

IntroductionDiabetics, smokers, patients with open fractures and drug addicts have shown to be at increased risk of having wound complications with traditional calcaneus fixation. The purpose of the study is to examine if high-risk patients with intra-articular calcaneus fractures can be managed safely using percutaneous reduction and fixation by examining a consecutive series of patients treated by the senior author. MethodsThe treatment group consisted of the senior author's first 17 percutaneously treated calcaneus fractures in high-risk patients. Risk factors included: open fracture, smoking, diabetes and cocaine, alcohol and solvent abuse. Reduction techniques included temporary external fixation, inflatable bone tamps, and arthroscopic assisted reduction manoeuvres. Fixation was accomplished with cannulated 4.5mm screws. Patients were followed up for 3 months minimum to look for wound complications and subsidence. ResultsSurgery was performed within 15 days from injury (average 6.7 days). Risk factors included: open fracture 1, smoking 16, diabetes 2, and substance abuse 9. Sanders’ classification described: six type 2, nine type 3 and two type 4. Bohlers’ angle increased from an average of −1.5° (range −37° to +30) to 25.8° (range 7–36°). There were no wound issues or infections with the calcaneal fixation. Reduction was deemed excellent or good in 14, fair in 2 and poor in 1. Loss of Bohlers’ angle of >4° occurred in four cases; in three of these, the patients were non-compliant with weight bearing. ConclusionHigh-risk patients with intra-articular calcaneus fractures that meet the criteria for surgical management can be managed with percutaneous surgical techniques with low risk of wound complications.

Major Contribution of Vasospasm-Induced Coronary Blood Flow Reduction to Anaphylactic Ventricular Dysfunction Assessed in Isolated Blood-Perfused Rat Heart

Cardiac anaphylaxis is accompanied by coronary spasm and decreased left ventricular (LV) contractility. However, it has not been determined experimentally whether LV dysfunction during anaphylaxis is induced mainly by reduced coronary blood flow (CBF) or direct negative inotropic actions of chemical mediators. To demonstrate the major role of CBF reduction in anaphylactic LV dysfunction, we determined LV contractility during anaphylaxis and forcible CBF reduction maneuver to reproduce the anaphylaxis-induced CBF reduction in isolated blood-perfused rat hearts. Isolated hearts from Wistar rats in the ovalbumin-sensitized anaphylaxis, non-sensitized flow reduction, and non-sensitized time control group were subjected to coronary perfusion with blood at a constant pressure and measurements of CBF and LV pressure. Cardiac anaphylaxis was induced by intracoronary injections of ovalbumin antigen. In response to antigen administrations, sensitized anaphylaxis group rat hearts showed decreases in CBF and the maximum increasing rate of systolic LV pressure (dP/dtmax) with an increased coronary vascular resistance as evidence of coronary spasm. The non-sensitized flow reduction group rat hearts whose CBF was forcibly reduced as in anaphylaxis showed the same degree of dP/dtmax reduction. The contractile failure during cardiac anaphylaxis is caused mainly by decreased CBF due to coronary spasm.

Indirect Reduction Maneuver and Minimally Invasive Approach for Displaced Proximal Humerus Fractures in Elderly Patients

BackgroundThis study examined the clinical outcomes of indirect reduction maneuver and minimally invasive approach for treating displaced proximal humerus fractures in patients older than 60.MethodsThirty-two patients (11 male and 21 female) who had undergone treatment for displaced proximal humerus fracture were evaluated. The mean age of the patients was 72.4 years (range, 60 to 92 years). All cases were followed up for at least 12 months. All patients were interviewed and evaluated on the visual analog scale, with gender-specific constant score correction for age, standardized X-rays to check the neck-shaft angle (NSA) and the presence of medial support, and bone mineral density. Statistical analysis was performed with a multiple regression analysis.ResultsThe average visual analog scale score was 2.4, and the average gender-specific constant score correction for age was 80.6 points. Final functional outcomes were 8 excellent, 15 good, 7 fair, and 2 poor. The average NSA was 122.8°; and the radiological results were 20 good, 11 fair, and 1 poor. There was significant difference of the gender-specific constant score for age between the group of NSA more than 110° and the group of NSA less than 110° (p = 0.00). There were 26 cases with and 6 cases without medial support, with significant difference between the gender-specific constant score correction for age of these groups (p = 0.01). Complications occurred in 4 patients (12.5%).ConclusionsThe indirect reduction maneuver and minimally invasive approach were safe and reliable options for the treatment of displaced proximal humerus fractures in the elderly patients. An inadequate reduction (i.e., less than 110° NSA) or lack of medial support (e.g., no cortical or screw support) were significant factors contributing to poor functional outcomes.

Evolutionary Ship Track Planning within Traffic Separation Schemes – Evaluation of Individuals

The paper presents an extended version of the author’s Evolutionary Sets of Safe Ship Trajectories method. The method plans safe tracks of all ships involved in an encounter including speed reduction maneuvers, if necessary, and taking into account Rule 10 of COLREGS, which specifies ships’ behavior within Traffic Separation Schemes governed by the International Maritime Organization (IMO). The paper focuses on the evaluation phase of the evolutionary process and shows how fitness function is designed to compare various possible tracks as well as to assess the quality of a final solution. The impact of the fitness function on the method’s results is illustrated by examples.

Evolutionary sets of safe ship trajectories with speed reduction manoeuvres within traffic separation schemes

ABSTRACT In the previous paper the author presented the evolutionary ship trajectory planning method designed to support Traffic Separation Schemes (TSS). This time the extensions of this method are described which allow to combine evolutionary trajectory planning with speed reduction manoeuvres. On TSS regions with higher than usual density of traffic and smaller distances between ships, the course alterations alone are not always sufficient or effective means of collision avoidance. Therefore they must be supplemented by speed reduction manoeuvres to a larger extent than on open waters. The paper includes a brief description of the optimisation problem, descriptions of the new elements of the method (fitness function, algorithms and the evolutionary cycle) and the examples of how the extended method successfully solves the problems unsolvable without applying speed reduction.

Surgical Technique for Balancing Posterior Spinal Fusions to the Pelvis Using the T Square of Tolo

Correcting pelvic obliquity and improving sitting balance in neuromuscular scoliosis often requires fixation to the pelvis. We describe the use of a T square instrument to assist intraoperatively in evaluating the alignment of these curves and achieving balance in the coronal plane. The T square instrument was constructed with a vertical limb perpendicular to 2 horizontal limbs in a T formation. At the conclusion of the instrumentation and preliminary reduction maneuvers, the T square was positioned with the horizontal limbs parallel to the pelvis and the vertical limb in line with the central sacral line. If the spine and pelvis were well balanced, fluoroscopic images demonstrated that the superior aspect of the vertical limb of the T square was crossing the vertebral body of T1. If this was not shown, then some combination of compression, distraction, or a change in the contouring of the rods was performed until this balance was achieved. In this series, we describe case examples in which the T square has been successfully used to aid in achieving balance in the coronal plane. This technique helps to overcome the challenges with positioning and imaging often encountered in managing these long, rigid curves. The T square is a useful adjunct in balancing posterior spinal fusions and evaluating the correction of pelvic obliquity in cases of neuromuscular scoliosis. This novel, yet simple, T square technique can be used for any method of posterior spinal fusion with lumbopelvic fixation to assist in the intraoperative evaluation and achievement of balance in the coronal plane and has become routine at our institution. IV.

Anterior Decompression and Nonstructural Bone Grafting and Posterior Fixation for Cervical Facet Dislocation With Traumatic Disc Herniation

A series study of patients with lower cervical facet dislocation accompanied by traumatic disc herniation treated with anterior decompression and nonstructural bone grafting and posterior fixation. To describe a surgical technique of anterior decompression and nonstructural bone grafting and posterior fixation and its clinical outcome in a group of patients with lower cervical facet dislocation accompanied by traumatic disc herniation. The optimal treatment for lower cervical facet dislocation with a prolapsed disc is still controversial. After discectomy and endplate preparation, a layer of morselized cancellous bone grafts from the iliac crest was placed in the interspace, and held in appropriate sagittal position by 2 layers of gelatin sponge and carefully sutured longus colli muscle. The anterior wound was then closed. The posterior elements were exposed and the reduction was performed. Fluoroscopy was used during reduction maneuver to ensure that the graft was still in the appropriate position. A posterior fusion was performed and the posterior wound was closed. Between January 2006 and February 2010, 21 patients with cervical facet dislocation accompanied by traumatic disc herniation (13 unilateral dislocations and 8 bilateral dislocations) were recruited for this study. All the patients completed at least 1-year follow-up. Average follow-up duration was 29 ± 3.5 months. Average Frankel scales were significantly improved at the end of follow-up, visual analogue scale decreased from 7.8 ± 1.2 before the operation to less than 1.6 ± 0.5 (P < 0.05) 6 months later. Kyposis was corrected from 17.7° ± 6.3° to 6.5° ± 4.1° (P < 0.05) and remained at 5.9° ± 4.2° (P > 0.05) 1 year later. The average subsidence of bone graft was 1.28 ± 0.16 mm at 12 months after the operation and remained 1.34 ± 0.20 mm at 36 months after the operation. All patients had consolidation of both anterior and posterior fusions. No cases of instrument failure occurred and no complications were attributed to the use of this technique. Although further study based on injury types as well as long-term follow-up is still needed, anterior decompression and nonstructural bone grafting and posterior fixation provides a promising surgical option for treating cervical facet dislocation with traumatic disc herniation.

The Functional Consequence of Syndesmotic Joint Malreduction at a Minimum 2-Year Follow-Up

To examine the correlation between syndesmotic malreduction and functional outcome. Prospective evaluation of bilateral computed tomography scans and functional outcome scores. Level I regional trauma center. From January 1, 2004, to December 31, 2006, 107 of 681 operatively treated ankle fractures (15.7%) had associated syndesmotic injuries requiring reduction and fixation. All patients available at a minimum of 2 years postindex procedure underwent clinical and radiographic examination, computed tomographic (CT) scanning of both ankles (injured and uninjured), and functional outcome scoring using the Short Form Musculoskeletal Assessment and Olerud/Molander questionnaires. Sixty-eight of 107 (63.5%) syndesmotic injuries in 68 patients were available for follow-up. Twenty-seven (39%) were malreduced (rotational or translational asymmetry) when compared with the contralateral uninjured syndesmotic joint. Fifteen percent of the open syndesmotic reductions were malreduced on postoperative CT scans, whereas 44% (A/B) of the closed syndesmotic reductions were malreduced on postoperative CT scan (P = 0.11). Patients with a malreduced syndesmosis recorded significantly worse functional outcome scores (P < 0.05) on both the Short Form Musculoskeletal Assessment and Olerud/Molander questionnaires when compared with those patients whose syndesmosis had healed in anatomic alignment. At a minimum of 2 years follow-up, patients with malreduced syndesmotic injuries demonstrated significantly worse functional outcome using the Short Form Musculoskeletal Assessment and Olerud/Molander questionnaires. Open reduction of the syndesmosis resulted in a substantially lower rate of malreduction when evaluated by postoperative CT scan. Based on these findings, we recommend that surgeons not only perform a direct, open visualization of the syndesmosis during the reduction maneuver, but obtain a postoperative CT scan with comparison to the contralateral extremity as well. If the syndesmosis is found to be malreduced, consideration must be given to revising the osteosynthesis. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The Usefulness of MRI in Atypical Pulled/Nursemaid’s Elbow

A nursemaid's elbow most frequently occurs with transient longitudinal traction of the pronated forearm and extended elbow, which can be reduced by manipulation without sedation. There are circumstances in which the history is atypical and reduction of the elbow is unsuccessful. Imaging may be helpful in these cases. A 33-month-old child was injured in a fall from a tire swing and sustained what was thought to be a nursemaid's elbow. Typical reduction maneuvers were unsuccessful. The patient underwent magnetic resonance imaging (MRI) with conscious sedation, which demonstrated the entrapment of the annular ligament in the radicapitellar joint. A presumed successful reduction was performed with confirmed reduction of the annular ligament by immediate MRI. To our knowledge, this is the first case report on MRI being used to diagnose and confirm treatment of an atypical nursemaid's elbow. IV.

Surgical Planning for the Treatment of Thoracolumbar Fractures: Anterior, Posterior, or Combined Approach?

Burst fractures commonly occur at the thoracolumbar junction. After the decision has been made for surgical stabilization, the surgeon must select a surgical approach based on the patients' pathology, comorbidities, and surgical familiarity. The posterior approach is the most commonly used approach, as it is extensile, allows stabilization of multiple segments, allows deformity reduction maneuvers, and is most familiar to spinal surgeons. Anterior stabilization is appropriate for direct decompression of anterior compressive pathology, although it is less familiar to most spinal surgeons and often requires an approach surgeon. Combined anterior–posterior stabilization is the most rigid construct and may be most appropriate for incomplete neurological deficit at the cauda equina or conus medullaris level due to retropulsed anterior bone. This article will review the advantages and disadvantages of each approach to facilitate surgeon selection.

Preface

Fractures of the foot present unique challenges for fixation because of the thin soft-tissue envelope, the need to support weight bearing, and possible complicating deformity. Predisposing deformities that may require concurrent correction include cavovarus, metatarsus adductus, and rocker bottom Charcot deformities. Inadequate fixation may lead to the development of secondary deformity and arthritis such as in talar neck and calcaneus fractures. The newer limited-incision techniques for calcaneal fractures seek to decrease problems with wound healing, peroneal tendon injury, and postoperative stiffness of the subtalar joint. Although the percutaneous techniques depend heavily on appropriate patient positioning, reduction maneuvers, and imaging to allow anatomic fracture reduction, a minimally invasive sinus tarsi incision is also presented to allow direct visualization of the posterior facet and its extension allowing direct visualization of the calcaneocuboid joint. The importance of preoperative work-up and planning to understand the fracture pattern and tips to obtain and maintain reduction are discussed in great detail. Although limited incision techniques may decrease complications of the standard extensile incision without compromising outcomes, there is a significant learning curve that requires patience, time, and willingness to convert to a more extensile approach if needed. The 2-incision approach to talar neck fractures takes into account both the delicate blood supply and the tendency to fail to achieve proper alignment and rotation when a 1-incision technique is attempted. Although avascular necrosis is the most feared outcome of talar neck fractures and surgery, posttraumatic subtalar arthritis is commonly seen and is likely associated with damage to the subtalar cartilage at the time of injury and inadequate reduction of any of the 3 subtalar facets. The presence of comminution of the medial wall of the talar neck makes it very difficult to anatomically reduce the fractures unless the less-comminuted tension side of the fracture is directly visualized with a lateral incision. Regardless, any incision balances visualization with a risk to the vascular supply, and the incision recommended in this paper preserves both the deltoid and the posterior tubercle branches of the posterior tibial artery. The development of an intramedullary device to correct and support midfoot collapse represents an important advancement in Charcot fracture deformity reconstruction. Intramedullary placement realigns the medial column reconstructing the arch, and is both load bearing and load sharing. However, careful joint preparation of each joint is required along with additional fixation to prevent rotation/micromotion and to promote bony fusion. As this device is fairly new, outcome studies are pending; however, the ability to correct and hopefully maintain the medial and lateral columns makes this new device and technique a potentially powerful new tool in fracture fixation for Charcot and crush-type injuries. The 2 contributions regarding operative fixation of metatarsal fractures stress the importance of not only treating the fractures, which can be challenging in itself, but also addressing potential structural deformities associated with the injury. A background of cavovarus and metatarsus adductus is often overlooked when treating these fractures, and likely contribute to failure of fixation, delayed or nonunions, and recurrence of the fracture. The thorough literature review on fifth metatarsal fractures is an excellent summarization of techniques and outcomes and a thorough guide to the varied operative techniques. The rationale for the location of screw insertion, the size and type of screw, and the depth of penetration are covered, along with indications for when to bone graft and/or perform corrective osteotomies and muscular releases. Corrective osteotomies for fifth metatarsal fractures associated with cavovarus typically involve dorsiflexion first metatarsal osteotomies in forefoot-driven heel varus, lateral calcaneal closing wedge osteotomies, and/or lateral calcaneal shift osteotomies to realign the hindfoot and the pull of the Achilles tendon for more rigid hindfoot-driven heel varus. Distal dorsiflexion osteotomies of the fifth metatarsal may also be useful in unloading the fracture site to allow healing. For metatarsus adductus, the associated deformity can be addressed through metatarsal closing wedge osteotomies or more involved midfoot closing wedge osteotomies. This volume has attempted to address more controversial foot fractures, because of the difficultly with soft tissues, reduction, and poor outcomes, by soliciting contributions from authors making advances in these areas. We hope you find this collection useful in terms of operative techniques for fixation of these fractures along with correction or prevention of deformity, maximizing patient outcomes in the face of these challenging issues.

Technique of Kirschner Wire Reduction and Fixation of Displaced Two-Part Valgus Angulated Proximal Humerus Fractures at the Surgical Neck

This article describes the technique of closed reduction with percutaneous fixation using Kirschner wires in helping the reduction of two-part valgus angulated and displaced proximal humerus fractures at the surgical neck. Traditional open reduction may lead to more accurate anatomic reduction; however, extensive tissue dissection increases the risk of avascular necrosis. Thus, closed reduction of unstable fracture mostly required forceful reduction maneuvers, which can harm the vascular supply and increase hematoma formation. Reduction of the fractured sides can easily be performed by engaging Kirschner -wires with a joystick method and fixation can be secured by using threaded pins. Thirty-six consecutive patients with displaced, two-part, valgus-angulated proximal humerus fractures at the surgical neck were treated by this method. The patients were followed for an average of 38 months. All fractures healed. According to the Constant scoring system, 21 patients (58%) had excellent, 9 patients (25%) had good, and 6 patients (17%) had fair results. The technique of closed reduction with a joystick method and percutaneous fixation is regarded as a reasonable treatment alternative in displaced two-part valgus angulated proximal humerus fracture.

Use of an external fixator pin to aid closed reduction of a displaced intracapsular hip fracture—A case report with a technical note

A displaced intracapsular hip fracture in a young patient is a surgical emergency. The fracture must be reduced anatomically and fixed in order to reduce the risk of subsequent avascular necrosis (AVN) of the femoral head. Various closed reduction methods, including the Whitman and Leadbetter manoeuvres have been described to reduce this fracture prior to fixation. Failure to achieve closed reduction mandates open reduction. We have found standard closed reduction manoeuvres have failed to reduce displaced intracapsular fractures in young adults following highenergy trauma on two occasions. We have found that the use of a percutaneously inserted external fixator pin can achieve closed anatomical reduction when standard closed reduction manoeuvres have failed.

A prospective randomised clinical trial comparing FARES method with the Eachempati external rotation method for reduction of acute anterior dislocation of shoulder

ObjectiveTo compare the safety, efficacy and reliability of FARES (fast, reliable and safe) method with the Eachempati external rotation method for reduction of anterior dislocation of shoulder. MethodsIn a single centre, prospective, randomised clinical trial, conducted in our institution from January 2010 to October 2011, 160 patients with acute anterior dislocation of shoulder (with or without an associated fracture of the greater tuberosity of the humerus) who satisfy the inclusion and exclusion criteria were enrolled in the study. Patients were randomised to receive reduction of dislocation with one of the two methods (FARES and Eachempati method) with 80 patients in each group, according to a table of random numbers. Following successful reduction, the following information was recorded: (i) intensity of pain perceived during reduction by using a visual analogue scale (VAS) ranging from 0 (no pain) to 100 (worst pain possible), (ii) time interval between the dislocation and the first attempt of reduction, (iii) time interval between the start of the reduction manoeuvre and completion of the reduction, (iv) number of attempts taken to complete the reduction and (iv) any post-reduction complications. ResultsThere were no significant differences between the two groups with regard to baseline characteristics. No post-reduction complications were noted in any of the patients in this study. Successful reduction of shoulder dislocation was achieved with the FARES method in 76 (95%) of 80 patients and with the Eachempati external rotation method in 73 (91.25%) of 80 patients. This difference was not statistically significant (p=0.53, Fisher's exact test). Post-reduction result analysis shows that there was a statistically significant difference between the two methods in favour of the FARES method in terms of speed of reduction, pain felt during reduction and number of attempts taken during reduction. ConclusionsFARES method, as compared with the Eachempati method, is significantly faster, less painful and less number of attempts required for reduction. As both the methods appeared to be safe and effective compared to the previous traditional techniques, we strongly recommend FARES method as the first-choice method compared to Eachempati method for reduction of acute anterior dislocation of shoulder. Level of evidenceTherapeutic Level I.

Closed Treatment of Overriding Distal Radial Fractures without Reduction in Children

Traditionally, distal radial fractures with marked displacement and angulation have been treated with closed or open reduction techniques. Reduction maneuvers generally require analgesia and sedation, which increase hospital time, cost, patient risk, and the surgeon's time. In our study, a treatment protocol for pediatric distal radial fractures was used in which the fracture was left shortened in an overriding position and a cast was applied without an attempt at anatomic fracture reduction. Consecutive patients three to ten years of age presenting between 2004 and 2009 with a closed overriding fracture of the distal radial metaphysis were followed prospectively. Our protocol consisted of no analgesia, no sedation, and a short arm fiberglass cast gently molded to correct only angulation. Patients were followed for at least one year. All parents or guardians were given a questionnaire assessing their satisfaction with the treatment. Financial analysis was performed with use of Current Procedural Terminology codes and the average total cost of care. Fifty-one children with an average age of 6.9 years were included in the study. Initial radial shortening averaged 5.0 mm. Initial sagittal and coronal angulation averaged 4.0° and 3.2°, respectively. The average duration of casting was forty-two days. Residual sagittal and coronal angulation at the time of final follow-up averaged 2.2° and 0.8°, respectively. All fifty-one patients achieved clinical and radiographic union with a full range of wrist motion. All parents and guardians answered the questionnaire and were satisfied with the treatment. Cost analysis demonstrated that closed reduction with the patient under conscious sedation or general anesthesia is nearly five to six times more expensive than the treatment used in this study. Adding percutaneous pin fixation increases costs nearly ninefold. This treatment protocol presents an alternative approach to overriding distal radial fractures in children and provides the orthopaedic surgeon a simple, effective, and cost and time-efficient method of treatment.

Early open reduction and internal fixation of Pilon fractures

After some general considerations concerning the blood supply to the bone and skin, and the timing of the surgery, the different approaches to Pilon fractures are presented. These approaches have to be planned according to 3D CT reconstructions to provide the best visual control over the reduction manoeuvres without creating supplementary damage to the blood supply to the bone and skin. This article then reviews in detail the steps of reduction and internal fixation for different types of fractures. As a principle, it is recommended to begin with the fixation of the fibular fracture unless it is comminuted. In these cases a bridge plate osteosynthesis is made after tibial reconstruction.Tibial articular reconstruction can be achieved “from outside” in case of simple large fragments (AO types B1 and C1), or under direct visual control in case of comminution. There are different options for fixation, from isolated screws, eventually combined with intramedullary nailing in some simple fractures, to locking plates for complex fractures. There is no place anymore for conventional plating in pilon fractures. Pre-shaped locking plates are frequently used. In contrast, the AO LCP pilon plate can be placed at any position around the distal tibia depending on the fracture anatomy and the approaches. It has to be cut and adapted individually to each case. The extremities of the plate have to be glided below the soft tissues and screws inserted through stab incisions when necessary, to avoid additional soft tissue damage. In the postoperative care a plaster cast for 6 weeks is a reliable option to avoid equinus and secondary rehabilitation problems.In conclusion, open reduction and internal fixation of pilon fractures remains a challenge, but preoperative 3D CT reconstructions for planning, and fixation with locking plates changed dramatically the way of treating and the prognosis of these severe fractures.

Effectiveness of intra-articular lidocaine injection for reduction of anterior shoulder dislocation: randomized clinical trial.

Shoulder dislocation is the most common dislocation among the large joints. The aim here was to compare the effectiveness of reduction of acute anterior shoulder dislocation with or without articular anesthesia. Prospective randomized trial conducted in Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-Unifesp). From March 2008 to December 2009, 42 patients with shoulder dislocation were recruited. Reductions using traction-countertraction for acute anterior shoulder dislocation with and without lidocaine articular anesthesia were compared. As the primary outcome, pain was assessed through application of a visual analogue scale before reduction, and one and five minutes after the reduction maneuver was performed. Complications were also assessed. Forty-two patients were included: 20 in the group without analgesia (control group) and 22 in the group that received intra-articular lidocaine injection. The group that received intra-articular lidocaine had a statistically greater decrease in pain over time than shown by the control group, both in the first minute (respectively: mean 2.1 (0 to 5.0), standard deviation, SD 1.3, versus mean 4.9 (2.0 to 7.0, SD 1.5; P < 0.001) and the fifth minute (respectively: mean 1.0; 0 to 3.0; SD = 1.0 versus mean 4.0; 1.0 to 6.0; SD = 1.4; P < 0.001). There was one failure in the control group. There were no other complications in either group. Reduction of anterior shoulder dislocation using intra-articular lidocaine injection is effective, since it is safe and diminishes the pain. ISRCTN27127703.

Kapalı önkol çift kemik kırığı sonrası ulnar sinir hasarı: Olgu sunumu

Closed double bone forearm fractures are among the most common fractures of childhood. These fractures often heal without problems with closed reduction and casting. The leading complications are known as malunion and compartment syndrome. The reports about nerve injuries related with these fractures are very limited. We present an eight years old boy who admitted to our hospital with ulnar nerve palsy symptomps three months after his initial trauma. His initial trauma was a simple fall which caused radius and ulna fractures. Radiological assessment showed proper union of the fractures. We performed surgical exploration to the ulnar nerve. We found a trapped and damaged nerve in the fracture region. Even though the rate of complications about nerve injuries are extremely rare in forearm fractures, neurologic examinations should be performed before and after the reduction maneuvers. Neurologic examination will be not only a guide for fracture management but also an important point for medicolegal problems.