Significant Ligamentous Injury Research Articles

Evaluation of cervical spine clearance scores in children younger than 3 years with blunt trauma.

The PEDSPINE I and PEDSPINE II scores were developed to determine when patients require advanced imaging to rule out cervical spine injury (CSI) in children younger than 3 years of age with blunt trauma. This study aimed to evaluate these scores in an institutional cohort. The authors identified patients younger than 3 years with blunt trauma who received cervical spine MRI from their institution's prospective database from 2012 to 2015. Patient demographics, injury characteristics, and imaging were compared between patients with and without CSI using chi-square and Wilcoxon rank-sum tests. Eighty-eight patients were identified, 8 (9%) of whom had CSI on MRI. The PEDSPINE I system had a higher sensitivity (50% vs 25%) and negative predictive value (93% vs 92%), whereas PEDSPINE II had a higher specificity (91% vs 65%) and positive predictive value (22% vs 13%). Patients with CSI missed by the scores had mild, radiologically significant ligamentous injuries detected on MRI. Both models would have recommended advanced imaging for the patient who required halo-vest fixation (risk profile: no CSI, 81.9%; ligamentous, 10.1%; osseous, 8.0%). PEDSPINE I would have prevented 52 (65%) of 80 uninjured patients from receiving advanced imaging, whereas PEDSPINE II would have prevented 73 (91%). Using PEDSPINE I, 10 uninjured patients (13%) could have avoided intubation for imaging. PEDSPINE II would not have spared any patients intubation. Current cervical spine clearance algorithms are not sensitive or specific enough to determine the need for advanced imaging in children. However, these scores can be used as a reference in conjunction with physicians' clinical impressions to reduce unnecessary imaging.

The sensitivity of limited-sequence magnetic resonance imaging in identifying pediatric cervical spine injury: A Western Pediatric Surgery Research Consortium multicenter retrospective cohort study.

Clinical clearance of a child's cervical spine after trauma is often challenging because of impaired mental status or an unreliable neurologic examination. Magnetic resonance imaging (MRI) is the criterion standard for excluding ligamentous injury in children but is constrained by long image acquisition times and frequent need for anesthesia. Limited-sequence magnetic resonance imaging (LSMRI) is used in evaluating the evolution of traumatic brain injury and may also be useful for cervical spine clearance while potentially avoiding the need for anesthesia. The purpose of this study was to assess the sensitivity and negative predictive value of LSMRI as compared with criterion standard full-sequence MRI as a screening tool to rule out clinically significant ligamentous cervical spine injury. We conducted a 10-center, 5-year retrospective cohort study (2017-2021) of all children (0-18 years) with a cervical spine MRI after blunt trauma. Magnetic resonance imaging images were rereviewed by a study pediatric radiologist at each site to determine if the presence of an injury could be identified on limited sequences alone. Unstable cervical spine injury was determined by study neurosurgeon review at each site. We identified 2,663 children younger than 18 years who underwent an MRI of the cervical spine with 1,008 injuries detected on full-sequence studies. The sensitivity and negative predictive value of LSMRI were both >99% for detecting any injury and 100% for detecting any unstable injury. Young children (younger than 5 years) were more likely to be electively intubated or sedated for cervical spine MRI. Limited-sequence magnetic resonance imaging is reliably detects clinically significant ligamentous injury in children after blunt trauma. To decrease anesthesia use and minimize MRI time, trauma centers should develop LSMRI screening protocols for children without a reliable neurologic examination. Diagnostic Test/Criteria; Level III.

Incidence and risk factors for poor ankle functional recovery, and the development and progression of posttraumatic ankle osteoarthritis after significant ankle ligament injury (SALI): the SALI cohort study protocol

BackgroundAnkle sprains are one of the most common musculoskeletal injuries, accounting for up to 5% of all Emergency Department visits in the United Kingdom. Ankle injury may be associated with future ankle osteoarthritis. Up to 70% of ankle osteoarthritis cases may be associated with previous ankle injury. There is limited research regarding the association between ankle sprain and ankle osteoarthritis development. The current study aims to phenotype those who suffer significant ankle ligament injuries, identify potential risk factors for ankle injuries and subsequent poor recovery, examine why individuals may develop osteoarthritis, and what factors influence this chance.MethodsIn this multicentre cohort study participants were recruited from nine Emergency Departments and two Urgent Care Centres in the United Kingdom. Participants (aged 18–70 years old) were defined as those who had suffered an isolated acute ankle sprain, which was Ottawa Ankle Rules positive, but negative for a significant ankle fracture on x-ray. Age and sex matched controls were also recruited. The controls were individuals who had not suffered a significant ankle injury, including ankle pain, function affected for more than 7 days, or the ankle caused them to report to an Emergency Department. Data is collected through a series of seven questionnaires (at baseline, 3 months, 1 year, 3 years, 5 years, 10 years, and 15 years later). The questionnaires include four sections (demographic questions; index injury, and injury history questions; functional assessment questions; and quality of life questions) and are designed to collect detailed information about the individual, their injury, potential risk factors for ankle sprains and ankle osteoarthritis, plus their medical history and any medication consumed.DiscussionThe Significant Ankle Ligament Injury (SALI) study aims to add to the limited knowledge regarding which factors can predict ankle sprains, complaints, and osteoarthritis. This is important because despite ankle sprains being regarded as a benign injury that resolves quickly, residual symptoms are not uncommon months and years after the injury.

Endovascular Stent Graft Repair of Traumatic Popliteal Artery Injuries

Introduction: Popliteal artery injury is a potentially-limb threatening complication of traumatic knee dislocation. The purpose of this study was to evaluate the feasibility and effectiveness of endovascular repair of traumatic popliteal a3.102rterial injuries. Methods: A retrospective analysis of 11 patients with clinical suspicion of popliteal arterial injuries that were confirmed by arteriography was performed from September 2015 to June 2017. Clinical data included demographics, mechanism of injury, type of injury, location of injury, concomitant injuries, time of endovascular procedures, time interval from trauma to blood flow restoration, and follow-up. All patients were male (mean age of 32.7 ± 8.5 years) and suffered traumatic knee dislocation along with significant ligament and neurovascular injuries. The type of lesion involved dissection (n = 3), partial transection (n = 5), complete transection (n = 2), arteriovenous fistula (n = 1). All patients underwent endovascular repair with Viabahnâ stent graft for popliteal arterial injuries. Results: Technical success rate was 100%. No perioperative death and procedure-related complication occurred. The length of the stent graft ranged between 5 and 10 cm; the diameter of the stents was 6 mm. The average follow-up was 22.4 ± 5.6 months (range 16–25 months). One patient who underwent knee arthroplasty with tourniquet treated with catheter directed thrombolysis due to stent thrombosis at 19 months after the procedure. All limbs were salvaged. Stent graft migration, deformation, or fracture was not found during the follow-up. Conclusion: Traumatic knee dislocations are rare injuries that may be associated with potentially devastating vascular complications. A prompt diagnosis and timely arterial repair is of paramount importance if limb salvage is to be achieved. In complicated traumatic popliteal artery injuries, an endovascular stent graft implantation as a backup or bail-out technique might be a valid option in some selected cases. Further studies are required to evaluate the long-term efficacy of endovascular stent graft repair.

Blunt cervical spine injury in adult polytrauma: incidence, injury patterns and predictors of significant ligament injury on CT

To describe the pattern of cervical spine fractures in adult major trauma and identify computed tomography (CT) parameters that can predict significant ligament injury when fractures are absent; to define the normal range for parameters used; and identify common variations due to position of cervical immobilisation in a trauma patient. In this retrospective study all polytrauma patients imaged using multidetector CT over a period of 5 years were identified. Patients with cervical spine fracture and suspected ligament injury in the absence of fracture were collated based on the polytrauma CT report. Predictors of ligament injury were defined based on published historical data on plain radiographs and posterior paraspinal fat pad assessment at CT. These parameters were recorded for each study with comparison to subsequent magnetic resonance imaging (MRI) as the reference standard. Significant ligament injury on MRI was detected at the craniocervical junction, when CT showed a basion dens interval of >10mm, widened incongruous C0/C1 facet joint space of >3mm, and widened C1/2 facet joint space of >6mm. In the subaxial cervical spine, facet subluxation >50% and obscured posterior paraspinal fat pad were the only reliable predictors of ligament injury, as confirmed on subsequent MRI. When fractures are absent, signs of significant ligament injury on CT at the craniocervical junction were increased basion dens interval and widened facet joints. In the subaxial cervical spine, >50% subluxation of a facet joint and obscured posterior paraspinal fat pad are indicators of significant ligament injury.

Anatomic patellar instability risk factors in primary lateral patellar dislocations do not predict injury patterns: an MRI-based study.

The primary goal was to describe the injury patterns in a population of primary (first time) lateral patellar dislocators (LPD) to lend clarity to commonly held notions about injury patterns in this population. A prospective study identifying patients presenting with LPD between 2008 and 2012. Inclusion criteria were a history and physical exam consistent with primary LPD, and an MRI consistent with the diagnosis without other significant ligamentous injury. On MRI, location of cartilage, medial patellofemoral ligament (MPFL) injury, and bone bruising were noted. Severity was categorized as partial or complete for MPFL and cartilage lesions. Anatomic patellar instability risk factors (patella alta, trochlear dysplasia, increased TT-TG, and lateral patella tilt) were recorded and compared to the injury patterns. This study involved 157 patients; 107 patients were skeletally mature. Of the 157 patients, 26 had surgery for this injury due to clinician-perceived need for cartilage debridement. MPFL injury severity was complete rupture (N = 69, 44%), partial (N = 67, 43%), and none (N = 19, 13%). MPFL injury location was isolated femoral (N = 16, 10%), isolated patella (N = 26, 17%), isolated mid-substance (0%), multiple locations (N = 95, 61%), and none (N = 20, 13%). Chondral injury location was patella (N = 67, 43%), lateral femoral condyle (N = 11, 7%), multiple locations (N = 53, 34%), and none (N = 26, 17%). A majority (61%) of patellar chondral lesions were at its inferomedial aspect; all medial patellar retinacular partial injuries involved the inferomedial aspect of the patella, consistent with the insertion of the medial patellotibial ligament (MPTL). Skeletally immature patients had a greater risk of isolated patellar MPFL and chondral injury. No clear relationship was found between/across the location and/or severity of bone bruising, MPFL, or chondral injury. Underlying anatomic patellar instability risk factors defined by MRI, do not predict injury patterns. MPFL and chondral injury, as well as bone bruising, are common following LPD. The medial patellotibial ligament is torn in patellar-based medial retinacular injuries, based on MRI injury location. Skeletal immaturity plays a role in the location of the injury pattern with isolated patellar-based MPFL/chondral injury being more common in the skeletally immature patient. Sex does not appear to be a factor in injury patterns after primary LPD. Knowledge of these injury trends will help focus the clinician in injury evaluation when managing primary patellar dislocations. Case series, Level IV.

Management of Fracture of Posterior Malleolus, Trimalleolar Fracture, Fracture Dislocations, and Syndesmosis Injury of Ankle Joint

ABSTRACT Background Malleolar fractures of ankle are usually complex injuries, as they are associated with significant ligament and soft tissue injury—injury to syndesmosis and injury to medial and lateral collateral ligaments. The open reduction and internal fixation is not feasible until recovery of significant soft tissue injury and subsidence of edema. Malleolar fractures are articular fractures and have associated subluxation and dislocation of talus. The aims of treatment are to restore normal anatomy and provide sufficient stability for early movements. Malleolar fractures more often require open reduction. Our study aimed to know efficacy and outcome of operative management of them. Materials and methods From January 2013 to March 2015, 35 patients with syndesmotic ankle injury and trimalleolar ankle fractures admitted to the Government Medical College, Latur, India, were operated and followed up prospectively. Results Mean age of patients is 35 years (25–60 years). Fracture union was seen radiologically in 3 to 4 months depending on fracture geometry. We achieved good to excellent results of 90%. Conclusion We conclude that malleolar fractures encountered in clinical practice need thorough assessment and meticulous surgical intervention, as they are associated with injury to ligament complex, i.e., ligament is a key structure in the stability of ankle mortise. Abduction and external rotation types of injuries are the most common types to be seen. We achieved stable fixation and performed early mobilization of the ankle joint, which limits the complications of mainly ankle stiffness. Each malleolus has got its inherent associated complications and calls for special attention for identifying associated conditions, such as syndesmotic injury, talus dislocation in posterior malleolar fractures, irreducible ankle dislocation with trimalleolar fracture, and entrapped fibula behind tibia with irreducible dislocation. How to cite this article Gawali SR, Kukale SB, Nirvane PV, Toshniwal RO. Management of Fracture of Posterior Malleolus, Trimalleolar Fracture, Fracture Dislocations, and Syndesmosis Injury of Ankle Joint. J Foot Ankle Surg (Asia-Pacific) 2017;4(2):90-96.

A Risk Prediction Model for Redislocation Following First Time Lateral Patellar Dislocation (LPD)

Objectives:There is not a formula that is regularly used to help predict the risk of redislocation for an individual patient following first time lateral patellar dislocation (LPD). Our objective was to develop a model to help predict the risk of redislocation that can be easily applied in a clinic visit following first time LPD.Methods:Between 2008-2012, patients were prospectively identified at 2 musculoskeletal outpatient clinics. Patients were included if they had a history, physical exam, & magnetic resonance imaging (MRI) consistent with LPD without other significant ligamentous injury. Multiple anatomic & injury variables were obtained from the MRI including tibial tubercle - trochlear groove distance, patellar tilt, trochlear depth, trochlear facet asymmetry, trochlear condyle asymmetry, lateral trochlear inclination angle, trochlear sulcus angle (SA), Insall-Salvati ratio (ISR), Caton-Deschamps index, patellotrochlear index, location & severity of chondral injury, location & severity of MPFL injury, location of bone bruising, & whether the patient had open or closed physes (GP). Demographic patient information was also collected to include age, sex, & whether the injury was contact or non-contact. Patients were contacted at a minimum of 2 years post injury to determine if they had experienced a redislocation injury. Demographic and MRI variables were compared between patients with and without patellar redislocation using two group t-tests for continuous variables and Fisher’s exact tests for categorical variables; the statistical analysis was completed by an independent professional statistician at our institution. Stepwise logistic regression models were used to identify potential predictors of redislocation. Initially, MRI variables that had continuous data were treated as continuous variables and then a second stepwise logistic regression model was run using binary indicator variables. A cutpoint for each variable was determined using an outcome-oriented approach; the cutpoint yielding the most significant association with the redislocation outcome in a simple logistic regression model was chosen. P-values less than 0.05 were considered statistically significant. A prediction model was then created using the statistically significant variables, and a receiver operating characteristic (ROC) curve was applied to the model to evaluate for diagnostic performance.Results:Inclusion criteria were met by 108 patients. Of all of the variables, the statistically significant variables were sex, GP, SA, and ISR. The cutpoints were SA ≥ 154 degrees and ISR ≥ 1.3. The predicted probability of redislocation (percent) was 6.4 for males and 2.3 for females if the patient had closed growth plates and normal SA and ISR. The predicted probability of redislocation (percent) was 89.9 for males and 75.7 for females if the patient had open growth plates and abnormal SA and ISR. If two of three variables (GP, SA, ISR) were positive, the risk was M70.4/F45.4 (GP, SA), M46.5/F23.3 (GP, ISR), and M72.5/F47.9 (SA, ISR). The area under the curve for the ROC curve was 0.81 indicating good diagnostic performance.Conclusion:Our model demonstrates high risk of redislocation with open growth plates and SA & ISR values above the cutpoints, whereas there are low rates of redislocation with the inverse findings. This model may serve as a clinically applicable means of predicting redislocation following first time LPD.

Elbow dislocation with complete triceps avulsion.

Radio-ulnar Fracture dislocation of the elbow is a high-energy trauma which can be associated with significant ligamentous injury in adults. We report an unusual triad of injury in a patient with avulsion injury of the triceps. This injury can be thought of as a variant of “terrible triad” with dislocation of radio-ulnar joint, radial head fracture, and medial collateral ligament injury with avulsion of the triceps. Elbow has to be stabilized with early repair of the ligaments for a successful outcome.

English

INTRODUCTION: Elbow dislocations are frequently encountered during clinical practice, posterior dislocation being most common while pure lateral being less. Lateral type indicates high energy trauma and significant ligament injury. CASE REPORT: We present here a case of a 55 year old male with a pure lateral dislocation who presented six hours after injury. Closed reduction, attempted under anesthesia, was unsuccessful and had to be open reduced. A tight band of brachialis muscle was noted as cause for failure of closed reduction. DISCUSSION: Pure lateral dislocation being very rare (incidence 0.7%) is associated with significant ligament injuries around the elbow. CONCLUSION: Lateral dislocation of elbow requires careful investigation, early reduction and assessment for elbow instability. INTRODUCTION: Posterior elbow dislocations are most common type of elbow dislocation seen in clinical practice (2).Other types of elbow dislocation such as anterior, medial, lateral and divergent are very rare. We are presenting a rare case of traumatic pure lateral dislocation of elbow in a 55 yr adult male. CASE REPORT: A 55 years-old male, farmer, fell off a bullock-cart, with trauma to partially flexed left elbow. After the trauma, patient noticed severe pain and deformity of his left elbow, for which patient came to the hospital about 6 hours after the injury. On examination, there was swelling around the elbow and lower arm. The medial epicondyle and trochlear groove were prominent and easily palpable. There was widening of the elbow along with lateral displacement of olecranon and radial head. The elbow was in 20-30 degree flexion and the forearm was in supination. There was no neurovascular deficit distally. On X-ray of the left elbow Antero posterior view (figure 1) the olecranon and radial head were lateral to the capitulum while on lateral view the radial head and coronoid process were anterior to capitulum. There was no evidence of any fracture. After 9 hours of injury under general anesthesia closed reduction was tried by traction and varus force on elbow to reduce the prominent medial part of humerus, but it was not reducible. Hence, anteromedial incision over the bony prominence was taken. The distal end of humerus was in subcutaneous plane. The ulnar nerve was identified, medial collateral ligament was found to be detached from the humeral side and flexor pronator origin were found torn (figure 2). Through the torn medial capsule, the anterior tight band of brachialis muscle was lifted anteriorly and the elbow

The daunting task of “clearing” the cervical spine

The evaluation of the cervical spine in the emergency department is a common and often challenging task. We report the case of a 70-year-old female who presented intoxicated with evidence of a recent fall. A 64-slice computed tomographic (CT) scan with sagittal and coronal reconstructions revealed no acute injury. The patient was re-examined when alert and had persistent neck pain. Flexion-extension static views revealed severe subluxation of C5 on C6 with jumped facets, and subsequent magnetic resonance imaging confirmed significant ligamentous injury. The evidence available suggests that although CT with reconstruction is highly sensitive for clinically significant cervical injury, the possibility of severe injury remains.

Open reduction and internal fixation for angulated, unstable odontoid synchondrosis fractures in children: a safe alternative to halo fixation?

External orthosis is the accepted and historical management of odontoid synchondrosis fractures; however, this conservative therapy carries a significant complication and fracture nonunion rate among young children. The purpose of this study was to evaluate the authors' own experience in the context of the literature, to explore surgical fixation as a primary treatment for unstable fractures. The authors retrospectively reviewed 2 cases of unstable odontoid synchondrosis fractures treated at their institution; both showed radiographic progression of deformity and subsequently underwent an open surgical reduction and fusion. A literature review was conducted to compare the authors' management strategy with those in published data. External orthosis for treatment of odontoid synchondrosis fractures has a strong history of success. However, in the literature, patients treated with a halo orthosis had a 43.3% rate of complications and an 11.4% risk of nonunion. There are radiographic findings that suggest instability, such as severe angulation and displacement of the odontoid process. Both patients in the present report underwent successful fusion without complication, as documented on CT scans obtained 3 months after surgery. Given the high rate of fusion attained with conservative therapy, it is recommended for most synchondrosis fractures. However, there is a recognized subgroup of synchondrosis fractures with severe angulation (> 30°) and displacement suggestive of significant ligamentous injury. In these patients, surgical fixation may be a safe and efficacious alternative to halo orthosis as the primary treatment.

Medial and Lateral Segond Fractures in a Skeletally Immature Patient: A Radiographic Marker for the Multiply Injured Knee

Marginal fractures of the medial tibial plateau have been reported in the literature as a secondary type of Segond fracture. Some reports described this entity in the setting of combined injuries such as root avulsions of the medial meniscus, complete disruption of the posterior cruciate ligament (PCL), partial tear of the anterior cruciate ligament (ACL), and tears of the medial meniscus and medial collateral ligament. It has been postulated that medial marginal fractures are secondary to compression of the medial aspect of the femoral condyle and tibial plateau with a corresponding posterolateral corner injury. However, this mechanism of injury may not always be as straightforward.This article presents a case of an alternate injury pattern in a skeletally immature patient. A 16-year-old boy sustained a varus force and twisting injury to his knee, resulting in radiographic evidence of multiple avulsion fractures of the knee, including a fibular epiphyseal avulsion fracture and medial and lateral Segond fractures. Usually, the avulsion fractures serve as markers for significant ligamentous injuries in adult patients, but our patient had minimal injury to the PCL, ACL, and posterolateral corner. Further physical examination and imaging studies revealed an anterior horn root avulsion, meniscocapsular separation, and anterior cortical rim fracture. A combination of imaging modalities helped us further characterize the injury pattern to devise the optimal surgical plan, especially the fixation of the anterior cortical fracture of the tibia.

Computed Tomography versus Magnetic Resonance Imaging for Evaluation of the Cervical Spine: How Many Slices do you Need?

Controversy exists regarding the correlation between CT and MRI for evaluation of the cervical spine. We hypothesize that newer-generation CT scanners will improve diagnostic accuracy and may obviate the need for MRI in patients with a normal CT. We compared the missed injury rate of four-slice CT and 64-slice CT performed to evaluate the cervical spine. We conducted a retrospective study from January 2004 to June 2008 of all blunt trauma patients who underwent both a CT and MRI to evaluate the cervical spine. One hundred six blunt trauma patients underwent both CT and MRI, including 43 with four-slice and 63 with 64-slice CT. CT missed three injuries (3%), all of which were clinically significant ligamentous injuries seen only on MRI. The 64-slice CT missed no injuries (0%), whereas the four-slice CT missed all three (7%) of the ligamentous injuries (P = 0.03). Older-generation CT scanners miss clinically significant injuries in blunt trauma patients and should not be independently relied on to evaluate the cervical spine. The newer 64-slice CT scan does not appear to miss clinically significant cervical spine injuries and may allow clearance of the cervical spine in blunt trauma patients without the addition of an MRI.

Practice Management Guidelines for Identification of Cervical Spine Injuries Following Trauma: Update From the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee

Injury to the cervical spine (CS) is common after major trauma. The Eastern Association for the Surgery of Trauma first published its Practice Management Guidelines for the evaluation of CS injury in 1998. A subsequent revision was published in 2000. Since that time a large volume of literature has been published. As a result, the Practice Management Guidelines Committee set out to develop updated guidelines for the identification of CS injury. A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed (www.pubmed.gov). The search retrieved English language articles regarding the identification of CS injury from 1998 to 2007. The questions posed were: who needs CS imaging; what imaging should be obtained; when should computed tomography, magnetic resonance imaging, or flexion/extension radiographs be used; and how is significant ligamentous injury excluded in the comatose patient? Seventy-eight articles were identified. From this group, 52 articles were selected to construct the guidelines. There have been significant changes in practice since the previous CS injury guidelines. Most significantly, computed tomography has supplanted plain radiography as the primary screening modality in those who require imaging. Clinical clearance remains the standard in awake, alert patients with trauma without neurologic deficit or distracting injury who have no neck pain or tenderness with full range of motion. Cervical collars should be removed as soon as feasible. Controversy persists regarding CS clearance in the obtunded patient without gross neurologic deficit.

Isolated Ligamentous Cervical Spinal Injury in the Polytrauma Patient with a Head Injury

The evaluation of the cervical spine in the unconscious trauma patient is a difficult and controversial topic in trauma management. Conventional cervical clearance protocols consisting of plain radiology and computed tomography may not adequately detect unstable cervical ligament and disc injuries, even though a high-risk mechanism of injury has occurred. We present two cases where cervical clearance protocols, utilising plain X-rays and multi-slice computed tomography, failed to identify significant ligamentous spinal injuries. A delay in diagnosis or a missed spinal injury can lead to delays in treatment, thereby increasing the risk of neurological deterioration with the potential devastating sequela of quadriplegia. Therefore, in the unconscious trauma patient who, by definition, has sustained a high-risk mechanism injury, we routinely recommend the use of magnetic resonance imaging in addition to plain X-rays and computed tomography, to evaluate further discoligamentous status.

Cervical Spine Clearance in the Blunt Trauma Patient

The risks of overlooking a cervical spine injury in a polytrauma patient still remain substantial even with the development of recent advanced radiologic imaging and practice management guidelines. Cervical spine clearance continues to pose a diagnostic dilemma to the trauma team providing care for these patients. There are several issues with legal, medical, and economic implications: which patient populations require cervical spine radiographs; which views should be obtained; is there efficacy in flexion/extension radiographs, CT scan, or MRI scans; in the obtunded patient can the absence of significant ligamentous injury be demonstrated; who should perform clearance methods and be ultimately responsible for valid clearance. The purpose of this article is to revisit current management strategies for clearance of the cervical spine and explore new findings if any, which have been accepted as standard of care by providers, faced with this challenging responsibility.

Clearing the cervical spine in critically injured patients: a comprehensive C-spine protocol to avoid unnecessary delays in diagnosis

Clearing the cervical spine in polytrauma patients still presents a challenge to the trauma team. The risk of an overlooked cervical spine injury is substantial since these patients show painful and life-threatening injuries to one or more organ systems so that clinical examination is usually not reliable. A generally approved guideline to assess the cervical spine in polytrauma patients might significantly reduce delays in diagnosis, but a consistent protocol for evaluating the cervical spine has not been uniformly accepted or followed by clinicians. One purpose of this study was to analyse the common methods for cervical spine evaluation in critically injured patients and its safety and efficacy at this trauma centre. The second purpose was to present a comprehensive diagnostic C-spine protocol, based on the authors' experiences with documented cases. From a prospectively gathered polytrauma database, we retrospectively analysed the clinical records of all polytrauma patients, with skeletal and/or non-skeletal cervical spine injuries, who were admitted to this level I trauma centre between 1980 and 2004. All patients were assessed following the trauma algorithm of our unit (modified by Nast-Kolb). Standard radiological evaluation of the cervical spine consisted of either a single lateral view or a three-view cervical spine series (anteroposterior, lateral, odontoid). Further radiological examinations (functional flexion/extension views, oblique views, CT scan, MRI) were carried out for clinical suspicion of an injury or when indicated by the standard radiographs. Sixteen patients (14%) had a single cross-table lateral view for radiological assessment of the cervical spine during initial trauma evaluation, Twenty-nine patients had a three-view cervical spine series (anteroposterior, lateral, odontoid) and 81 patients underwent extended radiological examinations by cervical CT scan (n=52), functional flexion/extension views (n=26) or MRI (n=3). Correct diagnosis was made in 107 patients (91%) during primary trauma evaluation, whereas in 11 patients (9%) our approach to clear the cervical spine failed to detect significant cervical spine injuries. In six patients skeletal injuries were missed by a single lateral view and in two patients by a three-view standard series because inadequate radiographs with poor technical quality or incomplete visualization of the cervical spine did not show the extent of the injury. In three cases ligamentous injuries were missed despite complete sets of standard radiographs and cervical CT scan, but without functional radiography. Common methods for cervical spine evaluation in critically injured patients were plain radiographs, cervical CT scan and functional flexion/extension views. Cervical CT scan was the most efficient imaging tool in detecting skeletal injuries, showing a sensitivity of 100%. A single cross-table lateral view appeared to be insufficient, as we found a sensitivity of only 63%. Functional radiography or MRI was also necessary, as plain radiographs and CT scan failed to detect significant ligamentous injuries in 6% of the patients. For more comprehensive assessment of the C-spine, we presented a new C-spine protocol based on the authors' experiences, with the aim to avoid unnecessary delays in diagnosis.

The “Floating” Meniscus: MRI in Knee Trauma and Implications for Surgery

We describe 21 cases involving meniscal injury in which the meniscus appears free-floating on MRI of the knee. In these cases, the meniscus is completely surrounded by fluid. Correlation with surgical reports shows that the "floating" meniscus corresponds to a meniscal avulsion or detachment from the tibial plateau with an associated disruption of the meniscotibial coronary ligaments, which attach the meniscus to the tibia, allowing fluid to encompass the meniscus. A floating meniscus on MRI may represent a new specific finding for an uncommon form of meniscal injury known as meniscal avulsion. The presence of a floating meniscus on MRI is a result of significant trauma to the knee leading to meniscal avulsion and is often associated with significant ligamentous injury. Alerting the surgeon to the presence of a meniscal avulsion facilitates appropriate surgical planning with meniscal reattachment to the tibial plateau.

Arthroscopic findings in wrists with severe post-traumatic pain despite normal standard radiographs

This study assessed the role of diagnostic arthroscopy following a wrist injury in patients with normal standard radiographs, an unclear clinical diagnosis and persistent severe pain at 4 to 12 weeks. Forty-three patients were included after conservative management had failed to improve their wrist pain so that a stability test could be performed satisfactorily and underwent arthroscopy within 12 weeks. Arthroscopy revealed recent pathology in 41 wrists, of which 17 had significant ligament lesions that might have benefited from acute repair. We conclude that patients with marked persistent post-traumatic symptoms despite conservative management are likely to have sustained ligament injuries despite normal radiographs. We therefore recommend that under these circumstances an arthroscopy is carried out within 4 weeks if the patient and surgeon wish to acutely repair significant ligament injuries.