Fracture Fragment Size Research Articles

Efficacy of K-wire combined with pull-out wire fixation in the treatment of acute bony mallet finger: a retrospective study

ObjectivesTo evaluate the clinical efficacy and safety of a novel surgical technique combining K-wire fixation with pull-out wire fixation for treating acute bony mallet finger.MethodsThis retrospective study included 23 patients with acute bony mallet finger treated between January 2023 and December 2024. Inclusion criteria were injuries within 4 weeks, failed conservative treatment, and fracture fragment size greater than one-third of the articular surface. Surgical details included stabilizing the DIP joint with a K-wire and supplementary fixation with pull-out steel wires to enhance stability. Postoperative outcomes were assessed using the Visual Analog Scale (VAS) score, range of motion (ROM), and Crawford criteria. Data were analyzed using SPSS software.ResultsThe mean age of patients was 33.78 ± 10.49 years. All 23 patients experienced no complications. The mean postoperative ROM of the affected DIP joint (75.09 ± 5.32°) was comparable to the healthy side (76.83 ± 5.91°). VAS scores indicated no pain, and Crawford criteria showed excellent or good outcomes in all cases.ConclusionsThe combined K-wire and pull-out wire technique appears to be a safe and effective option for treating acute bony mallet finger, offering stable fixation and good early functional outcomes.

Demographics, radiographic characteristics, treatment, and classification of pediatric thumb bony Ulnar Collateral Ligament (UCL) injuries

Background: Pediatric thumb ulnar collateral ligament (UCL) injuries usually have osseous involvement presenting as a Salter-Harris III avulsion fracture from the base of the proximal phalanx. There is limited guidance about when surgical or non-surgical treatment is more appropriate. Methods: Patients with thumb bony UCL injuries who presented to a large pediatric hospital between 2007 and 2017 were retrospectively identified. Demographics, fracture pattern, treatment, clinical course, and outcomes were collected. Radiographic measurements included size and displacement of fracture fragment as a percentage of the proximal phalanx base articular surface. A classification system was developed incorporating clinical stability of the metacarpophalangeal joint and quantity of displacement. Results: Sixty-five patients were included (47 males and 18 females). The mean age at time of injury was 14.8 SD 1.9 yrs old. 46 (71%) injuries occurred during sporting activities. 50 (77%) patients underwent nonsurgical management with immobilization, and 15 (23%) patients were treated surgically with open reduction internal fixation. For patients treated surgically, the mean fragment size was 28.2% SD 6.8% of the articular surface compared to 14.3% SD 12.5% of those treated non-surgically (P<0.0001). The mean fracture displacement for surgically treated patients was 32.7% SD 19.0% compared to 11.4% SD 7.3% of those treated non-surgically (P<0.0001). Overall, 100% of patients reported they were able to return to their previous level of activity. Conclusion: Many pediatric thumb bony UCL injuries can be treated non-surgically. A classification system based upon joint stability and fracture displacement may help guide appropriate management of these injuries.

2B or not 2B, should this not be the question? Comparison of 3D Surface Rendering CT to Plain Radiographs for Characterization of Posterior Malleolar Fracture Morphology.

The aim of this study was to compare plain lateral radiographs and 3D surface rendering (SR) CT imaging, in the characterization of posterior malleolar fracture (PMF) morphology using the Mason and Molloy classification. The null hypothesis was that there was no difference in characterization of morphology between plain radiographs and 3D SR CT. Morphology of the PMF was categorized initially by the CT scan as classified by Mason and Molloy on 180 trimalleolar ankle fractures. PM fracture fragment size on the lateral radiograph were compared to their respective 3D surface rendering CT reconstructions, by two independent observers. Morphology of the PMF was assessed using all preoperative radiographs as compared to 3D SR CT. On comparison of fracture fragment morphology, all fractures had poor categorization by plain radiographs although rotational pilon fractures (type 2A and 2B fractures) had the worse sensitivity and specificity (below 33% and below 50%, respectively). Radiographs underestimated joint involvement in type 2B fracture patterns because of the underappreciation of the posteromedial fragment. This study shows that the use of plain radiographs to categorize morphology of PMFs is poor. The study adds to the ever-growing body of evidence on the inaccuracy of using plain radiographs in PMFs to plan treatment. Additional CT imaging is imperative to allow for appropriate treatment planning in the management of PMF. Smaller fracture fragments are more susceptible to inaccuracies, especially the rotational pilon subtypes (2A and 2B) because of the obliquity of the posteromedial fragment to the plane of the X-ray source. Level III, retrospective comparative study.

Excellent clinical and radiological outcomes after arthroscopic reduction and double row-suture bridge for large-sized greater tuberosity fractures of the humerus.

Currently, there is limited information on the clinical outcomes of arthroscopic reduction and double-row suture bridge fixation for large greater tuberosity fractures of the proximal humerus. This study aimed to evaluate the radiological and clinical outcomes of arthroscopic reduction and double-row suture bridge fixation for these fractures, hypothesizing that arthroscopic reduction and double-row suture bridge fixation is a safe, effective and minimally invasive treatment for large greater tuberosity fractures. This retrospective study analysed patients with large greater tuberosity fractures (fracture fragment ≥30 mm in diameter) who underwent arthroscopic reduction and double-row suture bridge fixation and had a follow-up period exceeding 2 years. The anatomic reduction was confirmed by assessing the step-off on radiographs immediately after surgery, and the radiologic union time was recorded. At the final follow-up, range of motion and functional outcome scores were evaluated. Additionally, any surgery-related complications were evaluated. Fifteen patients with a mean follow-up of 57.7 ± 23.1 months were included in the study. The mean fracture fragment size was 32.5 ± 2.4 mm, with a mean displacement of 5.1 ± 1.6 mm. Immediately postsurgery, 13 of 15 patients (86.7%) had a fracture step-off of <3 mm, with an average union time of 3 months. At the final follow-up, patients demonstrated excellent outcomes, with an average forward flexion of 167 ± 9.7° and external rotation of 70 ± 16.3. Functional outcome scores showed significant improvement compared with preoperative scores (p < 0.001). No major surgery-related complications were reported. Arthroscopic reduction and double-row suture bridge fixation for large-sized greater tuberosity fractures is safe and shows good fracture reduction and excellent clinical outcomes. Therefore, this surgical method can be considered an alternative to open reduction for large greater tuberosity fractures. Level IV.

New Diagnostic-Based Systematic Classification for Skier's Thumb Injuries: A Revision That is Needed

Abstract Background Acute injuries to the ulnar collateral ligament (UCL) of the first metacarpophalangeal joint (MCPj), commonly referred to as Skier’s thumb injuries, can be further categorized into different types based on bone lesions and joint instability. However, none of the existing classifications encompasses all types and combinations of injuries. A unified classification system that provides direct treatment recommendations for each type is required, particularly for cases with no clear indications. Aims To develop a new classification system for acute UCL injuries of the first MCPj that comprehensively defines all possible combinations and types of injuries and facilitates treatment decision-making for each specific type in daily clinical practice. Methods The retrospective study included patients with acute UCL lesions who underwent conservative or operative treatment at our clinic between 2018 and 2023. This classification addresses ligamentous or osseous lesions, fracture fragment size and dislocation, ligament configuration (e.g. Stener lesions), and joint stability. Correlated radiography, ultrasonography, MRI, and intraoperative findings were used to define all combinations and variants of skier`s thumb injuries. Pre-therapeutic joint stability was characterized according to the criteria established in the literature. Dislocation criteria for bone lesions were defined in a preliminary observer trial. The classification was applied by three hand surgeons with different training levels. Treatment applied and a 3-months follow-up was documented. Results In 213 patients with acute UCL tears, the new classification was consistently applied, and the treatment derived was largely aligned with the recommendations in the literature for both absolute and relative indications for splint or operative therapy. The vast majority of the patients were stable after 3 months. Conclusion This new classification is the first to combine the clinical and radiological aspects of skier`s thumb injuries into one classification and encompasses all variants. It is comprehensive, can be easily applied retrospectively, and provides clear treatment recommendations in most cases.

Arthroscopic double-row bridge fixation provided satisfactory shoulder functional restoration with high union rate for acute anterior glenoid fracture.

To introduce a novel surgical technique for arthroscopic reduction and double-row bridge fixation using trans-subscapularis tendon portal for anterior glenoid fracture and to evaluate the clinical and radiological outcomes. A total of 22 patients who underwent arthroscopic reduction and double-row bridge fixation for an acute anterior glenoid fracture were retrospectively evaluated. Arthroscopic surgery was performed using four portals including a trans-subscapularis tendon portal. All patients underwent 3D-CT preoperatively and one day and one year postoperatively to evaluate the fracture fragment size, reduction status, and presence of fracture union. To evaluate the degree of fragment displacement, articular step-off and medial fracture gap were measured using 3D-CT. Clinical outcomes were assessed based on the ASES and Constant scores. Postoperative glenohumeral joint arthritis was evaluated using plain radiographs with the Samilson and Prieto classification. The average preoperative fracture fragment size was 25.9 ± 5.6%. Articular step-off (preoperative: 6.0 ± 3.3mm, postoperative one day: 1.1 ± 1.6mm, P < 0.001) and medial fracture gap (preoperative: 5.2 ± 2.6mm, postoperative one day: 1.9 ± 2.3mm, P < 0.001) were improved after surgery. On the postoperative one year 3D-CT, 20 patients achieved complete fracture union, and two patients showed partial union. Postoperative glenohumeral joint arthritis was observed in four patients. At the last visit, the ASES score was 91.8 ± 7.0 and the Constant score was 91.6 ± 7.0. Arthroscopic reduction and double-row bridge fixation using a trans-subscapularis tendon portal for acute anterior glenoid fracture achieved satisfactory clinical outcomes and anatomical reduction as demonstrated by a low degree of articular step-off and medial fracture gap. Level IV.

Coronoid Fractures and Varus Posteromedial Rotatory Instability

Coronoid Fractures and Varus Posteromedial Rotatory Instability

Metacarpal Fractures

Hand-related trauma is a common injury accounting for nearly a million emergency department visits annually. Fractures involving the metacarpals comprise approximately 40% of all hand injuries. Sports-related injuries are seen most often in children and young adults; middle-aged workers suffer more motor vehicle accident or work-related/industrial injuries; and the elderly seems to injure their hands from ground-level falls. The most commonly reported hand fracture involves the fifth metacarpal neck. Metacarpal fractures are described by their bone location in which they occur (head-neck-shaft-base). Fracture patterns are referred to as transverse, oblique (short/long), or comminuted based on fracture line configuration. The predominance of metacarpal fractures is closed injuries. However, open metacarpal fractures can result from severe bone and soft-tissue trauma caused by bone fragment(s) lacerating the skin. Small finger metacarpal neck fractures have the highest probability of being associated with an open fracture because of their injury mechanism. The primary goals of metacarpal fracture treatment are to achieve acceptable alignment, stable reductions, bony union, and full motion. Bone fracture location, fragment(s) size, and fracture pattern will influence treatment decisions. Most metacarpal fractures can be treated nonoperatively with closed reduction maneuvers and splinting. Metacarpal fractures associated with open injuries can be treated effectively with early detection, copious irrigation, antibiotic therapy, appropriate wound coverage, and fracture immobilization. Surgical considerations of metacarpal fractures include malunion, failure to maintain fracture reduction, polytrauma, and open fractures resulting in severe soft-tissue trauma.

Lithological controls on fault damage zone development by coseismic tensile loading

Lithological controls on fault damage zone development by coseismic tensile loading

Radial head fractures: a quantitative analysis.

Several classification systems for radial head fractures discuss the number of fragments and their displacement, but not the exact location. This study aimed to evaluate the location of the radial head fracture fragments and the influence of the Mason type on the size of the fracture fragment. Forty-one radial head fractures (31 Mason type I and 10 type II) with an elliptical radial head were included in this retrospective study and 3D reconstructed. First, the fragments were repositioned to their original location. Next, the orientation of the scanned forearm was evaluated using the position of the longest axis relative to the proximal radio-ulnar joint, and all radial heads were rotated to the neutral rotation. The radial head was divided into 4 quadrants (anteromedial, anterolateral, posteromedial, and posterolateral). The location of the fracture line in correlation with these 4 quadrants was evaluated. All fracture fragments were located in the anteromedial quadrant. Thirty-eight (93%) were located in the anterolateral quadrant. The posterolateral quadrant was involved in 32%. At last, the average fracture fragment size was evaluated according to the Mason classification. A significant difference was found in the average fracture fragment size between Mason type I (38% of the radial head surface) and type II (48% of the radial head surface). It was concluded that there is an important involvement of the anterior quadrants of the fracture. The mean size of the fracture is significantly larger in Mason type II compared to type I.

Isolated posterior malleolus fracture – magnetic resonance imaging diagnosis

Approximately 7% to 44% of ankle fractures involve the posterior tibial margin. These fractures tend to have a poorer prognosis than fractures without posterior involvement. Recognition of posterior malleolar fracture patterns is more important than fracture fragment size in decision making. Standard ankle radiographs are not effective for diagnosing isolated posterior malleolar fractures. There is consensus that the true size and geometry of the fragment, specifically its medial propagation, and intercalary fragments may be diagnosed only by computed tomography scanning. Magnetic resonance imaging may yield additional information about syndesmotic ligaments, tendons and osteochondral lesions, although it is used only exceptionally. There are controversies about the treatment of these fractures but authors agree that small fragments can be treated conservatively whereas larger fractures that involve more than 25% of articular surface should be fixed to avoid instability and degenerative changes. The authors report a case with a magnetic resonance imaging diagnosis of this fracture.

Nonoperative Treatment of Posterior Wall Acetabular Fractures After Dynamic Stress Examination Under Anesthesia: Revisited.

Performing an examination under general anesthesia (EUA) using dynamic stress fluoroscopy of patients with posterior wall acetabular fractures has been used as a tool to determine hip stability and the need for surgical intervention. The purpose of this study was to further evaluate the effectiveness of this technique, from a source other than its primary advocates, in patients with posterior wall acetabular fractures less than or equal to 50% who were stable on EUA and treated nonoperatively. Retrospective case series. University Level 1 Trauma Center. Seventeen patients with a posterior wall acetabular fracture stable on EUA treated nonoperatively. The patients were treated nonoperatively as guided by an EUA negative for instability. Patient follow-up averaged 30 months (range, 6-64 months). Outcome evaluation included the modified Merle d'Aubigné clinical score and the Short Musculoskeletal Function Assessment Questionnaire. Radiographic evaluation for subluxation or arthritis consisted of the 3 standard pelvic radiographs. Radiographic evaluation showed all hips to be congruent with a normal joint space. Sixteen of the 17 patients had radiographic outcomes rated as "excellent"; 1 patient was rated "good." The modified Merle d'Aubigné score (obtained in 12 patients) averaged very good, with only 1 having less than a good (graded as fair) clinical outcome. The Short Musculoskeletal Function Assessment Questionnaire scores (from 11 patients) were not significantly different from normal and were within the normal reported values for all indices and categories. There was no correlation between fracture fragment size and outcome. This study further supports the contention that a stable hip joint, as determined by EUA, after posterior wall acetabular fracture treated nonoperatively is predictive of continued joint congruity, an excellent radiographic outcome, and good-to-excellent early clinical and functional outcomes. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison of 3D Surface Rendering CT to Plain Lateral Radiographs for Quantification and Characterisation of Posterior Malleolar Fracture Fragment Size and Morphology

Category:Ankle; TraumaIntroduction/Purpose:The aim of this study was to compare the size of the posterior malleolar fracture (PMF) fragment on plain lateral radiographs compared to three-dimensional (3D) surface rendering CT imaging, and to compare both modalities in the characterisation of PMF morphology.Methods:Measurements of 180 lateral radiographs of PMF's were compared to their respective 3D surface rendering CT reconstructions, by two independent observers reviewing percentage articular involvement of the PMF fragment. Morphology of the PMF was categorised initially by the CT scan as classified by Mason and Molloy and was compared to this classification using radiographs.Results:When calculating the percentage joint surface involved by the PMF fragment, inter-observer variability was greater than 0.8 for radiographic and CT measurement. Significant differences in size of PMF on radiograph compared to CT were found for type 1 and type 2A fractures (p<0001 type 1, p=.071 type 2A). Radiographs consistently over-estimated the PMF fragment size, although in type 2B fracture patterns there was an equivalent number that were under-estimated due to the underappreciation of the posteromedial fragment. Comparison of fracture fragment morphology found that type 2A and 2B fractures (rotational Pilon's) had poor agreement between radiographs and CT (34.15%).Conclusion:This study shows that the use of a lateral radiograph in a PMF to estimate fracture size and morphology is poor. Additional CT imaging is imperative to allow for appropriate treatment planning in the management of PMF.

Size and location of posterior wall fragment on CT can predict hip instability in a cadaveric model

Size and location of posterior wall fragment on CT can predict hip instability in a cadaveric model

The anatomy of the anterior inferior tibiofibular ligament and its relationship with the Wagstaffe fracture

The anatomy of the anterior inferior tibiofibular ligament and its relationship with the Wagstaffe fracture

Characterization of the Dorsal Ulnar Corner in Distal Radius Fractures in Postmenopausal Females: Implications for Surgical Decision Making

Characterization of the Dorsal Ulnar Corner in Distal Radius Fractures in Postmenopausal Females: Implications for Surgical Decision Making

Magnetic Resonance Imaging Evaluation of the Anterolateral Ligament and the Iliotibial Band in Acute Anterior Cruciate Ligament Injuries Associated With Segond Fractures

Magnetic Resonance Imaging Evaluation of the Anterolateral Ligament and the Iliotibial Band in Acute Anterior Cruciate Ligament Injuries Associated With Segond Fractures

Posterior Approaches to the Ankle: An Analysis of 3 Approaches for Access to the Posterior Distal Tibia

Category:Ankle, TraumaIntroduction/Purpose:With the increase in the use of CT scanning and fragment specific fixation for complex ankle fractures, utilisation of multiple surgical approaches has increased. The posterolateral approach has been advocated by many, however in our experience, a large proportion of these fractures are not attainable by this approach. Our aim in this study was to analyse three posterior ankle approaches to find their use and efficacy in accessing the posterior tibia in the fixation of posterior malleolar fractures.Methods:We examined 5 fresh frozen cadaveric lower limbs. Three posterior ankle approaches (posterolateral (PL), posteromedial (PM) and medial posteromedial (MPM) approaches were performed, using a consistent repeatable incision of 7 cm extended proximal from the palpable distal extent of the medial malleolus. In both the PL and PM approaches, the flexor hallucis longus (FHL) was taken medially. In the MPM approach, the access was anterior to tibialis posterior (TP).K-wires were then placed parallel to one another at the 4 extremities of the approach. The ankles were imaged using an image intensifier and the distances measured.Our database of 172 consecutively treated posterior malleolar fractures in our department, was used to analyse the fracture fragment size and compare these fracture patterns to the approaches. The fractures were categorised using the Mason and Molloy classification. Only type 2 and 3 fractures were included, leaving 101 in the study.Results:On radiographic analysis, the type 2B and type 3 fractures incorporate 100% and 83% of the posterior width of the tibia respectively. Considering the PL approach only allows access to 40% of the posterior width of the tibia, another approach is required for these fracture patterns. Only 65% of fractures could be adequately exposed using the PL incision. In comparison, 78% of fractures could be exposed using the PM incision.The MPM incision gave the largest area for access to the posterior tibia, however it did not allow access to the constant posterolateral fragment. Only 35% of patients had posteromedial fractures that could be dealt with using the MPM incision, thus its usage is primarily as a supplementary incision, in conjunction with the PL incision.Conclusion:We conclude that the most commonly used approach (the PL approach) gives the least amount of access to the posterior tibia. In comparison to fracture fragment size, almost half of fractures would not be adequately exposed through the PL approach, and if fixing such fractures the surgeon should be comfortable with multiple approaches.

Quantitative 3-dimensional Computerized Tomography Modeling of Isolated Greater Tuberosity Fractures with and without Shoulder Dislocation.

The aim of this study was to assess differences in fracture morphology and displacement between isolated greater tuberosity (GT) fractures (i.e. fractures of the greater tuberosity without other fractures of the proximal humerus) with and without shoulder dislocation utilizing quantitative 3-dimensional CT imaging. Thirty-four CT-scans of isolated greater tuberosity fractures were measured with 3-dimensional modeling. Twenty patients (59%) had concomitant dislocation of the shoulder that was reduced prior to CT-scanning. We measured: degree and direction of GT displacement, size of the main fracture fragment, the number of fracture fragments, and overlap of the GT fracture fragment over the intact proximal humerus. We found: (1) more overlap -over the intact humerus- in patients without concomitant shoulder dislocation as compared to those with shoulder dislocation (P=0.03), (2) there was a trend towards greater magnitude of displacement between those without (mean 19mm) and those with (mean 11mm) a concomitant shoulder dislocation (P=0.07), and (3) fractures were comparable in direction of displacement (P=0.50) and size of the fracture fragment (P=0.53). We found substantial variation in degree and direction of displacement of GT fracture fragments. Variation in degree of overlap and displacement is partially explained by concomitant shoulder dislocation.

A proposed radiological classification system of Hoffa’s fracture based on fracture configuration and consequent optimal treatment strategy along with the review of literature

Background: Coronal fractures of distal end femur, referred as Hoffa’s fracture are not uncommon, yet easily missed injuries lacking proper classification system and consensus for ideal treatment. While most trauma surgeons adopt different strategies based on the fracture configuration and their own experience, there are no set ways to classify these based on the most appropriate treatment strategy. Methods: Thirty cases of Hoffa fracture from tertiary care centres were studied for the fracture pattern, fragment size, comminution and possible variations to formulate a radiological classification and treatment guidelines. Additionally, a literature search was used to analyze 77 case studies based on Hoffa fracture to find out the common fracture patterns and treatment modalities adopted for varying fracture patterns in these studies. Six independent observers participated in testing the inter-observer reliability of the proposed classification. Results: A new proposed radiological classification for Hoffa fracture consists of four main types. Type 1 is with fracture fragment >2.5 cm, Type 2 with fragment <2.5 cm, Type 3 is comminuted fracture, Type 4 are subdivided as Type 4a – Anterior, Type 4b – Bicondylar, Type 4c – Osteochondral type and Type 4d – With supracondylar extension. Optimum treatment modality depends on the type of Hoffa’s fracture and has been suggested in the study. Interobserver reliability demonstrated that overall agreement was 0.907692 with a fixed marginal Kappa of 0.881067 and free Marginal Kappa at 0.892308. Intra-observer reliability test for the classification system showed a strong Kappa value of +1.0. Conclusion: The new suggested classification helps identify different types of Hoffa’s fracture. This is likely to help decide optimal surgical treatment depending on the nature of the injury. The classification system has high inter and intra-observer reliability that enables its universal applicability.