Small Avulsion Fractures Research Articles

Injuries of the midfoot

Summary Injuries of the midfoot are relatively rare but they can lead to significant morbidity if missed. Serious injuries may present in a subtle manner and are often misdiagnosed as a sprain. Small avulsion fractures of the navicular and cuboid may be misdiagnosed as a simple avulsion when in fact they represent a more severe midfoot injury. A high index of suspicion is required. Good quality X-rays with three views must be obtained and if suspicion exists further imaging with a bone scan, CT or MRI is necessary. Prompt diagnosis and early treatment will prevent long-term disability and morbidity. Salvage procedures following these injuries often involve arthrodesis that limit mobility and frequently lead to an unsatisfactory outcome.

Arcuate sign of posterolateral knee injuries: anatomic, radiographic, and MR imaging data related to patterns of injury.

The "arcuate sign" is considered a pathognomonic sign for injuries of the posterolateral (PL) corner of the knee. The purpose of our study was to identify different patterns of injury to the fibular head that may associate with injuries to specific ligaments and tendons of the PL corner of the knee. The anatomic relations between the insertions of fibular collateral ligament (FCL), biceps femoris tendon (BFT), popliteofibular ligament (PFL), and arcuate ligament in normal cadaveric knees were also investigated. Magnetic resonance imaging was performed in two cadaveric knees which subsequently were dissected. Radiopaque markers were placed upon the fibular insertions of the FCL, BFT, PFL, and arcuate ligament in the dissected knees, and knee radiographs were then obtained. Twelve patients with radiographic or MR imaging evidence of isolated injury to the PL corner of the knee were retrospectively reviewed, with regard to avulsion fractures and marrow edema in the fibular head and the integrity of the ligaments of the PL corner of the knee. The PFL and arcuate ligament were seen to attach directly to the posterior and medial aspect of the styloid process of the fibular head. The FCL and BFT attached as a conjoined structure on the lateral aspect of the fibular head lateral, anterior and inferior to the attachment site of the PFL and arcuate ligament. Injury to the arcuate ligament or PFL was diagnosed in 8 patients who presented with a small avulsion fracture of the styloid process of the fibula (n=2), bone marrow edema in the medial aspect of the fibular head (n=3), or both (n=3). In 4 patients with injury to the conjoined tendon or FCL, a larger avulsion fragment and more diffuse proximal fibular edema were seen. Radiographic and MR imaging findings in injuries of the posterolateral corner of the knee may suggest injury to specific structures inserting in the fibular head.

KNEE INJURY-SOCCER

HISTORY A 13-year-old male soccer goalie sustained a left knee injury during a collision with another player in which he was kicked in the medial aspect of the knee. He continued play for approximately 5 minutes, at which time he left the game due to increasing anterior knee pain exacerbated by flexion and severe knee swelling and stiffness. PHYSICAL EXAMINATION Left knee: 3+ effusion. Held at position of comfort at 20 degrees of flexion. Tenderness over medial patellar retinaculum, lateral patellar facet, in inferior pole of patella. Range of motion 10–90 degrees flexion, with increasing pain in flexion. Ligamentous testing and meniscal provacative tests negative within pain limited range of motion. DIFFERENTIAL DIAGNOSIS Patellar dislocation/subluxation. Knee contusion. Patellar fracture. Ligamentous disruption. Quadriceps mechanism strain or rupture. TESTS AND RESULTS Left knee anterior-posterior and lateral radiographs – Fibrous cortical defect proximal left tibial shaft – Minimal irregularity inferior pole of patella Left knee MRI – Small nondisplaced avulsion fracture inferior patella – Large knee effusion – No ligamentous or meniscal injury. FINAL/WORKING DIAGNOSIS Avulsion fracture of inferior pole of the Patella (Patellar Sleeve Fracture). TREATMENT AND OUTCOMES Knee immobilizer non-weight bearing for two weeks. Passive extension range of motion exercises at 2 weeks. Gradual weight bearing in immobilizer at 3 weeks. Active knee extension range of motion exercises at 4 weeks. Gradual Weight bearing out of immobilizer at 4 weeks. Proprioceptive and gradual sport-specific training at 6 weeks. Return to play soccer at 9 weeks 8. Follow-up at 4 months – asymptomatic with full participation.

Application of the Maxillofacial Mini-plate Compact 1.0 in the Fracture Repair of 12 Cats/2 Dogs

SummaryThis study reports the application of the AO/ASIF maxillofacial mini-plate system, Compact 1.0a (MF mini-plate 1.0), in the repair of fractures in 12 cats and two small sized dogs. The malleability of these titanium mini-plates allows them to be precisely contoured and positioned to fit onto the most advantages sites of the bone. Selftapping mini-screws provide an easy application and a time-saving osteosynthesis. Fractures of miniature bones too small for the regular AO/ASIF miniimplants can be repaired successfully with this MF mini-plate 1.0 implant set. The special indications reported were the repair of fractures of the angle of the mandible in cats, articular digital fractures in small dogs and the stabilization of small avulsion fractures in cats and dogs.This study shows the successful application of the titanium maxillofacial mini-plate, Compact 1.0, in 12 cats and two toy breed dogs. Miniature fractures, such as mandible or digit fractures, too small for the AO/ASIF mini-plate system are indications for these implants. The self-tapping screws of the maxillofacial system, Compact 1.0, with a core diameter of 0.7 mm, can be used as plate screws or interfragmentarily.

Failure of cast immobilization for thumb ulnar collateral ligament avulsion fractures

To determine if small avulsion fractures of the thumb ulnar collateral ligament (UCL) with minimal (< or = 2.0 mm) displacement can successfully be treated by cast immobilization, the authors reviewed 9 patients with minimally displaced fractures initially treated by casting. Despite immobilization within an average of 2 days of the initial injury (range, 0-6 days), a minimum of 6 weeks of immobilization in a cast, and adequate rehabilitation, all 9 patients had persistent thumb pain, especially with activities requiring strong pinch. After undergoing open reduction and internal fixation, the patients had relief of thumb pain and pinch strength improved from 36% of the contralateral side to 89% (p < .01). Grip strength increased from 77% to 93% (p < .05), but the ranges of motion of the thumb metacarpophalangeal and interphalangeal joints were not significantly altered. Minimally displaced UCL avulsion fractures frequently have significant rotation that prevents successful fracture healing even with prompt cast immobilization.

Shear fracture-dislocation of the lumbar spine without paraplegia

Fracture-dislocation of the thoracic and lumbar spine resulting from hyperextension injury accounts for less than 3 per cent of all fractures of the spine. When these injuries do occur they are usually associated with a high incidence of dural tear and paraplegia. The presence of anterior disc space widening, sagittal translation and or a small avulsion fracture of the vertebral body on radiographs should alert the clinician to the possibility of this highly unstable hyperextension type of injury. The authors report a rare fracture-dislocation in the lumbar spine resulting from such a hyperextension injury in which only minor neurological deficit occurred. In one series of thoracic and lumbar injuries only 1 out of 1212 patients had a similar injury’.

Late carpal instability associated with dorsal distal radial fracture

Carpal instability has been recognized for two decades (Taleisnik, 1988). It is defined as a ‘carpal injury in which loss of normal alignment of the carpal bones develops early or late’. Four distinct patterns can be recognized, of which dorsiflexion intercalated segment instability (DISI) is the commonest. Although late development of the DISI deformity is well recognized, we present a case with radiological signs which have been hitherto unreported and may lead to earlier recognition of the patient at risk. A Lo-year-old man fell 2 m off a ladder onto both outstretched hands. He suffered a Barton’s fracture of the right radius and a small avulsion fracture of the dorsal aspect of the left radius, associated with two flake fractures which appear to have come from the dorsum of the capitate. The proximal fragment appears old with rounded edges. The age of the tiny distal fragment could not be determined. He denied any important trauma to the wrist in the past, but we also noted a probable old ulnar styloid fracture (Figure I). The right wrist was successfully fixed internally with a

Indications for radiography in patients with acute ankle injuries: role of the physical examination.

A prospective study was performed to test the hypothesis that a thorough physical examination can eliminate the need for a large number of radiographs obtained in patients with acute ankle trauma. Two hundred one patients were seen in the emergency department for acute ankle trauma and referred to the department of radiology for ankle radiographs. Radiology residents performed a brief but thorough physical examination of the ankle in all 201 patients. Solely on the basis of a strict set of physical examination criteria (examination for gross deformity, instability, crepitation, focal bony tenderness, severe soft-tissue tenderness, moderate or severe soft-tissue swelling, and ecchymosis), the radiologists determined whether or not the radiographs were indicated. All patients, irrespective of the physical examination, underwent ankle radiography, and the results were correlated with those of the physical examination. On the basis of the results of the physical examinations, 101 (50%) of the radiologic studies were not indicated. In only one of these patients was a fracture seen on radiographs. The radiograph in this case showed a small avulsion fracture of the dorsal aspect of the talus that was clinically insignificant (no cast or surgery was required). Our results suggest that a brief but thorough physical examination can eliminate the need for a large percentage of radiographs ordered in patients with acute ankle trauma.

Extension splinting of palmar plate avulsion injuries of the proximal interphalangeal joint

Hyperextension injuries of the proximal interphalangeal joint have traditionally been immobilized in flexion. This may lead to a proximal interphalangeal flexion contracture of the joint. In an effort to prevent flexion contracture and to simultaneously avoid hyperextension laxity, we have immobilized these injuries in zero degrees of extension for 7 to 10 days. Immobilization is followed by buddy taping and active range of motion until 3 weeks after injury. Protective buddy taping is used until the 6-week point. We report our results using this treatment for only palmar plate avulsion fractures. We did not include proximal interphalangeal joint injuries associated with dorsal dislocation or major collateral ligament injury. Twenty-two of 45 patients were available for follow-up evaluation. Length of follow-up averaged 30 months (range, 6 to 36 months). A high percentage of patients had good or excellent results. In no patient did hyperextension laxity develop and in only one was there a flexion contracture. On the basis of these results, we recommend this treatment protocol for hyperextension injuries of the palmar plate of the proximal interphalangeal joint associated with small avulsion fractures.

Segond tibial condyle fracture: lateral capsular ligament avulsion.

Avulsion fractures in the appendicular skeleton are a result of stress on a specific structure that is firmly attached to bone. A small avulsion fracture from the directly lateral surface of the lateral tibial condyle results from excessive tension on the lateral capsular ligament of the knee joint. Recognition of this fracture on an anteroposterior radiograph of a traumatized knee represents substantial evidence of major injury to the lateral joint capsule. This fracture also has a strong association with rupture of the anterior cruciate ligament. The avulsed tibial fragment is remarkably constant in site and appearance. The typical fragment is isolated by a longitudinal fracture line separating a small piece of bone from the lateral tibia. It is elliptical in outline (10 X 3 mm), with its proximal border lying 4 mm distal to the subarticular cortex of the lateral tibial condyle. A hemarthrosis of the knee joint is consistently visible.

Tension band wiring of avulsion fractures of the medial malleolus: a modified technique minimizing soft tissue injury

TENSION band wiring of small avulsion fractures of the medial malleolus is an accepted and popular technique (Heim and Pfeiffer, 1974; Miiller et al., 1979). The medial aspect of the lower tibia is flattened in an anteroposterior direction. When the recommended method is used, extra soft tissue dissection or stronger retraction is often required to expose the posterior end to drill the hole for the wire. Such retraction or dissection can jeapardize wound healing. This consideration is important, the more so when operating on elderly patients whose skin is often fragile. We have also encountered cases in which the wire has cut out of osteoporotic present an alternative method. bone. We

Magnification and high-resolution radiography in sports-related injuries

Magnification, or high-resolution radiography, is a widely accepted technique and is currently used in angiography, mammography and pediatric chest radiographs. Small avulsion fractures of the bones of the hand and stress fractures of th tibia are examples of two areas where the fracture may not be apparent on conventional films, although in many cases magnification radiography will demonstrate the lesions. Six representative case histories are provided to illustrate the use of magnification radiography in sports-related injuries.

Radiographic diagnosis of acute peroneal tendon dislocation

Acute dislocation of the peroneal tendons at the ankle is accompanied, in a significant proportion of cases, by a characteristic small shelllike avulsion fracture of the lateral malleolus, rendering the lesion diagnosable radiographically. This small fracture is usually best seen on internal rotation oblique or occasionally on anteroposterior films of the ankle. It is seen as a bone flake only a few millimeters thick but often 1 cm or more in vertical diameter lying adjacent to the posterolateral surface of the lateral malleolus. It is an infrequent injury, now usually the result of a ski accident. Failure to recognize and treat the lesion can result in chronic disability.