Tip Fractures Research Articles

Joint capsule attachment to the coronoid process of the ulna: an anatomic study with implications regarding the type 1 fractures of the coronoid process of the O'Driscoll classification

The attachment of the anterior joint capsule on the ulnar coronoid process is not yet completely understood. The purpose of this study was to clarify the anatomic relationship between the anterior capsule of the elbow joint and the tip of the coronoid process. Seventeen embalmed elbows were used for this anatomic study. The anterior capsule of the elbow joint was reflected, and the attachment of the capsule on the coronoid process was exposed. The attachment of the joint capsule on the coronoid process was macroscopically and histologically observed, its relationship to the coronoid tip was assessed, and the length of the attachment of the joint capsule was measured. The length of the capsule attachment at the radial side of the coronoid (11.9 mm) was greater than that at the ulnar side (6.1 mm). The bone thickness on the coronoid tip from the proximal edge of the joint capsule attachment was 1.9 mm; together, the cartilage and bone thickness was 4.7 mm. At the radial side of the coronoid, the thickness of the joint capsule at the proximal aspect of the attachment of 2 samples was 0.6 mm and 0.3 mm, and that at the tip of the coronoid was 2.6 mm and 1.7 mm, respectively. The anterior capsule of the elbow joint had a substantial attachment on the radial side of the coronoid process. The subtype 2 tip fractures of the O'Driscoll classification included the joint capsule attachment, joint cartilage, and subchondral bone.

Coronoid Fractures.

Fractures of the coronoid process of the ulna are usually part of a more complex injury. The type of coronoid fracture corresponds with a specific pattern of injury with known pitfalls and recommended treatments. Tip fractures usually correspond with dislocation of the elbow and fracture of the radial head (the so-called terrible triad of the elbow because it is prone to redislocation, subluxation, and arthrosis) and are best repaired with a suture passed through drill holes along with repair or replacement of the fractured radial head and reattachment of the lateral collateral ligament to the lateral epicondyle. Anteromedial fractures are usually part of a subluxation injury and are best addressed with a medial buttress plate and reattachment of the lateral collateral ligament. Large basilar coronoid fractures are usually part of an olecranon fracture-dislocation and are usually repaired with 1 or 2 plates and screws. Tenuous fixation is protected with temporary external fixation or cross-pinning of the joint because healing of the coronoid with concentric elbow alignment is critical. Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Quantitative 3-Dimensional Computed Tomography Measurements of Coronoid Fractures

Using quantitative 3-dimensional computed tomography (Q3DCT) modeling, we tested the null hypothesis that there was no difference in fracture fragment volume, articular surface involvement, and number of fracture fragments between coronoid fracture types and patterns of traumatic elbow instability. We studied 82 patients with a computed tomography scan of a coronoid fracture using Q3DCT modeling. Fracture fragments were identified and fragment volume and articular surface involvement were measured within fracture types and injury patterns. Kruskal-Wallis test was used to evaluate the Q3DCT data of the coronoid fractures. Fractures of the coronoid tip (n= 45) were less fragmented and had the smallest fragment volume and articular surface area involvement compared with anteromedial facet fractures (n= 20) and base fractures (n= 17). Anteromedial facet and base fractures were more fragmented than tip fractures, and base fractures had the largest fragment volume and articular surface area involvement compared with tip and anteromedial facet fractures. We found similar differences between fracture types described by Regan and Morrey. Furthermore, fractures associated with terrible triad fracture dislocation (n= 42) had the smallest fragment volume, and fractures associated with olecranon fracture dislocations (n= 17) had the largest fragment volume and articular surface area involvement compared with the other injury patterns. Analyzing fractures of the coronoid using Q3DCT modeling demonstrated that fracture fragment characteristics differ significantly between fracture types and injury patterns. Detailed knowledge of fracture characteristics and their association with specific patterns of traumatic elbow instability may assist decision making and preoperative planning. Quantitative 3DCT modeling can provide a more detailed understanding of fracture morphology, which might guide decision making and implant development.

The capsular attachment of the ulnar coronoid process

Background: Ulnar coronoid fractures are relatively rare injuries usually occurring in association with elbow dislocations and contributing to elbow instability. Recent evidence supports a role for coronoid tip fractures in elbow instability. The purpose of this study was to determine where the capsule inserts onto the ulnar coronoid process. Methods: Twenty MRI arthrograms from patients with no evidence of osteoarthrosis or posttraumatic changes were evaluated. The distance from the tip of the coronoid process to the proximal edge of the anterior elbow joint was recorded as was the coronoid height. Results: The average distance from the tip of the coronoid process to the proximal edge of the anterior elbow joint capsular insertion was 1.7±1.1 mm. The average coronoid height measured 17.6±1.9 mm. Conclusions: Elbow instability after posterior elbow dislocations is a difficult and well-described entity. There is recent evidence regarding the role of small coronoid fractures in posttraumatic instability. These data support the assertion that most coronoid tip fractures involve disruption of the anterior capsule, which potentially explains why instability can be associated with these fractures.

Wisdom tooth--complications in extraction.

The purpose of this study is to analyze the incidence of complications in a group of 171 patients in whom extractions of impacted mandibular third molar have been performed by two oral surgeons between the period April 2010 and March 2012. This retrospective study comprises evaluation of 270 impacted mandibular third molars which were classified into two groups A and B on the basis of procedure of osteotomy only and osteotomy and odontotomy both respectively. Total no of complications reported were 40 (14.81%). Maximum no of cases reported alveolar osteitis (AO) (11.11%) while other complications reported root tip fractures (2.22%), lingual nerve parasthesia and TMJ problems (each 0.74%) in descending frequency. Conclusion drawn is that the risk of complications in extractions of impacted mandibular third molars always exists, and extractions associated with both osteotomy and odontotomy are associated with higher risk of complications.

Coronoid fractures: evaluation and treatment

Abstract Coronoid fractures can be challenging to understand and treat. There are five common patterns of coronoid fractures, modified from the Regan Morrey classification: tip fractures, mid transverse fractures, basal fractures, anteromedial oblique fractures and anterolateral oblique fractures. Specific tools to understand the fracture pattern and associated injuries, and to develop a treatment plan, are presented.

Successful treatment of fractures of the base of the acromion after reverse shoulder arthroplasty: Case report and review of the literature

Fractures of the acromion and scapula are known to occur after reverse shoulder arthroplasty. We present a case of a fracture at the base of the acromion 5 months after arthroplasty treated successfully with dual plating of the acromion. Eighteen months after fracture fixation, the patient had 160 degrees of active forward flexion, a QuickDASH of 29.5, a Constant score of 69 and she was satisfied with the result. A concomitant review of the literature produced, in addition to our patient, 56 cases. These were used to produce a classification system, based on bony and functional anatomy as follows. Tip fractures are of the most lateral or anterior portion of the acromion, those of the body of the acromion are medial to the tip but lateral to the beginning of the scapular base. Fractures at the scapular base are termed fractures of the base of the acromion and those more medial to that, fractures of the scapular spine. The functional results of these case series demonstrated poorer functional outcomes for more medial fractures. As future research in this domain increases, clarity on the nomenclature of these fractures will allow for prognostication and treatment based on fracture location as well as comparison between studies.

Interobserver Reliability of Coronoid Fracture Classification: Two-Dimensional Versus Three-Dimensional Computed Tomography

This study tests the hypothesis that 3-dimensional computed tomography (CT) reconstructions improve interobserver agreement on classification and treatment of coronoid fractures compared with 2-dimensional CT. A total of 29 orthopedic surgeons evaluated 10 coronoid fractures on 2 occasions (first with radiographs and 2-dimensional CT and then with radiographs and 3-dimensional CT), separated by a minimum of 2 weeks. Surgeons classified fractures according to the classifications of Regan and Morrey and of O'Driscoll et al., identified specific characteristics, recommended the most appropriate treatment approach, and made treatment recommendations. The kappa multirater measure (kappa) was calculated to estimate agreement between observers. Regardless of the imaging modality used, there was fair to moderate agreement for most of the observations. Three-dimensional CT improved interobserver agreement in Regan and Morrey's classsication (kappa(3-dimensional) = 0.51 vs kappa(2-dimensional) = 0.40; p < .001) and O'Driscoll et al.'s classifications (kappa(3-dimensional) = 0.48 vs kappa(2-dimensional) = 0.42; p = .009). There were trends toward better reliability for 3-dimensional reconstruction in recognition of coronoid tip fractures (kappa(3-dimensional) = 0.19, kappa(2-dimensional) = 0.03; p = .268), comminution (kappa(3-dimensional) = 0.41 vs kappa(2-dimensional) = 0.29; p = .133), and impacted fragments (kappa(3-dimensional) = 0.39 vs kappa(2-dimensional) = 0.27; p = .094), and in surgeons' opinions on the need for something other than screws or plate for surgical fixation (kappa(3-dimensional) = 0.31 vs kappa(2-dimensional) = 0.15; p = .138). Interobserver agreement on treatment approach was better with 2-dimensional CT (kappa(3-dimensional) = 0.27, kappa(2-dimensional) = 0.32; p = .015). Three-dimensional CT reconstructions improve interobserver agreement with respect to fracture classification compared with 2-dimensional CT. Diagnostic III.

Influence of Nasal Bone Fracture and Its Reduction on the Airway

Studies regarding nasal bone fractures have mainly focused on esthetic aspects, but the nose also plays an important role as an airway. The purpose of this study was to evaluate the influence of nasal bone fractures and the treatment of nasal bone fractures on nasal obstruction. Nasal bone fractures were classified by fracture site and septal displacement. Nasal airways were investigated at 3 time points: before reduction (n = 84), 6 days postreduction (n = 84), and 1-year postreduction (n = 27). Airway changes were based on minimal cross-sectional area measurements. The severity of airway obstruction following fracture differed according to the fracture site and the presence of septal displacement. Bilateral fractures caused more profound airway obstruction than unilateral or tip fractures and septal displacement was the most important parameter in nasal obstruction. Airway obstruction improved immediately after reduction by 21% and deteriorated by 4% 1-year postreduction.

Ulnar styloid fracture in children: a retrospective study of 46 cases

Ulnar styloid fractures are frequently ignored in the treatment of wrist fractures in children. Forty-six untreated ulnar styloid fractures (40 tip and six base fractures) associated with radial injuries (45 patients) were retrospectively analysed. At the removal of the cast, we recorded that 80% had a nonunion of the styloid fracture. Thirty-five patients were reviewed at an average of 19 months after treatment. Thirty tip fractures and five base avulsions were found. We recorded 28 patients with a good clinical result despite 21 cases of nonunion, whereas seven patients (all nonunions) had a fair result. All the fair results suffered from intermittent pain during sports and movement, radioulnar joint instability and tears of the triangular fibrocartilage complex. It can be concluded that both distal radius and ulnar styloid fractures should be taken into account in the initial treatment and pain associated with a nonunion of the ulnar styloid in a child may be due to a tear of the triangular fibrocartilage complex.

Ultrasonographic Examination for Inversion Ankle Sprains Associated with Osseous Injuries

The study attempted to evaluate the value of ultrasonography in determining the therapeutic strategy for patients with osseous injuries caused by ankle sprains. A 10-MHz compact linear-array ultrasound transducer was used to assess patients with inversion ankle sprains. Eleven female and 12 male patients who had fractures detected by sonograms were included in the study. All 23 patients underwent radiographic examination for identification of fractures. Bone scintigraphy was performed for those who had negative x-ray findings. Eighteen patients had distal fibular tip fractures, three patients had the fifth metatarsal base fractures, one patient had a talar neck fracture, and one patient had a navicular fracture. These fractures were all detected by ultrasonography and then proved even by radiography or by bone scans. All the 23 patients had anterior talofibular ligament injuries. Among these patients, 11 had anterior ankle-joint recess effusion, and two had additional anterioinferior tibiofibular ligament injuries. Six weeks of immobilization with the ankle fracture brace was prescribed for all the patients after the identification of fractures. Their ankle pain symptoms soon improved. Ultrasonography is valuable in evaluating tiny foot and ankle fractures and coexistent soft tissue injuries. It can guide the treatment for patients with osseous injuries caused by ankle sprains.

Ulnar Coronoid Process Anatomy

Ulnar coronoid process fractures are relatively uncommon injuries usually occurring with elbow dislocations and contributing to elbow instability. Recent evidence suggests coronoid tip fractures have a role in the instability. We sought to quantify the capsular and brachialis attachments of the ulnar coronoid process to better understand why instability occurs. We prepared eight fresh-frozen cadaveric specimens to ascertain the specific attachment locations. After dissection, we isolated and resected the proximal ulna, including the coronoid process and its soft tissue attachments. We then embedded, sectioned, and stained the specimens. The average distance from the tip of the coronoid to the proximal capsule was 2.36 +/- 0.39 mm. The average distance from the tip of the coronoid to the proximal brachialis insertion was 10.13 +/- 1.6 mm. Most coronoid tip fractures included disruption of the anterior capsule, which potentially explains why instability can be associated with these fractures.

Use of CVDentUS Diamond Tips for Ultrasound in Cavity Preparation

The aim of this study was to evaluate the use of CVDentUS tips for preparing cavities with ultrasound by dentists certified to use the Chemical Vapor Deposition (CVD) system. One thousand sixty (1060) questionnaires were sent via e-mail inquiring about the use of the system with regard to the indication for use, need for anesthesia, final form of cavity preparation, and tip wear. Of the valid answers, 81.4% of the dentists used this system for tooth preparation in up to 60% of cases treated. For these procedures, 17.8% did not require use of local anesthesia while using the system. The final form of preparation compared to high speed diamond tips was considered to be more conservative by 48.3% of the certified professionals. With regard to wear, tip and/or adapter fractures, and low cutting speed, 44.4% of users reported problems. The CVD system seems to be used for tooth cavity preparation by the majority of the certified dentists. This is due to the resultant conservation of tooth structure despite the necessity of anesthesia and the limitations with regard to the lack of cutting efficiency of CVDentUS and tip wear. The CVD system seems to present limitations with regard to cutting efficiency, wear, and the use of anesthesia in a majority of restorative procedures.

Comminuted Refracture of the Distal Femur and Condyles in Patients with an Intramedullary Nail: A Report of 5 Cases

Patients with in situ intramedullary nails sustaining a second distal femoral fracture following high-velocity trauma are infrequently reported in the literature. We report 5 such patients who sustained a second injury after 6 to 24 months, resulting in another fracture at the nail-tip level. These second fractures severely comminuted the femoral condyles. These patients required removal of the intramedullary nail, reconstruction of the comminuted femoral condyles, and stabilisation using an angled or buttress plate. Four of the 5 patients were followed up for a mean period of 36 months and were evaluated for knee status and outcome using Judet's criteria. Postoperative knee stiffness was common, and further interventions such as manipulation, hardware removal, arthrolysis, and quadricepsplasty were needed. One patient was lost to follow-up. The final results of the knees were good, with more than 100 degrees range of movement. It is important to adhere to established internal fixation protocols in the treatment of these complex nail tip fractures.

Accurate, firm stabilization using external pins: a proposal for closed reduction of unfavorable nasal bone fractures and their simple classification.

Nasal bone fractures are the most common among facial fractures and are the third most common fractures in the human frame. Although many forms of treatment have been introduced, controversy regarding the optimal treatment still remains. Nasal bone fractures are complex, with significantly varying types that are often undermanaged in closed reduction procedures. The authors' experiences with nasal bone fractures have shown that the baseline for surgical intervention depends on the type of fracture and the method of maintenance after reduction, both of which have considerable impact on the final result. Therefore, it is very important and challenging to determine the proper method of reduction and maintenance. The periosteal covering plays an important role in the splinting action after closed reduction, but sagging, depression, and instability remain major complications in some cases. The authors devised a new method of accurate, firm stabilization of the fractured nasal bone by using external pins in those unfavorable fractures determined radiologically to gain optimal reduction and fixation. In the present study, fractures were grouped into favorable and unfavorable fractures, the latter being those that remained unstable or impacted even after reduction and thus needed open reduction. Unfavorable fractures were divided into four subclasses according to radiologic findings: (1) type I (frontal), including chip or tip fractures, which often depress the upper lateral cartilage and tend to sag after reduction; (2) type II (lateral), or laterally depressed segmental fractures with a lateral shift of the arch in fragments or as a unit; (3) type III (mixed), or type II with septal involvement; and (4) type IV (complex), including open or multiple comminuted fractures. After an initial evaluation to determine the fracture type, closed reduction and external fixation were performed for types I, II, and III fractures and open reduction was performed for type IV fractures 5 to 7 days after the fracture. Closed reduction with the use of external pins was done in eight cases: type I (two), type II (four), and type III (two). The mean age of the patients was 27.8 years, and the average follow-up period was 11.7 months. Functional and aesthetic results were satisfactory. This new method for support and fixation is an alternative to the conventional closed reduction and a promising way to prevent secondary deformity.

とう骨遠位端骨折に合併する尺骨茎状突起骨折放置例の治療成績

14 patients (15 wrists) who had been treated for fracture of the distal end of the radius and had not been treated for ulnar styloid fracture at Sasebo Kyousai Hospital between January 1994 to December 1998 were studied for tenderness, ulno carpal stress test, bone union, and ulnar variance. According to Hauck et al., ulnar styloid fractures were classificd into tip fractures (type I) and base fractures (type II) There were 10 type I and 5 type II, 3 men and 11 women, and 6 right and 9 left wrists. The mean age was 58 years.2 wrists (20%) showed ulnar side pain for type I, and 3 wrists (60%) for type II. Non-union was seen in 1 wrist (10%) for type I, and 4 wrists (80%) for type II. Wrists with both pain and non-union were 0 for type I, and 2 for type II. In 5 wrists with pain, 3 showed ulnar variance (more than 3mm) and the other 2 tested positive for ulnocarpal stress.Type II fractures tend to be accompanied with pain and be non-union, while type I does not. Procedures such we pinning are thus recommended for type II fractures.