University of Massachusetts, Amherst, MA. Background and Purpose. A stress fracture in the high performance collegiate athlete presents a difficult problem...et al. (1987) noted that varus malalignment (genu & tibial) was often present in athletes with stress fractures. This patient exhibits significant...force and neural potentiation in athletes . Medicine and Science in Sports and Exercise. 22:2, S69, April, 1990. Ebbeling, C. J., Hamill, J., Freedson
A convenience sample based on availability of tibial stress fracture cases a% local Sports Medicine Clinics will be selected over 4 years until forty subjects (20 male, 20 female) have been treated...
A convenience sample based on availability of tibial stress fracture cases at local Sports Medicine Clinics will be selected over 2-3 years until forty subjects (20 male, 20 female) have been treated...
A convenience sample based on availability of tibial stress fracture cases at local Sports Medicine Clinics will be selected over 2-3 years until forty subjects (20 male, 20 female) have been treated...
USA Corresponding author Belinda R. Beck, Ph.D. Griffith University School of Physiotherapy and Exercise Science, PMB 50 Gold Coast Mail Centre Q...accelerate tibial stress fracture healing? Medicine and Science in Sport and Exercise , 31(5, Suppl. 1): 2006 2. Beck B.R., Bergman G., Arendt E...Predicting Recovery from Tibial Stress Fracture Medicine and Science in Sport and Exercise , 31(5, Suppl. 1): 2007 (submitted) 15 Presentations
Selected structural characteristics of female ruimers with and without lower extremity stress fractures. Medicine and Science in Sports and Exercise, 34...potentiation in athletes . Medicine and Science in Sports and Exercise. 22:2, S69, April, 1990. Ebbeling, C. J., Hamill, J., Freedson, P. S., Rowland, T. W...Pollard, C. D., McKewon, K. A. Kinetic variables in subjects with previous lower extremity stress fractures. Medicine and Science in Sports and
because we initially advertised this study as a tibial stress fracture study and not as a running injury study. We have since changed this advertising ...1-0515. Appendix B Advertisement Flyer 1 ATTENTION FEMALE RUNNERS We are looking for Female Distance Runners who...Newsletter, Fall, 1990. Hamill, J., Clarkson, P. M., Holt, K. G., Freedson, P. S. Muscle Soreness. Nike Sport Research Review, December/March, 1991
Ruggles, A.J.; Moore, R.M.; Bertone, A.L.; Schneider, R.K.; Bailey, M.Q.
To determine clinical signs, radiographic and scintigraphic findings, and performance outcome of racing Standardbreds with tibial stress fractures. Retrospective case series. 13 racing Standardbreds with tibial stress fractures. Information concerning clinical signs, diagnostic evaluation, and recommendations was obtained by review of the medical records. Performance information before and after diagnosis of the fracture was collected from racing records, and follow-up information was obtained from the owners or trainers by use of a telephone questionnaire. Horses with tibial stress fractures were moderately lame, and diagnosis was made by nuclear scintigraphy and radiography. Fractures were more likely to occur in 2-year-old horses than in older horses. The fracture location was unique for Standardbreds; 11 of 13 developed stress fractures in the mid-diaphysis of the tibia, whereas fractures in Thoroughbreds are usually in the proximal caudal or caudolateral cortex. Fractures occurred in young horses that had raced or were in advanced race training. All horses were treated with rest alone, and 10 of 13 horses raced after injury. The horses that raced after injury were able to return to a level of performance that was equal to or better than the level raced before injury. 8 of 10 horses established a lifetime-best winning time after injury. Tibial stress fractures are a cause of lameness in young racing Standardbreds. Diagnosis is aided by nuclear scintigraphy. The prognosis for return to previous level of performance after a tibial stress fracture is good
Full Text Available Stress fractures of the proximal tibia metaphysis are rare in the elderly. We present a case of a 65-year old male who developed sequential proximal tibia stress fractures associated with prolonged usage of methotrexate and prednisolone within a span of 18 months. Magnetic Resonance Imaging revealed an incomplete stress fracture involving the medial proximal tibial region. The patient was treated with stemmed total knee arthroplasty (TKA bilaterally. Stress fractures should be considered in patients with atypical knee pain who have a history of methotrexate and prednisolone usage. TKA is an effective treatment in stress fractures of the proximal tibia.
Miyamoto, Ryan G; Dhotar, Herman S; Rose, Donald J; Egol, Kenneth
Treatment of tibial stress fractures in elite dancers is centered on rest and activity modification. Surgical intervention in refractory cases has important implications affecting the dancers' careers. Refractory tibial stress fractures in dancers can be treated successfully with drilling and bone grafting or intramedullary nailing. Case series; Level of evidence, 4. Between 1992 and 2006, 1757 dancers were evaluated at a dance medicine clinic; 24 dancers (1.4%) had 31 tibial stress fractures. Of that subset, 7 (29.2%) elite dancers with 8 tibial stress fractures were treated operatively with either intramedullary nailing or drilling and bone grafting. Six of the patients were followed up closely until they were able to return to dance. One patient was available only for follow-up phone interview. Data concerning their preoperative treatment regimens, operative procedures, clinical union, radiographic union, and time until return to dance were recorded and analyzed. The mean age of the surgical patients at the time of stress fracture was 22.6 years. The mean duration of preoperative symptoms before surgical intervention was 25.8 months. Four of the dancers were male and 3 were female. All had failed nonoperative treatment regimens. Five patients (5 tibias) underwent drilling and bone grafting of the lesion, and 2 patients (3 tibias) with completed fractures or multiple refractory stress fractures underwent intramedullary nailing. Clinical union was achieved at a mean of 6 weeks and radiographic union at 5.1 months. Return to full dance activity was at an average of 6.5 months postoperatively. Surgical intervention for tibial stress fractures in dancers who have not responded to nonoperative management allowed for resolution of symptoms and return to dancing with minimal morbidity.
Valdés-Martínez, Alejandro; Seiler, Gabriela; Mai, Wilfried; Bolt, David M; Mudge, Margaret; Dukti, Sarah A; Hubert, Jeremy D
To develop a quantitative method of interpreting tibial scintigrams of Thoroughbred racehorses with tibial stress fractures that may facilitate diagnosis of fractures and to provide prognostic information regarding future performance of affected horses. 35 Thoroughbred racehorses. Static bone-phase scintigrams of tibial stress fractures were quantitatively analyzed by use of ratios of the mean radionuclide counts per pixel in a region of interest (ROI) drawn around the area of increased uptake of radiopharmaceutical to mean counts per pixel in a second ROI drawn around an apparently normal area of the tibial diaphysis. In horses with unilateral fractures, ratios for the contralateral tibia were determined by use of 2 ROIs drawn at the same positions as the ROIs in the fractured tibia. Ratios were compared between fractured versus apparently normal tibias, between horses that returned to racing versus those that did not, and among horses with various grades of lameness. The association between ratios for fractured tibias and intervals between diagnosis and return to racing was also assessed. Mean ratio of ROIs in apparently normal tibias was 1.35 (95% confidence interval [CI], 1.21 to 1.50); that in tibias with stress fractures was 3.55 (95% CI, 2.50 to 4.60). These ratios were significantly different. None of the associations between ratios for fractured tibias and grades of lameness or performance outcomes were significant. Tibial stress fracture scintigrams can be quantitatively analyzed. A prospective study with a controlled rehabilitation period is necessary to evaluate the possible applications of this method.
Ofluoglu, Demet; Ofluoglu, Onder; Akyuz, Gulseren
Osteoporosis is commonly thought of as a disease of postmenopausal women, and older men have a lower risk of fracture than women. A stress fracture is an overuse injury and an important cause of disability in the athletic population. Presented here is a 30-year-old healthy man with pain on the anterior surface of the bilateral tibia. He did not communicate any trauma or overuse activity. The neurologic and locomotor system examinations were normal. Radiological examinations revealed tibial stress fractures in both left and right tibia and he had low bone mineral density. Routine hematological tests, bone resorption and formation markers were normal, except for hypercalciuria. After analyzing the results of these tests, the patient was diagnosed with bilateral tibial stress fractures due to hypercalciuric secondary osteoporosis. Osteoporosis should be considered in the differential diagnosis of atraumatic insufficiency fractures, especially in young healthy adults.
Clemetson, I.A.; Anderson, S.E. [Department of Radiology, University Hospital of Bern, Inselspital, 3010, Bern (Switzerland); Popp, A.; Lippuner, K. [Department of Osteology, University Hospital of Bern, Inselspital, 3010, Bern (Switzerland); Ballmer, F. [Knee and Sports Medicine Unit, Lindenhofspital Bern, 3012, Bern (Switzerland)
A 33-year-old woman presented with acute nonspecific knee pain, 6 months postpartum. MR imaging, computed tomography and radiography were performed and a proximal tibia plateau insufficiency fracture was detected. Bone densitometry demonstrated mild postpartum osteoporosis. To our knowledge these findings have not been described in this location and in this clinical setting. The etiology of the atraumatic fracture of the tibia is presumed to be due to a low bone mineral density. The bone loss was probably due to pregnancy, lactation and postpartum hormonal changes. There were no other inciting causes and the patient was normocalcemic. We discuss the presence of a postpartum stress fracture in a hitherto undescribed site in a patient who had lactated following an uncomplicated pregnancy and had no other identifiable cause for a stress fracture. (orig.)
Clemetson, I.A.; Anderson, S.E.; Popp, A.; Lippuner, K.; Ballmer, F.
A 33-year-old woman presented with acute nonspecific knee pain, 6 months postpartum. MR imaging, computed tomography and radiography were performed and a proximal tibia plateau insufficiency fracture was detected. Bone densitometry demonstrated mild postpartum osteoporosis. To our knowledge these findings have not been described in this location and in this clinical setting. The etiology of the atraumatic fracture of the tibia is presumed to be due to a low bone mineral density. The bone loss was probably due to pregnancy, lactation and postpartum hormonal changes. There were no other inciting causes and the patient was normocalcemic. We discuss the presence of a postpartum stress fracture in a hitherto undescribed site in a patient who had lactated following an uncomplicated pregnancy and had no other identifiable cause for a stress fracture. (orig.)
Narvaez, J.A.; Narvaez, J.; Lama, E.De; Sanchez, A.
The purpose of this article is to describe the association between spontaneous osteonecrosis and insufficiency stress fractures of the knee. To determine whether insufficiency stress fracture is associated with spontaneous osteonecrosis of the knee, we retrospectively reviewed the medical charts and imaging studies of all patients with spontaneous osteonecrosis of the knee, studied by MR imaging, seen in a tertiary hospital over an 8-year period. Four women (age range 66-84 years) presented spontaneous osteonecrosis of the knee associated with insufficiency stress fracture of the medial tibial plateau. One of these patients also presented a concomitant insufficiency stress fracture of the medial femoral condyle. Radiographs were diagnostic of spontaneous osteonecrosis of the medial femoral condyle in three cases, and insufficiency stress fracture of the medial tibial plateau was detected in one case. Magnetic resonance imaging allows the diagnosis of both conditions in all four cases. Spontaneous osteonecrosis of the knee may be associated with insufficiency stress fracture of the medial femoral condyle and the medial tibial plateau. This association provides additional arguments in favor of the traumatic etiology of spontaneous osteonecrosis of knee. (orig.)
Brand, J C; Brindle, T; Nyland, J; Caborn, D N; Johnson, D L
We sought to evaluate the efficacy of daily pulsed low intensity ultrasound (LIUS) with early return to activities for the treatment of lower extremity stress fractures. Eight patients (2 males, 6 females) with radiographic and bone scan confirmed tibial stress fractures participated in this study. Additionally, a case report of a tarsal navicular stress fracture is described. All patients except one were involved in athletics. Prior to the study, subjects completed a 5 question, 10 cm visual analog scale (VAS) regarding pain level (10 = extreme pain, 1 = no pain) and were assessed for functional performance. Subjects received 20-minute LIUS treatments 5 times a week for 4 weeks. Subjects maintained all functional activities during the treatment period. Seven patients with posterior-medial stress fractures participated without a brace. Subjects were re-tested after 4 weeks of treatment. Mann-Whitney U tests (VAS data) and paired t-tests (functional tests) assessed statistical significance (psports was prescribed for the patients with the tibial stress fractures. The patient with the anterior tibial stress fracture underwent tibial intramedullary nailing at the conclusion of a season of play. In this uncontrolled experience, treatment of tibial stress fractures with daily pulsed LIUS was effective in pain relief and early return to vigorous activity without bracing for the patients with posterior-medial stress fractures.
Yagi, Shigenori; Muneta, Takeshi; Sekiya, Ichiro
Medial tibial stress syndrome (MTSS) and tibial stress fracture (SF) are common lower leg disorders in runners. A prospective study was done to identify the incidence of MTSS and SF in high school runners and to determine risk factors. A total of 230 runners participating in high school running teams were evaluated. All runners aged 15 years as first grade of high school were involved in the study. They were followed up for 3 years. The measured items included height, weight, body mass index (BMI), range of hip and ankle motion, straight leg raising (SLR), intercondylar and intermalleolar interval, Q-angle, navicular drop test, hip abductor strength and physical conditioning. Each runner was followed for 3 years to report occurrence of MTSS and SF. A total number of 102 MTSS (0.29 athlete exposures) and 21 SF (0.06 athlete exposures) were identified. In females, BMI significantly increased the risk of MTSS after adjustment for the other variables in this study (adjusted odds ratio, 0.51; 95 % confidence interval, 0.31-0.86). Increased internal rotation of the hip significantly increased the risk of MTSS (adjusted odds ratio, 0.91; 95 % confidence interval, 0.85-0.99). In males, limited SLR also significantly increased the risk of SF with adjustment for the other variables in this study (adjusted odds ratio, 1.38; 95 % confidence interval, 1.04-1.83). A significant relationship was found between BMI, internal hip rotation angle and MTSS in females, and between limited SLR and SF in males. Prospective cohort study, Level II.
Tomčovčík, L; Tomčovčíková, A
Stress fractures of the anterior cortex of the mid-tibial shaft in dancers are rare, with a 1.4 % incidence in injured eli- te dancers. Treatment can be difficult and long-lasting and can seriously influence the dancer's career. The authors pre- sent the case of a 26-year-old professional dancer of a folk dance ensemble who suffered rare simultaneous bilateral mid-tibial shaft stress fractures. A conservative method of treatment with avoiding exercise and dancing activities resulted in the resolution of symptoms and healing of the fractures after 6 months. The patient finished his dancing career because of the necessity of a prolonged therapy interfering with his dancing activities. Current options of the treatment are also presented.
Borens, Olivier; Sen, Milan K.; Huang, Russel C.; Richmond, Jeffrey; Kloen, Peter; Jupiter, Jesse B.; Helfet, David L.
Stress fracture of the anterior tibial cortex is an extremely challenging fracture to treat, especially in the high-performance female athlete who requires rapid return to competition. Previous reports have not addressed treating these fractures in the world-class athlete with anterior plating. We
Zbeda, Robert M; Sculco, Peter K; Urch, Ekaterina Y; Lazaro, Lionel E; Borens, Olivier; Williams, Riley J; Lorich, Dean G; Wellman, David S; Helfet, David L
Anterior tibial stress fractures are associated with high rates of delayed union and nonunion, which can be particularly devastating to a professional athlete who requires rapid return to competition. Current surgical treatment strategies include intramedullary nailing, which has satisfactory rates of fracture union but an associated risk of anterior knee pain. Anterior tension band plating is a biomechanically sound alternative treatment for these fractures. Tension band plating of chronic anterior tibial stress fractures leads to rapid healing and return to physical activity and avoids the anterior knee pain associated with intramedullary nailing. Case series; Level of evidence, 4. Between 2001 and 2013, there were 13 chronic anterior tibial stress fractures in 12 professional or collegiate athletes who underwent tension band plating after failing nonoperative management. Patient charts were retrospectively reviewed for demographics, injury history, and surgical details. Radiographs were used to assess time to osseous union. Follow-up notes and phone interviews were used to determine follow-up time, return to training time, and whether the patient was able to return to competition. Cases included 13 stress fractures in 12 patients (9 females, 3 males). Five patients were track-and-field athletes, 4 patients played basketball, 2 patients played volleyball, and 1 was a ballet dancer. Five patients were Division I collegiate athletes and 7 were professional or Olympic athletes. Average age at time of surgery was 23.6 years (range, 20-32 years). Osseous union occurred on average at 9.6 weeks (range, 5.3-16.9 weeks) after surgery. Patients returned to training on average at 11.1 weeks (range, 5.7-20 weeks). Ninety-two percent (12/13) eventually returned to preinjury competition levels. Thirty-eight percent (5/13) underwent removal of hardware for plate prominence. There was no incidence of infection or nonunion. Anterior tension band plating for chronic tibial stress
Kojima, Kodi Edson; Ferreira, Ramon Venzon
The long-bone fractures occur most frequently in the tibial shaft. Adequate treatment of such fractures avoids consolidation failure, skewed consolidation and reoperation. To classify these fractures, the AO/OTA classification method is still used, but it is worthwhile getting to know the Ellis classification method, which also includes assessment of soft-tissue injuries. There is often an association with compartmental syndrome, and early diagnosis can be achieved through evaluating clinical...
This PhD thesis reported an incidence of tibial plateau fractures of 10.3/100,000/year in a complete Danish regional population. The results reported that patients treated for a lateral tibial plateau fracture with bone tamp reduction and percutaneous screw fixation achieved a satisfactory level...... of radiological outcomes and a level of health related quality of life (Eq5d) below but not significantly different from the Danish reference population at a mean of 5.2 years follow-up. Furthermore, a knee injury-specific questionnaire (KOOS) reported a level of disability close to a reference population...... with only the subgroup Sport significantly below the age matched reference population. The thesis reports a level of health related quality of life (Eq5d) and disability (KOOS) significantly below established reference populations for patients with bicondylar tibial plateau fracture treated with a ring...
Robertson, G A J; Wood, A M
This review aims to provide information on the time taken to resume sport following tibial diaphyseal stress fractures (TDSFs). A systematic search of Medline, EMBASE, CINHAL, Cochrane, Web of Science, PEDro, Sports Discus, Scopus and Google Scholar was performed using the keywords 'tibial', 'tibia', 'stress', 'fractures', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'. Twenty-seven studies were included: 16 reported specifically on anterior TDSFs and 5 on posterior TDSFs. The general principles were to primarily attempt non-operative management for all TDSFs and to consider operative intervention for anterior TDSFs that remained symptomatic after 3-6 months. Anterior TDSFs showed a prolonged return to sport. The best time to return to sport and the optimal management modalities for TDSFs remain undefined. Management of TDSFs should include a full assessment of training methods, equipment and diet to modify pre-disposing factors. Future prospective studies should aim to establish the optimal treatment modalities for TDSFs. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org.
Smith, Ralph; Moghal, M.; Newton, J.L.; Jones, N. [Oxford University Hospitals NHS Foundation Trust, Department of Sport and Exercise Medicine, Nuffield Orthopaedic Centre, Oxford (United Kingdom); Teh, J. [Oxford University Hospitals NHS Foundation Trust, Department of Radiology, Nuffield Orthopaedic Centre Oxford, Oxford (United Kingdom)
Anterior mid-tibial cortex stress fractures (ATCSF) are uncommon and notoriously challenging to treat. They are termed high risk due to their predilection to prolonged recovery, nonunion and complete fracture. Early diagnosis is essential to avoid progression and reduce fracture complications. Imaging plays a key role in confirming the diagnosis. Magnetic resonance imaging (MRI) is accepted as the gold standard modality due to its high accuracy and nonionizing properties. This report describes three cases of ATCSFs in recreational athletes who had positive radiographic findings with no significant MRI changes. Two athletes had multiple striations within their tibias. Despite the radiographic findings, their severity of symptoms were low with mild or no tenderness on examination. Clinicians should be mindful that the ATCSFs may not present with typical acute stress fracture symptoms. We recommend that plain radiographs should be used as the first line investigation when suspecting ATCSFs. Clinicians should be aware that despite MRI being considered the gold standard imaging modality, we report three cases where the MRI was unremarkable, whilst radiographs and computed tomography confirmed the diagnosis. We urge clinicians to continue to use radiographs as the first line imaging modality for ATCSFs and not to directly rely on MRI. Those who opt directly for MRI may be falsely reassured causing a delay in diagnosis. (orig.)
Smith, Ralph; Moghal, M.; Newton, J.L.; Jones, N.; Teh, J.
Anterior mid-tibial cortex stress fractures (ATCSF) are uncommon and notoriously challenging to treat. They are termed high risk due to their predilection to prolonged recovery, nonunion and complete fracture. Early diagnosis is essential to avoid progression and reduce fracture complications. Imaging plays a key role in confirming the diagnosis. Magnetic resonance imaging (MRI) is accepted as the gold standard modality due to its high accuracy and nonionizing properties. This report describes three cases of ATCSFs in recreational athletes who had positive radiographic findings with no significant MRI changes. Two athletes had multiple striations within their tibias. Despite the radiographic findings, their severity of symptoms were low with mild or no tenderness on examination. Clinicians should be mindful that the ATCSFs may not present with typical acute stress fracture symptoms. We recommend that plain radiographs should be used as the first line investigation when suspecting ATCSFs. Clinicians should be aware that despite MRI being considered the gold standard imaging modality, we report three cases where the MRI was unremarkable, whilst radiographs and computed tomography confirmed the diagnosis. We urge clinicians to continue to use radiographs as the first line imaging modality for ATCSFs and not to directly rely on MRI. Those who opt directly for MRI may be falsely reassured causing a delay in diagnosis. (orig.)
Joerring, S; Krogsgaard, M; Wilbek, H
Collagen turnover after tibial fractures was examined in 16 patients with fracture of the tibial diaphysis and in 8 patients with fracture in the tibial condyle area by measuring sequential changes in serological markers of turnover of types I and III collagen for up to 26 weeks after fracture...... collagen. A group comparison showed characteristic sequential changes in the turnover of types I and III collagen in fractures of the tibial diaphysis and tibial condyles. The turnover of type III collagen reached a maximum after 2 weeks in both groups. The synthesis of type I collagen reached a maximum...... after 2 weeks in the diaphyseal fractures and after 6 weeks in the condylar fractures. The degradation of type I collagen increased after 4 days and reached a maximum at 2 weeks in both groups. The interindividual variation was wide. On a group basis, the turnover of types I and III collagen had...
Kojima, Kodi Edson; Ferreira, Ramon Venzon
The long-bone fractures occur most frequently in the tibial shaft. Adequate treatment of such fractures avoids consolidation failure, skewed consolidation and reoperation. To classify these fractures, the AO/OTA classification method is still used, but it is worthwhile getting to know the Ellis classification method, which also includes assessment of soft-tissue injuries. There is often an association with compartmental syndrome, and early diagnosis can be achieved through evaluating clinical parameters and constant clinical monitoring. Once the diagnosis has been made, fasciotomy should be performed. It is always difficult to assess consolidation, but the RUST method may help in this. Radiography is assessed in two projections, and points are scored for the presence of the fracture line and a visible bone callus. Today, the dogma of six hours for cleaning the exposed fracture is under discussion. It is considered that an early start to intravenous antibiotic therapy and the lesion severity are very important. The question of early or late closure of the lesion in an exposed fracture has gone through several phases: sometimes early closure has been indicated and sometimes late closure. Currently, whenever possible, early closure of the lesion is recommended, since this diminishes the risk of infection. Milling of the canal when the intramedullary nail is introduced is still a controversial subject. Despite strong personal positions in favor of milling, studies have shown that there may be some advantage in relation to closed fractures, but not in exposed fractures.
Joerring, S; Krogsgaard, M; Wilbek, H
Collagen turnover after tibial fractures was examined in 16 patients with fracture of the tibial diaphysis and in 8 patients with fracture in the tibial condyle area by measuring sequential changes in serological markers of turnover of types I and III collagen for up to 26 weeks after fracture....... The markers were the carboxy-terminal extension peptide of type I procollagen (PICP), the amino-terminal extension peptide of type III procollagen (PIIINP), and the pyridinoline cross-linked carboxy-terminal telopeptide of type I collagen (ICTP). The latter is a new serum marker of degradation of type I...... collagen. A group comparison showed characteristic sequential changes in the turnover of types I and III collagen in fractures of the tibial diaphysis and tibial condyles. The turnover of type III collagen reached a maximum after 2 weeks in both groups. The synthesis of type I collagen reached a maximum...
Mallee, Wouter H.; Weel, Hanneke; van Dijk, C. Niek; van Tulder, Maurits W.; Kerkhoffs, Gino M.; Lin, Chung-Wei Christine
To compare surgical and conservative treatment for high-risk stress fractures of the anterior tibial cortex, navicular and proximal fifth metatarsal. Systematic searches of CENTRAL, MEDLINE, EMBASE, CINAHL, SPORTDiscus and PEDro were performed to identify relevant prospective and retrospective
Full Text Available Stress fractures are defined as a partial or complete fracture of bone due to an inability to endure a non-violent stress. Two factors have been proposed to explain the aetiology of stress fractures: muscle fatigue, and direct muscle action. We want to point to third factor with our case report: Osteoporosis. (From the World of Osteoporosis 2010;16:58-60
Couture, Christopher J.; Karlson, Kristine A.
Tibial stress injuries, commonly called shin splints, often result when bone remodeling processes adopt inadequately to repetitive stress. Physicians who are caring for athletic patients must have a thorough understanding of this continuum of injuries, including medial tibial stress syndrome and tibial stress fractures, because there are…
Maurício Kfuri Júnior
Full Text Available As fraturas do planalto tibial são lesões articulares cujos princípios de tratamento envolvem a redução anatômica da superfície articular e a restauração funcional do eixo mecânico do membro inferior. Contribuem para a tomada de decisões no tratamento dessas fraturas o perfil do paciente, as condições do envelope de tecidos moles, a existência de outros traumatismos associados e a infraestrutura disponível para abordagens cirúrgicas. Para as fraturas de alta energia, o tratamento estagiado, seguindo o princípio do controle de danos, tem como prioridade a manutenção do alinhamento do membro enquanto se aguarda a resolução das más condições de tecidos moles. Já nos traumas de baixa energia, desde que os tecidos moles não sejam um fator adverso, o tratamento deve ser realizado em tempo único, com osteossíntese definitiva. Fixação estável e movimento precoce são variáveis diretamente relacionadas com os melhores prognósticos. Desenvolvimentos recentes, como os implantes com estabilidade angular, substitutos ósseos e imagens tridimensionais para controle intraoperatório, deverão contribuir para cirurgias menos invasivas e melhores resultados.Tibial plateau fractures are joint lesions that require anatomical reduction of joint surface and functional restoration of mechanical axis of a lower limb. Patient profile, soft tissue conditions, presence of associated injuries and the available infrastructure for the treatment all contribute to the decision making about the best treatment for these fractures. High-energy fractures are usually approached in a staged manner respecting the principle of damage control, and are primarily targeted to maintain limb alignment while the resolution unfavorable soft tissue conditions is pending. Low-energy trauma can be managed on a single-stage basis, provided soft tissues are not an adverse factor, with open reduction and internal f-ixation. Stable fixation and early painless joint
Frey, Steven; Hosalkar, Harish; Cameron, Danielle B; Heath, Aaron; David Horn, B; Ganley, Theodore J
Tibial tuberosity fractures in adolescents are uncommon. We retrospectively reviewed all tibial tuberosity fractures in adolescents (10-19) who presented to our level 1 pediatric trauma center over a 7-year period to review fracture morphology, mechanism of injury, fracture management including return to play, as well as complications. Additionally, we present a review of the literature and treatment algorithm. We reviewed the clinical charts and radiographs of consecutive patients with tibial tuberosity fractures between 01 January 2000 and 01 January 2007. Data parameters included the following: patients age and gender, involved side, injury classification, co-morbidities, mechanism of injury, treatment, return to activity and complications. Data were extracted and reviewed, and a treatment algorithm is proposed with some additional insights into the epidemiology of the injury. Nineteen patients met the inclusion criteria. There were 19 patients with 20 tibial tuberosity fractures. The mean age was 13.7 years. There were 18 males and 1 female patient. There were nine left-sided injuries and eleven right-sided including one patient with bilateral fractures. Mechanism of injuries included basketball injury (8), running injury (5), football injury (3), fall from a scooter (2), high jump (1) and fall (1). Co-morbidities included three patients with concurrent Osgood-Schlatter disease and one with osteogenesis imperfecta. All were treated with ORIF, including arthroscopic-assisted techniques in two cases. Complications included four patients with pre-operative presentation of compartment syndrome all requiring fasciotomy, one post-operative stiffness and one painful hardware requiring removal. Range of motion was started an average of 4.3 weeks post-operatively and return to play was an average of 3.9 months post-operatively. Although uncommon, tibial tuberosity fractures in adolescents are clinically important injuries. Early recognition and treatment (closed or open
Mallee, W.H.; Weel, H.; van Dijk, C.N.; van Tulder, M.W.; Kerkhoffs, G.M.; Lin, C.W.C.
Aim To compare surgical and conservative treatment for high-risk stress fractures of the anterior tibial cortex, navicular and proximal fifth metatarsal. Methods Systematic searches of CENTRAL, MEDLINE, EMBASE, CINAHL, SPORTDiscus and PEDro were performed to identify relevant prospective and
Larsen, Peter; Elsøe, Rasmus; Hansen, Sandra Hope
Introduction: The literature lacks recent population-based epidemiology studies of the incidence, trauma mechanism and fracture classification of tibial shaft fractures. The purpose of this study was to provide up-to-date information on the incidence of tibial shaft fractures in a large and compl......Introduction: The literature lacks recent population-based epidemiology studies of the incidence, trauma mechanism and fracture classification of tibial shaft fractures. The purpose of this study was to provide up-to-date information on the incidence of tibial shaft fractures in a large...... the highest frequency between the age of 30 and 40. AO-type 42-A1 was the most common fracture type, representing 34% of all tibial shaft fractures. The majority of tibial shaft fractures occur during walking, indoor activity and sports. The distribution among genders shows that males present a higher...... frequency of fractures while participating in sports activities and walking. Women present the highest frequency of fractures while walking and during indoor activities. Conclusion: This study shows an incidence of 16.9/100,000/year for tibial shaft fractures. AO-type 42-A1 was the most common fracture type...
Johnson, P.J.; Allhands, R.V.; Baker, G.J.; Boero, M.J.; Foreman, J.H.; Hyyppa, T.; Huhn, J.C.
Incomplete linear tibial fractures were identified in two horses with the aid of scintigraphy. Both horses were treated successfully by strict stall confinement, and both returned to normal athletic activity. Scintigraphy can be used to facilitate the generally difficult diagnosis of incomplete tibial fractures
Pamukoff, Derek N; Blackburn, J Troy
Greater lower extremity joint stiffness may be related to the development of tibial stress fractures in runners. Musculotendinous stiffness is the largest contributor to joint stiffness, but it is unclear what factors contribute to musculotendinous stiffness. The purpose of this study was to compare plantar flexor musculotendinous stiffness, architecture, geometry, and Achilles tendon stiffness between male runners with and without a history of tibial stress fracture. Nineteen healthy runners (age = 21 ± 2.7 years; mass = 68.2 ± 9.3 kg; height = 177.3 ± 6.0 cm) and 19 runners with a history of tibial stress fracture (age = 21 ± 2.9 years; mass = 65.3 ± 6.0 kg; height = 177.2 ± 5.2 cm) were recruited from community running groups and the university's varsity and club cross-country teams. Plantar flexor musculotendinous stiffness was estimated from the damped frequency of oscillatory motion about the ankle follow perturbation. Ultrasound imaging was used to measure architecture and geometry of the medial gastrocnemius. Dependent variables were compared between groups via one-way ANOVAs. Previously injured runners had greater plantar flexor musculotendinous stiffness (P < .001), greater Achilles tendon stiffness (P = .004), and lesser Achilles tendon elongation (P = .003) during maximal isometric contraction compared with healthy runners. No differences were found in muscle thickness, pennation angle, or fascicle length.
Robertson, Greg A. J.; Wood, Alexander M.
Context: Acute tibial shaft fractures represent one of the most severe injuries in sports. Return rates and return-to-sport times after these injuries are limited, particularly with regard to the outcomes of different treatment methods. Objective: To determine the current evidence for the treatment of and return to sport after tibial shaft fractures. Data Sources: OVID/MEDLINE (PubMed), EMBASE, CINAHL, Cochrane Collaboration Database, Web of Science, PEDro, SPORTDiscus, Scopus, and Google Sch...
Wong, Christian Nai En; Mikkelsen, Mikkel Peter W; Hansen, Leif Berner
INTRODUCTION: Fractures of the tibial shaft are relatively common injuries. There are indications that tibial shaft fractures share characteristics in terms of site, type and local fracture mechanisms. In this study, we aimed to set up a mathematical, computer-based model using finite element...... analysis of the bones of the lower leg to examine if such a model is adequate for prediction of fracture locations and patterns. In future studies, we aim to use these biomechanical results to examine fracture prevention, among others, and to simulate different types of osteosynthesis and the process...... of bony healing. The biomechanical results are the basis for fracture healing, biomechanical fall analysis and stability analysis of osteosynthesis. MATERIAL AND METHODS: A finite element model of the bony part of the lower leg was generated on the basis of computed tomography data from the Visible Human...
Wong, Christian Nai En; Mikkelsen, Mikkel Peter W; Hansen, Leif Berner
INTRODUCTION: Fractures of the tibial shaft are relatively common injuries. There are indications that tibial shaft fractures share characteristics in terms of site, type and local fracture mechanisms. In this study, we aimed to set up a mathematical, computer-based model using finite element...... of bony healing. The biomechanical results are the basis for fracture healing, biomechanical fall analysis and stability analysis of osteosynthesis. MATERIAL AND METHODS: A finite element model of the bony part of the lower leg was generated on the basis of computed tomography data from the Visible Human...... Project. The data consisted of 21,219 3D elements with a cortical shell and a trabecular core. Three types of load of torsion, a direct lateral load and axial compression were applied. RESULTS: The finite element linear static analysis resulted in relevant fracture localizations and indicated relevant...
Kyrö, A; Lamppu, M; Böstman, O
Sixty-four displaced tibial shaft fractures were treated using intramedullary nailing, either primarily or after an attempt at conservative treatment, which consisted of closed reduction under anaesthesia and immobilisation in a long-leg plaster cast. There were 37 closed and 27 open fractures. Three patients had a fracture of both tibiae. The median time period from the intramedullary nailing of the closed solitary fractures to union was about the same after primary nailing as after delayed nailing. Although the fractures were different in these groups, it is possible that the time spent in conservative treatment before intramedullary nailing brings no additional benefits. The incidence of deep infection in open fractures after primary nailing was 1/16. The fractures, in which an acceptable position could not be maintained using conservative methods, were mainly spiral in configuration and located in the distal third or at the junction of the middle and distal thirds of the tibia.
Stress fractures Overview Stress fractures are tiny cracks in a bone. They're caused by repetitive force, often from overuse — such as repeatedly jumping up and down or running long distances. Stress fractures can also arise from normal use of ...
Tang, S F; Au, T L; Wong, A M; Lee, M Y
Sarmiento introduced the functional fracture brace for the management of tibial shaft fracture in 1963. However, tibial angulation with varus deformity cannot be prevented or corrected by such a device. In this paper, a case of tibial shaft fracture with varus angulation treated with a modified below-knee fracture brace was reported.
To assess patient outcome after nailing of the tibial shaft with the unreamed AO/ASIF nail. A retrospective study of 54 nailed fractures of the tibial shaft treated between 1990 and 1994. Follow-up was done at the outpatient clinic and included measurements of the lower limbs and x-rays. The study was conducted at the Hôpital de l'Enfant-Jésus, Québec, a centre specializing in trauma care. Fifty-four acute displaced fractures of the tibial shaft occurring in 52 patients were studied. Nailing with the Synthes AO/ASIF unreamed locked nails. Time to bone fusion, rate of infection, incidence of deformity and failure rate of the implants, especially the lock screws. The majority of fractures were associated with a high-speed trauma (40/54 or 74% of cases) and 18 (33%) were open fractures. Osteitis developed in one (1.8%) open type IIIA fracture. Bone fusion was observed clinically and radiologically after 29 weeks on average; none of the fractures presented residual deformity on rotation of more than 5 degrees or a difference in length of more than 1 cm or a frontal or sagittal displacement of more than 10 degrees. A single case of pseudoarthrosis was noted. One or more lock screws became deformed or broke in 16 (34%) tibias; however, this did not lead to any reduction loss. Four compartment syndromes were diagnosed. Excellent results were obtained with respect to limb alignment and length. Loss of joint mobility was minimal. The number of lock screw failures indicates that a delayed weight bearing could prevent this complication, especially when an interfragment space remains after the nail placement.
Robertson, Greg A. J.; Wood, Alexander M.
Context: Acute tibial shaft fractures represent one of the most severe injuries in sports. Return rates and return-to-sport times after these injuries are limited, particularly with regard to the outcomes of different treatment methods. Objective: To determine the current evidence for the treatment of and return to sport after tibial shaft fractures. Data Sources: OVID/MEDLINE (PubMed), EMBASE, CINAHL, Cochrane Collaboration Database, Web of Science, PEDro, SPORTDiscus, Scopus, and Google Scholar were all searched for articles published from 1988 to 2014. Study Selection: Inclusion criteria comprised studies of level 1 to 4 evidence, written in the English language, that reported on the management and outcome of tibial shaft fractures and included data on either return-to-sport rate or time. Studies that failed to report on sporting outcomes, those of level 5 evidence, and those in non–English language were excluded. Study Design: Systematic review. Level of Evidence: Level 4. Data Extraction: The search used combinations of the terms tibial, tibia, acute, fracture, athletes, sports, nonoperative, conservative, operative, and return to sport. Two authors independently reviewed the selected articles and created separate data sets, which were subsequently combined for final analysis. Results: A total of 16 studies (10 retrospective, 3 prospective, 3 randomized controlled trials) were included (n = 889 patients). Seventy-six percent (672/889) of the patients were men, with a mean age of 27.7 years. Surgical management was assessed in 14 studies, and nonsurgical management was assessed in 8 studies. Return to sport ranged from 12 to 54 weeks after surgical intervention and from 28 to 182 weeks after nonsurgical management (mean difference, 69.5 weeks; 95% CI, –83.36 to −55.64; P Fractures treated surgically had a return-to-sport rate of 92%, whereas those treated nonsurgically had a return rate of 67% (risk ratio, 1.37; 95% CI, 1.20 to 1.57; P displaced fractures
revealed that the peak tibial stress during running ( tension , 90.6 MPa; compression, 136.2 MPa) was more than three times as great as that during walking... tension , 24.1 MPa; compression, 40.3 MPa), whereas the cumulative stress within one stride did not differ substantially between running (15.2 MPa · s...corresponding to the location of the superficial posterior muscle compartment, including the gastrocnemius and soleus muscles. Similar to our previous
Gebuhr, Peter Henrik; Larsen, T K; Petersen, O C
Fifty-one tibial shaft fractures treated by ASIF compression osteosynthesis were seen at follow-up at a median time of 46 weeks after injury. Twenty-four were open fractures and the patients received prophylactic antibiotics. The median stay in hospital was 15 days for open fractures and 6 days...... for closed fractures. There were complications in 26 cases, with deep infection in 9 cases. At present we cannot advocate the use of ASIF compression osteosynthesis for displaced tibial fractures....
Full Text Available The study was aimed to identify the role of surgical treatment of tibial plateau fractures, its functional outcome and complications. Demographic data for the patients and details of current clinical and radiological follow-up findings were obtained to assess range of motion, clinical stability, alignment of the knee, and posttraumatic arthrosis (Kellgren/Lawrence score. 64 cases of tibial plateau fractures treated by different surgical methods and variuos implants type were studied from 2013 to 2015 and followed-up for minimum period of 6 months. The systematisation of the casuitry was made using Schatzker and AO classifications. The treatment methods consist of: percutaneous cannulated cancellous screws, ORIF with buttress plate with or without bone grafting, locking or nonlocking plates, external fixator. As complications we found: redepression 4 case, malunion 2 cases, knee stiffness 9, wound dehiscence in 1 cases and non-union or infection in none of our cases. The average flexion of the injured knee was significantly lower in comparison with the contralateral side (124.9°/135.2°. Knee stability did not differ statistically significantly. There were no signs of posttraumatic arthrosis in 45% of cases, mild signs in 30%, clear signs in 18%, and severe signs in 7%. As conclusion we found that surgical management of tibial plateau fractures will give excellent anatomical reduction and rigid fixation to restore articular congruity, facilitate early motion and reduce arthrosis risk and hence to achieve optimal knee function. The choice of optimal surgical methods, proper approach and implant is made in relation to fracture type according Schatzker and AO classification.
Full Text Available 【Abstract】A case of a 50-year-old pedestrian who was hit by a bike and suffered fractures of both bones of his right leg was presented. Complete clinical and radiographic assessment showed double segmental fractures of the tibia and multisegmental fractures of the fibula. Review of the literature revealed that this fracture pattern was unique and only a single case was reported so far. Moreover, we discussed the possible mechanisms which can lead to such an injury. We also discussed the management of segmental tibial fracture and the difficulties encountered with them. This case was managed by modern osteosynthesis tech- nique with a pleasing outcome. Key words: Fracture, bone; Tibia; Fibula; Nails
Mellema, Jos J.; Doornberg, Job N.; Molenaars, Rik J.; Ring, David; Kloen, Peter; Babis, George C.; Jeray, Kyle J.; Prayson, Michael J.; Pesantez, Rodrigo; Acacio, Ramos; Verbeek, Diederik O.; Melvanki, Parag; Kreis, Barbara E.; Mehta, Samir; Meylaerts, S.; Wojtek, S.; Yeap, Ewe J.; Haapasalo, Heidi; Kristan, Anže; Coles, Chad; Marsh, J. Lawrence; Mormino, Matthew; Memon, Matthew; Tyllianakis, Minos; Schandelmaier, Peter; Jenkinson, R. J.; Neuhaus, Valentin; Shahriar, Chegini M. H.; Belangero, William D.; Leonidovich, Golovakha M.; Davenport, J. H.; Kabir, Koroush; Althausen, Peter L.; Weil, Yoram; Toom, Alar; Sa da Costa, Daniel; Koukoulias, Nikolaos; Manidakis, Nikolaos; van den Bogaert, Max; Patczai, Balázs; Grauls, Anthony; Kurup, Harish; van den Bekerom, Michel P.; Lansdaal, Joris R.; Vale, Mário; Ousema, Paul; Barquet, Antonio; Cross, Brian J.; Broekhuyse, Henry; Haverkamp, Daniel; Merchant, Milind; Harvey, Edward; Stojkovska Pemovska, Emilija; Frihagen, Frede; Seibert, Franz Josef; Garnavos, Christos; van der Heide, Huub; Villamizar, Harold Alonso; Harris, Ian; Borris, Lars C.; Brink, Ole; Choudhari, Pradeep; Swiontkowski, Marc; Mittlmeier, Thomas; Tosounidis, Theodoros; van Rensen, Inge; Martinelli, N.; Park, D. H.; Lasanianos, Nikolaos; Vide, J.; Engvall, A.; Zura, R. D.; Jubel, Axel; Kawaguchi, Alan; Goost, Hans; Bishop, Julius; Mica, Ladislav; Pirpiris, Marinis; van Helden, S. H.; Bouaicha, Samy; Schepers, T.; Havliček, Tomo; Giordano, Vincenzo
The purpose of this study was to assess the interobserver reliability and diagnostic accuracy for 2-dimensional (2D) and 3-dimensional (3D) computed tomography (CT)-based evaluation of tibial plateau fracture characteristics. We hypothesized that recognition of specific tibial plateau fracture
Busel, Gennadiy A; Watson, J Tracy; Israel, Heidi
Comminuted fibular fractures can occur with pilon fractures as a result of valgus stress. Transverse fibular fractures can occur with varus deformation. No definitive guide for determining the proper location of tibial fixation exists. The purpose of this study was to identify optimal plate location for fixation of pilon fractures based on the orientation of the fibular fracture. One hundred two patients with 103 pilon fractures were identified who were definitively treated at our institution from 2004 to 2013. Pilon fractures were classified using the AO/OTA classification and included 43-A through 43-C fractures. Inclusion criteria were age of at least 18 years, associated fibular fracture, and definitive tibial plating. Patients were grouped based on the fibular component fracture type (comminuted vs transverse), and the location of plate fixation (medial vs lateral) was noted. Radiographic outcomes were assessed for mechanical failures. Forty fractures were a result of varus force as evidenced by transverse fracture of the fibula and 63 were due to valgus force with a comminuted fibula. For the transverse fibula group, 14.3% mechanical complications were noted for medially placed plate vs 80% for lateral plating ( P = .006). For the comminuted fibular group, 36.4% of medially placed plates demonstrated mechanical complications vs 16.7% for laterally based plates ( P = .156). Time to weight bearing as tolerated was also noted to be significant between groups plated medially and laterally for the comminuted group ( P = .013). Correctly assessing the fibular component for pilon fractures provides valuable information regarding deforming forces. To limit mechanical complications, tibial plates should be applied in such a way as to resist the original deforming forces. Level of Evidence Level III, comparative study.
Adams, John David; Della Rocca, Gregory J
Fractures involving the posterior aspect of the tibial plateau are challenging fractures to treat. Articular depression in tibial plateau fractures is usually addressed by elevation of the fragment(s), filling the residual defect with bone graft or bone substitute, and "raft" support of the articular fracture reduction with screws through a medially and/or laterally based plate. Posterior tibial plateau articular depression presents unique challenges for obtaining and maintaining fracture reduction. To obtain the goals of anatomic reduction and stable fixation, a thorough understanding of the fracture, specific approaches, reduction techniques, and stabilization strategies is needed. This article reviews the most current strategies for treating tibial plateau fracture patients with posterior articular depression. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Ellanti, Prasad; Hammad, Yassir; Kosutic, Damir; Grieve, Philip P
Fractures can be irreducible for several reasons, including soft tissue or bone fragment interposition. We report an unusual fracture configuration of a comminuted tibial pilon fracture in which the distal fibular shaft fragment was occupying the medullary canal of the proximal tibial shaft fragment and inhibiting reduction and fixation. To the best of our knowledge, this has not been previously reported in a published study. Copyright © 2012 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Milenković Saša; Mitković Milorad B.; Radenković Mile
Aim. To present the possibility of a successful use of external skeletal fixation in treating the open and closed tibial shaft fractures with Mitković’s external fixator. Methods. External fixation was used in 115 patients with 118 fresh tibial shaft fractures, 82 males (71.3%) and 33 females (28.7%), average age 43.92 years (16−84). Open tibial shaft fractures were present in 37 (31.36%). All the fractures were treated with Mitković’s external fixator type M 20. Results. The results of exter...
Moen, Maarten H.; Tol, Johannes L.; Weir, Adam; Steunebrink, Miriam; de Winter, Theodorus C.
Medial tibial stress syndrome (MTSS) is one of the most common leg injuries in athletes and soldiers. The incidence of MTSS is reported as being between 4% and 35% in military personnel and athletes. The name given to this condition refers to pain on the posteromedial tibial border during exercise,
The commonest cause of the injuries was motorcycle accidents (25.7%) followed closely by motor vehicular accidents (25%). The most common associated injuries in order of frequency were: ipsilateral fibular fractures, ankle injuries, ipsilateral femoral fractures and pelvic fractures. Conclusion: Tibial shaft fractures are ...
Sandeep Gurung; Dipendra KC; Roshni Khatri
Introduction: Tibia fractures in the skeletally immature patient can usually be treated with above knee cast or patellar tendon bearing cast. The purpose of our study was to evaluate epidemiology and outcome of Elastic stable intramedullary nailing fixation of pediatric tibial shaft fractures treated at our institution. Methods: Over a period of one year, fifty pediatric patients of tibial shaft fractures, with average age of 9.68 yr (SD=2.37), were treated with elastic stable intramedul...
Stress fractures in athletes . Int J Sports Med 1987;8: 221-226 2 Krause GR, Thompson JR. March Fracture of the Tibia. Radiology 1943;41:580-5 3 Bruce... stress fracture. Fig. 2: Axial CT showing the periosteal reaction. Female athletes have the greater tendency of acquiring tibial stress ...H Jones, Stephen B. Baker, Julie Gilchrist, Dexter Kimsey, Daniel M. Sosin: Prevention of Lower Extremity Stress Fractures in Athletes and Soldiers
Full Text Available Aim. To present the possibility of a successful use of external skeletal fixation in treating the open and closed tibial shaft fractures with Mitković’s external fixator. Methods. External fixation was used in 115 patients with 118 fresh tibial shaft fractures, 82 males (71.3% and 33 females (28.7%, average age 43.92 years (16−84. Open tibial shaft fractures were present in 37 (31.36%. All the fractures were treated with Mitković’s external fixator type M 20. Results. The results of external fixation were excellent or good in 94.07% of the cases, and bad in 5.08%. Pin tract infection appeared in 7 (5.93% patients. In only 3 cases an external fixator was removed and treatment continued with the functional braces. Nonunion occurred in 6 (5.08% patients, of which 4 were with open fractures (2 Gustilo type IIIB, 1 Gustilo type IIIA, 1 Gustilo type II and 2 with the segment fractures. Compartment syndrome was observed in 1 (0.85% patient with closed fracture. Malunion was found in 2 (1.69% patients. Conclusion. External fixation of tibial shaft fractures is a simple and effective method to enable the safe healing of fractures, early mobilization of the patients, early weight-bearing, as well as early rehabilitation. Fixation of tibial shaft fractures was unilateral with convergent pins orientation, and there was also a possibility of compression and distraction.
Milenković, Sasa; Mitković, Milorad; Radenković, Mile
To present the possibility of a succesfful use of external skelatal fixation in treating the open and closed tibial shaft fractures with Mitković's external fixator. External fixation was used in 115 patients with 118 fresh tibial shaft fractures, 82 males (71.3%) and 33 females (28.7%), average age 43.92 years (16-84). Open tibial shaft fractures were present in 37 (31.36%). All the fractures were treated with Mitković's external fixator type M 20. The results of external fixation were excellent or good in 94.07% of the cases, and bad in 5.08%. Pin tract infection appeared in 7 (5.93%) patients. In only 3 cases an external fixator was removed and treatment continued with the functional braces. Nonunion occurred in 6 (5.08%) patients, of which 4 were with open fractures (2 Gustilo type IIIB, 1 Gustilo type IIIA, 1 Gustilo type II) and 2 with the segment fractures. Compartment syndrome was observed in 1 (0.85%) patient with closed fracture. Malunion was found in 2 (1.69%) patients. External fixation of tibial shaft fractures is a simple and effective method to enable the safe healing of fractures, early mobilization of the patients, early weight-bearing, as well as early rehabilitation. Fixation of tibial shaft fractures was unilateral with convergent pins orientation, and there was also a possibility of compression and distraction.
Gary, Joshua L; Sciadini, Marcus F
Minimally invasive osteosynthesis of proximal tibial fractures has grown in popularity in recent years. This article describes a patient with a Schatzker type VI proximal tibial fracture (AO/OTA type 41.C3) and previous compartment syndrome treated with definitive fixation 8 weeks after initial injury with a precontoured proximal tibial plate and a distal targeting device. Brisk bleeding occurred during percutaneous insertion of a cortical screw at the midshaft of the tibia. Surgical exploration revealed sidewall tearing of the anterior tibial artery and vein, which were clipped at the screw insertion site. After the bleeding was controlled, the patient had a strong palpable posterior tibial pulse with no palpable dorsalis pedis pulse, and the foot remained well perfused. Function of the deep peroneal nerve was normal postoperatively. Previous concerns regarding the percutaneous treatment of proximal tibial fractures have focused on the risks of damage to the superficial peroneal nerve from distal screws. Based on cadaveric studies, percutaneously and laterally based screw placement in the distal tibial metaphysis threatens injury to the anterior tibial system. However, with alterations to the normal anatomy caused by severe trauma, previously described safe zones may be changed and neurovascular structures may be exposed to risk in locations that were previously thought safe. Copyright 2012, SLACK Incorporated.
Giulietti, Jeff A.; Denegar, Craig R.; Harner, Christopher D.
In general, tibial plateau fractures are rarely associated with noncontact, twisting, injuries to the knee in athletics. A 23-year-old woman sustained a noncontact valgus injury to her left knee while playing indoor soccer. Evaluation on-site and the following morning revealed no deformity and only mild pain over the anterolateral tibial plateau. All stress tests of the knee were negative. A 2+ effusion was noted the day after injury, causing us to suspect an internal derangement of the left ...
Qi, Yong; Sun, Hong-Tao; Fan, Yue-Guang; Li, Fei-Meng; Lin, Zhou-Sheng
The presence of large segmental defects of the diaphyseal bone is challenging for orthopedic surgeons. Free vascularized fibular grafting (FVFG) is considered to be a reliable reconstructive procedure. Stress fractures are a common complication following this surgery, and hypertrophy is the main physiological change of the grafted fibula. The exact mechanism of hypertrophy is not completely known. To the best of our knowledge, no studies have examined the possible relationship between stress fractures and hypertrophy. We herein report three cases of patients underwent FVFG. Two of them developed stress fractures and significant hypertrophy, while the remaining patient developed neither stress fractures nor significant hypertrophy. This phenomenon indicates that a relationship may exist between stress fractures and hypertrophy of the grafted fibula, specifically, that the presence of a stress fracture may initiate the process of hypertrophy.
Zelle, Boris A; Boni, Guilherme
Statically locked, reamed intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Establishing an appropriate starting point is a crucial part of the surgical procedure. Recently, suprapatellar nailing in the semi-extended position has been suggested as a safe and effective surgical technique. Numerous reduction techiques are available to achieve an anatomic fracture alignment and the treating surgeon should be familiar with these maneuvers. Open reduction techniques should be considered if anatomic fracture alignment cannot be achieved by closed means. Favorable union rates above 90 % can be achieved by both reamed and unreamed intramedullary nailing. Despite favorable union rates, patients continue to have functional long-term impairments. In particular, anterior knee pain remains a common complaint following intramedullary tibial nailing. Malrotation remains a commonly reported complication after tibial nailing. The effect of postoperative tibial malalignment on the clinical and radiographic outcome requires further investigation.
Jofre, M.J.; Sierralta, M.P.
During military training, the incidence of overuse injuries like stress fractures increase. The aim of the study was to investigate the utility of bone scan in a military population with clinical suspected stress fractures or periostitis. Material and methods: A three-year retrospective analysis was made on patients who were clinically diagnosed with stress fractures at the Military Hospital Nuclear Medicine Department. Thirty-seven patients were studied (mean age 23. +/- 8 y.o; 31 males), 28 cases of which (76%) had tibial stress syndrome. Other localizations were lumbar spine, femoral, fibular, tarsal or metatarsal. Bone scintigraphy was performed injecting 1036 MBq of Tc99m-MDP i.v. Whole body images and lateral projections of lower extremities were done. Results: Bone scan in tibial syndrome was positive for 23 cases (82%), 65% of them were bilateral and 13% also had femoral injuries. X-rays were done in 10 cases and were all negative. In other localizations, the bone scans were negative, but demonstrated other degenerative lesions. All stress fractures were conservatively treated with non-steroidal anti-inflammatories and suspension of physical activity. Conclusions: Bone scan is a reliable confirmatory tool for tibial stress syndrome diagnosis. In addition, it helps to determine both the severity and extension of the injury as well as support the indication of rest in the military population
Murcia, M.; Brennan, R.E.; Edeiken, J.
An athletic young female developed gradual onset of pain in the right leg. Plain radiographs demonstrated solid periosteal reaction in the tibia compatible with stress fracture. She stopped sport activites but her pain continued. Follow-up radiographs of the tibia revealed changes suspicious for osteoid osteoma. Computed tomography (CT) scan demonstrated periosteal reaction, but in addition, lucent fracture lines in the tibial cortex were evident. CT obviated the need for more invasive diagnostic procedures in this patient. In selected cases CT may be useful to confirm the diagnosis of stress fracture when plain radiographic or routine tomographic studies are not diagnostic. (orig.)
textabstractThe aim of fracture treatment is rapid bone union with the preservation of perfect function, resulting in the patients' early return to normal daily activities with a minimum of complications. Many conservative and operative methods are used for the treatment of tibial fractures.
Alho, A; Ekeland, A; Strømsøe, K; Follerås, G; Thoresen, B O
We analysed the results of 93 tibial shaft fractures treated with the Grosse-Kempf locked nail. Twenty-six fractures were comminuted, 19 were open grade I to II, and 54 were located outside the middle third of the tibia. The deep infection rate was 3.2%. There were only two poor results. The use of this method is recommended and discussed.
Chmielnicki, M; Prokop, A
Tibial shaft fractures are among the most common long bone fractures in humans. The incidence is 1-2 per 100,000. The gold standard of treatment for AO type 42 A-C fractures is a locking intramedullary nail. The development of new implants has extended the indications for this minimally invasive technique, so that now AO types 41 and 43 can also be treated with special nails. Fixed-angle screw anchors increase primary stability and supplemental locking devices located proximally and distally extend the spectrum of use to metaphyseal fractures. The cannulated Targon TX titanium nail can be introduced, either with or without reaming. Using an operative video, the treatment of a tibial fracture with an intramedullary nail is demonstrated in stages and the operative steps further illustrated on artificial bone. Georg Thieme Verlag KG Stuttgart · New York.
Tibial plateau fractures overall and especially in winter sports are rare. However, the incidence in recent years is increasing. In a retrospective study from 2009-2012, we found 52 injuries affiliated with winter sports. Noticeable was the high rate of severe injury patterns. In 20 of the 52 cases, there were complete articular or bicondylar fractures (38 %). In 25 cases (48 %), fragment dislocation corresponding to the Moore classification was observed. The operative algorithm was based on the initial soft tissue damage and the type of fracture. A two or more stage procedure with first line soft tissue management and temporary external fixation stabilization was performed 12 times. The final internal osteosynthesis was based on the morphology of the fracture, i.e., direct exposition and stabilization of relevant fracture patterns. In 24 cases (46 %), there was a need for two (or more) approaches. In the anterior aspect of the tibial head, customary implants were used; posterior pathologies were stabilized with low-dimension implants. Summarizing with regard to the literature, there is a more discriminating view of tibial plateau fractures, regarding all relevant fracture patterns. Thus, different options in operative access and choice of implants can be made.
When focal tibial pain, indicative of a stress fracture, or a medical history with a cruris fracture was present, subjects were excluded.. After item generation, the patients appraised the items in two rounds. In the first round, the authors asked 15 MTSS patients to provide feedback on readability and comprehension using a.
Böstman, O; Hänninen, A
A series of 200 consecutive junctional middle-distal third tibial shaft fractures caused by indirect violence was analysed with emphasis on the significance of the location of the fibular reciprocal fracture. The fibular fracture was eccentric, i.e. subcapital or malleolar, in 96 patients. This fracture pattern was encountered only in adults and showed significantly more severe initial displacement and with conservative treatment longer union time than fractures with intact fibula or the fibular fracture on the same level with the tibial fracture. Especially for fractures with an initial lateral displacement of more than one half of the diaphyseal diameter and with an eccentric fibular reciprocal fracture internal fixation with uncomplicated postoperative course shortened the union time and prevented residual deformity. A malleolar fibular fracture and the rare separate displaced posterior triangle fracture should in addition as such be regarded as indications for osteosynthesis.
Melis, G C; Sotgiu, F; Lepori, M; Guido, P
Thirty-eight consecutive segmental fractures of the tibia were treated by intramedullary nailing with the Küntscher-Herzog nail. Twenty-two fractures were closed and sixteen were open. Reaming of the medullary cavity was performed and adequate fixation was ensured by use of a plaster cast. Weight-bearing was allowed after thirty-days for closed fractures and sixty days for open fractures. All of the closed fractures healed without malunion or infection. Of the patients with open fractures, one had an infection; one, non-union; and one, malunion. In all cases but one, union was slower at the distal fracture.
Three currently favored methods of treatment are intramedullary locking nail , external Fixators (with their different constructs and versatility) and Plaster of Paris. It is important to note that more than two-thirds of segmental tibial fractures will require more than one surgical intervention. The surgeon therefore, needs to plan ...
We present a case of combined avulsion fracture of the tibial tubercle (AFTT) and avulsion of the patellar ligament in a 15-year-old boy. This injury was treated by open reduction and fixation of both lesions using staples with satisfactory results. This constellation of injury is rare but a high index of suspicion is needed when ...
Methods: This is a prospective observational study of all open tibial fractures seen at the Accident and Emergency department of the University of Port Harcourt Teaching Hospital (UPTH) over a twelve- month period (July 2002- June 2003). Data from a pre-designed proforma for the study was analyzed and descriptive ...
In this paper we present typical mechanism of the fracture of the tibial condyle, due tosudden turn of the ski with carved edges. Mathematical model explains how the force transmitted to the knee multiplies due to sudden decrease of the carved turn radius, or due tosudden additional bowing of skies
Zelle, Boris A.; Boni, Guilherme
Statically locked, reamed intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Establishing an appropriate starting point is a crucial part of the surgical procedure. Recently, suprapatellar nailing in the semi-extended position has been suggested as a safe and effective surgical technique. Numerous reduction techiques are available to achieve an anatomic fracture alignment and the treating surgeon should be familiar with these maneuvers. Open reduction ...
Cinque, Mark E.; Godin, Jonathan A.; Moatshe, Gilbert; Chahla, Jorge; Kruckeberg, Bradley M.; Pogorzelski, Jonas; LaPrade, Robert F.
Background: Tibial plateau fractures account for a small portion of all fractures; however, these fractures can pose a surgical challenge when occurring concomitantly with ligament injuries. Purpose/Hypothesis: The purpose of this study was to compare 2-year outcomes of soft tissue reconstruction with or without a concomitant tibial plateau fracture and open reduction internal fixation. We hypothesized that patients with a concomitant tibial plateau fracture at the time of soft tissue surgery...
Full Text Available Introduction. Open lower leg fractures are the most common open fractures of the locomotor system and their treatment is associated with a number of complications. Objective. The aim of the paper was to present the results of the treatment of 68 patients with open lower leg fractures, as well as the complications that accompany the treatment of these fractures. Methods. In the analyzed group, there were 45 (66.18% men and 23 (33.82% women. The majority of patients - 33 (48.53% of them - were injured in motor vehicle accidents, whereas 24 (35.29% patients sustained injuries due to falls from heights. In two (2.94% patients the cause of open tibial fractures was gunshot injuries. In the analyzed group, there were 18 (26.47% type I open fractures, 21 (30.88% type II open fractures, 19 (27.94% type IIIA open fractures, seven (10.29% type IIIB open fractures, and three (4.41% type IIIC open fractures. Results. The tibial shaft fracture healed without serious complications in 50 (73.53% patients, whereas in 18 (26.47% patients we observed some complications. Nonunion was found in 10 (14.71% patients, osteitis in four (5.88, malunion in two (2.94% patients. Milder complications such as soft tissue pin tract infection developed in 13 (19.12% patients, infection of the open fracture wound soft tissue was observed in four (5.88% patients. Conclusion. Basic principles in the treatment of open lower leg fractures in this study are thorough primary open fracture wound treatment followed by the delayed wound closure, stable fracture fixation using unilateral external skeletal device, proper antibiotic treatment and tetanus prophylaxis. The results correlate with similar studies. [Projekat Ministarstva nauke Republike Srbije, br. III 41017: Virtual Human Osteoarticular System and its Application in Preclinical and Clinical Practice
Haines, J F; Williams, E A; Hargadon, E J; Davies, D R
All tibial shaft fractures treated at one hospital during a five-year period were studied in a prospective trial. Ninety-one displaced fractures in adults were treated using a conservative policy that included early bone grafting when indicated. Sound bony union was obtained in all cases. Those that healed primarily took on average 16.3 weeks whereas the 24 per cent that required bone grafts took 35.1 weeks. The number of complications, most of which were minor, was considered acceptable. It is concluded that provided early bone grafting is performed when necessary, a basically conservative policy of treatment is satisfactory; bony union of all displaced tibial fractures is achieved in a reasonable period of time.
Khan, I.; Javed, S.; Khan, G.N.; Aziz, A.
Objective: To determine the outcome of intramedullary interlocking surgical implant generation network (SIGN) nail in diaphyseal tibial fractures in terms of union and failure of implant (breakage of nail or interlocking screws). Study Design: Case series. Place and Duration of Study: Orthopaedics and Spinal Surgery, Ghurki Trust Teaching Hospital, Lahore Medical and Dental College, Lahore, from September 2008 to August 2009. Methodology: Fifty patients aged 14 - 60 years, of either gender were included, who had closed and Gustilo type I and II open fractures reported in 2 weeks, whose closed reduction was not possible or was unsatisfactory and fracture was located 7 cm below knee joint to 7 cm above ankle joint. Fractures previously treated with external fixator, infected fractures and unfit patients were excluded. All fractures were fixed with intramedullary interlocking SIGN nail and were followed clinically and radiographically for union and for any implant failure. Results: Forty one (88%) patients had united fracture within 6 months, 5 (10%) patients had delayed union while 4 (8%) patients had non-union. Mean duration for achieving union was 163 + 30.6 days. Interlocking screws were broken in 2 patients while no nail was broken in any patient. Conclusion: Intramedullary interlocking nailing is an effective measure in treating closed and grade I and II open tibial fractures. It provides a high rate of union less complications and early return to function. (author)
Steinberg, Ely L; Geller, David S; Yacoubian, Shahan V; Shasha, Nadav; Dekel, Shmuel; Lorich, Dean G
To evaluate and present our experience using the expandable nail system for the treatment of acute tibial shaft fractures. Retrospective study. Two level-1 trauma centers-University teaching hospitals. Fifty-four consecutive patients were treated by this nail system for acute tibial shaft fracture. Two nail diameters were used, 8.5 mm and 10 mm. Operation, hospitalization and healing times, reaming versus nonreaming, isolated versus multiple injuries, and reoperations were recorded and analyzed statistically. Follow-up was obtained either until fracture healing or for a minimum of 1 year with an average of 14 months (12 to 24). All fractures healed in an average time of 72 days (21 to 204). The average healing times for patients treated with 8.5-mm and 10-mm nails were 77.2 days (27 to 204) and 63.4 days (21 to 121), respectively. Average operative time was 103 minutes (40 to 185) if reamed and 56 minutes (30 to 80) if unreamed. Average healing times were 65.4 days (21 to 190) if reamed and 79.5 days (42 to 204) if unreamed. There were 11 complications (20.4%) related to the nailing: 3 deep infections, 2 superficial infections, 2 bone shortenings of 1 cm secondary to nail protrusion in the knee, 1 compartment syndrome, 1 fracture propagation, 1 distal malalignment, and 1 delayed union. Hardware was removed in 6 patients (3 infections, 2 patients' request and 1 protrusion into the knee), and 1 additional patient underwent exchange nailing due to a delayed union. The expandable nail offers the theoretical advantages of improved load sharing and rotational control without the need for interlocking screws. This study demonstrates satisfactory healing and alignment for the treatment of tibial shaft fractures using this device. However, caution must be exercised when using this nail in cases of significant comminution and in cases where the fracture pattern involves the more proximal or distal aspect of the tibial shaft.
Full Text Available Intramedullary nailing of metaphyseal and segmental tibia fractures can be technically challenging for a variety of reasons. Restoring length, alignment and rotation of the injured limb requires careful preoperative planning and meticulous attention to surgical technique, while avoiding common pitfalls. Understanding the deforming forces on the fracture segments and normal tibial osteology provides a background for recognizing the most common pitfalls when nailing these fractures. Many adjuncts for obtaining and maintaining fracture reduction while nailing have been described, including extended positioning, use of the femoral distractor, blocking screws, and provisional plating. We discuss these techniques as well as the role of intramedullary fixation for treating metaphyseal fractures with articular extension. The purpose of this paper is to describe the background and technique for a variety of operative tips and tricks to facilitate intramedullary nailing of metaphyseal and segmental tibia fractures.
Venkateswara Rao; Chinta Shyam; Anvesh
Tibial fractures are one of the commonest orthopedic injuries. Tibial fractures are one of the commonest orthopedic injuries. In the past several years there has been a trend towards by use of small diameter nails without remaining in the management of unstable tibial shaft fractures. However it is important to remember that many closed fractures with less severe soft tissue injury, Treatment with an intramedullary nail with reaming allows placement of larger implan...
Colman, Matthew; Wright, Adam; Gruen, Gary; Siska, Peter; Pape, Hans-Christoph; Tarkin, Ivan
Fractures of the tibial plateau present a treatment challenge and are susceptible to both prolonged operative times and high postoperative infection rates. For those fractures treated with open plating, we sought to identify the relationship between surgical site infection and prolonged operative time as well as to identify other surgical risk factors. We performed a retrospective controlled analysis of 309 consecutive unicondylar and bicondylar tibial plateau fractures treated with open plate osteosynthesis at our institution's level I trauma centre during a recent 5-year period. We recorded operative times, injury characteristics, surgical treatment, and need for operative debridement due to infection. Operative times of infected cases were compared to uncomplicated surgical cases. Multivariable logistic regression analysis was performed to identify independent risk factors for postoperative infection. Mean operative time in the infection group was 2.8h vs. 2.2h in the non-infected group (p=0.005). 15 fractures (4.9%) underwent four compartment fasciotomies as part of their treatment, with a significantly higher infection rate than those not undergoing fasciotomy (26.7% vs. 6.8%, p=0.01). Open fracture grade was also significantly related to infection rate (closed fractures: 5.3%, grade 1: 14.3%, grade 2: 40%, grade 3: 50%, pinfection rates (13.9% vs. 8.7%, p=0.36). Multivariable logistic regression analysis of the entire study group identified longer operative times (OR 1.78, p=0.013) and open fractures (OR 7.02, psite infection. Operative times approaching 3h and open fractures are related to an increased overall risk for surgical site infection after open plating of the tibial plateau. Dual incision approaches with bicolumnar plating do not appear to expose the patient to increased risk compared to single incision approaches. Copyright © 2012 Elsevier Ltd. All rights reserved.
Methods The inclusion criteria of this study were skeletally mature patients with displaced fractures of the distal tibia treated with intramedullary nail with a minimum follow up of one year. Gustilo III open fractures and type C fractures of the AO classification (complete articular Stroke were excluded. The sample comprised 35 patients remained. The follow-up was 29.2 months. We evaluated the time of consolidation, malunion and complications. The functional results were described according to the AOFAS score. Results Of the 35 patients with fracture of the distal third of the tibia all of them presented fracture healing. The average time to union was 17.2 weeks (range: 11-26. Of the total sample, 5 patients had delayed union, requiring dynamic nail on average at 12 weeks. The malunion was present in 4 (11.4% patients. We found no difference (p = 0.201 in the time to union between fractures associated with fractures of the fibula treated (13sem or not (17sem. The AOFAS score was 86 points. Conclusion Intramedullary nailing with multiple distal locks like a good alternative treatment for distal tibia fractures AO type A or B, with low complication rate and a high rate of consolidation.
Sinigaglia, Riccardo; Gigante, Cosimo; Basso, Giampaolo; Turra, Sisto
Our purpose is to report a very rare case of proximal tibia triplane fracture, focusing the particular pattern of fracture and the long-term follow-up result. The triplane fracture is an exceptional fracture that occurs in the 3 planes (coronal, sagittal and transverse) close to the end of the growth period. A 15-year-old boy was admitted to our Center for a left femoral diaphyseal fracture and an ipsilateral lateral proximal tibia triplane fracture following a road accident. The femur was fixed with an intramedullary nail, the triplane fracture was anatomically reduced and percutaneously fixed. After 4 years follow-up, the knee was stable and with no complaints. Its range of motion was complete. Radiographs and MRI did not show any abnormality on the left leg and knee. In order to stabilize a proximal tibia triplane fracture a surgical internal fixation is usually required, with the possibility of a good long-term outcome also due to the growth potential remaining, if physeal arrest does not occur.
Schaffler, Mitchell B
.... Using a bisphosphonate (BIS) to suppress remodeling in the rabbit tibial stress fracture model, we found that antiresorptive therapy reduced the intensity of the stress fracture response in this model...
V. M. Shapovalov
Full Text Available The analysis of the frequency, structure, causes and circumstances of fractures of condyles of the tibia in 122 victims, as well as evaluated the results of treatment 57 patients using conventional techniques. Have been identified and systematized the main reasons for poor treatment outcomes, to develop modern diagnostic and treatment depending on the type of fractures of the condyles on the classification of J. Schatzker. The differentiated approach to the selection methodology reposition and fixation of fractures of condyles of the tibia from the limited or minimally invasive approaches with different variants bone grafting and stable functional osteosynthesis. Endovideohirurgicheskih determine the significance of technology in the diagnosis of injury and recovery of intraarticular soft tissue structures of the knee. Studied the immediate and long-term anatomical and functional results of the implementation developed tactics when choosing the method of reduction and fixation of the condyles of the tibia in 76 patients with fractures of various types.
Larsen, Peter; Læssøe, Uffe; Rasmussen, Sten
INTRODUCTION: Despite the high number of studies evaluating the outcomes following tibial shaft fractures, the literature lacks studies including objective assessment of patients' recovery regarding gait pattern. The purpose of the present study was to evaluate whether gait patterns at 6 and 12...... months post-operatively following intramedullary nailing of a tibial shaft fracture are different compared with a healthy reference population. PATIENTS AND METHODS: The study design was a prospective cohort study. The primary outcome measurement was the gait patterns at 6 and 12 months post......-operatively measured with a 6-metre-long pressure-sensitive mat. The mat registers footprints and present gait speed, cadence as well as temporal and spatial parameters of the gait cycle. Gait patterns were compared to a healthy reference population. RESULTS: 49 patients were included with a mean age of 43.1 years (18...
Full Text Available Introduction: Tibia fractures in the skeletally immature patient can usually be treated with above knee cast or patellar tendon bearing cast. The purpose of our study was to evaluate epidemiology and outcome of Elastic stable intramedullary nailing fixation of pediatric tibial shaft fractures treated at our institution. Methods: Over a period of one year, fifty pediatric patients of tibial shaft fractures, with average age of 9.68 yr (SD=2.37, were treated with elastic stable intramedullary nail. Demographic data, union and complication rate were evaluated. Results: There were 36 closed and 14 open fractures. The average time to union was 11.6 weeks (SD=2.65 for close and 14.3 weeks (SD=2.62 for open fracture. There were no instances of growth arrest, remanipulations, or refracture. Conclusion: We conclude that flexible intramedullary fixation is an easy and effective method of management of both open and closed unstable fractures of the tibia in children.
Muzaffar, Nasir; Bhat, Rafiq; Yasin, Mohammad
The management of distal tibia fractures continues to remain a source of controversy and debate. The aim of this study was to evaluate the various complications of minimally invasive percutaneous plate osteosynthesis (MIPPO) using a locking plate for closed fractures of distal tibia in a retrospective study. Twenty-five patients with distal tibial fractures, treated by minimally invasive percutaneous plate osteosynthesis, were evaluated in a retrospective study. We studied the rate, probable etiological factors and preventive and corrective measures of various complications associated with minimally invasive plating of distal tibia. Mean age of the patients was 41.16 years (range 22 - 65). There were 13 male and 12 female patients. All fractures united at an average duration of 16.8 weeks. There were two cases of superficial and two cases of deep infection, and deep infections required removal of hardware for cure. There were four cases of ankle stiffness, most of them occurring in intra-articular fractures, three cases of palpable implant, three cases of malunion, one case of loss of reduction and one patient required reoperation. The average AO foot and ankle score was 83.6. We found MIPPO using locking plate to be a safe and effective method for the treatment of distal tibial fractures in properly selected patients yet can result in a variety of complications if proper precautions before, during and after surgery are not taken care of.
Babis, George C; Benetos, Ioannis S; Karachalios, Theofilos; Soucacos, Panayotis N
Intramedullary nailing has become a popular and effective procedure for the treatment of most tibial fractures. However, concerns regarding difficulties with reduction, the use and extent of intramedullary reaming, and hardware failure are probably the only constraints to its widespread use. In this prospective study, we present the clinical and radiographic results of the Orthofix tibial nailing system used in the treatment of tibial shaft fractures. One hundred and fifteen fresh tibial fractures in the same number of patients with a mean age of 37.5 years (17-85 years) were treated with operative stabilisation using the Orthofix tibial nailing system. All of the operations took place in a conventional operating theatre, on a simple tranlucent operating table and with manual reduction of the fracture. In the majority of the cases closed reduction and conventional reaming were performed and the mean duration of the operation was 38 min. Fracture healing occurred at 16 weeks (11-30 weeks) and was confirmed both clinically and radiographically. In six cases (two severely comminuted and four segmental fractures) delayed union occurred, however there were no tibial non-unions necessitating re-operation. There were no substantial differences in time to fracture union or in the rate of complications related to minimal open reduction. In addition, there seem to be more benefits than risks in the use of power intramedullary reaming during intramedullary fixation of tibial shaft fractures. In conclusion, most tibial shaft fractures can effectively and safely be treated using this type of locking intramedullary nailing device, with relatively few complications, and with satisfactory long-term clinical results.
Zamboni, Caio; Campos, Felipe Augusto Garcez de; Foni, Noel Oizerovici; Souza, Rafael Carboni; Christian, Ralph Walter; Mercadante, Marcelo Tomanik
The authors report on a case of tibial shaft fracture associated with ankle injury. The clinical, radiological and surgical characteristics are discussed. Assessment of associated injuries is often overlooked and these injuries are hard to diagnose. When torque occurs in the lower limb, the ankle becomes susceptible to simultaneous injury. It is essential to make careful assessment based on clinical, radiographic, intraoperative and postoperative characteristics in order to attain functional recovery.
Full Text Available ABSTRACT The authors report on a case of tibial shaft fracture associated with ankle injury. The clinical, radiological and surgical characteristics are discussed. Assessment of associated injuries is often overlooked and these injuries are hard to diagnose. When torque occurs in the lower limb, the ankle becomes susceptible to simultaneous injury. It is essential to make careful assessment based on clinical, radiographic, intraoperative and postoperative characteristics in order to attain functional recovery.
Robertson, Greg A J; Wood, Alexander M
Acute tibial shaft fractures represent one of the most severe injuries in sports. Return rates and return-to-sport times after these injuries are limited, particularly with regard to the outcomes of different treatment methods. To determine the current evidence for the treatment of and return to sport after tibial shaft fractures. OVID/MEDLINE (PubMed), EMBASE, CINAHL, Cochrane Collaboration Database, Web of Science, PEDro, SPORTDiscus, Scopus, and Google Scholar were all searched for articles published from 1988 to 2014. Inclusion criteria comprised studies of level 1 to 4 evidence, written in the English language, that reported on the management and outcome of tibial shaft fractures and included data on either return-to-sport rate or time. Studies that failed to report on sporting outcomes, those of level 5 evidence, and those in non-English language were excluded. Systematic review. Level 4. The search used combinations of the terms tibial, tibia, acute, fracture, athletes, sports, nonoperative, conservative, operative, and return to sport. Two authors independently reviewed the selected articles and created separate data sets, which were subsequently combined for final analysis. A total of 16 studies (10 retrospective, 3 prospective, 3 randomized controlled trials) were included (n = 889 patients). Seventy-six percent (672/889) of the patients were men, with a mean age of 27.7 years. Surgical management was assessed in 14 studies, and nonsurgical management was assessed in 8 studies. Return to sport ranged from 12 to 54 weeks after surgical intervention and from 28 to 182 weeks after nonsurgical management (mean difference, 69.5 weeks; 95% CI, -83.36 to -55.64; P Fractures treated surgically had a return-to-sport rate of 92%, whereas those treated nonsurgically had a return rate of 67% (risk ratio, 1.37; 95% CI, 1.20 to 1.57; P displaced fractures and to attempt nonsurgical management for undisplaced fractures. Primary surgical intervention of undisplaced
Full Text Available Background: Fractures of the tibia are important for their commonness and controversy in their management. Both conservative and surgical techniques have been introduced in an effort to speed time to union while minimizing the occurrence of complications. Standard treatment for low-energy tibial shaft fractures includes closed reduction and cast immobilization.The purpose of our study was to analyze retention of reduction after cast immobilization of simple isolated closed tibial fractures.Methods:All cases of the diagnosed isolated closed tibial shaft fracture treated non-surgically at Shafa Yahyaeian Hospital, between 2006 and 2009 were retrieved from medical records. We reviewed all medical records and radiographs of these patients to inquire about the patients’ demographic data used to analyze the outcomes of the non-surgical treatment.Results:Of the 26 patients examined, males were more commonly affected. The mean age was 27.46 (SD=7.58.The most common causes of injury were direct blow and motorcycle to pedestrian accident. Followup duration for each patient had an average of 9.12 months (SD=2.36. Using AO/OTA classification, distributed as 38.5% A1.1, 26.9% A2.1 and 34.6% A3.1 fractures. Most fractures were sustained in the lower third of the tibia (53.85%. All fractures eventually healed in an average of 13.7 weeks (SD=3.24. There was one case of delayed union in the 22nd week. In 92.3% of patients, shortening of bone was less than 1 cm, while in 7.7% patients, was more than 1.5 cm. We observed an anterior or posterior angulation > 10 ° in 2 (7.69% patients. Moreover, in 4 (15.38% patients we found varus angulation > 5°. Therefore, final deformity was observed in 8 (30.77% patients. No patient had non-union, rotational malalignment of more than 10 degrees, an infection, or a compartment syndrome.Conclusion : Our non-surgical treatment’s outcomes were not satisfactory, despite applying all principles for conservative treatment and
Haak, Karl Tobias; Palm, Henrik; Holck, Kim
Immediate weight-bearing following osteosynthesis of proximal tibial fractures is traditionally not allowed due to fear of articular fracture collapse. Anatomically shaped locking plates with sub-articular screws could improve stability and allow greater loading forces. The purpose of this study...... was to investigate if immediate weight-bearing can be allowed following locking plate osteosynthesis of proximal tibial fractures....
Lakhotia, Devendra; Sharma, Gaurav; Khatri, Kavin; Kumar, G.N. Kiran; Sharma, Vijay; Farooque, Kamran
Purpose Soft tissue healing is of paramount importance in distal tibial fractures for a successful outcome. There is an increasing trend of using anterolateral plate due to an adequate soft tissue cover on anterolateral distal tibia. The aim of this study was to evaluate the results and complications of minimally invasive anterolateral locking plate in distal tibial fractures. Methods This is a retrospective study of 42 patients with distal tibial fractures treated with minimally invasive ant...
Galbraith, John G.; Daly, Charles J.; Harty, James A.; Dailey, Hannah L.
Background: For tibial fractures, the decision to fix a concomitant fibular fracture is undertaken on a case-by-case basis. To aid in this clinical decision-making process, we investigated whether loss of integrity of the fibula significantly destabilises midshaft tibial fractures, whether fixation of the fibula restores stability to the tibia, and whether removal of the fibula and interosseous membrane for expediency in biomechanical testing significantly influences tibial interfragmentary m...
large or multiple wounds. • extensive contamination. • imprints or ... age and thence to inadequate initial care. CLASSIFICATION OF ... It is a fallacy that com- pound (open) fractures do not cause compartment syn- drome. Betadine should be avoid- ed, as it delays wound healing in what may already be an ischaemic area.
Dimitrova, D.; Proichev, V.; Popov, I.
Full text: The knee is one of the most often injured joint. Fractures of tibial condyles are the most common articular damages. Koton and Berg call them „bumper“ fractures the tibia plateau is vulnerable to both high- and low-energy injury mechanisms due to its vulnerable position in the lower extremity. It must bear significant weight and sustain significant impact and deceleration forces with little skeletal constraint, and has scant surrounding soft tissue and a tethered medial and lateral integument. Furthermore, the tibial plateau has relatively forgiving ligamentous attachments that must allow for a large range of motion in a single plane. Not surprisingly, given the diversity of injury, management of these fractures has come to include a wide variety of treatment strategies. traditionally, ligament injury associated with plateau fractures has been diagnosed indirectly with stress radiographs and physical examination. With increasing use of more sensitive MRI and arthroscopy, associated ligament and meniscus injuries have been found in significant percentages of plateau fractures. these soft tissue injuries consist primarily of MCL lesions, meniscal injuries, and ACL disruptions. However, studies addressing associated soft tissue injuries all agree that neither the type of plateau fracture nor the presence or absence of ligament injury correlates with the incidence of meniscal tears
Meardon, Stacey A; Derrick, Timothy R
Narrow step width has been linked to variables associated with tibial stress fracture. The purpose of this study was to evaluate the effect of step width on bone stresses using a standardized model of the tibia. 15 runners ran at their preferred 5k running velocity in three running conditions, preferred step width (PSW) and PSW±5% of leg length. 10 successful trials of force and 3-D motion data were collected. A combination of inverse dynamics, musculoskeletal modeling and beam theory was used to estimate stresses applied to the tibia using subject-specific anthropometrics and motion data. The tibia was modeled as a hollow ellipse. Multivariate analysis revealed that tibial stresses at the distal 1/3 of the tibia differed with step width manipulation (p=0.002). Compression on the posterior and medial aspect of the tibia was inversely related to step width such that as step width increased, compression on the surface of tibia decreased (linear trend p=0.036 and 0.003). Similarly, tension on the anterior surface of the tibia decreased as step width increased (linear trend p=0.029). Widening step width linearly reduced shear stress at all 4 sites (p<0.001 for all). The data from this study suggests that stresses experienced by the tibia during running were influenced by step width when using a standardized model of the tibia. Wider step widths were generally associated with reduced loading of the tibia and may benefit runners at risk of or experiencing stress injury at the tibia, especially if they present with a crossover running style. Copyright © 2014 Elsevier Ltd. All rights reserved.
Stenroos, A; Pakarinen, H; Jalkanen, J; Mälkiä, T; Handolin, L
Alpine skiing and snowboarding share the hazards of accidents accounting for tibial fractures. The aim of this study was to evaluate the fracture patterns and mechanisms of injury of tibial fractures taking place in downhill skiing and snowboarding. All patients with tibial fracture due to alpine skiing or snowboarding accident treated in four trauma centers next to the largest ski resorts in Finland were analyzed between 2006 and 2012. The hospital records were retrospectively reviewed for data collection: equipment used (skis or snowboard), age, gender, and mechanism of injury. Fractures were classified according to AO-classification. There were 342 skiing and 30 snowboarding related tibial fractures in 363 patients. Tibial shaft fracture was the most common fracture among skiers (n = 215, 63%), followed by proximal tibial fractures (n = 92, 27%). Snowboarders were most likely to suffer from proximal tibial fracture (13, 43%) or tibial shaft fracture (11, 37%). Snowboarders were also more likely than skiers to suffer complex AO type C fractures (23% vs 9%, p jumping (46%). The most important finding was the relatively high number of the tibial plateau fractures among adult skiers. The fracture patterns between snowboarding and skiing were different; the most common fracture type in skiers was spiral tibial shaft fracture compared to proximal tibial fractures in snowboarders. Children had more simple fractures than adults. © The Finnish Surgical Society 2016.
Full Text Available Objective:Tibial shaft fractures are straightforward to treat but when associated with soft tissue injury particularly at the nail entry/plate insertion site or there is significant comminution proximally or a large butterfly fragment/a second split component in the posterior coronal plane, it is a challenge to the treating surgeon. The aim of the present report is to describe the technique of posterior coronal plating in such a scenario and its advantages. Methods:Between July 2008 and June 2011, 12 patients were pro spectively treated by this approach using 4.5 mm broad dynamic compression plates. Results:The time of bony consolidation and full weight bearing averaged 21.7 weeks (range, 16-26 weeks. Patients were followed up for at least 24 months (range, 24-48 months. At 1 year postoper atively, no loss in reduction or alignment was observed. Mean Hospital for Lower Extremity Measurement Functional Score was 72.8 (range, 64-78. All patients were satisfied with their treatment outcomes. Conclusion:Direct posterior approach and fixation using prone position helps to visualise the fracture fragments and provide rigid fixation. The approach is simple and extensile easily, apart from advantages of less soft tissue and hardware problems compared to standard medial or lateral plating. Key words: Tibial fractures; Bone plates; Orthopedic procedures
Özkul, Emin; Gem, Mehmet; Arslan, Hüseyin; Alemdar, Celil; Azboy, İbrahim; Arslan, Seher G
The aim of this study is to investigate the effectiveness and reliability of limited-contact locking plates in minimally invasive percutaneous osteosynthesis (MIPO) of the lateral tibia. A retrospective study. The retrospective study included 14 patients who were operatively treated with an MIPO technique due to open tibial fractures between 2006 and 2012. The patients were 11 males and 3 females with a mean age of 13.2 (range, 9 to 16) years. The patients were followed up for a mean period of 2.4 (range, 1 to 5) years. The mechanism of the injuries included a motor vehicle accident (n=11), a shotgun injury (n=2), and a fall from height (n=1). According to the Gustilo-Anderson classification, 10 patients had type I (72%), 2 had type II (14%), and 2 had type III (14%) open fractures. The mean time to radiologic union was 18 (range, 11 to 32) weeks. No infection was detected that would require implant removal. No complications such as early epiphyseal closure, angulation, or limb-length inequality were observed. Limited-contact locking plates in MIPO of the lateral tibia is an effective alternative method in the treatment of open pediatric tibial fractures. Level IV-therapeutic.
Rolvien, Tim; Barvencik, Florian; Klatte, Till Orla; Busse, Björn; Hahn, Michael; Rueger, Johannes Maria; Rupprecht, Martin
The use of beta-tricalciumphospate (ß-TCP, Cerasorb®) ceramics as an alternative for autologous bone-grafting has been outlined previously, however with no study focusing on both clinical and histological outcomes of ß-TCP application in patients with multi-fragment tibial plateau fractures. The aim of this study was to analyze the long-term results of ß-TCP in patients with tibial plateau fractures. 52 patients were included in this study. All patients underwent open surgery with ß-TCP block or granulate application. After a mean follow-up of 36months (14-64months), the patients were reviewed. Radiography and computed-tomography were performed, while the Rasmussen score was obtained for clinical outcome. Furthermore, seven patients underwent biopsy during hardware removal, which was subsequently analyzed by histology and backscattered electron microscopy (BSEM). An excellent reduction with two millimeters or less of residual incongruity was achieved in 83% of the patients. At follow-up, no further changes occurred and no nonunions were observed. Functional outcome was good to excellent in 82%. Four patients underwent revision surgery due to reasons unrelated to the bone substitute material. Histologic analyses indicated that new bone was built around the ß-TCP-grafts, however a complete resorption of ß-TCP was not observed. ß-TCP combined with internal fixation represents an effective and safe treatment of tibial plateau depression fractures with good functional recovery. While its osteoconductivity seems to be successful, the biological degradation and replacement of ß-TCP is less pronounced in humans than previous animal studies have indicated. Copyright © 2017 Elsevier B.V. All rights reserved.
Dall'oca, C; Maluta, T; Lavini, F; Bondi, M; Micheloni, G M; Bartolozzi, P
The purpose of this study is to compare arthroscopic assisted reduction internal fixation (ARIF) treatment with open reduction internal fixation (ORIF) treatment in patients with tibial plateau fractures. We studied 100 patients with tibial plateau fractures (54 men and 46 women) examined by X-rays and CT scans, divided into 2 groups. Group A with associated meniscus tear was treated by ARIF technique, while in group B ORIF technique was used. The follow-up period ranged from 12 to 116 months. The patients were evaluated both clinically and radiologically according to the Rasmussen and HSS (The Hospital for Special Surgery knee-rating) scores. In group A, the average Rasmussen clinical score is 27.62 ± 2.60 (range, 19-30), while in group B is 26.81 ± 2.65 (range, 21-30). HSS score in group A was 76.36 ± 14.19 (range, 38-91) as the average clinical result, while in group B was 73.12 ± 14.55 (range, 45-91). According to Rasmussen radiological results, the average score for group A was 16.56 ± 2.66 (range, 8-18), while in group B was 15.88 ± 2.71 (range, 10-18). Sixty-nine of 100 patients in our study had associated intra-articular lesions. We had 5 early complications and 36 late complications. The study suggests that there are no differences between ARIF and ORIF treatment in Schatzker type I fractures. ARIF technique may increase the clinical outcome in Schatzker type II-III-IV fractures. In Schatzker type V and VI fractures, ARIF and ORIF techniques have both poor medium- and long-term results but ARIF treatment, when indicated, is the best choice for the lower rate of infections.
von Pfeil, Dirsko J F; Glassman, Mathieu; Ropski, Meaghan
To retrospectively describe cases treated via percutaneous tibial physeal fracture repair (PTPFR), using intra-operative fluoroscopy (IFL) or digital radiography (DR). To describe a technique ("spiking"), used to treat tibial tuberosity avulsion fractures. Clinical data of 14 dogs and three cats were included. The "spiking" technique was described. Intra-operative fluoroscopy (n = 11) and DR (n = 6) were successfully used in 11 tibial tuberosity avulsion fractures, one combined proximal physeal and tibial tuberosity avulsion fracture, and five distal tibial/fibular physeal fractures. Surgery times ranged from eight to 54 minutes. The "spiking" technique was successfully applied in six tibial tuberosity avulsion fracture cases. Return to function was at a mean (± standard deviation) of 1.9 (± 1.6) weeks. Long-term (>12 months; n = 17) follow-up was available at a mean of 40.6 (± 13.4) months. Major complications consisted of skin irritation from a pin (distal tibia / fibula physeal fracture case; 8 weeks post-PTPFR), and a bilateral grade II medial patella luxation (tibial tuberosity avulsion fracture case; 1.5 years post-PTPFR). One case developed a mild tibial tuberosity avulsion fracture re-avulsion. All conditions in these three cases were not of clinical concern at follow-up and final outcome was graded as good in these and excellent in the other 14 cases. Percutaneous tibial physeal fracture repair can be considered as a technique to treat tibial physeal fractures. The "spiking" technique was successfully applied in six dogs. A larger, prospective case series is indicated to provide additional clinical information.
Sarmiento, A; Gersten, L M; Sobol, P A; Shankwiler, J A; Vangsness, C T
We have reviewed our recent results with functional bracing of tibial shaft fractures in adults in order to define its role in management. We also analysed several parameters of these fractures to discover those which influence healing. A total of 780 tibial fractures treated in prefabricated functional braces were followed to union; shortening of less than 10 mm and angulation of less than 5 degrees in any plane were our parameters for successful treatment. The average time before applying a brace was 3.8 weeks for closed fractures and 5.2 weeks for open ones. Closed fractures healed in an average of 17.4 weeks and open fractures in an average of 21.7 weeks, 90% of them with 10 mm of shortening or less. Varus angulation and posterior angulation were the most common deformities encountered at union. There were 20 nonunions (2.5%) and 46 braces were discontinued during treatment. We found no association between fracture healing and the patient's age, the mechanism of injury or the fracture location. The degree of soft tissue injury appeared to have most influence on the speed of fracture healing. Fracture comminution and initial displacement, the condition of the fibula and the time from injury to bracing also appeared to affect the speed of union.
Honkonen, S E; Kannus, P; Natri, A; Latvala, K; Järvinen, M J
The isokinetic performance of thigh muscles was evaluated in 37 patients at an average of 7 years after sustaining a fracture of the tibial plateau. The mean torque deficit in the quadriceps of the injured limb was an average of 15% at a speed of 60 degrees/s and 16% at 180 degrees/s, while the corresponding deficits in the hamstrings were 3% and 8%. The radiological appearance of the injured knee correlated significantly to the quadriceps deficit at both speeds. Limited knee movement and thigh atrophy also correlated with the deficit at the lower speed. The strength deficit tended to decrease during follow-up. A multiple step-wise regression analysis showed that the radiological result, length of follow-up and thigh atrophy accounted for 47% of the variation in loss of quadriceps strength. At the higher speed, the functional result was associated with the deficit in quadriceps strength, and older patients had greater deficits than younger. Regression analysis indicated that the radiological and functional result accounted for 31% of the variation in quadriceps strength. Anatomical restoration of the tibial plateau and good muscle rehabilitation are important in obtaining good long term results after this fracture.
van den Berg, Juriaan; Reul, Maike; Nunes Cardozo, Menno; Starovoyt, Anastasiya; Geusens, Eric; Nijs, Stefaan; Hoekstra, Harm
INTRODUCTION: Although regularly ignored, there is growing evidence that posterior tibial plateau fractures affect the functional outcome. The goal of this study was to assess the incidence of posterior column fractures and its impact on functional outcome and general health status. We aimed to identify all clinical variables that influence the outcome and improve insights in the treatment strategies. A retrospective cohort study including 218 intra-articular tibial plateau fractures was conducted. All fractures were reclassified and applied treatment was assessed according to the updated three-column concept. Relevant demographic and clinical variables were studied. The patient reported outcome was assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS). Median follow-up was 45.5 (IQR 24.9-66.2) months. Significant outcome differences between operatively and non-operatively treated patients were found for all KOOS subscales. The incidence of posterior column fractures was 61.9%. Posterior column fractures, sagittal malalignment and an increased complication rate were associated with poor outcome. Patients treated according to the updated three-column concept, showed significantly better outcome scores than those patients who were not. We could not demonstrate the advantage of posterior column fracture fixation, due to a limited patient size. Our data indicates that implementation of the updated three-column classification concept may improve the surgical outcome of tibial plateau fractures. Failure to recognize posterior column fractures may lead to inappropriate utilization of treatment techniques. The current concept allows us to further substantiate the importance of reduction and fixation of posterior column fractures with restoration of the sagittal alignment. 3.
Jöstl, Julian; Tiefenböck, Thomas Manfred; Hofbauer, Marcus; Winnisch, Markus; Lang, Nikolaus; Hajdu, Stefan; Sarahrudi, Kambiz
The purpose of this study was the comparison of the most commonly used surgical techniques (external fixation, intramedullary nailing, and plate fixation) for the treatment of distal tibial fractures (AO/OTA classification 42-A, B, C or 43-A, B1). A retrospective cohort study of patients who underwent surgical treatment for distal tibial fractures between 1992 and 2011 was performed. A total of 93 patients (52 male/41 female) met inclusion criteria. Statistically significant differences were found regarding the consolidation time of the intramedullary-nailing (147.32 ± 91.16 days) and the plate-fixation group (135.75 ± 110.75 days) versus the external-fixation group (163.12 ± 96.79 days; P = 0.001; P = 0.01). Significant differences were also observed in the range of motion (ROM) of the ankle joint in the intramedullary-nailing and plate-fixation group versus the ROM in the external-fixation group (P = 0.044; P = 0.025). The overall complication rate was 13/93 (14 %). Out of 66 patients treated with intramedullary nailing, 8 (12 %) suffered from complications. Out of the 15 patients treated with plate and 12 patients with external fixation, 2 (13 %) and 3 (25 %) showed complications, respectively. Our results demonstrate advantages in terms of shorter mobilization time and a better ROM of the ankle joint for intramedullary nailing and plate fixation compared with external fixation. Due to our results, we suggest internal fixation (intramedullary nailing or plate fixation) whenever patient's condition and the local fracture situation allow it.
Houben, I B; Raaben, M; Van Basten Batenburg, M; Blokhuis, T J
The relation between timing of weight bearing after a fracture and the healing outcome is yet to be established, thereby limiting the implementation of a possibly beneficial effect for our patients. The current study was undertaken to determine the effect of timing of weight bearing after a surgically treated tibial shaft fracture. Surgically treated diaphyseal tibial fractures were retrospectively studied between 2007 and 2015. The timing of initial weight bearing (IWB) was analysed as a predictor for impaired healing in a multivariate regression. Totally, 166 diaphyseal tibial fractures were included, 86 cases with impaired healing and 80 with normal healing. The mean age was 38.7 years (range 16-89). The mean time until IWB was significantly shorter in the normal fracture healing group (2.6 vs 7.4 weeks, p bearing is independently associated with impaired fracture healing in surgically treated tibial shaft fractures. Unlike other factors such as fracture type or soft tissue condition, early resumption of weight bearing can be influenced by the treating physician and this factor therefore has a direct clinical relevance. This study indicates that early resumption of weight bearing should be the treatment goal in fracture fixation. 3b.
Momaya, Amit M; Read, Connor; Steirer, Megan; Estes, Reed
The aim of this paper is to report the outcomes and any complications with arthroscopic bioabsorbable nail fixation of tibial eminence fractures in skeletally immature patients. We retrospectively reviewed all surgically treated tibial eminence fractures treated by a single surgeon and seven patients were identified with a minimum 2-year follow-up. Mean deficits of flexion and extension were minimal. Satisfactory Tegner levels, Lysholm knee scores, and International Knee Documentation Committee subjective scores were reported. Arthroscopic fixation of tibial eminence fractures with bioabsorbable nails yields satisfactory outcomes for this uncommon injury and obviates the need for future hardware removal.
Full Text Available Background: Management of open tibial diaphyseal fractures with bone loss is a matter of debate. The treatment options range from external fixators, nailing, ring fixators or grafting with or without plastic reconstruction. All the procedures have their own set of complications, like acute docking problems, shortening, difficulty in soft tissue management, chronic infection, increased morbidity, multiple surgeries, longer hospital stay, mal union, nonunion and higher patient dissatisfaction. We evaluated the outcome of the limb reconstruction system (LRS in the treatment of open fractures of tibial diaphysis with bone loss as a definative mode of treatment to achieve union, as well as limb lengthening, simultaneously. Materials and Methods: Thirty open fractures of tibial diaphysis with bone loss of at least 4 cm or more with a mean age 32.5 years were treated by using the LRS after debridement. Distraction osteogenesis at rate of 1 mm/day was done away from the fracture site to maintain the limb length. On the approximation of fracture ends, the dynamized LRS was left for further 15-20 weeks and patient was mobilized with weight bearing to achieve union. Functional assessment was done by Association for the Study and Application of the Methods of Illizarov (ASAMI criteria. Results: Mean followup period was 15 months. The mean bone loss was 5.5 cm (range 4-9 cm. The mean duration of bone transport was 13 weeks (range 8-30 weeks with a mean time for LRS in place was 44 weeks (range 24-51 weeks. The mean implant index was 56.4 days/cm. Mean union time was 52 weeks (range 31-60 weeks with mean union index of 74.5 days/cm. Bony results as per the ASAMI scoring were excellent in 76% (19/25, good in 12% (3/25 and fair in 4% (1/25 with union in all except 2 patients, which showed poor results (8% with only 2 patients having leg length discrepancy more than 2.5 cm. Functional results were excellent in 84% (21/25, good in 8% (2/25, fair in 8% (2/25. Pin
Full Text Available 【Abstract】Objective: To investigate the efficacy of the locking internal fixator (LIF, which includes the locking compression plate (LCP and the less invasive stable system (LISS, in the proximal and distal tibial fractures. Methods: We did a retrospective study on a total of 98 patients with either proximal or distal tibial fractures from January 2003 to January 2007, who had received the opera- tion with LIF by the minimally invasive plate osteosynthesis (MIPO technique. The data consisted of 43 proximal tibial fractures (type AO41C3 and 55 distal tibial fractures (type AO43C3. Results: No complications were observed in all patients after operation. The mean healing time was 8.4 months (range 5-14 months. Only two cases of delayed union occurred at postoperative 10 months. No infections were reported after the definitive surgery even in the cases of open fractures. All patients reached a full range of motion at postoperative 6 to 9 months and regained the normal functions of knee and ankle joints. Conclusion: Using LIF in MIPO technique is a reliable approach towards the proximal and distal tibial fractures that are not suitable for intramedullary nailing. Key words: Internal fixator; Tibial fractures; Fracture fixation, intramedullary; Bone plates
Kabukçuoğlu, Yavuz; Sökücü, Sami; Özcan, Çağrı; Beng, Kubilay; Lapçin, Osman; Demir, Bilal
The aim of this study was to compare solitary tibial diaphysis fractures and tibial diaphysis fractures associated with fibula fracture treated with the intramedullary nailing method. Records of 254 patients diagnosed with tibial diaphysis fracture and treated with intramedullary nailing between 2010 and 2013 were examined and 30 patients were included in the study. Group 1 comprised patients with solitary tibial diaphysis fracture, and Group 2 was made up of patients with tibial diaphysis fractures associated with fibula fracture. Patients in both groups were compared in terms of time to surgery, duration of surgical tourniquet, time to union, and varus, valgus, recurvatum, and antecurvatum deformities of the tibia at final follow-up. No statistically significant difference was found between the 2 groups in time to surgery, duration of surgical tourniquet, time to union, or varus, valgus, recurvatum, and antecurvatum deformities. Results indicated that intact fibula in tibial diaphysis fracture treated with intramedullary nailing was not a disadvantage; it did not affect rate of union or lead to loss of reduction, non-union, or malunion.
Durst, A; Clibbon, J; Davis, B
The fibula free flap is ideal for complex jaw reconstructions, with low reported donor and flap morbidity. We discuss a distal tibial stress fracture two months following a vascularised fibula free flap procedure. Despite being an unrecognised complication, a literature review produced 13 previous cases; only two were reported in the reconstructive surgery literature, with the most recent claiming to be the first. The majority of these studies treated this fracture non-operatively; none reported their patient follow-up. Each case presented with ipsilateral leg pain, which has been cited as an early donor site morbidity in as many as 40% of fibula free flap cases. It is known that the fibula absorbs at least 15% of leg load on weight bearing. Studies have shown severe valgus deformities in up to 25% of patients with fibulectomies. We treated our patient operatively, first correcting his worsening valgus deformity with an external fixator, then reinforcing his healed fracture with a long distal tibial plate. We believe that this complication is underreported, unexpected and not mentioned during the consenting process. By highlighting the management of our case and the literature, we aim to increase awareness (and thus further reporting and appropriate management) of this debilitating complication.
Stahel Philip F
Full Text Available Abstract Background Treatment options for comminuted tibial shaft fractures include plating, intramedullary nailing, and external fixation. No biomechanical comparison between an interlocking tibia nail with external fixation by an Ilizarov frame has been reported to date. In the present study, we compared the fatigue behaviour of Ilizarov frames to interlocking intramedullary nails in a comminuted tibial fracture model under a combined loading of axial compression, bending and torsion. Our goal was to determine the biomechanical characteristics, stability and durability for each device over a clinically relevant three month testing period. The study hypothesis was that differences in the mechanical properties may account for differing clinical results and provide information applicable to clinical decision making for comminuted tibia shaft fractures. Methods In this biomechanical study, 12 composite tibial bone models with a comminuted fracture and a 25 mm diaphyseal gap were investigated. Of these, six models were stabilized with a 180-mm four-ring Ilizarov frame, and six models were minimally reamed and stabilized with a 10 mm statically locked Russell-Taylor Delta™ tibial nail. After measuring the pre-fatigue axial compression bending and torsion stiffness, each model was loaded under a sinusoidal cyclic combined loading of axial compression (2.8/28 lbf; 12.46/124.6 N and torque (1.7/17 lbf-in; 0.19/1.92 Nm at a frequency of 3 Hz. The test was performed until failure (implant breakage or ≥ 5° angulations and/or 2 cm shortening occurred or until 252,000 cycles were completed, which corresponds to approximately three months testing period. Results In all 12 models, both the Ilizarov frame and the interlocking tibia nail were able to maintain fracture stability of the tibial defect and to complete the full 252,000 cycles during the entire study period of three months. A significantly higher stiffness to axial compression and torsion was
Conclusion: A wide variation was observed among orthopedics and traumatology specialists in Turkey regarding treatment of open tibial diaphysis fracture in adults. Data obtained from this study together with the available literature may be useful to further develop therapeutic approaches.
Bhandari, Mohit; Guyatt, Gordon; Tornetta, Paul; Schemitsch, Emil H.; Swiontkowski, Marc; Sanders, David; Walter, Stephen D.; Gregory Tennent Sanders, David W.; Macleod, Mark D.; Carey, Timothy; Leitch, Kellie; Bailey, Stuart; Gurr, Kevin; Konito, Ken; Bartha, Charlene; Low, Isolina; MacBean, Leila V.; Ramu, Mala; Reiber, Susan; Strapp, Ruth; Tieszer, Christina; Kreder, Hans J.; Stephen, David J. G.; Axelrod, Terry S.; Yee, Albert J. M.; Richards, Robin R.; Finkelstein, Joel; Ford, Michael; Gofton, Wade; Murnaghan, John; Schatztker, Joseph; Bulmer, Beverly; Conlan, Lisa; Laflamme, G. Yves; Berry, Gregory; Beaumont, Pierre; Ranger, Pierre; Laflamme, Georges-Henri; Gagnon, Sylvain; Malo, Michel; Fernandes, Julio; Poirier, Marie-France; McKee, Michael D.; Waddell, James P.; Bogoch, Earl R.; Daniels, Timothy R.; McBroom, Robert R.; Vicente, Milena R.; Storey, Wendy; Wild, Lisa M.; McCormack, Robert; Perey, Bertrand; Goetz, Thomas J.; Pate, Graham; Penner, Murray J.; Panagiotopoulos, Kostas; Pirani, Shafique; Dommisse, Ian G.; Loomer, Richard L.; Stone, Trevor; Moon, Karyn; Zomar, Mauri; Webb, Lawrence X.; Teasdall, Robert D.; Birkedal, John Peter; Martin, David Franklin; Ruch, David S.; Kilgus, Douglas J.; Pollock, David C.; Harris, Mitchel Brion; Wiesler, Ethan Ron; Ward, William G.; Shilt, Jeffrey Scott; Koman, Andrew L.; Poehling, Gary G.; Kulp, Brenda; Creevy, William R.; Stein, Andrew B.; Bono, Christopher T.; Einhorn, Thomas A.; Brown, T. Desmond; Pacicca, Donna; Sledge, John B.; Foster, Timothy E.; Voloshin, Ilva; Bolton, Jill; Carlisle, Hope; Shaughnessy, Lisa; Obremskey, William T.; LeCroy, C. Michael; Meinberg, Eric G.; Messer, Terry M.; Craig, William L.; Dirschl, Douglas R.; Caudle, Robert; Harris, Tim; Elhert, Kurt; Hage, William; Jones, Robert; Piedrahita, Luis; Schricker, Paul O.; Driver, Robin; Godwin, Jean; Kregor, Philip James; Tennent, Gregory; Truchan, Lisa M.; Sciadini, Marcus; Shuler, Franklin D.; Driver, Robin E.; Nading, Mary Alice; Neiderstadt, Jacky; Vap, Alexander R.; Vallier, Heather A.; Patterson, Brendan M.; Wilber, John H.; Wilber, Roger G.; Sontich, John K.; Moore, Timothy Alan; Brady, Drew; Cooperman, Daniel R.; Davis, John A.; Cureton, Beth Ann; Mandel, Scott; Orr, R. Douglas; Sadler, John T. S.; Hussain, Tousief; Rajaratnam, Krishan; Petrisor, Bradley; Drew, Brian; Bednar, Drew A.; Kwok, Desmond C. H.; Pettit, Shirley; Hancock, Jill; Sidorkewicz, Natalie; Cole, Peter A.; Smith, Joel J.; Brown, Gregory A.; Lange, Thomas A.; Stark, John G.; Levy, Bruce A.; Swiontkowski, Marc F.; Garaghty, Mary J.; Salzman, Joshua G.; Schutte, Carol A.; Tastad, Linda; Vang, Sandy; Seligson, David; Roberts, Craig S.; Malkani, Arthur L.; Sanders, Laura; Dyer, Carmen; Heinsen, Jessica; Smith, Langan; Madanagopal, Sudhakar; Frantz-Bush, Linda; Coupe, Kevin J.; Tucker, Jeffrey J.; Criswell, Allen R.; Buckle, Rosemary; Rechter, Alan Jeffrey; Sheth, Dhiren Shaskikant; Urquart, Brad; Trotscher, Thea; Anders, Mark J.; Kowalski, Joseph M.; Fineberg, Marc S.; Bone, Lawrence B.; Phillips, Matthew J.; Rohrbacher, Bernard; Stegemann, Philip; Mihalko, William M.; Buyea, Cathy; Augustine, Stephen J.; Jackson, William Thomas; Solis, Gregory; Ero, Sunday U.; Segina, Daniel N.; Berrey, Hudson B.; Agnew, Samuel G.; Fitzpatrick, Michael; Campbell, Lakina C.; Derting, Lynn; McAdams, June; Goslings, J. Carel; Ponsen, Kees Jan; Luitse, Jan; Kloen, Peter; Joosse, Pieter; Winkelhagen, Jasper; Duivenvoorden, Raphaël; Teague, David C.; Davey, Joseph; Sullivan, J. Andy; Ertl, William J. J.; Puckett, Timothy A.; Pasque, Charles B.; Tompkins, John F.; Gruel, Curtis R.; Kammerlocher, Paul; Lehman, Thomas P.; Puffinbarger, William R.; Carl, Kathy L.; Weber, Donald W.; Jomha, Nadr M.; Goplen, Gordon R.; Masson, Edward C. O.; Beaupre, Lauren A.; Greaves, Karen E.; Schaump, Lori N.; Jeray, Kyle J.; Goetz, David R.; Westberry, David E.; Broderick, J. Scott; Moon, Bryan S.; Tanner, Stephanie L.; Powell, James N.; Buckley, Richard E.; Elves, Leslie; Connolly, Stephen; Abraham, Edward P.; Steele, Trudy; Ellis, Thomas; Herzberg, Alex; Brown, George A.; Crawford, Dennis E.; Hart, Robert; Hayden, James; Orfaly, Robert M.; Vigland, Theodore; Vivekaraj, Maharani; Bundy, Gina L.; Miclau, Theodore; Matityahu, Amir; Coughlin, R. Richard; Kandemir, Utku; McClellan, R. Trigg; Lin, Cindy Hsin-Hua; Karges, David; Cramer, Kathryn; Watson, J. Tracy; Moed, Berton; Scott, Barbara; Beck, Dennis J.; Orth, Carolyn; Puskas, David; Clark, Russell; Jones, Jennifer; Egol, Kenneth A.; Paksima, Nader; France, Monet; Wai, Eugene K.; Johnson, Garth; Wilkinson, Ross; Gruszczynski, Adam T.; Vexler, Liisa
BACKGROUND: There remains a compelling biological rationale for both reamed and unreamed intramedullary nailing for the treatment of tibial shaft fractures. Previous small trials have left the evidence for either approach inconclusive. We compared reamed and unreamed intramedullary nailing with
Himanshu G. Ladani
Background: Closed reduction & plaster is standard and effective form of treatment in majority of paediatric tibial shaft fractures. Operative intervention is necessary in unstable fractures, open fractures, poly trauma patients and compartment syndrome or severe soft tissue compromise. Historically, external fixation and plating were the treatment options available, but having complications like infection, overgrowth and refracture. Reamed locked intramedullary nails pose unnecessary risk to...
Belangero, William Dias; Santos Pires, Robinson Esteves; Livani, Bruno; Rossi, Felipe Lins; de Andrade, Andre Luis Lugnani
Treatment of proximal tibial shaft fractures is always challenging. Despite the development of modern techniques, the literature still shows high complication rates, especially regarding proximal fragment malalignment. It is well known that knee position in flexion during tibial nailing is responsible for extension and valgus deformities of the proximal fragment. Unlike in tibial shaft fractures, nails do not reduce proximal tibial fractures due to the medullary canal width. This study aims to describe a simple, useful, and inexpensive technique to prevent valgus and extension deformities when treating proximal tibial fractures using conventional nails: the so-called clothesline technique.
Rotter, R; Gierer, P
The anatomical reconstruction of tibial pilon fractures is a major challenge with respect to preoperative planning, time management and the intraoperative procedure. Presentation of the various surgical procedures available and the clinical outcome. The established open reduction and internal plate fixation procedures form the basis for new minimally invasive treatment concepts. The current results of comparative studies and basic literature are discussed. The treatment result depends on the severity of the initial fracture and accompanying soft tissue damage. Essential is an anatomical reduction with an articular displacement of less than 2 mm. Overall, only approximately half of all patients return to work within 1 year. The fixation procedure used is not relevant for this purpose. Both plate fixation and the combination of external fixator plus minimally invasive articular reconstruction with and without arthroscopy achieve equivalent results. Good clinical results can be achieved by an accurate preoperative planning with respect to the surgical procedure, time of surgery and the surgical steps. In cases of disregarding these points and inadequate surgical expertise, loss of function and reduced quality of life are impending.
Schottel, Patrick C; Berkes, Marschall B; Little, Milton T M; Lazaro, Lionel E; Nguyen, Joseph T; Helfet, David L; Lorich, Dean G
To quantify the radiographic tibia and fibula shaft fracture characteristics that are associated with a concomitant ipsilateral ankle injury. Retrospective case-control study. Academic level I trauma center. Seventy-one adult patients with an operatively treated tibial shaft fracture met the inclusion/exclusion criteria. Preoperative radiographs were categorized according to tibia and fibula fracture pattern, location and spatial relationship to each other. Preoperative computed tomographic scans were then evaluated to assess for the presence of an articular ankle injury. (1) incidence of concomitant tibial shaft fracture and ipsilateral ankle injury; and (2) statistical association between tibia and fibula fracture characteristics in patients with and without an ipsilateral ankle fracture. Thirty-five of 71 (49.3%) tibial shaft fracture patients had a concomitant ipsilateral ankle injury. Of these, 31 (88.6%) ankle injuries occurred in patients with a spiral pattern tibia fracture of the distal third diaphysis (P fracture, a distal one-third tibial shaft fracture location, or a spiral pattern fibula fracture all were significantly associated with the presence of an ipsilateral ankle injury (P ≤ 0.001; P = 0.001; and P = 0.002, respectively). Patients with either a transverse pattern or absent fibula fracture, a nonspiral pattern tibia fracture, or a midshaft diaphyseal tibia fracture location were significantly less likely to have an associated ankle injury (P ≤ 0.001; P ≤ 0.001; and P = 0.012, respectively). Ipsilateral ankle fractures are commonly associated with tibial shaft fractures, specifically distal one-third spiral type injuries. Recognition of an associated ankle injury is important as it can alter operative and postoperative management. Clinical studies are needed to examine patient outcomes with or without ipsilateral ankle injury to determine the clinical significance of this entity. Prognostic level IV. See instructions for authors for a
Hooper, G J; Keddell, R G; Penny, I D
We performed a prospective randomised trial on matched groups of patients with displaced tibial shaft fractures to compare conservative treatment with closed intramedullary nailing. The results showed conclusively that intramedullary nailing gave more rapid union with less malunion and shortening. Nailed patients had less time off work with a more predictable and rapid return to full function. We therefore consider that closed intramedullary nailing is the most efficient treatment for displaced fractures of the tibial shaft.
E Albuquerque, Rodrigo Pires; Giordano, Vincenzo; Carvalho, Antônio Carlos Pires; Puell, Thiago; E Albuquerque, Maria Isabel Pires; do Amaral, Ney Pecegueiro
Simultaneous bilateral avulsion fracture of the tibial tuberosity in teenagers is a rare lesion. We describe the first case in the literature, in a teenage girl who sustained a fall while jumping during a volleyball match. No predisposing factors were iden tified. The lesions were treated with open surgical reduction and internal fixation. The aim of the present study was to present a case of simultaneous bilateral avulsion fracture of the tibial tuberosity in a teenage girl and the therapy used.
Rincon Plata, Gustavo A; Pardo Laverde, Carlos E; Munoz Vargas, Edgar
The paper is about of the fractures for extraction of the anterior tibial tuberosity, those which relatively frequent and they are generally presented in patients that carry out sport activities and in most of the cases they have association with the Syndrome of Osgood Schlatter; three cases are presented of patient with fractures with extraction of the anterior tibial tuberosity in immature skeleton, their treatment and their definitive result
Full Text Available Purpose. We evaluated whether intramedullary nail fixation for tibial diaphysis fractures with concomitant fibula fractures (except at the distal one-third level managed conservatively with an associated fibula fracture resulted in ankle deformity and assessed the impact of the ankle deformity on lower extremity function. Methods. Sixty middle one-third tibial shaft fractures with associated fibular fractures, except the distal one-third level, were included in this study. All tibial shaft fractures were anatomically reduced and fixed with interlocking intramedullary nails. Fibular fractures were managed conservatively. Hindfoot alignment was assessed clinically. Tibia and fibular lengths were compared to contralateral measurements using radiographs. Functional results were evaluated using the Knee Injury and Osteoarthritis Outcome Score (KOOS and the Foot and Ankle Disability Index Score (FADI. Results. Anatomic union, defined as equal length in operative and contralateral tibias, was achieved in 60 fractures (100%. Fibular shortening was identified in 42 fractures (68%. Mean fibular shortening was 1.2 cm (range, 0.5–2 cm. Clinical exams showed increased hindfoot valgus in 42 fractures (68%. The mean KOOS was 88.4, and the mean FADI score was 90. Conclusion. Fibular fractures in the middle or proximal one-third may need to be stabilized at the time of tibial intramedullary nail fixation to prevent development of hindfoot valgus due to fibular shortening.
Alho, A; Benterud, J G; Høgevold, H E; Ekeland, A; Strømsøe, K
Thirty-five displaced tibial shaft fractures, treated with functional bracing were compared with 43 similar fractures, treated with locked intramedullary nailing. There were 22 excellent/good results in the brace group and 38 in the nail group. There was one infection in the brace group and three in the nailed group. There were five delayed unions and two nonunions in the brace group and one delayed union in the nail group. The functional results in the nailed group were better than the braced group but locked intramedullary nailing of tibial shaft fractures require special resources and training. Locked intramedullary nailing fullfils all the functional criteria for acceptable fracture care.
... MD, Thompson SR, eds. DeLee and Drez's Orthopaedic Sports Medicine . 4th ed. Philadelphia, PA: Elsevier Saunders; 2015:chap 13. Safran MR, Zachazewski J, Stone DA. Metatarsal stress fracture. In: Safran MR, Zachazewski J, Stone DA, ...
Weber, Jason M; Vidt, Louis G; Gehl, Richard S; Montgomery, Travis
The majority of plantar heel pain is diagnosed as plantar fasciitis or heel spur syndrome. When historic or physical findings are unusual or when routine treatment proves ineffective, one should consider an atypical cause of heel pain. Stress fractures of the calcaneus are a frequently unrecognized source of heel pain. In some cases they can continue to go unrecognized because the symptoms of calcaneal stress fractures sometimes improves with treatments aimed at plantar fasciitis. Calcaneal stress fractures can occur in any population of adults and even children and are common among active people, such as athletes, sports enthusiasts, and military personnel. It is likely that the number of diagnosed calcaneal stress fractures will rise among practitioners with an increased recognition of their possibility.
Ma, Ju-Lei; Xu, Yun-Qin; Shen, Tu-Gang; Li, Qiang
To analyze the risk factor of infection for complex tibial plateau fractures after operation. Totally clinical data of 293 patients with complex tibial plateau fractures underwent open reduction and internal fixation were retrospectively analyzed from September 2010 to March 2015, including 199 males and 94 females, ranging in age from 17 to 80 years old with an average of 47.3 years old. The possible risk factors such as gender, age, smoking, diabetes, type of fracture(open/closed), classification of open fracture(Gustilo-Anderson classification), classification of soft tissue injury in closed fracture (Tscherne-Gotzen classification), fracture classification(Schatzker V/VI), osteofascial compartment syndrome, ASA score, anesthesia, timing of surgery, operative time(150 min), surgical approach, combined approach or not, internal fixation site were studied. The multivariate Logistic regression model was used to analyze the risk factors. Twelve patients were infected of all 293 patients after operation, the infection rate was 4.10%. Univariate analysis showed that fracture type(χ ² =14.496, P =0.001), fracture classification(χ²=4.560, P =0.033), osteofascial compartment syndrome(χ²=15.631, P =0.001), operative time(χ²=11.233, P =0.001) were correlated with complex tibial plateau fractures postoperative infection. Multivariate analysis showed that open fractures(χ²=9.696, P =0.002) and osteofascial compartment syndrome(χ²=9.119, P =0.003) were complex tibial plateau fracture risk factors for infection after operation. Open fractures and osteofascial compartment syndrome are risk factor of complex tibial plateau fracture for infection after operation. While through debridement for open fracture patients, early diagnosis and promt treatment for osteofascial compartment syndrome could reduce incidence of infection.
Xue, Deting; Zheng, Qiang; Li, Hang; Qian, Shengjun; Zhang, Bo
The choice between reamed and unreamed intramedullary nailing for the treatment of open and closed tibial fractures is an ongoing controversy. We carried out a comprehensive search strategy. Six eligible randomised controlled trials were included. Three reviewers independently assessed methodological quality and extracted outcome data. Analyses were performed using Review Manager 5.0. The results showed lower risks of tibial fracture nonunion and implant failures with reamed nails compared to unreamed nails in closed tibial fractures [relative risk (RR): 0.41, 95% confidence interval (CI): 0.21–0.89, P = 0.008 for nonunion and RR: 0.35, 95% CI: 0.22–0.56, P reamed and unreamed nails in open tibial fractures. In conclusion, our study recommended reamed nails for the treatment of closed tibial fractures. But the choice for open tibial fractures remains uncertain. PMID:19841919
Wybier, M; Hamze, B; Champsaur, P; Parlier, C
Stress fractures of the tibia may disclose a longitudinal orientation which is obvious at bone scanning; a mild periostosis may appear on plain films; CT demonstrates a radially-oriented fracture in one aspect of the diaphyseal cortex. A cortical dissection-like vertically oriented insufficiency fracture may involve the medial aspect of the femoral shaft underlying the lesser trochanter; the fracture is concentric to the femoral cortex at CT. Insufficiency fractures of the sacrum may be misdiagnosed on plain films; bone scanning displays a typical H-shaped increased uptake which is a specific pattern. Insufficiency fractures of the pubis may appear as tumoral bone destruction; however no soft tissue mass is present at CT which in addition demonstrates normal fat tissue abutting the osseous lesion.
Fernando Antonio Silva de Azevedo Filho
Full Text Available ABSTRACT OBJECTIVE: This study aimed to evaluate the inter- and intra observer reproducibility of the radiographic score of consolidation of the tibia shaft fractures. METHODS: Fifty-one sets of radiographs in anteroposterior (AP and profile (P of the tibial shaft treated with intramedullary nail were obtained. The analysis of X-rays was performed in two stages, with a 21-day interval between assessments by a group of nine evaluators. To evaluate the reproducibility of RUST score between the evaluators, the intra-class correlation coefficient (ICC with a 95% confidence interval was used. ICC values range from +1, representing perfect agreement, to -1, complete disagreement. RESULTS: There was a significant correlation among all evaluators: ICC = 0.87 (95% CI 0.81 to 0.91. The intraobserver agreement proved to be substantial with ICC = 0.88 (95% CI 0.85 to 0.91 . CONCLUSION: This study confirms that the RUST scale shows a high degree of reliability and agreement.
Kirschberger, R.; Henning, A.; Graff, K.H.
The early exclusion of the presence of a stress fracture may be decisive for the success of an athlete. Scintigraphy with a bone-seeking radiopharmaceutical is suitable for the early detection of stress lesions. Of 30 athletes, fractures were demonstrated in 17 whereas in 6 they were excluded. We found most fractures in the tarsal bones such as os naviculare pedis, ossa cuneiformia and talus. The type of sport engaged in appears to be an important factor in determining the location of the fracture. Scintiphotos were taken in several views using region of interest techniques and two phase-scintigraphy. This method is considered to be useful for localization and follow-up of skeletal stress lesions as well as for differential diagnosis. (orig.) [de
Kirschberger, R.; Henning, A.; Graff, K.H.
The early exclusion of the presence of a stress fracture may be decisive for the success of an athlete. Scintigraphy with a bone-seeking radiopharmaceutical is suitable for the early detection of stress lesions. Of 30 athletes, fractures were demonstrated in 17 whereas in 6 they were excluded. We found most fractures in the tarsal bones such as os naviculare pedis, ossa cuneiformia and talus. The type of sport engaged in appears to be an important factor in determining the location of the fracture. Scintiphotos were taken in several views using region of interest techniques and two phase-scintigraphy. This method is considered to be useful for localization and follow-up of skeletal stress lesions as well as for differential diagnosis.
S. Petrović Savić
Full Text Available Total knee replacement (TKR is considered, during last years, as a very successful surgical technique for removing knee joint deformities and eliminating pain caused by cartilage damage. In literature, as primary causes for knee joint endoprothesis damage are cited complex movements which cause occurrences of complex stress conditions, sagital radius conformity, sliding, types of materials etc. Aim of this study is analysis of contact stresses that occur on tibial implant for 15°, 45° and 60° knee flexion and 50 kg, 75 kg, 100 kg and 125 kg weight. Knee joint prosthesis model and finite elements method (FEM analysis are done in software Catia V5. For this analysis we used ultra-high molecular weight polyethylene (UHMWPE for tibial implant material and AISI 316, AISI 317, AISI 321, 17-4PH, CoCrMo, Ti6Al4V and SAE A-286 for femoral component materials. Results show that area of maximal contact stress is identified in medial and lateral part of tibial implant. Von Mises stress values vary regarding of flexion degree and weight, but values are approximate for types of chosen materials. Contact stress location corresponds to damage that occur on tibial implant during exploitation.
Richter, D; Hahn, M P; Laun, R A; Ekkernkamp, A; Muhr, G; Ostermann, P A
In a prospective study, 53 fractures of the distal fifth of the tibia were stabilized by unreamed nailing. Additional involvement of the ankle joint occurred in 18 patients. 50 patients returned for follow-up. In 30 patients tibia and fibula were fractured at the same (distal) level; in 20 patients the fracture of the fibula was located more proximally. In 12 patients the fractures extended into the tibial pilon. Severe soft tissue damage was seen in 24 fractures (18 open, 6 closed). Ninety percent of all fractures healed uneventfully without further surgical intervention after unreamed nailing. In two patients the unreamed nail had to be exchanged for a reamed tibial nail. Bone grafting and secondary dynamization of the nail by removal of a proximal interlocking bolt were performed in one case each. Thirty-one fractures healed in anatomical position. Valgus or varsus angulation of less than 5 degrees occurred in 18 patients. One fracture healed with rotatory angulation of 15 degrees. The highest rate of complications (22%) was seen in patients with distal fractures of the fibula without additional plating (of the fibula). There was no deep infection. Tibial fractures close to the ankle joint can be managed by unreamed nailing. Distal fractures of the fibula should be stabilized by additional plating. Because of the unreamed technique of implantation this procedure can also be used in grade II or III open fractures.
Medial tibial stress syndrome (MTSS), also known as shin splints, is one of the most common sports injuries. Although 20% of the jumping and running athletes have MTSS at some point while engaging in sporting activities, we know little about it. There is a lack of knowledge regarding making the
Winters, Marinus; Eskes, Michel; Weir, Adam; Moen, Maarten H.; Backx, Frank J. G.; Bakker, Eric W. P.
Medial tibial stress syndrome (MTSS) is a common exercise-induced leg injury among athletes and military personnel. Several treatment options have been described in the literature, but it remains unclear which treatment is most effective. The objective of this systematic review was to assess the
Background. Medial tibial stress syndrome (MTSS) is the most common lower-leg injury in athletes, and is thought to be caused by bony overload. To prevent MTSS, both pathophysiological and aetiological factors specific to MTSS need to be identified. The intrinsic risk factors that contribute to the development of MTSS are ...
Baltaci, G; Ozer, H; Tunay, V B
A sixteen-year-old boy suffered from sharp pain in the knee during a jump while playing basketball. He had a positive history of Osgood Schlatter disease. Radiographic evaluation demonstrated an avulsion fracture of the tibial tuberosity Type III according to the classification of Watson-Jones. Rehabilitation after avulsion fracture of the tibial tuberosity is an important consideration for this relatively uncommon adolescent injury. In such avulsion fractures, landing on the ground with the knee fully extended after a jump is the most likely cause. This case report reviews the rehabilitation program, and selected functional outcome measures after rehabilitation are reported. The patient returned to sporting activity after 12 months.
Zhang, Yu; Song, Lijun; Li, Xiang; Fang, Jiahu
The authors have identified a subset of unicondylar tibial plateau depression fracture patterns caused by a flexion-valgus force. The purpose of this study was to describe this fracture pattern and suggest a modified lateral approach that may allow for improved reduction and stabilization. The preoperative radiographs and CT scans of 102 patients who sustained unicondylar tibial plateau fractures (OTA 41B) were reviewed. Twenty-six fracture patients had posterolateral (PL) tibial plateau depression fractures. By medical record review and telephone follow-up, the injury mechanism of the 22 unicondylar tibial plateau fractures was confirmed as a flexion-valgus force. The radiographic features of those cases were analyzed and measured. To address this specific fracture pattern, a modified approach combined with a novel intra-articular osteotomy was applied. According to the morphological characteristics, this tibial plateau fracture pattern could be divided into two subtypes: type A was a confined, basin-like articular surface depression fracture located in the PL quadrant, and type B was a cancellous fracture involving the PL tibial plateau resulting in a decrease in the posterior slope. One radiographic hallmark of this fracture pattern is an anatomically or a mechanically intact posterior column wall. The novel approach was applied to both types. The postoperative radiographic measurements revealed excellent reduction quality. On axial scans, the distance between the most posterior rafting screw and the tangent line of the tibial plateau rim was 3.0 ± 2.07 mm (from -1.9 to 4.3), and the angulation between them was 8.9 ± 3.02° (from -7.3 to 15.6). These results indicated excellent PL quadrant coverage from the rafting screws. Flexion-valgus force-induced unicondylar tibial plateau depression fracture is a unique injury pattern. We suggest a novel surgical approach to address this injury's key features, which may facilitate exposure and enhance fixation
Zelle, Boris A; Boni, Guilherme; Hak, David J; Stahel, Philip F
Reamed locked intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Supra-patellar tibial nailing in the semiextended position has been suggested as a safe and effective surgical technique that allows mitigating certain challenges of the standard subpatellar approach. Suprapatellar nailing seems to facilitate achieving and maintaining fracture reduction, particularly in proximal third tibia fractures. Preliminary investigations have suggested that this technique is associated with a low rate of complications, including a reduced incidence of postoperative anterior knee pain. Further clinical investigations are necessary to establish overall complication rates and long-term subjective outcomes. Copyright 2015, SLACK Incorporated.
Nicolini, Alexandre P; Carvalho, Rogerio T; Ferretti, Mario; Cohen, Moises
Tibial tuberosity avulsion fractures are injuries accounting for less than 3% of all epiphyseal and 1% of all physeal injuries in adolescents. Bilateral injuries are very rare, with only 19 cases described in the literature. These types of fractures occur commonly in male teenagers during sport activities and are often associated with other orthopaedic disorders. We report the case of a male teenager with simultaneous bilateral tibial tubercle fractures, describe the evolution and treatment of this injury and review the literature on this subject. Case report.
Gross, Steven C; Galos, David K; Taormina, David P; Crespo, Alexander; Egol, Kenneth A; Tejwani, Nirmal C
To examine the potential benefits and risks associated with weight-bearing after intramedullary (IM) nailing of unstable tibial shaft fractures. Randomized controlled trial. Two New York State level 1 trauma centers, one level 2 trauma center, and 1 tertiary care orthopaedic hospital in a large urban center in New York City. Eighty-eight patients with 90 tibial shaft fractures were enrolled. The following were used as inclusion criteria: (1) skeletally mature adult patients 18 years of age or older, (2) displaced fractures of tibial diaphysis (OTA type 42) treated with operative intervention, and (3) radiographs, including injury, operative, and completion of follow-up. Sixty-eight patients with 70 tibial shaft fractures completed follow-up. All patients were treated with locked IM nailing. Patients were randomized to 1 of 2 groups: immediate weight-bearing-as-tolerated (WBAT) or non-weight-bearing for the first 6 postoperative weeks (NWB). Fracture union or treatment failure/revision surgery. There was no statistical difference in the observed time to union between groups (WBAT = 22.1 ± 11.7 weeks vs. NWB = 21.3 ± 9.9 weeks; P = 0.76). Rates of complications did not statistically differ between groups. No fracture loss of reduction leading to malunion was encountered. Short Musculoskeletal Function Assessment scores for all domains did not statistically differ between groups. Immediate weight-bearing after IM nailing of tibial shaft fractures is safe and is not associated with an increase in adverse events or complications. Patients should be allowed to bear weight as tolerated after IM nailing of OTA subtype 42-A and 42-B tibial shaft fractures. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Bode, G; Strohm, P C; Südkamp, N P; Hammer, T O
Treatment of tibial shaft fractures is still discussed controversial. In the present study current literature was reviewed with the objective to demonstrate current recommendations concerning tibial shaft fractures. Tibial shaft fractures are often caused by high-energy trauma with severe concomitant soft-tissue injuries. Solid bone union without hypertrophy, fast mobilization and full range of motion without further soft-tissue damages are the aims of the therapy. Non-displaced tibial shaft fractures in patients with good compliance can be treated conservatively. Deep venous thrombosis, compartment syndrome, soft tissue injury and chronic regional pain syndrome are the major risks of conservative treatment and need to be required. Operative treatment can be performed with several different implants. Intramedullary nailing with a huge biomechanical stability seems to be the implant of choice. Only rare indications for plate osteosynthesis can be found. The use of external fixation has declined even though external fixation is still the implant of choice in first line treatment of multiple trauma according to the damage control principles. Open fractures with precarious blood supply and weak soft tissue covering are vulnerable to complications and remain a challenge for every treating surgeon. Reconstruction of axis, length and rotation is essential for a good outcome. The choice of technique depends on fracture localization, type of fracture, history of concomitant disorders and soft tissue damage.
Hu, Xinji; Yang, Shuhua; Xiao, Deming; Lin, Bowen; Wang, Hua; Xu, Zhongshi; Zhao, Weidong; Zhang, Meichao
To research the biomechanical effect of different length bone plates on treatment of tibial shaft fracture. Forty-five tibia specimens from fresh adult corpse (20-40 years old) were donated (30-38 cm in length, 34 cm on average) and were divided into 3 groups randomly (n = 15). Under the following three conditions, the experiment was made separately. Compression stress-strain indexes of whole tibia were determined under the reverse, three spots curving and compression. The vertical elastic strain was 0-1 000 N, the reverse angle was 0-3 degrees, and three bending stress was 0-400 N. Then the center-section squint non-damage bone fracture model was made, fracture was fixed by 6, 10, 14 stainless steel AO LC-DCP, respectively. The compression stress-strain indexes were determined under reverse angle, three spots curving and compression, statistical analysis was done. The vertical direction strain value of 6, 10 and 14 hole steel plate under vertical compressions, was 0.449 +/- 0.241, 0.093 +/- 0.003, 0.139 +/- 0.005, respectively; showing significant difference between 10 and 14 hole steel plates and 6 steel plate (P 0.05). The lateral strain value of 6, 10 and 14 hole steel plate was 0.120 0 +/- 0.000 4, 0.127 5 +/- 0.010 0, 0.237 0 +/- 0.000 6 respectively, indicating a significant difference between stell plates of 6 and 10 hole and 14 hole steel plate (P 0.05). The torque of 6, 10 and 14 hole steel plate was (5.066 +/- 2.715) x 10(-3), (5.671 +/- 2.527) x 10(-3) and (4.570 +/- 2.228) x 10(-3) Nm, respectively and three spot curving vertical direction strain value was 0.049 +/- 0.009, 0.124 +/- 0.017, 0.062 +/- 0.009, respectively. There were significant differences between various steel plates (P < 0.01). For the fixation of tibial oblique fracture, 14 hole steel plate's stabilities of anti-vertical compression, anti-reverse and anti-curving are better than those of 6 hole steel plate under the condition of the same material quality, thickness, width and screw
Full Text Available Children and adolescents today, all before starting with regular sports activities and involvement in semi-professional and top professional sport, so it increases the num- ber of discovered stress fractures in this age. This type of injury can occur as a consequence of action one strong force, or the many repeated small force strength, to be exact, when the load (stress transcend ability reparations bones. Stress fractures are recorded and described up to the lower limbs. Research has been confirmed that the bones of lower leg are mostly made in injury, and with the el- derly and with the population of children and young adolescents. Occur in many sports, something to them is greater when the frequency of running and often are present in the female population. According to the results of numerous investigations, mistakes in the training are the most common cause of the emergence of stress fracture. In a direct comparison with complemented these injuries is the condition of muscles, so it is important that at the sa- me time carry out exercises strengthen muscles and stretching. Typical clinical signs of stress fractures are localized painful sensitivity to palpa- tion and runoff in a small number of cases. The basic diagnostic procedure is a medical check, it is the small, radiology and scintigraphyc diagnostics (most accurate and mag- netic resonance imaging. Treatment is usually without surgery and conservative, with rest and reducing stress, and its activity athlete breaks mainly between four and eight weeks. Only the very need surgical treatment The most important thing is that attention is focused on the proper prevention and to take all that it ever occurred to stress fractures that athletes ramble of the courts and the competition (better education of sports workers, separation of groups with increa- sed risk of the formation of an injury, adaptation activities age and abilities of athletes, adequate sports equipment, high-quality sports
Lakhotia, Devendra; Sharma, Gaurav; Khatri, Kavin; Kumar, G-N; Sharma, Vijay; Farooque, Kamran
Soft tissue healing is of paramount importance in distal tibial fractures for a successful outcome. There is an increasing trend of using anterolateral plate due to an adequate soft tissue cover on ante- rolateral distal tibia. The aim of this study was to evaluate the results and complications of minimally invasive anterolateral locking plate in distal tibial fractures. This is a retrospective study of 42 patients with distal tibial fractures treated with minimally invasive anterolateral tibial plating. This study evaluates the bone and soft tissue healing along with emphasis on complications related to bone and soft tissue healing. Full weight bearing was allowed in mean time period of 4.95 months (3-12 months). A major local complication of a wound which required revision surgery was seen in one case. Minor complications were identified in 9 cases which comprised 4 cases of marginal necrosis of the surgical wound, 1 case of superficial infection, 1 case of sensory disturbance over the anterolateral foot, 1 case of muscle hernia and 2 cases of delayed union. Mean distance between the posterolateral and anterolateral incision was 5.7 cm (4.5-8 cm). The minimally invasive distal tibial fixation with anterolateral plating is a safe method of stabilization. Distance between anterolateral and posterolateral incision can be placed less than 7 cm apart depending on fracture pattern with proper surgical timing and technique.
Wouters, Diederick B.; de Graaf, Joost S.; Hemmer, Patrick H.; Burgerhof, Johannes G. M.; Kramer, William L. M.
This article summarises the results of a newly developed technique that utilises Meniscus Arrows(A (R)) for the arthroscopic fixation of displaced tibial spine fractures in children and adolescents. Twelve tibial spine fractures in the knees of eleven children between 6 and 15 years old, with an
1996. Worthen, L., Hamill, J. Biomechanical issues in ballet : ankle alignment in pointe shoes. 15d, Annual Symposium on Medical Problems of Musicians... Mexico Race Walkers Association, Albuquerque, New Mexico , June, 1987. Biomechanics of fitness walking. American Diabetes Association, St. Louis, Missouri
Vicenti, G; Pesce, V; Tartaglia, N; Abate, A; Mori, C M; Moretti, B
The dynamic locking screw (DLS) in association with minimally invasive plate osteosynthesis (MIPO) in a bridging construct for simple metadiaphyseal long bone fractures enables modulation of the rigidity of the system and facilitates the development of early and triplanar bone callus. Twenty patients affected by distal tibial fracture were treated with MIPO bridging technique and DLS at the proximal side of the fracture. Time of consolidation, quality of the reduction, complications and American Orthopaedic Foot and Ankle Society (AOFAS) score were monitored and the results compared with those from a control group treated with only standard screws on both fracture sides. Student t-test for independent samples was used for the comparison of means between the two groups. Chi-square test was used for the comparison of proportions. A multiple logistic regression model was constructed to assess the possible confounding effects. Performance was considered significant for p<0.05. The mean healing time was 17.6 ± 2.8 weeks in the group treated with standard screws and 13.5 ± 1.8 weeks in the group treated with DLS (t=5.5, p<0.0001). The DLS was associated with early healing and triplanar bone callus. Copyright © 2014 Elsevier Ltd. All rights reserved.
Carrera, Ion; Gelber, Pablo Eduardo; Chary, Gaetan; Gomez Masdeu, Mireia; González Ballester, Miguel A; Monllau, Juan Carlos; Noailly, Jerome
The role of the proximal tibiofibular joint (PTFJ) in tibial plateau fractures is unknown. The purpose of this study was to assess, with finite-element (FE) calculations, differences in interfragmentary movement (IFM) in a split fracture of lateral tibial plateau, with and without intact fibula. It was hypothesized that an intact fibula could positively contribute to the mechanical stabilization of surgically reduced lateral tibial plateau fractures. A split fracture of the lateral tibial plateau was recreated in an FE model of a human tibia. A three-dimensional FE model geometry of a human femur-tibia system was obtained from the VAKHUM project database, and was built from CT images from a subject with normal bone morphologies and normal alignment. The mesh of the tibia was reconverted into a geometry of NURBS surfaces. The fracture was reproduced using geometrical data from patient radiographs, and two models were created: one with intact fibula and other without fibula. A locking screw plate and cannulated screw systems were modelled to virtually reduce the fracture, and 80 kg static body weight was simulated. Under mechanical loads, the maximum interfragmentary movement achieved with the fibula was about 30% lower than without fibula, with both the cannulated screws and the locking plate. When the locking plate model was loaded, intact fibula contributed to lateromedial forces on the fractured fragments, which would be clinically translated into increased normal compression forces in the fractured plane. The intact fibula also reduced the mediolateral forces with the cannulated screws, contributing to stability of the construct. This FE model showed that an intact fibula contributes to the mechanical stability of the lateral tibial plateau. In combination with a locking plate fixation, early weight bearing may be allowed without significant IFM, contributing to an early clinical and functional recovery of the patient.
Richter, D; Ostermann, P A; Ekkernkamp, A; Hahn, M P; Muhr, G
In a prospective study, 50 fractures of the distal fifth of the tibia with additional involvement of the ankle joint in 18 patients were stabilized by unreamed nailing. In all, 90% of all fractures healed uneventfully without further surgical intervention after unreamed nailing, the highest ratio of complications (22%) being seen in all patients with distal fractures of the fibula without additional plating (of the fibula). Tibial fractures close to the ankle joint can be managed by unreamed nailing; distal fractures of the fibula should be additionally stabilized by fibular plating.
Full Text Available The avulsion fractures of tibial tubercle are seen very rare and usually occur during sports activities in adolescence boys. The injury mechanism often is sudden and strong contraction of the quadriceps muscle. Rarely, it can be seen in Osgood- Schlatter disease (OSH with a simple trauma. In this case report, a 16 year-old male patient who admitted to emergency service because of knee pain with Ogden type IIB tibial tuberosity fracture in the basis OSH is discussed with literature.
Olesen, Ulrik Kähler; Pedersen, Nicolas Jones; Eckardt, Henrik
of treatment, and to determine the effect of delayed skin closure on this cost. METHODS: We reviewed all records of patients treated with a free flap in our institution for an open tibial fracture from 2002 to 2013. We calculated direct costs based on length of stay (LOS) and orthopaedic and plastic surgical...... rate from 60 to 27 %. CONCLUSIONS: Severe open tibial fractures covered with free flaps, cause over a year of absenteeism. Infection increases direct cost of treatment over 60 % and roughly doubles LOS. Early soft-tissue cover and correct antibiotics have been shown to improve outcomes...
Aleilimar Teixeira da Silva Júnior
Full Text Available ABSTRACT The objective here was to report two rare cases of anterior avulsion fracture of the tibial tuberosity in adolescents. Case 1 was a 15-year-old male who became injured through landing on his left knee and presented limited extension. Case 2 was a 16-year-old basketball player who presented sudden pain in the right knee and functional incapacity, after a jump. Imaging examinations (radiographs and computed tomography showed anterior avulsion fractures of the tibial tuberosity. Surgical fixation was performed using screws and anchors, while avoiding growth plate injury. The cases evolved without lower-limb deformities.
Butt Mohd Farooq
Full Text Available Background : In management of fracture of both tibia and fibula, intact fibula may delay union of tibial fractures. Method : Twenty five cases of ununited fractures of tibia were managed between 1997 and 2004, by partial fibulectomy done after 20 weeks after fracture and a POP cast given for 4 weeks which was changed to a PTB cast and weight bearing encouraged at the earliest. Result : All fractures united at an average time of 14 weeks (range 6 to 20 weeks after partial fibulectomy with acceptable alignment in coronal and sagittal planes. There was no neurovascular complication, limitation of joint motion or problem at the osteotomy site. Conclusion : Partial fibulectomy is a viable option in the management of tibial delayed and non-union.
Encinas-Ullán, C A; Fernandez-Fernandez, R; Rubio-Suárez, J C; Gil-Garay, E
Tibial plafond fractures are one of the most challenging injuries in orthopaedic surgery. Their results could be improved by following the new guidelines for the management, and modern plating techniques. The results and complication rate between anteromedial and anterolateral approach for open reduction and internal fixation of these fractures were compared. A study was conducted on 40 patients treated by open reduction an internal fixation between 2007 and 2008. The surgical approach was selected by the surgeon in charge, depending on fracture pattern and skin situation. Patients were evaluated clinically and radiographically by an independent orthopaedic surgeon, not involved in the surgical procedure, using clinical (American Orthopaedic Foot and Ankle Society score) and radiological criteria at a minimum of two years. The appearance of complications after both approaches was recorded. Forty patients were included. The mean age was 53 years, with 24 males and 16 females. Seventeen of the injuries were of high energy, and there were 8 open fractures (3 of type i, 4 type ii and one type iii), and 12 of the closed injuries were grade ii or iii in the Tscherne classification. Six patients (15%) had associated injuries. At final follow-up there were 33 (82%) excellent or good results. No statistical differences were found between either surgical approach regarding time to bone union, rate of delayed union and infection rate. Three plates of the anteromedial group and none of the anterolateral group needed to be removed. Open reduction and internal fixation of distal tibia fractures produced reliable results, with no statistical differences found between anteromedial and anterolateral surgical approaches. Clinical and radiological results and complication rate were mainly related to the fracture type. Copyright © 2012 SECOT. Published by Elsevier Espana. All rights reserved.
Bhandari, Mohit; Guyatt, Gordon H; Tornetta, Paul; Swiontkowski, Marc F; Hanson, Beate; Sprague, Sheila; Syed, Amena; Schemitsch, Emil H
Tibial fractures are the most common of all long bone fractures. Although many tibial fractures may be managed conservatively, a certain subset, including unstable fractures and open fractures, require operative stabilization. Intramedullary nails have become the popular choice of implant in the treatment of tibial shaft fractures. The variability in outcomes with tibial shaft fractures may reflect technical aspects of the surgical procedure and perioperative care regimens among surgeons. Identifying the distribution of surgeons' preferences in nailing technique, and the rationale for their choices, will aid in focusing educational activities for the orthopedic community and planning future clinical trials. Our objectives were to clarify surgeons' opinions regarding technical aspects of surgery and perioperative care after intramedullary nailing of closed and open tibial shaft fractures, and to identify predictors of surgeons' preferences in technique and perioperative care. This study was a cross-sectional survey using focus groups, key informants, and sampling to redundancy strategies to develop a survey to examine surgeons' preferences in the treatment of tibial shaft fractures. The survey was pilot tested for clarity and content validity. We mailed this survey in July 2000 to 577 orthopedic surgeons who have an interest in trauma care. These were members of the Orthopaedic Trauma Association, American Academy of Orthopaedic Surgeons, or European AO International affiliated trauma centers. We used several strategies to improve response rates including personalized cover letters, stamped return envelopes, follow-up telephone calls, and repeat mailing of questionnaires. Main outcome measures included technical issues such as reduction, exposure, intramedullary reaming, and interlocking screws; and factors associated with surgeons' preferences such as age, fellowship, academic practice, and geographic location. Four hundred forty-four surgeons (77%) responded
Hou Zhiyong; Zhang Liping; Zhang Qi; Yao Shuangquan; Pan Jinshe; Irgit, Kaan; Zhang Yingze
Objectives: To demonstrate radiographical characteristics of the relationship between distal spiral tibial shaft fractures and associated occult posterior malleolar fractures (PMF) that confirmed by CT and MRI. Materials and methods: X-rays for a ninety-six patients with spiral tibia fracture and associated PMF were reviewed. All patients additionally had an ankle CT. Patients with a negative CT scans underwent an ankle MRI. Radiographic observations included fracture location, characteristics, and a presence of a fracture line between the two injuries. Results: The spiral tibia fracture line was contiguous with PMF in 89 of 96 cases after evaluation with the CT and MRI. The line connecting the two injuries, which occurs between the medial inferior apex of the spiral tibia fracture line and the posterior superior apex of the PMF was identified as the “communication line”. In 47 of the 89 conjunction fractures, the “communication line” was detectable preoperatively and in 12 cases postoperatively by anteroposterior radiograph. By using the CT and MRI scans, we found that no “communication line” was present in only 7 cases. Conclusion: It is important to understand the nature of the association between distal spiral tibial shaft fractures and occult posterior malleolar fractures for optimal stabilization of the fracture and for appropriate rehabilitation. The “communication line” is a useful diagnostic clue for early recognition the occult PMF and alerts a closer evaluation of the lateral view and further CT examination.
Frederico Carlos Jaña Neto
Full Text Available OBJECTIVE: To analyze the characteristics of patients with Gustilo-Anderson Type III open tibial fractures treated at a tertiary care hospital in São Paulo between January 2013 and August 2014. METHODS: This was a cross-sectional retrospective study. The following data were gathered from the electronic medical records: age; gender; diagnosis; trauma mechanism; comorbidities; associated fractures; Gustilo and Anderson, Tscherne and AO classifications; treatment (initial and definitive; presence of compartment syndrome; primary and secondary amputations; MESS (Mangled Extremity Severity Score index; mortality rate; and infection rate. RESULTS: 116 patients were included: 81% with fracture type IIIA, 12% IIIB and 7% IIIC; 85% males; mean age 32.3 years; and 57% victims of motorcycle accidents. Tibial shaft fractures were significantly more prevalent (67%. Eight patients were subjected to amputation: one primary case and seven secondary cases. Types IIIC (75% and IIIB (25% predominated among the patients subjected to secondary amputation. The MESS index was greater than 7 in 88% of the amputees and in 5% of the limb salvage group. CONCLUSION: The profile of patients with open tibial fracture of Gustilo and Anderson Type III mainly involved young male individuals who were victims of motorcycle accidents. The tibial shaft was the segment most affected. Only 7% of the patients underwent amputation. Given the current controversy in the literature about amputation or salvage of severely injured lower limbs, it becomes necessary to carry out prospective studies to support clinical decisions.
Full Text Available Background: Tibial plateau fractures, intra-articular in nature and caused by high-velocity trauma, constitute approximately 1% of all fractures. Primary goal in the management of proximal tibial articular fracture aims for a stable, congruous, pain-free, mobile joint. Objective: To study the technique, results, and complications of percutaneous cancellous screw fixation for tibial plateau fractures. Materials and Methods: Twenty-three men and seven women aged 18-65 years (mean = 36.8 years underwent closed reduction and percutaneous screw fixation for closed tibial plateau fractures with <5 mm depression. According to the Schatzker classification, patients were grouped as type I (n = 18, type II (n = 4, type III (n = 0, type IV (n = 8, type V (n = 2, and type VI (n = 1. Closed reduction was achieved by manual ligamentotaxis technique under image intensifier control and fixed percutaneously with two cancellous screws (6.5 mm with or without washers in a parallel fashion. Results: Functional outcome was evaluated using the Mason Hohl evaluation system. A total score of 19-24 was considered as excellent, 13-18 as good, 7-12 as fair, and <6 as poor. Outcomes were excellent in 10 patients, good in 15, fair in 4, and poor in 1 patient. Patients were allowed partial weight bearing with walker after 1 month and full weight bearing after radiological union in approximately 3-4 months. The mean period of hospital stay was 5 (range 2-15 days. All the fractures united radiologically after a mean of 3 (range 2.5- 5 months. Patients were evaluated at a mean of 3 years after injury. No patient had any complication like infection, wound dehiscence, or hardware problem. Conclusion: Percutaneous cancellous screw fixation for closed tibial plateau fractures is minimally invasive. It reduces hospital stay and cost, enables early mobilization with minimal instrumentation, and achieves satisfactory outcomes.
Himanshu G. Ladani
Full Text Available Background: Closed reduction & plaster is standard and effective form of treatment in majority of paediatric tibial shaft fractures. Operative intervention is necessary in unstable fractures, open fractures, poly trauma patients and compartment syndrome or severe soft tissue compromise. Historically, external fixation and plating were the treatment options available, but having complications like infection, overgrowth and refracture. Reamed locked intramedullary nails pose unnecessary risk to the proximal tibial growth plate. Flexible intramedullary nailing in long bone fractures in children has gained wide spread popularity because of its clinical effectiveness & low risk of complications. Methodology: This is a study of 15 patients of unstable tibial shaft fractures in children treated with Ender’s nailing. 12 were closed & 3 were open grade I fractures with only punctured wounds. Age was ranging from 7 to 16 yrs. There were 8 middle third, one upper third and 6 distal third shaft tibia fractures. In all patients 3.5 Ender’s nails were used, two nails in 11 patients and three nails in 4 patients there was no post-operative wound infection. Average operative time was 40 minutes and average blood loss was 35 cc. Results: Average union time was 9 wks. All fractures united without 2nd operative intervention. In 2 patients there was some proximal migration of nails causing some knee irritation. In all patients implant removed 6 to 7 months after surgery. At final follow-up there were full knee & ankle movements. 2 patients had more than 50 malalignment in A-P or M-L plane. No rotational deformity, no limb length discrepancy or physical arrest. Conclusion: Ender’s nailing is an effective method of treatment in these cases, which allows rapid healing of tibial shaft fractures with an acceptable rate of complications. There is short learning curve with this treatment and implants are inexpensive.
Full Text Available BACKGROUND: Tremendous advance in mechanization and fastness of travel have been accompanied by steep increase in number and severity of fractures and those of tibial plateau are no exception. Knee being one of the major weight bearing joints of the body, fractures around it will be of paramount importance. AIM OF STUDY: This study is to analyze the functional outcome of CRIF or ORIF with or without bone grafting in tibial plateau fractures in adults. MATERIALS AND METHODS: 30 cases of tibial plateau fractures treated by various modalities were studied from 1 - 8 - 2012 to 31 - 1 - 2014 at our institution and followed for a minimum of 6 months. Fractures were evaluated using Modified Rasmussen’s Clinical, Radiological grading system. RESULTS : The selected patients were evaluated thoroughly and after the relevant investigations, were taken for surgery. The fractures were classified as per the SCHATZKER’S types and operated accordingly with CRIF with Percutaneous cannulated cancellous screws, ORIF with buttress plate/LCP with or without bone grafting. Immobilization of fractures continued for 3 weeks by POP slab. Early range of motion was then started. Weight bearing up to 6 - 8 weeks was not allowed. The full weight bearing deferred until 12 weeks or complete fracture union . The knee range of motion was excellent to very good, gait and weight bearing after complete union was satisfactory, knee stiffness in 3 cases , wound dehiscence and infection in 1 case and non - union in none of our cases was noted. CONCLUSION: Functional outcome is better in operatively treated tibial plateau fractures in adults, because it gives excellent anatomical reduction and rigid fixation to restore articular congruity and early motion thereby preventing knee stiffness.
Ahmad Mudussar A
Full Text Available Abstract Introduction We present a case of accelerated tibial fracture union in the third trimester of pregnancy. This is of particular relevance to orthopaedic surgeons, who must be made aware of the potentially accelerated healing response in pregnancy and the requirement for prompt treatment. Case presentation A 40 year old woman at 34 weeks gestational age sustained a displaced fracture of the tibial shaft. This was initially treated conservatively in plaster with view to intra-medullary nailing postpartum. Following an emergency caesarean section, the patient was able to fully weight bear without pain 4 weeks post injury, indicating clinical union. Radiographs demonstrated radiological union with good alignment and abundant callus formation. Fracture union occurred within 4 weeks, less than half the time expected for a conservatively treated tibial shaft fracture. Conclusion Long bone fractures in pregnancy require clear and precise management plans as fracture healing is potentially accelerated. Non-operative treatment is advisable provided satisfactory alignment of the fracture is achieved.
St-Jean, G; Clem, M F; DeBowes, R M
Medical records of 5 calves with tibial fractures that were reduced and stabilized by transfixation pinning and casting were reviewed. Multiple Steinmann pins were placed transversely through proximal and distal fracture fragments, and the pin ends were incorporated in fiberglass cast material after fracture reduction. Cast material serves as an external frame to maintain pin position and fracture reduction. Calves were between 2 weeks and 6 months old and weighed between 40 and 180 kg. Three fractures were spiral in configuration and 2 were comminuted. One tibial fracture was open. After surgery, all calves were ambulatory within 24 hours. To improve tarsal flexion and achieve normal stance in 3 calves, cast revision was required on the caudal aspect of the limb. Good radiographic and clinical evidence of stability was observed in 5 to 10 weeks (mean 8 weeks), at which time the pis and cast were removed. Return to normal function was rapid and judged to be excellent at follow-up evaluation 3 to 12 months later. Advantages of transfixation pinning and casting in management of tibial fractures include flexibility in pin positioning, adequate maintenance of reduction, early return to weight-bearing status, joint mobility, and ease of ambulation. The inability to adjust fixation and alignment after cast application is a disadvantage of this technique compared with other external fixators.
Galbraith, John G; Daly, Charles J; Harty, James A; Dailey, Hannah L
For tibial fractures, the decision to fix a concomitant fibular fracture is undertaken on a case-by-case basis. To aid in this clinical decision-making process, we investigated whether loss of integrity of the fibula significantly destabilises midshaft tibial fractures, whether fixation of the fibula restores stability to the tibia, and whether removal of the fibula and interosseous membrane for expediency in biomechanical testing significantly influences tibial interfragmentary mechanics. Tibia/fibula pairs were harvested from six cadaveric donors with the interosseous membrane intact. A tibial osteotomy fracture was fixed by reamed intramedullary (IM) nailing. Axial, torsion, bending, and shear tests were completed for four models of fibular involvement: intact fibula, osteotomy fracture, fibular plating, and resected fibula and interosseous membrane. Overall construct stiffness decreased slightly with fibular osteotomy compared to intact bone, but this change was not statistically significant. Under low loads, the influence of the fibula on construct stability was only statistically significant in torsion (large effect size). Fibular plating stiffened the construct slightly, but this change was not statistically significant compared to the fibular osteotomy case. Complete resection of the fibula and interosseous membrane significantly decreased construct torsional stiffness only (large effect size). These results suggest that fixation of the fibula may not contribute significantly to the stability of diaphyseal tibial fractures and should not be undertaken unless otherwise clinically indicated. For testing purposes, load-sharing through the interosseous membrane contributes significantly to overall construct mechanics, especially in torsion, and we recommend preservation of these structures when possible. Copyright © 2016 Elsevier Ltd. All rights reserved.
Boris A. Zelle
Full Text Available Isolated posterolateral corner (PLC injuries are rarely seen with tibial plateau fractures and can be missed during the initial assessment. The objective of this paper is to present a case of a Schatzker type 2 tibial plateau fracture with associated isolated PLC injury and give a discussion on physical exam, diagnostic studies, and treatment options. A twenty-five-year-old female sustained a concomitant Schatzker type 2 fracture and PLC injury. Magnetic Resonance Imaging showed an isolated PLC disruption. Open reduction-internal fixation was performed with subsequent PLC repair. At sixteen months postoperatively, the patient had full range of motion and strength of her knee and no signs of laxity. This case emphasizes the importance of physical exam and appropriate imaging modalities in order to diagnose and treat this significant injury in a prompt fashion. In this case, surgical fracture fixation and subsequent repair of the PLC provided a good clinical outcome.
Abdelhamid, Mohamed M; Bayoumy, Maysara Abdelhalim; Elkady, Hesham A; Abdelkawi, Ayman Farouk
Several techniques of arthroscopic treatment of tibial spine avulsion fractures have been described in the literature. These techniques include the use of various fixation devices such as screws, K-wires, wiring, sutures, and suture anchors. In this study, we evaluate a new wiring technique for the treatment of these injuries. This technique involves fixation by stainless steel tension wires passed over the fractured spine and tied over a bone bridge. The advantages of this technique are that it aids in reduction, allows for compression of the tibial spine fragment anatomically in its fracture bed, provides stable fixation in difficult comminuted fractures, and allows for early mobilization and weight bearing because of the solid fixation.
van der Linden, W; Larsson, K
One hundred consecutive patients with displaced fractures of the tibial shaft were randomly assigned to two groups, one treated with AO-plate fixation and the other with conservative methods. Strictly conservative treatment failed in two patients because of the interposition of muscles. Comparison of the groups showed that a longer duration of hospital stay was needed in the AO-plate group, and there were also more complications in that group. However, the median healing time was shorter and the anatomical end results were better than in the conservatively treated patients. Closed longitudinal fractures were found to be suitable and open fractures, unsuitable for AO-plate fixation. In the group that was treated conservatively most fractures that healed in malalignment were located in the distal third of the tibial shaft.
Balmat, P; Vichard, P; Pem, R
Avulsion fractures of the tibial tuberosity occur mainly during sport activities and are closely related to the strains exerted on the anterior tibial tuberosity by the extension complex of the thigh. A knowledge of the mechanical aspects of these avulsions may improve understanding of the mechanisms of such injuries. In such avulsion fractures, tensile forces due to the contraction of the quadriceps complex overcome the cohesive forces within the apophyseal cartilage. A 1-month cast immobilisation on an extended knee gives good results in the management of nondisplaced fractures. In minor displacements, such immobilisations follow closed external reductions. Open reductions and stable screw fixations precede a 3-week immobilisation for displaced fractures. Long term results are regularly good in well-managed cases.
Schwandt, C S; Montavon, P M
A six-month-old, male Bernese Mountain Dog in which radius-ulna and tibia-fibula concomitant fractures were treated each with a 3.5 mm Locking Compression Plate (LCP) is presented. Both fractures were approached and plated medially. The tibial fracture had to be revised with a 4.5 mm intramedullary nail and a new 3.5 mm LCP at the second post-operative day because of fixation breakdown. The follow-up radiographs taken at days 14 and 53 revealed uneventful healing of both fractures. Implants were removed 53 days after surgery.
Liu, Yong-gang; Zuo, Li-xin; Pei, Guo-xian; Dai, Ke; Sang, Jing-wei
To explore the establishment of Schatzker classification digital model of tibial plateau fractures and its application in virtual surgery. Proximal tibial of one healthy male volunteer was examined with 64-slice spiral computed tomography (CT). The data were processed by software Mimics 10.01 and a model of proximal tibia was reconstructed. According to the Schatzker classification criteria of tibial plateau fractures, each type of fracture model was simulated.Screen-captures of fracture model were saved from different directions.Each type of fracture model was exported as video mode.Fracture model was imported into FreeForm modeling system.With a force feedback device, a surgeon could conduct virtual fracture operation simulation.Utilizing the GHOST of FreeForm modeling system, the software of virtual cutting, fracture reduction and fixation was developed.With a force feedback device PHANTOM, a surgeon could manipulate virtual surgical instruments and fracture classification model and simulate surgical actions such as assembly of surgical instruments, drilling, implantation of screw, reduction of fracture, bone grafting and fracture fixation, etc. The digital fracture model was intuitive, three-dimensional and realistic and it had excellent visual effect.Fracture could be observed and charted from optional direction and angle.Fracture model could rotate 360 ° in the corresponding video mode. The virtual surgical environment had a strong sense of reality, immersion and telepresence as well as good interaction and force feedback function in the FreeForm modeling system. The user could make the corresponding decisions about surgical method and choice of internal fixation according to the specific type of tibial plateau fracture as well as repeated operational practice in virtual surgery system. The digital fracture model of Schatzker classification is intuitive, three-dimensional, realistic and dynamic. The virtual surgery systems of Schatzker classifications make
Mellema, Jos J.; Doornberg, Job N.; Molenaars, Rik J.; Ring, David; Kloen, Peter; Babis, George C.; Jeray, Kyle J.; Prayson, Michael J.; Pesantez, Rodrigo; Acacio, Ramos; Verbeek, Diederik O.; Melvanki, Parag; Kreis, Barbara E.; Mehta, Samir; Meylaerts, S.; Wojtek, S.; Yeap, Ewe J.; Haapasalo, Heidi; Kristan, Anž e; Coles, Chad; Marsh, J. Lawrence; Mormino, Matthew; Menon, Matthew; Tyllianakis, Minos; Schandelmaier, Peter; Jenkinson, R. J.; Neuhaus, Valentin; Shahriar, Chegini M. H.; Belangero, William D.; Kannan, S. G.; Leonidovich, Golovakha M.; Davenport, J. H.; Kabir, Koroush; Althausen, Peter L.; Weil, Yoram; Toom, Alar; Sa da Costa, Daniel; Lijoi, F.; Koukoulias, Nikolaos E.; Manidakis, Nikolaos; van den Bogaert, Max; Patczai, Balá zs; Grauls, Anthony; Kurup, Harish; van den Bekerom, Michel P.; Lansdaal, Joris R.; Vale, M.á rio; Ousema, Paul; Barquet, Antonio; Cross, Brian J.; Broekhuyse, Henry; Haverkamp, Daniel; Merchant, Milind; Harvey, Edward; Stojkovska Pemovska, Emilija; Frihagen, Frede; Seibert, Franz J.; Garnavos, Christos; van der Heide, Huub; Villamizar, Harold A.; Harris, Ian; Borris, Lars C.; Brink, Ole; Brink, Peter R. G.; Choudhari, Pradeep; Swiontkowski, Marc; Mittlmeier, Thomas; Tosounidis, Theodoros; van Rensen, Inge; Martinelli, N.; Park, D. H.; Lasanianos, Nikolaos; Vide, J.; Engvall, A.; Zura, R. D.; Jubel, Axel; Kawaguchi, Alan; Goost, Hans; Bishop, Julius; Mica, Ladislav; Pirpiris, Marinis; van Helden, S. H.; Bouaicha, Samy; Schepers, T.; Havlič ek, Tomo; Giordano, Vincenzo
Tibial plateau fracture classification systems have limited interobserver reliability and new systems emerge. The purpose of this study was to compare the reliability of the Luo classification and the Schatzker classification for two-dimensional computed tomography (2DCT) and to study the effect of
Larsen, Peter; Elsøe, Rasmus; Graven-Nielsen, Thomas
postoperatively after intramedullary nailing of tibial shaft fracture. METHODS: A total of 39 patients were included in this 12-month follow-up study. After 6 weeks, 3, 6, and 12 months postoperatively the pain intensity was measured on a visual analog scale (VAS) and the pressure pain sensitivity was assessed...
Busse, Jason W; Bhandari, Mohit; Sprague, Sheila; Johnson-Masotti, Ana P; Gafni, Amiram
Closed and open grade I (low-energy) tibial shaft fractures are a common and costly event, and the optimal management for such injuries remains uncertain. We explored costs associated with treatment of low-energy tibial fractures with either casting, casting with therapeutic ultrasound, or intramedullary nailing (with and without reaming) by use of a decision tree. From a governmental perspective, the mean associated costs were USD 3,400 for operative management by reamed intramedullary nailing, USD 5,000 for operative management by non-reamed intramedullary nailing, USD 5,000 for casting, and USD 5,300 for casting with therapeutic ultrasound. With respect to the financial burden to society, the mean associated costs were USD 12,500 for reamed intramedullary nailing, USD 13,300 for casting with therapeutic ultrasound, USD 15,600 for operative management by non-reamed intramedullary nailing, and USD 17,300 for casting alone. Our analysis suggests that, from an economic standpoint, reamed intramedullary nailing is the treatment of choice for closed and open grade I tibial shaft fractures. Considering financial burden to society, there is preliminary evidence that treatment of low-energy tibial fractures with therapeutic ultrasound and casting may also be an economically sound intervention.
Full Text Available We would like to highlight unusual sequelae of healed distal third diaphyseal tibia fracture that was treated conservatively 36 years ago, in which we incidentally detected peripheral CT angiography. The anterior tibial artery was enveloped three-quarterly by the healing callus of the bone (distal tibia.
Simon, A-L; Apostolou, N; Vidal, C; Ferrero, E; Mazda, K; Ilharreborde, B
Elastic stable intramedullary nailing is increasingly used for surgical treatment of tibial shaft fractures, but frequently requires immobilization and delayed full weight-bearing. Therefore, external fixation remains interesting. The aim was to report clinico-radiological outcomes of monolateral external fixation for displaced and unstable tibial shaft fractures in children. All tibial fractures consecutively treated by monolateral external fixation between 2008 and 2013 were followed. Inclusion criteria included skeletal immaturity and closed and open Gustilo I fractures caused by a direct impact. Patients were seen until two years postoperatively. Demographics, mechanism of injury, surgical data and complications were recorded. Anteroposterior and lateral side radiographs were performed at each visit. Full-limb 3D reconstructions using biplanar stereroradiography was performed for final limb length and alignment measures. A total of 45 patients (mean age 9.7 years ± 0.5) were included. In all, 17 were Gustilo I fractures, with no difference between open and closed fractures for any data. Mean time to full weight bearing was 18.2 days ± 0.7. After 15 days, 39 patients returned to school. Hardware removal (mean time to union 15.6 weeks ± 0.8) was performed during consultation under analgesic gas. There were no cases of nonunion. No fracture healed with > 10° of angulation (mean 5.1° ± 0.4°). Leg-length discrepancy > 10 mm was found for six patients. This procedure can be a safe and simple surgical treatment for children with tibial shaft fractures. Few complications and early return to school were reported, with the limitations of non-comparative study. IV.
Wani, Iftikhar H; Sharma, Siddhartha; Malik, Farid H; Singh, Manjeet; Shiekh, Irfan; Salaria, Abdul Q
Osteochondromas arising from the interosseous border of the distal tibia and involving distal fibula are uncommon. We present a 16 year old young boy with an impending fracture, erosion and weakness of the distal fibula, secondary to an osteochondroma arising from the distal tibia. Early excision of this deforming distal tibial osteochondroma avoided the future risk of pathological fracture of the distal fibula, ankle deformities and syndesmotic complications.
Li, Q; Zeng, B F; Luo, C F; Song, S; Zhang, C Q; Kong, W Q
The aim of this study was to compare the effects and indications of minimally invasive plate osteosynthesis (MIPO) and limited open reduction (LOR) for managing distal tibial shaft fractures. A total of 79 cases of distal tibial shaft fractures were treated surgically in our trauma center. The 79 fracture cases were classified into type A, B, and C (C1) according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification, with 28, 32, and 19 cases, respectively. Among the 79 fracture cases, 52 were closed fractures and 27 were open fractures (GUSTILO, I-II). After adequate preparation, 48 cases were treated with LOR and 31 cases were treated with MIPO. All cases were followed up for 12 to 18 months, with an average of 16.4 months. During the follow-up period, 76 fracture cases were healed in the first stage, whereas the 3 cases that developed non-union were treated by changing the fixation device and autografting. For types A, B, and some of C simple fractures (C1), LOR accelerated the fracture healing and lowered the non-union rate. One case suffered from regional soft tissue infection, which was controlled by wound dressing and intravenous antibiotics. Another case that developed local skin necrosis underwent local flap transplant. LOR promoted bone healing and lowered the non-union rate of several simple-distal tibial shaft fractures. Thereafter, the incidence of soft tissue complication was not significantly increased. However, for complex and comminuted fractures, MIPO was the preferred method for correcting bone alignment and protecting soft tissue, leading to functional recovery.
Full Text Available Background: The Taylor spatial frame (TSF is a modern multiplanar external fixator that combines the ease of application and computer accuracy in the reduction of fractures. A retrospective review of our prospective TSF database for the use of this device for treating open tibial fractures in pediatric, adolescent, and adult patients was carried out to determine the effectiveness and complications of TSF in the treatment of these fractures. Materials and Methods: Nineteen male patients with open tibial fractures were included. Of these fractures, 10 were Gustilo Type II, five were Gustilo Type IIIA (two had delayed primary closure and three had split thickness skin grafting, and four were Gustilo Type IIIB (all had rotational flaps. Twelve of our patients presented immediately to the emergency room, and the remaining seven cases presented at a mean of 3 months (range, 2.2-4.5 months after the initial injury. The fractures were located in proximal third (n=1, proximal/middle junction (n=2, middle third (n=3, middle/distal junction (n=8, distal third (n=3, and segmental fractures (n=2. Patients were of an average age of 26 years (range, 6-45years. Mean duration of follow-up was 3.5 years. Results: All fractures healed over a mean of 25 weeks (range, 9-46 weeks. All were able to participate in the activities of daily living without any difficulty and most were involved in sports during the last follow-up. Postoperative complications included pin tract infection in 12 patients. Conclusion: The TSF is an effective definitive method of open tibial fracture care with the advantage of early mobilization, ease of soft tissue management through gradual fracture reduction, and the ability to postoperatively manipulate the fracture into excellent alignment.
García Juárez, José Dolores; Aguilera Zepeda, José Manuel; Bienvenu, Alfonso Tohen; Encalada Díaz, Melchor Iván; Sheldon, Oscar Dáivila
Tibial shaft fractures are common since they account for 9% of all fractures. Intramedullary nailing is described in the literature as the gold standard for their treatment and the most recent research emphasizes minimum exposure. To present the clinical and radiological course of closed, unreamed intramedullary fixation for tibial shaft fractures in a group of patients seen at Medica Sur Hospital. Twenty-two male patients with a diagnosis of tibial shaft fracture were analyzed retrospectively; mean age was 28 years. In all of them the Orthofix nail was inserted through the patellar tendon, with a closed approach and without reaming the medullary cavity. Twenty patients had closed fractures (90.90%) and 2 patients had open fractures (9.09%). The mean time to starting ambulation with protected weight bearing was two weeks in 18 patients (81.81%); with full weight bearing, six weeks in 13 patients (91%). The mean time to full weight bearing without crutches was 10 weeks in 21 patients (95.45%). Mean radiographic grade III-IV healing time was 16 weeks. Complications were: delayed union in two patients (9.09%), compartmental syndrome, in one patient (4.45%). The Orthofix interlocking intramedullary nail placed with a closed approach provides immediate stability due to the proximal and distal locking. Patient rehabilitation is quicker, with total mobility, providing an early stimulation for callus formation and the added benefit of sparing the endosteal blood supply.
Una Gorospe; Jon Andoni; Isla Gallego, Concepcion; Santana Borbones, Aranzazu; Perera Romero, Carmen; Allende Riera, Ana J
There are many stress injuries in the lower extremities due to exercise, and the case we present is an example of two injuries which may present in children or young adults who train excessively. The patient complains of pain and tightness on exercise. The underlying pathology is probably rupture of insertion fibres of the tibial and soleus (Sharpey's fibres) muscles. Probably, there is also periostitis and myositis. Stress fractures and shin splints are often present at the same time in different stages, and both are typical pathologies due to excessive training. Scintigraphy allows identification and early management of shin splints and stress fractures (au)
Full Text Available Background: The work presents the assessment of the results of treatment of open tibial shaft fractures in polytrauma patients. Materials and Methods: The study group comprised 28 patients who underwent surgical treatment of open fractures of the tibial shaft with locked intramedullary nailing. The mean age of the patients was 43 years (range from 19 to 64 years. The criterion for including the patients in the study was concomitant multiple trauma. For the assessment of open tibial fractures, Gustilo classification was used. The most common concomitant multiple trauma included craniocerebral injuries, which were diagnosed in 12 patients. In 14 patients, the surgery was performed within 24 h after the injury. In 14 patients, the surgery was delayed and was performed 8-10 days after the trauma. Results: The assessment of the results at 12 months after the surgery included the following features: time span between the trauma and the surgery and complications in the form of osteomyelitis and delayed union. The efficacy of gait, muscular atrophy, edema of the operated limb and possible disturbances of its axis were also taken under consideration. In patients operated emergently within 24 h after the injury, infected nonunion was observed in three (10.8% males. These patients had grade III open fractures of the tibial shaft according to Gustilo classification. No infectious complications were observed in patients who underwent a delayed operation. Conclusion: Evaluation of patients with open fractures of the tibial shaft in multiple trauma showed that delayed intramedullary nailing performed 8-10 days after the trauma, resulted in good outcome and avoided development of delayed union and infected nonunion. This approach gives time for stabilization of general condition of the patient and identification of pathogens from wound culture.
Full Text Available Background: Comminuted fractures happen frequently due to traumas. Fixation without opening the fracture site,known as minimally invasive plate osteosynthesis (MIPO, has recently become prevalent. This study has beendesigned to assess the outcomes of this treatment for tibial and femoral comminuted fractures.Methods: A total of 60 patients with comminuted femoral or tibial fractures were operated with MIPO method in thiscross-sectional study at Alzahra university hospital in 2015. Eleven patients were excluded due to lack of adequatefollow-ups. Patients’data including union time; infection in the fractured site; hip and knee range of motion; and anymalunion or deformities like limb length discrepancy were collected after the surgery in every session.Results: Among 32 femoral and 17 tibial fractures, union was completed in48 patients, while only one patient withfemoral fracture had nonunion. The mean union time was 18.57±2.42 weeks. Femur fractures healed faster than tibia(17.76±2.36 compared to 19±2.37 weeks, respectively, P=0.09. None of the patients suffered from infections or fistula.The range of motion in hip and knee remained intact in approximately all patients. Malunion happened in 3 patients; 100internal rotation in 1 patient; and 1cm limb shortening in 2 patients.Conclusion: According to the result of this study, MIPO is a simple and effective method of fixation with a high rateof union as well as minimal complications for comminuted fractures of long bones. Infection is rare, and malunion orany deformity is infrequent. MIPO appears to be a promising and safe treatment alternative for comminuted fractures.
Chalidis, Byron E.; Petsatodis, George E.; Sachinis, Nick C.; Dimitriou, Christos G.; Christodoulou, Anastasios G.
The need for reaming and the number of locking screws to be used in intramedullary (IM) tibial nailing of acute fractures as well as routine bone grafting of tibial aseptic nonunions have not been clearly defined. We describe the results of reamed interlocked IM nails in 233 patients with 247 tibial fractures (190 closed, 27 open and 30 nonunions). Ninety-six percent of the fractures were united at review after an average of 4.9?years. No correlation was found between union and nail diameter ...
Lin, Shishui; Mauffrey, Cyril; Hammerberg, E Mark; Stahel, Philip F; Hak, David J
The aim of this study was to identify risk factors for surgical site infections and to quantify the contribution of independent risk factors to the probability of developing infection after definitive fixation of tibial plateau fractures in adult patients. A retrospective analysis was performed at a level I trauma center between January 2004 and December 2010. Data were collected from a review of the patient's electronic medical records. A total of 251 consecutive patients (256 cases) were divided into two groups, those with surgical site infections and those without surgical site infections. Preoperative and perioperative variables were compared between these groups, and risk factors were determined by univariate analyses and multivariate logistic regression. Variables analyzed included age, gender, smoking history, diabetes, presence of an open fracture, presence of compartment syndrome, Schatzker classification, polytrauma status, ICU stay, time from injury to surgery, use of temporary external fixation, surgical approach, surgical fixation, operative time, and use of a drain. The overall rate of surgical site infection after ORIF of tibial plateau fractures during the 7 years of this study was 7.8% (20 of 256). The most common causative pathogens was Staphylococcus aureus (n=15, 75%). Independent predictors of surgical site infection identified by multivariate analyses were open tibial plateau fracture (odds ratio=3.9; 95% CI=1.3-11.6; p=0.015) and operative time (odds ratio=2.7; 95% CI=1.6-4.4; psite infection. Both open fracture and operative time are independent risks factors for postoperative infection.
Ma, Ching-Hou; Wu, Chin-Hsien; Jiang, Jiun-Ru; Tu, Yuan-Kun; Lin, Ting-Sheng
This study aimed to evaluate the outcome of using a metaphyseal locking plate as a definitive external fixator for treating open tibial fractures based on biomechanical experiments and analysis of clinical results. A metaphyseal locking plate was used as an external fixator in 54 open tibial fractures in 52 patients. The mean follow-up was 38 months (range, 20-52 months). Moreover, static axial compression and torsional tests were performed to evaluate the strength of the fixation techniques. The average fracture healing time was 34.5 weeks (range, 12-78 weeks). At 4 weeks postoperatively and at the final follow-up, the average Hospital for Special Surgery knee score was 85 (range, 81-100) and 94 (range, 88-100), respectively, and the American Orthopaedic Foot and Ankle Society score was 88 (range, 80-100) and 96 (range, 90-100), respectively. Based on the static test result, the axial stiffness was significantly different among groups (p=0.002), whereas the torsional stiffness showed no significant difference (p=0.068). Clinical outcomes show that the use of locking plate as a definitive external fixator is an alternative choice for tibial fractures after obtaining appropriate fracture reduction. However, external locked plating constructs were not as strong as standard locked plating constructs. Therefore, the use of external locked plating constructs as a definitive treatment warrants further biomechanical study for construct strength improvement. Copyright © 2016 Elsevier Ltd. All rights reserved.
Full Text Available The aim of this study was to evaluate the results of reamed and locked intramedullary nailing for tibial diaphysis fractures.Materials and methods: The study included 38 patients (26 males, 12 females who were treated with reamed and locked intramedullary nailing for tibial diaphysis fractures. Fractures were classified according to Gustilo-Anderson classification and functional results were assessed using the Johner-Wrush criteria.Results: The mean age was 36 years (range 18-61. There were 21 AO/ASIF type A, 16 type B, and 1 type C fractures. Twenty-four fracture were closed (63.1% and 14 (36.9% were open fractures. According to the Gustilo-Anderson classification, 9 were grade I, 4 patients grade II, and one grade IIIA open fractures. Intramedullary nailing was performed following open reduction in 18 patients, and closed reduction in 20. The mean time to surgery was 9.4 days and the mean follow-up was 29 months. Union was achieved in all patients within a mean of 17.6 weeks. Anterior knee pain developed in 18 patients and infection developed in three patients. Angular deformity less than 10º was developed 12 patients (31.6%. There were screw breakacge and synostosis in four and two patients respectively. According to the Johner-Wrush criteria, functional results were very good in 23 patients (60.5%, good in 12 patients (31.6% and fair in 3 (7.9% patients.Conclusion: Treatment of tibial diaphysis fractures with reamed and locked intramedullary nailing gives satisfactory results. It should be considered as first choice in the treatment of these fractures. J Clin Exp Invest 2011;2(2:168-74
Bone, L B; Johnson, K D
We treated 112 fractures of the tibia by manipulative reduction, reaming of the medullary canal, and fixation of the fracture fragments with an intramedullary nail. Seventy-six of the fractures were acute, and eight of these were second or third-degree open fractures. The other thirty-six fractures had a non-union, osteotomy for malunion, or failure of other types of treatment. Follow-up of 100 fractures showed union in all but one, which was in a drug abuser who had an amputation due to infection. The main complication was infection, which was successfully treated in six of seven fractures. The method of treatment, employing either closed or open technique and recently making use of interlocking bolts to stabilize one or both principal fracture fragments on the nail, is an excellent one for unstable acute fractures and for secondary procedures in fractures that are not associated with infection. The infection rate was increased with the open surgical technique. The few contraindications to its use are described.
Iversen, Jonas Vestergård; Krogsgaard, Michael Rindom
Few reports have described avulsion fractures of the posterior root of the medial meniscus in skeletally immature patients. This lesion should not be overlooked as it damages the load absorptive (distributive) function of the meniscus, increasing the risk of cartilage degeneration. Two cases...... of displaced avulsion fractures of the posterior root of the medial meniscus in children are presented along with a concise report of the literature regarding avulsion fractures of the posterior root of the medial meniscus. Both avulsions were reattached arthroscopically by trans-tibial pull-out sutures...
Kreb, Dieuwertje L; Blokhuis, Taco J; van Wessem, Karlijn J P; Bemelman, Mike; Lansink, Koen W W; Leenen, Luke P H
Intramedullary fixation is the treatment of choice for diaphyseal fractures of the femur and tibia. Locking the implant can sometimes be cumbersome and time consuming. In our institution, fractures with axial and rotational stability are treated with intramedullary nailing without interlocking. All consecutive patients presented in the University Medical Center Utrecht from October 2003 to August 2009 with acute traumatic diaphyseal fractures of the tibia or femur that were considered axial and rotational stable were included. They underwent internal fixation using intramedullary nails without interlocking. Patient records were evaluated for duration of surgery, perioperative complications, consolidation time and re-operations. Twenty-nine long bone fractures were treated in 27 patients: 20 men and 7 women, with an average age of 28.9 years (range 15.6-54.4). There were 12 femoral fractures and 17 tibial fractures. Sixteen fractures were closed and 13 were open (10 Gustilo 1, 3 Gustilo 2). The mean operating time was 43 min (range 18-68 min) for tibial fractures and 55 min (range 47-150 min) for femoral fractures. Postoperative complications occurred in six patients. Two patients (three fractures) were lost to follow-up. Healing occurred in 25 of the 26 remaining fractures (96 %) without additional interventions. One tibia was secondarily converted to a standard locked nail because of axial and rotational instability. All patients returned to their pre-injury level of activity. The use of intramedullary nailing without interlocking is associated with minimal complications in selected fractures. The advantages include a short operating time and the simplicity of its application.
Ballard, Brooke L; Antonacci, Jennifer M; Temple-Wong, Michele M; Hui, Alexander Y; Schumacher, Barbara L; Bugbee, William D; Schwartz, Alexandra K; Girard, Paul J; Sah, Robert L
Intra-articular fractures may hasten posttraumatic arthritis in patients who are typically too active and too young for joint replacement. Current orthopaedic treatment principles, including recreating anatomic alignment and establishing articular congruity, have not eliminated posttraumatic arthritis. Additional biomechanical and biological factors may contribute to the development of arthritis. The objective of the present study was to evaluate human synovial fluid for friction-lowering function and the concentrations of putative lubricant molecules following tibial plateau fractures. Synovial fluid specimens were obtained from the knees of eight patients (twenty-five to fifty-seven years old) with a tibial plateau fracture, with five specimens from the injured knee as plateau fracture synovial fluid and six specimens from the contralateral knee as control synovial fluid. Each specimen was centrifuged to obtain a fluid sample, separated from a cell pellet, for further analysis. For each fluid sample, the start-up (static) and steady-state (kinetic) friction coefficients in the boundary mode of lubrication were determined from a cartilage-on-cartilage biomechanical test of friction. Also, concentrations of the putative lubricants, hyaluronan and proteoglycan-4, as well as total protein, were determined for fluid samples. The group of experimental samples were obtained at a mean (and standard deviation) of 11 ± 9 days after injury from patients with a mean age of 45 ± 13 years. Start-up and kinetic friction coefficients demonstrated similar trends and dependencies. The kinetic friction coefficients for human plateau fracture synovial fluid were approximately 100% higher than those for control human synovial fluid. Hyaluronan concentrations were ninefold lower for plateau fracture synovial fluid compared with the control synovial fluid, whereas proteoglycan-4 concentrations were more than twofold higher in plateau fracture synovial fluid compared with the control
Behera, Prateek; Aggarwal, Sameer; Kumar, Vishal; Kumar Meena, Umesh; Saibaba, Balaji
Fractures of the tibia are one of the most commonly seen orthopedic injuries. Most of them result from a high velocity trauma. While intramedullary nailing of tibial diaphyseal fractures is considered as the golden standard form of treatment for such cases, many metaphyseal and metaphyseal-diaphyseal junction fractures can also be managed by nailing. Maintenance of alignment of such fractures during surgical procedure is often challenging as the pull of patellar tendon tends to extend the proximal fragment as soon as one flexes the knee for the surgical procedure. Numerous technical modifications have been described in the literature for successfully nailing such fractures including semi extended nailing, use of medial plates and external fixators among others. In this study, it was aimed to report two cases in which we used our ingenious method of applying external fixator for maintaining alignment of the fracture and aiding in the entire process of closed intramedullary nailing of metaphyseal tibial fractures by the conventional method. We were able to get good alignment during and after the closed surgery as observed on post-operative radiographs and believe that further evaluation of this technique may be of help to surgeons who want to avoid other techniques.
Muzaffar, Nasir; Bhat, Rafiq; Yasin, Mohammad
Background The management of distal tibia fractures continues to remain a source of controversy and debate. Objectives The aim of this study was to evaluate the various complications of minimally invasive percutaneous plate osteosynthesis (MIPPO) using a locking plate for closed fractures of distal tibia in a retrospective study. Patients and Methods Twenty-five patients with dista...
The average time for application of the apparatus to fracture healing was 4.3 months. One fracture required autogenous bone graft for union. One patient is undergoing callus transportation for bone replacement. The most common complication was pin tract infection seen in nine (25.7%) patients. Conclusion: We treated 35 ...
Lesions of the articular cartilage are rarely observed in convensional radiography and CT, and may be one of the most important prognostic factors in assessing traumatic or degenerative disorders at the knee joints. To discuss the usefulness of MRI for detecting cartilage lesions, knees with tibial condylar fractures were examined with MRI. 47 patients with tibial condylar fractures were reviewed 4 months to 15 years (average of 4 years) after the fractures. Good to excellent results were obtained in 91.5% of them. It is known that anatomical reduction of conventional radiography is not consistent with the clinical outcome, because radiography can show the changes of bones only. However, the results of MRI examinations are consistent with the clinical outcome, because they can directly show the state of the articular surface, such as defects of cartilage in the joint. In my study, no abnormality of well repaired joint surfaces employing MRI were observed in the patients with excellent or good results, and various degrees of cartilage lesions were detected using MRI in the other patients. MRI is a useful method for noninvasively determining the integrity of articular cartilage, detecting cartilage lesions and degenerative disorders of tibial condyle, and also may be useful in studying and following the natural aging process in osteoarthritis following intra-articular fractures. (author) 52 refs
Chen, Hong-wei; Liu, Guo-dong; Ou, Shan; Jiang, Xie-yuan; Fei, Jun; Wu, Li-jun
The aim of this study was to compare the fixation effects of three fixation devices for tibial plateau fracture (AO/OTA classification 41 A1). Sixteen human cadaver tibial specimens were randomly divided into four groups. An A1 fracture model was established. The fractures were subsequently fixed by axial controlled intramedullary nail, external fixation and steel plate fixation. Each specimen was subjected to axial compression, torsion test and three-point bending test. Then a rat model was used to evaluate the therapeutic effect of these three fixations by evaluation of callus formation time and healing time. It was found that the axial controlled intramedullary nail group obtained superior biomechanical properties of resistance ability of bending, torsional and axial compressive, compared with external fixation and steel plate group. In animal experiments, the axial controlled intramedullary nail group had a significant shorter callus occurrence and healing time than steel plate and external fixator group. The axial controlled intramedullary nail fixation has a superior biomechanical characteristic and fixation effect for tibial plateau fractures than steel plate and external fixator. Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Rohan A Ramasubbu; Benjamin M Ramasubbu
Background: Management of open tibial fractures is well documented in adults, with existing protocols outlining detailed treatment strategies. No clear guidelines exist for children. Surgical stabilization of tibial fractures in the pediatric population requires implants that do not disrupt the open epiphyses (growth plate). Both elastic stable intramedullary nails and external fixation can be used. The objective of this study was to identify the optimal method of surgical stabilization in th...
Lam, S W; Teraa, M; Leenen, L P H; van der Heijden, G J M G
Nonunion after intramedullary nailing (IMN) in patients with tibial shaft fractures occurs up to 16%. There is no agreement whether reaming prior to IMN insertion would reduce the nonunion rate. We aimed to compare the nonunion rate between reamed and unreamed IMN in patients with tibial shaft fractures. A systematic search was conducted in Pubmed, Embase, and the Cochrane Library. The selected publications were: (1) randomised controlled trials; (2) comparing the nonunion rate; (3) in patients with tibial shaft fractures; (4) treated with either reamed or unreamed IMN. Seven studies that satisfied the criteria were identified. They showed that reamed IMN led to reduction of nonunion rate compared to unreamed IMN in closed tibial shaft fractures (risk difference ranging 7.0-20%, number needed to treat ranging 5-14), while the difference between compared treatments for open tibial shaft fractures was not clinically relevant. The evidence showed a consistent trend of reduced nonunion rate in closed tibial shaft fracture treated with reamed compared to unreamed IMN. 2010 Elsevier Ltd. All rights reserved.
Full Text Available The outcome of bicondylar tibial plateau fractures treated with either external fixation (35 patients or internal fixation (24 patients was reviewed. Outcome measures included the Rasmussen score, clinical complications, development of osteoarthritis and the requirement for total knee replacement (TKR. Twenty-two (92% anatomical reductions were achieved in the internal fixation group compared to 27 (77% in the external fixation group. Infective complications were more common in the external fixation group (9 patients, 26% due to pin tract infection. There were no deep infections in the internal fixation group. The mean Rasmussen score was not significantly different (mean score 32 in external fixation and 29 in internal fixation between the two groups and the incidence of osteoarthritis was the same in both groups. Four patients in the external fixation group underwent a TKR compared to 5 patients in the internal fixation group. Bicondylar tibial plateau fractures have similar outcomes following external or internal fixation.
den Outer, A J; Meeuwis, J D; Hermans, J; Zwaveling, A
The results of conservative (mainly, functional bracing) and operative treatment (mainly, plate fixation) have been compared in a retrospective study of 170 displaced noncomminutive tibial shaft fractures. The characteristics of the fractures in both treatment groups showed no significant differences. The follow-up analysis revealed no statistical differences in outcome between the two methods. However, because of the many factors analyzed and the restricted number of patients studied, it is impossible to compare all factors independently. Surgical treatment resulted in a higher rate of complications (such as implant failure, osteitis, and refracture) and a longer total hospitalization time. Conservative treatment showed a longer duration of fracture healing and a higher rate of malalignment. Malalignments of up to 10 degrees with no adverse effects have been seen so far. In conservative treatment, two fracture types were identified with a higher rate of malalignment: short oblique isolated tibial fractures and fully dislocated transverse crural fractures. Conservative therapy is favored, because there is less discomfort for the patient and the treatment is cost contained.
Ocegueda-Sosa, Miguel Ángel; Valenzuela-Flores, Adriana Abigail; Aldaco-García, Víctor Daniel; Flores-Aguilar, Sergio; Manilla-Lezama, Nicolás; Pérez-Hernández, Jorge
Closed tibiae plateau fractures are common injuries in the emergency room. The optimal treatment is not well defined or established. For this reason, there are several surgical management options: open reduction and internal fixation, closed reduction and percutaneous synthesis, external fixation, and even conservative treatment for this kind of fracture. The mechanism of production of this fracture is through large varus or valgus deformation to which is added a factor of axial load. The trauma may be direct or indirect. The degree of displacement, fragmentation and involvement of soft tissues like ligaments, menisci, vascular and nerve structures are determined by the magnitude of the force exerted. Any intra-articular fracture treatment can lead to an erroneous instability, deformity and limitation of motion with subsequent arthritic changes, leading to joint incongruity, limiting activity and significantly altering the quality of life. Open reduction and internal fixation with anatomic restitution is the method used in this type of fracture. However, the results of numerous publications can be questioned due to the inclusion in the same study of fractures treated with very different methods.
Toivanen, J.A.K.; Honkonen, S.E.; Koivisto, A.-M.; Järvinen, M.J.
We analyzed data from 87 patients who had displaced closed or open grade I simple or spiral wedge tibial shaft fractures caused by low-energy impact. Fifty-four patients were treated with plaster cast and 33 with intramedullary locking nail (IMLN). Delayed union only occurred in 8 patients after plaster cast treatment. Forty-two patients in the IMLN group and one in the plaster cast group suffered from anterior knee pain. Final treatment outcome, healing time, hospitalization time and duratio...
May, Jonathan David; Paavana, Thumri; McGregor-Riley, Jonathan; Royston, Simon
To review the outcomes of patients treated with the Ilizarov method for an isolated, closed, simple diaphyseal, Tibial fracture at our institution over the last decade. The Ilizarov frame database was used to identify 76 skeletally mature patients who sustained an isolated, closed, extra-articular, simple, diaphyseal Tibial fracture; the injury also known as a "nail-able Tibial fracture." The average age of the patient was 38 (17-70). All 76 patients progressed to union. The average time until union was 148 (55-398) days. The coronal and sagittal alignment was 3° (0-17°) and 4° (0-14°) respectively. No patient suffered from compartment syndrome. No patient developed septic arthritis. No patient had documented anterior knee pain or secondary knee specialist input post frame removal. On average, there were 9(4-29) follow up appointments and 10(5-26) radiographs post frame application. There is a 59% chance of a patient having a difficulty post frame application. The malunion rate was 5%. Persisting pinsite infection post frame removal occurred in 5 patients (6.5%). Drilling of the pinsite sequestrum resolved the infection in four of these patients, giving a deep infection rate of 1.3%. The Ilizarov method has a role to play in the treatment of simple closed Tibial shaft fractures in patients who need to kneel. Patient education is a priority however; the patient must be made aware of the difficulty rate associated with the Ilizarov method when compared to the complication profile of alternative treatments. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.
Metcalfe, David; Hickson, Craig J; McKee, Lesley; Griffin, Xavier L
It is uncertain whether external fixation or open reduction internal fixation (ORIF) is optimal for patients with bicondylar tibial plateau fractures. A systematic review using Ovid MEDLINE, Embase Classic, Embase, AMED, the Cochrane Library, Open Grey, Orthopaedic Proceedings, WHO International Clinical Trials Registry Platform, Current Controlled Trials, US National Institute for Health Trials Registry, and the Cochrane Central Register of Controlled Trials. The search was conducted on 3rd October 2014 and no language limits were applied. Inclusion criteria were all clinical study designs comparing external fixation with open reduction internal fixation of bicondylar tibial plateau fractures. Studies of only one treatment modality were excluded, as were those that included unicondylar tibial plateau fractures. Treatment effects from studies reporting dichotomous outcomes were summarised using odds ratios. Continuous outcomes were converted to standardized mean differences to assess the treatment effect, and inverse variance methods used to combine data. A fixed effect model was used for meta-analyses. Patients undergoing external fixation were more likely to have returned to preinjury activities by six and twelve months (P = 0.030) but not at 24 months follow-up. However, external fixation was complicated by a greater number of infections (OR 2.59, 95 % CI 1.25-5.36, P = 0.01). There were no statistically significant differences in the rates of deep infection, venous thromboembolism, compartment syndrome, or need for re-operation between the two groups. Although external fixation and ORIF are associated with different complication profiles, both are acceptable strategies for managing bicondylar tibial plateau fractures.
Gicquel, T; Najihi, N; Vendeuvre, T; Teyssedou, S; Gayet, L-E; Huten, D
Since the reproducibility of the Schatzker and AO tibial plateau fracture classification systems has already been assessed, the goal of this study was to evaluate the Duparc classification system and compare it to the other two. CT scan is better than X-rays for analyzing and classifying tibial plateau fractures. The Duparc classification system is more effective than the other two systems but could be improved by adding elements of each. Six observers analyzed images from 50 fractures and then classified them. Each fracture was evaluated on X-rays. Two weeks later, these same fractures were evaluated on X-rays and CT scans. The same process was repeated four weeks later. The Kappa coefficient (κ) was used to measure agreement and contingency tables were built. The interobserver reproducibility for the X-ray analysis was poor for the Duparc and AO classifications (κDuparc=0.365; κAO=0.357) and average for the Schatzker classification (κSchatzker=0.404). The reproducibility was improved overall when CT scans were also analyzed (κDuparc=0.474; κAO=0.479; κSchatzker=0.476). A significantly greater number of fractures could not be classified in the Schatzker system than in the others (14.3% versus 2% for Duparc and 7.33% for AO). Review of the contingency tables revealed that the Schatzker and AO classification systems did not take certain fracture types into account. Seventy-one percent (71%) of the lateral unicondylar split fractures were found to be combined fractures when CT scan analysis was added. Our results showed CT scan to be better at analyzing and classifying fractures. We also found the Duparc classification to be advantageous because it allowed more fractures to be classified than in other classification systems, while having similar reproducibility. Based on our study findings, the Duparc classification was revised by adding elements of the other two. We propose using the modified Duparc classification system to analyze tibial plateau fractures
Wang, Zhen; Tang, Zhibing; Liu, Chaoqun; Liu, Jinlian; Xu, Yaozeng
The purpose of this study is to explore whether arthroscopically assisted reduction and internal fixation (ARIF) is superior to traditional open reduction and internal fixation (ORIF) in the treatment of tibial plateau fractures. Fifty-seven patients with tibial plateau fractures (Schatzker type I-IV) treated by ARIF or ORIF from 2010 to 2013 were included in this retrospective study. All patients received pre-operative radiographs and CT scans. The patients were divided into two groups (ARIF or ORIF). All had a minimum follow-up of 24 months and an average follow-up of 44.4 months. The clinical and radiographic outcomes were evaluated according to the Rasmussen and KSS scores. There was no significant difference in KSS score or Rasmussen clinical score between the two groups. The average Rasmussen radiographic score was 14.1 (SD 2.4, range 10-18), for the ARIF group and 14.9 (SD 2.3, range 10-18) for the ORIF group (p ARIF. Both ARIF and ORIF yielded satisfactory clinical results for the treatment of Schatzker I-IV tibial plateau fractures. ARIF led to better radiological results than ORIF. Concomitant intra-articular soft tissue lesions are common and can be addressed during ARIF. III.
Hoekstra, H; Kempenaers, K; Nijs, S
Variable angle locking compression plates allow for lateral buttress and support of the posterolateral joint surface of tibial plateau fractures. This gives room for improvement of the surgical 3-column classification approach. Our aim was to revise and validate the 3-column classification approach to better guide the surgical planning of tibial plateau fractures extending into the posterolateral corner. In contrast to the 3-column classification approach, in the revised approach the posterior border of the lateral column in the revised approach lies posterior instead of anterior of the fibula. According to the revised 3-column classification approach, extended lateral column fractures are defined as single lateral column fractures extending posteriorly into the posterolateral corner. CT-images of 36 patients were reviewed and classified twice online according to Schatzker and revised 3-column classification approach by five observers. The intraobserver reliability was calculated using the Cohen's kappa and the interobserver reliability was calculated using the Fleiss' kappa. The intraobserver reliability showed substantial agreement according to Landis and Koch for both Schatzker and the revised 3-column classification approach (0.746 vs. 0.782 p = 0.37, Schatzker vs. revised 3-column, respectively). However, the interobserver reliability of the revised 3-column classification approach was significantly higher as compared to the Schatzker classification (0.531 vs. 0.669 p column, respectively). With the introduction of variable angle locking compression plates, the revised 3-column classification approach is a very helpful tool in the preoperative surgical planning of tibial plateau fractures, in particular, lateral column fractures that extend into the posterolateral corner. The revised 3-column classification approach is rather a practical supplement to the Schatzker classification. It has a significantly higher interobserver reliability as compared to the
G Thiruvengita Prasad
Full Text Available Background: Dual plate fixation in comminuted bicondylar tibial plateau fractures remains controversial. Open reduction and internal fixation, specifically through compromised soft tissues, has historically been associated with major wound complications. Alternate methods of treatment have been described, each with its own merits and demerits. We performed a retrospective study to evaluate the functional outcome of lateral and medial plate fixation of Schatzker type V and VI fractures through an anterolateral approach, and a medial minimally invasive approach or a posteromedial approach. Materials and Methods: We treated 46 tibial plateau fractures Schatzker type V and VI with lateral and medial plates through an anterolateral approach and a medial minimal invasive approach over an 8 years period. Six patients were lost to followup. Radiographs in two planes were taken in all cases. Immediate postoperative radiographs were assessed for quality of reduction and fixation. The functional outcome was evaluated according to the Oxford Knee Score criteria on followup. Results: Forty patients (33 men and 7 women who completed the followup were included in the study. There were 20 Schatzker type V fractures and 20 Schatzker type VI fractures. The mean duration of followup was 4 years (range 1-8 years. All patients had a satisfactory articular reduction defined as ≤2 mm step-off or gap as assessed on followup. All patients had a good coronal and sagittal plane alignment, and articular width as assessed on supine X-rays of the knee in the anteroposterior (AP and lateral views. The functional outcome, as assessed by the Oxford Knee Score, was excellent in 30 patients and good in 10 patients. All patients returned to their pre-injury level of activity and employment. There were no instances of deep infection. Conclusions: Dual plate fixation of severe bicondylar tibial plateau fractures is an excellent treatment option as it provides rigid fixation and
de Santos de la Fuente, F J; López Arévalo, R; Tena Carrillo, C; Ramos Salguero, J C; Fernández Medina, J M
We treated 167 diaphyseal tibial fractures without reaming and with intramedullary fixation, using an unlocked Küntscher nail. The patients were followed for a minimum of 2 years. The mean time to union was 16 weeks. There were no serious complications, but 1 case of nonunion, 1 case of deep infection and 2 cases of clinically relevant malalignment. Migration of the nail was observed in 11 cases. We conclude that this treatment is simple and gives satisfactory results in diaphyseal fractures after low- or mid-energy trauma.
Kim, Joon-Woo; Oh, Chang-Wug; Oh, Jong-Keon; Kyung, Hee-Soo; Park, Kyeong-Hyeon; Kim, Hee-June; Jung, Jae-Wook; Jung, Young-Soo
High-energy proximal tibial fractures often accompany compartment syndrome and are usually treated by fasciotomy with external fixation followed by secondary plating. However, the initial soft tissue injury may affect bony union, the fasciotomy incision or external fixator pin sites may lead to postoperative wound infections, and the staged procedure itself may adversely affect lower limb function. We assess the results of staged minimally invasive plate osteosynthesis (MIPO) for proximal tibial fractures with acute compartment syndrome. Twenty-eight patients with proximal tibial fractures accompanied by acute compartment syndrome who underwent staged MIPO and had a minimum of 12 months follow-up were enrolled. According to the AO/OTA classification, 6 were 41-A, 15 were 41-C, 2 were 42-A and 5 were 42-C fractures; this included 6 cases of open fractures. Immediate fasciotomy was performed once compartment syndrome was diagnosed and stabilization of the fracture followed using external fixation. After the soft tissue condition normalized, internal conversion with MIPO was done on an average of 37 days (range, 9-158) after index trauma. At the time of internal conversion, the external fixator pin site grades were 0 in 3 cases, 1 in 12 cases, 2 in 10 cases and 3 in 3 cases, as described by Dahl. Radiographic assessment of bony union and alignment and a functional assessment using the Knee Society Score and American Orthopedic Foot and Ankle Society (AOFAS) score were carried out. Twenty-six cases achieved primary bony union at an average of 18.5 weeks. Two cases of nonunion healed after autogenous bone grafting. The mean Knee Society Score and the AOFAS score were 95 and 95.3 respectively, at last follow-up. Complications included 1 case of osteomyelitis in a patient with a grade IIIC open fracture and 1 case of malunion caused by delayed MIPO due to poor wound conditions. Duration of external fixation and the external fixator pin site grade were not related to the
Background Currently, antegrade intramedullary nailing and minimally invasive plate osteosynthesis (MIPO) represent the main surgical alternatives in distal tibial fractures. However, neither choice is optimal for all bony and soft tissue injuries. The Retrograde Tibial Nail (RTN) is a small-caliber prototype implant, which is introduced through a 2-cm-long incision at the tip of the medial malleolus with stab incisions sufficient for interlocking. During this project, we investigated the feasibility of retrograde tibial nailing in a cadaver model and conducted biomechanical testing. Methods Anatomical implantations of the RTN were carried out in AO/OTA 43 A1-3 fracture types in three cadaveric lower limbs. Biomechanical testing was conducted in an AO/OTA 43 A3 fracture model for extra-axial compression, torsion, and destructive extra-axial compression. Sixteen composite tibiae were used to compare the RTN against an angle-stable plate osteosynthesis (Medial Distal Tibial Plate, Synthes®). Statistical analysis was performed by Student's t test. Results Retrograde intramedullary nailing is feasible in simple fracture types by closed manual reduction and percutaneous reduction forceps, while in highly comminuted fractures, the use of a large distractor can aid the reduction. Biomechanical testing shows a statistically superior stability (p nail meets the requirements of maximum soft tissue protection by a minimally invasive surgical approach with the ability of secure fracture fixation by multiple locking options. Retrograde tibial nailing with the RTN is a promising concept in the treatment of distal tibia fractures. PMID:24886667
Full Text Available The management of bicondylar tibial plateau fractures is challenging. A lateral locking plate offers an alternative method to traditional dual plating to avoid further stripping of soft tissue. Nevertheless, the rate of malreduction and fixation loss remains high. From 2007 to 2009, we performed open reduction and fixation with unilateral locked plating to directly reduce the fracture in 15 patients with bicondylar plateau fracture. The average follow-up duration was 16.2 months (range: 12–30 months, and the average age of the patients was 43 years (range: 19–64 years. All fractures were Orthopaedic Trauma Association type 41-C. Postoperative radiographic alignment was evaluated immediately and at 2–4 weeks, 8–12 weeks, 5–7 months, and 11–13 months. Both Oxford knee score and Hospital for Special Surgery knee score were used to evaluate functional outcomes. The average duration within which union was achieved was 4.8 months (range: 2–10 months. One patient incurred wound dehiscence; however, there was no case of deep infection. Malreduction occurred in one patient (6.7% while fixation loss occurred in three patients (20% with subsidence of the posteromedial fragment and varus malalignment. Despite the malreduction rate being lower in our study than in previous studies involving unilateral locked plating, a high rate of fixation loss was recorded. Per our limited experience, we believe that unilateral locked plating may have limitations in patients with selective patterns of bicondylar tibial plateau fractures.
Krishna, Sathya Vamsi; Pilar, Anoop; Pai, Sudhir N; Issac, Thomas
A 25-year-old man with no known comorbidities presented with pain and swelling of the left ankle following a twisting injury that had occurred during a road traffic accident. On examination, a 1 × 1-cm abrasion was noted on the medial malleolus and tenderness was noted over the medial and lateral malleoli. A radiograph of the left ankle revealed a fracture of the medial malleolus and an infrasyndesmotic avulsion fracture of the lateral malleolus (a supination-adduction injury). Immediate surgery was performed for the treatment of the medial malleolar fracture. On exploration, the posterior tibial tendon was found to be severed and frayed 2 cm proximal to the medial malleolar fracture. The medial malleolus was fixed with 2 parallel malleolar screws. The ruptured tendon was explored proximally, and the ends were debrided and repaired. At 1 year of follow-up, the ankle had good union and function of the tendon was restored. Posterior tibial tendon ruptures, although rare, should be suspected in cases of closed ankle fracture, irrespective of the mechanism of injury.
Open fractures of the tibia shaft are caused by major musculoskeletal injury, most times high energy transfer trauma. The determinants of a successful treatment outcome are effective infection control, skin coverage and adequate stabilization. We evaluated the outcome of a structured management protocol based on the ...
Kinney, Matthew C; Nagle, David; Bastrom, Tracey; Linn, Michael S; Schwartz, Alexandra K; Pennock, Andrew T
Displaced tibial shaft fractures are common in adolescent patients, yet there is no standardized management strategy. We compared surgical fixation and closed reduction and casting (CRC) of these fractures to assess treatment outcomes and determine predictors of failure. We retrospectively reviewed all patients aged 12 to 18 who presented with a displaced tibial shaft fracture that required reduction over an 8-year period. Exclusion criteria included open fractures and lack of follow-up to radiographic union or to 6 months from the index procedure. Fractures were initially treated based on surgeon preference either with CRC or with immediate intramedullary nailing. Seventy-four patients met inclusion criteria: 57 were initially managed with CRC and 17 with operative fixation. Radiographic healing was defined as bridging of 3 cortices and adequacy of final alignment was defined as 20% (odds ratio=7.8, Palignment (92.5% vs. 72.4%, P=0.10) but required longer hospitalization (5.4 vs. 1.9 d, P<0.001) and had a higher incidence of anterior knee pain (20% vs. 0%, P<0.01). There was no significant difference between groups with respect to time to healing. Treatment outcomes between initial operative fixation and closed reduction of displaced tibia fractures in adolescents are similar, but patients must be counseled about the high failure rates with CRC. Predictors of CRC failure include initial fracture displacement and the presence of a fibula fracture-these variables should be considered when selecting a treatment method. Level III-Therapeutic study.
Ji, Jianfei; Zhao, Yinsong; He, Xueyu; Zhou, Yang
To determine the effect of interlocking intramedullary nail in treatment of open tibial and fibula fractures and analyze the method to promote the bone union. From December 2003 to June 2006, thirty-five patients with open tibial and fibula fracture were treated with emergency debridement, interlocked intramedullary fixation for tibia and fixed fibula at the same time. During operation, the bone marrow was collected and grafted into the fracture gaps. Among them, there were 27 males and 8 females, involving in 22 left legs and 13 right legs. Their ages ranged from 19 to 65 years, with an average of 34.7 years. The location of fracture was the middle of the tibia and fibula in 16 cases, the distal 1/3 of the tibia and fibula in 12 cases and the proximal 1/3 in 7 cases. According to the Gustilo classification of open injuries, there were 7 cases of type I, 19 cases of type II, 8 cases of type III a and 1 case of type III b. The mean range of knee motion was 48.3 degrees (45-70 degrees). The mean time from injury to operation was 4.3 hours (50 minutes to 7 hours). The mean operation time was 94 minutes (60-132 minutes) and the mean blood loss was 122 mL (100-350 mL). The wound healed by first intention in 32 patients. Incision was sutured in 2 cases of type III a fractures after operation 4 days, gastrocnemius flap graft was performed in 1 case of type III b fracture 1 week after operation. They all achieve good healing. No fractures split off, no iatrogenic nerve and vascular injury occurred, no osteofascial compartment syndromes or deep vein thrombus happened. Tension blisters appeared in 1 case of type II fracture after operation and subsided after 5 days. Patients were followed up for 14-43 months (mean 22 months). The X-ray films showed that fracture union was observe in 30 cases after 14 weeks of operation, in 3 cases after 18 weeks and in 1 case after 22 weeks of operation. The fractures union time was 15.2 weeks on average. About 2 cm nonunion in lateral
Zhang, Shaodong; Wu, Xiaotao; Liu, Lei; Wang, Chen
To investigate the effects of intramedullary nail removal after tibial fracture repair. Sixty patients at our hospital were enrolled in a prospective study and divided into moderate/severe knee pain (visual analog scale (VAS) ≥ 4) and mild/no knee pain (VAS knee and ankle pain, the range of motion of the knee and ankle, and Johner-Wruhs criteria before, 6 weeks after operation, and at the last follow-up. Fifty-seven patients were followed for a mean of 8.4 (2-17) months. In patients with moderate or severe knee pain intramedullary nail removal led to significant pain reductions ( p anterior border of tibia (knee pain. Knee pain VAS scores significantly lowered 6 weeks postoperatively and at the last follow-up, compared to before the operation ( p pain VAS scores, range of motion, and Johner-Wruhs criteria ( p > 0.05). For patients complaining knee pain after interlocking intramedullary nailing of tibial fractures, especially with a short distance from the tip of the nail tail to the tibial plateau (anterior border of the tibia (pain significantly.
Background Open fractures of the tibial diaphysis are usually caused by high-energy trauma and associated with severe bone and soft tissue injury. Reamed and unreamed intramedullary nailing are often used for treatment of tibial injury. The purpose of this study was to investigate the clinical efficacy of reamed versus unreamed intramedullary nailing for open tibial fractures (OTF). Methods A meta-analysis was conducted according to the guidelines of the Cochrane Collaboration using databases containing the Cochrane Library, PubMed, EMbase, Chinese Biomedical Database, Chinese VIP information, and WanFang Database. Randomized and semi-randomized controlled clinical trials of both reamed and unreamed intramedullary nailing for OTF treatment were analyzed using Reviewer Manager (RevMan5.0) software. Results A total of 695 references were initially identified from the selected databases. However, only four studies were assessed, matching all the eligibility criteria conducted by two independent reviewers. The result showed that there was no statistical difference in healing rate, secondary surgery rate, implant failure rate, osteofascial compartment syndrome, and infection during the postoperative period between reamed and unreamed nails in OTF. Conclusions Findings of this study suggest that there was no statistical difference between reamed and unreamed intramedullary nailing in clinical treatment of OTF. However, the result of this meta-analysis should be cautiously accepted due to some limitations, and further studies are still needed. PMID:25149501
Pretell-Mazzini, Juan; Kelly, Derek M; Sawyer, Jeffrey R; Esteban, Eva M A; Spence, David D; Warner, William C; Beaty, James H
Systematic review of the literature was done to determine (1) the frequency and type of associated injuries, (2) frequency of concomitant Osgood-Schlatter disease, (3) methods of treatment, (4) functional and radiologic outcomes according to fracture type, and (5) complications of tibial tubercle fractures in pediatric patients. A systematic review of the English literature from 1970 to 2013 included 23 eligible articles reporting 336 fractures with a mean follow-up of 33.56 months (range, 5.7 to 115 mo). Fractures were classified by a comprehensive system that included characteristics of previous systems. Clinical outcomes were assessed by a qualitative scale (excellent/fair/poor), the rate of return to preinjury activity, and knee range of motion. Rate of fracture healing, associated injuries (patellar/quadriceps tendon avulsion and meniscal tears), compartment syndrome, and complications were also recorded. Mean age at surgery was 14.6 years and the most common fracture reported was type III (50.6%). The overall associated injury rate was 4.1%, most common in type III fractures (4.7%). Compartment syndrome was present in 3.57% of cases. Open reduction and internal fixation were done in 98% of surgical cases. Rates of return to preinjury activity and knee range of motion were 98%, regardless of the type of fracture. Fracture consolidation was achieved in 99.4% of cases. Overall complication rate was 28.3%; removal of an implant because of bursitis (55.8%) was most common. Tenderness/prominence (17.9%) and refracture (6.3%) were also common. Treatment of tibial tubercle fractures in adolescents produced good clinical and radiologic results regardless of fracture type, which was more related to potential complications. Fractures with intra-articular involvement tended to present with more associated injuries and to have fair functional outcomes, suggesting that advanced imaging may be justified with these fractures. Complications could be more common than expected
Alberts, K A; Loohagen, G; Einarsdottir, H
Unreamed intramedullary nailing is an alternative to external fixation in the treatment of open tibial fractures. We compared a prospective series of thirty-one patients managed with a solid nail with static interlocking without intramedullary reaming, with a retrospective series of thirty-one patients managed by external fixation. The protocol for soft tissue treatment was the same throughout the study period. Most fractures were caused by high energy trauma and included Grade I to III B injuries. The fracture wound infection rate was equal in both groups; there were two deep and three superficial infections in the nail group and three deep and two superficial infections in the external fixation group. In addition, eleven patients in the external fixation group had severe pin track infections. The mean time to union was five months in the nail group and eight months in the external fixation group. The incidence of delayed union was twice as high in the external fixation group as in the nail group. The number of surgical procedures performed to promote union was three times higher in the external fixation group. The malunion rate did not differ between the groups. Although the treatment groups are not fully comparable, the results indicate that intramedullary nailing is superior to external fixation in the treatment of most open tibial fractures.
Andersson, S M; Nilsson, B E
The bone mineral content in the upper ends of the tibia and the fibula was measured in 27 patients with tibial shaft fracture. The loss of bone mineral associated with the fracture did not differ between patients who were allowed weight-bearing in a functional below-knee brace and patients treated with a long leg plaster cast without weight-bearing.
Squyer, Emily R; Dikos, Gregory D; Kaehr, David M; Maar, Dean C; Crichlow, Renn J
To evaluate the ability of orthopaedic trauma subspecialists to predict early bony union in femoral and tibia shaft fractures. Eight orthopaedic trauma subspecialists prospectively predicted the probability of bony union at 6 and 12 weeks post-operatively for an aggregate of 48 femoral and tibial shaft fractures treated at a Level 1 trauma centre. An additional orthopaedic trauma subspecialist was blinded to treating surgeon and adjudicated healing at 18 weeks. The Squared-Error Skill Score (SESS) determined the likelihood of accurate forecasting for bony union. Nine patients were lost follow-up, resulting in 39 fractures (81.25% retention) including 20 femoral and 19 tibial fractures. Fourteen fractures were open, 15 were not-yet united at final follow-up. SESS values were 0.25-0.77. The ability to predict union (sensitivity) was 1.000. The ability to predict nonunions (specificity) was 0.330-0.500. The probability of a correct predicted union was 0.727 and correct predicted nonunion at final follow-up was 1.000. AO/OTA type A fractures pattern predictions were highly accurate. As body mass index increased, predictions trended toward decreased accuracy (p=0.06). Tobacco use, age, gender, associated injuries, open fractures, and surgeons' years in clinical practice were not associated with accuracy of predictions. At 12-weeks post-operatively orthopaedic trauma subspecialists can confidently predict the union state in this patient population. This data is most useful in the nonunion patient, directing early intervention, thereby decreasing patient disability and discomfort. Copyright Â© 2016 Elsevier Ltd. All rights reserved.
Fischbach, R.; Maintz, D.; Zaehringer, M.; Landwehr, P.; Prokop, A.
Purpose: To compare magnetic resonance imaging (MRI) and X-ray tomography in assessing the type of fracture, degree of comminution and amount of articular surface depression in acute tibial condylar fractures and to describe the associated soft tissue injuries diagnosed with MRI. Method: 27 patients with acute tibial plateau fractures were investigated usig linear X-ray tomography and MRI employing T 1 -weighted and proton density turbo spin echo, STIR, and T 2 -weighted gradient echo images. Fractures were classified according to the AO classification system. The degrees of depression and comminution were measured and soft tissue injuries were recorded. Results: Fractures were classified as type B1 in 7, as B2 in 6, and as B3 in 6 cases by MRI. More complex C-type fractures were diagnosed in 8 cases. MR and X-ray grading were consistent with the exception of two B3 fractures, which were graded as B1 by X-ray tomography. X-ray tomography under-estimated the degree of comminution. 63% of the patients had either meniscal tears or complete ruptures of their cruciate or collateral ligaments. Ten meniscal tears were diagnosed in 9 of 27 patients. Complete tears of the anterior cruciate ligament were seen in 4, and avulsions of the posterior cruciate ligament in 2 patients. Conclusion: MRI allows a detailed assessment of acute tibial plateau fractures and can replace conventional X-ray tomography. The high rate of fracture-associated soft tissue lesions makes MRI an especially valuable tool. (orig.) [de
Groshar, D.; Even-Sapir, E.; Lam, M.; Israel, O.; Front, D.
Stress fractures result from an unusual repetitive physical activity causing absorption of bone in excess of repair and bone formation. This leads to the weakening of the bone and subsequently to a fracture. It is a benign condition that if recognized in time does not need any treatment besides rest. However, if diagnosis is not made and physical activity continues it may result in severe injury to the bone and a frank fracture may result. Pain is the typical clinical feature and bone scintigraphy, being more sensitive than radiography, is done to establish early diagnosis. The presence of asymptomatic sites of abnormal bone uptake typical of stress fracture in which pain appeared only about 2 weeks after scintigraphy, drew the authors' attention to the question of how close is the relationship between stress fractures and bone pain. Sixty-four military recruits diagnosed as suffering from stress fracture were investigated in order to correlate sites with abnormal uptake of Tc-99m MDP on bone scintigraphy with sites of local pain. In 37 (58%) subjects multiple sites of abnormal uptake were recognised. Of 123 sites of abnormal uptake, 31 (25%) were asymptomatic. In three patients bone pain appeared at the site of the abnormal uptake two weeks after scintigraphy. Bone scintigraphy appears to be more sensitive than bone pain in the diagnosis of stress fractures. The osteoblastic activity which manifests itself by abnormal uptake appears in some cases earlier than the pain caused by the fracture. Present findings may suggest that under certain circumstances, in a population prone to stress fracture, bone scan should be considered as a screening method
Metsemakers, W-J; Handojo, K; Reynders, P; Sermon, A; Vanderschot, P; Nijs, S
Despite modern advances in the treatment of tibial shaft fractures, complications including nonunion, malunion, and infection remain relatively frequent. A better understanding of these injuries and its complications could lead to prevention rather than treatment strategies. A retrospective study was performed to identify risk factors for deep infection and compromised fracture healing after intramedullary nailing (IMN) of tibial shaft fractures. Between January 2000 and January 2012, 480 consecutive patients with 486 tibial shaft fractures were enrolled in the study. Statistical analysis was performed to determine predictors of deep infection and compromised fracture healing. Compromised fracture healing was subdivided in delayed union and nonunion. The following independent variables were selected for analysis: age, sex, smoking, obesity, diabetes, American Society of Anaesthesiologists (ASA) classification, polytrauma, fracture type, open fractures, Gustilo type, primary external fixation (EF), time to nailing (TTN) and reaming. As primary statistical evaluation we performed a univariate analysis, followed by a multiple logistic regression model. Univariate regression analysis revealed similar risk factors for delayed union and nonunion, including fracture type, open fractures and Gustilo type. Factors affecting the occurrence of deep infection in this model were primary EF, a prolonged TTN, open fractures and Gustilo type. Multiple logistic regression analysis revealed polytrauma as the single risk factor for nonunion. With respect to delayed union, no risk factors could be identified. In the same statistical model, deep infection was correlated with primary EF. The purpose of this study was to evaluate risk factors of poor outcome after IMN of tibial shaft fractures. The univariate regression analysis showed that the nature of complications after tibial shaft nailing could be multifactorial. This was not confirmed in a multiple logistic regression model, which
Chalidis, Byron E; Petsatodis, George E; Sachinis, Nick C; Dimitriou, Christos G; Christodoulou, Anastasios G
The need for reaming and the number of locking screws to be used in intramedullary (IM) tibial nailing of acute fractures as well as routine bone grafting of tibial aseptic nonunions have not been clearly defined. We describe the results of reamed interlocked IM nails in 233 patients with 247 tibial fractures (190 closed, 27 open and 30 nonunions). Ninety-six percent of the fractures were united at review after an average of 4.9 years. No correlation was found between union and nail diameter (P = 0.501) or the number of locking screws used (P = 0.287). Nail dynamization was effective in 82% of fractures. Locking screw(s) breakage was associated with nonunion in 25% of cases. Bone grafting during IM nailing was found not to increase the healing rate in tibial nonunions (P = 0.623). None of the IM nails were removed or revised due to infection. A dropped hallux and postoperative compartment syndrome were found in 0.8 and 1.6% of cases, respectively. Anterior knee pain was reported in 42% of patients but nail removal did not alleviate the symptoms in almost half. This series confirms the place of reamed intramedullary nailing for the vast majority of tibial diaphyseal fractures. It provides an optimum outcome and minimizes the need for supplementary bone grafting in aseptic nonunions.
Dailey, Hannah L
BACKGROUND: Animal studies and clinical trials have suggested that early application of controlled axial micromotion can accelerate healing of long bone fractures compared to rigid fixation. However, experimental investigations of micromotion constructs have been limited to external fixators, which have a higher incidence of complications than intramedullary nails. The purpose of this study was to assess whether a novel intramedullary nail design can generate stimulatory micromotion under minimal weight-bearing loads typical of the early healing period. METHODS: Eight cadaver tibiae were reamed, osteotomised, and implanted with commercially-available IM nails fitted with a custom insert that allowed 1mm of axial micromotion after proximal\\/distal interlocking. Specimens were mounted in a materials testing machine and subjected to cyclic axial loading while interfragmentary motion was measured using an extensometer. Implants were also tested in standard statically-locked mode. FINDINGS: The average force required to cause distraction of the fracture gap in micromotion mode was 37.0 (SD 21.7) N. The mean construct stiffness was 1046.8 (SD 193.6) N\\/mm in static locking mode and 512.4 (SD 99.6) N\\/mm in micromotion mode (significantly different, P<0.001). INTERPRETATION: These results support the development of a micromotion-enabled IM nail because the forces required to cause interfragmentary movements are very low, less than the weight of the hanging shank and foot. In contrast to rigid-fixation nails, which require significant weight-bearing to induce interfragmentary motion, the micromotion-enabled nail may allow movement in non-weight-bearing patients during the early healing period when the benefits of mechanical stimulation are most critical.
Yang, Kyu-Hyun; Won, Yougun; Kang, Dong-Hyun; Oh, Jin-Cheol; Kim, Sung-Jun
To determine the effect of interfragmentary appositional (gap-closing) screw fixation in minimally invasive plate osteosynthesis (MIPO) for distal tibial fractures on the clinical and radiologic results. Prospective nonrandomized study. Level I trauma center. Sixty patients who were diagnosed as distal metadiaphyseal oblique or spiral tibial fracture without displaced articular fragment. Thirty patients (group A) of the 60 patients were treated with MIPO without appositional screw fixation, and the other 30 (group B) were treated with the screw. Radiologic union, clinical union, clinical functional score [American Orthopaedic Foot and Ankle Society (AOFAS) score], and complications. The time for initial callus formation and radiologic union was significantly longer in group A than those in group B (76.8 vs. 58.0 days, P = 0.044; 409 vs. 258.7 days, P = 0.002, respectively). The rate of clinical union during 1 year was significantly higher in group B than in group A (P = 0.0063). Four nonunion patients in group A achieved bone union after placement of an additional bone graft. None of the patients in group B diagnosed with delayed union or nonunion (P screw fixation in distal tibia MIPO for the fixation of oblique or spiral fracture promoted callus formation and union rate compared with MIPO without appositional screw fixation. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Full Text Available Objective: To evaluate the effectiveness of the damage control, in emergency to treat the open tibial pilon fractures with Dolphix?External Fixator Frame(CITIEFFE? Calderara di Reno, Bologna, Italy. Methods: From January 2017 to August 2017, at the Department of Orthopedics and Traumatology of Vito Fazzi Hospital Lecce, we treated 23 open tibial pilon fractures with Dolphix?External Fixator Frame(CITIEFFE? Calderara di Reno, Bologna, Italy. The evaluation criteria of the case series were: the time needed to assemble the external fixator; the time taked to treat the ankle associated lesions; the time of skin healing; the ankle alignment; the subjective/objective Ovadia and Beals score; and complications. The Endpoint assessment was set at the days of the definitive surgery. Results: The results in terms of alignment, biomechanical stability of the frame, healing of soft tissue, complications were as good as the objective and subjective results according Ovadia and Beals score. Conclusion: Pilon fractures are complex and often present complications; the damage control treatment, in emergency, with Dolphix?External Fixator Frame(CITIEFFE? Calderara di Reno, Bologna, Italy permits a stable osteotaxis with minimal soft tissue damage and permit the repair of muscles, blood vessels and nerves with a stable bone and the soft tissue healing with vaccum therapy.
Robertson, Greg A J; Wood, Alexander M
Stress fractures in sport are becoming increasing more common, comprising up to 10% of all of sporting injuries. Around 90% of such injuries are located in the lower limb. This articles aims to define the optimal management of lower limb stress fractures in the athlete, with a view to maximise return rates and minimise return times to sport. Treatment planning of this condition is specific to the location of the injury. However, there remains a clear division of stress fractures by "high" and "low" risk. "Low risk" stress fractures are those with a low probability of fracture propagation, delayed union, or non-union, and so can be managed reliably with rest and exercise limitation. These include stress fractures of the Postero-Medial Tibial Diaphysis, Metatarsal Shafts, Distal Fibula, Medial Femoral Neck, Femoral Shaft and Calcaneus. "High risk" stress fractures, in contrast, have increased rates of fracture propagation, displacement, delayed and non-union, and so require immediate cessation of activity, with orthopaedic referral, to assess the need for surgical intervention. These include stress fractures of the Anterior Tibial Diaphysis, Fifth Metatarsal Base, Medial Malleolus, Lateral Femoral Neck, Tarsal Navicular and Great Toe Sesamoids. In order to establish the optimal methods for managing these injuries, we present and review the current evidence which guides the treatment of stress fractures in athletes. From this, we note an increased role for surgical management of certain high risk stress fractures to improve return times and rates to sport. Following this, key recommendations are provided for the management of the common stress fracture types seen in the athlete. Five case reports are also presented to illustrate the application of sport-focussed lower limb stress fracture treatment in the clinical setting.
Robertson, Greg A J; Wood, Alexander M
Stress fractures in sport are becoming increasing more common, comprising up to 10% of all of sporting injuries. Around 90% of such injuries are located in the lower limb. This articles aims to define the optimal management of lower limb stress fractures in the athlete, with a view to maximise return rates and minimise return times to sport. Treatment planning of this condition is specific to the location of the injury. However, there remains a clear division of stress fractures by “high” and “low” risk. “Low risk” stress fractures are those with a low probability of fracture propagation, delayed union, or non-union, and so can be managed reliably with rest and exercise limitation. These include stress fractures of the Postero-Medial Tibial Diaphysis, Metatarsal Shafts, Distal Fibula, Medial Femoral Neck, Femoral Shaft and Calcaneus. “High risk” stress fractures, in contrast, have increased rates of fracture propagation, displacement, delayed and non-union, and so require immediate cessation of activity, with orthopaedic referral, to assess the need for surgical intervention. These include stress fractures of the Anterior Tibial Diaphysis, Fifth Metatarsal Base, Medial Malleolus, Lateral Femoral Neck, Tarsal Navicular and Great Toe Sesamoids. In order to establish the optimal methods for managing these injuries, we present and review the current evidence which guides the treatment of stress fractures in athletes. From this, we note an increased role for surgical management of certain high risk stress fractures to improve return times and rates to sport. Following this, key recommendations are provided for the management of the common stress fracture types seen in the athlete. Five case reports are also presented to illustrate the application of sport-focussed lower limb stress fracture treatment in the clinical setting. PMID:28361017
Shen, Kaiying; Cai, Haiqing; Wang, Zhigang; Xu, Yunlan
Abstract Elastic stable intramedullary nailing (ESIN) has became a well-accepted method of osteosynthesis of diaphyseal fractures in the skeletally immature patient for many advantages, the purpose of this study is to evaluate the preliminary results of this minimally invasive treatment for severely displaced distal tibial diaphyseal metaphyseal junction (DTDMJ) fractures. This study was carried out over a 6-year period. Twenty-one severely displaced DTDMJ fractures treated using ESIN were evaluated clinically and radiographically. Complications were assessed: the patients were evaluated with regard to nonunion, malunion, infection, growth arrest, leg length discrepancy, implant irritation, and joint function. Mean age at the time of surgery was 7.8 years (range between 5.3 and 14.8 years), mean body weight 34.1 kg, all fractures were transverse or mild oblique type, including 3 open fractures, 5 multifragmented fractures, and 4 fractures associated with polytrauma; 6 cases were treated with antegrade ESIN of tibia while 15 cases need combined retrograde fibula and antegrade tibia fixation treatments. Follow-ups were ranging from 11 to 36 months, 19 fractures showed both clinical and radiographic evidence of healing within 5 months; all cases had full range motion of knee and ankle with symmetrical foot progress angle. Nail removal was at a mean 7.1 months, at final follow-up, no growth arrest or disturbances occurred. Five patients had complications; leg length discrepancy had decreased yet affected 2 patients, 2 cases showed delayed union, and 1 case developed restricted dorsal extension at the metatarsophalangeal joint of the hallux. ESIN is the treatment of choice for pediatric severely displaced DTDMJ fractures that cannot be reduced by closed reduction or ones that cannot be casted. The advantages include faster fracture healing, excellent functional and cosmetic results, safe and reliable surgical technique, and lower severe complication rate. PMID
Luo, Peng; Xu, Ding; Wu, Jia; Chen, Yi-Heng
This article is a systematic review of the published literature about the biomechanics, functional outcomes, and complications of a locked plate as an external fixator in treating tibial fractures. We searched the PubMed, Ovid Medline, Embase, ScienceDirect, and Cochrane Library databases to retrieve the relevant studies. Studies published in English and Chinese which assessed adult patients and more than 4 cases who had sustained any type of fresh tibial fracture treated with the external locking plate, provided that they reported functional outcomes, range of motion (ROM), union or complication rates, and the biomechanical studies of external locked plating are also included. The electronic search strategy revealed 248 studies, and 2 studies were identified as relevant through manual search of references. Finally, 12 studies were included in this systematic review. These consist of 3 pure biomechanical studies, 8 case series, and 1 study including both of biomechanics and case series. Due to the heterogeneity of biomechanical studies, we can only conclude that external locked plate shows inferior structural stiffness than internal locked plate. The clinical studies reported that external locked plating gave a satisfactory ROM of the knee and ankle, functional outcomes, union rate, and low complication rate. We can only conclude that external locked plate shows inferior structural stiffness than internal locked plate because of the heterogeneity of biomechanical studies. The clinical studies showed locked plating as an external fixator in treating tibial fractures can be considered as a safe and successful procedure. However, as yet, there is unconvincing evidence that it is superior to standard techniques with regards to clinical and functional outcomes. More and well-designed studies about this technique should be carried out.
Tibial shaft fractures present 15% of all fractures, which means about 2500 cases per year in Hungary. 90% of these fractures are treated surgically. Nowadays, the incidence of tibia fractures is increased, the severity of the fractures is intensified and in spite of new surgical techniques the rate of complications is not dramatically decreased. The treatment of the open tibia fractures has basically changed since the introduction of unreamed intramedullar nails. The unreamed nails turned into the primary method in the treatment of the Grade II and III open fractures and became sufficient for the fixation of the proximal and distal third tibia fractures. In Hungary, we used the Marchetti-Vicenzi nail for the treatment of tibia fractures in first time, with this method the tibial shaft and distal part fractures can be treated safely with low rate of complication. In year 1997 we prepared the treatment concept of the combination of the dynamic brace and the undreamed intramedullar nail. We proved that by the application of this method the advantages of the two treatment form could be attached and the healing period and the rehabilitation of the injured could be shortened. During the clinical exploration of the complications we proved that different pressure levels developed in the muscular compartment around the tibia during the usage of two different surgical techniques, the reamed and unreamed nailing. In the deep compartment we measured statistically higher pressure in the cases of unreamed nailing. In contrast to the literature we can draw the conclusion that there is no relationship between the compartmental pressure changes, the chance of the development of compartment syndrome and the insertion technique of the intramedullar nails. In pursuance of the basic research of the complications we investigated the muscle samples from compartment syndrome and from Volkmann ischemic contracture with differential scanning calorimetry. We proved that there is a
Tay, Wei-Han; de Steiger, Richard; Richardson, Martin; Gruen, Russell; Balogh, Zsolt J
Knowledge about the functional consequences of lower limb long bone fractures is helpful to inform patients, clinicians and employers about their recovery process and prognosis. This study aims to describe the epidemiology and health outcomes of femoral and tibial shaft fractures treated at two level I trauma centres, by comparing the differences between patients with delayed union or nonunion and patients with union. An analysis of registry data over two years, supplemented with medical record review, was conducted. Fracture healing was retrospectively assessed by clinical and radiological evidence of union, and the need for surgical intervention. SF-12 scores, and work and pain status were prospectively recorded at six and twelve months post injury. 285 fractures progressed to union and 138 fractures developed delayed union or nonunion. There was a significant difference between the two cohorts with regards to the mechanism of injury, association with multi-trauma, open fractures, grade of Gustilo classification, patient fund source, smoking status and presence of comorbidities. The SF-12 physical component score was less than 50 at both six and twelve months with improvement in the union group, but not in the delayed union or nonunion group. 72% of patients with union had returned to work at one year, but 54% continued to have pain. The difference compared to patients with delayed union or nonunion was significant. Even patients whose fractures unite in the expectant time-frame will have residual physical disability. Patients with delayed union or nonunion have still poorer outcomes, including ongoing problems with returning to work and pain. It is important to educate patients about their injury so that they have realistic expectations. This is particularly relevant given that the patients most likely to sustain femoral or tibial shaft fractures are working-age healthy adults, and up to a third of fractures may develop delayed union or nonunion. Despite modern
Full Text Available Fractures of the horizontal surface of the distal tibia are known commonly as pylon or plafond fractures, and represent 1-5% of lower extremity fractures, 7-10% of all tibial fractures. The protocol consisted of immediate (within eight to 24 hours open reduction and internal fixation of the fibula, using a fibular plate or one third tubular plate and application of an external fixator spanning the ankle joint. In the second stage, the treatment of proximal and distal tibial fractures with close reduction and MIPPO technique can preserve soft tissue, simplify operative procedure and decrease wound, obtain rigid internal fixation and guarantee early function exercises of ankle joint. In this study we evaluated 22 patients treated in Clinical Emergency Hospital Constanta between April 2012 - July 2013 diagnosed with multifragmentary fractures of the distal tibia. This study evaluates the treatment of complex fractures of distal tibia with locked plate after external fixation. There were 17 males and 5 females of mean age 51,7 years (31-68. The mean follow-up period was 14 weeks. (Ranging from 9-16 weeks. All patients were fully weight bearing at 16 weeks (ranging 9-16 weeks showing radiological union. There were no cases of failures of fixation, or rotational misalignment. No significant complication was observed in our patients. MIPO is an effective method of treatment for distal tibial fractures, reduce surgical trauma and maintain a more biologically favorable environment for fracture healing, reducing risks of infection and nonunion.
Greco, Nicholas; Goyal, Kanu; Tarkin, Ivan
Open tibial shaft fracture occurring below an ipsilateral total knee arthroplasty (TKA) is a unique injury pattern that presents an additional degree of complexity to an already challenging treatment algorithm. Tibial shaft fracture is a surgical emergency requiring respect for the soft-tissue envelope and consideration of the biomechanical and biologic factors involved in healing. Treatment with an intramedullary nail relative to other types of internal or external fixation methods optimizes these factors and minimizes the risks of nonunion, malunion, infection, soft-tissue compromise, and reoperation, which are prevalent after this fracture. However, tibial shaft fracture associated with an ipsilateral TKA complicates standard treatment principles and increases the risks after surgery. In many instances, this type of injury pattern in a patient with medical comorbidities that would impede fracture and wound healing would make a limb amputation the preferred method of treatment. However, in this case report, we examine treatment options for an open tibial shaft fracture in the setting of an ipsilateral TKA and propose a method of limb salvage in a patient with medical comorbidities sustaining this injury pattern.
Full Text Available To review the evidence from RCTs on clinical outcomes and benefit of acute tibial fracture and nonunion treated with and without BMPs.We searched multiple databases (MEDLINE, EMABSE, BIOSIS and Cochrane central as well as reference lists of articles and contacted authors. Evaluated outcomes included union rate, revision rate, hardware failure and infection. The weighted and standard mean difference (WMD and SMD or the relative risk (RR was calculated for continuous or dichotomous data respectively. The quality of the trial was assessed, and meta-analyses were performed with the Cochrane Collaboration's REVMAN 5.0 software.Eight RCTs involving 1113 patients were included. For acute tibial fracture, BMP group was associated with a higher rate of union (RR, 1.16; 95% CI, 1.04 to 1.30 and a lower rate of revision (RR, 0.68; 95% CI, 0.54 to 0.85 compared with control group. No significant differences were found in rate of hardware failure and infection. The pooled RR for achieving union for tibial fracture nonunion was 0.98 (95% CI, 0.86 to 1.13. There was no significant difference between the two groups in the rate of revision (RR, 0.48; 95% CI, 0.13 to 1.85 and infection (RR, 0.61; 95% CI, 0.37 to 1.02.Study on acute tibial fractures suggests that BMP is more effective that controls, for bone union and for decreasing the rate of surgical revision to achieve union. For the treatment of tibial fracture nonunion, BMP leads to similar results to as autogenous bone grafting. Finally, well-designed RCTs of BMP for tibial fracture treatment are also needed.
Tenforde, Adam S; Sayres, Lauren C; McCurdy, Mary Liz; Sainani, Kristin L; Fredericson, Michael
Adolescent females and males participating in running represent a population at high risk of stress fracture. Few investigators have evaluated risk factors for prospective stress fracture in this population. To better characterize risk factors for and incidence of stress fractures in this population, we collected baseline risk factor data on 748 competitive high school runners (442 girls and 306 boys) using an online survey. We then followed them prospectively for the development of stress fractures for a mean ± SD of 2.3 ± 1.2 total seasons of cross-country and track and field; follow-up data were available for 428 girls and 273 boys. We identified prospective stress fractures in 5.4% of girls (n = 23) and 4.0% of boys (n = 11). Tibial stress fractures were most common in girls, and the metatarsus was most frequently fractured in boys. Multivariate regression identified four independent risk factors for stress fractures in girls: prior fracture, body mass index dance. For boys, prior fracture and increased number of seasons were associated with an increased rate of stress fractures, whereas prior participation in basketball was associated with a decreased risk of stress fractures. Prior fracture represents the most robust predictor of stress fractures in both sexes. Low body mass index, late menarche, and prior participation in gymnastics and dance are identifiable risk factors for stress fractures in girls. Participation in basketball appears protective in boys and may represent a modifiable risk factor for stress fractures. These findings may help guide future translational research and clinical care in the management and prevention of stress fractures in young runners.
Thewlis, Dominic; Fraysse, Francois; Callary, Stuart A; Verghese, Viju Daniel; Jones, Claire F; Findlay, David M; Atkins, Gerald J; Rickman, Mark; Solomon, Lucian B
Tibial plateau fractures are complex and the current evidence for postoperative rehabilitation is weak, especially related to the recommended postoperative weight bearing. The primary aim of this study was to investigate if loading in the first 12 weeks of recovery is associated with patient reported outcome measures at 26 and 52 weeks postoperative. We hypothesized that there would be no association between loading and patient reported outcome measures. Seventeen patients, with a minimum of 52-week follow-up following fragment-specific open reduction and internal fixation for tibial plateau fracture, were selected for this retrospective analysis. Postoperatively, patients were advised to load their limb to a maximum of 20kg during the first 6 weeks. Loading data were collected during walking using force platforms. A ratio of limb loading (affected to unaffected) was calculated at 2, 6 and 12 weeks postoperative. Knee Injury and Osteoarthritis Scores were collected at 6, 12, 26 and 52 weeks postoperative. The association between loading ratios and patient reported outcomes were investigated. Compliance with weight bearing recommendations and changes in the patient reported outcome measures are described. Fracture reduction and migration were assessed on plain radiographs. No fractures demonstrated any measurable postoperative migration at 52 weeks. Significant improvements were seen in all patient reported outcome measures over the first 52 weeks, despite poor adherence to postoperative weight bearing restrictions. There were no associations between weight bearing ratio and patient reported outcomes at 52 weeks postoperative. Significant associations were identified between the loading ratio at 2 weeks and knee-related quality of life at six months (R 2 =0.392), and between the loading ratio at 6 weeks combined with injury severity and knee-related quality of life at 26 weeks (R 2 =0.441). In summary, weight bearing as tolerated does not negatively affect the
Khan, Sher Baz; Mohib, Yasir; Rashid, Rizwan Haroon; Rashid, Haroonur
Intra-medullary (IM) nailing is standard of care for unstable tibial shaft fractures. Malrotation is very common but it is under-recognised, inpart because of variation in normal anatomy and partly due to difficulty in accurately assessing rotation. This study was planned to evaluate the frequency of rotational mal-alignment after reamed tibia IMnailing. This cross-sectional study was conducted at Aga khan University Hospital, Karachi, and comprised patients with tibia shaft fractures managed with IMnailing from January to December 2014. All the patients were assessed intra-operatively for rotational alignment using the knee and ankle fluoroscopic images. There were 81 patients with a mean age of 38±16.9 years. There were 64(79%) male patients. Overall the incidence of malrotation was in 20(24.7%) cases. Rotational mal-alignment is one of the preventable complications after IMnailing which can be assesed intra-operatively under fluoroscope.
Heiney, Jake P; Redfern, Roberta E; Wanjiku, Stephen
There is a growing need to develop tools that allow for better reductions of difficult to treat fractures in minimally disruptive ways. One such technique has been developed using the inflatable bone tamp and a fast setting calcium phosphate. KYPHON(®) XPANDER Inflatable Bone Tamp and the KYPHON(®) Osteo Introducer(®) System were used to reduce the articular fractures and a fast-setting calcium phosphate was introduced into those voids and metal hardware was applied as deemed necessary. Subjects were skeletally mature patients treated for articular fractures of the calcaneus, tibial plateau, tibial pilon, or distal radius. Post-operative day zero and week 12 radiographs were objectively and subjectively evaluated by three independent orthopaedic surgeons. Their objective scores were then translated into subjective categories based on the Heiney-Redfern scaled scoring (H-R score) system established herein. Overall, the thorough radiographic analysis by independent reviewers indicates that the technique is capable of obtaining and maintaining articular reductions in a good or adequate manner at 12-weeks post-operatively. Introduced is a potential novel evaluation scale scoring system for these articular fractures that evaluates the important anatomic considerations reproducibly in fracture reductions. There are many potential benefits that remain speculative to this type of tool within a procedure, and therefore this tool and technique warrants further research. Copyright © 2013 Elsevier Ltd. All rights reserved.
Ozkaya, Ufuk; Parmaksizoglu, Atilla S; Gul, Murat; Sokucu, Sami; Kabukcuoglu, Yavuz
The purpose of this study was to evaluate the clinical performances of stainless steel nonlocking plates and titanium locking plates in minimally invasive medial plating of extra-articular metaphyseal fractures of the distal tibia. Between 2004 and 2006, 43 patients who sustained closed fractures of the distal tibia metaphysis were managed with either a stainless steel nonlocking plate (Group 1, n = 21) or a titanium locking plate (Group 2, n = 22). Clinical and radiographic data were retrospectively reviewed. Function was assessed with use of the American Orthopaedic Foot and Ankle Society ankle-hindfoot instrument. The average followup period was 25 months. The average AOFAS foot and ankle scores in Group 1 and Group 2 at final followup were 85 and 81, respectively. Fracture reduction was anatomical or nearly anatomical without angular displacement in all cases except one patient in Group 2. (p > 0.05) The average time to full, unprotected weightbearing in Group 1 and Group 2 were 15 weeks and 18 weeks, respectively (p plating with titanium locking plates resulted in prolonged secondary healing both in comminuted and simple fracture patterns compared to conventional stainless steel nonlocking plates. We believe that in biological fixation of distal tibial fractures, similarly good results may be obtained with both materials as the locking technology had a greater effect on stability.
Collinge, Cory A; Beltran, Michael J; Dollahite, Henry A; Huber, Florian G
The reduction of tibial shaft fractures during intramedullary nailing is important if limb alignment is to be restored and successful clinical outcomes are expected. We have used a percutaneously applied (or open) clamp or clamps to achieve and maintain reduction during nailing of all amendable tibial shaft fractures. In this article, we describe the technique and preliminary results comparing closed, simple spiral and oblique tibial shaft fractures (OTA 42-A1 and A2) managed with percutaneous clamp-assisted nailing (CAN) versus nailing using manual reduction (MRN) held by the surgical team. In the MRN group, there were an increased fracture gap (P = 0.04) and trends toward malalignment (P = 0.07) and healing time (P = 0.06) compared with the CAN group. There were also trends in clinical; no wound complications occurred in either group. We have found that percutaneous CAN of closed, simple spiral and oblique tibial shaft fractures seems safe and allows for early predictable union with reproducible alignment compared with nailing using MRN.
Krause, Matthias; Preiss, Achim; Meenen, Norbert M; Madert, Jürgen; Frosch, Karl-Heinz
To analyze the anatomic accuracy of fracture reduction controlled by fluoroscopy as compared with arthroscopically assisted reduction ("fracturoscopy") in patients with complex tibial plateau fractures (AO/OTA 41-C). Quality of fracturoscopy-guided reduction was checked with postoperative computed tomography. Prospective observational study. Urban level 1 trauma center. Seventeen consecutive patients, with a complex, bicondylar tibial plateau fracture. The intraoperative, open insertion of an arthroscope (2.4-mm or 2.8-mm optics), to visualize the articular surface and fracture reduction. Ability to detect residual fracture depression or gap after previous open reduction under fluoroscopic guidance. An open fracture reduction with fluoroscopic guidance was performed in all cases. In 7 cases, open reduction and fluoroscopy resulted in satisfactory fracture reduction (fluoroscopy group). In 10 of 17 cases, subsequent "fracturoscopy" showed persistent fracture depression (≥2 mm, fracturoscopy group) with the need for intraoperative correction. Patients in the fracturoscopy group demonstrated significantly greater preoperative fragment depression (12.55 ± 6.56 mm) and a larger preoperative fracture gap (7.83 ± 5.49 mm) compared with patients with a satisfactory reduction under fluoroscopy (depression 4.97 ± 4.02 mm, P = 0.016; gap 2.47 ± 1.07 mm, P = 0.023). Fluoroscopy was not successful in achieving satisfactory reduction in cases in which the postero-latero-central region was affected (P = 0.004, χ test). Postoperative computed tomography demonstrated satisfactory articular reconstruction in all cases. Intraoperative fracturoscopy permitted a significantly improved visualization of fracture fragment displacement, specifically in the postero-latero-central region of the tibial plateau, as compared with fluoroscopy. Fracturoscopy is recommended for fractures involving the postero-latero-central region of the tibial plateau. Therapeutic Level IV. See
Lee, Jun Woo; Xin, YuanZhu; Yang, Seok Jo [Chungnam National University, Daejeon (Korea, Republic of); Ji, Jong Hun; Panchal, Karnav; Kwon, Oh Soo [The Catholic University of Korea, Daejeon (Korea, Republic of)
High tibial osteotomy (HTO) has been used to successfully treat patients with genu varus deformities that can improve mechanical function and condition in the knee joint. Clinical studies have reported that bow legs often occur with a concentrated load on the varus of the tibia. This study aimed to analyze and verify the clinical test data result by utilizing the three-dimensional (3D) static finite element method (FEM). The 3D model of lower extremities, which include the femur, tibia, meniscus, and knee articular cartilage, was created using the images from a computer tomography scan and magnetic resonance imaging. In this report, we compared changes in stress distribution and force reaction on the tibial plateau because of critical problems caused by unexpected changes in the tibial posterior-slope angle because of HTO. The results showed that the 5 .deg. wedge-angle virtual opening wedge HTO without and with the posterior-slope angle shows has a load concentration of approximately 60% and 45% in the medial region, respectively.
Wysocki, Robert W; Kapotas, James S; Virkus, Walter W
Fractures of the proximal and distal one thirds of the tibial shaft have historically higher malunion rates than those of the midshaft. This retrospective case series evaluates the postoperative radiographic outcome of intramedullary nailing of proximal and distal one-third tibial shaft fractures using intraoperative two-pin external fixation, often referred to as traveling traction. Between 2000 and 2005, 15 consecutive patients with proximal third and 27 consecutive patients with distal third displaced extra-articular fractures of the tibia were treated with statically locked intramedullary nailing and supplementary intraoperative two-pin rectangular frame external fixation. The external fixation was removed once the proximal and distal locking screws were in place. The alignment of the fractures was determined using standard postoperative anteroposterior and lateral radiographs. Postoperatively, 14 of 15 patients with proximal fractures and 25 of 27 patients with distal fractures had less than 5 degrees of angular deformity in both the coronal and sagittal planes and less than 1 cm shortening. Statically locked intramedullary nailing with simultaneous intraoperative traveling traction external fixation as treatment for proximal and distal one-third extra-articular tibial shaft fractures is successful in achieving a high rate of acceptable postoperative alignment.
Prasad, Kodali Siva R K; Vali, Hamza; Hussain, Altaf
We are reporting an unusual combination of Hawkins Group I fracture of the neck of left talus in association with Salter Harris Type III distal tibial epiphyseal injury of medial malleolus in a child with cerebral palsy and hemiplegia of contralateral limbs and discussed the possible mechanism as well as management. Fractures of medial malleolus usually occur in Hawkins Group III fracture-dislocations in adults. Forced dorsiflexion of talus against the anterior edge of tibia appears to be the accepted common mechanism, despite limited experimental and clinical evidence incriminating axial compression. Fracture of medial malleolus implicates supination. We managed this unusual pattern of injury conservatively. At 15 months, the child was asymptomatic with no radiological evidence of avascular necrosis of body of talus or growth disturbance of distal tibial epiphysis. Copyright © 2013 Elsevier Ltd. All rights reserved.
Narayana Gowda, B S; Mohan Kumar, J
Osgood-Schlatter disease (OSD) is a well known condition, characterized by pain over the tibial tubercle with subsequent tubercle prominence. Avulsion fracture following OSD is a rare complication. We report an unusual case of simultaneous bilateral tibial tubercle avulsion fracture in a 16 year old boy who was a known case of OSD. A 16 year old boy a known case of OSD presented to the outpatient department with history of jumping from the school compound wall (two feet height) while playing, followed by severe pain around anterior aspect of both knees and difficulty in walking. Radiographs showed bilateral tibial tubercle avulsion fracture. He was treated successfully with open reduction and internal fixation with tension band wiring. At the end of 22 months the patient was symptomatically relieved and both the tuberosities were united with the main bone. Even though bilateral Osgood-Schlatter disease (OSD) is a well known condition, one should always keep in mind the risk of tibial tubercle avulsion fractures while treating a case of OSD. Patient should be advised not to involve in strenuous activities till the disease subsides radiologically or till skeletal maturity.
Janssen, K.W.; Biert, J.; Kampen, A. van
A study of 24 patients who sustained an extra-articular fracture of the distal third of the tibial shaft was performed to determine the effect of the type of treatment, open reduction and internal fixation (ORIF) or closed reduction and intramedullary (IM) nailing, on the occurrence of malalignment.
Arup K Daolagupu
Conclusion: IMLN group was associated with lesser duration of surgery, earlier weight bearing and union rate, lesser incidence of infection and implant irritation which makes it a preferable choice for fixation of extra-articular distal tibial fractures. However, larger randomized controlled trials are required for confirming the results.
Busse, Jason W.; Bhandari, Mohit; Guyatt, Gordon H.; Heels-Ansdell, Diane; Mandel, Scott; Sanders, David; Schemitsch, Emil; Swiontkowski, Marc; Tornetta, Paul; Wai, Eugene; Walter, Stephen D.; Bhandar, Mohit; Guyatt, Gordon; Sanders, David W.; Schemitsch, Emil H.; Sprague, Sheila; Buckingham, Lisa; Leece, Pamela; Viveiros, Helena; Mignott, Tashay; Ansell, Natalie; Sidorkewicz, Natalie; Agel, Julie; Bombardier, Claire; Berlin, Jesse A.; Bosse, Michael; Browner, Bruce; Gillespie, Brenda; Jones, Alan; O'Brien, Peter; Poolman, Rudolf; Macleod, Mark D.; Carey, Timothy; Leitch, Kellie; Bailey, Stuart; Gurr, Kevin; Konito, Ken; Bartha, Charlene; Low, Isolina; MacBean, Leila V.; Ramu, Mala; Reiber, Susan; Strapp, Ruth; Tieszer, Christina; Kreder, Hans J.; Stephen, David J. G.; Axelrod, Terry S.; Yee, Albert J. M.; Richards, Robin R.; Finkelstein, Joel; Gofton, Wade; Murnaghan, John; Schatztker, Joseph; Ford, Michael; Bulmer, Beverly; Conlan, Lisa; Laflamme, G. Yves; Berry, Gregory; Beaumont, Pierre; Ranger, Pierre; Laflamme, Georges-Henri; Gagnon, Sylvain; Malo, Michel; Fernandes, Julio; Poirier, Marie-France; McKee, Michael D.; Waddell, James P.; Bogoch, Earl R.; Daniels, Timothy R.; McBroom, Robert R.; Vicente, Milena R.; Storey, Wendy; Wild, Lisa M.; McCormack, Robert; Perey, Bertrand; Goetz, Thomas J.; Pate, Graham; Penner, Murray J.; Panagiotopoulos, Kostas; Pirani, Shafique; Dommisse, Ian G.; Loomer, Richard L.; Stone, Trevor; Moon, Karyn; Zomar, Mauri; Webb, Lawrence X.; Teasdall, Robert D.; Birkedal, John Peter; Martin, David Franklin; Ruch, David S.; Kilgus, Douglas J.; Pollock, David C.; Harris, Michael Brion; Wiesler, Ethan Ron; Ward, William G.; Shilt, Jeffrey Scott; Koman, Andrew L.; Poehling, Gary G.; Kulp, Brenda; Creevy, William R.; Stein, Andrew B.; Bono, Christopher T.; Einhorn, Thomas A.; Brown, T. Desmond; Pacicca, Donna; Sledge, John B.; Foster, Timothy E.; Voloshin, Ilva; Bolton, Jill; Carlisle, Hope; Shaughnessy, Lisa; Obremskey, William T.; LeCroy, C. Michael; Meinberg, Eric G.; Messer, Terry M.; Craig, William L.; Dirschl, Douglas R.; Caudle, Robert; Harris, Tim; Elhert, Kurt; Hage, William; Jones, Robert; Piedrahita, Luis; Schricker, Paul O.; Driver, Robin; Godwin, Jean; Kregor, Philip James; Tennent, Gregory; Truchan, Lisa M.; Sciadini, Marcus; Shuler, Franklin D.; Driver, Robin E.; Nading, Mary Alice; Neiderstadt, Jacky; Vap, Alexander R.; Vallier, Heather A.; Patterson, Brendan M.; Wilber, John H.; Sontich, John K.; Moore, Timothy Alan; Brady, Drew; Cooperman, Daniel R.; David, John A.; Cureton, Ruth Ann; Orr, R. Douglas; Sadler, John T. S.; Hussain, Tousief; Rajaratnam, Krishan; Petrisor, Bradley; Drew, Brian; Bednar, Drew A.; Kwok, Desmond C. H.; Pettit, Shirley; Hancock, Jill; Cole, Peter A.; Smith, Joel J.; Brown, Gregory A.; Lange, Thomas A.; Stark, John G.; Levy, Bruce A.; Swiontkowski, Marc F.; Garaghty, Mary J.; Salzman, Joshua G.; Schutte, Carol A.; Tastad, Linda; Vang, Sandy; Seligson, David; Roberts, Craig S.; Malkani, Arthur L.; Sanders, Laura; Dyer, Carmen; Heinsen, Jessica; Smith, Langan; Madanagopal, Sudhakar; Frantz-Bush, Linda; Coupe, Kevin J.; Tucker, Jeffrey J.; Criswell, Allen R.; Buckle, Rosemary; Rechter, Alan Jeffrey; Sheth, Dhiren Shaskikant; Urquart, Brad; Trotscher, Thea; Anders, Mark J.; Kowalski, Joseph M.; Fineberg, Marc S.; Bone, Lawrence B.; Phillips, Matthew J.; Rohrbacher, Bernard; Stegemann, Philip; Mihalko, William M.; Buyea, Cathy; Augustine, Stephen J.; Jackson, William Thomas; Solis, Gregory; Ero, Sunday U.; Segina, Daniel N.; Berrey, Hudson B.; Agnew, Samuel G.; Fitzpatrick, Michael; Campbell, Lakina C.; Derting, Lynn; McAdams, June; Goslings, J. Carel; Ponsen, Kees Jan; Luitse, Jan; Kloen, Peter; Joosse, Pieter; Winkelhagen, Jasper; Duivenvoorden, Raphaël; Teague, David C.; Davey, Joseph; Sullivan, J. Andy; Ertl, William J. J.; Puckett, Timothy A.; Pasque, Charles B.; Tompkins, John F.; Gruel, Curtis R.; Kammerlocher, Paul; Lehman, Thomas P.; Puffinbarger, William R.; Weber, Donald W.; Jomha, Nadr M.; Goplen, Gordon R.; Masson, Edward; Beaupre, Lauren A.; Greaves, Karen E.; Schaump, Lori N.; Jeray, Kyle J.; Goetz, David R.; Westberry, David E.; Broderick, J. Scott; Moon, Bryan S.; Tanner, Stephanie L.; Powell, James N.; Buckley, Richard E.; Elves, Leslie; Connolly, Stephen; Abraham, Edward P.; Steele, Trudy; Ellis, Thomas; Herzberg, Alex; Brown, George A.; Crawford, Dennis E.; Hart, Robert; Hayden, James; Orfaly, Robert M.; Vigland, Theodore; Vivekaraj, Maharani; Bundy, Gina L.; Miclau, Theodore; Matityahu, Amir; Coughlin, R. Richard; Kandemir, Utku; McClellan, R. Trigg; Lin, Cindy Hsin-Hua; Karges, David; Cramer, Kathryn; Watson, J. Tracy; Moed, Berton; Scott, Barbara; Beck, Dennis J.; Orth, Carolyn; Puskas, David; Clark, Russell; Jones, Jennifer; Egol, Kenneth A.; Paksima, Nader; Monet, France; Wai, Eugene K.; Johnson, Garth; Wilkinson, Ross; Gruszczynski, Adam T.; Vexler, Liisa
OBJECTIVE: To compare the Short Musculoskeletal Function Assessment Dysfunction Index (SMFA DI) and the Short Form-36 Physical Component Summary (SF-36 PCS) scores among patients undergoing operative management of tibial fractures. STUDY DESIGN AND SETTING: Between July 2000 and September 2005, we
Martínez-Rondanelli, Alfredo; Escobar-González, Sara Sofía; Henao-Alzate, Alejandro; Martínez-Cano, Juan Pablo
A four-column classification system offers a different way of evaluating tibial plateau fractures. The aim of this study is to compare the intra-observer and inter-observer reliability between four-column and classic classifications. This is a reliability study, which included patients presenting with tibial plateau fractures between January 2013 and September 2015 in a level-1 trauma centre. Four orthopaedic surgeons blindly classified each fracture according to four different classifications: AO, Schatzker, Duparc and four-column. Kappa, intra-observer and inter-observer concordance were calculated for the reliability analysis. Forty-nine patients were included. The mean age was 39 ± 14.2 years, with no gender predominance (men: 51%; women: 49%), and 67% of the fractures included at least one of the posterior columns. The intra-observer and inter-observer concordance were calculated for each classification: four-column (84%/79%), Schatzker (60%/71%), AO (50%/59%) and Duparc (48%/58%), with a statistically significant difference among them (p = 0.001/p = 0.003). Kappa coefficient for intr-aobserver and inter-observer evaluations: Schatzker 0.48/0.39, four-column 0.61/0.34, Duparc 0.37/0.23, and AO 0.34/0.11. The proposed four-column classification showed the highest intra and inter-observer agreement. When taking into account the agreement that occurs by chance, Schatzker classification showed the highest inter-observer kappa, but again the four-column had the highest intra-observer kappa value. The proposed classification is a more inclusive classification for the posteromedial and posterolateral fractures. We suggest, therefore, that it be used in addition to one of the classic classifications in order to better understand the fracture pattern, as it allows more attention to be paid to the posterior columns, it improves the surgical planning and allows the surgical approach to be chosen more accurately.
Olesen, Ulrik Kähler; Juul, Rasmus; Bonde, Christian Torsten
PURPOSE: Treatment of open fractures is complex and controversial. The purpose of the present study is to add evidence to the management of open tibial fractures, where tissue loss necessitates cover with a free flap. We identified factors that increase the risk of complications. We questioned wh...... predictors of complications. We suggest antibiotic prophylaxis with vancomycin and meropenem until the wound is covered in these complex injuries....
Arup K Daolagupu; Ashwani Mudgal; Vikash Agarwala; Kaushik K Dutta
Background: Extraarticular distal tibial fractures are among the most challenging fractures encountered by an orthopedician for treatment because of its subcutaneous location, poor blood supply and decreased muscular cover anteriorly, complications such as delayed union, nonunion, wound infection, and wound dehiscence are often seen as a great challenge to the surgeon. Minimally invasive plate osteosynthesis (MIPO) and intramedullary interlocking nail (IMLN) are two well-accepted and effectiv...
Khoury, A; Siewerdsen, J H; Whyne, C M; Daly, M J; Kreder, H J; Moseley, D J; Jaffray, D A
A mobile isocentric C-arm was modified in our laboratory in collaboration with Siemens Medical Solutions to include a large-area flat-panel detector providing multi-mode fluoroscopy and cone-beam CT (CBCT) imaging. This technology is an important advance over existing intraoperative imaging (e.g., Iso-C(3D)), offering superior image quality, increased field of view, higher spatial resolution, and soft-tissue visibility. The aim of this study was to assess the system's performance and image quality in tibial plateau (TP) fracture reconstruction. Three TP fractures were simulated in fresh-frozen cadaveric knees through combined axial loading and lateral impact. The fractures were reduced through a lateral approach and assessed by fluoroscopy. The reconstruction was then assessed using CBCT. If necessary, further reduction and localization of remaining displaced bone fragments was performed using CBCT images for guidance. CBCT image quality was assessed with respect to projection speed, dose and filtering technique. CBCT imaging provided exquisite visualization of articular details, subtle fragment detection and localization, and confirmation of reduction and implant placement. After fluoroscopic images indicated successful initial reduction, CBCT imaging revealed areas of malalignment and displaced fragments. CBCT facilitated fragment localization and improved anatomic reduction. CBCT image noise increased gradually with reduced dose, but little difference in images resulted from increased projections. High-resolution reconstruction provided better delineation of plateau depressions. This study demonstrated a clear advantage of intraoperative CBCT over 2D fluoroscopy and Iso-C(3D) in TP fracture fixation. CBCT imaging provided benefits in fracture type diagnosis, localization of fracture fragments, and intraoperative 3D confirmation of anatomic reduction.
Dijkman Bernadette G
Full Text Available Abstract Background Radiographic healing is a common outcome measure in orthopedic trials and adjudication by outcome assessors is often conducted on the basis of plain films alone. The degree to which this process reflects clinical practice, in which both plain films and clinical notes are available, is uncertain. We explored the effect of adding clinical notes to radiographs in the adjudication process of a feasibility trial of tibial shaft fractures. Methods Radiographic and clinical data from a multicenter randomized controlled trial of 51 patients with operatively treated tibial fractures formed the basis of the study data. At the completion of the trial, serial radiographs (anteroposterior and lateral were independently evaluated for progression of fracture healing, defined as bridging of at least 3 of 4 cortices, by an adjudication committee comprised of 3 blinded orthopaedic trauma surgeons. Immediately after determination of radiographic time to healing, each surgeon was provided with clinical notes associated with each radiographic follow up visit and asked to re-visit their initial impression. Consensus was achieved for both adjudications. We calculated the percentage of time to healing consensus decisions that changed after evaluation of clinical notes. We further examined the contents of clinical notes and their relative influence on the committee's decisions. Results 47 of 51 patients were determined to have healed radiographically during the trial follow-up period, and consideration of clinical notes resulted in a change of 40% (19 of 47 of time to healing consensus decisions; however, revised decisions were equally likely to support an earlier or a later time to healing. Clinical notes that resulted in a change to either a 'healed' or a 'not healed' decision contained significantly more comments of either pain resolution or deterioration, respectively, resumption of or failure to resume weightbearing, or either return or no
Canavese, Federico; Botnari, Alexei; Andreacchio, Antonio; Marengo, Lorenza; Samba, Antoine; Dimeglio, Alain; Pereira, Bruno; Mansour, Mounira; Rousset, Marie
The main objective of this study was to retrospectively evaluate the clinical and radiographic outcomes of displaced tibial shaft fractures with intact fibula in children after nonoperative management and operative treatment by elastic stable intramedullary nailing. A study was performed on 80 consecutive children, 56 males, 24 females from 2 Institutions, with displaced and closed tibial shaft fracture with intact fibula. All patients underwent regular clinical and radiographic follow-up visits for at least 2 years after injury. In total, 26 patients (group A-Institution I) were treated surgically by elastic stable intramedullary nailing and 54 patients (18 patients from group B-Institution I and 36 patients from group C-Institution II) were treated nonoperatively with closed reduction and casting. groups A, B, and C did not significantly differ on sex (P=0.37), side (P=0.54), and fracture site (P=0.14).Valgus deformity was significantly controlled in group A patients only (P=0.001); during follow-up in group B patients (P=0.017), and showed no significant change between pretreatment images and last follow-up in group C patients (P=0.71). Procurvatum deformity was significantly controlled in group A patients only (P=0.001); it showed no significant improvement after conservative treatment in group B (P=0.73) and C patients (P=0.8). Recurvatum was significantly improved in group A (Pfracture of tibial diaphysis without associated fibula fracture.On the basis of the findings reported here, it is not contraindicated to operate skeletally immature patients with displaced fracture of tibial diaphysis without associated fibula fracture. However, results were essentially the same and either method is a satisfactory choice for pediatric tibia shaft fractures with an intact fibula. In particular, we found that conservative treatment was as efficacious as surgical treatment apart from the length of time for immobilization. Level III.
Pun, W K; Chow, S P; Fang, D; Ip, F K; Leong, J C; Ng, C
Ninety-eight diaphyseal tibial fractures were treated with custom made functional braces in 97 patients older than 14 years of age. The average follow-up period was 1.86 years, and 53 patients had more than two years' evaluation (average, 2.83 years). The majority of the patients did not have full range of movement in the ankle and subtalar joints when the brace was removed after fracture healing. Although the stiffness decreased with time, a significant number of patients were left with residual joint stiffness. At an average follow-up period of 1.86 years, 68.4% of the patients had normal ankle motion and 60% had normal inversion and eversion of the hindfoot. In patients with more than two years' evaluation, 75.5% had normal ankle movement and 71.1% had normal inversion and eversion of the foot. In the knee joint, the incidence of residual joint stiffness was small and the amount of stiffness was clinically insignificant. Patients with an abnormal walking pattern after fracture healing had a high incidence of ankle and subtalar joint stiffness.
Chong, V.F.H.; Htoo, M.M.
Spondylolisthesis with or without spondylolysis is common in the lumbar spine. Associated fracture in the pedicle ('pediculolysis') is unusual. The margins of pedicular stress fractures, like spondylolysis, usually appear sclerotic. A patient with a pedicular stress fracture with minimal marginal sclerosis suggesting an injury of recent onset is presented here. There was associated bilateral spondylolysis. The findings in this patient suggest that established pediculolysis probably represents a stress fracture that has failed to heal. (authors)
Chong, V.F.H.; Htoo, M.M. [Singapore General Hospital, Singapore, (Singapore). Department of Diagnostic Radiology
Spondylolisthesis with or without spondylolysis is common in the lumbar spine. Associated fracture in the pedicle (`pediculolysis`) is unusual. The margins of pedicular stress fractures, like spondylolysis, usually appear sclerotic. A patient with a pedicular stress fracture with minimal marginal sclerosis suggesting an injury of recent onset is presented here. There was associated bilateral spondylolysis. The findings in this patient suggest that established pediculolysis probably represents a stress fracture that has failed to heal. (authors). 10 refs., 2 figs.
Alexander M. Wood
Full Text Available Currently, little is known about the length of time required to rehabilitate patients from stress fractures and their return to preinjury level of physical activity. Previous studies have looked at the return to sport in athletes, in a general population, where rehabilitation is not as controlled as within a captive military population. In this study, a longitudinal prospective epidemiological database was assessed to determine the incidence of stress fractures and the time taken to rehabilitate recruits to preinjury stage of training. Findings demonstrated a background prevalence of 5% stress fractures in Royal Marine training; femoral and tibial stress fractures take 21.1 weeks to return to training with metatarsal stress fractures being the most common injury taking 12.2 weeks. Rehabilitation from stress fractures accounts for 814 weeks of recruit rehabilitation time per annum. Stress fracture incidence is still common in military training; despite this stress fracture recovery times remain constant and represent a significant interruption in training. It takes on average 5 weeks after exercise specific training has restarted to reenter training at a preinjury level, regardless of which bone has a stress fracture. Further research into their prevention, treatment, and rehabilitation is required to help reduce these burdens.
Full Text Available Abstract Background Principles for the treatment of tibial intercondylar eminence fracture are early reduction and stable fixation. Numerous ways to treatment of this fracture have been invented. We designed a simple, low-invasive, and arthroscopic surgical strategy for tibial intercondylar eminence fracture utilizing the Meniscal Viper Repair System used for arthroscopic meniscal suture. Methods We studied 5 patients, who underwent arthroscopic suture fixation that we modified. The present technique utilized the Meniscal Viper Repair System for arthroscopic suture of the meniscus. With one handling, a high-strength ultra-high molecular weight polyethylene(UHMWPE suture can be passed through the anterior cruciate ligament (ACL and the loops for suture retrieval placed at both sides of ACL. Surgical results were evaluated by the presence or absence of bone union on plain radiographs, postoperative range of motion of the knee joint, the side-to-side differences measured by Telos SE, and Lysholm scores. Results The reduced position achieved after surgery was maintained and good function was obtained in all cases. The mean distance of tibia anterior displacement and assessment by Lysholm score showed good surgical results. Conclusion This method simplified the conventional arthroscopic suture fixation and increased its precision, and was applicable to Type II fractures that could be reduced, as well as surgically indicated Types III and IV. The present series suggested that our surgical approach was a useful surgical intervention for tibial intercondylar eminence fracture.
Haupt, Samuel; Frima, Herman; Sommer, Christoph
Lower leg fractures of the tibia with or without fracture of the fibula are very common. Proximal tibiofibular joint (PTFJ) dislocation is a very rare injury that can occur together with a tibia shaft fracture. As there is only scarce literature about this injury available, we would like to present our experience with the treatment of this entity. We present a small case series of seven patients. In most cases, the tibia fracture was nailed in a closed technique. After distal locking the proximal fibula was exposed by a lateral approach exposing and preserving the peroneal nerve. After anatomical reduction into the corresponding articular facet of the proximal tibia, the fibula was transfixed to the tibia with a positioning screw. This indirectly provided a correct length and rotation of the tibia, which could finally be locked to the nail by inserting the proximal locking bolts. The positioning screw was removed after six weeks prior to full loading. Six of seven patients had been followed up by at least 7 months post-treatment. Out of 663 prospectively collected tibia shaft fractures treated at our institution from 1/2001 to 7/2014, we found seven patients with associated PTFJ dislocation. All except one had been caused by a high energy trauma. After one year, five patients showed excellent results with full range of motion and returning to their sporting activities as before the accident. Two patients have impaired function due to associated injuries. None complained of persistent pain or instability of the PTFJ. PTFJ dislocation with tibia shaft fracture can easily be overlooked if one is not familiar with this injury. It is important to diagnose and treat this uncommon dislocation anatomically to achieve good results. Otherwise, as the literature shows, it can lead to chronic instability of the proximal fibula with snapping, proximal fibular pain and even peroneal nerve palsy. Furthermore in complex tibial fractures correct length and rotation only can be
Fabio Janson Angelini
Full Text Available Descreve-se neste artigo um padrão de lesão descrito na literatura apenas duas vezes, num total de quatro casos, denominado Segond reverso por apresentar achados clínicos e radiológicos exatamente opostos aos da clássica lesão de Segond. Semelhantemente aos casos previamente descritos, apresentou fratura avulsão do planalto tibial medial, na inserção do ligamento colateral medial profundo, associada a lesão do ligamento cruzado posterior. Assim como em um dos casos prévios, foi constatada lesão do ligamento cruzado anterior. Entretanto, diferiu dos anteriormente relatados por não apresentar lesão do menisco medial.This article reports an injury pattern described only twice in literature, totaling four cases, and referred to as reverse Segond injury for its clinical and radiological findings are precisely opposite to those observed in the classical Segond injury. Similarly to the previously described cases, our case reported avulsion fracture of the medial tibial plateau at the insertion of the deep tibial collateral ligament, associated to posterior cruciate ligament injury. Similarly to one of the previous cases, anterior cruciate ligament injury was found in our case, although it differs from the previous ones because it does not show medial meniscal injury.
van den Bekerom, Michel P. J.; Kerkhoffs, Gino M. M. J.; van Dijk, C. Niek
The incidence of medial malleolar stress fractures varies from 0.6%-4.1% of all stress fractures. These fractures occur almost entirely in athletes and runners, and more frequently in skeletally mature patients aged 20-40 years. Treatment depends on the result of diagnostic imaging, displacement of
Hu, Sun-Jun; Chang, Shi-Min; Zhang, Ying-Qi; Ma, Zhuo; Du, Shou-Chao; Zhang, Kai
The posterolateral (PL) tibial plateau quadrant is laterally covered by the fibular head and posteriorly covered by a mass of muscle ligament and important neurovascular structures. There are several limitations in exposing and fixing the PL tibial plateau fractures using a posterior approach. The aim of this study is to present a novel anterolateral supra-fibular-head approach for plating PL tibial plateau fractures. Five fresh and ten preserved knee specimens were dissected to measure the following parameters:1) the vertical distance from the apex of the fibular head to the lateral plateau surface, 2) the transverse distance between the PL platform and fibula collateral ligament (FCL), and 3) the tension of the FCL in different knee flexion positions. Clinically, isolated PL quadrant tibial plateau fractures were treated via an anterolateral supra-fibular-head approach and lateral rafting plate fixation. The outcome of the patients was assessed after a short to medium follow-up period. The distance from the apex of the fibular head to the lateral condylar surface was 12.2 ± 1.6 mm on average. With the knee extended and the FCL tensioned, the transverse distance between the PL platform and the FCL was 6.7 ± 1.1 mm. With the knee flexed to 60° and the FCL was in the most relaxed position, the distance increased to 21.1 ± 3.0 mm. Clinically, a series of 7 cases of PL tibial plateau fractures were treated via this anterolateral supra-fibular-head approach. The patient was placed in a lateral decubitus position with the knee flexed to approximately 60 degrees. After the posterior retraction of the FCL, the plate was placed more posteriorly to provide a raft or horizontal belt fixation of the PL tibial plateau fragment. After an average of 14.3 months of follow up, the knee range of motion(ROM) was 121.4° ± 8.8° (range: 105°-135°), the HSS score was 96.7 ± 2.6 (range: 90-100), and the SMFA dysfunction score was 22.4 ± 3.8 (range: 16-28) points. The
Taşkesen, Anıl; Demirkale, İsmail; Okkaoğlu, Mustafa Caner; Özdemir, Mahmut; Bilgili, Mustafa Gökhan; Altay, Murat
This study aims to assess the intra- and interobserver reliability of commonly used tibial plateau fracture classification systems. This retrospective cohort study included computed tomography (CT) and plain radiographic images (lateral and anteroposterior X-rays) of 60 patients (40 males, 20 females; mean age 45.9 years; range 18 to 80 years) who presented to two orthopaedic clinics between January 2011 and January 2015 with unilateral tibial plateau fractures. All plain X-rays (XR) and CT images were evaluated by four observers on two separate occasions, 1.5 months apart. All fractures were classified according to the Arbeitsgemeinschaft für Osteosynthesefragen-Orthopaedic Trauma Association (AO-OTA), Schatzker, Hohl and Moore, Luo and revised Duparc systems. Intraobserver reliability was measured with Cohen's kappa (κ) coefficient and interobserver reliability with Fleiss' kappa coefficient. When Schatzker classification was performed, interobserver reliability was in moderate level for (κ=0.51) for XR and in substantial level for CT (κ=0.61). When AO/OTA classification was used, interobserver reliability was in moderate level for both methods of diagnosis (κXR=0.43 and κCT=0.54, respectively). In the Hohl and Moore classification, the interobserver reliability was also moderate for both methods of diagnosis (κXR=0.45 and κCT=0.51, respectively). Revised Duparc classification showed the lowest interobserver reliability ranging from fair to moderate level (κXR=0.27-0.55 and κCT=0.44-0.61). Interobserver reliability for Luo classification was κCT=0.47. Intraobserver reliability for CT in Luo classification was in substantial level for observers 1, 2 and 3 (κCT=0.67-0.71) and in perfect level for observer 4 (κCT=0.84). Intraobserver reliability was in substantial level in Schatzker classification and in moderate level at the other classifications. Among the classification systems compared in this study, Schatzker was the most reliable particularly when
Haas Norbert P
Full Text Available Abstract Background The severity of associated soft tissue trauma in complex injuries of the extremities guides fracture treatment and decisively determines patient's prognosis. Trauma-induced microvascular dysfunction and increased tissue pressure is known to trigger secondary soft tissue damage and seems to adversely affect skeletal muscle function. Methods 20 patients with isolated tibial fractures were included. Blood pressure and compartment pressure (anterior and deep posterior compartment were measured continuously up to 24 hours. Corresponding perfusion pressure was calculated. After 4 and 12 weeks isokinetic muscle peak torque and mean power of the ankle joint in dorsal and plantar flexion were measured using a Biodex dynamometer. Results A significant inverse correlation between the anterior perfusion pressure at 24 hours and deficit in dorsiflexion at 4 weeks was found for both, the peak torque (R = -0.83; p Conclusion The functional relationship between the decrease in intramuscular perfusion pressures and muscle performance in the early rehabilitation period indicate a causative and prognostic role of early posttraumatic microcirculatory derangements and skeletal muscle function. Therapeutic concepts aimed at effective muscle recovery, early rehabilitation, and decreased secondary tissue damage, should consider the maintenance of an adequate intramuscular perfusion pressure.
Marcos Alexandre Barros
Full Text Available ABSTRACT OBJECTIVE: To objectively and subjectively evaluate the functional result from before to after surgery among patients with a diagnosis of an isolated avulsion fracture of the posterior cruciate ligament who were treated surgically. METHOD: Five patients were evaluated by means of reviewing the medical files, applying the Lysholm questionnaire, physical examination and radiological examination. For the statistical analysis, a significance level of 0.10 and 95% confidence interval were used. RESULTS: According to the Lysholm criteria, all the patients were classified as poor (<64 points before the operation and evolved to a mean of 96 points six months after the operation. We observed that 100% of the posterior drawer cases became negative, taking values less than 5 mm to be negative. CONCLUSION: Surgical methods with stable fixation for treating avulsion fractures at the tibial insertion of the posterior cruciate ligament produce acceptable functional results from the surgical and radiological points of view, with a significance level of 0.042.
Batta, Vineet; Dwyer, Amitabh J; Gulati, Aashish; Prakash, Jeevan; Mam, Maharaj K; John, Bobby
Abstract Background Cast bracing (CB) has been a well established method of treating tibial shaft fractures. Majority of the recent literature on treatment of tibial shaft fractures have upheld intramedullary nailing (IMN) as the treatment of choice. Most of these studies are from the west, in public funded health set ups and in hospitals with very low rates of infection. This has lead to bewilderment in the minds of surgeons wishing to opt for conservative treatment in countries with scarcit...
Full Text Available Aim: Partial patellectomy and patellotibial cerclage technique used in comminuted inferior pole patellar fractures were evaluated and the results were discussed. Methods: Thirteen patients who have undergone partial distal patellar excision were evaluated in the study. In all patients, the inferior pole of the patella was resected, patellar tendon was sutured to the proximal patellar fragment and patellotibial cerclage was performed. At the last visit, the patients were evaluated using measurement of the distance between the superior pole of the patella and the tibial tubercle, the Lysholm knee scoring scale, knee range of motion and thigh circumference measurement. Results: The mean flexion value was 131.10 (±4.6 in normal knees and 117.20 (±8.0 in operated knees. The mean thigh diameter was 49.5 (±3.7 cm and 46.4 (±4.5 cm in normal knees and in operated knees, respectively. The mean Lysholm knee score in the patient group was 84.3 (±17.1 points. The mean distance between the superior pole of the patella and the tibial tubercle was 10.6 (±1.0 cm in normal knees and 10.1 (±1.2 cm in operated knees. The exstensor mechanism was intact in all patients and no revision surgery was performed. Conclusion: Patellotibial cerclage technique performed after partial patellectomy permits early motion and protects patients from harmful effects of immobilization; and good functional results are obtained if patients start early knee motion.
Fayad, Laura M.; Kamel, Ihab R.; Kawamoto, Satomi; Bluemke, David A.; Fishman, Elliot K.; Frassica, Frank J.
Whereas stress fractures occur in normal or metabolically weakened bones, pathologic fractures occur at the site of a bone tumor. Unfortunately, stress fractures may share imaging features with pathologic fractures on plain radiography, and therefore other modalities are commonly utilized to distinguish these entities. Additional cross-sectional imaging with CT or MRI as well as scintigraphy and PET scanning is often performed for further evaluation. For the detailed assessment of a fracture site, CT offers a high-resolution view of the bone cortex and periosteum which aids the diagnosis of a pathologic fracture. The character of underlying bone marrow patterns of destruction can also be ascertained along with evidence of a soft tissue mass. MRI, however, is a more sensitive technique for the detection of underlying bone marrow lesions at a fracture site. In addition, the surrounding soft tissues, including possible involvement of adjacent muscle, can be well evaluated with MRI. While bone scintigraphy and FDG-PET are not specific, they offer a whole-body screen for metastases in the case of a suspected malignant pathologic fracture. In this review, we present select examples of fractures that underscore imaging features that help distinguish stress fractures from pathologic fractures, since accurate differentiation of these entities is paramount. (orig.)
As the profound health and cost benefits of physical activity to society are established and participation guidelines implemented, health practitioners are increasingly expected to utilize efficacious and justified injury management and prevention strategies. The complex and multifactorial nature of sports injury makes elucidation of multiple risk factors and how they may subtly and variably interact, difficult. The purpose of this case report is to discuss the differential diagnosis, acute management and rehabilitation of a case of medial tibial stress syndrome (MTSS) in a surf life-saving athlete, in the context of sports injury prevention. The subject of this case study, a 15 year old female surf life-saving competitor, presented to the physiotherapist (PT) with recent onset, first episode, bilateral, diffuse posteromedial shin pain. Differential diagnosis, acute management, rehabilitation and preventative strategies for the subject are presented. Emerging injury surveillance research in surf life-saving suggests minor and major trauma as primary causative factors, however, the significance of high training volumes is likely underestimated. The influence of biomechanical, and subtle arthrokinematic dysfunctions on established risk factors for MTSS injury and prevention of re-injury for this subject, are also discussed. Furthermore, the concept of preventing tibial stress fracture (TSF) by successfully managing acute MTSS, is presented. Lastly, a critical analysis of reliability of clinical assessment methodologies utilised with the subject is provided. Level 5; Single case report.
Winters, M.; Bakker, E. W. P.; Moen, M. H.; Barten, C. C.; Teeuwen, R.; Weir, A.
The majority of sporting injuries are clinically diagnosed using history and physical examination as the cornerstone. There are no studies supporting the reliability of making a clinical diagnosis of medial tibial stress syndrome (MTSS). Our aim was to assess if MTSS can be diagnosed reliably, using
Hou, Zhiyong; Irgit, Kaan; Strohecker, Kent A; Matzko, Michelle E; Wingert, Nathaniel C; DeSantis, Joseph G; Smith, Wade R
Vacuum-assisted closure (VAC) therapy has been shown to be effective at reducing bacterial counts in wounds until definitive bony coverage. However, there is continued debate over timing and type of definitive wound coverage even with VAC therapy application. From 2004 to 2009, 32 patients with Gustilo type IIIB open tibia fractures were initially treated with VAC therapy were included. The number of debridements, length of treatment with VAC dressing, definitive wound coverage management, and length of hospital stay, flap-related complications, and time to radiographic fracture healing were recorded. The mean Injury Severity Score was 17.3 ± 2.0. All wounds closed after being treated with the primary VAC closure. The mean interval between the initial injury and definitive intervention was 10.9 days ± 0.3 days. Twenty of 27 patients (74%) underwent rotational muscle flaps; four received free muscle flaps and three only with split-thickness skin grafts for definitive wound coverage. Nine of 32 patients (28%) underwent below knee amputation, five without flap coverage after several VAC sessions and four after definitive flap coverage. The average time to union was 10.0 months ± 2.0 months. Eight patients developed nonunion and 11 patients developed infections. The average follow-up time is 2.4 years ± 0.2 years. Patients were divided into two groups for analysis according to the interval time. The rate of infection was significantly increased in patients who had an interval of more than 7 days from the time of injury to flap coverage. The VAC therapy may help to reduce the flap size and need for a flap transfer for type IIIB open tibial fractures. However, prolonged periods of VAC usage, greater than 7 days, should be avoided to reduce higher infection and amputation risks.
Moed, B R; Subramanian, S; van Holsbeeck, M; Watson, J T; Cramer, K E; Karges, D E; Craig, J G; Bouffard, J A
Based on the results of a pilot study indicating the potential value of ultrasound (US) as a diagnostic tool for the early assessment of fracture healing and the related need for secondary operative procedures in patients treated by statically locked intramedullary (IM) nailing without reaming, a protocol was established for a larger scale prospective trial. The purpose of this study was to evaluate the outcome of this follow-up trial. All skeletally mature patients admitted to the Henry Ford Hospital (Detroit, Michigan) from January 1993 to August 1994 who had sustained an acute fracture of the tibial shaft and who were treated by statically locked IM nailing, without reaming, were candidates for study. Forty-seven patients with fifty fractures that could be evaluated by US were included. The adopted determinants for fracture healing were complete disappearance of the IM nail on US examination performed at six weeks postoperatively, or progressive disappearance of the nail noted between the initial six-week study and a second nine-week US examination, both in conjunction with periosteal callus formation. Radiographs were obtained to monitor maintenance of reduction and to further evaluate fracture healing. Of thirty-eight fractures with a positive US (thirty-two at six weeks, six at nine weeks), thirty-seven healed uneventfully, a positive predictive value of 97 percent. Radiographic fracture healing was not evident until, on average, nineteen weeks after injury. The single false-positive fracture progressed to nonunion. Of the twelve fractures with negative US studies, ten underwent secondary procedures (nine dynamization, one bone graft), with four progressing to nonunion. Two patients refused secondary surgery; screw failure occurred in both. Otherwise, there were no hardware failures in this series. The results of this study indicate that US may provide important prognostic information concerning fracture healing after unreamed tibial nailing, upon which
Busse, Jason W; Bhandari, Mohit; Einhorn, Thomas A; Schemitsch, Emil; Heckman, James D; Tornetta, Paul; Leung, Kwok-Sui; Heels-Ansdell, Diane; Makosso-Kallyth, Sun; Della Rocca, Gregory J; Jones, Clifford B; Guyatt, Gordon H
Objective?To determine whether low intensity pulsed ultrasound (LIPUS), compared with sham treatment, accelerates functional recovery and radiographic healing in patients with operatively managed tibial fractures. Design?A concealed, randomized, blinded, sham controlled clinical trial with a parallel group design of 501 patients, enrolled between October 2008 and September 2012, and followed for one year. Setting?43 North American academic trauma centers. Participants?Skeletally mature men or...
Coldwell, D.; Gross, G.W.; Boal, D.K.
Femoral neck stress fracture is extremely rare in childhood. We report a case of femoral neck stress fracture in an 11-year-old girl. Differentials diagnosis and a brief review of the literature follow. (orig.)
Ramasubbu, Rohan A; Ramasubbu, Benjamin M
Management of open tibial fractures is well documented in adults, with existing protocols outlining detailed treatment strategies. No clear guidelines exist for children. Surgical stabilization of tibial fractures in the pediatric population requires implants that do not disrupt the open epiphyses (growth plate). Both elastic stable intramedullary nails and external fixation can be used. The objective of this study was to identify the optimal method of surgical stabilization in the treatment of open tibial fractures in children. MEDLINE and Embase were searched from their inception to March 2014 using the following advanced search terms (Key words): "open tibia fracture," "fracture fixation," "external fixation," "intramedullary," and "bone nail." Only studies in English and pertaining to children with open fractures treated with elastic stable intramedullary nails or external fixation between 1994 and 2014 were included. Twelve clinical studies were critically appraised. Due to a paucity in the literature coupled with a nonsystematic presentation of results, it proved to be very difficult in extracting relevant results from the studies. This was further added by a variation in outcome measures. Consequently, the results we obtained were difficult to draw conclusions from. There is no conclusive evidence or best practice guidelines for their management. Thus, as is highlighted in this study, more research is needed to determine the optimum treatment strategy for this common pediatric injury. The existing literature is of poor quality; consisting mainly of retrospective reviews of patients' medical records, charts, and radiographs. Carefully designed, high-quality prospective cohort studies utilizing a nationalized multi-hospital approach are needed to improve understanding before protocols and guidelines can be developed and implemented.
Di Giorgio Luigi
Full Text Available 【Abstract】Objective: The anterolateral approach to the tibia has been popularized for the management of tibial pilon fractures. For complex fracture patterns a combined anterolateral/anteromedial approach is suitable buta high rate of complicat ion has been reported. In our retrospective study a two-choice strategy adopting a medial tibial approach was proposed for the treatment of pilon fractures with anterior or posterior fragmentation. Methods: Based on an anatomic study of tibial pilon fractures, we retrospectively analyzed the fractures with primary posterior, posterior-lateral or anterior, anterior-lateral (Tillaux-Chaput involvement of the distal tibia. This retrospective study consisted of 18 patients with a closed tibial plafond fracture. The inclusion criteria were: (1 presence of an anterior/anterolateral type fragment or a posterior (Volkmann type fragment involving >25% of the articular surface, (2 a minimum follow-upof 12 months, (3 a fibula f racture associated with a medial column fracture of the distaltibia, and (4 soft tissue conditions at the time of operation that did not compromise the choice of surgical access (Tscher ne classi fication for closed fr actures: grade 0 and grade 1. Tibial plafond fractures were classified into two groups: one presenting anterior and the other with posterior rim (Volkmann fragments. Resul ts: Most patients achieved a good clinical recovery in terms of range of motion and Olerud-Molander scale scores. Only three patient s presented a grade 2 osteoarthritis at the 12 month follow-up. Conclusion: Our two-choice strategy highlights concepts which have been previously debated and described in the literature. But a new extended protocol for surgical approach to the distal tibia, including more fracture patterns and their association should be further investigated. Key words: Tibial fractures; Fracture fixation; Surgical procedures, operative; Intraoperative complications
Full Text Available Background/Aim. Distal tibial pilon fractures include extra-articular fractures of the tibial metaphysis and the more severe intra-articular tibial pilon fractures. There is no universal method for treating distal tibial pilon fractures. These fractures are treated by means of open reduction, internal fixation (ORIF and external skeletal fixation. The high rate of soft-tissue complications associated with primary ORIF of pilon fractures led to the use of external skeletal fixation, with limited internal fixation as an alternative technique for definitive management. The aim of this study was to estimate efficacy of distal tibial pilon fratures treatment using the external skeletal and minimal internal fixation method. Methods. We presented a series of 31 operated patients with tibial pilon fractures. The patients were operated on using the method of external skeletal fixation with a minimal internal fixation. According to the AO/OTA classification, 17 patients had type B fracture and 14 patients type C fractures. The rigid external skeletal fixation was transformed into a dynamic external skeletal fixation 6 weeks post-surgery. Results. This retrospective study involved 31 patients with tibial pilon fractures, average age 41.81 (from 21 to 60 years. The average follow-up was 21.86 (from 12 to 48 months. The percentage of union was 90.32%, nonunion 3.22% and malunion 6.45%. The mean to fracture union was 14 (range 12-20 weeks. There were 4 (12.19% infections around the pins of the external skeletal fixator and one (3.22% deep infections. The ankle joint arthrosis as a late complication appeared in 4 (12.90% patients. All arthroses appeared in patients who had type C fractures. The final functional results based on the AOFAS score were excellent in 51.61%, good in 32.25%, average in 12.90% and bad in 3.22% of the patients. Conclusion. External skeletal fixation and minimal internal fixation of distal tibial pilon fractures is a good method for
Kodi Edson Kojima
Full Text Available A fratura de osso longo mais frequente é a da diáfise da tíbia, e seu tratamento adequado evita o aparecimento de falhas da consolidação, consolidação viciosa e reoperações. Para classificar a fratura ainda se utiliza a classificação AO/OTA, mas vale a pena conhecer a classificação de Ellis, que também inclui a avaliação da lesão das partes moles. A síndrome compartimental é uma associação frequente, e o diagnóstico precoce pode ser feito precocemente com avaliação dos parâmetros clínicos e uma monitorização clínica constante. Feito o diagnóstico, deve-se realizar a fasciotomia. A avaliação da consolidação sempre é difícil, mas o método de RUST pode ajudar nessa avaliação. Avalia-se a radiografia em duas projeções, dando-se pontos para a presença da linha de fratura e a presença de calo ósseo visível. Hoje em dia se discute o dogma das seis horas para a limpeza da fratura exposta. Considera-se de mais importância o início precoce da antibioticoterapia endovenosa e a gravidade da lesão. A questão do fechamento precoce ou tardio da lesão em uma fratura exposta passou por várias fases, com épocas se indicando o fechamento precoce e épocas o tardio. Atualmente se preconiza, sempre que possível, o fechamento precoce da lesão, pois isso diminui o risco de infecção. A fresagem do canal quando da introdução da haste intramedular ainda é um assunto controverso. Apesar de fortes posições pessoais a favor da fresagem, os estudos mostram haver alguma vantagem nas fraturas fechadas, mas não nas expostas.The long-bone fractures occur most frequently in the tibial shaft. Adequate treatment of such fractures avoids consolidation failure, skewed consolidation and reoperation. To classify these fractures, the AO/OTA classification method is still used, but it is worthwhile getting to know the Ellis classification method, which also includes assessment of soft-tissue injuries. There is often an
Meurman, K.O.A.; Somer, K.; Lamminen, A.
Amongst 936 stress fractures found in soldiers, there were 58 in the femora (6%); of these 31 were in the neck and 27 in the shaft. Two were bilateral, and two patients had other stress fractures. Three displacements were found in the necks. In the shaft, 20 fractures were proximal, four were in the middle third and three in the distal third. In the latter group, it is necessary to differentiate from a sarcoma. CT is a new aid in this respect. Sport in highly motivated individuals appears to contribute particularly to fractures of the shaft. The symptoms from these fractures are relatively mild. (orig.) [de
Full Text Available Background: Management of nonunion with bony defect and infection in long bones is a challenging problem for orthopedic surgeons. Objectives: Evaluation of Ilizarov circular fixation method of treatment for the management of nonunited and infected fractures of tibia. Materials and Methods: This prospective study was conducted in a tertiary care hospital of eastern region of India on 30 subjects in a time span of 3 years after taking clearance of the Institutional Ethical Committee and informed consent of the patients. Results: All the patients had infected nonunion before undergoing Ilizarov procedure. Following initial injury, 22 patients were treated with external fixation and 8 cases were treated with internal fixation. At the time of presentation, 18 patients had infected gap nonunion, 5 patients had infected hypertrophic and 2 patients had atrophic nonunion. The Ilizarov fixator was kept for an average period of 303.7 days. Based on Association for the Study and Application of Methods of Ilizarov scoring system, bony and functional results were assessed. The bony result was excellent in 16 patients, good in eight, fair in four and poor in two. The functional result was excellent in 10 patients, good in 16, fair in two, poor in two. Conclusion: Ilizarov ring fixator still remains an excellent treatment modality for tibial nonunion with a defect, regarding bone union, deformity correction, infection eradication, limb-length achievement, and limb function.
Bible, Jesse E; McClure, D Jake; Mir, Hassan R
To analyze the rate of postoperative infection and nonunion after tibial fractures in patients treated for acute compartment syndrome (ACS) using (1) single-incision versus (2) dual-incision fasciotomy technique. Retrospective. Level I trauma center. Review of all adult tibial fractures operatively treated (n = 2756) over a 12-year period identified 175 patients with concurrent ACS requiring fasciotomy. Of 60 patients treated with intramedullary nails, 36 patients had single-incision fasciotomy and 24 had dual-incision fasciotomy. Of 81 patients treated with plate fixation, 59 patients had single-incision fasciotomy and 22 had dual-incision fasciotomy. Tibial fixation with fasciotomy for ACS. Occurrence of postoperative infection and nonunion. Both fasciotomy groups were similar across recorded patient and treatment characteristics. Need for skin graft was similar between fasciotomy groups. For patients treated with intramedullary nail (n = 60), 1 infection (2.8%) occurred in single-incision group versus 2 (8.3%) in dual-incision group (P = 0.558). Seven nonunions (19.4%) occurred in single-incision group versus 3 (12.5%) in dual-incision group (P = 0.726). For plate fixation patients (n = 81), 15 infections (25.4%) occurred with single-incision fasciotomy versus 5 infections (22.7%) with dual-incision fasciotomy (P = 1.000). Seven nonunions (11.9%) occurred with single-incision group versus 4 nonunions (18.2%) with dual-incision group (P = 0.479). This is the first study to compare a single-incision fasciotomy technique to a dual-incision technique in the setting of tibial fractures with ACS, with similar infection and nonunion rates with either technique. The choice of fasciotomy technique can be based on surgeon experience or patient condition as opposed to a suspected elevated infection or nonunion risk with either technique. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Lopez, J.M.; Onatibia, A.; Galardi, A.; Laso, C.
We present two cases of lengthwise stress fracture in tibia. This is an atypical and uncommon presentation. We describe the major clinical and radiological findings, stressing the enormous importance of CT in the correct diagnosis. (Author) 6 refs
Vetter, Sven Yves; Euler, Finn; von Recum, Jan; Wendl, Klaus; Grützner, Paul Alfred; Franke, Jochen
The intraoperative assessment of the articular surface in displaced intra-articular distal tibia fractures can be challenging using conventional fluoroscopy. The aim of the study was to determine the frequency and the method of intraoperative corrections of fracture reductions or implant placements during open reduction, internal fixation by using cone beam computed tomography (CT) after conventional fluoroscopy. Displaced intra-articular distal tibia fractures were retrospectively analyzed from August 2001 until December 2011. The fractures were classified according to the standards of the AO/OTA as type B or C and treated with open reduction and internal plate fixation. After primary reduction using conventional fluoroscopy, an additional cone beam CT scan was used to determine the alignment of the joint line and the implant position. The number of intraoperative revisions of the primary reduction due to the use of cone beam CT was analyzed. A total of 143 patients with an intra-articular tibial plafond fracture were included in the analysis. In 43 patients (30%), an intraoperative correction was performed after the cone beam CT scan. In 34 (24%) of these cases, intraoperative correction was required because of inadequate joint line reduction. Nine (6%) corrections were required as a result of a malposition of the implant. The revision rate did not differ by fracture classification. Despite its acceptance as the standard method of imaging, intraoperative conventional fluoroscopy for the assessment of implant positioning and fracture reduction of tibial plafond fractures is limited. The intraoperative utilization of cone beam CT provided additional information for the surgeon to detect insufficient reduction or implant malposition. Level III, retrospective comparative series. © The Author(s) 2016.
Kakar, S; Tornetta, P
Does immediate tibial nail insertion without reaming as part of protocol-driven management provide a safe and effective treatment for open tibia fractures? Prospective cohort. Level 1 trauma center. A consecutive series of 161 patients with Gustilo grade I-IIIb open tibia fractures. Emergent incision and debridement of the wound with immediate tibial nail insertion without reaming, repeat incision and debridement, and soft-tissue coverage within 14 days. Time to union, number of secondary procedures performed to obtain union, implant failures, and the type and incidence of complications. One hundred and forty-three fractures were followed to union. Follow up averaged 2.2 years (0.6-5.5 years). Seventy-six fractures united in less than 6 months, 35 took between 6 and 9 months, and 32 took longer than 9 months. Twenty-five additional procedures were needed to obtain union in 16 of the delayed unions (12 nail exchanges, 4 bone grafts, 9 dynamizations). Complications included 3 patients with cellulitis, 1 superficial infection, 4 deep infections (1 grade I, 2 grade II, 1 grade IIIb), 3 loose screws, 2 broken screws, 5 malunions greater than 5 degrees, and 30 patients with decreased ankle motion when compared with the uninjured side. Not counting the ankle loss of motion, 18 complications occurred in 143 fractures (13%). Twenty-nine patients (20%) had complaints of minor knee pain and 30 (21%) had occasional fracture site pain after activity despite clinical and radiographic evidence of union. Eleven patients (8%) considered themselves completely disabled. Five patients were not treated by the standard protocol and are not included in the previously listed statistics; 3 were grade IIIB that did not have adequate coverage by 14 days, and 2 were grade II injuries that did not have a second debridement. Four of these 5 patients developed a complication. Protocol-driven management emphasizing meticulous soft-tissue management and the use of immediate tibial nailing without
Daolagupu, Arup K; Mudgal, Ashwani; Agarwala, Vikash; Dutta, Kaushik K
Extraarticular distal tibial fractures are among the most challenging fractures encountered by an orthopedician for treatment because of its subcutaneous location, poor blood supply and decreased muscular cover anteriorly, complications such as delayed union, nonunion, wound infection, and wound dehiscence are often seen as a great challenge to the surgeon. Minimally invasive plate osteosynthesis (MIPO) and intramedullary interlocking nail (IMLN) are two well-accepted and effective methods, but each has been historically related to complications. This study compares clinical and radiological outcome in extraarticular distal tibia fractures treated by intramedullary interlocking nail (IMLN) and minimally invasive plate osteosynthesis (MIPO). 42 patients included in this study, 21 underwent IMLN and 21 were treated with MIPO who met the inclusion criteria and operated between June 2014 and May 2015. Patients were followed up for clinical and radiological evaluation. In IMLN group, average union time was 18.26 weeks compared to 21.70 weeks in plating group which was significant ( P plating group. Lesser complications in terms of implant irritation, ankle stiffness, and infection, were seen in interlocking group as compared to plating group. Average functional outcome according to American Orthopedic Foot and Ankle Society score was measured which came out to be 96.67. IMLN group was associated with lesser duration of surgery, earlier weight bearing and union rate, lesser incidence of infection and implant irritation which makes it a preferable choice for fixation of extra-articular distal tibial fractures. However, larger randomized controlled trials are required for confirming the results.
Pranit N. Chotai
Full Text Available Constellation of ipsilateral posterior hip dislocation, intertrochanteric- and proximal tibial fracture with popliteal artery injury is rare. Management of this presentation is challenging. A motor vehicle accident victim presented with these injuries, but without any initial signs of vascular compromise. Popliteal artery injury was diagnosed intra-operatively and repaired. This was followed by external fixation of tibial fracture, open reduction of dislocated hip and internal fixation of intertrochanteric fracture. Patient regained bilateral complete weight bearing and returned to pre-accident activity level. Apt surgical management including early repair of vascular injury in such a trauma mélange allows for a positive postoperative outcome.
Korula Mani Jacob
Early intervention with minimally invasive surgery has significantly less morbidity and a reliable early return to active sports and is therefore the best option in high-performance athletes. Materials and Methods: Nine athletes with ten stress fractures of the navicular treated at our institution between April 1991 and October 2000. The mean age of the patients was 22.8 years (range 18-50 years. All patients were treated by minimally invasive screw fixation and early weight bearing mobilization without a cast. The average followup was 7 years (range 2-11 years. Results: Seven of the nine patients returned to their pre-fracture level of sporting activity at an average of 5 months (range 3-9 months. One patient returned to full sporting activity following a delay of 2 years due to an associated tibial stress fracture and one patient had an unsatisfactory result. Long term review at an average of 7 years showed that six of these eight patients who returned to sports remained symptom free with two patients experiencing minimal intermittent discomfort after prolonged activity. Conclusions: We recommend percutaneous screw fixation as a reliable, low morbidity procedure allowing early return to full sporting activity without long term complications or recurrences.
Full Text Available Background Treatment of comminuted fractures of the distal femur and proximal tibia is difficult, and a challenge in the field of orthopedic trauma. Objectives The aim of this study was to assess the short-term results of hybrid external fixation in the treatment of these fractures. Patients and Methods In a prospective study, 44 patients with comminuted fractures of the distal femur or proximal tibia, with an overlying soft tissue injury treated by closed reduction and hybrid external fixation, were included. Parameters such as pin-track infection, union, limb shortening, knee motion, and alignment were evaluated during a mean follow-up period of 14 months. Results Forty-four patients with distal femoral (n = 23 and proximal tibial (n = 21 fractures were treated using hybrid external fixation. Bone union was seen in 35 (80% of the patients. Pin tract infection was seen in three patients (6.8%, one case (4.6% with a PTF and two cases (8% with DFFs. Malunion was observed in 4 patients (9.1%; of these, three cases (13% had DFF and one case (4.8% of pain was detected in the DFF group. One case had malunion and three cases had union. Findings showed satisfactory results in more than 80% of patients. In general, lower postoperative complications were detected in the proximal tibial fractures than the distal femoral fractures. According to a chi-square test, the difference between the patients with PTFs and those with DFFs was not clinically significant. Conclusions Closed reduction and hybrid external fixation can be used as a definitive treatment for severe comminuted fractures of the distal femur and proximal tibia, when the concomitant contusion of the skin and soft tissue damage prohibits safe open reduction and internal fixation.
Troussier, B.; Drevet, J.G.; Lelong, C.; Juvin, R.; Phelip, X.
Stress fractures result from increased bone remodelling induced by intense, unusual and repeated physical activity. They occur mainly in young individuals who are either servicemen or athletes, and are usually located in the tibias, calcaneums, metatarsals and femurs. Stress fractures should be distinguished from fractures due to bone loss, which are fractures of weakened bones occurring after a moderate or even negligeable injury in adults over 50 years of age, mainly in the bones of the pelvic girdle and lower leg. The diagnosis of stress fracture is suggested by the history and unremarkable physical findings, and confirmed by roentgenologic and scintigraphic investigations. The early, marked, localized increase in bone uptake demonstrated by isotopic scans is suggestive. Roentgenologic changes are delayed and inconspicuous, explaining diagnostic mistakes. Prompt therapy consists in refraining from weightbearing and represents the most effective means for preventing the only possible complication, ie, true fracture.
Dai, Can; Yang, Liu; Guo, Lin; Wang, Fuyou; Gou, Jingyue; Deng, Zhilong
The aim of the present study was to develop a more realistic finite element (FE) model of the human anterior cruciate ligament (ACL) tibial insertion and to analyze the stress distribution in the ACL internal fibers under load. The ACL tibial insertions were processed histologically. With Photoshop software, digital images taken from the histological slides were collaged, contour lines were drawn, and different gray values were filled based on the structure. The data were exported to Amira software and saved as ".hmascii" file. This document was imported into HyperMesh software. The solid mesh model generated using HyperMesh software was imported into Abaqus software. The material properties were introduced, boundary conditions were set, and load was added to carry out the FE analysis. The stress distribution of the ACL internal fibers was uneven. The lowest stress could be observed in the ACL lateral fibers under tensile and shear load. The establishment of ACL tibial insertion FE model and mechanical analysis could reveal the stress distribution in the ACL internal fibers under load. There was greater load carrying capacity in the ACL lateral fibers which could sustain greater tensile and shear forces.
Dai, Can; Yang, Liu; Guo, Lin; Wang, Fuyou; Gou, Jingyue; Deng, Zhilong
Objective: The aim of the present study was to develop a more realistic finite element (FE) model of the human anterior cruciate ligament (ACL) tibial insertion and to analyze the stress distribution in the ACL internal fibers under load. Methods: The ACL tibial insertions were processed histologically. With Photoshop software, digital images taken from the histological slides were collaged, contour lines were drawn, and different gray values were filled based on the structure. The data were exported to Amira software and saved as “.hmascii” file. This document was imported into HyperMesh software. The solid mesh model generated using HyperMesh software was imported into Abaqus software. The material properties were introduced, boundary conditions were set, and load was added to carry out the FE analysis. Results: The stress distribution of the ACL internal fibers was uneven. The lowest stress could be observed in the ACL lateral fibers under tensile and shear load. Conclusion: The establishment of ACL tibial insertion FE model and mechanical analysis could reveal the stress distribution in the ACL internal fibers under load. There was greater load carrying capacity in the ACL lateral fibers which could sustain greater tensile and shear forces. PMID:26150858
Shao, Jiashen; Chang, Hengrui; Zhu, Yanbin; Chen, Wei; Zheng, Zhanle; Zhang, Huixin; Zhang, Yingze
This study aimed to quantitatively summarize the risk factors associated with surgical site infection after open reduction and internal fixation of tibial plateau fracture. Medline, Embase, CNKI, Wanfang database and Cochrane central database were searched for relevant original studies from database inception to October 2016. Eligible studies had to meet quality assessment criteria according to the Newcastle-Ottawa Scale, and had to evaluate the risk factors for surgical site infection after open reduction and internal fixation of tibial plateau fracture. Stata 11.0 software was used for this meta-analysis. Eight studies involving 2214 cases of tibial plateau fracture treated by open reduction and internal fixation and 219 cases of surgical site infection were included in this meta-analysis. The following parameters were identified as significant risk factors for surgical site infection after open reduction and internal fixation of tibial plateau fracture (p operative time (OR 2.15; 95% CI 1.53-3.02), tobacco use (OR 2.13; 95% CI 1.13-3.99), and external fixation (OR 2.07; 95% CI 1.05-4.09). Other factors, including male sex, were not identified as risk factors for surgical site infection. Patients with the abovementioned medical conditions are at risk of surgical site infection after open reduction and internal fixation of tibial plateau fracture. Surgeons should be cognizant of these risks and give relevant preoperative advice. Copyright © 2017. Published by Elsevier Ltd.
mechanisms could have included training mileage, training surface, nutrition and history of amenorrhea . In addition, prospective studies are essential...underlying mechanisms could have included training mileage, training surface, nutrition and history of amenorrhea . Although specific structural
Marsh, J L; Muehling, V; Dirschl, D; Hurwitz, S; Brown, T D; Nepola, J
Assess whether postoperative ankle motion after fixation of a fracture of the tibial plafond, treated with articulated external fixation, leads to a better outcome when compared with similar treatment without postoperative ankle motion. Multicenter randomized trial. Three Level I trauma centers. Fifty-five patients were enrolled and entered into a Web-based database and randomized into 1 of 2 groups. Forty-one patients were evaluated at a 1-year follow-up visit, and 31 were seen at 2 years or longer after injury. Patients were treated with a hinged external fixator and limited internal fixation of the articular surface. They were divided postoperatively into two groups, 1 of which had a locked hinge and the other had a mobile hinge and a motion protocol. A general health status questionnaire, the SF-36 (short-form 36); a joint-specific ankle questionnaire, the Ankle Osteoarthritis Score (AOS); and range of motion (ROM) of the ankle joint. There were no significant differences between the two groups at either follow-up interval in the ankle ROM measurement, the AOS pain and disability scale, or the SF-36 physical component summary (PCS) and mental component summary (MCS) scales. These results indicate that treatment protocols that use long periods of cross-joint external fixation that immobilizes the ankle as definitive treatment result in similar patient outcomes compared to otherwise identical treatment protocols that incorporate and use an articulated hinge for ankle motion. However, the results should be interpreted with caution because the patient numbers were too small to detect potentially meaningful differences in outcomes and the follow-up was too short to assess for differences in the development of arthrosis.
Ketz, John; Sanders, Roy
had radiographic evidence of joint space narrowing compared with 3 (33%) in the PL group. Ankle range of motion for the A group was 35.8° versus 34.2° for the PL group (nonsignificant). There were 2 delayed wound healing complications in the A group with one deep infection in the PL group. Two patients in the A group required arthrodesis procedures resulting from posttraumatic arthrosis compared with none in the PL group. No significant difference was seen in postoperative complications across both groups. The average Maryland Foot Score and American Orthopaedic Foot and Ankle Society/Ankle & Hindfoot score for the PL group was 86.4/85.2 compared with 69.4/76.4 for the A group. The addition of a posterior lateral approach offers direct visualization for reduction of the posterior distal fragment of the tibial pilon. Although the joint surface itself cannot be visualized, this reduction allows the anterior components to be secured to a stable posterior fragment at a later date. This technique improved our ability to subsequently obtain an anatomic articular reduction based on computed tomography scans and preservation of the tibiotalar joint space at a minimum 1-year follow-up. Furthermore, it correlated with an improvement in clinical outcomes with increases in Maryland Foot Score and Ankle & Hindfoot score for the posterior plating group. Although promising, continued follow-up will be needed to determine the long-term outcome using this technique for treating tibial pilon fractures.
Liang, Jinying; Zheng, Jiapeng; Ll, Qiang; Zhong, Shuyu; Chen, Minzhen
To investigate the clinical effects of the Ultrabraid suture with FOOTPRINT rivet by arthroscopic technique for the treatment of anterior cruciate ligament (ACL) tibial eminence avulsion fracture. Between May 2011 and December 2013, 19 adolescent patients with ACL tibial eminence avulsion fracture were treated with arthroscopic reduction and fixation by Ultrabraid sutures with FOOTPRINT rivet. There were 13 males and 6 females with an average age of 15.8 years (range, 8-18 years). The left knees were involved in 10 cases and the right knees in 9 cases. The injury causes included traffic accident injury in 8 cases, sport injury in 6 cases, and sprain injury in 5 cases. Three patients had old fractures, and the others had fresh fractures. The results of Lachman test and anterior drawer test were both positive. The International Knee Documentation Committee (IKDC) subject score was 54.2 ± 4.0. Based on Meyers-McKeever classification, there were 3 cases of type II, 10 cases of type III, and 6 cases of type IV. The operation time was 50-60 minutes (mean, 55.2 minutes). X-ray film showed satisfactory fracture reduction at 1 day after operation. Primary healing of incision was obtained with no infection. Eighteen patients were followed up for 1-3 years (mean, 1.7 years). All fractures healed with smooth joint surface on the X-ray film at 3 months after operation. The results of Lachman test and anterior drawer test were both negative in 17 cases, and the results was negative for anterior drawer test and was weakly positive for Lachman test in 1 case. The IKDC subject score was significantly improved to 96.1 ± 2.1 at last follow-up (t = 34.600, P = 0.000). It could achieve early restoration of knee joint function to treat the ACL tibial eminence avulsion fracture by arthroscopic technique of the Ultrabraid suture with FOOTPRINT rivet because of satisfactory reduction, reliable fixation, small wound, and early rehabilitation.
Briteño-Vázquez, M; Santillán-Díaz, G; González-Pérez, M; Gallego-Izquierdo, T; Pecos-Martín, D; Plaza-Manzano, G; Romero-Franco, N
The objective of this study is to analyze the effectiveness of low power laser irradiation in the bone consolidation of tibial fractures in rats. An experimental, comparative, prospective study with control group was designed. Twenty Wistar rats were grouped into control (n = 10) and experimental groups (n = 10). A tibial fracture, with a mechanical drill, was inflicted in all rats. The experimental group received ten days of low power arsenide-gallium laser irradiation of 850 nm (KLD, Sao Paulo, Brasil)-100 mW, 8 J/cm(2), 64 s. Before and after the laser treatment, a radiologic analysis was carried out in both groups, in which the rats were graded from 0 to IV according the Montoya scale of bone consolidation. Also, we histopathologically analyzed the bone to estimate the proliferation of fibroblasts, bone matrix, and angiogénesis with a microscopy, which were graded as I (thin layer of fibroblasts and osteoid matrix), II (thick layer of fibroblasts and osteoid matrix), or III (thick layer of fibroblasts and osteoid matrix and new blood vessels). Radiologic data showed that the experimental group had a higher bone consolidation of Montoya scale after ten days of laser irradiation compared to control group (P fractures in rats, according to radiologic and histopathologic analysis.
Berger, Ferco H.; Jonge, Milko C. de; Maas, Mario
Stress fractures are fatigue injuries of bone usually caused by changes in training regimen in the population of military recruits and both professional and recreational athletes. Raised levels of sporting activity in today's population and refined imaging technologies have caused a rise in reported incidence of stress fractures in the past decades, now making up more than 10% of cases in a typical sports medicine practice. Background information (including etiology, epidemiology, clinical presentation and treatment and prevention) as well as state of the art imaging of stress fractures will be discussed to increase awareness amongst radiologists, providing the tools to play an important role in diagnosis and prognosis of stress fractures. Specific fracture sites in the lower extremity will be addressed, covering the far majority of stress fracture incidence. Proper communication between treating physician, physical therapist and radiologist is needed to obtain a high index of suspicion for this easily overlooked entity. Radiographs are not reliable for detection of stress fractures and radiologist should not falsely be comforted by them, which could result in delayed diagnosis and possibly permanent consequences for the patient. Although radiographs are mandatory to rule out differentials, they should be followed through when negative, preferably by magnetic resonance imaging (MRI), as this technique has proven to be superior to bone scintigraphy. CT can be beneficial in a limited number of patients, but should not be used routinely
Berger, Ferco H. [Academic Medical Center, University of Amsterdam, Department of Radiology, Meibergdreef 9, 1105 AZ Amsterdam (Netherlands); Jonge, Milko C. de [Academic Medical Center, University of Amsterdam, Department of Radiology, Meibergdreef 9, 1105 AZ Amsterdam (Netherlands); Maas, Mario [Academic Medical Center, University of Amsterdam, Department of Radiology, Meibergdreef 9, 1105 AZ Amsterdam (Netherlands)]. E-mail: email@example.com
Stress fractures are fatigue injuries of bone usually caused by changes in training regimen in the population of military recruits and both professional and recreational athletes. Raised levels of sporting activity in today's population and refined imaging technologies have caused a rise in reported incidence of stress fractures in the past decades, now making up more than 10% of cases in a typical sports medicine practice. Background information (including etiology, epidemiology, clinical presentation and treatment and prevention) as well as state of the art imaging of stress fractures will be discussed to increase awareness amongst radiologists, providing the tools to play an important role in diagnosis and prognosis of stress fractures. Specific fracture sites in the lower extremity will be addressed, covering the far majority of stress fracture incidence. Proper communication between treating physician, physical therapist and radiologist is needed to obtain a high index of suspicion for this easily overlooked entity. Radiographs are not reliable for detection of stress fractures and radiologist should not falsely be comforted by them, which could result in delayed diagnosis and possibly permanent consequences for the patient. Although radiographs are mandatory to rule out differentials, they should be followed through when negative, preferably by magnetic resonance imaging (MRI), as this technique has proven to be superior to bone scintigraphy. CT can be beneficial in a limited number of patients, but should not be used routinely.
Keating, J F; O'Brien, P J; Blachut, P A; Meek, R N; Broekhuyse, H M
Ninety-one patients who had ninety-four open fractures of the tibial shaft were randomized into two treatment groups. Fifty fractures (nine type-I, eighteen type-II, sixteen type-IIIA, and seven type-IIIB fractures, according to the classification of Gustilo et al.) were treated with nailing after reaming, and forty-four fractures (five type-I, sixteen type-II, nineteen type-IIIA, and four type-IIIB fractures) were treated with nailing without reaming. The average diameter of the nail was 11.5 millimeters (range, nine to fourteen millimeters) in the group treated with reaming and 9.2 millimeters (range, eight to ten millimeters) in the group treated without reaming. Follow-up information was adequate for forty-five patients (forty-seven fractures) who had been managed with reaming and forty patients (forty-one fractures) who had been managed without reaming. No clinically important differences were found between the two groups with regard to the technical aspects of the procedure or the rate of early postoperative complications. The average time to union was thirty weeks (range, thirteen to seventy-two weeks) in the group treated with reaming and twenty-nine weeks (range, thirteen to fifty weeks) in the group treated without reaming. Four (9 per cent) of the fractures treated with reaming and five (12 per cent) of the fractures treated without reaming did not unite (p = 0.73). There were two infections in the group treated with reaming and one in the group treated without reaming. Significantly more screws broke in the group treated without reaming (twelve; 29 per cent) than in the group treated with reaming (four; 9 per cent) (p = 0.014). There was no difference between the two groups with regard to the frequency of broken nails (two nails that had been inserted after reaming broke, compared with one that had been inserted without reaming). The functional outcome, in terms of pain in the knee, range of motion, return to work, and recreational activity, did not
Mackey, V.S.; Trout, D.R.; Meagher, D.M.; Hornof, W.J.
The medical records, radiographic and nuclear scintigraphic findings of 26 racing horses with 27 stress fracture episodes of the humerus, radius, or tibia were reviewed. The purposes of this study were to describe the radiographic and/or scintigraphic features of stress fractures of the humerus, radius, or tibia, and to evaluate the signalment and history of horses in which stress fracture occurred. Stress fractures of the three long bones examined were primarily seen in 2- and 3-year-old male Thoroughbred horses; commonly, the onset of lameness was immediately following training gallops or racing. There were 13 humeral stress fracture episodes in 12 horses. Ten were in the proximal caudolateral cortex, and three were in the distal craniomedial cortex. Radical stress fractures were seen in three horses, all in the midshaft radius. Tibial stress fractures were diagnosed in 11 horses. They were located in the proximal lateral tibia in six horses, the distal caudolateral tibia in three horses, and the midshaft tibia in three horses. Fifteen stress fractures were diagnosed with radiography alone, one was diagnosed with scintigraphy alone, nine were diagnosed with radiographs and scintigraphy, and, in two horses, radiographs were negative, but the scintigraphic findings were consistent with stress fracture
Full Text Available Introduction: Intramedullary nailing is synthesis and consolidation of fracture fragments with the main goalto gain strength and permanent placement of the implants. Two techniques of intramedullary osteosynthesis are used: with dynamic or with static intramedullary nail. Dynamization include conversion of static nail by removing screws from the longest fragment. The aim of this study is to determine whether there is a difference in the speed and quality of healing of the type A and B fractures of the femur and tibia treated by static or dynamic intramedullary nails and to compare the results.Methods: The study was conducted on a total of 129 patients with closed fractures of the diaphysis of the femur and tibia type A and type B. Patients were divided into two groups, based on the applied operating method, static or dynamic intramedullary osteosynthesis.Results: The average number of weeks of healing femoral and tibial fractures was slightly in advantage of static intramedullary osteosynthesis, it was 17.08 weeks (SD=3.382. The average number of weeks of healing in 23 patients with fractures of the femur, treated by dynamic intramedullary osteosynthesis was 17.83 (SD=2.978.Conclusion: We can conclude that static intramedullary nailing osteosynthesis unable movements between fragments which directly stimulates bone formation and formation of minimal callus. Static intramedullary ostesinthesys resolve the problem of stabilizing the fracture, limb shortening and rotation of fragments.
Franzone, Jeanne M; Finkelstein, Mark S; Rogers, Kenneth J; Kruse, Richard W
Evaluation of the union of osteotomies and fractures in patients with osteogenesis imperfecta (OI) is a critical component of patient care. Studies of the OI patient population have so far used varied criteria to evaluate bony union. The radiographic union score for tibial fractures (RUST), which was subsequently revised to the modified RUST, is an objective standardized method of evaluating fracture healing. We sought to evaluate the reliability of the modified RUST in the setting of the tibias of patients with OI. Tibial radiographs of 30 patients with OI fractures, or osteotomies were scored by 3 observers on 2 separate occasions. Each of the 4 cortices was given a score (1=no callus, 2=callus present, 3=bridging callus, and 4=remodeled, fracture not visible) and the modified RUST is the sum of these scores (range, 4 to 16). The interobserver and intraobserver reliabilities were evaluated using intraclass coefficients (ICC) with 95% confidence intervals. The ICC representing the interobserver reliability for the first iteration of scores was 0.926 (0.864 to 0.962) and for the second series was 0.915 (0.845 to 0.957). The ICCs representing the intraobserver reliability for each of the 3 reviewers for the measurements in series 1 and 2 were 0.860 (0.707 to 0.934), 0.994 (0.986 to 0.997), and 0.974 (0.946 to 0.988). The modified RUST has excellent interobserver and intraobserver reliability in the setting of OI despite challenges related to the poor quality of the bone and its dysplastic nature. The application and routine use of the modified RUST in the OI population will help standardize our evaluation of osteotomy and fracture healing. Level III-retrospective study of nonconsecutive patients.
Cong, R J; Liu, J F; Jiang, Y; Dilixiati, Duolikun; Hou, X D; Zheng, L P
Objective: To explore the influence of the lower extremity abnormal alignment and the joint surface, and to explore the surgical skills. Methods: Twenty-two cases of tibial plateau Schatzker Ⅵ fracture internal fixation failure revision from January 2012 to January 2017 in Department of Orthopedics, Shanghai 10(th) Hospital.One year follow-up after initial surgery to make sure of failure.Three-dimensional CT scan, radiography, infection index, gait analysis, knee joint ROM, femur tibia angle, tibial plateau tibial shaft angle and posterior slope if tibial plateau were observed. The medial approach and bi-planer osteotoma were used.Autogenous iliac bone graft, postoperative fast recovery channel were used.Follow-up point included preoperative and postoperative 7 days, 6 weeks, 3 months, and 6 months.Obvervational index included double lower limbs radiography, knee society score(KSS), complications such as infection, skin necrosis, joint main passive activity, double lower limbs alignment the last follow-up SF-36 scale.Rate was compared by χ(2) test, measurement data using paired sample t test.Correlation was analyzed by Pearson correlation regression testing. Results: Twenty-two patients received follow-up.KSS, more than 21 cases were benign, with good gait.One case was poor, with claudication gait.Not skin necrosis, no deep infection cases, 1 case get blisters 2 days postoperatively, and disappear after 5 days with detumescence and cold therapy.Whether restoring force line affect the KSS significantly(χ(2)=22.000, P =0.000). Knee joint ROM, SF-36 score, KSS and lower limb alignment were improved significantly. In different individual the articular surface and anatomical angle recovered greatly but the posterior slope angle was quite difference which has no correlation with KSS and SF-36 scale( P >0.01). Conclusions: Revision of Schatzker type Ⅵ tibial plateau fracture failure should focus on the recovery of lower limb alignment.moderate overcorrect bone
Complex tibial fractures are associated with lower social classes and predict early exit from employment and worse patient-reported QOL: a prospective observational study of 46 complex tibial fractures treated with a ring fixator.
Elsoe, Rasmus; Larsen, Peter; Petruskevicius, Juozas; Kold, Søren
The long-term outcomes following complex fractures of the tibia are reported to carry a risk of knee pain, malalignment, articular injury and post-traumatic osteoarthritis. The main objective of this study was to account for the patient-reported quality of life (QOL) 12 months after ring fixator removal in patients with a complex tibial fracture. Secondary objectives included a review of the socio-economic characteristics of the patient group and the rate of return to work in the study period. A prospective follow-up study was conducted of 60 patients with complex fractures of the tibia treated with ring external fixation. Patient-reported outcomes, radiological outcomes and socio-economic status including employment status of the patients were obtained 12 months after frame removal. Forty-six patients completed the assessment 12 months after frame removal (77%). The mean age of the patient at the time of fracture was 54.6 years (range 31-86). There were 19 males and 27 females. At 12 months after frame removal, the mean EQ5D-5L index was 0.66 (CI 0.60-0.72). The mean EQ5D-5L VAS was 69 (CI 61-76). When this was compared to the established reference population from Denmark, the study population showed a significantly worse EQ5D-5L index. The majority of patients (87%) were in the lower social classes suggesting a higher degree of social deprivation in the study population. Twenty-seven per cent of patients who were employed prior to injury had returned to employment at approximately 19 months following fracture. The onset of post-traumatic osteoarthritis was present in the knee joint in 29% of patients following a proximal intra-articular fracture, whereas osteoarthritis was present at the ankle joint in 35% of patients following a distal intra-articular fracture 12 months after frame removal. This study indicates that at 12 months after frame removal there are poorer patient-reported QOL as when compared to reference populations. Furthermore, this study
Full Text Available Background: The purpose of this study was to evaluate contributing factors affecting deep infection and fracture healing of open tibia fractures treated with locked intramedullary nailing (IMN by multivariate analysis. Materials and Methods: We examined 99 open tibial fractures (98 patients treated with immediate or delayed locked IMN in static fashion from 1991 to 2002. Multivariate analyses following univariate analyses were derived to determine predictors of deep infection, nonunion, and healing time to union. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type, fracture grade by AO type, fracture location, timing or method of IMN, reamed or unreamed nailing, debridement time (≤6 h or> 6 h, method of soft-tissue management, skin closure time (≤1 week or> 1 week, existence of polytrauma (ISS< 18 or ISS≥18, existence of floating knee injury, and existence of superficial/pin site infection. The predictive variables of nonunion selected for analysis was the same as those for deep infection, with the addition of deep infection for exchange of pin site infection. The predictive variables of union time selected for analysis was the same as those for nonunion, excluding of location, debridement time, and existence of floating knee and superficial infection. Results: Six (6.1%; type II Gustilo n=1, type IIIB Gustilo n=5 of the 99 open tibial fractures developed deep infections. Multivariate analysis revealed that timing or method of IMN, debridement time, method of soft-tissue management, and existence of superficial or pin site infection significantly correlated with the occurrence of deep infection ( P < 0.0001. In the immediate nailing group alone, the deep infection rate in type IIIB + IIIC was significantly higher than those in type I + II and IIIA ( P = 0.016. Nonunion occurred in 17 fractures (20.3%, 17/84. Multivariate analysis revealed that Gustilo type, skin closure time, and
Tan, Hong-Lue; Dai, Peng-Yi; Liu, Wei-Feng; Yuan, Yan-Hao
To explore the clinical efficacy of double-plate fixation for the treatment of old tibial plateau fractures with Schatzker type IV through anterior midline and posteromedial approaches. From July 2013 to July 2015, 15 patients with old tibial plateau fractures were treated with internal fixation using locking reconstructive plate for the posteromedial fragment and anatomical locking plate for anteromedial fragment through antero midline and posteromedial approaches. There were 9 males and 6 females, with an average age of 49.2 years old (ranged, 21 to 61 years old). Eight patients had injured in the left side and 7 in the right side. According to Schatzker classification, all patients were type IV. The mean interval from injury to operation was 26.5 days (ranged, 21 to 65 days). The main clinical symptoms before operation were knee joint swelling, pain, deformity and limitation of motion. The X-ray and CT confirmed the fracture type. The indexes such as tibial plateau tibial shaft angle (TPA), femoral tibial angle (FTA) and posterior slope angle (PSA) were compared between immediate postoperation and final follow-up using postoperative X-ray film. The knee functions were evaluated using the HSS (Hospital for Special Surgery) knee score system. Two patients had incision complications which healed by correct treatment, 1 patient had traumatic arthritis. All patients were followed up for mean 16.6 months (ranged, 13 to 24 months). No infections, deep venous thrombosis, implant loosening and breakage, fragment displacement, plateau surface collapse and bone nonunion found. The bone union time ranged from 3 to 8 months (mean 6.07 months) after operation. The average immediate postoperative value of TPA, FTA and PSA were(86.81±1.67)°, (168.00±3.29)° and(10.20±1.47)° respectively; and(86.47±1.67)°, (168.53±3.03)° and (10.54±1.21)° respectively at the final follow-up evaluation, showing no statistical differences( P >0.05). According to the HSS score system, 26
Fernandes, Hélio Jorge Alvachian; Sakaki, Marcos Hideyo; Silva, Jorge dos Santos; dos Reis, Fernando Baldy; Zumiotti, Arnaldo Valdir
A prospective, randomized study to compare patients with closed, multi-fragmented tibial diaphyseal fractures treated using one of two fixation methods undertaken during minimally invasive surgery: nonreamed interlocking intramedullary nails or bridging plates. Forty-five patients were studied; 22 patients were treated with bridging plates, 23 with interlocking nails without reaming. All fractures were Type B and C (according to the AO classification). Clinical and radiographic healing occurred in all cases. No cases of infection occurred. The healing time for patients who received nails was longer (4.32 weeks on average) than the healing time for those who received plates (P = 0.026). No significant differences were observed between the two methods regarding ankle mobility for patients in the two groups. The healing time was shorter with the bridging plate technique, although no significant functional differences were found.
Dorne, H.L.; Lander, P.H.
The diagnosis of spontaneous stress fractures of the femoral neck, a form of insufficiency stress fracture, can be missed easily. Patients present with unremitting hip pain without a history of significant trauma or unusual increase in daily activity. The initial radiographic features include osteoporosis, minor alterations of trabecular alignment, minimal extracortical or endosteal reaction, and lucent fracture lines. Initial scintigraphic examinations performed in three of four patients showed focal increased radionuclide uptake in two and no focal abnormality in one. Emphasis is placed on the paucity of early findings. Evaluation of patients with persistent hip pain requires a high degree of clinical suspicion and close follow-up; the sequelae of undetected spontaneous fractures are subcapital fracture with displacement, angular deformity, and a vascular necrosis of the femoral head
Full Text Available Posttraumatic osteoarthritis (PTOA of the knee is a common complication after intra- and extra-articular fractures. Moreover, PTOA may also be a result of isolated cartilage defects, meniscus resections, and ligament injuries. There are various methods of treatment of knee joint fractures. However, in the final stage of a PTOA, when nonoperative treatment fails, endoprosthetic joint replacement is the method of choice. Primary total knee replacement (TKR for the treatment for a fracture of the knee joint is a rare indication, even at major treatment centers. It is performed in elderly patients with the inability to be mobilized with partial- or non-weight bearing; in cases with considerable bone destruction; in cases with symptomatic osteoarthritis (OA in the elderly; and, it is often associated with the primary use of a modular implant. However, TKR in the acute situation should always be an individual decision. Secondary TKR after knee joint fracture shows overall good functional results. However, the results are inferior when compared with TKR for primary OA. In addition, the complication rates of TKR for PTOA are much higher. Problems with the extensor mechanism after tibial plateau fractures are common. There are also problems caused by preexisting scars, nonunion (possibly due to a low grade infection, malalignment, restricted movement, or instability.
Wang, Tie-Jun; Ju, Wei-Na; Qi, Bao-Chang
Abstract Rationale: Anatomical characteristics, such as subcutaneous position and minimal muscle cover, contribute to the complexity of fractures of the distal third of the tibia and fibula. Severe damage to soft tissue and instability ensure high risk of delayed bone union and wound complications such as nonunion, infection, and necrosis. Patient concerns: This case report discusses management in a 54-year-old woman who sustained fractures of the distal third of the left tibia and fibula, with damage to overlying soft tissue (swelling and blisters). Plating is accepted as the first choice for this type of fracture as it ensures accurate reduction and rigid fixation, but it increases the risk of complications. Diagnosis: Closed fracture of the distal third of the left tibia and fibula (AO: 43-A3). Interventions: After the swelling was alleviated, the patient underwent closed reduction and fixation with an Acumed fibular nail and minimally invasive plating osteosynthesis (MIPO), ensuring a smaller incision and minimal soft-tissue dissection. Outcomes: At the 1-year follow-up, the patient had recovered well and had regained satisfactory function in the treated limb. The Kofoed score of the left ankle was 95. Lessons: Based on the experience from this case, the operation can be undertaken safely when the swelling has been alleviated. The minimal invasive technique represents the best approach. Considering the merits and good outcome in this case, we recommend the Acumed fibular nail and MIPO technique for treatment of distal tibial and fibular fractures. PMID:28328865
Kotsianos, D; Rock, C; Wirth, S; Linsenmaier, U; Brandl, R; Fischer, T; Euler, E; Mutschler, W; Pfeifer, K J; Reiser, M
To analyze a prototype mobile C-arm 3D image amplifier in the detection and classification of experimental tibial condylar fractures with multiplanar reconstructions (MPR). Human knee specimens (n = 22) with tibial condylar fractures were examined with a prototype C-arm (ISO-C-3D, Siemens AG), plain films (CR) and spiral CT (CT). The motorized C-arm provides fluoroscopic images during a 190 degrees orbital rotation computing a 119 mm data cube. From these 3D data sets MP reconstructions were obtained. All images were evaluated by four independent readers for the detection and assessment of fracture lines. All fractures were classified according to the Müller AO classification. To confirm the results, the specimens were finally surgically dissected. 97 % of the tibial condylar fractures were easily seen and correctly classified according to the Müller AO classification on MP reconstruction of the ISO-C-3D. There is no significant difference between ISO-C and CT in detection and correct classification of fractures, but ISO-CD-3D is significant by better than CR. The evaluation of fractures with the ISO-C is better than with plain films alone and comparable to CT scans. The three-dimensional reconstruction of the ISO-C can provide important information which cannot be obtained from plain films. The ISO-C-3D may be useful in planning operative reconstructions and evaluating surgical results in orthopaedic surgery of the limbs.
Hartwich, Kathleen; Lorente Gomez, Alejandro; Pyrc, Jaroslaw; Gut, Radosław; Rammelt, Stefan; Grass, René
We performed a biomechanical comparison of 2 methods for operative stabilization of pronation-abduction stage III ankle fractures; group 1: Anterior-posterior lag screws fixing the posterior tibial fragment and lateral fibula plating (LSLFP) versus group 2: locked plate fixation of the posterior tibial fragment and posterior antiglide plate fixation of the fibula (LPFP). Seven pairs of fresh-frozen osteoligamentous lower leg specimens (2 male, and 5 female donors) were used for the biomechanical testing. Bone mineral density (BMD) of each specimen was assessed by means of dual-energy x-ray absorptiometry. After open transection of the deltoid ligament, an osteotomy model of pronation abduction stage III ankle fracture was created. Specimens were systematically assigned to LSLFP (group 1, left ankles) or LPPFP (group 2, right ankles). After surgery, all specimens were evaluated via CT to verify reduction and fixation. Axial load was then applied onto each specimen using a servohydraulic testing machine starting from 0 N (Zwick/Roell, Ulm, Germany) at a speed of 10 N/s with the foot fixed in a 10 degrees pronation and 15 degrees dorsiflexion position. Construct stiffness, yield, and ultimate strength were measured and dislocation patterns were documented with a high-speed camera. The normal distribution of all data was analyzed using Shapiro-Wilk test. The group comparison was performed using paired Student t test. Statistical significance was assumed at a P value of .05. All specimens had BMD values consistent with osteoporosis. BMD values did not differ between the left and right ankles of the same pair ( P = .762). The mean BMD values between feet of men (0.603 g/cm 2 ) and women (0.329 g/cm 2 ) were statistically different ( P = .005). The ultimate strength for LSLFP (group 1) with 1139 ± 669 N and LPPFP (group 2) with 2008 ± 943 N was statistically different ( P = .036) as well as the yield in LSLFP (group 1) 812 ± 452 N and LPPFD (group 2) 1292 ± 625 N ( P
Zhao, Xing-Wen; Ma, Jian-Xiong; Ma, Xin-Long; Jiang, Xuan; Wang, Yin; Li, Fei; Lu, Bin
Both external fixation (ExFx) and open reduction and internal fixation(ORIF) were used to treat complex tibial plateau fractures, but it was not sure which one was better. So we did this meta-analysis to evaluate the outcomes of ExFx and ORIF in managing complex tibial plateau fractures. Articles published before August 5, 2016 were selected from PubMed, Cochrane library, and some other electronic database. Relevant journals were also searched manually with no language limited. Two independent reviewers searched and assessed the literature. A fixed effect model was initially used for meta-analyses with RevMan 5.3. When compared with ORIF, cases undergoing ExFx were more likely to return to the preinjury state at the early stage, but no difference in the later period of follow-up. However, ExFx group had higher infection rate (OR 1.98, 95% CI 1.08-3.63, P = 0.03), higher venous thromboembolism rate (OR 1.56, 95% CI 0.49-4.96, P = 0.45), higher re-operation rate (OR 0.87, 95% CI 0.47-1.62, P = 0.66) and lower compartment syndrome rate (OR 0.61, 95% CI 0.12-3.22, P = 0.56), lower TKA rate (OR 0.51, 95% CI 0.20-1.34, P = 0.17). There were no statistically significant differences in the rate of deep infection, venous thromboembolism, compartment syndrome and VTE between the two groups. Although external fixation may offer some advantages, both were acceptable strategies in managing complex tibial plateau fractures. According to our analysis results, we strongly recommend that selection of definitive fixators should base on the fracture patterns, soft-tissue condition as well as the injury stages in clinical practice. More important, further multicentered, randomized controlled studies should be implemented to get a more reliable and clear result. Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
Full Text Available Figure skating is a physically demanding sport that requires a unique combination of artistic ability, speed, agility, flexibility and power. During the last decades not only the competitive schedule has become tougher, but after introduction of the new judging system in 2003, also more emphasis is put on difficult technical elements, jumps, steps and spins (ISU Rules, 2006. More studies about possible increasing prevalence of stress fractures in figure skaters and contributing factors are lacking (Dubravcic-Simunjak et al., 2003; Moran, 2000; Pecina et al., 1990. Therefore the aim of this study was to obtain data about the current stress fracture cumulative risk among elite junior and senior figure skaters, as well as possible factors that may contribute to stress fracture incidence. An anonymous questionnaire, divided into 5 sections, inquired about the prevalence of stress fracture were mailed and distributed to all 62 International Skating Union (ISU members by the ISU headquarters in Lausanne, Switzerland. The guidelines of the Helsinki declaration 2004 were followed. From the 644 skaters who received the questionnaire, 412 completed ones were returned from 110 female juniors (78 single skaters, 12 pair skaters and 20 ice dancers and 135 female seniors (97 single skaters, 16 pair skaters and 22 ice dancers and from 79 male juniors (47 single skaters, 12 pair skaters and 20 ice dancers and 88 male seniors (50 single skaters, 16 pair skaters and 22 ice dancers, coming from different ISU members. The response rate was 62% in females and 67% in males. The median age for female skaters was 16 years and for males 18 years (range 12-25 years. All participants started to skate between 3 and 6 years of age and started to compete in national and international competitions when they were between 5 and 7 years old. At the time of this analysis, they had been skating between 9 and 20 years.In females 41 (16.7%, and in males 25 (13.8% figure skaters
Full Text Available INTRODUCTION Damage to the joint is more extensive in tibia plateau fractures than the roentgenograms Indicate. It may be associated with soft tissue trauma, ligament injuries (4-33% medial Collateral ligament being the most common, meniscal injuries (20%, lateral collateral Ligament injury (3%, peroneal nerve injuries (3%. Posttraumatic arthritis is associated with residual instability or axial malalignment rather than joint depression. So we use minimally invasive approach to the depressed tibial plateau fractures (Schatzker type II & III. MATERIALS AND METHODS 32 patients were studied. They were followed up for maximum of 3yrs and a minimum of 1.5yrs with an average of 2.2yrs. Inclusion criteria included those patients with an age group between 20yrs and 60yrs, joint depression more than 3mm. Patients with open fracture, severe osteoporotic bones and with radiographic evidence of osteoarthritis are excluded from the study. CT was done in all patients. Mean age group was 28.8yrs and 19(76% were males; the mean articular depression was 11.32 mm measured in CT. Pre-op evaluation includes x-rays of the knee, stress x-rays if needed, and CT was done with 2mm limited cuts. Cancellous Bone graft was taken from opposite tibia through a 3-4cm long incision made below the tibial tuberosity over the medial aspect of the tibia. Cortical window was made in the affected limb, just enough to introduce the punch, and its position was confirmed under c-arm and depressed fragment was elevated with punch and reduction was held with k wires in subarticular plane and later two cannulated cancellous screws was introduced and the defect packed with bone grafts, Post-operatively all patients were immobilized with plaster of Paris (POP for 3 weeks and then mobilized. RESULTS The mean duration of the follow up was 2.2yrs. Results were excellent in 21 patients (84%, good 3(12% and fair in 1 patients (4% according to anatomic and functional criteria by Hohl and Luck
Zhen, Ping; Hu, Yun-Yu; Luo, Zhuo-Jing; Liu, Xing-Yan; Lu, Hao; Li, Xu-Sheng
This study evaluated the usefulness of a single-stage, free-fibular vascularized osteoseptocutaneous flap transfer for Type III open tibial shaft fractures with segmental bone loss for the reconstruction of combined bone and soft tissue defects. Nonrandomized retrospective study. University Level I trauma center. All Gustilo Type III open tibial shaft fractures with segmental bone loss that were treated at one institution between 2000 and 2007 were identified from a trauma registry. The study group consisted of 28 patients with Type III open tibial fractures: 27 were Gustilo-Anderson Type IIIB and one was Grade IIIC. The cause of tibial injury included eight industrial accidents, seven motor vehicle accidents, five crushing injuries caused by heavy objects, five falls from a height, and three motorcycle crashes. The lengths of the preoperative segmental tibial bone loss ranged from 9 to 17 cm and the size of the associated soft tissue defects ranged from 8 × 6 cm to 15 × 7 cm. The free fibular vascularized osteoseptocutaneous flap was used to graft and reconstruct combined bone and soft tissue defects. The radical wound débridement, soft tissue and bone revision, fracture stabilization, and early soft tissue coverage were achieved by this technique in a one-stage procedure. The average duration from injury to one-stage reconstruction was 15.8 hours (range, 5.3 hours to 6.5 days). Radiographic and functional evaluation of the lower extremity. All free fibular osteoseptocutaneous flaps survived completely. The average time to overall union for the entire group was 32 weeks after surgery (range, 26-41 weeks). None of the patients in this series had a nonunion. Acceptable radiographic alignment, defined as 5° of angulation in any plane, was obtained in 22 patients (78.6%). Malunion affected six (21.4%) fractures. According to the lower extremity functional assessment, excellent and good results were achieved for 82.1% (23 of 28), fair results were seen in 14
Angus Chao Kun Chan
Full Text Available Percutaneous fixation method has been applied in Schatzker type III joint depressed-type lateral tibial plateau fracture. We report a 76-year-old man suffering from a small joint depressed-type posterolateral tibial plateau fracture with surgical reduction and fixation with a novel guidance of posterior cruciate ligament (PCL reconstruction femoral template under X-ray and arthroscopic assistance. The concept of sequential tunnel drilling in ligament reconstruction has been applied in bone impaction tunnel creation beneath the articular step with the PCL jig. Avoidance of multiple bone guide pin drilling and accurate guide pin insertion and hence screw fixation was also achieved by use of the PCL template. As illustrated, we believe that the PCL jig is a good armamentarium and adjunct equipment to achieve a more precise minimally invasive operation in special anatomical positions such as the postero-lateral tibial plateau under careful surgical planning.
Li, Jiaming; Wang, Decheng; He, Zhiliang; Shi, Hao
To determine the efficacy of modified titanium tension band plus patellar tendon tunnel steel 8 "reduction band" versus titanium cable tension band fixation for the treatment of patellar lower pole fracture. 58 patients with lower patella fracture were enrolled in this study, including 30 patients treated with modified titanium cable tension band plus patellar tibial tunnel wire "8" tension band internal fixation (modified group), and 28 patients with titanium cable tension band fixation. All patients were followed up for 9∼15 months with an average of 11.6 months. Knee flexion was significantly improved in the modified group than in the titanium cable tension band group (111.33 ± 13 degrees versus 98.21 ± 21.70 degrees, P = 0.004). The fracture healing time showed no significant difference. At the end of the follow-up, the improvement excellent rate was 93.33% in the modified group, and 82.14% in the titanium cable tension band group. Titanium cable tension band internal fixation loosening was found in 2 cases, including 1 case of treatment by two surgeries without loose internal fixation. The modified titanium cable tension band with "8" tension band fixation showed better efficacy for lower patella fractures than titanium cable tension band fixation.
Full Text Available We present a case of tibial tubercle fracture in a young male athlete with both bilateral bipartite patella at the lower pole (Saupe type I and Osgood-Schlatter disease. Open reduction and internal fixation were performed to restore the extensor mechanism of the knee.
Pascarella, Fabio; Ziranu, Antonio; Maccauro, Giulio
We present a case of tibial tubercle fracture in a young male athlete with both bilateral bipartite patella at the lower pole (Saupe type I) and Osgood-Schlatter disease. Open reduction and internal fixation were performed to restore the extensor mechanism of the knee.
Bhandari, Mohit; Tornetta, Paul; Rampersad, Shelly-Ann; Sprague, Sheila; Heels-Ansdell, Diane; Sanders, David W.; Schemitsch, Emil H.; Swiontkowski, Marc; Walter, Stephen; Guyatt, Gordon; Buckingham, Lisa; Leece, Pamela; Viveiros, Helena; Mignott, Tashay; Ansell, Natalie; Sidorkewicz, Natalie; Agel, Julie; Bombardier, Claire; Berlin, Jesse A.; Bosse, Michael; Browner, Bruce; Gillespie, Brenda; O'Brien, Peter; Poolman, Rudolf; Macleod, Mark D.; Carey, Timothy; Leitch, Kellie; Bailey, Stuart; Gurr, Kevin; Konito, Ken; Bartha, Charlene; Low, Isolina; MacBean, Leila V.; Ramu, Mala; Reiber, Susan; Strapp, Ruth; Tieszer, Christina; Kreder, Hans; Stephen, David J. G.; Axelrod, Terry S.; Yee, Albert J. M.; Richards, Robin R.; Finkelstein, Joel; Holtby, Richard M.; Cameron, Hugh; Cameron, John; Gofton, Wade; Murnaghan, John; Schatztker, Joseph; Bulmer, Beverly; Conlan, Lisa; Laflamme, Yves; Berry, Gregory; Beaumont, Pierre; Ranger, Pierre; Laflamme, Georges-Henri; Jodoin, Alain; Renaud, Eric; Gagnon, Sylvain; Maurais, Gilles; Malo, Michel; Fernandes, Julio; Latendresse, Kim; Poirier, Marie-France; Daigneault, Gina; McKee, Michael M.; Waddell, James P.; Bogoch, Earl R.; Daniels, Timothy R.; McBroom, Robert R.; Vicente, Milena R.; Storey, Wendy; Wild, Lisa M.; McCormack, Robert; Perey, Bertrand; Goetz, Thomas J.; Pate, Graham; Penner, Murray J.; Panagiotopoulos, Kostas; Pirani, Shafique; Dommisse, Ian G.; Loomer, Richard L.; Stone, Trevor; Moon, Karyn; Zomar, Mauri; Webb, Lawrence X.; Teasdall, Robert D.; Birkedal, John Peter; Martin, David Franklin; Ruch, David S.; Kilgus, Douglas J.; Pollock, David C.; Harris, Mitchel Brion; Wiesler, Ethan Ron; Ward, William G.; Shilt, Jeffrey Scott; Koman, Andrew L.; Poehling, Gary G.; Kulp, Brenda; Creevy, William R.; Stein, Andrew B.; Bono, Christopher T.; Einhorn, Thomas A.; Brown, T. Desmond; Pacicca, Donna; Sledge, John B.; Foster, Timothy E.; Voloshin, Ilva; Bolton, Jill; Carlisle, Hope; Shaughnessy, Lisa; Ombremsky, William T.; LeCroy, C. Michael; Meinberg, Eric G.; Messer, Terry M.; Craig, William L.; Dirschl, Douglas R.; Caudle, Robert; Harris, Tim; Elhert, Kurt; Hage, William; Jones, Robert; Piedrahita, Luis; Schricker, Paul O.; Driver, Robin; Godwin, Jean; Hansley, Gloria; Obremskey, William Todd; Kregor, Philip James; Tennent, Gregory; Truchan, Lisa M.; Sciadini, Marcus; Shuler, Franklin D.; Driver, Robin E.; Nading, Mary Alice; Neiderstadt, Jacky; Vap, Alexander R.; Vallier, Heather A.; Patterson, Brendan M.; Wilber, John H.; Wilber, Roger G.; Sontich, John K.; Moore, Timothy Alan; Brady, Drew; Cooperman, Daniel R.; Davis, John A.; Cureton, Beth Ann; Mandel, Scott; Orr, R. Douglas; Sadler, John T. S.; Hussain, Tousief; Rajaratnam, Krishan; Petrisor, Bradley; Drew, Brian; Bednar, Drew A.; Kwok, Desmond C. H.; Pettit, Shirley; Hancock, Jill; Cole, Peter A.; Smith, Joel J.; Brown, Gregory A.; Lange, Thomas A.; Stark, John G.; Levy, Bruce; Swiontkowski, Marc F.; Garaghty, Mary J.; Salzman, Joshua G.; Schutte, Carol A.; Tastad, Linda Toddie; Vang, Sandy; Seligson, David; Roberts, Craig S.; Malkani, Arthur L.; Sanders, Laura; Gregory, Sharon Allen; Dyer, Carmen; Heinsen, Jessica; Smith, Langan; Madanagopal, Sudhakar; Coupe, Kevin J.; Tucker, Jeffrey J.; Criswell, Allen R.; Buckle, Rosemary; Rechter, Alan Jeffrey; Sheth, Dhiren Shaskikant; Urquart, Brad; Trotscher, Thea; Anders, Mark J.; Kowalski, Joseph M.; Fineberg, Marc S.; Bone, Lawrence B.; Phillips, Matthew J.; Rohrbacher, Bernard; Stegemann, Philip; Mihalko, William M.; Buyea, Cathy; Augustine, Stephen J.; Jackson, William Thomas; Solis, Gregory; Ero, Sunday U.; Segina, Daniel N.; Berrey, Hudson B.; Agnew, Samuel G.; Fitzpatrick, Michael; Campbell, Lakina C.; Derting, Lynn; McAdams, June; Goslings, J. Carel; Ponsen, Kees Jan; Luitse, Jan; Kloen, Peter; Joosse, Pieter; Winkelhagen, Jasper; Duivenvoorden, Raphaël; Teague, David C.; Davey, Joseph; Sullivan, J. Andy; Ertl, William J. J.; Puckett, Timothy A.; Pasque, Charles B.; Tompkins, John F.; Gruel, Curtis R.; Kammerlocher, Paul; Lehman, Thomas P.; Puffinbarger, William R.; Carl, Kathy L.; Weber, Donald W.; Jomha, Nadr M.; Goplen, Gordon R.; Masson, Edward; Beaupre, Lauren A.; Greaves, Karen E.; Schaump, Lori N.; Jeray, Kyle J.; Goetz, David R.; Westberry, Davd E.; Broderick, J. Scott; Moon, Bryan S.; Tanner, Stephanie L.; Powell, James N.; Buckley, Richard E.; Elves, Leslie; Connolly, Stephen; Abraham, Edward P.; Eastwood, Donna; Steele, Trudy; Ellis, Thomas; Herzberg, Alex; Brown, George A.; Crawford, Dennis E.; Hart, Robert; Hayden, James; Orfaly, Robert M.; Vigland, Theodore; Vivekaraj, Maharani; Bundy, Gina L.; Miclau, Theodore; Matityahu, Amir; Coughlin, R. Richard; Kandemir, Utku; McClellan, R. Trigg; Lin, Cindy Hsin-Hua; Karges, David; Cramer, Kathryn; Watson, J. Tracy; Moed, Berton; Scott, Barbara; Beck, Dennis J.; Orth, Carolyn; Puskas, David; Clark, Russell; Jones, Jennifer; Egol, Kenneth A.; Paksima, Nader; France, Monet; Wai, Eugene K.; Johnson, Garth; Wilkinson, Ross; Gruszczynski, Adam T.; Vexler, Liisa
Inadequate sample size and power in randomized trials can result in misleading findings. This study demonstrates the effect of sample size in a large clinical trial by evaluating the results of the Study to Prospectively evaluate Reamed Intramedullary Nails in Patients with Tibial fractures (SPRINT)
Bandholm, Thomas Quaade; Boysen, Lisbeth; Haugaard, Stine
The objective of this study was to investigate (1) if subjects with medial tibial stress syndrome demonstrate increased navicular drop and medial longitudinal-arch deformation during quiet standing and gait compared with healthy subjects, and (2) the relationship between medial longitudinal......-arch deformation during quiet standing and gait. Thirty subjects aged 20 to 32 years were included (15 with medial tibial stress syndrome and 15 controls). Navicular drop and medial longitudinal-arch deformation were measured during quiet standing with neutral and loaded foot using a ruler and digital photography....... Medial longitudinal-arch deformation was measured during walking gait using 3-dimensional gait analysis. Subjects with medial tibial stress syndrome demonstrated a significantly larger navicular drop (mean +/- 1 SD, 7.7 +/- 3.1 mm) and medial longitudinal-arch deformation (5.9 +/- 3.2 degrees) during...
Yuwen, Peizhi; Lv, Hongzhi; Chen, Wei; Wang, Yefang; Yu, Yiyang; Hao, Jiandong; Liu, Song; Zhang, Tao; Feng, Chen; Guo, Jialiang; Yin, Bing; Zhang, Yingze
The purpose of this study was to verify the age-, gender- and Arbeitsgemeinschaft für Osteosynthesefragen (AO) type-specific clinical characters of adult tibial plateau fractures in 83 hospitals in China and to investigate whether altitude has potential relationships with adult tibial plateau fractures. A retrospective investigation was performed on consecutive patients with tibial plateau fractures treated in 83 hospitals in China between January 2010 and December 2011, data including age, gender and imaging were collected retrospectively through the PACS system and case reports checking system, imaging were classified into six types under fully qualified estimation based on AO classification. To further investigate imparities among different altitudes in China, all data were classified into four groups according to the centre altitudes of each city, G1 = plains group (2000 m). Comparison of gender distribution, age distribution and AO type were done. A total of 6,227 adult tibial plateau fractures were included. Men in the age range of 40-44 years were the most affected patients, and the overall high-risk injury type was 44-B. In four groups, the same peak age showed, namely, 40-44 years in males and 55-59 years in females. Age distribution showed no statistically significant difference in four groups (P > 0.05), while sex distribution and AO type indicated statistically significant differences (P age range are the most affected patients, and different sex distribution as well as injury type of adult tibial plateau fractures differed with various altitudes in China.
van der Vusse, M; Kalmet, P H S; Bastiaenen, C H G; van Horn, Y Y; Brink, P R G; Seelen, H A M
The standard aftercare treatment (according to the AO guideline) for surgically treated trauma patients with fractures of the tibial plateau is non-weight bearing or partial weight bearing for 10-12 weeks. The purpose of this study was to investigate the current state of practice among orthopaedic surgeons and trauma surgeons in choosing the criteria and the time period of restricted weight bearing after surgically treated tibial plateau fractures. A web-based survey was distributed among members of the Dutch Trauma Society and Dutch Orthopaedic Society to identify the most commonly applied protocols in terms of the post-operative initiation and level of weight bearing in patients with tibial plateau fractures. One hundred and eleven surgeons responded to the survey. 72.1% of the respondents recommended starting weight bearing earlier than the 12 weeks recommended by the AO guideline; 11.7% recommended starting weight bearing immediately, 4.5% after 2 weeks and 55.9% after 6 weeks. Moreover, 88.7% of the respondents reported deviating from their own local protocol. There is little consensus about the definition of 100% weight bearing and how to build up weight bearing over time. This study demonstrates that consensus about the weight bearing aftercare for tibial plateau fractures are limited. A large majority of surgeons do not follow the AO guideline or their own local protocol. More transparent criteria and predictors are needed to design optimal weight-bearing regimes for the aftercare of tibial plateau fractures.
Imerci, Ahmet; Incesu, Mustafa; Bozoglan, Muhammet; Canbek, Umut; Ursavas, Hüseyin Tamer
The majority of plantar heel pain is diagnosed as plantar fasciitis or heel spur syndrome. When history or physical findings are unusual or when routine treatment proves ineffective, one should consider an atypical cause of heel pain. Stress fractures of the calcaneus are a frequently unrecognized source of heel pain. In a normal populatıon, the possibility of calcaneal stress fractures must be borne in mind with patients who have bilateral heel pain. When a stress fracture is considered, clinicans have different imaging options. First of all, x-rays must be used to evaluate for any visible osseous pathology. If plain films are inconclusive, the clinician can proceed with a bone scan or Magnetic Resonance Imaging. In the literature, calcaneal stress fractures are mostly reported in soldiers or athletes, but our case is one of a 44-year-old housewife with bilateral heel pain treated as Achilles tendinitis and plantar faciitis for a long time. Her final diagnosis was bilateral calcaneal fracture by Magnetic Resonance Imaging.
Van Der Bracht, Hans; Tampere, Thomas; Beekman, Pieter; Schepens, Alexander; Devriendt, Wouter; Verdonk, Peter; Victor, Jan
To investigate the effect of tibial tunnel orientation on graft-bending angle and stress distribution in the ACL graft. Eight cadaveric knees were scanned in extension, 45°, 90°, and full flexion. 3D reconstructions with anatomically placed anterior cruciate ligament (ACL) grafts were constructed with Mimics 14.12 ® . 3D graft-bending angles were measured for classic medial tibial tunnels (MTT) and lateral tibial tunnels (LTT) with different drill-guide angles (DGA) (45°, 55°, 65°, and 75°). A pivot shift was performed on 1 knee in a finite-element analysis. The peak stresses in the graft were calculated for eight different tibial tunnel orientations. In a classic anatomical ACL repair, the largest graft-bending angle and peak stresses are seen at the femoral tunnel aperture. The use of a different DGA at the tibial side does not change the graft-bending angle at the femoral side or magnitude of peak stresses significantly. When using LTT, the largest graft-bending angles and peak stresses are seen at the tibial tunnel aperture. In a classic anatomical ACL repair, peak stresses in the ACL graft are found at the femoral tunnel aperture. When an LTT is used, peak stresses are similar compared to classic ACL repairs, but the location of the peak stress will shift from the femoral tunnel aperture towards the tibial tunnel aperture. the risk of graft rupture is similar for both MTTs and LTTs, but the location of graft rupture changes from the femoral tunnel aperture towards the tibial tunnel aperture, respectively. I.
Full Text Available Abstract Background Surgeons agree on the benefits of operative treatment of tibial fractures – the most common of long bone fractures – with an intramedullary rod or nail. Rates of re-operation remain high – between 23% and 60% in prior trials – and the two alternative nailing approaches, reamed or non-reamed, each have a compelling biological rationale and strong proponents, resulting in ongoing controversy regarding which is better. Methods/Design The objective of this trial was to assess the impact of reamed versus non-reamed intramedullary nailing on rates of re-operation in patients with open and closed fractures of the tibial shaft. The study to prospectively evaluate reamed intramedullary nails in tibial fractures (S.P.R.I.N.T was a multi-center, randomized trial including 29 clinical sites in Canada, the United States and the Netherlands which enrolled 1200 skeletally mature patients with open (Gustilo Types I-IIIB or closed (Tscherne Types 0–3 fractures of the tibial shaft amenable to surgical treatment with an intramedullary nail. Patients received a statically locked intramedullary nail with either reamed or non-reamed insertion. The first strategy involved fixation of the fracture with an intramedullary nail following reaming to enlarge the intramedullary canal (Reamed Group. The second treatment strategy involved fixation of the fracture with an intramedullary nail without prior reaming of the intramedullary canal (Non-Reamed Group. Patients, outcome assessors, and data analysts were blinded to treatment allocation. Peri-operative care was standardized, and re-operations before 6 months were proscribed. Patients were followed at discharge, 2 weeks post-discharge, and at 6 weeks, 3, 6, 9, and 12 months post surgery. A committee, blinded to allocation, adjudicated all outcomes. Discussion The primary outcome was re-operation to promote healing, treat infection, or preserve the limb (fasciotomy for compartment syndrome after
Bhandari, Mohit; Guyatt, Gordon; Tornetta, Paul; Schemitsch, Emil; Swiontkowski, Marc; Sanders, David; Walter, Stephen D
Surgeons agree on the benefits of operative treatment of tibial fractures - the most common of long bone fractures - with an intramedullary rod or nail. Rates of re-operation remain high - between 23% and 60% in prior trials - and the two alternative nailing approaches, reamed or non-reamed, each have a compelling biological rationale and strong proponents, resulting in ongoing controversy regarding which is better. The objective of this trial was to assess the impact of reamed versus non-reamed intramedullary nailing on rates of re-operation in patients with open and closed fractures of the tibial shaft. The study to prospectively evaluate reamed intramedullary nails in tibial fractures (S.P.R.I.N.T) was a multi-center, randomized trial including 29 clinical sites in Canada, the United States and the Netherlands which enrolled 1200 skeletally mature patients with open (Gustilo Types I-IIIB) or closed (Tscherne Types 0-3) fractures of the tibial shaft amenable to surgical treatment with an intramedullary nail. Patients received a statically locked intramedullary nail with either reamed or non-reamed insertion. The first strategy involved fixation of the fracture with an intramedullary nail following reaming to enlarge the intramedullary canal (Reamed Group). The second treatment strategy involved fixation of the fracture with an intramedullary nail without prior reaming of the intramedullary canal (Non-Reamed Group). Patients, outcome assessors, and data analysts were blinded to treatment allocation. Peri-operative care was standardized, and re-operations before 6 months were proscribed. Patients were followed at discharge, 2 weeks post-discharge, and at 6 weeks, 3, 6, 9, and 12 months post surgery. A committee, blinded to allocation, adjudicated all outcomes. The primary outcome was re-operation to promote healing, treat infection, or preserve the limb (fasciotomy for compartment syndrome after nailing). The primary outcome was a composite comprising the following
Larsen, Peter; Elsoe, Rasmus; Laessoe, Uffe
was measured with the questionnaire Eq5D-5L and compared to norm data from a reference population. Recordings of pain and contralateral muscle strength (isometric maximal voluntary contraction (MVC) for knee flexion and extension were collected at 6 weeks, 3, 6, and 12 months postoperatively. Ipsilateral MVCs......INTRODUCTION:To evaluate the development in patient-reported quality of life (QOL) and muscle strength in the period from surgery to 12 months postoperatively after intramedullary nailing of a tibial shaft fracture. MATERIALS AND METHODS:The design was a prospective, follow-up cohort study. QOL...... compared to the reference population. Six and 12 months after surgery patients demonstrated decreased muscle strength in the injured leg compared to the non-injured leg for knee extension and flexion (P muscle strength during knee...
BACKGROUND: Avulsion fractures of the tibial tubercle are an unusual injury pattern generally occurring in the adolescent male during sporting activities. Bilateral simultaneous fractures are extremely rare. They are often associated with other underlying orthopaedic pathology. AIMS: We present a case of bilateral tibial tubercle avulsions occurring in a 15 year-old male hurler. We describe the management and necessary investigations required for this type of trauma and present a literature review on this rarely encountered injury. CONCLUSION: Although this type of atypical fracture pattern is associated with high energy trauma and other underlying pathology, we have shown that once treated, the patient can expect to make a prompt return to sporting activities with no significant long-term functional deficit.
Rodrigo Pires e Albuquerque
Full Text Available OBJETIVOS: Revisar aspectos epidemiológicos das fraturas do planalto tibial em hospital de nível I. MÉTODOS: Analisamos, retrospectivamente, 239 fraturas do planalto tibial tratadas cirurgicamente. Levamos em consideração idade, sexo, mecanismo de trauma, classificações das lesões, lado acometido e lesões associadas. RESULTADOS: Dos pacientes estudados, 168 são do sexo masculino, a quinta década foi a mais acometida, quanto ao mecanismo de trauma o acidente de trânsito foi o principal fator causal, 128 casos foram do lado esquerdo e 22,6% tiveram lesões associadas. CONCLUSÕES: A maioria dos pacientes foi do sexo masculino, na quinta década de vida, e vítima de acidente de trânsito, sendo as fraturas por depressão e cisalhamento do planalto tibial as lesões mais comuns. Lesões associadas foram pouco frequentes em nossa casuística. Nível de Evidência II, Estudos Prognósticos. Investigação do Efeito de Característica de Um Paciente Sobre o Desfecho da Doença.OBJECTIVES: To review the epidemiological aspects of fractures of the tibial plateau in a level I trauma center. METHODS: We retrospectively analyzed 239 tibial plateau fractures treated surgically. We took into account age, sex, trauma mechanism, classification of the injury, associated injuries and affected side. RESULTS: Of the patients, 168 were male, most in the fifth decade of life; regarding the mechanism of trauma, the primary causal factor was car accident; 128 cases occurred on the left side and 22,6% had associated injuries. CONCLUSIONS: The majority of patients were male, in the fifth decade of life, and victim of traffic accidents; the depressed and shear fractures of the tibial plateau were the most frequent. Associated lesions were infrequent in our study. Evidence Level II, Prognostic Studies. Investigation of the Effect of a Patient Characteristics on the Outcome of the Disease.
Schwartz, Frederik; Heerfordt, Ida Marie
We report a case of an 81-year-old osteoporotic woman, who suffered stress fractures of the distal fibula on both sides within a two-year period. The risk factors for stress fractures are reviewed and the importance of a high index of suspicion for stress fractures is emphasized. When a stress fracture is suspected it should lead to plain radiography and treatment with protected weight-bearing with crutches or a brace.
Xiaofeng, Li; Daxia, Xu; Yunzhen, Chen
Fracture nonunion is a great challenge for orthopedic surgeons. Many surgical interventions are associated with significant pain and heavy economic burden. Therefore, our aim was to evaluate the outcomes of a new nonoperative treatment for fracture nonunion. A 44-year-old man suffered closed fractures of the right tibia and left femur. Eleven months after surgery, there was no radiographic healing between fracture fragments. Fracture nonunion of the right tibia and left femur. The patient received systemic treatment with teriparatide (recombinant human Parathyroid Hormone 1-34) 20 μg/d for 8 months, with further observation at 4 months after discontinuation. During treatment, bone metabolic markers were measured to evaluate metabolic activity of osteoblasts and osteoclasts. The Ethics Committee of Qilu Hospital of Shandong University approved this study. Satisfactory healing of fracture nonunion was obtained without further intervention. Anabolic treatment with teriparatide showed a positive effect on healing of fracture nonunion. Evaluation of bone metabolic markers during treatment is necessary to observe the curative effect. In view of the positive effect of teriparatide on healing of fracture nonunion in numerous animal models and clinical studies, it may be a promising alternative treatment for fracture nonunion in patients who are not suitable for surgical intervention.
Rathleff, Michael Skovdal; Samani, Afshin; Olesen, Christian Gammelgaard
Medial tibial stress syndrome is a common overuse injury characterized by pain located on the medial side of the lower leg during weight bearing activities such as gait. The purpose of this study was to apply linear and nonlinear methods to compare the structure of variability of midfoot kinemati...
OPTIMAL SURGICAL MANAGEMENT OF HIGH VELOCITY POSTERIOR TIBIAL PLATEAU FRACTURE SUBLUXATIONS (DUPARC, REVISED CLASSIFICATION, GROUP – V: POSTERO - MEDIAL FRACTURE BY DIRECT, DORSAL APPROACH – A CHANGING TREND: A PROSPECTIVE STUDY
Full Text Available INTRODUCTION : High - energy tibial plateau fractures are infrequent and technically demanding to treat especially if those are shearing type, coronal plane, displaced fractures. The most widely used the Schatzker system of classification ,  ( B ased on the AP radiograph is more than likely to miss postero - medial and postero - lateral shear fractures, best visible on the lateral, than the AP radiograph. These fractures have recently been characterised by two studies, highlighti ng their clinical relevance [ 2,3] and showing that less invasive surgery and indirect reduction techniques are often inadequate. Hohl described unicondylar c oronal plane splitting fractures of the medial tibial plateau, noted that these injuries be considered as fracture - dislocations. Connolly and others have suggested that the mechanism involved in this fracture pattern is one of knee flexion, varus, and inter nal rotation of the medial femoral condyle . [4,5,6 ] Consistent among these and other authors is that the occurrence of this fragment is relatively unusual and that the use of a posteriorly based exposure with direct fracture visualization, anatomic reductio n and absolute stability appears to result in satisfactory outcomes. Though variations of a postero - medial approach been previously described ( by Trickey et al and also by Burks et al.,, more recently, Lobenhoffer et al described direct posterior exposure , Wang et al described postero - medial approach and Luo et al. described the approach for the management of posterior bicondylar tibial plateau fractures . [7,8] These approaches have been used in isolation or as a dual - incision approach for treating tibial plateau fractures . [9,10,11,12,13,14, 15] PURPOSE : The purpose of this study is to describe this unfamiliar direct posterior surgical (Medial Gastrocnemius approach to a general orthopod, highlighting the relevant anatomy and presenting our experience using this approach in treating a
Batta, Vineet; Dwyer, Amitabh J; Gulati, Aashish; Prakash, Jeevan; Mam, Maharaj K; John, Bobby
Cast bracing (CB) has been a well established method of treating tibial shaft fractures. Majority of the recent literature on treatment of tibial shaft fractures have upheld intramedullary nailing (IMN) as the treatment of choice. Most of these studies are from the west, in public funded health set ups and in hospitals with very low rates of infection. This has lead to bewilderment in the minds of surgeons wishing to opt for conservative treatment in countries with scarcity of health resources. We therefore undertook this study to compare the two modalities in the scenario of the developing world. Sixty-eight consecutive patients were treated alternately with CB and IMN for high energy, displaced, closed and Gustilo Grade 1 open fractures of the tibial shaft, between 1995 and 2001. An average follow up at 4.3 years revealed no statistical difference in the final functional outcome as per Johner and Wruhs' criteria with modification to Indian lifestyle. IMN group had a) slightly shorter time to fracture union (mean 21.3 weeks versus 23.1 weeks for CB, p > 0.05), (b) lesser time off work (mean 17.6 weeks versus 25.6 weeks for CB, p treatment of CB group was less than half incurred by the IMN group (average USD 831 versus USD 2071 for nailed group, p tibial shaft fracture either with IMN or CB provided equally gratifying results with no statistical difference in final functional outcome. The economic cost to the patient in Indian conditions is significantly less with CB and therefore stands as an equally reliable treatment option, especially in countries with fewer resources.
Masse, Y; Aubriot, J H; Lamotte, N
The authors have studied a series of 521 fractures of the tibia treated by blind intramedullary nailing without reaming. Union by the 120th day was obtained in 93.3% of cases. Malunion was uncommon and was related to an inadequate initial reduction. A secondary procedure was only necessary in two cases of malunion. In closed fractures, no case suffered infection. In compound fractures, 4.3% became infected (5 osteitis, 4 septic non-union) but all cases were cured by secondary procedures. Aseptic non-union occurred in 2.3% of cases. The authors recommend the use of nails of at least 8 mm diameter driven down to the region of the lower articular surface. In patients with a narrow medullary canal, or in fractures of the lower third of the tibia, the authors consider that reaming would have given better results. In other types of fracture reaming is more hazardous than useful.
Kugelman, David N; Qatu, Abdullah M; Haglin, Jack M; Konda, Sanjit R; Egol, Kenneth A
Tibial plateau fractures can be devastating traumatic injuries to the knee, particularly in active athletes. The purpose of this study was to report on the return to participation in recreational athletics after operatively managed tibial plateau fractures. In addition, this study assessed factors associated with the ability to return to participation in recreational athletics after tibial plateau fractures treated with open reduction internal fixation and compared final outcomes between patients who were able to return to recreational athletics and those who could not. The hypothesis was that returning to participation in recreational athletics would be dependent on the time from surgery after operative fixation of tibial plateau fractures. Less severe injuries would be associated with a quicker return to athletics. Case-control study; Level of evidence, 3. All tibial plateau fractures treated by 1 of 3 surgeons at a single academic institution over an 11-year period were prospectively followed. Final outcomes were evaluated using the Short Musculoskeletal Function Assessment at latest follow-up. All complications were recorded at each follow-up. Differences between the groups were compared using Student t tests for continuous variables. Chi-square analysis was used to determine whether differences between categorical variables existed. Logistic regression was performed to assess independent variables associated with returning to participation in recreational athletics. A total of 169 patients who underwent operative management of their tibial plateau fracture reported participation in recreational athletics before their injury. By the 6-month time point, 48 patients (31.6%) had returned to participation in recreational athletics, and at final follow-up (mean, 15 months), 89 patients (52.4%) had returned to participation in recreational athletics. Predictors of returning to recreational athletics included white race, female sex, social alcohol consumption, younger
Full Text Available Displaced tibial intercondylar eminence fractures require early reduction and stable fixation to prevent nonunion, knee instability, and a lack of extension. Many types of surgical procedure are recommended including arthrotomy or an arthroscopic technique to stabilize the fracture segment using Kirschner wire, screws, staples, and suture fixation. However, contemporary arthroscopic techniques and devices can facilitate intra-articular surgery and have been applied to the treatment of this fracture. In our current report, we describe a simple suture fixation method under arthroscopy for the treatment of tibial intercondylar eminence fractures. We treated eight knees of eight patients. One patient had a Type II fracture and seven patients had a Type III fracture according to Meyer's classification. Following the arthroscopic inspection of concomitant injuries, debridement of hematoma, and reduction of the fragment, two nonabsorbable sutures (Ethibond No. 2, Johnson & Johnson, Somerville, NJ, USA were advanced through the suture passer device, which is used to penetrate the anterior cruciate ligament (ACL near to the insertion site of the displaced fragment. Two surgical sutures were pulled out by the suture retriever from the anterior proximal tibia hole and were fixed to the tibia cortex bone with a double-spike plate. At follow-up, radiographic examinations showed that bone union was achieved in all cases. All but one patient could resume normal activities with no restrictions and no ligamentous instability. All knees had a negative Lachman's test and showed a gain of stable ligament function by KT2000 arthrometer evaluation. One patient had an insignificant extension limitation and experienced slight pain after walking but these symptoms were minimal. In conclusion current arthroscopic surgery techniques for tibial intercondylar fractures can be easily performed and reproducibly achieve secure fixation and early mobilization of the knee.
Ong, J C Y
The goal of this study was to determine differences in fracture stability and functional outcome between synthetic bone graft and natural bone graft with internal fixation of tibia plateau metaphyseal defects.
Hughes, Travis M; Rowan, Flynn A; Truchan, Lisa M
The tibia is the most commonly fractured long bone. Tibia fractures are simple, and most are amenable to immediate closed reduction. Reported cases of irreducibility resulting from entrapment of soft-tissue structures are rare. We report the case of a 23-year-old man who, in a high-speed motor vehicle crash, sustained a closed lower leg fracture that was later found to have a unique pattern in which the fibula was entrapped in the medullary cavity of the tibia. Limited open reduction was performed, and the entrapped distal fibula was removed with use of a bone hook. The tibia was reduced, and a nail placed in standard fashion. The postoperative course leading to full recovery was unremarkable. This irreducible fracture pattern, not previously reported, should be considered during difficult closed reductions in order to prevent unnecessary neurovascular or bony injury.
Piórek, A; Adamiak, Z; Jaskólska, M; Zhalniarovich, Y
The treatment of comminuted tibial shaft fractures in canine patients is burdened by significant risk which involves bone healing complications, such as delayed bone union. Complications may result from iatrogenic damage to blood vessels during fracture stabilization. To minimize this risk, treatment methods increasingly often rely on the concept of biological osteosynthesis. One of such methods involves the treatment of fractures with the use of new hybrid fixator consisted of an interlocking nail connected with type I external fixator. Connection of the nail with external fixator has been recently developed to maximize treatment efficiency. This manner of stabilization increases bone-fixator construct strength on forces acting in the place of fracture. It also enables fracture fixation with minimal damage of the blood supply of bone fragments. This article describes surgical procedure of stabilization of comminuted tibial bone fractures in four dogs by the use of interlocking nail connected with external fixator type I, discusses and evaluates the results of clinical treatment with the involvement of the said fixator. To control bone consolidation process the radiograms were taken in 6 and 8 week of healing. In all cases, the reviewed methods of clinical treatment were successful in producing bone union after eight week of healing. During the whole period of observations no complication was observed. In all cases the intramedullary nail were left in the medullary canal after the healing process was finished. The fixator supported quick restoration of limb function after treatment.
Johnson, M D; Lewis, D D; Winter, M D
A 4-month-old female intact American Pit Bull Terrier was presented for right pelvic limb lameness 1 day after the dog had been hit by an all-terrain vehicle. Orthogonal radiographs of the right stifle revealed a Salter-Harris type IV fracture through the proximal tibial physis extending caudodistally through the proximal tibial metaphysis. The distal tibia was markedly displaced cranially, laterally and proximally, resulting in complete overriding of the fracture segments. An open approach was made in order to facilitate direct reduction, but the fracture could not be sufficiently distracted and the epiphyseal segment remained fixed caudal to the remainder of the tibia. Concerns regarding possible iatrogenic trauma to the epiphysis prompted the use of a transarticular circular fixator construct to distract the fracture segments to facilitate reduction. Distraction that facilitated reduction was performed using three TrueLok Rapid Quick Adjust Struts that were positioned between the two ring components. The struts also allowed for multiplanar adjustment of alignment, which allowed the fracture to be maintained in anatomic reduction as divergent interfragmentary Kirschner wires were placed. Radiographic union was confirmed 19 days after surgery. Transient intraoperative application of a circular construct incorporating the TrueLok components facilitated accurate fracture reduction without inflicting further iatrogenic trauma to the epiphysis, after traditional direct reduction techniques proved ineffective, and afforded a successful clinical outcome in the dog reported here. © 2017 Australian Veterinary Association.
Arnold, John B; Tu, Chen Gang; Phan, Tri M; Rickman, Mark; Varghese, Viju Daniel; Thewlis, Dominic; Solomon, Lucian B
To identify and describe the characteristics of existing practices for postoperative weight bearing and management of tibial plateau fractures (TPFs), identify gaps in the literature, and inform the design of future research. Seven electronic databases and clinical trial registers were searched from inception until November 17th 2016. Studies were included if they reported on the surgical management of TPFs, had a mean follow-up time of ≥1year and provided data on postoperative management protocols. Data were extracted and synthesized according to study demographics, patient characteristics and postoperative management (weight bearing regimes, immobilisation devices, exercises and complications). 124 studies were included involving 5156 patients with TPFs. The mean age across studies was 45.1 years (range 20.8-72; 60% male), with a mean follow-up of 34.9 months (range 12-264). The most frequent fracture types were AO/OTA classification 41-B3 (29.5%) and C3 (25%). The most commonly reported non-weight bearing time after surgery was 4-6 weeks (39% of studies), with a further 4-6 weeks of partial weight bearing (51% of studies), resulting in 9-12 weeks before full weight bearing status was recommended (55% of studies). Loading recommendations for initial weight bearing were most commonly toe-touch/bearing was positively correlated with the proportion of fractures of AO/OTA type C (r=0.465, p=0.029) and Schatzker type IV-VI (r=0.614, pbearing time before full weight bearing is recommended at 9-12 weeks. Partial weight bearing protocols and brace use were varied. Type of rehabilitation may be an important factor influencing recovery, with future high quality prospective studies required to determine the impact of different protocols on clinical and radiological outcomes. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.
Full Text Available Abstract Background Non-union continues to be one of the orthopedist’s greatest challenges. Despite effective culture methods, the detection of low-grade infection in patients with non-union following tibial fracture still presents a challenge. We investigated whether “aseptic” tibial non-union can be the result of an unrecognized infection. Methods A total of 23 patients with non-union following tibial shaft fractures without clinical signs of infection were investigated. Intraoperative biopsy samples obtained from the non-union site were examined by means of routine culture methods and by polymerase chain reaction (PCR for the detection of 16 S ribosomal RNA (rRNA. Control subjects included 12 patients with tibial shaft fractures. Results 23 patients (8 women and 15 men; mean age: 47.4 years were included into this study. Preoperative C-reactive protein levels (mean: 20.8 mg/l and WBC counts (mean: 8,359/μl in the study group were not significantly higher than in the control group. None of the samples of non-union routine cultures yielded microorganism growth. Bacterial isolates were found by conventional culturing methods in only 1 case of an open fracture from the control group. In this case, PCR yielded negative results. 16 S rRNA was detected in tissue specimens from 2 patients (8.7% with non-union. The analysis of these variable species-specific sequences enabled the identification of specific microorganisms (1x Methylobacterium species, 1x Staphylococcus species. Both PCR-positive patients were culture-negative. Conclusions The combination of microbiological culture and broad-range PCR seems to substantially add to the number of microbiological diagnoses obtained and may improve the clinican’s ability to tailor therapy to the individual patient’s needs.
Present article comprehensively explores the influence of specimen thickness on the quantitative estimates of different ductile fractographic features in two dimensions, correlating tensile properties of a reactor pressure vessel steel tested under ambient temperature where the initial crystallographic texture, inclusion content, and their distribution are kept unaltered. It has been investigated that the changes in tensile fracture morphology of these steels are directly attributable to the resulting stress-state history under tension for given specimen dimensions.
Page, Piers R J; Trickett, Ryan W; Rahman, Shakeel M; Walters, Angharad; Pinder, Leila M; Brooks, Caroline J; Hutchings, Hayley; Pallister, Ian
Severe open fractures of the lower limbs are complex injuries requiring expert multidisciplinary management in appropriate orthoplastic centres. This study aimed to assess the impact of open fractures on healthcare utilisation and test the null hypotheses that there is no difference in healthcare utilisation between the year before and year after injury, and that there is no difference in healthcare utilisation in the year post-injury between patients admitted directly to an orthoplastic centre in keeping with the joint BOA/BAPRAS standards and those having initial surgery elsewhere. This retrospective cohort study utilising secure anonymised information linkage (SAIL), a novel databank of anonymised nationally pooled health records, recruited patients over 18 years of age sustaining severe open lower limb fractures managed primarily or secondarily at our centre and who had data available in the SAIL databank. 101 patients met inclusion criteria and 90 of these had records in the SAIL databank. The number of days in hospital, number of primary care attendances, number of outpatient attendances and number of emergency department attendances in the years prior and subsequent to injury were recorded. Patients sustaining open fractures had significantly different healthcare utilisation in the year after injury when compared with the year before, in terms of days spent in hospital (23.42 vs. 1.70, p=0.000), outpatient attendances (11.98 vs. 1.05, p=0.000), primary care attendances (29.48 vs. 11.99, p=0.000) and emergency department presentations (0.2 vs. 0.01, p=0.025). Patients admitted directly to orthoplastic centres had significantly fewer operations (1.78 vs. 3.31) and GP attendances (23.6 vs. 33.52) than those transferred in subsequent to initial management in other units. There is a significant increase in healthcare utilisation after open tibial fracture. Adherence to national standards minimises the impact of this on both patients and health services. Copyright
Background Surgeons agree on the benefits of operative treatment of tibial fractures – the most common of long bone fractures – with an intramedullary rod or nail. Rates of re-operation remain high – between 23% and 60% in prior trials – and the two alternative nailing approaches, reamed or non-reamed, each have a compelling biological rationale and strong proponents, resulting in ongoing controversy regarding which is better. Methods/Design The objective of this trial was to assess the impac...
Balaji, S Muthukumar; Chandra, P Madhu; Devadoss, Sathish; Devadoss, A
Isolated tibial shaft (ITS) fracture with intact fibula is a common injury but records often fail to mention it. Our primary aim was to study the effect of the intact fibula in ITS fractures in closed and open injuries and that these fractures can unite without a primary fibulectomy. 56 patients who sustained an ITS fracture with an intact fibula who underwent closed or open reduction and reamed intramedullary interlocking nailing (IM IL nail) for closed and open fractures between August 2008 and April 2014 were included in this study. Four patients were lost to followup. One patient died due to causes not related to the surgery. At the time of final followup, 51 patients with 51 ITS fractures were available for the analysis. There were 33 closed and 18 open fractures. Patients were followed up at 4 weekly intervals until radiological signs of union were noted. They were assessed for functional outcome using the IOWA knee and ankle score systems at the time of final followup. The average time to union was 19.7 weeks. Closed fractures united in 17.7 weeks as compared to 23.5 weeks for open fractures (P fractures failed to unite (2 open). The functional outcome as per the knee score and ankle score evaluation system was 93.13 and 92.54, respectively. The knee scores were 93.81 and 91.8 for closed and open ITS fractures, respectively (P > 0.05). Similarly, the ankle scores were 94.96 and 88.1 for closed and open ITS fractures, respectively (P fracture with intact fibula is a common occurrence, and they can be treated safely with reamed IM nailing that provides good union rates and the excellent functional result even in open fractures.
Nachtrab, O.; Cassar-Pullicino, V.N.; Lalam, R.; Tins, B.; Tyrrell, P.N.M.; Singh, J.
MR imaging plays a vital role in the diagnosis and management of hip fractures in all age groups, in a large spectrum of patient groups spanning the elderly and sporting population. It allows a confident exclusion of fracture, differentiation of bony from soft tissue injury and an early confident detection of fractures. There is a spectrum of MR findings which in part is dictated by the type and cause of the fracture which the radiologist needs to be familiar with. Judicious but prompt utilisation of MR in patients with suspected hip fractures has a positive therapeutic impact with healthcare cost benefits as well as social care benefits.
... in damage activity a priori to fracture. The hypothesis of our study is that the onset of stress fractures can be predicted by monitoring the evolution of microdamage activity using acoustic emissions...
Akkus, Ozan; Wasserman, Nicholas
... in damage activity a priori to fracture. The hypothesis of our study is that the onset of stress fractures can be predicted by monitoring the evolution of microdamage activity using acoustic emissions...
Moon, B.S.; Price, C.T.; Campbell, J.B.
Stress fractures in children are rare compared with the incidence in [ults. This report describes an 11-year-old girl with stress fractures of the acromion, clavicle, and first rib on the left and contralateral fractures of the first and second ribs. It was eventually discovered that these fractures were caused by a nervous tic consisting of repetitive, vigorous shrugging and translation of the shoulders. (orig.)
O'Neill, Barry J
Antiphospholipid syndrome and systemic erythematosus have been associated with metatarsal stress fractures. Stress fractures of the Lisfranc joint complex are uncommon injuries but have been reported to occur most frequently in ballet dancers. We present a case of an avulsion fracture of the Lisfranc joint complex that occurred spontaneously. We have reviewed the association between systemic conditions and metatarsal fractures and proposed a series of hypothetical pathological events that may have contributed to this unusual injury.
Behrens, Steve B.; Deren, Matthew E.; Matson, Andrew; Fadale, Paul D.; Monchik, Keith O.
Context: Stress fractures are common injuries in athletes, often difficult to diagnose. A stress fracture is a fatigue-induced fracture of bone caused by repeated applications of stress over time. Evidence Acquisition: PubMed articles published from 1974 to January 2012. Results: Intrinsic and extrinsic factors may predict the risk of stress fractures in athletes, including bone health, training, nutrition, and biomechanical factors. Based on their location, stress fractures may be categorized as low- or high-risk, depending on the likelihood of the injury developing into a complete fracture. Treatment for these injuries varies substantially and must account for the risk level of the fractured bone, the stage of fracture development, and the needs of the patient. High-risk fractures include the anterior tibia, lateral femoral neck, patella, medial malleolus, and femoral head. Low-risk fractures include the posteromedial tibia, fibula, medial femoral shaft, and pelvis. Magnetic resonance is the imaging test of choice for diagnosis. Conclusions: These injuries can lead to substantial lost time from participation. Treatment will vary by fracture location, but most stress fractures will heal with rest and modified weightbearing. Some may require more aggressive intervention, such as prolonged nonweightbearing movement or surgery. Contributing factors should also be addressed prior to return to sports. PMID:24427386
Davy, P.; Darcel, C.; Mas Ivars, D.; Le Goc, R.
We analyze the spatial fluctuations of stress in a simple tridimensional model constituted by a population of disc-shaped fractures embedded in an elastic matrix with uniform and isotropic properties. The fluctuations arise from the classical stress enhancement at fracture tips and stress shadowing around fracture centers that are amplified or decreased by the interactions between close-by fractures. The distribution of local stresses is calculated at the elementary mesh scale with the 3DEC numerical program based on the distinct element method. As expected, the stress distributions vary with fracture density, the larger is the density, the wider is the distribution. For freely slipping fractures, it is mainly controlled by the percolation parameter p (i.e., the total volume of spheres surrounding fractures). For stresses smaller than the remote deviatoric stress, the distribution depends only on for the range of density that has been studied. For large stresses, the distribution decreases exponentially when increasing stress, with a characteristic stress that increases with entailing a widening of the stress distribution. We extend the analysis to fractures with plane resistance defined by an elastic shear stiffness ks and a slip Coulomb threshold. A consequence of the fracture plane resistance is to lower the stress perturbation in the surrounding matrix by a factor that depends on the ratio between ks and a fracture-matrix stiffness km mainly dependent on the ratio between Young modulus and fracture size. km is also the ratio between the remote shear stress and the displacement across the fracture plane in the case of freely slipping fractures. A complete analytical derivation of the expressions of the stress perturbations and of the fracture displacements is obtained and checked with numerical simulations. In the limit ks >> km, the stress perturbation tends to 0 and the stress state is spatially uniform. The analysis allows us to quantify the intensity of the
A. K. Dulaev
Full Text Available The authors evaluated of the effectiveness of new oral anticoagulants in patients with diaphyseal fractures of the femur and tibia.We analyzed the effectiveness of thromboprophylaxis in 85 patients with diaphyseal fractures of the femur and tibia in the early postoperative period. Patients were divided into 3 groups: group 1 - patients, who was taking enoxaparin, group 2 - dabigatran etexilate, group 3 - rivaroxaban. We evaluated the frequency of thromboembolic complications and bleeding for 4 weeks after intramedullary nailing of femur and tibia.The lowest frequency of postoperative bleeding was observed in patients treated with dabigatran etexilate. In addition, the minimum frequency of complications was observed among patients of the second group of the study (9.7% in the group receiving dabigatran etexilati compared with 27.8% for the combined group I and III.Statistically significant differences between groups of patients taking oral or parenteral anticoagulants was not obtained.
The posterior rings of the lower lumbo-sacral vertebrae are subject to stress fractures at any part - pedicle, pars, or lamina. The site of fracture is apparently determined by the axis of weight bearing. The three illustrative clinical examples cited include a jogger with a laminar fracture, a ballet dancer with pedicle fractures, and a nine-year-old boy with fractures of pars and lamina. Chronic low back pain is the typical complaint with stress fractures of the lower lumbo-sacral spine. Special imaging techniques are usually needed to demonstrate these lesions, including vertebral arch views, multi-directional tomography, and computed tomography (CT). (orig.)
Kang, P. K.; Brown, S.; Alves da Silva, J.; Juanes, R.
Fluid flow and tracer transport in fractured rock controls many natural and engineered processes in the geosciences, and therefore has been extensively studied. Geologic fractures, however, are always under significant overburden stress. While confining stress has been shown to impact fluid flow through rough-walled fractures in a fundamental way, studies of anomalous tracer transport at the scale of individual fractures have so far ignored the potential role of confining stress.Here, we report the emergence of anomalous (non-Fickian) transport through a rough-walled fracture as a result of increasing the normal stress on the fracture. We generate fracture surfaces with fractal roughness, and solve the elastic contact problem between the two surfaces to obtain the 3D fracture geometry for increasing levels of normal stress. We then simulate fluid flow and particle transport through the stressed rough fracture. We observe a transition from Fickian to anomalous transport as the normal stress on the fracture increases.We show that the origin of this anomalous transport behavior can be traced to the self-organization of the flow field into a heterogeneous structure dominated by preferential channels and stagnation zones, as a result of the larger number of contacts in a highly stressed fracture. We also propose a spatial Markov model that reproduces the transport behavior at the scale of the entire fracture with only three physical parameters. Our results point to a heretofore unrecognized link between geomechanics and anomalous particle transport in fractured media. Finally, we show preliminary laboratory experiment results that confirm our findings. (a) Magnitude of the volumetric flux at each discretization grid block at low stress. (b) Magnitude of the volumetric flux for a highly stressed fracture. Values are normalized with the mean volumetric flux.
Fourie, J A; Bowerbank, P
The aim of this research was to establish whether interferential currents (IFC) could significantly reduce the healing time for fractures of the tibia and thereby prevent nonunion. Males between the ages of 12 and 86, who had sustained fractures of the tibiae, were entered into this double blind clinical trial. According to strict inclusion and exclusion criteria, a final sample of 227 cases (208 subjects) were entered by block randomization into two groups; an experimental group (n = 41) and placebo group (n = 35). A further group was entered retrospectively--control group (n = 151). IFCs were applied to the experimental group via suction electrodes for 30 minutes per day for 10 days, using a beat frequency of 10-25 Hz and a swing mode of 6 integral of 6. The placebo group had only suction electrodes applied, the intermittent mode produced a rhythmical massage effect; subjects in this group commented on pain relief which resulted in the addition of the control group as a check on the possible effect of intermittent suction. The control group received no intervention. The data were analysed using analysis of covariance which resulted in a finding of no significant difference in the time taken to union for the three groups. This means that to date there is no reason to believe that IFCs (using the parameters of this trial) can reduce the healing time for new fractures of the tibia or prevent nonunion. However, further investigation is recommended.
Lee, Bong-Jin; Song, Jyewon
Stress fractures may occur at various sites in the femur including the head, neck, shaft, supracondylar and condylar regions. To the best of our knowledge, stress fracture occurring in the trochanteric region has not been previously reported. We report here a case of trochanteric stress fracture in a 53-year-old female window cleaner treated with hip nailing without adverse consequences. Careful consideration of this entity is needed when evaluating patients who have repetitive jumping up and...
Fines, Bonnie P.; Stacy, Scott G. [Department of Radiology, University of Chicago Hospitals, IL (United States)
Upper extremity stress fractures are rare, with the majority of those reported occurring in the ulna. The location of the fracture is influenced by the type of activity and mechanism of injury with which it is associated. We report the first case of a mid-ulnar stress fracture in a baton twirler due to chronic torsional stress. This patient was referred to our Orthopedic Oncology clinic with a preliminary diagnosis of osteoid osteoma. (orig.)
Hu, Xin-Jia; Wang, Hua
The aim of the present study was to investigate the biomechanical effects of varying the length of a limited contact-dynamic compression plate (LC-DCP) and the number and position of screws on middle tibial fractures, and to provide biomechanical evidence regarding minimally invasive plate osteosynthesis (MIPO). For biomechanical testing, 60 tibias from cadavers (age at mortality, 20–40 years) were used to create middle and diagonal fracture models without defects. Tibias were randomly grouped and analyzed by biomechanic and three-dimensional (3D) finite element analysis. The differences among LC-DCPs of different lengths (6-, 10- and 14-hole) with 6 screws, 14-hole LC-DCPs with different numbers of screws (6, 10 and 14), and 14-hole LC-DCPs with 6 screws at different positions with regard to mechanical characteristics, including compressing, torsion and bending, were examined. The 6-hole LC-DCP had greater vertical compression strain compared with the 10- and 14-hole LC-DCPs (P0.05). However, plates with 14 screws had greater vertical strain compared with those fixed with 6 or 10 screws (P<0.01). For 4-hole LC-DCPs with screws at different positions, vertical compression strain values were lowest for plates with screws at positions 1, 4, 7, 8, 11 and 14 (P<0.01). The lateral strain values and vertical strain values for plates with screws at positions 1, 3, 6, 9, 12 and 14 were significantly lower compared with those at the other positions (P<0.01), and torque values were also low. Thus, the 14-hole LC-DCP was the most stable against vertical compression, torsion and bending, and the 6-hole LC-DCP was the least stable. However, the use of 14 screws with a 14-hole LC-DCP provided less stability against bending than did 6 or 10 screws. Furthermore, fixation with distributed screws, in which some screws were close to the fracture line, provided good stability against compression and torsion, while fixation with screws at the ends of the LC-DCP provided poor
Kent, Michael; Mumith, Aadil; McEwan, Jo; Hancock, Nicholas
The surgical treatment of distal tibial fractures is challenging and controversial. Recently, locking plate fixation has become popular, but the outcomes of this treatment are mixed with complication rates as high as 50 % in the published literature. There are no reports specifically relating to the financial and resource costs of failed treatment in the literature. Retrospective service analysis of patients who had undergone locking plate fixation of a distal third tibial fracture between 2008 and 2011 with at least 12 months follow-up. Rates of readmission, reoperation, bony union and infection were ascertained. The financial and resource (hospital stay and number of outpatient appointments) implications of failed treatment were calculated. Forty-two patients were identified. There were 31 type A fractures, one type B fracture and 10 type C fractures. Three injuries were open. Twenty patients were treated with minimally invasive percutaneous osteosynthesis (MIPO). The readmission and reoperation rates were 26 % (n = 11) and 19 % (n = 8), respectively. A total of 89 % of readmissions were due to infection. All patients had received appropriate antibiotic regimens. The average costs of successful and failed treatment were £ 5538 and £ 18,335, respectively. The average time to union was 24.5 weeks. The rate of non-union was 21 % (n = 9). The rate of infection was 28 % (n = 12), with all patients with open fracture incurring an infection. Tourniquet time had no effect on the incidence of complications. Smokers were more likely to incur a complication (p service following failure of locking plate treatment of these fractures, but the outcomes were similar to series published in the literature. Readmission rates were high following these injuries, and failed treatment was costly and had a significant impact on hospital resources. The implementation of major trauma networks and centralised subspecialised units should improve quality and value for money.
Garnock, Cameron; Witchalls, Jeremy; Newman, Phil
Quantifying individual risk for medial tibial stress syndrome (MTSS) is valuable due to the high prevalence, substantial financial and service costs, and lengthy recovery time of the condition. Identification of those at risk is a key first step in prevention of the condition. This study aimed to test a suite of best evidence risk factors in a cohort of Navy recruits and to develop a predictive model for individuals at risk of MTSS. Prospective cohort study of Navy recruits undergoing initial training METHODS: A prospective cohort design, this study screened recruits by assessing gender, MTSS history, years of running experience, orthotic use, BMI, navicular drop, ankle plantarflexion and hip external rotation at the beginning of basic training. Follow-up was conducted at completion of training (11 weeks). Volunteers included 123 recruits (28 females and 95 males). Thirty developed MTSS (19 males and 11 females). Stepwise logistic regression of one half of the data produced a significant model (phistory (OR 18.3, 95% CI 3.6, 91.5, pcalculator for predicting an individual recruit's risk of MTSS. Copyright © 2017 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
Griebert, Maggie C; Needle, Alan R; McConnell, Jennifer; Kaminski, Thomas W
Medial tibial stress syndrome (MTSS) is an overuse injury occurring among the physically active. Linked to increased strain on the medial tendons of the ankle, studies emphasize controlling medial foot loading in the management of this condition. Kinesio taping (KT) has gained popularity for treating musculoskeletal pathologies; however, its effect on MTSS remains uninvestigated. This study aimed to determine if healthy participants and patients with current or previous history of MTSS differ in the rate of loading, and if KT affects plantar pressures in these participants. Twenty healthy participants and 20 participants with current or previous history of MTSS were recruited and walked across a plantar pressure mat prior to KT application, immediately after application, and after 24-h of continued use. Time-to-peak force was measured in 6 foot areas and compared across groups and conditions. ANOVA revealed a significant interaction between group, condition, and foot area (F = 1.990, p = 0.033). MTSS participants presented with lower medial midfoot time-to-peak force before tape application (95%CI: 0.014-0.160%, p = 0.021) that significantly increased following tape application (p < 0.05). These results suggest that KT decreases the rate of medial loading in MTSS patients. Future research might assess mechanisms by which this effect is achieved. Copyright © 2014 Elsevier Ltd. All rights reserved.
Winters, M; Bakker, E W P; Moen, M H; Barten, C C; Teeuwen, R; Weir, A
The majority of sporting injuries are clinically diagnosed using history and physical examination as the cornerstone. There are no studies supporting the reliability of making a clinical diagnosis of medial tibial stress syndrome (MTSS). Our aim was to assess if MTSS can be diagnosed reliably, using history and physical examination. We also investigated if clinicians were able to reliably identify concurrent lower leg injuries. A clinical reliability study was performed at multiple sports medicine sites in The Netherlands. Athletes with non-traumatic lower leg pain were assessed for having MTSS by two clinicians, who were blinded to each others' diagnoses. We calculated the prevalence, percentage of agreement, observed percentage of positive agreement (Ppos), observed percentage of negative agreement (Pneg) and Kappa-statistic with 95%CI. Forty-nine athletes participated in this study, of whom 46 completed both assessments. The prevalence of MTSS was 74%. The percentage of agreement was 96%, with Ppos and Pneg of 97% and 92%, respectively. The inter-rater reliability was almost perfect; k=0.89 (95% CI 0.74 to 1.00), phistory and physical examination, in clinical practice and research settings. We also found that concurrent lower leg injuries are common in athletes with MTSS. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Tony, G., E-mail: firstname.lastname@example.org [Stafford General Hospital, Weston Road, Stafford, Staffordshire ST16 3SA (United Kingdom); Charran, A., E-mail: email@example.com [Hillingdon Hospital, Pield Heath Rd, Uxbridge, Middlesex UB8 3NN (United Kingdom); Tins, B., E-mail: firstname.lastname@example.org [Department of Diagnostic Imaging, Robert Jones and Agnes Hunt, Orthopaedic Hospital, Oswestry, Shropshire SY10 7 AG (United Kingdom); Lalam, R., E-mail: email@example.com [Department of Diagnostic Imaging, Robert Jones and Agnes Hunt, Orthopaedic Hospital, Oswestry, Shropshire SY10 7 AG (United Kingdom); Tyrrell, P.N.M., E-mail: firstname.lastname@example.org [Department of Diagnostic Imaging, Robert Jones and Agnes Hunt, Orthopaedic Hospital, Oswestry, Shropshire SY10 7 AG (United Kingdom); Singh, J., E-mail: email@example.com [Department of Diagnostic Imaging, Robert Jones and Agnes Hunt, Orthopaedic Hospital, Oswestry, Shropshire SY10 7 AG (United Kingdom); Cool, P., E-mail: firstname.lastname@example.org [Orthopaedic Oncology, Robert Jones and Agnes Hunt, Orthopaedic Hospital, Oswestry, Shropshire SY10 7 AG (United Kingdom); Kiely, N., E-mail: email@example.com [Paediatric Orthopaedics, Robert Jones and Agnes Hunt, Orthopaedic Hospital, Oswestry, Shropshire SY10 7 AG (United Kingdom); Cassar-Pullicino, V.N., E-mail: Victor.Pullicino@rjah.nhs.uk [Department of Diagnostic Imaging, Robert Jones and Agnes Hunt, Orthopaedic Hospital, Oswestry, Shropshire SY10 7 AG (United Kingdom)
Highlights: • Purely intra-epiphyseal stress injuries of the proximal tibial epiphysis are described for the first time. • The variation in the MRI findings of these injuries depending on the stage of maturation is demonstrated. • We postulate a patho-mechanism to explain the variations in site and appearance of stress injuries in this region. - Abstract: Stress induced injuries affecting the physeal plate or cortical bone in children and adolescents, especially young athletes, have been well described. However, there are no reports in the current English language literature of stress injury affecting the incompletely ossified epiphyseal cartilage. We present four cases of stress related change to the proximal tibial epiphysis (PTE) along with their respective magnetic resonance imaging (MRI) appearances ranging from subtle oedema signal to a pseudo-tumour like appearance within the epiphyseal cartilage. The site and pattern of intra-epiphyseal injury is determined by the type of tissue that is affected, the maturity of the skeleton and the type of forces that are transmitted through the tissue. We demonstrate how an awareness of the morphological spectrum of MRI appearances in intra-epiphyseal stress injury and the ability to identify concomitant signs of stress in other nearby structures can help reduce misdiagnosis, avoid invasive diagnostic procedures like bone biopsy and reassure patients and their families.
Kang, P. K.; Lei, Q.; Lee, S.; Dentz, M.; Juanes, R.
Fluid flow and transport in fractured rock controls many natural and engineered processes in the subsurface. However, characterizing flow and transport through fractured media is challenging due to the high uncertainty and large heterogeneity associated with fractured rock properties. In addition to these "static" challenges, geologic fractures are always under significant overburden stress, and changes in the stress state can lead to changes in the fracture's ability to conduct fluids. While confining stress has been shown to impact fluid flow through fractures in a fundamental way, the impact of confining stress on transportthrough fractured rock remains poorly understood. The link between anomalous (non-Fickian) transport and confining stress has been shown, only recently, at the level of a single rough fracture . Here, we investigate the impact of geologic (tectonic) stress on flow and tracer transport through natural fracture networks. We model geomechanical effects in 2D fractured rock by means of a finite-discrete element method (FEMDEM) , which can capture the deformation of matrix blocks, reactivation of pre-existing fractures, and propagation of new cracks, upon changes in the stress field. We apply the model to a fracture network extracted from the geological map of an actual rock outcrop to obtain the aperture field at different stress conditions. We then simulate fluid flow and particle transport through the stressed fracture networks. We observe that anomalous transport emerges in response to confining stress on the fracture network, and show that the stress state is a powerful determinant of transport behavior: (1) An anisotropic stress state induces preferential flow paths through shear dilation; (2) An increase in geologic stress increases aperture heterogeneity that induces late-time tailing of particle breakthrough curves. Finally, we develop an effective transport model that captures the anomalous transport through the stressed fracture
National Aeronautics and Space Administration — The dream in stress and fracture analysis has always been to be able to simulate cracks initiating and then propagating in a stress field in a metal or composite...
Boone, Philip M; Chan, Yiu Man; Hunter, Jill V; Pottkotter, Louis E; Davino, Nelson A; Yang, Yaping; Beuten, Joke; Bacino, Carlos A
Haploinsufficiency of SATB2 causes cleft palate, intellectual disability with deficient speech, facial and dental abnormalities, and other variable features known collectively as SATB2-associated syndrome. This phenotype was accompanied by osteoporosis, fractures, and tibial bowing in two previously reported adult patients; each possessed SATB2 mutations either predicted or demonstrated to escape nonsense-mediated decay, suggesting that the additional bone defects result from a dominant negative effect and/or age-dependent penetrance. These hypotheses remain to be confirmed, as do the specific downstream defects causing bone abnormalities. We report a SATB2 mutation (c.2018dupA; p.(H673fs)) in a 15-year-old patient whose SATB2-associated syndrome phenotype is accompanied by osteoporosis, fractures, progressive tibial bowing, and scoliosis. As this homeodomain-disrupting and predicted truncating mutation resides within the final exon of SATB2, escape from nonsense-mediated decay is likely. Thus, we provide further evidence of bone phenotypes beyond those typically associated with SATB2-associated syndrome in individuals with potential dominant-negative SATB2 alleles, as well as evidence for age-dependence of bone features. Elevations in alkaline phosphatase, urinary N-telopeptide/creatinine ratio, and osteocalcin in the patient indicate increased bone turnover. We propose surveillance and treatment with osteoclast inhibitors to prevent fractures and to slow progressive bone deformities. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.
Full Text Available Background. Gymnasts have high mechanical loading forces of up to 14 times body weight. Overuse lesions are typical in wrists and stress fractures in the olecranon, while isolated fractures of the coronoid process are uncommon. We present a case of retraumatized nonunion stress fracture of the ulnar coronoid process. Case Description. A 19-year-old gymnast presented with elbow pain after training. Imaging confirmed an old fracture of the coronoid process. We describe a 6-month multiphase return to competition rehabilitation program, which allowed him to compete pain-freely. Literature Review. Acute and overuse injuries in gymnasts are known but no nonunion of the coronoid process has been described before. Only one case of stress fracture of coronoid process in a gymnast was reported. Purpose and Clinical Relevance. We could successfully and conservatively return to sport a reactivated nonunion of a stress fracture of the coronoid process.
Full Text Available To investigate the association of polymorphisms within candidate genes which we hypothesized may contribute to stress fracture predisposition, a case-control, cross- sectional study design was employed. Genotyping 268 Single Nucleotide Polymorphisms- SNPs within 17 genes in 385 Israeli young male and female recruits (182 with and 203 without stress fractures. Twenty-five polymorphisms within 9 genes (NR3C1, ANKH, VDR, ROR2, CALCR, IL6, COL1A2, CBG, and LRP4 showed statistically significant differences (p < 0.05 in the distribution between stress fracture cases and non stress fracture controls. Seventeen genetic variants were associated with an increased stress fracture risk, and eight variants with a decreased stress fracture risk. None of the SNP associations remained significant after correcting for multiple comparisons (false discovery rate- FDR. Our findings suggest that genes may be involved in stress fracture pathogenesis. Specifically, the CALCR and the VDR genes are intriguing candidates. The putative involvement of these genes in stress fracture predisposition requires analysis of more cases and controls and sequencing the relevant genomic regions, in order to define the specific gene mutations
Dufek, P; Ostendorf, U; Thormählen, F
This case report describes a stress fracture of the ulna in a 26-year-old professional table-tennis player. X-ray films remained negative so that the diagnostic is based on MRT. This stress fracture is caused by changing the intensity of training and changing the table-tennis-racket.
Saeki, Junya; Nakamura, Masatoshi; Nakao, Sayaka; Fujita, Kosuke; Yanase, Ko; Morishita, Katsuyuki; Ichihashi, Noriaki
A high proportion of flexor digitorum longus attachment is found at the posteromedial border of the tibia, which is the most common location of medial tibial stress syndrome (MTSS). Therefore, plantar flexion strength of the lesser toes could be related to MTSS; however, the relationship between MTSS and muscle strength of the hallux and lesser toes is not yet evaluated due to the lack of quantitative methods. This study investigated the muscle strength characteristics in runners with a history of MTSS by using a newly developed device to measure the muscle strength of the hallux, lesser toes, and ankle. This study comprised 27 collegiate male runner participants (20.0 ± 1.6 years, 172.1 ± 5.1 cm, 57.5 ± 4.0 kg). Maximal voluntary isometric contraction (MVIC) torque of the plantar flexion, dorsiflexion, inversion, and eversion of the ankle were measured by using an electric dynamometer. MVIC torque of the 1st metatarsophalangeal joint (MTPJ) and 2nd-5th MTPJ were measured by using a custom-made torque-measuring device. MVIC torques were compared between runners with and without a history of MTSS. MVIC torque of the 1st MTPJ plantar flexion was significantly higher in runners with a history of MTSS than in those without it. In contrast, there were no significant differences in the MVIC torque values of the 2nd-5th MTPJ plantar flexion and each MVIC torque of the ankle between runners with and without a history of MTSS. A history of MTSS increased the isometric FHL strength.
Saeki, J; Nakamura, M; Nakao, S; Fujita, K; Yanase, K; Ichihashi, N
Previous history of medial tibial stress syndrome (MTSS) is a risk factor for MTSS relapse, which suggests that there might be some physical factors that are related to MTSS development in runners with a history of MTSS. The relationship between MTSS and muscle stiffness can be assessed in a cross-sectional study that measures muscle stiffness in subjects with a history of MTSS, who do not have pain at the time of measurement, and in those without a history of MTSS. The purpose of this study was to compare the shear elastic modulus, which is an index of muscle stiffness, of all posterior lower leg muscles of subjects with a history of MTSS and those with no history and investigate which muscles could be related to MTSS. Twenty-four male collegiate runners (age, 20.0±1.7 years; height, 172.7±4.8 cm; weight, 57.3±3.7 kg) participated in this study; 14 had a history of MTSS, and 10 did not. The shear elastic moduli of the lateral gastrocnemius, medial gastrocnemius, soleus, peroneus longus, peroneus brevis, flexor hallucis longus, flexor digitorum longus, and tibialis posterior were measured using shear wave elastography. The shear elastic moduli of the flexor digitorum longus and tibialis posterior were significantly higher in subjects with a history of MTSS than in those with no history. However, there was no significant difference in the shear elastic moduli of other muscles. The results of this study suggest that flexor digitorum longus and tibialis posterior stiffness could be related to MTSS. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Full Text Available Despite improvements in prosthesis technology and use of high-quality materials in recent years, the number of revisions related to implant failures (4.7% remains high. Several phenomena were reported in literature as reasons for dislocation and fracture of tibial insert in mobile bearing prosthesis: incorrect positioning of components, discrepancy of extension and flexion balancing or ligament weakness. However, in our cases neither of these causes were observed. The authors consider that bio-physiological and biomechanical aspects of total knee arthroplasty and knee joint prosthesis should be thoroughly studied and implemented into the clinical practice. In the described cases, multiple damage of the insert due to flexion instability and “twist-hyperflexion” in overweight patients is perceived as the reason for failures.
McInnis, Kelly C; Ramey, Lindsay N
Stress fractures are common overuse injuries in athletes. They occur during periods of increased training without adequate rest, disrupting normal bone reparative mechanisms. There are a host of intrinsic and extrinsic factors, including biochemical and biomechanical, that put athletes at risk. In most stress fractures, the diagnosis is primarily clinical, with imaging indicated at times, and management focused on symptom-free relative rest with advancement of activity as tolerated. Overall, stress fractures in athletes have an excellent prognosis for return to sport, with little risk of complication. There is a subset of injuries that have a greater risk of fracture progression, delayed healing, and nonunion and are generally more challenging to treat with nonoperative care. Specific locations of high-risk stress fracture include the femoral neck (tension side), patella, anterior tibia, medial malleolus, talus, tarsal navicular, proximal fifth metatarsal, and great toe sesamoids. These sites share a characteristic region of high tensile load and low blood flow. High-risk stress fractures require a more aggressive approach to evaluation, with imaging often necessary, to confirm early and accurate diagnosis and initiate immediate treatment. Treatment consists of nonweight-bearing immobilization, often with a prolonged period away from sport, and a more methodic and careful reintroduction to athletic activity. These stress fractures may require surgical intervention. A high index of suspicion is essential to avoid delayed diagnosis and optimize outcomes in this subset of stress fractures. Copyright © 2016 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
Wright, Russell C; Salzman, Garrett A; Yacoubian, Stephan V; Yacoubian, Shahan V
Unilateral femoral neck stress fractures are well documented in active patients; however, the risk of a subsequent contralateral stress fracture remains unknown in patients who continue to be active. This article describes a 24-year-old male fire academy student who sustained a left femoral neck stress fracture, followed approximately 11 months later by a right femoral neck stress fracture, both of which went on to completely displace. A review of the index radiographs of each hip from outside institutions revealed femoral neck stress fractures that went undiagnosed until they displaced. The patient was referred to our institution and underwent closed reduction and internal fixation using cannulated screws in both cases. A full endocrine evaluation was performed in the following weeks and proved unremarkable. Although it is difficult to extrapolate the results from 1 patient beyond the case studied, there is cause for concern in patients who remain active following femoral neck stress fractures. Our case highlights the significance of obtaining a complete and thorough medical history on physical examination and appropriately counseling patients regarding activity level. Until further research explores this possible relationship, physicians evaluating patients with a history of a stress fracture are encouraged to be vigilant of subsequent contralateral fractures and educate patients of this potentially avoidable injury. Copyright 2010, SLACK Incorporated.
Full Text Available Background: Overuse injuries in children and adolescents are becoming increasingly common, particularly in those who regularly participate in a single sport. As a result, prevention, early detection and treatment of these injuries is vital. However, existing research in adult populations cannot always be directly applied to analogous cases in younger populations. This study attempts to provide an example of how both mathematical and computer modeling can be utilized to predict alterations in load locations, directions, and magnitudes resulting from maturational changes in a way not possible in vivo. Methods: A 2D leg extension model was created and used to calculate relevant forces at the proximal knee joint. Individual aspects of the model, such as quadriceps force and leg length, were changed to quantify how increases in a growing adolescent’s force generation and limb length may affect the forces at the joint. The derived forces were input into a 3D finite element model incorporating a growing young adult’s relatively weaker epiphyseal plate material to calculate the stresses and strains on the tibia of an adolescent. Results: Findings indicated that a shortened patellar tendon and increased quadriceps muscle strength were potentially greater contributors to increased stress on the proximal tibia, as opposed to aspects such as height and weight changes. Conclusions: The theoretical and computational methods employed show promise in their ability to predict potential injury risks in populations for whom evidence-based research is lacking. Models incorporating the elbow and shoulder have high impact potential for young baseball pitchers.
Full Text Available Sacral stress fractures are common in elderly people. However, sacral stress fracture should be always screened in the differential diagnoses of low back pain during the postpartum period. We present a case of sacral fracture in a thirty-six-year-old woman with low back pain and severe right buttock pain two days after cesarean section delivery of a 3.9 Kg baby. The diagnosis was confirmed by MRI and CT scan, while X-ray was unable to detect the fracture. Contribution of mechanical factors during the cesarean section is not a reasonable cause of sacral fracture. Pregnancy and lactation could be risk factors for sacral stress fracture even in atraumatic delivery such as cesarean section. Our patient had no risk factors for osteoporosis except for pregnancy and lactation. Transient or focal osteoporosis is challenging to assess and it cannot be ruled out even if serum test and mineral density are within the normal range.
Alt, Volker; Donell, Simon T; Chhabra, Amit; Bentley, Anthony; Eicher, Alexander; Schnettler, Reinhard
The purpose of this study was to determine the cost savings from a societal perspective for recombinant human Bone Morphogenetic Protein-2 (rhBMP-2) in grade III A and B open tibial fractures treated with a locked intramedullary nail and soft-tissue management in the UK, Germany, and France. Health care system costs (direct health care costs) and costs for productivity losses (indirect health care costs) were calculated using the raw data from the Bone Morphogenetic Protein Evaluation Group in Surgery for Tibial Trauma "BESTT study". Return-to-work time for estimation of productivity losses was assumed to correspond with the time of fracture healing. For calculation of secondary interventions costs and productivity losses the respective 2007/2008 national tariffs for surgical procedures and average national wages for the UK, Germany, and France were used. For a 1 year perspective, overall treatment costs per patient after the initial surgery of the control vs. the rhBMP-2 group were 44,757 euros vs. 36,847 euros for the UK, 50,197 euros vs. 40,927 euros for Germany and 48,766 euros vs. 39,474 euros for France in favour of rhBMP-2 with overall savings overall savings per case of rhBMP-2 treatment of 7911 euros for the UK, 9270 euros for Germany, and 9291 euros for France which was mainly due to reduced productivity losses by significant faster fracture healing in the rhBMP-2 group (p=0.01). These savings largely offset the upfront price of rhBMP-2 of 2266 euros (1790 pounds) in the UK, euros 2970 in Germany, and 2950 euros in France. Total net savings can be estimated to be 9.6 million euros for the UK, 14.5 million euros for Germany, and 11.4 million euros for France. The results depend on the methodology used particularly for calculation of productivity losses and return-to-work time which was assumed to correspond with fracture healing time. In summary, despite the apparent high direct cost of rhBMP-2 in grade III A and B open tibial fractures, at a national
Speziali, Andrea; Tei, Matteo Maria; Placella, Giacomo; Chillemi, Marco; Cerulli, Giuliano
Sacral stress fractures are common in elderly people. However, sacral stress fracture should be always screened in the differential diagnoses of low back pain during the postpartum period. We present a case of sacral fracture in a thirty-six-year-old woman with low back pain and severe right buttock pain two days after cesarean section delivery of a 3.9 Kg baby. The diagnosis was confirmed by MRI and CT scan, while X-ray was unable to detect the fracture. Contribution of mechanical factors d...
in U.S. Army Combat Medic Advanced individual training. Mil Med. 2000;165:647-652. 15. Hulkko A, Orava S. Stress fractures in athletes . Int J Sports ...379. 24. Miller C, Major N, Toth A. Pelvic stress injuries in the athlete : management and prevention. Sports Med. 2003;33:1003-1012. 25. Myburgh...recruits than has been reported in civilian athletes or male military recruits. Pelvic stress fractures are relatively rare in civilian male and female
Wang, Tie-Jun; Ju, Wei-Na; Qi, Bao-Chang
Anatomical characteristics, such as subcutaneous position and minimal muscle cover, contribute to the complexity of fractures of the distal third of the tibia and fibula. Severe damage to soft tissue and instability ensure high risk of delayed bone union and wound complications such as nonunion, infection, and necrosis. This case report discusses management in a 54-year-old woman who sustained fractures of the distal third of the left tibia and fibula, with damage to overlying soft tissue (swelling and blisters). Plating is accepted as the first choice for this type of fracture as it ensures accurate reduction and rigid fixation, but it increases the risk of complications. Closed fracture of the distal third of the left tibia and fibula (AO: 43-A3). After the swelling was alleviated, the patient underwent closed reduction and fixation with an Acumed fibular nail and minimally invasive plating osteosynthesis (MIPO), ensuring a smaller incision and minimal soft-tissue dissection. At the 1-year follow-up, the patient had recovered well and had regained satisfactory function in the treated limb. The Kofoed score of the left ankle was 95. Based on the experience from this case, the operation can be undertaken safely when the swelling has been alleviated. The minimal invasive technique represents the best approach. Considering the merits and good outcome in this case, we recommend the Acumed fibular nail and MIPO technique for treatment of distal tibial and fibular fractures.
Ando, Yoshihiro; Hirata, Soichiro; Ishikawa, Hitoshi; Kurosaka, Masahiro
A case of bilateral pedicle stress fracture of L4 in a patient with osteoporotic compression fracture of L5 and without a history of major trauma or surgery is reported, and the literature is reviewed. Bilateral pedicle fracture is a rare entity and few cases have been reported in the literature. All reported cases had some underlying causative factors like previous spine surgery or stress related activities. To the best of the authors’ knowledge, only one case of bilateral pedicle stress fracture without a history of trauma, previous spine surgery, or stress-related activities has been reported. A 77-year-old woman presented with severe low back pain and radiating pain in the right leg that was exacerbated after standing and walking. Plain radiograph showed pathological fracture at L5 level. Magnetic resonance imaging (MRI) revealed the compression of dural sac at L5 level. CT scan taken 3 months after admission revealed bilateral pedicle fractures through L4. The patient was treated with decompressive laminectomies of L4, followed by posterior spinal fusion with rigid pedicle screw fixation and autogenous bone graft mixed with hydroxyapatite. The patient achieved pain relief and returned to normal activity. Stress fracture of the pedicle within the proximal vertebra of an osteoporotic compression fracture of lumbar spine is an uncommon entity. It may, however, be an additional source of symptoms in patients with osteoporosis who present with further back pain. Surgeons caring for this group of patients should be aware of this condition. PMID:19005693
Full Text Available Background: Tibial plateau fractures are common due to high energy injuries. The principles of treatment include respect for the soft tissues, restoring the congruity of the articular surface and reduction of the anatomic alignment of the lower limb to enable early movement of the knee joint. There are various surgical fixation methods that can achieve these principles of treatment. Recognition of the particular fracture pattern is important, as this guides the surgical approach required in order to adequately stabilize the fracture. This study evaluates the results of the combined treatment of external fixator and limited internal fixation along with the advantages using postoperative computed tomography (CT scan after implant removal. Materials and Methods: 55 patients with a mean age of 42 years (range 17–65 years with tibial plateau fracture, were managed in our institution between October 2010 and September 2013., Twenty fractures were classified as Schatzker VI and 35 as Schatzker V. There were 8 open fractures (2 Gustilo Anderson 3A and 6 Gustilo Anderson 2. All fractures were treated with closed reduction and hybrid external fixation (n = 21/38.2% or with minimal open reduction internal fixation and a hybrid system (n = 34/61.8%. After the removal of the fixators, CT-scan was programmed for all the cases, for correlation with the results. At final followup, the American Knee Society Score (AKSS was administered. Results: All patients were evaluated with a minimum of 12 months (range 12–21 months followup. Average time to union was 15.5 weeks (range 13–19 weeks. The postoperative joint congruity as evaluated in the postoperative CT-scan was 5° in 19 cases (35%. Patients with residual joint depression 4.5 mm displayed a 100% chance of getting poor-fair scores both in AKSS knee and AKSS function score. The association of a postoperative mechanical axis within 5° of the contralateral limb and improved knee scores was statistically
Thomas, Robin N.; Paluszny, Adriana; Zimmerman, Robert W.
Accurate and flexible models of fracture interaction are sought after in the fields of mechanics and geology. Stress intensity factors (SIFs) quantify the energy concentrated at the fracture tips and are perturbed from their isolated values when two fractures are close to one another. Using a three-dimensional finite element fracture mechanics code to simulate static fractures in tension and compression, interaction effects are examined. SIF perturbations are characterized by introducing three interaction measures: the circumferential and maximum SIF perturbation provide the "magnitude" of the effect of interaction, and the amplification to shielding ratio quantifies the balance between increased and decreased SIFs along the tip. These measures are used to demonstrate the change in interaction with fracture separation and to find the separation at which interaction becomes negligible. Interaction maps are constructed by plotting the values of the interaction measures for a static fracture as a second fracture is moved around it. These maps are presented for several common fracture orientations in tension. They explore interaction by highlighting regions in which growth is more likely to occur and where fractures will grow into nonplanar geometries. Interaction maps can be applied to fracture networks with multiple discontinuities to analyze the effect of geometric variations on fracture interaction.
Mayer, Stephanie W.; Joyner, Patrick W.; Almekinders, Louis C.; Parekh, Selene G.
Context: Stress fractures of the foot and ankle are a common problem encountered by athletes of all levels and ages. These injuries can be difficult to diagnose and may be initially evaluated by all levels of medical personnel. Clinical suspicion should be raised with certain history and physical examination findings. Evidence Acquisition: Scientific and review articles were searched through PubMed (1930-2012) with search terms including stress fractures and 1 of the following: foot ankle, medial malleolus, lateral malleolus, calcaneus, talus, metatarsal, cuboid, cuneiform, sesamoid, or athlete. Study Design: Clinical review. Level of Evidence: Level 5. Results: Stress fractures of the foot and ankle can be divided into low and high risk based upon their propensity to heal without complication. A wide variety of nonoperative strategies are employed based on the duration of symptoms, type of fracture, and patient factors, such as activity type, desire to return to sport, and compliance. Operative management has proven superior in several high-risk types of stress fractures. Evidence on pharmacotherapy and physiologic therapy such as bone stimulators is evolving. Conclusion: A high index of suspicion for stress fractures is appropriate in many high-risk groups of athletes with lower extremity pain. Proper and timely work-up and treatment is successful in returning these athletes to sport in many cases. Low-risk stress fracture generally requires only activity modification while high-risk stress fracture necessitates more aggressive intervention. The specific treatment of these injuries varies with the location of the stress fracture and the goals of the patient. PMID:25364480
Jacob, Korula Mani; Paterson, Roger S
Background: Stress fractures of the naviculum bone are uncommon injuries occurring predominantly in athletes. These fractures are usually treated nonoperatively with a nonweight bearing cast for a minimum of 6 weeks followed by rehabilitation. Further, there is a paucity of literature on the long term clinical followup of these patients. These fractures do not heal predictably with conservative management, which does not inspire great compliance and their clinical outcome is variable. We repo...
Fink-Bennett, D.M.; Benson, M.T.
We describe two unusual exercise-related stress fractures, one in the sacroiliac joint of a long distance runner, the other in the body of the scapulae of an above-knee amputee. Each were detected on a 2-hour delay bone scan. To our knowledge, neither have been described scintigraphically. The bilateral scapular fracture is an unreported entity, and the fractured SI joint is a very uncommon site for an overuse injury.
Finkemeier, C G; Schmidt, A H; Kyle, R F; Templeman, D C; Varecka, T F
To determine if there are differences in healing, complications, or number of procedures required to obtain union among open and closed tibia fractures treated with intramedullary (IM) nails inserted with and without reaming. Prospective, surgeon-randomized comparative study. Level One trauma center. Ninety-four consecutive patients with unstable closed and open (excluding Gustilo Grade IIIB and IIIC) fractures of the tibial shaft treated with IM nail insertion between November 1, 1994, and June 30, 1997. Interlocked IM nail insertion with and without medullary canal reaming. Time to union, type and incidence of complications, and number of secondary procedures performed to obtain union. For open fractures, there were no significant differences in the time to union or number of additional procedures performed to obtain union in patients with reamed nail insertion compared with those without reamed insertion. A higher percentage of closed fractures were healed at four months after reamed nail insertion compared with unreamed insertion (p = 0.040), but there was not a difference at six and twelve months. More secondary procedures were needed to obtain union after unreamed nail insertion for the treatment of closed tibia fractures, but the difference was not statistically significant given the limited power of our study (p = 0.155). Broken screws were seen only in patients treated with smaller-diameter nails inserted without reaming, and the majority occurred in patients who were noncompliant with weight-bearing restrictions. There were no differences in rates of infection or compartment syndrome. Our findings support the use of reamed insertion of IM nails for the treatment of closed tibia fractures, which led to earlier time to union without increased complications. In addition, canal reaming did not increase the risk of complications in open tibia fractures.
Furuta, Atsuhiko; Tanohata, Kazunori; Otake, Toru; Hashizume, Toshiyuki (Kanto Rosai Hospital, Kawasaki, Kanagawa (Japan)); Kobayashi, Yozi; Nakazima, Hiroyuki
Clinical evaluation of stress fractures were performed in 58 athletes using bone scintigraphy with sup(99m)Tc-MDP. Stress fractures of the tibia were most often seen in the males with running type sports. They occurred more often in the proximal tibia and on the right side. Stress fractures of the fibula were most often seen in females with jumping type sports, such as volley ball. They occurred more often in the distal fibula and on the right side. Tarsal bone fractures were seen most often rugby players. Metatarsal fractures occurred in the third fourth and fifth metatarsals. No lesion was seen in the first and second metatarsals. We feel that stress fractures of the femur can be differentiated from osteosarcoma by small loculated radionuclide accumulation as well as symptoms, course and tomographic and CT findings. Bilateral involvement was seen in two cases in patellae and calcanei. Most of the other fractures were seen on the right side. Negative radiographs were seen in 36% of the patients and occurred most commonly in the tarsal bones excluding calcaneus. Bone scintigrams were positive in all cases and were most useful in fractures of the tarsal bones excluding calcaneus.
Furuta, Atsuhiko; Tanohata, Kazunori; Otake, Toru; Hashizume, Toshiyuki; Kobayashi, Yozi; Nakazima, Hiroyuki.
Clinical evaluation of stress fractures were performed in 58 athletes using bone scintigraphy with sup(99m)Tc-MDP. Stress fractures of the tibia were most often seen in the males with running type sports. They occurred more often in the proximal tibia and on the right side. Stress fractures of the fibula were most often seen in females with jumping type sports, such as volley ball. They occurred more often in the distal fibula and on the right side. Tarsal bone fractures were seen most often rugby players. Metatarsal fractures occurred in the third fourth and fifth metatarsals. No lesion was seen in the first and second metatarsals. We feel that stress fractures of the femur can be differentiated from osteosarcoma by small loculated radionuclide accumulation as well as symptome, course and tomographic and CT finding. Bilateral involvement was seen in two cases in patellae and calcanei. Most of the other fractures were seen on the right side. Negative radiographs were seen in 36% of the patients and occurred most commonly in the tarsal bones excluding calcaneus. Bone scintigrams were positive in all cases and were most useful in fractures of the tarsal bones excluding calcaneus. (author)
Chang, Eric Y.; Chung, Christine B. [VA San Diego Healthcare System, San Diego, CA (United States); University of California, San Diego Medical Center, San Diego, CA (United States); Fronek, Jan [Scripps Healthcare, La Jolla, CA (United States)
We report the occurrence of a medial supracondylar stress fracture in an adolescent pitcher. To our knowledge, this fracture has not been described in the literature, and awareness of this entity allows initiation of therapy and precludes further unnecessary work-up. The radiographic, computed tomography, and magnetic resonance imaging appearances are reviewed and the mechanism of injury is discussed. (orig.)
Zwas, S.T.; Elkanovich, R.; Frank, G.; Aharonson, Z.
There is no consensus on classifying stress fractures (SF) appearing on bone scans. The authors present a system of classification based on grading the severity and development of bone lesions by visual inspection, according to three main scintigraphic criteria: focality and size, intensity of uptake compare to adjacent bone, and local medular extension. Four grades of development (I-IV) were ranked, ranging from ill defined slightly increased cortical uptake to well defined regions with markedly increased uptake extending transversely bicortically. 310 male subjects aged 19-2, suffering several weeks from leg pains occurring during intensive physical training underwent bone scans of the pelvis and lower extremities using Tc-99-m-MDP. 76% of the scans were positive with 354 lesions, of which 88% were in th4e mild (I-II) grades and 12% in the moderate (III) and severe (IV) grades. Post-treatment scans were obtained in 65 cases having 78 lesions during 1- to 6-month intervals. Complete resolution was found after 1-2 months in 36% of the mild lesions but in only 12% of the moderate and severe ones, and after 3-6 months in 55% of the mild lesions and 15% of the severe ones. 75% of the moderate and severe lesions showed residual uptake in various stages throughout the follow-up period. Early recognition and treatment of mild SF lesions in this study prevented protracted disability and progression of the lesions and facilitated complete healing
Zhang, S.Q.; Jioa, D.; Meng, Y.F.; Fan, Y.
Three kinds of reservoir cores (limestone, sandstone, and shale with natural fractures) were used to study the effect of morphology of fracture surfaces on stress sensitivity. The cores, obtained from the reservoirs with depths of 2170 to 2300 m, have fractures which are mated on a large scale, but unmated on a fine scale. A specially designed photoelectric scanner with a computer was used to describe the topography of the fracture surfaces. Then, theoretical analysis of the fracture closure was carried out based on the fracture topography generated. The scanning results show that the asperity has almost normal distributions for all three types of samples. For the tested samples, the fracture closure predicted by the elastic-contact theory is different from the laboratory measurements because plastic deformation of the aspirates plays an important role under the testing range of normal stresses. In this work, the traditionally used elastic-contact theory has been modified to better predict the stress sensitivity of reservoir fractures. Analysis shows that the standard deviation of the probability density function of asperity distribution has a great effect on the fracture closure rate.
Watanabe, Toshifumi; Koga, Hideyuki; Horie, Masafumi; Katagiri, Hiroki; Sekiya, Ichiro; Muneta, Takeshi
The post-cam mechanism in posterior stabilized (PS) prostheses plays an important role in total knee arthroplasty (TKA). The purpose of this study is to clarify the difference of the contact stress on the tibial post between a rounded post-cam design and a squared design during deep knee flexion and at hyperextension using the three-dimensional (3D) finite element models. We created 2 types of 3D, finite element models of PS prostheses (types A and B), whose surfaces were identical except for the post-cam geometries: type A has a rounded post-cam design, while type B has a squared design. Both types have a similar curved-shape intercondylar notch of the femoral component. Stress distributions, peak contact stresses, and contact areas on the tibial posts at 90°, 120°, and 150° flexion with/without 10° tibial internal rotation and at 10° hyperextension were compared between the 2 models. Type B demonstrated more concentrated stress distribution compared to type A. The peak contact stresses were similar in both groups during neutral flexion; however, the stresses were much higher in type B during flexion with 10° rotation and at hyperextension. The higher peak contact stresses corresponded to the smaller contact areas in the tibial post. A rounded post-cam design demonstrated less stress concentration during flexion with rotation and at hyperextension compared with a squared design. The results would be useful for development of implant designs and prediction of the contact stress on the tibial post in PS total knee arthroplasty. Copyright © 2017 Elsevier Inc. All rights reserved.
Boyer, B.; Cordoliani, Y.S.; Naudinat, E.; Sylvestre, A.; Pharaboz, C. [Hopital des Armees Begin, 94 - Saint-Mande (France)
Nuclear Magnetic Resonance imaging can contribute to stress fractures diagnosis when it makes obvious the fracture line which signal is variable in function of site lesion. The importance of inflammatory reactions must not call the diagnosis in question again. 5 figs., 8 refs.
Adam, P; Bonnomet, F; Ehlinger, M
Intramedullary nailing is a common method of treating tibial shaft fractures. However, precise control of reduction at the proximal and distal quarters is difficult to achieve. The purpose of this study was to assess the results of plating using locking screws and the feasibility of a minimally-invasive approach. All patients with tibial shaft fracture treated by means of locking plates from January 2004 to October 2006. Thirty-two fractures were treated in 32 patients with a mean age of 43.8 years. Internal fixation with a locking plate and screw construct, using a minimally-invasive or standard approach. Surgical approach, time to weight bearing, complications and their type, time to bone union, alignment in the frontal and sagittal planes on anteroposterior and lateral radiographs. The minimally-invasive approach was performed in 28 cases and immediate full weight bearing allowed in 25 cases. At a mean follow-up of 27 months, two patients had died and two patients were lost to follow-up. The mean time to bone union was 9.1 weeks. Four cases had a complicated course: one infection, one compartment syndrome, one hardware breakage and one pseudarthrosis. Six cases ended up with valgus malunion exceeding 5° in the frontal plane, already present at the time of surgery. Where a minimally-invasive approach can be performed, immediate pain-free weight bearing can be allowed without further displacement at follow-up. The observed rate of malunion underlines the need for adequate reduction and shows that the rationale for success does not solely depend on the plate anatomic design but also on the skills of the operating surgeon. Level I university regional hospital Cohort study. Copyright © 2012. Published by Elsevier Masson SAS.
Richardson, Tom; Grant, Michael; Chandran, Prakash
Femoral neck stress fractures in young healthy individuals are rare and occur in those who take part in physical training with repetitive loading and those with osteoporosis. Bone density is related to sex hormone status, which is artificially manipulated during gender reassignment. Conflicting evidence currently exists on the effect of cross sex hormone treatment on bone density, with no literature suggesting a link between hormone treatment in gender reassignment and stress fractures. Our aim is to highlight the potential risk of stress fractures amongst transsexual patients receiving cross sex hormones as part of gender reassignment. The patient presented with groin pain after competing in a running event. Despite a number of risk factors, there was a delay in diagnosis, which could have led to complications compromising outcome. Femoral neck stress fractures should be considered in the differential diagnosis of transsexual patients receiving hormone treatment with non-specific groin/thigh pain following exercise. 2016 BMJ Publishing Group Ltd.
Clarke, A.W.; Connell, D.A. [Royal National Orthopaedic Hospital NHS Trust, Department of Radiology, London, Middlesex (United Kingdom)
A case report of bilateral ischial stress fractures in an elite tennis player initially mimicking hamstring pathology is described. This is an unusual site of stress fracture. Typical sites of stress fracture are well documented; however, awareness of less common sites of stress-related bone injury can aid early diagnosis and treatment before overt fracture occurs. (orig.)
Alves da Silva Junior, J.; Kang, P. K.; Yang, Z.; Cueto-Felgueroso, L.; Juanes, R.
Fluid flow and transport through geologic fractures plays a key role in several areas such as groundwater hydrology, geothermal energy, oil and gas production, CO2 sequestration and nuclear waste disposal. High-permeability zones associated with fracture corridors often serve as fast fluid conduits for both single and multiphase flow in otherwise low-permeability media. When multiphase flow occurs, the presence of one phase interferes with the flow of the other phase, resulting in complex displacement patterns through the fracture, and macroscopic descriptors (such as fracture-scale capillary pressure and relative permeability) that depend on the phase concentration of both phases. Here, we investigate the impact of normal stress on single and multiphase flow through rough-walled fractures: (1) we generate synthetic aperture fields that honor the fractal roughness structure observed in real fractures; (2) we model the effect of normal stress on the fracture aperture geometry by solving the contact problem between fracture walls; and (3) we use invasion percolation with trapping to model immiscible fluid displacement and then compute relative permeability numerically for each stress scenario. Our results indicate that normal stress increases the amount of contact area in the fracture wall, which results in an increase of the tortuosity of the available path for fluid displacement. Increasing normal stress results in low relative permeability for the wetting phase due to a decrease of the available path for fluid flow, and therefore a small amount of non-wetting fluid has a large impact on the flow of the wetting fluid. We find that the relative permeability of the non-wetting fluid shows less variation with stress than the wetting fluid, and that both fluids exhibit strong phase interference at intermediate saturations. Finally, we show early results from our experimental work currently underway to validate the modeling results.
Mostafavinia, Atarodalsadat; Masteri Farahani, Reza; Abbasian, Mohammadreza; Vasheghani Farahani, Mohammadmehdi; Fridoni, Mohammadjavad; Zandpazandi, Sara; Ghoreishi, Seyed Kamran; Abdollahifar, Mohammad Amin; Pouriran, Ramin; Bayat, Mohammad
Background: Fractures pose a major worldwide challenge to public health, causing tremendous disability for the society and families. According to recent studies, many in vivo and in vitro experiments have shown the positive effects of PW LLLT on osseous tissue. Objectives: The aim of this study was to evaluate the outcome of infrared pulsed wave low-level laser therapy (PW LLLT) on the fracture healing process in a complete tibial osteotomy in a rat model, which was stabilized by an intramedullary pin. Materials and Methods: This experimental study was conducted at Shahid Beheshti University of Medical Sciences in Tehran, Iran. We performed complete tibial osteotomies in the right tibias for the population of 15 female rats. The rats were divided randomly into three different groups: I) Control rats with untreated bone defects; II) Rats irradiated by a 0.972 J/cm2 PW LLLT; and III) Rats irradiated by a 1.5 J/cm2 PW LLLT. The right tibias were collected six weeks following the surgery and a three-point bending test was performed to gather results. Immediately after biomechanical examination, the fractured bones were prepared for histological examinations. Slides were examined using stereological method. Results: PW LLLT significantly caused an increase in maximum force (N) of biomechanical repair properties for osteotomized tibias in the first and second laser groups (30.0 ± 15.9 and 32.4 ± 13.8 respectively) compared to the control group (8.6 ± 4.5) LSD test, P = 0.019, P = 0.011 respectively). There was a significant increase in the osteoblast count of the first and second laser groups (0.53 ± 0.06, 0.41 ± 0.06 respectively) compared to control group (0.31 ± 0.04) (LSD test, P = 0001, P = 0.007 respectively). Conclusions: This study confirmed the efficacy of PW LLLT on biomechanical strength, trabecular bone volume, callus volume, and osteoblast number of repairing callus in a complete tibial osteotomy animal model at a relatively late stage of the bone
Conclusion: Although a rare injury, it is important that clinicians be aware of this type of stress fracture, as a timely diagnosis can avoid the need for surgical treatment and allow an early return to play.
Zhang, Yongping; Wei, Xu; Zhang, Ye; Xing, Libo; Xu, Jianjun
Currently, hydraulic fracturing is an important way to develop low permeability reservoirs. The fractures produced during the fracturing process are the main influencing factors of changing in-situ stress. In this paper, the influence of fracture extension on in-situ stress is studied by establishing a mathematical model to describe the relationship between fracture length and in-situ stress. The results show that the growth rate gradually decreases after the fracture reaches a certain length with the increase of fracturing time; the continuous extension of the fracture is the main factor to change the in-situ stress. In order to reduce the impact on the subsequent fracture extension due to the changing of in-situ stress, controlling fracturing time and fracture length without affecting the stimulated reservoir effect is an important way. The results presented in this study can effectively reduce the impact of changing of in-situ stress on subsequent fracturing construction.
Tralman, G; Andrianov, V; Arend, A; Männik, P; Kibur, R T; Nõupuu, K; Uksov, D; Aunapuu, M
The study compares the efficiency of a new bone fixator combining periostal and intramedullary osteosynthesis to bone plating in treatment of tibial fractures in sheep. Experimental osteotomies were performed in the middle third of the left tibia. Animals were divided into two groups: in one group (four animals) combined osteosynthesis (rod-through-plate fixator, RTP fixator) was applied, and in the other group (three animals) bone plating was used. The experiments lasted for 10 weeks during which fracture union was followed by radiography, and the healing process was studied by blood serum markers reflecting bone turnover and by histological and immunohistochemical investigations. In the RTP fixator group, animals started to load body weight on the operated limbs the next day after the surgery, while in the bone plating group, this happened only on the seventh day. In the RTP fixator group, consolidation of fractures was also faster, as demonstrated by radiographical, histological, and immunohistochemical investigations and in part by blood serum markers for bone formation. It can be concluded that application of RTP fixation is more efficient than plate fixation in the treatment of experimental osteotomies of long bones in sheep. © 2012 Blackwell Verlag GmbH.
Jamtveit, B.; Iyer, K.; Royne, A.; Malthe-Sorenssen, A.; Mathiesen, J.; Feder, J.
Hierarchical fracture patterns are the result of a slowly driven fracturing process that successively divides the rocks into smaller domains. In quasi-2D systems, such fracture patterns are characterized by four sided domains, and T-junctions where new fractures stop at right angles to pre-existing fractures. We describe fracturing of mm to dm thick enstatite layers in a dunite matrix from the Leka ophiolite complex in Norway. The fracturing process is driven by expansion of the dunite matrix during serpentinization. The cumulative distributions of fracture lengths show a scaling behavior that lies between a log - normal and power law (fractal) distribution. This is consistent with a simple fragmentation model in which domains are divided according to a 'top hat' distribution of new fracture positions within unfractured domains. Reaction-assisted hierarchical fracturing is also likely to be responsible for other (3-D) structures commonly observed in serpentinized ultramafic rocks, including the mesh-textures observed in individual olivine grains, and the high abundance of rectangular domains at a wide range of scales. Spectacular examples of 3-D hierarchical fracture patterns also form during the weathering of basaltic intrusions (dolerites). Incipient chemical weathering of dolerites in the Karoo Basin in South Africa occurs around water- filled fractures, originally produced by thermal contraction or by externally imposed stresses. This chemical weathering causes local expansion of the rock matrix and generates elastic stresses. On a mm to cm scale, these stresses lead to mechanical layer-by-layer spalling, producing the characteristic spheroidal weathering patterns. However, our field observations and computer simulations demonstrate that in confined environments, the spalling process alone is unable to relieve the elastic stresses. In such cases, chemical weathering drives a much larger scale hierarchical fracturing process in which fresh dolerite undergoes a
Giordano, Vincenzo; Koch, Hilton Augusto; Mendes, Carlos Henrique; Bergamin, André; de Souza, Felipe Serrão; do Amaral, Ney Pecegueiro
The aim of this study was to evaluate the inter- and intra-observer agreement in the initial diagnosis and classification by means of plain radiographs and CT scans of tibial plateau fractures photographed and sent via WhatsApp Messenger. The increasing popularity of smartphones has driven the development of technology for data transmission and imaging and generated a growing interest in the use of these devices as diagnostic tools. The emergence of WhatsApp Messenger technology, which is available for various platforms used by smartphones, has led to an improvement in the quality and resolution of images sent and received. The images (plain radiographs and CT scans) were obtained from 13 cases of tibial plateau fractures using the iPhone 5 (Apple Inc., Cupertino, CA, USA) and were sent to six observers via the WhatsApp Messenger application. The observers were asked to determine the standard deviation and type of injury, the classification according to the Schatzker and the Luo classifications schemes, and whether the CT scan changed the classification. The six observers independently assessed the images on two separate occasions, 15 days apart. The inter- and intra-observer agreement for both periods of the study ranged from excellent to perfect (0.75WhatsApp Messenger. The authors now propose the systematic use of the application to facilitate faster documentation and obtaining the opinion of an experienced consultant when not on call. Finally, we think the use of the WhatsApp Messenger as an adjuvant tool could be broadened to other clinical centres to assess its viability in other skeletal and non-skeletal trauma situations. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Yamada, K.; Sugiura, H.; Suzuki, Y.
The clinical and radiological characteristics of swelling in the region of the medial clavicle may suggest the presence of a neoplastic or inflammatory lesion. This report describes a 27-year-old man with a painful tumor-like lesion over the medial clavicle, which was found to be a stress fracture caused by a nervous tic resulting from mental stress. (orig.)
Yamada, K.; Sugiura, H.; Suzuki, Y. [Department of Orthopaedics, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa, 464-8681, Nagoya (Japan)
The clinical and radiological characteristics of swelling in the region of the medial clavicle may suggest the presence of a neoplastic or inflammatory lesion. This report describes a 27-year-old man with a painful tumor-like lesion over the medial clavicle, which was found to be a stress fracture caused by a nervous tic resulting from mental stress. (orig.)
Miller, Timothy L; Best, Thomas M
Stress fractures and other bony stress injuries occur along a spectrum of severity which can impact treatment and prognosis. When treating these injuries, it should be borne in mind that no two stress fractures behave exactly alike. Given that they are not a consistent injury, standardized treatment protocols can be challenging to develop. Treatment should be individualized to the patient or athlete, the causative activity, the anatomical site, and the severity of the injury. A holistic approach to the treatment of the most difficult stress fractures should be taken by orthopedists and sports medicine specialists. This approach is necessary to obtain optimal outcomes, minimize loss of fitness and time away from sports participation, and decrease the risk of recurrence.
Majeed, N.U.; Naqvi, A.N.; Majeed, H.
Objective: To identify patterns of Femoral Neck Stress Fractures (FNSF), its presentation and outcome of its treatment in PMA (Pakistan Military Academy) cadets. These findings would help suggest guidelines for their appropriate management. Study design: Case Series Place and duration of study: CMH Abbottabad and CMH Rawalpindi from May 2005 to January 2008. Materials and Methods: Twenty cases (20 hips in 18 patients) of FNSF were included in the study. Only male cadets from Pakistan Military Academy (PMA) were included. Diagnosis was made clinically and was confirmed by radiographs or bone scan. Incomplete fractures were managed conservatively where as complete fractures were fixed surgically. Results: All compression fractures healed conservatively where as tension fractures needed surgical fixation in all the cases, except one where fracture remained incomplete. Rest of tension fractures converted from incomplete fractures to complete fractures and hence needed surgical stabilization. There was no problem of avascular necrosis of femoral head (AVNFH) in any patient. Conclusion: FNSF are uncommon injuries with potentially serious complications and are difficult to diagnose clinically. When diagnosed early and managed appropriately, they carry good prognosis. (author)
Deckert, Hagen; Drews, Michael; Fremgen, Dominik; Wellmann, J. Florian
A meaningful qualitative evaluation of permeabilities in fractured reservoirs in geothermal or hydrocarbon industry requires the spatial description of the existing discontinuity pattern within the area of interest and an analysis how these fractures might behave under given stress fields. This combined information can then be used for better estimating preferred fluid pathway directions within the reservoir, which is of particular interest for defining potential drilling sites. A description of the spatial fracture pattern mainly includes the orientation of rock discontinuities, spacing relationships between single fractures and their lateral extent. We have examined and quantified fracture patterns in several outcrops of granite at the Costa Brava, Spain, and in the Black Forest, Germany, for describing reservoir characteristics. For our analysis of fracture patterns we have used photogrammetric methods to create high-resolution georeferenced digital 3D images of outcrop walls. The advantage of this approach, compared to conventional methods for fracture analysis, is that it provides a better 3D description of the fracture geometry as the entity of position, extent and orientation of single fractures with respect to their surrounding neighbors is conserved. Hence for instance, the method allows generating fracture density maps, which can be used for a better description of the spatial distribution of discontinuities in a given outcrop. Using photogrammetric techniques also has the advantage to acquire very large data sets providing statistically sound results. To assess whether the recorded discontinuities might act as fluid pathways information on the stress field is needed. A 3D model of the regional tectonic structure was created and the geometry of the faults was put into a mechanical 3D Boundary Element (BE) Model. The model takes into account the elastic material properties of the geological units and the orientation of single fault segments. The
Full Text Available Osteoporosis is a common problem affecting people after 4 - 5 decade of life. There are various treatment options available for Osteoporosis and Bisphosphonates are widely used. Bisphosphonates work by blocking osteoclast mediated bone resorption and can be given in oral and injectable forms. R ecent studies have brought to light the risk of sub trochanteric stress fracture secondary to bisphosphonate therapy. Here we are presenting a case with bilateral sub trochanteric fracture following prolonged bisphosphonate therapy
Hong, Seoung Hwan; Chu, In Tak
Background We wanted to report on stress fracture of the proximal fibula and to suggest the pathomechanism of this fracture. Methods Between April 2004 through April 2005, the military recruits who complained of leg pain during the 6 weeks basic training in the Republic of Korea Marine Corps education and training group were evaluated according to their clinical manifestations and plain radiographs. Results Twelve recruits of 635 recruits who complained leg pain were diagnosed as having fibul...
Full Text Available Break dancing is a popular activity in teenagers and is associated with severe trauma to bones and tissues. We report the first known case of a break dancer with an ulnar stress fracture. Such injuries occur in a variety of sports due to substantial stress on the ulna and repetitive excessive rotation of the forearm. In this study we describe a patient who experienced an ulnar stress fracture during break dancing training. The diagnosis was established by history and physical examination. Initial radiographic findings were negative. However, radiographs taken 3 months after initial presented revealed callus formation over the ulnar shaft. This suggested that readjustment is required in break dancing training protocols. It is important to increase awareness of this injury among physicians to expedite the diagnosis and to prevent the possibility of conversion to an overt fracture in the future
Full Text Available Postpartum sacral stress fracture is a very rare clinical entity. Because of the ambiguous clinical and radiological findings, it is often diagnosed late. A case of a postpartal 25-year-old female patient presented with acute onset of low back pain radiating to the right extremity, mimicking lumbar radiculopathy. Magnetic resonance imaging of sacrum revealed a non-displaced stress fracture of the right sacral ala. The 25-hydroxy vitamine D level of the patient was very low; dual energy X-ray absorptiometry measurements were in the normal range. The patient is completely cured as a result of conservative treatment. As a result, sacrum stress fracture should be kept in mind in the presence of back pain during pregnancy and postpartum period.
Campos, Roberto E; Soares, Paulo V; Versluis, Antheunis; de O Júnior, Osmir Batista; Ambrosano, Gláucia M B; Nunes, Isabella Ferola
The outcomes from load-to-failure tests may not be applicable to clinical situations. The purpose of this study was to critically evaluate the efficacy of load-to-failure tests in the investigation of the fracture load and pattern of metal-free crowns. Four groups were formed from 128 bovine roots restored with metal posts, resin cores, and feldspathic, leucite, or lithium disilicate ceramic systems or polymer crowns. Each group was divided into 4 (n=8) according to the cement: zinc phosphate, self-adhesive resin, autopolymerizing resin, and glass ionomer. Mean fracture loads from compressive tests were submitted to ANOVA and Tukey HSD test. Finite element and fractographic analyses were performed and associated with the fracture load and pattern. Significantly higher fracture load values were obtained for the lithium disilicate ceramic, but finite element and fractographic analyses showed that the cement effect could not be determined. The finite element analysis showed the cement likely affected the fracture pattern, confirmed that stresses in the cements were little affected by the crown materials, and found that the stressed conditions were lowest in the lithium disilicate compared with other crowns for all cement combinations. The stressed conditions in the crowns depended more on the adhesive properties than on the elastic modulus of the cement materials. The level of the stressed condition in the crowns at the occlusal surface was about the same or higher than along their cement interface, consistent with the fractography, which indicated fractures starting at the load point. Higher stress levels in the crowns corresponded with a lower number of catastrophic fractures, and higher stresses in the cements seemed to reduce the number of catastrophic fracture patterns. The highest stressed conditions occurred along the occlusal surface for crown materials with a low elastic modulus or in combination with adhesive cements. The method used was not appropriate
Bone, L B; Sucato, D; Stegemann, P M; Rohrbacher, B J
A study of ninety-nine patients who had a unilateral, displaced, isolated closed fracture of the tibial shaft was performed to determine the effect of the type of treatment on the clinical outcome. Forty-seven patients were managed with closed intramedullary nailing with reaming, and fifty-two were managed with closed reduction and a cast. The two groups were comparable with regard to the ages of the patients, the locations and amounts of displacement of the fractures, and the number of patients who had a history of smoking. The time to union was shorter in the patients who had been managed with intramedullary nailing than in those who had been managed with a cast (mean, eighteen compared with twenty-six weeks; p = 0.02). A non-union occurred in one patient (2 per cent) who had been managed with nailing and in five patients (10 per cent) who had been managed with a cast. There were no infections in either group. Removal of the nail was performed electively in twenty-six patients. Twenty-five patients who had been managed with nailing and twenty-five who had been managed with a cast were followed for a mean of 4.4 years. With use of the Iowa Knee Evaluation and the Ankle-Evaluation Rating System, the patients who had had nailing had mean scores of 96 points (range, 68 to 100 points) and 97 points (range, 74 to 100 points) for the knee and the ankle, respectively, compared with 89 points (range, 62 to 100 points) and 84 points (range, 62 to 100 points) for those who had been managed with a cast (p nailing than after treatment with a cast (a mean of 85 points [range, 27 to 99 points] compared with a mean of 74 points [range, 20 to 97 points]; p treatment of displaced closed fractures of the tibial shaft with closed intramedullary nailing with reaming provides functional results that are superior to those obtained with use of a cast.
Henderson, J.; Ferguson, F.R.
The implementation of correct criterion in creep design, has been shown to be of fundamental significance in the assessment of component life. The present report considers the problem of the means whereby the criterion may be derived for a particular metal without the availability of sophisticated complex-stress testing equipment and procedures such as the combined tension and torsion tests on thin walled tubular specimens employed in the earlier fundamental researches on the subject. By investigating a wide spectrum of engineering metals it was established that for homogeneous stress conditions two criteria appeared to be sufficient to cover all the metals studied for complex-stress creep fracture, either the maximum principal stress or the octahedral shear stress criterion. Further, it was found that those metals which developed random and continuous cracking during creep were controlled with respect to fracture time by the maximum principal stress, while metals which showed virtually no cracking were governed by the octahedral shear stress or second order invariant. The physical nature of the final fracture (transcrystalline or inter-crystalline), contrary to considerable current concepts, was found to be unrelated to which criterion was operative. Having reduced the possible fracture criteria to two, it only remained to develop a simple test method exploiting this finding to achieve the precise identification for a particular metal. Seven metals including aluminium, copper, titanium, cast iron and three steels have been investigated in the present report at temperatures where creep conditions are operative. The results have shown that the method leads to sufficiently accurate prediction of the complex stress creep fracture criterion for the metals studied
Schütte, Kurt H; Seerden, Stefan; Venter, Rachel; Vanwanseele, Benedicte
Medial tibial stress syndrome (MTSS) is a common overuse running injury with pathomechanics likely to be exaggerated by fatigue. Wearable accelerometry provides a novel alternative to assess biomechanical parameters continuously while running in more ecologically valid settings. The purpose of this study was to determine the influence of outdoor running fatigue and MTSS on both dynamic loading and dynamic stability derived from trunk and tibial accelerometery. Runners with (n=14) and without (n=16) history of MTSS performed an outdoor fatigue run of 3200m. Accelerometer-based measures averaged per lap included dynamic loading of the trunk and tibia (i.e. axial peak positive acceleration, signal power magnitude, and shock attenuation) as well as dynamic trunk stability (i.e. tri-axial root mean square ratio, step and stride regularity, and sample entropy). Regression coefficients from generalised estimating equations were used to evaluate group by fatigue interactions. No evidence could be found for dynamic loading being higher with fatigue in runners with MTSS history (all measures p>0.05). One significant group by running fatigue interaction effect was detected for dynamic stability. Specifically, in MTSS only, decreases mediolateral sample entropy i.e. loss of complexity was associated with running fatigue (p<0.01). The current results indicate that entire acceleration waveform signals reflecting mediolateral trunk control is related to MTSS history, a compensation that went undetected in the non-fatigued running state. We suggest that a practical outdoor running fatigue protocol that concurrently captures trunk accelerometry-based movement complexity warrants further prospective investigation as an in-situ screening tool for MTSS individuals. Copyright © 2017 Elsevier B.V. All rights reserved.
Allen, J C; Lindsey, R W; Hipp, J A; Gugala, Z; Rianon, N; LeBlanc, A
Intramedullary nailing has become a standard treatment for adult tibial shaft fractures. Retained intramedullary nails have been associated with stress shielding, although their long-term effect on decreasing tibial bone mineral density is currently unclear. The purpose of this study was to determine if retained tibial intramedullary nails decrease tibial mineral density in patients with successfully treated fractures. Patients treated with statically locked intramedullary nails for isolated, unilateral tibia shaft fractures were studied. Inclusion required that fracture had healed radiographically and that the patient returned to the pre-injury activity level. Data on patient demographic, fracture type, surgical technique, implant, and post-operative functional status were tabulated. Dual energy X-ray absorptiometry was used to measure bone mineral density in selected regions of the affected tibia and the contralateral intact tibia. Image reconstruction software was employed to ensure symmetry of the studied regions. Twenty patients (mean age 43; range 22-77 years) were studied at a mean of 29 months (range 5-60 months) following intramedullary nailing. There was statistically significant reduction of mean bone mineral density in tibiae with retained intramedullary nails (1.02 g/cm(2) versus 1.06 g/cm(2); P=0.04). A significantly greater decrease in bone mineral density was detected in the reamed versus non-reamed tibiae (-7% versus +6%, respectively; Pnails. Intramedullary reaming appears to be a factor potentiating the reduction of tibia bone mineral density in long-term nail retention.
Full Text Available Objective: To report our experience with the hybrid external fixator in emergency. Methods:We assessed 80 cases of pilon fracture treated with the external fixator during the period of January 2009 and December 2016:55 men (69% and 30 women (33% with a mean age of 40 years (range between 16 and 70 . About 45 occurred as isolated trauma, 35 instead were politrauma. Each patient underwent standard radiographic examination and a CT examination. There were 28 open fractures (35%, (Gustilo type 1, 2 and 3 while closed fractures showed soft tissue involvement of various grade (2-3 Tscherne classification. In all cases, the external fixation, sometimes associated with other reduction and synthesis techniques, was used. The timing of surgery was dictated by the condition of the soft tissues. For clinical evaluation, the Mazur score with mean follow-ups at 12 months was utilized. Results: The final range of ankle motion was 15° dorsal and 10 plantar flexion. In about 80 cases there was an average Mazur score of83. The mean score was 90; in open fractures 85 to 72. Radiographic healing of fractures in 60 patients occurred in 120 days (mean 105 days, at the time when the external fixator was removed. Conclusion: Pilon fractures are complex and often present complications; the definitive treatment, in emergency or delayed, with hybrid external fixator permits a stable synthesis with minimal soft tissue damage. Weight bearing maybe allowed early and functional recovery is generally good.
Full Text Available Stress fracture of the ulna is a rare overuse injury often arising from repetitive excessive forearm rotation. Here we report the first case of ulnar stress fracture in a female ice dancer. Diagnosis was made by history and physical examination, with the aid of imaging studies (plain x-ray, computed tomography, and magnetic resonance imaging, and biomechanical analysis of forearm pronation and supination. Following identification and modification of the causal technical element, the ice dancer was able to continue training and competing without cessation of activity. Treatment was with a 30-day course of capacitively coupled bone stimulation to promote fracture healing, confirmed on radiography and magnetic resonance imaging. Such injuries to ice dancers may be prevented at the planning stage of technical elements in the dance program if coaches place more attention on the potentially deleterious effects of difficult positions the lifted dancer must sustain to reward points on the technical elements score.
Full Text Available We report a 45-year-old male archer with stress fracture in his left ulna on the background of adult type of hypophosphatasia. The patient presented to several medical centers for pain around the left elbow and received medical treatment upon diagnosis of tenosynovitis. History of the patient revealed that he had had diagnosis of hypophosphatasia ten years ago and underwent percutaneous screwing for stress fracture on both of his femoral necks. Upon finding nondisplaced stress fracture on proximal metaphysis of the ulna on X-ray, the patient underwent magnetic resonance imaging (MRI in order to exclude pathological causes. No additional pathology was observed in MRI scanning. The patient’s sportive activities were restricted for 6 weeks and he received conservative management with arm slings. Adult type of hypophosphatasia is a disease manifesting with widespread osteoporosis and presenting with low serum level of alkali phosphatase (ALP. Stress fracture should definitely be considered in the patients with history of hypophosphatasia and refractory extremity pain.
Full Text Available Abstract Objective To determine the relationship between lower extremity alignment and MTSS amongst non-professional athletes Design In a prospective Study, sixty six subjects were evaluated. Bilateral navicular drop test, Q angle, Achilles angle, tibial angle, intermalleolar and intercondylar distance were measured. In addition, runner's height, body mass, history of previous running injury, running experience was recorded. Runners were followed for 17 weeks to determine occurrence of MTSS. Results The overall injury rate for MTSS was 19.7%. The MTSS injury rate in girls (22% was not significantly different from the rate in boys (14.3%. Most MTSS injuries were induced after 60 hours of exercise, which did not differ between boys and girls. There was a significant difference in right and left navicular drop (ND in athletes with MTSS. MTSS had no significant correlation with other variables including Quadriceps, Tibia and Achilles angles, intercondylar and intermaleolar lengths and lower extremity lengths. Limitation All measurements performed in this study were uniplanar and static. The small sample size deemed our main limitation. The accurate assessment of participants with previous history of anterior leg pain for MTSS was another limitation. Conclusion Although a significant relationship between navicular drop and MTSS was found in this study; there was not any significant relationship between lower extremity alignment and MTSS in our sample study.
Chen, Yin-Ting; Tenforde, Adam S.; Fredericson, Michael
Stress fractures are a common type of overuse injury in athletes. Females have unique risk factors such as the female athlete triad that contribute to stress fracture injuries. We review the current literature on risk factors for stress fractures, including the role of sports participation and nutrition factors. Discussion of the management of stress fractures is focused on radiographic criteria and anatomic location and how these contribute to return to play guidelines. We outline the curren...
MacKinnon, M C; Bonder, D; Boston, R C; Ross, M W
There is limited information regarding the impact of training track surface on the occurrence of stress fractures. To evaluate the impact of training track surface on the proportion of long bone and pelvic stress fractures associated with lameness in Thoroughbred horses in flat race training undergoing nuclear scintigraphic examination. Retrospective study. Scintigraphic examinations of Thoroughbred flat racehorses were evaluated from 2 hospitals (hospital A [Toronto Equine Hospital], 2003-2009, and hospital B [George D. Widener Hospital for Large Animals, School of Veterinary Medicine, University of Pennsylvania], 1994-2006). Horses admitted to hospital A trained at a single track, at which the main training surface changed from dirt to synthetic on 27 August 2006. Two distinct populations existed at hospital B: horses that trained on dirt (numerous trainers) and those that trained on turf (single trainer). All scintigraphic images were evaluated by a blinded reviewer. Fisher's exact test and logistic regression were used when appropriate, and significance was set at Pfractures detected in scintigraphic examinations from horses training on a synthetic surface (31.7%) in comparison to scintigraphic examinations from horses training on a dirt surface (23.0%) at an earlier point in time (P = 0.03). There was a greater proportion of hindlimb/pelvic and tibial stress fractures diagnosed in horses from the synthetic surface-trained group than from the dirt-trained group at hospital A (Pfractures diagnosed, but other factors, such as training philosophy, appear to be important. Future prospective investigations to fully elucidate the relationship between training track surface and the proportion of stress fractures and other nonfatal musculoskeletal injuries are warranted. © 2014 EVJ Ltd.
Forman, Jordanna M; Urruela, Adriana M; Egol, Kenneth A
The purpose of this retrospective chart and radiographic review is to describe an effective reduction technique during intramedullary nailing of distal metaphyseal tibia fractures with the use of a pointed percutaneous clamp. Between 2007 and 2010, 100 patients who sustained 102 tibia fractures were definitively treated with an intramedullary nail at one of two medical centers. Diaphyseal fractures and injuries with an associated disruption of the distal tibiofibular joint were excluded from our study. A total of 27 patients with 27 distal metaphyseal tibia fractures (OTA types 42-A, 43-A, and 43-B) were included. All 27 patients underwent IM nailing of their fractures with anatomic reduction achieved using a percutaneously placed pointed reduction clamp prior to insertion of the IM implant. Fracture alignment and angular deformity was assessed using goniometric measurement functions on the PACS system (GE, Waukeshau, WI) obtained from preoperative and postoperative anteroposterior and lateral images for all subjects. Malalignment was defined as more than 5 degrees of angulation in any plane. Fourteen of the fractures were classified as OTA 42-A, 9 were OTA 43-A, and 4 were OTA 43-B. Analysis of post-closed reduction, preoperative anteroposterior radiographs revealed a mean of 7.9 degrees of coronal plane (range: 0.9 degrees-26 degrees) angulation. Post closed reduction preoperative lateral radiographs revealed a mean of 6.8 degrees sagittal plane (range: 0 degrees-24.6 degrees) angulation. Postoperative anteroposterior and lateral radiographs showed the distal segment returned to its anatomical alignment with a mean angulation of 0.5 degrees (range, 0 degrees-3.5 degrees) and 0.7 degrees (range, 0 degrees-4.2 degrees) of varus/ valgus and apex anterior/posterior angulation, respectively. These results showed an acceptable postopertative alignment in all 27 distal third fractures. No intra-operative or postoperative complications were noted in the study group. This
Guthrie, J W; Kalff, S
To evaluate the clinical and radiographic outcomes following surgical stabilisation of ilial fractures in dogs and cats using a laterally applied Synthes TPLO locking compression plate. Medical records and radiographs of seven dogs and two cats which had undergone surgical repair of an ilial body fracture with a TPLO locking compression plate were reviewed. Long-term clinical follow-up was obtained from an owner or referring veterinarian questionnaire. Fracture reduction was anatomic in six of nine ilia and near-anatomic in three of nine. All but one fracture achieved osseous union by 6 weeks after surgery. No screw loosening or implant-related complications occurred in any patient. There was pelvic canal narrowing in six of nine patients (median reduction in pelvic canal diameter was 4·9%). No intraoperative or postoperative complications were reported. Lateral plating of canine and feline ilial fractures with a Synthes TPLO locking compression plate was associated with a low complication rate and satisfactory radiographic and clinical outcomes in this small case series. © 2017 British Small Animal Veterinary Association.
Full Text Available Phil Newman, Jeremy Witchalls, Gordon Waddington, Roger Adams Faculty of Health, Physiotherapy, University of Canberra, Bruce, ACT, Australia Background: Medial tibial stress syndrome (MTSS affects 5%–35% of runners. Research over the last 40 years investigating a range of interventions has not established any clearly effective management for MTSS that is better than prolonged rest. At the present time, understanding of the risk factors and potential causative factors for MTSS is inconclusive. The purpose of this review is to evaluate studies that have investigated various risk factors and their association with the development of MTSS in runners. Methods: Medical research databases were searched for relevant literature, using the terms “MTSS AND prevention OR risk OR prediction OR incidence”. Results: A systematic review of the literature identified ten papers suitable for inclusion in a meta-analysis. Measures with sufficient data for meta-analysis included dichotomous and continuous variables of body mass index (BMI, ankle dorsiflexion range of motion, navicular drop, orthotic use, foot type, previous history of MTSS, female gender, hip range of motion, and years of running experience. The following factors were found to have a statistically significant association with MTSS: increased hip external rotation in males (standard mean difference [SMD] 0.67, 95% confidence interval [CI] 0.29–1.04, P10 mm (RR 1.99, 95% CI 1.00–3.96, P=0.05. Conclusion: Female gender, previous history of MTSS, fewer years of running experience, orthotic use, increased body mass index, increased navicular drop, and increased external rotation hip range of motion in males are all significantly associated with an increased risk of developing MTSS. Future studies should analyze males and females separately because risk factors vary by gender. A continuum model of the development of MTSS that links the identified risk factors and known processes is proposed
Tetsuo Hagino; Satoshi Ochiai; Yoshiyuki Watanabe; Shinya Senga; Yoshihiro Takayama; Hirotaka Haro
We report a case of cuboid bone stress fracture in a 17-year-old rugby athlete. Cuboid bone stress fractures are rare in athletes. When an athlete with no history of trauma presents with pain on the lateral side of the foot and no abnormality on plain radiograph, cuboid bone stress fracture should be suspected and magnetic resonance imaging should be conducted.
Moon, Tae Yong; Jung, Hyun Woo; Park, Chung Hun; Chun, Kyung Ah; Koo, Bong Sig; Lee, Sang Yong
To determine correlation between stress fracture of the posterior tibia and flexor digitorum longus muscle injury caused by athletic or sporting activity during adolescence. Eleven cases diagnosed as stress fracture after X-ray and MR imaging of the lower leg were reviewed. With regard to each fracture, the following features were noted : age, sex, and athletic or sporting activity of the patient, and site. Using MR imaging techniques, axial and sagittal T1 and T2 weighted imaged were obtained in all cases and T1-Gd DTPA images in seven. The activities undertaken were running (n=3), football (n=2), ballet (n=2), taekwando (n=1), badminton (n=1), field hockey (n=1), and basketball (n=1). MR images revealed localized cortical thickness (n=11), linear intramedullary callus showing a low signal on T1 and T2 weighted images (n=9), marrow hyperemia (n=7), and flexor digitorum longus muscle injury showing a high signal on T1-Gd DTPA and T2 weighted image (n=7). Stress fracture of the posterior tibia might be induced by flexor digitorum longus muscle activity induced by athletic or sporting activities during adolescence
Full Text Available Introduction: The purpose of this investigation was to evaluate the outcomes following reamer-irrigator-aspirator (RIA autogenous bone grafting (ABG of high-grade open tibia fracture nonunions stabilized via multiplanar external fixation. Methods: We retrospectively reviewed all patients with Gustilo-Anderson type III open tibia fractures treated with multiplanar external fixation and who underwent RIA ABG for nonunion at our institutional Level 1 Trauma Center between 2008 and 2015. All patients between 15 and 65 years of age with a minimum of six-month follow-up were included. The primary outcomes of interest were achievement of union, time to union, and incidence of revision surgery. Complications and all-cause reoperation were recorded as secondary endpoints. Results: Fifteen patients met the inclusion criteria with a mean age of 41.1 ± 14.0 years. RIA ABG was harvested from the femur in all cases, with a mean volume of 34 ± 15 mL. At an average follow-up of 13.3 ± 6.8 months, all patients achieved union, including two who required repeat RIA ABG. One patient experienced a femoral shaft fracture four months following RIA that required intramedullary fixation. The average time to union was 6.0 ± 6.3 months. Twelve patients (80% went on to union within six months and 13 (86.7% within one year. Five patients experienced a total of six post-operative complications including three deep infections, one refracture through the nonunion site, and one gradual varus deformity. Two patients in this series required a subsequent RIA autografting procedure secondary to persistent nonunion despite initial RIA. Conclusion: We found that RIA ABG offered a reliable solution to nonunion of Gustilo-Anderson type III open tibial fractures treated with multiplanar external fixation, circumventing the need to change the method of fixation.
O'Sullivan, S T
The patient with severe lower limb trauma presents a management dilemma; whether to amputate primarily or to attempt limb salvage. In recent years, many predictive indices have been published which purport to identify limbs which are non-viable. We retrospectively applied two recently described indices, the Mangled Extremity Severity Score (MESS) and the Limb Salvage Index (LSI), to 54 limbs in 50 patients with either Gustilo IIIB or IIIC complex tibial fractures. There were 22 amputations (40.7 per cent) in the series. The mean MESS score in the limb salvage group was 3.8 (range 2-10), and the mean MESS score in the amputation group was 7.7 (range 4-13) (P < 0.0001). The mean LSI score in the limb salvage group was 3.6 (range 3-8), and the mean LSI score in the amputation group was 6.9 (P < 0.01). However, in the group with MESS scores > 7 (which recommends amputation), there were three limbs which were salvaged with acceptable functional outcome. Similarly, in those with LSI scores > 6 (which recommends amputation), there were seven limbs successfully salvaged. A MESS > 7 offered a greater relative risk of amputation (9.2) than a LSI score > 6 (5.3). We found both indices of use in predicting limb salvage and functional outcome. However, neither is sufficiently accurate to be considered absolutely reliable in clinical practice.
Full Text Available Volume fracturing in shale gas forms complex fracture networks and increases stimulated reservoir volume through large-scale fracturing operation with plug-perforation technology. However, some perforation clusters are stimulated unevenly after fracturing. This study aims to solve this problem by analyzing the shortcomings of the conventional fracturing model and developing a coupled model based on the 2D fracture motion equation, energy conservation law, linear elastic mechanics, and stress superposition principle. First, a multi-fracture in-situ stress model was built by studying the induced stress produced by the fracture initiation to deduce the multi-fracture induced stress impact factor on the basis of the stress superposition principle. Then, the classical Perkins–Kern–Nordgren model was utilized with the crustal stress model. Finally, a precise fracturing design method was used to optimize perforation and fracturing parameters under the new model. Results demonstrate that the interference effect among fractures is the major factor causing the non-uniform propagation of each fracture. Compression on the main horizontal stress increases the net pressure. Therefore, both the degree of operation difficulty and the complexity of fracture geometry are improved. After applying the optimal design, the production is increased by 20%, and the cost is reduced by 15%.
Discussion: Our study results indicate a superiority of IMN over LP in terms of lower rates of infections and statistically significant shorter time to full weight bearing. Whereas LP appeared to be advantageous over IMN in terms of leading to a better anatomical and fixed reductions of the fracture and a lower rate of union complications. The two treatments achieved comparable results in terms of operation time, hospital stay, union time and functional outcomes.
Taketomi, Shuji; Uchiyama, Eiji; Iwaso, Hiroshi
Stress fracture of the anterior process of the calcaneus is rare. We present a case of a 14-year-old female basketball player who suffered a stress fracture of the anterior process of the calcaneus that was not associated with a calcaneonavicular coalition. After conservative treatment failed, drilling of the fracture site was required to facilitate healing. A possible cause of this rare type of stress fracture seemed to be a long anterior process of the calcaneus. Therapeutic, Level IV: Case study.
Derek Elsworth; Abraham S. Grader; Chris Marone; Phillip Halleck; Peter Rose; Igor Faoro; Joshua Taron; André Niemeijer; Hideaki Yasuhara
This work has investigated the interactions between stress and chemistry in controlling the evolution of permeability in stimulated fractured reservoirs through an integrated program of experimentation and modeling. Flow-through experiments on natural and artificial fractures in Coso diorite have examined the evolution of permeability under paths of mean and deviatoric stresses, including the role of dissolution and precipitation. Models accommodating these behaviors have examined the importance of incorporating the complex couplings between stress and chemistry in examining the evolution of permeability in EGS reservoirs. This document reports the findings of experiment [1,2] and analysis [3,4], in four sequential chapters.
Lyon, Thomas; Scheele, Wim; Bhandari, Mohit; Koval, Kenneth J; Sanchez, Eduardo Gomez; Christensen, Jared; Valentin, Alexandre; Huard, Francois
Recombinant human bone morphogenetic protein-2 (rhBMP-2) applied on an absorbable collagen sponge improves open tibial fracture-healing as an adjunct to unreamed intramedullary nail fixation. We evaluated rhBMP-2 and a new, injectable calcium phosphate matrix (CPM) formulation in acute closed tibial diaphyseal fractures treated with reamed intramedullary nail fixation. Patients were randomized (1:2:2:1) to receive standard of care, which consisted of definitive fracture fixation within seventy-two hours of injury with a locked intramedullary nail after reaming; standard of care and injection with 1.0 mg/mL of rhBMP-2/CPM; standard of care and injection with 2.0 mg/mL of rhBMP-2/CPM; or standard of care and injection with buffer/CPM, to evaluate the activity of the CPM delivery matrix and provide for sponsor and investigator blinding. The co-primary end points of the study were the effects of rhBMP-2/CPM on the time to fracture union (based on blinded assessment of radiographs) and the time to return to normal function (based on blinded assessment of the time to full weight-bearing without pain at the fracture site) compared with standard of care alone. Three hundred and sixty-nine patients were randomized and included in the intent-to-treat population. This study was terminated after an interim analysis (180 patients with six months of follow-up) revealed no shortening in the time to fracture union in the active treatment arms compared with the standard of care control (the SOC group). In the final primary analysis, the median time to radiographic fracture union was not significantly different for the SOC (13.1 weeks), 1.0-mg/mL rhBMP-2/CPM (13.0 weeks), 2.0-mg/mL rhBMP-2/CPM (15.9 weeks), or buffer/CPM (15.4 weeks) treatment groups. The median time to pain-free full weight-bearing was also not significantly different among the SOC (13.4 weeks), 1.0-mg/mL rhBMP-2/CPM (13.4 weeks), 2.0-mg/mL rhBMP-2/CPM (14.3 weeks), and buffer/CPM (16.4 weeks) treatment groups. In
Williams, T.R. [Portsmouth Naval Medical Center, Radiology Department, Charette Health Care Center, Portsmouth, VA (United States); Puckett, M.L.; Shin, A.Y.; Gorman, J.D. [Naval Medical Center San Diego, Radiology Department, San Diego, CA (United States); Denison, G. [US Naval Hospital Guam (United States)
Objective: To evaluate the incidence and the MRI and scintigraphic appearance of acetabular stress (fatigue) fractures in military endurance athletes and recruits. Design and patients: One hundred and seventy-eight active duty military endurance trainees with a history of activity-related hip pain were evaluated by both MRI and bone scan over a 2-year period. Patients in the study ranged in age from 17 to 45 years. They had hip pain related to activity and had plain radiographs of the hip and pelvis that were interpreted as normal or equivocal. The study was originally designed to evaluate the MRI and scintigraphic appearance of femoral neck stress fractures. Patients had scintigraphy and a limited MRI examination (coronal imaging only) within 48 h of the bone scan. Twelve patients demonstrated imaging findings compatible with acetabular stress fractures. Results: Stress fractures are common in endurance athletes and in military populations; however, stress fracture of the acetabulum is uncommon. Twelve of 178 patients (6.7%) in our study had imaging findings consistent with acetabular stress fractures. Two patterns were identified. Seven of the 12 (58%) patients had acetabular roof stress fractures. In this group, two cases of bilateral acetabular roof stress fractures were identified, one with a synchronous tensile sided femoral neck stress fracture. The remaining five of 12 (42%) patients had anterior column stress fractures, rarely occurring in isolation, and almost always occurring with inferior pubic ramus stress fracture (4 of 5, or 80%). One case of bilateral anterior column stress fractures was identified without additional sites of injury. Conclusions: Stress fractures are commonplace in military populations, especially endurance trainees. Acetabular stress fractures are rare and therefore unrecognized, but do occur and may be a cause for activity-related hip pain in a small percentage of military endurance athletes and recruits. (orig.)
Miller, Timothy L; Jamieson, Marissa; Everson, Sonsecharae; Siegel, Courtney
Few studies have documented expected time to return to athletic participation after stress fractures in elite athletes. Time to return to athletic participation after stress fractures would vary by site and severity of stress fracture. Retrospective cohort study. Level 3. All stress fractures diagnosed in a single Division I collegiate men's and women's track and field/cross-country team were recorded over a 3-year period. Site and severity of injury were graded based on Kaeding-Miller classification system for stress fractures. Time to return to full unrestricted athletic participation was recorded for each athlete and correlated with patient sex and site and severity grade of injury. Fifty-seven stress fractures were diagnosed in 38 athletes (mean age, 20.48 years; range, 18-23 years). Ten athletes sustained recurrent or multiple stress fractures. Thirty-seven injuries occurred in women and 20 in men. Thirty-three stress fractures occurred in the tibia, 10 occurred in the second through fourth metatarsals, 3 occurred in the fifth metatarsal, 6 in the tarsal bones (2 navicular), 2 in the femur, and 5 in the pelvis. There were 31 grade II stress fractures, 11 grade III stress fractures, and 2 grade V stress fractures (in the same patient). Mean time to return to unrestricted sport participation was 12.9 ± 5.2 weeks (range, 6-27 weeks). No significant differences in time to return were noted based on injury location or whether stress fracture was grade II or III. The expected time to return to full unrestricted athletic participation after diagnosis of a stress fracture is 12 to 13 weeks for all injury sites. Athletes with grade V (nonunion) stress fractures may require more time to return to sport.
Williams, T.R.; Puckett, M.L.; Shin, A.Y.; Gorman, J.D.; Denison, G.
Objective: To evaluate the incidence and the MRI and scintigraphic appearance of acetabular stress (fatigue) fractures in military endurance athletes and recruits. Design and patients: One hundred and seventy-eight active duty military endurance trainees with a history of activity-related hip pain were evaluated by both MRI and bone scan over a 2-year period. Patients in the study ranged in age from 17 to 45 years. They had hip pain related to activity and had plain radiographs of the hip and pelvis that were interpreted as normal or equivocal. The study was originally designed to evaluate the MRI and scintigraphic appearance of femoral neck stress fractures. Patients had scintigraphy and a limited MRI examination (coronal imaging only) within 48 h of the bone scan. Twelve patients demonstrated imaging findings compatible with acetabular stress fractures. Results: Stress fractures are common in endurance athletes and in military populations; however, stress fracture of the acetabulum is uncommon. Twelve of 178 patients (6.7%) in our study had imaging findings consistent with acetabular stress fractures. Two patterns were identified. Seven of the 12 (58%) patients had acetabular roof stress fractures. In this group, two cases of bilateral acetabular roof stress fractures were identified, one with a synchronous tensile sided femoral neck stress fracture. The remaining five of 12 (42%) patients had anterior column stress fractures, rarely occurring in isolation, and almost always occurring with inferior pubic ramus stress fracture (4 of 5, or 80%). One case of bilateral anterior column stress fractures was identified without additional sites of injury. Conclusions: Stress fractures are commonplace in military populations, especially endurance trainees. Acetabular stress fractures are rare and therefore unrecognized, but do occur and may be a cause for activity-related hip pain in a small percentage of military endurance athletes and recruits. (orig.)
Dec 2, 2005 ... triplane fracture was described for the distal tibial physis, and is presumed to result from a combination of shear and rotational stresses on the incompletely fused growth plate15,16. Triplane fractures have also been described for other epiphyses: proximal tibia17, distal humerus18, distal radius19, and in ...
Full Text Available While 22 articles have reported on sacral stress fractures, it is a rare injury and its etiology is not well known. We present the case of a 16-year-old male who presented with low back pain in 2015. He was a high school soccer player with a previous history of a bilateral L5 lumbar spondylolysis in 2014. The patient refrained from soccer and wore a brace for six months. Two months after restarting soccer, he again complained of low back pain. After 1 year, a lumbar spine computed tomography revealed the bone union of the spondylolysis. At his first visit to our hospital, his general and neurological conditions were normal and laboratory data were within the normal range. Sacral coronal magnetic resonance imaging (MRI of the left sacral ala revealed an oblique lineal signal void surrounding bone marrow edema. Based on his symptoms, sports history, and MRI, he was diagnosed with a sacral stress fracture. He again refrained from soccer; his low back pain soon improved, and, after 1 year, the abnormal signal change had disappeared on sacral MRI. Recurrent low back pain case caused by a sacral stress fracture occurring after the bone union of lumbar spondylolysis is uncommon.
.... Pulsing electromagnetic fields (PEMFs)have been shown to speed the healing of non-union fractures and we have used them successfully to treat stress fractures in the lower limbs. All women at Ft...
Tornese, Davide; Curci, Domenico; Nardo, Alice; Cuccia, Alessandra; Pozzi, Grazia
Stress fracture of the ulna is a rare overuse injury often arising from repetitive excessive forearm rotation. Here we report the first case of ulnar stress fracture in a female ice dancer. Diagnosis was made by history and physical examination, with the aid of imaging studies (plain x-ray, computed tomography, and magnetic resonance imaging), and biomechanical analysis of forearm pronation and supination. Following identification and modification of the causal technical element, the ice dancer was able to continue training and competing without cessation of activity. Treatment was with a 30-day course of capacitively coupled bone stimulation to promote fracture healing, confirmed on radiography and magnetic resonance imaging. Such injuries to ice dancers may be prevented at the planning stage of technical elements in the dance program if coaches place more attention on the potentially deleterious effects of difficult positions the lifted dancer must sustain to reward points on the technical elements score. Key pointsThe technical elements in ice dancing can overload joints and bones due to the positions held by the skaters.To project a competition program as much as possible safe regarding overuse injury prevention an accurate knowledge of physiological parameters of the ice dancer and of ISU rules is necessary.
Roche Vincent; van der Baan Mirko; Preisig Giona
Hydraulic fracture growth is simulated in homogeneous granite with a fully coupled hydromechanical discrete element method. Three models are considered namely an intact rock and two models with pre existing fractures connected or disconnected to the incipient hydraulic fracture plane. In all scenarios the hydraulic fracture grows in a plane with a mostly circular front despite anisotropic stresses. In the intact rock and disconnected models a hydraulic fracture propagates normal to the minimu...