tag:blogger.com,1999:blog-36087889350397945562024-03-05T20:47:41.038-08:00Case of the Month: Fracture cases at Harborview Medical Center, University of Washington in SeattleThis blog highlights interesting, unusual, or complex fracture cases that were treated at or referred to the Orthopaedic Trauma Surgery Service at Harborview Medical Center, University of Washington in Seattle, Washington.Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.comBlogger19125tag:blogger.com,1999:blog-3608788935039794556.post-17089062460035597812012-09-01T23:56:00.001-07:002012-09-02T00:02:53.170-07:00Irreducible Femoral Head Fracture-Dislocation<!--[if !mso]>
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</b></span></div>
<h2>
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: large; line-height: 21px;">September 2012: Treatment of Irreducible Femoral Head Fracture-Dislocation</span></h2>
<div align="center" class="MsoNormal" style="text-align: center;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><span style="line-height: 115%;">This month's trauma case of the month was submitted by </span><span class="Apple-style-span"><span style="line-height: 21px;"><a href="http://www.orthop.washington.edu/?q=faculty-profiles/ml-chip-routt-jr-md.html" style="font-weight: bold;" target="_blank">M.L. Chip Routt, Jr.,M.D.</a><b> </b>and features the case of a</span><span class="Apple-style-span" style="font-weight: normal; line-height: 21px;"> 55 years old male police officer was injured in a
motorcycle crash. At the accident scene, he complained of severe right hip pain.
He presented to the emergency room with similar complaints. His vitals signs
were stable. On physical exam, his pelvic ring was stable but he was unable to
actively move his right lower extremity due to hip discomfort. There were no
obvious deformities. The injured hip was very slightly flexed and abducted, and
in neutral rotation. The remainder of his exam was normal including his
peripheral neurological assessment. The paramedics had applied a
<a href="http://www.orthop.washington.edu/?q=patient-care/articles/trauma/traumatology-biosketches.html" target="_blank">circumferential pelvic</a> binder at the accident scene.</span></span></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">A screening pelvic anteroposterior radiograph identified a
right hip fracture-dislocation. The binder was removed and the patient then
underwent a <a href="http://www.orthop.washington.edu/orthodev/drupal/sites/default/files/2012rr.pdf" target="_blank">pelvic computed tomography</a> with reconstructed oblique images.<span style="mso-spacerun: yes;"> </span>A displaced and comminuted femoral head
fracture-dislocation along with a peripheral posterior wall acetabular fracture
were noted on the imaging. The pelvic ring and the femoral necks were uninjured.
The screening AP film was obtained with the binder in place.<o:p></o:p></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjk_7BqxreK3pcvtbi9sihiiAyeFAmmTq6d22JV6bY7ZGc98PGdt3TIUteuPjwdg5THguYEnKphcg0hRaKu16GGGOiqBtJ15uayaFvvHp0OYnw5exkpO5LD1-2xlfvnXI7jIqdSOdicASI/s1600/Femoral+Head+Fracture+1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="222" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjk_7BqxreK3pcvtbi9sihiiAyeFAmmTq6d22JV6bY7ZGc98PGdt3TIUteuPjwdg5THguYEnKphcg0hRaKu16GGGOiqBtJ15uayaFvvHp0OYnw5exkpO5LD1-2xlfvnXI7jIqdSOdicASI/s320/Femoral+Head+Fracture+1.jpg" width="320" /></span></a></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">The obturator and iliac oblique reconstructed images from the
CT scan demonstrate the close apposition of the dislocated proximal femur to
the cortical surface of the acetabular posterior wall. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPFgzriN1W3485PXZPl7OSzYq8RIHALxAnqHQcHWeSAM50A0-58f3Fo_1EWa219wLMUl7zgBDjVRsBr7lkG1qK24NXsB66ydg5x9PeS2iBhsxkhNPoPJswUW4u_pkdxNGRuE8vVdWYyUA/s1600/Femoral+Head+Fracture+2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="223" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPFgzriN1W3485PXZPl7OSzYq8RIHALxAnqHQcHWeSAM50A0-58f3Fo_1EWa219wLMUl7zgBDjVRsBr7lkG1qK24NXsB66ydg5x9PeS2iBhsxkhNPoPJswUW4u_pkdxNGRuE8vVdWYyUA/s320/Femoral+Head+Fracture+2.jpg" width="320" /></span></a></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJIDK4F5XUFnFVElRSgqZA2b0ECRo_mNfyAikJHq2M5hEeYFCurI9AOmDMXNT-CxxKXwu4hymrc85_mVuny7nkhdGXlesGMrzlh2lPz6R8yYEaVuA-GCY0SeOsg4AWpIaXQFQ1JeeFtRU/s1600/Femoral+Head+Fracture+3.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="229" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJIDK4F5XUFnFVElRSgqZA2b0ECRo_mNfyAikJHq2M5hEeYFCurI9AOmDMXNT-CxxKXwu4hymrc85_mVuny7nkhdGXlesGMrzlh2lPz6R8yYEaVuA-GCY0SeOsg4AWpIaXQFQ1JeeFtRU/s320/Femoral+Head+Fracture+3.jpg" style="cursor: move;" width="320" /></span></a></div>
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">The outlet pelvic reconstructed image is very interesting
since the <a href="http://www.orthop.washington.edu/orthodev/drupal/sites/default/files/Portals/21/www/Research/Publications/Research%20Reports/Research%20Report%202002.pdf" target="_blank">dislocated proximal femur </a>and acetabulum are nearly perfectly superimposed.
The diagnosis could be missed if this particular image was used alone.<o:p></o:p></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0sodnc_utEx6ncw79NFvr06ClRKEGqduaIy_3wN2Z60cWDnk7pAVK70V5HoNsqdC0tW8lXcx-T6tCGh-eurkcO-jd9O71hj-3zcHeiZhn8n8WE33Xex0zTgA4sS4Un0GCR9OOpX8AQGc/s1600/Femoral+Head+Fracture+4.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="214" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0sodnc_utEx6ncw79NFvr06ClRKEGqduaIy_3wN2Z60cWDnk7pAVK70V5HoNsqdC0tW8lXcx-T6tCGh-eurkcO-jd9O71hj-3zcHeiZhn8n8WE33Xex0zTgA4sS4Un0GCR9OOpX8AQGc/s320/Femoral+Head+Fracture+4.jpg" width="320" /></span></a></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal" style="display: inline !important;">
<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">The inlet pelvic image also shows the dislocation and tight
relationship of the dislocated proximal femur and the posterior acetabulum
cortical surface, alerting the treating physician to the possibility of an
irreducible injury using standard closed manipulative techniques.</span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj93ZCIk7kHeecSqsScUJpOah1K94JXbbNTJFq0MY3m_N-UYBHy0Q6JLv4c01xoRQCzN6rip48aMtq0rblp6FttelR77J4UbDuQyc4hHj5rVoY9gTZPn164f5rZNkqTaFD9VAXYDkawvr4/s1600/Femoral+Head+Fracture+5.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="216" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj93ZCIk7kHeecSqsScUJpOah1K94JXbbNTJFq0MY3m_N-UYBHy0Q6JLv4c01xoRQCzN6rip48aMtq0rblp6FttelR77J4UbDuQyc4hHj5rVoY9gTZPn164f5rZNkqTaFD9VAXYDkawvr4/s320/Femoral+Head+Fracture+5.jpg" width="320" /></span></a></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">The axial CT image indicates the injury details including but
not limited to dislocation direction, femoral head fracture extent and
comminution, acetabular posterior wall injury, loose fragments within the
joint, the overall bone quality, patient body habitus, underlying conditions
such as <a href="http://www.orthop.washington.edu/?q=patient-care/articles/what-is-hip-replacement-a-review-of-total-hip-arthroplasty.html" target="_blank">inguinal hernia</a>, pelvic ring and soft tissue assessment, and status of
the femoral neck.<o:p></o:p></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTiTXKCEYAJLCWkxCMRjJXJx2ioAMWwyXvkHy4_nyx6_DxBTQYws33MGwGG2Bg0Vb5J_ud85f8VqNOKd3QhJIe7kNhm14J3thR9y_Ajqk7PdYgPSV4QwTyppC2oTiTubaV5MYBCuJ8YDU/s1600/Femoral+Head+Fracture+6.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="239" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiTiTXKCEYAJLCWkxCMRjJXJx2ioAMWwyXvkHy4_nyx6_DxBTQYws33MGwGG2Bg0Vb5J_ud85f8VqNOKd3QhJIe7kNhm14J3thR9y_Ajqk7PdYgPSV4QwTyppC2oTiTubaV5MYBCuJ8YDU/s320/Femoral+Head+Fracture+6.jpg" width="320" /></span></a></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">Despite the radiographic indicators of a femoral head
fracture dislocation that would likely be irreducible using standard closed
manipulation techniques, the patient was counseled and opted for an attempted
closed reduction. He was sedated with sufficient intravenous medications only
after consenting to closed and potential urgent open reduction as needed. The
attempted manipulative closed reduction was unsuccessful and the hip
essentially had no movement. The attending orthopedic surgeon on call had
performed the manipulative closed reduction but failed to move the hip. He
noted that the injured hip felt “fixed and stable”. He concluded that despite
more than adequate sedation, the hip injury was irreducible using closed
reduction methods.</span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><div class="MsoNormal" style="display: inline !important;">
<span style="line-height: 115%;">The patient was then taken urgently to the operating room
where general anesthesia with full muscle relaxation was provided to the
patient, and he was positioned supine on a radiolucent operating table. Using
real time fluoroscopic guidance, the hip was imaged during a careful manipulative
attempted reduction, but the dislocated proximal femur was essentially fixed in
its position.</span></div>
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<br /></div>
</span><div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">An open reduction was then performed. The patient was
elevated from the table on two folded blankets placed posterior to the sacrum.
The entire abdomen and right lower extremity were prepped and draped carefully
after the perineum had been cleansed and isolated form the planned surgical
field. Intravenous antibiotics were administered and a modified Smith-Petersen
anterior surgical exposure of the hip was accomplished. <o:p></o:p></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgSayxpzVjUeleoxJWrOyxDfNqwW8gHj73SiAuOI3btChgsxZNAnpFxcXjUYwo6GQ2PZOh26UAg8VoSIfr0APfqdM2O5TJoUpUjO_vgKKxmXgwzLqyilRfCohBQk_beVHx8P_VM3wJox9Y/s1600/Femoral+Head+Fracture+7.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="239" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgSayxpzVjUeleoxJWrOyxDfNqwW8gHj73SiAuOI3btChgsxZNAnpFxcXjUYwo6GQ2PZOh26UAg8VoSIfr0APfqdM2O5TJoUpUjO_vgKKxmXgwzLqyilRfCohBQk_beVHx8P_VM3wJox9Y/s320/Femoral+Head+Fracture+7.jpg" width="320" /></span></a></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal" style="display: inline !important;">
<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">The 10cms incision began in the region of the anterior
superior iliac spine and paralleled the interval between the tensor and
sartorius muscles.</span></div>
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<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiarzGSzj04hMK37lJhiBoSonvhjslBPLyBjKmwvXpJ37zsdmJtQdDRLPjSG-7M1RekRJgO0oCS478a2yZbyRIxS_HvzmbJj2ZkD3avy3T4wehiuWpuyEfZ19_vQoltTWAV5KfvP6eOgxI/s1600/Femoral+Head+Fracture+8.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiarzGSzj04hMK37lJhiBoSonvhjslBPLyBjKmwvXpJ37zsdmJtQdDRLPjSG-7M1RekRJgO0oCS478a2yZbyRIxS_HvzmbJj2ZkD3avy3T4wehiuWpuyEfZ19_vQoltTWAV5KfvP6eOgxI/s320/Femoral+Head+Fracture+8.jpg" width="320" /></span></a></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><div class="MsoNormal" style="display: inline !important;">
<span style="line-height: 115%;">The rectus femoris muscle common tendon was isolated.</span></div>
<div class="MsoNormal" style="display: inline !important;">
<br /></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiDO6x5rwTwNntIXa5TPdXi99a1wF5K6932B2jvT5xzmB1lzVokm7P8wNinV6dm7xAcUu3t1uIfY7zK6qWDxG_2EdnM97SFTdyxa87gCO-CCZ9WJvxMnui9FUYm1Nw8PjbMzmhOyiRFiQI/s1600/Femoral+Head+Fracture+9.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiDO6x5rwTwNntIXa5TPdXi99a1wF5K6932B2jvT5xzmB1lzVokm7P8wNinV6dm7xAcUu3t1uIfY7zK6qWDxG_2EdnM97SFTdyxa87gCO-CCZ9WJvxMnui9FUYm1Nw8PjbMzmhOyiRFiQI/s320/Femoral+Head+Fracture+9.jpg" width="320" /></span></a></div>
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<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">Next the rectus femoris common tendon was incised leaving a
stump for later repair. The rectus femoris tendon was tagged with a suture
distally and the muscle belly was retracted distally.<o:p></o:p></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8nNrw2wMrK0bX5A6759inhfW3gIEvEn0UqaZ2IS1EwwG_vhbh_-YUmmOhC0MUO77mO5KkjIbQ-CtXvb54evi4tLnqidDvflxiO2-tPWH0Ii1IhJ2yQfKzAqgIqs16HB2ooPcaOKolpzg/s1600/Femoral+Head+Fracture+10.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8nNrw2wMrK0bX5A6759inhfW3gIEvEn0UqaZ2IS1EwwG_vhbh_-YUmmOhC0MUO77mO5KkjIbQ-CtXvb54evi4tLnqidDvflxiO2-tPWH0Ii1IhJ2yQfKzAqgIqs16HB2ooPcaOKolpzg/s320/Femoral+Head+Fracture+10.jpg" width="320" /></span></a></div>
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<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">The anterior hip capsule was easily exposed completely by
elevating the lateral<span style="mso-spacerun: yes;"> </span>portion of the
iliocapsularis muscle from it. The anterior capsule was completely intact. An
oblique T-shaped capsulotomy was then used to expose the hip joint. The upper
limb paralleled the uninjured anterior labrum and the lower limb paralleled the
normal position of the femoral neck. <o:p></o:p></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPDiuwOjZBrHR0kGfP8DZLsySNQtwx2Ay66qp8O88Ouun7FgExsU2c46rNirSVLfQMr8tTi2d-Xzmli8E97y21FEwoO1x1AVOS8nJegU1sPjS9kgTbipxd20xQzZyqaftYTfOvAx5bSN0/s1600/Femoral+Head+Fracture+11.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="272" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPDiuwOjZBrHR0kGfP8DZLsySNQtwx2Ay66qp8O88Ouun7FgExsU2c46rNirSVLfQMr8tTi2d-Xzmli8E97y21FEwoO1x1AVOS8nJegU1sPjS9kgTbipxd20xQzZyqaftYTfOvAx5bSN0/s320/Femoral+Head+Fracture+11.jpg" width="320" /></span></a></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">Retraction of the T-shaped capsulotomy revealed the injury,
related hematoma, femoral head fracture fragments, otherwise empty acetabulum, and
the posteriorly dislocated proximal femur. The femoral head fracture fragments
were removed from the acetabulum and placed in a blood-saline soaked sponge in
a protected area of the surgical assistant’s instrument table. The acetabulum
was then thoroughly inspected visually including palpation of the anterior wall
area to assure that there were no remaining bone cartilage, or other tissue
fragments in the joint.<span style="mso-spacerun: yes;"> </span>Then looking
through the acetabulum, the posterior wall fracture and posterior labral
injuries were easily seen. Very taut tendon structures were identified between
the posterior wall area and the dislocated proximal femur. These tissues were
located anterior to the femoral neck and were visualized through the wound.
They were obstructing manual manipulation attempts. When traction was applied
to the limb, these tendons became extremely tight and prevented all but minimal
movement of the proximal femur. The sciatic nerve was noted on deeper
inspection of the wound to be medial and posterior relative to the dislocated
proximal femur. The tight tendons directly anterior to the femoral neck were
then incised and the dislocated proximal femur became mobile immediately. Tight
<a href="http://www.orthop.washington.edu/?q=patient-care/articles/arthritis/surgical-release-for-stiff-frozen-shoulders.html" target="_blank">capsular tissues</a> were then incised along the cranial aspect of the dislocated
femoral head fracture surface and under direct visualization through the wound,
the dislocated proximal femur was carefully and easily reduced into the acetabulum
using manual traction on the lower limb. C-arm orthoganol fluoroscopy was used
at this point to assure a congruent relationship between the reduced proximal
femur and the acetabulum.</span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">The femoral head fracture fragment was then prepared for
reduction and fixation on the surgical assistant’s table. The cancellous
surface hematoma and loose debris were removed. Three glide holes were then
drilled through the femoral head fracture fragment perpendicular to the
fracture plane. These were positioned caudally on the femoral head fracture
fragment and with sufficient separation between the glide holes to allow stable
fixation. The depth of the cartilage was identified to plan for countersinking
of the screw heads. <o:p></o:p></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjU-cwHPd_ZqdwYN1BB81EdHyH_2A_4TcBcqr2U9BFR6_1QuHa83jzGqNOScUJk_kLbSv6G6Neg0Ui9PyQ2djZwHMO6PYNPkiQJtPw3SbMZgRgkx_q5W9ATEgN1Os24gNGtK7aw7xZqmRE/s1600/Femoral+Head+Fracture+12.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjU-cwHPd_ZqdwYN1BB81EdHyH_2A_4TcBcqr2U9BFR6_1QuHa83jzGqNOScUJk_kLbSv6G6Neg0Ui9PyQ2djZwHMO6PYNPkiQJtPw3SbMZgRgkx_q5W9ATEgN1Os24gNGtK7aw7xZqmRE/s320/Femoral+Head+Fracture+12.jpg" width="320" /></span></a></div>
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<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">The proximal femur was then atraumatically manipulated and
surgically dislocated anteriorly through the oblique T-shaped capsulotomy so
the femoral head fracture fragment could be reduced under direct visualization
onto the proximal femur. Narrow diameter wires inserted through the area of the
fovea centralis held the reduction initially, the pathways drilled, and then
small fragment screws were inserted using the glide holes. Chondral surface
comminution and missing cartilage of the cranial femoral head area made that
aspect of the reduction challenging, but the caudal cortical fracture surfaces
were used to guide the reduction. The temporary wires were removed and the hip
was carefully relocated. <o:p></o:p></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhrTGfnk06ZCjogm7m67sIGeQm6-0vpWH40wtXM9LiutYfWCIXFnGkWdXTg_zTwDAKtlm2AREYqI6okD1QTotLtfWyQmbbXBTxtPYlcoUuionXVznB1xLlTu9ZMLlq4bJwf13KcfdBXaOw/s1600/Femoral+Head+Fracture+13.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhrTGfnk06ZCjogm7m67sIGeQm6-0vpWH40wtXM9LiutYfWCIXFnGkWdXTg_zTwDAKtlm2AREYqI6okD1QTotLtfWyQmbbXBTxtPYlcoUuionXVznB1xLlTu9ZMLlq4bJwf13KcfdBXaOw/s320/Femoral+Head+Fracture+13.jpg" width="320" /></span></a></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><span style="line-height: 115%;">Intraoperative fluoroscopy confirmed the reduction accuracy
and screw locations. Dynamic real time C-arm images showed that the screws were
completely contained within the bone and did not extrude. The hip joint was
stressed to extremes of passive motion (including full flexion, adduction,
internal rotation) while observing the fluoroscopic imaging to assure
stability. The peripheral posterior wall and capsular avulsion injuries were
treated without surgical stabilization. After throrough irrigation of the wound
and hip joint, the T-shaped capsulotomy and the rectus femoris tenotomy were
repaired.</span><span style="line-height: 115%;"> </span></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiufDm9dV1rrF9Wpvs9TlmyXUgBueB5Arwtx04Hc1cwoWDy1UN26mZTymzfd6vhnB5TerTKBdXcoRQP9ktsbtSLtYqpglEnkF9h8fOCCApXgW6dj3mRIEDdB0kGcOemYsguWDImkQFq7I4/s1600/Femoral+Head+Fracture+14.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiufDm9dV1rrF9Wpvs9TlmyXUgBueB5Arwtx04Hc1cwoWDy1UN26mZTymzfd6vhnB5TerTKBdXcoRQP9ktsbtSLtYqpglEnkF9h8fOCCApXgW6dj3mRIEDdB0kGcOemYsguWDImkQFq7I4/s320/Femoral+Head+Fracture+14.jpg" width="320" /></span></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLicu0zf8oTcvVUCtZmcZlwenINT_4pEkhkp09EdaePBVsHSZTvqLvuyPiylOvQpj2cQqfc0H_zCcFf-orsDgrmCBZJXGgXQNjEuul_Yt19uh8FyO09IQVIBkLXBs_9iz4OXFS20RgBWQ/s1600/Femoral+Head+Fracture+15.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="211" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLicu0zf8oTcvVUCtZmcZlwenINT_4pEkhkp09EdaePBVsHSZTvqLvuyPiylOvQpj2cQqfc0H_zCcFf-orsDgrmCBZJXGgXQNjEuul_Yt19uh8FyO09IQVIBkLXBs_9iz4OXFS20RgBWQ/s320/Femoral+Head+Fracture+15.jpg" width="320" /></span></a></div>
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<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">The wound was closed routinely in layers over two suction
drains.<o:p></o:p></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">Plain pelvic radiographs and a CT scan demonstrated the
reduction and screw locations. <o:p></o:p></span></div>
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</div>
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxvnbDDIdlxFHcKHf8KLfega51kETKtFN7J8S1UYEwOzZ9sQYuWbdGIFoD8fg-U3Pu-zKFxOef6g5BgcLy7FMI5xbBgf6FMexB-c_wciyXTIWMKZ5kC4dAHIrwJoi3el0SCtz4DQuL620/s1600/Femoral+Head+Fracture+17.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="145" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxvnbDDIdlxFHcKHf8KLfega51kETKtFN7J8S1UYEwOzZ9sQYuWbdGIFoD8fg-U3Pu-zKFxOef6g5BgcLy7FMI5xbBgf6FMexB-c_wciyXTIWMKZ5kC4dAHIrwJoi3el0SCtz4DQuL620/s200/Femoral+Head+Fracture+17.jpg" width="200" /></span></a><br />
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<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">After surgery, intravenous antibiotics were administered for
24 hours, and venous thrombosis prophylaxis provided. He began his
rehabilitation on the first day after surgery with unrestricted passive range
of hip motion, isometric exercises, and protected weight bearing on the injured
side. Oral indomethacin was prescribed for 6 weeks after surgery to avoid
symptomatic ectopic bone formation. During the second six weeks postoperative
phase, he advanced to progressive resistance exercises and weight bearing. At
his three months postoperative clinic visit, he was full weight bearing, reported
a slight limp due to residual weakness “ at the end of the day”, denied hip pain,
and had 15 degrees of decreased hip internal rotation compared to the
contralateral normal hip. His pelvic radiographs demonstrated a symmetrical and
normal hip joint space, no implant changes, no signs nor symptoms of <a href="http://www.orthop.washington.edu/?q=patient-care/articles/hip/osteoarthritis-of-the-hip-hip-arthritis.html" target="_blank">aseptic necrosis</a>, and no evidence of ectopic bone formation.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSJm_q_Lv0XbgjcbTntFjeuAg4DlTo1GYF_1knXZS7tahsN6GQMGnk94ocw1Ho7qcnLBOiS0H3_8QPO-hnjnXFB_LjGVv0vM6sryQNxQFmVWJaoffZQRAEVy357NXju8690atucWyi-oM/s1600/Femoral+Head+Fracture+19.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="218" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSJm_q_Lv0XbgjcbTntFjeuAg4DlTo1GYF_1knXZS7tahsN6GQMGnk94ocw1Ho7qcnLBOiS0H3_8QPO-hnjnXFB_LjGVv0vM6sryQNxQFmVWJaoffZQRAEVy357NXju8690atucWyi-oM/s320/Femoral+Head+Fracture+19.jpg" width="320" /></span></a></div>
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZKmXDk9BLMKVXzv4NBmHZoXU0dWWz3qMuD9AjnbzPuZ3bUue9tF4fjhw1qY2-Ntlw0ERcWp5cKrRrwETFZXTywQjn604RUdNTqMGwvgSKffSZJ_mhktzZUhvIcTKKHalz4BzC0ifMCEI/s1600/Femoral+Head+Fracture+20.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="148" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZKmXDk9BLMKVXzv4NBmHZoXU0dWWz3qMuD9AjnbzPuZ3bUue9tF4fjhw1qY2-Ntlw0ERcWp5cKrRrwETFZXTywQjn604RUdNTqMGwvgSKffSZJ_mhktzZUhvIcTKKHalz4BzC0ifMCEI/s200/Femoral+Head+Fracture+20.jpg" width="200" /></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiexa2IFvuOPTRaSGsKDHxa9Jy9Hc8thsx3S7UH5cWRhk89MGNAypVktlywziYM8FISONUDbnJPVGKVOLU-0koNNO2LOmK15r4u4TlBgATIA9cmAPne2m-AnLMWHNHy4mI5oraW98gH3d0/s1600/Femoral+Head+Fracture+21.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="148" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiexa2IFvuOPTRaSGsKDHxa9Jy9Hc8thsx3S7UH5cWRhk89MGNAypVktlywziYM8FISONUDbnJPVGKVOLU-0koNNO2LOmK15r4u4TlBgATIA9cmAPne2m-AnLMWHNHy4mI5oraW98gH3d0/s200/Femoral+Head+Fracture+21.jpg" width="200" /></a></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">Femoral head fracture dislocations usually are associated
with posterior directional dislocations and antero-medial femoral head fracture
locations. The peripheral posterior wall and capsule and labrum are also
commonly avulsed in these injuries. For the common injury patterns, the femur
is flexed, adducted, and internally rotated on the injury anteroposterior
pelvic film. Prior to any closed reduction attempts, the treating physician
must first assure that adequate pharmacological relaxation is achieved and the
femoral neck is intact.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;">While uncommon, irreducible femoral head fracture dislocations
have a characteristic radiographic appearance in that the femur is only
slightly flexed, is in neutral rotation, and is without adduction or abduction.
The dislocated femoral head is tightly positioned against the cortical surface
of the posterior acetabular wall. Soft tissue structures are displaced and
cause the dislocated proximal femur to be relatively immobile. The piriformis
tendon, obturator internus tendon, labrum, and hip capsular and labral tissues
have all been identified intraoperatively as obstructing both closed and open
reduction. These obstructing tissues are located anterior to the proximal femur
and therefore best seen using an anterior surgical exposure. The anterior
exposure also allows improved access to the antero-medial femoral head fracture
fragment and proximal femur for accurate reduction and stable fixation. The
oblique T-shaped capsulotomy spares the anterior labrum and does not compromise
femoral head blood supply. The rectus femoris tenotomy allows the repaired
femoral head to be easily reduced back into the acetabulum after the anterior
surgical dislocation. Once repaired and reduced, the hip joint must be examined
in the operating room using fluoroscopy to assure stability. If the hip joint
is still unstable with passive flexion and internal rotation after accurate
reduction and stabilization of the femoral head fracture, the posterior
capsular-labrum-wall warrant repair. Oral indomethacin seems to decrease the
incidence and severity of hip region ectopic bone formation after open
reduction and internal fixation of femoral head fracture dislocations via the
anterior surgical exposure. <o:p></o:p></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif; line-height: 115%;"><a href="http://www.orthop.washington.edu/orthodev/drupal/sites/default/files/Portals/21/www/Research/Publications/Research%20Reports/Research%20Report%202002.pdf" target="_blank">Symptomatic ectopic bone formation</a> resulted in this different
patient who was unable to take indomethacin after surgery.<span style="mso-spacerun: yes;"> </span>Because the hip cartilage relies on motion
for its preservation, early ectopic bone excision is indicated in these
patients.<o:p></o:p></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgE7LvZQFG7TgBsFEZtIUTwRYj4DVr2CifNR5ncnZwpYbvNsgnNfWYIwL8FlD9PND8NpquJ5DV3H421rNMvsB7CVpKm-CWXNwhngohkwM2Ax1jNnErC3BaoYDTi6LYfcqBoX-WHhs5oLyA/s1600/Femoral+Head+Fracture+22.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="242" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgE7LvZQFG7TgBsFEZtIUTwRYj4DVr2CifNR5ncnZwpYbvNsgnNfWYIwL8FlD9PND8NpquJ5DV3H421rNMvsB7CVpKm-CWXNwhngohkwM2Ax1jNnErC3BaoYDTi6LYfcqBoX-WHhs5oLyA/s320/Femoral+Head+Fracture+22.jpg" width="320" /></span></a></div>
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<span class="Apple-style-span" style="line-height: 21px;"><span class="Apple-style-span" style="color: #333333; font-family: Arial, Helvetica, sans-serif; line-height: 18px;"><span class="Apple-style-span" style="color: #333333; line-height: 18px;">Authored By:</span><span class="Apple-style-span" style="color: #333333; line-height: 18px;"> </span><span class="Apple-style-span" style="line-height: 21px;"><span class="Apple-style-span" style="color: red;">M.L. Chip Routt, Jr.,M.D</span></span></span></span></div>
<!--EndFragment--><br />
<!--EndFragment-->Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com0University of Washington Medical Center, 1959 NE Pacific St, Seattle, WA 98195, USA47.6500204 -122.307893447.6473464 -122.3128289 47.6526944 -122.3029579tag:blogger.com,1999:blog-3608788935039794556.post-76644671592004291352012-08-06T15:05:00.002-07:002012-08-06T15:05:25.629-07:00FEMORAL NECK FRACTURE IN A YOUNG PATIENT<br />
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<span class="Apple-style-span" style="font-family: 'Times New Roman'; font-size: 16px; line-height: 18px;">The Case for August 2012 is of a
35 year old male who sustained a fracture to his hip during a motorcycle
accident.<span style="mso-spacerun: yes;"> </span>He sustained a displaced
<a href="http://www.orthop.washington.edu/sites/default/files/Portals/21/www/Research/Publications/Research%20Reports/Research%20Report%202005.pdf" target="_blank">femoral neck fracture</a>.<span style="mso-spacerun: yes;"> </span>He was seen by
the trauma team and was cleared for operative intervention for his fracture
once other injuries had been ruled out.</span></div>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: "Times New Roman";"><span class="Apple-style-span" style="font-family: Times; font-size: small; line-height: normal;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg4uYfb6lZK4rTH2EjrtlygShdkkdW-MGc9rBES3XIdfia8coCpTsejWOk2tAlAvSE-YUnMRKEngM2ptuCxQOYoeuBzTg8HLknx1I39yNiZ9UTM3FZaSLnmii_Hn7ZLKxqWb2UMWrQhRzI/s1600/femoral+neck+fracture+1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg4uYfb6lZK4rTH2EjrtlygShdkkdW-MGc9rBES3XIdfia8coCpTsejWOk2tAlAvSE-YUnMRKEngM2ptuCxQOYoeuBzTg8HLknx1I39yNiZ9UTM3FZaSLnmii_Hn7ZLKxqWb2UMWrQhRzI/s1600/femoral+neck+fracture+1.jpg" /></a></span></span><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgwxEbpI15qcdQktJS0rYm0XBGVh6gMb4cNGV8XWbR6I-RCJhDnXo12r0smoLSyBvHm8Pz6xH3SjMWJ6W68EZDOahCryaymHMS4Ba2Xa_wgqDm9LZsQiV1JiU2qcmQNTAw91jXEh1UAVKA/s1600/FEMORAL+NECK+FRACTURE+2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgwxEbpI15qcdQktJS0rYm0XBGVh6gMb4cNGV8XWbR6I-RCJhDnXo12r0smoLSyBvHm8Pz6xH3SjMWJ6W68EZDOahCryaymHMS4Ba2Xa_wgqDm9LZsQiV1JiU2qcmQNTAw91jXEh1UAVKA/s1600/FEMORAL+NECK+FRACTURE+2.jpg" /></a></div>
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<span class="Apple-style-span" style="font-family: 'Times New Roman'; font-size: 16px; line-height: 18px;">The fracture had both
medial and posterior superior comminution.</span><span class="Apple-style-span" style="font-family: 'Times New Roman'; font-size: 16px; line-height: 18px;"><span style="mso-spacerun: yes;">
</span></span><span class="Apple-style-span" style="font-family: 'Times New Roman'; font-size: 16px; line-height: 18px;">There was a retroversion deformity on the lateral view.</span><span class="Apple-style-span" style="font-family: 'Times New Roman'; font-size: 16px; line-height: 18px;"><span style="mso-spacerun: yes;"> </span></span><span class="Apple-style-span" style="font-family: 'Times New Roman'; font-size: 16px; line-height: 18px;">This injury carries with it a significant
risk of developing <a href="http://www.orthop.washington.edu/?q=patient-care/articles/arthritis/osteonecrosis.html" target="_blank">avascular necrosis</a> of the <a href="http://www.orthop.washington.edu/?q=patient-care/articles/childrens/developmental-dysplasia-of-the-hip.html" target="_blank">femoral head</a> which can lead to
early arthritis and disability.</span><span class="Apple-style-span" style="font-family: 'Times New Roman'; font-size: 16px; line-height: 18px;"><span style="mso-spacerun: yes;"> </span></span><span class="Apple-style-span" style="font-family: 'Times New Roman'; font-size: 16px; line-height: 18px;">Fracture
union can also be problematic as there are significant shear forces across the
fracture during healing.</span></div>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: "Times New Roman";"><a href="http://www.orthop.washington.edu/sites/default/files/Portals/21/www/Patient%20Care/Our%20Services/Hand%20&%20Upper%20Extremity/Surgeons%20&%20Care%20Providers/Doglas%20P%20Hanel/PDFs/A%20Biomechanical%20Comparison.pdf" target="_blank">Anatomic reduction</a> in
a timely manner is key to maintaining blood flow to the <a href="http://www.orthop.washington.edu/?q=patient-care/articles/childrens/developmental-dysplasia-of-the-hip.html" target="_blank">femoral head</a> and
allowing for the best chance of fracture healing.<span style="mso-spacerun: yes;"> </span>The patient was brought to the operating room
when cleared for an open reduction of his fracture.<span style="mso-spacerun: yes;"> </span>This was accomplished through a
Smith-Peterson anterior approach allowing for direct visualization of the
fracture.<span style="mso-spacerun: yes;"> </span>With this approach we were
able to clean the fracture, clamp it on the anterior tension side to restore
anteversion, and restore anatomic alignment under direct visualization.<span style="mso-spacerun: yes;"> </span>Also, the hip capsule was incised allowing
for decompression of the joint to hopefully improve blood flow to the head.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: 'Times New Roman'; font-size: 16px; line-height: 18px;">The
<a href="http://www.orthop.washington.edu/?q=patient-care/articles/shoulder/compartmental-syndromes.html" target="_blank">fracture reduction</a> was held with a clamp and wire and then guide wires for 7.0
mm cannulated screws were placed through a separate small lateral incision.<span style="mso-spacerun: yes;"> </span>We avoided the posterior superior neck region
with our fixation so we would not further compromise blood flow to the <a href="http://www.orthop.washington.edu/?q=patient-care/articles/childrens/developmental-dysplasia-of-the-hip.html" target="_blank">femoral head</a>.<span style="mso-spacerun: yes;"> </span>A screw was placed inferiorly
abutting the neck and then two further screws were placed more superiorly with
good spread.<span style="mso-spacerun: yes;"> </span>Partially threaded screws
were used to allow for fracture compression.</span></div>
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<span class="Apple-style-span" style="font-family: 'Times New Roman'; font-size: 16px; line-height: 18px;">Final
intraoperative plain films showed an excellent reduction.</span></div>
<br />
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: 'Times New Roman';"><span class="Apple-style-span" style="line-height: 18px;"><br /></span></span></div>
<div class="MsoNormal">
</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjaqBJ3ZC_kdGsUbaGAMC6tRsc7nR4-9bBwQAQ-IoEXsAyJofriB_J1IQ8CMFTdVjf4v1Z8LPtVWl_lKzevboj0_p7NSs1LnIqZ3p4Y_XKgPFDRbauCcaMM_NM9RYLYDcg8f6F7chHDRF8/s1600/FEMORAL+NECK+FRACTURE+8.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjaqBJ3ZC_kdGsUbaGAMC6tRsc7nR4-9bBwQAQ-IoEXsAyJofriB_J1IQ8CMFTdVjf4v1Z8LPtVWl_lKzevboj0_p7NSs1LnIqZ3p4Y_XKgPFDRbauCcaMM_NM9RYLYDcg8f6F7chHDRF8/s1600/FEMORAL+NECK+FRACTURE+8.jpg" style="cursor: move;" /></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7B371EfYREwR0DLCWq21P0d_xXG_qRiCbftlzzDdD-OD_rlXPWjn8gUANG5nKytPu8G0gLiXQBEprsbc0YC1T27HIXHVPnAknYPzjgJLHbds95nXP4o0Ga7a-BiZJfyhxhWz5VhgSC5g/s1600/FEMORAL+NECK+FRACTURE+9.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7B371EfYREwR0DLCWq21P0d_xXG_qRiCbftlzzDdD-OD_rlXPWjn8gUANG5nKytPu8G0gLiXQBEprsbc0YC1T27HIXHVPnAknYPzjgJLHbds95nXP4o0Ga7a-BiZJfyhxhWz5VhgSC5g/s1600/FEMORAL+NECK+FRACTURE+9.jpg" style="cursor: move;" /></a></div>
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<br /></div>
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<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: 'Times New Roman'; font-size: 16px; line-height: 18px;">The patient was
allowed to perform toe-touch weightbearing for three months.<span style="mso-spacerun: yes;"> </span>He then progressed to full weight bearing as
tolerated.<span style="mso-spacerun: yes;"> </span>Serial radiographs were taken
throughout his follow-up at six weeks and three months showing no loss of
reduction.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman"; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: "Times New Roman";">The patient was seen
9 months following surgery.<span style="mso-spacerun: yes;"> </span>He walked
with a normal gait, had no hip pain, and had returned to all vocational and
avocational activities.<span style="mso-spacerun: yes;"> </span>Although the
patient is still at risk of developing <a href="http://www.orthop.washington.edu/?q=patient-care/articles/arthritis/osteonecrosis.html" target="_blank">avascular necrosis</a> in the future,
radiographs showed a healed fracture with no evidence of <a href="http://www.orthop.washington.edu/?q=patient-care/articles/arthritis/osteonecrosis.html" target="_blank">avascular necrosis</a> of the
<a href="http://www.orthop.washington.edu/?q=patient-care/articles/childrens/developmental-dysplasia-of-the-hip.html" target="_blank">femoral head</a> at last follow-up.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman"; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: "Times New Roman";"><br /></span></div>
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<div class="MsoNormal">
</div>
<div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">
<br /></div>
<div style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">
<span class="Apple-style-span" style="font-family: 'Times New Roman'; font-size: 16px; line-height: 18px;">A <a href="http://www.orthop.washington.edu/sites/default/files/Portals/21/www/Research/Publications/Research%20Reports/Research%20Report%202005.pdf" target="_blank">femoral neck fracture</a> in a young patient is a serious injury as it can lead to pain and
<a href="http://www.orthop.washington.edu/?q=patient-care/arthritis.html" target="_blank">arthritis</a> secondary to <a href="http://www.orthop.washington.edu/?q=patient-care/articles/arthritis/osteonecrosis.html" target="_blank">avascular necrosis</a>.</span><span class="Apple-style-span" style="font-family: 'Times New Roman'; font-size: 16px; line-height: 18px;"><span style="mso-spacerun: yes;">
</span></span><span class="Apple-style-span" style="font-family: 'Times New Roman'; font-size: 16px; line-height: 18px;"><a href="http://Anatomic reduction" target="_blank">Anatomic reduction</a> with secure fixation contributes to a successful
outcome.</span></div>
<br />
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: 'Times New Roman';"><span class="Apple-style-span" style="line-height: 18px;"><br /></span></span></div>
<div class="MsoNormal">
Author by <a href="http://depts.washington.edu/orthodev/drupal/faculty-profiles/daphne-m-beingessner-md.html" target="_blank"><span class="Apple-style-span" style="color: red;">Daphne M. Beingessner, MD</span></a></div>Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com0Harborview Medical Center, 325 9th Ave, Seattle, WA 98104, USA47.6035175 -122.323087147.592811000000005 -122.34282809999999 47.614224 -122.3033461tag:blogger.com,1999:blog-3608788935039794556.post-55397541607817683842012-07-08T10:55:00.000-07:002012-07-08T10:55:03.640-07:00Complex Ankle Fracture DislocationThe Case of the Month for July 2012 is of a 60 year old healthy woman who fell down some stairs and suffered a Complex Ankle Fracture Dislocation<br />
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<br />
The Patient was splinted, but not reduced at an outside facility
and then transferred to HMC<br />
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Plain films confirmed the trimalleolar ankle
fracture-dislocation and a CT scan revealed a rather large posterior malleolus
fracture, which some might categorize as a posterior pilon fracture</div>
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We chose a posterolateral incision to address<span style="mso-spacerun: yes;"> </span>the posterior malleolus and fibular
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We worked on both sides of the peroneal tendons<o:p></o:p></div>
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Here we are with the posterior malleolus fracture exposed<o:p></o:p></div>
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We then worked anteriorly to the peroneals to access access
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Once we fixed the fibula, we turned our attention to the
medial or inside part of the ankle to address the medial malleolar fracture<o:p></o:p></div>
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Below are the final radiographs taken in the operative suite
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Author by <span class="Apple-style-span" style="color: red;"><a href="http://depts.washington.edu/orthodev/drupal/faculty-profiles/robert-p-dunbar-jr-md.html" target="_blank">Robert P. Dunbar, Jr,, M.D.</a></span><br />
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Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com0Harborview Medical Center, 325 9th Ave, Seattle, WA 98104, USA47.6035175 -122.323087147.592811000000005 -122.34282809999999 47.614224 -122.3033461tag:blogger.com,1999:blog-3608788935039794556.post-75278852004270027232012-06-01T23:08:00.003-07:002012-06-01T23:45:49.364-07:00Adolescent Supracondylar Humerus Fracture – should it be treated as a pediatric or adult injury?The Case of the Month for June 2012 is of a 12 year old healthy young lady who sustained a displaced supracondylar humerus fracture after a fall from a balance board. She presented with a completely displaced distal humerus fracture, similar in appearance to a pediatric Type III supracondylar humerus injury. She had mild paresthesias in her thumb but otherwise had an unremarkable neurovascular examination. Her injury radiographs are shown below:<br />
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Of note, her distal humerus growth plate was closed but she still had a partially open olecranon growth plate and radial head growth plate.<br />
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This fracture represents a very unstable pattern. Given the patient’s age and the fact that her growth plates were nearly closed, it was felt that she would be better treated with a plate construct that would allow for early range of motion. Also, at age 12, she does not have much, if any, potential to remodel so an accurate and anatomic reduction is imperative to restore elbow function. Therefore, an adult approach to this fracture was felt to be appropriate.<br />
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The patient was taken to the operating room within 24 hours of her injury. She was placed in the lateral position and a paratricipital (triceps-sparing) approach to the distal humerus was performed. The ulnar nerve was identified but not transposed. A significant amount of force was required to reduce the fracture and it was held provisionally with Kirschner wires.<br />
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It was clear that the Kirschner wires would not have been adequate fixation (as would be used in a younger child) as the fracture deformed once the clamp was removed. A posterior plate was chosen of sufficient thickness to help reduce the residual extension deformity, to buttress the articular segment and prevent it from going back into the extended position it was in at the time of injury.</div>
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A second plate was added medially for extra stability and the construct was stable through a full range of motion.<br />
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The arm was placed into a padded splint for 48 hours to allow the incision to seal and then active and active assisted motion was started. The majority of motion was regained by 6 weeks. At three months, the fracture was completely healed and the patient had regained full range of motion. At final follow-up at six months, she had returned to all activities including dance and gymnastics with no pain and no limitations.<br />
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This patient had an excellent result with her injury. This fracture pattern in adolescents should not be confused with a pediatric supracondylar fracture that is readily treated with percutaneous pinning and a cast for 3 to 4 weeks. Intraoperatively, it was clear in this case that wire fixation would have been inadequate since multiple wires were not sufficient to maintain the reduction, even provisionally. In adolescents, stiffness and loss of fixation and subsequent malunion may occur with percutaneous fixation and an adult approach is appropriate.<br />
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Author by <a href="http://depts.washington.edu/orthodev/drupal/faculty-profiles/daphne-m-beingessner-md.html" target="_blank"><span class="Apple-style-span" style="color: red;">Daphne M. Beingessner, MD</span></a>Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com1Harborview Medical Center, 326 9th Ave N, Seattle, WA 98109, USA47.6212883 -122.339631547.6105858 -122.35937249999999 47.631990800000004 -122.3198905tag:blogger.com,1999:blog-3608788935039794556.post-28668938281671051602012-04-30T22:37:00.002-07:002012-05-16T18:48:53.627-07:00Femur fracture nonunion with leg length discrepancy: a treatment strategy for difficult post-traumatic problem. *Updated with New Images<div class="separator" style="clear: both; text-align: left;">
<span class="Apple-style-span" style="font-family: Arial;">This month’s case features a 40-year old healthy
man who, unfortunately, was struck by a vehicle 13 months earlier. He sustained a closed femoral shaft fracture
in the distal metadiaphyseal region. He
was treated at an outside facility with open reduction of the fracture followed
by antegrade trochanteric nailing.
Suboptimal placement of the initial distal interlocking bolts was not
appreciated until 5 weeks postoperatively, at which time the bolts were revised
and placed accurately through the distal interlocking holes in the nail. </span></div>
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<span class="Apple-style-span" style="font-family: Arial;"><span style="font-family: Arial;">Approximately one year from the date of his
injury, he presented to Harborview Medical Center for an opinion regarding his
ongoing pain and limitations. His
complaints include significant weightbearing and activity-related pain located
to the distal thigh and anterior knee area.
While this pain was a predominant symptom, his most frustrating problem was
the perception that his left leg was shorter than his right. He is otherwise healthy and was previously an
avid athlete, particularly involved in long distance running and bicycle
riding. He is a nonsmoker, and takes no
medications on a regular schedule. He
has been unable to wean himself off of a walking aid because of continuing
lower thigh discomfort and the inability to correct his “limp”. He has been unable to participate in any of
his running or bicycling activities. The
physical examination demonstrates well-healed surgical scars at the left hip
and distal thigh regions. The quadriceps
musculature of the left thigh is atrophic.
Clinically, there is an approximate 2cm leg length discrepancy with the
left leg shorter than the right. There
are no significant rotational abnormalities.
The passive hip and knee ranges of motion are symmetric to the
contralateral side. The pedal pulses were
palpable, and the patient’s motor and sensory examination was normal, within
the limitations of pain. Initial
bloodwork demonstrated a number of normal values, including the white cell
blood count, ESR, C-reactive protein, and bone metabolism profile.</span></span></div>
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<span class="Apple-style-span" style="font-family: Arial;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhV8onvDoZF8pAfw0u2yi4Yp2Bir6oJ9rh3P-BMsMQppBdZgRUfY5lf7cGq7j3LPFnVYO9j_4yaqH9ZoyeMuWri236vb5QfLQ9yubGMeCFutUU5RNrzxUkBtHYDxia4k0qERPHE1oTRMPo/s1600/3.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhV8onvDoZF8pAfw0u2yi4Yp2Bir6oJ9rh3P-BMsMQppBdZgRUfY5lf7cGq7j3LPFnVYO9j_4yaqH9ZoyeMuWri236vb5QfLQ9yubGMeCFutUU5RNrzxUkBtHYDxia4k0qERPHE1oTRMPo/s320/3.jpg" width="104" /></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg-A5VHDSbaXCI9d9ryU0boe59sH_pKmu5S0NlhbYPbv48lTV86FBf9Cu5OmvHMKvHAW8dAktfuYebnGT63LC2YFDxzLZjIptDFGN86ANZn6AYgseBfJ0VYGrDHWfpWA1_5Fp0HFh5UTRY/s1600/4.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg-A5VHDSbaXCI9d9ryU0boe59sH_pKmu5S0NlhbYPbv48lTV86FBf9Cu5OmvHMKvHAW8dAktfuYebnGT63LC2YFDxzLZjIptDFGN86ANZn6AYgseBfJ0VYGrDHWfpWA1_5Fp0HFh5UTRY/s320/4.jpg" width="93" /></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgu-uM1n9npmjIvT7k1ZwfuIWZRBjuTk6wKji4Yif8CZCmRRWiEJzBXqgVkd4YCMtj6dXdKVOo7EGfcvU5mI4hjxymj124VNDnIRVctzy4sv2_Gh58TyanlYv_1DHg1TCFEz9XuSfWiEdY/s1600/5.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgu-uM1n9npmjIvT7k1ZwfuIWZRBjuTk6wKji4Yif8CZCmRRWiEJzBXqgVkd4YCMtj6dXdKVOo7EGfcvU5mI4hjxymj124VNDnIRVctzy4sv2_Gh58TyanlYv_1DHg1TCFEz9XuSfWiEdY/s320/5.jpg" width="113" /></a></span></div>
<div class="separator" style="clear: both; text-align: left;">
<span class="Apple-style-span" style="font-family: Arial;">The presenting anteroposterior plain
radiographs of the left femur demonstrate a well-aligned hypertrophic
metadiaphyseal nonunion. A trochanteric
antegrade femoral nail is identified, and the single distal interlocking bolt
is noted to be broken. The long leg
standing radiographs confirm an approximate 2cm leg length discrepancy with the
left femur shorter than the right. The
operative records from the index procedure confirm the size, length, and
manufacturer of the medullary implant, and also indicate that the femur
fracture was reduced using an open technique prior to the placement of the
nail.</span></div>
<div class="separator" style="clear: both; text-align: left;">
<span class="Apple-style-span" style="font-family: Arial;">The diagnosis is a well aligned, but clinically
shortened, hypertrophic, aseptic distal metadiaphyseal femoral nonunion. </span></div>
<span class="Apple-style-span" style="font-family: Arial;">
</span><br />
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial;">The patient was extensively counseled regarding
the options regarding the treatment of this problem. Typically, the well vascularized
hypertrophic nonunion develops because of fracture site instability. Enhancing the stability of the
fracture/nonunion site with a traditional compression plating technique
typically results in predictable and rapid healing of the nonunion site. Unfortunately, this strategy, by itself, does
not correct the significant and clinically bothersome leg length
discrepancy. Alternatives include
contralateral shortening osteotomy of the femur to equalize leg lengths,
ipsilateral oblique osteotomies to regain length while still compressing the
nonunion, or lengthening through the nonunion, either acutely or
gradually. Each of these options comes
with risks related to healing and increased surgical complexity. Given the patient’s desire to restore his
anatomy as accurately as possible, we decided to treat this problem with acute
lengthening through the nonunion site followed by stabilization with a locked
reamed medullary nail with plate augmentation. </span></div>
<span class="Apple-style-span" style="font-family: Arial;">
</span><br />
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial;">The patient was medically stable and cleared
for surgery. A general anesthetic was
administered and he was positioned supine on a radiolucent operating
table. The patient was supported with a soft
left-sided lumbo-sacral support. The
entire left lower extremity was then included in the sterile operating field,
and the preoperative patient/procedure verification was completed. Antibiotic prophylaxis was withheld until
deep cultures of the nonunion site were obtained.</span><br />
<span class="Apple-style-span" style="font-family: Arial;">The patient’s pre-existing trochanteric femoral
nail was removed percutaneously. Through
the same skin incision, a piriformis fossa start point was obtained and an
entry hole created into the proximal femur in the appropriate trajectory. A curved ball-tipped guide wire was then
placed down the femur, across the nonunion site and into the distal femur
beyond the endpoint of the previously placed nail. The canal was enlarged with sequential
reaming to a total of 13mm. The
anticipated nail length was estimated using a two-guide rod technique taking
into consideration the additional 2 cm of femoral lengthening. Multiple specimens of fibrous tissue and
reamings from the endosteal surface of the femur were sent for culture and
sensitivity. Subsequent to this,
prophylactic antibiotics were administered.</span><br />
<span class="Apple-style-span" style="font-family: Arial;">The curved ball-tip guide rod was then
retracted into the proximal femoral segment and the nonunion was then
approached with a lateral extensile exposure to the femur. After elevation of the vastus lateralis, the
nonunion itself was exposed using an osteo-periosteal technique as described by
Judet and Judet. Two 2.4mm Steinmann
pins were placed into the anterolateral surface of the femur on either side of
the nonunion. The distance between these
two pins was measured and recorded. Peripheral
to these pins, two bicortical 5mm Schanz pins were placed and attached to a
large Universal Distractor.</span></div>
<span class="Apple-style-span" style="font-family: Arial;">
</span><br />
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial;"><br /></span></div>
<span class="Apple-style-span" style="font-family: Arial;">
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<span class="Apple-style-span" style="font-family: Arial;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj9__FLNoVlhYYLZmybgzpKqg2RQqGf7mnowNYMsQXRrbNYYadJ_UEyrmXGAWlaPUtGJbjoT9tu28bLk-RYEQuHfnAQhKM1Fs2cE-vML8l_v2ukKmOQAbO8S3PMwMdtCucvNhhsXbawh18/s1600/6.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj9__FLNoVlhYYLZmybgzpKqg2RQqGf7mnowNYMsQXRrbNYYadJ_UEyrmXGAWlaPUtGJbjoT9tu28bLk-RYEQuHfnAQhKM1Fs2cE-vML8l_v2ukKmOQAbO8S3PMwMdtCucvNhhsXbawh18/s320/6.jpg" width="172" /></a></span></div>
<span class="Apple-style-span" style="font-family: Arial;">
</span><span class="Apple-style-span" style="font-family: Arial;">The nonunion site was mobilized then distracted
2cm and confirmed accurate by repeat measurement using the 2.4mm Steinmann
pins.</span><span class="Apple-style-span" style="font-family: Arial;"></span><br />
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial;"><br /></span><br />
<span class="Apple-style-span" style="font-family: Arial;"><br /></span><br />
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<center><span class="Apple-style-span" style="font-family: Arial;">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLd34T46IazHQjJLMwtjXqfkTYE7HjGDzvwCrLQ8srQ19RMDFv1SWapsKlKzC5NL_lUZk5cSnUWO4fo7RaxqQPiZXs2fkP5GrsYbLKWQ-spW4_dJJqMAOWXxw-HQ0paiZ6c4Ze62RuBCo/s1600/7.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLd34T46IazHQjJLMwtjXqfkTYE7HjGDzvwCrLQ8srQ19RMDFv1SWapsKlKzC5NL_lUZk5cSnUWO4fo7RaxqQPiZXs2fkP5GrsYbLKWQ-spW4_dJJqMAOWXxw-HQ0paiZ6c4Ze62RuBCo/s320/7.jpg" width="131" /></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjnyMvLBi6NVHJz0SQmXw5NNPyA_7K-VcSBL_JLJGcsCay705gy9Wr79UgDwunKRxpRuyjNLsn9ySnKX5Dg5gMDKOWYelBncFei3j-7RikfvGZNeNFms_oImFv6vFmjVqTj5R9n7-oaQfs/s1600/8.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="290" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjnyMvLBi6NVHJz0SQmXw5NNPyA_7K-VcSBL_JLJGcsCay705gy9Wr79UgDwunKRxpRuyjNLsn9ySnKX5Dg5gMDKOWYelBncFei3j-7RikfvGZNeNFms_oImFv6vFmjVqTj5R9n7-oaQfs/s320/8.jpg" width="320" /></a></div>
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<tr><td align="center" colspan="2"><div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgy56oV89PvJEw0qVkly6x5Qajrzu_Ymsq7KnucRZa0J6seiKAB0PhAg8SZrWUsNk_pjwgaGWiapVC87hdnZ9oUqFbC0bghaEPGFJUv6gBLl-UhMTzRN9nvxmQWk4pOdgeWyfyC0W80y50/s1600/9.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="214" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgy56oV89PvJEw0qVkly6x5Qajrzu_Ymsq7KnucRZa0J6seiKAB0PhAg8SZrWUsNk_pjwgaGWiapVC87hdnZ9oUqFbC0bghaEPGFJUv6gBLl-UhMTzRN9nvxmQWk4pOdgeWyfyC0W80y50/s320/9.jpg" width="320" /></a></div>
</td></tr>
</tbody></table>
</span></center><span class="Apple-style-span" style="font-family: Arial;">
</span></div>
<span class="Apple-style-span" style="font-family: Arial;">
</span><span class="Apple-style-span" style="font-family: Arial;">The nonunion site was then stabilized with a
posterolateral locking plate using screws strategically placed to be out of the
way of the anticipated nail pathway.</span><span class="Apple-style-span" style="font-family: Arial;"><div class="MsoNormal">
<br />
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<td><div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7MTiq4yZ_t730ucbWyQZo2peffdDChpJE_qX4_g2uokFCv3lSzvMDOdP2EPN8Ae4mBxe1XUv6C6tex_8wkszVVJblHWasa5TR5S2mKNZrOsja9Mf4kWS9lpZ8jmMZHp6cfP9T98qCAz4/s1600/10.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7MTiq4yZ_t730ucbWyQZo2peffdDChpJE_qX4_g2uokFCv3lSzvMDOdP2EPN8Ae4mBxe1XUv6C6tex_8wkszVVJblHWasa5TR5S2mKNZrOsja9Mf4kWS9lpZ8jmMZHp6cfP9T98qCAz4/s320/10.jpg" width="142" /></a></div>
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<td><div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikE691jX77WlwvSPqafJeR2eVqiCfU2wlRTWhIoCp4VbfyOWjQH0OC4Cj6mG9i2O6-wH9pMDDwOGiMVwuzTccL7LAxsZXxK9_wedypsQ4BAzSbecqY7zGylTUtnrSloSY08J3fmIODkkc/s1600/11.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="245" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikE691jX77WlwvSPqafJeR2eVqiCfU2wlRTWhIoCp4VbfyOWjQH0OC4Cj6mG9i2O6-wH9pMDDwOGiMVwuzTccL7LAxsZXxK9_wedypsQ4BAzSbecqY7zGylTUtnrSloSY08J3fmIODkkc/s320/11.jpg" width="320" /></a></div>
</td>
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</tbody></table>
</center>
</div>
</span><span class="Apple-style-span" style="font-family: Arial;">The 2.4mm Steinmann pins, the 5mm Schanz pins,
and the Universal Distractor were then removed.
A straight insertion rod was then placed through the piriformis fossa
nail entry point and positioned into the distal femur, followed by the
definitive statically locked medullary nail.
A portion of the anterior and anterolateral aspects of the hypertrophic
nonunion were removed with an osteotome, morselized and reinserted into the
nonunion gap created by the lengthening.
The wounds were then closed and final clinical and radiographic
assessments in the operating room demonstrated symmetric leg lengths, angulation, and rotation.</span><span class="Apple-style-span" style="font-family: Arial;"><div class="MsoNormal">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUuAnqKazW1kYuYvagIhpFltoGqSwZCGjO79ckXmiqNY60R1IxhwyeTu6MbIQvkDH_oH6wCF1pu8ULNEN6-EEAv2xgbbRpKDQDi-EStDJvuIW0eOu4phcygR4BxfALRYrJtvZuLlnS5WY/s1600/immedicate+postop.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUuAnqKazW1kYuYvagIhpFltoGqSwZCGjO79ckXmiqNY60R1IxhwyeTu6MbIQvkDH_oH6wCF1pu8ULNEN6-EEAv2xgbbRpKDQDi-EStDJvuIW0eOu4phcygR4BxfALRYrJtvZuLlnS5WY/s320/immedicate+postop.jpg" width="128" /></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhqV_LGeEKvR2r7r6cWFTcfbe2DoVJ61X_mx9U-1QbGQgMnaQN0ISdWqRdu4GaJvU1vdFmtB2y8NbFsn8rgmQxCkbpkKhy5LHXEXmtF2luAuLr2fDQjeHCJc1Iusnv5lOmg2M7h_9Prd6M/s1600/12.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhqV_LGeEKvR2r7r6cWFTcfbe2DoVJ61X_mx9U-1QbGQgMnaQN0ISdWqRdu4GaJvU1vdFmtB2y8NbFsn8rgmQxCkbpkKhy5LHXEXmtF2luAuLr2fDQjeHCJc1Iusnv5lOmg2M7h_9Prd6M/s320/12.jpg" width="89" /></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpLrGC3lBb-DvKKZvWjhRUmBTZMoOZmzckMj6PHeGHNVIcYV9TlFOhTna3AScqh4t1PEcvcoDkKB4699uUnS218YCtgARaP6TfKLa2X_peRACYPhma4d1MVicg2dfFV2QW12PphToKpus/s1600/13.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpLrGC3lBb-DvKKZvWjhRUmBTZMoOZmzckMj6PHeGHNVIcYV9TlFOhTna3AScqh4t1PEcvcoDkKB4699uUnS218YCtgARaP6TfKLa2X_peRACYPhma4d1MVicg2dfFV2QW12PphToKpus/s320/13.jpg" width="93" /></a></div>
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</center>
<span style="font-family: Arial;">
</span></div>
<div class="MsoNormal">
<div style="text-align: center;">
<br /></div>
</div>
</span><span class="Apple-style-span" style="font-family: Arial;">The patient had an uneventful postoperative
recovery course and the intraoperative specimens sent for microbiologic
examination demonstrated no growth of organisms at the two week mark. Six weeks postoperatively, he was progressed
to from touchdown to full weightbearing.
He had no pain and full knee range of motion. Twelve weeks postoperatively strengthening
exercises were initiated and the patient
was weaned from his walking aids. Two
months later, the patient began light jogging and workouts with a stationary
bicycle. Approximately one year
postoperatively, the patient has no pain and is back to his recreational
activiities, including completion of the “Escape From Alcatraz” triathlon.</span><br />
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</span><span class="Apple-style-span" style="color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; line-height: 18px;">Authored By:</span><span class="Apple-style-span" style="color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; line-height: 18px;"> </span><span class="Apple-style-span" style="font-family: Calibri; line-height: 21px;"><span class="Apple-style-span" style="color: red;"><a href="http://depts.washington.edu/orthodev/drupal/faculty-profiles/david-p-barei-md.html" target="_blank">David P. Barei.,M.D</a></span></span></div>Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com0325 9th Ave, Seattle, WA 98104, USA47.6035148 -122.323049747.6008383 -122.3279852 47.6061913 -122.3181142tag:blogger.com,1999:blog-3608788935039794556.post-61115322299402413852012-04-04T22:18:00.001-07:002012-04-04T22:19:56.812-07:00Minimally Invasive Manipulative Reduction and Fixation of Pelvic (Pubic & Sacral) Fractures<div class="MsoNormal"><span class="Apple-style-span" style="line-height: 18px;"> </span><br />
<div class="MsoNormal"><span style="font-size: 12pt; line-height: 115%;">This month's case features a 19 years old male who was injured in a high-speed automobile accident. He was the driver of the vehicle and medics at the scene noted significant intrusion of the driver’s side of the car. He was extracted from the vehicle, complained of pelvic and back pain. On presentation to the emergency department, he was awake and alert, and continued to complain of severe left sided low back and hip area pain. He was initially hemodynamically unstable but responded to routine volume resuscitation. His physical examination revealed left pelvic and back pain with any attempted passive movement. Compressive pelvic exam identified pelvic mechanical instability and related exacerbation of his complaints. There was no pelvic deformity or abnormal other findings. The lower extremity neurological and vascular examinations were within normal limits, excepting muscle power limitations due to pain.<o:p></o:p></span></div></div><span class="Apple-style-span" style="font-family: Calibri;"><span class="Apple-style-span" style="line-height: 21px;"><br />
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</div><div class="separator" style="clear: both; text-align: left;"></div><div class="MsoNormal"><span style="font-size: 12pt; line-height: 115%;">Plain pelvic radiographs and a computed tomography scan demonstrated displaced left sided pubic ramus and sacral fractures. The axial CT images demonstrated the fracture and deformity details. The left hemipelvis was flexed and internally rotated relative to the uninjured right side. The patient was fully resuscitated and evaluated. He and his parents were counseled regarding the various non-operative and operative treatment options, as well as the risks and benefits of each. They opted for attempted manipulative reduction and percutaneous fixation if possible, and agreed to open reduction and internal fixation if needed.</span></div><table><tbody>
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<div class="MsoNormal"><span style="font-size: 12pt; line-height: 115%;">On the day after injury, the patient was medically stable and cleared for surgery. He was anesthetized, positioned supine on the radiolucent operating table, elevated on a soft lumbo-sacral support, and the entire abdomen and bilateral flanks were included in the sterile operating field. After the preoperative patient/procedure verification was completed and antibiotic prophylaxis administered, a simple 2 pin anterior oblique pelvic external fixation device was applied using bilateral 5mm pins inserted into the right iliac crest and left supra-acetabular areas. The single bar oblique frame was oriented to correct the left hemipelvic flexion and internal rotation deformities. The compression-distraction device was applied to the bar remote from the injured areas so to not obstruct pelvic fluoroscopic imaging. <o:p></o:p></span></div></div><div class="MsoNormal"><span style="line-height: 115%;"><br />
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<div class="MsoNormal"><span style="font-size: 12pt; line-height: 115%;">The manipulative reduction was assessed using fluoroscopy until satisfactory ramus and sacral re-alignment reductions were achieved. <o:p></o:p></span></div></div><div class="MsoNormal"><span style="line-height: 115%;"><br />
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</div><div class="separator" style="clear: both; text-align: left;"></div><div class="MsoNormal"><span style="font-size: 12pt; line-height: 115%;">Then antegrade superior pubic ramus medullary screw and iliosacral screw fixations were placed percutaneously through small stab wounds under multiplanar fluoroscopic guidance. The postoperative imaging confirmed the reduction accuracy, deformity correction, and screw safety.<o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span style="font-size: 12pt; line-height: 115%;">On the day after surgery, he was comfortable and began his rehabilitation including weight of limb protected weight bearing using crutches, and isometric exercises for the subsequent 6 weeks. He returned for follow up evaluation with no complaints, radiographic union of his fractures, and was released to his normal activities 3 months after injury.<o:p></o:p></span></div><br />
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</tbody></table><span class="Apple-style-span" style="color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; line-height: 18px;">Authored By:</span><span class="Apple-style-span" style="color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; line-height: 18px;"> </span><span class="Apple-style-span" style="font-family: Calibri; line-height: 21px;"><span class="Apple-style-span" style="color: red;">M.L. Chip Routt, Jr.,M.D</span></span>Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com0tag:blogger.com,1999:blog-3608788935039794556.post-4150588627944391752012-03-01T21:24:00.002-08:002012-03-01T21:30:37.508-08:00Posterior Wall Acetabular Fracture-Dislocation<div class="MsoNormal"><span style="line-height: 115%;">A 67 years old factory worker was injured in a high-speed automobile accident while carpooling to work. He complained of left hip pain when medics evaluated him at the accident scene, and they noted deformity of the injured lower extremity. In the emergency room, the injured hip was flexed, adducted, and internally rotated. He had diminished strength of the hip area muscles due to pain but his peripheral neurological examination was otherwise normal. There was a contusion at the anterior ipsilateral knee region, but no effusion. His patella was nontender. <o:p></o:p></span></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><span style="line-height: 115%;">Pelvic plain radiographs and a computed tomography scan identified a displaced posterior wall acetabular fracture-dislocation. The displaced posterior wall fracture fragment involved a significant portion of the acetabular dome region. The femoral neck was not fractured.<o:p></o:p></span></div><span class="Apple-style-span" style="font-family: Calibri;"><span class="Apple-style-span" style="line-height: 21px;"><br />
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<tr><td><span style="font-family: Calibri; line-height: 115%;">He was sedated with intravenous medications only after consenting to closed or open reduction as needed. The manipulative closed reduction was atraumatic and successful. Skeletal traction was applied to maintain the reduction, and radiographs confirmed the reduction of the femoral head </span><br />
<span style="font-family: Calibri; line-height: 115%;">beneath the intact acetabular dome without obvious articular debris.</span><br />
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</div><div class="separator" style="clear: both; text-align: left;"></div><div class="MsoNormal"><span style="line-height: 115%;">Two days after injury, he underwent open reduction and internal fixation of the posterior wall acetabular fracture using a Kocher-Langenbeck surgical exposure. The superior gluteal neurovascular bundle and sciatic nerve were visualized, mobilized, and protected throughout the operation.<o:p></o:p></span></div><div class="MsoNormal"><span style="line-height: 115%;"><br />
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</span></div><div class="MsoNormal"><span style="line-height: 115%;">The fracture surfaces were cleansed of hematoma, reduced, and temporarily held in place with K-wires. The reduction was definitively stabilized using a contoured and balanced malleable reconstruction plate along with interfragmentary screws.<o:p></o:p></span></div><div class="MsoNormal"><span style="line-height: 115%;"><br />
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</span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: Calibri; line-height: 115%;">Intraoperative fluoroscopy confirmed the reduction accuracy and extra-articular screw locations. The hip joint was stressed under direct visualization to assure fracture stability. The traumatic capsular injury plus the tenotomies of the piriformis and obturator internus muscles were repaired. The necrotic caudal portion of the gluteus minimus musculature was debrided.</span></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: Calibri; line-height: 115%;"><br />
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</div><div class="separator" style="clear: both; text-align: left;"></div><div class="MsoNormal"><span style="line-height: 115%;">He began his rehabilitation on the first day after surgery with unrestricted passive range of motion, isometric exercises, and partial weight bearing. Six weeks after surgery he started resistance exercises and progressive weight bearing. At his three months postoperative clinic visit, he was full weight bearing, denied complaints, and had symmetrical hip range of motion. Oblique pelvic radiographs demonstrated a symmetrical and normal hip joint space, no implant changes, and no evidence of ectopic bone formation. He reported a slight limp at the end of each day due to some residual weakness. His hip power returned to normal over the next month and he returned to his previous job.<o:p></o:p></span></div><br />
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</tbody></table><span class="Apple-style-span" style="color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; line-height: 18px;">Authored By:</span><span class="Apple-style-span" style="color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; line-height: 18px;"> </span><span class="Apple-style-span" style="font-family: Calibri; line-height: 21px;"><span class="Apple-style-span" style="color: red;">M.L. Chip Routt, Jr.,M.D</span></span>Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com0tag:blogger.com,1999:blog-3608788935039794556.post-27182019712150967902012-02-01T21:21:00.000-08:002012-02-01T21:25:24.698-08:00Complex Midfoot InjuryA 24 year old fell awkwardly at a Fourth of July celebration, injuring her left foot. She presented to a local community hospital, where X-rays and a CT scan were obtained.<br />
The plain X-rays showed evidence of a non-displaced fracture in one of the cuneiform bones.<br />
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The CT scan confirmed a fracture in the middle cuneiform, along with several small bone fragments suggestive of ligament injuries in the dorsal midfoot. A small about of subluxation is seen in the talonavicular joint.<br />
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She was placed in a boot type orthotic and instructed to keep her weight off of it. During the course of her follow-up, there was increasing displacement. Nine weeks after her fall, she was referred to the Orthopaedic Trauma Clinic at Harborview Medical Center, where the X-rays showed collapse of the midfoot.<br />
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At this point she was diagnosed with dislocation of the navicular at both the talo-navicualr and navicular-cuneiform joints. In contrast to the navicular-cuneiform joints, which are very stable joints without motion, the talo-navicular joint is a mobile joint, known in the foot as an “essential joint”. The architecture of this part of the foot, as well as the motion in the essential joints, contributes to the painless function of the foot. Surgery was indicated to restore the anatomic relationships of the midfoot, and to provide for normal motion in the talonavicular joint.<br />
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She underwent an open reduction of the navicular-cuneiform joints, which realigned the talo-navicular joint.<br />
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In addition, a stress X-ray was taken in the operating room, and demonstrated significant instability at the first tarso-metatarsal joint, a normally stable articulation. It is important when treating midfoot injuries to identify all sites of instability, some of which may not be immediately apparent. Stress X-rays are helpful in identifiying unstable joints, which may be injured but not significantly displaced. These are typically treated so that displacement will not occur once normal activity is resumed.<br />
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The Xrays after surgery show that the stable midfoot joints, the navicular-cuneiform, and tarso-metatarsal, have been reduced and stabilized with several plates, multiple screws, and Kirschner wires. At the same time, the talonavicular joint has been reduced and will stay reduced as long as the stable joints remain reduced.<br />
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Nine months after her surgery, she is walking unlimited distances with minimal pain. Once the stable joints have healed more completely, the hardware can be removed if desired.<br />
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Midfoot injuries can be challenging to diagnose. Once diagnosed, the goals of treatment are to restore and maintain the normal relationships of the bones. Stable joints must heal solidly, and essential joints must have motion spared in order to optimize the functional outcome.<br />
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<span class="Apple-style-span" style="color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; line-height: 18px;">Authored By:</span><span class="Apple-style-span" style="color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; line-height: 18px;"> </span><span class="Apple-style-span" style="color: #333333; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 13px; line-height: 18px;"><a href="http://www.orthop.washington.edu/PatientCare/OurServices/FracturesTrauma/SurgeonsCareProviders/JamesCKriegMD.aspx" style="color: #d52a33; text-decoration: none;" target="_blank">James Krieg, MD</a></span>Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com0tag:blogger.com,1999:blog-3608788935039794556.post-46101210446262066002012-01-04T10:09:00.000-08:002012-01-04T11:12:31.181-08:00Minimally Invasive Screw Fixation of Symptomatic Pubic Ramus Nonunions<span style="font-size: small; line-height: 115%;">A 46 years old female had incidental trauma related to her equestrian activities. She noted some left groin pain but did not seek medical treatment initially. Several weeks later her left groin pain persisted and she consulted her local physician. </span><br />
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<span style="font-size: small; line-height: 115%;">She had a slight antalgic gait and mild tenderness to palpation of her pubis. She had no other relevant findings on physical examination an anteroposterior pelvic plain radiograph revealed no fracture or other abnormailty. </span><br />
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<span style="font-size: small;"><span style="font-family: inherit; line-height: 115%;">Her pain worsened over the subsequent months and she was seen again and noted to have a more notable limp due to pain and persistent pubic tenderness. </span></span><br />
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<span style="font-family: inherit; font-size: small;"><span style="font-family: inherit; line-height: 115%;">Another plain pelvic film identified left sided peripheral superior and mid-inferior pubic ramus fractures. </span><span style="line-height: 115%;"> </span></span><br />
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<span style="font-size: small;"><span style="line-height: 115%;">Pelvic computed tomography confirmed the diagnosis and detailed the well-aligned hypertrophic nonunion sites. There were no other areas of fracture or instability seen on these imaging studies. </span></span><br />
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She was not able to work or participate in her routine activities due to her left inguinal-pubic pain. A complete medical evaluation ruled out any form of metabolic bone diseases. She was counseled regarding the variety of operative and non-operative treatment options, and she chose percutaneous stabilization of the symptomatic pubic ramus nonunion sites. <br />
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At surgery, medullary screws were inserted through small stab wounds under fluoroscopic guidance to stabilize the nonunion sites. First the superior ramus site was fixed with an antegrade superior ramus medullary lag screw. The inferior ramus site was then secured using a large cortical lag screw.<br />
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<div style="font-family: inherit;"><span style="font-size: small;">Immediately after surgery, she noted good relief from her prior symptoms. She used crutches for 6 weeks thereafter limiting her weight bearing to light pressure only during the stance phase of gait. During weeks 7-12 after surgery, she progressed from partial weight bearing to full weight bearing along with light strengthening exercises. </span></div><div style="font-family: inherit;"><span style="font-size: small;"><br />
</span></div><div style="font-family: inherit;"><span style="font-size: small;">Four months after surgery, she had radiographic union at the nonunion sites, no pain complaints, and had returned to her previous job and recreational impact activities.</span></div><br />
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Authored By: <a href="http://www.orthop.washington.edu/PatientCare/OurServices/FracturesTrauma/SurgeonsCareProviders/MLChipRouttJrMD.aspx" target="_blank">M.L. Chip Routt, Jr., M.D. </a>Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com0tag:blogger.com,1999:blog-3608788935039794556.post-82177281295707161502011-12-06T14:08:00.000-08:002011-12-06T14:31:02.194-08:00Unstable Pubic Ramus and Y-Shaped Sacral FracturesA 72 years old female with a history of inflammatory bowel disease was injured while on vacation with her family. She fell down 4-5 steps onto a grassy lawn and noted immediate anterior and posterior pelvic pain. She was taken to a local emergency room where physical examination and plain pelvic radiographs revealed no abnormalities.<br />
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She was unable to ambulate without significant assistance and returned home. One week after injury, she consulted her primary physician and complained of worsening pelvic pain. She had no bowel or bladder symptoms.<br />
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She was referred to our clinic on that same day. On physical exam, she had pelvic mechanical instability. She had diminished strength of the hip area and lower extremity muscles bilaterally due to pain.<br />
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Her detailed neurological examination was otherwise normal. Pelvic plain radiographs and a computed tomography scan identified a right-sided displaced pubic ramus fracture and a displaced Y-shaped sacral fracture. On the anteroposterior image, she had a paradoxical inlet appearance of the sacrum.<br />
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The sagittal sacral CT scan images best demonstrated the displacement of the upper sacrum through the fracture’s transverse component.<br />
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She opted for surgical treatment of he unstable and displaced pelvic fractures. She underwent surgery the next day. After being anesthetized, she was positioned supine on a radiolucent table and elevated on a soft lumbosacral support. Manual compression of the pelvis under fluoroscopy identified the pubic ramus displacement due to instability. <br />
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Manipulative reduction using manual distraction at the iliac crests reduced the pubic fracture. Medullary fixation was performed percutaneously using a retrograde superior pubic ramus screw. The Y-shaped sacral fracture was stabilized percutaneously using two trans-iliac, trans-sacral iliosacral screws located safely within the upper sacral segment.<br />
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She had dramatic pain relief immediately after surgery. A licensed physical therapist monitored her rehabilitation for the next 3 months. For the initial six weeks after operation, light resistance strengthening exercises were selected along with right-sided protected weight bearing using a walker. Between weeks 7-12, progressive partial weight bearing and more vigorous strength training was performed. Four months after injury, she had returned to her normal activities without pain. Her plain pelvic radiographs demonstrated fracture union.<br />
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U, Y, and H-shaped sacral fractures are unusual and are often delayed diagnoses. The AP pelvic plain film may demonstrate a paradoxical inlet of the sacrum when the upper sacral component is displaced and kyphotic. Mid-sagittal sacral CT imaging better defines the fracture details. Percutaneous pelvic fixation is used when the fracture fragments and therefore osseus fixation pathways are adequately reduced/realigned.<br />
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Authored By: <a href="http://www.orthop.washington.edu/PatientCare/OurServices/FracturesTrauma/SurgeonsCareProviders/MLChipRouttJrMD.aspx" target="_blank">M.L. Chip Routt, Jr., M.D. </a>Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com0tag:blogger.com,1999:blog-3608788935039794556.post-79220963507721115622011-11-02T10:54:00.000-07:002011-11-02T11:31:34.595-07:00Complex Monteggia Fracture DislocationA 25 year old male was involved in a severe motor vehicle collision in which his car collided with a transport truck. He sustained an isolated open fracture dislocation of his dominant elbow. On physical examination he had multiple small open wounds over the posterior aspect of his elbow and forearm. He had a normal neurologic and vascular examination.<br />
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Radiographs were performed which demonstrated an extremely comminuted fracture dislocation of his elbow. He had complete disruption of his proximal radioulnar joint with anterior dislocation of the radial head representing a Type I Monteggia injury variant.<br />
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The patient was brought emergently to the operating room for irrigation and debridement of his open wounds as well as open reduction and internal fixation of his fracture. He had massive disruption of the deep soft tissues and musculature around the elbow.<br />
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The joint was meticulously reduced and repaired and the ulnar shaft component was held with clamps. However, the radial head was not reduced indicating that length had not been completely restored to the comminuted ulnar shaft. Length was then added and held with a minifragment plate on the shaft of the ulna and the radial head was then reduced. A plate spanning the joint and ulnar shaft components was then placed to hold the reduction. The plate was a 3.5 mm LCDC thickness plate.<br />
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The elbow was then brought through a full range of motion and the radial head remained reduced and stable throughout the full arc of flexion and extension in full pronation and supination. <br />
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Postoperatively, the patient was started on a rehabilitation program of elbow range of motion exercises 48 hours after surgery. He was able to regain excellent motion and return to his full time manual job within six months of injury. Final radiographs demonstrated a healed ulna with a concentrically reduced joint.<br />
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Type I (anterior) Monteggia injuries are fracture dislocations of the elbow in which the ulna is fractured and the proximal radioulnar joint is disrupted. The radial head dislocates anteriorly in this type of injury. In adults, these injuries typically result from high energy mechanisms and can have a high incidence of nerve or vascular injury. The key to restoring elbow stability is anatomic reduction and length restoration of the ulnar shaft.<br />
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Most cases do not involve such an extensive fracture of the joint as was seen in this patient. However, like other Monteggia injuries, anatomic ulnar alignment was the key to restoration of elbow joint stability in this case. This patient had an excellent result which was only possible by accurately restoring his anatomy and placing sufficient sized implants to ensure a rigid and stable construct that allowed for early range of motion and elbow rehabilitation.<br />
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Authored By: <a href="http://www.orthop.washington.edu/PatientCare/OurServices/FracturesTrauma/SurgeonsCareProviders/DaphneMBeingessnerMD.aspx" target="_blank">Daphne Beingessner, M.D. </a>Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com0tag:blogger.com,1999:blog-3608788935039794556.post-70863088082737160552011-10-04T13:39:00.000-07:002011-10-04T21:49:41.714-07:00Anterior ColumnA 54 years old male fell approximately four feet from a ladder onto the ground. He complained of left hip pain and was unable to stand. On presentation to the emergency department, he was awake and alert, and only complained of severe left hip pain.<br />
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He was hemodynamically stable and his physical examination confirmed left hip pain with any attempted passive movement. There was no obvious limb deformity or abnormal other findings. The injured lower extremity’s neurological and vascular examinations were within normal limits, yet the muscle power evaluation was limited due to pain.<br />
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<div>Pelvic radiographs and a computed tomography scan demonstrated a displaced left anterior column acetabular fracture. The axial CT images demonstrated the details including the dome involvement. Three-dimensional surface rendered images further defined the osseus anatomy of the fracture.<br />
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The fracture line extended from the posterior aspect of the iliac crest, through the iliac fossa, along the pelvic brim, and divided both the acetabular dome and anterior acetabular wall regions in half. Skeletal traction was used to protect the femoral head and acetabular fracture surfaces, relax muscle spasm, provide comfort, and alert the ancillary staff to the injury before surgery.</div><div><br />
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One day after injury, the patient underwent open reduction and internal fixation of the fracture using an ilioinguinal surgical exposure. The fracture surfaces were cleansed and then the fragments manipulated and clamped. The clamp was applied onto the pelvic brim and quadrilateral surface using the Stoppa interval of the ilioinguinal exposure.<br />
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A malleable plate and interfragmentary lag screws were used to definitively stabilize the fracture. The plate was secured initially onto the stable iliac bone and located just lateral to the sacroiliac joint. Then lag screws were inserted through the plate and between the tables of the iliac crest bone.<br />
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The antegrade medullary superior pubic ramus lag screw was inserted percutaneously safely within the osseus fixation pathway using fluoroscopic biplanar imaging. On the postoperative anteroposterior pelvic image, the surgical staples indicate the ilioinguinal skin incision.<br />
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On the first postoperative day, the patient began his rehabilitation program with passive range of hip motion and isometric muscle strengthening exercises. He used crutches to protect and unload the hip repair during ambulation for 6 weeks after surgery. During weeks 7-12, a routine conditioning and strengthening program was used along with progressive weight bearing.<br />
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At his follow up evaluation 3 months after surgery, he had no complaints nor limp, his hip range of motion was symmetrical with his uninjured side, and his hip and lower extremity strength had returned to normal. He returned to his regular job four months after surgery as a laborer.<br />
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Authored By: <a href="http://www.orthop.washington.edu/PatientCare/OurServices/FracturesTrauma/SurgeonsCareProviders/MLChipRouttJrMD.aspx">M.L. Chip Routt, Jr., M.D. </a>Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com0tag:blogger.com,1999:blog-3608788935039794556.post-11279074558296806582011-09-11T15:01:00.000-07:002011-09-11T15:20:23.024-07:00Distal Humerus Fracture43 year old female fell on the ice sustaining an intraarticular distal humerus fracture. This is a complex break of the end of the humerus thus involving the elbow joint. The elbow joint was in several pieces. The patient is an active, healthy female who is right hand dominant. Radiographs demonstrate a comminuted (multifragment) fracture of the distal humerus.<br />
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Standard radiographs are challenging to interpret, so additional xrays are taken with gentle traction applied to the arm. This helps delineate the fracture fragments.<br />
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A posterior approach was utilized to access the elbow. Given the severity of the fracture, including the multiple articular (joint) pieces, an olecranon osteotomy was performed to allow for visualization of the joint. The olecranon is the proximal part of the ulna. Posteriorly, it covers and contains the distal humerus, forming part of the hinge of the elbow joint. An olecranon osteotomy is a surgical procedure in which the olecranon (proximal ulna) is broken in a controlled manner and repaired at the end of the operation. With the olecranon osteotomy complete, the multiple pieces of the distal humerus fracture are fixed anatomically and secured with plates and screws.<br />
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Once the distal humerus is repaired, the final part of the operation involves fixing the olecranon osteotomy with a plate and screws.<br />
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At one year, the patient is pain free with near full range of motion. She lacks the last 5 degrees of extension and flexes to 135 degrees. She has full pronation and supination. She is back to her usual activities.<br />
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Distal humerus fractures are complex injuries which are challenging to fix and can result in significant functional limitations. When dealing with these injuries, it is important to properly identify the complexity of the fracture and adhere to good surgical principles and techniques to maximize patient outcomes.<br />
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Authored By: <a href="http://www.orthop.washington.edu/Faculty/Taitsman">Lisa A. Taitsman, M.D. </a>Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com1tag:blogger.com,1999:blog-3608788935039794556.post-86388099131059635432011-08-02T17:09:00.000-07:002011-08-02T17:31:57.326-07:00Geriatric Hip FractureAn active 89 year old female presented to our Emergency Department following a fall complaining of left hip pain and an inability to walk. Radiographs revealed an intertrochanteric hip fracture.<br />
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She was admitted to the hospital and evaluated by the internal medicine team. She was cleared for surgery and on the following day she was taken to the operating room for closed reduction and internal fixation with a Dynamic Hip Screw (DHS).<br />
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Following the surgery, she was allowed to put weight on her leg as she tolerated. Her immediate postoperative course was uncomplicated. Her xrays at six weeks demonstrate good alignment and evidence of early healing.<br />
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</tbody> </table>Unfortunately, just before her three month follow up appointment, she fell again and sustained a right hip fracture.<br />
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</tbody> </table>Again, the patient was evaluated and co-managed by the medical team. This fracture was treated with a closed reduction and stabilized with a medullary hip screw. We chose to use this implant due to concerns that the fracture extended distally. For fractures that extend into the subtrochanteric region, a medullary implant is preferred over the DHS. At 2 months, the following xrays were obtained.<br />
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The patient is now almost 3 years out from her second surgery and is doing well. She uses a walker to ambulate and lives in an assisted living community. When caring for geriatric patients with hip fractures it is important to provide a quality operation, but also a team approach as to optimize patient outcome.<br />
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Authored By: <a href="http://www.orthop.washington.edu/Faculty/Taitsman">Lisa A. Taitsman, M.D. </a><span style="font-family: arial; font-size: 14px;"> </span>Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com1tag:blogger.com,1999:blog-3608788935039794556.post-61648142200712246032011-07-08T22:25:00.000-07:002011-08-03T22:26:50.591-07:00Complex Tibia FractureThis 55 year old female sustained an injury to her right leg after a fall from a ladder. The patient sustained an intraarticular fracture of the distal tibia combined with a non-contiguous fracture of the distal tibial shaft. Both injuries were closed. The short oblique fracture of the tibial shaft is shown in the injury radiographs (a, b). Further, at the ankle joint, there is a significant fracture intraarticular injury of the distal tibia which is characterized by a spiral fracture that separates a large posterior articular segment (c, d, e). There is a small piece of cortical comminution proximally at the posterior aspect of the fracture. <br />
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<tr> <td>(a)</td> <td>(b)</td> </tr>
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<tr> <td>(c)</td> <td>(d)</td> <td>(e)</td> </tr>
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The CT scan help to further characterize the articular injury pattern. The axial images demonstrate the posterior articular segment that comprises the vast majority of the articular surface. The plane of the fracture at the joint line is largely coronally oriented with a medial cortical exit point that extends from the medial malleolus distally (a, b). The sagittal and coronal CT reformations further demonstrate the fractures and confirm the lack of significant impaction or comminution (c, d, e). These CT scans demonstrate that the medial malleolar fracture from the AP plain radiographs is actually a large articular fracture of the posterior aspect of the medial distal tibia.<br />
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<tr> <td>(a)</td> <td>(b)</td> </tr>
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<tr> <td>(c)</td> <td>(d)</td> <td>(e)</td> </tr>
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The shaft fracture, if in isolation, would certainly be optimally managed with an intramedullary nail. The displaced articular injury, if in isolation, would be optimally managed with open reduction and internal fixation. However, the leg was initially quite swollen and open reduction of the articular surface at the initial operative intervention was felt to be risky. Further, it was felt that primary stabilization of the shaft fracture with a nail would potentially block an accurate reduction of the articular injuiry. For that reason, it was elected to fix the fibular fracture and place a spanning external fixator that provided temporary stability of both the shaft fracture and the pilon injury. The fibular was plated through a posterolateral surgical exposure. The external fixator was placed from the proximal tibia (2 Schanz pins) to the foot (transcalcaneal pin with a medial pin at the cuneiforms) to span both fractures and to reasonably center the talus relative to the tibial shaft (a, b). The repeat CT scan adds very little information and was probably unnecessary. The fractures are and the orientation of the articular injury is confirmed (c, d, e).<br />
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<tr> <td>(a)</td> <td>(b)</td> </tr>
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<tr> <td>(c)</td> <td>(d)</td> </tr>
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</tbody></table>The patient elevated the lower extremity for seven days to allow adequate resolution of the soft tissues at the distal tibia. As mentioned previously, the ideal operative plan combined open reduction and internal fixation of the articular injury combined with intramedullary nailing of the tibial shaft component. The articular injury was approached first to prioritize the joint reduction. The patient was positioned supine. Given the long medial cortical exit of the fracture, a posteromedial skin incision was used to allow exposure of the posteromedial proximal aspect of the fracture. Distally, a full thickness flap was used to allow exposure of the medial distal tibia. An incision directly over the medial face of the distal tibia was avoided to minimize potential wound healing issues. The fracture was cleaned from proximal to distal, allow visualization of the fracture line at the joint. Despite a thorough removal of all hematoma from the fracture and the presence of a well-corticated fracture read, the fracture could not be perfectly reduced as judged visually and radiographically. Therefore, an anterolateral surgical exposure was performed to allow for control and clamping at the opposite fracture exit point. This allowed for simulataneous clamp applications and improved control of the fracture. No identifiable block to reduction was found, however, improved fracture reduction was obtained with the additional approach. Fixation consisted of multiple independent 2.4 mm lag screws placed perpendicular to the fracture line, and additional lag screws placed through a 2.0 mm plate along the anterior distal tibia. The lag screws and plate were placed in a location that was felt to allow for placement of an intramedullary nail for the tibial fracture (a, b, c).<br />
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<tr> <td>(a)</td> <td>(b)</td> </tr>
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<tr> <td>(c)</td> </tr>
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An attempted closed reduction of the shaft fracture was performed but regaining length was difficult. Given the proximity of the posteromedial approach which was used for the articular injury and the shaft fracture, this incision was simply extended proximally five additional centimeters to allow for reduction and clamp placement at the shaft fracture. No significant soft tissue dissection was performed (a, b). This allowed for atraumatic nail placement without vigorous manipulation of the reduced articular injury. The clamp was left in position distally to ensure that the distal fracture did not displace (c, d). A reamed nail was placed. The three distal interlocking screws (medial to lateral, anterior to posterior, anteromedial to posterolateral) were placed. An additional lag screw was then placed posterior to the nail to support the articular fracture reduction. A small lag screw was placed at the medial malleolus (e, f). Final radiographs demonstrate the reductions of the tibial shaft as well as the distal tibial articular injury (g, h).<br />
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<tr> <td>(a)</td> <td>(b)</td> </tr>
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<tr> <td>(c)</td> <td>(d)</td> </tr>
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<tr> <td>(e)</td> <td>(f)</td> </tr>
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<tr> <td>(g)</td> <td>(h)</td> </tr>
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Initially, unrestricted range of motion exercises of the ankle joint and subtalar joint was encouraged two weeks following the definitive articular reconstruction. Weight bearing was restricted until 12 weeks given the articular injury. Healing of both fractures progressed uneventfully as demonstrated in the radiographs at 6 months (a, b, c, d e).<br />
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<tr> <td>(a)</td> <td>(b)</td> <td>(c)</td> <td>(d)</td> </tr>
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<tr> <td>(e)</td> </tr>
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<b>Criticisms and Alternatives:</b><br />
Alternatively, a short intramedullary nail could have been used to treat the shaft component of the fracture, followed by delayed open reduction and internal fixation of the articular injury. This would have a required an extremely short nail that would have terminated quite close to the proximal extent of the articular fracture posterior cortical extension. However, this approach would have allowed primary stabilization of the tibial fracture, combined with fibular fixation. An ankle joint spanning external fixator would still have been required. The shaft component of the injury pattern could have been treated with a plate at the time of reduction and internal fixation of the pilon fracture. This could have been accomplished with a direct open reduction, or with a minimally invasive technique.<br />
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Authored By: <a href="http://www.orthop.washington.edu/Faculty/Nork">Sean E. Nork, M.D.</a>Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com0tag:blogger.com,1999:blog-3608788935039794556.post-9125421140858430462011-05-30T17:34:00.000-07:002011-06-01T08:35:06.199-07:00Open pilon fracture with bone lossThis 24 year old male sustained an open right pilon fracture while skiing. The patient was initially seen at an outside hospital and was ultimately referred approximately 16 hours following the injury. There was a large posteromedial open wound approximately five centimeters above the ankle joint, and the proximal tibial shaft was still extruded through the open wound at presentation. Surprisingly, the patient had intact plantar sensation and a well perfused foot. There was obvious damage to the posterior musculature. The injury radiographs demonstrate significant shortening and the extrusion of the tibial shaft posteriorly.<br />
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A CT scan was obtained prior to transferring the patient. In most circumstances, the CT scan would be obtained after fibular fixation and spanning external fixation in cases where a staged approach is planned. The injury CT scan images demonstrate the three major articular segments. The posterior segment is large and includes the entire posterior and central portions of the articular surface, and extends to the medial shoulder of the joint. The anterolateral articular segment extends to the medial shoulder.<br />
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The patient underwent initial irrigation and debridement, fibular stabilization, and spanning external fixation shortly after arrival to the hospital. At the same time the intercalary cortical fragment was reduced and stabilized. A posteromedial approach was used given the location of the open wound, the presence of a tibial shaft extruded through the skin, and the perceived need for debridement in this location. The incision was extended over a distance of approximately ten centimeters and was located posterior to the palpable posteromedial border of the tibia. This allowed for access to the tibial shaft, and the associated soft tissue structures. A significant portion of the flexor hallucis longus muscle was debrided and free cortical fragments were removed. The large intercalary cortical segment could be accurately reduced to the tibial shaft. This was felt to be important to decrease the ongoing pressure on the soft tissues, to allow for wound closure, and to allow for the future reduction of the articular surface. A posterolateral approach was used for fibular stabilization to allow for future anterior approaches. An external fixator was placed using a transcalcaneal pin, a medial cuneiform pin, and two tibial pins placed well proximal to the anticipated future surgical approaches. Antibiotic beads were placed into the osseus defect of the distal tibial metaphysis.<br />
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The patient was sent home for elevation and to allow for resolution of the soft tissue swelling. Twenty days after injury, the patient underwent definitive fixation of the pilon fracture. The injury pattern is amenable to fixation through either an anteromedial or anterolateral approach. Similarly, a direct anterior approach could be used. An anteromedial approach would actually allow for the best visualization of the medial articular segment reduction to the posterior articular segment; as well as the reconstruction of the medial column through the cortical read between the medial malleolus and the medial cortical fragment. However, given the presence of an extensive and lengthy posteromedial approach which was used for the initial operative debridement of the open fracture, an anterolateral approach was felt to be safer. The anterolateral and posterior segments were first stabilized, followed by reduction of the remainder of the joint.<br />
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The entire articular block was then reduced relative to the tibial shaft and an anterolateral plate was placed in a submuscular fashion beneath the anterior compartment musculature through the anterolateral incision. In order prevent varus, a medial plate was slid along the subcutaneous anteromedial face of the distal tibia through a one centimeter incision over the medial malleolus Finally, antibiotic beads were placed into the osseus defect.<br />
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</tbody> </table>Approximately six weeks later, the patient was brought back to the operating room for a planned bone grafting of the large osseus defect. The anterolateral approach allowed for access to the defect, retrieval of the antibiotic beads, and placement of graft. Bone graft (approximately 30 cc) was obtained from the proximal tibia and combined with allograft and demineralized bone matrix (10 cc).<br />
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Initially, unrestricted range of motion exercises of the ankle joint and subtalar joint was encouraged two weeks following the definitive articular reconstruction, despite the presence of the large osseus defect. The implants were felt to be of sufficient strength and the patient was compliant. The patient was allowed to begin weight bearing at 12 weeks from his definitive articular reduction, which was 6 weeks following his bone grafting procedure. Weight bearing was initially restricted to a walking boot for 6 weeks given the presence of the grafted defect, followed by unrestricted weight bearing with regular shoe wear. Radiographs at 6 months from his articular reconstruction demonstrate maintenace of alignment and the presence of the bone graft.<br />
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Radiographs at one year show incorporation of the bone graft. The patient was full weight bearing without restrictions. Ankle range of motion was 15 degrees dorsiflexion and 30 degrees plantar flexion. The patient had some persistent discomfort and stiffness.<br />
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Authored By: <a href="http://www.orthop.washington.edu/Faculty/Nork">Sean E. Nork, M.D.</a>Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com0tag:blogger.com,1999:blog-3608788935039794556.post-79726944991784480312011-05-16T08:59:00.000-07:002011-05-16T10:33:02.581-07:00Complex proximal humerus fracture dislocationA 25 year old female fell 12 feet from a ladder sustaining a complex fracture dislocation of her left shoulder. This fracture pattern carries a high risk of avascular necrosis of the humeral head which can lead to painful arthritis of the shoulder joint. Maintaining fixation to union can be challenging.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgKwiG_BvT40TBS_yvp9Ew60Dghuq4ttPthN4AeaCafflnrMnPvccYexX7RFVnm1H34q1TthQ-aB1wQKwtEYcIRuKaqotKcWlIbqB8-MYlF0Nt1s7r3XN8jfekeQW_KEzk2VpzBk4TnvHY/s1600/Untitled2.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="178" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgKwiG_BvT40TBS_yvp9Ew60Dghuq4ttPthN4AeaCafflnrMnPvccYexX7RFVnm1H34q1TthQ-aB1wQKwtEYcIRuKaqotKcWlIbqB8-MYlF0Nt1s7r3XN8jfekeQW_KEzk2VpzBk4TnvHY/s200/Untitled2.png" width="200" /></a></td> </tr>
</tbody> </table>Computed tomography confirmed the diagnosis and demonstrated a small amount of bone for fixation in the humeral head. Given the patient’s young age, hemiarthroplasty was not considered as a treatment option.<br />
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<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQdgEws8eYvhwah5wJF6tfQ7HrmfuPb7oR6Op9xEgf8VBlAIfOnkurXIQepK4KY7GKVmuUR90HUljYdMv-NPM9XzM_6sn4WpE-Hfw3t4HqFmGtIipCN9V1_YMhs8EJMz1XxFDwaLR3RTE/s1600/Untitled3.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="144" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQdgEws8eYvhwah5wJF6tfQ7HrmfuPb7oR6Op9xEgf8VBlAIfOnkurXIQepK4KY7GKVmuUR90HUljYdMv-NPM9XzM_6sn4WpE-Hfw3t4HqFmGtIipCN9V1_YMhs8EJMz1XxFDwaLR3RTE/s320/Untitled3.png" width="126" /></a></div><br />
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The humeral head was reduced after the fracture was exposed through a deltopectoral incision.<br />
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The fracture was then fixed with a periarticular locking proximal humerus plate and screw fixation of the coracoid. <br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjYZycMQx-il3ouMFiQcgax-Zwb6sd5eNh6SU4QVvsdpvzXax_GcIpdMAn1U4NrHs-GgGsiUy0qjhE2BYcVMbcq6dYJ7CrvxX1EFYlp53X44mbfgomwltnGg_71aO1KWE2J5aU4kcJjZs/s1600/Untitled5.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="144" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjYZycMQx-il3ouMFiQcgax-Zwb6sd5eNh6SU4QVvsdpvzXax_GcIpdMAn1U4NrHs-GgGsiUy0qjhE2BYcVMbcq6dYJ7CrvxX1EFYlp53X44mbfgomwltnGg_71aO1KWE2J5aU4kcJjZs/s320/Untitled5.png" width="158" /></a></td> <td><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgURixPNxJF0qFMBkgBWbHFSLSAIsmV5cLhDUG8mH9_yL0aL_qnAwQp0PgXbx_bN5MYEBJbOBccfcgf1zxeQy3BZgZwv-5U79tlaSLAF5RnrhsOBh7IrjIPGJ_m6KrK-F_5sxFTWjpVGKk/s1600/Untitled7.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="135" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgURixPNxJF0qFMBkgBWbHFSLSAIsmV5cLhDUG8mH9_yL0aL_qnAwQp0PgXbx_bN5MYEBJbOBccfcgf1zxeQy3BZgZwv-5U79tlaSLAF5RnrhsOBh7IrjIPGJ_m6KrK-F_5sxFTWjpVGKk/s200/Untitled7.png" width="200" /></a></td> <td><br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2tijtQhOJdXavwTenWGmQMLa457Kiu8dc9jrW1Jhm7yoh2El2dX8douQe5v-jI_HNwvhRVZ7JIud7opl6b4xlPlMdeIfQdXEcXp_QPCNJziSoFFt9uc2UanKUFpk85DEGQ1ai_1FPT7k/s1600/Untitled8.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="144" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2tijtQhOJdXavwTenWGmQMLa457Kiu8dc9jrW1Jhm7yoh2El2dX8douQe5v-jI_HNwvhRVZ7JIud7opl6b4xlPlMdeIfQdXEcXp_QPCNJziSoFFt9uc2UanKUFpk85DEGQ1ai_1FPT7k/s320/Untitled8.png" width="150" /></a></td> </tr>
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At 18 month follow-up, the patient had maintained the vascularity of the humeral head and had healed the fracture. There was slight restriction of forward flexion compared to the opposite shoulder (10 degrees). The patient had minimal pain and had returned to all baseline activities.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiglKdaPpSPT3LwFxeo4acyT34O6XhMiu3_c1rjiHsWFQIpmbiZ6ULeSA6iesQhbYs5n4K3s4Euh3GONsuhlDyXd8UR4D8Bnpv4838aqSLffiiv5q1s2RNhd2tOQBzc-nm05zAD-nPCPl4/s1600/Untitled9.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="144" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiglKdaPpSPT3LwFxeo4acyT34O6XhMiu3_c1rjiHsWFQIpmbiZ6ULeSA6iesQhbYs5n4K3s4Euh3GONsuhlDyXd8UR4D8Bnpv4838aqSLffiiv5q1s2RNhd2tOQBzc-nm05zAD-nPCPl4/s320/Untitled9.png" width="118" /></a></td> <td><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi5jYkknnFlh3nZ5cGCOXYewmo6fzPg81_d7-8gQmRJi9mFgO7_q4CrQt67x8rXax2_12AD5o0oSBo8NWrXUDHEXL3R2s_jonx7AFuSO_vpE41uz6aSwAQ-GmfbjK3xI-Fgw6jmJsTsJXI/s1600/Untitled10.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="145" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi5jYkknnFlh3nZ5cGCOXYewmo6fzPg81_d7-8gQmRJi9mFgO7_q4CrQt67x8rXax2_12AD5o0oSBo8NWrXUDHEXL3R2s_jonx7AFuSO_vpE41uz6aSwAQ-GmfbjK3xI-Fgw6jmJsTsJXI/s320/Untitled10.png" width="150" /></a></td> <td><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiNyDXGSwzvyMLfx_Vh36TvjvYCJ64UjZcwO4X7YHrnJPrYywKV9Z-qQiIG78ZQNhRfydBwdvDaMpFRCB_LVtH3-fPmF4ketBfLPbnyB2t9VsQxJdXu8lwDubnuZprAaAhyrN3nEllEldk/s1600/Untitled11.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="144" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiNyDXGSwzvyMLfx_Vh36TvjvYCJ64UjZcwO4X7YHrnJPrYywKV9Z-qQiIG78ZQNhRfydBwdvDaMpFRCB_LVtH3-fPmF4ketBfLPbnyB2t9VsQxJdXu8lwDubnuZprAaAhyrN3nEllEldk/s320/Untitled11.png" width="180" /></a></td> </tr>
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Complex proximal humerus fracture dislocations in young adults are challenging injuries. We have extensive experience treating this injury at Harborview Medical Center and with adherence to sound surgical technique, good results are possible.<br />
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Authored By: <a href="http://www.orthop.washington.edu/Faculty/Beingessner">Daphne M. Beingessner, M.D.</a><span style="font-family: arial; font-size: 14px;"></span>Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com0tag:blogger.com,1999:blog-3608788935039794556.post-57052715001623546662011-04-21T12:30:00.001-07:002011-04-21T14:46:28.073-07:00Infected Humeral NonunionA sixty year old underwent attempted open reduction and internal fixation of a humeral shaft fracture. The fixation failed and was removed but resulted in an infected nonunion of the humerus with significant bone loss. Antibiotic beads had been placed and the patient had an open draining wound.<br />
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At this point, she presented to Harborview Medical Center for treatment of her complex nonunion.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgoCZRguwlaFXKfutYKMzLVNDdH6SLv77yTmrSajJocu2YZ-guJdaFD28lSwlFIAKCQGIoFez1_aXemCNrsII4txpu-OrA7bF_42qnfK_JlDMlYkaukkqj_5wi0HPo449H3IFjUHxg3qYM/s1600/image-9.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgoCZRguwlaFXKfutYKMzLVNDdH6SLv77yTmrSajJocu2YZ-guJdaFD28lSwlFIAKCQGIoFez1_aXemCNrsII4txpu-OrA7bF_42qnfK_JlDMlYkaukkqj_5wi0HPo449H3IFjUHxg3qYM/s200/image-9.jpg" width="160" /></a></td> </tr>
</tbody> </table>She was treated with irrigation and debridement of the infection, stabilizing with a locked plate, insertion of antibiotic beads into the bone defect and bacteria-specific intravenous antibiotics.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLgv1sNxiIwxpIrdnxvxUm6nn83GQ5GnAVGX3tQI2ArIj7Me3ohhC1wbQn1tzWttfh-gk3YMZzeH3vrS5n5V_s4n6xwUiEPlkSaXeLITB9ciPXRKsrm9SjrWTyaAilIVfnqt56S2ym5Ns/s1600/image-10.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLgv1sNxiIwxpIrdnxvxUm6nn83GQ5GnAVGX3tQI2ArIj7Me3ohhC1wbQn1tzWttfh-gk3YMZzeH3vrS5n5V_s4n6xwUiEPlkSaXeLITB9ciPXRKsrm9SjrWTyaAilIVfnqt56S2ym5Ns/s200/image-10.jpg" width="96" /></a></td> <td><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhuS_1ekbEvDVjZul1BCjV2LNu5W-DQmEScBSHXwpMq1iQAzrvhlo_98VBXEH_GFRd4QNyR2QtUbO474RK2noj2rbDJXptHo59fOFJmyt1rAEBj9tzzlw_sOZGrzKSMGqzlubYBb1bgH6c/s1600/image-11.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhuS_1ekbEvDVjZul1BCjV2LNu5W-DQmEScBSHXwpMq1iQAzrvhlo_98VBXEH_GFRd4QNyR2QtUbO474RK2noj2rbDJXptHo59fOFJmyt1rAEBj9tzzlw_sOZGrzKSMGqzlubYBb1bgH6c/s200/image-11.jpg" width="76" /></a></td></tr>
</tbody></table>After 10 weeks, she was brought to the operating room for bone grafting. An intramedullary fibular allograft as well as autograft from her ipsilateral femur were placed. Intraoperative cultures were negative for continued infection.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgefIfICB11LIFaDzHBeM51i4P4R6ngYEU7SQbv6ePdPEx92y7oedR6AqAILVQtFveD-JSVb71IatKM-jQ8K0v8LmX-5oj142AXIZ0U80EQJYTYRWkAgD1hngaoFOoHHQZY1CQhsfLrHmk/s1600/image.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgefIfICB11LIFaDzHBeM51i4P4R6ngYEU7SQbv6ePdPEx92y7oedR6AqAILVQtFveD-JSVb71IatKM-jQ8K0v8LmX-5oj142AXIZ0U80EQJYTYRWkAgD1hngaoFOoHHQZY1CQhsfLrHmk/s200/image.jpg" width="90" /></a></td> <td><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7mbf3UHW_v4yHHdZuCagRPfaFk_MKxYHCmkejAzHKxXVySQqnqitvEq5YaFXv219JX8HQ1lbSfVt8HStJarjUOau63YoZtNoWku578dxix5w4Qit7G4ukNzc_lUGW_7ZQmXwYw7t4vvw/s1600/image-1.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7mbf3UHW_v4yHHdZuCagRPfaFk_MKxYHCmkejAzHKxXVySQqnqitvEq5YaFXv219JX8HQ1lbSfVt8HStJarjUOau63YoZtNoWku578dxix5w4Qit7G4ukNzc_lUGW_7ZQmXwYw7t4vvw/s200/image-1.jpg" width="91" /></a><br />
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At seven month follow-up, she had successful healing of her humeral shaft fracture with no infection and no pain. She had returned to all baseline activities and was happy with her outcome.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEghzL57Ndy6sJglksbCf_8qZGUFZYSLjgx9uUxiM2W5kUM-CTc97KDj0I8K_Gjim2dpA9SiO9PuSO6OQ-wzygJuc61Iqt7_A4b8Fqtvgv07DIEbQ1GXoxyQdmw_HuTwFv2PM-av3K36RvA/s1600/image-2.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEghzL57Ndy6sJglksbCf_8qZGUFZYSLjgx9uUxiM2W5kUM-CTc97KDj0I8K_Gjim2dpA9SiO9PuSO6OQ-wzygJuc61Iqt7_A4b8Fqtvgv07DIEbQ1GXoxyQdmw_HuTwFv2PM-av3K36RvA/s200/image-2.jpg" width="65" /></a></td> <td><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSiAGLHi20D4mQobJszjJhyMoiTQv5ei0sDOKXCbdedNxGcjQKbTAKfDsm52E-52qv5AiGdgxtcqyyw2LHmnq79An0u4jPSNV5ee-vIwsM94oJRcdqQLDFfuEB-Fvw2QLH3gjwvsevd_Y/s1600/image-3.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSiAGLHi20D4mQobJszjJhyMoiTQv5ei0sDOKXCbdedNxGcjQKbTAKfDsm52E-52qv5AiGdgxtcqyyw2LHmnq79An0u4jPSNV5ee-vIwsM94oJRcdqQLDFfuEB-Fvw2QLH3gjwvsevd_Y/s200/image-3.jpg" width="50" /></a></td> </tr>
</tbody> </table><br />
Authored By: <a href="http://www.orthop.washington.edu/Faculty/Beingessner">Daphne M. Beingessner, M.D.</a>Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com0tag:blogger.com,1999:blog-3608788935039794556.post-32181331164615896312011-04-21T11:24:00.000-07:002011-04-21T14:45:30.050-07:00Periprosthetic Fracture Nonunion85 year old healthy, independent man, trip and fall 5 years after a total hip arthroplasty and ipsilateral total knee arthroplasty. He did not have any previous hip pain.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVLYcnNumwNFrzVbIbPePG4Vg-BYgAPHGHqlZWFw4k4I8N12uy-pCKoIDob-Dj8J2I_aq-sdBG0nP3rl-STNJavtJ6IKX__PhXlryRO_S3ykm2RXS43GbYUAAYe_DnURq-2XDLDGnQ9RA/s1600/image-1.jpg" imageanchor="1" style="clear: left; float: left;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVLYcnNumwNFrzVbIbPePG4Vg-BYgAPHGHqlZWFw4k4I8N12uy-pCKoIDob-Dj8J2I_aq-sdBG0nP3rl-STNJavtJ6IKX__PhXlryRO_S3ykm2RXS43GbYUAAYe_DnURq-2XDLDGnQ9RA/s200/image-1.jpg" width="100" /></a></td> <td><br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0bIhEDsLTkC-sx9SakNa7riuf-gCXkAQkYF4jVsk1_DnePBK2V2ET6QogdZv-DlC9RT8Bb7eDmZlz_YAZRrhB2Kwdd91kpom397-AcZxi7eFuW1g9ynbGOQ6zND53PvolCMvwu0FBlH8/s1600/image.jpg" imageanchor="1" style="clear: left; float: left;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj0bIhEDsLTkC-sx9SakNa7riuf-gCXkAQkYF4jVsk1_DnePBK2V2ET6QogdZv-DlC9RT8Bb7eDmZlz_YAZRrhB2Kwdd91kpom397-AcZxi7eFuW1g9ynbGOQ6zND53PvolCMvwu0FBlH8/s200/image.jpg" width="100" /></a></td> </tr>
</tbody> </table>Treated with internal fixation:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhRhYaihcshoB6yb3RcSGpRZucmS4B6Jj8IS7E28TcFRC94S38U7yB2mttkqjRYyRIfSjsX42ppGmSzjylc0nj9kjX6jQ1_weQC7POT15RNHHOgEyl1j9AjQNH3qbPo_AjZbzjsknsSQsU/s1600/image-2.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhRhYaihcshoB6yb3RcSGpRZucmS4B6Jj8IS7E28TcFRC94S38U7yB2mttkqjRYyRIfSjsX42ppGmSzjylc0nj9kjX6jQ1_weQC7POT15RNHHOgEyl1j9AjQNH3qbPo_AjZbzjsknsSQsU/s200/image-2.jpg" width="100" /></a></td> <td><br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglChK5IbZCn6zXH69oIt90Blv_LronjErAPPwR9VVCqf8TXMlJVjXlVOc26xrta_6sGQKFjCa2Z2uxdDIIjxmgFBsZmd-kCFFTVEzd1CW5mDoTw_Phxp3F8TMY2zWyauY00RIu34Sctj0/s1600/image-3.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglChK5IbZCn6zXH69oIt90Blv_LronjErAPPwR9VVCqf8TXMlJVjXlVOc26xrta_6sGQKFjCa2Z2uxdDIIjxmgFBsZmd-kCFFTVEzd1CW5mDoTw_Phxp3F8TMY2zWyauY00RIu34Sctj0/s200/image-3.jpg" width="100" /></a></td> </tr>
</tbody> </table>Construct failed at one month postoperatively:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQehSNfDogRhCtyDLzRGIh9K0w5A6pWuGb8N6Bzgr3C8F6abY0e9yDPiGDLqyMSWNNSr2xue1la2HSqWT8l5oFaIQue4KCF1GOi1rvbD4u2doYIonFhbGt83JfV_Vrq2ETJeeNPu507As/s1600/image-4.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em;"><img border="0" height="176" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQehSNfDogRhCtyDLzRGIh9K0w5A6pWuGb8N6Bzgr3C8F6abY0e9yDPiGDLqyMSWNNSr2xue1la2HSqWT8l5oFaIQue4KCF1GOi1rvbD4u2doYIonFhbGt83JfV_Vrq2ETJeeNPu507As/s200/image-4.jpg" width="150" /></a><br />
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Presented to Harborview 8 months after failure, now wheelchair bound. Nonunion was repaired with a locking condylar plate spanning the entire hip prosthesis with secure proximal fixation. At one year follow-up, patient was living independently and ambulating with a cane or walker as needed. <br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDvHT031eudXvB9be5OdX1Cp-IEIzrscIolLPwYXLmUOAFq0fYZcC_EXBMw4Bzptrvbs1IQ5OWFVRD1-kJQIfKsA3i7zcZxvPzsD9aC3fKMJr81T8Umb2gvWo6jWC899TXHJFrfLXuO_Y/s1600/image-5.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhDvHT031eudXvB9be5OdX1Cp-IEIzrscIolLPwYXLmUOAFq0fYZcC_EXBMw4Bzptrvbs1IQ5OWFVRD1-kJQIfKsA3i7zcZxvPzsD9aC3fKMJr81T8Umb2gvWo6jWC899TXHJFrfLXuO_Y/s200/image-5.jpg" width="100" /></a></td> <td><br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjuYFbosNV9NDrfEB9HEUB4cDTRLE60-9J4SkDRzFRuKQuEylONdY98Pep9Kn6k0I_qQ9XhG0VYtcvKlJV-6XOzjemiwotgACvGSXZW0hvBtYgS5_fj4_vgPU8d_INKQLWcNHx_Ox0pjs0/s1600/image-6.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjuYFbosNV9NDrfEB9HEUB4cDTRLE60-9J4SkDRzFRuKQuEylONdY98Pep9Kn6k0I_qQ9XhG0VYtcvKlJV-6XOzjemiwotgACvGSXZW0hvBtYgS5_fj4_vgPU8d_INKQLWcNHx_Ox0pjs0/s200/image-6.jpg" width="100" /></a></td> <td><br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYrKrdUTWzl3DUudWGCtnzUyPA60S8Z0CU3_bBWnoxkmOH8wMUueScJ8MkdezFgK_IElVLaqwmRsXOQeSEi5uxx-uR9dFiuhU20bV9BTkf9K6mVC8qdQYIWRdGk87lHC4JtZnT2ZDlnxs/s1600/image-7.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYrKrdUTWzl3DUudWGCtnzUyPA60S8Z0CU3_bBWnoxkmOH8wMUueScJ8MkdezFgK_IElVLaqwmRsXOQeSEi5uxx-uR9dFiuhU20bV9BTkf9K6mVC8qdQYIWRdGk87lHC4JtZnT2ZDlnxs/s200/image-7.jpg" width="100" /></a></td> <td><br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhy_TQeH-o31iEc1OBRubJLcWYgewli_PCKJGYOD0o5wkmp1eBKcjNxj1viah0Zsco0X52-7e-v6jfx0U3J8MT7ziOCk7lcKXfythxVtvo7BrtL4jc6R0a0Pd6N-6qIAYqXDmwpEhd81bU/s1600/image-8.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhy_TQeH-o31iEc1OBRubJLcWYgewli_PCKJGYOD0o5wkmp1eBKcjNxj1viah0Zsco0X52-7e-v6jfx0U3J8MT7ziOCk7lcKXfythxVtvo7BrtL4jc6R0a0Pd6N-6qIAYqXDmwpEhd81bU/s200/image-8.jpg" width="100" /></a></td> </tr>
</tbody> </table><br />
This case highlights the importance of appropriate proximal fixation and the importance of spanning the entire femur in the setting of a perprosthetic fracture.<br />
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We have successfully treated a series of these patients with this technique as published in the following article: <b>Isolated locked compression plating for Vancouver Type B1 periprosthetic femoral fractures</b>.<br />
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Bryant GK, Morshed S, Agel J, <a href="http://www.orthop.washington.edu/Faculty/Henley">Henley MB</a>, <a href="http://www.orthop.washington.edu/Faculty/Barei">Barei DP</a>, <a href="http://www.orthop.washington.edu/Faculty/Taitsman">Taitsman LA</a>, <a href="http://www.orthop.washington.edu/Faculty/Nork">Nork SE</a>. Injury. 2009 Nov;40(11):1180-6.<br />
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Authored By: <a href="http://www.orthop.washington.edu/Faculty/Beingessner">Daphne M. Beingessner, M.D.</a>Case of the Monthhttp://www.blogger.com/profile/16729290968653477815noreply@blogger.com2