Faculty Bibliography

We report an unusual case of a femoral neck stress fracture leading to the fatigue failure of an AO spiral blade. An unreamed femoral nail with a spiral blade was inserted to treat an unstable subtrochanteric femoral fracture. which lead to fracture union at 5 months. Eight months post-operatively the patient started to complain of left hip pain. Serial radiographs revealed progressive osteoporosis of the proximal femur possibly due to the stress sharing effect of a stiff intramedullary device, which continued to bear a significant amount of the transmitted load. The cause of pain was a stress fracture of the femoral neck and the AO spiral blade, which only became radiologically visible 4 months after the start of the symptoms (1 year after the initial operation). The implant was removed and replaced by a cemented hemiarthroplasty. This case reaffirms the difficulty in diagnosing a stress fracture through a metallic implant. The delay in diagnosis may be shortened if stress fracture were included as an expected complication following an intramedullary nailing.

OBJECTIVE:To determine the functional and radiographic outcome of low Weber C ankle fractures and to evaluate the contribution of the syndesmotic screw in their outcome. DESIGN/METHODS:Prospective evaluation of a consecutive series. SETTING/METHODS:Level I trauma center. PATIENTS/METHODS:Forty-five patients divided into two groups matched for age, sex, and severity of injury. Twenty-six patients were treated with open reduction, internal fixation, and a supplemental syndesmotic screw, and nineteen patients were treated without a syndesmotic screw. Minimum time to follow-up was three years. METHODS:A subjective, objective, and radiographic ankle scoring system was used. Logistical regression analysis was performed to determine whether the presence or absence of a syndesmotic screw was a predictor of a poor outcome. The likelihood ratio test was used to evaluate the significance of each variable in both univariate and multivariate analyses. RESULTS:There was no statistically significant difference between either group, either using subjective outcome criteria (p = 0.86) or in ankle range of motion (p = 0.94). Logistical regression analysis indicated that fracture dislocation could be used as a predictor of a poor outcome for either group. Inadequate reduction and advancing age were also found to be significant predictors of a poorer outcome regardless of the use of a syndesmotic screw (p = 0.003, p = 0.004). CONCLUSIONS:Judicious fixation of Weber C type injuries within five centimeters of the ankle joint, with or without a syndesmotic screw, gives similar results. Obligatory fixation of these fractures with syndesmotic screws appears to have no benefit and creates the need for an additional procedure.

Cauda equina syndrome is rare, but when it does occur it can lead to poor outcomes with significant legal implications. Controversy exists as to whether the timing of surgical intervention may affect these outcomes. Recent studies have reinforced that early surgical decompression may be beneficial to early return of function. Expeditious surgery is, however, only one factor that can affect outcome in this syndrome

We describe the imaging features of a giant geode of the distal humerus in a patient with rheumatoid arthritis, which presented initially as a pathological fracture. The value of magnetic resonance imaging in establishing this diagnosis is emphasized.

We present the case of a child who developed a massive subperiosteal hemorrhage and subsequent osteonecrosis of her right femur after treatment with tissue plasminogen activator for post-varicella streptococcal purpura fulminans. Radiographs showed posteromedial translation of the capital femoral epiphysis on the necrotic shaft, and the hip was immobilized. The femur slowly remodeled and has continued to grow. The child is independently ambulatory with a 2.1-cm leg length discrepancy, a varus deformity of the hip, and a valgus distal femur.

BACKGROUND:A prospective, randomized controlled trial was used to compare the efficacy of the arteriovenous (AV) impulse system and aspirin in reducing venous thrombosis after fracture to the femoral neck. METHODS:A total of 143 patients underwent hemiarthroplasty, after which 70 patients were treated with the AV pump and a second group of 73 patients were commenced on 325 mg of aspirin. Duplex ultrasound was used to assess both proximal and distal venous thrombi on days 7 to 10. Calf and thigh circumferences were also measured. RESULTS:Thrombi developed in seven of the patients treated with aspirin and in four patients treated with the AV pump. No statistically significant difference could be established (p = 0.109). There was a significant reduction in both calf (p = 0.003) and thigh (p = 0.002) swelling in the group treated with the AV pump. Neither treatment group was a significant predictor of a poorer outcome by using logistical regression analysis (p = 0.258). CONCLUSIONS:Both aspirin and the AV pump are effective in reducing thromboembolic events after hemiarthroplasty of the hip.

We present a case of post-traumatic subchondral cyst formation in the talus. No evidence of an osteochondral defect was observed, however, the histological findings suggested a synovial origin. This implicates synovial herniation through traumatized articular cartilage into subchondral bone in a fashion analogous to osteoarthritic pathogenesis

Previously reported cases of fracture dislocation of the tarsal navicular bone have implicated dorsiflexion and longitudinal compression as the mechanism of injury. We report a case of navicular fracture dislocation which, by the description of the incident and the reduction manoeuvre employed, suggests that plantarflexion combined with inversion were the forces required to produce the deformity. Understanding of the mechanism of injury in these fractures may lead to easier closed reduction and improved outcome.