41/860. Free fat interpositional graft in acute physeal injuries: the anticipatory Langenskiold procedure. Free fat graft interposition has been used extensively in management of physeal injuries with established growth disturbances. The use of this technique as part of the management of acute physeal injuries has not been reported. Here we report on its application in acute physeal injuries, where it has prevented the formation of an anticipated physeal arrest. ( info) |
42/860. The changed preliminary report: a repeatedly missed paediatric tibial tumour. This report describes a malpractice case involving a delayed diagnosis of a malignant bone tumour in the proximal tibia in a 10-year-old child. This was caused by a combination of factors. The final report on the first examination failed to reach the patient files, and two subsequent X-ray exams failed to diagnose the tumour, due to misinterpretation in one and obscuring plaster of paris in the other. ( info) |
43/860. Percutaneous electrical stimulation for clinical tibial fracture repair. Observations on stress generated electrical currents in bone have stimulated interest in the possible osteogenetic effect of externally applied electrical energy to establish diaphyseal bone defects in animals and man. This report records the observed effects of pulsed electrical energy directed through a metal (Riordan pin) electrode placed in a large proximal tibial shaft dedect in a young man who sustained loss of bone from a gunshot wound. The fixation pin placed directly into the defect provided the cathode (-) electrode. The anode ( ) electrode consisted of an aluminum foil band placed on the skin adjacent to the leg. The tibia had 282 consecutive days of electrical stimulation and provided X-ray and clinical evidence of enhanced osteogenetic activity. The degree of osteogenetic response attributable to the electrical stimulation is undetermined because other factors, including cast immobilization, time and minimal touchdown (25 pounds) weight-bearing in the cast during the period of observation, may also have had some influence on the healing response. Circumstantial clinical evidence indicates that the applied electrical energy was of primary importance in the healing process. This theoretically and technically acceptable source of osteogenetic activity merits continued, intensive investigation. ( info) |
44/860. Does pulsed low intensity ultrasound allow early return to normal activities when treating stress fractures? A review of one tarsal navicular and eight tibial stress fractures. We sought to evaluate the efficacy of daily pulsed low intensity ultrasound (LIUS) with early return to activities for the treatment of lower extremity stress fractures. Eight patients (2 males, 6 females) with radiographic and bone scan confirmed tibial stress fractures participated in this study. Additionally, a case report of a tarsal navicular stress fracture is described. All patients except one were involved in athletics. Prior to the study, subjects completed a 5 question, 10 cm visual analog scale (VAS) regarding pain level (10 = extreme pain, 1 = no pain) and were assessed for functional performance. Subjects received 20-minute LIUS treatments 5 times a week for 4 weeks. Subjects maintained all functional activities during the treatment period. Seven patients with posterior-medial stress fractures participated without a brace. Subjects were re-tested after 4 weeks of treatment. Mann-Whitney U tests (VAS data) and paired t-tests (functional tests) assessed statistical significance (p<0.05). Although the intensity of practice was diminished in some instances, no time off from competitive sports was prescribed for the patients with the tibial stress fractures. The patient with the anterior tibial stress fracture underwent tibial intramedullary nailing at the conclusion of a season of play. In this uncontrolled experience, treatment of tibial stress fractures with daily pulsed LIUS was effective in pain relief and early return to vigorous activity without bracing for the patients with posterior-medial stress fractures. ( info) |
45/860. Frozen allogenic spongy bone grafts in filling the defects caused by fractures of proximal tibia. The authors present the way of using the allogenic, frozen, radio-sterilized, spongy bone grafts in operational filling of defects after infra-articular fracture of proximal tibia. Fifteen patients (11 men and 4 women) classified between 30 and 66 years old were evaluated. These patients were operated from 1996 to 1998. The operational treatment with using frozen spongy bone grafts was performed on patients with comminuted split fracture of lateral condyle and depression of tibial plateau. In each case after elevating depressed fragment of tibial plateau bone grafts and screws were used to create a stable joint surface. In the same time other injured structures of the joint (ligaments, meniscus) were being reconstructed. To evaluate the stage of grafts incorporation, radiological examinations were made in; 4 weeks, 8 weeks, 6 months, 1 year from the date of the operation. We observed the process of calcification and forming trabeculac in bone grafts. The mechanical abilities of the reconstructed joint were evaluated according to the IKDS and Lysholm score. In all cases the spongy bone grafts in the joint were reconstructed and rebuild successfully. Thirteen patients had good and very good results in further clinical examinations. We claim that frozen, allogenic grafts of the spongy bone are very useful in filing detects of that bone caused by complicated injuries. This method of treatment with its good results is recommended. ( info) |
46/860. Occult fractures of tibial plateau detected employing magnetic resonance imaging. We describe two cases of spontaneous fracture at the tibial metaphysis not diagnosed by standard X-ray. In both cases, only magnetic resonance imaging supplied a precise diagnosis and allowed us to follow the evolution of the pathology. Scintigraphy is equally sensitive but unspecific. osteoporosis was noted in all cases. Hypothetically, similar pathological situations could be present without being diagnosed since they are not always detected by standard x-rays. ( info) |
47/860. Minimally invasive plate osteosynthesis of distal fractures of the tibia. Minimally invasive plate osteosynthesis of distal tibial fractures is technically feasible and may be advantageous in that it minimizes soft tissue compromise and devascularization of the fracture fragments. The technique involves open reduction and internal fixation of the associated fibular fracture when present, followed by temporary external fixation of the tibia until swelling has resolved. Subsequent limited, but open reduction and internal fixation of the articular fragments when displaced followed by minimally invasive plate osteosynthesis of the tibia utilizing precontoured tubular plates and percutaneously placed cortical screws is performed. The semitubular plate was chosen because it adapts more easily to the bone contours than the stiffer small fragment LC-DCP does. Twenty patients (age 25-59 years) with unstable intraarticular or open extraarticular fractures have been treated including 12 A-type, 1 B-type and 7 C-type fractures according to the AO classification. Two fractures were open (both Gustilo Type I). Closed soft tissue injury was graded according to Tscherne with 3 type C0, 7 type C1, 7 type C2 and 1 type C3. All fractures healed without the need for a second operation. time to full weight-bearing averaged 10.7 weeks (range 8-16 weeks). Two fractures healed with > 5 degrees varus alignment and 2 fractures healed with > 10 degrees recurvatum. No patient had a deep infection. The average range of motion in the ankle for dorsiflexion was 14 degrees (range 0-30 degrees) and plantar flexion averaged 42 degrees (range 20-50 degrees). With longer follow-up and a larger number of patients, the authors feel confident that the minimally invasive technique for plate osteosynthesis for the treatment of distal tibial fractures will prove to be a feasible and worthwhile method of stabilization while avoiding the severe complications associated with the more standard methods of internal or external fixation of those fractures. ( info) |
48/860. Isolated tibial shaft fracture. A nineteen-year-old otherwise healthy woman is seen in the emergency room after being struck by a car. The patient reports left lower extremity pain and has no other injuries. Exam shows a Tscherne grade I soft tissue injury with otherwise normal motor and sensory exam. There are no signs of compartment syndrome. A closed reduction was performed. ( info) |
49/860. Successful free flap transfer following venous thrombectomy in recipient vessel. We report the case of a 53-year-old male patient who suffered a high velocity multiple trauma with bilateral open tibial fractures. At definitive orthopaedic and plastic surgical reconstruction 5 days post initial trauma, he was found peroperatively to have an existing deep venous thrombosis in his popliteal vein on one side. He underwent venous thrombectomy and had subsequent successful latissimus dorsi flap transfer using the unblocked popliteal vein as a recipient vessel. ( info) |
50/860. Reconstruction of a tibial defect with microvascular transfer of a previously fractured fibula. A 43-year-old man sustained severe injuries to his lower limbs with extensive soft-tissue damage and bilateral tibial-fibular fractures. Acutely, the patient underwent external fixation and a free latissimus dorsi flap for soft-tissue coverage of the left leg. However, the tibia had a nonviable butterfly fragment that left a 7-cm defect after debridement. Subsequently, the contralateral fractured fibula was used as a bridging vascularized graft for this tibial defect. The transfer of a fibula containing the zone of injury from a previous high-energy fracture has not been reported. This case demonstrates the successful microvascular transfer of a previously fractured fibula for the repair of a contralateral tibial bony defect. ( info) |