A 51-year-old right-hand-dominant male fell onto his left arm and sustained the isolated injury shown in Figures A and B approximately 6 months prior to presentation. Examination of the wrist is notable for a stable DRUJ and no tenderness. The elbow shows no ligamentous laxity, and the patient reports isolated elbow pain during attempted pronation/supination Current radiographs reveal a malunited radial head fracture. Treatment should now consist of?
Radial head resection
Radial head replacement
ORIF of the malunited fracture
Total elbow replacement
Thanks. very helpful.
Int Orthop. 2015 Jan;39(1):73-9. Epub 2014 Nov 16.
Dr. Dean - replacement and resection both do well in these scenarios, but you have the added cost of an implant with replacement. I've listed an article below that suggests resection is better unless stability is an issue and replacement would be required to provide this:Comparative study of radial head resection and prosthetic replacement in surgical release of stiff elbows.Yu SY, Yan HD, Ruan HJ, Wang W, Fan CYInt Orthop. 2015 Jan. doi: 10.1007/s00264-014-2594-5. 39. (1). :73-9PMID: 25398474 (Link to Abstract)Comparative study of radial head resection and prosthetic replacement in surgical release of stiff elbows.Yu SY, Yan HD, Ruan HJ, Wang W, Fan CYInt Orthop. 2015 Jan. doi: 10.1007/s00264-014-2594-5. 39. (1). :73-9PMID: 25398474 (Link to Abstract)
A 34-year-old man is involved in a motor vehicle accident and sustains an open tibia fracture and is treated with intramedullary nailing. For the next 4 years, he continues to have pain and persistent discharge from a sinus over his shin. He ambulates with crutches and refrains from putting weight on the extremity. The clinical appearance and radiographs are seen in Figures A and B. Wound culture reveals methicillin-resistant Staphylococcus aureus (MRSA). What is the next step in treatment?
Retention of tibial nail, lifelong intravenous antibiotic suppression
Debridement and lavage, exchange nailing using a larger diameter nail, intravenous antibiotics for 6 weeks.
Debridement and lavage, excision of sinus tract, implant removal, intravenous antibiotics for 6 weeks.
Debridement and lavage, addition of ring fixator, intravenous antibiotics for 6 weeks.
Debridement and lavage, excision of sinus tract, exchange nailing using antibiotic impregnated-cement nail, intravenous antibiotics for 6 weeks.
Don't like this question. The lack of mention of soft tissue coverage is a strange omission, that would clearly need a free flap.
Acetabulum fracture with ipsilateral segmental femur (C2765)
46 / F - 46yo F in MVC. Presents with severe head injury, thoracic injury and deformity to left hip/thigh.
How would you classify this acetabular fracture pattern?
I agree with Ben's comments. Initial management would have to include closed reduction the central fracture dislocation of the acetabulum which has been done nicely here. Based on the limited views available I would classify this as a transverse fracture and would approach anteriorly with combined Stoppa and Lateral window. Adjuncts to improve visualization of the anterior fracture line would include ASIS osteotomy to release the ilioinguinal ligament versus opening the middle window. In terms of nailing the fracture I would favor antegrade nailing due to the proximal third fracture position. I'm not aware of any studies dictating femoral nail placement based on acetabular fracture pattern. I think nailing is "dealer's choice" in this scenario and the fracture can be addressed via antegrade or retrograde nailing. The patient can be maintained supine or semi lateral with antegrade nailing.Osteotomy of the Anterior Superior Iliac Spine as an Adjunct to Improve Access and Visualization Through the Lateral Window.Sagi HC, Bolhofner BJ Orthop Trauma. 2015 Aug. doi: 10.1097/BOT.0000000000000283. 29. (8). :e266-9PMID: 25932529 (Link to Abstract)
Scapular Fracture in a 24M following MVC (C2767)
24 / M - RTA - 2 wheeler rider collided with a stationary vehicle - closed fracture of the left clavicle, scapula and left multiple rib fractures with haemopneumothorax - haemodynamically stable.
Normal neurovascular examination of the upper limb. Other injuries - L3 wedge #, Left iliac crest fracture.
How would you manage the scapular fracture?
If the scapula is treated conservatively, will the comminuted fragment block scapulithoracic movements?
Chronic Elbow Dislocation (4 months old) (C1890)
23 / M - Fall from motor bike 4 mths ago. Patient refused surgery and got it treated by a bone setter who put him in a cast for a month.Minimal to no motion at the elbow.
How would you treat this patient?
Intra-articular anteromedial malleolus fracture of distal tibia in a 23M (C2760)
23 / M - A 23 year old male patient presented to ER after a RTA where he injured his left ankle.
Patient was non-weight bearing. Severe left ankle pain, swelling, and limited ROM.
Would you order a CT scan for this patient?
nice operation and excellent result
why is resection better than replacement?
Radius and Ulnar Shaft Fractures
I would like to know about infected non union
Dr. Yadav - are you looking for an overall rate or with open fractures or ?
J Knee Surg. 2016 Oct 27;:. Epub 2016 Oct 27.
Injury. 2013 Sep;44 Suppl 3:S40-5.
Instr Course Lect. 2015;64:521-30.
Anonymous - Good question. I went through pubmed and found a few decent articles, including the three below, on timing of treatment of these injuries. The three below, as well as a recent meta-analysis, didn't find any difference in outcome between early or late treatment, although the staging of treatment into one versus two (or even three) surgical reconstructions has different outcomes, depending on the article - some note best outcomes with one definitive surgery, and others report better outcomes with a staged approach. Two consistent factors noted for worse outcomes are presence of knee dislocation upon evaluation as well as need to reconstruct 3 or more ligaments.Factors Associated with Knee Stiffness following Surgical Management of Multiligament Knee Injuries.Hanley J, Westermann R, Cook S, Glass N, Amendola N, Wolf BR, Bollier MJ Knee Surg. 2016 Oct 27. doi: 10.1055/s-0036-1593624PMID: 27788528 (Link to Abstract)Acute Management and Surgical Timing of the Multiligament-injured Knee.Gella S, Whelan DB, Stannard JP, MacDonald PBInstr Course Lect. 2015. 64. :521-30PMID: 25745935 (Link to Abstract)Staged management of knee dislocation in polytrauma injured patients.Darabos N, Gusic N, Vlahovic T, Darabos A, Popovic I, Vlahovic IInjury. 2013 Sep. pii: S0020-1383(13)70196-7. doi: 10.1016/S0020-1383(13)70196-7. 44 Suppl 3. :S40-5PMID: 24060017 (Link to Abstract)
what's the percentage of non union in fractures of both bone forearm
It is mentioned in the topic about early treatment of multilig knee injuries is associated with better outcomes. Could you point me in the direction of the evidence for this statement please?